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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
Comparison between Epidural Bupivacaine with and without Magnesium Sulphate in Patients undergoing Elective Total Abdominal Hysterectomy: A Double-blinded Randomised Clinical Trial
Correspondence Address :
Dr. Aishwarya Guru,
316, Damoh Road, Yagshala Ke Pass- 470666, Patharia, Madhya Pradesh, India.
E-mail: aishwarya.gurus1994@gmail.com
Introduction: The effectiveness of a local anaesthetics increased by the addition of an adjuvant. Magnesium sulphate along with bupivacaine is effective in reducing the pain and extending the analgesia period.
Aim: To compare the duration of analgesia among subjects receiving plain bupivacaine and bupivacaine with magnesium sulphate among patients undergoing total abdominal hysterectomy.
Materials and Methods: This double-blinded randomised clinical trial was conducted in Department of Anaesthesiology at Shri Sathya Sai Medical College and Research Institute, Ammapettai, Tamil Nadu, India, (tertiary care center) between November 2019 to October 2021. The study was done among 50 subjects undergoing elective total abdominal hysterectomy. The subjects were divided into two groups: one group received only bupivacaine while the other group received bupivacaine with 500 mg magnesium sulphate. Onset and duration of blocks were observed. Haemodynamic parameters were monitored intraoperatively and postoperatively. Data was analysed using Chi-square test and Fischer’s-exact test.
Results: Demographic variables like age (p-value=0.17), height (p-value=0.62), weight (p-value=0.14) and Body Mass Index (BMI) (p-value=0.24) were comparable between the two groups. The mean duration of analgesia was significantly more among the bupivacaine with magnesium sulphate group (416.72±93.6) in comparison to the bupivacaine alone group (204.96±71.25). The bupivacaine with magnesium sulphate group required two doses of rescue analgesia in 24 hours, while the other group required four doses of analgesia. Significantly more side-effects were noted among the bupivacaine alone group (12 vs 6) (p-value=0.04).
Conclusion: The study showed that bupivacaine with magnesium sulphate group showed less intraoperative side effects, reduced postoperative Visual Analogue Scale (VAS) score, increased duration of analgesia, decreased requirement of analgesia required in 24 hours and reduced postoperative side-effects.
Epidural anaesthesia, Perioperative management, Postoperative analgesic requirement, Rescue analgesia
Perioperative management, which includes effective intraoperative monitoring and relief of postoperative pain, is an essential objective for anaesthesiologists. Effective perioperative pain management can have analgesic benefits, patients are less probable to suffer cardiac, respiratory, or gastrointestinal side effects during or immediately after the intervention. Ineffective perioperative pain is related with deep vein thrombosis and formation of an embolus in the lung, it may decrease life’s quality and delayed recovery (1),(2). Effective postoperative pain management delivers enhanced patient comfort, earlier mobilisation, and speedy recovery (3),(4).
Total Abdominal Hysterectomy (TAH) is a surgical technique which is related to significant postoperative pain and morbidity and is regarded to be a major surgery (5). A variety of anaesthetic methods containing general anaesthesia or different modalities of regional anaesthesiahas been utilised to perform TAH (6). Epidural analgesia has been extensively utilised in patients requiring TAH. Epidural anaesthesia technique is an efficient approach, with the advantage of safety, effectiveness, and sustained postoperative pain alleviation (1),(6).
The selection of local anaesthetic is based on potency of the agent, onset and period of anaesthesia, and adverse reactions to the drug (7). Bupivacaine amide group of local anaesthetic, enters nerve fibres as a neutral free base, stops transmission by their interaction on the inner surface of the sodium ion (Na+) channel. The blockade causes reduction in conduction of vascular smooth muscle, leading to relaxation (8),(9),(10).
The addition of adjuvant extends and reinforces the sensory blockade formed by local anaesthetics with decrease in dose of the latter, thus dipping the side-effects. Adjuvants are drugs that augment the efficacy of other drugs when given simultaneously (11). Magnesium is a physiological blocker of calcium channel and non competitive antagonist of N-methyl-D Aspartate (NMDA) receptor. It has been utilised with a local anaesthetic solution in diverse regional/ local anaesthesia method (12),(13).
The effectiveness of a local anaesthetic would be increased by addition of an adjuvant with the use of magnesium sulphate along with bupivacaine is effective in reducing the pain and extending the analgesia period. There are few studies on magnesium as adjuvant, but none compared the intraoperative and postoperative effectiveness and also the rescue analgesia in addition to the adjuvant. This study aimed to assess the duration of analgesia of epidural block with plain bupivacaine and bupivacaine with magnesium sulphate in patients undergoing total abdominal hysterectomy. The primary measure of the study aimed to see the onset and intraoperative requirement of analgesia. The secondary outcome was the side-effects for the same.
