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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
Evaluation of Serum Cortisol Levels in Patients with Hypothyroidism at a Tertiary Care Hospital, Telangana, India: A Case-control Study
Correspondence Address :
Mohd Iqbal Ahmed,
Flat No. 102, Sri Sai Hoames, Nachram, Hyderabad-500076, Telangana, India.
E-mail: yaamarthy@gmail.com
Introduction: Serum Cortisol is a glucocorticoid hormone released from the zona fasciculata layer of the adrenal cortex, which plays an important role in regulation of blood pressure and metabolism. Hypothyroidism causes elevated cortisol levels due to both decreased clearance and negative feedback of cortisol on the hypothalamic pituitary-adrenal axis.
Aim: To investigate the correlation of serum cortisol and with Triiodothyronine (T3), Thyroxine (T4), Thyroid Stimulating Hormone (TSH) and serum cortisol levels in patients with hypothyroidism.
Materials and Methods: Present case-control study was carried out in the Department of Biochemistry, Gandhi Medical College and Hospital, Secunderabad, Telangana, India, July 2022 to August 2022. A total of 60 patients with hypothyroidism (cases) aged between 35-60 years, and 60 controls were selected from Gandhi Medical College and Hospital. Samples were analysed in Siemens Advia centaur XPT. T3, T4, TSH and cortisol levels were estimated by “CLIA” method. Data were statistically analysed using Karl Pearson’s correlation test.
Results: In present study, there were five males and 55 females in control group, 23 males and 37 females were in case group. The mean age in cases was 39.39±6.44 years and in control group was 39.38±10.97 years. The mean T4 in subjects cases was 10.74±5.34 ng/mL, as compared to 8.99±2.43 ng/mL, in controls. The mean TSH level in cases was 13.38±20.43 mIU/L, as compared to 3.47±4.20 mIU/L, in controls. The mean cortisol level in cases was 64.88.44±16.25 μg/dL, as compared to 9.55±5.59 μg/dL, in controls. There was significant positive correlation between serum cortisol level and T3 (r=0.12, p-value 0.02), T4 (r=0.12, p-value 0.02), and TSH Levels (r=0.31, p-value 0.01) in case group.
Conclusion: The results of present study showed that serum levels of cortisol were significantly increased in hypothyroidism patients as compared to normal healthy controls.
Adrenal cortex, Glucocorticoid hormone, Metabolism, Thyroid hormone
Thyroid is a large endocrine gland located in the neck, attached to the trachea just below the larynx (1). Thyroxine (T4) and Triiodothyronine (T3) are thyroid hormones, which play an important role in basal metabolism and the functioning of almost all tissues and systems in the body (2). Hypothyroidism is defined by a decrease in thyroid hormone production and thyroid gland function, leading to metabolism slow down (3). Thyroid function test evaluate the levels of TSH and T4 in the blood (4),(5). The prevalence of overt hypothyroidism is approximately 1-2% in women and 0.1% in men (6),(7).
Hypothyroidism is a condition caused by insufficient production of thyroid hormones. Subclinical hypothyroidism can be defined as a state of high serum Thyroid Stimulating Hormone (TSH) levels with normal serum free thyroxine (T4) levels (8). Cortisol is a steroid hormone that is released in response to stress and low blood glucose concentration. It was observed by the researchers that hypothyroid patients have elevated cortisol levels (7),(9) and the serum TSH level was positively correlated with serum cortisol levels in subclinical hypothyroidism (7). It was also observed that in the case of primary hypothyroidism (elevated TSH) cortisol was elevated, but in the setting of primarily elevated cortisol, TSH level was suppressed (9).
Hypothyroidism causes elevated cortisol levels, due to decreased clearance of cortisol and negative feedback of cortisol on the hypothalamic pituitary-adrenal axis. T3 and T4, TSH secretion is maintained within relatively narrow limits via a sensitive negative feedback loop in which TSH stimulates the synthesis and release of thyroid hormones. Cortisol by negative feedback mechanism stimulates the synthesis and release of Adrenocorticotropic Hormone (ACTH) (9). Hypothyroidism is more common in older persons than younger individuals, especially among women, principally due to the rising incidence and prevalence of autoimmune thyroiditis (10).
