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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
An Audit of the Length of Bone Marrow Trephine Biopsy in Adult Patients: A Cross-sectional Study
Correspondence Address :
Dr. Vandana Bhatti,
Associate Professor, Department of Pathology, Christian Medical College and Hospital, Ludhiana-141008, Punjab, India.
E-mail: vandanarajeshwar@gmail.com
Introduction: A bone marrow trephine biopsy is a minor surgical procedure used to diagnose various haematological and non haematological diseases, such as leukaemia, multiple myeloma, and parasitic disorders like histoplasmosis and leishmaniasis. It is often performed alongside bone marrow aspiration to gather additional information about cellularity, the arrangement of marrow components, and the presence of focal diseases. According to the World Health Organisation (WHO), the recommended minimum adequate length for a trephine biopsy is ≥1.5 cm (before processing).
Aim: To conduct an audit of trephine biopsy lengths and assess their diagnostic utility among adult patients.
Materials and Methods: This cross-sectional study analysed all bone marrow biopsies from adult patients received at the Department of Pathology, Christian Medical College and Hospital in Ludhiana, Punjab, India, over a three-year period (January 2019 to December 2021). The biopsies were categorised into three groups based on their length at the time of grossing: Group A (≥1.5 cm), Group B (1-1.4 cm), and Group C (0.5-0.9 cm). The length of each trephine biopsy was recorded and its diagnostic usefulness was evaluated.
Results: The study included 1,155 trephine biopsies performed over the three-year period. Out of these, 1042, 97, and 16 biopsies were allocated to Groups A, B, and C, respectively. Biopsies meeting the recommended length (>1.5 cm) accounted for 90.2% of the cases. Longer biopsies were associated with a higher rate of conclusive diagnosis compared to shorter biopsies (p-value=0.02). However, when comparing Groups A and B individually, no significant difference was observed in terms of the conclusive diagnosis (p-value=0.9).
Conclusion: Trephine biopsy is a vital tool for diagnosing haematological disorders, particularly focal lesions. Obtaining longer trephine biopsies should be emphasised, as they contribute to a more definitive diagnosis.
Biopsy length, Diagnostic concordance, Haematological disorders
Bone marrow examination is an important investigation in any haematological diagnosis. It plays a crucial role in diagnosing conditions such as leukaemia, lymphoma, multiple myeloma, unexplained anaemia, and myelodysplastic syndrome (1),(2),(3),(4). It also aids in the diagnosis of fungal and parasitic disorders like histoplasmosis, leishmaniasis, and cryptococcosis (5),(6),(7). In some cases, the aspiration technique may fail to yield sufficient marrow particles, even when performed by experts. This can result in dry taps or the inability to make a diagnosis based on the aspirate alone (8).
To address the issue of “dry tap,” where inadequate or no material is obtained during the aspiration procedure, McFarland W and Dameshek W introduced a method of obtaining bone marrow core biopsies in the late 1950s (9). Additionally, histological examination of the trephine biopsy can provide valuable information about various types of focal bone marrow diseases, including lymphomas, metastases, granulomas, and myelomas (2),(10),(11),(12). In conditions like myelodysplasia, the trephine biopsy offers additional information about cellularity, the arrangement of marrow elements, and focal disease (13). Trephine biopsies can also be used for performing immunohistochemistry, which is beneficial in the diagnostic evaluation of haematological disorders involving the bone marrow (14). Due to these advantages, bone marrow trephine biopsy is a commonly performed procedure. The posterior iliac crest is the preferred anatomical site for bone marrow aspiration and trephine biopsy (15). Other sites that may be used include the anterior iliac crest, sternum, or medial surface of the tibia in infants (1),(16). The bone marrow trephine biopsy can be performed before or after the aspirate (1). The recommended length of the core trephine biopsy from an adult is ≥1.5 cm, as recommended by the WHO (17). The biopsy specimen shrinks by approximately 20% after processing. This study presents an audit of trephine biopsy length and diagnostic concordance among different biopsy lengths.
