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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
Management Strategies and Outcomes of Paediatric Blunt Abdominal Trauma at a Tertiary Care Centre in South Kerala: A Retrospective Observational Study
Correspondence Address :
Dr. Liya Joseph,
2E, Artech Palmgrove, Polayathode, Kollam-691010, Kerala, India.
E-mail: drliyajoseph1550@gmail.com
Introduction: Blunt abdominal trauma is a leading cause of injury in paediatric population. The management of paediatric abdominal injury has shifted from Operative Management (OM) to Non Operative Management (NOM) over years. NOM is the standard treatment for clinically stable patients with blunt trauma abdomen.
Aim: To describe retrospectively the management strategies and outcomes of paediatric patients with blunt abdominal trauma in a tertiary care centre.
Materials and Methods: This was a retrospective observational record-based study that included 96 medical records of children admitted in Government Medical College, Thiruvananthapuram, Kerala, India, with blunt trauma abdomen from January 2018 to December 2022. Patients were characterised according to the treatment they received as- NOM and OM. Ultrasound Focused Assessment with Sonography in Trauma (USG FAST) and Contrast Enhanced Computed Tomography (CECT) abdomen were done in all the patients. The factors recorded were- age, gender, mechanism of injury, concomitant injury, tachycardia, hypotension, respiratory rate, blood transfusion requirement, injuries (American Association of Surgery of Trauma (AAST) organ injury scale), length of Intensive Care Unit (ICU) and hospital stay and mortality. Univariate analysis of the clinical features were done using Chi-square test using Statistical Package for the Social Sciences (SPSS) 27.0 statistical software. The p-value <0.05 was considered statistically significant.
Results: About 83 patients (86.46%) were in NOM group while 13 patients (13.54%) were in OM group. The most common age group involved was 6-12 years with male predominance. Median age was 9.2 years. The most common mechanism of injury was road traffic accident 31 (32.29%). Among 84 patients with isolated solid organ injury, only 5 (5.9%) required surgical intervention. Among nine patients with isolated hollow viscous injury, 5 (55.5%) required surgical intervention. All 3 (100%) patients with both hollow viscous and solid organ injury required surgery. Hypotension and blood transfusion requirement were statistically significant factors in the OM group p<0.05. Complications, length of hospital and ICU stay were more in operatively managed group with mortality rate of 1.04%.
Conclusion: The success of NOM of blunt trauma abdomen depends on proper selection of the patient. Patients who are haemodynamically stable can be safely managed non operatively with adequate monitoring in a tertiary care centre.
Child, Conservative treatment, Injuries, Laparotomy, Trauma centre
Blunt abdominal trauma is a leading cause of injury in paediatric population. Though less frequent than isolated head and limb injuries, it is often the cause of morbidity and mortality in paediatric trauma patients (1). It is usually associated with road traffic accidents, fall from height, bicycle and contact sport injuries (2). Care of the injured child needs early and precise management (3). After initial assessment, resuscitation, and stabilisation of trauma patients, USG FAST is done to detect presence of free fluid suggestive of intraabdominal injury. CECT abdomen is the gold standard to identify intra abdominal injury (4). The management of paediatric abdominal injury has shifted from OM to NOM over the years. Until recently, the grade of abdominal organ injury was the key factor in deciding the management protocol. Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium (ATOMAC) guidelines in 2012 emphasised haemodynamic status as main factor in decision-making in paediatric blunt abdominal trauma (5). NOM is the standard treatment for clinically stable patients with blunt abdominal trauma (6). Presence of free intraperitoneal air suggesting a hollow viscus injury and haemodynamic instability despite maximum resuscitative efforts are indications for OM (4). Conservative management requires continuous monitoring with an experienced multidisciplinary team, that is ready for intervention if necessary (1). Angiographic embolisation is a useful addition in treatment protocol (7). Criteria for admission in ICU for blunt abdomen trauma should not be guided only by CT grading of the injury. Shock index and haematocrit are decisive factors for admission to ICU (8). Length of hospital stay for children would also depend on these factors (9).
There are very few studies from developing countries discussing the management strategy and outcomes of blunt abdominal trauma in paediatric population (10),(11),(12). Knowledge about paediatric abdominal trauma is essential for planning and implementing preventive measures. This will also help in effective utilisation of hospital resources and manpower (13),(14). The aim of this study was to describe the management strategies and outcomes of paediatric patients with blunt trauma abdomen.
