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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
Botulinum Neurotoxin Injection as a Therapeutic Option in Thoracic Outlet Syndrome Caused by a Supernumerary Scalenus Muscle: A Case Report
Correspondence Address :
Dr. Margarida Mota Freitas,
Avenida Torrado Da Silva, Almada, Portugal.
E-mail: margaridafmfreitas@gmail.com
Thoracic Outlet Syndrome (TOS) is a neurovascular syndrome and may occur as a result of compression of brachial plexus elements and/or subclavian vessels as they traverse the cervicoaxillary canal. One of the causes of TOS is the existence of a supernumerary scalene muscle, usually denominated as scalenus minimus. Botulinum Toxin Type A (BoNT-A) acts by binding presynaptically to high-affinity recognition sites on the cholinergic nerve terminals and decreases the release of acetylcholine, suppressing muscle overactivity. BoNT-A reduces contraction in injected muscles, causing focal chemodenervation and has been described as a non surgical effective treatment in selected cases of TOS. Here, is the case of a 44-year-old woman diagnosed with refractory TOS, who presented with paresthesia in the fourth and fifth fingers of her right hand, associated with a feeling of lack of coordination in the same hand. On Magnetic Resonance Imaging (MRI), a supernumerary scalene muscle was identified as a probable cause of TOS. She was treated with chemodenervation of the scalenus anterior muscle (30 Units) and scalenus medius muscle (30 Units), using incobotulinumtoxin A. The patient had a very significant clinical improvement after Anterior Scalene (AS) and Middle Scalene (MS) muscle BoNT-A injections. Incobotulinumtoxin A neurotoxin injection is a therapeutic option in TOS.
Anatomic variation, Botulinum toxin type A, Brachial plexus, Scalenus minimus
A previously healthy 44-year-old woman presented with paresthesia in her right fourth and fifth fingers, oedema, and cyanosis of the hand, which she described as “tingling and discomfort with a bluish discoloration of the skin”. The patient was right-hand sided, and she worked as a bank officer. Her complaints had started insidiously about a year before the patient presented to the clinical neurophysiology department.
She had no known history of musculoskeletal injuries in the affected limb and no known changes of radiculopathy, disc herniation or spondylarthrosis. The symptoms were not continuous as paresthesia was more severe during the night as she slept with her right hand on the back of the head with an abducted shoulder. All the symptoms were triggered and worsen by the execution of physical activities, such as walking and playing tennis, and with daily life overhead movements. About six months before being referred to the clinical neurophysiology department, the patient noticed a decrease in her right-hand fine motor skills, which she noticed in tasks such as brushing teeth or writing, due to loss of sensation, numbness, and decreased coordination. These complaints would last for 10-15 minutes, around four times a week.
Right upper limb Electromyography (EMG) and nerve conduction studies did not reveal any abnormalities. Brachial plexus and cervical spine MRI showed the existence of a right accessory scalene muscle between the AS and MS muscles, with a significant reduction in the interscalene space (Table/Fig 1). Computed tomography angiography revealed compression of the right subclavian vein at the costoclavicular junction with a shoulder abduction maneuver.
The patient had previously been diagnosed with TOS. About six months prior to the first appointment at the clinical neurophysiology department, she started first-line treatment with physiotherapy and anti-inflammatory drugs (naproxen 500 mg every 12 hours, for periods always shorter than 10 days), that proved insufficient, after three months of treatment. Physiotherapy sessions included relaxation techniques and deep friction massage. In order to open the thoracic outlet by raising the shoulder girdle and opening the costoclavicular space, the patient was prescribed strengthening exercises of the levator scapulae, sternocleidomastoid and upper trapezius, serratus anterior and lower trapezius. The treatment also included stretches and postural correction exercises. Symptoms persisted, although less continuous, with longer intervals between the onset of oedema and paresthesia (about two episodes per month). According to the patient’s description, functionality remained compromised. She had difficulty lifting weights above her head, opening lids and reported decreased sensitivity and coordination during repetitive tasks. At that point, the patient was referred to our hospital.
On physical examination, she presented with normal muscle strength and sensitivity, and deep tendon reflexes were symmetrical. All passive and active articular ranges of motion were preserved. The patient had a negative Adson maneuver (1) as the radial pulse was not markedly diminished nor absent during neck extension and cervical rotation towards the symptomatic side. Ulnar nerve compression and stretching tests did not reproduce symptoms. Ulnar Nerve Tinel test (2) was negative. Regarding functionality, the patient scored 46/80 on the Upper Extremity Function Scale (UEFS) (3). The UEFS consists of eight questions that are scored out of a possible 10 points. The scale is calculated by summing the points from each individual question, with a range of 0 (no disability) to 80 (maximum disability).
