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

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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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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.
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.
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Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

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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.


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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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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 : 2021 | Month : August | Volume : 15 | Issue : 8 | Page : SC06 - SC08 Full Version

Correlation of Oxygen Saturation Index and Oxygenation Index in Hypoxaemic Respiratory Failure among Neonates


Published: August 1, 2021 | DOI: https://doi.org/10.7860/JCDR/2021/49411.15237
B Sunil, E Nithya

1. Professor, Department of Paediatrics, Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India. 2. Resident, Department of Paediatrics, Kempegowda Institute of Medical Sciences, Dharmapuri, Tamil Nadu, India.

Correspondence Address :
Dr. E Nithya,
7/1, C.K Srinivasa Rao Street, Dharmapuri-636701, Tamil Nadu, India.
E-mail: nithi.sankari@gmail.com

Abstract

Introduction: Hypoxaemic Respiratory Failure (HRF) is severe arterial hypoxaemia that is refractory to supplemental oxygen. Oxygen Saturation Index (OSI) can be an alternate method of diagnosing and assessing the severity of HRF as it uses Oxygen Saturation (SpO2) in place of Partial Pressure of Oxygen (PaO2) and may be utilised with reasonable sensitivity and specificity.

Aim: To evaluate the correlation between OSI and Oxygenation Index (OI) in HRF in neonates.

Materials and Methods: The prospective observational study was conducted in Kempegowda Institute of Medical Sciences and Hospital, Bengaluru, Karnataka, India, from December 2016 to July 2018. Fifty neonates who were admitted to Neonatal Intensive Care Unit (NICU) and conventionally ventilated in view of HRF were included. Arterial blood gases in the first 24 hours of life and corresponding oxygen saturations and ventilator settings were recorded. OI and OSI was calculated using the standard formula and their correlation was analysed.

Results: The neonates were all on first day of life at admission to NICU and were invasively ventilated due to HRF. The mean birth weight was 1.89±0.84 kg. Of the 50 neonates, 22 (44%) were preterm babies ( < 34 weeks), 17 (34%) belonged to late preterm group (34 weeks to 36 weeks +6 days), 9 (18%) were term babies ( > 37 weeks), two neonates were extremely preterm (less than 28 weeks). In this study, OSI and OI significantly associated and correlated (p-value < 0.01) with a correlation coefficient r=0.727. Area under the Receiver Operating Characteristic (ROC) curve for OSI was 0.912 which indicates that OSI is an excellent test to assess the severity of HRF.

Conclusion: That OSI can be used to diagnose and assess the severity of lung disease in neonates having HRF.

Keywords

Arterial hypoxemia, Arterial blood gases, Neonatal intensive care unit, Pulse oximetry

The HRF is a relative deficiency of oxygenation, often associated with insufficient ventilation. This deficiency is reflected by progressive respiratory and metabolic acidosis and remains a persistent challenge in the management. The overall scope of the problem was described in a large cohort study by Angus DC et al., who found that the overall incidence of HRF in very low, low, and normal birth weight infants, as measured by the overall rate of mechanical ventilation, was 18 per 1000 live births (1). In a study conducted by Eriksen V et al., babies treated for Persistent Pulmonary Hypertension (PPHN) of the newborn were followed up 5-11 years of age and had found a higher frequency of learning disabilities, higher rates of sensorineural hearing loss than a matched control group (2). Other morbidities include neurodevelopmental abnormalities, cognitive delay, and a high rate of chronic childhood diseases. The incidence of Acute Lung Injury (ALI) has been described recently in the adult population, with the estimate that, each year in the United States, there are >190,000 cases of ALI, with a mortality rate of almost 40% (3).

In 1994, the American-European Consensus Conference on Acute Respiratory Distress Syndrome (ARDS) agreed to standardised definitions in adults that continue to be used presently (4). These well accepted definitions require: a) an acute onset of the process; b) bilateral infiltrates on chest radiograph; c) no evidence of left atrial hypertension; and d) a defined degree of hypoxia. The extent of hypoxia is defined by a partial pressure of oxygen/fraction of inspired oxygen, or PaO2/FiO2 (P/F) ratio, of ≤300 to meet the definitions of ALI, and a P/F ratio of ≤200 to meet the definition of ARDS. Many clinicians consider (OI) {FiO2 ×Paw/PaO2} to be a better indicator of lung injury. Though, both PaO2/FiO2 ratio and OI have been used frequently to diagnose ALI and ARDS, it is difficult in critically ill newborns of NICU in view of serial arterial punctures for arterial blood sampling.

The HRF is a clinical syndrome that occurs in diverse settings. HRF can occur in infants with Meconium Aspiration Syndrome (MAS), Respiratory Distress Syndrome (RDS), idiopathic PPHN of the newborn, and congenital diaphragmatic hernia (5).

