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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
Monitoring Blood Glucose as a Perioperative Stress Response Marker and the Effect of Dexmedetomidine Premedication in Laparoscopic Surgery Patients: A Randomised Controlled Study
Correspondence Address :
Sunanda Gupta,
Qtr. D/8, Near Old Paediatric Ward, Burla-768017, Odisha, India.
E-mail: gupta1410sunanda@gmail.com
Introduction: Perioperative stress increases cortisol levels, which in turn elevates glucose production. Thus, regular monitoring of glucose during the perioperative period can predict intraoperative stress and the depth of anaesthesia. Dexmedetomidine (Dex) is used as an adjunct during anaesthesia to attenuate the pressor response during tracheal intubation.
Aim: To assess sequential blood sugar values in Dex-mediated attenuation of the perioperative neuroendocrine stress response.
Materials and Methods: A randomised, controlled, double-blinded study was conducted at the Department of Anaesthesiology, M.K.C.G Medical College and Hospital, Berhampur, Odisha, India on 80 patients undergoing laparoscopic surgery, divided into two groups (n=40). Group-I was administered 50 mL of Normal saline i.v. over 10 minutes, whereas Group-II received Dex 1 mcg/kg in 0.9% normal saline diluted to 50 mL over 10 minutes i.v. Blood glucose levels and haemodynamic parameters such as Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Mean Arterial Pressure (MAP), and Heart Rate (HR) were evaluated in the preoperative room, 30 minutes after surgical incision, after extubation, one hour after surgery, and 2.5 hours following surgery. Unpaired Student’s t-test was used to compare the variables at different time points.
Results: There was no significant difference in age (48.58±5.89 and 46.25±6.51 years; p>0.05), weight (57.07±7.84 and 56.8±7.4 kg; p>0.05), and American Society of Anaesthesiologists (ASA) status among the Group-I and Group-II patients. Female preponderance was observed, but it was not significant between Group-I and Group-II patients (27 vs 31; p>0.05). In Group-II, Dex-administered patients, the mean blood sugar levels at 30 minutes past surgical incision, after extubation, one hour, and 2.5 hours following surgery were 104.35±13.58, 97.15±5.86, 98.4±7.45, 94.08±7.37 mg/dL, respectively. This was lower when compared to Group-I saline-treated patients, 135.95±14.4, 137.38±7.93, 138.08±8.84, and 137.70±15.13 mg/dL, and was found to be significant (p<0.05).
Conclusion: Serial blood glucose estimation can be a useful marker to evaluate the perioperative neuroendocrine response. Dex premedication has effectively modulated the neuroendocrine stress response during anaesthesia.
Cortisol, Mean arterial pressure, Saline
Anxiety and excitability are more frequent in patients undergoing anaesthesia during surgery. The fear among the patient during this event is associated with several factors and mediates the stress. During surgery, there exists a complex stress response mediated by alteration in metabolic, neurohumoral, and immunological activity (1). Surgery induces a state of hyperglycaemia due to the metabolic response, which depends on various factors such as the patient’s age, mode of anaesthesia, extent of tissue damage, surgery type and duration, blood loss during surgery, and postoperative pain (2).
Laryngoscopy, endotracheal intubation, as well as extubation stimulate the sympathetic nervous system, leading to exaggerated haemodynamic changes. Surgical procedures induce further complex stress responses, manifested by metabolic, neurohumoral, and immunological changes. Within minutes of the start of the surgical procedure, the plasma concentration of Adrenocorticotropic Hormone (ACTH) and cortisol increases (3),(4). Cortisol promotes protein breakdown, lipolysis, and gluconeogenesis and inhibits cellular glucose utilisation. Thus, the blood glucose concentration rises synchronously with an increase in the level of serum cortisol (5). All these contribute towards perioperative neuroendocrine response. Therefore, the level of glucose in the blood is directly influenced by cortisol levels. Meanwhile, blood glucose measurement is a simple, reliable method and involves low cost for the evaluation of stress response.
The choices of premedication, anaesthetic agents, and techniques modulate the pathophysiological pathways and influence this neurohormonal stress response. Dex, an alpha 2 agonist, initially used for Intensive Care Unit (ICU) sedation, is being used as an anaesthetic adjuvant in different doses and by different routes. Studies have shown that there is a reduction of dose requirement of the induction agent as well as opioids and prevention of perioperative stress-induced haemodynamic changes with the use of Dex (6),(7).
