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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
Histological Recovery Profiles Of Patients With Celiac Disease- An Indian Perspective.
Correspondence Address :
Dr Rahul Mannan,C/O Dr V. K Rampal,5-Court Road, Amritsar-143001,Punjab(India)Ph- +91946354525 (O), 091-0183-2504062 (R)
ABSTRACT
Aim
Celiac disease is characterized by malabsorption, abnormal small bowel structure and intolerance to gluten. The present study was planned to determine the histological recovery profiles of patients with celiac disease especially, north Indians who consume wheat as the staple diet.
Methods
56 patients were selected for the present study, who were diagnosed to have celiac disease on the basis of their clinical profiles (according to the criteria enumerated by the European society for pediatrics gastroenterology and nutrition), serological examination and confirmation on endoscopic biopsy. Repeat biopsies were taken in all 56 cases. Marsh classification was employed to score the biopsies.
Results
The most common histological presentation at the first biopsy was total villous atrophy (Marsh stage IIIc, 83.9%) followed by subtotal villous atrophy (Marsh stage IIIb, 12.5%) and partial villous atrophy (Marsh stage IIIa, 3.6%). At the end of minimum one year of gluten free diet it was observed that 42 cases (75%) of showed some degree of histological down staging. Of these, 26 (46.42%) recovered completely i.e. to marsh stage 0 (normal villous pattern). Also, 14 out of 56 (25%) cases did not down stage, implying a lack of histological recovery.
Conclusions
The study adds to the limited literature which is available on the histological recovery profiles of patients with celiac disease in the Indian population. The study emphasizes on two facts, one, a time dependency of the response of gluten free diet and second, the importance of proper categorization at the initial biopsy, as higher grades lead to therapeutic refraction.
Histological Recovery Profile, Celiac Disease, India, Marsh Classification.
BACKGROUND
Celiac disease is a disorder which is characterized by malabsorption, abnormal small bowel structure, intolerance to gluten (a protein found in wheat and wheat products) and prompt improvement after a gluten free diet.(1).
Although celiac disease is still considered to be uncommon among some Asian and African populations (2) its prevalence in India is reported to be on the rise (3).
Surprisingly, follow up data on small intestinal recovery in celiac disease are scarce and contradictory, with paucity of literature on the histological recovery profiles of patients with celiac disease in the Indian population. The present study was planned to determine histological recovery profiles of patients with celiac disease, especially North Indians who consume wheat as staple diet.
The present study was carried out in conjunction with the departments of pathology and gastroenterology of our referral centre. 56 patients were selected in the present study who were diagnosed to have celiac disease on the basis of their clinical profiles, serological investigations mainly anti tissue transglutaminase (TTG)) and on confirmation by endoscopic biopsy. The histological confirmation was done on the basis of the Marsh classification (4),(5) (Table/Fig 1). The histological findings and TTG levels were noted carefully at the time of diagnosis (before initiation of a gluten free diet).
These cases (who were initiated on a gluten free diet) were followed up closely over a period of at least one year or more and repeat biopsies were taken; also, TTG levels were noted. A comparison was done mainly to assess the patient recovery by means of hemoglobin levels, clinical symptoms, serological levels and histological findings in the initial and the subsequent biopsies.
The duodenal biopsies were retrieved by an endoscope from the second part of the duodenum. Four samples were taken and were carefully oriented on filter paper and were fixed in 10% neutral formalin. The sections which were processed, were examined in a double blinded fashion by two pathologists. In case of discrepancy, the opinion of a third pathologist was taken and two concordant observations were treated as final. The data collected was subjected to statistical analysis and p-values were calculated wherever possible.
In the 56 cases of the present study; the age distribution was varied, which ranged from 3-52 years. The mean age in the study group was 20.16+13.38 years. Patients from a younger age group (18 years) constituted the largest cohort, comprising of 60.71% of all the cases (Table/Fig 2). There were 30 males and 26 females in the present study group with a male to female ratio of 1.2:1.
The most common presenting complaint was diarrhoea (42.8%), followed by abdominal discomfort (37.5%) (Table/Fig 3). The mean hemoglobin of these patients at presentation was 9.131.094 grams/dl, and at the end of at least one year of follow up with a gluten free diet, it was 11.041.45 grams/dl. The mean percentage improvement in hemoglobin was 17.2, which was statistically significant.
The most common histological presentation at the first biopsy was total villous atrophy (Marsh stage IIIc, 83.9%) followed by subtotal villous atrophy (Marsh stage IIIb, 12.5%) and partial villous atrophy (Marsh stage IIIa, 3.6%). There were no cases of stage 0, I and II of the Marsh classification in all the 56 cases which were included in the present study at the initial biopsy (Table/Fig 4) (Fig. 1, 2, 3, 4, 5, and 6).
