Article in PDF
How to Cite
Citation Manager
Readers' Comments (0)
Audio Visual Article Statistics
Link
to PUBMED
Print this Article
Send to a Friend
Advertisers
Access Statistics Resources
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
Sexual Dimorphism in Decompensated Non Ethanol-related Chronic Liver Disease: A Retrospective Cohort Study
Correspondence Address :
E Kandasamy Kumar,
No: 10, Rajarajeshwari Nagar, 1st Street, Opposite to New Stand, Tirunelveli-627007, Tamil Nadu, India.
E-mail: drkandasamy66@gmail.com
Introduction: Women exhibit a distinct natural history of chronic liver disease compared to men, particularly regarding progression and outcomes. Although liver disease prevalence is generally higher in men, the incidence of non ethanol-related liver disease is increasing among females. Metabolic syndromes and their consequences are less recognised in the female population until they develop end-stage cirrhosis. Limited studies have explored the differences between male and female cirrhosis. The present study aimed to address the knowledge gap in female Decompensated Chronic Liver Disease (DCLD).
Aim: To identify the differences in presentation and outcomes between females and males with non ethanol-related cirrhosis.
Materials and Methods: The present retrospective cohort study was conducted in the Department of Medical Gastroenterology and Hepatology,Tirunelveli Medical College, Tirunelveli, Tamil Nadu, India, involving 27 males and 33 females with non ethanol-related decompensated cirrhosis. A comparison was made between the aetiologies, presenting symptoms, complications, laboratory values, Model for End-stage Liver Disease (MELD) score, and in-hospital mortality during the first decompensation. Data analysis was performed using Statistical Packages for Social Sciences (SPSS) version 24.0 Quantitative variables were expressed as mean and Standard Deviation, while qualitative variables were expressed as frequency and percentage. The association between categorical variables was analysed using the Chi-square test, and the comparison of continuous variables between the two groups was analysed using independent sample t-test. A p-value of <0.05 was considered statistically significant.
Results: The mean age of decompensation was 56.5 years for men and 50.9 years for women. The most common aetiology in men was Non Alcoholic Fatty Liver Disease (NAFLD) (63%), while in females, it was NAFLD (45%) and cryptogenic cirrhosis (45%) (p=0.020). Diabetes Mellitus (DM) was more prevalent in males (55.6% versus 33.3%). Variceal bleed was more common in females (66.7% versus 48.1%). Jaundice was more frequently observed in males (44.4% versus 21.2%) (p=0.05). Ascites was more prominent in males (70.4% versus 45.5%) (p=0.05). Hepatic Encephalopathy (HE) was more prevalent in males (22.2% versus 15.2%). Females had a lower MELD scores compared to males (12.4±6.1 versus 15.2±6.4). Mortality was higher in males (22.2% versus 12.1%).
Conclusion: Women with Decompensated Chronic Liver Disease tend to decompensate at a younger age compared to males and have a higher risk of Upper Gastrointestinal (UGI) bleeding. NAFLD was the most common aetiology in both groups. Ascites and HE were more commonly observed in men. Females had lower MELD scores, resulting in a longer waiting period on the transplant list compared to males. Mortality was higher in males.
Cirrhosis, Diabetes, Gender, Varicies
Sexual dimorphism is evident in the pathophysiology, disease manifestations, and treatment response of chronic liver disease. Possible causes include differences in immune response, the effect of sex hormones on metabolic pathways, and variations in gene transcription (1),(2). The liver is a sexually dimorphic organ, with more than 1000 genes expressed differently between males and females (3). Liver fibrosis, which is the precursor to cirrhosis, also exhibits gender disparity across all aetiologies (4),(5),(6).
Hepatic decompensation, or Decompensated Chronic Liver Disease (DCLD), represents the end stage of liver diseases, characterised by the full manifestation of symptoms and the identification of the underlying liver disease. It is interesting to note that most chronic liver diseases, such as Alcoholic Liver Disease (ALD), Metabolic Dysfunction Associated Fatty Liver Disease (MAFLD), and Chronic viral hepatitis, often go unnoticed due to their subclinical nature, until the decompensation stage (7),(8). These diseases have a different natural histories in males and females. During the premenopausal period, women are generally protected from fibrosis progression compared to men. This observation has been linked to oestrogen, as circulating estradiol seems to suppress lipid accumulation, inflammation, and fibrosis progression (9).
