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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
Role of Corticosteroids in Tubercular Pleural Effusion: A Prospective Interventional Study from a Tertiary Care Teaching Hospital, Telangana, India
Correspondence Address :
Dr. I Sridhar,
Associate Professor, Department of Pharmacology, Government Medical College, Amaravadi Nagar, Thallagadda, Suryapet-508213, Telangana, India.
E-mail: dr.sridhar99@gmail.com
Introduction: Tuberculosis is a major public health problem in majority of the developing countries. Pleural effusion develops when fluid accumulates between the parietal and visceral pleura.
Aim: To evaluate the efficiency of corticosteroids in rapid clinical and radiological resolution of Tubercular Pleural Effusion (TPE). Also to study the recurrence of pleural effusion and find incidence of pleural fibrosis in patients treated with corticosteroids.
Materials and Methods: This prospective interventional study was conducted at Government Chest Diseases and TB hospital (tertiary care teaching hospital), Telangana, India, from October 2014 to October 2016. Total 80 patients with TPE were divided into two groups. Steroid group (n=40), patients received standard Antitubercular Treatment (ATT) that was alternate day regimen along with prednisolone 0.75 mg/kg body weight per day for two weeks there after tapering of the dose done every second weekly in next four weeks. Non steroid group (n=40), patients received standard ATT alone that was alternate day regimen under Directly Observed Treatment Short course (DOTS) therapy based on Revised National TB Control Programme (RNTCP) guidelines respectively. All patients were followed in the Outpatient Department at the end of second, fourth, sixth, 24th week. At every follow-up visit, history obtained from patients regarding symptoms and chest radiographs for comparison of reabsorption of pleural fluid between two groups. At the end of treatment ultrasound of the chest was performed to confirm the presence of pleural thickening seen on chest radiograph. Descriptive measures obtained included as mean and standard deviation. The association between two categorical variables done by using Chi-square test. The p-values <0.05 was considered as statistically significant.
Results: There was early initiation of symptomatic relief in patients treated with steroid group as compared to non steroid group (p-value <0.001). Average duration for symptomatic relief in steroid group was 3.42 days (range 1-7 days) and in non steroid group 8.3 days (range 1-42 days). There was significant difference between two groups in duration taken for symptomatic relief (p-value <0.001).
Conclusion: Results of the present study suggest that corticosteroids still play some role in the treatment of TPE. Addition of the corticosteroids to the standard ATT exerts more rapid relief of clinical symptoms. The rapidity in pleural fluid absorption is not influenced significantly by adding corticosteroids to the ATT. There was no recurrence of pleural effusion after addition of corticosteroids to ATT. The incidence of pleural thickening was not influenced by steroids.
Extrapulmonary, Pleural fibrosis, Pleural thickening, Prednisolone, Tuberculous pleuritis
Tuberculosis (TB) is a major public health problem in majority of developing countries (1). In most of the cases TB is caused by a pathogenic bacteria Mycobacterium tuberculosis. It belongs to the family of Mycobacteriaceae (2). An estimated nine million people developed active TB in the year 2013 with 1.5 million deaths attributed to the disease (3). Total 80% of the TB affects the lungs and remaining 20% Extrapulmonary TB (EPTB) primarily involves the lymph nodes and pleura. Pleural disease is one of the most common extrapulmonary involvement in TB in developing countries (4). The lung parenchyma, the mediastinum, the diaphragm, and the rib cage are covered by the serous membrane called the pleura (5). In normal individuals the mean amount of fluid in the right pleural space is 8.4±4.3 mL. Normally, the volume of fluid in the right and left pleural spaces is quite similar (6).
Pleural effusion develops when fluid accumulates in between the visceral and parietal pleura (7). One-fifth of new TB cases notified in 2014 in India were extrapulmonary (8). Tubercular Pleural Effusion (TPE) is the second common form, constituting about 28% of EPTB (9),(10),(11). In many different diseases pleural effusions can occur as a complication. The first step in assessing a pleural effusion is to determine whether it is a transudate or exudate. Initially this was carried out by taking history and performing physical examination. The biochemical analysis of pleural fluid is considered later (12).