The OI is used to assess the severity of hypoxic respiratory failure and the intensity of ventilator support required to maintain oxygenation. As it uses Mean Airway Pressure (MAP) it is the better indicator than PaO2/FiO2 ratio. But it is invasive, requires an indwelling arterial line or arterial puncture to obtain a blood gas sample. Oxygenation can be continuously and non invasively assessed using pulse oximetry. The use of OSI can be an alternate method of assessing severity of HRF (6). It uses saturation instead of PaO2 which can be measured by a simple pulse oximetry thereby avoiding painful arterial punctures in sick neonates.

Hence, this study aimed to correlate OI with OSI in neonates with HRF thereby invasive technique can be avoided for further management purposes.

Material and Methods

The prospective observational study was conducted in Kempegowda Institute of Medical Sciences and Hospital, Bengaluru, Karnataka, India, from December 2016 to July 2018. Ethical clearance was obtained from Institutional Ethical Committee with reference letter no. KIMS/IEC/D-56/2016. Fifty newborn who were admitted to KIMS NICU in the Department of Paediatrics were chosen. This study included both term and preterm neonates who had respiratory distress and mechanically ventilated in view of respiratory failure and who were continuously and serially monitored by arterial blood gases and pulse oximetry. Sample size of 50 was considered with purposive sampling with 95% confidence level and margin of error of ±15%.

Inclusion criteria: Term and preterm newborn intubated and mechanically ventilated due to HRF were included in this study.

Exclusion criteria: Newborn on ventilator due to apnoea of prematurity, congenital heart disease, congenital lung malformations were excluded in this study.

Study Procedure

Postductal arterial blood gases in the first 24 hours of life and corresponding oxygen saturations were collected in neonates. Blood samples of around 0.5 mL each neonate was drawn by standard technique and sampling errors were avoided. Samples were sent at ideal temperature and blood gas analysis was done. Corresponding saturation was recorded by pulse oximetry.

Neonates were mechanically ventilated by dragger ventilator and before starting the therapeutic measures ventilator settings was recorded. Ventilator settings taken were Peak Inspiratory Pressure (PIP), Positive End Expiratory Pressure (PEEP), Fraction of Inspired Oxygen (FIO2), Mean Arterial Pressure (MAP):

OI was calculated by the formula:

OI=MAP (in cmH2O)×FiO2×100/PaO2.

OSI was calculated by the formula:

OSI=(MAP)×(FiO2))/(SpO2).

Statistical Analysis

Descriptive and inferential statistical analysis was carried out in the present study Significance was assessed at 5% level of significance. Analysis of variance (ANOVA) was used to find the significance of study parameters between PaO2/FiO2, OI and OSI. Chi-square/Fisher-Exact test was used to find the significance of study parameters on categorical scale like PaO2/FiO2, PIP, FiO2 and OI with OSI. Pearson correlation between study variables was performed to find the degree of relationship between OI and OSI with oxygen saturation, PIP and PaO2/FiO2. The p-value of < 0.05 < p < 0.10 was suggestive of significance. Receiver Operating Characteristic (ROC) curve analysis was performed to find the predictability of study variables for predicting the outcome. The statistical software namely Statistical Package for the Social Sciences (SPSS) version 18.0, and R environment version 3.2.2.

Results

The neonates were all on first day of life at admission to NICU and were invasively ventilated due to HRF. The mean birth weight was 1.89±0.84 kg. Of the 50 neonates, 22 (44%) were preterm babies ( < 34 weeks), 17 (34%) belonged to late preterm group (34 weeks to 36 weeks +6 days), 9 (18%) were term babies ( > 37 weeks), two neonates were extremely preterm ( < 28 weeks).

The most common cause for HRF in neonates was RDS which comprised of Hyaline Membrane Disease (HMD) and congenital pneumonia. Other causes were MAS (10%) and PPHN of newborn (4%). An 86% of neonates admitted for HRF had HMD.

Postductal SpO2 was between 90-94% in 16 (32%) neonates, 23 (46%) neonates had SpO2 between 75-89%, 11 (22%) neonates had SpO2 between 95-97%. PaO2 observed in this study was > 80 mmHg in 34 (64%) neonates, 60-79 mmHg in 15 (30%) neonates, and 40-59 mmHg in 1 (2%) neonate.

Partial pressure of oxygen/Fraction of inspired oxygen (PaO2/FiO2) ratio, which indicates the severity of HRF, were calculated. Mild hypoxemia (PaO2/FiO2 200 to ≤300 mmHg) was seen in 1 (2%) patient, moderate (PaO2/FiO2 100 to ≤200 mmHg) in 33 (33%), and severe (PaO2/FiO2 ≤100 mmHg) in 16 (32%).

The OI observed was ≤5 in 13 neonates (26%), 5.1-15 in 37 (74%) neonates and > 15 in none. The OSI was ≤3 in 2 (4%) neonates, 3.1 to 6.5 in 26 (52%) neonates, > 6.5 in 22 (44%) neonates.

In this study, four neonates who had PaO2/FiO2 of < 100 mmHg had a OSI between 3.1 to 6.5 and 12 had OSI more than 6.5. Only two neonates with PaO2/FiO2 of 100-200 mmHg had OSI < than 3, 22 neonates had OSI between 3.1-6.5 and 9 had OSI of more than 6.5 (Table/Fig 1).