Injection of incobotulinumtoxin-A (BoNT-A) was then proposed by the medical team and was accepted by the patient. EMG-guided chemodenervation of the scalenus anterior muscle (20 units-U of BoNT-A) and scalenus medius muscle (20 U of BoNT-A) was performed using a two-channel EMG machine (Medelec® Synergy; Oxford Instruments, UK). Follow-up was carried out through reassessment appointments. The intensity of paresthesia was measured using a Visual Analogue Scale (VAS). Since, this condition affected functionality, UEFS was applied. Follow-up appointments were scheduled one month after the first injection, at three months, at four and at six months.
At the first re-evaluation, she presented a very significant clinical improvement, with total oedema regression and very rare paresthesia complaints. UEFS score dropped significantly from 46/80 to 8/80, revealing a very satisfactory functionality gain. At three months assessment, she was treated again with chemodenervation of the scalenus anterior muscle (30 U) and scalenus medius muscle (30 U), using BoNT-A. Because chemical denervation is reversible, BoNT-A has temporary effects, with the muscle being progressively reinnervated by nerve sprouting. Usually, intramuscular BoNT-A treatment requires 3-5 months intervals between injections, depending on the anatomical region and symptoms. At the six months assessment, the patient reported significant clinical improvement and improved quality of life. More specifically, the patient reported a decrease in the intensity of paresthesia from 8/10 to 1/10 during physical exercise and from 4/10 to 0/10 at rest, using the VAS. She had a UEFS score of 4/80. The patient will return for follow-up appointments and eventually repeat incobotulinumtoxin toxin injections, if needed. The patient was asked to carefully read and sign an informed consent, regarding publishing her clinical data and MRI.
The TOS is defined as an association of clinical signs and symptoms caused by congenital or acquired compression of the brachial plexus or subclavian vessels as they pass through the superior thoracic aperture (4). TOS can be classified according to aetiology, symptoms, clinical presentation, or anatomy (5). The most widely used classification is based on the anatomical structures being compressed, dividing it in neurogenic, venous or arterial. Neurogenic TOS (NTOS) is caused by compression of the brachial plexus roots at the interscalene triangle and/or retropectoral space (6). Symptoms may include pain, upper limb oedema, decreased manual dexterity, paresthesia or numbness in the neck, shoulder, arm, or hand (5),(7). A differentiating feature is that these symptoms worsen with shoulder elevation, overhead movements, or outstretched positions of the arm (5),(7),(8).Compression in TOS can be caused by a variety of structures, such as cervical ribs, congenital fibrous and muscular band anomalies, supernumerary scalene muscles, or first rib abnormalities (9). A supernumerary scalene muscle, denominated as scalenus minimus, may be present in the lower part of the interscalene triangle (10). The incidence of scalenus minimus muscle ranges between 7.8-71.7% (11),(12).
The TOS first-line treatments include physiotherapy, anti-inflammatory drugs and analgesic agent injections (12). Scalenectomy, first rib resection or pectoralis minor tenotomy are reserved for severe cases. Torriani M et al., showed that botulinum toxin injection of AS and pectoralis minor muscles provided temporary relief of symptoms and functional recovery in over two thirds of 41 subjects with suspected NTOS (7). Foley JM et al., reviewed several case reports and studies using BoNT-A injection to reduce scalene muscle hypertrophy and brachial plexus compression (13). BoNT-A acts by binding to high-affinity recognition sites on muscle cholinergic nerve terminals, decreasing the release of acetylcholine, hence reducing muscle contraction. Also, analgesic effects of BoNT-A have been described (14). Due to its analgesic features and its ability to treat muscle overactivity, BoNT-A has been tested in TOS cases refractory to conservative treatment.
In this case report, diagnosis was relatively simple as the patient presented the classic symptoms of oedema, paresthesia, decreased manual dexterity, all aggravated by overhead movements. The identification of an accessory scalene muscle on MRI allowed the identification of a cause, with high sensitivity and specificity. Differential diagnosis would be a cervical disc injury, cervical discogenic pain syndrome, cervical radiculopathy or elbow and forearm overuse injury. Treatment with botulinum toxin was effective. Repeating the injection three months after the first, is a sign of therapeutic success, as the patient showed a significant clinical improvement with incobotulinumtoxin. Botulinum toxin always has a temporary effect, because chemodenervation is reversible. To our knowledge, this is the first case report to describe in detail the complaints, functionality, physical examination and therapeutic approach with incobotulinumtoxin chemodenervation in a case of TOS caused by the existence of a supernumerary scalene muscle, including a six-month follow-up.
This case highlights the therapeutic efficacy of incobotulinumtoxin injection in the treatment of TOS caused by an accessory scalene muscle, with compression of the brachial plexus. The patient presented a significant reduction of oedema and paresthesia and showed important gain in functionality.
DOI: 10.7860/JCDR/2022/52959.15957
Date of Submission: Oct 20, 2021
Date of Peer Review: Dec 16, 2021
Date of Acceptance: Jan 14, 2022
Date of Publishing: Feb 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: Oct 21, 2021
• Manual Googling: Jan 13, 2022
• iThenticate Software: Jan 18, 2022 (12%)
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