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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 Series
Full Version
Acute Mesenteric Ischaemia: A Case Series
Correspondence Address :
Dr. T Jeyalaksmi,
157/4, Golden Jubilee Flats, Padikuppam Road, Anna Nagar West, Chennai-600001, Tamil Nadu, India.
E-mail: jeyatr@gmail.com
Acute Mesenteric Ischaemia (AMI) is a group of disorders characterised by a sudden occlusion of blood supply to varing portions of the small intestine, eventually progressing to ischaemia and peritonitis. The present case series highlights a total of seven cases, three of which are classified as acute superior mesenteric artery thrombosis and four as acute superiormesenteric vein thrombosis. The typically symptoms reported were sudden onset of abdominal pain, distension, and melena (a late finding). Among the seven cases, four patients who received early intervention had favourable outcomes. All patients presented late with peritonitis symptoms, except for one patient. Emergency laparotomy was performed on all patients, except for one who underwent diagnostic laparoscopy. Therefore, although abdominal pain is an uncommon symptom, physicians need to exercise a high level of diligence. If left untreated, the overall mortality rate consistently exceeds 70-90%. This case series emphasises the importance of timely diagnosis, early intervention, and immediate postoperative heparinisation, which significantly decrease morbidity and mortality.
Abdominal pain, Melena, Superior mesenteric artery thrombosis
Acute Mesenteric Ischaemia (AMI) is defined as an abrupt interruption of the blood supply to a segment of the small intestine, leading to ischaemia, cellular damage, intestinal necrosis, and eventual patient death, if left untreated (1). Conventionally, AMI is classified as Non Occlusive Mesenteric Ischaemia (NOMI) or occlusive, with the primary aetiology further defined as mesenteric arterial embolism (50%), mesenteric arterial thrombosis (15%), or mesenteric venous thrombosis (5-15%) (1). Intestinal viability is the most important factor that influences outcomes in AMI. Currently, emerging technologies have an edge of high resolution contrast-enhanced imaging in the arterial/ venous phase, which has a leverage in early diagnosis and management.
Despite the fact that various models have been designed to predict the course of AMI and prevent worse outcomes, mortality from AMI yet remains high. This series of cases vividly describes the plethora of presentations and intraoperative findings associated with various outcomes of AMI (Table/Fig 1).
Case 1: A 50-year-old male presented to the Emergency Department (ED) with abdominal pain, distension, vomiting (five episodes), and melena for two days. Upon admission the patient was haemodynamically stable. Clinically, the abdomen was distended with diffused tenderness and guarding. Without bowel sounds and blood-stained stools were noted on digital rectal examination. Contrast-enhanced Computed Tomography (CECT) abdomen revealed a thrombus in the superior mesenteric vein. Emergency laparotomy showed a gangrenous small bowel segment extending 30 cm from the Duodenojejunal (DJ) flexure to 15 cm proximal to the Ileocecal (IC) junction (Table/Fig 2). The gangrenous bowel segment was resected, and a proximal jejunostomy with distal ileal mucous fistula. Total parenteral nutrition and liquid diet was initiated on Postoperative Day (POD) 2. However, on POD 4, the patient deteriorated to renal failure and required haemodialysis. Total parenteral nutrition and nutritional supplements were used to manage postoperative short bowel syndrome and acid-base imbalance. Jejunoileal anastomosis was performed on POD 40, and the patient was discharged on POD 50 with oral anticoagulants.
Case 2: A 45-year-old male, chronic alcoholic and smoker, presented with vague, diffuse abdominal pain and diarrhoea for past two days. On clinical examination, abdomen was distended, tense and rigid. The patient was haemodynamically unstable. Initial resuscitation with crystalloids and inotropes was initiated. Emergency laparotomy showed massive gangrenous bowel loops extending 15 cm from the DJ flexure to the middle 1/3rd of the ascending colon (Table/Fig 3),(Table/Fig 4). The gangrenous segment was resected, and a proximal jejunostomy with distal transverse colostomy was performed. However, due to sepsis and haemodynamic instability, the patient required mechanical ventilation. Unfortunately, the patient succumbed to multiorgan dysfunction syndrome on day 2.
