AUCTORES
Globalize your Research
Case Report | DOI: https://doi.org/10.31579/2693-4779/193
*Corresponding Author: John S.M. Leung St. Paul’s Hospital, Hong Kong S.A.R., China.
Citation: John S.M. Leung St, (2024), Parsonage-Turner Syndrome following axillary nerve injury from an intramuscular injection of COVID-19 vaccine and proposal of the intradermal route as an alternative route of vaccination, Clinical Research and Clinical Trials, 10(1); DOI:10.31579/2693-4779/193
Copyright: © 2024, John S.M. Leung St. 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: 16 February 2024 | Accepted: 29 March 2024 | Published: 22 May 2024
Keywords: parsonage-turner syndrome; covid-19 vaccination; axillary nerve injury; intramuscular injection; intradermal injection
A case of Parsonage-Turner syndrome (brachial plexus neuropathy) occurred following intramuscular (IM) injection of mRNA COVID-19 vaccine into the deltoid muscle. The symptoms were highly suggestive of the needle hitting the anterior branch of the axillary (circumflex) nerve which set up a sequence of distressful events including instant severe pain and palsy of upper limb muscles lasting up to six months. To avoid such adverse events, the intradermal (ID) route is proposed as an alternative to IM injection as no nerve runs in the skin. Review of studies showed that the ID route is the most extensively used route in vaccination. With rare exceptions, it is considerably more effective than the IM route so that smaller doses can be used. When correctly placed in the skin layer, no other structure could be damaged. However, vaccine development is no longer led by physicians and scientists but controlled by pharmaceutical executives who tend to favor the IM route, so that most vaccines today are built on IM trials. Deviation to the ID route incurs extra trials, more expenses and less profit. Yet, to ignore the plight of the unfortunate few who suffer from IM-induced debilitating events is to add fuel to the ongoing trend of vaccine hesitancy. It is hoped, that the authorities should step in and lend support to this issue.
One of the fundamental principles to control an epidemic is to enhance the population’s immunity, and one of the most effective ways to enhance immunity is vaccination. A vaccine would only work if it is widely accepted in the community and its acceptance has to be gained not only by proven efficacy but also reassured safety. Such confidence is often won not by a one-off roll-out promotion from the producer but by continuous fine-tuning adjustments on the formulation and methodology of administration. In such ways, many epidemics have been brought under control. For the current on-going COVID-19 pandemic we seem to have encountered a different trend of events. In spite of much hyped rhetoric, that the new vaccines were developed with unprecedented speed using unprecedented technology we also encountered unprecedented vaccine hesitancy. To be sure, vaccine hesitancy always happened but usually could be resolved by further research and refinement. This time, such hesitancy seems to have been summarily brushed off as paranoid phobia of statistically insignificant issues. It is the purpose of this study to report on a rare and “statistically insignificant” but extremely traumatizing adverse event following an intramuscular injection (IM) of mRNA COVID-19 vaccine, and to propose a simple and effective method to avoid such complications and win back the confidence of the potential vaccine recipients.
A 23-year-old young man of rather slim stature (BMI 17.73 Kg/M2) received his first dose of IM mRNA COVID-19 vaccine in his right deltoid muscle during the summer of 2021. During the injection he instantly felt excruciating pain over the right shoulder. Over the next few hours, the pain receded to just bearable levels but marked weakness and tenderness was noticed in the right upper limb. Being left-handed, he was able to carry on most daily activities. Remarkably, he was soon able to use his right fingers on the computer keyboard, but the proximal muscles of the right arm remained very weak, to the extent that he could not lift a pile of files with both hands, a handicap which markedly compromised his career which mainly involved clerical work. The pain largely eased off after one month but the palsy relentlessly persisted. Assessment by a neurologist confirmed severe brachial plexus neuropathy or neuralgic amyotrophy, often labelled with the eponym of Parsonage-Turner syndrome (PTS) in honor of the two physicians who first reported a large series of the disorder.1 He was advised to maintain an active living within the limits of his disabilities and patiently wait for a spontaneous recovery. Review at six months showed almost complete recovery with minimal residual muscle weakness. By that time, however, he had lost his job and, given the recession during the pandemic, was unable to get another employment.
