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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
Prescription Practices of Antifungal Agents at Gynaecology and Oncology Departments of a Tertiary Hospital in Mwanza, Tanzania: A Retrospective Study
Correspondence Address :
Dr. Martha F Mushi,
P.O. BOX 1464, Mwanza, Tanzania.
E-mail: mushimartha@gmail.com
Introduction: Irrational antifungals prescription results in inappropriate use of antifungals, leading to emergence of antifungal resistance.
Aim: To determine the prescription patterns of antifungal agents in Gynaecology and Oncology Departments of the tertiary hospital in Tanzania.
Materials and Methods: This was a retrospective hospital-based study involving files of patients who attended Gynaecology and Oncology Department of Bugando Medical Centre between January 2017 to December 2017. All files of patients with fungal infections were analysed. The analysis of the data was done from January 2018 to August 2018. Checklist was used to collect information such as clinical diagnosis, age, name of antifungal, number of antifungals, dosage form and dose frequency. Descriptive analysis was done using STATA version 13.0.
Results: A total of 1,070 files of patients who attended Gynaecology and Oncology Departments in the year 2017 were retrieved, of which 860 (80.4%) were from patients who attended Gynaecology Department. A total of 156 (14.6%) files out of 1,070 were of patients with fungal infections. Of the patients from gynaecology 116 (n=860, 13.48%) had fungal infection. While of the patients from oncology 40 (n=210, 19.1%) had fungal infection. The most common fungal infection diagnosed were vaginal candidiasis 112 (96.6%) and oral candidiasis 33 (82.5%) from gynaecology and oncology department, respectively. Common antifungal prescribed were azoles (clotrimazole 56.9% in gynaecology and fluconazole 30% in oncology). The prevalence of irrational antifungal prescription in gynaecology and oncology departments was 22.4% (26/116) and 20% (8/40), respectively.
Conclusion: About one in five antifungal prescriptions for vaginal candidiasis in gynaecology and oral candidiasis in oncology are irrational as evidenced in standard treatment guideline. Clinicians should adhere to the national standard treatment guidelines in order to reduce irrational prescriptions of antifungal agents.
Clotrimazole, Fluconazole, Oral candidiasis, Vaginal candidiasis
Antifungal stewardship program are crucial in guiding, monitoring and directing the appropriate use of antifungal agents for best clinical outcome of patients (1). The demand of antifungal stewardship program increases with the increase in prevalence of fungi infections worldwide (2),(3),(4). Trends of opportunistic fungal infections in different countries of Africa have been documented to increase from about 18% (documented from 1999 to 2000) (5),(6) to over 60% (between 2011 and 2014) (7),(8),(9), in patients with different immunocompromised conditions. The growing burden of fungi infections is associated with the use of broad spectrum antibiotics, anticancer therapy, immune suppressive therapy and increased prevalence of immune suppressive conditions such as malignancy (10),(11). The consequences of increased prevalence of fungal infections include the increased use and misuse of antifungal agents. Irrational prescription of antifungal agents is one of the major misuses of antifungal agents that can lead to the development of antifungal drug resistance.
According to World Health Organisation (WHO) rational or good prescription of drug is based on five crucial elements: (i) Appropriate indication, (ii) Appropriate drug (based on efficacy, safety, suitability and cost), (iii) Appropriate patient without contraindications or likelihood of developing adverse reactions, (iv) Patients should be provided with appropriate, accurate relevant clear information about their conditions and the medications to be used, and (v) Appropriate monitoring of all anticipated and expected effect of the medications (12),(13). The irrational prescription of antifungal agents is a broad term which includes prescription with either of the following; wrong drug, wrong formulation, wrong dosage, wrong route of administration, wrong duration of therapy or unnecessarily expensive drug for the clinical condition of the patients in question (14),(15). Irrational prescription further includes prescription of the antifungal agents using a brand name instead of generic name which might lead to dispensing errors, increase treatment costs, reduce drug availability and influence the pharmaceutical companies (16). With the antifungal stewardship program the correct prescription will be promoted together with optimal use of antifungal agents by careful selection of agents based on the patients profile, targeted pathogens, agents’ toxicity, cost and local resistance profile (17).
