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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
Predictive Significance of High Sensitive C-reactive Protein in Subclinical Hypothyroidism: A Prospective Observational Study
Correspondence Address :
Dr. HA Krishnamurthy,
Associate Professor, Department of General Medicine, Krishna Rajendra Hospital, Mysore Medical College and Research Institute, Mysuru-570001, Karnataka, India.
E-mail: kmha79@gmail.com
Introduction: Subclinical hypothyroidism (SCH) is more common than overt hypothyroidism. It is associated with increased risk of dyslipidaemia, Coronary Artery Disease (CAD), left ventricular diastolic dysfunction, peripheral vascular diseases and chronic inflammation. Chronic inflammation plays a significant role in clinical manifestations and systemic organs injury in hypothyroidism. High-sensitivity C-Reactive Protein (hs-CRP) is a pentameric protein produced by the liver, and its level increases in response to inflammation. There are not much studies to prove that chronic inflammation could be a major risk factor for conversion of subclinical hypothyroidism in to overt hypothyroidism.
Aim: To study the role of chronic inflammation as a risk factor for conversion of SCH in to overt hypothyroidism with lipid abnormalities and cardiac dysfunction, by using inflammatory markers like hs-CRP.
Materials and Methods: This prospective observational study was conducted at KR hospital, Mysuru, Karnataka, India, from August 2019 to September 2020 among 112 subjects of subclinical hypothyroidism attending the Outpatient Department. The data regarding detailed history and clinical examination were collected from all the patients. Investigations such as Thyroid Stimulating Hormone (TSH), Triiodothyronine (T3), Thyroxine (T4) levels hs-CRP level, lipid profile, Electrocardiogram (ECG), Random Blood Sugar (RBS), Renal Function Test (RFT), Complete Blood Count (CBC), 2D-Echocardiography were done on day one and after six months. The data analyses was done by using the Chi-square test or Fisher’s-Exact test. The factors which were significant as per the Chi-square test were selected and subjected to multivariate analysis.
Results: The number of cases of subclinical hypothyroidism (hs- CRP >3 mg/L, mean TSH=9.1±2.1 microIU/mL) at first day were 23 (20.53%). At the end of six months, those converted to overt hypothyroidism (mean TSH=11.4±2.3 microIU/mL) were 14 (12.5%) patients. The patients with hs-CRP of >3 mg/L, with mean TSH of 11.4±2.3 microIU/mL at the end of six months of study, had left ventricular dysfunction in 68 (60.07%) patients. In the same group, the low-density lipoprotein cholesterol >160 mg/dL was found in 60 (53.57%) patients and serum triglycerides level >200 mg/dL was found in 51 (45.53%) patients (p-value <0.05).
Conclusion: Chronic inflammation is one of the major risk factors for conversion of subclinical hypothyroidism in to overt hypothyroidism with associated cardiovascular dysfunction and dyslipidaemia.
Cardiovascular system, Chronic inflammation, Dyslipidaemia
Subclinical Hypothyroidism (SCH) is defined by raised Thyroid Stimulating Hormone (TSH) value and normal levels of thyroid hormones- Triiodothyronine (T3), Thyroxine (T4), associated with few or no symptoms and signs of hypothyroidism (1). It is referred as a state of mild thyroid failure and is essentially a laboratory diagnosis. The prevalence of SCH increases with age and is the most common thyroid abnormality in older subjects (2). SCH is more common than overt hypothyroidism (1).
The prevalence of overt hypothyroidism is 4%, while prevalence of subclinical hypothyroidism has been reported to range from 6-8% for women (10% over the age of 60 years) and 3% for men (1). Euthyroidism is diagnosed, if the TSH is 0.3-4.5 microIU/mL, T3 is 80 to 220 ng/dL, and T4 is 5 to 12 microgm/dL. SCH is diagnosed if TSH is 4.5 to 10 microIU/mL with normal thyroid hormones. Overt hypothyroidism is diagnosed if TSH is >10 microIU/mL (1),(2).
