Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
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Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


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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.
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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.
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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

Important Notice

Original article / research
Year : 2022 | Month : April | Volume : 16 | Issue : 4 | Page : PC21 - PC23 Full Version

Impact of COVID-19 Pandemic on Paediatric Appendicitis at a Tertiary Care Paediatric Hospital in New Delhi- A Retrospective Study


Published: April 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/52235.16289
Mamta Sengar, Chhabi R Gupta, Pritesh Maheshwari, Niyaz Khan, Shefalika Sharma

1. Professor and Head, Department of Paediatric Surgery, C.N.B.C, Geeta Colony, New Delhi, India. 2. Professor, Department of Paediatric Surgery, C.N.B.C, Geeta Colony, New Delhi, India. 3. Senior Resident, Department of Paediatric Surgery, C.N.B.C, Geeta Colony, New Delhi, India. 4. Assistant Professor, Department of Paediatric Surgery, C.N.B.C, Geeta Colony, New Delhi, India. 5. Resident, Department of Paediatric Surgery, C.N.B.C, Geeta Colony, New Delhi, India.

Correspondence Address :
Niyaz Khan,
J 738, Gaur Sportswood, Sector 79, Noida, Uttar Pradesh, India.
E-mail: khanniyaz82@yahoo.in

Abstract

Introduction: Across the globe the healthcare system was severely affected by Coronavirus Disease-19 (COVID-19) pandemic. Measures taken to curtail the spread of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) virus have severely affected the paediatric patients presenting with Acute Appendicitis (AA).

Aim: To assess the impact of COVID-19 on paediatric Acute Appendicities patients at tertiary care center in New Delhi.

Materials and Methods: This retrospective study was conducted at Chacha Nehru Bal Chikitsalaya, New Delhi. Patient demographics, symptomatology including delay in presentation to hospital, haematological, intraoperative findings and complications of all paediatric AA patients who underwent appendectomy from 23rd March 2020 to 22nd July 2020 (Pandemic Group- PG group) were recorded. Patients presenting in corresponding time period in the year 2019 was also compared {Non Pandemic Group (NPG) group}. Group comparisons for continuously distributed data were made using Independent sample t-test. For non normally distributed data, non parametric tests in the form of Wilcoxon test was used. Chi-squared test was used for group comparisons for categorical data.

Results: A total of 72 patients were included with 39 in NPG and 33 in PG group, respectively. There were no significant differences between the two groups in terms of age (p-value=0.759) and sex distribution (p-value=0.93). Patients in PG group had higher leukocyte counts as compared to NPG group (16748.48±7744.08 vs 12510.26±7736.58, p-value <0.007). There was no significant difference in delay in presentation, symptomatology, duration of hospital stay and postoperative complications rate between the two groups.

Conclusion: There has been no significant change in the number of patients presenting with AA and the symptomatology during COVID-19 pandemic.

Keywords

Acute appendicitis, Children, Coronavirus disease-19, Severe acute respiratory syndrome coronavirus-2

With the emergence of Coronavirus Disease-19 (COVID-19) pandemic, there has been an unintended consequence on other health conditions. Many countries applied nationwide lockdown to control the spread of disease (1). India’s first lockdown began on March 23, 2020 and continued for six months with phases of relaxation. During the pandemic, there has been a drastic decrease in the number of non COVID-19 patients attending the Emergency Department. The collateral damage due to various logistics problems as well as suspended emergency care in hospitals, had severely affected the emergency care received by paediatric surgical patients. Delay in seeking care has leads to increased mortality and morbidity (2).

Children suffering with AA have been affected most, as AA is one the most common abdominal emergencies affecting paediatric patients (3),(4). In case of AA in children, an early surgical treatment can prevent complications such as appendicular perforation and other postoperative complications. Delay in diagnosis of AA leads to an increased risk of peritonitis, abscess formation, sepsis, wound infection, and bowel obstruction. Generally, appendicular perforation occurs 3 to 5 days after the onset of symptoms, and its rate in children aged 10-17 years is around 20% (5). Abscess formation rate in children with perforated appendicitis is approximately 20% (6). During COVID-19 pandemic, it is expected that patients receive medical care at a later stage of the disease and present with significant complications. This study aimed to assess the impact of COVID-19 on the time elapsed between onset of symptoms to the diagnosis of AA and also the effect of delayed presentation on length of hospital stay and postoperative complications.

Material and Methods

This was a retrospective study conducted at Chacha Nehru Bal; Chikitsalaya, New Delhi a tertiary care paediatric surgery centre in New Delhi, India. Approval was obtained from Institutional Ethical Comittee (F.1/IEC/CNBC/13/09/2020/84/17210). A retrospective chart review of all patients who underwent open appendectomy from 23rd March 2020 to 22nd July 2020 was done (PG group). Patients with incomplete records were excluded from the study. As it was intended to compare with non COVID-19 period, a similar cohort from 23rd March 2019 to 22nd July 2019 was taken (NPG group).

