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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
A Retrospective Study of Puerperal Infection and its Aftermath: Current Scenario from a Tertiary Healthcare Centre, Telangana, India
Correspondence Address :
Dr. Sangeeta Shah,
Professor and Head, Department of Obstetrics and Gynaecology, Gandhi Medical College, Hyderabad-500003, Telangana, India.
E-mail: drsshah19@yahoo.com
Introduction: Even after decades of the development of low-cost and effective antibiotics, puerperal infections remain an important cause of preventable maternal morbidity and mortality.
Aim: The aim of the present study was to determine the risk factors, morbidity, and mortality associated with puerperal infections.
Materials and Methods: A retrospective study was conducted from March 2021 to October 2021, at the Obstetrics and Gynaecology Department of Gandhi Hospital in Telangana, India. The study included all women who delivered in this hospital and were referred within 42 days after delivery with fever and any of the following symptoms: pain abdomen, malodorous lochia, abdominal distention, subinvolution of the uterus, pelvic abscess, peritonitis, any system/organ failure, or shock. Various risk factors such as age, parity, socioeconomic status (according to the modified Kuppuswamy scale), BMI, rupture of membranes, mode of delivery, and comorbidities associated with puerperal infection were assessed. Complications following puerperal infection were also studied. Data analysis was performed using SPSS version 23.0, and the results were presented in frequency and percentages of categorical variables.
Results: During the study period, there were 161 cases of puerperal infection. The majority of cases were between the age group of 26-30 years, constituting 72 (44.7%) cases. Among them, 86 (53.4%) cases were multiparous, 50 (31%) cases were primiparous, 10 (6.2%) cases were second gravida, and 15 (9.3%) cases were third gravida. Lower middle-class women accounted for 67 (41.6%) cases, and 85 (52.7%) cases were in the overweight range. Prolonged premature rupture of membranes for more than 24 hours was observed in 78 (48.4%) cases. Caesarean section was the mode of delivery for 90 (56%) cases of puerperal infection cases. The most commonly associated comorbidities were anaemia in 63 (39.1%) cases, severe preeclampsia in 47 (29.1%) cases, abruption in 31 (19.2%) cases, and diabetes in 20 (12.4%) cases. Prolonged hospital stay was observed in 144 (89.4%) cases, wound gaping in 26 (16.1%) cases, and disseminated intravascular coagulation in 24 (14.9%) cases. A total of 31 (19.2%) cases of women succumbed, mostly due to multi-organ failure.
Conclusion: Early diagnosis, proper ICU facilities at all levels of healthcare, timely referral to tertiary facilities, health education, and strict aseptic measures would be crucial in tackling this menace.
Maternal mortality, Morbidity, Prevention, Puerperal infection, Septicaemia
One of the immediate threats to any mother delivering her child worldwide is “Puerperal Sepsis,” as noted by Buddeberg BS et al., and Montgomery AL et al., in their national surveys [1,2]. The leading cause of maternal mortality was postpartum haemorrhage, followed by puerperal sepsis, and the subsequent cause was preeclampsia and eclampsia (3). It was noted that puerperal infections cause approximately 17.2% of maternal deaths in the esteemed “Million Death Study” published in 2014 (1). It accounts for approximately 12,300 maternal deaths that could have been prevented by appropriate protocols and aseptic precautions (1).
Puerperal sepsis is defined by the WHO as an infection of the genital tract, occurring any time between rupture of membranes or labor and the 42nd day postpartum, with two or more of the considered symptoms being pelvic pain, fever, abnormal vaginal discharge, and delay in the reduction of the size of the uterus. The WHO has also defined “Puerperal Infection” as including both genital and non-genital infections in the obstetric population (4).
Normally, the abdominal wall and reproductive, genital, and urinary tracts are highly sterile environments that can be introduced to bacteria either from physiological or iatrogenic trauma during childbirth or abortion (5). While pregnancy is a unique immunological state undergoing a multitude of variations, increasing the infection load on the immune system can have serious consequences. Improperly managed puerperal infections can lead to acute kidney injury, acute liver injury, disseminated intravascular coagulation, wound gaping, the need for mechanical ventilation, and even death (6). Various maternal predisposing factors have been identified, such as maternal obesity, mode of delivery, and comorbidities such as diabetes mellitus, anaemia, and preeclampsia (6). Multiple pathogens have been identified as the cause of infections, with the most common being E. coli, Klebsiella, Pseudomonas, and Methicillin-Resistant Staphylococcus Aureus (MRSA) (7).
