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

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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




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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 : 2012 | Month : September | Volume : 6 | Issue : 7 | Page : 1178 - 1180 Full Version

The Pattern of the Initial Anti-retroviral Drug Regimens in HIV Patients at a Tertiary Care Hospital


Published: September 1, 2012 | DOI: https://doi.org/10.7860/JCDR/2012/.2467
Prakash Raju GJK, Mukta N. Chowta, Zahoor Ahmad Rather, Faheem Mubeen

1. Postgraduate, Department of Pharmacology, 2. Associate Professor, Department of Pharmacology, 3. Postgraduate, Department of Pharmacology, 4. Postgraduate, Department of Pharmacology, Department of Pharmacology, Kasturba Medical College, Mangalore, Manipal University India.

Correspondence Address :
Dr. Mukta N Chowta,
Associate Professor, Department of Pharmacology,
Kasturba Medical College, Light House Hill Road,
Mangalore-575001Manipal University, India.
Phone: 0825-2431122, 9448790524,
E-mail: muktachowta@yahoo.co.in

Abstract

Background and objective: The choice of the anti-retroviral drug therapy has been evolving over the last decade. The objective of this study was to evaluate the current prescribing pattern of the anti-retroviral drugs in treatment-naĂŻve patients before initiating the anti-retroviral therapy.

Materials and Methods: A retrospective review of the antiretroviral drugs which had been prescribed to the HIV-infected patients was conducted at a tertiary care hospital in South India. Only adults patients who were of more than 18 years of age, with a positive serology, who had started or had already been receiving the anti-retroviral therapy were included. Their main demographics, the details of the AIDS diagnoses, the laboratory data (CD4 cell counts) and the history of the antiretroviral therapy were collected.

Result: The total number of patients was 108. Among them, 76 (70.4%) were males and 32 (29.6%) were females. The mean age of the patients was 38.67 ±10.02years, the mean weight was 52.47± 11.2kg and the mean CD4 count was 256.57 ± 204.6cells/cumm. Among these patients, 34(31.5%) were on the lamivudine+ zidovudine+ nevirapine regimen, 70(64.8%) were on the lamnivudine + nevirapine+ stavudine regimen (3TC + NVP+ d4T) and 4(3.7%) were on the tenofovir+ emtricitabine +efavirenz regimen. In the first regimen, the mean age of the patients was 39.09 ±9.1years, the mean weight was 51.87±10.7kg and the mean CD4 count was 253.21±177.8cells/cumm. In the second regimen, the mean age of the patients was 38.73 ±10.59 years, the mean weight was 52.37±12.24kg and the mean CD4 count was 262.02± 221.4 cells /cumm. The comparison of the mean age and the mean CD4 count among the patients in the different regimens did not show any statistical significance.

Conclusion: The most frequently used antiretroviral drug regimen was the 3TC + NVP+ d4T combination. The prescription pattern was quite in contrast to that which was followed in the developed countries. Newer NRTIs were less frequently used.

Keywords

ART regimens, HIV, CD4 count

Introduction
The achievement of an effective treatment for the HIV infection has been one of the most remarkable milestones in the recent history of medicine. This is true, not only for the number of lives that have been saved, but also for the amount of scientific information that has been generated alongside the daily treatment of HIV-infected individuals. The analysis of the changes in the prescription of anti-retroviral drugs is a good exercise of how clinical practice and research may meet continuously to improve the management of HIV-infected patients (1). Despite the availability of successive national and international guidelines on antiretroviral prescribing, anecdotal evidence suggests a considerable variation in the use of different antiretroviral drugs across and within different the HIV centres. Previous studies have examined the compliance with the guidelines on the timing of the initiation of the therapy, and other aspects of the HIV care, but the interpretation of these findings has been confounded by late presentations (2). More than 20 approved ARV drugs in 6 mechanistic classes are available to design combination regimens. These 6 classes include the nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs), the non-nucleoside reverse transcriptase inhibitors (NNRTIs), the protease inhibitors (PIs), the fusion inhibitors (FIs), the CCR5 antagonists, and the integrase strand transfer inhibitors (INSTIs) (3). The choice of antiretroviral drugs has evolved over the last decade. The recognition of the trends and the determinants of the changes may help in makingectionpredictions on the prescription patterns. A variety of factors may influence the physician prescribing practices, which include the patient demographic characteristics, physician training, physician perceptions about the relative importance of various drug characteristics, such as the ease of the use and the side-effect profile and the availability of treatment guidelines, local practice patterns and the pharmaceutical industry. Studies in other areas have demonstrated the effectiveness of various educational strategies which are employed by the pharmaceutical industry in influencing the physician prescribing (4),(5). Hence, this study was planned to evaluate the prescribing pattern of the antiretroviral drugs in treatment-naĂŻve patients for initiating the antiretroviral therapy (ART) over a 5 year period (2007-2011).

