AUCTORES
Globalize your Research
Research Article | DOI: https://doi.org/10.31579/2578-8868/184
*Corresponding Author: Wengui Yu, Department of Neurology, University of California, Irvine, CA, USA
Citation: Shimeng Liu, Zhu Zhu, Mohammad Shafie, Hermelinda Abcede, Jay Shah, Shuichi Suzuki, Li-Mei Lin, Kiarash Golshani, Dana Stradling, Wengui Yu., (2021) Ongoing Improvement in Acute Ischemic Stroke Therapy Per Concurrent Guidelines and Easily Implementable Quality Improvement Protocol. J. Neuroscience and Neurological Surgery. 9(1); DOI:10.31579/2578-8868/184
Copyright: © 2021 Wengui Yu, 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: 03 May 2021 | Accepted: 20 May 2021 | Published: 27 May 2021
Keywords: acute ischemic stroke; benchmarks; endovascular thrombectomy; intravenous thrombolysis; outcomes; quality improvement
Background: Despite proven efficacy of intravenous tissue plasminogen activator (tPA) and endovascular thrombectomy (EVT) in acute ischemic stroke, there has been slow administration of these therapies in the real world practice. We examined the ongoing quality improvement in acute stroke care at our comprehensive stroke center.
Methods: Consecutive patients with acute ischemic stroke from 2013 to 2018 were studied. Patients were managed using Code Stroke algorithm per concurrent AHA guidelines and a simple quality improvement protocol implemented in 2015. Demographics and clinical data were collected from Get-With-The-Guideline-Stroke registry and electronic medical records. Patients were divided into 3 groups per admission and implementation date of quality improvement initiatives. Quality measures, including rates of intravenous tPA and EVT, door-to-needle (DTN) time, and door-to-puncture (DTP) time, were analyzed with general mean linear regression models and Jonckheere-Terpstra test.
Results: Of the 1,369 eligible patients presenting within 24 hours of symptom onset or wakeup stroke, the rate of intravenous tPA was 20%, 30% and 22%, respectively, in 2013-2014, 2015-2016, and 2017-2018. In contrast, EVT rate was 9%, 14% and 15%, respectively. Based on Jonckheere-Terpstra test, there was significant ongoing improvement in the median DTN time (57, 45, 39 minutes; p < 0.001) and DTP time (172, 130, 114 minutes; p =0.009) during the 3 time periods, with DTN time ≤
60 and ≤
45 minutes in 80% and 63% patients, respectively, in 2017-2018.
Conclusions: Getting with the guidelines and simple quality improvement initiatives are associated with satisfactory rates of acute stroke therapy and ongoing improvement in door to treatment times.
Running Title：Recurrent Hemorrhagic Transformations
Stroke is the 5th cause of death and a leading cause of long-term disability in the United States [1,2]. Intravenous thrombolysis with tissue plasminogen activator (tPA) is the only proven medical therapy for acute ischemic stroke (AIS) within 4.5 hours of symptoms onset [3, 4]. The benefit of tPA is time-dependent, with better outcome from earlier treatment [5, 6]. In patients with AIS from large vessel occlusion (LVO), endovascular thrombectomy (EVT) within 6 to 24 hours of last-known-well (LKW) has become the standard of care since 2015 [2,7-13]. EVT is also time sensitive. Every 1-hour delay from LKW to arterial puncture was associated with more severe disability [14].
The American Heart Association (AHA)’s Get With the Guidelines (GWTG)-Stroke programme was established in 2003 to collect data on patient characteristics, hospital adherence to guidelines and inpatient outcomes [15]. For time-sensitive quality measures in stroke care, American Heart Association /American Stroke Association (AHA/ASA) launched the Target: Stroke initiative in January 2010 [16]. Two years later, the Joint Commission started comprehensive stroke center (CSC) certification [17]. Despite these initiatives, only 50% of AIS patients registered in GWTG-Stroke from October 2012 to April 2015 received intravenous tPA within 60 minutes of emergency room arrival [18].
