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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
Use of TWIST Score and BAL Score in Diagnosing Testicular Torsion in Children with Acute Scrotum: A Retrospective Study
Correspondence Address :
Dr. Liya Joseph,
2E, Artech Palmgrove, Polayathode, Kollam-691010, Kerala, India.
E-mail: drliyajoseph1550@gmail.com
Introduction: Early diagnosis and management of Torsion Testis (TT) in children is challenging. To improve the reliability of diagnosis, various clinical scoring systems have been proposed. Testicular Workup for Ischaemia and Suspected Torsion (TWIST) score and Boettcher Alert (BAL) score have been used for the diagnosis of TT in children with acute scrotum.
Aim: To find the utility of TWIST and BAL score for diagnosing testicular torsion in children with acute scrotum.
Materials and Methods: This was a retrospective record-based study that included medical records of children with acute scrotum who underwent surgery between January 2019 and December 2021 in a tertiary care hospital. A total of 112 patients were included in the study. TWIST and BAL scores were calculated, retrospectively. Univariate analysis of the clinical features were done using Chi-square test. Sensitivity, specificity, Positive Predicitive Value (PPV) and Negative Predicitive Value (NPV) for scoring systems were calculated.
Results: There were 73 patients in TT group and 39 in Non Torsion Testis (NTT) group. The mean age was 4.5±2.98 years in torsion group and 5.2±2.2 years in non torsion group. Among the components of TWIST and BAL score, absent cremasteric reflex, hard testicle, high riding testis, nausea/vomiting and pain duration <24 hours were found to be statistically significant. PPV and specificity of TWIST score ≥5 were 98.15% and 97.44%, respectively whereas NPV and sensitivity of BAL score ≥2 group was 100%.
Conclusion: TWIST and BAL scores are reliable bedside and easy to perform clinical diagnostic tools for TT. These scores can help in early detection and plan surgical intervention to reduce ischaemia time of TT.
Boettcher alert, Cremasteric reflex, High riding testis, Ischaemia, Testicle, Testicular workup for ischaemia and suspected torsion
Testicular torsion is a major, known cause of morbidity in the paediatric age group. The annual incidence of testicular torsion in males less than 18 years of age is 4 per 100,000 (1). Acute scrotum is defined as new onset pain with tenderness or swelling of contents within the scrotum. The common aetiology of acute scrotum in paediatric age group include testicular torsion, torsion appendage of testis, and acute epididymo-orchitis (2). The most common presenting symptom of TT is the acute onset of testicular pain. The clinical examination findings are scrotal swelling, horizontal lie of testis and absence of cremasteric reflex (3). The clinical spectrum of TT and NTT are similar (4). Management and intervention within six hours is crucial to avoid permanent testicular loss from a compromised arterial flow. Absence of timely intervention has resulted in orchiectomy rates of 35-40% (5),(6).
The standard tool for diagnosing acute scrotum is ultrasonography and doppler study of scrotum (7). The limitation of this tool is high investigator dependence and false negative reports. The delayed presentation of cases to the hospital may be due to various reasons. These include lack of awareness, embarrassment and denial by the patient or caregiver, delayed diagnosis, and missed investigations at peripheral hospitals (8). Hence, the need arises for a Clinical scoring tool. Barbosa JABA et al., described TWIST score based on easy to elicit five clinical variables (9). Another simple prediction score was described by Boettcher M et al., BAL score based on four clinical variables (10),(11). Such clinical scores may be used by non specialists with accuracy (12). Use of a clinical scores along with ultrasonography may be the best approach for diagnosis of testicular torsion (13). As these clinical scores (TWIST and BAL Score) are easy to perform at bedside, this will help medical personnel to diagnose testicular torsion without delay.
Many a times, a delay in diagnosis at peripheral hospitals and delay in ultrasound scan can result in patients ending up with a gangrenous testis. Thus, clinical scores like TWIST and BAL score, which are easy to perform at bedside will aid doctors in emergency department to diagnose TT without delay. The aim of the study was to find the utility of TWIST and BAL score for testicular torsion in paediatric population presenting with acute scrotum.
The present retrospective study was conducted at Government Medical College Thiruvanthapuram, Kerala, India from records of patients admitted between January 2019 to December 2021 and data analysis was done in November 2022. This study was approved by Institutional Research and Human Ethics committee review board (HEC NO: 10/04/2022/MCT).
Inclusion criteria: All children who were treated surgically in Department of Paediatric Surgery with acute scrotum during the study period were included in the study.
Exclusion criteria: (i) Children with penetrating trauma to scrotum and where clinical assessment was difficult; (ii) Children whose complete clinical data/imaging report/relevant surgical data were unavailable were excluded from the study.
Study Procedure
Data was collected from case records of 129 children with acute scrotum who underwent surgical exploration with high clinical suspiscion of TT as per institutional protocol. Findings at surgery was taken as gold standard. The patients were then categorised into TT group and NTT group. The TWIST and BAL scores were calculated retrospectively for all the patients based on symptoms and signs at admission. TWIST score is based on five variables: (a) Testicular swelling (2 points); (b) hard testis (2 points); (c) nausea or vomiting (1 point); (d) high position of testis (1 point); (e) abnormal cremasteric reflex (1 point). Patients are divided into low (0-2), intermediate (3-4) or high risk groups (5-7) according to total score (9).
The BAL score is based on four variables: (a) <24 hour duration of pain; (b) nausea or vomiting; (c) high position of testis; (d) abnormal cremasteric reflex. Each factor is marked as one point. Total score being 4. A score ≥2 has high probability of TT (10),(11).
