AUCTORES
Globalize your Research
Research Article
*Corresponding Author: Gninkoun Comlan Jules, Service d’Endocrinologie & Diabétologie du CNHU-HKM, Faculté des Sciences de la Santé, Cotonou (Bénin).
Citation: Gninkoun C Jules, A Adébayo, DIALLO A Mamadou, O Edwige, DIALLO M Mansour, et al. (2021) Therapeutic and evolutionary characteristics of Diabetic ketoacidosis after a decade at the University Hospital of Cotonou, Benin. Journal of Endocrinology and Disorders. 5(2): Doi:10.31579/2640-1045/105
Copyright: © 2021 Gninkoun Comlan Jules. 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: 16 March 2021 | Accepted: 30 March 2021 | Published: 26 April 2021
Keywords: diabetes; diabetic ketoacidosis; metabolic complications; infections
Aim: To evaluate the therapeutic and evolutionary aspects of diabetic ketosis decompensation, a decade after its previous report in our center.
Materials and Method: This was a 3-year retrospective study, including all patients admitted from June 1, 2016 to May 31, 2019 for DKA at the Endocrinology and Metabolic Diseases Department of the National and University Hospital Hubert Koutoukou Maga (CNHU-HKM). Ketosis was defined by the presence of at least 2 acetone crosses on the urine strip.
Results: A total of 196 patients were included. The mean age was 43.73 years ± 16.2 years with a sex ratio of 0.96. The prevalence of DKA was 28.99%. The main precipitating factors of DKA were infections (67.86%) and non-compliance to the treatment (29.59%). The most common infections were urogenital (23.30%), respiratory (18.04%) and malaria (32.33%). The mortality was 2.55%. Male subjects (84.36%) had blood glucose levels above 3g/L with a higher mean dose of insulin used (84.71 IU versus 54.29 IU for women p=0.008). Duration of recovery (p=0.008) and length of hospitalization (p=0.006) were statistically longer for men.
Conclusion: The prevalence of ketosis decompensations remains high. The main decompensation factors found were infections and non-compliance to treatment. Improving patient care over the past decade had produced a positive impact on mortality, recovery time and length of hospitalization.
Diabetes mellitus is a public health concern worldwide and particularly in low and middle-income countries due to its increasing prevalence while access to care remains challenging [1].
In Benin, between 2001 and 2008, the prevalence increased from 1.1% [2] to 2.6% [3]. In 2015, this prevalence was as high as 12.4% [4]. The course of diabetes mellitus can be marked by acute or chronic complications [5]. Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS) are the most common acute complications [1,5]. The hospital frequency of these acute complications is high in developing countries. In fact, in Ivory Coast and Burkina-Faso the prevalence of DKA was respectively 30.7% [5] and 59.1% [1]. The main factors for decompensation were infections, poor adherence to treatment, and lack of awareness toward the disease [1, 5, 6]. In Benin, a study carried out in the endocrinology department of the CNHU-HKM in 2009 reported a prevalence of 21.40 % of diabetic ketosis decompensations (DK). The main triggers found in that study were infections (51.49%) and non-compliance to treatment (25.74%). In addition, the outcome was favorable in 89.1% and mortality rate was 7.9 % [7].
After a decade, we aimed to evaluate the current prevalence of DK, to identify the main decompensation factors, and to assess the outcome of patients hospitalized for DK at the University hospital CNHU-HKM of Cotonou, Benin.
This was a retrospective, descriptive and analytical study involving diabetic patients hospitalized at the endocrinology department of CNHU-HKM from June 1, 2016 to May 31, 2019. The hospitalized diabetic patients with a ketonuria at least equal to two crosses [7] with glycemia equal or higher than 250 mg/dL, and positive glycosuria were included in the study.
The following features were collected: age, sex, profession, duration of diabetes, type of diabetes, decompensation factors, body mass index (BMI), blood glucose, glycosuria, ketonuria, kalemia, natremia, parasitic density for malaria, bacteriological analysis of urine, chest x-ray, blood culture, method of insulin administration (continuous versus discontinuous), overall resuscitation duration, length of hospitalization, and outcome (favorable, death).
The ketosis decompensation of diabetes mellitus was defined by a glycemia ≥ 250 mg/dL and a ketonuria ≥ two crosses with positive glycosuria. [7] Regarding the factors causing decompensation, we defined two variables: the infectious causes including pulmonary, urogenital, digestive, skin (other than diabetic foot) infections, diabetic foot and malaria; and the non-infectious causes defined by the non-compliance to treatment, lack of awareness toward diabetes, and intercurrent diseases other than infections (myocardial infarction and stroke).
