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Basics of Quality Control in Clinical Laboratory

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Review Article | DOI: https://doi.org/10.31579/2768-0487/154

Basics of Quality Control in Clinical Laboratory

  • Padmanabhan P *

Professor, Department of Biochemistry, SSPM Medical College & Lifetime Hospital, Padve, Sindhudurg, Maharashtra 416534.

*Corresponding Author: Padmanabhan P., Professor, Department of Biochemistry, SSPM Medical College & Lifetime Hospital, Padve, Sindhudurg, Maharashtra 416534.

Citation: Padmanabhan P., (2024). Basics of Quality Control in Clinical Laboratory., Journal of Clinical and Laboratory Research 7(8); DOI:10.31579/2768-0487/154

Copyright: © 2024, Padmanabhan P. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Received: 05 November 2024 | Accepted: 20 November 2024 | Published: 29 November 2024

Keywords: quality; quality control; errors, internal; external; control charts

Abstract

The clinical laboratory involves processes and procedures that form an integral part of its management.  Until quality control of the clinical laboratory is executed, performed and monitored continuously and progressively, the results generated from the clinical laboratory cannot be accepted or even relied upon. The main purpose of quality control is to rectify and make the entire functioning of clinical laboratory error-free. Until the importance and purpose of quality control is not appreciated and implemented; the international standards (ISO: 15189 ) shall not be fulfilled. The personnels working in the clinical laboratory should be aware, capable and trained in the various quality control methods and policies generated thereof. Quality Control is a systematic process which reduces as well as eradicates the various types of errors; measures that can be taken so as to facilitate and increase the quality standards of the clinical laboratory.

Introduction

Clinical laboratories contribute significantly to the health care system. The important stakeholders such as patients, physicians, nurses etc. are provided with results in terms of “reports” supporting the diagnosis, prognosis, monitoring and treatment. They also provide the health authorities with statistical data.  This data is utilized to develop, implement and evaluate national health policies. Additionally, clinical laboratories also enable the surveillance and monitoring of communicable diseases at the international and national level [1]. The clinical laboratory has major role in health as well as training the laboratory personnel. Without the presence and able support from the laboratory personnel; the following can happen:

  1. Patients are less likely to receive the proper or even the best health care
  2. Resistance to essential drugs will continue to spread
  3. The disease neither its source can be identified
  4. The check on epidemics nor communicable disease is possible
  5. There will be ineffective control measures in the allocation of financeas and human resources [2]

The obstacle or challenge in providing the health –care is the lack of confidence in the medical laboratory results, especially in countries with poor economic resources. The delivery of health care in terms of reliable reports is critical for variety of diagnostic, treatment and control procedures. Major hindrances to the provision of such reports are the occurrence of errors during their generation [3].

Non-conforming reports or results are produced due to laboratory errors and mistakes. Non-conforming results with statistical meaning, caused due to non-human action are known as “errors”. Whereas, mistakes are non-conformance with no statistical meaning; and includes all types of human errors.

These errors maybe classified on the basis of time and stage of their occurrence in the various stages of procedures of the clinical laboratory-as pre-analytical stage, analytical stage and post-analytical stage. Majority of the pre-analytical and post-analytical non-conformance are “mistakes” whereas analytical outliers are “errors”.

Stages of the Analytical Procedure:

Pre-analytical stage: includes all the procedures occurring prior to analysis of patient’s samples e.g. blood drawing, sample transportation, centrifuging, dilution etc.

Analytical stage: includes the procedure in which the intended analyte or parameter is measured.

Post-analytical stage: refers to the tr4ansmission of data to LIS and validation of the results to the physician [4].

In order to detect the errors and reduce their occurrence; a set of procedures have been developed known as “ quality Control “ for clinical laboratories [5].