A previous report showed that perioperative administration of Dex mitigated the stress response by decreasing the blood levels of epinephrine, norepinephrine, cortisol, and blood glucose in patients undergoing surgery (4). Dex administration also elicits anti-inflammatory effects by reducing the level of proinflammatory cytokines and C-reactive protein and enhances the activity of B cells and CD4+ cells, as well as the ratio of CD4+:CD8+ and Th1:Th2. Thus, these effects of Dex in patients undergoing surgery are mediated through the hypothalamic pituitary adrenal axis and sympathoadrenal tone (8).
So, the present study was conducted to evaluate the Dex premedication to attenuate the blood glucose level changes, which was the primary outcome, and the secondary outcome was to evaluate the haemodynamic changes before and after administration of Dex at various time intervals.
It was a randomised controlled, double-blind study conducted at the Department of Anaesthesiology, M.K.C.G Medical College and Hospital, Berhampur, Odisha, India, during the period November 2017 to October 2019. Approval from the hospital Ethical Committee was obtained (vide letter no. 525/Chairman-IEC). Written informed consent was obtained from all patients. Both patients and anaesthesiologists involved in the study were blinded.
Sample size calculation: To calculate the sample size in an Randomised Controlled Trial (RCT), the authors need to consider the power, the effect size, the standard deviation, and the dropout rate. One of the methods to do this is to use the formula for Analysis of Covariance (ANCOVA):
n=2×{(Zα/2 Zβ)2×σ2}/{(μ1-μ2)2×(1+r)}
where,
• n is the sample size per group,
• Zα/2 is the critical value of the normal distribution at α/2 (for a confidence level of 95%, α is 0.05 and the critical value is 1.96),
• Zβ is the critical value of the normal distribution at β (for a power of 80%, β is 0.20 and the critical value is 0.84),
• σ is the standard deviation of the outcome variable,
• μ1 and μ2 are the means of the outcome variable in the control and intervention groups, respectively, and
• r is the dropout rate.
Plugging in the given values
n=2×{(1.96+0.84)2×152}/{(11)2×(1+0.12)}
n=39.6
Rounding up to the nearest integer, we get n=40 per group.
Inclusion criteria: The study population constituted 80 patients of both sexes belonging to ASA grades I and II in the age group of 18-60 years. All of them were posted for routine laparoscopic surgeries under general anaesthesia.
Exclusion criteria: Patients suffering from diabetes, hypertension, renal and other endocrinal diseases, or receiving drugs known to affect sympathetic response or hormonal response were excluded from the study. Cases in which the intubation attempts were more than one and the cases which were converted to open laparotomy were also excluded. Patients with any known hypersensitivity to any of the drugs used were not included in the study.
Study Procedure
All the patients underwent scrutiny, physical examination, and investigation for a complete haemogram, routine examination of urine and stool, blood urea and serum creatinine, blood sugar, cardiological evaluation, and chest X-ray before the operation. They were advised to take Tab Alprazolam (0.25 mg) and Tab Ranitidine (150 mg) the night before surgery and asked to remain fasting after midnight. In order to avoid diurnal variations in hormones affecting our study, these cases were scheduled as the first morning cases.
On the day of surgery, the preoperative baseline blood sugar value was estimated in the preoperating preparation room. In the operating room, baseline HR and blood pressure values were recorded. The study medications were prepared and administered by individuals not associated with data observation and analysis. Laryngoscopy and intubation were performed by an experienced anaesthetist, and cases needing more than two attempts for intubation were excluded from the study.
The patients were divided into two groups as follows, and the Consolidated Standards of Reporting Trials (CONSORT) flow of the study participants was shown in (Table/Fig 1).
Group-I (n=40): Administered with 50 mL of 0.9% normal saline i.v. over 10 min (9).
Group-II (n=40): Administered with Dexmedetomidine 1 mcg/kg in 0.9% normal saline diluted to 50 mL over 10 minutes (9).