The other variables were defined as follows:
Patient weight was assessed using de BMI and classified into four (4) categories: Underweight BMI less than 18.5 kg/m2; Normal: BMI between 18.5 and 24.9 kg/m2; overweight: BMI between 25 and 29.9 kg/m2; Obese: BMI ≥ 30 kg/m² [9].
Method of administration of insulin: Continuous insulin infusion protocol (insulin administered continuously by infusion pump) and multiple insulin injections protocol (administered each hour).
Total recovery time: period from the first insulin injection to the second negative ketonuria.
Length of hospitalization: period from the date of entry to the date of discharge.
Data were collected via an electronic questionnaire designed from the Kobocollect application suite based on the CAPI (Computer Assister Personal Interview) system. The data source was the hospitalized diabetic patient’s records and the hospitalization registry.
We checked the consistency of the data and the outliers and duplicates were removed. The analysis was done using the SPSS software version 21 and R version 3.6.1. We used frequency measurements to describe and analyze the data collected. Thus, the qualitative variable had been described in the form of proportions and quantitative variables in the form of position parameters. The comparisons of the means were made using the t test and those of proportions were made using the χ² test or the Fisher test as appropriate. Differences were considered statistically significant for p-value less than 0.05.
Study population characteristics
A total of 676 records of hospitalized diabetic patients were examined, among which we identified 196 records of diabetic patients hospitalized for ketosis decompensation. The mean age of the patients was 43.73 years ± 16.2 years with ranges of 13 and 100 years. There was a female predominance with a sex ratio of 0.96. The study population consisted of 37 type 1 diabetics (18.87%) and 157 type 2 diabetics (80.10%). Decompensation was inaugural in 39.8% of patients and, for known diabetic patients, the mean duration of diabetes was 6.09 years ± 6.62 years with extremes of 0 and 30 years. Excess weight (overweight or obesity) was present in 38.51% of the subjects included. (Table 1)
Prevalence and decompensation factors
The prevalence of ketosis decompensations was 28.99% with a 95% confidence interval of [25. 57-32.41].
Among the decompensation factors, infections were found in 67.86% (133) of cases, non-compliance with treatment in 29.59% (58) of cases and in 9.61% (18) of cases, no factor has not been identified. The infectious sites were dominated by genitourinary site (23.30%), respiratory site (18.04%) and malaria (32.33%). (Table 2).
Biochemical abnormalities of patients at admission
The mean blood glucose level was 411 mg/dL ± 1.40 with extremes of 153mg/dL and 900 mg/dL. Among the patients admitted for ketosis decompensations, 71.94% had ketonuria greater than or equal to 3 crosses.
The electrolytic disturbances were hypokalemia (26.53%), hyperkalemia (3.06%) and hyponatremia (24.49%).
Therapeutic and evolutionary aspects
Intensive insulin therapy with an electric syringe pump (continuous) was used in 23.97% of cases and in 62.75% of cases it was an hourly (discontinuous) intravenous bolus. The mean duration of resuscitation was 11.16 hours ± 8.29 with a minimum of 2 hours and a maximum of 53 hours. The average amount of insulin used per patient during resuscitation was 68.84 IU ± 60.40 with a minimum of 10 IU and a maximum of 436 IU. For continuous insulin therapy the mean dose was 63.19 IU ± 54.02 with a minimum of 10 IU and a maximum of 309 IU and for discontinuous insulin therapy the mean was 71.75 IU ± 63.59 with a minimum of 10 IU and a maximum of 436 IU.
The outcome of DKA was favorable in 92.85% of cases. Mortality was 2.55% and 4.60% of patients left against advice.
Male sex was the factor found statistically associated with prolonged resuscitation duration (p = 0.008). (Table 3).
Male sex (p = 0.008) and higher baseline glycemia (p = 0.005) were statistically associated with a higher mean insulin dose. (Table 4).
The mean length of hospitalization was 10.35 days ± 8.85 with extremes of 1 day and 78 days. Male gender (p = 0.006) and baseline glycemia (p = 0.010) were statistically associated with mean length of hospitalization. (Table 5).
The mean age of the patients was 43.73 years ± 16.2 years, ranging from 13 to 100 years. This result is similar to the one reported in our previous study [7] in 2009 and to the one reported by Kakoma and al. in 2014 in the Democratic Republic of Congo [6] who found a mean age of 44.8 years with minimum and maximum of 20 and 79 years respectively.
Results are controversial in the literature regarding the sex-ratio [7, 10-12]. In our study, a slight predominance of female sex (53%) was found.
