AUCTORES
Globalize your Research
Chat with us
Research article | DOI: https://doi.org/10.31579/2642-973X/057
1 Neurosurgery Service, Maciel Hospital, ASSE, Uruguay
2 Department of Quantitative Methods, Faculty of Medicine, Montevideo. University of the Republic. Uruguay
3 Chair of Imaging Hospital de Clínicas, Montevideo. University of the Republic. Uruguay
4 Chair of Neurosurgery, Hospital de Clínicas de Montevideo, University of the Republic. Uruguay
*Corresponding Author: Alejandra Jaume, Neurosurgery Service, Maciel Hospital, ASSE, Uruguay
Citation: Fernando Martínez, Alejandra Jaume, Pedro Macadam, Verónica De los Santos, Lucia Pereira, et al (2023), Prognostic Factors in Patients with Aneurysmal Subaraconid Hemorrhage in Uruguay: Presentation of a Multi-Center Prospective Study, J. Brain and Neurological Disorders, 6(3): DOI:10.31579/2642-973X/057
Copyright: © 2023, Alejandra Jaume. 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: 01 May 2023 | Accepted: 10 May 2023 | Published: 17 May 2023
Keywords: subarachnoid hemorrhage; aneurysm; treatment; prognosis
Subarachnoid hemorrhage (SAH) usually attacks sectors of the population in productive ages (mostly between 30 and 60 years old), which represents a very high social burden for the system and destroys family nuclei. According to a study by the ACROSS Group, overall mortality one month after diagnosis of SAH was 39%. The objective of this work is to identify the factors of poor prognosis for mortality or poor evolution of our population.
All patients older than 18 years with a diagnosis of HSAea, who consulted in a healthcare center in the country between 11/01/2019 and 10/31/2020, were included in the study. The clinical-epidemiological characteristics and comorbidities at the time of diagnosis, the type of treatment received and variables of clinical evolution during the following 6 months were surveyed. The statistical analysis of the data was based on the period evaluated, description of the variables studied and the identification of predictors of poor clinical evolution. Due to the multicenter and national nature of the study, it had to be submitted for evaluation by all the Ethics Committees of the participating health institutions, and by the National Research Ethics Commission (CNEI).
This is a prospective and multicenter study, including all patients over 18 years of age who presented aneurysmal spontaneous SAH in Uruguay between November 1, 2019 and July 31, 2020.
Variables relevant to the pathology under study such as age, sex, arterial hypertension, smoking, diabetes, alcoholism, and personal or family history of aneurysm were analyzed. Regarding the clinical grading ofdiagnostic classification, they were classified as mild SAH at Hunt and Hes-World Federation Neurosurgical Score (HyH-WFNS) 1 and 2, moderate SAH at HyH-WFNS 3, and severe SAH at HyH-WFNS 4 and 5. In addition was analyzed: Vascular study(s) performed, topography of the aneurysm that bled, indicated traten, care center where the treatment was performed, complication related to the indicated treatment, complication related to SAH, modified ranking score (mRS) at 6 months, post-treatment control vascular study, cause of death, date of death, discharge date, and end of follow-up date. Good evolution was defined as patients with mRS equal to or less than 2, and poor evolution was considered to be patients with mRS equal to or greater than 3.
Regarding the statistical analysis of the data pTo estimate the survival of the patients in the analyzed cohort, the Kaplan-Meier method was used and for the statistical comparison between survival functions by strata of another variable, the Log-Rank test was used. To identify possible prognostic factors for mortality and poor clinical evolution at 6 months of follow-up after SAH diagnosis and treatment, a Cox proportional hazards regression model was used. In view of the multivariate analysis, a preliminary selection of the candidate variables was first performed (p-value < 0>
All the information collected in this study is confidential and was handled according to the ethical standards for epidemiological research studies. The research was previously approved byall institutional Ethics Committees, as well as analyzed by the National Research Ethics Commission (CNEI), as it is a multicenter study. It also had the support and endorsement of the Uruguayan Society of Neurosurgery (SUNC).
Result:
A total of 211 cases were observed in the evaluated period. The average age was 57 years with a predominance of the female sex (75%). Mortality 6 months after diagnosis was 54.5%, and 64.5% of the cases presented a "poor clinical evolution."Median estimated survival time was 70 days.
