AUCTORES
Globalize your Research
Case report | DOI: https://doi.org/10.31579/2640-1045/138
1 Third year Resident Doctor,Dept. Of Medicine, S.S.G Hospital, Medical College Baroda, Vadodara, Gujarat, India
2 Intern Doctor, Dept. Of Medicine, S.S.G Hospital, Medical College Baroda, Vadodara, Gujarat, India
3 Associate Professor, Dept. Of Medicine, S.S.G Hospital, Medical College Baroda, Vadodara, Gujarat, India
4 Third year Resident Doctor, Dept. Of Medicine, S.S.G Hospital, Medical College Baroda, Vadodara, Gujarat, India
5 Undergraduate, Final Year MBBS, Dept. Of Medicine, S.S.G Hospital, Medical College Baroda, Vadodara, Gujarat, India
6 Dept. Of Medicine, S.S.G Hospital, Medical College Baroda, Vadodara, Gujarat, India
7 Dept. Of Medicine, S.S.G Hospital, Medical College Baroda, Vadodara, Gujarat, India
*Corresponding Author: Karan Jaykrushna Pandya, Third year Resident Doctor, Dept. Of Medicine, S.S.G Hospital, Medical College Baroda, Vadodara, Gujarat, India.
Citation: Karan Pandya, Parth Adrejiya, Jaya Pathak, Radhay Parikh, Bansari Parmar, Meghal Varma, Jugal A. Parikh (2023) “Late Presentation of Bartter Syndrome as Refractory Hypokalemia, J. Endocrinology and Disorders. 7(4): DOI:10.31579/2640-1045/138
Copyright: © 2023, Karan Jaykrushna Pandya. 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: 17 May 2023 | Accepted: 31 May 2023 | Published: 29 June 2023
Keywords: sporadic; inherited genetic; limb; nephron; hypokalemia
Bartter syndrome is a rare salt-wasting nephropathy characterized by sporadic or inherited genetic defects in transporters and channels in the thick ascending limb of the loop of Henle and distal tubule of Nephron leads to renal potassium wasting with hypokalemia, metabolic alkalosis, increased renin-angiotensin-aldosterone system, normal blood pressure. Most of the cases have been noted in the pediatric age group and adult-onset cases are very rare. Here we report an unusual case report of Bartter's syndrome in a 52 years old male patient.
Background:
Hypokalemia is a common electrolyte derangement in approximately 20% of hospitalized patients and 2-3% of patients in outpatient clinics. Many diseases alter the equilibrium of K+ between the Extracellular compartment and intracellular spaces by causing excess K+ loss, sequestration inside cells, or under influence of hormones, or drugs. Hence, it is more common to find hypokalemia as a single episode in such cases. Treatment of the disease and K+ correction will help to achieve normal homeostasis. However, unusual is to find cases of recurrent hypokalemia where despite treatment of predisposing factor & K+ correction, hypokalemia persists and episodes recur. These are relatively uncommon incidences that not only pose diagnostic challenges but also increase morbidity and mortality due to life-threatening cardiac conduction disturbances and neuromuscular dysfunction hence appropriate emergency management and diagnosis and treatment of underlying etiology becomes very important.
Bartter et al. in 1962 described a clinical syndrome characterized by hypokalemia, metabolic acidosis, hyperreninemia, hyperaldosteronism, normal blood pressure, and resistance to the pressor effects of norepinephrine and angiotensin ll. Histologically, there is hyperplasia of the juxtaglomerular cell. It occurs mostly in childhood or adolescence, and initial presentation over 40 years of age was very rare.
This case report is highlighting the diagnostic approach and management of the rare causes of recurrent hypokalemia in an older aged male with persistent hypokalemia, metabolic alkalosis, normotension, hyperreninemia, and hyperaldosteronism eventually diagnosed with Bartter's syndrome.