Only one neonate had PaO2/FiO2 between 200-300 and the corresponding OSI was between 3.1-6.5. From the above data it was observed that there is a significant association between PaO2/FiO2 and OSI with p-value of 0.006. The (Table/Fig 2) showed a significant association between OI and OSI with p-value of 0.007.

Pearson correlation coefficient was calculated to find correlation between OI and OSI which showed a positive correlation with r value of 0.727 (Table/Fig 3). ROC curve analysis was done for OSI which showed a high sensitivity of 97.37% and a specificity of 75.00%. The area under the ROC curve was 0.912 which implies the overall accuracy of the test is good and hence OSI can be used with good accuracy in place OI in neonates with HRF (Table/Fig 4), (Table/Fig 5).

Discussion

Hypoxemic respiratory failure remains an important cause of morbidity and mortality in neonates of NICU. As there is only a few studies on HRF among neonates as it requires an invasive procedure to calculate PaO2. The authors hope this study might bring out the importance of using OSI in place of OI as it is non invasive.

In a study by Gnanaratnem J and Finer NN hypoxic respiratory failure was the most common problem seen in the infants admitted to NICU units (7). In preterms, the most common condition observed was RDS due to HMD caused by surfactant deficiency. In term and near term infants it is usually the result of MAS, sepsis, pulmonary hypoplasia, and primary pulmonary hypertension of the newborn. The present study had a similar result that RDS being the most common in preterm neonates.

In this study, RDS was more common in preterm then in late preterm which is similar to the study by Stoelhorst GMJ et al., and Ventolini G et al., where the incidence of RDS decreases with advancing gestational age. A 60-80% occurs in infants born at 26-28 weeks to approximately 15-30% in those born at 32-36 weeks (8),(9).

As O2 saturation varies non linearly with the PaO2, SpO2 can be used in place of PaO2 for specific saturation ranges because at extreme values oxygen saturation does not correlate well with Pao2. Sarkar M et al., studied the relation between SpO2 and PaO2 (10). The sigmoid shape of the oxyhaemoglobin (Hb) dissociation curve reflects this co-operative interaction.

A study by Thomas NJ et al., on defining acute lung disease in children with the OSI, the correlation coefficient observed between OSI: P/F ratio < 200 was 0.84 and OSI: P/F ratio < 300 was 0.84 again which is more towards positive correlation (6). It is similar to the present study where OI and OSI were positively correlated with correlation coefficient of 0.727.

This was similar to the study done by Doreswamy SM et al., where the Pearson product moment correlation (r) for OSI and OI was 0.91; which in the present study was 0.727 both being a positive correlation (11). In another study by Rawat M et al., OSI was used to define severity of HRF; the mean values of OSI and OI showed a correlation coefficient of 0.952 in neonates (12).

Similarly, in the study by Doreswamy SM et al., OSI had a sensitivity of 89.4% and specificity of 93.6% with moderate severity of OI value 5-15 (11). OSI had a sensitivity of 100% and specificity of 93.7% with OI value of more than 15. In the same study, OSI of 3 and 6.5 corresponded to OI of 5 and 15, respectively with high sensitivity and specificity whereas in present study sensitivity was 97.37% and specificity was 75%.

Limitation(s)

Movement of the limb during the technique of pulse oximetry may interrupt reading. Due to non linear correlation of PaO2 and SpO2 in oxygen haemoglobin dissociation curve OSI can only be utilised in patients < 98% saturated.

Conclusion

In this study, OSI and OI are significantly associated with positive correlation by Pearson correlation test. Oxygen saturation has been used to assess the severity of HRF previous studies, in this study, ROC analysis was done for OSI which showed the area under the ROC of 0.912 which again indicates that OSI is an excellent test to assess the severity of HRF. Hence, it was concluded that OSI has more of positive correlation with OI in neonates with HRF, and it can be used to diagnose and quantify the severity of lung disease.

References

1.
Angus DC, Linde-Zwirble WT, Clermont G, Griffin MF, Clark RH. Epidemiology of neonatal respiratory failure in the United States: Projections from California and New York. Am J Respir Crit Care Med. 2001;164(7):1154-60. [crossref] [PubMed]
2.
Eriksen V, Nielsen LH, Klokker M, Greisen G. Follow-up of 5- to 11-year-old children treated for persistent pulmonary hypertension of the newborn. Acta Paediatr. 2009;98(2):304-09. [crossref] [PubMed]
3.
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DOI and Others

10.7860/JCDR/2021/49411.15237

Date of Submission: Mar 14, 2021
Date of Peer Review: Apr 28, 2021
Date of Acceptance: Jun 12, 2021
Date of Publishing: Aug 01, 2021

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Mar 15, 2021
• Manual Googling: May 17, 2021
• iThenticate Software: Jul 07, 2021 (25%)

ETYMOLOGY: Author Origin

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