Light’s criteria was used to categorise the pleural effusions into transudative or exudative (13). Even after extensive effort as many as 15-20% of all pleural effusions remain undiagnosed (14). In all patients with an undiagnosed pleural effusion it is essential to consider the possibility of tuberculous pleuritis (15). Pleural biopsy provides diagnostic value for patients with exudative effusions who remain undiagnosed after thoracentesis (16).
Even without specific Antitubercular Treatment (ATT), some of the TPEs resolve spontaneously. However, two-third of patients with TPE may show clinical symptoms with pleural thickening later. It is evaluated that corticosteroids like prednisolone enhance the resolution of pleural effusion as well as reduce the clinical symptoms (17).
It was found that corticosteroids like prednisolone extensively decreased the duration of symptoms by about 4.3 days in some trails (18),(19). Unexpectedly, Engel ME et al., found that corticosteroids significantly reduced the risk of pleural thickening by about 31% (17). The role of corticosteroids in the management of TPE is controversial. Hence, the present study was undertaken to evaluate:
i) The efficiency of corticosteroids in rapid clinical and radiological resolution of TPE.
ii) The recurrence of pleural effusion in patients on corticosteroids.
iii) The incidence of pleural fibrosis in patients treated with corticosteroids.
This prospective interventional study was conducted at Government Chest Diseases and TB hospital (tertiary care teaching hospital), Telangana, India, from October 2014 to October 2016, on 80 patients with TPE. This study was approved by the Institutional Ethics Committee (MGM/KMC) Warangal (KMC/IEC/O79). An informed written consent was taken from all the patients involved in the study after explaining regarding the study.
Inclusion criteria: Patients aged between 20-50 years and presenting with mild and moderate TPE, who were not treated with corticosteroids previously were included in the study. For patients included in the study, baseline chest radiograph was taken and size of pleural effusion was estimated according to the area of opacification caused by the pleural fluid on the chest radiograph (20). Patients was also assessed for symptomatic relief like decrease in chest pain, dyspnea, dry cough.
Exclusion criteria:
• Age <20 and >50 years
• Patients with massive pleural effusion, malignant pleural effusion and pleural effusion due to other conditions other than tuberculosis, loculated pleural effusion, bilateral pleural effusion, empyema, parapneumonic effusions, pericardial effusion and ascities.
• Patients with parenchymal diseases including tuberculosis and Human Immunodeficiency Virus (HIV) patients
• Defaulters or relapse cases of TPE
• Critically ill patients
• Patients with co-morbid conditions like diabetes, hypertension, Chronic Kidney Disease (CKD) and patients with cushing syndrome.
Total 80 patients with TPE were divided into two groups,
• Steroid group (n=40): Patients received standard ATT that was alternate day regimen along with prednisolone 0.75 mg/kg body weight per day for two weeks there after tapering of the dose done every second weekly in next four weeks.
• Non steroid group (n=40): Patients received standard ATT alone that was alternate day regimen under Directly Observed Treatment Short-course (DOTS) therapy based on Revised National TB Control Programme (RNTCP) guidelines respectively (21).
Study Procedure
All patients were followed in the Outpatient Department at the end of 2nd, 4th, 6th, 24th week (at the end of treatment). At every follow-up visit, history obtained from patients regarding symptomatic relief and chest radiographs for comparison of reabsorption of pleural fluid between two groups.
Reduction of pleural effusion:
• 50% reduction in pleural effusion: If the amount of fluid decreased to a lower grade. It can be stated as clear.
• 25% reduction in pleural effusion: If there was reduction in the amount of fluid but still within the same grade. It can be stated as unclear.
The obliteration of costophrenic angle was used when the angle was >90° (20).
