AUCTORES
Globalize your Research
Research Article
*Corresponding Author: Yansong Xu, Emergency department, the first affiliated hospital of guangxi medical university, Nanning city, China.
Citation: Y Xu, Z Liang. (2021) A novel model for predicting the death risk of severe traumatic brain injury during hospitalization. Journal of Clinical Surgery and Research. 2(3); DOI: 10.31579/2768-2757/021
Copyright: ©2021 Yansong Xu, 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: 07 July 2021 | Accepted: 22 July 2021 | Published: 26 July 2021
Keywords: traumatic brain injury; death risk; prediction model
BACKGROUND: Patients with severe traumatic brain injury (sTBI) often presents with extracranial injuries, which may contribute to fatal outcome. The aim of this study was to construct the best death prediction model for sTBI and provide a feasible basis for early prognosis.
METHODS: A retrospective study from the First Affiliated Hospital of Guangxi Medical University from January 2012 to September 2020 was performed. Relevant risk factors at admission and record survival were collected at discharge. Logistic regression was used to establish a death prediction model. The performance of the model was predicted by fitting goodness test and calculating the area under the ROC curve (AUC). The DCA curve was used to show the net benefit rate of patients.
RESULTS: Of the 190 patients with sTBI, 91 died during hospitalization, with a mortality rate of 47.8 percent. Pupillary dilation, occipital lobe injury, SAH, cerebral hernia, and APACHE II score could predict the probability of death alone, with AUC of 0.636, 0.595, 0.611, 0.599 and 0.621 respectively. The AUC of death prediction for patients with sTBI was 0.860, and its sensitivity and specificity were 88.60% and 81.60%. The calibration and decision curve analysis (DCA) were conducted to validate the performance and clinical value of the novel model.
CONCLUSIONS: The clinic-radiomic model incorporating both clinical factors and radiomic signature showed good performance for mortality risk prediction of sTBI. The predictive model can identify sTBI with high sensitivity and can be applied in patients with sTBI.
TBI is a critical global public health problem. The incidence of TBI is increasing, and it ranks the first in the morbidity and mortality after injury [1-3]. In particular, sTBI has high mortality and disability rates, which has been the focus of clinical attention not only on treatment but also on adult death risk prediction [4]. Moreover, accurate determination of the prognosis is crucial for the practitioners, in order to optimize and personalize treatment strategies. There is a degree of uncertainty in clinicians' expectations of patient outcomes,and prognostic models can help improve these expectations by providing probabilities of specific outcomes. Compared with the experience of physicians to judge the prognosis of patients, objective prognostic models would be able to give more accurate projections about specific variables such as number of hospitalizations and deaths. At present, the predictors of mortality modules used are Glasgow Coma Scale (GCS), APACHE II and Sequential Organ Failure Assessment (SOFA) scores. And in our view, such estimates introduce a methodological innovation, whereby deaths among untreated patients are used to estimate the risk of death for the treated group if they had remained untreated. GCS provides an objective recording of the state of consciousness of a person, which is the only variable referring to brain function in the APACHE II score. APACHE II score was primarily designed to predict mortality in ICUs. SOFA is originally created for sepsis, but their quality is now used in other medical conditions. The famous models: the IMPACT model and the CRASH model were weighted towards mixed TBI (moderate and severe TBI) [5, 6]. But these models mainly used postoperative parameters to evaluate the prognosis of patients; Moreover, all the above models lack imaging parameters. Therefore, there is a strong need for prognostic signatures which are more efficient, more and easier to calculate for clinicians and preoperative patients in emergency department.
Patients with mild to moderate TBI often had inaccurate GCS scores due to sedation and labor medications. Therefore, patients with sTBI were selected as the research objectives. The author works in the emergency department of the largest general hospital in Guangxi province, and undertakes prehospital and in-hospital emergency rescue, but our hospital had not yet formed a set of sTBI death risk prediction model. Risk models are important to help clinicians to provide reliable information to patients and relatives. Due to the differences in economic reasons and social concepts, the vast majority of people find it is difficult to accept that patients still cannot live on their own after several months of treatment. In China, the family members of patients are more concerned about whether the patients can have a high-quality survival, because the lack of self-care ability will consume more family income and increase the pain of family members. It is particularly important to construct a risk model of death from traumatic brain injury suitable for emergency department, which can not only assess the risk of death of patients in advance, but also help doctors to allocate medical resources equitably. To this end, this study systematically analyzed the relevant risk factors at admission, and expected to establish a novel model to more accurately predict the risk of death.