Quality Control

The first recommendation of Quality Control was published in 1965. Now Quality Control is a major part of the total clinical laboratory program.Quality Control is the control of the errors in the performance of the analytical tasks and verification of the test results. The check is on the reliability of the results as well as its correctness when compared to any laboratory in the world , provided that the same method is followed [6].                           

The types of procedures conducted in the clinical laboratory or analytical examinations are:

  1. Quantitative examination: measures quantity of the analyte in terms of numeric value and particular unit of measurement.
  2. Qualitative examination: measures just the presence or absence of a substance or evaluate cellular characteristics, such as morphology; in terms such as “positive” or “negative”. “reactive” or “non-reactive”, “normal” or

 “abnormal” and “growth” and “no growth” are used

  1.  Semi quantitative: to measure how much of the measured substance is present. Results maybe expressed as “trace amounts”. “moderate amount” or 1+,2+, 3+ [7].

Terminologies used in Quality Control

Accuracy: it denotes the agreement or closeness between the test results obtained by a method to the true or acceptable reference value.

Analytical method: a laboratory procedure utilized to measure a physicochemical entity or its attribute.

Precision: the reproducibility and repeatability between two measurements on multiple sampling under the prescribed conditions. Classified as Repeatability –intraassay variability, Intermediate precision ( Intra laboratory variability), Reproducibility (Inter Laboratory Variability)

Purity assay: quantitative analytical procedure used to measure the purity of an active ingredient

Purity method: a qualitative analytical procedure used to determine the purity of an active ingredient

Specificity: demonstrates the ability of a method to measure an analyte in the presence of components present such as impurities, degradants and matrix components of the sample utilized.

Standard deviation: the variation or the measure of the dispersion of the values from the average value or the mean

Mean: the average value of the analyte obtained post multiple analysis in clinical laboratory [8].

Sources of Laboratory Errors:

The potential errors occur which affect the quality of the laboratory results.The three distinct stages are prone to specific , characteristic types of errors

A] Errors in pre-analytical stage: Occur and impact prior to the analysis of the patient’s sample , in the clinical laboratory.these  types of errors include:

  1. Wrong patient identification: The demographic details maybe noted wrongly which may finally affect the laboratory test results e.g., name, gender, age, patient ‘s posture, effects of exercise, dietary effects, medical history, effects of drugs, alcohol etc.
  2. Improper collection of blood samples: The blood sample maybe collected in another vacutainer than the one actually recommended e.g.; sodium citrate vacutainer utilized instead of fluoride vacutainer.
  3. Inadequate quantity of sample: the sample collected in vacutainer may not be adequate quantity required in order to test the analyte.
  4. Improper handling of the sample: if the sample in the vacutainer is not handled well may lead to hemolysis; which directly affects the biochemical testing.
  5. Incorrect sample storage: the sample in the vacutainer should be stored properly in a refrigerator, if required to store for longer period of time
  6. Other factors: Heat or light exposure may lead to erroneous results of analytes in vacutainer on analysis e.g. photo-degradation of bilirubin by light exposure.

B] Errors in Analytical phase: the analytical phase means the period of analysis of the patient’s specimen and between period involves both entry and exit of the patient’s report. These patient’s report are affected by the sample pre-treatment , reagent volume measurement, sample measurement, sample and reagent mixing time, incubation, reaction timing , dilutions and calculations involved. These errors are also dependent on the additional apparatuses used such as glassware, pipettes etc;  which may not be washed or calibrated properly. The quality of the reagents and the deionized water used for the reconstitution of calibrators and controls has a direct influence on the values generated. The reagents should be prepared as per manufacturer’s instructions. The accuracy and precision of the analytical method as well as proper maintenance of the equipment aid in the reduction of the analytical errors.

C] Errors in Post-analytical stage: After the analytical phase within the acceptable time frame or turnaround time (TAT), the reporting of the results is enabled in the post-analytical stage. The data, generated has to be presented in a format to be accepted clinically and comprehended and interpreted by the health –care professionals. The errors occurring are the typographical errors, delay in the transcript of reports, delay in the dispatch [9].