In a large population-based multicentre study from India, the incidence of chronic liver disease was found to be 1.28%, with alcohol-related liver disease being the most common aetiology (10). A meta-analysis study reported a community prevalence of 28.2% for Non Alcoholic Fatty Liver Disease (NAFLD), which increased to 40.8% in hospital-based data (11). However, there is a lack of studies from India investigating gender disparity in the diagnosis and treatment of non ethanol-related chronic liver disease. This knowledge gap will become problematic in the future when MAFLD becomes the leading cause of cirrhosis in India, especially if women at risk remain unidentified. A recent large retrospective study from the United States comparing gender differences in hospitalised cirrhosis patients found that women had a lower incidence of decompensating events but higher co-morbidities (12). However, similar studies have not been conducted in India. Despite the limitations of a small sample size due to the short-term period and being a single-centre study, the present research aimed to serve as a stepping stone for future prospective studies, filling the knowledge gap in understanding the sexual dimorphism exhibited by Indian cirrhotics. The present hospital-based study compares non ethanol-related decompensated cirrhosis in men and women to explore their diverse presentations and prognoses.
The present retrospective cohort study was conducted at the Department of Medical Gastroenterology and Hepatology, Tirunelveli Medical College, Tirunelveli, Tamil Nadu, India. Data collection was carried out from January 2022 to January 2023, and data analysis, interpretation, and manuscript drafting were completed from March 2023 to May 2023. The study was approved by the Institutional Ethics Committee (TVMC/IEC/SS/8, dated 6/12/21), and informed consent was obtained from all patients. A total of 27 males and 33 females were included.
Inclusion criteria: The study included patients with new-onset ascites, acute variceal bleeding, Hepatic Encephalopathy (HE), or combinations of these conditions. Patients presenting with acute-on-chronic liver failure and/or hepatorenal syndrome were also included
Exclusion criteria: Patients with a previous history of decompensation, alcoholics, pregnant women, and those who went against medical advice were excluded from the study.
Study Procedure
Data were obtained from inpatient records. The study compared decompensation events, complications, and laboratory values including haemoglobin, platelet count, bilirubin levels, serum albumin, International Normalised Ratio (INR), urea, creatinine, and prognostic scores such as Model for End-stage Liver Disease (MELD) (13) and Child-Pugh scores (14). The presence of Diabetes Mellitus (DM), decompensation events, and mortality were considered qualitative variables. The grading of esophageal varices was done using the Westaby classification (15).
Statistical Analysis
Data analysis was conducted using SPSS version 24.0 Quantitative variables were expressed as mean and standard deviation, while qualitative variables were expressed as frequency and percentage. The association between categorical variables was analysed using the Chi-square test, and the comparison of continuous variables between the two groups was analysed using independent sample t-test. A p-value less than 0.05 was considered statistically significant.
The mean age of decompensation was 56.6 years for males and 50.9 years for females (Table/Fig 1). For the same level of decompensation, males had a higher MELD score than females (Table/Fig 1). Diabetes was more prevalent in males and likely contributed to metabolic dysfunction leading to cirrhosis (Table/Fig 2). The most common decompensating event in females was haematemesis, while ascites was the most common in males (Table/Fig 3). Jaundice was a predominant sign in males. The most common aetiology of liver disease in both males and females was NAFLD (Table/Fig 4). In females, a significant proportion had no known aetiology due to the inability to perform liver biopsy and the absence of metabolic dysfunction features. Whether these cases are still classified as burned out NAFLD or cryptogenic cirrhosis remains inconclusive. There was no statistically significant difference between males and females in terms of laboratory values. In both groups, the majority of patients had large, grade 3 varices on endoscopy (Table/Fig 5). Mortality was higher in the male group (Table/Fig 6).
In present study of non alcohol-related cirrhosis, NAFLD was found to be the most common aetiology in both males and females with DCLD. This contradicts a previous study where Hepatitis B Virus infection (HBV) was the most common aetiology in chronic liver disease in India, with NAFLD being more prevalent in western parts and HBV-related cirrhosis more prevalent in South India. These variations in observations are significant because NAFLD-related cirrhosis is rising in India, while it is already the leading cause of cirrhosis in the developed world.
It is important to implement screening programs to identify at-risk populations with obesity and metabolic syndromes, allowing for the early detection of hepatic fibrosis or compensated cirrhosis (16). This would enable effective interventions to reverse the condition.
