Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Archana Dambal

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Department of General Medicine,
Belgaum Institute of Medical Sciences,Belgaum, Karnataka,INDIA,
On 30 Nov 2018




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Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




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On Sep 2018




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"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




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Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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Dr. Arunava Biswas
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Best regards,
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On Aug 2018




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Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2009 | Month : June | Volume : 3 | Issue : 3 | Page : 1523 - 1528

Epidemiology, Clinical Presentation And Final Outcome Of Patients With Scorpion Bite

SINGHAL A*, MANNAN R**, RAMPAL U***

*(MD),Senior Resident Department of Neurology Sanjay Gandhi Post Graduate Institute Lucknow (India).**(MBBS),(MD),Assistant Prof. Department of Pathology Sri Guru Ram Das Institute of Medical Sciences and Research Amritsar, Punjab (India).***(MBBS),(Int),KMC, Mangalore Karnataka (India).

Correspondence Address :
Rahul mannan
E.mail:rahulmannan@gmail.com

Abstract

Most of the scorpion sting cases are acute life-threatening and time-limiting medical emergencies. The present study was undertaken to analyze the varied clinical presentations in patients admitted with a history of scorpion bite, with a special emphasis to find out whether any difference existed in the presentation of paediatric patients in comparison to the adult patients and to understand whether any particular signs and symptoms were associated with increased mortality and morbidity in different age groups. Also, the final outcomes in all the age groups were noted.This study was conducted at a tertiary care hospital (SRN Hospital, Allahabad) from April 2006 to September 2007. In all the age groups, 74 cases presenting with a history of scorpion sting were either observed or admitted to the intensive coronary care unit (ICCU). They were classified into different groups (A-D) depending upon the clinical presentation. GROUP A included patients who presented only with local signs or those who were asymptomatic; GROUP B included patients having signs of acute pulmonary oedema (APO); GROUP C included patients with signs of APO and myocarditis and GROUP D included patients with APO, myocarditis and encephalopathy or encephalopathy alone. The final outcome was tabulated and the results were analyzed to associate the mortality with any particular clinical parameter. The treatment protocol was designed according to the groups divided. The older age group (5-15 years) comprised of the asymptomatic group (Group-A) in which survival was excellent (100%). Group B comprised of the maximum number of patients ie.52 (70.27%). In this group, the patients in the age group of 5-15 years were the largest cohort. Survival in this group was quite satisfactory, with a recovery rate of 96.16%. Group C patients had an additional element of myocarditis which affected the younger individuals i.e. age groups less than 5 and 5-15 years comprising of 3 patients each. In this group, mortality was seen in 2 (33.33%) patients. Group D had the worst outcome with 100% mortality rates and affected the extremes in the age groups from very young (less than 5 years) to the elderly (above 15 years) patients. An incidental finding of priapism was noted in 27.02% of the patients. The point to be noted was that it was present in 100% of the cases in the age group of less than 5 years in male children and in 40 % of the cases in the age group of 5-15 years in males. There was no incidence of priapism in males above 15 years.

Keywords

Scorpion bite, epidemiology, outcome, treatment

How to cite this article :

SINGHAL A, MANNAN R, RAMPAL U. EPIDEMIOLOGY, CLINICAL PRESENTATION AND FINAL OUTCOME OF PATIENTS WITH SCORPION BITE. Journal of Clinical and Diagnostic Research [serial online] 2009 June [cited: 2019 Aug 19 ]; 3:1523-1528. Available from
http://jcdr.net/back_issues.asp?issn=0973-709x&year=2009&month=June&volume=3&issue=3&page=1523-1528&id=535

Introduction
Scorpion sting is an acute life-threatening, time-limiting medical emergency among the rural population in most places in India (1). Reliable statistics are not readily available for this common rural accident. Case fatality rates of 3-22% were reported among children who were hospitalized for scorpion stings in India (2),(3).

Among the 86 species of scorpions in India, Mesobuthus tamulus and Palamneus swammer-dami are of medical importance. Cardiovascular effects are particularly prominent following the stings by the Indian red scorpion (Mesobuthus tamulus) (4).

The clinical features post scorpion bite, include pain in and around the sting site, florid autonomic signs such as hypertension, tachycardia, hypotension, pulmonary oedema, priapism and infrequently; central nervous manifestations such as encephalopathy, convulsions and coma (5),(6).

The present study was undertaken to analyze the varied clinical presentations in patients who were admitted with a history of scorpion bite, with a special emphasis to find out whether any difference existed in the presentation of paediatric patients in comparison to the adult patients and to understand whether any particular signs and symptoms were associated with increased mortality and morbidity in different age groups. Also, the final outcomes in all the age groups were noted.

