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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
Correct Use Of A Metered Dose Inhaler: A Prospective Interventional Study Among Healthcare Professionals In A Nepalese Teaching Hospital
Correspondence Address :
Dr. P.V. Kishore MD (Pulmonology), Associate Professor Department of Medicine, Manipal Teaching Hospital/ Manipal College of Medical Sciences, Pokhara, Nepal.
Background: Asthma and Chronic Obstructive Pulmonary Disease (COPD) are common in Nepal. Inhaled medications form the cornerstone of the management of these diseases. Metered Dose Inhalers (MDIs) are a common mode of delivering inhaled medications, and hence knowledge of the healthcare professionals regarding MDIs is the cornerstone for educating the patients about the correct use of MDIs.
Objectives: To study the correct use of MDIs by the doctors, nurses, pharmacists and medical interns, and to evaluate the impact of an educational intervention on the use.
Methods: A prospective, interventional study was carried out at the Manipal Teaching Hospital, Pokhara, Nepal. The subjects were asked to demonstrate the technique using a placebo inhaler, and the steps were graded as per the National Asthma Education and Prevention Program (NAEPP) criteria. Intervention was done by demonstrating correct MDI use with the help of placebo inhalers and an information leaflet. The post intervention response was analyzed using appropriate statistical tests.
Results: Altogether 143 health professionals (male 53.8%, female 46.1%) were studied prior to intervention, and 101 (male 41.5%, female 58.4%) of them in the post interventional phase. The overall mean ± SD score obtained by the professionals was 4.44 ± 2.07 (pre intervention), and 7.68 ± 1.74 (post intervention). (P< 0.001, Z value - 10.020, Mann Whitney test). With regard to the individual scores of different categories of healthcare professionals, the scores for the nurses were 3.99 pre intervention and 8.14 post intervention, for doctors it was 5.96 and 7.18, for pharmacists it was 5.8 and 7.1, and for interns it was 4.72 and 7.12. None of the professionals could initially demonstrate all the ten steps involved in the correct use of MDI. Following the intervention one doctor, four medical interns, and eight nurses all demonstrated the steps correctly.
Conclusion: MDI use among healthcare professionals was poor before the intervention. The intervention was substantially effective in improving the technique.
Doctors, Education, Intervention, Metered dose inhalers, Nurses, Pharmacists
Introduction
Respiratory diseases like asthma (1) and Chronic Obstructive Pulmonary Disease (COPD)(2) are a common cause of morbidity and mortality worldwide. In Nepal, a combination of asthma and bronchitis constitutes a major cause of mortality(3). Bronchodilators and anti-inflammatory agents are important for the treatment of these diseases. On systemic administration, these agents produce considerable side effects. In order to overcome this problem and to have a quicker onset of action and better efficacy, inhaled medications are preferred(4). However failure of treatment is still a common problem for these diseases(5). One of the reasons for this is incorrect use of Metered Dose Inhalers (MDIs), the commonest method of inhaled drug delivery(6). It has been demonstrated to occur approximately in 75% of the patients using MDIs. 1
In order to improve MDI use, healthcare professionals should teach the patients to correctly use MDIs. Two studies from Nepal have demonstrated the usefulness of counseling by pharmacists in using MDIs(7),(8). To correctly teach MDI use, healthcare professionals like doctors, pharmacists and nurses should have adequate knowledge about the use of MDIs(9). Studies from different countries have demonstrated poor knowledge among these professionals regarding MDI use(10),(11),(12). Poor knowledge among healthcare professionals can lead to an incomplete and improper information about the patients. Studies have recommended training programs for healthcare professionals in order to improve their knowledge about the correct use of inhalers(10),(13),(14). These type of studies are lacking in Nepal.
Moreover, in Nepal, a large proportion of the patient population is illiterate, and hence the role of healthcare professionals in the education of the patients is very important. The doctors at our hospital educate the patients regarding the correct use of MDIs while prescribing them to the ambulatory patients. The nurses teach the ambulatory as well as the hospitalized patients about MDI use. The pharmacists at our hospital counsel the patients about the proper use of inhalers at the Medication Counseling Center (MCC) located adjacent to our out-patient pharmacy(15). Before educating patients, healthcare professionals need to have an adequate knowledge about the correct use of inhalers.
Thus, at the Manipal Teaching Hospital, a 700 bedded tertiary care center, doctors, nurses and pharmacists are involved in teaching the patients about the correct use of inhalers. However, their knowledge level regarding the correct use of inhalers is not known. Hence, the present study was carried out.
Objectives:
The present study was conducted with the following objectives.
1. To study the proficiency of the proper use of MDI demonstrated by the doctors, nurses, pharmacists and medical interns
2. To evaluate the impact of an educational intervention on the improvement in MDI use, if any.
Study site: Manipal Teaching Hospital, Pokhara, Nepal, a 700 bedded tertiary care teaching hospital.
Study type: Prospective, interventional study
Study period: The study was carried out in three phases, the pre interventional, interventional, and the post interventional phase, with a one week gap between the phases.
Inclusion criteria: Doctors (only who prescribe MDIs), nurses and pharmacists were included in the study.
Study tool:An ‘MDI use evaluation score chart’ was prepared as per the National Asthma Education and Prevention Program (NAEPP) criteria(16), and was used in the study. For every correctly carried out step, a score of ‘1’ was given, and for every incorrect step, a score of ‘0’ was given. The score chart used is listed in Appendix 1.
