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

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Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
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On Sep 2018




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Prof. Somashekhar Nimbalkar
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Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
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




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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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Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Professor and Head
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Lucknow
On Sep 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.
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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 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
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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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

Important Notice

Original article / research
Year : 2012 | Month : May | Volume : 6 | Issue : 4 | Page : 688 - 691

An Indian Study of a Novel Non-invasive Method of Screening for Foetal Anaemia

Sushil. G. Kachewar, Siddappa.G. Gandage, Hemant. J. Pawar

1. Corresponding Author, Associate Professor, Department of Radio-diagnosis, RMC, PIMS 2. Professor and Head, Department of Radio-diagnosis, RMC, PIMS 3. Associate Professor & Head, Medical Statistics, RMC, PIMS, Loni, India.

Correspondence Address :
Dr. Sushil Ghanshyam Kachewar,
MD, DNB (Radio-diagnosis)
Associate Professor, Rural
Medical College, PIMS, Loni, India.
Phone: 0091-9921160357
E-mail: sushilkachewar@hotmail.com

Abstract

Purpose: The assessment of foetal Middle Cerebral Artery Peak Systolic Velocity (MCA-PSV) is useful in non-invasively diagnosing foetal anaemias, irrespective of their cause. A study was therefore undertaken to find out its effectiveness in the local obstetric population.

Materials and methods: Doppler ultrasound measurements of foetal MCA-PSV were done in 1200 pregnant women who were referred for antenatal ultrasound between 12-40 weeks of gestation. The statistical analysis was done by using Microsoft Excel 2007 and SPSS software, version 12.

Results: A statistically significant (p < 0.05) positive correlation was found to exist between the gestational age and MCA-PSV. 14 foetuses had their MCA-PSV elevated enough to label them as being anaemic. Iso-immunization was seen in 4 foetuses, severe maternal hypertension in 4, foetal parvo virus B19 infection in 3 and thalassemia in 3. Also, a disturbed MCA waveform pattern (The K-G waveform) was transiently seen in few cases with normal MCA-PSV values (The Pravara Effect).

Conclusion: Foetal MCA-PSV can objectively demonstrate foetal anaemia in pregnant patients, irrespective of the underlying cause. Every effort must therefore be made to use this non-invasive test to look for foetal anaemia in the obstetric population.

Keywords

Foetal Anaemia, Middle cerebral artery, Non-invasive test, Color Doppler Ultrasound, KG Waveform, Pravara Effect, Mind

Introduction
The accurate figures of foetal anaemia are scarce throughout the world, as those who are afflicted are often unreported, undiagnosed and even unsuspected. It is possible that many unexplained intrauterine deaths may in fact be due to the yet undiagnosed foetal anaemia. The inadequate knowledge about the availability of a rapid and effective non invasive diagnostic test also plays a vital role in this grim scenario.

Until recently, everyone relied on invasive measures like cordocentesis to obtain foetal blood and amniocentesis to obtain liquor for spectrophotometry, to assess the presence of foetal anaemia. But, the mounting evidence that the elevated values of foetal Middle Cerebral Artery Peak Systolic Velocities (MCAPSV) can indicate foetal anaemia has ushered in a new angle to the entire perspective on foetal anaemia. This test soon became popular due to its non-invasive nature and it is now being routinely used for the non-invasive assessment and the follow up of foetal anaemias (1), (2), (3), (4). As very few studies have been reported (1),(5) on this topic from the developing world, we undertook a prospective, cross sectional study on foetal MCA-PSV to evaluate its utility in the local community and also to validate whether the value of the foetal MCA-PSV increased with the advances in pregnancy, as had been reported earlier, (1), (2), (3), (4), (5), (6).

Material and Methods

After prior approval from the institutional ethical and research committees, this study was carried out in the ultrasound section. An informed written consent was obtained from each participant. Radiology Section 1200 women who had singleton pregnancies with a gestational age between 12 to 40 weeks were randomly selected for the study.

The foetal MCA-PSV was recorded by a single observer who had more than ten years of experience in ultrasound, by using a Siemens G-60 Doppler ultrasound machine. With the patient lying supine and at ease on the bed, a transverse section of the foetal head was obtained on the B mode imaging by using a 3.5 MHz curvilinear transducer. The colour mode was then switched on and the foetal MCA was localized near the circle of Willis. After the visualization of the entire length of the MCA, a pulse Doppler was used to sample it just after its origin from the internal carotid arteries, while the angle of insonation was kept at nearly zero degrees. After obtaining a steady waveform, the image was freezed and the peak of the systolic velocity was measured (Table/Fig 1). The entire process took around 5-15 minutes.

