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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
Original article / research
Full Version
Topical use of Autologous Platelet Rich Fibrin in Tympanoplasty: A Prospective Interventional Study
Correspondence Address :
Dr. Shibani Vittal Anchan,
Associate Professor, Department of Ear, Nose and Throat, SDM Medical College, Dharwad, Karnataka, India.
E-mail: shib700@gmail.com
Introduction: Tympanoplasty is the surgery performed in Chronic Otitis Media (COM) to improve the hearing function and prevent ear discharge. Platelet Rich Fibrin (PRF) is one of the materials that can be used to improve the graft uptake and hearing outcome. It is obtained by centrifugation of blood. The PRF contains leukocytes, cytokines, structural glycoproteins and growth factors which accelerates healing. It has been used in various surgical procedures to improve the outcome.
Aim: To determine the efficacy of autologous PRF in closure of tympanic membrane perforation after tympanoplasty and to study the influence of PRF on the hearing outcome in the study population.
Materials and Methods: This prospective interventional study was conducted in Department of Ear, Nose and Throat at SDM Medical College, Dharwad, Karnataka, India, from November 2018 to June 2020. The study included 60 patients with safe type of COM, who underwent tympanoplasty. Two group were made, group A consisted of 30 consecutive patients with safe type COM who underwent tympanoplasty with PRF application and group B, consisted of 30 patients who underwent tympanoplasty without PRF application. The outcome was assessed by endoscopic evaluation every month for three months to look for graft uptake. Hearing gain was evaluated by Pure Tone Audiometry (PTA) after three months of surgery. Statistical analysis was done using Chi-square test.
Results: The majority of cases belonged to young adults between 21 to 30 years of age. Group A had 29 cases with complete tympanic membrane closure and only one failure. However in group B, three out of 30 cases had failure. Thus, the overall the success rate was 96.66% in group A and 90% in group B. Postoperative PTA in group A showed that 18 cases (60%) had an improvement of >15 dB whereas in group B, 12 cases (40%) had hearing improvement of >15 dB.
Conclusion: Considering the higher success rate of tympanoplasty with group A compared to group B and no noticeable side effects, it is recommended that tympanoplasty with autologous PRF should be preferred.
Chronic otitis media, Graft uptake, Hearing gain, Myringoplasty, Perforation
Chronic Otitis Media (COM) is characterised by discharge through a perforated tympanic membrane for a duration of at least three months. Other symptoms are decreased hearing and tinnitus. The aim of treatment in mucosal type of COM is to eliminate infection, prevent complications and to restore normal hearing mechanism (1). Once adequate control of infection is achieved with topical antibiotics, tympanoplasty with cortical mastoidectomy is done with the aim of aerating the middle ear cleft and removal of chronically inflamed tissue.
The success rate of surgery is excellent overall and reperforation after surgical repair is mainly due to secondary infection. Thus it is important to augment the healing process and graft uptake which can be achieved with use of PRF. It is obtained from patients own blood by centrifugation. The process in turn leads to platelet degranulation and release of growth factors. It plays an important role in cellular process like chemotaxis, mitogenesis, differentiation and metabolism (2). The secretary proteins released from the platelets namely Platelet Derived Growth Factor (PDGF), Transforming Growth Factor-beta (TGF-beta), Vascular Endothelial Growth Factor (VEGF), Epidermal Growth Factor (EGF), Fibroblast Growth Factors (FGFs), Insulin-like Growth Factor-I (IGF-I) initiates wound healing process. The activated proteins diffuse into the surrounding tissues and binds to transmembrane receptors of target cells. The intracellular signal proteins gets activated and causes the expression of a gene sequence that directs cellular proliferation, osteoid production and collagen synthesis thus triggering tissue repair (3).
Platelet Rich Plasma (PRP) is similar to blood clot and it initiates a more rapid and complete healing process. A natural blood clot usually contains around 95% Red Blood Cell (RBC), 5% platelets, and less than 1% of White Blood Count (WBC) and large amount of fibrin strands. A PRP blood clot contains 95% of platelet, 4% of RBCs and 1% of WBCs (4). The use of PRP has several advantages. The growth factors obtained from platelets are autologous and hence chances of reaction are minimal and it is free from transmissible diseases such as Human Immunodeficiency Virus (HIV), hepatitis (5).
