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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
Prevalence of Arrhythmic Events in Paediatric Patients with Congenital Heart Disease-A Retrospective Study
Correspondence Address :
Dr. Asish Banerjee,
JD5, 4c, IQ City Residential Complex, Bijra, Sovapur Village,
Durgapur, West Bengal, India.
E-mail: asishbnrj@gmail.com
Introduction: Various types of arrhythmias occur in patients with Congenital Heart Disease (CHD) and are the leading cause of morbidity and mortality. Knowledge regarding arrhythmias in CHD is important for safe and effective management of arrhythmia and in reduction of sudden cardiac deaths.
Aim: To assess the profile of various arrhythmic events in children with CHD.
Materials and Methods: A retrospective study was conducted from January 2018 to December 2020. Data were collected from the Department of Paediatrics of a tertiary care hospital in Durgapur, West Bengal, India. A total of 232 children of the age group 0-18 years, diagnosed with CHD were included in this study. Children who underwent cardiac intervention were excluded from the study. Age, sex, age at diagnosis, nature of CHD, clinical findings, Electrocardiogram (ECG) findings were recorded. Data analysis was performed using Fisher’s-Exact test on Statistical Package for the Social Sciences (SPSS), version 27.0. A p-value <0.05 was considered as statistically significant.
Results: A 20.3% children of 0-18 years of age with CHD had conduction abnormalities. Statistically significant association was found between atrial septal defect with Atrial Fibrillation (AF) (p-value <0.001) and atrial flutter (p-value=0.008), Ventricular Septal Defect (VSD) with Premature Ventricular Contractions (PVC) (p-value=0.0001), Atrioventricular (AV) canal defect with first degree AV block with (p-value=0.0004), Tetralogy Of Fallot (TOF) with Ventricular Tachycardia (VT) (p-value=0.021), L-Transposition of Great Vessels (L-TGA) with complete AV block (p-value=0.012), Ebstein’s anomaly with Supraventricular Tachycardia (SVT) (p-value <0.001).
Conclusion: Specific conduction abnormalities are significantly associated with specific CHD. These results demand attention for effective management of arrhythmia and reduction of sudden cardiac death in children with CHD.
Conduction abnormalities, Congenital cardiac defect, Sudden cardiac death
The incidence of haemodynamically significant CHD is 8 per 1000 live births (1),(2),(3),(4). Nearly 1,80,000 children per year are born with CHD in India (5),(6). Incidence of paediatric arrhythmias is approximately 55.1 per 100,000 patients evaluated in paediatric emergency departments (7). Sinus tachycardia is by far the most commonly reported arrhythmia, followed by SVT which represents about 13%, and bradycardia accounting for about 6% of all cases (8).
Arrhythmias are seen in children with structurally normal hearts as well as those associated with CHD and cardiomyopathies. Cardiac arrhythmia is a common cause of acute deterioration, emergency hospital admission and sudden cardiac death (9). The incidence generally increases with age. There are multifactorial predisposing features for development of arrhythmias in CHD that may include congenitally malformed or displaced conduction systems, altered haemodynamics and mechanical or hypoxic stress (10),(11).
The care of the patient with CHD and arrhythmias may involve pharmacological therapy, catheter ablation, implantable cardiac devices, and surgical interventions (11). In developing countries like India, majority of CHD remain undiagnosed and uncorrected due to lack of accessible heathcare facilities. Prompt diagnosis and management of arrhythmias comprises of a significant role in management of congenital heart defect (12). Electrocardiography should be included in routine care of children with CHD.
In most of the previous studies regarding arrhythmic events in CHD, study participants were selected from post cardiac intervention patients in Intensive Care Unit (ICU) set-up. There is higher chance of detection of arrythmia in post cardiac intervention patients because most of the patients stay in ICU under cardiac monitoring in the immediate postoperative period and are under regular follow-up. Moreover, multiple confounding factors like surgery technique, postoperative medications and electrolyte imbalance may affect the results significantly (10),(11),(12).
