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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
Clinical and Radiological Profile in Non Hypertensive Intracerebral Haemorrhage- A Prospective Observational Study
Correspondence Address :
Dr. Siddaganga,
Hallikeri Farm Vinayak Nagar, Kelgeri Raod, Dharwad-58000, Karnataka, India.
E-mail: drsiddaganga@gmail.com
Introduction: Intracerebral Haemorrhage (ICH) is less frequent than ischemic stroke, but has higher mortality and morbidity, it being one of the first causes of severe disability. Hypertension is the most common cause of ICH but Non Hypertensive Intracerebral Haemorrhages (NHICH) are not rare. Hence, the importance of recognizing these conditions and need for urgent specific therapy which may play a vital role in therapeutic planning and prevention of ICH. Hence this study was performed to study.
Aim: To study the clinical and radiological profile in NHICH, to identify risk factors, and to determine whether clinical/neuronradiological parameters would predict the prognosis of ICH.
Materials and Methods: The present prospective observational study was conducted in the Department of General Medicine Mahadevappa Rampure Medical College Gulbarga, Karnataka, India, from January 2016-January 2017. It involved 50 subjects with NHICH. Demographic details, clinical and radiological data were collected in patients presenting with signs and symptoms of stroke and confirmed by Computed Tomography (CT) scan/Magnetic Resonance Imaging (MRI) brain as ICH, who were non hypertensive and with age more than 18 years. Clinical outcome of the patients was measured based on Glasgow Coma Scale (GCS), site and volume of haemorrhage. Descriptive statistics of the explanatory and outcome variables were calculated by mean, Standard Deviation (SD) and Chi-square test was applied for qualitative variables.
Results: In the present study 31 (62%) were males, and 19 (38%) were females. The age of patients ranged from 18-85 years. The most common risk factor associated with intracerebral haemorrhage was alcohol consumption 16 (32.0%), followed by smoking 13 (26%), and anticoagulant intake 13 (26%). Most common clinical presentation were hemiplegia/hemiparesis, speech defect, vomiting, convulsion, pupillary defect and cranial nerve involvement, in decreasing frequency. High ICH score and low GCS were poor prognostic factors for outcome of intracerebral haemorrhage patient in the present study. In hospital mortality rate was 28%. During 30 days follow-up, there was 22.2% mortality among the discharged patient.
Conclusion: Although hypertension remains as a most common risk factor for intracerebral bleed, other risk factors such as significant alcohol consumption, coagulopathy should also be kept in mind especially in young. Non hypertensive haemorrhage usually occurs at sites not typical for hypertensive bleed. All efforts should be directed to establish the aetiological factors for intracerebral bleed, so that appropriate timely therapy can be provided to prevent further morbidity and mortality.
Aetiology, Glasgow coma scale, Mortality, Outcome
Intracerebral haemorrhage accounts for 10-15% of total cerebral vascular accident. ICH is less frequent than ischemic stroke, but has higher mortality and morbidity, it being one of the first causes of severe disability (1). Non traumatic intracerebral haemorrhage results from rupture of blood vessels in the brain parenchyma. It accounts as a major public health problem with an annual incidence of 10-30 per 100 000 population, accounting for 2 million (10-15%) of about 15 million strokes worldwide each year (2),(3),(4). There are many non hypertensive causes of ICH including Cerebral Amyloid Antipathy (CAA), vacuities, vascular malformations, and the use of anticoagulants, fibrinolysis, antiplatelet agents, underlying co-morbidities like diabetes mellitus, alcohol intake, smoking, drug abuse like cocaine, and finally genetic and ethnicity also play an important role in causation of intracerebral bleed (5),(6),(7),(8),(9). Primary and secondary (anticoagulant induced) intracerebral haemorrhages have similar underlying pathological changes (10). Hence, the importance of recognising these conditions and need for urgent specific therapy which may play a vital role in therapeutic planning and prevention of ICH (11).
Spontaneous ICH has still remained a serious disease despite attempts at improving outcome by medical and neurosurgical treatment. There are many clinical/neuro-radiological parameters like GCS, severity of neurological deficit, site, size, volume of haemorrhage, presence of intraventricular extension, hydrocephalous and others that would predict the outcome of ICH (12),(13). Hence this study was performed to study clinical and radiological findings in non hypertensive intracerebral haemorrhage with an aim to find out the other non hypertensive risk factors and causes for intracerebral haemorrhage, and to determine whether clinical/neuron-radiological parameters would predict the outcome of ICH.