Pleural thickening: The pleural thickening was measured in millimeters (mm), a visible line between the inside of the chest wall and the outer border of the lung in response to inflammation of the pleura in TPE. The thickness of the line may be 1-10 mm. The pleural thickening results from fibrosis of the visceral pleural surface (20). At the end of treatment ultrasound of the chest was performed to confirm the presence of pleural thickening seen on chest radiograph (Table/Fig 1),(Table/Fig 2),(Table/Fig 3) (22).
Statistical Analysis
Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 16.0. Numerical data was entered as such. Categorical data was appropriately coded. Descriptive measures obtained included as mean and standard deviation. The association between two categorical variables done by using Chi-square test. Summary of the data was done by number and percentage. The p-values <0.05 was considered as statistically significant.
Both groups were identical in terms of sex, age, duration of symptoms and initial amount of pleural effusion.
Initiation of symptomatic relief in TPE: The symptomatic relief in steroid group was started within three days. In non steroid group, symptomatic relief started within seven days. There was earlier initiation of symptomatic relief among patients of steroid group as compared with non steroid group. The difference was statistically significant (p-value <0.05) (Table/Fig 4).
All 40 patients in steroid group showed symptomatic relief with an average duration of 3.42 days (range 1-7) and in non steroid group showed symptomatic relief with an average duration of 8.3 days (range 1-42). The difference was statistically significant (p-value <0.001) (Table/Fig 5).
Out of 40 patients in steroid group, 23 patients showed complete radiological resolution (Table/Fig 6). In the non steroid group, out of 40 patients, 22 patients showed complete radiological resolution. There was no difference between two groups in radiological resolution at the end of treatment. The result was statistically not significant (p-value=0821).
Total 23 patients in steroid group showed radiological resolution. Out of 23 patients, 11 patients were showed radiological resolution in less than four weeks. Total eight patients showed radiological resolution between 4-6 weeks and four patients took more than six weeks (Table/Fig 7).
In non steroid group, 22 patients showed radiological resolution. Out of 22 patients, only four patients showed radiological resolution within four weeks, 12 patients showed between 4-6 weeks, six patients taken more than six weeks.
There was rapid reabsorption of pleural fluid in patients in steroids group as compared with non steroid group, but the result was not significant statistically (p-value >0.05).
Incidence of pleural fibrosis/pleural thickening in TPE: Out of 40 patients in steroid group, 17 patients improved with no radiological clearance at the end of treatment, five patients showed blunting of costophrenic angles and 12 patients had pleural thickening at the end of treatment (Table/Fig 8).
Out of 40 patients in non steroid group, two patients had blunting of Costophrenic (CP) angle and 16 patients had pleural thickening. There was no statistical significance in the incidence of pleural fibrosis/pleural thickening between two groups (p-value >0.05).
Recurrence of pleural effusion in steroid group: No patient experienced a recurrence of pleural effusion in either treatment group.
Side-effects: Serious side-effects with corticosteroids were not observed during this study. Only two patients developed transient impaired glucose tolerance after administration of prednisolone and this side-effect subsided after tapering of the dose of prednisolone.None of the patients developed the symptoms of cushing’s syndrome like moon face, buffalo hump, abdominal stretch marks, thinning of legs.
The role of corticosteroids in the treatment of TPE is controversial. The administration of corticosteroids did not decrease the degree of residual pleural thickening (15).
Symptomatic improvement: In the present study, out of 80 patients, 40 patients treated with prednisolone showed early initiation of symptomatic improvement within three days as median compared to non steroid group, which showed initiation of symptomatic improvement within seven days. With ATT, most patients become afebrile within two weeks, and pleural fluid resorbed within six weeks (20). In the present study, corticosteroids hastened the recovery of constitutional symptoms and led to early initiation in symptomatic relief. In a previous study conducted by Lee CH et al., patients receiving corticosteroids were free from complaints within two days after treatment, clinical symptoms and signs subsided an average of 2.4 days (range 1-7) in the steroid group and 9.2 days (range 1-75) in non steroid group and showed the positive effect of the additional use of corticosteroids in TPE, in terms of a more rapid relief of symptoms (18).