A 52-year-old male presented to the SSG hospital complaining of acute onset of weakness in both lower limbs in the form of not being able to get up from the bed and walk for one day. It is non-progressive and symmetric in both limbs and no such complaints in the upper limbs. Additionally, there were no complaints of breathlessness, speech, deglutition, or urinary or bowel incontinence. There were no complaints of paresthesia or impaired sensations in the lower limbs and upper limbs. There was no history of trauma, backache, vomiting, diarrhea, fever, or headache. There was no previous history of stroke and no known case of hypertension and diabetes mellitus, no chronic prescription use (like Thiazide or Loop diuretics, theophylline, chloroquine). Looking at previous medical history, we found that the patient had 7-8 similar episodes of recurrent weakness in all limbs over 2 years.
Out of which 2 episodes were precipitated following diarrhea and vomiting and the symptoms resolved with the administration of intravenous fluids. Periodic follow-up with Serum K+ levels reveal persistent hypokalemia. No family history of such symptoms was elicited. An initial general examination was done which revealed intact sensorium, normal body temperature, pulse was 80 beats per minute (bpm) with normal characteristics, respiration was 14/min and regular, Blood pressure was 100/78 mmHg, RBS:104mg/dl. Central nervous system examination showed intact higher functions, no abnormalities in cranial nerves, and reactive pupils. Upper limb nervous system examinations were normal. There was hypotonia, and power was 2/5 in both lower limbs, absent deep tendon reflexes, and flexor plantar response. Cerebellar examinations were normal. Sensory examination in all four limbs was normal.
Cardiovascular, Gastrointestinal, and Respiratory system examinations were normal and yielded no diagnostic clues. Initial history and examination implied acute flaccid areflexic motor paralysis mostly likely due to electrolyte imbalance.
Initial investigations were done. The results were as follows:
| Tests | Reported Values | Reference Values |
| Hemoglobin | 13.3 g/dL | 13.2 – 16.6 g/dL |
| RBC Count | 4.64 million/mm3 | 4.0-5.9 million/mm3 |
| WBC Count | 8,510/mm3 | 4,500 – 11,000/mm3 |
| Platelet count | 3,23,000/mm3 | 2,50,000 – 3,50,000/mm3 |
| Serum Potassium | 1.5 mEq/L | 3.5 – 5.5 mEq/L |
| Serum Sodium | 126 mEq/L | 135 – 145 mEq/L |
| Serum Creatinine | 1.30 mg/dL | 0.74 – 1.35 mg/dL |
Table 1: Preliminary Laboratory Investigations
Immediately, Electrocardiogram (ECG) was done. ECG revealed PR prolongation and T-wave flattening. Despite the symptomatic improvement of flaccid paralysis after intravenous potassium correction, K+ values were low (2.5 mEq/L) after 2 days. This along with past clinical history, Serum Sodium, Urine K+, TTKG (Trans tubular potassium gradient), S. Mg2+, ionized and normal calcium were done for further evaluation of persistent hypokalemia. TTKG was 20.53 (normal value 8-9) suggesting renal potassium wasting. Serum sodium was 126 mEq/L, serum magnesium (2.20 mg/dL), total calcium was 5.0mEq/l and ionized calcium was 2.0mEq/L. Urinary K+ excretion could be falsely low in a spot sample, so the Urine K+/Creatinine ratio was done. This ratio (816.8mEq/gm Creatinine) was significantly higher (indicating renal K+ wasting) in this patient. 24 hours urinary excretion of potassium was 70 mEq, sodium 185 mEq, chloride 248 mEq, calcium 120 mg, protein 150 mg, glucose 40 mg/dl, and urine amounts 2500cc. Serum osmolarity was reduced(257mOsmol/kg) while urine osmolarity was 116mOsmol/kg (hypoosmolar urine). On further evaluation, Arterial Blood Gas analysis was done which showed Metabolic alkalosis (pH: 7.541) with high normal serum Bicarbonate levels (30.8 mEq/L). This along with normal Blood pressure excludes mineralocorticoid excess and Metabolic acidosis. There was no proteinuria, hematuria, or abnormality of urinary sediment. The plasma renin activity was 48.1 ng/ml/hr and the aldosterone level was 34.3 ng/dl.