Subclinical hypothyroidism was associated with increased risk of dyslipidaemia, Coronary Artery Disease (CAD), left ventricular diastolic dysfunction and peripheral vascular diseases and chronic inflammation (3). Chronic inflammation plays a significant role in clinical manifestations and systemic organs injury in hypothyroidism. If the chronic inflammation is untreated, it damages the thyroid gland and may lead to hypothyroidism (4). Later it may lead to increased morbidity and mortality due to systemic organ dysfunction (5). The high-sensitivity C-reactive Protein (hs-CRP) is a pentameric protein produced by the liver and its level increases in response to inflammation (6). An early diagnosis and treatment may prevent the onset of overt hypothyroidism and its associated complications (4). Hence, the present study was under taken to evaluate the role of chronic inflammation as a risk factor for conversion of SCH in to overt hypothyroidism with lipid abnormalities and cardiac dysfunction, by using inflammatory markers like hs-CRP.
This prospective observational study was conducted at KR Hospital, Mysuru, Karnataka, India, from August 2019 to September 2020 among 112 subjects of subclinical hypothyroidism attending the Outpatient Department. The data collection was started after obtaining ethical clearance from Institutional Ethics Committee, Mysore Medical College and Research Institute, (IEC No.ECREG:ECR/134/ Inst/KA/2013).
Inclusion criteria: Subjects with subclinical hypothyroidism with normal thyroid hormone levels with TSH level between 4.5 to 10 microIU/mL (1).
Exclusion criteria: Patients with familial hyperlipidaemia, coagulation disorders, severe systemic disease, overt hypothyroid patients, systemic arterial hypertension, diabetes mellitus, renal failure, underlying known cardiac disorder, pregnancy, connective tissue diseases and malignancy were excluded from the study.
Sample size calculation: The sample size was calculated based on the average prevalence rate of SCH (5%) by using the Cochran’s formula (7):
Z2PQ/e2
Where Z is z score (1.962),
p is prevalence of subclinical hypothyroidism,
q was (1-p),
e2 was precision value
The actual sample size by calculation was 76, but it was increased to 112 to have adequate number and to draw significant conclusion.
Study Procedure
Information was collected as per proforma after obtaining the informed consent from the study subjects. The subjects underwent detailed history, clinical examination, investigations such as Thyroid Stimulating Hormone (TSH), Triiodothyronine (T3), Thyroxine (T4) level, hs-CRP, Electrocardiogram (ECG), Random Blood Sugar (RBS), Renal Function Test (RFT), Complete Blood Count (CBC), 2DEchocardiography on day one. The study subjects were followedup for six months and the same investigations were repeated.
• TSH of 0.30 to 4.5 microIU/mL was considered normal.
• hs-CRP levels (4)
0.01 to 1 mg/L was considered as low-risk group,
1 to 3 mg/L intermediate-risk group, and
>3 mg/L as severe-risk group
• LDL cholesterol >160 mg/dL and Triglycerides >200 mg/dL were taken as abnormal values, as per National Cholesterol Education Programme Adult Treatment Panel III (NCEP ATP III) guidelines for metabolic syndrome (8).
The T3, T4, and TSH was measured by using electro chemiluminescent immunoassay, fasting lipid profile was measured by enzymatic calorimetric method, and hs-CRP was measured by infrared particle immunoassay method (9).
Statistical Analysis
The data analyses was done by using the Statistical Package for Social Sciences (SPSS, Inc, Chicago) for windows software, version 18.0. Descriptive statistics such as mean and Standard Deviation (SD) for continuous variables, frequency, and percentage for categorical variables were determined. Chi-square and Fisher’s-Exact tests (wherever appropriate) was used to find association between chronic inflammation with SCH and overt hypothyroidism and its complications. The level of significance was set at 0.05. The factors which were significant by Chi-square test were selected and subjected to multivariate analysis.
In this study 84 (75%) patients were in the age group of <60 years. The majority were female, 68 (60.7%) patients (Table/Fig 1). The number of patients with SCH converted to overt hypothyroidism by the end of six months of study were 12.5% (Table/Fig 2).
