AUCTORES
Globalize your Research
Case Report
*Corresponding Author: Ruli Ge or Jinbo Chen or Hongcai Wang, PhD, Department of Neurology, Binzhou Medical University Hospital, No. 661, the 2nd Yellow River Road, Binzhou City, 256603, Shandong Province, China.
Citation: Qingqing Zhang, Mengdi Wang, Wenxiang Xu, Zhenghao Shi, He Ma, et all (2022). Atypical Septic Cerebral Embolism in the Fatal Infective Endocarditis. J. Neuroscience and Neurological Surgery. 11(4); DOI:10.31579/2578-8868/223
Copyright: © 2022 Ruli Ge or Jinbo Chen or Hongcai Wang, 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: 04 January 2022 | Accepted: 26 January 2022 | Published: 01 February 2022
Keywords: infective endocarditis (ie); streptococcus agalactiae (gbs); cerebral embolism; heart failure
Streptococcus agalactiae (GBS) is an unusual cause of infectious endocarditis. At present, evidence suggest that the increasing impact invasive GBS disease occurs on adults. A 51-year old man, had a history of cirrhosis, fundus, esophageal varices, upper gastrointestinal bleeding for 11 years, with spleen resection, fundus and esophageal varices ligation. First clinical feature as right wrist and finger movement dysfunction with low-grade fever was described. Cerebral embolism induced by severe infectious endocarditis was confirmed by MRI+DWI in the early stage. The cardiac color Doppler showed the development of aortic valve vegetation (10 mm x 10 mm), which moved into the aortic sinus in systolic phase and the left ventricular outflow tract, severely affecting hemodynamics. ST-segment depression in the ECG and the elevated serum troponin were indicated. Bacterial isolates from blood cultures revealed that Streptococcus agalactiae (Group B Streptococcus) infection. Despite the infection control and supportive treatment, the patient's condition continued to deteriorate, characterized by intermittent fever, chest pain, sitting breath and coughing up pink and foam sputum. Acute left heart failure was confirmed by echocardiography. The cardiac surgery was complicated and have high risk. The patient eventually died of myocardial infarction and heart failure. Infectious endocarditis should be considered in patients without native valve disease who have cerebral infarction involving anterior and posterior circulation of cerebral artery and prolonged fever. Considering the severity of GBS infection, early recognition and prompt treatment was cardinal importance for the forward prognosis of infectious endocarditis.
Infective endocarditis (IE) is rare but potentially lethal disease, with an incidence of approximately 3 to 9 per 100 000 persons per year in developed countries [1]. Furthermore, left-sided infective endocarditis caused by Streptococcus agalactiae (group B streptococci, GBS) have low probability of occurrence [2]. The most prevalent underlying diseases associated with GBS infection are intravenous drug addiction and valve heart disease. In this paper, we report a rare case of low immunity with irrhosis, fundus, esophageal varices, upper gastrointestinal bleeding acquired Streptococcus agalactiae infection and presented with brain infarction as well as myocardial infarction and heart failure.
A 51-year old man, had a history of cirrhosis, esophageal varices, upper gastrointestinal bleeding for 11 years, with spleen resection, fundus and esophageal varices ligation. He has a history of 30 years of smoking. No family history, no dental visits, no history of use of steroids or immunosuppressive drugs and was not an intravenous drug user.
In the beginning, the patient with high fever 39.0 °C was recognized as influenza virus in community hospital and treated with antivirus medicine. The impaired physical mobility was mild and he did not seek medical attention. He was received antivirus and antibiotics treatment for high fever. After 6 days treatment, the high fever was controlled. But deterioration of right wrist and finger dysfunction leads him to seek medical care. Sustained worsening of the patient's condition indicated that intermittent fever, chest pain, orthopnea and coughing up pink-tinged, foamy sputum. Considering the coronary artery was blocked by the aortic vegetation. Due to the severe complication of heart, the risk of surgery is extremely high. The patient eventually died of severe acute cerebral infarction, myocardial infarction and heart failure.
Admission examination indicated that the patient’s temperature was 38.3 °C, blood pressure was 120/55 mmHg, heart rate was 78 beats per minutes, respiratory rate was 22 breaths per minute, and oxygen saturation was 98% on room air. No obvious bleeding spots or erythema were seen on his skin. The patient had no disturbance of consciousness and meningitis. The state of mind is clear with clumsy speech. The muscle strength of right finger grade 0 and wrist grade 1. The remainder of the neurological exam were normal including normal muscular tension, bilateral Babinski sign (-). Cardiac auscultation indicated that low heart tone and grade 4/6 diastolic murmur of aortic valve.
Blood test: AST 29.3U/L(normal: 29~35 U/L), albumin28.7 g/L(normal: 3~50 g/L), alkaline phosphatase 116.0 U/L(normal: man45~125 U/L), g-glutamyltranspeptidase 73.4 U/L(normal: 3~50 U/L), lactate dehydrogenase 275.4 U/L(normal: 135.0~215.0 U/L), a-hydroxybutyrate dehydrogenase 213.5 U/L(normal：90~182 U/L), LDL 2.71 mmol/L(normal: 2.07~3.37 mmol/L), tumor marker: NSE 16.89ng/ml (normal:<12>
Two days later, AST 51.3 U/L, albumin 29.0 g/L, white blood cell 21.86x10^9/L, neutrophilic granulocyte 19.77x10^9/L, BNP 1374.8 pg/ml, troponin I 2.66 ng/ml.