Empirical treatment by antifungal agents without having the epidemiological susceptibility data in low-and middle-income countries is one of the major factor that leads to irrational prescription of antifungal agents (18). The WHO estimates 50% of the prescribed drugs include antifungal agents are irrational (19), the situation might be worse in low-and middle-income countries like Tanzania. Gynaecology and Oncology Departments are among the wards with significant number of fungal infections ranging from superficial infections like dermatophytosis to serious systemic infection like invasive fungal infection (20),(21),(22). Here, authors report the prescription practices of clinicians in gynaecology and oncology departments. Furthermore, the patterns of irrational prescription in these departments have been detailed.
This was a retrospective hospital-based study conducted in the Gynaecology and Oncology Departments of Bugando Medical Centre in Tanzania. The protocol to conduct this study was approved by the joint CUHAS/BMC research ethics and review committee (CREC) with certificate number CREC 576/2018. Permission to conduct the study was requested from the Director General of the BMC.
The hospital serves a population of 18 million people from eight different surrounding regions and is attended by around 300,000 patients each year from north western Tanzania. The oncology department caters for around 50-150 cancer patients from nine different regions of the Lake zone per month. The gynaecology department serves more than 500-1000 patients in a year.
From the medical records unit, files of patients who attended or were admitted in gynaecology and oncology departments from January 2017 to December 2017 were retrieved and reviewed if they had antifungal prescriptions or not. The analysis of the data was done from January to August 2018. Data were extracted from all files with antifungal prescription using structured checklist. The extracted data included demographic (like age, gender, and clinical parameters like ward, diagnosis and antifungal prescribed) data of the patients with antifungal prescription.
Case definitions: Fungal infection in this study was based on the clinical diagnosis (symptomatic diagnosis) made by the clinician attending the respective patient. Polypharmacy in the current study was defined as prescription of more than two antifungal agent in one file. Furthermore, the irrational prescription was defined as prescription with either of the following wrong drug, wrong formulation, wrong dosage, and wrong route of administration, wrong duration of therapy or unnecessarily expensive drug for the clinical condition of the patients in question.
Statistical Analysis
Data were entered in Microsoft excel sheet for cleaning and coding before being transferred to STATA version 13.0 for analysis. Categorical data like clinical condition, type of antifungal prescribed were summarised as proportions while continuous variables were summarised as median with interquartile ranges.
A total of 1,070 files of patients who attended in both departments for the year 2017 were retrieved, majority were from gynaecology department 860 (80.4%). Out of 1070, 156 (14.6%) files had diagnosis of fungal infections (Table/Fig 1). The overall median age of patients with fungal infections were 31 IQR (24-38) years. A total of 116 (n=860, 13.48%) and 40 (n=210, 19.1%) files from gynaecology and oncology departments had fungal infection diagnosis, respectively. Of the studied files, only three files from gynaecology department and one file from oncology department had laboratory request for fungi diagnosis. A total of 34 (21.8%) files had irrational antifungal prescription from both gynaecology and oncology departments.
Gynaecology department: The median age of patients with fungal infections in gynaecology department was 33 IQR (27-38.5) years. The most common fungal infection diagnosed in gynaecology department was vaginal candidiasis 112 (n=116, 96.6%). Three (n=112, 2.7%) patients with vaginal candidiasis had recurrent vaginal candidiasis (clinical diagnosis as indicated in the file). Other fungal infections documented in gynaecology department included two cases of Tinea pedis, one case of oral candidiasis and one case of cutaneous candidiasis.
In gynaecology department, a total of 137 antifungals were prescribed to 116 patients. The average number of antifungals prescribed per file was 1.2 (137/116). Two different types of antifungals were prescribed in 21 (n=116, 18.1%) patients. The most commonly prescribed antifungals were clotrimazole either pessaries or cream to 66 (56.9%) patients, followed by miconazole nitrate either pessaries or cream to 26 (22.4%) patients as shown in (Table/Fig 2).
Irrational prescription of antifungal at gynaecology department: In this department, the irrational prescription of antifungal was found in 26 (22.4%) files. Polypharmacy was the most frequently documented cause of irrational prescription in 20 (n=26, 76.9%). Miconazole nitrate 10 (n=26, 38.5%) was the most frequently antifungal agents prescribed with wrong duration, frequency or combination of wrong duration and frequency (Table/Fig 3).
