AUCTORES
Globalize your Research
Research Article | DOI: https://doi.org/10.31579/2690-1919/148
1 Division of Infectious Diseases
2 Department of Medicine
3 cahn School of Medicine at Mount Sinai, New York NY 10003 United States.
*Corresponding Author: Veenu Gill, Infectious Disease Physician Banner Thunderbird Medical Center 5555 W. Thunderbird Road Glendale, Arizona 85306 United States
Citation: Veenu Gill, Jorg Ruhe, David C. Perlman, (2021) Specific Magnetic Resonance Imaging Findings as Predictors of Osteomyelitis in Routine Clinical Practice. Journal of Clinical Research and Reports, 7(2); DOI:10.31579/2690-1919/148
Copyright: © 2021 Veenu Gill, 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: 04 March 2021 | Accepted: 12 March 2021 | Published: 22 March 2021
Keywords: osteomyelitis; bone biopsy; histology; MRI
Background: The gold standard for the diagnosis of osteomyelitis is histopathology combined with positive bone cultures. Magnetic Resonance Imaging (MRI) is often used to aide diagnosis and guide treatment decisions. The purpose of the study was to examine the association of MRI findings with, and their sensitivity and specificity in identifying osteomyelitis as proven by bone histopathology and bone culture in routine clinical practice.
Materials and Methods: A retrospective analysis of patients with bone specimens obtained by biopsy or at resection for suspected osteomyelitis during 2010-2014 at an academic medical center in New York City. We used bivariate analysis to compare findings of patients who did or did not have osteomyelitis confirmed on histopathology (Analysis 1) and those who had either bone histopathology demonstrating osteomyelitis, positive bone cultures or both or who had neither (Analysis 2).
Results: We identified 103 patients with an MRI in the week prior to bone biopsy or bone resection. In Analysis 1, 52 (50.5%) of 103 patients had osteomyelitis confirmed on histopathology. In Analysis 2, 72 (70%) patients had proven osteomyelitis. These groups with and without osteomyelitis did not differ significantly with respect to the frequency of marrow edema, cortical erosions, decreased T1 signal or increased T2 signal in either analysis and the sensitivity and specificity of MRI findings for detecting osteomyelitis was lower than reported in prior studies.
Conclusions: Based on the above results, clinicians should be aware that the sensitivity and specificity of MRI findings for histologic and microbiologic osteomyelitis may be less in real world practice than is reported in formal studies.
Osteomyelitis is a major public health issue. Osteomyelitis contributes to one in 675 United States (US) hospital admissions each year or about 50,000 cases annually [1]. The direct medical charge per episode of osteomyelitis is estimated to be $35,000 US [2]. The gold standard for the diagnosis of osteomyelitis is evidence of bone infection on pathologic specimens obtained through biopsy, debridement or resection) plus the presence of positive bone cultures [2, 3]. A variety of radiologic studies can be useful both in guiding biopsy or surgical intervention and in the presumptive diagnosis of osteomyelitis, including plain radiography, nuclear medicine studies, computed tomography (CT) or particularly Magnetic Resonance Imaging (MRI) [4].
MRI is a key imaging modality for the detection of osteomyelitis because it has superior overall sensitivity approaching 90%, but it has a lower specificity ranging from 70-80% in different clinical studies depending upon the diagnostic criteria used and specific MRI findings considered [4,5,6]. In prospective studies with double blind reading of both MRIs and of bone pathology, MRI can identify certain findings which are highly sensitive e.g., bone marrow edema and can reveal findings which can be highly specific e.g., cortical destruction [5,6,7]. However, MRI cannot always distinguish between infection and non-infectious etiologies such as Charcot arthropathy, particularly when the relatively non-specific finding of bone marrow edema is identified [8, 9]. Further, in routine clinical settings, it is not uncommon to encounter situations in which the sole MRI finding e.g. bone marrow edema is sensitive but nonspecific and in which MRI findings may then interpreted as ‘consistent with’ or ‘not able to exclude’ osteomyelitis; treatments decisions may then be made based on these nondefinitive imaging findings and the clinical context [6,7,9].
MRI and other imaging studies may inform the clinical decision to do a bone biopsy or to proceed to resection, yet there are many situations in which bone specimens are not, or cannot, be obtained. These radiographic (including MRI) findings themselves, often in the presence of overlying or adjacent skin and soft tissues infections, may lead to the institution of empiric antibiotic therapy prior to, or instead of, bone specimens being obtained for pathologic or microbiological analysis. Hence, another issue that arises in routine clinical practice is that patients may have received antibiotics prior to either bone biopsy or surgical resection, thus potentially reducing the sensitivity of subsequently obtained bone cultures [10,11,12].
