AUCTORES
Globalize your Research
Research Article
*Corresponding Author: Mohammed A. Gomaa, Department of Otolaryngology, Minia faculty of Medicine at Minia University, Minia, Egypt.
Citation: Gomaa M A, Mamdouh H, khalaf Z, Abd El-hakeem WH, Zaky EA. (2021) Cognitive Impairment in Children with Adenotonsillar Hypertrophy. J. Neuroscience and Neurological Surgery. 8(1); DOI:10.31579/2578-8868/147
Copyright: © 2021 Mohammesd A. Gomaa, 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: 11 November 2020 | Accepted: 21 December 2020 | Published: 01 January 2021
Keywords: obstructive sleep apnea; adenotonsillectomy; cognition.
Pediatric OSA affects 1 to 3% of the population and appears to affect boys and girls equally [4]. The most commonly cause of pediatric OSA is adenotonsillar hypertrophy. Thus, the primary treatment is adenotonsillectomy. Pediatric OSA has been associated with some psychological problems, of which neurocognitive and depression , difficulties particularly in memory , attention, learning and executive function, are the most widely reported. The neurocognitive deficits is due to the adverse effects of sleep fragmentation and/or intermittent hypoxia .Scholastic performance have been reported in little studies of pediatric OSA, and such findings may underscore more extensive behavioral disturbances such as restlessness, aggressive behavior, excessive daytime sleepiness and poor test performances. The aim of this study was to evaluate the effect of adenotonsillectomy (AT), in children with Obstructive Sleep Apnea (OSA), on the cognitive and scholastic achievement.
Obstructive sleep apnea (OSA) in children is a breathing disorder that results in repeated and/or prolonged airway obstructions during sleep, in the form of apneas and hypopneas throughout the night [1]. The highest incidence of pediatric OSA occurs in early childhood [2], particularly between 2 and 8 years of age [3]. Pediatric OSA affects 1 to 3% of the population and appears to affect boys and girls equally [4]. The most [5] commonly cause of pediatric OSA is adenotonsillar hypertrophy. Thus, the primary treatment is adenotonsillectomy, which accounts for more than 500,000 procedures annually in the United States alone [5]. OSA is known as sleep-disordered breathing [6] (SDB). This spectrum ranges in severity from habitual snoring to upper airway resistance syndrome (UARS) to OSA. As OSA influence about one to three percent of pediatric population [6], it has been associated with some psychological problems, of which neurocognitive and depression , difficulties particularly in memory , attention, learning and executive function, are the most widely reported. The neurocognitive deficits is due to the adverse effects of sleep fragmentation and/or intermittent hypoxia [7]. Some studies have reported the presence of significantly reduced IQ scores compared with control children [8]. Scholastic performance have been reported in little studies of pediatric OSA, and such findings may underscore more extensive behavioral disturbances such as restlessness, aggressive behavior, excessive daytime sleepiness and poor test performances [9]. While Marcus et al. [10] pointed that the surgical treatment of pediatric OSA didn’t did not significantly improve attention or executive function as measured by neuropsychological testing but did reduce symptoms and improve secondary outcomes of behavior, quality of life, and polysomnographic findings, thus providing clues of beneficial effect of early AT.
The purpose of the present study is to evaluate the effect of adenotonsillectomy (AT) on the scholastic and cognitive achievement of children with OSAin order to establish a plan for proper management of those children.
Materials and Methods
The current study is a prospective one that done at the Department of Otorhinolaryngology from October 2016 to July 2019. It was approved by the Research ethics committee of the Faculty of Medicine, Minia University and signed informed consent was obtained from parents/ guardian of the children. One hundred Fifty children suffering from recurrent attacks of tonsillitis with or without chronic nasal obstruction were selected as pool for the present study. They were 73 males (48 %) and 77females (52%), with a mean age 101.5±15.6 of and a range of (72-120) months.
Inclusion criteria were as follows: (1) Children with age ranging (5-12) years. (2) Well diagnosed with obstructive sleep apnea (OSA) due to adenotonsillar hypertrophy.