On the other hand, in children with uncorrected CHD arrythmias often remain undiagnosed as ECG is not advised routinely by treating physician. Undetected arrythmias in uncorrected CHD may be fatal due to risk of sudden cardiac death. In India, as there is huge burden on uncorrected CHD (5), prevalence and profile of arrythmia in uncorrected CHD and risk of sudden cardiac death should be extensively studied. In the present study, patients with a history of cardiac intervention were excluded because the present study was conducted with the aim to emphasise upon the true prevalence and profile of arrhythmia in uncorrected CHD for early detection and effective management of arrhythmia and reduction of sudden cardiac death.
A retrospective study was conducted over a period of three and half years in the Department of Paediatrics of IQ City medical college and hospital, Durgapur, West Bengal, India. Data were collected from January 2018 to December 2020 and data were analysed from January 2021 to June 2021. Ethical clearance was obtained from Institutional Ethical Committee (IEC) (Ethical committee approval number IQMC/IEC/LTR/17/02/29). Informed consent was obtained from all the parents of children included in the study.
Inclusion criteria: Children of 0-18 years of age diagnosed with CHD by 2D echocardiography and colour doppler examination were included in the present study.
Exclusion criteria: Patient with previous history of cardiac intervention were excluded from the present study.
Sample size calculation: A total of 232 children, who presented to the department within the study period were enrolled in the present study.
Study Procedure
Data were collected from the data record of outpatient and inpatient Department of Paediatrics of IQ City Medical College and Hospital, Durgapur, West Bengal, India. Age, sex, age at diagnosis, nature of CHD (acyanotic or cyanotic, diagnosis), clinical examination findings (presence of cyanosis, presence of murmur), ECG findings (any conduction anomaly) were recorded.
All the children were broadly categorised into two groups- cyanotic heart disease and acyanotic heart disease. Among 232 children with CHD, 66 children had cyanotic heart disease and 166 children had acyanotic heart disease. Congenital cyanotic heart disease is a heterogeneous group of abnormalities of cardiac development that result in deoxygenated blood being pumped to the body without first passing through the lungs. Acyanotic heart defects are congenital cardiac malformations that affect the atrial or ventricular walls, heart valves, or large blood vessels pathophysiologically characterised by a left-to-right shunt (12).
Statistical Analysis
Data was collected in a semi-structured data tool and finally entered into and analysed using SPSS 27.0. Descriptive statistics were generated as frequencies and distributions. Associations were derived between the independent and the outcome variables (arrhythmias). Fisher’s-Exact test was applied for statistical analysis of the data. A p-value <0.05 was considered as statistically significant.
The study population consisted of 232 children of 0-18 years of age diagnosed with CHD (mean age 6±4.7 years) of which 151 (65.1%) of the study population were males, while 81 (34.9%) were females. Among 232 children, 66 (28.4%) of the children had cyanotic heart disease and 166 (71.6%) had acyanotic heart disease. (Table/Fig 1) shows detailed distribution of CHD in the study population. About 47 (20.3%) children of 0-18 years of age with congenital heart disease had conduction abnormality. (Table/Fig 2) shows number of different types of conduction abnormality present in the present study population. Among different conduction abnormalities AF was most common in the present study population (8.6%).
(Table/Fig 3) shows distribution of different types of conduction abnormalities in different CHD. Statistically significant association was found between Atrial Septal Defect (ASD) with AF (p-value=0.0012) and Atrial Flutter (p-value=0.0087), VSD with PVC (p-value=0.0001), AV canal defect with first degree AV block with (p-value=0.0004), TOF with VT (p-value=0.0218), L-TGA with complete AV block (p-value=0.0129), Ebstein’s anomaly with SVT (p-value=0.0011).
The number of individuals with CHD is continuously on the rise. Increased number of patients are reaching adulthood. A significant portion of this population will suffer from arrhythmias due to the underlying CHD itself or as a sequalae of interventional or surgical treatment (12),(13). After thorough search of existing literature, it is clear that, even though majority of children with arrhythmias have structurally normal heart, they are frequently found in children with underlying heart disease (14).
Prevalence of arrhythmias among children with CHD in other studies ranges from 6-27% (15),(16). Prevalence was slightly lower in present study when compared to the study by Batte A et al., (16), probably because patients with cardiac intervention were excluded from the study population. However, the prevalence in the present study was lower than the prevalence of arrhythmias detected by Holter ECGs, which showed a prevalence of upto 41.2% in infants and children with uncorrected heart defects (17). Holter ECGs are not widely available in developing countries and thus, standard 12 lead ECG was used in present study.
