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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
Ethiodised Oil Lymphangiography in the Management of Chyluria
Correspondence Address :
Dr. Vishal Nandkishor Bakare,
Assistant Professor, Department of Interventional Radiology, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune-411018, Maharashtra, India.
E-mail: vishalnb1154@gmail.com
Chyluria is clinical condition in which there is excretion of chyle in urine. The most common cause of chyluria is lymphatic filariasis. This case report (67-year-old female) describes imaging findings of non filarial chyluria due to retroperitoneal lymphatic cyst and its successful management by minimally invasive percutaneous lymphangiography procedure. The patient presented with complaints of passing milky white urine which was confirmed to be chyluria. After a non successful trial of conservative approach in form of high-protein and low-fat diet, percutaneous ethiodised oil lymphangiography was performed, which resulted in immediate symptomatic improvement and no recurrence on follow-up.
Chyle, Chylomicrons, Interventional radiology, Lymphatic cyst, Sclerotherapy
A 67-year-old female presented to the Department of Interventional Radiology with complaints of intermittent left flank pain and persistent milky white urine, since one year. She had no co-morbidities, no surgical history, and no visit to filarial endemic areas.
The woman weighed 56 kg, with a body temperature of 37°C, pulse rate of 76/min, and blood pressure of 110/70 mmHg. The heart and lung examinations were normal. The abdomen was soft with non palpable liver and spleen. There was no shifting dullness.
Urine analysis revealed sterile urine, massive proteinuria (2g/24 hours), and elevated triglyceride levels (600 mg/dL) in post prandial urine samples, thus diagnosing Chyluria. As per protocol, she was advised conservative management in form of low-fat, high-protein diet. However, even after five months follow-up, she did not had any symptomatic improvement.
As part of further investigations, Computed Tomography (CT) scan was done which revealed a well-defined spherical retroperitoneal cystic lesion of approximate size 22×23×23 mm (CC×AP×TT) in left para-aortic region, medial to the lower pole of left kidney likely Cystic Lymphangiectasia (Table/Fig 1). The possible cause for chyluria was fistulous communication between this cyst and left renal pelvis or proximal left ureter.
As part of definitive treatment, minimally invasive percutaneous lymphangiography was planned in the Cathlab, under fluoroscopy guidance. Under ultrasound guidance and local anaesthesia (5 mL of 2% Lignocaine), three inguinal nodes on either side were punctured with 22 G needle. With the needle tip at the junction of cortex and medulla of each lymph node, five mL ethiodised oil (Lipiodol, Guerbet) was slowly injected under fluoroscopy guidance on either side, to visualise it ascend in the lymphatic channels (Table/Fig 2). and prevent its entry into veins. Approximately, 40 minutes post completion of the injection, there was intense opacification of the left-sided lymphatic cyst (Table/Fig 3),(Table/Fig 4), and immediate non contrast CT scan of the pelvis revealed ethiodised oil inside the lumen of urinary bladder (Table/Fig 5), confirming the presence of fistulous communication. As the definitive site of fistulous communication was not demonstrated, it was decided to stop at this stage.
The patient was shifted to Intensive Care Unit (ICU) postprocedure for close monitoring. Post 24 hours of procedure, the urine became completely normal in appearance. Microscopic urine examination revealed resolution of proteinuria and absence of triglycerides in urine. After discharge, the patient was followed after two weeks, one, three and six months with no recurrence of chyluria.
Chyle is a combination of proteins, emulsified fat and fibrin. It is formed by lymph and absorbed dietary fats which are converted to chylomicrons. It is transported by the lymphatic channels to thoracic duct which opens into the left subclavian vein. Chyluria is classified as parasitic and non parasitic (1). In endemic areas, Wuchereria bancrofti is considered to be the parasitic cause for Chyluria (2). Tuberculosis, congenital anomalies, trauma, pregnancy, abscess, postsurgery, infections and malignancy are the common causes of non parasitic Chyluria (2). Chyluria occurs when there is formation of abnormal communication between the lymphatic vessels and urinary tract resulting in milky white urine. The site of fistulous communication can be at the renal pelvis, ureter, urinary bladder or the prostatic urethra (2). The patients of chyluria may present with renal colic due to the passage of milky-white urine along with clots, dysuria, haematuria and urinary tract infections. In some severe forms, weight loss, cachexia, malnutrition, hypoproteinaemia and immunosuppression can be seen (2).
Majority of the patients present with milky white colour of urine (3). Chyluria due to parasitic cause presents with concomitant genital manifestations, lymphatic obstruction in limbs, cellulitis, abscesses and haematuria (4).
