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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
Clinicoradiological Profile of Endobronchial Tuberculosis: A Cross-sectional Study
Correspondence Address :
Dr. Parvathi Rajendran,
Karichalil House, Kuttenkulangara Lane East, Punkunnam P.O., Thrissur-680002, Kerala, India.
E-mail: parvathi0487@gmail.com
Introduction: Tuberculosis (TB) is a disease that causes severe mortality and morbidity worldwide, including India. Endobronchial Tuberculosis (EBTB) is an uncommon form of TB, which is often underdiagnosed due to the difficulty in diagnosis. This form of TB often has a poor prognosis and long-lasting sequelae.
Aim: To study the proportion of EBTB in clinically diagnosed pulmonary TB and to study the clinicoradiological and bronchoscopic profile of EBTB.
Materials and Methods: This study was a hospital-based record-based cross-sectional study that included patients with sputum smear negative for Acid-Fast Bacilli (AFB) and Mycobacterium tuberculosis (M. tuberculosis) not detected on Nucleic Acid Amplification Test (NAAT), who were clinically diagnosed with TB. Bronchoscopy was performed on such patients, and samples were sent for investigations, including histopathology and NAAT. Demographic characteristics, bronchoscopy and radiology findings, and microbiology results were documented. Quantitative variables were summarised as means, and categorical variables were presented as percentages.
Results: A total of 198 underwent bronchoscopy, of which 20 (10%) were diagnosed with EBTB. The mean age was 22 years, and 65% were females. The most common clinical feature in these patients was fever, the most common radiological presentation was lobar collapse, and the most common bronchoscopy feature was a tumorous lesion. NAAT detected M. tuberculosis in the bronchial wash in 50% of patients diagnosed with EBTB. A total of 45% of patients had TB which was diagnosed on histopathology.
Conclusion: EBTB was diagnosed in 10% of smear-negative, NAAT-negative cases. The use of NAAT on bronchoscopy wash samples resulted in a high yield in diagnosis.
Bronchial diseases, Bronchoscopy, Pulmonary, Radiology
TB is a major health problem that results in significant mortality and morbidity. In 2020, the World Health Organisation (WHO) estimated an incidence of 10.6 million cases worldwide, with 1.4 million cases in India (1). India reported 1.8 million TB cases in 2020, with 1.29 million cases being pulmonary TB (2). In the state of Kerala, 20,832 cases were reported in 2020, with 12,426 (59.6%) being pulmonary TB (2).
EBTB is defined as tuberculosis infection of the tracheobronchial tree with microbial and histopathological evidence (3). The diagnosis of EBTB is difficult due to non specific symptoms, signs, and radiological presentation. EBTB may present with or without parenchymal involvement. In 10-20% of patients with EBTB, a normal Chest X-Ray (CXR) may be observed. The yield of sputum microscopy is as low as 16% (16-53%) (3),(4),(5),(6),(7),(8). When sputum smear and CXR findings are not definitively indicative of TB, bronchoscopy and Computed Tomography (CT) thorax play a role in the diagnosis. Morbidity is high as it heals with scarring and functional impairment of airways; hence, early diagnosis and treatment are necessary (8). Bronchoscopic biopsy is the best method for diagnosing EBTB, with a yield of 30-84% (9). The availability of newer molecular tests like Cartridge-Based Nucleic Amplification Test (CB-NAAT) can increase the yield in Broncho-Alveolar Lavage (BAL) compared to sputum AFB smears (10).
The diagnostic algorithm for the National TB Elimination Program in India (NTEP) recommends AFB smears and CXR for all presumptive pulmonary TB patients (11). For those with CXR suggestive of TB but AFB smear negative, a NAAT is recommended. For those negative for M. tuberculosis on NAAT too, a clinical diagnosis of TB can be made by the treating physician (11). In patients with a microbiologically confirmed TB (either AFB smear positive or NAAT result of M. tuberculosis detected), further evaluation for EBTB is not done.
In clinical practice, a diagnosis of TB is mostly made based on radiological grounds. Further evaluation by bronchoscopy, which would reveal the diagnosis of EBTB, is not usually conducted. This study examines the proportion of EBTB in clinically diagnosed TB and the clinicoradiological and bronchoscopy profile in patients with EBTB in the setting, which has not been previously reported. Hence, this study was conducted to evaluate these aspects and describe this profile with the aim of determining the proportion of patients with sputum AFB smear-negative, NAAT-negative TB who have features of EBTB on bronchoscopy and to describe clinicoradiological features in such patients.
