AUCTORES
Globalize your Research
Research Article
*Corresponding Author: Irami Araújo-Neto, Undergraduate Student of Medicine at UnP - Potiguar University - Laureate International Universities – Natal/Brazil.
Citation: Natassia Vianna Bocchese, Noele Gurgel Dávila, Maria Beatriz Maia Rodrigues, Irami Araújo-Neto, Mariana de Oliveira Costa, Diniz de Meiroz Grillo Barbalho, Amália Cinthia Meneses Rêgo, Irami Araújo-Filho. Clinical Medical Reviews and Reports. 2(3); DOI: 10.31579/2690-8794/020
Copyright: © 2020 Natassia Vianna Bocchese, 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: 26 May 2020 | Accepted: 12 June 2020 | Published: 19 June 2020
Keywords: covid-19 virus infection; sars-cov-2 infection; coronavirus infections; liver; liver diseases; liver dysfunctions
SARS-CoV-2, a severe acute respiratory syndrome caused by Coronavirus 2, discovered in 2019 in China, is responsible for the current pandemic declared by the WHO since March 2020. The clinical syndrome caused by Covid-19 has a broad spectrum of severity. The most common clinical manifestations are fever, dry cough, dyspnea, fatigue, and anosmia. The virus binds to receptors for angiotensin-converting enzyme 2 (ECA2) and serine protease TMPRSS2 for protein S initiation, which are expressed not only in the lungs but also in the liver, colonic, esophageal and biliary epithelial cells. In this context, the liver is a potential target for COVID-19 infection. Liver damage occurs during the course and treatment of viral infection in patients with or without previous liver disease. Therefore, the characteristics of liver injury associated with COVID-19 were reviewed based on research related, in the context of the pandemic.
In December 2019, a new RNA virus appeared in the world through the coronavirus mutation, known as SARS-Cov-2, capable of causing the severe acute respiratory syndrome, initially detected in a province of China, in the city of Wuhan. As of March 5, 2020, 96,000 cases of the disease and 87 affected countries had already been reported [1].
The infection is acquired by inhaling droplets containing the virus or through fomites, being able to remain alive on surfaces for a long time. Viral particles were detected in the feces, making fecal-oral transmission possible. The incubation period varies from 7 to 14 days [1].
Clinical manifestations vary, from asymptomatic to respiratory failure. The most prevalent signs are fever (50%) and cough (38%). The severity of the disease is related to the increase in inflammatory cytokines, such as IL1, IL6, IL8, and TNF-alpha. Headache, nausea, vomiting, and diarrhea have also been reported [1,2].
The levels of liver enzymes and bilirubin are abnormal in severe infections, with difficulties in the management of patients with liver disease, especially those with autoimmune hepatitis or cirrhosis using immunosuppressants [3-5].
The definition of liver injury by COVID-19 is not standardized in the scientific community; some scholars consider any change in liver function parameters as injury, and others require the need to raise the hepatogram's standard limit by three times [4,6].
Thus, it is necessary to study the hepatic manifestations in patients with COVID-19, from the mechanism by which the liver is injured, the tools for rapid recognition of the injury, including changes in the management of patients with previous liver disease.
The research was carried out in Pubmed / Medline, Scopus, Scielo, Embase, and Web of Science databases, in addition to searching Google Scholar, considered as a source of gray literature, as it does not contain peer-reviewed articles. The articles were selected according to the focus of the study: hepatic repercussions of COVID-19 and research on fecal-oral transmission. The studies were chosen by combining the following keywords: COVID-19 virus infection, SARS-CoV-2 infection; Coronavirus Infections; Liver; Liver Diseases; Liver Dysfunctions. All relevant studies published between January 2019 to the present were included in the cohort, systematic review, case-control, cross-sectional, case series studies, reviews, and editorials. The filters chosen were studies carried out in humans, complete articles, and published in the last year, totaling 24 articles. The analysis, review, and selection of articles was carried out in pairs, separately, based on the reading of the title and summary of the study, with a third reviewer in case of disagreement between the other two reviewers.
Pathophysiology
SARS-CoV uses the angiotensin-converting enzyme 2 (ACE2) and the serine protease TMPRSS2 to initiate protein S. ACE2, and TMPRSS2 is not only expressed in the lung, but also the epithelia of the small intestine, upper esophagus, liver, colon, and bile duct cells [5,6].
After viral binding to the respiratory epithelium, the expression of ACE2 becomes lower in this tissue, concomitantly with the period in which the individual progresses to acute respiratory failure, a condition present in severe forms of the disease [7-9].
In the gastrointestinal tract, an association was observed between viremia, diarrhea, and other enteric manifestations. Even after viral bleaching, clinical signs attributed to epithelial changes and disabsorption caused by Covid-19 persisted [7,8].
Liver manifestations do not have an exact mechanism. It is believed that liver damage can be caused by cytopathic damage induced directly by the virus by binding to ACE2. They were also found in patients with SARS-CoV-2, high expression of ACE2 in cholangiocytes concerning hepatocytes (59.7% x 2.6%) [6, 8].
In addition to the mechanism, as mentioned earlier, the inflammatory response to COVID-19 contributes to liver damage through the exacerbated production of pro-inflammatory cytokines [7-9].
On the other hand, studies have shown a relationship between critically ill patients infected with COVID-19 and increased levels of creatinine kinase, lactate dehydrogenase, and myoglobin. Therefore, the possibility was raised that elevations of aminotransferases did not result only from liver damage. Still, that infection by COVID-19 could cause a myositis similar to that which occurs in cases of severe flu [9,10].
