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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
Correlation of Motor and Functional Recovery with Neuroimaging in Ischaemic Stroke: An Observational Study
Correspondence Address :
Dr. Nitish Dhiman,
85, Lajpat Nagar, Vinobapuri, New Delhi, India.
E-mail: nitish_dhi@yahoo.com
Introduction: Stroke is a leading cause of long-term disability worldwide. Neuroimaging plays a critical role in diagnosing and planning the treatment of stroke. Early prognostic markers help in predicting the prognosis after stroke.
Aim: To correlate the motor recovery and functional outcome with Computed Tomography (CT) brain findings using Alberta Stroke Programme Early Computed Tomography Score (ASPECTS) in patients with ischaemic stroke.
Materials and Methods: This observational cross-sectional study was conducted in Department of Physical Medicine and Rehabilitation at Vardhman Mahavir Medical College and Safdarjung Hospital (tertiary care centre), New Delhi, India from October 2016 to March 2018. A total of 45 patients diagnosed with Middle Cerebral Artery (MCA) territory Ischaemic Stroke were included. Motor and functional assessment were done using Fugl-Meyer Assessment (FMA), and Barthel Index (BI). FMA and BI were correlated with the radiological assessment using ASPECTS on Non Contrast Computed Tomography (NCCT) of head.
Results: The mean age of the study population was 60.98±8.61 years. The mean BI score was 70.34±25.2, and FMA score was 61.56±32.8. The mean ASPECTS was 7.5, with 26 patients having ASPECTS 8-10 and 19 with ASPECTS 0-7. Patients with higher ASPECTS (8-10) had moderate to no dependence in Activities of Daily Living (ADL) and mild to no motor impairment respectively (p-value <0.0001). Patients having lower ASPECTS (0-7) had severe dependency in ADL and motor impairment (p-value <0.0001).
Conclusion: Alberta stroke programme early computed tomography score has a significant correlation with motor and functional recovery and is a strong predictor of outcome after ischaemic stroke. The higher the score on ASPECTS, the better will be the motor and functional outcome. The computed tomography findings of brain will help in stroke rehabilitation by enabling to set realistic goals at an early (acute) stage poststroke.
Alberta stroke programme early computed tomography score, Barthel index, Brain, Fugl-meyer assessment, Non contrast computed tomography, Rehabilitation
Stroke represents a major source of global mortality and is the second leading cause of death worldwide (1). Stroke accounts for the largest proportion of total Disability Adjusted Life Years (DALYs) (47.3%) among all neurological disorders worldwide (2). Functional and motor impairment are major complications poststroke. Only a small proportion of stroke survivors (˜14%) achieve full recovery; whereas, 25-50% require some assistance and approximately half experience long-term dependency in activities of daily living (3). Rehabilitation following stroke is essential to overcome the disabilities and enable the patient to function independently at physical, social, and community levels (4).
Computed Tomography (CT) is the imaging technique of choice for the initial assessment of suspected stroke as it is readily available, effective, and affordable. The CT brain is an effective neuroimaging marker to evaluate acute care outcomes and permits rapid assessment of patients with acute stroke (5),(6),(7). For quantifying the ischaemic changes on CT within the territory of the Middle Cerebral Artery (MCA) the Alberta Stroke Programme Early Computed Tomography Score (ASPECTS) was developed (8). It is extensively used in clinical practice to assess the magnitude of early ischaemic changes on brain imaging for acute stroke management (9). ASPECTS has shown good correlation with BI, modified Rankin Scale, National Institute of Health Stroke Scale, Glasgow Coma Scale and Functional Independence Measure in acute ischaemic stroke patients. Higher ASPECTS is significantly associated with better functional outcomes, and reduced mortality and is an independent predictor of long-term functional independence poststroke (6),(10),(11),(12),(13),(14),(15),(16),(17),(18).
Prediction of the outcome at an early stage after stroke is important for setting treatment goals, aiding in rehabilitation management, and anticipating possible consequences. The aim of the present study was to correlate motor recovery and functional outcome, six months after ischaemic stroke with CT brain findings at stroke onset using ASPECTS.
