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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
An Autopsy of Acute Adrenal Insufficiency Resulting from Infarction of Both Adrenal Glands, in a Pregnant Woman with Metastatic Carcinoma of the Breast
Correspondence Address :
Gwendolyn Fernandes,
C-802, Swayam, Poonam Gardens, Mira Road, Thane District, Maharashtra, India.
E-mail: drgwenfern@yahoo.co.in
Acute Adrenal Insufficiency (AAI) is a life-threatening medical emergency, associated with high mortality, and requires early diagnosis and prompt management. This is an unusual case report of a 34-year-old female who was diagnosed with breast cancer, in the second trimester of pregnancy. She presented at 33 weeks gestation, in the emergency services, with convulsions, weakness, altered sensorium and high-grade infiltrating duct carcinoma of breast with liver metastasis. She had also received a single cycle of chemotherapy with adriamycin and cyclophosphamide, at 33 weeks of pregnancy. Her condition deteriorated within 12-16 hours, and she developed abdominal pain, generalised weakness and convulsions. The patient was induced into labour, which was complicated, and delivered a still born male child. She also developed acute kidney injury and severe electrolyte imbalance, and died within four days of admission. A complete postmortem examination was performed where the cause of death was AAI following infarction of both adrenal glands in a background of metastatic carcinoma of the breast. It is strongly suspected that chemotherapy with adriamycin and cyclophosphamide is the primary cause of AAI in the present case. However, the etiology could also be multifactorial as factors like, sepsis, intrauterine foetal death and Disseminated Intravascular Coagulation (DIC) were also present.
Adrenal crisis, Adriamycin, Chemotherapy, Cyclophosphamide, Invasive breast carcinoma
A 34-year-old female, a known case of breast cancer, with 33 weeks of pregnancy, was referred to the emergency services of our tertiary care hospital. She had a short history of convulsions, weakness and altered sensorium prior to admission. She did not have any oedema, proteinuria or hypertension.
The patient was induced into labour, which was complicated with foetal distress and delivered with outlet forceps. At the time of labour, the foetal heart rate dropped to 80 beats/minute, a tight loop of cord with two knots was seen around the neck of the fetus, and the liquor was meconium stained. She delivered a 2.2 kg, stillborn, male fetus. Placenta was delivered spontaneously and completely.
At six months of pregnancy, the patient noticed lumps, in her left breast and left axilla. Ultrasonography done showed a large breast lump measuring 5×2 cm, Breast Imaging Reporting and Database System (BIRADS) Category V, with satellite lesions in the left axilla. Abdominal sonography revealed hepatic lesions, strongly suggestive of metastasis. Biopsy and histopathology of the breast lump revealed an infiltrating ductal carcinoma, Not Otherwise Specified (NOS) Grade 3. She was then referred to an Oncology Institute at 33 weeks pregnancy, and treated with one cycle of chemotherapy which included adriamycin and cyclophosphamide, following which she developed generalised weakness and dull abdominal pain, within 12-16 hours.
The haematological investigations revealed haemoglobin 9.2 gm%, total leucocyte count of 5200/mL, platelets 1.9 lac/mL. Biochemical investigations were as follows: blood urea nitrogen 92 mg/dL, serum creatinine 4.0 mg/dL, serum uric acid 17.5 mg/dL, serum calcium 15.7 mg/dL, serum sodium was 132 mEq/l, serum potassium was 2.9 mEq/L. A nephrology opinion was sought and an opinion of acute kidney injury with hypercalcaemia, hypokalemia, hypermagnesemia and hyperuricaemia was made, and corrections for the same were given. The patient however progressed into shock, despite medications and Sustained Low Effusion Dialysis (SLED) was started. Her condition worsened, and her coagulation profile was altered with fibrinogen raised to >500 mg/dL, fibrin degradation products were raised to >80 mg/dL and D-dimer was raised to 4.1 mg/dL. Prothrombin time was 9.1 sec (control: 9.9 sec, INR: 0.9), activated infiltrating ductal thromboplastin time was 17.1 (control: 26.0). The clinical diagnosis was acute kidney injury, DIC, with left breast carcinoma, in post partum period.
The patient had a ward stay of four days at the hospital, during which her general condition kept deteriorating, and she succumbed to the illness. A complete autopsy was performed. The left breast showed a firm tumour of 5×2 cm. The entire skin of the breast had a blackish discolouration with peau d’orange and nipple and areola were unremarkable (Table/Fig 1)a. A left axillary mass of 2.5×2 cm was also seen. Both the adrenal glands were moderately enlarged in size, weighing 8 gm each, and were haemorrhagic (Table/Fig 1)b. There was no pallor, oedema, icterus, cyanosis, clubbing and no free fluid in the pleural cavity or abdominal cavity.
The liver weighed 2.2 kg and showed a nodule measuring 2.2 cm in diameter in the inferior portion of the left lobe (Table/Fig 1)c. Kidneys were enlarged in size, each weighing 210 gm, with a few superficial scars. Both lungs were congested, while the heart, spleen, brain, intestines, uterus and ovaries, were unremarkable.