A record-based retrospective cross-sectional study was conducted in the Department of Pulmonary Medicine, Government Medical College, Thrissur, Kerala, India, during the period 2017 to 2020. Institutional Ethical Committee (IEC) clearance was obtained in March 2022, and data collection and analysis were carried out from 1st April 2022 for a period of six months. Ethics clearance was obtained from the IEC of Government Medical College, Thrissur, with clearance number IEC/GMCTSR/2022/025 dated 24-03-2022.
Inclusion criteria: Patients with a clinical diagnosis of Pulmonary TB, with sputum smear results negative for AFB and sputum NAAT results showing M. tuberculosis not detected, were included in the study.
Exclusion criteria: Patients who were not fit or unwilling for bronchoscopy were excluded from the study.
Patients were recruited at the NTEP unit of the Medical College. Presumptive TB patients, whose sputum samples were negative on both AFB smear microscopy and sputum NAAT, underwent bronchoscopy. Among these, those with endobronchial lesions on bronchoscopy and meeting the diagnostic criteria of EBTB were further evaluated. During the study period, 3,052 patients were diagnosed with TB in the institution. Of these, 1,543 patients diagnosed with EPTB were excluded. Among the remaining 1509 cases with pulmonary TB, 1165 with microbiologically confirmed (Smear and NAAT) were also excluded. Of the remaining 344, 198 underwent bronchoscopy.
EBTB was diagnosed based on the following diagnostic criteria (6),(7),(8):
• Endobronchial or tracheal lesions with the following:
• AFB smear positive from Bronchial washing sample
• CBNAAT positive for M. tuberculosis from Bronchial washing sample
• Histopathologically caseating granuloma consistent with TB from bronchial brushing or bronchial biopsy.
The patient records were extracted from the department’s documents, including the NTEP reports, bronchoscopy register, and case sheets. Patient identifiers were removed before the data was analysed. The parameters included in the study were clinical features, blood investigations, radiological investigations, sputum AFB and sputum CBNAAT, Fiberoptic Bronchoscopy (FOB) appearance, bronchoscopic washing cytology, AFB staining and CB-NAAT, Bronchial brushing cytology and AFB, and bronchoscopic biopsy histopathology.
Statistical Analysis
The data were collected using a structured questionnaire and then entered into MS Excel for analysis using EpiInfo7. Quantitative variables were summarised as the mean and categorical variables were presented as percentages.
Out of the total 3052 patients diagnosed with TB from 2017-2020, 1509 had Pulmonary TB. Among the 344 patients with smear-negative Pulmonary TB, 198 underwent bronchoscopy, and 20 were diagnosed with EBTB. All EBTB cases were sputum AFB and CBNAAT negative. Sixty-five percent of the EBTB cases were female, and the mean age was 22 years and age range of (14-71 years).
Clinical Features
Fever was the most common presenting symptom (85%), followed by loss of appetite and weight loss (75%), and cough (70%) (Table/Fig 1). Mean duration between onset of symptoms and presentation was one month in 80% of patients.
Radiological Features
Lobar collapse:
The most common radiological feature was lobar collapse, observed in six patients, followed by consolidation and hilar prominence, each seen in four patients (Table/Fig 2),(Table/Fig 3). Centrilobular nodules in CT were observed (Table/Fig 4).
Bronchoscopic Features
The most common bronchoscopic pattern in patients with EBTB was a tumorous pattern, seen in 7 (35%) patients with EBTB (Table/Fig 5),(Table/Fig 6).
Diagnosis of Endobronchial TB (EBTB)
The diagnosis of EBTB is made by histopathology (HPR), AFB staining, and CBNAAT. Bronchial washing showed positive AFB staining in four patients (20%) and positive AFB culture in LJ media in two patients (10%), other findings are shown in (Table/Fig 7).
The most common histopathology pattern was caseating granuloma (Table/Fig 8). Others were epithelioid granuloma without necrosis both consistent with TB. Chronic inflammatory cell infiltration was seen in six patients (30%), and non specific results were found in five patients (25%). Biopsy CBNAAT and culture were not available during that period in our setting (Table/Fig 9).
