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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
Correlation of Lactate Dehydrogenase Level with Severity of Disease and In-hospital Outcome in Individuals Diagnosed with COVID-19: A Retrospective Study
Correspondence Address :
Intisar Ahmad Siddiqui,
Lecturer, Department of Dental Education, College of Dentistry, Imam Abdulrahman Bin Faisal University, King Faisal Road, Dammam, Eastern Province, Saudi Arabia.
E-mail: iasiddiq@iau.edu.sa
Introduction: The presence of tissue damage in the lungs, kidneys, heart, or other organs can be detected by monitoring the level of Lactate Dehydrogenase (LDH) in the blood and considered a reliable biomarker in early prediction of patients’ prognosis.
Aim: To determine extent of correlation between LDH level with the spectrum and in-hospital outcome of Coronavirus Disease-2019 (COVID-19) infected patients.
Materials and Methods: This retrospective research was undertaken during March 2020 to May 2020, based on the data of 205 COVID-19 infected patients, reported at Dammam Medical Complex, Dammam, Eastern Province, Saudi Arabia. Patients’ records were retrieved and the following data were recorded-age, gender, nationality, co-morbidities, lactate dehydrogenase level, number of days since the patient tested positive (upto 7,14 and >14 days), COVID-19 symptoms [mild, moderate, or severe as per British Thoracic Society guidelines (CURB (Confusion, Blood Urea Nitrogen, Respiratory Rate, Blood Pressure)-65)]. The data was collected and tabulated as mean±SD, frequency and percentages. Analysis was carried out using specialised software of Statistical Package for Social Sciences (SPSS) version 20.0.
Results: On analysis of the collected data of all 205 included patients, the LDH level was found significantly high among males, 46-60 years old, and among non Saudi patients. The severity of COVID-19 symptoms and LDH levels were found to have a strong relationship (p-value <0.001). Patients between the ages of 46 and 60 were more likely (4.3 times) to have poor outcomes, and diabetes mellitus was predicted to be 2.32 times more likely to be associated with poor COVID-19 outcomes. Raised LDH levels were >5 times more likely to lead to in-hospital poor outcomes compared to those with borderline LDH levels.
Conclusion: The LDH level is a reliable predictor for the cause of COVID-19. The results of the present study suggest that patients aged 46-60 years, diabetic patients, or those suffering from severe symptoms of COVID-19 have raised levels of LDH.
Biomarkers, Coronavirus disease-2019, Co-morbidities, Liver
Monitoring the level of LDH in the blood helps to determine if there is any tissue damage in the lungs, kidneys, heart, and other organs (1). Therefore, LDH has been considered a reliable biomarker in early prediction of outcome and prognosis of critically ill patients in Intensive Care Unit (ICU) suspected to have bacterial sepsis, Systemic Inflammatory Response Syndrome (SIRS) and respiratory distress syndrome (2). LDH was studied among other serum or clinical factors, trying to find out some potential prognostic markers (3),(4).
The recent pandemic of the novel coronavirus COVID-19 has appeared as an urgent challenge for frontline clinicians to effectively triage COVID-19 patients as an infectious disease that can cause severe respiratory illness and develop co-morbidities, which can lead to irreversible organ damage and, eventually, death [5,6]. The accuracy and reliability of the established early risk scores, such as the Sequential Organ Failure Assessment (SOFA) and the Modified Early Warning Score (MEWS) (MEWS), in predicting COVID-19 severity have been questioned (7),(8),(9).
The levels of lactate dehydrogenase (LDH), ferritin, alanine aminotransferase (ALT), and aspartate aminotransferase (AST) have shown changes among those with a severe disease (10). LDH among three biochemical parameters has shown highest sensitivity (75%) with positive predictive value of 71.6% and diagnostic accuracy of 65.3% (AUC=0.65) in relation to RT-PCR gold standard test (11),(12). The use of a combination of common laboratory biomarkers (C-reactive Protein (CRP), LDH, and ferritin D dimer) to predict the diagnosis of COVID-19 having an established sensitivity and specificity may provide accurate diagnosis (13),(14).
As the COVID-19 disease progresses (>7 days after the onset of symptoms), lymphopenia gets worse while neutrophil count, C-reactive protein levels, and lactate dehydrogenase levels rise (15). Significant relationships were reported between hospitalisation in intensive care unit and LDH, lymphocyte count, LDH/lymphocyte ratio, CRP, highest D-dimer, initial Interleukin (IL)-6, neutrophil/lymphocyte ratio, and highest IL-6 values (16),(17). In a meta-analysis based on 264 records, LDH levels were significantly lower in the group of survivors than who died in-hospital, and lower LDH levels were observed in non severe groups compared to severe course of COVID-19 (18).