This double-blinded randomised clinical trial was conducted in Department of Anaesthesiology at Shri Sathya Sai Medical College and Research Institute, Ammapettai, Tamil Nadu, India, (tertiary care center) between November 2019 to October 2021. The ethical clearance was obtained from Institutional Ethical Committee (IEC 2019/560) and Clinical Trials Registry India (CTRI) registration (CTRI No.:CTRI/2020/02/023169). An informed consent was obtained from each patient.
Sample size calculation: Sample size was calculated based on previous study (14) and 95% confidence interval with 80% power, the sample size required for each group was 25 with the total sample size of 50.
Inclusion criteria: Female patients undergoing elective total abdominal hysterectomy, in the age group 40 to 60 years, and American Society of Anesthesiologists (ASA) grade I and II were included in the study.
Exclusion criteria: Patient refusing for epidural, allergy to local anesthetics/magnesium sulphate, patients having coagulation disorders, local site infection, Body Mass Index (BMI) >30 kg/m2 were excluded.
The patients and respective anaesthesiologist were blinded with the study drug (Table/Fig 1).
The subjects were randomly divided into two groups, by computer generated list of random number.
• Control group: Patient received 0.5% 20 mL of bupivacaine through epidural catheter.
• Study group: Patient received 0.5% 20 mL of bupivacaine with 500 mg magnesium sulphate through epidural catheter.
Procedure
The patients fulfilling the inclusion criteria were kept nil per oral 8 hours before surgery. After shifting the patients to the operation theatre, standard ASA monitors were connected and their baseline values was recorded. Intravenous (i.v.) access was secured using an 18 gauge cannula. Under all aseptic precautions, epidural block was performed by using 18G Tuohy needle, advanced at L1-L2 or L2-L3 intervertebral space. Space was identified using loss of resistance technique, then a 22 gauge multiorifice catheter was advanced, 5 cm of the catheter was kept in-situ through which a test dose of 3 mL solution of 1.5% lidocaine with 5 μg/mL adrenaline was given to rule out intravascular placement of the catheter. The epidural catheter was safely secured with plaster.
The duration of analgesia was assessed using Visual Analogue Scale (VAS) - 0 to 10 score from no pain to worst pain - at 15, 30, 60 minutes and thereafter at 4 hour interval for 24 hour postoperative period. Patients above score 4 received rescue analgesia in the form of inj. tramadol 50 mg i.v. in the postoperative period. Patient haemodynamics were monitored for any postoperative complications like bradycardia and hypotension. Total amount of rescue analgesic given was monitored along with haemodynamic vitals of the patient.
Statistical Analysis
Data was entered in Microsoft Excel sheet and analysed using Statistical Package for Social Sciences (SPSS) software version 16.0. For test of significance, Chi-square test was used. Fisher’s exact test was used when more than 20% of the cell values have expected cell value less than 5. A p-value <0.05 was considered statistically significant.
Demographic variables were comparable between two groups (Table/Fig 2).
The association of postoperative pulse rate and oxygen saturation (SpO2) among the groups showed nil significant association between the groups. The association of postoperative Systolic Blood Pressure (SBP) among the groups showed nil significant association between the groups in terms of SBP at 15 minutes, 30 minutes, 60 minutes, 8th hour, 16th hour, 20th hour and 24th hour. At 4th hour there was significant difference between the groups where bupivacaine with magnesium sulphate showed increased systolic blood pressure in comparison to Bupivacaine alone group (112.96±9.24 mmHg vs 107.88±6.82 mmHg). At 12th hour there was significant difference between the groups where bupivacaine with magnesium sulphate group showed decreased systolic blood pressure in comparison to bupivacaine alone group (107.20±7.92 mmHg vs 113.68±9.20 mmHg).
The association of postoperative Diastolic Blood Pressure (SBP) among the groups showed nil significant association between the groups in terms of DBP at 15 minutes, 30 minutes, 60 minutes, 4th hour, 16th hour, 20th hour and 24th hour. At 8th hour there was significant difference between the groups where bupivacaine with magnesium sulphate showed decreased diastolic blood pressure in comparison to bupivacaine alone group (71.76±6.91 vs 68.04±6.15 mmHg). At 12th hour there was significant difference between the groups where bupivacaine with magnesium sulphate group showed decreased diastolic blood pressure in comparison to bupivacaine alone group (71.60±8.78 vs 66.56±5.58 mmHg).
The association of postoperative MAP among the groups showed nil significant association between the groups in terms of MAP at 15 minutes, 30 minutes, 60 minutes, 4th hour, 8th hour, 16th hour, 20th hour and 24th hour. At 12th hour there was significant difference between the groups where bupivacaine with magnesium sulphate group showed decreased mean arterial blood pressure in comparison to bupivacaine alone group (85.64±8.53 vs 80.12±5.66 mmHg).