Among all the arrhythmias detected in the present study population, two most life-threatening arrhythmias were complete AV block and VT. Complete AV block was detected in 1 child (0.4%) with L-TGA. This arrhythmia in association with structural heart disease has a case fatality rate of 29% in infancy and 10% in childhood (15). Complete AV dissociation has been described in literature in children with L-TGA (up to 22% cases), complete AV canal defect and TOF (16),(18),(19),(20),(21).
In present study, VT another life-threatening arrhythmia was detected in 8 patients (3.5%). Statistically significant relationship was found between TOF and VT in the present study. VT occurs in approximately 10% of patients with TOF (22) and a major cause of sudden cardiac death in uncorrected TOF (20). Implantable Cardioverter-Defibrillators (ICD) are increasingly utilised in the primary and secondary prevention of sudden death in patients with TOF (23).
The SVT was detected in 3 patients (1.3%) in the present study. Statistically significant relationship was found between SVT with Ebstein’s anomaly. Right-sided accessory pathways, classically associated with Ebstein’s anomaly, have been reported in 25% cases. They may be multiple, which is the major predisposing factor for the development of SVT (24),(25),(26),(27). For the patients with recurrent SVT related to an AV re-entrant mechanism, radiofrequency catheter ablation technique has been successful. Success rate was 95% in those with isolated right sided accessory pathways and 76% in those with multiple pathyways (28),(29).
Prevalence of atrial fibrillation was 8.6% and atrial flutter was 2.1% in present study. Similar studies among children with CHD detected comparable prevalence of these arrhythmias (27). AF and atrial flutter significantly associated with ASD due to dilated atria with volume overload. AF has also been reported in children with TOF at a prevalence of 6.7% (30),(31). In the present study, prevalence of AF in TOF was 5.5% but, no statistically significant association found between TOF and AF. Early detection and management of atrial arrythmias are significant to prevent the thromboembolic events.
PVC was detected in 8 patients (3.5%) in the present study. PVCs have been described in children with VSD and Complete AV canal defect (32). Though occasional PVC is benign in nature, complex PVC (frequent PVC, multiform PVC, ventricular couplets) should always be treated with β blocker and other antiarrhythmic drugs.
In present study, 1st degree AV block was detected in 2 patients (0.9%) and was significantly associated with complete AV canal defect. First degree heart block is present in the majority and prolongation of the QRS complex in over half of patients with complete AV canal defect (29). There is also an increased risk of complete heart block due to displacement of the atrioventricular node (33). In the present study, it was found that overall prevalence of conduction abnormality in patient with CHD was 20.3% which is comparable with the other studies (Table/Fig 4) (16),(17),(34),(35).
As reflected by the results of the present study, arrhythmias occur in approximately one in five children with CHD. In a developing country like India, these arrythmias often remain undetected due to limited knowledge amongst paediatricians about the relatively high incidence of arrythmias and lack of access to medical facilities. It is suggested that Electrocardiography should be included in routine care of all children diagnosed with CHD. Early detection and effective management of arrythmias should be the mainstream strategy for reduction of sudden cardiac death in uncorrected CHD.
Limitation(s)
The present study was carried out using a standard 12 lead ECG and not a Holter ECG thus the prevalence of arrhythmias reported may be lower than the actual prevalence. The present study was unable to assess other factors which could predispose these children to arrhythmias such as genetic factors, infections, electrolyte imbalance, effect of cardiac medication like digoxin.
According to the present study, arrhythmias occur in approximately one in five children with CHD and specific conduction abnormalities are significantly associated with specific CHD. Electrocardiography should be included in routine care of children with CHD. Further large scale studies are required to find significant association between specific conduction abnormalities with specific CHD in uncorrected CHD.
DOI: 10.7860/JCDR/2022/53670.16444
Date of Submission: Jan 01, 2022
Date of Peer Review: Feb 25, 2022
Date of Acceptance: Apr 08, 2022
Date of Publishing: Jun 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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