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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
Left Ventricular and Right Ventricular Functional Changes in Cases of COPD and its Correlation with Severity-A Cross-sectional Study
Correspondence Address :
Dr. Keertivardhan D Kulkarni,
H No. 671/B, Baba Nivas, Behind Godavari Lodge, Athani Road,
L B Shashtri Nagar, Bijapur, Vijayapura-586101, Karnataka, India.
E-mail: keertivardhandk@bldedu.ac.in
Introduction: Chronic Obstructive Pulmonary Disease (COPD) is a global health problem, mainly in developing countries. It affects pulmonary blood vessels, right ventricle, and also left ventricle leading to pulmonary hypertension, cor pulmonale and right and left ventricular dysfunction.
Aim: To assess the cardiac, right and left ventricular changes in subjects with increasing COPD severity staged according to Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines and to compare Arterial Blood Gases (ABG), St. George’s Respiratory Questionnaire (SGRQ) percentages and BODE (Body-mass index, airflow Obstruction, Dyspnoea, and Exercise) scores to cardiac changes in COPD.
Materials and Methods: The present study was a cross-sectional study conducted at tertiary care hospital in Southern Karnataka, India. The sample size was 60. A structured questionnaire was administered which included demographic, clinical variables followed by a detailed clinical examination, spirometry, Electrocardiograph (ECG), ABG, chest radiograph, echocardiography and a 6-Minute Walk Test (6MWT). Data collected was analysed using Statistical Package for the Social Sciences (SPSS) and Epi Info software for mean, Standard Deviation (SD) and multivariate analysis.
Results: All the patients diagnosed with COPD (using GOLD criteria) were included in study and assessed for right and left ventricular changes. Out of 60 patients, 58 were males and two were females, with mean age being 64.71±28.28 years. Among the study population, 45 (75%) patients had one or the other cardiac condition. Cardiac changes included left ventricular diastolic dysfunction (58.3%), right ventricular dilatation (33.3%), right ventricular hypertrophy, right atrial dilation, tricuspid regurgitation and pulmonary hypertension and left heart changes included left ventricular hypertrophy.
Conclusion: The study highlights the need for early and active cardiac screening of all COPD patients. This will help in early treatment and good prognosis, and will further contribute in reducing the morbidity and mortality.
Global initiative for chronic obstructive lung disease guidelines, Right and left ventricular changes, St George respiratory questionnaire percentages
The COPD, defined by GOLD as a preventable and treatable disease with significant extrapulmonary effects, is a common clinical entity in clinical practice (1). The COPD is one of the leading causes of death and disability worldwide. According to World Bank data, it has moved from its status in 2000 as the 4th and 12th most frequent cause of mortality and morbidity, respectively, to the 3rd and 5th leading cause of mortality and morbidity, respectively (2),(3).
The COPD is associated with significant extrapulmonary (systemic) effects among which cardiac manifestations are the most common. Cardiovascular disease accounts for approximately 50% of all hospitalisation and nearly one third of all deaths, if predicted FEV1 (Forced Expiratory Volume in 1st second) is less than 50% (4). In more advanced cases, cardiovascular disease accounts for 20-25% of all deaths in COPD (5). The COPD affects pulmonary blood vessels, right ventricle, as well as left ventricle leading to development of pulmonary hypertension, cor pulmonale, right ventricular dysfunction and left ventricular dysfunction too. Echocardiography provides a rapid, non invasive portable and correct method to evaluate the right ventricle function, right ventricular filling pressure, tricuspid regurgitation, left ventricular function and valvular function (6). Some studies have confirmed that echocardiography derives estimates of pulmonary arterial pressure correlate closely with pressures measured by right heart catheter (r>0.7) (7),(8).
In human beings, the respiratory and circulatory systems are so intimately related those changes in one eventually may cause changes in the other. The various respiratory diseases may secondarily cause changes in the heart, which may be detected by ECG (9). In clinical practice, cases having respiratory problems especially COPD should also be assessed for ECG changes. The BODE index (10) is a tool used by healthcare professionals to help predict COPD morbidity and mortality. Presumably, a higher BODE score correlates with an increased risk of death. Cardiovascular disease accounts for approximately 50% of all hospitalisation and nearly one third of all deaths. Hence, the present study aimed to assess the cardiac, right and left ventricular changes in subjects with increasing COPD severity staged according to GOLD guidelines and to compare ABG, SGRQ percentages and BODE scores to cardiac changes in COPD (11).
The present study was a cross-sectional study, done at tertiary care centre, at Southern Karnataka, India. Duration of the study was from January 2014 to December 2016. Institutional Ethical Committee (IEC) clearance was obtained (JSS/2011-12).
Inclusion criteria: Patients who consented, aged above 40 years, diagnosed as COPD according to GOLD criteria of spirometry, smoked at least 10 pack years/exposed to biomass fuel, absence of other chronic pulmonary diseases such as congenital bronchiectasis/Interstitial Lung Disease (ILD)/active tuberculosis or its sequelae, absence of co-morbidities such as liver or renal failure or cardiac diseases not related to COPD.