The exclusion criteria were as follows: (1) Age below 5 years and above 12 years; (2) Children taking sleep (hypnotics) or neurobehavioral drugs; (3) Children with Previous adenotonsillectomy; (4) Children with craniofacial syndromes; (5) Children with hearing impairment (SNHL); (6) Obese children (Body Mass Index (BMI) ≥ 30).
All one hundred fifty children were subjected to the following protocol to classify the study and control groups
2-Auditory perceptual assessment (APA) of speech (degree of closed nasality). The speech of each case were assessed from two expert phoniatricians for the degree of closed nasality (From I to IV) after recording of the patient's speech for a nasal sentence [11].
3- (ENT) Examination Otolaryngological examination: Oral and oropharyngeal examination (lips, teeth, tongue, hard and soft palates, uvula, tonsillar pillars, tonsils, lateral and posterior pharyngeal walls) was examined by Otolaryngologist with a tongue blade and a good light. Then tonsillar hypertrophied were graded by Brodsky scale (From zero to 4) [5].
Examination of the nasopharynx through nasopharyngoscopy, for evaluation of the velopharyngeal area (velar mobility, lateral pharyngeal wall mobility, presence of adenoid and degree of narrowing the air column, type of closure, presence or absence of passivent's ridge).
4- Polysomonography PSG was performed using a digital polygraph system (Grass-Telefactor Twin version 2.6; Astro-Med Inc., West Warwick, RI, USA). The data were manually scored according to the American Academy of Sleep Medicine , Version 2.0 Berry et al., [11].polysomnography (PSG) study using standard clinical pediatric techniques and a commercially available sleep system for diagnosis of OSA. The current gold standard for the diagnosis of OSA, as recommended by the American Academy of Pediatrics (AAP), is a PSG study. Polysomnographic diagnostic criteria for OSA depends on the following parameters Apnea-Hypoapnea index (AHI) (represents the average number of obstructive or partially obstructive events per hour of sleep and considered abnormal if greater than 1 in children), a minimum oxygen saturation (less than 92 percent (average: 96 percent ± 2 percent) is considered abnormal in children).According to the inclusion criteria in table-2 we classified the patient to study group and control group [1].
We selected one hundred patients according to inclusion and exclusion criterias which were mentioned before , fifty child as study group with OSA that documented by PSG and fifty child suffer from chronic tonsillitis without OSA as a control group, . Both groups were subjected to protocol of evaluation the psycholinguistic abilities and IQ preoperatively as follow:
1-Parents interview and history including complaint, personal data, personal history, in addition to the clinical findings of prolonged upper airway obstructive symptoms, including OSA (recurrent episodes of apnea and hypopnea, secondary to collapse of the upper airways during sleep), snoring, mouth breathing, adenoid fancies, enuresis, and restlessness during sleep (if accompanied by snoring at night). History of arousal or awakening, and distrust sleep continuity.
2-Auditory perceptual assessment of speech (degree of closed nasality). The speech of each case were assessed from two experts for the degree of closed nasality after recording of the patient's speech for a nasal sentence [11].
3-Audiological evaluation included middle ear assessment through immitancemetry (Tympanometry and Acoustic Reflex threshold recording) and hearing assessment. According to the age of child. Hearing assessment was performed through one of the following methods: Free field audiometry and Behavioral Observational Audiomety (BOA).pure tone audiometry (Conditioned play or conventional audiometry).
4-Psychometric evaluation by Intelligence Quotient "IQ" using Stanford Binet Intelligence Scale (4th edition). The Stanford-Binet scale tests intelligence across four areas: verbal reasoning, quantitative reasoning, abstract /visual reasoning, and short-term memory. The areas are covered by 15 subtests. Raw scores were based on the number of items answered, and were converted into a standard age score corresponding to age group. Mental age was determined for each child: I.Q = Mental age chronological age ×100Gary [13].
5-Illinois test of psycholinguistic abilities (ITPA):
It is an individually administered battery of tests designed to measure the spoken and written language abilities of children aged 5-12 .it may be used for determining specific strengths and weakness among language abilities, for early identification of children at-risk for school failure.
It consists of twelve subtests Adel Aziz A et al., [14].
6-Percentage of the child's scores of his subjects (Academic performance) in two academic terms, which were obtained from academic reports taken from the school.
