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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
Evaluation of Hearing Impairment and Levels of Trace Elements in Patients with Oral Submucous Fibrosis
Correspondence Address :
Dr. Surekha Rathod,
Professor, Department of Periodontics and Implantology, VSPM Dental College and Research Centre, Nagpur, Maharashtra, India.
E-mail: drsurekhar@gmail.com
Introduction: Oral Submucous Fibrosis (OSMF) is a slowly progressive premalignant condition. Trace elements like Copper (Cu) and Zinc (Zn) were found to have diagnostic and prognostic values in malignancies. Disease activity at in an earlier stage by determining the exact stage of OSMF based on eustachian tube dysfunction and serum Cu, Zn, and Iron (Fe) levels.
Aim: To assess the Eustachian tube dysfunction and level of trace elements in OSMF patients.
Materials and Methods: This case-control study was carried out in VSPM Dental College and Research Centre Nagpur and Department of Ear, Nose and Throat (ENT) and Biochemistry of NKP Salve Medical College, Nagpur, Maharashtra, India, from March 2018 to February 2019. Two hundred patients were equally divided into individuals without OSMF and with OSMF. A Pure Tone Audiometry (PTA) was used to measure degree of hearing impairment while estimation of trace elements Cu, Zn and Fe was done by atomic absorption spectrophotometry. The unpaired t-test, Chi-square test and one-way Analysis of Variance (ANOVA) test were used for statistical analysis.
Results: All 200 individuals were matched with age and sex in both the groups. Normal hearing was found in 61% of the ears and Conductive Hearing Loss (CHL) in 39% of the ears with OSMF. A positive association of hearing loss in both the ears with stages of OSMF were seen which was statistically significant with p-value of 0.001. The level of Cu (103.44 mg/dL) was found increased in OSMF individuals while the levels of Zn (78.93 mg/dL) and Fe (84.05 mg/dL) was reduced.
Conclusion: Within the limitations of the study, there was association between the severity of OSMF, degree of hearing loss and levels of trace elements. One of the most serious side-effects of OSMF is hearing loss. Level of copper increased while level of zinc and iron were reduced in OSMF patients.
Eustachian tube, Hearing loss, Nutritional deficiency, Premalignant lesion
The OSMF is a slowly progressive premalignant condition commonly encountered in India and South Asian countries. It is characterised by fibrosis of oral mucosa leading to severe restriction of jaw and tongue movements (1). The pathogenesis of OSMF has multifactorial origin including nutritional deficiencies, ingestion of chilies, habit of chewing areca nut, factors like pollution, genetic and immunologic processes. Various researchers have reported that OSMF affects the muscles of the soft palate like tensor veli palatine and levator veli palatine and subsequently may affect the Eustachian tube function and patency (2).
Trace elements like copper and zinc were found to have diagnostic and prognostic values in malignancies like lymphoma, carcinoma of lung and breast etc., (3). Due to increased iron usage in collagen formation and subsequent reduced epithelial vascularity in OSMF, iron levels are decreased (4). It produces erosion and fibrosis, as well as a burning sensation. Vesicle development precedes OSMF, which is linked to juxtaepithelial condensation. To distinguish healthy mucosa from OSMF-affected mucosa, clinical and histopathologic characteristics are often used. However, these technologies have the drawback of detecting disease at a later stage, necessitating intensive treatment, including non surgical and surgical therapy. As a result, treatment costs and patient morbidity rise (5). It is preferable to predict future disease activity in earlier stage by determining the exact stage of “OSMF” based on Eustachian tube dysfunction and serum Cu, Zn, and Fe levels (6),(7). Literature is scarce on Eustachian tube function and trace elements leading to hearing impairment in OSMF. The early detection of OSMF and hearing loss, the provision of appropriate and limited therapy, and the reversal of the sickness state by proper prophylactic measures would all be aided by this. Therefore, the objective of this study was to assess hearing impairment in individuals with OSMF and compare it to Eustachian tube function and blood levels of Cu, Zn, and Fe.
bThe present case-control study was carried out in Department of VSPM Dental College and Research Centre Nagpur and Department of ENT and Biochemistry of NKP Salve Medical College, Nagpur, Maharashtra, India. The study was initiated from March 2018 to February 2019. The study protocol was approved by Institutional Ethics Committee and which was abided by the Declaration of Helsinki of 1979 (revised 2000) and was registered in Clinical Trial Registry India (CTRI/2017/10/010161).
Inclusion criteria: Individual ranging between the age group of 13-35 years, healthy individual without OSMF (n=100), individual with OSMF (n=100), systemically healthy individual and patients who had consumed kharra for more than 3 years (8) were included in the study.
Exclusion criteria: Exclusion criteria were individuals with more than one type of lesion, undergoing treatment for OSMF, smokers and alcoholics, perforation of tympanic membrane, middle ear pathology and cholesteatoma, other condition causing restrictive mouth opening, having sensorineural hearing loss, having iron deficiency anaemia, history of drug intake containing iron, copper and zinc, pregnant women and patients on oral contraceptives.
Sample size calculation: The sample size was calculated based on the study by Shah M et al., (9).
