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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
Assessment of Subclinical Cardiovascular Disease Risk by Measuring Carotid Intima Media Thickness in Rheumatoid Arthritis Patients: A Cross-sectional Study
Correspondence Address :
Dr. Ranjan Bhattnagar,
Associate Professor, Department of General Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221005, Uttar Pradesh, India.
E-mail: dr.rbngaya@gmail.com
Introduction: Rheumatoid Arthritis (RA) is a chronic inflammatory disease that affects both synovial joints and extra-articular regions. Patients with RA have an increased risk of Cardiovascular Disease (CVD), leading to premature mortality.
Aim: To assess subclinical atherosclerosis in RA patients using Carotid Intima Media Thickness (CIMT) and compare it with age-matched healthy individuals.
Materials and Methods: This cross-sectional study included 50 RA patients and 50 healthy age- and sex-matched controls. Ultrasound was used to measure CIMT, which serves as an indicator of subclinical atherosclerosis. Framingham, Atherosclerotic CVD (ASCVD) risk scores, and QRISK3 scores were used to estimate the 10-year CVD risk. Student’s t-test and Chi-square test were used to identify statistically significant differences.
Results: RA patients had significantly higher mean CIMT values compared to controls (p-value <0.001), indicating an increased burden of atherosclerosis. While ASCVD scores were comparable, Framingham scores were significantly lower (p-value=0.028), and QRISK3 scores were significantly higher (p-value=0.007) in RA patients. This suggests an underestimation of CVD risk by Framingham and potentially better prediction by QRISK3.
Conclusion: The study highlights that RA patients have a higher burden of atherosclerotic disease compared to healthy adults of the same age when CIMT is used as a marker of atherosclerosis. These findings indicate the need for early CVD risk assessment and intervention in RA patients using appropriate risk-scoring systems and tools. Further research with larger sample sizes and longitudinal follow-up is warranted to confirm these findings.
Atherosclerosis, Carotid ultrasound, Inflammation
The RA is a chronic inflammatory disease that affects not only the synovial joints but also various extra-articular regions, such as the lungs, skin, eyes, kidneys, heart, and other organs (1),(2). The worldwide prevalence rate of RA is approximately 1% (3). RA patients have a higher risk of premature death, primarily driven by an increased risk of CVD compared to the general population (4). The CVD risk in RA patients is comparable to that of patients with Diabetes Mellitus (DM) (5),(6),(7). The heightened risk of premature death from CVD in RA patients remains a significant challenge in managing these individuals (8),(9),(10).
Atherosclerosis is the main underlying pathogenesis behind CVDs, and inflammation is the common link between atherosclerosis and RA (11). Recent studies have highlighted the crucial role of inflammation in mediating all stages of atherosclerosis, including initiation, progression, and thrombotic complications (12),(13). Early identification of individuals at risk for cardiovascular events is essential as proactively addressing risk factors can be more successful than treating established atherosclerotic disease. However, traditional risk assessment tools based on conventional factors often fall short in detecting many individuals who will eventually develop CVDs, especially those considered low-risk (14),(15),(16).
Subclinical atherosclerosis serves as an early indicator of atherosclerotic burden. CIMT, measured non invasively using ultrasound, is a validated surrogate marker for early subclinical atherosclerosis (17). A meta-analysis has demonstrated a 10-15% increase in myocardial infarction risk and a 13-18% increase in stroke risk per 0.1 mm increment in CIMT, independent of age and sex. Therefore, CIMT independently predicts coronary heart disease and stroke, even after adjusting for age, sex, race, and conventional risk factors (18).
This study aimed to detect subclinical atherosclerosis by measuring CIMT in patients with RA and compare it with age- and sex-matched healthy individuals.
This cross-sectional study was conducted among 50 cases of RA and 50 age- and sex-matched healthy controls. The patients were selected from the medicine and rheumatology outpatient department and ward of Sir Sunderlal Hospital, Banaras Hindu University, Varanasi, Uttar Pradesh, India. The study duration was from September 2020 to July 2022. The study was reviewed and approved by the Institutional Ethics Committee (IEC number: ECR/526/Inst/UP/2014/RR-20).
Inclusion criteria: Patients diagnosed with RA who had symptoms for at least six weeks and were aged 18 years or older and willing to provide informed consent were included in the study. Cases were classified as RA according to the 2010 American College of Rheumatology-European League Against Rheumatism classification criteria (ACR-EULAR) if they had symptoms for at least six weeks (19). An equal number of age- and sex-matched healthy controls were selected after obtaining informed consent.
