Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
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Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


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

Important Notice

Original article / research
Year : 2021 | Month : September | Volume : 15 | Issue : 9 | Page : BC08 - BC13 Full Version

Plasma Levels of Fetuin B and Fibrinogen in Chronic Obstructive Pulmonary Disease: A Preliminary Cross-sectional Study


Published: September 1, 2021 | DOI: https://doi.org/10.7860/JCDR/2021/49391.15377
CV Shri Swathini, MVP Chowdary

1. Residential Intern, Department of Biochemistry, Karpagam Faculty of Medical Sciences and Research, Coimbatore, Tamil Nadu, India. 2. Associate Professor, Department of Biochemistry, KMCH Institute of Health Sciences and Research, Coimbatore, Tamil Nadu, India.

Correspondence Address :
Dr. MVP Chowdary,
99, Avinashi Road, Coimbatore, Tamil Nadu, India.
E-mail: chowdarymvp@gmail.com

Abstract

Introduction: Recent exploratory proteomics study reported increased blood levels of Fetuin B (FETUB) in Chronic Obstructive Pulmonary Disease (COPD). Growing body of evidence demonstrates fibrinogen not only as acute phase reactant but also possesses features advocating as biomarker of COPD.

Aim: To determine the blood levels of FETUB and fibrinogen independently as well as in combination COPD and among severity of COPD.

Materials and Methods: A single-centred cross-sectional study of eight months duration was conducted during May to December 2017. A total of 76 blood samples (38 COPD patients and 38 controls) were recruited. Based on distribution, parametric and non parametric statistical tools were used. Analysis of co-variance and multiple multivariate linear regression models were utilised to assess the influence of clinical data on FETUB. Steel-Dwass-Critchlow-Fligner method was employed for multiple pairwise comparisons. Receiver Operating Characteristic (ROC) curve were generated to compute cut-off of FETUB, fibrinogen and their combination.

Results: The median age of subjects were 57 years with an IQR of 50-66 years for controls whereas 58 years (IQR 50-65 years) for COPD subjects. In comparison to controls, a significant increase in blood levels of both FETUB and fibrinogen in COPD and Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages of COPD was prominent. Among COPD grades, differences of FETUB levels were significant in GOLD I vs II and GOLD IV vs I, II and III whereas fibrinogen levels in GOLD III from GOLD IV. FETUB showed independent correlation with Forced Expiratory Volume (FEV) 1% pred and severity of COPD. A moderate improvement in combined (FETUB+fibrinogen) analysis of control vs COPD was noticed.

Conclusion: The present study demonstrates significant increase in blood levels of FETUB in COPD and among the severity of COPD in comparison to fibrinogen. Hence, FETUB can be a more promising probable inflammatory biomarker in COPD.

Keywords

Forced expiratory volume, Global initiative for chronic obstructive lung disease, Smoking and biomass exposure

The COPD is a devastating condition posing major health challenge and recognised as fourth leading cause of death in the world (1). In India, it is the second biggest cause of mortality (2),(3). The pathogenesis is attributed to aberrant inflammatory response to cigarette smoke, aerotoxins and biomass fumes (4). Most of the recent studies were targeted to understand the patterns of various inflammatory markers in COPD and their relation with respect to clinical outcome, response to therapy and prognosis. Plasma fibrinogen has been demonstrated to exhibit the features of relatively stable prognostic indicator relative to Body Mass Index (BMI), Airflow Obstruction, Dyspnea and Exercise Capacity (BODE) index; the exacerbation rate; and the mortality (5). On the other side, in one of the recent exploratory studies, on gel free isobaric Tags for Relative and Absolute Quantification (iTRAQ)-based proteomic technique, elevated plasma levels of Fetuin-B (FETUB) along with fibrinogen in stable COPD and Acute Exacerbation COPD (AECOPD) was demonstrated only in cigarette smoking male subjects (6),(7).