Quality Control Material: These are materials that are liquid in condition or freeze-dried (lyophilized) material. These are similar in condition containing the same analytes present as in human serum , plasma, blood , urine and cerebrospinal fluid. The QC materials ideally should be capable of long periods of storage and dispense, free from microbial antigens like bacterias, viruses, fungi and affordably priced. The abnormal level control material may be prepared at a concentration above or below the reference range of the analytes. Minimum two levels of the control materials are prepared by the reagent manufacturer or analyzer manufacturer or can be prepared even by the laboratory personnel [10].

Properties of Control Material 

  1. Quantity should be sufficient
  2. Stability should extend to at least one year
  3. Kept in aliquots (small measurable volumes)
  4. Its concentration should vary minimally
  5. Their composition should be homogenous in aliquots stored in vials
  6. Control sample should be treated similar to test or patient sample [11]

The two levels of controls should be spaced by a time gap of 8hours. QC material should be run additionally after

  1. After an instrument’s servicing
  2. Change in reagent lots
  3. After calibration and
  4. Whenever patient’s sample seems inappropriate in order to confirm the results produced [10]

Purposes of Quality Control Process

  1. To assess the precision of the results over a period of time
  2. To give a prior warning of the control trends such that early action can be taken before actual mistakes occur
  3. It provides an idea that the accuracy of the results by comparison with the known sera
  4. It is important to test the performance of the analyser
  5. Monitor the analytical methods so as toassess the accuracy
  6. To monitor the technical skills of the laboratory personnel
  7. Prevent the incorrect patient’s value as compared to the known standards with the expected values [11]

Types of Quality Control

I] Internal Quality Control: set of procedures undertaken by a particular laboratory for continuously monitoring the operation and results of the measurements so as to assess its quality. Internal Quality Control involves the attempts and steps involved to ensure errors in the analytical data are of magnitude appropriate for usage.

It involves two approaches a) the analysis of the reference materials to monitor trueness and statistical control b) duplication to monitor precision

The basic approach to Internal Quality Control involves the analysis of control materials alongside the analyte under examination. The outcome forms the basis of decision of acceptability of the data produced. However, the interpretation of the control data should be documented based on objective, criteria and on statistical principles. The results of control analyses are indicators of the performance of the analytical system, also as guide to errors to individual test results [12].

According to ISO 15189 (International requirements) “The laboratory shall design internal quality control systems that verify the attainment of the intended quality of the results [13].

Pre-requisites for Internal Quality Control Program

It is primarily essential to set up QC protocols to implement that are statistical tools or control rules, number of control measurements as per the required quality of analytical test. The following is necessary to implement an internal quality control program.

  1. Create standard operative procedures and policy
  2. Assign personnel or staff for monitoring and reviewing
  3. All staff should be trained
  4. Obtain the control materials
  5. Collect the data
  6. Set target or true values and calculate mean and SD
  7. Establish Levy-Jenning charts
  8. Plot the control data
  9. Establish , implement, troubleshoot and corrective action protocols
  10. Document the entire procedure
  11. Control specimens should be tested in the same manner as the test samples by the same staff of the laboratory
  12. The calibrator obtained from the obtained from the manufacturer and used as control, it should be a diffe3rent lot no from that used to calibrate
  13. For a new lot QC material, numeric QC data, QC statistics ( mean , SD and CV) should be calculated at least 20-30 data interval to dete3ct the precision.
  14. The data of the control should be recorded or plotted to detect a malfunction in the instrument or the analytic system. The control records must be readily available to the laboratory staff performing the analytic method.
  15. To detect problems and trends the staff must review QC data on days when control are run
  16. The results of control should be verified for acceptability before patient
  17. The results of the control should be verified for acceptability
  18. The laboratory director should review the Internal Quality Control at least monthly
  19. Controls must be run prior to reporting patient’s results after critical changes [14]

