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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
Pathological Features of Lung in COVID-19 Disease Subjects: A Postmortem Study
Correspondence Address :
Dr. Bhanu Rekha Bokam,
Professor and Head, Department of Pulmonary Medicine, Dr. Pinnamaneni Siddhartha
Institute of Medical Sciences and Research Foundation,
Vijayawada, Andhra Pradesh, India.
E-mail: bhanurekha96@gmail.com
Introduction: The current Coronavirus Disease-19 (COVID-19) pandemic is considered as one of the most serious public health crises which caused more than 1.62 million deaths from October 2020 to November 2020. Acute respiratory failure is leading cause of death followed by sepsis, cardiac failure and haemorrhage. Since the pathological findings are diverse in COVID-19 and majority of studies in literature were by open autopsy; the present study was done using percutaneous core needle biopsy. Postmortem lung biopsies are rather easy and quick to perform and decrease the infective risk caused by full autopsies. This could be an essential tool for diagnosis, surveillance and research.
Aim: To study the pathological features of lung in COVID-19 deceased patients by postmortem.
Materials and Methods: This cross-sectional study was conducted in the Department of Pulmonary Medicine, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Vijayawada, Andhra Pradesh, India from October 2020 to November 2020. In present study, postmortem percutaneous core needle biopsies from lung were performed within two hours of death from eight deceased patients who died of COVID-19. Clinical history, inflammatory markers and treatment details were collected from case sheets, biopsy was done, specimen was collected and sent for pathological examination. Data was presented in the descriptive form for each variable.
Results: Out of eight cases, five were men and three were women with a mean age of 54.12 years. Majority of patients presented with complaints of shortness of breath and fever. Hypertension, type 2 diabetes mellitus, obesity, hypothyroidism, history of pulmonary tuberculosis were the co-morbidities noticed. Four biopsies presented acute lung injury with hyaline membrane changes, Diffuse Alveolar Damage (DAD) with hyaline membrane was seen in two cases, squamous metaplasia was seen in two cases and acute lung injury with organising pneumonia was seen in two cases.
Conclusion: Postmortem lung biopsies are safe, easy to perform and provide insights of possible undergoing pathology of the disease with regard to clinical presentation.
Acute lung injury, Core needle biopsy, Coronavirus disease-2019
An outbreak of a novel coronavirus caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) occurred in Wuhan, China in late 2019 (1). The illness was named COVID-19 by World Health Organisation (WHO) (2). The outbreak was declared a pandemic in just three months after emerging (3). SARS-CoV-2 utilises Angiotensin Converting Enzyme 2 (ACE2) as a source of cellular entry. ACE2 is expressed in lung alveolar cells, bronchial epithelium and vascular endothelial cells, therefore the respiratory tract and lung serve as a primary point of viral entry (4). There was evidence that about 12% of patients presenting with severe symptoms require hospitalisation and the case fatality rate is about 2.3% (5). COVID-19 has been shown to affect different organ systems, of which respiratory system pathology predominates with mortality primarily due to Acute Respiratory Distress Syndrome (ARDS) (6).
Clinical and laboratory data have identified lung, heart and liver as the three organs involved by the novel coronavirus (7). Although the disease results in diverse, multiorgan pathology, only a sparse data is obtainable about pathological changes in patients infected with SARS-CoV-2.
Barton LM et al., autopsy reports of the lungs in COVID-19 study has been done and primarily shown DAD or acute lung injury (8). A study has been done on microscopic evaluation of lungs by Borczuk AC et al., which showed presence of airways inflammation and alveolar zones with hyaline membranes and type 2 pneumocyte (AT2 cell) hyperplasia (9). Knowledge regarding the underlying pathological variations can lead us to better understanding of the disease and could be of utmost significance in clinical management (10). Most of the studies were on open autopsy. The present study was done using postmortem percutaneous core needle biopsy with the aim to identify the pathological findings of lung in COVID-19 patients.
