AUCTORES
Globalize your Research
Case Report
*Corresponding Author: Malin Zaddach, Department of Pediatric Cardiology, Klinikum Großhadern, Ludwig-Maximilians-University, Marchioninistraße 15, 81377 Munich, Germany.
Citation: Malin Zaddach, Julia Winter, Robert Dalla Pozza, Joachim J. von der Beek, Tobias Prell, et al, (2023), A Novel Ryanodine Receptor 2-Mutation associated with Catecholaminergic Polymorphic Ventricular Tachycardia, J. Clinical Cardiology and Cardiovascular Interventions, 6(6); DOI:10.31579/2641-0419/326
Copyright: © 2023, Malin Zaddach. 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: 31 May 2023 | Accepted: 12 June 2023 | Published: 05 July 2023
Keywords: schizophrenia; bipolar disorder; speckle tracking echocardiography; global longitudinal strain; cardiovascular disorders
Catecholaminergic polymorphicic ventricular tachycardia (CPVT) is a genetically determined arrhythmic disorder characterized by bidirectional and polymorphic dysrhythmias. Physical and/or emotional stress may trigger tachycardia, which can lead to sudden cardiac death. If not treated, CPVT has a high mortality rate of up to 31% by the age of 30 years. The prevalence of CPVT is estimated to be 1:10.000. Mutations of the ryanodine receptor 2, calsequestrin 2 and, less frequently, triadin and calmodulin are found in CPVT patients. We report the case of a four-year old boy with an unreported de novo mutation in the ryanodine receptor 2 (RYR2) confirmed by genetic sequencing. Interestingly, the first cardiac event of our patient was potentially be favoured by inhalative treatment with a short-acting beta-2 agonist.
Catecholaminergic polymorphic ventricular tachycardia (CPVT) is characterized by adrenergic stimulus triggered arrhythmia [1]. The clinical diagnostic criteria include typical history, absence of structural abnormalities, normal resting ECG and provocation of polymorphic ventricular tachycardia under sympathetic stimulation [2,3]. Other typical ECG findings include bidirectional ventricular tachycardia [4]. Alternatively, diagnosis can be made by detection of a causative genetic variant. Correct diagnosis can be significantly delayed by misinterpretation of syncopes as seizures and learned avoidance behaviour of the patient [1,5]. Differential diagnoses include Brugada syndrome, Long QT syndrome, Short QT syndrome and arrhythmogenic right ventricular dysplasia. If not treated, CPVT has an extremely high mortality, which is 30-50% by the age of 40 years [6].
Mutations in six different genes have been identified to cause CPVT, which accounts for 60-75% of CPVT patients [7]. All currently known genes encode for proteins which are crucial for regulation of the Ca2+-induced Ca2+-release from the sarcoplasmic reticulum in cardiac myocytes. In 55-60% of CPVT cases, an autosomal-dominant inherited RYR2 (encoding ryanodine receptor calcium release channel) mutation is detected. Several proteins are known to interact with RyR2 to regulate calcium release (compare figure 3), including i.e. calmodulin, FKBP12.6, protein kinase A, junctin, triadin and calsequestrin. Mutations in CASQ2 (encoding for calsequestrin 2) are found in 2-5% of cases and can be inherited autosomal dominant and recessive. Rarely, mutations in TRDN (encoding triadin) and CALM1, CALM2 or CALM3 (encoding identical calmodulin proteins) are detected [7,8]. In all cases, Ca2+ homeostasis is disrupted and elevated intracellular Ca2+ levels lead to activation of the Na+/Ca2+ pump. In gain of function mutations delayed afterdepolarization, which may cause arrhythmias, is the consequence [8,9]. Loss-of-function mutations are also reported, promoting early afterdepolarizations and re-entrant arrhythmias [3]. In cases of loss-of-function mutations, exercise stress testing is negative and CPVT does present atypical and can be associated with left ventricular non-compaction [10]. Therefore, pharmaceutical therapy depends on either reduction of adrenergic receptor activation using β-blockers or modulation of calcium efflux from the sarcoplasmic reticulum using flecainide [11]. The article aims at the description of a clinical case, to discuss the pathophysiology related to the genetic findings, treatment options and influential factors.
Our patient is a 4-year-old boy without relevant previous diseases or long-term medication. The family history of sudden cardiac death was negative. The first cardiac event occurred while the boy had bronchitis for several days. Hence, the paediatrician had prescribed a short-acting beta-2 agonist (SABA, here: salbutamol) and budesonide inhalation. The mother left her son’s room for a moment right after he had inhaled. On her return, she found the boy lifeless and immediately started resuscitation. On arrival of the emergency physician, the ECG showed ventricular tachycardia (Figure 1) and a total of three defibrillations were performed before return of spontaneous circulation was achieved.
Figure 1: ECG on arrival of emergency physician. Left: Pre-defibrillation ECG showing ventricular tachycardia. Right: Post-defibrillation.