To our knowledge, there are few data specifically correlating specific MR findings with bone biopsy and intraoperative bone cultures in routine “real-world” clinical practice. We sought to examine the correlation between specific MRI findings and pathologic evidence of osteomyelitis on bone specimens and on intraoperative bone cultures in routine practice at an academic medical center. The aim of the study was to identify specific MRI findings of osteomyelitis as confirmed by bone histopathology and cultures.
Study design:
We conducted a retrospective review of electronic pathology records at our institution for the years 2010-2014 using search terms "bone inflammation", " bone biopsy" and "osteomyelitis". All adult aged >18 years) patients seen at our institution from 2010-2014 who had a bone biopsy or bone resection as part of management of possible or suspected osteomyelitis and had an MRI performed within one week prior to the bone specimen being obtained, were identified. Among this group who had bone pathologic specimens, we subsequently identified those patients who had an MRI of the affected area within one week prior to the date the bone specimen was obtained, to identify patients with bone pathologic specimens, MRIs and a clinical a priori consideration of osteomyelitis.
The patients’ medical records were reviewed to identify baseline characteristics including the presence of comorbidities, descriptions of the involved area, the presence or absence of erythema, purulence, ulcers, ulcer size, exposed bone, and whether ulcers probed to bone. Laboratory values such as sedimentation rate, C-reactive protein, white blood cell count, and the route and duration of antibiotics before the specimens were recorded. MRI reports were reviewed to identify specific findings noted and final interpretations; pathology reports were reviewed to identify specific findings noted and final interpretations, and included pathologic findings such as the presence or absence of bone necrosis, acute or chronic inflammation and gram stain results. We also identified whether cultures of intraoperatively obtained bone specimens were performed and the results of these cultures.
All data gathered was entered into an Excel spread sheet. Two separate analyses were conducted. In the first analysis (Analysis 1), clinical characteristics and MRI findings of patients who had osteomyelitis confirmed on histopathology and those who did not were compared. In the second analysis (Analysis 2), clinical characteristics and MRI findings of patients who had either bone histopathology demonstrating osteomyelitis, positive bone cultures or both (=proven osteomyelitis) were compared with those who had neither (=no proven osteomyelitis)
Statistical analysis:
Bivariate analyses using the Pearson's 2 test, the Fisher's exact test, and the Mann-Whitney U test were performed to compare categorical and continuous variables, respectively.
The sensitivity, specificity, positive and negative predictive values of specific individual MRI findings for the identification of osteomyelitis (as defined in Analysis 1 and 2) were calculated. We also calculated the sensitivity, specificity of the combined MRI findings of a) marrow edema plus cortical erosions, and b) decreased T1 signal intensity plus increased T2 signal intensity.
A total of 520 distinct patients were identified in the study time period 2010-2014 as having possibly relevant bone specimens. Of those, 417 were excluded for the following reasons: resection for anatomic (noninfectious) bone deformity (82), pathologic diagnosis of malignancy (146), wrong specimen (42), incomplete records where relevant data were contained in outpatient records which were not available (120), no MRI done (20) and duplicate records (7). This resulted in 103 patients who were included in the study and who had both MRI and pathology records available (Table 1).
Among the 103, the mean age of patients in the total cohort was 60 years. 64% had diabetes mellitus, 23% had peripheral vascular disease and 12% had diabetic peripheral neuropathy.
Analysis 1
Of the 103 patients, 52 (50.5%) patients did have osteomyelitis confirmed on histopathology and 51 (49.5%) patients had negative histopathologic results. The only finding on physical examination significantly associated with osteomyelitis was presence of an open ulcer (p=0.01; Table 1). Probing to bone, ulcer size, exposed bone and signs of peripheral vascular disease were not significantly associated with the presence of underlying osteomyelitis. The mean ESR value was 65mm/hour and the mean CRP value was 8.7mg/L. Eighty-three (80.5%) of the 103 studied had baseline X-rays performed (Table 2).
Only 6% of the patients had periosteal elevation on x-ray whereas 43% had cortical erosions. Only 25 out of 103 patients (30.1%) had findings identified on plain x-ray interpreted as compatible with osteomyelitis (Table 2). There was no significant difference with regard to the presence of cortical erosions among those with or without osteomyelitis on histopathology (Table 2).