The mean follow up duration after putting the patients on a gluten free diet was 1.98 years. The majority of the patients (53/56) showed a dramatic clinical improvement, such as gain in weight and relief from diarrhoea along with improvement in hemoglobin levels.
Of the 47 patients who presented with total villous atrophy, (Marsh Stage III c) initially; 19 cases (40.42%) recovered completely and 12 cases (25.53%) remained at the same stage even after adhering to a gluten free diet for one year (Table/Fig 5).
Five (71.42%) out of the seven cases which presented with subtotal villous atrophy, (Marsh Stage III b) initially recovered completely, whereas; two (28.57%) remained at the same stage at the end of one year of follow up. However; both of the cases presenting with partial villous atrophy, (Marsh Stage III a) initially recovered completely.
Thus, at the end of minimum one year of gluten free diet adherence, it was observed that 42 cases (75%) of the total cases showed some degree of histological down staging. Of these, 26 (46.42%) recovered completely i.e. to marsh stage 0 (normal villous pattern). Also, 14 out of 56 (25%) cases did not down stage, implying lack of histological recovery. Maximum recovery rates were seen in patients presenting with stage IIIa (100%) and minimum recovery was seen in patients presenting with total villous atrophy, i.e. Marsh stage IIIc (44.6%). The p values of the recovery profiles in all the three categories are statistically significant (Table/Fig 6),(Table/Fig 7).
The recovery rate was highest in the age group 41-50 years and males documented better recovery than females (Table/Fig 8),(Table/Fig 9).
No known complications of celiac disease like collagenous sprue or enteropathy associated T-cell lymphoma were documented during the course of the present study.
The name sprue was coined in the 18th century and has been derived from the Dutch word ‘spruw’, which means ‘aphthous disease’, which was so named because of the high prevalence of aphthous ulcers in such patients (6).
Thin perhaps gave the first account of the pathological appearances of the small intestine in ‘sprue’ (7). Royer and his colleagues in Argentina described a technique for per oral duodenal biopsy by aspiration (8). Since then, endoscopic biopsy has become a routine procedure for the investigation of celiac patients.
A serendipitituous observation in Netherlands during World War II led to the finding that wheat exacerbates celiac sprue. As the cereals which were used to make bread were particularly scarce, the children with celiac disease improved; only to relapse after the replenishment of cereal supply at the end of the war. Subsequent work showed that it was the water insoluble portion or the gluten moiety of the wheat that produced malabsorption in patients with celiac sprue (9) ,(10).
Celiac disease affects women more commonly than men, with male to female ratio described in the range of 1: 1.3-2 (11). In our study, male patients were more common, which can be explained firstly, on the basis of higher male to female sex ratio in Punjab and secondly on the probable basis of prevalent social ill of ignoring the female child in resource challenged countries like India.
The most common presenting complaint in the present study was diarrhoea (42.8%), followed by abdominal discomfort /distension (37.5%), as stated in other studies also(12),(13).
After starting a gluten free diet, there was an improvement in the mean hemoglobin as pointed out in earlier studies (14). Recovery from anemia occurs between six and twelve months after starting on a gluten free diet as a consequence of the normalization of the histological alterations of the intestinal mucosa.
The most common histological presentation according to the Marsh classification in the present study was total villous atrophy – stage IIIc, followed by sub-total villous atrophy - stage IIIb and partial villous atrophy - stage IIIa. These findings are in variance with other studies; including a study conducted in India, where a higher incidence of stages IIIa and IIIb have been quoted (12),(15). The possible reason for the majority of Indian patients diagnosed in Stage III is, a lack of awareness about celiac disease. Also, these patients generally reach the hospital late as the symptoms are easily confused with those of gastrointestinal infectious diseases, for which over the counter drugs are easily available and/or nutritional deficiencies.
All the patients in our study after the first biopsy were counseled to go on a gluten free diet and were then followed up at monthly intervals. Most of them (53/56) showed dramatic clinical improvement including a fall in TTG levels. Three patients, who had initially responded clinically to a gluten free diet, later relapsed due to non-compliance with a gluten free diet. Literature states that lack of adherence to strict gluten-free diet is the main reason of poorly controlled disease (16). Dietary compliance as assessed by interview is the best marker for celiac disease control due to low cost, non-invasiveness, and a strong correlation with intestinal damage.
