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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
Anaesthetic Management of a Patient with Advanced Abdominal Pregnancy, Intrauterine Foetal Death and Celiac Disease
Correspondence Address :
Dr. Mamta Jain,
Associate Professor, Department of Anaesthesia and Critical Care,
Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India.
E-mail: mamtajainsingh@gmail.com
Abdominal pregnancy is a rare form of ectopic pregnancy where implantation of fertilised ovum occurs in the abdominal cavity. If diagnosed late maternal and foetal mortality is very high. The major cause of death in abdominal pregnancy is haemorrhage. The case report is about a 31-year-old gravida two with 36 weeks of gestation period with Intrauterine Foetal Death (IUFD) and celiac disease. Celiac disease is a chronic malabsorptive disease of the small intestine occurring due to hypersensitivity to gluten ingestion. Due to chronic malabsorption, the patient presented with calcium deficiency. She also had lesions of dermatitis herpetiformis over the whole body sparing only the face. It is a rare case of advanced abdominal pregnancy with the IUFD, with celiac disease. The patient was managed successfully under general anaesthesia with preparedness for difficult airway management, securing wide bore peripheral cannulas, central venous cannulation and invasive blood pressure monitoring. Massive haemorrhage intraoperatively was managed with crystalloids, colloids, blood products and tranexamic acid. The intraoperative period was uneventful. The patient was extubated at the end of the surgery, and followed-up in a high dependency unit.
Gluten sensitive, Haemorrhage, Laparotomy
A 31-year-old female complained of pain abdomen and absent foetal movements for one day. She was gravida two with 36 weeks period of gestation with IUFD. She had one previous spontaneous abortion. She was diagnosed with celiac disease four years back and had dermatitis herpetiformis for which she was on the tab. cetirizine 10 mg once a day and tab. chlorpheniramine 4 mg twice a day. She did not have a history of any other chronic illness and no history of any surgery and exposure to anaesthesia.
On examination, the patient was conscious, oriented to time, place and person and vitally stable. She had pallor and lesions of dermatitis herpetiformis all over the body except face. Her weight was 40 kgs and her airway examination was unremarkable. On per abdominal examination, fundal height corresponded to 32 weeks with breech presentation. Foetal heart sounds could not be heard.
Her haemoglobin was 8.6 g/dL after which one unit packed cell volume was transfused which was uneventful. Her total leukocyte count was 22,500/mm3, serum calcium 7.2 mg/dL, and the rest of investigations including bleeding and clotting profile were within normal limits. For hypocalcaemia she was taking tablets of calcium carbonate 500 mg with vitamin D3 250 IU three times a day. Ultrasound examination showed a single foetus in breech presentation lying in the abdominal cavity with no myometrial outline visible surrounding foetus. Foetal movements and foetal heart sounds were not appreciated. The placenta was visualised anterior to foetus.
As the patient had to undergo laparotomy and the large volume of blood loss was anticipated and she also had dermatitis herpetiformis lesions on her back, a decision to proceed with general anaesthesia along with all preparations for massive blood transfusion and difficult airway management was taken. After taking informed and written high risk consent, the patient was shifted to the operation table.
Routine monitors ECG, non invasive blood pressure, and pulse oximeter were attached. Her baseline heart rate was 86 beats/min, blood pressure 130/80 mmHg and SpO2 was 99% on room air. Intravenous (i.v) access was secured with one 16 G cannula in the right hand and 18 G cannula in the left hand. Induction of anaesthesia was done with inj fentanyl 80 μg i.v, inj thiopentone 200 mg i.v. After checking for the ability to ventilate inj vecuronium 5 mg i.v was given and the airway was secured with a cuffed endotracheal tube of size 7 mm internal diameter. After induction of anaesthesia, ultrasound guided central venous cannulation was done in the right internal jugular vein. Radial artery cannulation was done in the left hand under all aseptic precautions after doing Allen’s test and invasive blood pressure monitoring was started. A nasopharyngeal temperature monitoring probe was placed. The patient was covered with forced air blanket to maintain normothermia during surgery. A midline vertical incision was made and a non macerated dead female foetus of 2.2 kg was delivered from the abdominal cavity after clamping the cord. The placenta was found to be adhered to omentum, descending colon and peritoneum. Placenta was separated from the underlying structures. Intraoperative blood loss was around 2 L. Along with crystalloids and colloids, three units of packed cell volumes and four units of fresh frozen plasma were transfused. Inj tranexamic acid 1 gm i.v was given. To maintain normal blood pressure, nor adrenaline infusion was required to be started at the rate of 0.05 μ/kg/min. Urine output was maintained at ≥0.5 mL/kg/hr during the intraoperative period. The temperature was maintained at around 37°C during surgery. The 10 mL of 10% calcium gluconate was given.
Towards the end of the surgery, noradrenaline support was stopped and the patient’s blood pressure was 100/60 mmHg off inotropes. Her blood gas analysis had pH 7.38, partial pressure of oxygen and carbon dioxide 141.7 and 36 mmHg, bicarbonates 24.3, base excess -2.3 and oxygen saturation was 98.5%. The patient was extubated after giving inj glycopyrrolate 0.4 mg i.v and inj neostigmine 2 mg i.v and shifted to high dependency unit for postoperative monitoring. In postoperative investigations patient’s haemoglobin was 7.5 gm/dL, serum calcium was 7.8 mg/dL and all other investigations were within normal limits. The patient’s vitals were stable. Calcium replacement was continued in postoperative period. She was shifted to ward on third postoperative day and discharged home on tenth postoperative day.