The patient was admitted to the hospital and extensive diagnostic workup was performed. Resting ECG showed normal sinus rhythm with QTc of 459 ms and incomplete right bundle branch block. Echocardiography did not reveal any structural anomalies and EEG did not show any epileptiform activity. Holter-ECG recorded a tendency to atrial extrasystoles (total of 3%), partially occurring in couplets. There was no ventricular extrasystole or tachycardia recorded. The patient was discharged with recommendation for further evaluation in a specialized referral center. An appointment was arranged for three weeks after discharge. Two days before the planned admission, an episode of fatigue, pallor and tachycardia prompted a further consultation at the emergency room. This time, recurrent ventricular extrasystoles were visible in the ECG on arrival and sinus rhythm was reconstituted after application of amiodarone (5 mg/kg of body weight). The patient was transferred to our department for further diagnostics, including electrophysiological study and cardiac magnetic resonance imaging. During electrophysiological investigation, a stress test using orciprenalin was performed revealing intermittent prolonged QTc to a maximum of 700 ms (amiodarone effect?). Therefore, Long QT syndrome was suspected. During continuous monitoring on our pediatric ward, occurrence of several arrhythmic events was noticed (Figure 2). Mostly, arrhythmogenic events precipitated by preceding stressing incidents (i.e. blood sampling, IV access, etc.), thus, offering the clinical possibility of CPVT. With the main suspicion of an ion channelopathy, genetic diagnostics was performed to identify the causative mutation. The patient received pharmaceutical therapy using propranolol with a dosage of 3 mg/kg of body weight [12]. No adverse effects were seen. On the last follow-up, the 50 h spanning Holter-ECG was graded 2 in the Lown grading system.
Figure 2: Examples for arrhythmogenic events: (1) Recurrent ventricular extrasystoles, (2) 180° turn of QRS-vector, (3) Ventricular salvo.
Trio whole exome sequencing (Illumina DNA Prep & TWIST comprehensive exome-enrichment with sequencing on NovaSeq 6000) revealed heterozygosity for a de novo Ile4094Val missense mutation, which had not been described elsewhere (GRCh37.p13: 1:237947292 A->G;
ENST00000366574: c.12280A>G). In silico analysis of our patient’s variant, using the algorithms Sorting Intolerant from Tolerant (SIFT) and Polymorphicism Phenotyping (PolyPhen), predicted a deleterious (0) and possibly damaging (0.809) effect concordant with a CADD Score of 25,6. In summary, the results of all applied bioinformatic prediction tools indicated a pathogenicity of the variant found.
We present a case of a 4-year-old patient presenting with sudden cardiac arrest due to ventricular tachycardia who was finally diagnosed with CPVT. Genetic testing revealed a novel Ile4094Val mutation in this case. The nonpolar, neutral amino acid isoleucine is substituted by the equally nonpolar, neutral, but smaller valine within the I-domain (interacting domain, amino acids 3722-4610) of RyR2, which has been characterized as a mutational hotspot (Figure 3). This region plays a key role in transducing regulatory cytoplasmic events to the C-terminal pore-forming transmembrane domain and mutations promoted abnormal Ca2+ release [4,8]. A variant in immediate vicinity to our patient’s mutation has been described as pathogenic before and bioinformatics analysis predicted a damaging effect underlining the pathogenicity of the identified mutation [13].
Figure 3: Schematic overview of the four subunits forming RyR2 and its interactions with protein kinase A (PKA), FKBP 12.6, protein phosphatase 1 (PP1), protein phosphatase 2A (PP2A) and triadin-junctin-complex, which interacts, in turn, with calsequestrin. Mutational hotspot regions of RyR2 are marked A-D. The variant found in our patient (Ile 4094Val) is highlighted with a yellow star. Figure created with BioRender.com.
Interestingly, the first cardiac event took place after inhalation of a SABA. Although, reports of arrhythmic events in connection with SABA inhalation are missing, there is evidence of a higher rate of supraventricular tachycardia in pediatric patients who underwent SABA treatment [14]. One large study reports an elevated risk of 1.89 (95% CI 1.31-2.73) of arrhythmia (mostly atrial tachyarrhythmia and premature ventricular and atrial beats) for children prescribed a SABA [15]. Seen the genetic predisposition of our patient, a interrelation between an increased vulnerability to arrhythmias triggered by beta agonist treatment seams possible.
RyR2 is not only found in cardiac myocytes but is also widely expressed in the brain, exerting a key role in Ca2+ homeostasis. RYR2 mutations were identified in some cases of benign epilepsy of childhood with centrotemporal spikes. The prevalence of intellectual disability is reported to be higher (8%) in CPVT patients as compared to the general population [16,17]. Interestingly, our patient showed mild cognitive delay and had been in occupational and speech therapy. Although the EEG was normal, we recommended further neurological follow-up for early recognition of epileptogenic activity.
Our patient was placed under appropriate medical therapy with β-blocker. Implantation of a cardioverter-defibrillator (ICD) was dispensed, as the events, which had occurred, had not been under pharmaceutical protection. In addition, occurrences of extrasystoles in physical or emotional stress situations were significantly reduced under monotherapy with propranolol. Complications such as infections, need for revision and non-adequate shock application are frequently seen in ICD-therapy, turning it into a second line therapy option in CPVT patients [18]. In selected cases medical therapy with propafenone, flecainide or carvediolol might be an option [19].
Although not obvious at the very first glance, the typical history of arrhythmic events provoked by inhalation of a sympathomimetic or emotional stress, a structural normal heart, normal resting ECG, a typical novel receptor mutation, which is located in the typically causative RyR2 protein, confirmed the final diagnosis of CPVT. In CPVT patients, a multidisciplinary approach on an individual basis including all therapeutic management strategies (i.e. medication, ICD, left cervical sympathetic denervation), is essential to achieve the best treatment possible, balancing safety and quality of life. [10,19]
Care-for-Rare Foundation, Munich
None.
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
