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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Case report
Full Version
Long-term Implication of Metronidazole Induced Reversible Cerebellar Toxicity and Peripheral Neuropathy- A Case Report
Correspondence Address :
Hardev Ram Nehra,
77, Adrash Colony, Near Varsha Ritu, Ambedkar Circle, Bikaner-334001, Rajasthan, India.
E-mail: drnehara@gmail.com
Metronidazole Induced Encephalopathy (MIE) is rare and serious central nervous system toxicity. A 40-year-old male, on long-term self treatment with metronidazole (cumulative dose: 102 gm) presented with dysarthria, nystagmus, unsteadiness, and numbness in both legs. A Magnetic Resonance Imaging (MRI) scan of the brain revealed a symmetric hyperintensity in both the dentate nuclei of cerebellum on both T2 weighted and Fluid Attenuated Inversion Recovery (FLAIR) imaging. Discontinuation of metronidazole resulted in resolution of the imaging findings and clinical improvement occurred within one month. Metronidazole-induced neurotoxicity should be considered in patient who present with cerebellar symptoms and characteristic lesion on MRI in close temporal relation with metronidazole intake and drug should be discontinued to prevent permanent neurological deficit.
Central nervous system, Dentate nuclei, Encephalopathy, Magnetic resonance imaging
A 40-year-old male presented in the Emergency Department of a tertiary care center with complaints of sudden onset of slurring of speech, unsteadiness while walking, vomiting and numbness in both legs and arms for three days. The patient was admitted to the same hospital six weeks back with a complaint of fever and right upper quadrant abdominal pain since two weeks. He was diagnosed with amoebic liver abscess and was treated with intravenous metronidazole 2500 mg/day in divided doses for 10 days with significant improvement in symptoms. He was discharged with oral metronidazole 800 mg thrice a day for 10 more days, but he continued to take oral metronidazole for more than four weeks till readmission without any consultation and follow-up. No history of any addiction, hypertension, diabetes mellitus, and head injury was present.
On general physical examination, the patient was alert, afebrile, vitals were within normal limits, without any evidence of pallor, icterus, cyanosis, clubbing, oedema feet, or lymphadenopathy. Central Nervous System (CNS) examination revealed dysarthria, horizontal nystagmus, dysdiadochokinesia and wide-based ataxic gait without any motor deficit. Sensory examination revealed diminished pain and temperature sensation in both hands and feet and altered joint position sense in small joints of both feet. The rest of the CNS examination including fundoscopy was unremarkable.
The patient underwent MRI brain which showed an altered signal intensity in bilateral dentate nuclei of cerebellum appearing hyperintense on both T2 weighted and FLAIR imaging while hypointense in T1 weighted images with mild restricted diffusion (Table/Fig 1)a,b. The radiologist suggested the cause to be toxic encephalopathy. Complete blood count, plasma glucose, liver function tests, renal function test were within normal ranges. Human Immunodeficiency Virus (HIV), Hepatitis B surface Antigen (HBsAg) and Hepatitis C serology were negative. Vitamin B12, folate levels, and thyroid function tests were within normal limits. Cerebrospinal Fluid (CSF) examination was unremarkable. Electroencephelogram (EEG) was unremarkable. Nerve conduction study revealed sensory axonal affection of bilateral sural and ulnar nerves.
Based on the clinical picture, characteristic MRI findings and temporal relation with metronidazole intake, a diagnosis of metronidazole induced cerebellar toxicity and peripheral neuropathy was made. Abdominal ultrasound revealed liquefied liver abscess and almost 250 mL anchovy sauce abscess was aspirated percutaneously guided by ultrasound. The patient was treated symptomatically with intravenous fluid, antiemetic, antihistaminic, multivitamins and metronidazole was withdrawn which resulted in gradual improvement of symptoms. On day eight of admission, the patient was discharged with advice of regular follow-up.
The patient was followed-up after four weeks and reported gradual improvement in numbness in his extremities. Repeat MRI brain revealed complete resolution of lesions of dentate nuclei (Table/Fig 2)a,b.