The study found that females in the group decompensated at a younger age than males. Premenopausal women have protective factors, such as oestrogen, that slow down hepatic fibrosis. However, these factors decrease in postmenopausal women, putting them at an increased risk of cirrhosis (17),(18),(19). Early decompensation in females could have been delayed if they had undergone cirrhosis screening earlier.
Cirrhosis attributed to NAFLD-related cirrhosis is becoming a significant public health burden, leading to significant Disability Adjusted Life Years (DALY). In the past 10 years, there has been a rising trend in the contribution of NAFLD-related cirrhosis to DALY (20).
Mortality was higher in the male population. A recent study from China showed a declining Age Standardised Mortality Rate (ASMR) in their patients, but the ASMR in males was up to 3.65 times higher (21). In India, the death rate for liver cirrhosis and DALY reduced by 12.3% for cirrhosis in India (22). However, according to present study liver cancer-related mortality is increasing. The reduction in the mortality rate of cirrhosis is likely due to better healthcare and decreased alcohol consumption. However, NAFLD is showing an increasing trend in incidence and mortality. NAFLD is associated with significantly higher mortality from hepatocellular cancer and an increased risk of non-liver-related deaths, particularly cardiovascular-related deaths (23),(24).
The most common decompensating event in females was variceal bleeding, while in males, it was ascites. This contradicts another study where ascites was the index decompensating event in most of the study population (25). Variceal bleeding is a complication of cirrhosis with a mortality rate of 10% (26) with an increased crude death rate for the female population (27). It is a sequela. It occurs due to portal hypertension, leading to the rupture of oesophageal and gastric varices. Fibrosis screening and upper gastrointestinal endoscopy could have prevented variceal bleeding if conducted as advised by the Baveno committee (28).
The MELD score was higher in male patients than in females, possibly due to higher creatinine levels associated with higher muscle mass in men. This disparity has implications in MELD-dependent transplant enlisting, where females are less likely to receive a liver transplant due to lower MELD scores (29). The modified MELD 3.0 score aims to address this disparity and provide equal opportunities for liver transplants to females (30). Gender-based treatment strategies, such as hormonal replacement therapies for female NAFLD patients, are also being studied (31),(32). Alongside screening programs, these interventions may help prevent the progression of cirrhosis in female patients.
Overall, the present study highlights the importance of understanding the etiological variations, implementing screening programs, and addressing gender disparities in the management of cirrhosis to improve outcomes and reduce the burden of the disease.
Limitation(s)
The present study had the drawback of a low sample size, and the data was collected retrospectively from in-hospital records. It is important to note that this was a single-centre study. Several additional factors, such as sepsis, sarcopenia, functional status, and causes of mortality, could have been included in the study variables for more effective comparisons.
The present study clearly demonstrates gender differences in non alcohol-related chronic liver disease, particularly in terms of age of decompensation, decompensation events, and mortality. These findings have important clinical implications for both preventive clinics and advanced liver clinics. They highlight the need to identify high-risk groups and implement preventive measures to avoid decompensation and treat specific complications. The study also emphasises the necessity for special screening programs targeting women, especially during the perimenopausal period when they are at a high-risk for fibrosis progression and cirrhosis. While gender-specific hormonal therapies are still being investigated, there is promising research being conducted in the field of NAFLD. Overall, the present study contributes valuable insights into the understanding and management of gender-specific differences in chronic liver disease, offering a foundation for future research and the development of targeted interventions.
DOI: 10.7860/JCDR/2024/64558.18911
Date of Submission: Apr 17, 2023
Date of Peer Review: Aug 08, 2023
Date of Acceptance: Oct 11, 2023
Date of Publishing: Jan 01, 2024
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: Apr 19, 2023
• Manual Googling: Aug 23, 2023
• iThenticate Software: Oct 09, 2023 (3%)
ETYMOLOGY: Author Origin
EMENDATIONS: 8
- Emerging Sources Citation Index (Web of Science, thomsonreuters)
- Index Copernicus ICV 2017: 134.54
- Academic Search Complete Database
- Directory of Open Access Journals (DOAJ)
- Embase
- EBSCOhost
- Google Scholar
- HINARI Access to Research in Health Programme
- Indian Science Abstracts (ISA)
- Journal seek Database
- Popline (reproductive health literature)
- www.omnimedicalsearch.com