Bacteria isolation and blood culture: Streptococcus agalactiae (Group B Streptococcus) (GBS) were positive. The procedures were repeated 2 times.
The MRI of the brain showed the increased signal intensity on Diffusion-weighted imaging (DWI) in the left frontal lobe and bilateral cerebellar hemispheres, implying acute lacunar infarction, multiple intracranial arteriosclerosis, and local stenosis of the right cerebral anterior artery A1 segment (Figure.1).
The ultrasonography of carotid artery revealed an increase in blood flow resistance of the left vertebral artery. Cardiac color Doppler showed a moderately strong echo of the aortic valve 10 mm x 10 mm (aortic valve vegetation). The aortic valve vegetation moved into the aortic sinus in systolic phase, and into the left ventricular outflow tract, severely affecting hemodynamics (Figure. 2).
The heart color ultrasound was further confirmed that acute left heart failure occurred. The ECG indicates that the ST segment is significantly depressed, and the serum troponin are elevated.
In this paper presented as a case of severe IE induced by GBS with neurological complications in a patient with an history of cirrhosis, esophageal varices, upper gastrointestinal bleeding. As more evidence suggest that endocarditis is a clinical definable and treatable disease [3]. Despite improvement in the prevention and therapeutic strategies, the fatality rate due to IE has not significantly reduced [3]. The most prevalent underlying diseases associated with IE is devices, congenital heart lesions, underlying native valve disease including rheumatic heart disease, calcific aortic stenosis and mitral valve prolapse. The risk for IE in patients with no previously seen structural changes in the heart is intravenous drug abuse, chronic hemodialysis and central venous access. Young patients tend to have chronic rheumatic heart disease or congenital heart disease and elderly patients are likely to have degenerative valve disease [4]. Although there is no artificial valve or heart disease for this case, the patient has low immunity such as diabetes and cirrhosis. The history of cirrhosis, fundus, esophageal varices, upper gastrointestinal bleeding revealed that the low immunity exist.
The patient's bacterial blood culture was positive for the second time as Streptococcus agalactiae. Left-sided infective endocarditis caused by Streptococcus agalactiae is rare and serious [2]. Streptococcus agalactiae frequently affects patients with debilitating diseases and was involved in native valves. It is charactered by a rapid clinical worsening and severe valve destruction, and high mortality has been reported [5-7]. The condition of patients worsened significantly due to the infection of Streptococcus agalactiae.
Streptococcus agalactiae often occurs in chronic diseases with immunosuppressive conditions, such as diabetes mellitus, alcoholism, pregnancy, intravenous drug abuse, and genitourinary disease [5]. Streptococcus agalactiae still have a high mortality rate, although the prognosis of infective endocarditis has improved significantly with the development of cardiac surgery [6]. Although GBS induced left-sided IE is much less frequent than Staphylococcus aureus left-sided IE, GBS infective endocarditis represented less than 3% of all IE cases throughout the years. GBS has similarly aggressive and onset as Staphylococcus aureus. Both present with acute fever, but GBS is not accompanied by skin lesions. It usually develops serious complications and a heart surgery is frequently required during the admission. Despite its easy medical treatment and the performance of early surgery, it has high mortality [2]. Thus, early recognition and treatment for GBS carried great weight.
There are four main factors that influence the prognosis of infective endocarditis: patient characteristics, presence or absence of cardiogenic or non-cardiac complications, infected microbes, and echocardiographic findings. Echocardiography is central to the diagnosis and helpful for the management of patients with IE. Echocardiographic evidence of an oscillating intracardiac mass or vegetation, an annular abscess, prosthetic valve partial dehiscence, and new valvular regurgitation are major criteria in the diagnosis of IE. Several echocardiographic features suggest patients at high risk for a complicated course or with a need for surgery. These features include large (>10 mm in diameter) vegetations, severe valvular insufficiency, abscess cavities or pseudoaneurysms, valvular perforation or dehiscence, and evidence of decompensated heart failure [8]. The greatest risk of embolic complications appears to occur with large (≥10 mm) vegetations on the anterior mitral leaflet [9]. Left-sided IE is always associated with stroke onset [9]. The aortic valve vegetation induced the cerebral embolism. As everyone known that embolism is one of the most severe complications of IE, and it is accepted as one of major determinants of prognosis increasing mortality. Embolism usually occurs in the first two weeks after the diagnosis of IE [11-12]. Surgical treatment is urgent to do because vegetation of >1 cm in left-sided IE is associated with higher mortality [13]. In this case, vegetation was >1 cm, the aortic valve vegetation moved into the aortic sinus in systolic phase, and into the left ventricular outflow tract, severely affecting hemodynamics.
The low resistance and tolerance to infection in patient prone to GBS infection with high mortality, suggesting a poor prognosis. Early surgery (during initial hospitalization and before completion of a full course of antibiotics) is indicated in patients with IE who present with mobile vegetations >10 mm and valve dysfunction resulting in symptoms or signs of heart failure. Because and high risk for surgery and the family members of the patients refused surgical treatment, the patient eventually died of severe acute cerebral infarction, myocardial infarction and heart failure [14].
This work was supported by grants from the National Natural Science Foundation of China (NSFC) (81601108), Natural Science Foundation of Shandong Province of China (ZR2016HQ14).
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