On macroscopic examination, chyluria has milky appearance which may be sometimes mixed with fibrin and blood clots. A postprandial urine sample is usually recommended for investigations (2). The milky white urine turns clear on addition of fat solvent such as ether. When Sudan III stain is added, there is superficial layer of red-stained fatty particles lying on clear urine after resting. Estimation of urinary chylomicrons is the most specific and sensitive test for chyluria (5). Triglyceride levels above levels 15 mg/dL are indicative of chyluria. Filarial antigen detection in the urine and serum can be done in suspected parasitic causes (6).
Conservative management is successful in upto 70% cases of chyluria (7). High fluid intake, fat restriction with addition of green leafy vegetables and multivitamins is recommended. In some severe intractable cases, total parenteral nutrition has been proposed.(8). There is very limited information on recommended duration of conservative management in literature, however, increasing severity of symptoms and signs of nutritional deficiencies warrant additional treatment options. In filarial patients, dietary modifications along with medications are needed. The recurrence rates after conservative management have been as high as 80% (9).
The minimally invasive therapy includes sclerotherapy, ethiodised oil lymphangiography or endoscopic coagulation. 0.1-3% silver nitrate, 0.2% povidone iodine, 1-25% sodium iodide, 10-25% potassium bromide, 50% dextrose and hypertonic saline are the various sclerosing agents utilised (3). In this sclerotherapy procedure, under optimal anaesthesia, 5F ureteric catheter is passed into the renal pelvis and sclerosant injected at site of fistulous communication which reaches the adjacent lymphatics via fistulous communication (8). It induces oedema and inflammation which results in subsequent fibrosis for long lasting symptomatic relief (6). However, this usually requires multiple treatment sessions over 6-8 weeks (6). The minor and self-limiting complications post sclerotherapy include nausea, flank pain and haematuria (10). More serious conditions like renal failure, anuria, pelvicalyceal cast formation and acute necrotising ureteritis have been also reported (11). The recurrence rates post sclerotherapy have been reported to be 13-41% (12).
Image-guided lymphatic interventions utilise imaging modalities to provide minimally invasive targeted therapies to block the abnormal lymphatic connections, which was previously performed by open surgery (13),(14),(15). Recently published reports describe diagnostic and therapeutic role of lymphangiography for lymphatic leakage (16),(17). The ethiodised oil undergoes inflammatory and granulomatous reaction during its extravasation leading to its therapeutic effect along with its embolic properties due to high viscosity (17). For cases of massive postoperative chylothorax, thoracic duct embolisation is minimally invasive procedure alternative to surgical ligation of thoracic duct (18). The lymphatic system is opacified by lymphangiography and then the cistern chyle or thoracic duct is catheterised through transabdominal approach and subsequently embolised. When the thoracic duct cannulation is not successful, thoracic duct obliteration of cistern chyle obliteration can be done. Needle perforation of the proximal thoracic duct/cistern chyle is done within the abdomen which prevents ascend of lymph which leaks into the peritoneal cavity and is absorbed by visceral organs. (18). The complications of ethiodised lymphangiography include intraalveolar haemorrhage, oil embolism to pulmonary vasculature, allergic reactions and oil extravasation in soft tissue at site of injection (17). The contraindications for the procedure are pulmonary insufficiency (can be exaggerated due to pulmonary embolism) and right to left cardiac shunt (risk of cerebral embolism). The overall complication rates are low when volume of ethiodised oil used is less than 10 mL.
When conservative and minimally invasive treatment options fail, invasive surgical treatments are considered. The various operative techniques described are chylolymphatic disconnection and creation of lymphovenous anastomoses, omental wrapping and autotransplantation or nephrectomy (19). The overall success rate above 98% has been described for chylolymphatic disconnection (1). Simple nephrectomy is done in cases of non functioning kidney after conventional lymphovenous disconnection (6). Lymphovenous anastomosis results in lymphatic diversion and reducing intralymphatic pressures and is more physiological (20). With the introduction of advanced laparoscopic and robotic techniques, the complication rates have significantly reduced (21).
Lymphangiography is a relatively safe, minimally invasive, and reliable interventional modality which has diagnostic and therapeutic role in cases of lymphatic leakages. The need for morbid surgery is avoided.
DOI: 10.7860/JCDR/2022/58956.17151
Date of Submission: Jul 08, 2022
Date of Peer Review: Sep 13, 2022
Date of Acceptance: Oct 04, 2022
Date of Publishing: Nov 01, 2022
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: Jul 09, 2022
• Manual Googling: Sep 10, 2022
• iThenticate Software: Oct 03, 2022 (11%)
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