Material and Methods

A retrospective review of the anti-retroviral drugs which had been prescribed to HIV-infected patients was conducted at a tertiary care hospital of South India. This study was approved by the institutional ethics committee. Only adults who were older than 18 years, with a positive serology, who had started on or were already receiving antiretrovirals were included. Their main demographics, which included the age, gender and the risk group were recorded. The data was collected in a suitably designed proforma, which included the demographic characteristics, the details of the AIDS diagnoses, the laboratory data (CD4 cell counts) and the ART history.

Statistical analysis
All the descriptive results were given as total numbers and percentages. The continuous variables were analyzed by the Student’s ‘t’ test and the categorical variables were analyzed by the Chi square test. A p value of less than 0.05 was considered as significant.

Results

The total number of patients was 108. Among them, 76 (70.4%) were males and 32 (29.6%) were females. The mean age of the patients was 38.67 ±10.02years, the mean weight 52.47± 11.2kg and the mean CD4 cell count was 256.57±204.6cells/cumm. There was a significant difference between the mean age and the weight among the males and the females respectively (p=0.042and 0.008 respectively). Also, there was significant difference in the mean CD4 count among the males and females (Table/Fig 1). Around 34(31.5%) patients were on the 3TC +NVP+ZDV (lamivudine + nevirapine+ zidovudine) regimen, 70(64.8%) were on the 3TC +NVP+d4T (lamnivudine + nevirapine+ stavudine) regimen and 4(3.7%) were on the TDF+FTC+EFV (tenofovir+ emtricitabine + efavirenz) regimen. In the 3TC +NVP+ZDV regimen, the mean age of the patients was 39.09 ±9.1years, the mean weight 51.87±10.7kg and the mean CD4 count was 253.21±177.8cells/cumm. In the 3TC +NVP+d4T regimen, the mean age of the patients was 38.73 ±10.59 years, the mean weight was 52.37±12.24kg and the mean CD4 count was 262.02± 221.4 cells/cumm. The comparison of the mean age and the mean CD4 count among the patients in the different regimens did not show any statistical significance (Table/Fig 2).

Discussion

A combination ART regimen generally consists of two NRTIs + one active drug from one of the following classes: NNRTI, PI (generally boosted with ritonavir), INSTI, or a CCR5 antagonist. The selection of a regimen should be individualized, based on the virologic efficacy, toxicity, pill burden, dosing frequency, drug-drug interaction potential, resistance testing results, and the patient’s comorbid conditions. The “preferred regimens” are those regimens which have been studied in randomized controlled trials and have been shown to have optimal and a durable viro2logic efficacies, favourable tolerability and toxicity profiles, and ease of use. The “alternative regimens” are those regimens that are effective but have potential disadvantages as compared to the preferred regimens. In certain situations and based on the individual patient’s characteristics and needs, a regimen which has been listed as an alternative may actually be the preferred regimen for a specific patient. Some regimens are classified as “acceptable regimens” because of their reduced virologic activity, lack of efficacy data from large clinical trials, or other factors (such as greater toxicities, the need for additional testing, pill burden, or the drug interaction potential) compared. The preferred regimens include efavirenz (EFV)/TDF/FTC, ATV/r + TDF/FTC, DRV/r (once daily) + TDF/FTC, raltegravir (RAL) + TDF/FTC (3). The most frequently used regimen in our patients was 3TC + NVP+ d4T, which was used in 64.8% of the patients. The 3TC + NVP+ ZDV regimen was taken by 30.5% of the patients. Because of the higher prevalence of anaemia in our patients, zidovudine was less commonly used. The regimens which were followed in our patients were at par with the standard guidelines which were laid down by National Aids Control Organization (NACO) (6). The current NACO treatment guidelines for first-line ART recommends two classes of drugs for the initial treatment i.e. 2 NRTI + 1 NNRTI. The preferred first line regimen is 3TC + NVP+ ZDV if the haemoglobin level is above 8gm/dl. Stavudine is used in place of zidovudine if the haemoglobin level is less than 8 gm/dl. The current NACO treatment guidelines recommend that the protease inhibitor (PI) class is reserved for, and therefore characterizes the second-line ART. Ritonavir boosted protease inhibitors (bPIs) are recommended, supported by two agents from the NRTI class. There was no significant difference between the patients who were on different regimens with regards to the mean CD4 count, the mean weight or the mean age. Very few patients were on the newer NRTIs like tenofovir and emtricitabine, which may have been due to the fact that these are drugs were comparatively more expensive. Abacavir was almost not used in our patients, as it required the HLA testing facility to predict the risk of acute hypersensitivity reactions. Hence, it could be used in specialized centres which have the facility for these tests. Stavudine, though it is more toxic in terms of the lactic acidosis and the peripheral neuropathy, is very commonly used in the first line regimens (as an alternative to zidovudine) because of its easy availability at all the ART centres and its affordability. The trend of the prescription in our patients was quite different from the trends which were observed in the western literature. In contrast to our reports, JimĂ©nez-NĂĄcher, et al., (1). reported that the relative use of nucleoside reverse transcriptase inhibitors (NRTIs) and protease inhibitors (PIs) had risen in the recent years, while the prescription of non-nucleoside reverse transcriptase inhibitors had declined, as compared to that in the period from 1999-2001, when it had peaked. Among the NRTIs, the use of zalcitabine, stavudine and didanosine had dramatically declined or vanished, while the use of zidovudine, lamivudine, abacavir and tenofovir had gained relevance. Among the PIs, indinavir and nelfinavir had almost disappeared, being replaced by ritonavir-boosted PIs, mainly atazanavir and lopinavir. After its first introduction in the year 1999, efavirenz has been generally preferred over nevirapine. EFV has been compared with a number of other antiretroviral drugs in the combination regimens which contained two NRTIs (7). To date, no regimen has been proven superior to the EFV-based regimens with respect to the virologic responses.