Demers LM and Spencer CA in their study showed an elevation of serum cortisol level in hypothyroid patients group and positive correlation between TSH and serum cortisol. Authors also suggested that the conversion of T4 to T3 is influenced by adrenal cortisol. High cortisol levels induce a conversion of T4 to an improper form of T3 called reverse T3 (rT3) (3). Gopalakrishnan A et al., suggested a physiologic feedback loop where lower thyroid function increases serum cortisol. Their result suggested a positive relationship between TSH and serum cortisol also showed high values of cortisol in 12.5% of hypothyroid patients (4).
Hollowell JG et al., found that significant hypercortisolemia in primary hypothyroidism is primarily due to decreased metabolic clearance of cortisol and a presumptive decrease in the negative feedback effect of cortisol on the hypothalamo-pituitary axis (5). No such study is conducted in Telangana population also, the findings of present study have a possibility of being helpful in establishing the role of cortisol as additional marker in the diagnosis of hypothyroidism.
Hence, the present study was undertaken to determine the correlation of serum cortisol and TSH, T3 and T4 in patients with hypothyroidism.
This case-control study was carried out in the Department of Biochemistry, Gandhi Medical College and Hospital, Secunderabad, Telangana, India, over a period of two months, from July 2022 and August 2022. The study was approved by the Human Research Committee review at Gandhi Medical College and Hospital, Musheerabad, Secunderabad as part of a biochemistry research project (Ethical approval no- IEC/GMC/2002/06/06 dated 29th June 2022).
Inclusion criteria: Subjects aged between 30-70 years, with confirmed diagnosis of hypothyroidism, whose cortisol level is more than 25 μg/dL were included as cases. Age and gender matched healthy euthyroid subjects with normal thyroid hormone levels and cortisol level <25 μg/dL was included as controls. Women were randomly assigned to participate during the late luteal phase or follicular phase of their menstrual cycle, because of menstrual phase effects on cortisol levels.
Exclusion criteria: Patients on thyroxin treatment, with history of smoking (in the span of last one year), patients with renal disease, liver disease, cardiovascular disease and diabetes mellitus, any neurological disorders or depression, critically ill patients admitted in intensive care unit, patients with confirmed or suspected cases of pancreatic pathology were excluded. Women with a partial or complete hysterectomy, tubal ligation, history of menstrual irregularities and who were pregnant or lactating within the past 12 months were excluded.
Sample size calculation: Sample size was calculated at 5% level of significance, to maintain power of study at 99% and it comes out to be 60 per group. Therefore, the total sample size for the present study has been calculated to be 120 (60 cases and 60 controls)
Total of 120 subjects were divided into two groups of 60 each:
Cases: 60 subjects with hypothyroidism were enrolled, based on American Thyroid Association (ATA) criteria for the diagnosis of hypothyroidism (11).
Controls: 60 healthy euthyroid subjects with normal thyroid hormone levels and cortisol level <25 μg/dL were enrolled as controls.
Study Procedure
The cases were selected from those attended, the Medicine Outpatient Department (OPD) Gandhi Hospital, Secunderabad. The Investigations were carried out in Biochemistry laboratory, Gandhi Medical College and Hospital, Secunderabad. The subjects were selected based on the medical history obtained from a health proforma and from recent lab reports, established diagnosed cases of hypothyroidism. Demographic data for age and gender were collected from all the study subjects. T3, T4, TSH and cortisol levels were assessed and compared among cases and controls.
After informed consent from patients, 5 mL of venous blood sample was obtained from every volunteer into red tubes. All the blood samples were immediately carried to the biochemistry laboratory. Samples were analysed in Siemens Advia centaur XPT. T3, T4, TSH and serum cortisol were estimated by “CLIA” method.
Normal reference range as per American Thyroid Association (ATA) guidelines (11):
• T3 - 0.8-2 ng/mL
• T4 - 5.0-11.0 μg/dL
• TSH - 0.4-5.5 mIU/L.
• Serum cortisol - 5-25 μg/dL
Statistical Analysis
The data were statistically analysed using Graph Pad Prism 7.0. The measured parameters were expressed as mean±Standard Deviation (SD). Unpaired t-test was used to compare the groups. Relationship between the variables was assessed by Karl Pearson’s correlation test. The p-value of 0.05 or less was considered statistically significant.
The mean age in control group and case group were 39.38±10.97 years and 39.99±6.44 years. There were 23 male and 37 female in case group and five males and 55 females in control group. There was statistically no significant difference was found between both the groups regarding age and gender distribution (Table/Fig 1). In present study TSH (p-value=0.01), T3 (p-value=0.02), T4 (p-value=0.02) and serum cortisol level (p-value=0.01) were significantly increased in case group as compared to control group (Table/Fig 2).