Conclusions: The independent predictors of higher mortality were: presence of "severe" SAH from the onset of the symptoms, presence of a dissecting or spindle-shaped aneurysm, presence of a wide neck or absence of a neck in the neck-bottom relationship of the aneurysm, and presenting a Age greater than 60 years at the time of diagnosis.The factsThe independent predictors of poor clinical evolution demonstrated were: presence of "severe" SAH from the onset of symptoms, presence of a dissecting or fusiform aneurysm,presence of large ischemia as a complication of the treatment performed, and be older than 60 years at the time of diagnosis
A total of 213 patients were included in the study period. Two patients were excluded because they had a negative vascular study for aneurysm. Thus, the total number of patients analyzed was 211.
The mean age of the patients was 57 years, the female sex predominated in 75% of the cases, and 66% of the patients were hypertensive; and 40% of patients smokers.
Regarding the diagnostic classification or initial diagnosis, 35% of the patients were classified as mild SAH by HyH and 45% by WFNS; 15% and 3% of moderate SAH by HyH and WFNS respectively, and 50% and 52% of severe SAH.
The average hospital stay of the patients analyzed was 26 days, with a minimum of 0 and a maximum of 6 months.
Se The clinical evolution of the patients was assessed using the mRS scale at 6 months, defining "poor clinical evolution" as mRS values greater than or equal to 3, and "good clinical evolution" as mRS values less than or equal to to 2.
The mortality observed in the cohort at 6 months of follow-up was 54.5% (115 patients), and according to the previously defined criteria, 64.5% of the cases presented a "poor clinical evolution".
Median estimated survival time was 70 days. The cumulative survival function curve, estimated using the Kaplan-Meier method, is shown in Figure 1.
Figure 1: Survival function (Kaplan-Meier) of the 211 included patients.
Within the "declared" causes of death, 42% were due to the disease itself, 10% were linked to a complication due to the chosen treatment, and 2% were due to extra-neurological causes.
All the variables that could favor a fatal outcome of the patients were evaluated, both during their hospital stay and during their evolutionary control at 6 months. The results of the univariate analysis for qualitative and quantitative variables are detailed in tables 1 and 2 respectively.
It is necessary to clarify at this point that the significant effect shown by the variable "treatment performed" reflects the fact that the treatment that would have been indicated could not be given to seriously ill patients. When a sub-analysis was carried out comparing only the patients who were treated, it was possible to verify that said difference became statistically insignificant between surgery and embolization.
In turn, when we analyzed the complications related to the treatment, we observed that it was not significant overall, but when we analyzed each of them separately, the presence of major ischemia as a complication was the only one that showed a statistically significant effect (p= 0.002). Similarly, it was observed with SAH-related complications; When performing a sub-analysis of each of them, vasospasm was the only one that showed a predictive effect on mortality (p= 0.005).
| Variable | Deceased n: 115 (%) | Alive n: 96 (%) | p-value* |
| female gender | 86 (75) | 72 (75) | 0.550 |
| Coming from the interior | 49 (42) | 45 (46) | 0.315 |
| strict pandemic | 28 (24) | 23 (23) | 0.554 |
| Afro-descendant race | 3 (2) | eleven) | 0.381 |
| Arterial hypertension | 82 (71) | 58 (60) | 0.064 |
| smoking | 42 (36) | 46 (46) | 0.063 |
| Drug Addiction | 5 (4) | 3 (3) | 0.464 |
| Personal and Family History of Aneurysm | twenty-one) | 6 (6) | 0.089 |
| Obesity (BMI greater than 30kg/m2) | 13 (11) | 11 (12) | 0.570 |
| Alcoholism | 4 (3) | eleven) | 0.246 |
| Diabetes | 13 (11) | 3 (3) | 0.021 |
| Headaches and vomiting as the main symptom | 48 (42) | 48 (50) | 0.244 |
| Coma from baseline (GSC equal to or less than 8) | 24 (20) | 4 (4) | <0> |
| Severe SAH from onset (WFNS andHH greater than3) | 83 (72) | 27 (28) | <0> |
| diagnostic error | 18 (15) | 33 (34) | <0> |
Aneurysm Type: Saccular Aneurysm Dissecting Aneurysm Fusiform Aneurysm |
105 (91) 5 (4) 5 (4) |
95 (98) 0 (4) eleven) |
0.039
|
Neck-bottom relationship of the aneurysm: boy neck big neck Neckless |
71 (62) 40 (35) 4 (3) |
74 (77) 22 (23) 0 (0) |
0.022
|
treatment performed Surgery embolization nothing by gravity |
35 (30) 25 (22) 55 (48) |
56 (58) 40 (42) 0 (0) |
<0> |
| Treatment-related complication | 24 (21) | 28 (29) | 0.109 |
| HSA-related complication | 86 (75) | 72 (75) | 0.550 |
*Chi-square test.