The present retrospective observational study was conducted at Department of Paediatric Surgery, Government Medical College, Thiruvananthapuram, Kerala, India on paediatric cases of blunt abdominal injury admitted between January 2018 and December 2022. The data analysis was done in January 2023. This study was approved by Institutional Research and Human Ethics committee review board (HEC NO: 10/05/2022/MCT).
Inclusion criteria: All children ≤12 years of age who were admitted in Department of Paediatric Surgery between January 2018 and December 2022 with blunt trauma abdomen were included in this study.
Exclusion criteria: Children who could not be evaluated with USG FAST and CECT abdomen, children with concomitant penetrating trauma abdomen and children who were discharged against medical advice during treatment period and in whom information on condition of child was unavailable were excluded from the study.
Blunt injury abdomen was considered as any injury to one of the following structures: spleen, liver, kidney, mesentery, duodenum, jejunum, ileum, colon, adrenal, pancreas, major intra-abdominal vascular structure, bladder, ureter, gallbladder, or abdominal wall fascial disruption. Injuries included in the analysis were diagnosed on abdominal CT scan or identified during surgery. Solid organ injury was defined as injury to the spleen, liver, kidney, adrenal, or pancreas. Hollow viscous injury was defined as injury to the duodenum, jejunum, ileum, colon, or small bowel or colonic mesentery or urinary bladder (15).
Study Procedure
All patient charts were reviewed. Patient and trauma characteristics were documented. These included age, gender, mechanism of injury, concomitant injury, pulse rate (beats/minute), blood pressure (mm of mercury), respiratory rate (breaths/minute), Glasgow coma scale, haemoglobin (gm/dL), blood transfusion requirement, length of ICU and hospital stay and mortality (16). USG FAST and CECT abdomen were done in all the patients. Organs injured were identified based on CECT report. The injuries ranged from haematoma, parenchymal laceration to devascularisation. The injuries were graded according to on AAST Organ injury scale by radiologist. Severity Grade-I to V indicated increasing complexity and severity of organ injury (17).
Patients were characterised according to the treatment they received as- NOM and OM. NOM was defined as non surgical management strategy of intra-abdominal injury which usually consists of observation with close monitoring and resuscitation. OM group of patients are those who underwent treatment with laparotomy, laparoscopy or interventional radiological procedures (18). Patients with haemodynamic instability despite maximum resuscitative efforts or suspected hollow viscus injury were operated.
Statistical Analysis
Qualitative variables were summarised as numbers and percentages and quantitative variables in mean and standard deviation. Data was analysed using SPSS 27.0 statistical software. Univariate analysis was analysed with Chi-square test. The p-value <0.05 was considered statistically significant.
There were 98 paediatric cases of blunt abdominal injury admitted between January 2018 and December 2022. Of these, 2 patients with polytrauma who succumbed to death within 12 hours due to traumatic brain injury and whose abdominal imaging could not be performed were excluded from the study. Thus, a total of 96 patients were included in this study.
Children were categorised into two groups depending upon the type of management provided- (a) NOM group; and (b) OM group. More than four fifths of the children (86.46%) were successfully managed using non operative methods, and only n=13 (13.54%) of the children required surgical therapy. Baseline characteristics are shown in (Table/Fig 1).
The study group consisted of 78 (81.25%) males and 18 (18.75%) females, with a median age of 9.2 years. The most common mechanism of injury was road traffic accident 31 (32.29%). There were concomitant injuries in 46 children (47.9%). There were no statistically significant differences found in mechanism of injury or presence of concomitant injuries between the two study groups (Table/Fig 1). Among the clinical parameters, hypotension and blood transfusion requirement showed a statistically significant difference between the two groups (Table/Fig 2).
An overview of the abdominal injuries is shown in (Table/Fig 3). Among the 96 patients, 84 (87.5%) patients had isolated solid organ injury, 9 (9.4%) patients had isolated hollow viscous injury and 3 (3.1%) patients had solid organ along with hollow viscous injury. The most common solid organ injured was spleen and hollow viscous injured was duodenum. Among 13 patients in OM group, three underwent resection anastomosis of bowel, two underwent primary closure of bowel, three underwent splenectomy, one underwent liver suturing, three underwent resection anastomosis of bowel along with liver suturing and one underwent liver suturing along with splenorraphy.