Patients were premedicated with Inj. Glycopyrrolate (0.2 mg), Inj. Midazolam (0.02 mg/kg), Inj. Butorphanol (0.03 mg/kg) i.v. Anaesthesia was induced with Inj. Thiopentone (5 mg/kg). Oro-tracheal intubation with an appropriate size low-pressure high-volume cuffed PVC endotracheal tube was done under direct laryngoscopy facilitated by Inj. Vecuronium bromide (0.1 mg/kg). Anaesthesia was maintained with an oxygen and nitrous oxide mixture (2:3 ratio) and Isoflurane 1-1.5%, and intermittent i.v. Inj. Vecuronium. Patients were manually ventilated in a closed circuit with carbon dioxide absorption. At the end of surgery, anaesthetics were withdrawn. Residual neuromuscular paralysis was reversed by intravenous Inj. Neostigmine (0.05 mg/kg) mixed with Inj. Glycopyrrolate (0.01 mg/kg).
Haemodynamic variations were recorded intraoperatively at regular intervals up to 2.5 hours into the postoperative period.
Following the preoperative baseline evaluation, blood sugar was again estimated 30 minutes after surgical incision, one hour after extubation, and 2.5 hours following surgery. The haemodynamic variables such as SBP, DBP, HR, and MAP were also measured preoperatively, 30 minutes after surgical incision, one hour after extubation, and 2.5 hours following surgery.
Statistical Analysis
The data obtained were statistically analysed using the Statistical Package for the Social Sciences software (version 16.0). As the data were found to be normally distributed, unpaired Student’s t-tests were applied for continuous variables, and p<0.05 was considered to be statistically significant.
The demographics and clinical characteristics of the patients were similar between the groups and were not significant. The results are shown in (Table/Fig 2). The mean age of the patients in Group-I and Group-II was 48.58±5.89 and 46.25±6.51 years, respectively, and it was not significant. The weight of the patients in Group-I and Group-II was 57.07±7.84 and 56.8±7.4 kg, and it was not significant. The majority of the patients in Group-I had ASA status I (n=22), and in Group-II had ASA status II (n=22), respectively, and it was not significant between the groups.
The comparison of blood glucose levels between the groups is shown in (Table/Fig 3). There were no marked differences in the baseline blood sugar level between the groups, and it was not significant (p=0.76). However, 30 minutes after surgical incision, one hour, and 2.5 hours following extubation, the blood glucose level was significantly lower in Group-II Dexmedetomidine administered patients compared to Group-I (p<0.001).
The SBP and DBP variations between both the groups are shown in (Table/Fig 4). The mean SBP and DBP were lower in Group-II compared to Group-I. The difference between baseline values was statistically non significant with p-values of 0.888 and 0.188 for SBP, respectively (p>0.05). But in the subsequent comparisons at one minute, five minutes, 15 minutes after intubation, 30 minutes after surgical incision, one hour after extubation, and 2.5 hours following surgery; the p-values were <0.05 (statistically highly significant).
The MAP variation between both the groups is shown in (Table/Fig 5). The mean MAP was lower in Group-II compared to Group-I. The difference between baseline values was non-significant between the groups (p=0.56). But in the subsequent comparisons at one minute, five minutes, 15 minutes after intubation, 30 minutes after surgical incision, one hour after extubation, and 2.5 hours following surgery, the MAP values were significantly lower in Group-II Dexmedetomidine-treated patients compared to the group, and it was significant (p<0.05).
There was a significant reduction in HR following the loading dose of Dexmedetomidine, at one minute, five minutes, 15 minutes after intubation, 30 minutes after surgical incision, after extubation, one hour, and 2.5 hours following surgery in Group-II (p<0.05) compared to Group-I, where there was an increase in HR following the various interventions of anaesthesia and surgery. The results are shown in (Table/Fig 6).
The neuroendocrine response, or stress response, during surgery is a frequently encountered condition and has significant effects on patient-related outcomes. Blood glucose level is one of the indirect measures that reflect the neuroendocrine response during surgery, and so anaesthesia techniques can be modified or changed accordingly (1). Increased blood glucose after surgical incision displayed a good correlation with the extent of tissue injury during surgery (10).
