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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
Ultrasonographic Evaluation and Clinico-biochemical Association in Patients with Polycystic Ovarian Disease in a Tertiary Care Hospital: A Cross-sectional Study
Correspondence Address :
Dr. Sangram Panda,
Assistant Professor, Department of Radiodiagnosis, Kalinga Institute of Medical Sciences, Patia, Bhubaneswar-751024, Odisha, India.
E-mail: sangram.aju@gmail.com
Introduction: Polycystic Ovarian Syndrome (PCOS) is an endocrinological disorder characterised by a combination of polycystic ovarian morphology, diverse clinical features, and abnormal biochemical indices that affects women of reproductive age.
Aim: To assess the sonographic appearance of ovaries and endometrium in clinically suspected cases of PCOS and to determine the association between the sonographic appearance of ovaries and endometrium with the clinical and hormonal profile of the patient.
Materials and Methods: This cross-sectional study included 53 female patients in the reproductive age group (18-35 years) who were referred to the Department of Radiology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India for pelvic ultrasonography in clinical suspicion of PCOS from September 2020 to September 2022. All patients underwent transabdominal sonography, only married individuals with abdominal obesity underwent transvaginal ultrasonography. Complete biochemical hormonal analysis was performed. Association between volume, size of the ovary, number of follicles, and stromal thickness with hormones like Follicle Stimulating Hormone (FSH), Luteinising Hormone (LH), testosterone, prolactin, Thyroid Stimulating Hormone (TSH) were analysed. All continuous variables were expressed as mean±standard deviation and categorical variables as percentages. Chi-square test was used for statistical analysis.
Results: The mean age was 25.60±4.09 years and the majority 26 (49.1%) were between 18 to 25 years and presented with menstrual abnormalities. Volume of ovary was ≥10 cc in 41 (93.18%) patients with LH >6.7 IU/mL which was statistically significant (p=0.03) and LH/FSH ratio was >2:1 in 30 patients of which 28 (93.3%) had ovarian volume ≥10 cc which was statistically significant (p=0.03). A number of follicles >12 showed a significant association with LH (p=0.04), LH/FSH (p=0.01), testosterone (p=0.002). Stromal thickness also showed significant association with LH (p=0.018), LH/FSH (p=0.001), testosterone (p=0.04).
Conclusion: Predominant patients with PCOS had enlarged ovaries with multiple (>12), small-sized (<9 mm) peripherally arranged follicles and low FSH and elevated LH, LH/FSH ratio, testosterone, TSH, and prolactin levels.
Abdominal obesity, Luteinising hormone, Prolactin, Testosterone, Thyroid stimulating hormone
The PCOS is a complex endocrinologic disorder characterised by a combination of polycystic ovarian morphology, diverse clinical features, and abnormal biochemical indices that affects women of reproductive age (1). According to the World Health Organisation (WHO), PCOS affects 116 million women (3.4%) worldwide (2). Prevalence varies greatly around the world, ranging from 2.2-26%. PCOS affects approximately 10% of the women in India (3). PCOS affects 50% of women who visit infertility clinics (4). Women with PCOS present with three main clinical complaints-menstrual irregularities (mean incidence 70%), infertility (mean incidence 40%), and hyperandrogenism (mean incidence of Hirsutism 70%, acne 15-30%) (5). PCOS is distinguished by low levels of FSH and elevated levels of LH. Low FSH levels cause anovulation, elevated LH levels cause hyperandrogenism, and insulin resistance symptoms range from simple cystic acne, cephalic hair loss, or mild facial hirsutism to oligomenorrhoea or amenorrhoea, sterility, and severe generalised hirsutism (6),(7). In the 1970s, the development of pelvic ultrasonography increased the diagnostic specificity of PCOS recognition. Following the Rotterdam Consensus meeting in 2003, ultrasound diagnostic criteria for PCOS diagnosis were developed (8).
Thus, from a clinical, biochemical, and imaging standpoint, the PCOS has progressed through many stages. Transvaginal sonography has improved our understanding of the internal structure of the ovary and endometrial morphology. In light of this, the current study was designed to identify and evaluate the sonological features in patients with clinical and biochemical features of PCOS. This study minimises the burden of expensive hormonal analyses in PCOS patients by assessing the association between hormonal status and ultrasonographic features.