Looking at the clinical history, examination, and lab investigation of persistent hypokalemia with high TTKG, normotension, metabolic alkalosis, normocalciuria, normal magnesia, high renin, and aldosterone activity with no use of laxatives or any diuretics would suggest the presence of Bartter's syndrome (BS). Thus, it was a very unusual case of BS with late onset of presentation. Investigations to look for coexisting complications and systemic defects were carried out. USG of the kidney, ureter, and Urinary bladder to look for nephrocalcinosis and audiometric testing to exclude Sensorineural Hearing Loss (SNHL) was done. No SNHL and Nephrocalcinosis were noted. Thyroid function tests (TFTs) were within normal limits.
Outcome and follow-up:
Emergency management of severe hypokalemia was started with 2 large bore IV (intravenous) lines placed for fluid replacement and K+ correction was initiated. A total deficit of 400mEq/L was estimated which reflects a drop in serum from 3.5mEq/L to 1.5mEq/L. So, KCL diluted in Normal Saline at 40mEq/L concentration was administered at the rate of 40 mEq/hr intravenously under cardiac monitoring carefully. Response to therapy was assessed by improvement of symptoms and measuring S. K+ levels. Our patient showed rapid and complete reversal of symptoms over 48 hours.
So for bartter syndrome diagnosis patient had been treated with potassium chloride 40 mEq
twice daily, Spironolactone 50 mg two times a day, indomethacin 25 mg three times a day, and enalapril 2.5 mg day followed up with serum and urinary K+ as a marker for prognosis. On further follow-up every month for 6 months there was a normal range serum K+(3.5-4.5 mEq/L) with improved muscle strength and no further episode of acute limb paresis.
In most cases of neuromuscular weakness secondary to electrolyte imbalance etiology of hypokalemia can be derived from the clinical presentation and relevant history, and routine laboratory investigations. However, it poses a significant challenge in cases of recurrent episodic paresis with persistent hypokalemia when neither the history examination points to the diagnosis.
Our preliminary clinical examination and history ruled out GI (gastrointestinal) and Integumentary losses. There was no history of drug use, no previous history of DM, or hyperthyroidism and our investigations confirm the same (TFT is normal, RBS:104 mg/dl). Serum Magnesium levels were normal(2.2mg/dl) ruling out refractory hypokalemia.
This curtails the differential diagnosis of renal potassium wasting. Urinary potassium levels in a 24-hour urine sample can differentiate renal (>15 mmol/L or >15-20mmol/day) from extrarenal causes (<15>
Trans tubular potassium gradient (TTKG) is a superior marker of renal K+ wasting as compared to urinary potassium levels [3] a d also differentiates renal potassium wasting according to its pathophysiology [4]. TTKG (<2>4 indicates excess K+ secretion from the cortical collecting tubules). TTKG of our patient was 20.53.
Another marker Urinary K+/Cr ratio can be used to differentiate renal vs extrarenal loss and it especially becomes important since it's not affected by urine volume [2]. Studies by Lin C et al. [2] found this ratio effective in distinguishing renal potassium wasting from hypokalemic periodic paralysis (HPP).
HPP is an autosomal dominant ion channelopathy characterized by the transient intracellular shifting of K+ inside cells manifesting as periodic weakness in muscle groups. The urine K/Cr ratio is lower in extra renal disorder (HPP) and higher in Renal disorders. This is necessary before initiation of K+ correction because transient K+ shifts reverse following K+ replacement which increases the risk of rebound Hyperkalemia and its complication. Thus, it is necessary to differentiate HPP from Renal K+ wasting disorders. In our patient, this ratio was significantly higher (816.8mEq/gm Creatinine). This along with the absence of clinical findings and persistent hypokalemia in between attacks of weakness ruled out HPP.
Normal Blood pressure and normovolemia rule out high mineralocorticoid activity which can cause excess Renal K+ wasting from DCT. Further, ABG analysis revealed metabolic alkalosis which negates the possibility of hypokalemia due to Renal tubular acidosis (RTA). Metabolic alkalosis can be due to chronic diuretic use, Bartter's syndrome, Gitelman's syndrome, and GI loss (vomiting, diarrhea). There is no history of diuretic ingestion, negative GI complaints, and urinary chloride [5] (differentiate causes hypokalemia with metabolic alkalosis due to renal loss) excretion >20 mmol/L brings down the differential to Bartter's and Gitelman's syndrome which can be differentiated by Urinary Calcium excretion and serum magnesium levels. Normocalciuria and normal magnesium levels in our patient exclude Gitelman's syndrome.
