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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
Spontaneous Bacterial Peritonitis In Ascites: A Prospective Study In A Tertiary Care Hospital
Correspondence Address :
Dr.G.B.Doddamani,
Asso.Professor
Department of Medicine
S.Nijalingppa Medical College
Bagalkot-587 102, Karnataka
Phone No.: 9480183063
e-mail: drsunitapujar@gmail.com
Background: Spontaneous bacterial peritonitis is a common and fatal complication occurring in cirrhotic patients with ascites. It is defined as infected ascites in the absence of any recognisable secondary cause of infection.
Objective: To evaluate the relative frequency, clinical presentation and microbial spectrum of spontaneous bacterial peritonitis in ascites patients.
Design: A Hospital based prospective study carried out in patients with ascites.
Place And Duration Of Study: The study was conducted in the departments of Medicine and Biochemistry from August 2008- July 2009 at S.Nijalingappa Medical College and HSK hospital and Research Center, Bagalkot, Karnataka.
Material And Methods: 100 patients admitted to the Department of Medicine with the diagnosis of ascites were selected. They were divided into cirrhotic and non cirrhotic ascites cases. Ascitic fluid from these patients was analysed for cytology, culture/sensitivity and biochemical parameters. Based on these investigations, the cases were further categorized into the SBP (Spontaneous bacterial peritonitis), CNNA (Culture Negative Neutrocytic Ascites) and MNB (Monomicrobial non-Neutrocytic Bacterascites) groups. Statistical analysis was done by using the unpaired “t” test.
Results: 81 patients were cirrhotic and the rest of the 19 cases were non cirrhotic. Among the patients of cirrhotic ascites, SBP was diagnosed in 8 cases (9.81%) and CNNA and MNB were diagnosed in 3(3.7%) and 1(1.23%) cases, respectively. In the SBP group, Escherichia.coli was the most frequently cultured organism and it was isolated in 4 cases (50.0%), followed by Klebsiella pnuemoniae in 3(37.5%) cases and Pseudomonas aeruginosa in 1 (12.5%) case. In the CNNA group, the culture was negative, while in MNB one case was E.coli positive. Abdominal pain, hepatic encephalopathy and fever were the common presenting features in 75%, 75% and 62.5% cases in the 3 groups, respectively. The ascitic fluid protein was 0.92 ± 0.25 gms/dl in the SBP group, 1.13 ± 0.49 gms/dl in the CNNA group and 1.4gms/dl in MNB patients.
Conclusion: SBP is a fatal complication of cirrhosis with ascites. It has a heterogenous clinical presentation. Ascitic fluid should be analysed routinely in all cases of cirrhosis with ascites for the early detection of SBP.
Ascites, cirrhotic ascites, SBP, CNNA, MNB.
Introduction
Ascites is a Greek term (askos) which refers to a bag or sac. It is the most frequent complication of cirrhosis and is associated with increased susceptibility to infection and has poor long term outcome (1). Spontaneous bacterial peritonitis is
an infection of ascitic fluid in the absence of any obvious intra-abdominal source (2)(3).The prevalence of the disease in cirrhotic patients has been estimated to be between 8-27%, with resulting mortality ranging from 48-57% (4).
The diagnosis of SBP can be difficult, as there are no typical signs and symptoms and it can be detected only if the ascitic fluid is subjected to cytological examination and culture/sensitivity. Low protein concentrations (1gm/dl) in ascites are particularly prone to develop SBP due to a defect in the opsonisation and neutrophil phagocytosis of bacteria (5).
SBP(Spontaneous Bacterial Peritonitis), CNNA (Culture Negative Neutrocytic Ascites) and MNB (Monomicrobial non-Neutrocytic Bacterascites) are diagnosed on the basis of leucocyte count per cubic mm and absolute polymorphonuclear leucocyte (PMN) count in the routine examination of ascitic fluid, along with the result of its bacterial culture.(6).
In SBP, the bacterial culture is found to be positive, along with a leucocyte count of >500 cells mm3 or an absolute PMN count > 250 cells mm3, whereas in CNNA, the ascitic fluid culture is found to be negative and the absolute PMN count is similar to that of SBP. In MNB, the culture is positive, but the leucocyte count is < 500 cells mm3 and the absolute PMN count is < 250 cells mm3 (7)(8).
In view of the high rate of morbidity and mortality which is associated with SBP, this study was carried out to find out the relative frequency, clinical presentation and the organisms which are involved in this condition.
The study was conducted in the department of Medicine and Biochemistry from August 2008-July 2009 at the S.Nijalingappa Medical College and HSK hospital and Research Center, Bagalkot, Karnataka.
100 patients who were admitted to the Department of Medicine with the diagnosis of ascites were selected. They were evaluated by detailed history, clinical examination and sonographical findings. Based on the above tests and their findings, the patients were divided into cirrhotic and non cirrhotic ascites categories. Ascitic fluid tapping was done and sent for cytology, biochemical analysis and culture/sensitivity. Based on these investigations, SBP was diagnosed and it was further categorized into SBP, CNNA and MNB.
Exclusion Criteria
a) Patients who had undergone abdominal paracentesis within 3 weeks.
b) Patients on antibiotics.
c) Patients with secondary causes of peritonitis like gut perforation and liver abscess.