This cross-sectional study was done from September 2020 to September 2022 on 53 female patients in the reproductive age group (18-35 years), who were referred to the Department of Radiology, Kalinga Institute of Medical Sciences Bhubaneswar, Odisha, India for pelvic ultrasonography in clinical suspicion of PCOS (infertility, menstrual abnormalities, hirsutism, obesity). This study was approved by Ethics Committee (KIIT/KIMS/IEC/440/2022), and each woman gave informed consent. Consecutive sampling technique was adopted to recruit the study population.
Inclusion criteria: Patients with symptoms of menstrual irregularities, obesity, hirsutism, acne and infertility and have undergone ultrasound and hormonal investigations were included in study.
Exclusion criteria: Patients with ovarian hyperstimulation syndrome, pregnancy, patients with underlying endocrine disorders and on treatment were excluded from the study.
Study Procedure
All patients underwent transabdominal ultrasound and only married patients with abdominal obesity underwent transvaginal ultrasound. Ultrasound scans were performed between days 3 and 7 of the menstrual cycle by using GE-VOLUSON S10 ultrasound scanner using curvilinear probes of frequency ranging from 1 to 5 MHZ and transvaginal sectorial probe with frequency ranging from 5 to 9 MHZ. Volume and stromal thickness of the ovary was measured [Table/Fig-1a,b]. The total number of follicles were counted manually when scanning from one ovarian margin to the other, and it contain those with a diameter of 2 to 9 mm [Table/Fig-1c]. Whether follicles were mostly dispersed in a peripheral pattern or unevenly across the stroma is determined by the follicle distribution pattern. The diagnosis was made by Rotterdam criteria [9,10]. Fasting blood samples were collected and chemoluminescent assay was used to measure FSH and LH. TSH and serum prolactin levels were determined using Enzyme Linked Immunosorbent Assay (ELISA). By using high-performance liquid chromatography mass spectrometry testosterone was detected.
Outcome measured was to assess the association between volume of the ovary, size and number of follicles, and stromal thickness with hormones like FSH, LH, testosterone, prolactin, TSH.
Statistical Analysis
Categorical data was represented in the form of frequencies and proportions. Chi-square test was used to assess association between volume, size of the ovary, number of follicles, and stromal thickness with hormones like FSH, LH, testosterone, prolactin, TSH. Continuous data was represented as mean and standard deviation. The p-value of <0.05 was considered as statistically significant after assuming all the rules of statistical tests. All the analyses were done using Statistical Package for the Social Sciences (SPSS) software version 22.0.
The study included 53 participants with the mean age being 25.60±4.09 years and majority 26 (49.1%) were in between 18 to 25 years, 19 (35.8%) were in the age group of 26 to 30 years, and the rest were in age group 31 to 35 years. The common clinical presentation was oligomenorrhoea, seen in 39 (73.6%) of study population. On ultrasonography of abdomen, 48 (90.5%) study had ovarian volume of >10 cc, with follicles arranged peripherally in all patients. More than 12 follicles were observed in 32 (60.4%) of patients with majority 51 (96.1%) had follicle size of <9 mm. Ovarian stromal thickness of >10 mm was observed in 46 (86.79%) patients and endometrium was thickened and heterogenous in 1 (1.9%) patients while rest had homogenous endometrium (Table/Fig 2).
In this study, out of 44 patients with LH >6.7 IU/mL, volume of ovary was >10 in 93.18% patients (p-value=0.03). LH/FSH ratio was >2:1 in 30 patients of which 93.3% had ovarian volume >10 cc which was statistically significant (p-value=0.03) (Table/Fig 3).
Out of 53 patients, majority (96.2%) had ovarian follicular size of <9 mm of which 86.2% had LH >6.7 IU/mL (p-value=0.001) (Table/Fig 4). Number of follicles >12 was observed in 32 patients of which 26 patients had LH >6.7 IU/mL (p-value=0.04), LH/FSH >2:1 was seen in 21 patients (p=0.01), testosterone >10 ng/mL was seen in 27 patients (p-value=0.002) were statistically significant (Table/Fig 5). Stromal thickness >10 mm was observed in 46 patients of which 43 patients had LH >6.7 IU/mL (p=0.018), LH/FSH >2:1 was seen in 29 patients (p<0.001), testosterone >10 ng/mL was seen in 32 patients (p-value=0.04) were statistically significant (Table/Fig 6).