Globally tobacco smoke is projected as the major prevalent cause of COPD. Especially in Low- and Middle-Income Countries (LMICs) like India, beedi and cigarette are the most common sources of tobacco smoke with varying degree of harmful impact (8). Whereas biomass smoke exposure group encompassing household utilisation of wood, coal, dung cakes, agricultural residues or Liquefied Petroleum Gas (LPG) for domestic energy purposes attributing to indoor air pollution is well-recognised as an independent major risk factor of COPD. More than 70% of population utilises biomass fuels for domestic purpose attributing indoor air pollution (4),(9). In view of that even non smokers are also prone to develop COPD. Hence, smoking in males and biomass smoke exposure in females are recognised as more predominant hazard and cause of COPD in India. Though, various causal factors lead to different types of inflammatory response yet the pattern of inflammation seen in indoor air pollution induced COPD was reported as similar to that of smoking induced COPD (10).

Hence, the aberrant inflammatory response of respiratory tract is similar in both cigarette smoking and indoor air pollution induced COPD. However, external validation in an independent population of various races under different conditions is warranted before contemplating to routine use in clinical setup. In view of this, the present pilot study was undertaken to determine the variations in the plasma levels of both FETUB and fibrinogen in newly diagnosed stable COPD subjects comprising either genders with cigarette smoking in males and biomass fumes in females as the causal agents.

Material and Methods

The present cross-sectional study was carried out for eight months during May to December 2017 in Karpagam Faculty of Medical Sciences and Research, Coimbatore, Tamil Nadu, India. Institutional Human Ethics Committee (IHEC) Ref No: IHEC/91/Biochemistry/04.2017 dated: 26-04-2017 has approved the present cross-sectional study. The study was conducted in accordance with the Declaration of Helsinki. Informed consent was procured from each subject.

Sample size calculation: As evident from literature and in accordance to ‘flat rule of thumb’ (11),(12), a minimum composite sample size of 30 or 12 per arm (i.e., controls and COPD) is warranted for a pilot study. As well as, in accordance to ‘stepped rule of thumb’ (13), for a study design with standardised effect size of 0.8 and power >90%; the recommended sample size for a pilot study is 32 per arm. Hence, a total of 76 participants were enrolled in the present study. It comprises 38 newly diagnosed and clinically approved COPD patient samples procured from the Department of Tuberculosis (TB) and Chest Disease, Karpagam Faculty of Medical Sciences and Research, Coimbatore, Tamil Nadu. The remaining 38 participants of control group comprised healthy volunteers belonging to either relatives/attendees of patient (or) relatives/attendees of other patients visiting the hospital on Outpatient Department (OPD) basis. A medical questionnaire for gathering subject’s characteristics (smoking details, exposure period to biomass fumes, medical, surgical and gynaecological-obstetrics history, current medications if any and dyspnea) was used.

Inclusion criteria: Only newly diagnosed and clinically approved COPD patients were involved in the present study. Age, gender, BMI, smoking status, smoking index, Biomass Exposure Index (BEI) and menopausal status matched healthy volunteers were recruited as controls.

Exclusion criteria: The patients with hypertension, hepatitis, coronary artery disease, hyperlipidemia, diabetes mellitus, nonalcoholic fatty liver disease, abnormal Aspartate Aminotransferase (AST) and Alanine Transaminase (ALT) levels were excluded. Even the patients under long-term treatment with anticoagulant, statin or systemic glucocorticoids were not included.

Anthropometric, Smoking and Biomass Fumes Exposure Indices Measurements

A trained person was reserved for the extraction of blood pressure and anthropometric indices comprising weight, height and BMI. These measurements were carried out on all participants with light clothes and no shoes. Stadiometer with an accuracy of ±0.1 cm and seca scale with 0.1 Kg accuracy were used as standard approaches for extracting height and weight information, respectively. BMI was computed as weight (Kg) per height squared (m2). The smoking status, smoking index and BEI were stratified according to the earlier studies on Indian population (14),(15). BEI was computed as product of average hours spend on cooking per day and number of years of cooking.

