Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018

Prof. Somashekhar Nimbalkar

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Ex-Member, Governing Body, National Neonatology Forum, New Delhi
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Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

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Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Dr. Saumya Navit

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Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

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Calcutta National Medical College & Hospital , Kolkata

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Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
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Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

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)
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.
On April 2011

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
On Jan 2020

Important Notice

Case report
Year : 2007 | Month : October | Volume : 1 | Issue : 5 | Page : 409 - 412

Streptococcal Shock Syndrome


*Reader, Medical ICU, Christian Medical College & Hospital, Vellore 632 004, India, **Staff Physician, Division of Medicine, Lyell McEwin Health Centre, Haydown Road, South Australia 5112, ***Senior Consultant & Physician, The Queen Elizabeth Hospital, Woodville South, South Australia 5011.

Correspondence Address :
Dr. J V Peter, Medical ICU, Christian Medical College & Hospital, Vellore 632 004, INDIA.Phone:91-416-228 2693 E-mail:


There appears to be a worldwide resurgence of invasive Group A streptococcal infections. We report a 41-year old male who presented with septic shock and multi-organ failure, secondary to Streptococcus pyogenes infection. We have reviewed the current knowledge on toxic streptococcal syndrome and the basis for the therapeutic recommendations of combination antibiotic therapy. Adjunct therapy with immunoglobulins may improve survival, possibly by enhancing neutralisation of bacterial exotoxins.


toxic strep syndrome, septicaemia, streptococcal infections

Invasive S. pyogenesinfections, once considered a thing of the past, have re-emerged over the last 2 decades. The spectrum of clinical manifestations of S. pyogenes, includes skin and soft tissue infections such as impetigo and necrotising fasciitis, to pneumonia and septicaemia (1), (2).

We report a patient who presented with clinical and laboratory features, consistent with a diagnosis of streptococcal shock syndrome.

Case Report

A 41-year old man with hepatitis-C related liver disease and previous drug abuse, presented with a 3-day history of fever and haematuria. He was febrile (38.4oC) and toxic, with a thready pulse (120 beats/minute), hypotension (97/54), and tachypnea (50 breaths/minute). His cardiorespiratory examination was normal. Abdominal examination revealed a palpable liver and left iliac fossa tenderness, but no signs of peritonitis. Baseline investigations are summarised in the (Table/Fig 1). Admission chest radiograph was normal. Broad-spectrum antibiotic therapy comprising imipenem, vancomycin and gentamicin, was commenced after cultures. Following resuscitation and intubation, he was transferred to the intensive care unit (ICU) with a provisional diagnosis of multi-organ failure, secondary to septic shock, severe metabolic acidosis, and possible disseminated intravascular coagulation. The post intubation radiograph showed bi-basal alveolar opacities. He subsequently developed bilateral large pleural effusions. His blood culture grew Streptococcus pyogenes. He gradually improved from his shock, metabolic acidosis, and coagulopathy, with supportive therapy, ventilation and antibiotics, and was weaned off respiratory and cardiovascular supports.

Following recovery from his critical illness, his stay in hospital was complicated by myocardial infarction, as well as an episode of hepatic encephalopathy, secondary to severe decompensation of his liver disease. Two months after the initial episode, he succumbed, following an episode of nosocomial Klebsiella pneumonia.


Invasive S. pyogenes infections, once considered a thing of the past, have re-emerged over the last 2 decades. A proportion of patients present with a syndrome of shock, and designated Toxic Streptococcal Syndrome (TSS) that is exotoxin mediated (1). This syndrome is usually seen in patients presenting with necrotising fasciitis (48%), and is associated with a mortality of 30-60% (1). The bacteraemic form without a septic focus is seen only in about 14% of patients presenting with TSS (2). A recent report from Canada showed an increase in the proportion of patients presenting with S. pyogenes pneumonia from <1% in the early 1980s, to >10% in the late 1990s. The development of TSS in these patients was associated with a significant risk (odds ratio 19) of death (3). In addition to necrotising fasciitis, pneumonia, and bacteremia, S. pyogenes has been reported to be the causative organism in surgical site infections, septic arthritis, osteomyelitis, meningitis, thrombophlebitis, peritonitis, pelvic infections, central venous line bacteraemia, endocarditis, urinary tract infection, endophthalmitis etc. (4).

Several risk factors predispose to the development of invasive group A Streptococcal infections, and include human immunodeficiency virus, cancer, diabetes, alcohol abuse, and chickenpox (2). It is likely that the patient’s chronic liver disease and alcohol abuse, known risk factors for streptococcal shock syndrome, pre-disposed him to the development of S. pyogenes septicaemia, as well as the second episode of pneumonia. There was no evidence of any other immuno-compromised state.