In a study of patients treated at 134 CSCs and 1047 primary stroke centers (PSCs) in the United States from 2013 to 2015, the median door-to-needle (DNT) times were 52 and 61 minutes, respectively [19]. The rate of intravenous tPA was 14.3% at CSCs and 10.3% at PSCs, while the EVT rate was only 4.1% at CSCs and 1.0% at PSCs, respectively [19]. In a most recent study, Menon et al. analyzed data from 195 CSCs and identified 2929 patients treated with EVT from October 2014 to September 2016. The median annual EVT volume per center was 16 and the median door to first pass time was 130 minutes [20].
Benchmarking is critical for quality improvement in stroke care. Our stroke center received CSC certification in 2013 and implemented a simple quality improvement protocol in January 2015 [21]. The aim of this study was to investigate the evolution of stroke care and ongoing improvement in quality indicators since CSC certification.
Consecutive patients with AIS admitted at a 417-bed comprehensive stroke center in California, USA, from January 1, 2013 to December 31, 2018 were included in the study. The patient list was generated from the prospectively maintained AHA/ASA GWTG-Stroke Registry at our hospital. The registry uses a web-based patient management tool to collect clinical data on consecutively admitted patients, to provide decision support, and to enable real-time online reporting [22]. Patients with TIA, stroke mimics, subacute stroke, inpatient stroke and brain hemorrhage were excluded. Patients who were transferred from outside facilities were also excluded. The screening flow chart for eligible patients is shown in Figure 1.
From January 1, 2013 to December 31, 2018, 1759 patients were admitted to the medical center for acute ischemic stroke AIS. After excluding ineligible patients (n=390), 1369 patients were included in final analysis.
All patients were managed by the emergency department (ED) and stroke team using standard ED code stroke algorithm per concurrent AHA guidelines (Figure 2).
A simple quality improvement protocol was implemented in January 2015 to minimize delays in DTN time for tPA as previously described [21]. It allowed stroke team to treat hypertension in the emergency room to keep blood pressure (BP) < 185/110 mmHg, to give tPA before getting blood test results unless patients were taking anticoagulants, and to give tPA in the CT scan suite. To continuously improve stroke care, we update our ED Code Stroke Algorithm and order sets annually per guidelines and advances in the field. In addition, we have a weekly stroke quality improvement committee meeting and case conferences to review every stroke admission for ongoing quality improvement.
The following data, including patient demographics, co-morbidities, National Institutes of Health Stroke Scale (NIHSS), BP, LKW-to-door time, door-to-imaging time, DTN time for tPA, door-to-puncture (DTP) time for EVT, symptomatic intracranial hemorrhage (sICH), length-of-stay (LOS) in the Intensive Care Unit (ICU) or hospital, and modified Rankin Scale (mRS) at hospital discharge, were collected from the registry and electronic medical record by experienced neurologists.[21] Laboratory results, including comprehensive metabolic panel, fasting lipid profile, and glycol-hemoglobin A1c (HbA1c), were also collected. sICH was defined as intraparenchymal hematoma, subarachnoid hemorrhage, or intraventricular hemorrhage associated with a worsening of the NIHSS score by ≥ 4 points within 24 h of tPA and/or EVT [5]. A mRS score of 0-3 at discharge was defined as favorable outcome. NIHSS, sICH and mRS were estimated by the stroke team. Uncertain cases or disagreement were adjudicated by experienced neurologists.
To investigate the ongoing quality improvement in acute stroke therapy, patients were categorized into three groups according to admission and implementation date of quality improvement initiatives [16-21]: January 1, 2013 to December 31, 2014; January 1, 2015 to December 31, 2016; and January 1, 2017 to December 31, 2018. Time sensitive-quality indicators, including LKW-to door time, DTI time, DTN time, DTP time, rates of tPA and EVT, sICH rate, LOS in the ICU and hospital, and functional outcome at hospital discharge, were analyzed and compared among the three time periods.
Statistical analysis
Categorical variables were expressed as frequencies and percentages (%), and continuous variables as median and interquartile range (IQR). General linear means regression models and Jonckheere-Terpstra test were used to assess the estimated difference of continuous variables. Univariate logistic regression analysis was performed to test the crude ORs (95% CI) of quality benchmarks between groups. Multivariate logistic regression models were performed to determine the adjusted ORs (95% CI) of favorable outcomes (mRS score 0-3) at hospital discharge, in association with the admission time. In the multivariate models, we adjusted age, initial NIHSS scores, and DTN time to exclude the potential confounding factors. The SAS statistical software (version 9.4; SAS Institute, Cary, NC, USA) was used to perform the data analysis.