Exclusion criteria: Not willing to give informed consent, associated with other chronic pulmonary diseases such as congenital bronchiectasis/ILD/tuberculosis and associated with other major co-morbidities such as liver or renal failure or cardiac diseases not related to COPD.
Sample size calculation: Sample size was calculated to be 60, using formula n=4pq/l2, where ‘n’ is the sample size calculated, p is 32% proportion of right ventricular changes in COPD patients (12), q=100-p, l is 0.37 relative proportion at 95% of confidence interval.
All the patients were explained about the study details and procedures. After informed consent, a detailed structured questionnaire was administered which included demographic, clinical variables followed by a detailed clinical examination, spirometry, ECG, ABG, chest radiograph, echocardiography and a 6MWT. The various changes in the right and left ventricles were evaluated and compared with different severity of COPD staged according to the GOLD criteria.
Statistical Analysis
Epi Info, Microsoft excel and SPSS software were used for data analysis in the present study. A descriptive analysis was conducted and the association of various demographic and clinical variables with cardiac, right heart and left heart changes were analysed, using univariate analysis and independent association confirmed with multivariate analysis. Receiver Operating Characteristic (ROC) analysis was performed to find the threshold with highest sensitivity and specificity and that threshold was used for classification in univariate and multivariate analysis. The level of significance was fixed at p-value of <0.05.
As shown in (Table/Fig 1), during the study period, a total of 134 patients with significant history of exposure to risk factors (>10 pack years or 10 years of biomass exposure) were screened; 74 patients were excluded for one of the following reasons: refused to perform Pulmonary Function Test (PFT) or 6MWT, unable to perform PFT and/or refused to undergo blood investigations, echocardiography or other essential tests for the study. Finally, 60 patients were included in the study.
Mean age of 64.71 years, mean pack years of 43.72 years, Body Mass Index (BMI) of 20.83 (Table/Fig 2). Mean FEV1/FVC (Forced Vital Capacity) ratio was 54.86 and FEV1% predicted was 47.51 (Table/Fig 3) among study sample. There were 58 males and two females. Among the study population, 45 (75%) patients had one or the other cardiac condition as diagnosed using ECG or 2D echocardiography (Table/Fig 4). Among those 45 patients, 23 patients had right heart changes, 37 patients had left heart changes and 15 patients had changes in both right and left heart. Cardiac changes included right heart changes or left heart changes. Right heart changes included cor pulmonale and right ventricular hypertrophy criteria in ECG and right ventricular dilation, right atrial dilation, tricuspid regurgitation and pulmonary hypertension (Table/Fig 5). Left heart changes included left ventricular hypertrophy criteria of ECG and echocardiography findings include left ventricular hypertrophy, left ventricular systolic dysfunction and left ventricular diastolic dysfunction (Table/Fig 5).
On univariate analysis, for any cardiac changes, the following were found significant (Duration >3.5 y, Pack year >40 years, Modified Medical Research Grading >1, 6MW distance <290 m, BODE index >3, St. George’s Respiratory Questionnaire (SGRQ) activity% >15.01, SGRQ impact% >18.81, SGRQ total% >20.86). But among the above only pack year >40 years, SGRQ activity% >15.01, were independently found to be significant in multivariate analysis (Table/Fig 6). Other parameters which were found to be significant on univariate analysis were not found to be significant as shown in the (Table/Fig 6).
On univariate analysis for right cardiac changes, the following were found significant (Duration >2.5 y, 6MW distance <261 m, BODE index >4, paO2 <78 mmol/L, SGRQ activity% >15.31, SGRQ impact% >18.99, SGRQ total% >26.6). But among the above only duration >2.5 y, PaO2 <78 mmol/L, SGRQ impact% >18.99, were independently found to be significant in multivariate analysis (Table/Fig 7).
On univariate analysis for left cardiac changes, the following were found significant (Pack year >39 years, Modified Medical Research Council (MMRC) >1, 6MW distance <267 m, SGRQ impact% >18.81). But among them only pack year >39 years and MMRC >1 were independently found to be significant in multivariate analysis (Table/Fig 8).
There are many cardiac manifestations seen in COPD, ranging from mild pulmonary hypertension to severe cor pulmonale requiring long term oxygen therapy and heart failure medications. Conduction defects range from benign arrythmias to right bundle branch block. COPD is also associated with left ventricular dysfunction also. Impairment of right ventricular dysfunction and pulmonary blood vessels are well known to complicate the clinical course of COPD and correlate inversely with survival (13). Significant changes occur in the pulmonary circulation in patient with COPD (13). The presence of hypoxaemia and chronic ventilator insufficiency is associated with early evidence of intimal thickening and medial hypertrophy in the smaller branches of pulmonary arteries. Coupled with these pathological changes are pulmonary vasoconstriction arising from presence of alveolar hypoxaemia, destruction of pulmonary vascular bed. All these lead to significant increase in pulmonary vascular resistance, leading to pulmonary hypertension, hypertrophy of right ventricle. In patient with COPD, hypoxic vasoconstriction is associated with not only right ventricular hypertrophy but also right ventricular dilatation which eventually leads to clinical syndrome of right heart failure with systemic congestion and inability to adapt right ventricular output to the peripheral demand on exercise (13).