Abdominal pregnancy is a rare form of ectopic pregnancy, with incidence ranging from 1:1000 to 1:30,000, where implantation of fertilised ovum occurs in the abdominal cavity (1). Abdominal pregnancy can be primary or secondary. In primary abdominal pregnancy implantation of fertilised ovum occurs directly in the abdominal cavity but secondary abdominal pregnancy is usually a tubal pregnancy where after tubal rupture reimplantation occurs in the abdominal cavity (2). Various risk factors for abdominal pregnancy are previous ectopic pregnancy, advanced maternal age, endometriosis, multiparity, assisted reproductive techniques, pelvic inflammatory disease and tubal occlusion (3),(4),(5). Abdominal pregnancy needs to be diagnosed early to prevent maternal and foetal morbidity and mortality. But despite advances in technology, only one out of nine women who reached the hospital alive has preoperative diagnosis of abdominal pregnancy (6). In this case, also it was not diagnosed in previous scans. It was diagnosed very late at 36 weeks when the intrauterine of death of foetus had already occurred.
In the case of intra-abdominal pregnancy, placental implantation can occur at any site like a uterine wall, adnexa, omentum, small bowel, pouch of Douglas, liver and spleen (7). The placenta can separate at any time during the antenatal period leading to a massive haemorrhage. So, the most common cause of maternal and foetal mortality during the antenatal and intraoperative periods is massive haemorrhage (8). Placental removal is done if the blood supply to the placenta can be controlled. If the placenta is adhered to some vital structures and is required to be left in-situ, methotrexate is used to expedite the removal of residual trophoblastic tissue. But if the placenta is left in-situ, it may result in a lot of complications like disseminated intravascular coagulation, postpartum pre-eclampsia, intestinal obstruction, fistula formation, perforation, abscess formation and sepsis (9).
It is critical to establish adequate intravenous access in case massive blood transfusion is required intraoperatively. So, two wide bore peripheral cannulas were secured and central venous access along with invasive blood pressure monitoring was done before the start of surgery. Blood and blood products were cross matched and arranged. Tranexamic acid was also administered at the start of bleeding as it has been reported to decrease postpartum bleeding (10). Intraoperative embolisation of blood vessels supplying the placenta can be performed by intervention radiology whenever such facilities are available (11).
Celiac disease is a gluten sensitive enteropathy in which there is an inflammatory T-cell response in the small intestine leading to a decrease in surface area available for absorption (12). Signs and symptoms of this disease are mainly due to malabsorption. Most patients present with recurrent aphthos stomatitis, paraesthesia, skin disorder like dermatitis herpetiformis, infertility, poor development of bone structure, osteoporosis, lack of muscle co-ordination and malignancies (13). It is important to rule out hypoalbuminemia, hypocalcaemia, hypomagnesemia and vitamin K deficiency which may be present due to malabsorption. So appropriate laboratory investigations should be done and any deficiency should be corrected preoperatively. Hypomagnesemia should be given special attention as magnesium helps in the presynaptic release of acetylcholine (14). Vitamin K deficiency, if present, can cause prolongation of prothrombin time (14). But the patient was adherent to gluten 5free diet, so only calcium deficiency was present in her for which replacement was started preoperatively. She also had lesions of dermatitis herpetiformis all over her body except her face, for which she was on tab. cetirizine and tab. chlorpheniramine. In patients with dermatitis herpetiformis, for short-term relief from itching, dapsone can be prescribed; but this patient was not on dapsone therapy. Dapsone use may be associated with methemoglobinemia (15). Methaemoglobin interferes with pulse oximetry, oxygen saturation falls and plateaus at 85% as the level of methaemoglobin rises because pulse oximeter can only measure oxyhaemoglobin and reduced haemoglobin (16). Patients may have other associated autoimmune diseases with dermatitis herpetiformis like type 1 diabetes, hypothyroidism and pernicious anaemia (17). The index patient only had anaemia for which blood transfusion was done preoperatively. As lesions of dermatitis herpetiformis were also present over the back and a large volume of blood loss was anticipated, so subarachnoid block with epidural anaesthesia was not chosen. These patients are at increased risk of aspiration because of delayed gastric emptying so a long fasting period of eight hours for solids and ant aspiration prophylaxis was given before surgery (14). Due to growth retardation, difficult airway may be present. Hence the authors were prepared for management of unanticipated difficult airways. Airway examination was unremarkable in this patient.
The patient had celiac disease with abdominal pregnancy and IUFD. Abdominal pregnancy and celiac disease both are rare occurrences in themselves but in this patient both were present in the same patient making the anaesthetic management even more challenging. The patient was managed successfully by proper preanaesthetic check-ups to rule out any deficiencies, and complications due to celiac disease and IUFD. Massive haemorrhage intraoperatively was managed successfully by securing adequate i.v access, invasive blood pressure monitoring, crystalloids, colloids, blood products, tranexamic acid and inotropes.
DOI: 10.7860/JCDR/2022/56212.16665
Date of Submission: Mar 14, 2022
Date of Peer Review: Apr 08, 2022
Date of Acceptance: May 04, 2022
Date of Publishing: Jul 01, 2022
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. NA
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Mar 23, 2022
• Manual Googling: May 03, 2022
• iThenticate Software: Jun 29, 2022 (11%)
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