Study population from 2012 to 2020, the basic information of patients with sTBI were obtained through our hospital's HIS system, and the imaging results were inquired according to the PACS system. The study was approved by the ethics committee of First Affiliated Hospital of Guangxi Medical University. Informed consent from patients were waived for this retrospective study. The inclusion criteria are as follows: ① Patients with sTBI over 18 years of age. ② Patients suffering from sTBI without other injuries. ③ GCS score＜8 at the time of admission. ④ Patients were diagnosed by CT or MRI in emergency department. ⑤ The survival status at discharge.The main outcome was inpatient mortality. Subjects who meet any of the following exclusion criteria will be excluded from participation in the study. ① A death occurring within 24h of admission. ② Patients did not suffered from hypertension, heart disease and diabetes at admission. ③ Those patients with incomplete clinical information. ④ Forgoing medical care for economic reasons.
Baseline characteristics including age, sex, GCS,endotracheal intubation or not, etc.; The vital signs were recorded at the time of admission, such as temperature, pupillary dilation, respiratory rate, heart rate, systolic blood pressure, etc.; After admission, blood samples were obtained within 24h, including creatinine, white blood cell count (WBC), platelet count (PLT), hematocrit (HCT), etc.; In addition, the APACHE II score (within 24h of ICU admission) were registered. Outcome in hospital was recorded as dead or alive at discharge.
Nomogram model performance was validated using internal validation by examining calibration. Final model was internally validated using bootstrapping resampling of the construction data set (with 1000 bootstrap samples per model) to obtain optimism corrected discrimination via the concordance index for survival data and calibration plots. In internal calibration plots, points parallel to the reference line would indicate similar predicted effect of the nomogram covariates in the development set. DCA was used to evaluate the clinical usefulness of the models.
Baseline characteristics
After rigorous screening, a total of 190 patients were enrolled, including 154 males and 36 females. The mean age was (46.2±18.0) years. Ninety-one of these patients died, with a mortality rate of 47.8 percent.
Univariate and Multivariate logistic regression analysis
This study identified the following parameters impacting survival: Age(p=0.026), Endotracheal intubation( P=0.001), GCS(P=0.000), Temperature (P=0.008), PLT( P=0.000), CR(P=0.003), Pupillary dilation(P=0.000), occipital lobe injury( P=0.003), SAH( P=0.002), cerebral hernia( P=0.006) and APACHE Ⅱ score (P=0.002) (Table 1). Next, all the factors with a p value less than 0.05 were involved in multivariate logistic analysis. Finally, pupillary dilation, occipital lobe injury, SAH, cerebral hernia and APACHE Ⅱ score retained their statistical influence on survival (all p<0>
SPSS 26.0 software and R 3.1 language were used to calculate the independent factors affecting death The predicted risk of mortality for each patient was calculated according to the following equation: Logit（P）＝- 2.053- 1.736 x (unilateral pupillary dilation) to 3.088 x (bilateral pupillary dilation) + 1.364 x (occipital injury) + 1.663 x (cerebral hernia ) + 1.112 x (SAH) + 0.150 x (APACHE Ⅱ score). Graphic interpretation (The basic data of the patient no. 5): SAH (No), cerebral hernia (Yes), occipital lobe injury (Yes), dilated pupil (bilateral), APACHE (15 points). Each parameter corresponds to a point at the top of the graph, the sum of all points corresponds to the total score at the bottom, and finally corresponds to the risk probability at the bottom column (Figure 1). The AUC of death warning score predicting the death of critically injured patients was 0.860. The sensitivity and specificity of the model were 86.6% and 81.6% respectively (Figure 2). The AUC of critically injured patients predicted death by death warning score was the largest, which was significantly higher than the predictive value of other indicators (Table 2). Moreover, calibration plots indicated that in comparison with an ideal model, the nomogram had a similar performance (Figure 3). DCA was applied to evaluate the performance of predicting mortality risk of sTBI (Figure 4). The novel model had greater net benefit than individual indicators at any probability.