Calculation and Use of Quality Control Statistics

  1. Mean: Is the average or the laboratory’s best estimate of the value of estimated specific level of control 
  2. Standard deviation: is a statistic that quantifies the closeness between the3 numerical values (QC values) are in relation to each other. It gives an idea with regards to repeatability or consistency; where the consistency may vary when repeatability is obtained
  3. Co-efficient of Variation: Is the ration of the standard deviation to the mean expressed in the form of percentage                 
  4. Westgard Rules: Dr.James Westgard of the University of Wisconsin established clinical laboratory quality control rules on the basis of evaluation of quality of analytical run  for medical laboratories. These quality control rules are used since 1950s 
  5. Rule 12s:   This is a warning rule that is violated when a single control observation is outside the ± 2s limits
  6. Rule 13s: This rule identifies unacceptable random error and is a rule for action plan to remove the error 
  7. Rule 22s:  This rule identifies systematic error only. The criteria for violation are Two consecutive QC results greater than 2s are on the same side of the mean
  8. Rule R4s:   This rule applies for the random error in a single run. If there is a 4s difference between control values within a single run
  9. Rule31s:This rule is violated when three consecutive results are on one side of mean greater than 1s on the same side of the mean
  10. Rule41s: This rule is violated when four consecutive results greater than 1 s are on the same side of the mean
  11. Rules :7 ꭓ,8 ꭓ,9 ꭓ,10 ꭓ,12 ꭓ: these rules are violated when there are 7 or 8or 9 or 10 or 12 control results on the same side of the mean; regardless of the specific standard deviation in which they are located
  12. Levy-Jennings Chart: The graphical representation of the quality control data (QC data) in order to analyze it on statistical basis by the application of QC rules such as Westgard Rules [15].
  13. Standard Deviation Index (SDI): It is a peer –based estimate of reliability.

It is calculated as SDI = (Lab- Group)/s Group

Where 1.25 or less is considered acceptable

            1.25 -1.49 is considered accepted marginally

           1.5 -1.99 is considered marginal performance and investigation of the 

           test system is recommended

          2.0 or greater unacceptable performance and remedial action is usually required [15]

II] External Quality Control: Widely known as External Quality Assessment Scheme (EQAS) in the late 1940s pioneered by Belk and Sunderman. It is an integral part of Total Quality Management System. EQA is a continuous process for quality improvement in which the participating laboratory was an outside, unbiased source to compare the quality of the patient’s results.

By comparison the similarity and variation if any is recorded on a fortnight , monthly or six-monthly basis with the outside laboratory.                     

Steps in EQAS

  1. Providing and sending QC material to  all the participating laboratories
  2. Measurement of the analytes to send best value and results by the participating laboratories
  3. Data analysis and reporting the results to the laboratories participating
  4. Interpretation of the evaluation report and take corrective actions for unacceptable results by each of the respective participating laboratory
    1. The EQAS co-ordinator calculates the mean value (µ) and the standard deviation (s) of each peer group ( individual participating laboratories)

Proficiency testing or External Quality Assurance (EQA) are terms used synonymously but there are slight differences between the two. The former is utilized in accreditation purposes whereas the later for quality control by an external agency [16].

Types of errors which is a measured of inaccuracy in the EQA results are transcription errors, pre –survey issues of outside laboratory ( provider), sample receipt /handling ,test performance, data handling of EQA by provider , report and interpretation [17].

EQA is an important component of a laboratory’s total Quality Management and is required by many national regulations of International Organization for Standardization (ISO) 15189 accreditation and by the Clinical and Laboratory Standards institute (CLSI) .QMS 24 document.

Although EQA is applied to analytical performances, the EQA process is also applied to pre-analytical stage.

Type I : registration of procedures by means of questionnaires .Few resources are required to organize and participate and relevant recommendations included.