Data on patient demographics, clinical history, haematological and radiological features and outcome were collected. Clinical history was thoroughly reviewed and time from onset of symptom till the surgery (delay) was noted. The operative notes review included presence of intraperitoneal collection, appendicular and cecal gangrene which were referred as complicated AA. Other clinical course markers were collected including length of hospital stay, need for any bowel diversion and Surgical Site Infection (SSI). Haematological parameters review included Total Leucocyte Counts (TLC), C-Reactive Protein (CRP), serum creatinine, blood and pus culture.

Statistical Analysis

Data were coded and recorded in MS Excel spreadsheet program. The Statistical Package for Social Sciences (SPSS) for windows software version 23.0 (IBM Corp.) was used for data analysis. Descriptive statistics were elaborated in the form of means/standard deviations and medians/Interquartile Range (IQRs) for continuous variables, and frequencies and percentages for categorical variables. Group comparisons for continuously distributed data were made using independent sample t-test when comparing two groups. If data were found to be non normally distributed, appropriate non parametric tests in the form of Wilcoxon test was used. Chi-squared test was used for group comparisons for categorical data. In case the expected frequency in the contingency tables was found to be <5 for >25% of the cells, Fisher’s-exact test was used instead. Statistical significance was kept at p-value <0.05.

Results

A total of 72 patients met the inclusion criteria; among them 39 were in NPG group and 33 were in PG group. There were no significant differences between the two groups in terms of age (p-value=0.759) and sex distribution (p-value=0.93). Abdominal pain was the most common symptom followed by fever and vomiting. The number of patients with delayed presentation did not vary significantly between the two groups (Table/Fig 1).

There was a significant difference in mean total leukocyte counts between both the groups p-value=0.007 (Table/Fig 2). A 9.1% of patients in PG had growth in blood culture as compared to only 2.7% in non pandemic period (p-value=0.337) (Table/Fig 1).

Cecal gangrene was seen in five patients in PG. All of these patients required small bowel diversion. None of the patients in NPG had cecal gangrene (p-value=0.017).

The median (IQR) of duration of hospital stay (days) in the non pandemic year was 6 (4-10.5) days which was less as compared to pandemic year in which it was 7.5 (4.75-13) days. However, this difference was not statistically significant (W=550.500, p-value=0.397).

Discussion

The Acute Appendicitis (AA) is one of the most common paediatric surgical emergencies (3),(4). Studies from different parts of world have found that the number of paediatric surgical emergencies had significantly decreased during the initial pandemic phase (7),(8). Various reasons have been cited to explain this reduction in number of cases. Some authors proposed that many patients could not reach the paediatric surgical centres and were treated conservatively (9). It has also been proposed that the decreased exposure to other infectious agents due to lockdown might be a contributory factor in reduction of incidence of AA. In this study, 33 patients of AA were operated during the pandemic times which were although less but comparable to 39 patients in non pandemic times. It was observed that during the pandemic, most of the paediatric surgery centres in were converted to dedicated COVID-19 centre and their non COVID-19 patients were referred to the centre where study was conducted. This could be one of the reasons for similar number of cases in both the groups.

In this study, the male to female ratio was similar in both PG and NPG group. However, Zhou Y and Cen LS reported male preponderance in patients with AA during the pandemic times (10). There was no change in symptomatology of AA during COVID-19 pandemic. Abdominal pain was the most common presentation in this study followed by fever and vomiting. In their study, Gerall CD et al., found that fever was significantly more common in population presenting during pandemic period (11). They also reported that duration of symptoms was longer in pandemic times and opined that fear of visiting the hospital may be the reason for this delay. In the present study, the average delay in presentation was more in PG group as compared to NPG group (3.56±2.25 vs 4.94±5.69 days). On verbal communication with the caregivers, it was found that transport restrictions during the lockdown and fear of exposure to COVID-19 infection in hospital deterred them from seeking hospital care.

In this study, higher rate of perforated appendix in year 2020 (69.7%) was observed as compared to non pandemic year (53.8%). Various other studies done in other parts of world such as Italy, Israel and Colombia supports similar views and results (7,8,12). Snapiri O et al., from Israel found complication rates twice as high (22% vs 11%) when compared to the same time period in 2019, with various complications like perforation and appendicular abscess (8). Romero J et al., from American University of Radiology also found that Computed Tomography (CT) done during pandemic times found more severe appendicitis cases compared to previous year (12). It was also observed that mean leucocyte counts were much higher in PG group as compared to NPG group. There was also higher rate of dyselectrolytemia, CRP values and positive blood and pus cultures in patients presenting during pandemic times. Zhou Y and Cen LS also published similar results with higher TLC counts and also high neutrophil ratio in Chinese population suffering from AA (10). These markers indirectly suggest increased severity of disease during COVID-19 pandemic. In our country, patients take primary treatment from neighbourhood general practitioners for abdominal pain and fever where they are usually prescribed antibiotics and anti-inflammatory drugs. During the lockdown period these consultations were not available and authors believe that this could have contributed to patients presenting with more severe illness during the pandemic.