All patients (cases and control groups) underwent Adenotonsillectomy (AT) under general anesthesia. Then finally after eight months of adenotonsillectomy all the patients were followed by:
The data was collected from every battery of evaluation and subjected to I.B.M. compatible computer using software SPSS (Statistical Package for social science) for windows version 13 for statistical evaluation. Graphics were done by Excel. Quantitative data were presented by mean and standard deviation, while qualitative data were presented by frequency distribution. Wilcoxon signed-rank test for ordinal qualitative data between the two times: Significant level at P-value <
0.05. Paired samples T-test for parametric quantitative data between the two times: Significant level at P-value < 0.05. Pearson’s correlation: Significant level at P-value < 0.05. Spearman’s rho correlation. Significant level at P-value < 0.05 P-value was considered statistically significant (S) if <0.05 and highly significant (HS), if <0.001 and no significant (NS) if >0.05.
Results
The study group had age range between (7-10 years) and mean 8.8±14.6.They were 29 males and 21 females.
All patients in case group suffer from Moderate to severe closed nasality according to auditory perceptual assessment, Grade III to IV with tonsillar hypertrophied as measured by Brodsky scale, positive signs of Adenoid faces, Symptoms of OSA, the adenoid occupied 50-100 % of the choanal area. PSG of the study group revealed that Apnea-Hypopnea index (AHI) ˃ 1 and oxygen saturation less than 92 percent. The control group (children without OSA) included 50 children, they have mild closed nasality according to auditory perceptual assessment, Grade 0 to I of tonsillar hypertrophied with by Brodsky scale, negative signs of Adenoid faces, no Symptoms of OSA, the adenoid occupied less than 25 % choanal area and with the PSG the had Apnea-Hypopnea index (AHI) <1 and oxygen saturation more than ≥ 96 percent. The age of control group between (7-9 years) and mean 7.9±14.6.They were 26 male and 24 female (table 1-2).
Also, we found 30% of the children in the study group had type B tympanogram in comparison to 6% in the control group (table-5).
The children in the study group had low IQ and low mental age in comparison to the control group (table-6).
The children in the study group had low score in all subtest of Illinois test of psycholinguistic abilities (table-7) and had low percentile of academic performance in comparison to the control group (table-8).
After eight months of adenotonsillectomy, the children in the study group had improvement in nasal tone of speech as 2% only has marked closed nasality (table-9) and most symptoms of OSA disappeared (table-10), only 8% had type B tympanogram (table-11).
The results revealed no statistically significant difference were obtained between the two groups regarding the mental age, IQ (table-12), as well as subtest of Illinois test of psycholinguistic abilities (table-13). Also, our data showed improvement in percentile of academic performances of the study group in comparison to the control group (table-14).
Our results showed that, there were a Statistical significant differences between preoperative and postoperative results of the study group in the following parameters, the PLA of AR (auditory reception), VR (visual reception), auditory sequential memory, VE (Visual Expression), ME (Mental Expression) as p<0.05). Also, Statistically significant differences were obtained between the preoperative and postoperative of the study group concerning the PLA of VSM (Visual sequential memory), AA (Auditory association) VA (Visual association), AC (Auditory closure), VC (Visual closure), GC (Grammatical closure) and SB (Sound Blending) as p<0.001). The current study pointed out that a statistically significant differences were obtained between the preoperative and postoperative results of the study group in the the Total PLA. (p<0.001). The mean Total PLA in the preoperative examination of the study group were 72.6±12.1 with a range (50-98) months, and the mean Total PLA in the postoperative data of the study group were 83.1±12 with a range (50-98) months (Table-15).
A Statistical significant differences were obtained between the preoperative and postoperative results of the study group as regard Academic performance. (p<0.05). The mean Academic performance in the preoperative examination of the study group were 66.6±12.1 with a range (46-70) percentage, and the mean Total row score in the postoperative examination of the study group were 83.1±12 with a range (60-98) percentage (Table-16).