sTBI involves complex pathophysiological mechanisms, which is unquestionably the leading cause of mortality in China [7]. It is estimated that half of the world's population will live with one or more TBIs in their lifetime [8]. Early management of patients with sTBI has always been a thorny issue. Patients with sTBI received active surgical treatment in time, but the high mortality rate made doctors and patients' families dissatisfied. Overall, present studies strengthen -ed the idea that patients with sTBI had poor prognosis and high mortality. A recent multicenter cohort study demonstrated that the overall mortality of sTBI was 27% [9], which was similar to the reported rates in Europe and North America [10, 11]. And most deaths after sTBI were due to withdrawal of lifesupporting measures, often based on perception of unfavorable chances of meaningful neurologic recovery [12, 13]. Therefore, how to make a scientific judgment on the prognosis of this kind of patients is particularly important. The results of this research supported the idea that there were many factors affecting the prognosis of patients with sTBI. 21 clinical variables were included in this study, and the results showed that the pupillary dilation (including the unilateral and bilateral), occipital lobe injury, SAH, cerebral hernia and APACHE Ⅱ score were the independent factors of death in patients with sTBI. The death risk model had an AUC of 0.860, which was significantly higher than the predictive value of any indicator. According to the analysis of the model, doctors take timely measures which can effectively and quickly reduce secondary brain injury. APACHE Ⅱ score related observation index (heart rate, breathing, red blood cell pressure, etc.), may help reduce the mortality. There is a certain relationship between pupil condition and consciousness disorder, which can judge the prognosis of patients. Pupillary dilation was a major factor of decision making. Dilated pupils on one side or dilated on both sides indicate a critical condition, for these patients, mannitol treatment was used as a control of osmotic pressure. No reduction of bilateral pupil after mannitol injection indicated severe brain stem compression and poor prognosis. The GCS score remains a valuable tool to indicate prognosis and especially for most well-validated index of overall neurologic injury severity [14, 15]. With a GCS>4 score, pupil dilation was an important basis for stratification, with dilated pupil on one side accounting for 81.2% and dilated pupil on both sides accounting for only 47.4%, indicating that the change of pupil was related to death [16]. APACHE Ⅱ scoring system is now the most commonly used in critical care clinical scoring system, which has certain value for the forecast of trauma patients died. In critically ill patients, APACHE Ⅱ score < 10> 14.5, the mortality rates closed to 50%, but the death rate was as high as 80% when the APACHE Ⅱ score > 20 points. APACHE Ⅱ scoring system is very complex and affected by many factors. The admission APACHE II model, as with other ICU scoring systems such as the APACHE III model, needs an accurate diagnosis to accurately predict the hospital mortality. Especially, history-taking in the early phase of sTBI patients was typically difficult. The scoring system records the worst clinical test data, it is affected by a variety of factors and is difficult to carry out, hence using APACHE II score to predict the prognosis of patients will be more difficult in the emergency department. GCS might be a most significant indicator in APACHE II scoring. It has been reported that the APACHE II score was more accurate than the GCS score for predicting late mortality of patients with sTBI, although the APACHE II score may be less accurate than the GCS score to predict early mortality, which was similar to this finding[17]. The complex pathophysiological process after TBI and its precise regulatory mechanism has not been fully understood, however, it is assumed that the process of TBI can be divided into primary brain injury and secondary brain injury. After CT era, due to its ability to demonstrate the nature, sites, and multiplicity of TBI [19]. Hence, it provides an objective and invaluable evaluation of structural brain damage following head injury. Similar to other results [20], several individual CT features, such as occipital lobe injury, SAH and cerebral hernia were associated with adverse outcomes after sTBI in this study. Multivariable logistic regression model of this research found that Characteristic of single CT to predict death probability was unsatisfactory, the risk factors to predict the AUC of death were: 0.636 (pupil dilation), 0.595(occipital injury), 0.599 (subarachnoid hemorrhage) and 0.611 (cerebral hernia) and 0.621 (APACHE Ⅱ) respectively. The optimization prediction probability model AUC was 0.860, which significantly improved the sensitivity and specificity. It should be noted that although predictive tools can assist clinicians in determining patient prognosis, predictive tools cannot completely replace clinicians' judgment. In the process of using the prediction tool, accurate judgment should be made according to patients' specific conditions and doctors' own experience. The strengths of the study included the in-depth analysis of the risk of death in patients with sTBI, which provides a theoretical basis for further treatment decision and medical resource allocation. A number of limitations need to be noted regarding the present study: 1. The neurological function and self-care conditions that patients were most concerned about need to be further improved. 2. This study is a retrospective study, with certain design deviation, which needs to be further analyzed through prospective data. 3. Clinical physical examination can partly reflect the severity and prognosis of the disease, but the deterioration or improvement of micro-circulation in vivo will first be reflected in the change of some biochemical indicators. Due to limited conditions, relevant data such as cell metabolites and serum markers were not collected for inclusion in the model in this study. 4. This study tested the internal authenticity of the model, but lacked the verification of external authenticity. We know that good clinical benefits need to be demonstrated through a comprehensive evaluation of interventions, preferably by designing multicenter RCTs. It intends to further collect data to verify the applicability of the model. After continuous improvement, the early prediction model for the prognosis of sTBI has achieved relatively high prediction ability and accuracy. Although no universally applicable clinical guidelines have been formed, it has been able to provide great help for emergency departments, neurosurgeons and patients' families in treatment decision-making.
From this retrospective study, the predictive model can identify sTBI with high sensitivity and can be applied in patients with sTBI. However, a good clinical prediction model requires external validation and RCTs. We intend to gradually improve the above work in the next step Funding: None. Ethical approval: Not needed.
The authors declare that there are no conflicts of interest regarding the publication of this paper.
Yansong Xu proposed and wrote the first draft. All authors contributed to the design and interpretation of the study and to further drafts.
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.