Both the adrenal glands showed complete infarction of the adrenal cortex and medulla, with haemorrhages and venous thrombi in the glands as well as the surrounding peri-adrenal fat. Focal calcification was also seen in both adrenal glands (Table/Fig 2)a-c.
The liver showed a metastatic nodule with similar histomorphological features. The kidneys showed patchy tubular necrosis and mild chronic pyelonephritis. The uterus showed areas of hemorrhage within the myometrium and congested vasculature. The rest of the organs were within normal histological limits.
Histopathology of the breast lump showed a high-grade infiltrating duct carcinoma, NOS, Grade 3 (Table/Fig 2)d. The tumour was composed of sheets of malignant ductal epithelial cells with hyperchromatic, pleomorphic nuclei, prominent nucleoli and scant cytoplasm. Many tumour giant cells and brisk mitoses were seen. The final autopsy diagnosis was primary AAI following infarction of both adrenal glands, in a background of invasive carcinoma of the breast with liver metastasis.
Primary AAI is an uncommon, but life-threatening medical emergency, requiring prompt diagnosis and emergency treatment. It results from insufficient levels or absence of hormone cortisol and mineralocorticoids. Chronic adrenal insufficiency was first described by Thomas Addison, in 1855, in patients with adrenal failure due to tuberculosis (1).
AAI can present with a variety of nonspecific symptoms and its diagnosis requires a high index of clinical suspicion. Symptoms of AAI include nausea, abdominal pain, vomiting, diarrhoea, severe lethargy, fever, convulsions, syncope, hypotension, shock etc. (2),(3). Biochemical abnormalities include hyponatremia, hyperkalemia, hypercalcaemia and hypoglycaemia (2),(3).
The aetiology of AAI is complex with common precipitating factors like gastrointestinal illness, physical stress, pain, dehydration, and post-surgery etc promoting its development (1). Chemotherapy and pregnancy are lesser-known precipitating factors leading to AAI (1),(4). In present case, chemotherapy is a significant precipitating factor, since the symptoms of adrenal insufficiency developed within 12-16 hours of chemotherapy. The present patient also had other predisposing factors like intrauterine foetal death, sepsis, and DIC, which was evident in the deranged coagulation profile, as well as the extensive fibrin thrombi in both the infarcted adrenal glands and periadrenal tissue. In addition, the presence of an underlying carcinoma breast with metastasis to the liver, leading to sepsis and DIC, has also to be kept in mind with this case. Severe coagulopathies have been associated with adrenal vein thrombosis and haemorrhagic infarction as was seen in our case (5). In present case, the aetiology could also be multifactorial with pregnancy, DIC, intra-uterine foetal death, sepsis and chemotherapy (adriamycin and cyclophosphamide) given to the patient. Despite extensive search in English literature, no case of AAI has been reported following use of these two chemotherapy agents. Her blood pressure was within the normal range throughout the ward stay and with the absence of proteinuria, hence eclampsia was ruled out.
Diagnosis of AAI, in general, is based on the demonstration of inappropriately low cortisol secretion and the diagnosis is made by the ACTH stimulation test. In general, serum cortisol level determined at 8:00 am at <3 mcg/dL strongly supports the diagnosis of AAI (6). The diagnostic cut-offs for adrenal insufficiency in pregnancy are not well established and the diagnosis is difficult, because of the altered endocrine changes, and the symptomatology of adrenal insufficiency closely resembling the symptoms of pregnancy (7). Normal cortisol levels vary during the various trimesters of pregnancy and in third trimester of pregnancy, the level is 12-50 mcg/dL. Peak cortisol levels are higher in pregnancy following the ACTH stimulation test (8). Cortisol levels in this patient were not done, as a diagnosis of acute adrenal failure was not suspected.
The principle of management of adrenal crisis is steroid replacement, and intravenous fluid resuscitation with isotonic saline to correct the hypovolemia and hyponatremia (9). This patient was given dexamethasone, thiamine, metronidazole, vancomycin, dextrose, calcitonin, vasopressin and dopamine and replacement for electrolytes with SLED.
Acute adrenal crisis can develop only when >90% of the adrenal cortex is destroyed. Histopathological examination in our case showed complete infarction of both adrenal glands, with no viable adrenal tissue seen. Extensive thrombosis of the adrenal vasculature was also seen. Adrenal insufficiency is rare in pregnancy and it may be associated with significant maternal and foetal mortality, if left untreated, as was seen in our case (9).
Acute Adrenal Insufficiency (AAI) is a treatable disease but a high level of clinical suspicion and prompt treatment is required for its management. In view of the sequence of events, chemotherapy with adriamycin and cyclophosphamide is strongly suspected to be the cause of AAI in this case. Other factors like sepsis, intra-uterine foetal death and DIC could also be significant contributors to AAI.
10.7860/JCDR/2021/49231.15097
Date of Submission: Mar 01, 2021
Date of Peer Review: May 15, 2021
Date of Acceptance: May 15, 2021
Date of Publishing: Jul 01, 2021
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Mar 02, 2021
• Manual Googling: May 15, 2021
• iThenticate Software: May 20, 2021 (2%)
ETYMOLOGY: Author Origin
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