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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
Neutrophil-lymphocyte Count Ratio as an Indicator of Culture Positive versus Culture Negative Sepsis: A Single-centre Cross-sectional Study
Correspondence Address :
Dr. G Rakesh Kumar,
House No. #1296, 21st B Main, 11th Cross HSR Layout, Sector-1, Bengaluru-560102, Karnataka, India.
E-mail: rakeshkumarvinay@gmail.com
Introduction: In sepsis patients, the Neutrophil-lymphocyte Count Ratio (NLCR) is a laboratory statistic that can indicate bacterial infection.
Aim: To measure NLCR in patients with sepsis and compare the NLCR in patient with culture positive and culture negative sepsis.
Materials and Methods: This single-centre, cross-sectional study was conducted in the Department of General Medicine at R.L. Jalappa Hospital (Sri Devaraj URS Medical College), Kolar, Karnataka, India, from October 2021 to December 2021. A total of 120 patients above 18 years of age with sepsis, diagnosed as per the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), were included in the study. Participants were evaluated for sepsis and septic shock (society of critical care medicine conference definitions) the principles of initial resuscitation (fluid therapy, vasopressors, inotropic support), and infection issues (source identification and control, appropriate antibiotic therapy) were followed regularly and the outcome studied. Neutrophil count, lymphocyte count, and calculation of NLCR were done at the time of admission. The correlation studies of NLCR in culture-positive and culture-negative was done and compared. Data was analysed by using coGuide software (version 1.03).
Results: The mean age of patients was 58.98±17.78 years, ranged from 20 to 96 years, 47 (39.17%) were male and 73 (60.83%) were female, majority 93 (77.50%) out of 120 patients had fever. Majority 78 (65%) had type 2 diabetes mellitus. Neutrophil-to-Lymphocyte ratio (NLR) was 10±1.67, ranging from 7.40 to 14.50. The area under the ROC curve was 0.522. There was no statistically significant relationship between the NLCR and culture report (p-value=0.216). The NLCR had poor predictive validity in predicting culture positive, as indicated by the area under the curve {0.522 (95% CI: 0.417 to 0.626, p-value= 0.988)}.
Conclusion: NLCR can be considered as predictor for the initiation of treatment of patients with sepsis.
Inotropic support, Resuscitation, Septic shock, Vital signs
Sepsis and septic shock have an 85% morbidity and death rate, making it a public health issue (1).There were 4711 admissions in an Indian tertiary care hospital throughout the course of a five year prospective observational research on severe sepsis, with 282 (6.2%, 95% Confidence Range: 2.3- 13.1) having severe sepsis. The Intensive Care Unit (ICU) death rate was 56%, the hospital mortality rate was 63.6%, and the 28 day mortality rate was 62.8% (2).
Severe sepsis was widespread in Indian Intensive Treatment Units (ITUs), according to a multicentre, prospective, observational study done in four ITUs in India. In comparison to the western literature, ITU mortality was greater (3). Bacteria are by far the most prevalent causal microorganisms in sepsis, with positive cultures occurring in roughly half of the cases. Failure to use antibiotics that the microorganisms are sensitive to is linked to a higher risk of death (4),(5).
Neutrophils make up 50 to 70% of all circulating leukocytes in humans, and they constitute the first line of defence against a variety of infectious diseases such as bacteria, fungus, and protozoa. Bacteria are by far the most common cause of sepsis, with positive cultures appearing in nearly half of the cases. Failure to utilise antibiotics that are sensitive to the bacteria is connected to a greater risk of mortality. As a result, between 55% and 60% of bone marrow is committed to their creation (6),(7). Neutrophils are a significant arm of the innate immune system, armed with a range of weapons against infections. Because of their effect on immunological responses to pathogenic microbes and other foreign substances, lymphocytes play a critical function in the immune system. Absolute neutrophil (immature granules, rods, and segments) and absolute lymphocyte values based on the number of leukocytes are used to calculate the Neutrophil-Lymphocyte Count Ratio (NLCR) (5). The Neutrophil-Lymphocyte Ratio (NLR) is a well-known inflammatory measure that reflects systemic inflammatory response, infectious diseases, and surgical sequelae (8),(9),(10).
