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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
Case report
Full Version
Successful Management of Rituximab Refractory Warm Autoimmune Haemolytic Anaemia with Splenectomy: A Case Report
Correspondence Address :
Dr. Zuber Ansari,
Assistant Professor, Unit of Surgical Gastroenterology, Department of Surgery, FH Medical College, Agra-282005, Uttar Pradesh, India.
E-mail: zubair_mohammad@yahoo.ca
Autoimmune Haemolytic Anaemia (AIHA) is a rare haematological disorder characterised by autoantibodies directed against autologous red blood cells. It can be idiopathic or secondary and classified as Warm type AIHA (WAIHA), cold, or mixed. The primary treatment for WAIHA is a long course of steroid administration, which has an early response rate of 80-90%. However, up to 20-30% of patients require second-line therapy. In the last decade, rituximab has replaced splenectomy as the first-choice therapy for refractory WAIHA patients due to its efficacy and safety. There is a paucity of reported cases of WAIHA refractory to both steroids and rituximab that have responded to splenectomy. This is a case of a 35-year-old female with a history of jaundice and anaemia for the past two years. The patient was diagnosed with WAIHA with a Direct Antibody Test (DAT) positive, IgG positive, and C3d negative results, and massive splenomegaly that was initially refractory to steroids and rituximab but responded to splenectomy. Significant splenomegaly may be an indication for choosing splenectomy over rituximab as a second-line treatment in steroid-refractory WAIHA.
Multisection computed tomography, Splenomegaly, Steroid
A 35-year-old female with no co-morbidities presented to us in September 2022 with chief complaints of breathlessness, jaundice, and mild dull pain in the left upper quadrant. Upon taking a detailed history and reviewing medical records, it was found that the patient was an established case of Warm AIHA with a history of onset of jaundice and anaemia in March 2020 when the patient’s Haemoglobin (Hb) level dropped to 4.7 g/dL. The patient had previously sought care at a different tertiary care institute (Institute A) in June 2021, where the diagnosis of Warm AIHA was established based on Direct Antibody Test (DAT) positive, IgG positive, and C3d negative results. The patient was started on prednisolone 40 mg per day in January 2021 by Institute A; however, the Hb level remained between 5-7 g/dL during the steroid course over the next 15 months, indicating a lack of response to steroids.
At the time of presentation to us, the patient had a pulse rate of 105/min, blood pressure of 106/66 mmHg, oxygen saturation on room air of 93%, height of 155 cm, weight of 43 kg, and a body mass index of 17.9 kg/m2. A physical examination of the patient revealed anaemia and jaundice. Abdominal examination revealed Hackett’s Grade IV splenomegaly and mild hepatomegaly. Laboratory findings revealed Hb of 5.9 g/dL, White Blood Cells (WBC) of 9.3×103/μL, platelet count of 127×103/μL, total/indirect bilirubin of 7.7/6.5 mg/dL, Lactate Dehydrogenase (LDH) of 732 μ/L, and Alkaline Phosphatase of 527 μ/L. Computed Tomography (CT) revealed a spleen length of 22.5 cm and a liver length of 17.4 cm in craniocaudal length (Table/Fig 1). The patient was taking tablet prednisolone 40 mg per day at the time of presentation.
Injection Rituximab 100 mg weekly for four cycles was started in October 2022, and the patient was followed for the next eight weeks to evaluate the response. The patient did not show significant improvement after rituximab therapy, and the Hb levels remained between 5-7 g/dL, indicating non responsiveness to rituximab.
Laparotomy and splenectomy were performed on the 1st of January 2023. The operative time was 130 minutes, and blood loss was 150 mL. No blood transfusion was required during surgery. The spleen weighed 2400 grams (Table/Fig 2). Gross pathological examination revealed no obvious mass. Histopathological examination revealed no evidence of lymphoma. The postoperative period was uneventful.
By postoperative day 7, the Hb level reached 9 g/dL, and the indirect bilirubin level was reduced to 0.3 mg/dL. The patient was discharged on postoperative day 12. Prophylactic aspirin was given for three months because of postsplenectomy thrombocytosis as per institute protocol. Hb levels remained between 9-11 g/dL during three monthly follow-ups. The steroid dose was tapered down over four months after surgery. At the 15-month follow-up, the Hb was 10 g/dL, and the indirect bilirubin was 0.7 mg/dL, signifying a complete response after splenectomy (Table/Fig 3).