Exclusion criteria: Patients with established ischaemic heart disease, other inflammatory diseases, smokers, malignancies, stroke, diabetes, chronic liver disease, or diseases known to cause dyslipidaemia (e.g., nephrotic syndrome, hypothyroidism) were excluded from the study. Additionally, patients who received lipid or urate-lowering drugs, treatment with Disease-Modifying Antirheumatic Drugs (DMARDs), female patients on hormone replacement therapy or oral contraceptive pills, patients with a diagnosis of familial dyslipidaemia, pregnant patients, those with overlap syndrome, and those with other multiple connective tissue disorders besides RA were also excluded from this study.
Sample size: The total sample size was 100, consisting of 50 RA patients and 50 age- and sex-matched healthy controls. The sample size was determined based on a pilot study with 10 cases (RA patients) and 10 healthy controls, considering a confidence level of 95% and a study power of 90%. Detailed clinical history, clinical examinations, and all necessary investigations were conducted for all the patients.
Methods and procedures: The eligible individuals underwent anthropometric, clinical, biochemical, and radiological investigations. Patient details such as age, sex, gender, and place were recorded. A detailed history was obtained regarding the onset, progression, and duration of the disease, including the number of joints involved, morning stiffness, presence of deformity, and activity restriction.
Following the history, all patients underwent a general physical examination and a systemic examination. The disease activity of RA was assessed using Disease Activity Score-28 (DAS-28) scores (20). Biochemical investigations for all patients included complete blood count, renal function tests, liver function tests, lipid profile, and fasting blood sugar levels. Special serological investigations, including RA factor (using the agglutination technique), anti-Cyclic Citrullinated Peptides (anti-CCP) antibodies (using the ELISA method), and C-Reactive Protein (CRP) levels (using the agglutination technique), were conducted for classification purposes.
Carotid ultrasonography was performed on all cases and controls to measure CIMT values and detect subclinical atherosclerosis. Subclinical atherosclerosis was defined as a CIMT >0.9 mm (21). The 10-year CVD risk was calculated for all study participants using the Framingham, ASCVD, and QRISK3 online calculators.
Statistical Analysis
For statistical analysis, the Student’s t-test was used to assess the significance of observed differences in quantitative data presented as mean±SD. The Chi-square test was employed for data represented as median and Interquartile Range (IQR). A p-value of 0.05 at a two-sided test was considered statistically significant. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 28.0 software.
In the present study, a total of 100 individuals were evaluated. The study population showed a predominant female representation, with 76 (76%) females. Both study groups were comparable in terms of mean age and sex. The control group consisted of slightly more males, with 15 (30%) compared to 9 (18%) in the cases group, but this difference was statistically insignificant (p-value=0.160). The mean BMI was significantly higher in individuals from the control group (p-value=0.01) (Table/Fig 1).
The mean haemoglobin was significantly lower (p-value 0.047), while the mean TLC (p-value <0.001) and platelet counts (p-value 0.001) were significantly higher in cases compared to controls. The mean alkaline phosphatase, serum albumin, and serum creatinine were comparable between the two groups (Table/Fig 2). Cases (RA patients) had a mean CRP level of 3.218±5.171, mean RA factor of 127.675±149.9, and mean anti CCP2 levels of 220.734±209.333 IU/mL. Disease activity was assessed using the DAS-28 score in cases, which was 5.3968±0.893 (Table/Fig 2). These parameters (CRP, RA factor, Anti CCP, and disease activity score DAS28) were only measured for cases.
Bilateral mean CIMT was significantly higher (p-value <0.001) in RA patients compared to healthy controls (Table/Fig 3). Among the 50 cases, only two RA patients had CIMT >0.9 mm, while all controls had CIMT below 0.9 mm, but this difference was statistically insignificant (p-value 0.49).
When comparing the median Framingham score, ASCVD, and QRISK3 score between group 1 (cases) and group 2 (controls), the median Framingham score was significantly lower (p-value=0.028) in group 1, while the median QRISK3 score was significantly higher (p-value=0.007) in group 1 compared to group 2. The median ASCVD score was comparable between the two groups (Table/Fig 4).