Depending on their cell content and fibrin architecture Dohan Ehrenfest DM et al., defined four main families of PRP. Pure Platelet-Rich Plasma (P-PRP) is preparation without leucocytes and with a low-density fibrin network after activation. Leucocyte-PRP (L-PRP) products are preparations with leucocytes and with a low-density fibrin network after activation. Pure Platelet-Rich Fibrin (P-PRF) is without leucocytes and with a high-density fibrin network. The Leucocyte- PRF (L-PRF) or second-generation PRP products are preparations with leucocytes and with a high-density fibrin network (6).
The prerequisites for tympanoplasty are dry ear and healthy middle ear mucosa, patent eustachian tube and good cochlear reserve. The various graft materials used are temporalis fascia, fascialata, tragal or conchal perichondrium, tragal or conchal cartilage, periosteum, vein graft, fat from ear lobule, skin and dura. The graft acts like scaffold supporting the regenerating tympanic membrane (7),(8). The PRF also protects the graft from infection (9). The aim of the study was to determine the efficacy of autologous PRF in closure of tympanic membrane perforation after tympanoplasty and to study the influence of PRF on the hearing outcome in the study population.
This prospective interventional study was conducted in Department of Ear, Nose and Throat at SDM Medical College, Dharwad, Karnataka, India, from November 2018 to June 2020. The study included 60 patients with safe type of COM, who underwent tympanoplasty. Patients who gave written informed consent and were willing for regular follow-up were included in this study. The Ethical Committee of the hospital has approved this study (SDMIEC/PG/0179/2018).
Sample size calculation: Total 60 patients who met the inclusion and exclusion criteria were divided into two groups. Sample size was estimated using the formula for quantifiable variables.
Inclusion criteria: Cases of safe type of COM in inactive stage with hearing loss less than 50 dB between the age of 10 to 60 years were included in the study.
Exclusion criteria: Age below 10 years and above 60 years, hearing loss more than 50 dB, unsafe type of COM, only hearing ear, revision surgery, and active infection in paranasal sinuses, throat and nose were excluded from the study. Children below 10 years were excluded from the study due to poor eustachian tube function, frequent upper respiratory tract infection and immature immune system were also excluded.
All eligible patients who met the inclusion criteria were enrolled.
• Group A (n=30): Tympanoplasty with autologous PRF
• Group B (n=30): Tympanoplasty without PRF
Study Procedure
Assessment of the patients was done including history, general physical examination, and examination of ear, nose and throat. Perforations were classified according to the size (10):
• Small: less than 50%
• Medium: 50-75%
• Large: more than 75%
Pure tone audiogram was done to assess the degree and type of hearing loss and average at
• 500 Hz
• 1000 Hz, and
• 2000 Hz frequencies was obtained.
All patients were subjected to otoscopic examination and imaging (bilateral mastoid x-rays). All the cases underwent underlay tympanoplasty with cortical mastoidectomy under general anaesthesia.
Preparation of PRF
During the surgery, 10 mL of blood was taken in test tubes. No anticoagulant was added to the blood. It was centrifuged using a laboratory centrifuge machine for 12 min at 2,700 rpm. The resultant product consisted of the following three layers:
• Topmost layer contains acellular platelet poor plasma,
• PRF clot is in the middle and
• RBCs at the bottom.
The superficial platelet poor plasma layer was discarded and the middle layer (buffy coat) containing platelet clot was utilised. Blood begins to coagulate as soon as it comes in contact with glass surface. Hence, blood should be drawn and centrifuged just before PRF is needed for application to surgical site (11). It was applied to the edges of perforation after the graft is placed and the tympanomeatal flap was reposited and ear canal packed with gelfoam.
All the patients received a course of oral antibiotic for the first postoperative week and topical antibiotic thereafter for two weeks and regular follow-up was done every 15 days for three months. The outcome was measured by endoscopic evaluation every month for at least three months to look for graft uptake. Hearing gain was evaluated by Pure Tone Audiometry (PTA) after three months of surgery. The failed cases were takern for the surgical procdure again.
Statistical Analysis
Statistical analysis for the study was done using Statistical Package for Social Sciences (SPSS) software version 20.0. Chi-square test was used for categorical and independent t-test was used for continuous variable analysis.
Most cases belonged to young adults between 21 to 30 years of age (Table/Fig 1). Among group A, 11 were males and 19 were females and among group B, 16 were males and 14 were females (Table/Fig 2).