Parsonage-Turner syndrome may be idiopathic or due to trauma, inflammation, autoimmune reaction or vaccination.2 The sudden sharp pain and palsy during the IM injection is strongly suggestive of a nerve trunk being hit by the needle with the vaccine ingredients delivered into the nerve, or its close vicinity.3 By location, the nerve involved would have been the anterior branch of the axillary nerve, also known as the circumflex nerve, which comes from the brachial plexus and runs deep under the deltoid muscle, passing round the neck of the humerus, and supplying both the deltoid and the shoulder joint. The vaccine contents might tract along the nerve and spread to the joint and the muscle as well as upstream back to the brachial plexus. The risk would be greater for a vaccine recipient with low BMI as in this case, since a standard IM needle would have reached deeper and closer to the plane of the axillary nerve. The exact incidence of Parsonage-Turner syndrome due to axillary nerve injury from an IM COVID-19 vaccine is not known. Given the fact that 6.9 million people in our city have been vaccinated4 and this is, to our knowledge, the only case known, it is likely to be less than one in a million even after making generous allowance for under-reporting. Still, it is no consolation to tell the patient it was just bad luck that he fell into the wrong side of that 1:1,000,000 ratio. Since no nerve trunk runs in the skin, giving the injection by the intradermal (ID) route would have avoided such a risk altogether. How much better if we could reassure the patient with a positive message, that he had not suffered in vain, and that we had taken the cue from his case and will eliminate such devastating events in future with ID vaccine injection. Ironically, as shown in subsequent sections, hesitancy of vaccine producers to change to ID vaccines proved worse than vaccine hesitancy.
Historically there have been many routes of vaccine administration: percutaneous, intradermal (ID), subcutaneous (SC), intramuscular (IM), oral, nasal and pharyngeal. Such diversity enables scientists and physicians to find the safest and most effective means of giving a particular vaccine. E.g., giving BCG (Bacille Calmette-Guerin) vaccine by IM or SC injections would lead to local abscesses, regional lymphadenitis or even systemic illness,5 so we are now giving it by ID injection. Great pioneers like Jenner, Koch, Pasteur, Salk, Sabin monitored the response of their vaccines and made prompt appropriate adjustments.6 Louis Pasteur for one was reputed to have personally injected his newly developed vaccine subcutaneously to a boy bitten by a rabid dog.7 Come the 21st century, we know more about the basic science of immunology. We know that one of the best sites to introduce an antigen to elicit an immune response is the skin which contains far more resident antigen presenting cells (macrophages/Langerhans cells/dendritic cells) and they instantly and effectively initiate the immune process by presenting the pathogenic antigen sequence to T-cells, which are then carried by an efficient lymphatic system to the regional lymph nodes to activate further steps of immune reaction.8 Subcutaneous tissue and muscle have little or no such resident antigen presenting cells. They have to wait for an inflammatory reaction to set up (which, depending on the potency of the vaccine’s adjuvant, usually takes up to a few hours) and attract the phagocytes and macrophages from the circulation.9 Vaccine adjuvants, by definition, are tissue toxic and enhance such reactions. Conceivably, if the vaccine is injected into the axillary nerve an inflammatory reaction will be set up and it might spread upstream to involve the brachial plexus and downstream to involve the deltoid and the shoulder joint. One certain way to avoid such injury is by avoiding the IM and choose the ID route instead.
Subsequent Studies on intradermal vaccination
The worldwide adoption of ID BCG has been mentioned. It has been applied to billions of recipients over many decades with proven safety, efficacy and feasibility. Other more recent studies have repeatedly shown the advantage of ID over IM vaccine injection in the prevention of various other infectious diseases.
Wahl and Hermodsson compared the three methods of vaccination: ID, SC and IM injection of hepatitis B vaccine.10 They administered 20 μg of vaccine for IM and 2 μg for both SM and ID. Seroconversion was obtained in 96% subjects by IM injection, 100% by ID injection and 63% by SC injection. Thus, at 1/10 of the dosage of the IM injection, the ID injection could equal or even surpass the IM injection results. Moreover, if an ID injection is inadvertently delivered subcutaneously, there would still be some protection, albeit at a moderately lower level. Obviously, it was not originally designed for a head-to-head comparison of IM with SC injection, otherwise the dose would have been identical between the two groups. However, the results were misinterpreted or exploited by IM protagonists that SC was inferior to IM injection.
Schnyder et al. used a different approach.11 They reviewed 26 studies of vaccinations on various infectious diseases employing “fractional doses”, i.e., with the dose of antigen equally reduced to 20-30% of the standard dose across the three routes of administration, ID, IM or SC injections. In 19 studies, the immune responses were similar across all three routes, while in 7 studies the efficacy of IM and SC routes remained similar, but the ID was clearly superior to the other routes. Notably, Schnyder et al. did not find any trial including the two most extensively administered vaccines, smallpox vaccine and BCG. Such a comparison would have been unethical as the IM route is well-known to be highly deleterious for recipients of these two vaccines.
Migliore et al.8 pleaded for ID injection of COVID-19 vaccines at 1/10 or 1/5 of the standard IM dose to boost vaccine availability to more people. The review covered vaccinations of influenza, hepatitis A and B, poliomyelitis, diphtheria-tetanus-pertussis, human papillomavirus, Japanese encephalitis, meningococcus, yellow fever, varicella zoster virus and rabies. Results uniformly showed that small fractional doses of ID delivered vaccines were equally effective if not superior to the standard full-dose IM vaccines.