Spirometric Measurements

As per guidelines of American Thoracic Society (16), spirometry indices were computed from the best out of the three technically satisfactory performances for the assessment of pulmonary function under the supervision of specially trained and dedicated personnel. Forced Expiratory Volume in 1 second (FEV1), Forced Vital Capacity (FVC), and FEV1/FVC ratio were measured. Individuals with FEV1% predicted ≥80% were selected as controls. The severity of clinically diagnosed COPD subjects was graded as per the guidelines of GOLD (17). Reversibility assessment was conducted after the inhalation of short acting β2 agonist i.e., 400 μg salbutamol.

Laboratory Measurements

The White Blood Cells (WBC) in whole blood was analysed in the cell counter Sysmex XS-800i (Sysmex India Pvt., Ltd., New Delhi). Quantia-CRP-US turbidometric immunoassay kit (Coral Clinical System) was employed for detecting serum high-sensitivity C-Reactive Protein (hs-CRP) levels. Concentration of ALT and AST were measured on clinical chemistry automatic analyser Erba Manheim EM360 (Transasia Bio-medicals Ltd., Mumbai, 400 072) using system pack kits. Only the plasma samples for FETUB analysis were stored at -20°C until their analysis. A 96-well plated Enzyme-Linked Immunoassay (ELISA) kit was utilised according to the manufacturer’s protocol (BOSTER Biological Technology, 3492 B Valley, Pleasanton, CA 94566) for assaying FETUB with intra-assay and inter-assay coefficient of variations <9% and <11.8%. The sensitivity of the assay was <12 pg/mL. Clauss method was used for quantification of plasma fibrinogen (18). The entire process of sample collection, processing and analysis were strictly performed under aseptic conditions in accordance to standard laboratory protocols.

Statistical Analysis

Statistical analysis was conducted with SPSS version 24.0 software (Statistical Package for the Social Sciences, Chicago, IL., USA), Trial version of GraphPad Prism 7.0 (GraphPad, San Deigo, CA, USA) and Trial version of NCSS 12 (NCSS Statistical, LLC, Utah 84037, USA). All data were examined with Shapiro-Wilk (S-W) and Levene’s test for normal distribution and homogeneity of variance, respectively. Continuous variables were presented as means±standard deviation (SD), or median {Interquartile Range, (IQR)} in accordance with their distribution state. Chi-square test analysed categorical variables were presented as observed number and percentage. The correlation coefficients between FETUB levels and other variables were analysed using the Pearson’s or Spearman’s test. Normally distributed data of the patients with COPD and healthy controls were compared using Student’s t-tests, and non-normally distributed data were analysed using Mann-Whitney U and Kruskal-Wallis H test. Analysis of Covariance (ANCOVA) and multiple Multivariate Linear Regression (MVLR) with step method were used to evaluate the relationship between dependent and independent variables. Steel-Dwass-Critchlow-Fligner method was employed for pairwise multiple comparisons. Plasma levels of FETUB and fibrinogen were subjected to ROC curve to compute the Area Under Curve (AUC) with 95% confidence interval (95% CI) and cut-off value with corresponding sensitivity and specificity. All assumptions of each statistical approach employed were respected. A two-sided p<0.05 was considered significant for all analyses.

Results

A total of 76 subjects (38 Control+38 COPD) were enrolled. Only newly diagnosed COPD subjects without any co-morbid conditions and in accordance to inclusion and exclusion criteria were recruited. General characteristics of the participants in the study are provided in (Table/Fig 1). The median age of subjects were 57 years with an IQR of 50-66 years for controls whereas 58 years (IQR 50-65 years) for COPD subjects. The computed gender based distribution in each group i.e., control and COPD was 57.89% and 42.11% for males and females, respectively. The mean of BMI was 25.5±3.6 for healthy participants and 24.8±3.9 for COPD diagnosed patients. Among the males 17 (77.3%) comprised current smokers. The remaining 5 (22.7%) were ex-smokers. Current smokers with similar proportions in either groups (control and COPD) were further stratified into heavy (36.3%), moderate (59.09%) and mild smokers (4.5%). The BEI of females was 83.3±6.8 and 83.5±9.3 in controls and COPD subjects, respectively. All the female subjects were in postmenopausal phase and without a history of tobacco consumption. In the present study, the gender based differences in the blood levels of FETUB within controls and COPD group were not significant.