42(41%) of the 103 of the had MRIs performed with gadolinium. The two groups did not differ significantly in the findings of marrow edema [27(54%) vs. 31(59.6%), p=0.60], cortical erosions
[30(60%) vs 34( 65%), p=0.60], decreased T1 signal [16(32%) vs. 14(26.9%), p=0.60] or increased T2 signal [16(32%) vs. 19(36.5%), p=0.60]. The majority of the patients (79.6%) underwent bone biopsy. Sixty-three biopsies were of bones of the foot and 19 were vertebral bone specimens. Twenty-five (24.2%) of 103 underwent resection of the affected bone, 20 (38.4%) of whom had confirmed osteomyelitis on histology. Of the 19 patients who had a vertebral biopsy performed for suspected vertebral osteomyelitis, 7 (20%) had osteomyelitis confirmed on histopathology.
Data on antibiotic use prior to obtaining bone specimens were available for 100 of the 103 patients. Seventy-seven (77%) patients received one or more systemic antibiotics for a mean of five days prior to bone biopsy or resection.
We calculated the sensitivity and specificity of either marrow edema, cortical erosions or the combination of both to predict the presence of osteomyelitis on histopathology. Marrow edema alone had a sensitivity of 59.6%, a specificity of 46%, a positive predictive value of 53.4% and a negative predictive value of 52.2% (Table 3).
Analysis 1: compared those with histopathologic confirmed osteomyelitis (n=51) to those without histopathologic confirmed osteomyelitis (n=52); Analysis 2 compared those with histopathologic osteomyelitis, positive bone cultures or both (n=72) to those with neither (n=31).
The presence of cortical erosions had a sensitivity of 65.3% with a specificity of 40%. The positive predictive and negative predictive values of cortical erosions were 53.1% and 52.6% respectively (Table 3).
The presence of both marrow edema and cortical erosions had a specificity of 68% with a sensitivity of 46.1%. The positive predictive value of the combination of both bone marrow edema and cortical erosions was 60% and the negative predictive value was 54.8%. Changes in the T1 and T2 signal intensities by themselves had sensitivities of 26.9% and 36.5% respectively; the specificity of each was 68%. The combination of a decreased T1 signal and an increased T2 signal intensity had a specificity of 82% with a sensitivity of 25%; the positive predictive value of the combination was 59% with a negative predictive value of 51.8% (Table 3).
Analysis 2
Data on bone cultures was available for 84 patients; 48 (57%) of these were positive. Of the 48 patients with positive bone cultures, all had osteomyelitis confirmed on histology. 36 patients had negative bone cultures; 24 of which were negative on histopathologic diagnosis and 12 were positive on histology.
A total of 72 (69%) of the 103 patients had either osteomyelitis on histopathology, positive bone cultures or both (=proven osteomyelitis); 31 (31%) had neither (=no proven osteomyelitis; Table 1). Ulcer size, the duration of the ulcerative lesions and positive results on the probe to bone maneuver were not significantly different between the two groups; neither ESR nor CRP differed between the two groups (Table 1).
The presence on X-ray of periosteal elevation, cortical erosions and osteopenia did not statistically differ between the two groups (Table 2). There was also no difference with regard to frequency of MRI findings such as cortical erosions, T1 and T2 signal intensity changes and marrow edema. Of 103 patients, 82 (79.6%) patients had bone biopsy and 25 (24.2%) of 103 had bone resected. Twenty-two (88%) of the 25 resected bones had histopathologic findings of osteomyelitis. Seventy-seven (77%) of the 100 patients for whom data were available, had received one or more systemic antibiotics for a mean of 5 days prior to bone biopsy. The most commonly prescribed antibiotics were vancomycin, penicillin derivatives and cephalosporins. Bone cultures were performed for 84 people, 48 (57.1%) of whom had positive cultures. All 48 patients with positive bone cultures also had histological evidence of confirmed osteomyelitis on pathology.
The organisms most commonly isolated from bone cultures were: methicillin sensitive Staphylococcus aureus (MSSA), methicillin resistant Staphylococcus aureus (MRSA), coagulase negative Staphylococci, Streptococcus species, Corynebacterium, Enterococcus species; among gram negative bacteria, Pseudomonas species were common. Forty one of 103 patients had deep (non-bone) wound cultures obtained; 31 (87%) were positive and the most common organisms were MSSA, MRSA and Streptococcus species.