Earlier reports showed that the clinical utility of an α2-adrenergic receptor agonist decreases this response, but the activation of α2-adrenergic receptors leads to the inhibition of insulin release (11),(12). Dexmedetomidine (Dex) is a selective α2-adrenergic receptor agonist with a greater affinity towards the α2 receptor and thus elicits a potential effect on glucose levels (13). Previous reports showed that perioperative administration of Dex could attenuate stress and also decrease the levels of stress inducers such as catecholamines and cortisol (14),(15). In spine and abdominal surgery, Dex treatment reduces the incidence of hyperglycaemia and also minimises the variation in glucose levels (16). Therefore, the present study was carried out to find the effect of Dex on blood glucose levels and haemodynamic parameters during the perioperative period in patients undergoing laparoscopic surgeries under general anaesthesia.
In the present study, there was a significant decrease in blood glucose levels following Dex infusion in Group-II patients at 30 minutes after surgery, after extubation, and 1.5 and 2 hours after extubation when compared to Group-II patients infused with saline. Similar to the present study report, Li CJ et al., reported that the glycaemic variation in dexmedetomidine was slightly lower as compared to the control group, and it was significant (p=0.03)(17). In another study done by Mostafa RH et al., in patients undergoing laparoscopic bariatric surgery, Dex at a dose of 1 μg/kg reduced the blood glucose level at 30 minutes after the initiation of surgery (88.77±14.46 vs 95.3±14.2; p=0.08) but was not significant when compared to the control group (18). However, at one hour (84.27±20.1 vs 101.3±14.6 mg/dL; p<0.001), two hours (81.57±19.3 vs 103.6±14.36 mg/dL; p<0.001), and six hours (82.53±12.95 vs 106.97±15.2 mg/dL; p<0.001), there was a significant decrease in blood glucose level in the Dex group compared to the control group, and it was significant. In Kameshwar YV and Upadhyay MR study, Dex administration showed a significant decrease in blood glucose level 30 minutes after laryngoscopy and intubation (117.3 vs 156.3 mg/dL; p<0.001), one hour postoperative (103.8 vs 136.7 mg/dL; p<0.001) and 2nd hour postoperative (106 vs 119.9 mg/dL; p<0.001) when compared to placebo (19). In Harsoor SS et al., study Dex administration showed a significant decrease in blood glucose level at 1 hour postoperative when compared to placebo (118.2±16.24 vs 136.95±19.76; p<0.0001) (20).
The haemodynamic stress response is a common complication during laparoscopic cholecystectomy, laparoscopic hysterectomy, or laparoscopic nephrectomy surgeries (21). Mounting studies showed that Dex attenuates the intraoperative stress response and maintains haemodynamic stability during laparoscopic surgeries (22),(23). Likewise, in the present study, Dex infusion significantly reduced the SBP, DBP, MAP, and HR at 1, 5, and 15 minutes after intubation, 30 minutes after surgical incision, after extubation and 1.5 and 2.5 postoperatively when compared to saline-infused patients (p<0.05). In Zheng L et al., study Dex significantly decreased the HR and blood pressure during the perioperative period as compared to remifentanil and sufentanyl in patients undergoing radical gastrectomy for cancer (24). Likewise, in Mostafa RH et al., study Dex administration significantly reduced the HR and MAP starting from postinduction till 120 minutes of the surgery period (p<0.001) (18).
Limitation(s)
The major limitation of the study was that simultaneous serum cortisol estimation to correlate with perioperative hyperglycaemia was not measured. Additionally, intraoperative Bispectral Index (BIS) monitoring for the depth of anaesthesia would have helped to assess the stress level and provided better results.
Dexmedetomidine administration significantly maintained the blood glucose level until the end of the postoperative period and thus attenuated the stress response. Additionally, it affected the haemodynamic variables such as SBP, DBP, MAP, and HR, respectively. Therefore, Dex will be a suitable agent to reduce the stress response in patients undergoing laparoscopic surgery, and in addition, it also maintained the blunting of the laparoscopicmediated haemodynamic changes.
DOI: 10.7860/JCDR/2024/58983.19140
Date of Submission: Aug 04, 2022
Date of Peer Review: Aug 31, 2022
Date of Acceptance: Jan 10, 2024
Date of Publishing: Feb 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
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