Material and Methods

This study was conducted at a tertiary care hospital (SRN Hospital, Allahabad) from April 2006 to September 2007. In all the age groups, 74 cases presenting with a history of scorpion sting were either observed or admitted to the intensive coronary care unit (ICCU). They were classified into different groups (A-D) depending upon the clinical presentation.

GROUP A- Local signs/ Asymptomatic

GROUP B- Acute Pulmonary Oedema (APO)

GROUP C- APO+ Myocarditis

GROUP D- APO+ Myocarditis + Encephalopathy OR Encephalopathy alone

All the asymptomatic patients or those complaining of pain and paresthaesia at the sting site, with no systemic manifestations, were kept under Group A.

Group B consisted of patients with APO which were identified clinically on the basis of cold and clammy skin, tachycardia with elevated blood pressure, retractions, nasal flaring and grunting, pink frothy sputum, impaired percussion note over lung fields, crepitations and radiological findings; complemented with decreased oxygen saturation.

Group C consisted of patients with APO and Myocarditis. Myocarditis was diagnosed on the basis of clinical features such as tachycardia, arrhythmia, gallop rhythm, systolic murmurs, ECG changes and elevated LDH (lactate dehydrogenase).

Group D consisted of patients with features of APO and Myocarditis as well as encephalopathy, or patients presenting acutely with encephalopathy alone. Patients with persistent irritability or altered sensorium, convulsions and neurological deficit were classified as cases of encephalopathy.

Group A patients were monitored closely for signs of toxicity and were administered analgesics like acetaminophen and ice packs to relieve the signs of inflammation.

All of the symptomatic patients in Group B, C and D received a dose of prazosin (30 microgram per Kg body weight) in the supine position, with monitoring of blood pressure (BP), heart rate (HR), respiration rate (RR) and hydration status. In addition, patients with APO were put on sodium nitroprusside drip and dobutamine along with supportive measures and were ventilated as and when required. These patients were tapered off the sodium nitroprusside drip after they got stabilized haemodynamically and were continued on prazosin. Similarly, dobutamine was tapered and stopped in a phased manner.

Patients of Group D, presenting with additional signs of encephalopathy such as seizures, were managed with anti-convulsant medication. Also, an unusual association in the paediatric age group was seen in the form of the presence of priapism, which was managed conservatively with ice-packs only.

In the present study, the presence of signs and symptoms in the various age groups were tabulated according to Groups A to D. The final outcome was tabulated and the results were analyzed to associate the mortality with any particular clinical parameter. The differences in presentation and progression towards the final outcome were studied and assessed to compare paediatric patients with adult patients.

Observations
There were 74 patients in the present study, of which 46 (62.16%) were males and 28 (37.83%) were females. The mean time interval between the scorpion sting and the clinical presentation was 8 hours (range 4–16 hours). Of these 74 patients, 70 (94.59%) were from the rural background and 66 (89.18%) patients were admitted during the months from April to August. In the present study, the age groups of 5-15 years and >15 years comprised the largest subgroup, with each having 30 cases (40.54%). The maximum number of males- 20 (43.47%) were seen in the age group of 5-15 years; whereas, the maximum number of females- 16 (57.14%) constituted the age group above 15 years (Table/Fig 1).

The clinical manifestations and presentation at the time of admission were tabulated along with the biochemical and radiological profiles of the patients, as given in (Table/Fig 2).

The older age group (5-15 years) comprised of the asymptomatic group (Group-A) in which survival was excellent (100%). Group B comprised of the maximum number of patients-52 (70.27%). In this group, the patients in the age group of 5-15 years were the largest cohort. Survival in this group was quite satisfactory, with a recovery rate of 96.16%. Group C patients had an additional element of myocarditis which affected the younger individuals i.e. age groups less than 5 and 5-15 years, comprising of 3 patients each. Out of these, mortality was seen in 2 (33.33%) patients. Group D had the worst outcome, with 100% mortality rates and affected the extremes in the age groups from very young (less than 5 years) to the elderly (above 15 years) patients (Table/Fig 3), (Table/Fig 4).

Discussion

Scorpion stings increase dramatically in summer months and are lowest in winter. In our study also, the maximum number of scorpion stings were reported in the months from April to August. Scorpions commonly inhabit the crevices of dwellings, underground burrows, the areas under logs or debris, paddy husk, sugarcane fields and coconut and banana plantations. In our study, the finding that out of 74 patients admitted in the ICCU, 70 (94.59%) were from the rural background, correlates well with the natural habitat of the scorpion (7). Also, most of the patients were male i.e. 46 (62.16%) who venture out more in fields in the rural setting (Table/Fig 1).

Of the initial signs and symptoms, intense pain and paresthaesia were present in 70.27% of cases; however, breathlessness was the most common (78.37%) initial presentation in the study conducted. Serotonin found in scorpion venom is thought to contribute to the pain associated with scorpion sting (8).