This cross-sectional study was conducted in the Department of Pulmonary Medicine, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Gannavaram, Andhra Pradesh, India from October 2020 to November 2020. Informed consent from their legal relatives was taken. Institution Ethical Committee clearance was taken [PG/552/20]. The present study included eight patients that were tested positive for SARS-CoV-2; admitted and subsequently died between October 2020 and November 2020.
With appropriate personal protective equipment as dictated by standard guidelines, percutaneous core needle biopsies were performed from each lung within two hours of death in mid axillary line from 4th or 5th intercostal space. Each specimen was placed into individually labelled specimen bottle. The specimens were fixed in 10% neutral buffered formalin. After 24 hours of fixation, tissue processing was performed by using automated tissue processor. The histopathology was assessed by expert pathologists. Clinical information such as age, gender, co-morbidities, duration of illness, methods of ventilation and treatment (antimicrobials, anticoagulant therapy, and corticosteroid therapy) were collected from the case sheets.
Statistical Analysis
Descriptive form of data was collected for each variable and presented.
Out of eight cases studied, five were men and three were women with mean age of 54.12 years (39-75 years). Majority of patients presented with complaints of shortness of breath and fever. Every patient had at least one co-morbidity like hypertension (5/8), type 2 diabetes mellitus (6/8), obesity (1/8), hypothyroidism (1/8), history of pulmonary tuberculosis (1/8). Saturation of Peripheral Oxygen (SpO2) on Room Air (RA) at the time of admission was within the range of 40-85%. The duration of stay ranged from one day to four days. Initially, six patients were receiving ventilation in the form of Non Invasive Ventilation (NIV) with Bilevel Positive Airway Pressure (BIPAP) ventilation; one patient was on High Flow Nasal Oxygen (HFNO) and one patient was on oxygen support with Non Rebreathable Mask (NRBM).
Five out of eight patients had D-dimer value >500 ng/mL (40-2500 ng/mL); four patients had Ferritin >500 ng/mL (30-1300 ng/mL); seven patients had C-Reactive Protein (CRP) >100 mg/L (6 to 200 mg/L). All the patients had bilateral non homogenous opacities (consolidations) on Chest X-ray (CXR). Treatment included antimicrobials, corticosteroid therapy, anticoagulant therapy and details are presented with summarised clinical features in (Table/Fig 1).
Histology: The histopathological findings are summarised in (Table/Fig 2). Acute lung injury with hyaline membrane changes were seen in four patients, acute lung injury with organising pneumonia was seen in two cases, inflammatory cell infiltrates seen in all eight cases, hyaline membrane was seen in six cases (Table/Fig 3), squamous metaplasia was seen in two cases (Table/Fig 4), pneumocyte proliferation was seen in five cases, diffuse alveolar damage with hyaline membrane and squamous metaplasia was seen in two patients (Table/Fig 5), organising pneumonia was seen in two cases, fibrin thrombi was seen in three cases and alveolar septal thickening was seen in four cases. Anthracotic pigment laden macrophages were also seen (Table/Fig 6).
The present study described the histopathological findings of lung in COVID-19 obtained through postmortem biopsies, which demonstrated diverse pathology. SARS-CoV-2 infected patients start experiencing flu symptoms like fever, cough, nasal congestion and fatigue (11). As the infection progresses, patients experience dyspnoea and consistent symptoms of viral pneumonitis such as decreased oxygen saturation, lymphopenia and ground glass opacities in chest imaging (12). Thus, the end result of these patients is a severe condition of acute lung injury named ARDS (13). In the present study, four among eight patients demonstrated features suggestive of acute lung injury with hyaline membrane changes.