There are contradicting studies of involvement of left heart in patients with COPD. Some suggests left ventricular function remains normal while others suggest left ventricular dysfunction (14),(15). The data highlights left ventricular changes with a range of factors associated with COPD. Abnormal left ventricular performance in persons with COPD may be due hypoxaemia and acidosis, concurrent coronary artery disease, ventricular interdependence. Left ventricular diastolic dysfunction in COPD may be explained by chronic hypoxaemia leading to abnormalities of myocardial relaxation, lung hyperinflation and distension leading to increased stiffness of parietal pleura and thus wall of cardiac fossa leading to added load on ventricle (13).
Spirometry is the diagnostic test for COPD, which suggests airflow obstruction when post broncodilator FEV1/FVC is <0.7 and this airflow obstruction seen in COPD patients is irreversible. In a study conducted by Holtzman D et al., sensitivity of 12 lead electrocardiogram in diagnosing right ventricular hypertrophy was 50% as compared to right ventricular hypertrophy diagnosed by 2D echocardiography (16). Hence, in the present study echocardiography was considered for the cardiac changes. However, electrocardiogram is helpful in knowing the conduction defects such as arrhythmias, right bundle branch block, which are difficult to be diagnosed by echocardiography.
Various parameters like age, co-morbid illnesses, severity of signs and symptoms have been evaluated and assessed with chest X-ray, ABG analysis, echocardiography, 6MWT, BODE index, while quality of life was assessed using SGRQ percentages.
Values of thresholds for numerous factors were taken at their highest sensitivity and specificity using ROC analysis for various outcome measures i.e., any cardiac dysfunction, right ventricular dysfunction and left ventricular dysfunction. In a similar study done by Kaushal M et al., showed 32%, 48%, and 8% changes of right ventricular dilatation, pulmonary hypertension and left ventricular hypertrophy respectively in COPD patients while 14% of them were normal (12). Dave L et al., showed right ventricular dilatation in 33.5%, right ventricular hypertrophy in 34.5%, right atrial dilatation in 29.55%, pulmonary hypertension in 41%, left ventricular hypertrophy in 10.5% and right bundle branch block in 7.5% of COPD patients. The study also revealed that 12% of the COPD patients had no heart changes (17). Gupta NK et al., conducted a similar study in 2012 demonstrating 17, 5% right ventricular dilatation, 67.5% tricuspid regurgitation, 42.5% of pulmonary hypertension and 47.5% of left ventricular diastolic dysfunction (13).
In the present study, right ventricular dilatation was found in 33.3% of COPD patients, which was similar to the study by Kaushal M et al., (32%), and 39.5% in Dave L et al., (39.5%) (12),(17), but higher than what Gupta NK et al., found (17.5%) (13). Right atrial dilatation was found in 25% of COPD patients, which was less than the findings of Dave L et al., (29.5%) (17).
Other changes like tricuspid regurgitation, pulmonary hypertension, left ventricular hypertrophy and right bundle branch block were recorded as 18.33%, 16.67%, 6.67% and 3.33%, respectively. These findings are much lower than the studies by Kaushal M et al., Gupta NK et al., and Dave L et al., (12),(13),(17). Some more studies have been compiled in (Table/Fig 9) (18),(19),(20),(21),(22).
Limitation(s)
The gender differences for right and left ventricular functions in COPD patients could not be assessed, as there were only two females.
The study evaluated various factors associated with severity of COPD and cardiac dysfunction and observed that GOLD grading of severity of COPD was not associated with right ventricular or left ventricular dysfunction, BODE index of more than 4 was associated with right ventricular dysfunction, MMRC grading of breathlessness more than 1 was associated with left ventricular dysfunction, SGRQ impact % scores above 18.99% was associated with right ventricular dysfunction and pack years >40 years was associated with left ventricular dysfunction. Hence, apart from right ventricular dilatation which is commonly seen one should also be also be vigilant about other cardiac changes as mentioned above and should actively look for them in 2D echocardiography. Special emphasis should be given to left ventricular diastolic dysfunction left ventricular diastolic dysfunction as it will progress to systolic dysfunction in future.
DOI: 10.7860/JCDR/2022/50524.15907
Date of Submission: May 25, 2021
Date of Peer Review: Jul 07, 2021
Date of Acceptance: Nov 16, 2021
Date of Publishing: Jan 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
PLAGIARISM CHECKING METHODS:
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