This retrospective cross-sectional study was conducted in the Department of Pathology at a tertiary care centre in North India over a three-year period (January 2019 to December 2021). The study received approval from the Institutional Research and Ethics Committee (ref CMC/4693).
Inclusion criteria: All bone marrow trephine biopsies performed on adult patients (>18 years of age) were included in the study.
Exclusion criteria: Biopsies from children (<18 years of age) were excluded from the study.
Procedure details: After obtaining consent from the patient, trained physicians/physician assistants performed the trephine biopsies using a trephine biopsy needle (Jamshidi needle of gauge 11G/13G) from the posterior superior iliac spine. The biopsies were then placed in 10% formalin for fixation and sent to the histopathology department. The length of the biopsies was measured, and they were subsequently decalcified in 10% formic acid for 24 hours. After decalcification, the biopsies were processed in a Leica automatic tissue processor following standard protocols, and then embedded in paraffin wax. Thin sections measuring 3-4 μm were cut, and slides were prepared. The slides were stained with Haematoxylin and Eosin (H&E) as per routine procedure.
These H&E slides were retrieved from the records and studied. Relevant information was obtained from bone marrow requisition forms and bone marrow reports in the departmental records. The biopsies were divided into three groups based on their measured length at the time of grossing: Group A (≥1.5 cm), Group B (1-1.4 cm), and Group C (0.5-0.9 cm) (Table/Fig 1). The conclusive diagnosis of the trephine biopsy was noted and compared among the three groups. A conclusive diagnosis was defined as one in which the pathologist was able to provide an opinion based on the trephine biopsy that contained sufficient bone marrow tissue for evaluation.
Statistical Analysis
The data were analysed using GraphPad InStat Version 3.06 statistical software. Percentages and proportions were calculated, and descriptive analysis was performed with measures of variance including mean, median, and standard deviation for continuous variables. Nominal variables were expressed as percentages. The Chi-square test was used to calculate the p-value.
A total of 1155 biopsies were included in the study, comprising 685 males (59.3%) and 470 females (40.7%) with a male-to-female ratio of 1.4:1. The age of the patients ranged from 18 to 94 years, with a mean age of 51.7±16.6 years. The indications for bone marrow examination are presented in (Table/Fig 2). Among the biopsies, 659 were malignant and 496 were non malignant. The most common indication for malignant biopsies was leukaemia, while for non malignant biopsies, it was cytopenia under evaluation.
The number of biopsies in Groups A, B, and C were 1042 (90.2%), 97 (8.4%), and 16 (1.4%), respectively. When comparing these three groups, a significant p-value of 0.02 was obtained, suggesting an association between the length of the trephine biopsy and a conclusive diagnosis (Table/Fig 3).
In Group A, a conclusive diagnosis was given in 97.8% of cases, in Group B, it was 97.9% of cases, while in Group C, a conclusive diagnosis was given in 87.5% of cases. However, when Groups A and B were compared, no difference was observed in terms of trephine biopsy length and a conclusive diagnosis, as the p-value was not significant (p-value=0.9) between these two groups. This suggests that even a trephine biopsy length of 1 to 1.4 cm, with adequate tissue for examination, yielded comparable results to that of a trephine biopsy length >1.5 cm.
It was observed that 27 out of 1155 (2.33%) trephine biopsies were suboptimal and did not yield a conclusive diagnoses. These included 2.21% (23/1042), 2.06% (2/97), and 12.50% (2/16) biopsies in Groups A, B, and C, respectively. No diagnosis could be given for these biopsies, and they were reported as suboptimal for comments.
Bone marrow examination is a commonly performed procedure for diagnosing various haematological and non haematological disorders. It helps in obtaining specimens to assess bone marrow morphology and cellularity, as well as for special tests such as cytogenetic studies, molecular studies, and flow cytometric immunophenotyping (11). Bone marrow trephine biopsy, when performed in conjunction with bone marrow aspiration, provides better information on cellularity and is better at detecting focal lesions (1),(18).
