AUCTORES
Globalize your Research
Research | DOI: https://doi.org/10.31579/2690-1919/206
1 Undergraduated in medical school by the University of Southern Santa Catarina (UNISUL), Campus Tubarão, Brazil.
2 Department of Otorhinolaringology, University of Southern Santa Catarina, 787 José Acácio Moreira St, Tubarão/SC, Brazil.
*Corresponding Author: Zappelini CEM, Department of Otorhinolaringology, University of Southern Santa Catarina, 787 José Acácio Moreira St, Tubarão/SC, Brazil.
Citation: Zappelini CEM, Jeremias LA, Borba IN, Machado LZ, Nicoladelli SJ, et al., (2021). Association between Flexible Nasal Endoscopy, Polysonography Findins and Obstructive Sleep Apnea Severety. J Clinical Research and Reports, 9(3); DOI:10.31579/2690-1919/206
Copyright: © 2021, Zappelini CEM. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 01 October 2021 | Accepted: 02 November 2021 | Published: 13 November 2021
Keywords: obstructive sleep apnea; polysomnography; otorhinolaringology; nasal endoscopy; OSA severity
Introduction: Obstructive Sleep Apnea (OSA) is a condition with recurrent collapses of the pharyngeal region that result in partial or total reduction in airflow. Its diagnosis and severity depends on the Apnea-Hypopnea Index (AHI), data from the polysomnography exam (PSG). Its pathophysiology includes anatomical disorders of the upper airways that can be assessed through Flexible Nasofibroscopy (FN).
Objective: To identify the alterations present in the tests of FN and PSG in patients with OSA and correlate with the AHI.
Methods: Cross-sectional study, with data collected from reports of the FN and PSG exams of 81 patients with OSA, seen at an otorhinolaryngology clinic in Tubarão - SC. It was verified the association between the outcome –AHI- and other exposure variables - sociodemographic and clinical.
Results: Among the 81 patients, 75.31% were male, 41.98% had mild apnea, 30.86% moderate and 27.16% severe apnea. There was no correlation between FN findings and AHI (p> 0.05). There was a difference between the mean age, number of obstructive episodes per hour of sleep and minimum saturation between the groups with severe and mild apnea (p <0.05). Patients with severe apnea had a higher percentage of sleep phase one and a shorter REM sleep time compared to the mild apnea group (p <0.05). A positive correlation was obtained between: obstructive episodes with sleep stage 1 (p <0.01) and age (p <0.05); between minimum saturation and sleep stage 3 (p <0.05). There was an inverse correlation between obstructive episodes with minimal saturation (p <0.001), with sleep stage 3 (p <0.01) and with REM sleep (p <0.01); between age and minimum saturation (p <0.01).
Conclusion: OSA directly interferes with sleep architecture. The present study did not find association between upper airway alterations and OSA severity.
Obstructive Sleep Apnea (OSA) is characterized by recurrent collapses of the pharyngeal region during sleep that result in partial or total reduction of airflow [1]. Which results in hypoxemia, hypercapnia, and activation of the nervous system that directly influences quality of the individual's life [2]. It has a prevalence of 19% in the general population and is associated with several comorbidities that lead to a reduction in life expectancy [3].
The diagnosis of OSA and its severity in adults are determined by polysomnography’s (PSG) parameter Apnea Hypopnea Index (AHI). OSA is classified as mild (AHI 5 to 15), moderate (AHI 15 to 30) and severe (AHI greater than or equal to 30) [4,5]. Other parameters that are monitored during the sleep include pulse oximetry, sleep stages, sleep fragmentation, obstructive episodes and effort during respiratory events [6,7].
OSA is related with anatomical abnormalities and pathologies of the Upper Airways changes (UA) [8]. Flexible Nasal Endoscopy (FNE) is the best instrument to visualize the nasal cavity, rhinopharynx, oropharynx, hypopharynx and larynx [9]. During the exam, the Müller Maneuver is used to allow a better view of the location and degree of obstruction [10]. This maneuver results in negative pressure in the pharynx and induces the collapse of the retropalatal and retro lingual regions, simulating the phenomenon that occurs during sleep [11].
OSA is a chronic and progressive disease with high morbidity and mortality. It leads to metabolic, neurological, and behavioral outcomes that significantly reduce the quality and life expectancy of patients. Thus, the identification of UA disfunction through the FNE may indicate the need for further investigation reducing the timing for diagnosis and directing the appropriate therapeutic approach.
This study seeks to identify the variations present in Flexible Nasal Endoscopy and Polysomnography exams in patients with Obstructive Sleep Apnea and correlate with its severity.