Classically, DKA occurs in patients with type 1 diabetes [13-15]. This is not the case in our work where it was found a predominance of type 2 diabetes. In fact, our study population consisted of 37 type 1 diabetes patients (18.87%) and 157 type 2 diabetes patients (80.10%). In addition, ketosis decompensations inaugurated diabetes in 39.8% of cases. This frequency of inaugural decompensation in black subjects is comparable to that found by other authors such as: Leye and al. [10] in 2013 in Senegal with a frequency of 38.24, Gninkoun and al. [7] in Benin in 2009 with a frequency of 49.5%, and Lokrou and al. [5] in 2014 in Ivory Coast with 49.3%. This predominance of type 2 diabetes found in a context of inaugural decompensations in black individuals could be explained by the existence in black individuals of a form of atypical diabetes occurring in adult patients and whose discovery would be inaugurated by an episode of diabetic ketoacidosis [16, 17]. Indeed, Djrolo and al. [18] in the same center found a prevalence of 5.70% for this atypical form of diabetes in Cotonou in 2011.
The prevalence of DKA remains high according to the literature. The frequency of 28.99% found in our work is close to those reported by Bazin and al. [19] in France in 2014 (30.1%), Lokrou and al. [5] in 2014 in Ivory Coast (30.7%). The precipitating factors have not changed over time in our context. Indeed, 10 years ago, Gninkoun and al. reported in the same center that the main precipitating factors of decompensation were infections (51.49%), and diabetes treatment interruption (25.74%)[7].In the current study, these factors are dominated by infections (67.9%) and (non-compliance to treatment (’29.6%). These factors seem to be the most reported in other studies as well [5, 7, 10, 20, 21].
For DKA treatment, intensive insulin therapy was the main protocol used (86.8% of patients). The mean duration of recovery was 11.16 hours ± 8.29 and the mean amount of insulin used per patient was 68.84 ± 60.40 IU. Lokrou and al. [5] in 2014 in Ivory Coast reported a mean duration of resuscitation of 11.37 ± 4.5 hours with a mean amount of insulin of 52.6 ± 29.0 IU. This difference related to the insulin dose would probably be due to the lower frequency of obesity (16% versus 38.51%) in the Lokrou‘s study, the insulin requirements being function of the patients' weight. A decade earlier, Gninkoun and al. [7] had found in the same center a mean duration of 13.39 hours versus 11.16 hours found in the present work. This improvement observed for the duration of recovery could be explained by a better care of patients due to the implementation of DKA treatment protocol with continuous insulin infusion and telephone call-duty by endocrinologists in 2012.
We reported a favorable outcome in 92.9% of cases and death was observed in 2.55% of patients.Sarr and al. [11] in 2011 and Pouye and al. [22] in 2003 in Senegal had respectively noted a favorable evolution in 91.7% and 94.1% of cases respectively. Mortality has declined sharply in recent years and this is confirmed by current data. However, it is worth to notice that high mortality rates are still observed in developing countries. Lokrou and al. [5] in Ivory Coast in 2014 reported a death rate of 5.1%; Gninkoun and al. [7] in Benin in 2009 found a mortality rate of 7.9%. On the other hand, some authors have reported higher rates of mortality: 17.14% in South Africa in 2017 [23]; 27.5% in the Democratic Republic of Congo in 2014 [6]; 40.5% in Mali in 2007 [24] and 48.7% in Burkina Faso in 2017 [1]. In the northern countries, the death rates are rather lower: less than 1% in the USA in 2017 and 2016 [25, 26]; 1.2% in Spain in 2015 [27]; 1.7% in China in 2016 [28]. In addition, taking into account the publication dates of the various studies, there is a decrease in mortality rates in the most recent studies and certainly because of therapeutic progress and improvements in technical facilities. In Benin particularly, the lethality of ketosis decompensations has decreased considerably in our de, dropping from 7.9% in the work of Gninkoun and al. [7] to 2.55% after a decade confirming the improvement in the care and monitoring of patients in the department. This improvement in patient care has also resulted in a reduction in the length of hospitalization, which decreased from 13.23 days in 2009 to 10.35 days in 2019. While the level of the technical platform, which is higher in developed countries therefore promotes more effective care for patients who otherwise have health insurance; the seriousness of the clinical feature, the delay in admitting patients and the precarious socio-economic conditions constitute the factors of poor prognosis in the developing countries.
Male individuals seemed to present specificities in our work. Indeed, our results have shown that 84.36% of male subjects had a glycemia above 300mg/dL. Even if it is not obvious to explain this result, the fact that the mean insulin dose was higher in men (84.71I IU versus 54.29 IU in women p = 0.008) is quite understandable. The hourly doses of insulin are determined by the glycemia during resuscitation and the men had the highest blood sugar levels. In addition, the much longer duration of resuscitation found in our study in men (p = 0.008) constitutes an additional argument.
Our study showed that the prevalence of DK is still high and that the main decompensation factors have not changed significantly over time. Improving patient care over the past decade had produced a positive impact on mortality rate, which has been reduced by a factor of three, with a marked decrease in the duration of resuscitation and length of hospitalization.
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
