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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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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 ones 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.
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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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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.
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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

Important Notice

Original article / research
Year : 2011 | Month : August | Volume : 5 | Issue : 4 | Page : 804 - 807

A Study of Cardiovascular Autonomic Functions in Congenitally Deaf Children with a Long QTC Interval

Surekharani Chinagudi, Shiddanna M. Patted, Anita Herur

Corresponding Author. Associate Professor, Department Of Orthopaedics, S.Nijalingappa Medical College, Navanagar, Bagalkot-587102, Karnataka, India. Associate Professor, Department Of Physiology, S.Nijalingappa Medical College, Navanagar, Bagalkot-587102, Karnataka, India.

Correspondence Address :
Dr. Surekharani Chinagudi
Associate Professor, Department Of Physiology,
S.Nijalingappa Medical College, Navanagar,
Bagalkot-587102, Karnataka, India.
Mobile: +919448236457


Background: Congenitally deaf children are at a risk of cardiac abnormalities in the form of the Long QT syndrome. It can be because of an intracardiac abnormality or autonomic dysfunction.

Aim: To study the cardiovascular autonomic functions in congenitally deaf children with a prolonged QTc interval.

Material and Methods: Congenitally deaf children who were aged between 6-18 years and having a prolonged QTc interval on ECG were selected as the cases and were compared with matched controls. Children with conductive deafness or those having any cardiovascular disorder were excluded. The tests which were done were Heart rate variation during deep breathingHeart rate response to standing, blood pressure response to standing and blood pressure response to a sustained hand grip. Statistical analysis was done by using the unpaired t test.

Results: No abnormal response was recorded in the cases or in the controls with respect to the above tests. The autonomic functions were normal.

Conclusion: Since there are no abnormalities in the cardiovascular autonomic functions in the congenitally deaf children, the autonomic imbalance theory for the Long QT syndrome stands invalid. The aetiology goes more in favour of intracardiac abnormality which predisposes to the Long QT syndrome.


Autonomic function tests, Long QT syndrome, Congenital deafness; Jervel Lange Nielsen Syndrome; QTC interval

Thomas Carlyle’s statement “Our main business is not to see what lies dimly at a distance but to do what lies clearly at hand”, was an integral part of William Osler’s Physiology of life, which he discussed in his 1913 address, ‘A Way Of Life’. In the genetic disorders of the heart, such as inherited long QT syndrome or hypertrophic cardiomyopathy, what lies clearly at hand has been clouded by a reduced penetrance and a variable expression of the phenotype. The more obvious and severe cases of these disorders were of course, identified and they provided the basis for the subsequent diagnosis and for the assessment of the clinical course; yet this phenotype was only the tip of the iceberg, representing only a small proportion of the patients. The broader spectrum of the disease which was manifested by a larger proportion of the patients at the base of the iceberg was not recognized until the diagnosis could be made by genetic analysis (1).

As we know, ‘Today’s children are tomorrow’s citizens of the country’. But for no fault of theirs, some children are born deaf and nature has been still harsh on them by not bestowing them with good hearts. There is some evidence that deaf children are more threatened than the general population by dangerous heart arrhythmias (2).

Children who are born deaf become deaf mute. Deaf mute children cannot bring out their problems like other children and the problems remain unrecognized unless they become severe enough to express themselves but by then, it would have reached a ‘no return stage’.

In 1957, Jervel and Lange Nielsen, for the first time described four siblings in whom deaf mutism was associated with peculiar heart disease. Deaf mute children, who otherwise seemed to be quitehealthy, suffered attacks of fainting, which were often provoked by exercise or fear. Three of the four children died suddenly at the ages of 4, 5 and 9 years (3). This condition was named as the Jervel – Lange Nielsen Syndrome or the Surdo cardiac Syndrome, where there was a prolongation of the QT interval on ECG.

The Long QT Syndrome represents the intriguing link between cardiac electrophysiology, the autonomic nervous system and lethal arrhythmias (4).

The aetiology of the Long QT syndrome is either an ion channellopathy or an autonomic imbalance. The ion channellopathy could be in the form of a K+ ion channel defect which predisposes to congenital sensory neural hearing loss (the function of which is much required at the stria vascularis in the inner ear) and cardiac repolarisation defects in the form of a prolonged QT interval. The autonomic imbalance in these congenitally deaf children could also cause a prolonged QT interval (5). So, the present study was taken up to know the status of the autonomic nervous system in these congenitally deaf children with a prolongation of the QT interval on ECG.