In this study, approximately 10% of clinically diagnosed TB cases were diagnosed as EBTB when bronchoscopy was performed. A significant proportion of these cases were diagnosed by NAAT, and a nearly equal number were diagnosed by histopathology. The most common symptom in this study was fever. However, in other studies (Sharma D et al., Valdès CLH et al., and Simsek A et al.,) cough was reported as the most common symptom (12),(13),(14). Similarly, the most common CXR finding in this study was collapse, whereas study by Simsek A et al., found upper lobe mass-like lesion and nodular shadow as the most common features, respectively (14).
The primary bronchoscopy feature in this study was a tumorous lesion. In a study by Chung HS and Lee JH, 10 out of 34 cases were tumorous lesions (15). In a study by Simsek A et al., four out of 18 cases were of the tumorous type (14). These findings differ from those reported by Ozkaya S et al., where 34.7% were edematous hyperemic type, and Kim HJ et al., who found actively caseating, oedematous-hyperemic, and ulcerative EBTB to be the most common EBTB subtypes, occurring in 49%, 21%, and 20% of their patients, respectively (10),(16). The diagnostic test yielding more positive results in this study was NAAT on bronchial lavage specimens, which is a microbiology test. A study by Simsek A et al., revealed BAL AFB positivity of 62.5% and 97.5% for culture. 44% had a definite histopathological picture suggestive of TB (14).
EBTB is a tuberculous infection of the tracheobronchial tree. EBTB in the earlier era was a postmortem finding until bronchoscopy became available (17). While this is not a different disease entity, it evokes interest because of the difficulty in diagnosis and the worse prognosis. These changes may be visible through the bronchoscope starting with an area of reddishness in the airways, progressing to multiple tubercles, which may develop into ulcers, finally resulting in granulation tissue formation, giving the appearance of an intrabronchial tumor (3),(13). This was the most common presentation in this study.
The diagnostic yield in expectorated sputum specimens may be low in EBTB (15 to 60%) (3),(10),(16). The yield can be increased when BAL is performed. Bronchoscopy is the best investigation in a patient with sputum AFB and NAAT negative, with a high yield resulting in establishing a diagnosis (3),(7),(10),(16). Biopsy and histopathology generally show caseating granulomas. The yield of bronchoscopic biopsy is 30-84% (3),(18). NAAT of bronchial washing, if positive, is diagnostic. Strictures can occur after treatment (18),(19),(20). Interventional pulmonology may improve treatment in patients with EBTB with such sequelae (21).
This study shows that EBTB is diagnosed in about 10% of clinically diagnosed TB cases, i.e., those negative on sputum smear examination for AFB and NAAT. Bronchoscopy is essential for the diagnosis of these patients. Hence, it is essential that bronchoscopy is available and used in all patients with clinically diagnosed TB. The strength of this study is that such data is not available from this part of the country.
Limitation(s)
The limitation of this study was that not all patients with smear-negative/NAAT-negative results could undergo bronchoscopy. This should be seriously looked into in the future, as there is a high possibility of underlying malignancy mimicking TB. Biopsy CBNAAT and Biopsy AFB culture were not available at the time of the study, which might have missed many cases of TB. Further, Rifampicin sensitivity of these cases couldn’t be done. Hence, in the time of genetic testing, testing by CBNAAT and culture may be done for all suspected cases.
EBTB was present in 10% of smear-negative/NAAT-negative cases. The most common radiological feature in these patients was lobar collapse, and the most common bronchoscopy finding was a tumorous lesion. Availability of NAATs has resulted in better diagnosis of patients, and the yield of NAAT positivity was 50%. The other patients could be diagnosed based on histopathology. This study suggests that all patients with presumptive TB who were smear AFB-negative and NAAT-negative may undergo bronchoscopy, which can lead to the diagnosis of EBTB, confirming the diagnosis and also prognosticating the disease.
DOI: 10.7860/JCDR/2024/64561.19084
Date of Submission: Apr 09, 2023
Date of Peer Review: Jun 05, 2023
Date of Acceptance: Jan 17, 2024
Date of Publishing: Feb 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? No
• For any images presented appropriate consent has been obtained from the subjects. No
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Apr 10, 2023
• Manual Googling: Dec 21, 2023
• iThenticate Software: Jan 13, 2024 (9%)
ETYMOLOGY: Author Origin
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