This observational cross-sectional study was conducted in Department of Physical Medicine and Rehabilitation at Vardhman Mahavir Medical College and Safdarjung Hospital (tertiary care centre), New Delhi, India from October 2016 to March 2018. This study was approved by the Institutional Ethics Committee (IEC/VMMC/SJH/Thesis/October/2016).
Inclusion criteria: All patients diagnosed with middle cerebral artery ischaemic stroke with a minimum poststroke duration of six months with Non Contrast Computed Tomography (NCCT) head done after 24 hours of stroke onset were enrolled in the study after obtaining written informed consent.
Exclusion criteria: Patients with haemorrhagic stroke and recurrent stroke were excluded from the study.
Sample size calculation: The prevalence of stroke in the Indian population, as observed by Pandian JD et al., was 334-424 per 100000 in urban areas (19). Taking this value as reference, the minimum required sample size with 2% margin of error and 5% level of significance was 41 patients. To reduce the margin of error total sample size taken was 45. Formula used was:
ME=z×Sqrt[{p(1-p)}/N]
Where, Z is value of Z at two-sided alpha error of 5%, ME is margin of error, and p is prevalence rate.
Study Procedure
Clinical assessment was done by a rehabilitation physician using Fugl-Meyer Assessment (FMA) and Barthel Index (BI) six months poststroke.
Fugl-Meyer assessment: FMA of motor function examines the synergistic and isolated movement patterns, reflex activity, coordination, and hand grasp. A maximum score of 100 is given which includes 66 for the upper limb and 34 for the lower limb (20).
Barthel index: BI is composed of ten components that inspect ADL with a total score of 100 (21),(22). Higher score represents a higher degree of independence in the ADL.
The BI and FMA are frequently used in clinical practice as outcome measures in stroke and have excellent inter-rater reliability for administration after stroke (22),(23),(24),(25).
FMA score was divided into three groups (26):
• ≤55: Severe to moderately severe impairment,
• 56-79: Moderate impairment and
• >79: Mild impairment
BI score was divided into three groups (27):
• 0-20: Total dependence,
• 21-60: Severe dependence
• >60: Moderate to slight dependence
Alberta Stroke Programme Early Computed Tomography Score (ASPECTS): Radiological assessment was done using ASPECTS in NCCT head by an expert radiologist. Based on ASPECTS patients were divided into two groups (12):
• Better (Aspects 8-10)
• Worse (Aspects 0-7): The worse group was further subdivided into:
ASPECTS 0-4 group and;
ASPECTS 5-7 group.
Correlation of FMA and BI was done with the ASPECTS.
Statistical Analysis
Categorical variables were presented in number and percentage (%) and continuous variables were presented as mean±SD and median. Normality of data was tested by Kolmogorov-Smirnov test. Quantitative variables were compared using the Independent t-test between the two groups. Qualitative variables were correlated using the Chi-square test. A p-value <0.05 was considered statistically significant. The data was entered in the Microsoft excel spreadsheet and analysis was done using Statistical Package for Social Sciences (SPSS) version 21.0.
Total 45 cases were enrolled in the study. The mean age of the patients was 60.98±8.61 years, ranging from 40-78 years, with a maximum number of patients in the age group of 60-69 years (40%) There were 29 males and 16 females. Overall, 73.33% patients had involvement of the left hemisphere, and in 75.55% dominant side was affected. Total 82.22% patients had poststroke duration between six months to two years (Table/Fig 1).
On baseline NCCT brain, ASPECTS varied from 4-9 with 26 (57.78%) patients in the better outcome group (ASPECTS: 8-10) and 19 (42.22%) in the poor outcome group (ASPECTS: 0-7) with mean ASPECTS of 7.5. At the time of assessment 32 patients had moderate to slight dependency and 13 had severe to complete dependency according to BI. Motor function according to FMA elicited mild to moderate impairment in 29 patients and severe to very severe impairment in the rest of them (Table/Fig 2). The mean BI score was 70.34±25.2, and FMA score was 61.56±32.8. Wheelchair was used as a means of ambulation by 8 (17.78%) patients, 20 (44.44%) were ambulating with support of assistive devices, while 17 (37.78%) were able to ambulate independently without any assistance.