Material and Methods

This study was done on 20 congenitally deaf children with a prolongation of the QTc interval on ECG and those who were aged between 6–18 years. An equal number of healthy matched controls was included for the study.

Clearance from the ethical committee of the S. N. Medical College, Bagalkot, Karnataka, India, was obtained for this study. Informed consent was obtained from the guardians of each subject.

Children who were deaf by birth, who had a prolonged QTc interval (>0.43 seconds) on ECG and who were aged between 6–18years were selected for the study. They were certified as having congenital sensory neural hearing loss by the ENT surgeon and the prolongation of the QTc interval on ECG was confirmed by the physician.

Five children were brought from their respective schools at each time. Along with the deaf children, their respective class teachers were also brought because of a language problem. The teachers used to convey the messages to the deaf children in sign language.

After bringing the children to the laboratory, they were made to relax for five minutes. Then, their brief history was noted. After noting the history, their height and weight were noted and their body mass index was calculated.

Blood pressure in mm of mercury, pulse rate in beats per minute, respiratory ratein breaths per minute and body temperature in degree Celsius, were recorded subsequently. This was followed by a routine clinical examination of all the systems namely, the cardiovascular system the respiratory system, the central nervous system, and per abdominal examination. This was followed by an ECG recording in lead II at rest and after exercise (the child was made to run on the tread mill at an inclination of 7 degrees and at 3 km per secs of speed till exhaustion).

Once the ECG recording was over, child was made to relax for fifteen minutes. During this time, the QT interval i.e., the interval between the start of the QRS complex and the end of the T wave was calculated in seconds. Since the QT interval changes with the heart rate, the corrected QT interval [QTC] was calculated by using Bazzet’s formula (6), QTC = QT / √ R-R

For example, QT interval = 0.32 sec and R-R interval = 0.8 sec, QTc = 0.32/√ 0.8 = 0.357 seconds or 357 milliseconds.

Then, cardiovascular autonomic function tests were done.

Four standard cardiovascular autonomic function tests were selected. The equipments which were required, included- a sphygmomanometer, an ECG machine, a hand – grip dynamometer, a couch and a chair. Due care was taken to remove the factors which could interfere with the results of the tests.

Methods of Assessment
Detailed instructions regarding the procedure which was employed for each test were given to the subjects. The different maneouvers were demonstrated to the subjects and they were trained to perform the tests. Actual recordings were made only after they were able to perform the tests satisfactorily. When the tests were performed by one subject, the others were asked to observe him/ her performing the tests.

The following cardiovascular autonomic function tests were performed (7),(8),(9): 1. Heart – rate variation during deep breathing. 2. Heart – rate response to standing {30: 15 ratio}.

3. Blood pressure response to standing. 4. Blood pressure response to a sustained hand grip. The results of the tests were expressed as ratios and differences and they were analyzed by applying the unpaired “t” test (10), (11). P values <0.05 were considered to be statistically significant.


The cardiovascular autonomic function tests of 20 congenitally deaf children with a prolongation of the QTc interval on ECG and those of an equal number of children as matched controls were studied.

The cases and the controls who were selected for this study were of comparable ages and physical characteristics i.e., height, weight and body mass index. The ages (in years) of the cases ranged from 10 to 18 years, their mean age being 13.9 ± 2.15 and those of the controls ranged from 10 to 18 years, their mean age being 13.8 ± 1.7.

Out of the 20 cases and 20 controls, 13 were males and 07 were females in each group.

The mean height (in meters) of the cases was 1.43 ± 0.11 and that of the controls was 1.42 ± 0.11.

The mean weight (in kg) of the cases was 34.8 ± 7.33 and that of the controls was 34.82 ± 7.9. The mean BMI (in kg/sq.m.) of the cases was 16.82 ± 2.27 and that of the controls was 16.86 ± 2.27. The mean body temperature (in degree Celsius) of the cases was 36.9 ± 0.9 and that of the controls was 36.8 ± 0.7.

The mean haemoglobin concentration (in gram %) of the cases was 11.8 ± 2.2 and that of the controls was 12.0 ± 2.1.

The above data of the baseline characteristics is shown in (Table/Fig 1).