Blood cell analysis and the NLR, together with other diagnostic tests, were revealed to be predictors for the severity of gram negative sepsis by Gharebaghi N et al., (11). According to the findings of a meta-analysis research, NLR may be a useful predictive biomarker for patients with sepsis, and greater NLR values may suggest a worse prognosis in these individuals (12). Hence, this study was conducted to measure NLCR in patients with sepsis and compare the NLCR in patient with culture positive and culture negative sepsis.
This single-centre, cross-sectional study was conducted in the Department of General Medicine at R.L. Jalappa Hospital (Sri Devaraj URS Medical College), Kolar, Karnataka, India, from October 2021 to December 2021. The study was approved by the Institutional Human Ethics Committee and Institutional Review Board (Reference DMC/KLR/IEC/308/2021-22). Data confidentiality was maintained. Written informed consent was obtained from the patients.
Inclusion criteria: A total of 120 Patients of above 18 years of age with sepsis {diagnosed as per Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)} (13) were included in the study.
Exclusion criteria: Patients with pre-existing organ dysfunction prior to infection (chronic kidney disease, decompensated liver disease, cardiac disease), blood product transfusion in the week before admission, patients with haematological diseases such as, hypersplenism, haematological malignancy, etastatic bone marrow infiltration by malignancy, recovery after bone marrow hyperplasia and those with recent chemotherapy as well as pregnant women were subjected for exclusion from the study.
Procedure
Clinical, and laboratory data was obtained and studied before administration of broad-spectrum antibiotics. Study participants were assessed for sepsis and septic shock (society of critical care medicine conference definitions) (13). The principles of initial resuscitation (fluid therapy, vasopressors, inotropic support) and infection issues (source identification and control, appropriate antibiotic therapy) were followed regularly and the outcome studied. Investigations like complete blood count, Electrocardiogram (ECG), chest X-ray, blood culture, urine culture, Endotracheal tip Test (ET) culture, sputum culture were carried out on all the study participants. Neutrophil count, lymphocyte count and calculation of NLCR were done at the time of admission. The correlation studies of NLCR in culture positive and culture negative was done and compared.
Statistical Analysis
Categorical data like gender, presenting illness etc. is represented in the form of frequencies and proportions. Continuous data like age, temperature (Fahrenheit), pulse (beats per minutes), haemoglobin (g/dL), mean platelet volume and red blood cell distribution width was represented as mean and standard deviation. The count variables are analysed by the Chi-square test expressing as proportion. The utility of neutrophil lymphocyte ratio in predicting culture report was assessed by Receiver Operative Curve (ROC) analysis. Area under the ROC curve along with its 95% CI and p-value are presented. Basing on the ROC analysis, it was decided to consider 9.50 as the cut-off value. The sensitivity, specificity, predictive values and diagnostic accuracy of the screening test with the 95% CI are presented. A p-value <0.05 was considered statistically significant. Data was analysed by using coGudie software (version 1.0.3) (14).
A total of 120 subjects were included in the final analysis. The mean age was 58.98±17.78 years, ranged from 20 to 96 years, 47 (39.17%) were male and 73 (60.83%) were female, majority 93 (77.50%) out of 120 patients had fever. Majority 78 (65%) had type 2 diabetes mellitus (Table/Fig 1).
The mean body temperature was 99.98±1.33 °F, ranged between 98 to 102 °F, the mean pulse was 106.23±15.79 beats per minute, ranged between 60 to 140, 2 (40.00%) had pallor, 6 (5.08%) had hepatomegaly, 3 (2.59%) had splenomegaly, 98 (83.76%) had reported normal urine routine, the mean haemoglobin was 13.71±1.43 (g/dL) ranged from 11.20 to 17.50 g/dL. The NLCR was 10±1.67, ranged from 7.40 to 14.50; the mean platelet volume was 9.25±1.07, ranged from 7.50 to 11.40; and mean red blood cell distribution width was 15±1.11%, ranged from 13 to 17.80%. The mean Glasgow Coma Scale (GCS) score from day 1 to 5 increased gradually (Table/Fig 2).
Among the study population, more than half in proportion required ventilation support and inotropic support, while few required renal replacement. The mean ICU stay 3.41 days, but the survival rate was only 65.83% (79 out of 120). The mean SOFA score at day 1 to day 5 was decreasing in trend from almost 6.52 to 4.04. Major diagnosis was LRTI followed by urosepsis and ARS (Table/Fig 3).
The NLCR had poor predictive validity in predicting culture positive, as indicated by area under the curve of 0.522 (95% CI: 0.417 to 0.626, p-value=0.988) (Table/Fig 4).