The findings of this study indicate that the mean CIMT, which is a surrogate marker of carotid atherosclerosis, was significantly higher (p-value <0.001) in RA patients compared to healthy age-sex matched controls. This suggests a higher atherosclerotic burden in RA patients relative to their age-sex matched controls. A meta-analysis revealed that even a mere 0.1 mm increase in CIMT translates to a striking 10%-15% increase in myocardial infarction risk and a 13%-18% increase in stroke risk, even after adjusting for age and sex (18). This indicates that a higher CIMT predicts a higher risk of future CVD in RA patients compared to age-sex matched controls.
Achieving optimal cardiovascular health outcomes in RA patients, with the aim of preventing premature deaths from CVD, remains a significant challenge in the management of RA (8),(9),(10). Therefore, early correction of emerging risk factors offers a more efficient approach in preventing cardiovascular events than therapy for advanced atherosclerotic disease. Early identification of at-risk individuals is crucial. Subclinical atherosclerosis, an early warning sign of increased atherosclerotic burden, can be identified through non invasive measurement of CIMT, which is a well-established marker of the early stages of this subclinical condition (17). Early recognition of subclinical atherosclerosis through CIMT opens the door for timely intervention and the potential to slow or even prevent the progression of cardiovascular risk. The present study assessed naïve RA patients for CIMT and compared them with their healthy age and sex matched controls.
On demographic analysis of study participants, 76% were females and 24% were males. The mean age of both groups was comparable, with cases having a mean age of 38.60±12.403 years and controls having a mean age of 35.56±12.203 years. A similar study conducted by Muhammed H et al., included 332 Indian patients, among whom 85% were females and 15% were males (21).
RA patients were diagnosed based on clinical history and laboratory tests. In this study, RA patients had a mean CRP level of 3.218±5.171 mg/L, mean RA factor of 127.675±149.9 IU/mL, and mean anti-CCP2 levels of 220.734±209.333 IU/mL. Disease severity was assessed using the DAS-28 score in cases, and it was 5.3968±0.893.
In the present study, the mean CIMT was higher among RA patients compared to the healthy controls. A meta-analysis conducted by Wang P et al., concluded that CIMT in RA patients is thicker than in healthy controls (22). Mazario R et al., also found that RA patients had thicker CIMT than healthy individuals, and this was positively associated with longer disease duration and higher disease activity (DAS28 score) (23). Another study by Grover S et al., revealed that CIMT increased in RA patients, and the tender joint count was an independent predictor of abnorma CIMT (24). Therefore, the higher CIMT thickening observed in RA patients compared to healthy controls in this study was consistent with previous research (22),(23),(24). These findings suggest a greater burden of subclinical atherosclerosis in patients with RA compared to the general healthy population.
In this study, the Framingham, ASCVD, and QRISK3 cardiovascular risk scores were calculated for both groups. The median values of the 10-year CVD risk QRISK3 (p-value 0.007) were significantly higher among cases compared to controls. However, the ASCVD scores were comparable between both groups, while the Framingham scores were significantly lower (p-value 0.028) among RA patients. This suggests that the Framingham and ASCVD scores may underestimate the CVD risk in RA patients, and the QRISK3 risk calculator may be more effective in predicting CVD risk in RA patients. A similar study by Muhammed H et al., concluded that ASCVD and QRISK3 3 scores exhibited the highest utility in predicting subclinical atherosclerosis (defined by CIMT >0.9 mm) in the Indian RA population (21).
Limitation(s)
One limitation of the present study was its small sample size. Due to the relatively small number of participants, the findings may not be generalisable to larger populations. Secondly, it was a cross-sectional study, which means that it cannot determine the cause of the increased burden of carotid atherosclerosis in RA patients. Since the present study was a cross-sectional study with a small sample size, these findings should be confirmed through a longer follow-up study with a larger sample size.
Despite these limitations, the present study provides important evidence that RA patients have an increased burden of carotid atherosclerosis, as measured by CIMT. Additionally, RA patients had higher QRISK3 scores than healthy controls, suggesting that QRISK3 scores may better predict CVD risk in RA patients compared to ASCVD scores. Therefore, RA patients may benefit from early and aggressive preventive interventions, such as lifestyle modification and pharmacotherapy, to reduce their risk of CVD.
DOI: 10.7860/JCDR/2024/67951.18925
Date of Submission: Oct 08, 2023
Date of Peer Review: Nov 10, 2023
Date of Acceptance: Dec 20, 2023
Date of Publishing: Jan 01, 2024
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. NA
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Oct 09, 2023
• Manual Googling: Nov 11, 2023
• iThenticate Software: Nov 25, 2023 (8%)
ETYMOLOGY: Author Origin
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