The present study was planned to determine the extent of correlation of serum LDH with the severity of COVID-19 disease among the patients admitted in ICU to demonstrate a strong correlation between elevated LDH level in relation to poor outcome of patients. LDH might be viewed as the ideal biomarker because it is affordable, reproducible, and simple to obtain in any laboratory.
This retrospective study was undertaken at Dammam Medical Complex Hospital, Dammam, Eastern Province, Saudi Arabia, during March 2020 to May 2020. Ethical approval was taken from the Institutional Review Board (IRB), [reference No. IRB-D-2020-5]. Data of 205 suspected patients of COVID-19 infection were recorded.
Inclusion criteria: Confirmed case of COVID-19 on a polymerase chain reaction (PCR) test positive, either gender, or age greater than 14 years were included.
Exclusion criteria: Patients with haemoglobinopathies and/or malignancies were excluded from the study. Incomplete data records or patient’s Leaving Against Medical Advice (LAMA) were also excluded from the study.
As per the routine protocol, the patient’s signed a consent statement having the description of all pros and cons of the procedures prior to being performed along with a Terms of Reference (TOR).
Study Procedure
Variables extracted from patients’ medical records were age, gender, nationality, co-morbidities, lactate dehydrogenase level, COVID-19 severity, and the number of days since the patient tested positive (upto 7,14 and >14 days). LDH was classified into three categories i.e. normal upto 200 U/L, borderline 200-500 U/L, and raised >500 U/L (12). At the time of admission, COVID-19 patients’ severity was determined by using the following criteria (Saudi MoH protocol version 2.1;2020) (19):
1 Mild COVID-19 disease: If chest radiography or chest Computed Tomography (CT) findings revealed only mild pneumonia or no evidence of pneumonia at all;
2 Moderate COVID-19 disease: If within 24-48 hours there was dyspnoea, respiratory rate less than 30 breaths per minute, blood oxygen saturation less than 93%, PaO2/FiO2 ratio less than 300, and/or lung infiltrates greater than 50%.; and
3 Severe COVID-19 infection: If there was respiratory failure, septic shock, and/or multiple organ dysfunction or failure.
Statistical Analysis
Statistical data testing was carried out using specialised software of Statistical Package for Social Sciences (SPSS) version 20.0. An International Business Management (IBM) product from Chicago (USA). Numeric type data variables (e.g. age) were presented as mean±SD. Frequencies and percentages were used to present qualitative variables, for instance gender, nationality, co-morbidities, lactate dehydrogenase level, symptoms, course of disease, and in-hospital outcome of patients. All these qualitative variables were compared by using a Chi-square test in relation to lactate dehydrogenase levels (LDH). To evaluate the predictors of COVID-19 outcome, logistic regression analysis was performed by taking COVID-19 in-hospital outcome as the dependent variable; the panel of independent covariates consisted of gender, age, nationality, co-morbidity, and COVID-19 severity. If a p-value ≤0.05, it reveals a significant result and non significant elsewhere.
Amongst total 205 COVID-19 confirmed cases, male preponderance (90.2%) was evident (M:F ratio=9.3:1). The mean age was 45.4±13.0 years (range from 18-89 years), and majority were non Saudi patients (79.5%). The LDH was normal in 37 (18.1%), borderline in 138 (67.3%), and raised in 30 (14.6%) patients. A significantly higher proportion of male patients 132 (95.7%) had borderline, and 25 (83.3%) had raised LDH levels (p=0.001). The age group of 46-60 years was found to be significantly affected (p=0.005), with borderline and raised LDH levels of 46.4% and 46.7%, respectively. Significantly higher proportions of the patients with borderline (82.6%) and raised (86.7%) LDH levels were non Saudis (p=0.014) as detailed in (Table/Fig 1).
Around two-thirds of the COVID-19 patients had no co-morbidities (64.4%). However, the proportions of patients with atleast one co-morbid condition were 39.9% and 36.7% of those with borderline and raised LDH levels, respectively. There was a significantly higher proportion of patients with raised LDH levels who had moderate and severe symptoms of COVID-19 disease. It revealed a significant association between the severity of disease symptoms and raised LDH level (p<0.001). A remarkably greater proportion of patients with borderline LDH had a course of disease of 7-14 days (52.5%) and those with raised LDH levels (33.3%) had a >14-day course of disease (p=0.004) as presented in (Table/Fig 2).
