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On Sep 2018




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"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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On Aug 2018




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Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
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.
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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.
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Dr. Mamta Gupta
Consultant
(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.
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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

Important Notice

Original article / research
Year : 2010 | Month : February | Volume : 4 | Issue : 1 | Page : 1999 - 2004 Full Version

Role Of Cerebral Protection In Carotid Angioplasty And Stenting


Published: February 1, 2010 | DOI: https://doi.org/10.7860/JCDR/2010/.633
KARANAM L S P * , AHLMAN P**, DEV B *** JOSEPH S ****

Department of Radiology and Imaging Sciences, Sri Ramachandra University, Chennai – 600 116, India.

Correspondence Address :
Dr . Lakshmi Sudha prasanna
Resident in Radiology.
Department of Radiology and Imaging Sciences
Sri Ramachandra Medical College and Research Institute
Chennai – 600 116, India
Ph: 91- 9940517748(R), 91- 44- 24766917 (O), Fax: 91- 44- 24767008

Abstract

Aim:To study the role of protective devices in improving the efficacy of percutaneous transluminal angioplasty (PTA) and stenting, in the treatment of symptomatic atherosclerotic stenosis of carotid arteries.
Materials and Methods:This study was performed in a teritiary care center in a period of 4 years, which included 66 patients. A majority of the patients presented with transient ischaemic attacks, with the youngest being 19 years and oldest was 82 years. Preprocedural workup with Doppler, MR angiogram and Digital subtraction angiogram was done in all the patients. The degree of stenoses was classified on the basis of the NASCET (North American Society Carotid Endarterectomy Trial) trial. PTA and stenting with self expandable stent and balloon was done in all the patients under local anaesthesia. Cerebral protective devices were used in all the patients and the patients were regularly followed up at intervals of 1, 3, 6 and12 months.
Results:PTA and stenting with cerebral protection was done in all the patients. Technical successs was achieved in all the patients. Four patients had filter choking. Major stroke occurred in one patient. No deaths occurred in our study. Bradycardia occurred in 3 patients, hypotension in 4 patients and puncture site haematoma in 2 patients. The results of the present study were analysed and compared with the literature.
Conclusion: PTA and stenting is effective for the management of carotid artery stenosis with higher success rate and less complications. The role of cerebral protection in avoiding migration of the plaque material and thus preventing cerebral circulation was emphasized.

Introduction
One of the important limitations of carotid artery stent placement in stenotic disease is the potential risk of developing embolic stroke by the plaque dislodgement of atheromatous material (1),(2).The role of cerebral protection devices have gained popularity in the recent years in preventing the adverse events of carotid artery stenting .Cerebral protection can be done using various types of balloons and filters. In our study, we share our experience with the use of cerebral protection devices in sixty six patients who underwent carotid artery stent placement and the results were studied and analysed with those from the literature review.

Material and Methods

The study was conducted in our institution, which is a tertiary care centre, in a period of 4 years. 66 patients were included in the study, the youngest being 19 years and oldest was 82 years. Among the 66, 48 were male patients and 18 were females (M:F=4:1.5) . Four of the patients underwent PTA and stenting of both the carotids .Preprocedural workup was done in all the patients. All the patients underwent either Doppler or MR angiogram for the assessment of the carotid stenoses. These patients subsequently underwent Digital substraction angiography. Colour doppler was performed in ALOKA SSD 5500 and the stenoses was assessed, based on direct measurement using callipers on the machine and velocity criteria derived from spectral analysis. MRA was done with the 3D Time of Flight and phase contrast sequences and stenoses were assessed on the post processed MIP (Maximum intensity projection) and VR (Volume rendered) images.

Digital subtraction angiogram was performed using Advantax LCN+ (GE BIPLANE SYSTEM) by femoral catheterization. The degree of stenoses was measured using the NASCET criteria, where the smallest luminal diameter at the level of stenosis was compared to the normal arterial diameter distal to the stenosis. 33 patients had 30-69% stenosis and 37 patients had more than 70% stenosis. All the procedures were done under local anaesthesia. The femoral artery was accessed with a 7F sheath and 5000 I.U. of heparin was given intravenously. 1 mg of Atropine was given intravenously prior to the dilatation. Thecarotid artery was accessed and the stenosis was crossed with a 0.035” guide wire. A self expandable stent was used in all the cases. The stenosis was post dilated over the stent with approximately sized balloon and the entire length was dilated to oppose the stent to the vessel wall.

Protection devices in the form of the EPI filters were used in 56 patients, Percusurge in 3 patients, Emboshield in 2 patients and spider in 5 patients. Associated co morbidities were also present in these patients, which included hypertension (61 patients), Diabetes mellitus (43 patients), TIA(56 patients) Vertebro basilar insufficiency (05 patient), Major stroke (01 patient) and minor stroke in 17 patients.
Premedication was given to all the patients in the form of oral aspirin (150mg) and clopidogrel (75mg) 4 days prior to the procedure, intravenous Glycopyrrolate (0.4 mg) prior to angioplasty and heparin (5000 I.U.(intravenous) prior to the guide wire placement.