Type II : sample analysis with simulated problems. However,  only limited pre-analytical deviations can be assessed.

Type II : registration of incidences. This is utilized for harmonization of quality indicators (QIs) to pre-analytical stage to EQA providers.

Pre-analytical EQA schemes are more difficult to standardize however requires attention and improvement since the pre-analytical stage in error-prone and subjected to maximum chances of error [18].

External Quality Assurance Scheme program enables to improve the efficiency of the laboratory services, thereby optimizing the quality of the health –care facilities. It enables the participating laboratories to compare activities and modify their practices based on their own interpretations and provider laboratory. In clinical laboratory, EQAS evaluates the performance of procedures, equipment, materials, personnel and recommends areas of improvement. In India, CMC Vellore Christian Medical College , Vellore is one of the provider for EQAS program [19].

Calculation in EQA: Although there are variopus calculation methods wherein the final results maybe expressed in terms of Standard Deviation Index, Precision Index (PI)  or Co-efficient of Variation Ratio or Z-score. However, an EQAS co-ordinator normally takes the following steps

  1. Calculates the range µ ± 3s (Mean ± 3SD)
  2. If the participating laboratories results are over 3s , these results are rejected
  3. Calculates the range µ ± 2s (Mean ± 2SD)
  4. If the participating laboratories results are over 2s , these results are rejected
  5. The steps 4-5 are repeated until no values are outside the new range µ± 2s
  6. Standard deviation Index is calculated

SDI= Laboratory result- Mean value of peer group

                     Standard deviation of peer group

  1. Precision Index (PI) = Standard deviation of the laboratory

                     Standard deviation of peer group

  1. Co-efficient of Variation Ratio: CV of laboratory /month

                    CV of Peer group /month (4)

Maintenance of Quality or State of Control involves overall controlled 

  1. Chemical and critical reagents
  2. Compliance audits
  3. Instruments Maintenance & Qualification 
  4. Laboratory Investigations
  5. Analyst training and certification
  6. Assay Quality, Validation and Performance Evaluation (8)

Conclusions:

The modern clinical laboratory plays an active role in the health –care settings. Since the basis of diagnosis , prognosis , treatment and monitoring in the laboratory reports generated by the clinical laboratory. To prevent legal hassles and to  satisfy the aware general public ; it becomes imperative to implement quality control policies and adhere to generating quality reports (20).

This article is an insight into the basics of the quality control and the processes and procedures directly and indirectly related to it. It is to understand that quality control is only a part of Total Quality Management system. However, it does contribute to a major role in producing results of clinical laboratory which can be relied upon due to the simultaneous Internal and External Quality Control Program which are administered simultaneously and continuously. Also due importance should be given to the procurement and maintenance of Control materials. The retrospective and progressive monitoring of  Internal Quality control charts and EQAS program results further lays emphasis on the purpose of Quality control to take  necessary corrective and preventive actions in the present and for the future . 

Acknowledgments

Nil

Conflict of Interest

None

References

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I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!

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Baheci Selen

"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".

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Jesus Simal-Gandara

I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.

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Douglas Miyazaki

We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.

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Dr Griffith

I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.

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Dr Tong Ming Liu

I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.

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Husain Taha Radhi

I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.

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S Munshi

Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.

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Tania Munoz

“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.

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George Varvatsoulias

Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.

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Rui Tao

Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.

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Khurram Arshad

Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.

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Gomez Barriga Maria Dolores

The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.

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Lin Shaw Chin

Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.

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Maria Dolores Gomez Barriga

Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.

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Dr Maria Dolores Gomez Barriga

Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.

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Dr Maria Regina Penchyna Nieto

Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.

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Dr Marcelo Flavio Gomes Jardim Filho

Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”

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Zsuzsanna Bene

Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner

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Dr Susan Weiner

My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.

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Lin-Show Chin

My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.

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Sonila Qirko

My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.

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Luiz Sellmann