From January 1, 2013 to December 31, 2018, 1,759 patients were admitted to the medical center for AIS within 24 hours of symptom onset or wakeup stroke. During the initial screening, 390 patients were excluded from the study for the following reasons (Figure 1): 1). 274 patients were transferred from outside hospitals for higher level of care, including 58 treated with intravenous tPA at outside facilities; 2). 78 patients were inpatient consultations for suspected ischemic stroke; 3). 25 patients presented with subacute infarction that was confirmed by brain imaging, 4). 12 patients were outliners for LOS (≥ 28 days) and discharge outcome due to insurance issue; and 5). 1 patient left hospital against medical advice.
A total of 1,369 patients were included in the final analysis. Of note, 53 patients had 2 admissions, 3 patients had 3 admissions, and 1 patient had 4 admissions during the study period. The median age and interquartile range (IQR) of the patients was 71 (24). There were 755 men and 614 women. There were 52% White, 23% Asian, 18% Hispanic, 2% American African, and 5% other ethnic patient population. Of the entire cohort, 71% listed English as primary language, 16% spoke Spanish, and 12% spoke other languages. The most common past medical histories were hypertension (71%), diabetes mellitus (36%), and hyperlipidemia (39%). The baseline demographics and clinical data of the 3 groups were shown in Table 1.
There were no significant differences among the 3 groups in age, gender, race, preferred language, major co-morbidities, initial BP, NIHSS scores, LDL and Hb A1c levels.
Ongoing improvement in treatment rate and quality benchmarks
A total of 328 patients received intravenous tPA in the cohort (Table 2).
The tPA rate was 20%, 30% and 22% in 2013-2014, 2015-2016, and 2017-2018, respectively (Table 2). In the crude logistic regression model, tPA rate was significantly higher in 2015-2016 than that in 2013-2014 (OR, 1.77; 95% CI, 1.30-2.40; p = 0.0003). There was no significant difference in tPA rate between 2017-2018 and 2013-2014 (OR: 1.17; 95% CI: 0.85-1.61; p = 0.33). There was no significant difference in DTI time among the 3 time periods. However, there was significant ongoing improvement in median DTN time (57, 45, and 39 minutes, respectively) during the 3 groups per trend analysis, with DTN time 60, 45 and 30 minutes in 80%, 63% and 30% of patients, respectively, during 2017-2018. There was no significant difference in sICH rate, LOS in the ICU or hospital, and mortality at hospital discharge among the 3 groups. Of note, significantly more patients had favorable outcomes (mRS score 0-3) at hospital discharge in 2015-2016 than in 2013-2014. There was no difference between 2013-2014 and 2017-2018. (Table 2)
A total of 167 patients received EVT with or without intravenous tPA. The rate of EVT was 9%, 14% and 15%, respectively, during the 3 time periods. Significantly more patients were treated with EVT in 2015-2016 (OR, 1.70; 95% CI, 1.11 - 2.59; p = 0.01) and 2017-2018 (OR, 1.77; 95% CI, 1.16 - 2.68; p = 0.008) than in 2013-2014, due to acceptance of EVT as standard of care for patients with AIS from LVO in 2015.
There was also continual improvement in median DTP time (172, 130, 114 minutes) during the 3 time periods per trend analysis with Jonckheere-Terpstra test. There was no significant difference in sICH rate, LOS in the ICU and Hospital, or favorable outcome among the 3 groups. There appeared to be a trend of decreased mortality rate at hospital discharge during the 3 time periods. The overall rates of sICH and mortality after EVT were 2.4% and 16%, respectively.
Multivariate logistic regression analysis of favorable outcomes with Wald Model
To examine the predictor of favorable outcomes after intravenous tPA, we performed a multivariate logistic regression model with Wald Chi-Square test (Table 3). After adjusting for age, NIHSS scores and DTN time, age and initial NIHSS were independently associated with favorable outcomes at hospital discharge.