Case 3: A 50-year-old male chronic alcoholic, presented with abdominal pain and melena for past two days. Clinically, he was icteric, with an abdominal finding of splenomegaly, and diffuse tenderness and guarding. Laboratory parameters showed leucocytosis with elevated serum total and direct bilirubin levels of 8 mg/dL and 4 mg/dL, respectively. CECT abdomen revealed mesenteric haziness with complete occlusion of the superior mesenteric vein by a thrombus extending into the portal vein and intrahepatic inferior vena cava. Emergency laparotomy showed gangrenous bowel loops extending 15 cm distal to the DJ flexure up to 150 cm from the IC junction (Table/Fig 5),(Table/Fig 6). On POD 5, the patient developed electrolyte imbalance with Multiple Organ Dysfunction Syndrome (MODS) and died on POD 6.
Case 4: A 62-year-old male presented with abdominal pain for 10 days, along with vomiting and melena. Laboratory parameters showed leucocytosis and elevated serum total and direct bilirubin levels of 6 mg/dL and 3 mg/dL, respectively). CECT abdomen revealed a partial thickness thrombus in the superior mesenteric vein, extending 5.8 cm into one of its branches and causing complete occlusion. A corresponding short segment of ileal loops (10 cm) showed no enhancement, along with surrounding mesenteric haziness and features of a liver abscess. Intraoperatively, multiple enlarged necrotic mesenteric lymph nodes were noted (Table/Fig 7). The bowel was viable, and tissue nodal biopsy showed non specific 2inflammation without evidence of malignancy or tuberculosis. The patient was discharged on POD 14.
Case 5: A 45-year-old male, a chronic smoker, presented with abdominal pain lasting for one day. On examination, the abdomen was soft with diffused tenderness. Due to the disproportionate abdominal pain to clinical findings, a CECT abdomen was performed, which revealed 70% occlusion of the superior mesenteric artery with multiple collaterals. Emergency diagnostic laparoscopy showed pale small bowel loops extending proximally 30 cm from the DJ flexure to 200 cm proximal to the IC junction.
Case 6: A 50-year-old male presented with abdominal pain and obstipation for the past two days. Urgent CECT abdomen revealed mesenteric haziness, free fluid, and complete occlusion of the superior mesenteric artery at its origin. Emergency laparotomy showed a gangrenous small bowel segment extending 30 cm from the DJ flexure to 50 cm proximal to the IC junction. The gangrenous segment was resected, and a proximal jejunostomy with distal ileal mucous fistula was started. Intravenous anticoagulants were initiated, and oral medications started on POD 2. Postoperatively, the patient developed short bowel syndrome with electrolyte imbalance, which was managed with total parenteral nutrition and nutritional supplements. Jejunoileal anastomosis was performed on POD 54 (Table/Fig 8),(Table/Fig 9). The patient recovered with oral anticoagulants.
Case 7: A 65-year-old female presented with abdominal pain and diarrhoea for past two days and initially was admitted to the medicine ED. Emergency CECT abdomen revealed complete occlusion of the superior mesenteric artery and 70% occlusion of the celiac artery, with fluid-filled bowel wall and dilated bowel loops were observed (Table/Fig 10),(Table/Fig 11),(Table/Fig 12). Emergency laparotomy was performed, revealing a gangrenous small bowel segment extending 20 cm from the DJ flexure up to 50 cm proximal to the IC junction. Resection of the gangrenous small bowel segment was done, along with the creation of a proximal jejunostomy and distal ileal mucous fistula. On POD 4, she developed a burst abdomen and underwent emergency relaparotomy. It was found that gangrene had further progressed proximally in the jejunum, and there was also gangrenous discoloration in the gallbladder and cystic duct. The gangrenous segment was resected, and a proximal tube jejunostomy, tube cholecystostomy, and distal mucous fistula were created. Unfortunately, the patient expired on POD 7 due to severe sepsis and MODS.
