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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
A Study Of Serum Electrolyte Levels During Nebulised Salbutamol Therapy
Correspondence Address :
Dr. Vittal BG,
Assistant Professor,
Department of Biochemistry,
Government Medical College,
Hassan-573 201,
Karnataka
Mobile No: 09141400766
Email: vittal.bg@gmail.com
Background and objectives: Asthma is a very common disease with immense social impact. Nebulised salbutamol is the mainstay of therapy in acute severe asthma. This prospective study was done to determine the magnitude of changes in serum magnesium, potassium, phosphate and calcium during the treatment of acute severe asthma with nebulised salbutamol alone in a larger sample size, as previous studies were carried on a smaller sample size and yielded ambiguous results.
Subjects and Methods: Sixty patients who met the inclusion criteria were included and their baseline electrolyte levels were measured. Nebulised salbutamol was administered every thirty minutes till the symptoms subsided and repeat serum levels of electrolytes were determined after 90 minutes.
Results: Serum magnesium levels decreased significantly (p < 0.001) from 2.058 ± 0.0263 mg/dl to 2.048 ± 0.0268 mg/dl. Serum potassium levels decreased from 4.053 ± 0.0485 mEq/L to 3.983 ± 0.0482 mEq/L (p < 0.001). Serum phosphate levels decreased significantly (p < 0.001) from 3.899 ± 0.0299 mg/dl to 3.872 ± 0.0296 mg/dl, but no statistical difference was seen in the Serum calcium levels. Interpretation and Conclusion: Nebulised salbutamol therapy is associated with statistically significant decreases in serum magnesium, potassium and phosphate levels.
Asthma, electrolyte levels, salbutamol therapy.
INTRODUCTION
Bronchial asthma is one of the most common diseases globally and it currently affects ~ 300 million people. Asthma is a very common disease with immense social impact, with a prevalence of ~10-12% in adults and 15% in children. It is known to occur at all ages, with a slight male preponderance (1).
Asthma is defined as a chronic inflammatory disease of the airways, that is characterised by increased responsiveness of the tracheobronchial tree, leading to the narrowing of the air passages, which may be relieved spontaneously or as a result of therapy and clinically by paroxysms of dyspnoea, cough and wheezing. It is an episodic disease with acute exacerbations which are interspersed with symptom free periods. Typically, most attacks are short lived, lasting minutes to hours and clinically, the patient seems to recover completely after an attack. However, there can be a phase in which the patient experiences some degree of airway obstruction daily. This phase can be mild or serious, with severe obstruction persisting for days or weeks; the latter condition is known as acute severe asthma. Acute episodes of asthma are one of the most common respiratory emergencies (2).
Drug therapy is the most commonly used mode of treatment for asthma. The drugs which are used to treat asthma are β–adrenergic agonists, methyl xanthines, glucocorticoids and mast cell stabilizing agents.
β – Adrenergic agonists have been the primary focus of the emergency management of acute severe asthma for over 50 years (3). Multiple inhalations of short acting sympathomimetic drugs such as salbutamol, are the cornerstone of most regimens (2). The administration of nebulised salbutamol during the emergency treatment of acute severe asthma was shown to be associated with a significant decrease in serum magnesium, potassium and phosphate levels (4),(5).
Literature search revealed few groups that have studied the changes in electrolyte levels during nebulised salbutamol therapy. Previous studies were conducted on a very small sample size and yielded ambiguous results.
This study intended to measure and evaluate the changes in serum magnesium and other electrolyte levels on the administration of nebulised salbutamol in 60 patients of acute severe asthma.
This study included 60 clinically diagnosed cases of acute severe asthma who got admitted to the emergency department of a teaching hospital, who fulfilled the inclusion criteria and who gave consent to participate in the study. The study spanned over a period of 15 months from August 2008 to October 2009.
Clinically diagnosed patients of acute severe asthma who were treated with nebulised salbutamol were included in the study. All patients with chronic liver diseases, chronic renal failure and acute myocardial infarction were excluded. Patients who were aged less than 16 years, those with metabolic disorders, pregnant women and psychiatric patients were also excluded from this study group.
Blood samples were drawn under aseptic precautions from clinically diagnosed cases of acute severe asthma before and after the administration of nebulised salbutamol. Both the blood samples were analysed for the study parameters.
After getting the written consent, 3ml of venous blood sample was drawn in a disposable syringe before the start of nebulised salbutamol therapy. Precaution was taken to prevent sepsis and haemolysis. The sample was then transferred to a mineral free acid washed glass test tube and was allowed to stand for 20-30 minutes, after which it was centrifuged to separate serum. Nebulised salbutamol (2.5mg) was administered every 30 minutes until the patient was discharged from the emergency department. Each dose was administered over a period of 10 minutes. Apart from inhaled oxygen supplementation, no other drug was administered during the course of the treatment. A repeat blood sample was drawn 90 minutes after starting nebulised salbutamol therapy, as the peak serum concentration of salbutamol is reached at 90 minutes (6). The repeat samples were processed similarly to separate serum.
The serum levels of magnesium, calcium, potassium and phosphate were measured in both the sets of the serum samples.
Serum magnesium levels were assayed by Mann and Yoe’s Xylidyl blue method, which is an in vitro colourimetric method for the quantitative determination of magnesium in serum (7). Serum Calcium levels were measured by the modified O- Cresolpthalein Complexone method (8). Serum phosphorus levels were estimated by the ammonium molybdate method, based on the modified Daly and Ertingshausen’s method (9). Serum potassium was measured by an electrolyte analyser that measures ionic potassium by a K+ ion selective electrode.
