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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
Comparison of Alkalinized and Non-Alkalinized Lignocaine in the Brachial Plexus Block
Correspondence Address :
Ramesh Koppal,
Associate Professor, Dept of Anaesthesiology,
S N Medical College.Navnagar, Bagalkot- 587102.
Karnataka, India.
E-mail: rameshkoppaldr@rediffmail.com
Introduction: Interruption of pain is central to the anaesthetic practice. Regional anaesthesia is one of the widely practiced ways for mitigating surgical pain. Many long acting local anaesthetics have been tried, viz.. bupivacaine, ropivacaine … but they are limited by the drawbacks of delayed onset, the varying quality of the blockades and their unpredictable duration of action. The alkalinization of lignocaine has been shown to fasten the onset, potency and the duration of the block.
Type of study: Randomized single blind clinical trial.
Materials and Methods: After obtaining the institutional ethical committee clearance and their written informed consent, fifty patients who were aged between 25-50 yrs, of either sex, who belonged to ASA grade 1 and 2, who were posted for elective/ emergency surgery of the upper limb were enrolled for the study. Group 1 received 30ml of 1.5% lignocaine with adrenaline and Group 2 received 30 ml of 1.5% alkalinized lignocaine with adrenaline. A supra-clavicular block by a classical approach was made and the degree of the blockade was graded. The results were tabulated and analyzed by using appropriate statistical tests.
Conclusion: Alkalinization of lignocaine offers an earlier onset and it provides a good intensity and adequate depth and a satisfactory distribution of the regional block.
Anesthesia, Local block
Introduction
The central axis of anaesthesia is predicated by the interruption of pain. Over a period of several years, many local anaesthetic agents have evolved viz, bupivacaine, ropivacaine, etc .The main drawbacks of these long acting drugs are their delayed onset of action, the varying quality of the blockade and their unpredictable duration of action. To overcome these drawbacks, the following have been tried viz. the addition of enzymes, oils, alkalinization, potassium, glycol and vaso-constricting agents, warming up of the local anaesthetic solutions, potentiation of the blockade by pain and muscular exercises.
Out of all the above, alkalinization has been shown to hasten the onset, the potency and the duration of the block (1) (2). Hence, in our study, an attempt was made to evaluate the effect of alkalinized lignocaine with respect to the onset and the degree and duration of the blockade in the supraclavicular brachial plexus block.
After obtaining the institutional ethical committee clearance and their written informed consent, fifty patients in each group who were aged between 25-50 yrs, of either sex, who belonged to ASA grade 1 and 2, who were posted for elective surgery of the upper limb, were enrolled for the study. The exclusion criteria were renal, liver and neurological disorders and a history of an allergic reaction to local anaesthetics.
All the patients were investigated by assessing their haemoglobin levels, random blood sugar, serum electrolytes, serum creatinine, urine albumin, chest X-ray and ECG. The study population was randomly assigned into two groups by using a randomization table.
Group 1 received 30 ml of 1.5% lignocaine with adrenaline and Group 2 received 30 ml of alkalinized 1.5% lignocaine with adrenaline for the block.
30 ml of 1.5% lignocaine with adrenaline (for group 1) was prepared with 22.5 ml of 2% lignocaine, 1.5 ml of adrenaline (1 ml=100 microgram diluted), and 6 ml of normal saline. This solution was tested for pH, which revealed a pH of 6.38.
30 ml of alkalinized 1.5% lignocaine (for group 2) was prepared by adding 3.5 ml of 7.5% sodium bicarbonate 1.12 ml=1 mEq), 1.5 ml of adrenaline (1 ml=100 microgram diluted), 2.5 ml of normal saline and 22.5 ml of 2% lignocaine. Finally, the prepared solution was tested for pH, which revealed a pH of 7.25.
A supra-clavicular block by using a classical approach was made and the degree of the blockade was graded 2 as follows;
Proximally • Grade-0 Difficulty in elevating the arm off the table (paresis) • Grade-1 Inability to move the arm at all (paralysis).