The need for ileostomy was significantly higher during the pandemic times which were mostly due to the more complicated cases presenting in later stage of disease with cecal gangrene. Data on this aspect has not been published, so this study results could not be compared. Higher rate of ileostomy could be due to poor nutritional status in developing countries like ours, propelling a surgeon to choose ileostomy (being a safer option).

Duration of stay in hospital was found to be higher during the pandemic times compared to non pandemic times in our study, though it was not statistically significant. Other authors have found statistically significant higher duration of stay in the pandemic times and reason being the more complicated cases operated during these times which needed more time to stabilise. Present study population was less and it was felt that studies with large sample size is required to reach a better conclusion. Gerall CD et al., did a multivariate analysis in their study, and found that duration of stay and number of days until symptom resolution remained significantly longer during the pandemic, further suggesting that the severity of disease patients presented with correlated outcomes (11).

Limitation(s)

There are few limitations of the present study. The retrospective monocentric design of this study makes it difficult to generalise our results. Due to missing data this study is not able to determine the exact incidence of the disease.

Conclusion

During COVID-19 pandemic the management of non COVID-19 paediatric diseases were severely affected. The present study showed no significant change in number of patients presenting with AA and the symptomatology. The delay in access to primary treatment facility for patients with AA has lead to increased severity of the disease.

References

1.
Chan JFW, Yuan S, Kok KH, To KKW, Chu H, Yang J, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-toperson transmission: A study of a family cluster. The Lancet. 2020;395:514-23. [crossref]
2.
DeFazio JR, Kahan A, Fallon EM, Griggs C, Kabagambe S, Zitsman J, et al. Development of paediatric surgical decision-making guidelines for COVID-19 in a New York City children’s hospital. J Paediatr Surg. 2020;55:1427-30. [crossref] [PubMed]
3.
Sivit CJ, Siegel MJ, Applegate KE, Newman KD. Special focus session: When appendicitis is suspected in children. Radiographics. 2001;21:247-62. [crossref] [PubMed]
4.
Ferris M, Quan S, Kaplan BS, Molodecky N, Ball CG, Chernoff GW, et al. The global incidence of appendicitis. Ann Surg. 2017;266:237-41. [crossref] [PubMed]
5.
Pepper VK, Stanfill AB, Pearl RH. Diagnosis and management of paediatric appendicitis, intussusception, and Meckel diverticulum. Surg Clin North Am. 2012;92:505-26. [crossref] [PubMed]
6.
St Peter SD, Sharp SW, Holcomb GW, Ostlie DJ. An evidence-based definition for perforated appendicitis derived from a prospective randomized trial. J Paediatr Surg. 2008;43:2242-45. [crossref] [PubMed]
7.
Lazzerini M, Barbi E, Apicella A, Marchetti F, Cardinale F, Trobia G. Delayed access or provision of care in Italy resulting from fear of COVID-19. Lancet Child Adolesc Health. 2020;4:e10-11. [crossref]
8.
Snapiri O, Rosenberg Danziger C, Krause I, Kravarusic D, Yulevich A, Balla U, et al. Delayed diagnosis of paediatric appendicitis during the COVID-19 pandemic. Acta Paediatr. 2020;109:1672-76. [crossref] [PubMed]
9.
England RJ, Crabbe DCG. Delayed diagnosis of appendicitis in children treated with antibiotics. Paediatr Surg Int. 2006;22:541-45. [crossref] [PubMed]
10.
Zhou Y, Cen LS. Managing acute appendicitis during the COVID-19 pandemic in Jiaxing, China. World J Clin Cases. 2020;8:4349-59. [crossref] [PubMed]
11.
Gerall CD, DeFazio JR, Kahan AM, Fan W, Fallon EM, Middlesworth W, et al. Delayed presentation and sub-optimal outcomes of paediatric patients with acute appendicitis during the COVID-19 pandemic. J Paediatr Surg. 2020;S0022-3468(20):30756-59.
12.
Romero J, Valencia S, Guerrero A. Acute appendicitis during Coronavirus Disease 2019 (COVID-19): Changes in clinical presentation and CT findings. J Am Coll Radiol. 2020;17:1011-13. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2022/52235.16289

Date of Submission: Sep 03, 2021
Date of Peer Review: Dec 15, 2021
Date of Acceptance: Feb 11, 2022
Date of Publishing: Apr 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? No
• For any images presented appropriate consent has been obtained from the subjects. No

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Sep 04, 2021
• Manual Googling: Feb 08, 2022
• iThenticate Software: Feb 10, 2022 (18%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com