The AIHA is a relatively uncommon disorder caused by autoantibodies directed against self-red blood cells. The disease may be primary (idiopathic) or secondary to autoimmune diseases (20%), lymphoproliferative syndromes (20%), tumours, and infections (1). The disease course is greatly unpredictable, ranging from cases developing gradually or fully compensated to patients with rapid onset of life-threatening anaemia. Diagnosis is based on haemolytic anaemia and serological evidence of antierythrocyte antibodies, detectable by the DAT (1).
Two serological types of the disease, WAIHA, and Cold Agglutinin Disease (CAD), are recognised based on the thermal range of the autoantibodies. In WAIHA, the DAT usually shows positive results with anti-IgG antisera like in the present case, and in CAD, the DAT shows positive results with anti-C3d antisera, indicating the presence of high-titre cold agglutinins. In rare cases, there is the co-existence of high-titre cold agglutinins and warm antibodies, which are designated as mixed-type AIHA. The DAT can demonstrate negative results in 10% of AIHA cases designated as atypical AIHA (1).
For many years, the standard first-line therapy has been glucocorticoids, which are effective in 80-90% of patients (2). Prednisolone is usually started at a dose of 0.5-1.5 mg/kg for 1-3 weeks until haemoglobin levels greater than 10 g/dL are reached. The response mainly occurs during the second week, and if no or minimal improvement is observed in the third week, this therapy is assumed to be ineffective (3),(4). However, 10-20% of patients are either refractory to steroid therapy or relapse after an early response and need additional second-line therapies, which consist of various immunosuppressive agents such as azathioprine, cyclosporin, mycophenolate mofetil, rituximab, and splenectomy, which are reported to provide a 40%-75% response rate (5). However, high clinical heterogeneity in the disease, encompassing both presentation and treatment response, necessitates an empirical approach to second-line therapy selection due to a lack of well-established guidelines. Currently, no reliable prognostic factors are available to guide treatment decisions. Traditionally, after initial steroid treatment, splenectomy was the established second-line intervention. However, in recent years, rituximab has emerged as the preferred strategy. This shift likely reflects the advantages of rituximab, including its minimally invasive nature compared to surgery and the preservation of essential splenic function (2),(6).
Recent American (7) and United Kingdom (1) guidelines have also recommended rituximab. In a meta-analysis, the overall response rate of WAIHA to rituximab was 79% (8). In a recent multicentre retrospective study, the time to respond to rituximab was one month in 87.5% and three months in 12.5% of patients (9). Therefore, authors waited for eight weeks after completing rituximab therapy before deciding on splenectomy in the present case. Low-dose rituximab (100 mg fixed weekly dose for four weeks) has been reported to be as effective as the conventional dose (375 mg/m2 weekly for four weeks) in WAIHA (10), and that was the basis of using low-dose rituximab in the present case. The long-term response of splenectomy in medically refractory AIHA has been reported as 70-80% (11),(12). Authors still do not have a clear answer as to why some patients respond and others do not respond to steroids or other medical therapy. The course of the disease and treatment outcome remain largely unpredictable. There is also a lack of research on the predictive factors that may help in choosing appropriate therapy from the beginning, which could potentially reduce the incidence of refractory cases. In the present case, authors hypothesise that the inadequate response to rituximab and steroids was partly due to the massive size of the spleen, which becomes the dominant factor for haemolysis because extravascular haemolysis in WAIHA occurs mainly in the spleen due to the action of Immunoglobulin G, and the adequate response could have been achieved only after splenectomy. However, because of the lack of data in the literature, especially on the role of spleen size in disease outcome and treatment planning, this hypothesis requires validation in prospective or randomised larger studies.
The treatment outcomes of AIHA are mostly unpredictable, with high rates of primary treatment failure often requiring second or third-line treatments. Authors hypothesise that the size of the spleen should be considered before selecting a treatment option for WAIHA. The presence of significant splenomegaly in patients with WAIHA may serve as a useful indicator for choosing splenectomy over rituximab as second-line therapy in cases of WAIHA that are refractory to steroids, in selected cases.
DOI: 10.7860/JCDR/2024/70930.19701
Date of Submission: Mar 27, 2024
Date of Peer Review: May 16, 2024
Date of Acceptance: Jun 05, 2024
Date of Publishing: Aug 01, 2024
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. No
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Mar 27, 2024
• Manual Googling: May 18, 2024
• iThenticate Software: Jun 04, 2024 (9%)
ETYMOLOGY: Author Origin
EMENDATIONS: 6
- Emerging Sources Citation Index (Web of Science, thomsonreuters)
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