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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.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
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 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
The Diagnostic Value of Hyperbilirubinemia and Total Leucocyte Count in the Evaluation of Acute Appendicitis
Correspondence Address :
Dr. SALAMAT KHAN drsalamatkhan63@yahoo.co.uk
Background: Acute appendicitis (AA) is a common abdominal emergency encountered in general surgery. In most of the cases, the diagnosis can be made clinically by assessing the symptoms and physical findings and can be confirmed by laboratory tests and ultrasonography. However, diagnosis is difficult sometimes even after all these tests and in such doubtful cases, either the diagnosis is missed or the patient’s normal appendix is operated on, leading to increase in mortality and morbidity.
Aims: It is to evaluate the importance of total leukocyte count (TLC) and total serum bilirubin (TSB) in the diagnosis of clinically suspected cases of AA.
Settings And Design: This is a prospective study conducted at the Department of Surgery at NGMC, Teaching Hospital, Nepalgunj, Nepal, from December 2004- Jan 2008.
Methods And Material: 122 patients suspected of having appendicitis at clinical evaluation underwent prospective evaluations which included laboratory tests (TLC, LFT, Urine analysis) and ultrasonography (USG) of the abdomen. They were operated on and their diagnosis was confirmed per-operatively and post-operatively by histo-pathological examination. Laboratory results, operative findings and histo-pathological findings were compiled, analyzed and compared with reference values. The TLC and total serum bilirubin (TSB) were considered positive for appendicitis when their values were greater than 1010cell/cmm and > 1.1 mg/dL, respectively.
Results: The ages ranged from 8-73 years with a mean of 29.36 years. Out of 122 patients, 21(17.81%) cases belonged to the early group of cases (reported <24hours after the onset of the symptoms), while 101(82.78%) cases belonged to the delayed group of cases (reported >24 hours after the onset of the symptoms). The histological examination revealed that of the 122 specimens, 118(96.72%) had a positive histology for AA, while 4 (3.22%) had normal histology. TLC was elevated in 93 (76.22%) cases and it was normal in 29 (23.77%) cases. Among the cases that had elevated TLC, only 91(97.84%, CI 14010±254) had a positive histology for AA, while the remaining 2 (2.15%) had normal histology. Among 29 cases that had normal TLC, 27 had positive histology for AA, while the remaining 2 had normal histology. The specificity, sensitivity, positive predictive value (PPV), negative predictive value (NPV) and overall diagnostic accuracy are 50%, 77%, 97.8%, 7.4% and 76.22%, respectively. TSB was elevated in 95 cases (77.86%, CI 2.06±0.73), while it was within normal limits in 27 (22.13%) cases. Among the cases that had elevated TBS, all had positive histology for AA, while in cases with normal TBS, 23 had a positive histology for AA, while 4 had normal histology. The specificity, sensitivity, PPV, NPV, and overall diagnostic accuracy are 100%, 80%, 100%, 14% and 81.14%, respectively Liver enzyme changes if any, were not helpful in the diagnosis.
Conclusion: Elevated TSB (without severe changes in liver enzymes) was found to be a better laboratory test with 100% specificity, 80% sensitivity and 81.14% overall diagnostic accuracy than TLC with 50% specificity, 77% sensitivity and 76.22% overall diagnostic accuracy in the diagnosis of AA. But the diagnosis can be further improved if positive results of either tests alone or in combination are taken into consideration. This will reduce the missing rate of AA without increasing the rate of negative appendicectomies.
Hyperbilirubinaemia, Total Leukocyte Count, Total Serum Bilirubin, Acute Appendicitis
Appendicitis is the most common cause of acute abdominal pain that necessitates surgical intervention in the Western world and around Kathmandu valley in Nepal (1), (2). The clinical diagnosis of acute appendicitis is based primarily on symptoms and physical findings. However, this diagnosis is often difficult and up to 50% of the patients hospitalized for possible appendicitis do not actually have this disorder. Authors of large prospective studies reported a 22%-30% removal rate of normal appendices at surgery (3), (4), (5), (6). To reduce the frequency of unnecessary appendectomy, the importance of laboratory findings that include both white blood cell (WBC) counts and C-reactive protein (CRP) values has been stressed (7), (8), (9) and the use of USG as a diagnostic tool for appendicitis has been widely evaluated (10),(11), (12), (13). Various scores combining clinical features and lab investigations have also been developed and are good enough to reach the diagnosis. These are the Alvarado score(14) and the Modified Alvarado score(15). Recently, elevation in serum bilirubin, was reported, but the importance of the raised total has not been stressed(17).
It is well established that when microbes invade the body, leucocytes defend it. This leads to increase in the leucocyte count. Bacterial invasion in the appendix leads to transmigration of bacteria and the release of TNF-alpha, IL6, and cytokines. These reach the liver via Superior mesenteric vein (SMV ) and may produce inflammation, abscess or dysfunction of liver either directly or indirectly by altering the hepatic blood flow(18),(19),(20),(21),(22),(23),(24).
Aim
To evaluate the specificity, sensitivity, PPV, NPV and diagnostic accuracy of TLC and TSB in the diagnosis of acute appendicitis.
This is a prospective study conducted at Nepalgunj Medical College, Teaching Hospital, Nepalgunj, Nepal, from December 2004 to January 2008. Consecutive patients suspected of having appendicitis at clinical evaluation underwent prospective evaluations which included laboratory tests (TLC, LFT, Urine analysis) and USG of the abdomen. They were operated on and their diagnosis was confirmed per-operatively and post-operatively by histo-pathological examination. Laboratory results, operative findings and histo-pathological findings were compiled, analyzed and compared with the reference values. The TLC and TSB were considered positive for acute appendicitis when their values were greater than 1010cll/cmm and > 1.1 mg/dL, respectively.