According to a recent study, approximately 1-6 people in every 10,000 deliveries had maternal morbidity due to puerperal sepsis, and approximately 17 deaths in every 100 maternal deaths were due to sepsis (8). As it is a significant contributor to both maternal mortality and morbidity, its burden in present-day society needs to be regularly monitored by studies in order to establish advanced and appropriate regulations and protocols wherever required. In the Indian scenario, apart from medical morbidity, it can also have economic consequences for the families involved. There is a requirement for an in-depth analysis of such causes concerning the cases, aetiopathogenesis, varied clinical presentations, and principles of management to prevent the progression of infection to puerperal sepsis, its complications, and bacterial resistance (9). With this background, the present retrospective study was conducted with the aim of determining the risk factors, morbidity, and mortality associated with puerperal infections.
A retrospective study was conducted from March 2021 to October 2021 in the Department of Obstetrics and Gynaecology at Gandhi Medical College, Telangana, India. Institutional Ethical Committee approval was obtained (IEC/GMC/2021/01/09).
During the study period (January 2019 to September 2019), there were approximately 7,150 admissions in the Department of Obstetrics and Gynaecology. Out of 5,168 deliveries, 17 (0.3%) resulted in puerperal infection. Among the 161 cases of puerperal infection, 144 cases (89.4%) were referred cases.
Inclusion and Exclusion criteria: The inclusion criteria for the study included all women who delivered in the hospital and were referred within 42 days after delivery with fever and any of the following symptoms: abdominal pain, malodorous lochia, diarrhea, vomiting, wound infection, abdominal distention, sub-involution of the uterus, pelvic abscess, peritonitis, any system/organ failure, or shock. Patients with fever during pregnancy, more than 42 days after delivery, miscarriage, or fever due to COVID-19 infection were excluded.
Various risk factors such as age, parity, socioeconomic status (according to the modified Kuppuswamy scale (10)), BMI, rupture of membranes, mode of delivery, and comorbidities associated with puerperal infection were assessed. Complications following puerperal infection were studied.
Statsitical Analysis
Data analysis was performed using SPSS (version 23.0) for Windows, and the results were presented in frequencies and percentages of categorical variables.
The results showed an incidence of 161 (2.2%) cases of puerperal infection. The majority of cases belonged to the age group of 26-30 years, with 72 (44.7%) cases (Table/Fig 1) (11). Most of the cases were multigravida, accounting for approximately 86 (53.4%) cases, while 50 (31%) cases, 10 (6.2%) cases, and 15 (9.3%) cases were primiparous, second gravida, and third gravida, respectively. Out of the 161 cases, 144 (89.4%) cases were referred cases. Among the cases, 98 had a history of premature rupture of membranes, with 78 (48.4%) cases having a rupture history of 5more than 24 hours and 20 cases (12.4%) having a rupture history of less than 24 hours.
Approximately 90 (56%) cases of the puerperal infection cases were delivered by caesarean section, while 71 (44%) cases were delivered vaginally.
The most prevalent comorbidity associated with puerperal infection was anaemia (52.4%), followed by severe preeclampsia (29.5%) (Table/Fig 2).
In the present study, fever was the presenting complaint in 92% (148) cases, which was also associated with abdominal distension in 42 (26%) cases and wound site discharge and induration in 36 (22%) cases.
Prolonged hospital stay was the most common complication associated with puerperal infection, constituting about 144 cases. Approximately 31 maternal deaths were due to complications following puerperal infection (Table/Fig 3). MRSA was the most common pathogen isolated from the blood, accounting for 68 (42.2%) cases, followed by E.coli in 42 (26.08%) cases, Klebsiella in 32 (19.8%) cases, and pseudomonas in 19 (11.8%) cases. Puerperal infection was more common in women with rupture of membranes lasting more than 24 hours, observed in 61 (38%) cases.
The present study indicates that the incidence rates have relatively improved, while the mortality rate is relatively higher due to it being a state-level tertiary care centre. Early and appropriate interventions at peripheral healthcare facilities can significantly reduce this mortality rate as well.