Sample size calculation was done using the formula:
n=(Zα/2+Zβ)2 (P1(1-P1)+(P2(1-P2))
Where, Zα/2 was the critical value for 5% significance level, which is 1.96, Zβ was the critical value at β. To attain 80% power of the test, the value of β was 0.2 and thus the value Zβ was 0.84. Here, p1 and p2 the two-proportion, ‘n’ was the sample size per group. Using the estimates of reference study and above constants in the formulation, the estimated sample size per group was 99 (rounded to 100 per group). Thus, the total sample size was 200.
All the patients were categorised into two groups as control group without OSMF (100 patients) and case group with OSMF (100 patients).
Study Procedure
The OSMF patients were recruited according to the clinical staging of Khanna JN and Andrade NN in 1995 classification (10). A Vernier calliper was used to measure the interincisal distance between the maxillary and mandibular central incisal edges and maximum mouth opening. A general physical examination was carried out to look for any gross debilitating condition.
Audiological assessment was carried out in the Department of ENT. All the participants underwent otoscopy to rule out for any pathology associated with ear. Afterward the individuals with and without OSMF underwent procedure for PTA (3) to check the air Bone (AB) gap measurement for hearing impairement by ELKON Advanced Digital Audiometer in sound proof room. The PTA was performed to analyse Bone Conduction (BC) and Air Conduction (AC) threshold for tones from 250, 500, 1000, 2000 and 4000 Hz. The level of “hearing impairment” at a certain frequency was measured if the intensity was elevated over the normal level. “Hearing impairment” was quantitatively rated after reading the audiogram and relying on AC-BC gap values (Table/Fig 1) (11).
Biochemical analysis of trace elements (12),(13),(14) was done as follows:
For the serum preparation 5 mL venous blood was collected and stored at 37° C for one hour followed by centrifugation at 3000 rpm for six minutes. Separated serum was stored in a plain sterile glass bulb at 4°C and estimation of trace elements Cu, Zn and Fe was done by atomic absorption spectrophotometry (Table/Fig 2).
Statistical Analysis
The data was recorded and analysed using Statistical Package for Social Sciences (SPSS) v 17. All values expressed in terms of Mean±Standard Deviation (SD). The p-value at 95% confidence interval was calibrated as the level of significance. The comparison of mean hearing loss was in decibels in OSMF and without OSMF group was done by unpaired t-test. The Chi-square test was used for comparison of hearing loss with stages of OSMF in left and right ear. The unpaired t-test was used to compare trace element in OSMF and without OSMF group. Unpaired t-test was used for comparison of hearing loss and trace elements with and without OSMF group and comparison of trace elements with stages of OSMF was done by one-way ANOVA test.
All 200 individuals were matched with age and sex in both the groups. Out of the total 200 ears in group with OSMF, 61% of the ears showed normal hearing while 39% of the ears showed CHL. All of the total 200 ears showed normal hearing in without OSMF group.
(Table/Fig 3) provides the descriptive statistics of age and gender in both the group. The mean age in group without OSMF was 23.81±3.67 years with the range of 14-35 years. The distribution of individual ratio of male and female in both the groups was equal that is 95:5.
In the present study, comparison of hearing loss in terms of AB gap was done amongst both the group. In group with OSMF, mean level of hearing loss in decibels was 16.4 dB, whereas in group without OSMF, it was 13.02 dB. In both the group the results were statistically significant (Table/Fig 4).
(Table/Fig 5) is showing the comparison of hearing loss with stages of OSMF in right and left ear. It was seen that in right ear in stage I of OSMF maximum number of patients (35) were having normal hearing. In stage II, OSMF there were 18 individuals with normal and no individuals with mild hearing loss.
Copper level in OSMF group with normal hearing was 103.44 mg/dL and with hearing loss was 97.46 mg/dL. Similarly, the zinc level in OSMF group with normal hearing, the mean was 78.93 mg/dL, and with hearing loss was 75.24 mg/dL. Iron level (Fe) with OSMF individual with normal hearing was 84.05 mg/dL, and with hearing loss was 76.51 mg/dL which was statistically significant with p-value=0.001 (Table/Fig 6).
(Table/Fig 7) is showing comparison of trace elements with stages of OSMF. Copper level was increased as stage increased and it was statistically significant. Whereas, zinc and iron levels were decreased as stage increased.
The present study consisted of 100 patients without OSMF and 100 with OSMF, between 14-35 years of age. Males were predominated with 95% in both groups. Similar results were found by Lai DR et al., who reported 97.67% of male predilection (13). Other studies on OSMF by Yeh CJ reported Males (M)-88.89%, Females (F)-11.11% and Hazarey VK et al., reported general male predilection as M- 90.91% F- 9.09% (14),(15). However, in contrast, the general female preponderance was found in OSMF group as reported by Haque MF et al., with F-62.07% M- 37.93% (16).