The diagnosis of streptococcal shock syndrome is made on the basis of (a) identification of S. pyogenes, and (b) clinical signs of severity – hypotension (systolic blood pressure of  90 mm Hg in the adult), along with two or more of the following signs; renal impairment, coagulopathy, liver involvement, acute respiratory distress syndrome, and generalised erythematous macular rash or soft tissue necrosis (4). Streptococcal shock syndrome is thought to be mediated by streptococcal pyrogenic exotoxins and other antigens, which function as super-antigens (4).

Reports of invasive/fulminant S. pyogenes infections are sparse in Australian and Indian literature, and may reflect under-reporting rather than true absence of infection. A study from Melbourne showed increasing severity of S. pyogenes infections in children, from 1982 to 1993 (5). There has also been renewed interest recently in Indian literature, with several publications of invasive group A streptococcal infections from Australia (6), the USA (7), and Denmark (8). In Northern Queensland, Australia, the crude incidence rate was reported to be 82.5 per 100,000 per year in the indigenous population, and 10.3 per 100,000 per year in the non-indigenous patients (6). Abuhammour et al (7), studying the incidence of invasive Group A streptococcal infections in children, identified more infections in the latter half of a 9 year audit.

Given the rapid progression of invasive streptococcal infection, as seen in our patient, early recognition and appropriate treatment is important. In experimental S. pyogenes myositis in a mouse model, penicillin was ineffective if treatment was commenced >2 hours after initiation of infection (1). Recent in vitro studies have shown that clindamycin was superior to penicillin and ampicillin in reducing the production of streptococcal pyrogenic exotoxins A and B (9). Hence, c

Key Message

1.Shock related to Streptococcus pyogenes infection appears to be on the increase worldwide.
2.Combination antibiotic therapy with penicillin and clindamycin appears logical, based on in vitro studies.


Stevens DL. Streptococcal toxic shock syndrome associated with necrotising fasciitis. Ann Rev Med 2000; 51:271-288.
Davies HD, McGeer A, Schwartz B, Green K, Cann D, Simor AE, et al. Invasive group A streptococcal infections in Ontario, Canada. Ontario Group A Streptococcal Study Group. N Engl J Med. 1996; 335:547-54.
Muller MP, Low DE, Green KA, Simor AE, Loeb M, Gregson D, et al. and the Ontario Group. A streptococcal study. Arch Intern Med 2003; 163:467-472.
Baxter F, McChesney J. Severe Group A streptococcal infection and streptococcal toxic shock syndrome. Can J Anesth 2000; 47 :1129-40.
Carapetis J, Robins-Browne R, Martin D, Shelby-James T, Hogg G. Increasing severity of invasive group A streptococcal disease in Australia: clinical and molecular epidemiological features and identification of a new virulent M-nontypeable clone. Clinical Infect Dis 1995; 21:1220-7.
Norton R, Smith HV, Wood N, Siegbrecht E, Ross A, Ketheesan N. Invasive group A streptococcal disease in North Queensland (1996-2001). Indian J Med Res. 2004; 119 (Suppl): 148-51.
Abuhammour W, Hasan RA, Unuvar E. Group A beta-hemolytic streptococcal bacteremia. Indian J Pediatr. 2004; 71:915-9.
Ekelund K, Lemcke A, Konradsen HB. Evaluation of gastrointestinal symptoms as the primary sign of severe invasive group A streptococcal infections. Indian J Med Res 2004; 119 (Suppl):179-82.
Mascini EM, Jansze M, Schouls LM, Verhoef J, Van Dijk H. Penicillin and clindamycin differentially inhibit the production of pyrogenic exotoxins A and B by group A streptococci. Int J Antimicrob Agents 2001; 18:395-8.
Darenberg J, Ihendyane E, Sjolin J, Aufwerber E, Haidl S, Follin P et al. Intravenous immunoglobulin G therapy in streptococcal toxic shock syndrome: a European randomized, double-blind, placebo-controlled trial. Clin Infect Dis 2003; 37:333-40.
Kaul R, McGeer A, Norrby-Teglund A, Kotb M, Schwartz B, O’Rourke K et al. Intravenous immunoglobulin therapy for streptococcal toxic shock syndrome – a comparative observational study. The Canadian Streptococcal Study Group. Clinical Infect Dis 1999; 28:800-7.
Tables and Figures
[Table / Fig - 1]

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