Gitelman's syndrome typically presents in adolescence and late adulthood, and since our patient presented to us within this age group, this becomes an essential differential to Bartter syndrome. The clinical presentation of GS is similar to chronic thiazide ingestion and is milder in severity as compared to Bartter's syndrome [6].
Bartter syndrome-like presentation i.e Pseudo Bartter's syndrome had been reported with abuse of agents like laxatives, Furosemide, in eating disorders like Bulimia nervosa, Gentamicin nephrotoxicity, Sjogren's syndrome, and Cystic fibrosis. Since our patient lacked history and clinical features indicative of these causes.
In bartter's syndrome, the primary defect occurs in Sodium, Potassium Chloride cotransporter, or Potassium chloride in the thick ascending limb of the loop of Henle which results in increased delivery of solutes to the distal segment, where selective absorption of Na+ and excretion of K+ occurs. Traditionally Barter’s syndrome (BS) is sub-classified into five different categories based on genetic defects [7] which is
summarized in the table below:
| FEATURES | Type 1BS: | Type 2BS: | Type 3BS: | Typ e 4BS: | Type 5BS: | GS |
| Age of Presentation | Antenatal | Antenatal | <1year> | Antenatal /Infancy | Variable | Late childhood, Adulthood |
| Mode of Inheritance | AR | AR | AR | AR | AD | AR |
Involved Genes /Protein | KCN J1/ RO MK
| CLC NKB/ ClC- Kb, Distal tubular chloride channel | BSN D/ Bartt in, Chlo ride chan nel Beta subunit | CASR / Ca2+- Mg2+ sensing receptor | SLC12A 3/ NCCT | |
| Pregnancy | Polyhydramnios | Polyhydramnios | - | Poly hydr amnios, failure to thrive | - | - |
Electrolyte Imbalance
| Hypochloremic, hypokalemic alkalosis with high urinary Prostaglandins E2 | Hypochloremic, Hypokalemicalkalosiswith high Urinary Prostaglandins E2 | Hypo chloremic, hypokalemic alkalosis
| Hypochloremic, hypokalemicalkalosis
| Hypochl oremic, hypokale micalkalosis | |
| Serum K+ | Low | Low | Low | Low | Low | Low |
| Urine CA2+ | High | High | Norm al | High | High | Low |
| Serum MG2+ | Norm al | Nor mal | Normal/low | Normal | Low | |
| Nephrocalcinosis | Yes | Yes | No | No | Yes | No |
| Prematurity | Sensori neural hearing loss. |
Table 2: Differentiating features between Subtypes of Bartter Syndrome and Gitelman's Syndrome:
The therapeutic goal is to correct the K+ deficit and minimize ongoing losses through the treatment of underlying causes. Presently, there is no cure for BS and GS. Studies by Walsh et. al. [8] show that degree of hypokalemia (a marker of chronic K+ depletion) doesn’t correlate well with GFR. Ongoing sodium and water losses and consequent high renin-angiotensin aldosterone activation (RAAS) are responsible for chronic renal impairment. Therefore, blockade of aldosterone receptors to decrease the effects of RAAS or prostaglandin-kinin system will provide better renal protection than correcting hypokalemia per se. Hence, potassium supplementation, Spironolactone, ACE Inhibitors, and prostaglandin inhibitors are important treatment modalities.
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.
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.
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¨.
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.
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!”
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
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.
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.
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.
I would like to offer my testimony in the support. I have received through the peer review process and support the editorial office where they are to support young authors like me, encourage them to publish their work in your esteemed journals, and globalize and share knowledge globally. I really appreciate your journal, peer review, and editorial office.
Dear Agrippa Hilda- Editorial Coordinator of Journal of Neuroscience and Neurological Surgery, "The peer review process was very quick and of high quality, which can also be seen in the articles in the journal. The collaboration with the editorial office was very good."
