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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 Ratio as a Predictor of COPD Exacerbations: A Cross-sectional Study
Correspondence Address :
Dr. Kranti Garg,
Associate Professor, Department of Pulmonary Medicine, Government Medical College, Patiala, Punjab, India.
E-mail: drkrantigarg@yahoo.com
Introduction: Chronic Obstructive Pulmonary Disease (COPD) is characterised by a modified inflammatory response to chronic irritants, which is often associated with some degree of systemic inflammation. Exacerbations in COPD are characterised by exaggeration of the ongoing inflammation. A number of inflammatory mediators are found to be raised in COPD exacerbations, but most of them are expensive and not readily available. The Neutrophil-lymphocyte Ratio (NLR) is a rapid, easy and cheap biomarker, that has been shown to be raised in patients of COPD.
Aim: To evaluate the role of NLR in patients of stable and acute exacerbation of COPD.
Materials and Methods: This cross-sectional observational study was conducted in Department of Pulmonary Medicine at Government Medical College, Patiala, Punjab, India. Study included 150 patients of stable COPD, 150 patients of Acute Exacerbation COPD (AECOPD) and 100 subjects as controls. NLR was calculated from a peripheral blood sample of the study participants. Continuous variables were summarised as mean with standard deviation and compared between groups using Unpaired t-test. A p-value <0.05 was considered statistically significant.
Results: The mean age in AECOPD group was 61.7±10.4 years, in stable COPD group was 63.1±8.9 years and 63.2±7.8 years in controls. Mean NLR was found to be highest in AECOPD group (4.0±1.7) followed by stable COPD (2.9±0.8) and then control (1.8±0.4). NLR showed good predictive value for predicting exacerbations in stable COPD patients with sensitivity and specificity of 75.3% and 70.7%, respectively (cut-off=3.4 and AUC=0.806).
Conclusion: The NLR is an easily available biomarker of inflammation and can be used as a predictor of exacerbation in patients of COPD.
Biomarker, Chronic obstructive pulmonary disease, Inflammation
Chronic Obstructive Pulmonary Disease (COPD) is characterised by a modified inflammatory response to chronic irritants. There is an increase in the number of macrophages, activated neutrophils, and lymphocytes in peripheral airways, lung parenchyma, and vessels (1). The role of the neutrophils in the pathogenesis of COPD is only partially known. The imbalance between proteases and their inhibitors cause parenchymal destruction and emphysematous changes, while the production of cytokines, enzymes, adhesion molecules, and growth factors from activated neutrophils promote infiltration of the airways by inflammatory cells and further production of proinflammatory factors, creating a vicious circle, which maintains and enhances the local and systemic effects of the disease (2),(3).
Along with pulmonary inflammation, some degree of systemic inflammation is also seen in COPD, although the mechanism of this systemic inflammation remains unclear. Several pathways have been suggested that may lead to systemic inflammation in COPD, these include; overflow of inflammatory mediators from pulmonary compartment; proinflammatory reaction to bacterial products; inflammatory reaction to tissue hypoxia, and inflammation induced due to smoking (4). During exacerbations of COPD, pulmonary as well as systemic inflammation is accentuated characterised by cellular activation, cytokine production and tissue injury. The infective (bacterial or viral (5)) and non infective triggers of exacerbations accentuate the ongoing inflammation in patients of COPD (6).
Increased inflammation in lungs is associated with raised inflammatory markers in circulation leading to an increase in systemic inflammation as well (4). Several biomarkers of inflammation which are found to be raised in COPD are C-Reactive Protein (CRP), Interleukin-8 (IL-8), Tumour Necrosis Factor (TNF-α), leptin, endothelin-1, fibrinogen, IL-6, Leukotriene (LT) B4 and E4 (7). Although some of these novel biomarkers can identify the severity of disease and acute exacerbation in COPD, most of them are time-consuming, expensive, and not readily available (8). The Neutrophil-Lymphocyte Ratio (NLR) is a rapid, easy and cheap biomarker that is calculated from Complete Blood Count (CBC). Blood NLR has been demonstrated to be an indicator of inflammatory states and is utilised for risk stratification of several disorders, including acute coronary syndrome (9), pancreatitis (10), sepsis, and infectious conditions (11). NLR is also been used as a prognostic indicator in several diseases like breast cancer (12), sepsis (13), and most recently in Coronavirus Disease 2019 (COVID-19) (14).