Both abdominal and non abdominal complications were higher in operatively managed group and was statistically significant (Table/Fig 4). One patient in operatively managed group died on postoperative day seven due to septicaemia.
The management strategy of blunt abdominal injury has changed from mandatory surgical exploration to selective conservative approach. The management depends on clinical and haemodynamic stability of the patient. Non operative treatment is now considered as the standard of care for the treatment of blunt injury abdomen; with a success rate of 80-90% [19,20]. In this study, 86.46% patients were successfully managed by non operative treatment. In study by Sabounji SM et al., success rate for non operative treatment was as high as 93.3% (21). The advantage of NOM in solid organ injury is lowered risk of non therapeutic laparotomy with preserved organ function (22).
In this study, the management and outcomes of blunt trauma abdomen in children were investigated. The most common mechanism of injury was road traffic accidents (32.29%). In study by Kundal VK et al., the most common mechanism of injury was fall (58.08%) (13). In this study, males predominated and most common age group being 6-12 years. In study by Djordjevic I et al., injuries 33were most common in children with 6-10 years age group and male:female ratio was 3:1 (1). In study by Nimanya SA et al., the most common age group was 5-9 years with male preponderance (23). Restlessness and playfulness of boys in this age group could be reason for the same. In this study, most common isolated organ injured was spleen (37.5%) followed by liver (18.8%). In study by Spijkerman R et al., most common organ involved was spleen (48.7%) (2). Partial protection by pliable ribs, less overlying fat and weaker abdominal musculature may be the reason for the easy vulnerability of spleen and liver to trauma in children.
A 13.54% of all children with blunt trauma abdomen required surgical interventions. Among 84 patients with isolated solid organ injury, only 5 (5.9%) required surgical intervention. Among nine patients with isolated hollow viscous injury, 5 (55.5%) required surgical intervention. All 3 (100%) patients with both hollow viscous and solid organ injury required surgery. These findings were in line with other paediatric studies (2),(15). Patients with hollow viscous injury are more likely to undergo surgery than those with solid organ injury and account for most of the patients requiring operation.
In this study, hypotension (69.2%) and requirement of blood transfusions (92.3%) (markers of haemodynamic instability) was more common and statistically significant in the OM group. This was in concurrence with the study by Echavarria Medina A et al., where, hypotension (55.5%) and blood transfusion (66.7%) were associated with the failure in NOM (24). Abnormal haemodynamics suggests ongoing haemorrhage in the trauma patients, which may necessitate intervention.
In this study, the most common concomitant injury was extremity injury (21.9%) followed by head injury (14.6%). The most common abdominal complication was wound infection (4.2%) and non abdominal complication was pneumonia (6.3%). In the study by Spijkerman R et al., the most common concomitant injury was thoracic injury (31.4%) followed by extremity injury (27%) and the most common abdominal and non abdominal complications were bile leak (1.7%) and pneumonia (5.8%), respectively (2). Mean length of hospital stay and ICU stay was more in the operative managed group and was statistically significant. This was similar in the study by Spijkerman R et al., (2). The use of haemodynamic parameters and CT findings for observing stable patients with isolated abdominal organ injuries will reduce the need for ICU care.
Mortality rate in this study was 1.04%. This was in concurrence with other studies by Spijkerman R et al., (1%), Arbra CA et al., (less than 1%) [2,15]. This was nil in the study by Sabounji SM et al., (21). The clinical outcome and prognosis of children with isolated blunt abdominal trauma are favourable if managed appropriately.
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.
Non operative treatment in blunt trauma abdomen is safe and effective. Assessment of haemodynamic stability is the most important concern in initial evaluation of a child with blunt trauma abdomen. Haemodynamically stable patients can be safely managed non operatively with adequate monitoring in a tertiary care centre.
DOI: 10.7860/JCDR/2023/63522.17787
Date of Submission: Feb 15, 2023
Date of Peer Review: Mar 13, 2023
Date of Acceptance: Mar 29, 2023
Date of Publishing: Apr 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. No
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