Radiological resolution: In a previous study conducted by Galarza I et al., reported that 93% of patients showed radiological resolution at the end of one month in steroid group and 89% of patients showed radiological resolution in non steroid group (23). There was no significant difference between two groups. In the present study, 47.82% of patients showed radiological resolution at the end of one month of treatment in steroid group as compared with non steroid group (18.18%). The present study shows significant difference between two groups in radiological resolution at the end of one month of treatment. The present study is different from previous study due to less sample size and short period of follow-up (20).
Duration taken for radiological resolution in TPE: In the present study, out of 40 patients in steroid group, 23 patients showed radiological resolution within an average duration of 23.3 days (3.3 weeks) and 40 patients in non steroid group showed radiological resolution within an average duration of 29.26 days (4.18 weeks). There was no big difference in duration taken for radiological resolution between two groups, but early disappearance of fluid occurred in steroid group as compared with non steroid group. Complete resolution of pleural fluid after initiation of treatment can take 6-12 weeks (24).
A previous study conducted by Lee CH et al., roentgenologic evidence of clearing of the lung field, with visualisation of the diaphragm and costophrenic angle occurred at an average of 54.5 days in steroid group in contrast to an average of 123.2 days in non steroid group (18). Another study conducted by Bang JS et al., an average duration for radiological resolution in steroid group was 88 days as compared to 101 days in non steroid group (19). The present study deviated from other studies because of difference in duration of observation. In this study, follow-up done at the end of second week, fourth week, 6th week and 24th week. When compared to present study there is a huge difference observed in the above cited study duration. This is because in present times the ATT protocols have changed and management regimens have become more aggressive.
Incidence of pleural fibrosis/pleural thickening in TPE: In the present study, out of 40 patients in steroid group 17 patients improved with pleural fibrosis/pleural thickening and 18 patients in non steroid group improved with pleural fibrosis/pleural thickening. About half of the patients with TPE developed Residual Pleural Thickness (RPT) despite appropriate treatment. A more than 2 mm pleural thickness (at the point of maximal thickness) at 24 weeks was defined as residual pleural thickening (25). Pleural effusion causes blunting of the costophrenic angle. RPT is a consequence of an inflammatory mechanism in TPE (25). Chest X-ray is more readily available and inexpensive and also reported that High-resolution ComputedTomography (HRCT) was not more sensitive than conventional chest radiography in diagnosing pleural thickening (26). The RPT exceeding 10 mm in size may have important clinical and functional consequences (27). Repeated thoracentesis does not appear to alter the degree of residual pleural thickening (27).
In a previous study conducted by Wyser C et al., reported that 17 patients in steroid group and 18 patients in non steroid group showed pleural thickening at the end of treatment, which is similar to the present study (25). Another study conducted by Bang JS et al., reported that 17 patients in steroid group and 32 patients in non steroid group showed pleural thickening at the end of treatment, which is close to the present study (19).
Limitation(s)
The sample size was small and short period of follow-up was done. The present study was to mild and moderate pleural effusions and more studies need to be done on patients with large or massive pleural effusions to know the efficiency of corticosteroids in pleural fluid reabsorption and effect on pleural thickening.
Results showed that corticosteroids still play some role in the treatment of TPE. Addition of the corticosteroids to the standard ATT provides rapid relief of clinical symptoms. The rapidity in pleural fluid absorption is not influenced significantly by adding corticosteroids to the ATT. There was no recurrence of pleural effusion after addition of corticosteroids to ATT and non steroid group. The incidence of pleural thickening was not influenced by steroids. Further large studies are needed to be re-emphasise the beneficial role of corticosteroids in the treatment of TPE.
DOI: 10.7860/JCDR/2022/57821.16726
Date of Submission: May 16, 2022
Date of Peer Review: Jun 15, 2022
Date of Acceptance: Jul 25, 2022
Date of Publishing: Aug 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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