Distally • Grade-0 No motor block • Grade-1 Paresis • Grade-2 Paralysis (of hand was determined by checking for inability in flexing the wrist against gravity and movements)
The person who performed the procedure was blinded with regards to the drug which was used. The study drug which was to be used was selected based on a computer generated randomization. The onset and the spread of the sensory and motor blockade were assessed every minute after injecting the local anaesthetic solution.
The sensory block was assessed by checking for a pin prick sensation in the axillary, median and the ulnar distribution areas.
The heart rate, ECG and SpO2 were monitored continuously and the noninvasive blood pressure was recorded every 5 minutes. The patients were watched for bradycardia (Heart rate <60), convulsions, drowsiness and any other complications.
The onset of the sensory and the motor blockade was determined proximally and distally to allow the differentiation of their onset in the mantle and core fibers. Proximally, the onset of analgesia and anaesthesia was determined over the lower deltoid muscle in the distribution of the axillary nerve and distally, over the thumb and the little fingers in the distribution of the median and ulnar nerves respectively.
The onset of the motor blockade was determined proximally in the deltopectoral group of muscles and distally in the muscles of the hand to allow the differentiation of the onset in the mantle and core fibers.
Definitions
Analgesia: The time of injection to the time of onset of the loss of pain on pinprick
Anaesthesia: The time of injection to the time of onset of the loss of touch and pressure by pin prick.
Paresis: Grade 1, The time of injection to the time of onset of the loss of the motor power (partial motor block)
Paralysis: Grade 2, The time of injection to the time of complete motor loss ( complete motor block)
Penetration time: The time of injection to the time of the proximal paresis.
Intra-neural-diffusion: The time of the proximal paresis to the time of the complete distal sensory block.
Duration of sensory blockade: The time in minutes from the onset of analgesia to the recurrence of the pain to pinprick at the proximal and the distal levels was noted.
Duration of motor blockade: The time in minutes from the onset of the paresis to the recurrence of the motor movements at both the proximal and the distal groups.
Results and observation
Both the groups (50 in each group) were compared for any difference in height, weight, age, sex, distribution, time of onset, duration and the degree of the blockade. The statistical analysis consisted of the 1) Two tailed student t test and the 2) Z test. A p value of less than 0.05 (P < 0.05) was considered as statistically significant, In the Z test, a value of more than 1.96 (Z>1.96) was considered to be significant.
(Table/Fig 1) shows the sex distribution of the study subjects. (Table/Fig 2) shows their age, height and weight (mean ± S.D). (Table/Fig 3) shows the onset of the sensory blockade (mean ± S.D in minutes). (Table/Fig 4) shows the onset of the motor blockade (mean ± S.D in minutes). (Table/Fig 5) shows the duration of the sensory and the motor blockade (mean ± S.D in minutes). (Table/Fig 6) shows the rate of penetration and diffusion (mean in minutes).
Brachial plexus blocks are widely used for upper limb surgeries. A supraclavicular approach for a brachial block results in a homogenous blockade. Lignocaine is an amide local anaestheticwhich is widely used because of its shorter latency, but it has the disadvantage of a shorter duration of action.
Morrisson D H suggested that a volume of 0.05 ml/2.45 cm2 of height (3), to give this volume with 2% lignocaine with adrenaline toxic limits would exceed. With a 1% lignocaine solution, the dose would be highly inadequate to provide good analgesia and motor blockade. Hence, in our study, we used an optimal concentration of 1.5% lignocaine with adrenaline to give an adequate volume dosage within the therapeutic range.
The present study assessed the effect of the addition of 3.5 ml of 7.5% sodium bicarbonate to 22.5 ml of 1.5% lignocaine. Normal saline was added to make the volume final to 30 ml, which produced the lignocaine strength of 1.5%. Fresh adrenaline was added to the solution to make the lignocaine 1.5% with adrenaline 1:200000 (5 microgram/ml) solution. The present study was aimed at bringingthe pH of lignocaine towards the pka value without changing the preparation.