The RTV-boosted PI-based regimens have shown good virologic and immunologic responses but they are often associated with more gastrointestinal symptoms, whereas the EFV-based regimens are associated with more rash and central nervous system adverse effects. Both the types of regimens may be associated with hepatic transaminase elevations (8). The EFV-based regimens had a comparable virologic activity when they were compared with NVP. Studies that compared the EFV-based regimens with other regimens demonstrated that the combination of EFV with two NRTIs was superior virologically to some PI-based regimens (9). Tenofovir (TDF) and emtricitabine (FTC) were the latest NRTIs to enter the market, but they have rapidly gained positions, which is most likely, due to a combination of good tolerance, convenience and potency. TDF is a nucleotide analogue with a potent activity against both HIV and the hepatitis B virus and with a long intracellular half-life that allows for once-daily dosing. TDF, when it was used with either 3TC or FTC as a part of an EFV-based regimen in ART-naive patients, demonstrated a potent virologic suppression and it was superior to ZDV/3TC in the virologic efficacy (up to 144 weeks) (10).

The dual-NRTI combination of zidovudine (ZDV)/3TC has extensive durability, safety, and tolerability experience. Bone marrow suppression, which was manifested by macrocytic anaemia and/ or neutropaenia, was seen with ZDV. ZDV was also associated with gastrointestinal toxicity, fatigue, and possibly, mitochondrial toxicity, which included lactic acidosis/hepatic steatosis and lipoatrophy. Because of its greater toxicity as compared to TDF/ FTC or abacavir (ABC)/3TC and the need for a twice daily dosing, the panel recommends ZDV/3TC as an acceptable, rather than a preferred or alternative, dual-NRTI option (11). Jiménez-Nåcher et al., (1) showed that three major forces have driven the prescription of different antiretrovirals in the last decade, namely their efficacy, safety profile and simpler administration. It is vital to make these assessments in both clinical trials (reflecting the efficacy of the therapy which is given under experimental conditions) and community-based settings (reflecting the effectiveness of the therapy as it is prescribed and used in practice). To conclude, the most frequently used antiretroviral regimen was the 3TC + NVP+ d4T combination. Its prescription pattern was quite in contrast to that which was followed in the developed countries. The newer NRTIs were less frequently used and this may be because of the affordability of the patients and their availability.

References

1.
Jiménez-Nåcher I, García B, Barreiro P, Rodriguez-Novoa S, Morello J, Gonzålez-Lahoz J, et al. The trends in the prescription of anti-retroviral drugs and their impact on the plasma HIV-RNA measurements. J. Antimicrob. Chemother. 2008; 62 : 816-22.
2.
Easterbrook P, Phillips A, Hill T, Matthias R, Fisher M, Gazzard B, et al. The UK Collaborative HIV Cohort (CHIC) Study Steering Committee. The patterns and the predictors of the use of different antiretroviral drug regimens at the treatment initiation in the UK. HIV Medicine, 2008;9: 47–56.
3.
The Panel on Anti-retroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. October 14, 2011; 48–63. Available at http://www.aidsinfo.nih.gov/ ContentFiles/AdultandAdolescentGL.pdf. Accessed [accessed on 16 march 2012].
4.
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DOI and Others

ID: JCDR/2012/4301:2467

Date of Submission: Mar 19, 2012
Date of Peer Review: Jun 22, 2012
Date of Acceptance: Aug 04, 2012
Date of Publishing: Sep 30, 2012

JCDR is now Monthly and more widely Indexed .
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