Plasma levels of both FETUB and fibrinogen significantly increased in COPD, as apparent in (Table/Fig 2). Mean distribution of FETUB was 2672±417 pg/mL for controls and 4234±844 pg/mL for COPD group (Table/Fig 2)a. Similarly, fibrinogen indicated median of 348 mg/dL (IQR: 320-382 mg/dL) and 450 mg/dL (IQR: 392-567 mg/dL) for controls and COPD, respectively (Table/Fig 2)b. Among the COPD group, a gradual rise in the blood levels of both FETUB and fibrinogen with increasing severity of disease was apparent. Pairwise multiple comparisons elucidated significant differences among control, GOLD I, GOLD II, GOLD III and IV as evident from the scattered plots of FETUB (Table/Fig 3)a and fibrinogen (Table/Fig 3)b. In both scattered plots the pairwise differences of GOLD I, II, III and IV against control were significant. Among the COPD subjects, significant variations in distribution of FETUB in GOLD I vs GOLD II and GOLD IV against remaining grades (GOLD I, II and III) in a pairwise comparisons were noticed. Whereas the fibrinogen exhibited limited differences among the COPD group i.e., only between GOLD III and GOLD IV.

Among the various combinations (Table/Fig 4), FETUB has exhibited significant linear correlation only with FEV1%pred, severity of lung disease and age. Although, FETUB showed significant negative correlation with both FEV1%pred (-0.771) and severity of lung disease (-0.843) yet FETUB had relatively very strong correlation with severity of lung disease. Despite of significance in positive correlation of FETUB with age but the strength of association (0.267) was negligible. Moreover, ANCOVA (Table/Fig 5)a,b and multiple MVLR (Table/Fig 6) corrected for age, BMI, smoking status, smoking index, BEI, WBC, hs-CRP demonstrated independent correlation of FETUB only with FEV1%pred and severity of lung disease.

The AUC with 95% CI computed from ROC curve analysis of FETUB, fibrinogen and their combination were apparent from (Table/Fig 7). In the present study, ROC plots of control vs COPD were significant with respect to FETUB (cut-off value: 3031.2 pg/mL; sensitivity: 89.4%; specificity: 86.8%; positive predictive value: 0.8718; and accuracy: 0.8816), fibrinogen (cut-off value: 390 mg/dL; sensitivity: 78.9%; specificity: 86.8%; positive predictive value: 0.8718; and accuracy: 0.8816). A combination of both exhibited a moderate improvement in discrimination of COPD group from control in terms of AUC with 95% CI.

Discussion

As is well known, involvement of both innate and adaptive immune responses linked through activation of dendritic cells is a classical feature of COPD inflammatory response. Though, systemic inflammation is considered as hallmark of COPD yet not all patients are consistent with elevated concentrations of popular inflammatory biomarkers (19),(20),(21),(22),(23). However, accumulating data of evidence demonstrated the association of poor clinical outcomes (including exacerbations and mortality) in the subjects persistent with elevated level of systemic inflammation biomarkers (20),(21),(22). Hence, subjects with persistent systemic inflammation may be considered as a distinct COPD subgroup or phenotype. A constantly growing body of evidence unraveled the pivotal attributes of fibrinogen in describing the degree of local or systemic inflammation (23) and also the latest proteomics based study (7) explored as well as demonstrated the probable role of FETUB in the same direction. In lines with previous studies (7),(8),(19),(24), in the present study also blood levels of both fibrinogen and FETUB were elevated in COPD.