There has been extensive research on the role of NLR in COPD. Multiple studies have corroborated that NLR increases during exacerbations of COPD [8,15-24] and other studies have explored its role as a predictor of exacerbations (8),(15),(16),(18),(25),(26) and mortality (17),(24),(25),(27),(28),(29),(30). However, data in the Indian population is scarce. Prasannan G et al., and Sharma K et al., found that NLR was raised in COPD exacerbations when compared to stable patients (21),(22). Prasannan G et al., also found that NLR has a positive correlation with mMRC and BODE score of the patients (21). While Arya V et al., found no correlation between NLR and severity of COPD exacerbation (31). Hence, the present study was conducted to evaluate the role of NLR in patients of COPD, especially as a predictor of exacerbations.
This cross-sectional observational study was conducted from June 2019 to November 2020, in Department of Pulmonary Medicine at Government Medical College, Patiala, Punjab, India. Institutional Ethical Committee approval was obtained for the study (BFUHS/2K19p-TH/2073).
Inclusion criteria: All patients attending the study Institute with diagnosis of COPD {as per GOLD 2018 report criteria (1)} were included in the study.
Exclusion criteria: Pregnant and lactating females, and patients with bronchiectasis, active tuberculosis, malignancy, or other inflammatory diseases such as arthritis, inflammatory bowel diseases, or connective tissue disorders were excluded from the study.
Patients of COPD were divided into two groups of 150 patients each.
COPD group (n=150): One group was of stable patients of COPD, defined as those with no significant change in symptoms and no need for additional therapy for the past three months (32).
AECOPD group (n=150): All patients with Acute Exacerbation of COPD (AECOPD) which was defined as an acute worsening of symptoms in COPD patient that requires additional therapy (1).
Controls (n=100): Healthy subjects with no history of smoking or biomass exposure, no co-morbidities, and no clinical symptoms.
Data Collection
Baseline demographic data and clinical history was noted. Blood samples were collected from participants and subjected to total and differential leucocyte count, absolute eosinophil and neutrophil counts. Neutrophil-lymphocyte ratio was calculated by dividing neutrophil count with lymphocyte counts.
Statistical Analysis
Categorical variables were summarised as proportions. Continuous variables were summarised as mean with Standard Deviation (SD) and compared between groups using Unpaired t-test. A p-value <0.05 was considered statistically significant. Data was analysed using R software version 4.0.1.
The mean age in AECOPD group was 61.7±10.4 years, in stable COPD group was 63.1±8.9 years and 63.2±7.8 years in controls. Male predominance was seen in all three groups studied. The mean BMI of participants was significantly lower in stable COPD patients, as compared to AECOPD and controls. Only 82% patients of AECOPD and 77.3% of stable COPD patients were smokers, biomass fuel exposure was present in 23.3% and 26.7% of patients of AECOPD and stable COPD respectively. Current smokers were significantly higher in AECOPD group, as compared to stable COPD group (Table/Fig 1).
When comparing haematological parameters between AECOPD and stable COPD groups, total leucocyte count, neutrophil percentage, absolute neutrophil count, and absolute eosinophil count were significantly higher in the AECOPD group compared to stable COPD group. Mean NLR was significantly higher in AECOPD group (4.0±1.7) compared to stable COPD group (2.9±0.8). However, there was no significant difference in haemoglobin levels or eosinophil percentage between the two groups.
Comparative evaluation of haematological parameters between stable COPD patients and controls showed that the total leucocyte count, neutrophil and eosinophil percentage, and absolute eosinophil and neutrophil counts were significantly lower in control group compared to stable COPD group. The mean NLR was significantly higher in stable COPD group compared to control group. Comparison of haematological parameters between AECOPD and controls revealed that the total leucocyte count, neutrophil and eosinophil percentage, absolute eosinophil count, and absolute neutrophil count were significantly higher in the AECOPD patients, compared to controls group. NLR was significantly higher in AECOPD group compared to control group (Table/Fig 2).