Prolonged use of metronidazole may produce neurological toxicity in the form of encephalopathy, cerebellar toxicity, seizure and neuropathy. Metronidazole induced peripheral neuropathy is predominantly sensory and usually gets resolved partially or completely after discontinuation of drug (1). Metronidazole Induced Encephalopathy (MIE) is a very rare but is a serious adverse effect of metronidazole (2).
The pathophysiology of metronidazole induced neurotoxicity is not well-known. It has been proposed that metabolites of metronidazole may inhibit protein synthesis via binding to Ribonucleic Acid (RNA), and finally result in axonal degeneration (3). Metronidazole may modulate the Gamma Aminobutyric Acid (GABA) receptor within the vestibular and cerebellar systems (4). Metronidazole is structurally similar to the thiazole precursor of thiamine and could thereby lead to a reduction in thiamine absorption by acting as a thiamine analog (5). Metronidazole induced acute neurotoxic effects are possibly due to axonal swelling because of increased water content. Furthermore, possible mechanism of neurotoxicity is mild reversible localised ischemia due to vascular spasm (6).
A recent review reported that the most common clinical manifestations of MIE are dysarthria, limb dyscoordination, gait instability, and altered consciousness (7). Various risk factors reported with metronidazole induced neurotoxicity are uremia, hepatic dysfunction, and alcoholism (8). According to a recent review, the duration of treatment with metronidazole before the appearance of CNS toxicity is variable ranging from 3 days to 8 years (average 101.6 days), and cumulative doses range from 5 g to 2000 g (average 125.7 gm) (7). In this case, the total dose of metronidazole that the patient received was 102 gm and the total duration was 42 days. (Table/Fig 3) shows the clinical manifestations, cumulative dose and duration of metronidazole intake, neuroimaging findings and outcome of selected cases of previously reported MIE (1),(9),(10),(11),(12),(13),(14).
Several characteristic MRI findings of MIE have been reported. Bilateral symmetrical T2-weighted hyperintense lesions are characteristically seen in cerebellar dentate nuclei. The midbrain, dorsal pons, dorsal medulla, and corpus callosum can also be affected. Rarely, lesions may affect the inferior olivary nucleus and the white matter of the cerebral hemispheres. Lesions are typically bilaterally symmetrical in metabolic encephalopathy (1). The location of T2-weighted hyperintense lesions in our patient is consistent with the reported distribution of the most frequently affected regions. A recent review concluded that the lesions of the cerebral white matter may correlate with a worse prognosis (7). Sometimes, lesions of the dentate nuclei may not be present initially but show on repeat-imaging. Therefore, serial imaging may be indicated when diagnostic uncertainty remains (15).
The differential diagnoses of symmetrical T2 hyperintensity in dentate nuclei are multiple sclerosis, disseminated encephalomyelitis, methyl bromide intoxication, enteroviral encephalomyelitis and maple syrup urine disease (16).
MIE should be considered in any patient who presents with cerebellar deficits with or without altered sensorium and peripheral neuropathy in close temporal relation to metronidazole intake. According to recent systemic review, almost one-third of patients were simultaneously present with polyneuropathy and making the clinical picture more complex (7). Also, a history of exposure may not be immediately available in patients with altered sensorium. If the condition is suspected, the drug must be immediately withdrawn and MRI brain performed. Nerve conduction studies generally show an axonal sensory or sensorimotor polyneuropathy (7). Patients who receive larger total doses of metronidazole may be at higher risk of peripheral neuropathy, but most cases of metronidazole-induced polyneuropathy recover with time (17).
Metronidazole induced neurotoxicity is a rare but serious complication with characteristic MRI features in form of bilateral symmetrical T2-weighted hyperintense lesions in cerebellar dentate nuclei. Early recognition of these imaging findings with immediate cessation of the drug improves prognosis and prevents irreversible neurological damage.
10.7860/JCDR/2021/48155.15200
Date of Submission: Dec 16, 2020
Date of Peer Review: Jan 21, 2021
Date of Acceptance: Apr 09, 2021
Date of Publishing: Aug 01, 2021
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Dec 17, 2020
• Manual Googling: Apr 07, 2021
• iThenticate Software: May 29, 2021 (19%)
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