Typically occurrence of AMI is considered as a disease of the elderly in Western nations with an average diagnosis age of 65 years, is being diagnosed at least a decade earlier in the Indian population (2),(3). The present study represents, the average age of diagnosis was 52 years, significantly younger than the Western population. While SMA disease is more commonly encountered than SMV disease, the present case series is predominantly characterised by SMV thrombosis (4). Proximal occlusion leads to extensive bowel necrosis, whereas distal disease is often associated with patchy intestinal necrosis. Similarly, complete occlusion is linked to increased morbidity and mortality, while partial occlusion or occlusion with collaterals is associated with milder disease. Among the seven patients in the present case series, only two had viable bowel, while the remaining five experienced extensive bowel gangrene. Three patients who underwent extensive bowel resections succumbed to death due to various factors, while the survivors experienced short gut syndrome and required immediate bowel anastomosis to establish intestinal continuity. AMI presents with a wide spectrum of symptoms, ranging from non specific abdominal pain to signs of diffuse peritonitis. Unfortunately, most patients are identified after the critical period due to paucity of abdominal signs, as observed in the present study (5). The patients in the present study, who presented late with guarding and rigidity could not be successfully resuscitated, while those with non specific symptoms had a better prognosis. Therefore, a high index of suspicion is crucial for early diagnosis and prevention of mortality. While the prognosis in AMI is influenced by multiple factors, and multivariate analysis in previous studies has identified leucocytosis, elevated lactate, bilirubin, and creatinine as independent predictors of mortality (6). In the current case series, the association of leucocytosis and hyperbilirubinemia increased the morbidity rate but was not significantly associated with mortality. Overall, the mortality rate associated with AMI is high, with certain literature studies reporting over 50% (7),(8). In the present case series patient group, three out of seven patients died (42%) as a result of sepsis-induced MODS. Several studies have highlighted the relationship between smoking and alcoholism, with some suggesting a causal relationship and others demonstrating a synergistic relationship (9). Nicotine smoke has various toxic substances which is considered as one of the aetiological factors for AMI (10). In the present study, three patients reported a history of smoking or alcoholism, and two of them died due to MODS. The direct role of these addictive habits in mortality is yet to be determined. Anticoagulation therapy plays a critical role in patients presenting with intestinal necrosis, as surgical revascularisation procedures may not be feasible (11). All patients in the current case series were initiated with intravenous unfractionated heparin initially, and those who were discharged continued oral warfarin therapy with close monitoring of prothrombin time. We ruled out Coronavirus Disease 2019 (COVID-19) infection and COVID-19-associated pneumonia as rare causes of mesenteric thromboembolism leading to bowel gangrene, as all the present study patients tested negative for COVID-19 and had no history of COVID-19 vaccination (12). CT angiography is considered the gold standard for diagnosing AMI, with a sensitivity of 0.96 and specificity of 0.94 (13). Different endovascular revascularisation techniques, combined with pharmacological agents, have gained popularity in recent years [14,15]. However, these techniques are contraindicated in cases of bowel ischaemia and infarction. The choice of permanent maintenance nutrition treatment should be determined on an individual basis. Long-term total parenteral nutrition plays a significant role in determining the prognosis and survival of the patient. Small bowel transplantation is an option for cases of long-term parenteral nutrition and short bowel syndrome, but it carries a higher risk of graft rejection due to increased immunogenicity and infection compared to solid organ transplantation (4).
As AMI frequently affects the elderly population, physicians need to be aware and cautious of the possibility of this condition, even with mild sudden onset of abdominal pain. The diagnosis of AMI is challenging and often delayed, leading to irreversible bowel ischaemia which necessitates emergency surgery. CECT of the abdomen is the frontrunner for early diagnosis and appropriate management. Mortality and morbidity rates for AMI remain high, and the survival rate is low in cases requiring extensive bowel resection.
The authors express their heartful thanks to Dr. Bhavik Rajesh Shah for the help and support evinced to complete the present study.
DOI: 10.7860/JCDR/2023/64864.18281
Date of Submission: Apr 19, 2023
Date of Peer Review: May 08, 2023
Date of Acceptance: Jun 18, 2023
Date of Publishing: Aug 01, 2023
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• 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
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Apr 20, 2023
• Manual Googling: May 09, 2023
• iThenticate Software: Jun 15, 2023 (7%)
ETYMOLOGY: Author Origin
EMENDATIONS: 8
- Emerging Sources Citation Index (Web of Science, thomsonreuters)
- Index Copernicus ICV 2017: 134.54
- Academic Search Complete Database
- Directory of Open Access Journals (DOAJ)
- Embase
- EBSCOhost
- Google Scholar
- HINARI Access to Research in Health Programme
- Indian Science Abstracts (ISA)
- Journal seek Database
- Popline (reproductive health literature)
- www.omnimedicalsearch.com