In the present study, comparison of hearing loss in different stages of OSMF had been done and it was found to be significant i.e., as the stage progressed the AB gap shifted from normal, that is suggestive of eustachian tube involvement. “Hearing loss” in right and left ear was found to be positively associated with OSMF stages I, II, and III in this investigation. The OSMF disease produced ear pain owing to Eustachian Tube (ET dysfunction and patency due to the involvement of surrounding muscles, resulting in mild to severe hearing loss. In “CHL”, normal BC threshold and AC threshold decreases than normal threshold (17). Results of present study were similar with earlier studies and showed that hearing loss was more in advanced condition of OSMF (3),(9).
The percentage of normal hearing in OSMF individuals was 61% whereas the percentage of CHL was 39%. However, study done by Gupta SC et al., reported 72.2% showed normal hearing and mild to moderate CHL in 18% of individuals (18).
The OSMF is a slowly progressing condition in which “fibrous bands” grow in the “oral mucosa”, limiting tongue movement severely. Degenerative alterations in the soft palate muscles, oedema, as well as atrophy of the palatal and paratubal muscles have all been observed by various authors (19). The nasopharynx connects the ET to the middle ear chamber. Hearing loss occurs when the function of closure and opening is impaired (4). The tensor veli palatine and levetor veli palatine muscles are linked to the soft palate. Some of the writers looked at the tissues of people with OSMF under a microscope and found dense “collagen bundles” that are directed and stretched into the underlying muscle, as well as muscle fibre degradation (15),(18).
In present study, when the comparison of the serum trace elements was done between both groups, it was found that the level of Cu were statistically increased in OSMF group whereas the level of Zn and Fe gradually decreased in OSMF group in comparision to without OSMF group patients. In present study, association of trace elements with different stages of OSMF was also found. In the present study, a rise in serum Cu levels was seen and reduced Zn and Fe levels were observed in serum as the stages increased. The elevated level of serum Cu in patients with OSMF could cause upregulation of lysyloxidase enzyme for crosslinking of collagen and elastin (20),(21),(22). The findings of present study are in accordance with the previous studies done by Luquman M et al., Yadav A et al., Srilekha M (7),(23),(24).
When serum trace elements were compared with the level of hearing loss in OSMF individuals, increased levels of copper was found amongst OSMF group with normal hearing and in hearing loss, but it was not statistically significant. The reason for the increase in the level of Cu levels in the OSMF individuals was areca nut as it has high content of Cu and chewing areca nut releases Cu into the saliva regardless of normal or hearing loss (25). So, in OSMF whether the hearing loss is present or not the Cu will always be increased. Similarly, decreased levels of Zn and Fe were found amongst OSMF group with normal hearing and in individuals with hearing loss. Though decreased amount of Zn and Fe were seen in OSMF group, it was statistically significant with Fe levels only.
While the cause of the decline in zinc and iron levels is similar for zinc levels, the Zn dependent superoxide dismutase is said to be an indicator of early mucosal changes preceding carcinogenesis (26). This finding is in accordance with previous studies like those of Shettar SS (27). However, decreased Fe levels in OSMF might be due to more use of iron in collagen synthesis leading to utilisation of Fe in collagen synthesis, epithelial vascularity declined. It causes burning sensation, erosion and fibrosis (3).
At present, detection of established carcinoma and progression of disease from premalignant to malignant relies heavily on histopathological examination. Recently much emphasis has been given towards recognition of trace elements in “oral cancer” and “precancerous” condition because of the encouraging result of the studies on head and neck carcinoma, lymphoma, lung and breast carcinoma (5).
The well known consequences and impact of OSMF on overall health leads to increased risk of developing hearing loss which subsequently would influence the quality of life. The results support the concept of determining the degree of OSMF and hearing loss with the levels of trace elements. Detection of trace elements in OSMF can open the doors for novel analytic and therapeutic modalities in areas of medicine and oncology. Thus, Eustachian tube functions may be affected in OSMF; hence individuals with OSMF should be screened for hearing loss.
Limitation(s)
The level of trace element, hearing status and OSMF were not recorded after treatment. It was a cross-sectional observational study. Long-term analysis is needed to determine the stability of results. Follow-up study of OSMF is also needed which may help and guide us further for considering trace elements as prognostic marker.
Within the limitations of the study, there are significant association between grades of OSMF, hearing loss and levels of trace elements. As the OSMF stage progresses, the hearing impairment increases. One of the most serious side-effects of OSMF is hearing loss. All OSMF patients should be evaluated for hearing loss. Therefore, all OSMF patients should be referred to the ENT consultation for further treatment.
The authors thank Dr. Madhur Gupta, head and Dr. Suresh Chari, professor, Department of Biochemistry, NKPSIMS, Nagpur; Mr Sunil Dadarao Gawande, technical officer, Sant Gadge Baba Amravati University for technical support and help.
Authors contribution: All authors have given final approval and agreed to be accountable for the work done, ensuring its integrity and accuracy. All the author contributed to conception, design, literature search, analysis, interpretation and drafted the manuscript. Contributed to literature search, analysis, interpretation and critically revised the manuscript.
DOI: 10.7860/JCDR/2023/57580.17428
Date of Submission: May 05, 2022
Date of Peer Review: Jun 02, 2022
Date of Acceptance: Oct 22, 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. Yes
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