Table 1: Factors associated with higher mortality in the 211 patients included: Univariate analysis (qualitative variables).
| Variable | Deceased md (RIQ) | Alive md (RIQ) | p-value* |
| Age (years) | 61 (20) | 53 (15) | <0> |
| Diagnostic Interval (days) | 1 (2) | 1 (3) | 0.004 |
| Indicated Treatment Interval (days) | 0 (1) | 0 (1) | 0.009 |
| Interval Treatment Performed (days) | eleven) | eleven) | 0.141 |
| Delayed start of treatment (days) | 0 (1) | 0 (1) | 0.664 |
| Hospitalization time (days) | 13 (22) | 28.5 (27) | <0> |
Table 2: Factors associated with higher mortality in the 211 patients included: Univariate analysis (quantitative variables).
Md: Medium. IQR: interquartile range; Diagnostic Interval: time between the onset of symptoms and the diagnosis of SAH. Indicated Treatment Interval: time between the diagnosis of SAH and the indicated treatment. Interval Treatment Performed: time between the diagnosis of SAH and the treatment performed. Treatment start delay: time between the indicated treatment and the treatment performed.
*Mann Whitney test P value
As a result of the multivariate analysis (identification of the independent predictors of mortality), the detail of the final model obtained with the 4 identified variables and their respective Hazard Ratio (HR) and 95% confidence intervals (95%CI), is shown in table 3.
| Variable | p-value* | HR (95%CI) |
Severe SAH from onset (WFNS and HH greater than 3) Aneurysm Type | <0> 0.023 | 3,488 (2,307-5,274) 2,198 (1,113-4,343) |
| Neck-bottom relationship of the aneurysm | 0.050 | 1,479 (0.997-2,196) |
| Age over 60 years. | <0> | 2,0665 (1,418-3,007) |
RR: relative risk; 95% CI: 95% confidence interval
Table 3: Independent predictors of mortality in the 211 patients studied: Multivariate analysis. Cox regression.
A total of 136 patients (64%) had a poor clinical evolution. In order to identify the characteristics of the patients that could predict or anticipate a "poor clinical evolution" in the short or medium term (follow-up period of this study, limited to 6 months from the diagnosis of SAH), all of them were analyzed. its characteristics at the time of diagnosis (demographics, comorbidities, habits and clinical presentation of SAH). The detail of the results of the univariate analysis is detailed in Tables 4 and 5. From the univariate analysis in this case, we must once again highlight that the type of treatment variable (surgery, embolization or none due to severity) should be interpreted with caution because This translates the difference between not performing any type of treatment and yes performing it, as we saw in the case of mortality analysis. Again here, after analyzing only the patients who were treated, no difference was observed between performing surgery versus embolization (p= 0.342).
Regarding the variable "complication linked to treatment", evaluated as the appearance of some type of complication attributable to treatment during follow-up, it was distributed in a similar way between patients with good and poor evolution (p=0.505). However, when each type of complication was analyzed separately, the presence of large ischemia did appear associated with a poor evolution of the patients, in the univariate analysis (p < 0> Aneurysm Type: Saccular Aneurysm Dissecting Aneurysm Fusiform Aneurysm 74 (98) 0 (0) eleven) 126 (92) 5 (4) 5 (4) 0.050 Neck-bottom relationship of the aneurysm: boy neck big neck Neckless 57 (76) 18 (24) 0 (0) 88 (64) 44 (32) 4 (2) 0.053 Type of treatment Surgery embolization nothing by gravity 42 (56) 33 (44) 0 (0) 49 (35) 32 (25) 55 (40) <0>Variable good evolution n: 75 (%) bad evolution n: 136 (%) p-value* female gender 55 (73) 103 (75) 0.410 Coming from the interior 38 (50) 56 (41) 0.118 strict pandemic 20 (26) 31 (23) 0.470 Afro-descendant race eleven) 3 (2) 0.553 Arterial hypertension 44 (58) 96 (70) 0.050 smoking 39 (52) 49 (36) 0.018 Drug Addiction 2 (2) 6 (4) 0.412 Personal and Family History of Aneurysm 5 (6) 3 (2) 0.108 Obesity (BMI greater than 30kg/m2) 8 (10) 16 (11) 0.501 Alcoholism 0 (0) 5 (3) 0.108 Diabetes 2 (2) 14 (10) 0.036 Headaches and vomiting as the main symptom 38 (50) 58 (43) 0.194 Coma from baseline (GSC equal to or less than 8) eleven) 27 (20) <0> Severe SAH from onset (WFNS and HH greater than 3) 13 (17) 97 (71) <0> diagnostic error 29 (38) 22 (16) <0> Treatment-related complication 18 (24) 34 (25) 0.505 HSA-related complication 53 (70) 105 (77) 0.188
*Chi-square test P value.