On correlating ASPECTS with BI, patients with lower ASPECTS had poor outcome according to BI and were more dependent in ADL and those with higher ASPECTS showed higher score on BI (p-value <0.0001) (Table/Fig 3). Patients with lower ASPECTS had severe impairment whereas those in the high ASPECTS group had mild to moderate impairment according to FMA (p-value <0.0001) (Table/Fig 4). The average ASPECTS for patients who were wheelchair bound was 5.38, whereas, for those who were independent in ambulation was 8.59, indicating that with higher ASPECTS more are chances of being independent in ambulation poststroke (p-value=0.0001) (Table/Fig 5). There was a statistically significant difference in functional independence and motor function between the better and worse ASPECTS group (Table/Fig 6). No significant association was found between the side involved in stroke with ASPECTS, BI and FMA (Table/Fig 7).
Stroke is a major global health problem and a leading cause of long-term adult disability. Imaging plays a critical role in assessment of acute stroke and assists in decision making for initiating treatment [5-7]. The extent of early ischaemic changes on neuroimaging has been found to be associated with the functional outcome. ASPECTS is a reliable method to determine the degree of early ischaemic changes in stroke (8). Very few studies have been done to assess the long-term functional outcome using BI and correlating with ASPECTS and no studies were found correlating the motor recovery using FMA and ambulatory status poststroke with ASPECTS. In the present study, motor recovery (FMA) and functional outcome (BI) in patients with a poststroke duration of more than six months were correlated with ASPECTS at stroke onset.
The mean age of the patients was 60.98±8.61 years with a male preponderance which is comparable with previous studies (2),(8),(12),(15),(16),(17). Although most of the patients in this study were more than 60 years of age but in the study by Zanzmera P et al., and Prabhakar A and Kishore L, the median age of stroke patients was less than 60 years. This could be attributed to the increase in number of young adults presenting with stroke in recent years (12),(17).
It was observed that higher ASPECTS (8-10) was associated with higher BI (>60) and FMA (>79) score suggesting that patients with favourable ASPECTS had less stroke severity and thus were more likely to be independent in ADL and have minimal motor impairment. There was significant positive correlation of ASPECTS with BI and FMA (p-value <0.0001) which was similar to the studies correlating ASPECTS with functional outcome (8),(12),(13),(14),(15),(18),(28),(29).
The BI score was statistically significantly better in group with better ASPECTS (8-10) compared to worse ASPECTS (0-7) group and the mean BI score was 87.7±9.62 in patients with higher ASPECTS. This was similar to what was observed by Zanzmera P et al., who found that mean BI at three months poststroke was 84.33±13.90 (12). Chatterjee D et al., also found good correlation between baseline ASPECTS and BI three months poststroke (18).
The average FMA score of patients with better ASPECTS (8-10) was 87.6 and those with worse ASPECTS (0-7) was 29.94. The correlation between ASPECTS and FMA score was statistically significant and interpreted that patients with better ASPECTS have better chances of recovery and less likely to have motor impairment in long-term. The patients who had a favourable ASPECTS could walk without support, whereas, those with a lower ASPECTS were either using wheelchair or were ambulating with support of assistive devices (p-value <0.0001). This implies that patients with higher ASPECTS at stroke onset have better ambulatory potential.
Hence, it can be said that ‘better’ ASPECTS has a significant association with better functional independence more than six months after stroke, also ASPECTS can be considered as a reliable tool for predicting the functional outcome of patients. Good prognostic value of higher ASPECTS may be explained by its association with good collateral blood flow allowing ischaemic brain tissue to survive for longer time periods and more chances of recanalisation and reperfusion which improves the outcome as observed by Hill MD et al., (14).
Limitation(s)
This study had its own limitations in the form of lack of comparison with the baseline motor and functional status.
On the basis of present study, it can be concluded that ASPECTS has a good correlation with BI and FMA. Higher ASPECTS at stroke onset is associated with better functional and motor outcome in long-term. ASPECTS can be used to plan the rehabilitation interventions based on the expected recovery of the patients and set realistic goals on individual basis at an early stage to improve the functional outcome, preventing complications and help the stroke survivors to be more independent in the activities of daily living.
DOI: 10.7860/JCDR/2022/58320.17153
Date of Submission: Jun 08, 2022
Date of Peer Review: Jul 25, 2022
Date of Acceptance: Sep 15, 2022
Date of Publishing: Nov 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• 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. NA
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