The prospective observational cohort study in the Department of General Medicine, conducted at Mahadevappa Rampur Medical College Gulbarga, Karnataka, India; from January 2016-January 2017. The Institutional Ethical Committee (HKES/MRMCK/IEC/17/11/24) clearance was obtained. The study involved 50 subjects with non hypertensive intracerebral haemorrhage.
Inclusion criteria: Patients presenting with signs and symptoms of stroke and confirmed by CT scan/MRI brain as ICH, who were non hypertensive and were more than 18 years of age were included in the study.
Exclusion criteria: Known case of chronic hypertension on antihypertensive medication, patient with ischemic stroke and traumatic origin of intracerebral haemorrhage were excluded from the study.
Study Procedure
Demographic details, clinical and radiological data were collected. Clinical outcome of the patients was measured based GCS and site, and volume of haemorrhage.
Initial workup of patients included:
• CT scan head (plain)
• Complete haemogram
• Coagulation profile
• Random Blood Sugar (RBS), Blood urea, Serum creatinine
• Lipid profile
• Other investigations like chest radiograph, MRI brain with Magnetic Resonance Angiography (MRA), echocardiography, liver function tests, were done whenever needed. The following data were extracted by a radiologist from the patient’s CT scan, obtained at the time of admission:
• Site of haematoma-infratentorial.
• Volume of haematoma by ABC/2 formula. Haematoma volume were calculated by using ABC/2 formula of Kothari & coworkers by plan metric methods, and expressed either as >30 cm3 or <30cm3 (14).
Elements which comprise the ICH Score: age, Glasgow Coma Scale (GCS) score at the time of hospital admission , hematoma volume on the initial CT scan (as measured manually using the ABC/2 method by a single examiner , presence of intraventricular hemorrhage (IVH) on the initial CT scan, and hematoma origin (either infratentorial or supratentorial). The ICH Score was determined by creating a sumscore of points assigned for individual components: GCS (3–4=2, 5–12=1, 13–15=0), hematoma volume (≥30 mL=1, <30 mL=0), presence of IVH (yes=1, no=0), infratentorial origin (yes=1, no=0), and patient age ≥80 (yes=1, no=0). Patient ICH Scores ranged from 0 to 5. Increasing points on the ICH Score with increased risk of mortality or decreased likelihood of favorable functional outcome (15).
Statistical Analysis
Descriptive statistics of the explanatory and outcome variables were calculated by mean, Standard Deviation (SD), and Chi-square test was applied for qualitative variables. Data was entered in Microsoft excel and analysed using Statistical Package for the Social Sciences (SPSS) statistical software (SPSS, version 20.0,). A p-value <0.05 was considered statistically significant.
The study was conducted on 50 non hypertensive cases of CT scan/MRI brain proven intracerebral haemorrhage. The male to female ratio was 1.6:1. The mean age of study population was 51.51±17.9 years. Maximum number of cases 22 (44%) belonged to the age group of 51-70 years, followed by 31-50 years 14 (28%). Youngest age was 18 years and oldest was 85 years in the study. (Table/Fig 1). The most common presentation was hemiplegia/hemiparesis 39 (78%), followed by vomiting 29 (58%) and speech defect 29 (58%) (Table/Fig 2). Alcohol consumption 16 (32.0%) of about 30 to 40 gram for 10 to 15 years followed by smoking a pack year were >20 packs /day were associated with intracerebral bleed. Other factors like intake of anticoagulant were seven cases all were on warfarin (3-4 mg/day) for Cerebral Venous Thrombosis (CVT) and Atrial Fibrillation (AF), antiplatelet intake were six patient for Cerebrovascular Accident (CVA), clotting disorder like factor XIII deficiency was present in one case, other two cases had liver failure due to HbsAg positive and cirrhosis of liver, three patient had immune thrombocytopenic purpura all were female patient, four patients had aneurysmal bleed all were in anterior circulation confirmed by MRA, two had microbleed, one patient had Arteriovenous Malformation (AVM), (Table/Fig 3), (Table/Fig 4). Lower the GCS patients had a higher mortality (Table/Fig 5). RBS level was significantly higher among the patients who died (Table/Fig 6). The most common site for intracerebral haemorrhage was basal ganglia followed by lobar and least common was brain stem. A total of 100% mortality was seen in brain stem lesion, followed by thalamus (Table/Fig 7).