Table 4: Factors associated with poor evolution in the 211 patients included: Univariate analysis of qualitative variables.
From the personal history of the patients, arterial hypertension, diabetes, and smoking habits were also found in the univariate analysis to be associated with a poor clinical evolution of the patients (Table 4).
| Variable | good evolution Median (IQ range) | bad evolution Median (IQ range) | p-value* |
| Age (years) | 52 (16) | 57 (20) | 0.005 |
| Diagnostic Interval (days) | 1 (4) | 0 (1) | <0> |
| Indicated Treatment Interval (days) | 0 (1) | 0 (0) | 0.057 |
| Interval Treatment Performed (days) | eleven) | eleven) | 0.322 |
| Delayed start of treatment (days) | 0 (1) | 0 (1) | 0.836 |
| Hospitalization time (days) | 25 (15) | 23 (47) | <0> |
Md: Medium. Diagnostic Interval: time between the onset of symptoms and the diagnosis of SAH. Indicated Treatment Interval: time between the diagnosis of SAH and the indicated treatment. Interval Treatment Performed: time between the diagnosis of SAH and the treatment performed. Treatment start delay: time between the indicated treatment and the treatment performed.
*Mann-Whitney test.
Table 5: Factors associated with poor clinical evolution in the 211 patients included: Univariate analysis of quantitative variables.
For the multivariate analysis, all the variables that in the univariate analysis presented statistical significance at a significance level less than or equal to 0.25 were then retained. The variables identified as independent predictors of poor clinical evolution of the patients are shown in Table 6, with their respective Hazard Ratio (HR) estimates and 95% confidence intervals (95%CI).
| Variable | p-value* | HR (95% CI) |
Severe SAH from onset (WFNS and HH >3) Type of Aneurysm (dis or fus vs. saccular) | <0> 0.002 | 3,844 (2,631-5,617) 2,767 (1,436-5,333) |
| Major ischemia as a complication of treatment | 0.026 | 1,854 (1,077-3,193) |
| Age over 60 years. | <0> | 1,861 (1,316-2,632) |
*Wald's test
Table 6: Predictors of poor clinical evolution in the 211 patients included: Multivariate analysis. Cox regression.
Age, as in most neurological diseases, has a predictive role in clinical evolution, as evidenced in this study, with the breaking point being 60 years, which is much lower than for other diseases.
The symptoms at the onset of the symptoms, as well as the type of aneurysm, were confirmed in this work as expected from international reports, as independent predictors of poor clinical evolution.
It is interesting to evaluate, among the complications due to the treatment carried out, that large ischemia at the treatment site was significant as a predictor of poor clinical evolution, which provides information little published in the literature.
Regarding the clinical state at the onset of the symptoms, in the present work a high percentage of severe SAH was evidenced both by the H&H classification (65%) and the WFNS (55%). These percentages are higher than those reported in the international literature, where 20-30% of SAHs are classified as severe from the onset of the symptoms6,7. This is extremely important in order to study in the future whether our country has a predisposing factor for more serious SAH, since the initial clinical state is one of the main prognostic factors, evidencing an unfavorable prognosis in published works.the rest40% in severe SAH, falling to less than 20% with mild SAH (grades I-II)8.
In our work, a 6-month cumulative mortality of 54% was observed, which, according to the causes of death, was distributed as follows: 42% due to the disease itself, 10% linked to a complication of the chosen treatment, and 2% due to extra-neurological causes.By the way, we found that the mortality observed in our work is significantly higher than that reported in other works (30-40%)9,3. One possible explanation would be the fact that in our case material we have a high number of patients with severe SAH from the onset of the symptoms (50%) compared to other series in the literature where percentages of between 20 and 30% of severe SAH are reported10.
The independent predictors of mortality identified in our work were: presence of “severe” SAH from the onset of symptoms (HR= 3.4; 95%CI: 2.3-5.2), presence of dissecting or fusiform aneurysm (HR= 2.1; 95%CI: 1, 1-4.3), presence of a wide neck or absence of a neck in the neck-fundus relationship of the aneurysm (HR= 1.4; 95% CI: 0.9-2.1), and being older than 60 years at the time of diagnosis (HR= 2.0; 95% CI: 1.4-3.0).