Out of 70 participants with culture positive, the NLCR was high (≥9.50) for 36 (51.43%) and low (<9.50) for 34 (48.57%). There was no statistically significant relationship between culture report and NLCR (p-value=0.216). The ratio had a sensitivity of 51.43% (95% CI: 39.17% to 63.56%) in predicting culture positive, specificity was 60.00% (95 CI: 45.18% to 73.59%), false positive rate was 40% (95 CI: 26.41% to 54.82%), false negative rate was 48.57% (95 CI: 36.44% to 60.83%), positive predictive value was 64.29% (95 CI: 50.36% to 76.64%), negative predictive value was 46.88% (95 CI: 34.28% to 59.77%), and the total diagnostic accuracy was 55.00% (95 CI: 45.65% to 64.09%) (Table/Fig 5).
The finding of the present study represents that NLCR was higher in the culture positive patients when compared with culture negative patients and NLCR was 1.67, ranged from 7.40 to 14.50. The NLCR was substantially greater (p-value=0.001) in the severe sepsis group (median = 21.1 with quartiles=11.1 to 42.4) compared to the group without severe sepsis (median = 11.6 with quartiles=7.6 to 18.9) in a study by Ljungstrom L et al., (15). Sen V et al., found that the incidence of sepsis was significantly higher in patients with NLCR ≥2.50 than in patients with NLCR <2.50 (p-value=0.006) (16).
The results of current research demonstrate that sensitivity of NLCR was 51.43% with specificity of 60%. With the help of the present study data, the NLCR specificity for sepsis diagnosis was higher could be related. We found that NLCR had positive predictive value of 64.29% and diagnostic accuracy of 55%. Orfanu A et al., estimated the optimal cut-off value of NLCR at 8.18, with a sensitivity of 70.5% and a specificity of 72.2% (17). These findings were similar to our results. In another study by Hota PK and Reddy BG, NLR was found to have 86.2% sensitivity, 85.7% specificity, positive predictive value of 89.2%, negative predictive value of 81.1% in predicting diagnosis and prognosis of sepsis (18). Their results showed higher sensitivity than specificity but with minor difference.
Similarly, another study by Mandal RK and Valenzuela PB, reported that sensitivity and specificity of NLCR was 97.37% and 93.18, respectively (19). In a meta-analysis the pooled analyses from eight studies results depicted that the diagnostic accuracy of the NLCR in terms of its bacteraemia-sensitivity was 0.723, and specificity was 0.596. The area under the summary receiver operating characteristic curve was 0.69 (20).
In this study, there were majority of females diagnosed with sepsis as compared to males. Pietropaoli AP et al., also found that among 18,757 ICU patients (median age, 66 years; interquartile range, 53-77 years), 8702 were females (46%). Female patients had a greater hospital mortality rate than male patients (35% versus 33%, respectively; p-value=0.006). After accounting for differences in baseline characteristics and care procedures, they discovered that females were more likely than men to die in hospitals (odds ratio=1.11; 95% CI: 1.04-1.19; p-value=0.002) (21). There were 2,345 (64.37 %) male and 1,298 (35.63 %) female patients in the study by Zhou X et al., they also reported that female patients with septic shock had a greater in-hospital death rate (55.54% vs. 49.29%, p-value=0.01) than male patients (22). Majority of the study population suffered from fever. However, a clinical review suggest that fever is a cornerstone diagnostic sign in clinical practice that helps to start early appropriate therapy and to follow the infection course (23). Hence, it can be concluded that high NLCR score can be considered for initiation of treatment of patients with sepsis.
Limitation(s)
The sample size was limited. Although blood culture-positive and culture-negative groups were similar in terms of age and gender, there may have been other important differences between them. For example, information regarding diagnostic group, co-morbidities and discharge status was not available.
In the present study, NLCR ranged from 7.40 to 14.50 and showed a high positive predictive value. Out of the 70 culture positive participants, 36 (51.43%) had a high NLCR. NCLR is simple, easily measured, reacts very early in the course of acute inflammation and easy to use in daily practice without extra costs compared to blood culture report which was considered as gold standard.
DOI: 10.7860/JCDR/2022/56649.16974
Date of Submission: Mar 26, 2022
Date of Peer Review: Apr 25, 2022
Date of Acceptance: Jun 24, 2022
Date of Publishing: Sep 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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