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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
Case report
Full Version
Duloxetine Induced Discontinuation Syndrome: A Case Report On Drug Safety
Introduction: Discontinuation symptoms are those which are experienced on stopping prescribed drugs that are not drugs of dependence, with predictable onset, duration and cessation of action. The symptoms can be suppressed by the reinstitution of the discontinued medication. Antidepressant discontinuation symptoms can cause morbidity, they can affect compliance, they can prevent the cessation of antidepressant therapy and can be misdiagnosed, thus leading to inappropriate treatment. The alertness of clinicians regarding the possibility of the antidepressant-induced discontinuation syndrome is necessary for its prevention and management. Hence, we wanted to assess the causality of a suspected case of discontinuation reaction with duloxetine. Case report: Suspected adverse drug reaction (ADR) data which were collected retrospectively from the case records of patients attending the Psychiatry Outpatients Clinic of a teaching hospital in Pondicherry was analysed for causality by using Naranjo’s scale. A 50 year old female who was diagnosed with mixed anxiety and depressive disorder with somatoform disorder, was prescribed duloxetine for six months along with zolpidem. Later on, zolpidem was changed to lorazepam. On stopping the drug after a gradual taper over eight weeks, she developed a feeling of tension and irritability, insomnia, indigestion, dizziness and a crawling sensation in the scalp on the next day. On readministration of duloxetine, the symptoms disappeared within a day. Naranjo’s score was 6 (probable) for the ADR. Discussion: The ADR fulfils the diagnostic criteria for discontinuation reaction for the onset, duration, type of symptoms, risk factors and the response to the reinstitution of the withdrawn drug. Conclusion: This is a probable case of duloxetine induced discontinuation reaction which appeared even though a gradual taper was done over eight weeks before stopping treatment. The current guidelines require a taper over four weeks only. A high index of suspicion is helpful in identifying antidepressant induced discontinuation symptoms for their proper management and prevention in future.
Duloxetine, discontinuation symptoms
INTRODUCTION
Discontinuation symptoms are those which are experienced on stopping prescribed drugs that are not drugs of dependence and they may be new symptoms or those which are similar to the original symptoms of the illness. The onset, duration and cessation of action are predictable and the symptoms can be suppressed by the reinstitution of the discontinued medication. These may manifest as gastrointestinal symptoms, irritability, increased dreaming, ataxia, sweating or paraesthesias. (1) About one third of the patients who are on antidepressants, suffer from discontinuation symptoms. (2) Antidepressant discontinuation symptoms can cause morbidity, they can affect the adherence to antidepressant treatment, they can prevent the cessation of antidepressant therapy and can be misdiagnosed, thus leading to inappropriate treatment. (3) The alertness of clinicians regarding the possibility of antidepressant-induced discontinuation syndrome is necessary for its prevention and management. Hence, we wanted to assess the causality of a suspected case of discontinuation reaction with duloxetine.
We report here, a suspected case of Discontinuation Syndrome with the use of the antidepressant, Duloxetine, which was detected during a retrospective adverse drug (ADR) monitoring study conducted in the Psychiatry unit of a teaching hospital in Pondicherry. A 50 year old female was diagnosed in the outpatients clinic of the Psychiatry Department as a case of Mixed anxiety and depressive disorder with somatoform disorder. She was prescribed Duloxetine at a dose of 40mg for 124 days, followed by a 30mg dose for 48 days and a 20mg dose for seven days, after which the drug was stopped. On the withdrawal of Duloxetine, she developed a feeling of tension and irritability, insomnia, indigestion, dizziness and a crawling sensation in the scalp, one day after the stoppage of the drug. Concurrently, she was being administered zolpidem as an anxiolytic, which was later changed to lorazepam. Duloxetine was re-started and the symptoms disappeared over the next day.We applied the Naranjo’s ADR Causality Assessment scale(4)and found that it could be categorized as Probable only, with a score of six.
Duloxetine is known to cause discontinuation symptoms on withdrawal,(5) with an onset within seventy two hours of stoppage of the drug. They often occur on abrupt stoppage or missed doses, or even during the tapering of the drug. (6),(7) Increased risk is seen in patients who are on treatment for more than eight weeks, patients with anxiety symptoms at the start of antidepressant treatment and patients receiving other centrally acting drugs. (8),(9),(10) The symptoms are manifested within 24 hours. Duloxetine was continued for 180 days (six months) along with lorazepam and zolpidem, which are both centrally acting drugs. Anxiety was present at the start of the treatment. The common manifestations of the discontinuation reaction of duloxetine are dizziness, nausea, headache, paresthaesia, vomiting, irritability, and nightmares. (5) In our patient, affective (irritability), gastrointestinal (indigestion), neurological (dizziness, insomnia) and neurosensory (crawling sensation in the scalp, that is, paraesthaesia) components were observed. The discontinuation symptoms usually resolve fully within twenty four hours if the original antidepressant is recommenced, (4) which happened in our patient as well. The discontinuation symptoms with duloxetine can be avoided by careful tapering of the doses over four weeks. But in our patient, they appeared even though a gradual taper was done over a period of eight weeks. The confounding factors in the causality assessment were the possibility of relapse of depression and/or anxiety. Considering the symptoms that distinguish the antidepressant discontinuation syndrome from the relapse of depressive illness and anxiety (e.g., dizziness, “electric shock” sensations, “rushing” sensations in the head) and the complete resolution of the symptoms in one week (not characteristic of depressive relapse), (11) we made a diagnosis of discontinuation syndrome. Depressive relapses typically occur after two weeks or more after the cessation of the medication and are most often marked by the gradual worsening of depression, insomnia, and psychomotor symptoms. Although discontinuation syndrome is not dangerous and is normally mild and self resolving, it is uncomfortable and distressing to the patients. The symptoms are occasionally severe and prolonged, wherein they interfere with daily functioning and may affect the future compliance with antidepressants. The treatment approach is reassurance in mild cases and the reintroduction of duloxetine or another drug in the same class, that is, selective noradrenaline reuptake inhibitor (SNRI) with a longer half life in severe cases, followed by gradual tapering and monitoring. To improve compliance, the patients should be informed about the possibility of experiencing discontinuation symptoms on the stoppage of the drug and the clinician should stress that such drugs are not addictive.
This is a probable case of duloxetine induced discontinuation reaction which appeared even though a gradual taper was done over eight weeks before stopping the treatment. The current guidelines require a taper over four weeks only. A high index of suspicion is helpful in identifying the antidepressant induced discontinuation symptoms for their proper management and prevention in future.
Duloxetine may cause discontinuation symptoms even if a gradual taper is done over the recommended fourweek
period. The risk is increased if co-existing anxiety, treatment beyond eight weeks and the concurrent administration of centrally
acting drugs is present. The discontinuation symptoms need to be identified early for proper management. The prolongation of
symptoms due to misdiagnosis causes morbidity and may hamper the compliance with future drug treatment.
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