Criteria of selection for the cases
Patients with a history of alcohol intake with AST/ALT <2 or no history of alcohol and hepatotoxic drug intake, those who were HBsAg negative or those with no past history of jaundice with acute appendicitis were included in the study, whereas patients with a history of alcohol intake and AST/ALT >2, a history of hepatotoxic drug intake, those which were HBsAg positive and /or those with a past history of jaundice and acute appendicitis were excluded from the study.
A total of 122 patients were included in the present study. Their ages ranged from 8-73 years with a mean age of 29.36 years. The male to female ratio in adults and children were 1.57: 1:: 3.8:1, respectively. The commonest age group was 30 -40 years in adult patients. Out of the 122 cases, 21(17.81%) belonged to the early group of cases (duration of the onset of the symptoms- <24hours), while 101 (82.87%) belong to the delayed group of cases (duration of the onset of symptoms- >24 hours). Among the 21 early cases, 2 reported <12 hours, while the rest of the 19 reported >12 hours for the onset of symptoms (Table/Fig 1), (Table/Fig 2), (Table/Fig 3).
Histological examination reports revealed that out of the 122 appendix specimens, 118 (96.72%) had a positive histology for AA, while the remaining 4(3.22%) had normal histology (Table/Fig 4).
Of the 122 patients, 93 were found to have elevated TLC (76.22%) (18early&75 delayed) and it was normal in 29 (23.77%) (3 early&26 delayed) cases. Among the cases that had elevated TLC, only 91(97.84%, CI 14010±254) had a positive histology for AA and the remaining 2(2.15%) had normal histology. Among 29 cases that had normal TLC, 27 had a positive histology for AA, while the remaining 2 had normal histology. The specificity, sensitivity, PPV, NPV and DA are 50%, 77%, 97.8%, 7.4% and 76.22%, respectively (Table/Fig 5).
Of the 122 patients, 95 were found to have elevated TSB (77.86%, CI 2.06±0.73) (17early &78delayed), while it was within normal limits in 27 (22.13%) cases. Among the cases that had elevated TSB, all had a positive histology for AA, while in cases with normal TBS, 23 had positive histology for AA, while 4 had normal histology. The specificity, sensitivity, PPV, NPV, and DA are 100%, 80%, 100%, 14% and 81.44%, respectively (Table/Fig 6).
Liver enzymes e.g. serum alanine amino trasferase (ALT/SGPT) was normal in 86(70.49%), marginally elevated (<1time) in 26(21.31%), minimally elevated (>1-<2time) in 5(4.09%), moderately elevated (<3times) in 3(2.45%) and severely elevated (>3times) in 2(1.63%) of the cases. Serum aspertate aminotrasferase(AST/SGOT) was normal in 75(61.47%), marginally elevated (<1time) in 37(30.32%), minimally elevated (>1time-<2times) in 8(6.55%), moderately elevated (3times) in 1(0.84%) and no case of severe elevation was observed. Age and sex adjusted ALP was normal in 62(50.81%), slightly elevated (1 time) in 46(37.70%), moderately elevated (< 2 times) in 9(7.37%) and severely elevated (>2 times) in 5(4.09%) of the cases (Table/Fig 7), (Table/Fig 8), (Table/Fig 9).
A majority of the cases are reported to the hospital only 24 hours after the onset of symptoms. Histopathological reports of the appendix specimens revealed that 96.27% had a positive histology for AA, whereas TLC and TSB were elevated in 76.22% and 77.86% of the cases, respectively. This indicates that the elevation of both TLC and TSB strictly does not follow the acute inflammation of the appendix.
If TLC alone is taken into consideration to reach the diagnosis in a clinically suspected case of AA, then there is a possibility that about 1.7% results could be false positive (elevation of TLC without inflammation of appendix) and 22.13% results could be false negative (positive histology without elevation of TLC), which means that there are chances that 1.7% normal appendices will be removed, while in 22.13% of the cases, the diagnosis will be missed.
If TSB alone is taken into consideration to reach the diagnosis in a clinically suspected case of AA, there will be no false positive results, but there could be 18.85% false negative results, which means that none of the normal appendices will be removed, but in 18.85% of the cases, the diagnosis will be missed.
On comparing both test results, TSB was found to be a better test than TLC, because the missing percentage of the diagnoses was nearly similar in both tests (22.13% Vs 18.85%), but the percentage of negative appendicectomy with TSB was nil as compared to TLC (1.7%).
If both are elevated, both TLC and TSB are taken into account to reach the diagnosis in clinically suspected cases of AA. The correct diagnosis is usually made only in 55% of the cases. This is because both the tests do not show elevated values at the same time in 45% of the cases. This can cause the real diagnosis to be missed out in too many cases, while if both test results show elevated values which are taken into account either alone or together, the chances of a correct diagnosis is increased to 99.3% and the chances of a missed diagnosis is reduced to <1% at the expense of 1.7% unnecessary appendicectomies (false positive cases). This is much higher than either of the two tests individually and together. Thus, in cases where TLC is normal, TSB can be used as an alternative lab test, or vice –versa, to reach the diagnosis. This may reduce the rate of missed diagnoses without increase in the percentage of negative appendicectomies (7), (25).
Elevated TSB (without severe changes in liver enzymes) is a better laboratory test (with 100% specificity, 80% sensitivity and 81.14% overall diagnostic accuracy) than TLC (with 50% specificity, 77% sensitivity and 76.22% overall diagnostic accuracy) in the diagnosis of AA. But, the diagnostic accuracy is further improved if positive results of either tests alone or in combination are taken into consideration for the diagnosis. This will reduce the rate of missed diagnoses of AA without increasing negative appendicectomies.
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