In children, OSA is a disorder characterized by repeated and/or prolonged airway obstructions during sleep, in the form of apneas and hypopneas throughout the night [1]. OSAS exhibits specific cognitive dysfunctions that include deficits in memory, problem-solving, and behavioral functioning [14-15]. This is problematic, as SDB with AHI < 1 can still impact children's academic performance and behavior [16]. Friedman et al. [17] reported that young children who snore frequently and loudly during sleep are at greater risk for poor academic performance in later years, even well after snoring has resolved, suggests that the neurocognitive deficits may be only partially reversible after treatment. AT results in significant improvement in clinical as well as polysomnography parameters. Improvement in learning and behavior has been reported following the treatment of OSAS in children. The purpose of our present study was to evaluate the effect of AT on the academic and cognitive achievement of children with OSA so proper management of those children can be established. The study group included 50 children well diagnosed as OSA due to adenotonsillar hypertrophy confirmed by polysomnography compared to another control group of 50 children without symptoms of OSA.
The study group reported nighttime symptoms, including mouth breathing, apneic episodes, frequent awakenings, and restlessness. Children also had enuresis, behavior problems, deficient attention span, and daytime somnolence. The study group improved most of OSAS symptoms post AT, and this attributed to the removal of the upper airway obstruction. 60% of patients in our study had a severe degree of hyponasal speech, and 40% had a moderate degree of hyponasal speech pre-AT, but 8 months post AT only 4 % of the patients had moderate hyponasal speech, and 12 % had a mild degree of hyponasal speech. This improvement of the auditory perceptual assessment can be attributed to the removal of the obstructive effect of adenoid on the choana, i.e., get rid of the anatomic and physiological factors that constrict the space of nasopharynx and compromising the soft tissues surrounding the pharynx that predispose to upper airway collapse and change in normal resonance of the vocal tract.
Cognition is a mental act that includes perception, reasoning, awareness, and intuition. Executive function encompasses the mental processes that enable children to plan, focus, remember instructions, and juggle multiple tasks successfully.
Psycholinguistics evaluations were carried out before and after AT for our patients revealed a significant difference between children in the study and the control group. The mean IQ of children in our study was increasing from 80.9±5.9 (pre AT) to 84.1±5.6 (post AT). Our result revealed a negative significant correlation between AHI and IQ, of the study group (p<0.001). This improvement of IQ in our patients with OSA can be attributed to the improvement of the upper airway obstruction during sleep, disappearance of intermittent hypoxemia, improvement of ventilation, and enough hours of a deep sleep. Eight months post AT considered enough duration to raise intellectual functions, so improvement in IQ was detected. These results match most of the published data about the improvement of IQ after AT in children with OSA. As Friedman et al., [17] conducted a prospective study to evaluate neurocognitive functions of children with OSAS, before and after AT, he found that six to ten months after adenotonsillectomy, the children with OSAS demonstrated significant improvement in sleep characteristics, as well as in daytime behavior, and their neurocognitive performance improved considerably in most tests conducted. However, on the other side Abd-Allatif et al. [18] in their study stated that the intelligent quotient (IQ) as an indicative parameter of neurocognitive function in children with adenoid hypertrophy not improved with adenoidectomy and there is no relation between adenoid hypertrophy and IQ. Taylor et al. [19] stated that significant improvement in the NESPY Auditory attention and response set of children with OSA seven months after early AT Children with primary snoring, as well as those with OSA, are at higher risk for deficits in attention compared to control children when measured on parental report scales, and that such deficits are substantially improved following treatment with AT [9].
The mean PLA of Auditory association, visual association, auditory closure, visual closure, and manual expression, were raised 8 months after AT. This wide improvement in neurocognitive functions was attributed to the correction of the obstructive symptoms, improvement of sleep disruption, intermittent hypoxemia and inattention after AT, and in turn the improvement of the neurocognitive function as well as the intellectual functions demonstrated from the results of the IQ. We think that normal language development in children is such an important factor in acquisition of reading and writing skills. Most children with OSA had a history of delayed language development during their early life. Phonetic sounds are acquired between ages 3–7 years, which is also the peak age for hypertrophy of the tonsils and childhood OSA. Our results matched to Correa et al., [20] who stated that the late diagnosis and treatment of OSA is associated with a delay in verbal skill acquisition.