Study patients
A retrospective cross-sectional study was conducted in the setting of an otorhinolaryngology clinic in Tubarão, Brazil. All reports of Flexible Nasal Endoscopy and Polysomnography from 2017-2019 were analyzed. A total of 81 medical records from patients with AHI greater than or equal to 5 were selected for this study. The inclusion criteria were patients with of nocturnal snoring complaints in the anamnesis who underwent endoscopic nasal examination with the performance of the Muller Maneuver.
Study procedures
This study was approved by the UNISUL Research Ethics Committee (opinion number 4,323,611).
The data was collected through a protocol written by the authors based on similar studies. Sociodemographic variables were evaluated as: a) Gender: female/male; b) Age: collected in complete years. Clinical variables were divided into data from flexible Nasal Endoscopy and polysomnography exams as: a) Septal deviation: non-obstructive, obstructive; b) Inferior turbinate hypertrophy: absent, present 1 or 2+/4+, present 3 or 4+/4+; c) Pharyngeal Tonsilla Hypertrophy: absent or present; d) Shape of the pharynx during the performance of the Muller maneuver: presence of circular or elliptical narrowing; e) Degree of obstruction during the Muller maneuver: up to 50%, greater than or equal to 50%; f) Apnea/hypopnea Index: mild (5 ≤ AHI < 15>
Statistical analyses
In the description of the data, absolute (n) and relative (%) frequencies were used for qualitative variables and measures of central tendency and dispersion for quantitative ones. Normality was identified by the Shapiro-Wilk test. The existence of an association between the Apnea-Hypopnea Index outcome and other exposure variables (sociodemographic and clinical) was assessed using Pearson's chi-square test. To compare the means of exposure variables (sociodemographic and clinical) according to the outcome (Apnea-Hypopnea Index), the analysis of variance test (ANOVA) was used. Bonferroni's post hoc test was used to identify the difference between means in the three groups evaluated. To assess the correlation between variables, the Pearson correlation coefficient (r) was used. The strength of the association was classified considering r values as follows: 0=null; 0-0.3=weak; 0.3|-0.6=regular; 0.6|-0.9= strong; 0.9|-1= very strong; 1=complete or perfect [12]. The significance level used in the research was 5% (p<0>
Of the 81 participants 61 (75.31%) were males and 20 females (24.69%), the mean age was 43.34 years (± 14,93y). The patients were divided into three groups according to OSA severity: Mild OSA 34 (41.98%) people, 25 (30.86%) moderate OSA and 22 (27.16%) severe OSA. The mean age of the severe OSA group was significantly higher than the mild group (47.82y vs 38.36y) (p<0>
In the Nasal Endoscopy reports was observed that 8 (9.88%) participants had an obstructive septal deviation; 14 (17.28%) presented grade 3+/4+ or 4+/4+ inferior turbinate hypertrophy; 4 (4.94%) with pharyngeal tonsil hypertrophy; 74 (91.36%) manifested circular narrowing of the pharynx during the MM; 73 (90.12%) had an airway obstruction degree >50% during the Muller Maneuver. There was no statistically significant association between the alterations in the UA structures and OSA severity (p>0.05). (Table 1).
Data | OSA Severety |
p* |
Total | ||||||
| Mild (5 ≤ AHI < 15> | Moderate (15 ≤ AHI< 30) | Severe (AHI ≥30) | |||||||
| N | % | N | % | N | % | N | % | ||
| Sex | |||||||||
| Female | 07 | 28,00 | 06 | 27,27 | 07 | 20,59 | 0,766 | 20 | 24,69 |
| Male | 18 | 72,00 | 16 | 72,73 | 27 | 79,41 | 61 | 75,31 | |
| Deviated septum | |||||||||
| Unobtrusive | 23 | 92,00 | 22 | 100 | 28 | 82,35 | 0,090 | 73 | 90,12 |
| Obstructive | 02 | 8,00 | 0 | 0,00 | 06 | 17,65 | 8 | 9,88 | |
| Turbinate Hypertrophy | |||||||||
| 1+/4+ e 2+/4+ | 18 | 72,00 | 19 | 86,36 | 30 | 88,24 | 0,167 | 67 | 82,72 |
| 3+/4+ e 4+/4+ | 7 | 28,00 | 3 | 13,64 | 04 | 11,78 | 14 | 17,28 | |
| Pharyngeal Tonsilla Hypertrophy | |||||||||
| Abscent | 23 | 92,00 | 20 | 90,92 | 34 | 100,00 | 0,215 | 77 | 95,06 |
| Present | 02 | 8,00 | 02 | 9,09 | 0 | 0,00 | 4 | 4,94 | |
| Shape of the Pharynx in Muller's Maneuver | |||||||||
| Circular narrowing | 24 | 96,00 | 21 | 95,45 | 29 | 85,39 | 0,255 | 74 | 91,36 |
| Elliptical narrowing | 01 | 4,00 | 01 | 4,55 | 5 | 14,71 | 07 | 8,64 | |
| Obstruction’s degree during Muller's Maneuver | |||||||||
| < 50> | 04 | 16,00 | 03 | 13,64 | 01 | 2,94 | 0,198 | 08 | 9,88 |
| ≥ 50% | 21 | 84,00 | 19 | 86,63 | 33 | 97,06 | 73 | 90,12 | |
N: absolute number; %: percentage; *: related to Pearson's chi-square test.