Oncology department: The age of patients with fungal infection from oncology department ranged from 1 year to 56 years. The median age was 21.5 years with IQR (4-34) years. The most common fungal infection documented from oncology department was oral candidiasis 33 (82.5%). Other fungi infections included vaginal candidiasis 5 (12.5%), Tinea corporis 1 (2.5%) and Tinea capitis 1 (2.5%).
A total of 46 antifungal were prescribed to 40 patients with different fungi infections in oncology department. The average number of antifungals prescribed per file was 1.2 (46/40). Majority of patients were prescribed with one type of antifungal agent 36 (78.2%). One patient with oral candidiasis was prescribed with three different types of antifungal agents (miconazole nitrate, fluconazole, clotrimazole). Fluconazole tablets to 12 (n=40, 30%) patients were most frequently prescribed in the oncology department (Table/Fig 4). A total of 8 (20%) files from oncology department had irrational prescription mainly polypharmacy and wrong drug duration (Table/Fig 3).
Irrational use of antifungal agents significantly contributes to the global burden of antifungal resistance. On the other hand antifungal resistance is the major factor that led to the shift of the fungi pathogens causing invasive fungal infections, persistent infections and increased treatment cost (23). In the current study, irrational prescription of antifungal agents was documented in 20% and 22.4% files from the Oncology department and Gynaecology department, respectively. This was higher than previously reported in a tertiary hospital in Madrid Spain back in 2014 when they were advocating for the need of having antifungal stewardship program (2). The observed difference is contributed by the limited use of fungal diagnosis services as evidenced in the current study were only 2.5% of files had documentation of laboratory diagnosis request. Accurate and timely diagnosis of fungi infection has been documented to be critical in the reduction of unnecessary use and ultimate reducing the antifungal resistance (24).
In the current study fungal infections like dermatophytosis, vaginal and oral candidiasis were the only documented type of infections in 156 files studied. This has also been documented in previously studies (25),(26). Nevertheless, in recent decades upsurge documentation of invasive fungal infections in patients with underlying diseases like cancer has been observed (20),(27). In the current study no clinical diagnosis of invasive fungal infection was observed justifying low use of laboratory investigations for fungi infections in the study. Cutaneous and mucocutaneous fungi infections have wrongly been taken as simple infections that do not require laboratory diagnosis such as culture and sensitivity as a results this has led to recurrent and disseminated infections (28).
Azole antifungal agents like fluconazole was documented to be the leading agent used for fungal infections like oral candidiasis in sub-Saharan Africa, including Tanzania (25),(29),(30). This has also been observed as the most prescribed antifungal for oral candidiasis in the current study. Our previous study on over the counter medication of antifungal agents in Mwanza observed fluconazole as one of the most dispensed antifungal agent among patients with vaginal candidiasis in the similar study settings (25). The easy availability, low toxicity, easily administering and ability to cover a broad range of fungi pathogens is among the reasons for fluconazole being more used (31).
This study has found one in every five files with antifungal prescription from gynaecology or oncology department had irrationally antifungal prescription. This irrational prescription is alarming and of public health importance as the rational use of antifungal agents has been documented to be usefully in preserving antifungal agents, reduce antifungal resistance development and adoption of essential drug list (32).
Limitation(s)
Not having files with invasive fungi infections might overestimate the underuse of laboratory investigations for fungi infections.
About one in five antifungal prescriptions for vaginal candidiasis in gynaecology and oral candidiasis in oncology are irrational as evidenced in standard treatment guideline. This is enhanced by the underuse of mycological investigations available like culture and sensitivity. Clinicians should adhere to the national standard treatment guidelines in order to reduce irrational prescriptions of antifungal agents.
DOI: 10.7860/JCDR/2022/55087.16786
Date of Submission: Jan 20, 2022
Date of Peer Review: Apr 15, 2022
Date of Acceptance: May 27, 2022
Date of Publishing: Aug 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? No
• For any images presented appropriate consent has been obtained from the subjects. NA
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