In this study, most of the women belonged to the age group of 26-30 years (46%). The majority were multiparous, constituting 53.4% (86 cases), which is similar to a study conducted by Khaskheli M et al., where 78.2% were multiparous (6). Most of them were referred and unbooked cases, constituting about 144 cases (89.4%). A similar study was conducted by Marwah S et al., in which 94% of cases were unbooked and belonged more commonly to a lower socioeconomic status (46%) (12). The authors stated that 67% of cases had a caesarean section as the mode of delivery, prolonged rupture of membranes was seen in 42% of cases, anaemia in 42% of cases, pain abdomen in 70% of cases, fever in 100% of cases, and malodorous discharge in 27% of cases (12).
In the present study, the majority of cases belonged to the lower-middle socioeconomic status (41.6%) according to the modified Kuppuswamy scale, which is similar to the study by Marwah S et al., (12). Women who underwent caesarean sections had a higher risk of infection, constituting 56% of cases. In contrast, the studies conducted by Khaskheli MN et al., found that 77.5% were delivered vaginally and 22.48% underwent caesarean section. Karsnitz DB et al., in their clinical review, stated that caesarean birth carries the greatest risk for uterine infection [6,13].
Analyses of risk factors for puerperal infection showed that it is more commonly seen in patients with a BMI greater than 25, anaemia, and gestational diabetes mellitus, which are independent risk factors for infection, similar to a study conducted by Bhaktawar S et al., (3). Therefore, proper pre-pregnancy counseling and correction of GDM and anaemia should be done antenatally to prevent puerperal infection. Proper vigilance is also important for patients with antepartum haemorrhages and severe preeclampsia during labour and postpartum to enable early identification and treatment of infection. In the study conducted by Song H et al., puerperal infection was found in patients with a BMI greater than 25 (31 cases), premature rupture of membranes in 29 cases, diabetes mellitus in 32 cases, and anaemia in 30 cases (7).
In the present study, the incidence of puerperal wound infection was seen in 16.3% of cases, which is almost in line with Karsnitz DB et al., who stated that the incidence in developing countries is about 20% (13). MRSA was the most common pathogen isolated from the blood in the present study, accounting for about 42.6%, followed by E.coli (26.2%), Klebsiella (19.6%), and Pseudomonas (11.4%). In the study conducted by Song H et al., gram-negative bacteria were detected in 60% of cases, gram-positive bacteria in 35% of cases, and fungi in two cases (5%) (7). Staphylococci accounted for 14.5%, E.coli accounted for 27.5%, Klebsiella for 5%, and Pseudomonas for 10% (7).
In the present study, puerperal infection was more common in women with rupture of membranes longer than 24 hours (38%), which is relatively less compared to the study by Khaskheli M et al., where absent membranes were found in 83.7% of cases (6).
The most common clinical features seen in the present study were fever (92%), abdominal distention (26%), and wound site discharge and induration (22%). Prolonged hospital stay was seen in 90.1% of cases. Similar results were seen in the study conducted by Khaskheli MN et al., (6). Fever was the most prevalent symptom (98.1%) in the study by Singh P et al., (9). In the study conducted by Khaskheli MN et al., DIC was seen in 17.8% of women with puerperal infection, and 8.5% of cases resulted in maternal deaths (6).
Proper education at the patient level, early diagnosis, management, and timely referral to higher centres at every healthcare facility, as well as audit of cases and development of new interventions, clinical protocols, training of healthcare personnel, and infection control programs should be implemented at the government level. These measures together can decrease the disease burden and improve the quality of women’s lives, which is an indirect indicator of a better country.
Limitation(s)
The data in this study does not represent the data at every level of the healthcare system as many cases go unreported at peripheral healthcare facilities. Therefore, more studies are required to formulate protocols and reduce maternal mortality and morbidity.
The study indicates that the incidence rates of puerperal infection have relatively improved, but the recorded mortality rate is relatively higher due to the referral of more complicated cases to this tertiary care centre in the state. The responsibility to reduce the burden of the disease lies at every level: patients, healthcare personnel, and the government.
DOI: 10.7860/JCDR/2023/61833.18429
Date of Submission: Nov 26, 2022
Date of Peer Review: Jan 23, 2023
Date of Acceptance: Mar 31, 2023
Date of Publishing: Sep 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
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Nov 27, 2022
• Manual Googling: Mar 25, 2023
• iThenticate Software: Mar 29, 2023 (12%)
ETYMOLOGY: Author Origin
EMENDATIONS: 6
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