Table 1: Description of the number, percentage and significance value of nasal endoscopy data of OSA patients from 2017-2019, according to the OSA severity. Tubarão, 2020.
Regarding the PSG data there was a significant difference (p<0>
| Data | OSA Severety | N | Mean | SD | |
| Age (years) | |||||
| Mild (5 ≤ AHI < 15> | 25 | 38,36 a | 13,93 | ||
| Moderate (15 ≤ AHI< 30> | 22 | 42,09 | 16,71 | ||
| Severe (AHI ≥30) | 34 | 47,82 | 13,46 | ||
| Total | 81 | 43,34 | 14,93 | ||
| Obstructive episodes per hour of sleep | |||||
| Mild (5 ≤ AHI < 15> | 25 | 11,14 a, b | 4,65 | ||
| Moderate (15 ≤ AHI< 30> | 22 | 25,11 c | 7,75 | ||
| Severe (AHI ≥30) | 34 | 58,30 | 21,31 | ||
| Total | 81 | 34,73 | 25,40 | ||
| Lowest Blood Oxygen Saturation (%) | |||||
| Mild (5 ≤ AHI < 15> | 25 | 89,12 b | 4,76 | ||
| Moderate (15 ≤ AHI< 30> | 22 | 85,22 c | 4,61 | ||
| Severe (AHI ≥30) | 34 | 78,29 | 8,33 | ||
| Total | 81 | 83,52 | 7,95 | ||
| N1 (%) | |||||
| Mild (5 ≤ AHI < 15> | 25 | 7,10 a | 5,67 | ||
| Moderate (15 ≤ AHI< 30> | 22 | 9,80 | 10,84 | ||
| Severe (AHI ≥30) | 34 | 13,87 | 12,36 | ||
| Total | 81 | 10,67 | 10,59 | ||
| N2 (%) | |||||
| Mild (5 ≤ AHI < 15> | 25 | 50,84 | 11,67 | ||
| Moderate (15 ≤ AHI< 30> | 22 | 52,81 | 9,63 | ||
| Severe (AHI ≥30) | 34 | 52,67 | 12,26 | ||
| Total | 81 | 52,14 | 11,32 | ||
| N3 (%) | |||||
| Mild (5 ≤ AHI < 15> | 25 | 20,38 | 10,26 | ||
| Moderate (15 ≤ AHI< 30> | 22 | 21,55 | 10,56 | ||
| Severe (AHI ≥30) | 34 | 15,62 | 10,32 | ||
| Total | 81 | 18,70 | 10,58 | ||
| REM Sleep (%) | |||||
| Mild (5 ≤ AHI < 15> | 25 | 21,67 a | 7,03 | ||
| Moderate (15 ≤ AHI< 30> | 22 | 18,09 | 6059 | ||
| Severe (AHI ≥30) | 34 | 16,95 | 6,88 | ||
| Total | 81 | 18,72 | 7,06 | ||
Note: N: absolute number; *: related to the analysis of variance test (ANOVA); a: statistically significant difference (p<0>b: statistically significant difference (p<0>c: statistically significant difference (p<0>
Table 2: Description of the number, mean, standard deviation and significance level of and sociodemographic and Polysomnography data according to OSA severity (AHI). Tubarão, 2021.
The average time obtained for sleep stage 1 non-REM (N1) was 10.67% of total sleep, with a statistically significant difference (p<0>
There was a positive correlation between obstructive episodes and age (p<0>
Age (N) | Obs. Eps. (N) | Low. Sat. (%) | N1 (%.) | N2 (%) | N3 (%) | REM (%) | |
| Age | 1 | ||||||
| Obs. Eps. | 0,2601* | 1 | |||||
| Low. Sat. | -0,3577** | -0,6382*** | 1 | ||||
| N1 | 0,1634 | 0,4495*** | -0,2069 | 1 | |||
| N2 | -0,2205* | 0,1427 | -0,1772 | -,01248 | 1 | ||
| N3 | -0,0408 | -0,4336** | 0,2575* | -0,3474* | -0,6591*** | 1 | |
| REM | -0,0802 | -0,3041** | 0,1375 | -0,3902** | -0,2251* | -0,0025 | 1 |
Note: N: absolute number; Obs. Eps.: Number of Obstructive Episodes per hour of sleep; Low. Sat: Lowest Blood Oxygen Saturation; N1: stage 1 non-REM sleep; N2: stage 2 non-REM sleep; N3: stage 3 non-REM sleep; REM: REM sleep; Significance level: * p<0>** p<0> *** p<0>
Table 3: Pearson's linear correlation coefficient with sociodemographic variables and PSG data. Tubarão, 2021.
