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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
Oral Zinc as an Adjunct in the Treatment of Enteric Fever: A Randomised Double-blinded Controlled Trial
Correspondence Address :
Dr. Aparna Jayaraman,
Flat A, Hayagreeva Apartments, 7/2, State Bank Colony, Shastri Nagar, Adyar, Chennai-600020, Tamil Nadu, India.
E-mail: drjaparna18@gmail.com
Introduction: Enteric fever is an important tropical disease which takes an average of five days for defervescence even with effective antibiotic therapy. Zinc has been successfully used as an adjuvant in diarrhoeal disease. If addition of oral zinc can lead to reduction in time to defervescence, it will be a useful adjuvant in the therapy of enteric fever.
Aim: To determine the effect of oral zinc supplementation, along with standard antibiotic therapy, for early defervescence among children with enteric fever.
Materials and Methods: This double-blinded, randomised controlled trial was conducted in the Department of Paediatrics, ESICMC and PGIMSR, Chennai, Tamil Nadu, India from November 2014 to August 2016. A total of 58 children aged <12 years with enteric fever were included and were randomised to receive 40 mg elemental zinc per day (n=29) or placebo (n=29) for one week. All children received intravenous ceftriaxone (75 mg/kg every 12 hours) until five days after defervescence. The main outcome measures studied were time taken for defervescence of fever and resolution of toxaemia. Kaplan-Meier survival analysis was used to compare differences in the time to resolution of toxaemia and defervescence of fever between the two groups and the log rank test was used to test for significance.
Results: The mean age of the children of the two groups was 6.48±3.15 years and 7.55±2.59 years, respectively. The mean time for fever defervescence was shorter among the zinc supplemented children than among the children in the control group (2 vs 3 days, p-value=0.043). Resolution of toxaemia was noted earlier in the zinc group than in the control group (75% vs 43%, p-value=0.054).
Conclusion: Zinc when used as an adjunct along with standard antibiotic therapy in children with enteric fever, resulted in earlier defervescence of fever.
Early defervescence, Placebo, Toxaemia, Tropical disease
Enteric fever is a systemic infection caused predominantly by Salmonella enteric serotype typhi and paratyphi (A, B, and C) which leads to significant morbidity and mortality (1). Children in South-central and Southeast Asia experience the greatest burden of this disease (1). The economic burden due to prolonged hospital stay and loss of wages for the parents is an important consideration. Over the past few decades, micronutrients are gaining prominence in the field of preventive and therapeutic medicine, especially infections. One such important micronutrient is zinc (2). Zinc is necessary for maintaining the integrity of the immune system, starting from the barrier of the skin (2),(3). Immunologically, zinc is necessary for the normal development of immune cells and affects the function of almost all cells namely neutrophils, macrophages and lymphocytes (4),(5). Brown KH et al., estimated that over half of the world’s population may be affected by zinc deficiency (2). Its beneficial effects have been definitively established in diarrhoea [6,7]. It has also been used as an adjunct in bacterial sepsis and found to reduce treatment failure when used along with antibiotics. This has been attributed to its immunomodulatory effect and antioxidant properties (6). A few studies have shown its effectiveness in the treatment of other gram negative infections like shigellosis and cholera (8),(9),(10).
Enteric fever is also an infection spread by the feco-oral route similar to the infections such as acute gastroenteritis or shigellosis and zinc supplementation may favourably impact the treatment. To the best of our knowledge, there is no study, evaluating the role of zinc as an adjunct in the treatment of enteric fever. Hence, the present study was conducted to determine the effect of oral zinc supplementation, when used as an adjunct with standard antibiotic therapy, for early defervescence in children with enteric fever.
This randomised, double- blinded, controlled trial was conducted at the Depaertment of Paediatrics, ESICMC & PGIMSR, Chennai, Tamil Nadu, India from November 2014 to August 2016. The study was approved by the Institute Ethics Committee (IEC) (Approval no. 11/27/10/2014).
Inclusion criteria: Paediatric patients, aged <12 years with enteric fever, admitted in paediatric ward, were included after informed written consent was obtained from the caregiver.