Fibrinogen, a soluble heterohexameric glycoprotein of hepatic origin with a molecular weight of ~340,000 and a half-life of approximately three to five days (25). It is not only popular as major circulating coagulation protein but it is also renowned as an acute-phase reactant with IL-6 being an important cytokine mediating its release (26). Despite of unclear underlying mechanism in various chronic conditions (27),(28); especially in COPD subset of population with adverse outcomes in terms of exacerbations and all cause mortality, persistence of increased plasma levels of fibrinogen emerged as a distinct feature (18),(19). In one of the largest meta-analysis (28), every 1-g/L raise of plasma fibrinogen is associated with an increased risk of 3.7 fold COPD specific mortality. In another multicenter intervention and characterisation study based on COPD-related hospitalisations also demonstrated the association of 1-g/L increase in plasma fibrinogen with a risk of 77% raise in severe COPD exacerbations (24). In view of the above attributes, in the present study, the fibrinogen was included as reference blood inflammatory biomarker of COPD. In the present study, blood fibrinogen levels were significantly elevated in COPD. The pairwise comparisons of COPD GOLD stages, the statistically significant differences in distribution was noticed only between GOLD III and GOLD IV. These observations are in lines with earlier studies (18),(19),(24).

The FETUB, a novel adipokine/hepatokine, member of fetuin family belongs to cystatin superfamily of cysteine protease inhibitors (29),(30),(31),(32),(33). The underlying molecular mechanism of FETUB is not yet clearly elucidated in various clinical conditions. However, FETUB is an unambiguous paralogue of fetuin A. The role of fetuin A in regulation of inflammatory signaling mediated via Toll-like receptors and as an endogenous inhibitor of human metalloproteases is well-addressed (34). Hence, it is apparently plausible that even FETUB might possess similar property in the inflammatory progression of COPD also. The farnesoid X-receptors were shown to induce FETUB expression (35). In the present study also, the blood levels of FETUB were elevated in COPD. A distinct and significant gradual rise of FETUB levels with increasing severity of COPD was also apparent. Among the GOLD stages of COPD pairwise comparisons, significant difference in FETUB levels was apparent only in GOLD I vs GOLD II, GOLD I vs IV, GOLD II vs IV and GOLD III vs IV. The remaining pairwise comparisons were insignificant. The ROC curve based computations also substantiated significant AUC with 95% CI and cutoff values with reasonable sensitivity, specificity, positive predictive value and accuracy in control vs COPD analysis. Whereas in the earlier study comprising only tobacco smoke induced COPD male subjects (7), significant differences were apparent in: control vs COPD, control vs GOLD II, III and IV, GOLD I vs GOLD II and GOLD IV. As apparent in the present study, FETUB and fibrinogen exhibited disparity in their blood levels only among GOLD stages of COPD. A significant difference was noticed in FETUB levels of GOLD I from GOLD II and GOLD IV from GOLD I, II and III in pairwise comparisons whereas fibrinogen levels were different only between GOLD III and GOLD IV.

Till date, ineptitude of most of the explored biomarkers of COPD in to aid diagnosis, define clinical phenotypes or monitoring response to therapeutic strategies enforced the attention towards the feasibility of composite biomarkers. In the same perspective, especially fibrinogen as a part of multiple biomarker is evident in literature (19),(22),(26). Epidemiological study reported the prognostic value of fibrinogen alongwith CRP and WBC in COPD with respect to incident co-morbidities (19). In another combination study fibrinogen alongwith CRP and IL-8 is correlated with disease severity as measured by GOLD stage of COPD (36). In view of that, in the present study also, the feasibility of combination of fibrinogen with FETUB in distinguishing the COPD group from controls was explored. The ROC computations derived from combination of fetuin B and fibrinogen expressed slightly superior AUC with 95% CI in Control vs COPD.