Receiver-Operating Characteristic (ROC) analysis revealed a good predictive value of NLR for predicting an exacerbation of COPD. At a cut-off of 3.4, the sensitivity, specificity and Area Under Curve (AUC) were 75.3%, 70.7% and 0.806, respectively (Table/Fig 3).
Study participants were characterised, based on blood eosinophil percentage into two groups i.e., blood eosinophils <2% and ≥2%. In patients of AECOPD, NLR was found to be significantly higher in non eosinophilic group (blood eosinophils <2%) and in those, with blood eosinophils ≥2%. NLR was similar in two groups in patients of stable COPD and controls (Table/Fig 4).
In the present study, the Total Leucocyte Counts (TLC) in patients of stable COPD were significantly higher than controls, a finding that was present consistently in previous studies (8),(15),(19),(20),(24). COPD is characterised by an altered inflammatory response to airway irritants leading to parenchymal and airway destruction which further causes persistent symptoms and airflow limitation. Apart from airway inflammation, an abnormal systemic inflammation is also seen in COPD, which in turn is responsible for most of the systemic manifestations of the disease. Several mechanisms have been proposed in order to explain systemic inflammation in COPD, like systemic spread of inflammatory mediators from pulmonary compartment, an inflammatory response to tissue hypoxia or bacterial components, smoking induced inflammation, pulmonary hyperinflation (4). Furthermore, exacerbation of COPD is characterised by increased inflammation as a result of infective aetiology in most cases and hence, leads to higher TLC, which is seen in the present study, as well as, in previous literature (8),(15),(19),(20),(24), when compared to controls or stable COPD patients.
In the present study, it was found that NLR was significantly higher in stable COPD, when compared to controls and even higher in AECOPD when compared to stable COPD and controls. Similar findings have been reported by a number of studies (Table/Fig 4). NLR is an established marker of inflammation and has been shown to increase in several inflammatory conditions (9),(10),(11),(12),(13),(14). Exacerbations in COPD are characterised by flaring of the chronic inflammatory process of COPD at pulmonary and systemic level. Bacterial, viral as well as non infectious causes of exacerbations lead to increased inflammation in airways and release of proinflammatory cytokines and chemokines (6). These markers of inflammations are often increased in AECOPD and lead to heightened systemic inflammation in form of neutrophil recruitment and activation. These result in a higher NLR in AECOPD, when compared to stable COPD and controls.
Since, NLR is significantly higher in AECOPD, it could be used as a biomarker of exacerbation in patients of COPD. In the present study a cut-off value of 3.4 showed a sensitivity and specificity of 75.3%, and 70.7%, for predicting an exacerbation. Several previous studies have also found a good predictive value of NLR in predicting an exacerbation of COPD (Table/Fig 5) (8),(15),(17),(18),(20),(21),(22),(23),(24),(26).
A significantly higher NLR was found in patients of AECOPD with blood eosinophil percentage <2%, when compared to those with eosinophils ≥2% but no significant difference was found when categorising controls and stable COPD patients into these categories. Moreover, the number of AECOPD patients showing this trend was very less, hence, no conclusion could be drawn from this finding.
Limitation(s)
The NLR was not evaluated with respect to other variables like severity of underlying COPD, severity of exacerbations, frequency of previous exacerbations. Since, it was a cross-sectional study and no follow-up was done, prognostic role of NLR was not studied.
Frequent and severe exacerbations of COPD adversely affect the health status of the patient and also, contribute to progression of disease and mortality (1). Predicting exacerbations early can help in early detection and management. Current study shows that, NLR is an inflammatory biomarker that raises significantly during COPD exacerbations and can be used to predict COPD exacerbations, and help in detecting exacerbations early.
DOI: 10.7860/JCDR/2023/59293.17337
Date of Submission: Aug 26, 2022
Date of Peer Review: Oct 06, 2022
Date of Acceptance: Nov 03, 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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