The data was compiled and statistically analyzed by using Microsoft Excel 2007 and SPSS software, version 12. The correlation between MCA-PSV and the gestational age was assessed by using the Karl Pearson`s Correlation Coefficient (r) and the ‘t’-test as a test of significance. The MCA-PSV values were compared with the standard published international values to evaluate whether foetal anaemia was present or not.

Results

The scatter diagram (Table/Fig 2) shows the correlation between the gestational age of the foetus and its MCA-PSV. As shown by the upward slope of the line, a positive correlation was found to exist between the two, indicating that there was an increase in the MCA-PSV as the pregnancy advanced. This correlation was statistically significant (p < 0.05).

In this study, 14 foetuses had their MCA-PSV elevated enough to label them as being anaemic. These cases with anaemia had focally elevated values as has been demonstrated in the Radar diagram (Table/Fig 3).

The causes of anaemia in these patients are shown in (Table/Fig 1). Iso-immunization was seen in 4 patients, severe maternal hypertension in 4, foetal parvo virus B19 infection in 3 and thalassemia in 3. The mean foetal MCA-PSV which was found at various gestational ages in the foetus with its normal outcome, is shown in the Bar diagram (Table/Fig 5). In this study, we also came across a disturbed MCA waveform pattern (named as the K-G waveform- after Kachewar and Gandage; the researchers in this project) that was transiently seen in few cases with normal MCAPSV values (Table/Fig 6). The foetus however was not anaemic. As this effect in which the foetal MCA velocity waveform was disturbed while the foetal haemoglobin was within normal limits was first documented successfully at our institute, we would like to label it as the ‘Pravara Effect’ (after the name of our Medical University).

Discussion

A study (7) which was done to assess the need of blood transfusions in various categories of newborns, showed that 39% premature babies, 31% low birth weight babies, and 10% of the newborns required blood transfusions as compared to a control group. This implies that foetal anaemia was quite common and hence a timely diagnosis would ensure a satisfactory outcome. The compliance and monitoring would be better if this foetal anaemia could be suspected, suggested, graded and even diagnosed noninvasively.

The commonly known causes of foetal anaemias are red blood cell alloimmunization, parvo virus B-19 infection, the twin-twintransfusion syndrome and foeto-maternal haemorrhage (1), (2), (3), (4), (5), (6), (7). Unusually severe haemolytic diseases of newborns with the ABO Rh incompatibility have been reported from India, Sri Lanka and Bangladesh, which often require multiple exchange transfusions (8), (9), (10). Severe haemolytic diseases due to the anti C and anti E antibodies in two Rh D positive women, have been reported postnatally, (11) thereby showing that severe haemolytic disease due to an alloantibody other than anti D is also possible.

Not long ago, amniocentesis and cordocentesis were exclusively used for quantifying foetal anaemias. But inherent complications of amniocentesis like foeto-maternal haemorrhage may even worsen the severity of the disease, (12).Cordocentesis is known to have a higher risk for foetal loss than amniocentesis and foeto-maternal haemorrhage and an increased sensitization is possible after a transplacental puncture, (13). Procedure-related pregnancy loss, foetal bradycardia, bleeding, a premature rupture of membranes and enhanced risks of infection due to an intravascular access for the direct measurement of foetal haemoglobin and for transfusions have also been reported, (3).

Hence, a global search was on for a satisfactory non-invasive method to assess foetal anaemia. The doppler ultrasound based quantification of MCA-PSV was shown to be a more sensitive, specific and a non-invasive test than other parameters like intrahepatic umbilical venous maximum velocity, liver length, and spleen perimeter (14),(15). The confidence in the foetal MCA PSV has reached such levels that invasive diagnostic techniques can safely be avoided if the MCA flow velocity is found to be normal (16). Moreover, the changes in the foetal cerebral arteries are more useful and reliable than those in the umbilical arteries, (17).

The global acceptance of the Doppler ultrasound based foetal MCA-PSV measurement as a non-invasive method of foetal haemoglobin estimation stems from the very fact that it is quick easy, and widely reproducible and that it has minimal inter or intra observer variability. It is the reduced viscosity of the blood in foetal anaemia which manifests as an elevation in the peak systolic velocity, so as to provide adequate nutrients and oxygen to the brain. The peak velocity is thus inversely related to the haemoglobin value and to the results from the increased cardiac output, (3),(18).

The inverse correlation between foetal haemoglobin and MCAPSV is weaker to begin with, when the foetus is normal or mildly anaemic and it gradually becomes stronger and statistically significant with the increasing severity of the anaemia (3). These elevated values gradually reduce and even fall in the normal range when the foetal aneamia is adequately treated, so that ultimately the number of the unnecessary and invasive amniocentesis and cordocentesis prescriptions for diagnosing foetal anaemia can be effectively reduced, (19).