Follow up biopsies taken after a minimal interval of one-year (mean 1.98 years) showed that 46.42 % cases recovered completely i.e. to stage 0 of Marsh classification and 25% patients persisted with villous atrophy (stage IIIc/IIIb) (Table/Fig 10),(Table/Fig 10 and Table/Fig 11) . This is in concordance with the studies conducted by various researchers, noticeably by Ciacci C et al and McNicholl B et al who have showed similar recovery rates and persistent change on repeat biopsy with a gluten free diet (17),(18). However, the work conducted by Wahab et al reported greater recovery rates in the range of 85.3 % on a gluten free diet (15).
This can be explained by the longer duration of follow up, that is 5 years in these cases, as compared to the mean follow up of 1.98 years in the present study. This very fact is highlighted by the reports by various researchers that the recovery of the intestinal mucosa with gluten sensitive enteropathy during a gluten free diet continues beyond 9-19 months and is still incomplete after 2-4 years; so, recovery rates increase with time (19).
Findings in the present study of maximal recovery rates in patients presenting initially with stage IIIa (100%) and minimal recovery rates in patients presenting with total villous atrophy that is Marsh stage IIIc (44.6%), correlate with the findings observed by other researchers (15). Thus, the present study also concludes that patients presenting with lower histological stage show recovery in a larger percentage of cases (Table/Fig 10) (Table/Fig 10 &11).
Also, recovery rates in children are reported to be higher in comparison to that in adults by many researchers (15). This fact is corroborated in the study undertaken, which shows a higher percentage of complete recovery (50%) as compared to the adult population, which showed complete recovery to the tune of 45.45%.
Long term complications in the cases which were considered to be refractory, show symptoms of active celiac disease. The mortality rate though low, has been reported in such cases. Disseminated enteropathy-associated T-cell lymphomas are known to develop in patients with refractory disease, which is usually not seen in any of the patients with non-refractory disease. No such complications were seen in our study, as these complications are encountered on long-term follow up (20),(21).
A decade ago, celiac disease was considered to be a comparatively uncommon disorder with a prevalence of 1 in 1000 or lower. The greater awareness of its presentation and the availability of new accurate serological tests such as IgA endomysial antibodies, anti tissue transglutaminase and anti glidan antibodies have lead to the realization that it is relatively common, affecting 1 out of every 120-300 persons in Europe and North America (22).
Clinical applications of serological tests include not only the evaluation of patients with suspected celiac sprue depending on their pre-test probability of having the disease, but also the monitoring the adherence and response to a gluten free diet, as well as possibly screening asymptomatic persons for the disease.
The incidence of celiac disease in India is on the rise. The varied atypical clinical symptoms of the patients with celiac disease call for a greater awareness of this pathology amongst health professionals in the emerging countries in Asian countries where, this is still regarded as a disease of the west.
Literature regarding the histological recovery profile is limited and that too, especially for the Indian sub-continent. The present study adds to the available literature and statistical analysis on celiac disease, by having a substantial sample size (56 cases) and interval (minimal interval of one and a half year).
The study further emphasizes the fact of time dependency on the response of gluten free diet in celiac disease and also, the importance of proper categorization (histological grading) at the initial biopsy, as higher grades lead to therapeutic refraction. In all such higher grade cases, prompt and strict adherence to a gluten free diet, along with shorter follow up duration by the physician in charge is required.
These cases in turn, may be the ones which present with aberrant and neoplastic complications.
1. Celiac disease is a disorder which is characterized by malabsorption, abnormal small bowel structure, intolerance to gluten (a protein found in wheat and wheat products) and prompt improvement after a gluten free diet
2. It is important to properly categorize (histological grading) at the time of initial biopsy, as higher grades lead to therapeutic refraction. In all such higher grade cases, prompt and strict adherence to a gluten free diet along with shorter follow up duration by the physician in charge is required.
3. The most common histological presentation according to the Marsh classification in the present study was total villous atrophy – stage IIIc followed by sub-total villous atrophy - stage IIIb and partial villous atrophy - stage IIIa.
4. Maximal recovery rates were seen in patients presenting initially with stage IIIa (100%) and minimal recovery rates were seen in patients presenting with total villous atrophy, i.e. Marsh stage IIIc (44.6%). Thus, the patients presenting with lower histological stage showed recovery in a larger percentage of cases.
5. Recovery of the intestinal mucosa with gluten sensitive enteropathy during a gluten free diet continues beyond 9-19 months and is still incomplete after 2-4 years; so recovery rates increase with time.
6. The varied atypical clinical symptoms of the patients with celiac disease call for a greater awareness of this pathology amongst health professionals in the emerging countries in Asian countries, where this is still regarded as a disease of the west.
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