Results

Technical success was achieved in all our patients without any major complications or restenoses.

Four patients had filter choking, from which one was severe, but the carotid flow was normal after the removal of the filter. We had no deaths in our study. Minor complications like carotid spasm were seen in four patients (5.7%), bradycardia in 3 patients (4.3%), hypotension in 4 (5.7%) and puncture site haematoma in 2 patients(2.9%).

Discussion

Carotid angioplasty with or without stenting is a minimally invasive alternative to open endarterectomy. The most common complication of PTA and stenting is an embolic shower causing stroke. This can be prevented by the use of the cerebral protection devices. Percutaneous transluminal angioplasty and stenting is a very successful and effective procedure and has pushed carotid endarterectomy to the back seat in recent years. The protection devices avoid the migration of plaque material distally, henceforth, preserving the cerebral circulation and the impending complication rate. The role of these devices is emphasized in the present study.

Stroke is the third leading cause of disability worldwide (5). Carotid artery disease is responsible for one third of all ischaemic strokes (7). A third of these patients die and another third are permanently disabled (7). Thus, the management of carotid artery disease is undergoing thorough scientific evaluation.

Randomized prospective surgical trials like NASCET and ESCT have shown a significant reduction in the risk of stroke in symptomatic patients with carotid stenosis, who undergo carotid endarterectomy versus optimal medical therapy (3),(4) . In the NASCET study, symptomatic patients with greater than 70% stenosis had a 2 year cumulative risk of stroke of 26%, with optimal medical therapy versus 9% risk with carotid endarterectomy (CEA). For major stroke and death, a risk reduction of 10.6% was identified with surgery. A reassessment by the American Heart Association Stroke Council indicated that CEA is three times as effective as medical therapy by itself in reducing the frequency of stroke (5).

While the demonstrated utility of surgery for improving outcome in the patients with severe carotid stenoses is an important advance, complication rates, while acceptable, leave room for improvement. Carotid artery balloon angioplasty and stenting offer the same efficacy and less morbidity. It’s advantages over surgery include, the ability to monitor the neurological status during the entire procedure, to reach very high cervical and petrous level stenosis and to avoid the 7.6% risk of cranial nerve injury as reported in NASCET. Other indications for considering an endovascular approach include such conditions as radiation-induced carotid fibrosis, fibromuscular dysplasia and severe medical co-morbidity. Contralateral carotid occlusion has also been proposed as an indication for angioplasty and stenting. Dissection, with or without pseudoaneurysm, may also occasionally be treated effectively with angioplasty and stenting.

Since its development by Gruentzig in early 1970, the use of balloon angioplasty for the treatment of atherosclerotic and other stenoses has gained wide acceptance (6). The CAVATAS study compares the surgery and angioplasty (7). A large number of series of carotid angioplasty and stenting studies have been published. The major ones include those by Theron etal (8), Diethrich etal (9) and Henry etal (10).

The most important persistent risks shared by the CEA and PTA procedures are stroke and death (11) Wholey etal (12) published a review of 2048 PTAS procedures. These results show that CEA and PTAS are nearly equal in terms of procedure related deficits and stroke. Thus, the role of cerebral protection devices came into existence, in an attempt to prevent stroke which is the most worrisome complication of the procedure. Different studies conducted by Wholey etal , Al-Mubarak etal and Kasturp etal showed a reduction of about 50 % in the stroke rate by using a protective device during the carotid artery stenting procedure (13),(14),(1)

A majority of the patients who were included in our study had associated co morbidities, which further added to the risk factor of the occurrence of stroke in these patients. Hence, the intraprocedural risk of distal migration of the embolic material during carotid arterial stenting was high in this group. Distal protective devices have been shown to be safe and effective in preventing distal embolisation. They are categorised as Distal occlusion Balloons and Filters. Distal occlusion balloon is of lower crossing profile, but causes temporary cessation of blood flow during the procedure. We used Percusurge which is of this type in three patients in the initial period. Though we did not encounter any adverse effects in these three patients, this temporary cessation may not be tolerated in all the patients. The series published by Henry etal (15) is the first clinical experience using the PercuSurge Guidewire system.

The largest consecutive series of carotid stent implantation using filter devices for cerebral protection, emphasizing the reduction in the risk of embolisation, was published by Bernhard Reimers (16). Filter devices maintain the antegrade flow as against the interrupted flow caused by the distal occlusion balloons. The filter devices were used in 63 patients. EPI (Embolic protection Incorporated cerebral protection device) by BOSTON scientific were used in 56 patients. Emboshield by Abbot was used in 2 patients and Spider by ev3 was used in 5 patients.