Heart Rate Variation during Deep Breathing (HRDB)
The mean heart rate variation (beats per minute) i.e., the difference between the maximum and the minimum heart rates during deep breathing in the cases was 26.76 ± 8.11 and that in the controls was 26.7 ± 6.25. The difference between the two groups was not statistically significant

Heart Rate Response to Standing (HRS)
The mean value of the 30:15 ratio which was used to assess the heart rate response to standing, in the cases was 1.22±0.07 and that in the controls was 1.21±0.05. The difference between the two groups was not statistically significant (Table/Fig 2) (Table/Fig 3).

Blood Pressure Response to Standing (BPS)
The mean reduction in the systolic blood pressure (mmHg) in the cases was 7.32±2.28 and that in the controls was 7.84±1.86. The difference between the two groups was not statistically significant (Table/Fig 2) (Table/Fig 3).

Blood Pressure Response to a Sustained Hand Grip (BPSH)
The mean increase in the diastolic blood pressure (mmHg) in the cases was 22.16 ± 4.37 and that in the controls was 21.64 ± 4.43. The difference between the two groups was not statistically significant (Table/Fig 2) (Table/Fig 3).

The tests for the sympathetic and the parasympathetic systems did not reveal any abnormal response in both the cases and the controls.


After screening about 100 congenitally deaf children by ECG for the QT interval, we got about 20 congenitally deaf children with a long QT interval and these cases were selected for the study. The main aim of the study was to know the aetiology of the Long QT syndrome.

We knew that the aetiology could be K+ ion channellopathy which predisposed to sensory neural hearing loss because of the malfunctioning of the stria vascularis and similar K+ ion channels in the heart, thus causing the repolarisation defects.

But, the Long QT Syndrome or the Jervel-Lange Nielsen syndrome as it was previously called, is the one that shows an intriguing link between the autonomic nervous system and cardiac electrophysiology (4). Srivasthava et al (5) suggested a sympathetic imbalance hypothesis as well as a repolarisation defect in the deaf children’s hearts. An abnormal adrenergic neural control, along with ion channellopathies are responsible for the QT interval, the ST segment and the T wave changes which are found on the electrocardiogram (12).

Hence, we decided to investigate the aetiology of this syndrome – whether it was because of ion channellopathy or because of autonomic imbalance or whether both of these existed together in congenitally deaf children? So, we decided to study the autonomic function tests in these children, as studying the ion channels and their defects was beyond the scope of our set up.

In our study, none of the children exhibited defects in the autonomic function tests. The results of the tests were same in both the controls and in the congenitally deaf children.

Therefore, according to our study, the aetiology of the Long QT Syndrome is more in favour of ion channellopathy which predisposes to sensory neural hearing loss and cardiac repolarisation defects. The autonomic imbalance theory, as the aetiology of the Long QT syndrome can be stated as invalid from the present study.

A study on these K+ ion channels and their typing, as to which type of K+ channels and what type of defect-whether the opening or the closing of these ion channels is responsible for this syndrome, would lead to a deeper understanding of this disorder.


Vincent GM. The long QT syndrome - bedside to bench to bedside. New Engl J Med 2003; 19: 348.
Rokicki W, Markiewicz-Loskot G, Michalewska A, Wludarczyk W, Mizia M. Preliminary cardiological examination in deaf children. Przegl Lek 2002; 59(9): 737-739.
Jervell A, Thingstad R, Endsjo T. The surdo cardiac syndrome. American Heart Journal 1966; 72(5): 582-593.
Priori. SG, Napolitano C, Diehl L, Schwartz PJ. Dispersion of the QT interval, a marker of therapeutic efficacy in the idiopathic long QT syndrome. Circulation 1994; 89(4): 1681-1689.
Srivasthava RD, Pramod J, Deep J, Jaison T.M, Singh S, Soni K. Electrocardiographic changes following exercise in the congenitally deaf school children and their relationship with the Jervell Lange Neilsen syndrome (the long QT syndrome). Indian J Physiol Pharmacol 1998; 42(4): 515-520.
Colin S, Leo S. An introduction to electrocardiography, 7th edition. Oxford, Blackwell Science Ltd., 1990, pp 28-31.
Noronha JL, Bhandarkar SD, Shenoy PN, Retnam VJ. Autonomic neuropathy in diabetes mellitus. Journal of Post Graduate Med 1981; 21(1): 1-6.
Mishra UK, Kalita J. Clinical neurophysiology. New Dehi: Elsevier India Private Ltd., 1999, pp 97–105.
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Olley PM, Fowler RS. The surdo-cardiac syndrome and therapeutic observations. Br.Heart J 1970; 32: 467-471.

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