Overall, the results of this study are in harmony with those of other studies, in that the MCA-PSV increases with the advancing gestational age (2), (5), (6), (20), (21), (22). In our study, elevated MCAPSV values were seen in 14 patients and they were labeled as anaemic. Their causes are shown in (Table/Fig 4).

The strength of this study was that it was the first regional study to demonstrate the successful utilization of the non invasive method of foetal MCA-PSV Doppler measurement to diagnose foetal anaemia, although few case reports had been reported earlier (23),(24). The usage of this method enables the visualization of the cases which result in intra and perinatal mortality and morbidity, with fresh eyes. The strength of this study was that it was population based and that a representative sample from the rural population was involved. An internationally standardized protocol was followed in this research project. The measurements were made as they were made by other researchers.

However, we feel that this study should be conducted on a wider scale and in populations who reside in different geographic localities. We feel that this is the first regional study on this topic as till date, we have not come across any such study from this geographic locality. Moreover, this study adds a new dimension to the current literature on the foetal MCA velocity waveform in the form of the contribution of the K-G wave (6) and the Pravara effect (6).

Conclusion

The positive correlation between the MCA-PSV values and the gestational age which has been described in international studies, was confirmed by this regional study. The successful utilization of this non invasive test adds a silver lining to the management of foetal anaemia. The identification of the K-G wave and the description of the Pravara effect indicate that although a lot has been done globally on this topic, still there are certain dimensions of the foetal MCA waveform that are lying unexplored. There is therefore a scope for more research.

References

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Tan KBL, Fook-Chong SMC, Lee SL, Tan LK. Foetal peak systolic velocity in the middle cerebral artery: an Asian reference range. Singapore Med J 2009; 50(6): 584-6.
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Kurmanavicius J, Streicher A, Wright EM, Wisser J, Muller R, Royston P, et al. Reference values of foetal peak systolic blood velocity in the middle cerebral artery at 19-40 weeks of gestation. Ultrasound Obstet Gynaecol 2001; 17: 50-3.
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Mari G, Deter RL, Carpenter RL, Rahman F, Zimmerman R, Moise KJ, et al. Non-invasive diagnosis by Doppler ultrasonography of foetal anaemia due to maternal red-cell alloimmunization. Collaborative Group for Doppler Assessment of the Blood Velocity in Anemic Fetuses. N Engl J Med 2000; 342:9–14.
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Marwaha N, Dhawan HK, Thakral B, Kaur R, Basu S, Parmar V. Severe ABO haemolytic disease of the newborn with a positive direct anti-globulin test. Indian J Pathol Microbiol 2009; 52:292-5.
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Haque KM, Rahman M. An unusual case of ABO-haemolytic disease of the newborn. Bangladesh Med Res Counc Bull 2000; 26:61-4.
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Lucas GN. Neonatal jaundice due to ABO incompatibility in Sri Lanka. Indian J Paediatr 1996; 63:381-4.
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Thakral B, Agrawal SK, Dhawan HK, Saluja K, Dutta S, Marwaha N. The first report from India on haemolytic disease of newborns due to the anti C and anti E antibodies in Rh (D) positive mothers. Haematology 2007; 12:377-80.
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Bowman JM, Pollock JM. Transplacental foetal haemorrhage after amniocentesis. Obstet Gynaecol. 1985; 66: 749-54.
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MacGregor SN, Silver RK, Sholl JS. Enhanced sensitization after cordocentesis in a rhesus-isoimmunized pregnancy. Am J Obstet Gynaecol. 1991; 165:382-3.
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Dukler D, Oepkes D, Seaward G, Windrim R, Ryan G. Non-invasive tests to predict foetal anaemia: A study which compared the Doppler and ultrasound parameters. Am J Obstet Gynaecol 2003; 188:1310- 1314.
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Hobbins JC. Use of ultrasound in complicated pregnancies. Clin Perinatol 1980; 7:397–411.
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Oepkes D, Meerman RH, Vandenbussche FP, Van Kamp IL, Kok FG, Kanhai HH. Ultrasonographic foetal spleen measurements in red blood cell-alloimmunized pregnancies. Am J Obstet Gynaecol 1993; 169:121–28.
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DOI and Others

ID: JCDR/2012/3411.3964:0035

Date of Submission: Jan 10, 2012
Date of Peer Review: Jan 11, 2012
Date of Acceptance: Jan 13, 2012
Date of Publishing: May 31, 2012

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