Figure 1, Inverse (-0.6382) and statistically significant (p<0>
Structural alterations in the UA are an important factor in the pathophysiology of OSA. An increase in resistance to the passage of airflow through the nasal cavity leads to a decrease in intraluminal pressure and collapse of pharyngeal tissues, causing respiratory disorders, including sleep apnea [8]. Our hypothesis would be that from an endoscopic evaluation, the appearance of lesions characteristics could identify patients at higher risk for OSA. The present study identified the alterations in the FNE exam in OSA patients, but there was no correlation between the findings and OSA severity.
The literature reports that the presence of nasal alterations is highly prevalent in patients with OSA [14]. Even though, smilar studies also showed no statistical significance between the presence of OSA and structural pathologies of the nasal cavity [15,16]. A systematic review carried out in 202017 showed in most of the analyzed studies that the presence of nasal obstruction was not related to the AHI. The main hypothesis is that nasal obstruction does not lead to a complete obstruction of the upper airways, but increases the negative intrathoracic pressure and causes sleep fragmentation, altering its quality without interfering with the AHI [16].
The use of MM is still controversial in the scientific community regarding the prediction of OSA severity [18]. The present study did not find statistical relevance between the findings during MM (degree of obstruction, elliptical and circular narrowing) and the AHI, as well as Suresh RK et al, 2015 [10]. Other studies have shown a correlation between elliptical pharyngeal narrowing and apnea severity [19,20]. MM, in awake patients, is a good instrument to identify the degree of obstruction during sleep, but it did not present a significant relation with the AHI.
Among the risk factors for the progress of OSA, age is of great importance. In our study, there was a positive correlation between increasing age and apnea severity. Other studies that evaluated the prevalence of OSA in the population also showed a direct relation between age and the AHI [3, 21-23]. It is directly related to the presence of other risk factors, such as obesity, neck circumference and with decreased activity of the pharyngeal dilator muscles, promoting the worsening of OSA [8].
Furthermore, an inverse association was found between age and the SpO2 obtained in the PSG exam. Other studies that evaluated polysomnographic data also found this correlation [3,21,23]. This finding corroborates the previous data that shows a direct relation between age and AHI, showing that the older the age, the greater the number of obstructive events and, consequently, the lower the blood oxygen saturation.
The decline in SpO2 causes numerous micro-awakenings that alter the sleep architecture and lead to consequences such as excessive daytime sleepiness, morning headaches, sexual impotence, personality changes such as irritability and depression. It is also associated with cardiovascular risks, such as increased blood pressure, increased risk of acute myocardial infarction, stroke and cardiac arrhythmias [24]. In our study, it was possible to observe a strong negative correlation between obstructive episodes and blood saturation. The literature presents similar data [21,23].
Regarding sleep stages, patients with severe OSA had a longer duration of N1 sleep than patients with mild OSA. Other studies have shown data that are similar to our results [21,23]. This shows a direct relation between the severity of apnea and the duration of N1, which can be justified by the recurrent micro-arousals caused by periods of apnea with a drop in SpO2. These events make it difficult to maintain sleep, and hinder the evolution to deeper stages, increasing the latency time of the initial sleep stages.
As for the REM sleep, it was observed that the group with severe OSA presented a lower percentage than the group with mild OSA. Other studies have also found this relation between a reduction in the REM sleep percentage and OSA severity [21,23]. The normal percentage of REM sleep range from 20-25 % [25] of total sleep, while in our study severe OSA group only reached 16,95%, which shows the influence of OSA on sleep architecture. This reduction in the REM sleep, increases the risks for the development of dementia and harms the cognitive processes of learning, memory and creativity [26].
Our study only explored the relation between sex and age in patients with OSA. To a better understanding of socio-demographic factors influence on OSA, we suggest carrying out studies with the inclusion of other known risk factors under study. As for the alterations in the FNE exam, we believe that a larger sample and the presence of a control group would increase the degree of reliability of the study.
The present study did not find a relation between alterations in the FNE exam and the severity of OSA. However, upper airway obstruction is an important element in the pathogenesis of OSA and should be investigated in patients complaining of obstructive sleep disorders.
OSA plays an important role in the distribution of sleep stages. Its gravity intervenes directly in the sleep architecture, increasing the time spent in superficial stages and hindering the evolution to deeper stages of sleep. And yet, causing metabolic, neurological and behavioural changes that significantly reduce the quality and life expectancy of patients.
There is no conflict of interest.
No founding sources.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
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!
"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".
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.
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.
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.
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.
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.
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.
“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”.
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.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
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.
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.
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.