The earlier study encompassed COPD group with varying degree of co-morbid conditions (7). The ROC curve computations (AUC; 95% CI, Cut-Off value; sensitivity and specificity) of fetuin B (0.747; 0.642-0.834; 1375 ng/mL; 73.6% and 67.6%), fibrinogen (0.715; 0.608-0.806; 2.9 g/L; 66.0% and 73.5%) and combination (0.804; 0.705-0.881) were shown to be significant in their control vs COPD analysis. Even in the present study observation were in corroboration with the earlier study. However, in comparison to present study, reasonably decreased ROC attributes in control vs COPD analysis of earlier study reveals the declination in predictive ability of COPD on association with comorbid conditions (7). Owing to the poor sample size, ROC curve analysis was not extended among the GOLD stages of COPD in the present study.

The strengths of the present study is involvement of both genders; inclusion of smoking status, smoking index, and BEI (as per Indian references); and recruitment of age, gender, menopausal status, BMI, smoking status, smoking index and BEI matched healthy volunteers as controls. Another lucrative aspect of the present pilot study is involvement of newly diagnosed COPD subjects of either gender without any co-morbid conditions to understand the difference in primary pattern of these biomarkers before commencement of clinical management of COPD. Whereas in the previous analogous study only the active cigarette smoking males with varying degree of co-morbid conditions were involved (7).

Growing body of evidence demonstrates the increased blood levels of FETUB in type 2 diabetes mellitus (31), Acute myocardial infarction (32) and COPD (6),(7). Literature survey further evidences COPD as an independent risk factor for a range of cardiovascular disease but a reciprocal relationship with type 2 diabetes mellitus. Most of these conditions commonly shares oxidative stress and inflammation as the underlying components. Hence, the complex and multifaceted mechanistic that underpin this association have yet to be elucidated. And such understandings in the future studies will lead to the discovery of sorely needed novel targets for therapy.

Limitation(s)

The limitations of the present study comprise: sample size especially in severity of COPD, non adoption of new classification system and a bias in the participant selection based on the exclusion criteria. Though, the present pilot study suffers with weak sample size in severity of COPD related analysis yet the most of the interpretations are in corroboration with previous studies. However, robust studies with increased sample size is warranted for an unbiased understanding of FETUB levels among the severity of COPD.

Conclusion

Plasma levels of both FETUB and fibrinogen exhibited significant variations in their plasma levels between control and COPD. It was also apparent between controls and severity of COPD as per GOLD guidelines. Pairwise multiple comparisons revealed limited significance in differences among severity of COPD. FETUB levels in GOLD I showed significant differences from GOLD II and GOLD IV from GOLD III, II and I whereas fibrinogen levels only between GOLD IV and GOLD III. The multiple MVLR model indicated independent correlation of severity of COPD and FEV1% pred with FETUB. ROC curve analysis of FETUB, fibrinogen and combination of both (FETUB+fibrinogen) suggested significant AUC with 95% CI between COPD vs control. In view of the above observations, the present pilot study further demonstrates the feasibility of relative plasma levels of FETUB discretely and also in coalition with fibrinogen as a probable inflammatory index of COPD group and may assist in assessing risk of CVD and type 2 diabetes mellitus at an early stage.

Acknowledgement

This work was carried out under the project entitled: “Utility of the combination of fetuin B and fibrinogen as a plasma biomarker index of COPD”. We extend our sincere thanks to Ms. B Sangeetha for her cooperation in organising the patient samples and data procuring process. Dr N Prasada Rao is acknowledged for his administrative support.

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DOI and Others

10.7860/JCDR/2021/49391.15377

Date of Submission: Mar 11, 2021
Date of Peer Review: May 06, 2021
Date of Acceptance: Jun 18, 2021
Date of Publishing: Sep 01, 2021

AUTHOR DECLARATION:
• Financial or Other Competing Interests: ICMR-STS (2017-07098) Fellowship
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. No

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Mar 15, 2021
• Manual Googling: Jun 17, 2021
• iThenticate Software: Jul 16, 2021 (14%)

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