At six months, in patients of SCH, with hs-CRP >3 mg/L had significant Left Ventricular (LV) dysfunction with high LDL cholesterol and triglycerides level (p-value <0.05) (Table/Fig 3).
The present study was done to know the association between chronic inflammation and conversion of SCH in to overt hypothyroidism with cardiac dysfunction with lipid abnormalities. There were significant changes found at the end of six months of study, with respect to conversion of SCH to overt hypothyroidism with cardiac dysfunction and lipid abnormalities.
As per the study by Anwer MS et al., the prevalence of conversion of SCH to overt hypothyroidism was 14%, and patients with SCH have 2.8 times more risk of conversion to overt hypothyroidism as compared to healthy volunteers. The female gender and initial level of high serum TSH (4.5 to 10 microIU/mL) were the most important predictors of conversion of SCH in to overt hypothyroidism (10).
As per Amouzegar A et al., the Thyroid Peroxidase Antibodies (TPOAb) positive cases had a high-risk of converting in to overt hypothyroidism after 3 years with a relative risk of 4.14, 95% confidence interval 2.57-6.67 (11). Overt hypothyroidism was associated with reduced myocardial contractility, heart rate, and stroke volume (12). In the present study, 14 (12.5%) patients had hs-CRP level >3 mg/L in subjects, who converted from SCH in to overt hypothyroidism. The chronic inflammation with increased hs- CRP was found with progressive thyroid failure and was considered as a risk factor for the development of coronary artery disease (6),(13). The SCH patients were associated with high level of cardiac risk factors. Early treatment of SCH may prevent further progression to overt hypothyroidism, correct dyslipidaemia and decrease the risk of death from cardiovascular disease (14). Diastolic dysfunction was common in SCH, therefore early diagnosis and treatment may prevent cardiovascular complications (15).
The SCH has been shown to be associated with increased risk of CAD, peripheral vascular disease and dyslipidaemia (4),(16). SCH needs no intervention, if the serum TSH value is <10 microIU/L, and unless it is associated with co-morbidities like cardiac dysfunction, dyslipidaemia, and significant elevation of antiTPO antibodies (14),(16). The present study attempted to find the association between chronic inflammation (hs-CRP), and conversion of SCH in to overt hypothyroidism (17).
In the present study, among patients with hs-CRP level >3 mg/L patients, 68 (60.07%) had LV dysfunction, 60 (53.57%) had LDL cholesterol >160 mg/dL, and 51 (45.53%) had triglycerides >200 mg/dL at the end of six months. As per the study by Tuzcu A et al., the SCH patients were found to have elevated hs-CRP levels, high total cholesterol, high LDL cholesterol, and triglyceride levels (5). An elevated TSH level correlates with dyslipidaemia and adversely affects the cardiovascular function (18).
A cross-sectional study on the lipid abnormalities in SCH demonstrated a significant elevation of total cholesterol, LDL-cholesterol, apolipoprotein B and Lp(a) in SCH compared with euthyroidism (19). The treatment of SCH with thyroxine would have a favourable effect on the lipid profile by decreasing the total cholesterol and LDL-C (20),(21). A study in Naples, Italy, on 26 SCH subjects found a high incidence of LV dysfunction (22). Age more than 60 years and high hs-CRP level are the strong independent predictors of cardiovascular abnormalities in SCH, and also for the conversion to overt hypothyroidism (22),(23).
Limitation(s)
The outcomes need to be further studied for a longer duration of follow-up.
The present study found that chronic inflammation plays a big role in converting SCH to overt hypothyroidism. It was also associated with significant elevation in lipid levels, cardiovascular abnormalities in undetected and untreated subjects. So, a close follow-up is needed in all patients with SCH to prevent cardiac morbidity and mortality.
DOI: 10.7860/JCDR/2022/58886.16998
Date of Submission: Jul 06, 2022
Date of Peer Review: Aug 20, 2022
Date of Acceptance: Sep 27, 2022
Date of Publishing: Oct 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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