The alkalinization of lignocaine hydrochloride led to a higher pH of > 6 and thus it was less dependent on the buffering capacity of the tissues. On injecting the alkalinized solution, the free base was liberated, the carbon dioxide rapidly diffused into the axon interior and the pH fell, which helped in the dissociation of the local anaesthetic to the active cationic form. This effect resulted in ion trapping, hence favouring the rapid movement of the local anaesthetic into the axon.
A tenfold increase in the degree of the block was observed with alkalinized lignocaine as compared to the hydrochloride salt by Catchlov et al (4) in vivo solutions.
In our study, the mean onset time of analgesia in the shoulder was 3.12 minutes, in the hand ulnar nerve area, it was 4.08 minutes and in the median nerve area, it was 4.52 minutes. In the control group, the mean onset time of analgesia in the shoulder was 6.24 minutes, in the hand ulnar region, it was 9.04 minutes and in the median region, it was 7.48 minutes.
The complete sensory blockade with the study group in the shoulder occurred within 4.4 minutes, in the hand (median), it occurred within 6.3 minutes and in the hand (ulnar), it occurred within 9 minutes . In the control group, a complete sensory blockade in the shoulder occurred after 8.24 minutes, in the hand (median), it occurred after 11.52 minutes and in the hand (ulnar), it occurred after 14.68 minutes.
The onset time for the motor block in the study group was only 2.28 minutes (proximal) and 4 minutes (distal). Complete paralysis occurred within 3.72 minutes (proximal) and 10.34 minutes (distal). In the control group, the onset time (paresis) was 4.88 minutes (proximal) and 6.92 minutes (distal). A complete motor blockade in the proximal area took more than 7.16 minutes and in the distal area, it took 17.08 minutes.
The average duration of the sensory blockade in the study group was 132 minutes as compared to 131 minutes in the control group and that of the motor blockade in the study group was 139.2 minutes and it was 138 minutes in the control group. So, in this study, the duration was nearly the same and it was statistically insignificant.
With alkalinization, the efficacy of the blockade improved significantly in the patients as compared to that in the control group. In the study group, 21 out of 25 patients achieved complete motor blockade (distal paralysis) and the depth of the sensory blockade was adequate, which reduced the need of adjuvants intraoperatively. In the control group, only 8 patients out of 25 achieved complete distal paralyses.
In 1986, Radha Sukani and Alon P Winnie (5) carried out a study which compared alkalinized and non-alkalinized lignocaine in the brachial plexus blockade by using a supra-clavicular technique. They found that alkalinized lignocaine reduced the latency by 45% as compared to non alkalinized lignocaine and that it produced a complete motor block in almost twice as many patients as non alkalized lignocaine (54% vs 31%). The duration of anaesthesia which was provided by the two agents was virtually identical, as was the motor blockade.
In 1995, Giorgio and Capogna et al (1) found that using alkalinized lignocaine in the axillary brachial plexus block produced a fasteronset and an earlier peak effect time and the onset of the motor block. Similar results were observed in a study which was conducted by A V Gormley W F et al in 1996.
The present study confirmed the results of Radha Sukani and Alon Winnie, W P Gormly et al and Giorgio Capogna et al regarding the onset, the degree of the blockade and its duration.
However, a study which was conducted by D G Ririe et al (6) on the effect of alkalinization of lignocaine on the median nerve block, observed an increased rate of motor block without any change in the onset or extent of the sensory block. In another study which was conducted by Ruby et al (7) to study the effect of the alkalinization of lignocaine hydrochloride on brachial plexus blocks, it was observed that alkalinization reduced the latency of the sensory and motor blockade and that it also increased the duration of the blockade.
Mark et al (8) observed that alkalinization did not have any significant effect and that it provided no clinical advantage.
In a recent study which was done by Jaichandran V et al, it was found that alkalinization also decreased the pain on injection of the local anaesthetic for the peribulbar block (9).
No drug related or technique related complications were observed during the study.
The alkalinization of lignocaine offers an earlier onset and it provides good intensity and adequate depth and a satisfactory distribution of regional block. There was not much difference in the duration of the blockade. The need of a intraoperative adjuvant was significantly reduced with the use of alkalinization.
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