Almost 53% of the study group had medium sized perforation, 26% had small and 21% had large sized central perforation (Table/Fig 3). Graft uptake was compared between group A and B at 1, 2 and 3 months.
In group A, 96.66% success rate was seen at one month and similar results were noted in group B. At two months, the success rate was 96.66 % and 93.33% and at three months it was 96.66% and 90% respectively (Table/Fig 4).
The left side showed large central perforation preoperatively. The endoscopic picture on the right side was of the healed tympanic membrane of patient in group A, three months after surgery (Table/Fig 5).
The mean hearing gain in group A and group B was 16.3 dB and 15.5 dB respectively (Table/Fig 6). Total 60% of the patients in group A have good hearing gain whereas only 40% in group B have good hearing gain following surgery (Table/Fig 7).
Choukroun JI et al., was the first to develop PRF and since then it is popular as second generation platelet rich plasma (12). This study was done to evaluate whether PRF augments the healing of tympanic membrane perforation following tympanoplasty. The etiology for perforation was safe type of COM. The age of distribution of chronic otitis media in the present study population was compared to the study conducted by Taneja MK (13). The disease is common in 20 to 30 years of age group in the present study population. Total 44% of the study group were males and 56% females. The perforation was classified as small (<50%), medium (50-75%) and large (>75%) based on the size. In this study, majority (53%) of the patients had medium sized perforation. Outcomes were not compared with the size of the perforation in each group which could be a shortcoming of the study.
Erkilet E et al., studied the effect of PRP in healing of traumatic membrane perforations in 44 rats. They noticed a statistically significant (p-value <0.001) decrease in the mean healing time in the study group compared to the control group (14). Similar outcome in humans was reported by Habesoglu M et al., with 64.3% closure of perforation in study group compared to 22.2% in control group at the end of one month (15). Both these studies were on acute or traumatic tympanic membrane perforation whereas the present study was on perforation of chronic middle ear disease.
In the present study, the success of graft uptake was 96.66% in group A. Regular follow-up and endoscopic examination was done for atleast three months postoperatively. The success rate in group B was 96.66% at the end of one month which dropped to 90% at the end of three months. Similar results of 96% success rate with use of PRF have been achieved in other studies too [16,17]. Taneja MK, randomised controlled trial on 82 patients also had a success rate of 95% in PRP group which was comparable to the current study (13). Nair NP et al., had a higher success rate of 98% in the study group (18). The success rate in control group was 80 to 85% in various studies whereas it was 90% in the current study (17),(18).
Sharma D et al., achieved 100% graft uptake rate in small perforation, 92% in medium size and 80% in large perforation in the case group (19). Though the study had results comparable to the present study, the correlation of graft uptake rate to the size of perforation has not been done in the present study.
In the present study, the postoperative hearing gain among cases shows that 18 cases (60%) had an improvement of >15 dB whereas among controls 12 cases (40%) had hearing improvement of >15 dB. The p-value=0.3804 which was statistically not significant. Similar study conducted by Sharma D et al., on 100 patients showed significant improvement in air-bone gap at speech frequencies (19).
The present have achieved a mean hearing gain of 16.3 dB in the PRF group compared to 15.5 dB in the control group. The p-value was 0.86 was not statistically significant. A similar study by Anwar FM et al., with 70 patients showed an audiological improvement of >10 dB in 88.6% of cases and 77% of the controls (20).
This study showed improved outcomes in terms of graft uptake and hearing gain with use of PRF. It encourages routine use to prevent tympanoplasty failure. However, the present study observed no statistically significant outcomes in terms of graft uptake or hearing gain as the p-value was >0.05.
Limitation(s)
The association of outcome of surgery with other factors like the size and location of perforation and status of middle ear mucosa was not ascertained which could also be a shortfall of this study. Diabetic status and blood group of the patient should be considered in future studies.
Newer advances are necessary to prevent graft rejection and improve functional outcomes of tympanoplasty In our study population, the success in PRP group in terms of postoperative hearing gain and graft uptake was encouraging, though not statistically significant. Authors concluded that tympanoplasty with PRF has a higher success rate.
DOI: 10.7860/JCDR/2022/56206.16465
Date of Submission: Mar 08, 2022
Date of Peer Review: Mar 25, 2022
Date of Acceptance: May 02, 2022
Date of Publishing: Jun 01, 2022
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? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
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