Pathophysiologically ARDS is characterised by acute and diffuse inflammatory damage into alveolar capillary barrier associated with an increase in vascular permeability, decreased compliance and the size of aerated lung tissue, compromising gas exchange and causing hypoxemia (14). Histopathologically this clinical picture was named by Katzenstein AL et al., as DAD, corresponding to all cases of SARS-CoV-2 (15). It consists of permanent damage to capillary endothelial cells, with consequent leakage of protein-rich fluid into interstitial and alveolar space, resulting in hyaline membrane formation and eventually intracapillary thrombi (16). Two out of eight patients demonstrated DAD. In a study of postmortem lung biopsies from four patients by Bruce-Brand C et al., only one out of four patients reported DAD (17).
The acute phase of DAD is associated with hyaline membrane formation, fibrinoid exudates and alveolar wall oedema (18). In present study, hyaline membrane formation was reported in six out of eight patients. In a study done by Beigmohammadi MT et al., all the seven deceased SARS-CoV-2 infected patients demonstrated the acute phase of DAD (10). In a study done by Tian S et al., four postmortem lung pathological reports of COVID-19 patients were presented, referring to hyaline membrane formation, establishing DAD as the pathologic basis of lung involvement (19). Similarly, DAD was the main finding in a case reported by Xu Z et al., of a patient who died of COVID-19 (20).
Corresponding to first 10 days of viral infection, the first or exudative phase is characterised by intense inflammatory cells infiltration into the intra-alveolar space (21). Inflammatory cell infiltrates were reported in all the cases in present study. The second or proliferative phase is marked by fibroblast and myofibroblast proliferation which can form organising pneumonia, resulting in parenchymal remodelling, pulmonary fibrosis and squamous metaplasia (22). Squamous metaplasia has been demonstrated in few cases of COVID-19 particularly with a span of illness beyond 14 days (23). These stages do not occur sequentially but often occur simultaneously through the lung tissue i.e., while the immune system tries to contain the microorganism (exudative phase) in one region, another lung tissue area begins to organise itself in order to repair the affected areas (24). In the present study, two out of eight patients revealed squamous metaplasia with span of illness less than 14 days.
In a study done by Nicholls JM et al., histopathological findings of squamous metaplasia were reported in one out of six cases (22). In a study done by Bruce-Brand C et al., one out of four patients were reported with squamous metaplasia (17).
Pneumocyte proliferation was reported in four out of eight patients in the present study. Similar finding was also observed in studies done by Konopka K et al., and Pei F et al., (25),(26).
Evidence suggests that COVID-19 causes an intense inflammatory reaction marked by upregulation of cytokines which result in lung injury (27). Evidence suggested that corticosteroid therapy can markedly reduce hospital mortality in patients with severe COVID-19 (28). The presence of organising pneumonia may be explained by the efficacy of corticosteroid therapy. In the present study, two out of eight patients demonstrated organising pneumonia despite all the eight patients received corticosteroid therapy from the time of admission. This may be due to manifestation of far progressed disease by the time of admission.
Similar findings of organising pneumonia were described in a study done by Zhang H et al., (29). In a study done by Bruce-Brand C et al., three out of four patients were reported with organising pneumonia (17).
Much has been written regarding endothelial damage and coagulopathy caused by COVID-19 (30). In the present study, three patients demonstrated fibrin thrombi and only one among three had elevated D-dimer levels. All patients were on anticoagulant therapy. In a study done by Bruce-Brand C et al., three out of four had fibrin thrombi with elevated D-dimer levels, despite all being on anticoagulant therapy (17).
Limitation(s)
Sample size being small, limits our ability to draw conclusions and it is not statistically significant. Single centered study results cannot be extrapolated to other population.
Most common histopathological findings in COVID-19 affected lung biopsy included acute lung injury, hyaline membrane formation and DAD. Targeted core needle biopsy of lung is guarded, trouble free procedure and effective to study postmortem COVID-19 cases.
DOI: 10.7860/JCDR/2022/52180.15950
Date of Submission: Aug 30, 2021
Date of Peer Review: Oct 21, 2021
Date of Acceptance: Dec 01, 2021
Date of Publishing: Feb 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
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Sep 01, 2021
• Manual Googling: Nov 29, 2021
• iThenticate Software: Jan 03, 2022 (24%)
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