I would like to express my sincere gratitude for the support and efficiency provided by the editorial office throughout the publication process of my article, “Delayed Vulvar Metastases from Rectal Carcinoma: A Case Report.” I greatly appreciate the assistance and guidance I received from your team, which made the entire process smooth and efficient. The peer review process was thorough and constructive, contributing to the overall quality of the final article. I am very grateful for the high level of professionalism and commitment shown by the editorial staff, and I look forward to maintaining a long-term collaboration with the International Journal of Clinical Case Reports and Reviews.
To Dear Erin Aust, I would like to express my heartfelt appreciation for the opportunity to have my work published in this esteemed journal. The entire publication process was smooth and well-organized, and I am extremely satisfied with the final result. The Editorial Team demonstrated the utmost professionalism, providing prompt and insightful feedback throughout the review process. Their clear communication and constructive suggestions were invaluable in enhancing my manuscript, and their meticulous attention to detail and dedication to quality are truly commendable. Additionally, the support from the Editorial Office was exceptional. From the initial submission to the final publication, I was guided through every step of the process with great care and professionalism. The team's responsiveness and assistance made the entire experience both easy and stress-free. I am also deeply impressed by the quality and reputation of the journal. It is an honor to have my research featured in such a respected publication, and I am confident that it will make a meaningful contribution to the field.
"I am grateful for the opportunity of contributing to [International Journal of Clinical Case Reports and Reviews] and for the rigorous review process that enhances the quality of research published in your esteemed journal. I sincerely appreciate the time and effort of your team who have dedicatedly helped me in improvising changes and modifying my manuscript. The insightful comments and constructive feedback provided have been invaluable in refining and strengthening my work".
I thank the ‘Journal of Clinical Research and Reports’ for accepting this article for publication. This is a rigorously peer reviewed journal which is on all major global scientific data bases. I note the review process was prompt, thorough and professionally critical. It gave us an insight into a number of important scientific/statistical issues. The review prompted us to review the relevant literature again and look at the limitations of the study. The peer reviewers were open, clear in the instructions and the editorial team was very prompt in their communication. This journal certainly publishes quality research articles. I would recommend the journal for any future publications.
Dear Jessica Magne, with gratitude for the joint work. Fast process of receiving and processing the submitted scientific materials in “Clinical Cardiology and Cardiovascular Interventions”. High level of competence of the editors with clear and correct recommendations and ideas for enriching the article.
We found the peer review process quick and positive in its input. The support from the editorial officer has been very agile, always with the intention of improving the article and taking into account our subsequent corrections.
My article, titled 'No Way Out of the Smartphone Epidemic Without Considering the Insights of Brain Research,' has been republished in the International Journal of Clinical Case Reports and Reviews. The review process was seamless and professional, with the editors being both friendly and supportive. I am deeply grateful for their efforts.
To Dear Erin Aust – Editorial Coordinator of Journal of General Medicine and Clinical Practice! I declare that I am absolutely satisfied with your work carried out with great competence in following the manuscript during the various stages from its receipt, during the revision process to the final acceptance for publication. Thank Prof. Elvira Farina
Dear Jessica, and the super professional team of the ‘Clinical Cardiology and Cardiovascular Interventions’ I am sincerely grateful to the coordinated work of the journal team for the no problem with the submission of my manuscript: “Cardiometabolic Disorders in A Pregnant Woman with Severe Preeclampsia on the Background of Morbid Obesity (Case Report).” The review process by 5 experts was fast, and the comments were professional, which made it more specific and academic, and the process of publication and presentation of the article was excellent. I recommend that my colleagues publish articles in this journal, and I am interested in further scientific cooperation. Sincerely and best wishes, Dr. Oleg Golyanovskiy.
Dear Ashley Rosa, Editorial Coordinator of the journal - Psychology and Mental Health Care. " The process of obtaining publication of my article in the Psychology and Mental Health Journal was positive in all areas. The peer review process resulted in a number of valuable comments, the editorial process was collaborative and timely, and the quality of this journal has been quickly noticed, resulting in alternative journals contacting me to publish with them." Warm regards, Susan Anne Smith, PhD. Australian Breastfeeding Association.