Other authors also report the H&H, WFNS and GSC scales as good predictors of mortality11,12. Julien et al.10 also state, based on their prospective study of 1,532 patients, that the presence of vasospasm, HCF, and intracerebral hematoma also have a significant prognostic role. We must mention on this point that, during the analysis to identify potential factors associated with a higher risk of mortality in our work, there were a series of variables that, although they did not show a statistically significant effect (p<0>
SThe clinical evolution of the patients was evaluated according to the value of the mRS in the control 6 months after the diagnosis of SAH. “Poor clinical evolution” was defined as patients with mRS values greater than or equal to 3. Poor clinical evolution was evidenced in 64.5% of cases. Although this percentage is considered high compared to what has been reported in the international literature, analyzing mild and severe SAH separately at the beginning, we observed poor clinical evolution in 25% and 73%, respectively. These results are comparable to different publications, where it is reported that mild SAH have poor results and a worse prognosis in approximately 20, and SHTo serious in approximately 60%7.When the univariate analysis was performed, the following variables emerged as predictors of poor outcome: advanced age at diagnosis (>60 years), presence of diabetes as comorbidity, presence of hypertension, smoking habit, error at diagnosis, presence of coma from the onset of the symptoms, severe SAH from the onset, presence of a dissecting or fusiform aneurysm, no type of treatment, shorter diagnostic interval (time between onset of symptoms and diagnosis) and shorter hospital stay. These last two variables could be explained by the fact that the most severe patients are the ones that are diagnosed the fastest and die before.The presence of obesity, in turn, had a tendency to appear as a potential factor for poor clinical evolution, but its effect was not shown to be statistically significant.
Finally, when the multivariate analysis was performed, the independent predictors of poor outcome were:presence of “severe” SAH from the onset of symptoms (HR= 3.8; 95%CI: 2.6-5.6), presence of dissecting or fusiform aneurysm (HR= 2.7; 95%CI: 1, 4-5,3),presence of large ischemia as a complication of the treatment performed(HR= 1.8; 95%CI: 1.0-3.1), and being older than 60 years at diagnosis (HR= 1.8; 95%CI: 1.3-2.6). VanDonkelaar et al. in 201914 they published the SAFIRE scale, which is a modelAccurate, generalizable and easy to apply to predict the prognosis in patients with SAH such as: age, Fisher scale, WFNS scale, and aneurysm size. Almatter et al. in 201815 they reported as the main prognostic factors in SAH: age, initial clinical status, rebleeding, parenchymal hemorrhage, and middle cerebral artery aneurysm topography. For mild onset SAHs,Zijlmans et al. in 201813, they publishedas factors of poor prognosis and poor evolution at age: late cerebral ischemia, pneumonia, and meningitis. In severe SAHs,Mocco et al. in 20067 they reported as predictors of poor evolution and poor prognosis: age, severe HH scale in the preoperative period, aneurysm size, and hyperglycemia.
The follow-up of the patients in this study was 6 months, but we must clarify that, in the international literature, a follow-up during the first 10 years is recommended, with a vascular study every 5 years (CT angiography, MRI angiography or angiography), being stricter in patients with risk factors (female sex, smoker, AHT, and multiple aneurysms)16.
the HSAcontinues to be a disease with high associated morbidity and mortality and in the present work it was possible to identifyas independent predictors of higher mortality, the following factors: presence of “severe” SAH from the onset of the symptoms, presence of a dissecting or fusiform aneurysm, presence of a wide neck or absence of a neck in the neck-bottom relationship of the aneurysm, and be older than 60 years at the time of diagnosis.The factsThe independent predictors of poor clinical evolution demonstrated were: presence of "severe" SAH from the onset of symptoms, presence of a dissecting or fusiform aneurysm,presence of large ischemia as a complication of the treatment performed, and be older than 60 years at the time of diagnosis.
the independent predictive factors of higher mortality were: presence of “severe” SAH from the onset of the condition, presence of a dissecting or fusiform-type aneurysm, presence of a wide neck or absence of a neck in the neck-bottom relationship of the aneurysm, and be older than 60 years at the time of diagnosis. The independent predictors of poor clinical outcome demonstrated were: presence of “severe” SAH from the onset of the condition, presence of a dissecting or fusiform-type aneurysm, presence of large ischemia as a complication of the treatment performed, and being older than 60 years at diagnosis
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