Diagnosis of enteric fever was made in patients with fever and blood culture showing growth of Salmonella typhi or paratyphi or Widal suggestive of enteric fever (O antigen titre >1:160, or a four-fold rise in titre of blood Widal in two weeks) (11).
Exclusion criteria: Children with enteric fever with septic shock requiring inotropes, or perforation and those with no response to i.v. ceftriaxone even after 10 days of therapy were excluded from the study.
Sample size: As there are no previous studies of zinc use in enteric fever, authors attempted to estimate a 25% reduction in the time taken for defervescence of fever between the intervention and control groups for a 95% confidence level and 80% power. The sample size was calculated using the formula,
N=2×SD2/d2
Where, N- sample size, SD- standard deviation of time taken for defervescence of fever (1 day), d- required reduction in time taken for defervescence (25%). The sample size thus arrived was 32 for each group. In the present study, a total 58 children with enteric fever were enrolled and randomised to 29 children in each group. Method of randomisation used was simple randomisation and allocation concealment was done by using sealed envelopes (Table/Fig 1). The key investigator and participants were blinded in the present study.
Data collection: Data of all the study participants, including demographic and anthropmometric details such as age, gender, weight, height, clinical findings, investigations, treatment details, and response to treatment were documented in a prestructured study proforma. Children were classified as normal, Severe Acute Malnutrition (SAM), Moderate Acute Malnutrition (MAM) or thinness based on the World Health Organisation (WHO) charts (12).
Intervention: Both groups were treated with Inj. ceftriaxone 75 mg/kg/day in two divided doses intravenously until five days after defervescence of fever or for a total of 10 days, whichever was earlier. Intervention group was given tablet zinc sulphate 40 mg (children >6 months) or 20 mg (children <6 months) once daily as powdered sachets without label and the other group was given placebo (powdered calcium tablets) without label for seven days. The above dose of zinc was chosen based on the study by Sachdev HP et al., (7). Oral zinc and placebo were both administered as powders in sachets and they were similar in colour, smell and taste.
The primary outcome observed was the time taken for defervescence of fever and resolution of toxaemia in both groups. Secondary outcome was the duration of hospital stay after start of intervention in both groups. Monitoring for side-effects was done meticulously. Upon completion of intravenous therapy and defervescence of fever, the child was discharged on oral antibiotics to complete a 14-day course. The principal investigator monitored all the patients through the entire course of the study.
Statistical Analysis
The statistical software used was Statistical Package for the Social Sciences (SPSS) version 15.0. Student’s t-test was used to find the significance of study parameters on continuous scale between two groups. Chi-square/Fisher-exact test was used to find the significance of study parameters on categorical scale between two or more groups. Kaplan-Meier survival analysis was used to compare differences in the time to resolution of toxaemia and defervescence of fever between the two groups and the log-rank test for significance. A p-value <0.05 was considered significant.
A total of 58 enteric fever cases were found eligible for recruitment and were enrolled in this study. They were randomised into two arms of 29 each. Analysis was done for all these patients as there were no drop outs.
Of 58 patients, 43 (74.1%) of the study population was normally nourished, 12 (20.7%) were malnourished and 3 (5.2%) were obese. There was no significant difference in the nutritional status in the patients of the two groups. History of prior treatment with antibiotics was observed in 16 (55%) of cases in the zinc group and 21 (72.4%) patients in the placebo group. Only one child in the placebo group and none in the zinc group were given prior vaccine for typhoid fever.
A total of 41 (70.7%) of the study population grew enteric bacilli in blood culture i.e., 19 (46.3%) of children in the zinc group and 22 (53.7%) in the placebo group. Blood Widal was positive in 24 (41.4%) of children in the study population; 13 (44.8%) in the zinc group and 11 (37.9%) in the placebo group. Blood culture and Widal positivity were comparable in both the groups (p-value=0.387 and 0.594, respectively) (Table/Fig 2).