Statistical Analysis:
The results of the study were analysed by the unpaired “t” test. P values lesser than 0.05 were considered to be statistically significant.
100 cases of ascites were enrolled in the study. 81 patients were of cirrhosis and 19 were of non-cirrhotic ascites [Table/Fig 1). The incidence of SBP, CNNA and MNB were 8(9.87%), 3(3.7%) and 1(1.23%) respectively in cirrhotic patients. The majority of cases [69(85.18%)] were that of sterile ascites i,e ascitic fluid PMN count < 250 cells/mm3 and culture negative.
The present study comprised of patients in the age group of 21-60 yrs. SBP and CNNA were more common in the age group of 41-60 yrs, while MNB was seen in the age group of 21-40 yrs. 68 patients were males and 13 were females and the disease was more common in males, with statistical significance (P<0.05) . Abdominal pain, fever and hepatic encephalopathy were the leading clinical presentations of SBP and CNNA One case of MNB was asymptomatic (Table/Fig 2).The levels of ascitic PMN count, proteins and total serum bilirubin in SBP, CNNA and MNB are shown in (Table/Fig 3). The ascitic fluid PMN count was raised in SBP and CNNA cases as compared to that in the MNB cases (P<0.05 ).The protein level was significantly decreased in SBP cases as compared to that in the CNNA cases (P<0.05). The levels were further more increased in MNB cases as compared to that in the CNNA cases (P<0.05). Serum bilirubin levels were raised in SBP cases as compared to that in the CNNA cases (P<0.05). The levels were lower in MNB cases as compared to that in the CNNA cases (P<0.05).
The microbial spectrum in the SBP, CNNA and MNB cases: 8 cases of SBP and one case of MNB revealed the presence of various bacteria in their ascitic fluid cultures. E.coli was the most frequently cultured organism which was isolated in 5 cases (Table/Fig 4).
Cirrhosis of liver was the most common cause of ascites, followed by CCF, TB, peritonitis, anaemia,hypoprotinemia, malignancy and nephrotic syndrome . These findings are in accordance with previous studies where they suggested that it may be caused due to poor nutritional status, as the body is prone to develop infectious diseases in this region (9). In the present study, the prevalence of SBP, CNNA and MNB were 9.81%, 3.7% and 1.23 respectively. This is similar to the results found in other studies (10). Cirrhosis was common in the age group of 41-60 yrs, which is almost consistent with the available data (11).
The most common presenting symptoms of SBP were hepatic encephalopathy (75%) and abdominal pain (75%), followed by fever (62.5%). Gastrointestinal bleeding was seen in 25% of the cases. The clinical features of CNNA were similar to those of SBP. Previous authors have reported abdominal pain in 78.5%, fever in 28.5% and hepatic encephalopathy in 50%, while GIT bleed was seen in 78.56% of cases (12).
Most of the patients with SBP had features of liver dysfunction at admission and the mean of serum bilirubin and serum albumin were 6.87mg/dl and 2.46 ± 0.54mg/dl respectively. Serum albumin values less than 2.5gm% were associated with an increased risk of infection and mortality for SBP (13). The mean ascitic fluid protein concentration in patients with SBP was decreased. It has been demonstrated that cases of cirrhosis with ascitic fluid protein concentration less than 1 gm% are 10 times more prone to develop SBP as compared to others (14).
In this study, 6 out of 8 cases with SBP had a raised peripheral leukocyte count. It was normal in 3 cases of CNNA and in 1 patient of MNB. Previous studies observed a raised peripheral leukocyte count in only 1 out of 7 cases of CNNA and in 1 out of 3 cases with MNB (15).
The culture of ascitic fluid has undergone a dramatic change. The conventional method of ascitic fluid culture is the collection of the fluid in a sterile culture tube and inoculation of the fluid in enriched chocolate agar. In the modified method, ascitic fluid was inoculated at the bed side of the patient in a blood culture bottle and was cultured on blood and Mckonkey’s agar plates. Runyon et al introduced the improved technique of ascitic fluid culture and observed marked improvement in the culture yield of ascitic fluid upto 9%, as compared to 42% yield by the conventional method (16). In this study, the ascitic fluid culture was positive in 25% cases of SBP by the conventional method, as compared to 100% positive cases by the modified method.
These are in line with other documented studies on the microbial spectrum of SBP, including the gram negative aerobic flora of the gut. The common organisms which were isolated included E.coli, Klebsiella pnuemoniae and Proteus mirabilis. However, gram positive cocci and anaerobic organisms have also been reported to be found in in 10-15% of the cases (17). In the study, gram negative organisms were commonly isolated by the ascitic fluid culture. E.coli was isolated in 5 cases (62.5%), Klebsiella pnuemoniae in 2 cases (25%) and Pseudomonas aeruginosa in 1 case (12.5%)
SBP is a commonly encountered complication of liver cirrhosis with ascites. It has aheterogenous clinical presentation. A high index of suspicion is required to establish early diagnosis and treatment. SBP is associated with a high rate of morbidity and mortality. Hence, it is recommended that ascitic fluid samples should be obtained routinely in all patients with cirrhosis. Use of modified techniques instead of conventional methods increases the culture yield of the ascitic fluid. SBP, if diagnosed early, can be treated with a very good success rate.
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