Scorpion venoms are species-specific complex mixtures of short neurotoxic proteins (31-64 aminoacid sequences) (9). The venom contains numerous free aminoacids, appreciable quantities of serotonin, hyaluronidase and various enzymes that act on trypsinogen. Voltage dependant ion channels are altered by the venom. The toxin acts by opening sodium channels at presynaptic nerve terminals and by inhibiting calcium dependant potassium channels. An autonomic storm is thus initiated (4). The unopposed effects of the alpha-receptor stimulation are thought to result in autonomic disturbances, and this has been the rationale for treatment with the alpha-blocker prazosin (10), as also instituted in the present study. Tachycardia, hypertension, myocardial dysfunction, pulmonary oedema and shock are important manifestations of the ‘autonomic storm’ found in patients stung by a scorpion (7). These very signs and symptoms were also recorded in our study where tachycardia was seen in the maximum number of patients ie. 60 (81.08%); followed by pulmonary oedema in 52 (70.27%) patients. Hypotension was seen in 13 (17.56%) patients who presented later than the average reporting time of 8 hours in the present study; which points towards the fact that in the early hyperdynamic phase, the blood pressure is elevated and LV contraction is enhanced. This is followed by a hypokinetic phase in which hypotension and impaired LV function occurs (Table/Fig 2) (11),(12),(13),(14).

All of the cases with myocarditis had APO and many had S3 gallop and apical murmur of mitral regurgitation, similar to the tachyarrhythmia myocarditis in 3-75% of the cases and apical murmur in 43.9% of the cases in other studies (15),(16),(17). The myocarditis was corroborated with an increased level of lactate dehydrogenases (LDH).

An incidental finding of priapism was noted in 27.02% of the patients. The point to be noted was that, it was present in 100% of the cases in the age group of less than 5 years in male children and in 40 % of the cases in the age group of 5-15 year old males. There was no incidence of priapism in males above 15 years. This phenomenon is due to the parasympathetic over stimulation in children, as they are more likely to develop a more rapid progression and increased severity of symptoms because of their lower body weight. These findings need to be corroborated in further studies, as to the best of our knowledge this has not been addressed in the literature so far.

Central nervous system manifestations are infrequently encountered. They are however, invariably fatal. Generalized seizures and tonic posturing was seen in 2.70% of cases in comparison to 2-13% from India, Israel and South Africa (18).

In the pre-prazosin era (1961-1983), 25-30% fatality due to pulmonary oedema was reported in scorpion victims from Western India. Ever since prazosin started being used (1984 onwards), the mortality in these victims reduced to less than 1% (7). In the present study, 90.54% cases recovered fully and mortality was seen in 9.46% cases. Of these, 100% mortality was seen in Group D patients having CNS involvement. The next most affected group was Group C, having evidence of the involvement of the myocardium where mortality was in the range of 35.71%.

Prazosin is now clinically accepted for scorpion sting cases. There must be no delay in administration of prazosin. The importance of treating pulmonary oedema effectively with sodium nitroprusside or nitroglycerin infusate and dobutamine support cannot be over emphasized as this is a major cause of subsequent mortality (18).

Key Message

1. In the present study, most of the patients suffering from the scorpion bite were males and from the rural background.
2. Of the initial signs and symptoms, intense pain and paresthaesia were present in 70.27% of the cases; however, breathlessness was the most common (78.37%) initial presentation in the study conducted.
3. The patients were classified into different groups (A-D) depending upon the clinical presentation. GROUP A included patients presenting with only local signs or those who were asymptomatic; GROUP B included patients having signs of acute pulmonary oedema (APO); GROUP C included patients with signs of APO and myocarditis and GROUP D included patients with APO, myocarditis and encephalopathy or encephalopathy alone.
4. An incidental finding of priapism was noted in 27.02% of the patients. The point to be noted was that it was present in 100% of the cases in the age group of less than 5 years in male children and in 40 % of the cases in the age group of 5-15 years in males. There was no incidence of priapism in males above 15 years.
5. Central nervous system manifestations were infrequently encountered. They were however invariably fatal. Generalized seizures and tonic posturing were seen in 2.70% of the cases.
6. In the pre-prazosin era (1961-1983), 25-30% fatality due to pulmonary oedema was reported in scorpion victims from Western India. Ever since the use of prazosin (1984 onwards) started, the mortality in these victims reduced to less than 1%. In the present study, 90.54% cases recovered fully and mortality was seen in 9.46% of the cases.

Acknowledgement

Prof P. C Saxena MD, DM (Cardio), Head, Deptt of Cardiology, SRN Hospital, Allahabad (India).

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