Hung and Yuen12 observed that for influenza vaccination the ID route at reduced dosage was equivalent to the IM route. With a new device they were able to deliver larger volumes of vaccine accurately into the skin’s epidermis and proved beyond all doubts that with the same standard dose, the ID route proved significantly superior to the IM route. They also showed that prior topical application of imiquimod to the ID injection site further enhanced the immunogenicity and clinical protection value of the vaccine.
As often happens, one size does not fit all. Leung et al.13, studying on influenza vaccine, showed that among atopic dermatitis patients with skin colonized by Staphylococcus aureus, the ID route has lost its immunological advantage and the vaccine is best given by IM route. This is no surprise as S aureus produced superantigens and proteins such as SpA which tend to down regulate the skin’s immune elements, depleting the Langerhans cells, suppressing the B-cells and reducing the antibody response.14 Unfortunately, this study was not endowed with the same or a similar ID injection device as used by Hung and Yuen, so that no standard IM dose could be delivered into the skin for a fair comparison; otherwise it might be able to show whether Staphylococcal skin colonization merely deprived the skin of its immunological advantage over other tissues like the muscle or rendered the skin immunologically incompetent altogether.
The problem with changing the IM stereotype
Vaccine producers today almost uniformly adhere to the stereotype method of IM injection. All suggestions of trying alternative methods have fallen on deaf ears. Whereas vaccine development was led by medical scientists in the past, it is now controlled by gigantic business enterprises with profit as the prime aim. Most of the time, drug developers are dealing with agents that directly produce certain desirable effects e.g., antibiotics against bacteria, cytotoxic drugs and targeted agents against cancer, immune suppressants to put down autoimmune reactions, and so on. For this purpose, the IM route seems simpler, easier, faster and more effective. This “antibiotic mentality” has been carried over to the executive planning for vaccine development and taken a toll on vaccination decisions. But do we really want vaccines to be quickly absorbed into the blood stream like antibotics and reach various organs in the body to expedite immune reaction. Vaccination involves a very different discipline from antibiotics. A vaccine does not directly fight the infective agent. Instead, it mimics the infective agent and train the body’s own immune system to recognize the invader and fight against it. The best place to start such training is not in the muscle or the blood stream, but in the skin with its large constituent of resident antigen presenting cells ready for initiating such training. However, to divulge into further trials of ID vaccination would incur more labor, more time and higher cost, without bringing in more revenue. In fact, revenue might diminish because the ID route, being more efficient, will end up consuming less vaccine. Such prospects are far from attractive to the business executive.
Can the physician independently proceed with ID vaccination? Nowadays, the answer is likely “no”. Formerly a physician has more liberty to try out new methods of treatment. Over the years, in the name of patient safety and public interest, everything is tightly regulated. The physician needs to follow guidelines. Any new proposition has to be “evidence based” and approved by the authority, and the authority today needs extensive and expensive Phase III trials to consider the approval. No physician could afford hundreds of millions of dollars to conduct such trials. Furthermore, with the increasing litigation trend in society, any new move by a physician might present an attractive target for seekers of astronomical compensations.
Our society has “advanced” to the present situation in which vaccine development is almost entirely in the hands of big pharmaceutical corporates. To maximize profit, trials are often stripped down to the bare minimum just to gain authority’s approval. Further trials to explore the possibility of avoiding serious side effects but without bringing more revenue would not easily gain acceptance. In this brief presentation of a rare adverse event following IM injection, the Parsonage-Turner syndrome, we have proposed a simple solution of substituting the IM with the ID route. Many problems are foreseen in carrying out such trials. The authority should take the lead to support such trials, since the best way to overcome vaccine hesitancy is not by brushing the adverse events aside as being statistically insignificant but by eliminating them altogether with a safer alternative.
This study is limited by the typical constraints of a single case report. It is narrowly focused on a rare subgroup of a direct hit of the IM needle at the axillary nerve and depositing its payload into the nerve and the immediate vicinity. The pain and palsy occurred immediately and stretched over the next few months. Switching to ID injection would almost certainly prevent such a event. Most other cases had a time gap of a few days to a few weeks between the IM vaccination and the onset of acute pain and palsy,15 the needle was unlikely to make a direct hit and the vaccine was probably deposited only around the nerve and not into it. Switching to ID might still provide prevention as there would be no reaction nearby to affect the nerve. In a third subgroup, there was a wide spatial gap between the injection site and the affected nerves, e.g., the vaccine may be injected to the left deltoid but the right brachial plexus would be affected or vice versa. For such cases, the preventive value of switching to ID might be less certain. Still, since ID vaccination would be using a much smaller dose, there would be a good chance that any side effect might be mitigated.
I am grateful to the patient for permission to publish this case report.
I declare no conflict of interest in any form. This work has received no sponsorship or subsidy of any kind.
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.