Operational modality: The study had three phases, the pre interventional, interventional, and post interventional phase. The healthcare professionals were asked, after obtaining verbal consent, to demonstrate the use of the placebo inhaler, and the steps were graded as per the NAEPP criteria. Following the evaluation, the healthcare professionals were educated about the proper use of MDI. The educational intervention was carried out for doctors, nurses and pharmacists separately. Doctors and medical interns were contacted individually, nurses were trained in small groups, and pharmacists were educated during the Continuing Pharmacy Education (CPE), which is carried out by the Drug Information Center (DIC) members of our hospital on a fortnightly basis. All the healthcare professionals were also given information leaflets which described the ten steps involved in the correct use of MDIs. Following the intervention, the technique of the use of MDI was studied after a period of one week.
Statistical methods: We used the Mann Whitney test to compare the overall improvement in the scores of the health care professionals if any, following the intervention (P< 0.05). For the analysis, we used the Microsoft excel spread sheet and the Statistical Package for Social Sciences (SPSS) version 9.5.
Age distribution: The details regarding the demographic distribution of the healthcare professionals are listed in (Table/Fig 1).
The overall knowledge regarding correct use of MDIs: The percentage of the professionals demonstrating each step of the MDI use correctly was identified and the details are listed in (Table/Fig 2).
Evaluation of the impact of the intervention: The impact of the intervention program was evaluated and the scores obtained by the health professionals were compared. The overall mean SD score obtained by the professionals was 4.44 2.07 (pre intervention) and 7.68 1.74 (post intervention).
Distribution of the score based on their profession: The mean score obtained by the professionals were calculated as per their profession. The scores pre intervention and post intervention amongst nurses were 3.99 and 8.14, for doctors it was 5.96 and 7.18, for pharmacists it was 5.8 and 7.1, and for interns it was 4.72 and 7.12 respectively.
Distribution of the score based on the age of the professionals: The scores obtained by the professionals were grouped, based on their age. The average score obtained during pre intervention and post intervention by the professionals in the age group of 11-20 years was 3.07 and 8.38, followed by 4.5 and 7.62 for the age group 21-30 years, 6.1 and 7.8 for the age group 31-40 years, and lastly, 2 and 0 for the age group 41 and above.
Distribution of the score based on the length of service: The average score obtained by the professionals was grouped, based on their length of service. The details are listed in (Table/Fig 3)
Number of professionals who demonstrated all the steps correctly: None of the professionals in our study could demonstrate all the ten steps involved in the correct use of MDI during the pre intervention period. Following the intervention, 1 doctor, 4 interns, and 8 nurses demonstrated all the steps correctly.
The present study identified a substantial improvement in the technique of inhaler use by the health care professionals of the hospital following the intervention.
Non-compliance to pharmacotherapy is a common reason for therapeutic failure(17). Studies have identified that up to 10% of hospital admissions, and more than 20% of nursing home admissions can be attributed to non-compliance(18),(19). In Nepal, respiratory diseases like asthma and COPD are highly prevalent(8). Non-compliance and treatment failure in these diseases may arise due to improper use of MDIs. In Nepal, the local manufacturers do not manufacture MDIs, and hence Patient Information Leaflets (PILs) in the native language for the patients, are not available.
The present study identified that healthcare professionals had a poor knowledge about the correct use of MDIs. It was surprising to know that none of the healthcare professionals could demonstrate the proper use of MDIs. In a study from Iran, which included physicians and nurses, only 6.93% could demonstrate MDIs correctly(13). In another study from Oman, 15% of respondents performed all the steps correctly(14). Our study has thus recorded a very poor understanding of healthcare professionals regarding MDI use. We could not identify the reason behind such a finding. The burden of respiratory diseases is so high in our region, that the use of MDI is unavoidable. In such a circumstance, the poor understanding of the healthcare professionals regarding the use of MDI can be dangerous. However, a few of the healthcare professionals could demonstrate the correct steps of MDI use. A study from Turkey, conducted amongst nurses, had demonstrated a significant improvement in MDI use after a training program(20). The authors also suggested a training program for nurses, and recommended repeat programs for better outcomes. The findings of our study also recommend training programs for the professionals to improve their knowledge. This training needs to be linked with managerial interventions as well.
The most difficult step identified by the professionals was the ‘step 5’, which included ‘Start breathing in slowly and deeply’. This step is very essential so that the medication can reach the respiratory tract. If one fails to inhale, the medication can deposit in the oral cavity, and can lead to wastage of the drug. This step can also be difficult for the patient. The study from Turkey reported the most improperly performed step to be ‘hold breath for 10 seconds’(10). Thus the difficult steps observed by the population can vary from place to place. In general, the steps that require hand to mouth coordination (steps 5-7) can be challenging. In such cases, a spacer can be beneficial, and can solve the co-ordination problem to a greater extent(20). However, in a poor country like Nepal, one should communicate to the patients, the cost factor before prescribing a spacer.
In our study, we found that overall, nurses had a poor score prior to the intervention. The knowledge of the nurses in this regard is very vital, as they teach the patients regarding MDI use when the patients get admitted in the hospital. However, the overall improvement in the score was higher in nurses than all the other professionals.
For the ambulatory patients using MDIs, the role of Pharmacists is very essential. The Pharmacists at the MCC of our hospital provide counseling to the patients regarding appropriate MDI use. In a preliminary evaluation carried out at our MCC, asthma or COPD was the commonest presumed diagnosis among the patients visiting the center, and MDIs were the most commonly used counseling aids(19). Inadequate knowledge of t
The present study identified poor understanding among healthcare professionals, regarding the correct use of inhalers. It was also surprising to know that even pharmacists who provide counseling to the patients were not able to demonstrate the different steps of the use of MDI correctly. Though the intervention was successful in increasing the knowledge of the healthcare professionals, there is scope for further improvement. It would be beneficial to have a periodic educational program for the healthcare professionals regarding MDI use.
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