A total of 4 (8.0%) patients had aneurysmal bleed, and all were seen in anterior circulation - two patients underwent aneurysm clip procedure, 2 (4.0%) had microbleed and 1(2.0%) patient had AVM. All these patients survived (Table/Fig 8). Aroud 3 (6.0%) patients had low platelet count, and were diagnosed with immune thrombocytopenic purpura. They were on steroid and intermittent platelet transfusion, and all of them survived (Table/Fig 9). A total of 11 (22.0%) cases had intracerebral bleed because of increased Prothrombin Time/International Normalised Ratio (PT/INR) (INR was >3.5) due to warfarin overdose (Table/Fig 9). As the Intracerebral Haemorrhage (IHC) score increased the mortality also significantly increased. Mortality was seen in those with an ICH score of 3 and 4 (Table/Fig 10). Telephonic follow-up on 30 days revealed that six patients died-six patients were males and two patients were females. So, the 30 days mortality was 22.2% (all had more than 1 ICH score) (Table/Fig 11).
In the present study, ICH was highest in the age group 51-70 years (44% of the patients). There was significant gender difference also. The distribution was similar to several other studies (16),(17). The most common presentation was hemiplegia/hemiparesis, followed by vomiting and speech defect. The occurrence of headache (56%), vomiting (58%), and seizures (36%) were comparable with other similar studies (18),(19). Most common factors like alcohol intake, cigarette smoking, anticoagulant/antiplatelet, coagulation disorder, aneurysm, arteriovenous malformation and diabetic’s mellitus were associated with intracerebral bleed. This is comparable to other studies (20),(21),(23). It is proposed that high blood glucose at admission contributes to poor outcome, due to exacerbation of cerebral edema and cerebral damage. A recent meta-analysis by Zheng J et al., in 2018, concluded that hyperglycemia was associated with poor outcome in patients with ICH as seen present study (24). The most common site of haematoma was the basal ganglia (42%) followed by, cerebral lobes, thalamus,cerebellum and brain stem (28%, 8%,8% and 4%, respectively), which is in agreement with the pattern described for the non white races in the United States of America (USA) (25).
In present study, based on the GCS, 84.6% of the patients had poor outcome. Poor outcome was associated with lower baseline GCS larger baseline ICH volume, and the presence of IVH at baseline, conforming to a pattern described previously (26),(27),(28),(29),(30). A study from Cincinnati, USA, reported a high sensitivity (96%) and specificity (98%) for the combined ICH volume and baseline GCS score to predict the 30 day mortality (28).
The most important factors predicting the final outcome were the size of haematoma, intraventricular extension, midline shift, GCS score and ICH score. These results indicated that high ICH score, low GCS score at the time of admission, presence of IVH, and midline shift were significantly associated with poor clinical outcome. These results are similar to other studies (15),(31).
The ICH still remains a grave medical emergency with high mortality and morbidity. In spite of improvement in outcomes in ischemic stroke, outcomes in patients with ICH still remain poor with no specific medical treatment and poor consensus and controversial outcomes of surgical interventions (32),(33). The mortality rate in hospital and 30 days in the present study was 28.7% and 22.2% repectively. It was lesser than other studies, where the mortality ranged from 35 to 52%. Variations in mortality could be because of early intervension in the present study, and that it excluded hypertension patients which is an independent risk factor (34),(35),(36).
Limitation(s)
This hospital based study from a single center did not aim to provide true prevalence or burden of ICH in the community. The sample size was limited, and the follow-up period of one month allowed only short-term outcome assessment.
The ICH has remained a serious disease despite recent improvements in management. So, efforts must be directed towards better understanding and modification of risk factors. ICH had slight affinity towards male sex and mostly occurred after 5th decade of life hemiplegia/hemiparesis, speech disturbances and vomiting were frequent presenting features found in this study. All efforts should be directed to establish the etiological factors for intracerebral bleed, so that appropriate timely therapy can be provided to prevent further morbidity and mortality.
DOI: 10.7860/JCDR/2022/55362.16736
Date of Submission: Feb 02, 2022
Date of Peer Review: Apr 04, 2022
Date of Acceptance: May 31, 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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