Patients with COVID-19 disease who had a raised LDH level (>500 U/L) had a higher mortality rate (26.7%), and admitted to Intensive Care Unit (ICU) (10%), revealed a significant correlation of in-hospital poor outcomes of patients with an increased LDH level (p=0.001) presented in (Table/Fig 3).
A panel of 12 covariates was selected to detect the predictors of COVID-19 severity and in-hospital mortality. According to regression analysis, patients between the ages of 46 and 60 years were more likely (4.3 times) to have poor outcomes, and diabetes mellitus was predicted to be 2.32 times more likely to be associated with poor COVID-19 outcomes. Raised LDH levels were >5 times more likely to lead to in-hospital poor outcomes compared to those with borderline LDH levels (Table/Fig 4).
The results of the present study confirmed a significant correlation between the in-hospital poor outcome of patients with an increased lactate dehydrogenase level (LDH) among tested positive cases. It also indicated that LDH levels were significantly high among males (46-60 years old), and among non Saudi patients. In addition, elderly people are at high-risk of getting infected (20),(21), and the results of the present study showed the same too. It was found that those aged between 46 and 60 years old had the highest proportion of borderline or raised levels of LDH.
Henry BM et al., reported LDH as a strong predictor of the outcome of COVID-19 disease. They evaluated that LDH level increases the odds of developing the severity of the disease by a 6-fold and a 16-fold increase in odds of mortality in patients with COVID-19 (22). Other studies have also reported LDH as one of the predictors of the progression of the disease (COVID-19), alongside the patients’ demographics and other co-morbidities (23),(24).
The proportion of males were high in which most of them were non Saudis. This finding is quite obvious as there is majority of male expatriates than females in Saudi Arabia (25). Hence, it could be possible reason high proportion of cases among non Saudi males compare to others.
Statistical analysis revealed that the relationship between LDH level and severity of disease was significant, that is, symptoms were severe as the LDH level increased. It was also observed that an increase in the number of days after testing positive for COVID-19 had a significant association with an increase in LDH level. The release of LDH is directly associated with tissue damage and is involved in various pathological processes. Wu MY et al., demonstrated that monitoring LDH levels could aid in determining the progression or improvement of COVID-19, and they concluded that the time to normalise the LDH level is directly related to radiographic absorption (26). Furthermore, COVID-19 infected patients with high LDH levels at the time of hospitalisation are more likely to develop Acute Respiratory Distress Syndrome (ARDS) (27).
The linear association between symptom severity and LDH level supports the hypothesis of the present study. Hence, regular monitoring of the LDH level could help to find the course of the disease. Furthermore, early detection of the course of the disease, can help to take necessary and preventive measures early. It was also found that COVID-19 patients with diabetes mellitus were 2.32 times more exposed to a poor outcome. Fang L et al., hypothesised that diabetic patients who were using ACE-stimulating drugs had a high-risk of developing severe symptoms of COVID-19 (28). However, Guan W et al., (29) and Zhang JJ et al., (30) reported that 16.2% and 12% of their sampled COVID-19 patients had diabetes mellitus, respectively.
Limitation(s)
The duration of the planned study was very short, i.e., three months, because there was a general impression that the pandemic would be controlled in a short span of time by the enforcement of complete lockdown and strict precautionary measures. Two major factors related to the patient’s data, i.e., occupation and standard of living, that could be associated with a greater risk of COVID-19 infection, especially in expatriate male workers, were neglected in the present study.
Hence, it is concluded that monitoring LDH level is a reliable predictor for the cause of COVID-19. The results of the present study suggest that patients aged 46-60 years, diabetic patients, or those suffering from severe symptoms of COVID-19 have raised levels of LDH. Early measurements could be taken to control the increase in LDH level, which ultimately reduces the chances of severe symptoms endangering a patient facing the worst outcome of COVID-19.
We acknowledge the staff of patients’ record section, Dammam Medical Complex, for providing us patient’s files and notes.
DOI: 10.7860/JCDR/2023/56184.17239
Date of Submission: Apr 27, 2022
Date of Peer Review: Jun 24, 2022
Date of Acceptance: Oct 07, 2022
Date of Publishing: Jan 01, 2023
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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