The levels of the four electrolytes (Magnesium, Calcium, Phosphate, and Potassium) were estimated twice, before and after the administration of nebulised salbutamol to the same study group. The study group consisted of 60 clinically diagnosed cases of acute severe asthma. The results were tabulated and analysed by using the “Paired ‘t’ test” for any statistically significant changes in the electrolyte levels before and after the treatment.
Among the 60 subjects who were a part of the study, 36 (60%) were men and 24 (40%) were women. 24 of the 60 patients were aged less than 30 years, while 30 patients were between the age group of 31 to 50 years and 6 were aged more than 50 years. (Table/Fig 1)
(Table/Fig 1): Age – Sex Distribution of Study Group
The changes in serum magnesium, potassium, phosphate, and calcium levels before and 90 minutes after nebulised salbutamol therapy were measured and tabulated. (Table/Fig 2)
(Table/Fig 2): Changes in Serum Electrolyte Levels
Serum concentrations are depicted as Mean± Standard Error
The baseline magnesium level before the administration of salbutamol in patients of acute severe asthma was 2.058 ± 0.026 mg/dl (Mean ± Standard error) and it decreased significantly (p < 0.001) 90 minutes after the administration of salbutamol, to 2.048 ± 0.027 mg/dl.
The serum potassium level which was measured before the administration of salbutamol was 4.053 ± 0.048 mmol/L, which decreased after treatment with salbutamol to 3.983 ± 0.048 mmol/L. This decrease was found to be statistically significant (p < 0.001) on applying the paired t test to find the level of significance.
The baseline serum phosphate level which was measured at admission was 3.899 ± 0.030 mg/dl, which decreased to 3.872 ± 0.029 mg/dl after the administration of β–adrenergic agonists. This decrease was statistically significant (p < 0.001).
The serum calcium level which was measured before the administration of the β–adrenergic agonist, salbutamol (base line calcium levels) was 9.532 ± 0.051 mg/dl and it decreased after the administration of salbutamol to 9.532 ± 0.050 mg/dl. This decrease was statistically not significant (p > 0.10).
The patients of acute severe asthma were treated with nebulised salbutamol alone and serum electrolytes were measured before and after 90 minutes of therapy to determine the magnitude of change in the serum concentrations.
Serum magnesium, potassium, and phosphate levels decreased significantly after the initiation of nebulised salbutamol therapy, as compared to the baseline levels or the electrolyte levels before the initiation of nebulised salbutamol therapy. Serum calcium levels did not show any significant changes during the course of the study.
The cause of hypomagnesaemia due to the β2–adrenergic agonists is still unclear, which can probably be explained by the epinephrine like action of the β2–adrenergic agonists on magnesium uptake by the adipocytes. Hypomagnesaemia is associated with tremor, low potassium and ventricular ectopic activity. Interestingly, these adverse effects are seen in therapeutic or excessive doses of salbutamol. Therefore, hypomagnesaemia can be considered as a common denominator to help explain these effects of β2–adrenergic agonists (10).
Hypomagnesaemia may increase the neuromuscular irritability, thus making a few individuals more susceptible to the bronchial spasms. It is noteworthy that hypomagnesaemia which causes bronchoconstriction is a side effect of salbutamol, which is a potent bronchodilator. However, this bronchoconstriction might be of a very small magnitude.
A statistically significant decrease (p<0.001) in serum magnesium levels was observed in our study after the treatment with nebulised salbutamol, when compared with the baseline levels. A serial and statistically significant decrease (p<0.001) was also observed by Bodenhamer in his study, with an aggressive administration of nebulised salbutamol (4). Khilnani also reported a decrease in serum magnesium levels with the use of the β2–adrenergic agonists (10). However, a few studies have reported that no statistically significant change of serum magnesium levels was observed in patients who were treated with nebulised salbutamol (11).
In our study, serum potassium levels were found to decrease significantly after the treatment with nebulised salbutamol (p<0.001). A statistically significant decrease in serum potassium levels was also observed after salbutamol therapy in other studies (4), (10), (12), (13) and also in a study on patients of the paediatric age group (14). Nevertheless, a study pointed out that only intravenous salbutamol led to a decrease in serum potassium levels, while nebulised salbutamol did not result in significant changes (15).
Hypokalaemia is known to occur in therapeutic and excessive doses of β2– agonists. This effect is attributed to the activation of the Na+-K+-ATPase enzyme and β2 receptor mediated insulin release, with a consequent intracellular shift of potassium (12).
The serum phosphate levels were found to decrease significantly in our study (p<0.001) after treatment with nebulised salbutamol and a similar observation was made by Bodenhamer in his study (4).
Serum calcium levels did not show any statistically significant changes during the salbutamol therapy in our study.
The limitation of this study was that randomisation and placebo control were not done, as they were not practically feasible in our setup. If the study had taken into account, the history of the asthma medications that the patients took before therapy, the results could have been attributed more directly to salbutamol therapy.
Our study results indicated that serum electrolytes like magnesium potassium and phosphate decreased significantly in patients with acute severe asthma who were on treatment with nebulised salbutamol. The decrease in electrolyte levels was only statistically significant and the levels did not decrease below the decision limits. The mechanism and clinical significance of these findings are unclear and they warrant further studies.
It is recommended that further studies must be carried out on a larger sample size and also, the clinical findings should be correlated with the dose dependent variation in electrolyte levels during salbutamol therapy.
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