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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
Case Series
Full Version
Neurological Complications after Deceased Donor Liver Transplant: A Case Series from a Public Sector Hospital
Correspondence Address :
Dr. Satish Logidasan,
13, Raji Street, Manavala Nagar, Thiruvallur, Tamil Nadu, India.
E-mail: drsatishlogi@gmail.com
This is a case series of neurological complications which occurred after Deceased Donor Liver Transplant (DDLT) in a public sector hospital. The clinical presentations were bizarre. This is because patients with End Stage Liver Disease (ESLD) commonly have hepatic encephalopathy and postoperatively can present with similar clinical picture, like tremors and altered mentation. The first patient in the series presented with tremors due to Calcineurin Inhibitor (CNI) toxicity, second had Posterior Reversible Encephalopathy Syndrome (PRES), third with Osmotic Demyelination Syndrome (ODS) with coma and fourth with Extrapyramidal Syndrome (EPS). Patients 1 and 4 had involuntary movements and other clinical manifestations which interfered with recuperation in the postoperative period. So, the dosages of the immunosuppressants were adjusted and serum tacrolimus assay were serially monitored on alternate days. Case 3 developed PRES due to hypertension, as a result of high serum tacrolimus levels. The patient presented with headache and seizures, which if uncontrolled would have been lethal. In Case 4 clinical features and management of a patient who suffered prolonged coma due to ODS for about three months has been discussed. Also, the same patient had a cerebral infarct due to embolic phenomenon inspite of thromboprophylaxis. From this case series, it needs to be emphasised that postoperative occurrence of neurological complications are likely. So careful selection of the recipients, steady titration of immunosuppressants and watchful monitoring of the neurological signs are essential to improve the outcome of the transplant. Imaging of the brain, preferably Magnetic Resonance Imaging (MRI) should not be delayed to rule out other differential diagnosis.
Alcoholism, Headache, Immunosuppression, Tremors
This is a case series of neurological complications which occurred in four DDLT recipients, who presented in the institute between March 2017 and June 2019. The incidence of neurologic complications is around 15-30% in liver transplantation (1),(2). Clinical presentations of CNI toxicity, ODS, cerebrovascular accidents, cerebral opportunistic infections can occur (2). Eventually leading to increased morbidity and mortality of the recipient. The mortality related to neurological complications is around 10.98% (2),(3).
Case 1
This is a case of a liver transplant recipient who presented with coarse tremors due CNI toxicity in the immediate postoperative period. He was a 24-year-old ESLD patient that occurred secondary to hepatitis B virus, for whom DDLT was performed. He was started on Tacrolimus at 1 mg BD dosage on the first Postoperative Day (POD) and the daily dosage was escalated to 3 mg BD by the first week. Serum tacrolimus assay of 8-10 ng/mL was targeted, since this was considered an optimal level of immunosuppression to avoid acute cellular rejection and related complications in our institute. From the 12th day the patient gradually developed coarse tremors of hand which present both at rest and while doing physical activities. The tremors restricted his daily activities, ambulation, drug compliance which are essential for the graft survival. The corresponding serum tacrolimus assay was 14 ng/dL. Other causes for tremors were ruled out, except tacrolimus, which is known to cause the clinical presentation. Tablet Mycophenolate Mofetil (MMF) 500 mg BD was added and tacrolimus dose was reduced to 2 mg BD. In spite of reducing the dose, the patient did not show any symptomatic improvement. So, it was decided to discontinue tacrolimus and cyclosporine 500 mg BD was added. The tremors resolved in three days after stopping tacrolimus. His level of immunosuppression was stabilised and was discharged in the next week.
Case 2
A 42-year-old male patient with ESLD, due to alcoholic cirrhosis, developed PRES after DDLT. The patient was epileptic and taking levetiracetam for the past 10 years. Serum tacrolimus assay was maintained around 8-10 ng/L postoperatively. He had an acute cellular rejection with deranged liver enzymes, during the 8th postoperative day. So steroid pulse therapy using intravenous methylprednisolone 1 gm was administered. The patient was optimised and discharged on the 3rd week. On the 45th day, inspite of high serum tacrolimus, he had mild acute cellular rejection, and showed raised Liver Function Tests (LFT) and his blood pressures were high (Table/Fig 1). The patient was admitted and amlodipine was started. Three days after admission, he had throbbing headache with hypertension. Within a few minutes he developed generalised tonic clonic seizure which was managed by intravenous lorazepam 5 mg. MRI brain showed hyperintense lesion in territories of posterior cerebral artery with subacute haemorrhage of size 31×15×21 mm in right posterior parietal cortex with surrounding vasogenic oedema, suggestive of PRES Blood pressures was optimised. Tacrolimus assays were planned to be kept in a lower range between 5-7 ng/mL.
Hence, MMF 500 mg twice daily was added and tacrolimus dose was reduced. Based on the LFT, MMF dose was increased to 1 gm BD and levetiracetam 500 mg was continued. His LFT got normalised. MRI taken one week later revealed a decrease in vasogenic oedema. The patient was asymptomatic, had no further headache or seizures and was discharged.
Case 3
This was a case of alcoholic ESLD male patient, who suffered coma due to ODS and also had cerebral embolic infarct in the postoperative period. Preoperative blood biochemistry were within normal limits, Echo showed normal left ventricular systolic function, mild tricuspid regurgitation, MRI showed, T1 hyperintensity in the bilateral basal ganglia, suggestive of ESLD (Table/Fig 2).
Tacrolimus 0.5 mg BD was started in day 1, then dose was escalated to 1.5 mg BD (Table/Fig 3). He was on Low Molecular Weight Heparin (LMWH) 40U OD for thromboprophylaxis. Patients muscle power was only 3/5, had tremors in the upper limb and dysarthria. Tacrolimus toxicity was suspected it was switched over to cyclosporine, but there was no clinical improvement.