We have reduced the median DTP times from 172 minutes in 2013-2014 to 114 minutes in 2017-2018. The results were similar to the reported 130-145 minutes at the CSCs registered in GWTG-Stroke program [19, 20], but very suboptimal compared to the median 47 minutes reported at high-volume center with standardized protocol and conscious sedation for EVT [23]. Of note, DTP times were reduced to 17 - 20.5 minutes when the patients were directly transferred from ED to angiography suite [24, 25].
The median annual EVT volume per CSC in the United States was 16 (IQR, 10–27) [20].That was only slightly more than one EVT a month. Each 5-case increase in EVT volume per year was found to be associated with a 3% shorter door to first pass time, up to a case volume of 40 per year (P<0.001) [20]. Currently, only a minority of CSCs in the United States are providing EVT to > 40 patients per year partly due to very lenient criteria for CSC certification [17]. EVT is a labor-intensive procedure that requires a coordinated effort among numerous healthcare providers and timely access to angiography facilities. In addition to the Code Stroke team 24/7 in house, patients may also need intubation for the procedure, timely transport to the angiography suite, anesthesiologist, angiography suite nurses and technicians [24, 26]. Overnight and weekends pose additional challenges. Due to low EVT volume, it is financially impossible for individual CSC to implement rapid EVT protocol that requires the entire stroke team to be brought in for each possible code stroke [23].
Currently, three strategies, including transporting patients directly from emergency medical services to the CT scanner, conscious sedation, and transferring patients with suspected LVO from ER to angiography suite directly, were reported to have large independent effect on reducing door to treatment times [23-26].
Of note, significantly more patients were treated with iv tPA at our center in 2015- 2016 due to the implementation of a simple quality improvement initiative in January of 2015 [20]. However, the release of the PRISMS Trial results at the International Stroke Conference in January of 2018 led to decreased treatment of minor non-disabling stroke with tPA at our center in 2017-2018. PRISMS is a randomized trial of tPA versus aspirin for patients with minor nondisabling stroke (NIHSS 1-5). The primary outcome was minimal or no neurologic deficit (mRS 0–1) at 90 days. The study was stopped early, after enrollment of 313 patients with median NIHSS 2 and median DTN time 2.7 hours. There was no significant difference in functional outcome at 90 days (81.5% in the aspirin group and 78.2% of patients in the tPA group). Thrombolysis showed no benefit even after exclusion of stroke mimics. sICH rate was 3.2% with tPA and 0% with aspirin [28].
Our study has many limitations. First, this is a single center retrospective study. The data were collected from GWTG-Stroke Registry and chart review. There could be data collection bias. Second, there was no long-term follow up information. However, benchmarking is essential for continuous quality improvement in stroke care. To further improve the door to treatment times, we plan to implement new initiatives on transporting patients directly from emergency medical services to the CT scanner, conscious sedation, and transferring patients with suspected LVO from ER to angiography suite. We will also start long-term outpatient follow-up on all patients after hospital discharge.
We demonstrated satisfactory rates of acute stroke treatment and ongoing improvement in door to treatment times at our CSC. Our findings suggest that implementation of concurrent AHA guidelines and new quality improvement initiatives are essential for continuous quality improvement in acute stroke care.
Ethics approval and consent to participate: The study was approved by the Institutional Review Board (IRB) at University of California Irvine Comprehensive Stroke Center. No identifiable information was indicated in the retrospective database-based study, so informed consent was not applicable.
Consent for publication: Not applicable.
Competing interests: Dr. Yu has received compensation for activities with Stryker and Amgen as a scientific consultant. However, the activities are not related to this research project. Other authors have nothing to disclose.
Funding: None.
Authors' contributions: Concept and design: Liu, Yu. Acquisition, analysis, and interpretation of the data, Liu, Zhu, Stradling, Yu. Drafting of the manuscript: Liu. Critical revision of the manuscript for important intellectual content: Zhu, Shafie, Abcede, Shah, Suzuki, Li, Golsahni, Yu. Statistical analysis: Liu, Zhu, and Yu
Acknowledgements: We appreciate the support from the University of California Irvine Xiaoqi Cheng & Dongmei Liao International Stroke Research Scholarship.
Availability of data and materials: Dr. Yu has full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
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.