Twenty children in the zinc group (69%) and 23 (79.3%) in the placebo group had toxaemia. The mean toxaemia resolution time after intervention in the zinc group was 1.45±1.18 days and in the placebo group was 2.00±1.22 days, half a day earlier (13 hours) for the zinc group than for placebo (p=0.054). The Kaplan Meier survival curve showed early resolution of toxaemia (improvement in appetite and general well-being) in both groups (Table/Fig 3).
The mean fever resolution time in zinc group was 2.83±1.31 days and in the placebo group it was 3.69±2.21 days. Mean time for defervescence of fever was about one day (21 hours) earlier for the zinc group than for the placebo group. The median time until recovery too was shorter among the zinc supplemented children than among the children in the control group (2 vs 3 days, p-value=0.043). The Kaplan Meier survival curve showed early defervescence in the Zinc supplemented group (Table/Fig 4).
The mean duration of hospital stay in the zinc group was 10.31±2.21 days and in the placebo group was 11.17±2.32 days. Children in the placebo arm stayed a day longer in hospital (21 hours) as compared to the intervention group. This difference was not statistically significant (p-value=0.152). There were no adverse effects in either group due to the treatment.
The management of enteric fever is plagued by several problems like difficulty in diagnosis, multidrug resistance and a long time to defervescence even with successful antibiotic therapy. Any intervention that can reduce the time to defervescence would be desirable. Hence, the authors decided to explore the possibility of zinc as an adjunct in the therapy of enteric fever. In the present study, resolution of toxaemia was faster and hospital stay was also shorter in the group treated with zinc fever, however the significance of these findings could not be established (p-value >0.05).
The time taken for resolution of fever was significantly lesser by 21 hours (p-value=0.043) in the group treated with zinc and standard antibiotics as against the one treated with antibiotics and placebo alone. This was the most important outcome of the present study as it illustrates the efficacy of zinc as a simple yet useful adjunct in the treatment of enteric fever. Though published literature for zinc in enteric fever is lacking, role of zinc in reducing the duration of acute gastroenteritis has been proved in several studies and has been the basis of zinc administration in diarrhoeal diseases (6),(7). Zinc as an adjunct for enteric fever seems even more promising than in shigellosis; Rahman MJ et al., found increased levels of Shigellocidal antibodies but definite evidence for clinical effect was lacking (8). Another important aspect of this intervention is its absolute safety. The present study has, for the first time, indicated that zinc supplementation may have benefits over and above antibiotic use in children with enteric fever.
In tropical countries, malnutrition and consequent zinc deficiency is common and this may play a crucial role in the morbidity caused by infectious diseases (9),(10). However, most of the study population (76%), were normally nourished and did not have any overt features of zinc deficiency. Though the exact mechanism by which zinc helps in the defervescence is unknown, some hypothesis may be postulated. The beneficial effect may be due to the effective stimulation of the immune cells as zinc has an important role in immunomodulation as described earlier. Also, zinc deficiency may be induced by infections and stress as an acute phase response as evidenced by several studies and correction of this deficit is likely to prove beneficial for recovery (13),(14),(15).
Limitation(s)
There were some important limitations of present study. The sample size of the present study was small. Also, baseline zinc levels could not be performed in the patients to find an underlying zinc deficiency, due to logistical constraints.
Oral zinc was found to be a useful adjunct in the treatment of enteric fever along with standard antibiotics as it reduced the duration of fever by atleast one day. This reduction is significant considering that enteric fever takes a long time to defervesce even with appropriate antibiotic therapy leading to prolonged hospital stay, parental anxiety and increased direct and indirect costs of therapy to both the family and the healthcare system. Larger studies are needed to confirm these findings. Considering the absolute safety of zinc, it may be used effectively as an adjunct to standard antibiotic therapy in enteric fever.
DOI: 10.7860/JCDR/2023/61222.18130
Date of Submission: Nov 06, 2022
Date of Peer Review: Dec 28, 2022
Date of Acceptance: Mar 18, 2023
Date of Publishing: Jun 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
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Nov 08, 2022
• Manual Googling: Feb 04, 2023
• iThenticate Software: Mar 11, 2023 (16%)
ETYMOLOGY: Author Origin
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