The study that done by Marcus et al, [10] it evaluate the difference between adenotonsillectomy and wait and watch policy for management of OSAS, the study was randomized, multicenter and controlled trial. It measures cognitive, Polysomnography and behavioral patterns, At baseline and seven months after AT, they found that As compared with a strategy of watchful waiting, surgical treatment for OSAS in school-age children did not significantly improve executive function or attention when measured by neuropsychological testing but did reduce symptoms and improve secondary outcomes of behavior, quality of life, and polysomnographic findings, thus providing evidence of beneficial effects of early AT.
we found that children with OSA due to adenotonsillar hypertrophy had poor academic achievement owing to obstructive symptoms of upper respiratory tract but eight months post adenotonsillectomy there were improvement of 12 points of Illinois test in the Mental Processing and increasing in the academic performance also Parents of our children noticed that their children became more attentive and slept better without snoring, less impulsive and hyperactive.
The diagnosis and treatment of OSA should be emphasized, not only because of the possible implications for oral language, as demonstrated in the reviewed studies, which tend to worsen as the chronological age increases but also for the benefits in neurocognitive performance and quality of life. Weber et al. [21] stated that OSA children show a higher frequency of disorders of receptive and expressive language skills, mostly under diagnosed and thus not treated. A more multi-disciplinary investigation of OSA children is needed to foster the evidence. In current study, there were increase in the score of PLA of VE (Verbal Expression) and grammatical closure. This improvement can be attributed to children with OSA due to adenotonsillar hypertrophy and Eustachian tube dysfunction, positive middle ear pressure, middle ear fluid accumulation, conductive hearing loss, all these causes impaired language acquisition, causing impairment in language development (semantic, syntactic, phonological and pragmatic development).
Ikedia et al [22] reported that to assess whether tonsillectomy and AT surgeries would bring benefits as far as school performance is concerned in children with OSA, psychological evaluations were carried out before and after the surgery. Gozal& Pope [22] investigated 300 children with the worst grades in a school, 18.1% of them had gas-exchange (O2 and CO2) disorders during sleep. Of those with obstructive sleep disorders, half were submitted to adenoidectomy. They noticed that the group submitted to adenoidectomy had a significant increase in school performance. The other half, without disorders, kept their mean scores. AT is effective in treating breathing problems in most children with OSAS and also appears to help improve their academic and intellectual performance and general behavior [17].
In the current study, eight months post AT, the mean Academic performance was increasing from (post AT) in comparison to the control group. This improvement was demonstrated from increasing in the scores of the children' school subjects also from the results of the tests carried out (Stanford Binet Intelligence Scale and Illinois tests). Parents / guardian of the study group noticed that their children became more attentive, no snoring, sleep better, less hyperactive and less impulsive All these changes will Benefit the entire family. The improvement in the previous parameters attributed to correction of frequent arousals during sleep, intermittent nocturnal hypoxia, anxiety, impulsivity, deficits in emotional regulation, alertness, inattentive behaviors, And attention to tasks after removal of Adenoid and tonsils that obstruct upper airway. This correction leads to improvement in the memory and IQ, resulting in an increase in academic performance. The improvement of language expression,, which was impaired in the Illinois subsets, after surgical correction of OSA, This correction lead to increase in the mean age of the verbal expression, grammatical closure and sound blending subtests of Illinois test After eight months post AT than pre AT.
Language is a very important factor for good academic achievement so this important finding can help in the prediction of poor academic achievement or learning disabilities through appreciation of language impairment; also we raise attention to the importance of early detection or screening for language impairment in children in the hope of preventing possible late severe learning disabilities. This study (up to our knowledge) is the first study to use Illinois test to determine specific strengths and weaknesses among language abilities, for early identification of children at-risk for school failure. An improvement of 12 points of Illinois’ test in the Mental Processing following AT is a very substantial improvement. This change enables the children to reach their original abilities and fulfill their cognitive potential. Cognitive factors such as memory, attention, intellectual and school performance improved significantly after AT. Visual and auditory short-term memory, as well as the ability to solve problems and to think analytically improved. These findings suggest that OSAS is a reversible disruptive factor to the neurocognitive function and school performance of children, at least in the short term (8 months after therapy).
The study was approved by the research ethics committee of the Faculty of Medicine and in agreement with Helsinki declaration. Informed signed consent is taken from the parents/ guardian of the children.
Conflict of interest: None
Funding: 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