On the 6th day, the patient developed sudden Supraventricular Ventricular Tachycardia (SVT) with a heart rate of 190/min BP-74/50 mmHg. Carotid massage was given. Inj. Amiodarone loading dose 300 mg was given. The arrythmia reverted in three minutes. Since then, the patient was drowsy and became comatose by 8th day he was managed with mechanical ventilation. MRI brain, done on the 11th POD, showed features suggestive of acute embolic infarct involving left middle frontal gyrus, bilateral gyri, right frontal white matter (lacunar) and left precentral gyrus (lacunar), extrapontine myelinosis due to osmolyte imbalance, hyperintensity in transverse pontine fibres (Table/Fig 4).
The patient was started on citicholine 500 mg OD, atorvastatin 20 mgHS, capsule amantadine 100 mg OD, Tablet Clopidogrel 75 mg OD. Gradually the patient regained consciousness over the next two months. It took another 120 days to gain the motor power and his tracheostomy was decannulated by 150th day. The patient was discharged the next week.
Case 4
This was case of EPS in an 18-year-old female, which aggravated after liver transplant. DDLT was done for ESLD due to Wilson’s disease. Preoperatively, she had history of EPS with Parkinson’s features, for which she was taking Levodopa 250 mg and Trihexyphenidyl 2 mg, for two years. The patients preoperative MRI brain showed hyperintensity in the outer margin of putamen.
2The dose of tacrolimus was adjusted and her tacrolimus assay was adequately built. Tacrolimus assay was 1.5, 5,7 ng/mL on day 1, 3, and 7, respectively. Levodopa and trihexyphenidyl were stopped in the postoperative period, in view of the drug interactions, which might compromise the immunosuppression. From the 5th POD, she had dystonic limb movements, staccato speech and behavioral changes. Tacrolimus toxicity was suspected and was switched over to cyclosporine. But no improvement of symptoms was present. MRI revealed no new findings. In view of clinical deterioration in behaviour and movement disorder, levodopa 125 mg and trihexyphenidyl 1 mg were restarted in half of the original doses. The Parkinson’s symptoms resolved and the patient was discharged.
Thus, the patient’s immunosuppression and movement disorder, both were balanced and managed.
The predisposing factors for neurological complications are immunosuppression, sepsis, multiple organ failure, hepatic dysfunction and alcoholism (1). Among the 112 cases done in our low volume centre four patients had suffered the neurological complications.
In the 1st case report except for the tremors other manifestations of CNI toxicity like hyperglycaemia, hypertension was not seen. Tremors are more severe due to tacrolimus than cyclosporine as suggested by Erro R et al., (4). The tremors subsided after switching over to cyclosporine. Thus, the tremors due to CNI must be treated for the optimal outcome of the liver transplantation.
In case 2 PRES typically presented with headache and seizure, similar to the study by Cruz RJ et al., on 1923 liver recipients (5). In PRES the endothelial cell dysfunction of the brain barrier results in vasogenic oedema. PRES can present as intracranial haemorrhage in 5-15% of patients (5). It has unique CT or MRI imaging appearance with an incidence of 0.49% (6). The most common triggering factor is sudden surge in blood pressures (7). PRES occurs more in patients taking cyclosporine rather than tacrolimus. Though the patient 2 was not on cyclosporine, had hypertension which was one of the toxic effects of higher tacrolimus levels. The management was to eliminate the triggering factor, which in present case was hypertension. Hence tacrolimus dose was reduced and immunosuppression maintained by adding MMF and BP was controlled in a stringent manner. Any liver transplantation patient with a headache and accelerated hypertension, it is advisable to do MRI brain (8).
In case 3 ODS developed while there was normal serum sodium. The common perception is that ODS is a dreadful complication that occurs after aggressive therapy for hyponatremia. But ODS can develop in patients with low, normal, or elevated plasma levels of sodium [9,10]. The inability of brain cells to respond to rapid changes in osmolality of the extracellular compartment of the brain, leads to ODS (11). ODS, occurs especially in alcoholic malnourished patients (11). Optimising nutritional status of the recipients preoperatively, avoiding perioperative changes in the electrolytes, minimising the duration of the surgery thereby the major fluid shifts are recommended to avoid osmotic stress to the brain (12). Timely imaging, supportive measures were done for this case.
Case 3 had embolic infarct inspite of thromboprophylaxis with LMWH. The stasis associated with clot formation during the SVT could have been the source of emboli, in case 3. In a retrospective study on 461 patients, postoperative atrial fibrillation occurred in 47 patients a median of three days after transplantation with embolic episodes (13).
Case 4 suggests the intricacies of polypharmacy in liver transplant (14) and knowing the drug interactions. The clinicians must be able to titrate doses, if clinical scenario warrants. It is essential that titration of immunosuppressants must be done on individual basis with anticipation and close monitoring for neurological disorders.
Neurological complications can complicate the liver transplant surgery. So high index of clinical suspicion is essential. The discussed case of tacrolimus induced tremors, PRES, ODS and EPS would have turned the liver transplant futile, endangering the patient’s life. So, there is a need for delicate titration of the immunosuppressive agents based on individual response. MRI brain must not be delayed if clinical scenario warrants.
DOI: 10.7860/JCDR/2023/61490.17865
Date of Submission: Nov 16, 2022
Date of Peer Review: Dec 31, 2022
Date of Acceptance: Jan 30, 2023
Date of Publishing: Apr 01, 2023
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• 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
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Nov 24, 2022
• Manual Googling: Dec 20, 2022
• iThenticate Software: Jan 21, 2023 (7%)
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