In this study, almost half of the patients in 18-25 years of age group presented with clinical features like-oligomenorrhoea, obesity, acne, infertility, hirsutism, and amenorrhoea in descending order. Upon detailed evaluation, volume of ovary had statistically significant association with LH, LH/FSH ratio while ovarian follicular size had only with LH. Follicular number and stromal thickness of ovary had significant association with serum LH, testosterone levels and LH/FSH ratio.
In a prospective study with 214 patients by Jonard S et al., concluded that, median age was 27 years with majority in 21-34 years age group (11). The most common presentation was oligomenorrhoea, seen in 39 (73.6%) patients while amenorrhoea was seen only in 7 (13.2%). In a study by Sangabathula H and Varaganti N in a similar setting observed that 87% had oligomenorrhoea and 13% had amenorrhoea which was consistent with the present study (12). While another study by Peri N and Levine D with 245 patients with polycystic ovarian disease stated that 146 (59.5%) of these patients had irregular menstrual cycles, 38 (15.5%) had hirsutism and 15 (6.1%) had infertility. This difference was due to geographical variations and inclusion of older women in the study ranging from 16-49 years (4).
Of 50 patients, the mean volume of the ovary was 13.64±3.32 cc with ≥10 cc in 48 (90.5%) patients while the rest had <10 cc. Adams J et al., provided support for this finding that the majority 70% of PCOS patients displayed 10 cc (13). In a study by Hann LE et al., with 28 patients concluded what 71% of them had enlarged ovarian volume with mean volume at 14 cc and 71% had peripherally arranged follicles which was consistent with the present study (14).
On detailed examination of follicle, the mean size of follicle was 4.47±1.87 mm with ≤9 mm in majority of patients with only 2 (2.4%) had >9 mm. In a study by Adams J et al., they concluded that 2-9 mm follicles were seen in 60% of patients which was consistent with current study (13). Evaluation of stroma revealed thickened and echogenic in 46 (86.79%) of patients. In a study by Ardaens Y et al., with majority (64.9%) had abnormal stroma which was consistent with the present study (15). Majority had normal and homogenous endometrium while only around 2% had thickened and heterogenous which was consistent with findings of a study by Peri N and Levine D with 245 patients concluded that 93% patients had homogenous endometrium (4).
Ultrasonographic features when correlated with biochemical hormonal analysis revealed that larger ovarian volume had significant association with LH level and LH/FSH ratio. In a study by Nardo LG with 23 patients, concluded that ovarian volume had significant association with LH, while stromal volume had no significant association (16). In a study by Sidhmalswamy AG et al., with 74 PCOS patients, concluded that ovarian volume had a significant association with hyperandrogenism (17).
Ovarian follicular size had a statistically significant association with LH, which was consistent with a study by Pache TD et al., (18). Follicular number and stromal thickness had significant association with LH, testosterone and LH/FSH ratio. Takahashi K et al., noted a positive correlation between number of small follicles (2-8 mm) and serum testosterone level (5).
In a study by Dolz M et al., concluded that follicular number had significant association with LH, LH/FSH ratio (19). In a study by Loverro G et al., with 24 PCOS patients stated that increased ovarian stomal thickness had significant association with elevated serum LH, and testosterone levels (20).
Limitation(s)
Antimullerian hormone level an important parameter, was not evaluated in the study and the patients underwent biochemical hormonal analysis on multiple days of menstrual cycle.
Patients of PCOS had enlarged ovaries (>10 cc) with multiple (>12) small sized (<9 mm) peripherally arranged follicles. Upon hormonal analysis patients had low FSH and elevated LH, LH/FSH ratio, testosterone, TSH, and prolactin levels. Sonographic features had significant association with LH, LH/FSH, testosterone levels. So, it is concluded that clinicians should advise screening ultrasonography in cases of suspected PCOS for early diagnosis and prompt management.
DOI: 10.7860/JCDR/2023/62547.17746
Date of Submission: Dec 29, 2022
Date of Peer Review: Feb 01, 2023
Date of Acceptance: Mar 03, 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. Yes
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