Statistical Analysis
Data was presented as numbers and percentages. Data was analysed using Statistical Package for the Social Sciences (SPSS) version 27.0 statistical software. Univariate analysis of the clinical features between the TT and NTT group was analysed with Chi-square test. The p-value <0.05 was considered statistically significant. PPV, NPV, sensitivity, and specificity of both clinical scoring systems were calculated for different risk groups.
In this study, 129 patients with acute scrotum underwent surgery for suspected TT. Seventeen patients were excluded from the study as complete details were not available to score them. Thus a total of 112 patients were included in the study. A total of 73 patients were in TT group and 39 patients in NTT group. There were 26 patients (23.2%) with torsion appendage of testis, 12 patients (10.7%) with acute epididymo orchitis and 1 patient (0.9%) with infected hydrocele in NTT group.
The youngest patient in testicular torsion group was 10-day-old and NTT group was one year. The oldest patient in testicular torsion group was 12 years of age and NTT group was 12.5 years (Table/Fig 1). Of the 112 patients, 104 patients underwent scrotal ultrasound scan with doppler and TT was reported in 58 patients. Torsion detorsion episode and suspected TT was reported in five patients.
Among the components of TWIST and BAL score, absent cremasteric reflex, hard testicle, high riding testis, nausea/vomiting and pain duration <24 hours were found to be statistically significant (Table/Fig 2).
A total of 42 patients with TT presented within 24 hours; in which seven patients presented within eight hours. Thirty three patients (45.2%) underwent orchipexy and 40 (54.8%) underwent orchiectomy in TT group. In NTT group, 26 (60%) patients with torsion appendage of testis underwent excision of torted appendage.
In TT group, mean TWIST score was 5.5±1.44 (range=2-7). In NTT group, mean TWIST score was 2.3±0.69 (range=0-5) (Table/Fig 3). In TT group mean BAL score was 2.8±0.81 (Range 2-4) and in NTT group, the mean BAL score was 0.44±0.77 (Range 0-3) (Table/Fig 4).
The PPV and specificity of TWIST score for high-risk patients (Score ≥5) were 98.15% and 97.44%, respectively whereas the NPV and sensitivity of BAL score ≥2 group was 100% (Table/Fig 5). Clinical images of the patients of both the groups is depicted in (Table/Fig 6),(Table/Fig 7),(Table/Fig 8).
The aetiology of acute scrotum includes testicular torsion, torsion of testicular appendage, acute epididymo-orchitis, and infected hydrocele (14). In this study, testicular torsion was found in 65.2% of patients with acute scrotum. In study by Manohar CS et al., TT comprised of 38% of boys with acute scrotum and in a study by Sheth KR et al., incidence of TT was 34.4% (5),(12). Selection bias may have contributed to higher incidence of TT in this study. Patients who underwent surgery were only included in this study. It could also be because of the fact that this institution is a referral tertiary care centre for paediatric patients.
The mean duration of pain in torsion group was 38.2 hour. Only 9.6% of the torsion cases presented to the hospital within eight hour. The orchiectomy rate in this study was 54.8%. In the study by Manohar CS et al., the mean duration of pain was 50.6 hours, 20% of torsion cases presented within eight hours and orchiectomy rate was 76% (5). Literature reported orchiectomy rates of 28-50% in various series (15),(16). High orchiectomy rate in this study was due to delay in presentation to the centre. This emphasises the need of clinical diagnostic score for the early detection of TT. In this study, 72.6% had nausea/vomiting, 100% had testicular swelling and 76.7% had absent cremasteric reflex. In the study by Sazgar M et al., 37.1% had vomiting, 84.3% had testicular swelling and 81.4% had absent cremasteric reflex (17). Thus, absence of cremasteric reflex does not rule out TT.
In this study, 72.6% of patients in testicular torsion group were in TWIST high risk (Score ≥5). There were none in TWIST low risk in TT group (Score 0 or 1). None in TT group had BAL score <2. All testicular torsion patients had BAL score ≥2. One patient with TWIST high risk (score 5) and BAL 3 was a case of infected hydrocele; for whom scrotal exploration and drainage was done. In study by Manohar CS et al., 57.8% of patients in TT group were in TWIST high risk and 4.4% in TWIST low risk group (5). In study by Klinke M et al., all patients with testicular torsion showed BAL score ≥2 (13).
The NPV of TWIST score for low risk patients was 93.94% and PPV for high-risk patients was 98.15%. Barbosa JABA et al., reported NPV and a PPV of 100% in their series and stated that no patient with TT would be missed with TWIST score (9). Manohar CS et al., reported NPV of TWIST score for low risk patients as 96.6% and a PPV for high-risk patients as 92.8% (5). Although the NPV and PPV this study are not as high as the Barbosa JABA et al., study, this is still within acceptable limits. BAL score showed excellent capability to predict testicular torsion and reduce negative exploration as shown by 100% sensitivity and NPV. This was in concurrence with study by Klinke M et al., (13). Clinical scores TWIST and BAL are helpful to assess and diagnose testicular torsion in patients presenting with acute scrotum. As both are convenient and easy to perform bedside tests for patient evaluation, these can be used even by non specialist medical personnel. However, future prospective studies are required to validate them.
Limitation(s)
The greatest limitation of the present study was the retrospective design. Conclusions were based on observation from a single study centre. Thus, a prospective multicentre study is required to validate the scores.
The TWIST and BAL are simple to perform clinical scores to diagnose TT. This will help to reduce complications and aid in early management of TT patients.
DOI: 10.7860/JCDR/2023/62616.17602
Date of Submission: Jan 02, 2023
Date of Peer Review: Jan 19, 2023
Date of Acceptance: Feb 08, 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. Yes
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