There was significant positive correlation between serum cortisol level and T3 (r-value=0.12, p-value=0.02), T4 (r-value=0.12, p-value=0.02), TSH level (r-value=0.31, p-value=0.01) in case group (Table/Fig 3).
Hypothyroidism is caused by inadequate function of the thyroid gland itself (primary hypothyroidism), inadequate stimulation by TSH from the pituitary gland (secondary hypothyroidism), or inadequate release of thyrotropin-releasing hormone from the brain’s hypothalamus (tertiary hypothyroidism) (12). The present study consisted of 120 participants with 60 controls and 60 patients of hypothyroidism. If hypothyroidism patients present with high serum cortisol the TSH, T3 and T4 can serve as a novel marker for the prediction of the risk of diseases. In present study, the mean serum cortisol level in hypothyroid group was 64.88±16.25 μg/dL, where mean serum cortisol level in controls was 9.55±5.59 μg/mL, showing a statistically significant increase in serum cortisol levels in hypothyroid group as compared to the healthy controls. This is in accordance with the previous similar studies (3),(4),(5).
In present study there was hypercortisolemia in hypothyroid patients, this findings is consistent with a study by Iranmanesh A et al., they found significant increase in serum cortisol level in primary hypothyroidism. This change in serum cortisol primarily may be due to decreased metabolic clearance of cortisol and a presumptive decrease in the negative feedback effect of cortisol on the hypothalamo-pituitary axis (6). In present study, there was an elevation of cortisol level in hypothyroid patients and positive correlation between TSH and cortisol, which is in the line with the findings of previous similar study by Ali SS and Dhelal AKJ (8). An explanation for the above mentioned changes in cortisol levels is that, overt hypothyroidism causes elevation of cortisol by reducing peripheral disposal and blunting feedback of cortisol on the hypothalamic-pituitary-adrenal axis, another explanation for positive relationship between TSH and cortisol as elucidated in a previous study is that hypothyroidism is associated with subtle metabolic stress which could be imposing an effect on the Adrenocorticotropic hormone-adrenal axis leading to an increase in release and production of stress hormone (cortisol) (4),(5).
In present study, there was a significant positive correlation between serum cortisol level and T3, T4 and TSH level in healthy controls also. Similarly, Kimberly NW et al., conducted a cross-sectional study on 54 healthy adults and found a positive relationship between TSH and cortisol that is maintained down to a TSH level of 2.5 mIU/L (but not below) in apparently healthy young individuals (9) also, in a study. Walter KN et al., found a positive relationship between TSH and cortisol in apparently healthy young individuals (13). This relationship may be physiological rather than pathological and the explanation for this positive relationship found between TSH and cortisol in healthy controls was that thyroid hormone production is associated with subtle metabolic stress which could be imposing an effect on the adrenocorticotropic hormone-adrenal axis leading to an increase in release and production of stress hormone cortisol (8).
In present study, serum cortisol level was elevated in the hypothyroidism as compared to the control group. Also, the level of TSH, T3 and T4 levels were in correlation with increased serum cortisol levels. So, screening of TSH and must be done in patients with hypothyroidism to decrease the incidence of metabolism, mental functions, energy level, and bowel movements.
Limitation(s)
The main limitation was that thyroid function tests only measure the total or free T4 and/or T3 and TSH serum concentrations in peripheral blood. They do not measure the effect of the hormone on target organ. Also, serum cortisol can be increased in stress condition, which was not measured in present study.
Based on the findings of present study, it can be clearly stated that, serum levels of cortisol significantly increased in hypothyroidism patients as compared to normal healthy controls. Also, there was a significant positive correlation between serum cortisol and thyroid profile. Keeping in consideration with the study, it can be concluded that, subclinical hypothyroidism with early diagnosis and treatment may prevent the onset of overt hypothyroidism. These results, along with similar reports suggest that, the study of these parameters in hypothyroidism may help in better understanding the aetiopathogenesis of hypothyroidism and may act as additional markers of this condition. All the patients suffering from hypothyroidism can be investigated for serum cortisol, as additional markers.
DOI: 10.7860/JCDR/2023/59976.17588
Date of Submission: Sep 01, 2022
Date of Peer Review: Nov 03, 2022
Date of Acceptance: Jan 06, 2023
Date of Publishing: Mar 01, 2023
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. NA
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