In the study by Reimers etal, macroscopic debris was seen in 53% of their cases. Embolic material was demonstrated in the device in 28 of our cases. Major cardiac events occurred in 2.3% of their series, but we did not encounter any such events in our study.

Zahn etal, in their study, compared the effectiveness of both the distal occlusion balloon and Filter Embolic protective devices and showed that Filter Embolic protective device is by far the most preferred choice (17)

Major adverse effects like spiral dissection, subocclusive ostial stenosis and intracranial haemorrhage were reported in the literature (18.) None of these were seen in our study. Minor complications like transient carotid spasm were encountered in four of our patients (5.7%), but the flow was completely restored after the filter removal. In these cases, large particles of debris are lodged in the devices. All the patients were followed up at regular intervals for a period of 3 years. Major stroke occurred in one patient in our study. There was no incidence of any other major events or restenosis in any of the cases in the study group.

Conclusion

Cerebral protection devices are safe and effective methods for preventing distal embolization by thus, decreasing the potential risk of stroke with the carotid artery stenting procedure, thereby increasing the efficacy of the procedure, making it widely acceptable for treatment of the cases of symptomatic carotid stenosis.

References

1.
Kastrup A, Groschel K, Krapf H, et al. Early outcome of carotid angioplasty and stenting with and without cerebral protection devices: a systematic review of the literature. Stroke 2003; 34:813–19
2.
Castriota F, Cremonesi A, Manetti R, et al. Impact of cerebral protection devices on early outcome of carotid stenting. J Endovasc Ther 2002; 9:786–92
3.
North American symptomatic carotid endarterectomy trial collaboration .Beneficial effect of carotid endarterectomy in symptomatic patients with high grade carotid Stenosis.N Engl J.Med.1991;325:445-53
4.
European carotid surgery Trialists collaborative Group.MRC European carotid surgery trial:interm results for symptomatic patients with severe (70-90%)or mild(0-29% Stenosis.Lancet.1991;337:1235-43.
5.
Biller J,Feinberg WM,Castaldo JE,etal. Guidelines for carotid endarterectomy .A statement for healthcare professionals from a special writing group of the stroke council,American Heart Associaiton.Stroke 1998;29:554-22
6.
Gruentzig A,Hopff M. Perkutane Rekanalisation Chromischer arteriller Verschloss mit eineur neuen Dilatatious catheter:Modification der Dotter-Technik. Deutsch Med Wochenscriff.1974;99:2502-10
7.
Major ongoing stroke trials:carotid and vertebral artery transluminal study(CAVATAS). Stroke 1996;27:358
8.
Theron JG,Payelle GG,Coshun O,Huet HF,Guimareaus L. Carotid artery Stenosis: treatment with protected balloon angioplasty and stent placement.Radiology,1996;201:627-536
9.
Diethric EB,Ndiaye M,Reid DB:stenting in the carotid artery :Initial experience in 110 patients.J E ndovasc surg 1996;3:42-62
10.
Henry M,Amor M,Klonaris C,etal :Angioplasty and stenting of the extracranial carotid arteries .Tex Heart Inst J 2000;27:150-58
11.
Hugh S.Markus ,DM; Andrew Clifton etal:Improvement in cerebral hemodynamics after carotid angioplasty.Stroke. 1996;27:612-16
12.
wholey MH, Wholey M,Bergeron P,Yadav JS etal ,Current Global status Carotid artery stent placement .Catheterization. cardiac diagnosis, 1998; 44:1-6,
13.
Al Mubarak N, Roubin GS, Vitek JJ, et al. Effect of the distal-balloon protection system on microembolization during carotid stenting. Circulation. 104. 2001. pp. 1999
14.
Wholey MH, Al Mubarek N, Wholey MH. Updated review of the global carotid artery stent registry. Catheter. Cardiovasc. Interv.. 2003; 60.. pp. 259-66
15.
Henry M, Amor M, Henry I,etal:Carotid stenting with cerebral protection:First clinical experience using Percusurge Guard Wire system.J Endovasc Surg 1999;6:321-31
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Reimers, B, Corvaja, N, Moshiri, S, et al. Cerebral protection with filter devices during carotid artery stenting. Circulation 2001; 104:12.
17.
Ralf Zahn, Thomas Ischinger, Bernd Mark, Sabine Gass, Uwe Zeymer, etal for the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte (ALKK) J. Am. Coll. Cardiol. 2005;45;1769-1774 doi:10.1016/j.jacc.2005.02.067
18.
Cremonesi A, Manetti R, Setacci F, et al. Protected carotid stenting: clinical advantages and complications of embolic protection devices in 442 consecutive patients. Stroke 2003;34:1936–41

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