The length of the trephine biopsy is one factor that can affect its diagnostic yield. Firstly, a longer biopsy provides a larger amount of tissue for evaluation. Secondly, it may contain more representative tissue, leading to a more accurate evaluation. A study by Ur Rehman S et al., on 393 trephine biopsies showed that the rate of diagnostic positivity on trephine biopsies is directly proportional to the length of the biopsy (19). A larger size of trephine biopsy also allows for a more comprehensive evaluation of the architecture of the bone marrow, its cellular composition, and the identification of focal lesions involving the marrow. In a study by Campbell JK et al., they found that the rate of conclusive diagnosis of lymphoma (which can have focal involvement of the marrow) increased with the increasing length of the biopsy. They noticed that 20% of biopsies <2 cm in length yielded a positive diagnosis of lymphoma, while the percentage increased to 35% in biopsies ≥2 cm (p-value=0.023) (20).
Present study analysed 1155 trephine biopsies performed on patients with an average age of 51.7±16.6 years. The most common indication for bone marrow examination was leukaemia, while other indications are listed in (Table/Fig 1).
According to WHO guidelines, the recommended length for a trephine biopsy is >1.5 cm (17). In present study, 90.2% of the trephine biopsies were of the recommended length. In contrast, Ur Rehman S et al., found that only 22.3% of biopsies were of the recommended length in their study (19). Authors observed that out of the 90.2% of biopsies that were of the recommended length, 97.8% were optimal for a conclusive diagnosis, while the rest were mixed with fibro-collagenous tissue and skeletal muscle fibres and showed crush artifacts, hence they were considered suboptimal.
It was noted that out of the 8.4% of biopsies in the range of 1-1.4 cm (Group B), 97.9% were optimal for a conclusive diagnosis. When comparing Group A and Group B, the p-value was not significant, suggesting that there was not much difference in the rate of conclusive diagnosis between the two groups. Similar findings were observed by Ur Rehman S et al., (19). Thus, even biopsies in the length range of 1-1.4 cm can provide a conclusive diagnosis if there are adequate inter-trabecular spaces for evaluation.
When all three groups were compared for the rate of conclusive diagnosis, a significant p-value was obtained. This suggests that as the length of the biopsy increases, the rate of obtaining a conclusive diagnosis also increases. Longer biopsies provide more material for evaluation, resulting in a higher rate of conclusive diagnosis compared to smaller biopsies. Similar findings were observed by Campbell JK et al., and Ur Rehman S et al., (19),(20).
In present study, 27 out of 1155 (2.33%) trephine biopsies were suboptimal and yielded an inconclusive diagnosis. These included 2.21% (23/1042), 2.06% (2/97), and 12.50% (2/16) biopsies in groups A, B, and C, respectively. Most of these suboptimal biopsies were from Group C, which had a length of less than 0.5 cm (12.5%). Ur Rehman S et al., observed that 6.5% of biopsies were suboptimal, with the majority (50%) being 0.5 cm in length, which was similar to present study findings (19).
Limitation(s)
This study included biopsies from adult patients only, and biopsies from children (under 18 years of age) were not included. Another limitation was that the representation of cases in Group B and C was lower compared to Group A.
Trephine biopsy plays a vital role in diagnosing haematological disorders, especially focal lesions. Longer trephine biopsies are beneficial in reaching a conclusive diagnosis, so physicians should prioritise obtaining longer trephine biopsies. While WHO recommends a trephine biopsy length of more than 1.5 cm, it is worth noting that a trephine biopsy length of 1-1.4 cm, with sufficient tissue for evaluation, can also provide a conclusive diagnosis.
DOI: 10.7860/JCDR/2023/64980.18352
Date of Submission: Apr 25, 2023
Date of Peer Review: Jun 15, 2023
Date of Acceptance: Jul 20, 2023
Date of Publishing: Aug 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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