At 15 minutes, 30 minutes, 60 minutes, 4th hour, 12th hour, 16th hour, and 24th hour VAS score was significantly more among bupivacaine alone group in comparison to bupivacaine with magnesium sulphate group (1.64±0.64 vs 1.12±0.33), (1.60±0.50 vs 1.00±0), (2.56±0.92 vs 1.08±0.28), (3.44±0.92 vs 1.52±0.51), (3.04±1.34 vs 2.12±0.73), (2.36±1.25 vs 3.00±0), (2.60±1.41 vs 1.36±0.49), respectively. At 8th hour the VAS score was significantly more among bupivacaine with magnesium sulphate group in comparison to bupivacaine alone group (4.08±0.28 vs 3.16±0.85) (Table/Fig 3).
Number of analgesia required in 24 hours among the groups showed that 23 (92%) of bupivacaine with magnesium sulphate group required 2 doses and 15 (60%) of bupivacaine alone group required 4 doses (Table/Fig 4).
The mean duration of analgesia was significantly more among bupivacaine with magnesium sulphate in comparison to bupivacaine alone group (416.72±93.86 vs 204.96±71.25). The result shows the association of intraoperative side-effects among the groups. Intraoperatively, more side-effects were noted among bupivacaine alone group in comparison to bupivacaine with magnesium sulphate {12 (48%) vs 6 (24%)} (Table/Fig 5).
The main objective was to compare the duration of analgesia among subjects receiving plain bupivacaine and bupivacaine with magnesium sulphate in patients undergoing total abdominal hysterectomy. The association of intraoperative pulse rate, SBP, DBP, mean arterial pressure, SpO2 and intraoperative analgesia requirement among the groups showed nil significant association between the groups in terms of these variables.
The present study has shown that the duration of analgesia among subjects receiving Plain Bupivacaine (PB) was less, when compared with subjects receiving Bupivacaine with Magnesium Sulphate (BM).
Tramer MR et al., showed that subjects who were administered magnesium sulphate, utilised lesser morphine during the first 48 hour (65 mg vs 90 mg), which was more during the initial six hours, and they suffered less discomfort in the course of the first and second postoperative days (15). In the present study too, the mean duration of analgesia was more in the BM group, and the patients had a reduced postoperative hospital stay.
Similar findings were reported by Arcioni R et al., They concluded that adding intra-thecal magnesium sulphate to bupivacaine showed extended the period of anaesthesia and devoid of side-effects (16). Ghatak T et al., studied The impact of magnesium or clonidine, as accessory, to epidural bupivacaine in abdominal and limb surgeries. Beginning of anaesthesia was fast in the magnesium group. In the clonidine category there was a longer period of anaesthesia and sedation with reduced pain score, but there was an elevated incidence of shivering (17). In contrast, the present study found a prolonged pain score in the BM group.
Malleeswaran S et al., showed that the duration of spinal anaesthesia was considerably longer in the magnesium category in comparison to saline group. Both groups had additional bupivacaine and fentanyl. Diclofenac needs for one day subsequent to surgery was considerably lower in the magnesium category (147.5 versus 182.5 mg) (18). The present study did not record the duration of spinal anaesthesia, but the intraoperative and postoperative rescue analgesia were recorded. In the BM group, lesser subjects had single dose requirement of analgesia during intraoperative period.
Abd-Elsalam KA et al., also showed that the mean postoperative AS score was significantly decreased in bupivacaine with magnesium group, compared to the bupivacaine alone group. The mean value of time of the first call for rescue analgesia was considerably lengthened in bupivacaine with magnesium category (15.67 hours) compared to the other (7.33 hours) (19). In the present study, it was noted that the number of analgesic required in 24 hours among the group was two doses against four doses in the PB group.
Thus, it was found that the BM group had less intraoperative and postoperative side-effects, reduced postoperative VAS score, increased duration of analgesia, and decreased requirement of analgesia required in 24 hours.
Limitation(s)
The non inclusion of patient satisfaction score and surgeon satisfaction measures like volume of bleeding. Varied dosages of magnesium sulphate were not studied. The blood level of magnesium and its influence on the effects were also not studied.
Patients that were administered bupivacaine along with magnesium sulphate had less intraoperative and postoperative side-effects, reduced postoperative VAS score, decreased requirement of analgesia required in 24 hours, and also showed an increased duration of analgesia. Thus, magnesium sulphate is indeed efficacious for epidural use. In future, multiple age groups and surgical techniques need to be compared, to assess disparity in efficiency. Different doses of magnesium sulphate, blood level of magnesium, and its influence on the effects also need to be studied.
Authors are grateful to Dr. Krishna prasad for drafting the manuscript.
DOI: 10.7860/JCDR/2022/56755.16972
Date of Submission: Mar 30, 2022
Date of Peer Review: Apr 25, 2022
Date of Acceptance: Jun 21, 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. No
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