We calculated the sensitivity and specificity of marrow edema, cortical erosions and a combination of edema plus erosions to predict the presence of proven osteomyelitis as identified by either histopathology, bone cultures or both, compared to no proven osteomyelitis. Marrow edema alone had a sensitivity of 59.6% and a specificity of 50% with a positive predictive value of 74.4% and a negative predictive value of 34% (Table 3). The presence of cortical erosions had a sensitivity of 66.6% and specificity of 46.6%. The positive predictive and negative predictive value of cortical erosions were 75% and 36.8% respectively.
The presence of marrow edema and cortical erosions had a specificity of 73.3% with a sensitivity of 45.8%. The positive predictive value of the combination was 80% with a negative predictive value of 36%. Changes of the T1 or T2 signal intensity alone had sensitivities of 25% and 30.5%, respectively. The specificity of each was 60% and 62.8%, respectively. The combination of a decreased T1 signal and an increased T2 signal intensity had a specificity of 83.8%, with a sensitivity of 19.4%. The positive predictive value of the combination was 73.6%; the negative predictive value was 30.9%.
Osteomyelitis continues to cause significant morbidity and health care costs (1). Despite the availability of diagnostic procedures including biopsy and a range of imaging tests such as MRI osteomyelitis continues to pose diagnostic challenges. Biopsies are not always feasible, and consequently clinicians are often required to rely on imaging tests to support or exclude the diagnosis. However, despite data in which double blind readings of MRIs often have high sensitivity and specificity for the diagnosis of osteomyelitis confirmed by double blind histopathologic analysis in study settings (5,6,7,10,11), our data suggests that MRIs may have a lower sensitivity and specificity for the diagnosis of osteomyelitis in routine clinical practice.
The presence of single findings compatible with osteomyelitis e.g. bone marrow edema, cortical erosions, T1 signal or T2 signal changes were associated with sensitivities in the 25-65% range, with specificities of 40-68%. The presence of combinations of both bone marrow edema and cortical erosions yielded roughly comparable sensitivity, specificity and negative predictive values, but did yield somewhat superior positive predictive values in the 60-80% range. Similarly, a combination of T1 and T2 signal changes had a lower sensitivity (approximately 19-25%), but a higher specificity of approximately 82-84%. This is in contrast to a prior study that reported a sensitivity close to 80% and a specificity of 72% (11).
More patients had open ulcers on physical exam in the groups without osteomyelitis in both analyses (approximately 92-95%) than in the groups without evident osteomyelitis, suggesting that this commonly used physical exam finding may not be a reliable predictor of osteomyelitis. 20(24%) of the 83 patients had positive bone cultures in the absence of histopathologic evidence of osteomyelitis, suggesting either that histopathology alone may either miss some cases of true bone infection or that cultures may have been falsely positive because of contamination by wound colonizing flora or skin commensals.
Many limitations should be noted. The majority of pathology specimens were from biopsy rather than bone resection; this could potentially cause sample bias. Further, this was a retrospective analysis of routinely generated clinical MRI and pathologic data. Neither MRIs nor pathologic specimens were re-reviewed, nor were they double read, both methods which might enhance the diagnostic accuracy of both procedures, and as has been done in idealized setting such as prospective studies (10, 11). The interpretation of the MRI findings used in our study was solely based on those documented in the final radiologist MRI reports; not all MRI reports specifically addressed the presence or absence of each potential MRI finding. Similarly, the final pathologic reports varied in the degree of detail provided, again differing from the rigor that might be obtained by blinded or double review in a prospective study. Further, MRI findings and pathology specimens were not all reviewed by the same radiologist or pathologist as part of the study protocol. Thus, the potential inter-reader variability may have affected the sensitivity and specificity of MRI findings in our study. However, while either prospective blinded double reading of both MRIs and histopathology or post-hoc re-review of MRI and histopathologic reports might have enhanced the ability to identify the potential of MRI to identify or exclude osteomyelitis under ideal conditions, such as in formal studies, the value of examining the results based on the routinely generated clinical reports is that this analysis then more accurately reflects the data routinely available to clinicians in real world practice.
We did not observe significant difference in the frequency of specific MRI findings or in the final MRI impression between patients with and without proven osteomyelitis. The sensitivity, specificity, positive and negative predictive value of MRI in the detection of osteomyelitis identified in this clinical setting were lower than that generally reported in formal clinical studies. Clinicians should be aware that the correlation between MRI findings and histopathologic or microbiological results obtained in routine practice may be lower than suggested by the literature. Further studies in well-defined but real-world clinical cohorts are warranted.
The authors report no conflict of interest.
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.