Pathological studies in patients with SARS confirmed the presence of the virus in liver tissue, although the viral titer was relatively low because no viral inclusions were observed [8]. In this context, a liver biopsy performed on a patient who died due to infection presented microvesicular steatosis, mild lobular, and portal inflammation, findings commonly found in sepsis [9,10].
Hematological and hepatic changes
Blood cellularity changes with the onset of the disease and indicates severity. In a study with 1099 patients, 83.2% had lymphopenia, 36.2% thrombocytopenia, and 33.7% leukopenia. In contrast, an increase in ALT and AST levels was found, indicating liver injury, especially in severe cases [2,8,11-13].
Some studies have revealed the presence of mild steatosis, attributed mainly to drug-induced liver damage and not to the virus [12,13]. Also, inflammation mediated by the immune system, such as cytokine storm and hypoxia associated with pneumonia, contributes to mild liver damage or liver failure in severely affected patients with COVID-19 [8]. There is evidence that the virus can replicate in the liver and influence normal liver functions, as well as multiple respiratory infections [13,14].
Xie et al. observed among hospitalized patients with moderate COVID-19 (without the need for intensive care or mechanical ventilation), there was an increase in transaminases above 30%, with an elevation of AST slightly higher than that of ALT (35.4% x 31, 6%, respectively). There was also an increase in bilirubin in 5.1% of patients, with an average age of 60 years, and ⅓ had comorbidities [15].
Another trial conducted in China showed that of 13 patients in the intensive care unit, 62% had elevated AST compared to 28 patients who were not serious, where only 25% of these showed such change [4].
Patients with more severe changes demonstrated on chest computed tomography; liver changes were also more significant. In this respect, a more intense inflammatory response causes a systemic imbalance, promoting liver damage. Therefore, it is prudent that the liver function of these patients with moderate or severe lung damage is monitored early [15].
Other hepatic manifestations caused by COVID-19 were hypoproteinemia and changes in coagulation, with an extension of prothrombin time [7,16,17]. This phenomenon is believed to occur due to a viral tropism in the liver tissue, causing acute viral hepatitis, or even secondary to the use of hepatotoxic drugs [7,16-18].
The disseminated intravascular coagulation (DIC), the elevation of D dimer, and thrombocytopenia were found in 36.2%-46.4% of critically ill patients, determining a worse prognosis [18,19].
The changes in the coagulation cascade are explained by the imbalance between the pro and anticoagulant factors induced by the systemic inflammatory response to the virus. There is an increase in the production of fibrinogen, factors II, III, and X [18-20].
Changes in ferritin were observed as a nonspecific marker of inflammation and changes in iron metabolism secondary to the activation of macrophages. [9]
In addition to hepatocytes, the bile ducts are affected by the coronavirus, since viral RNA could be found in the intrahepatic bile ducts [7,8]. Children may have hematochezia as a symptom of infection with the new coronavirus. However, the most common in the general population is that manifestations, such as diarrhea and vomiting, are seen. [8,16]
Finally, biopsies performed on patients with liver disorders; lymphocytic were observed, in addition to dilation of sinusoids in symptomatic patients with COVID-19 [17-19].
Hepatopathy/risk factor
Asia and China, in particular, have a high incidence of Hepatitis B; however, data is scarce regarding its influence on COVID-19. One report suggests that about 2% of severe cases had Hepatitis B infection compared to those with mild disease (0.06%) [12].
Patients with previous hepatitis B or C infected with COVID-19 are more likely to develop severe hepatitis, just as patients with cirrhosis are more susceptible to the development of severe immunodeficiency infection [6,8,13]. Liver disease patients have a leukocytosis with neutrophilia and elevated C-Reactive Protein compared to others, who develop leukopenia and lymphocytosis more commonly [15].
People with primary gastrointestinal neoplasms have a higher expression of angiotensin two receptors, which contributes to a higher risk of infection with the new coronavirus since it has been shown to enter the cell through this enzyme. However, angiotensin 2 acts in the modulation of the systemic inflammatory response at the gastrointestinal tract level, which could contribute to regulate this response [16].
Vulnerable groups are liver transplantation, in the use of immunosuppressants, cirrhosis, chronic-acute liver failure, immune dysfunction, and those with hepatocellular carcinoma. Patients with non-alcoholic steatohepatitis associated with diabetes and cardiovascular disorders are at high risk of being infected and progressing to severe SARS-CoV-2. [12].
It is essential to highlight that data on other underlying chronic liver diseases, non-alcoholic fatty liver disease, alcohol-related liver disease, and autoimmune hepatitis and its prognostic effect in the face of COVID-19, need to be better evaluated [13].
Jin et al. point out that among patients with chronic liver disease, 10.81% evolved with gastrointestinal manifestations. In comparison, only 2.85% did not have such expressions, demonstrating a significant relationship between previous liver disease and gastrointestinal symptoms [19].
Coronavirus-infected patients exhibited elevated serum levels of monocyte-1 chemoattracting protein (MCP-1), known to aggravate COVID-19-promoted steatohepatitis [14].
Clinical studies have shown an incidence rate of diarrhea between 2% -50% of cases, which may precede or accompany respiratory symptoms [5]. This evidence reinforces the liver's exposure to the virus with malabsorption syndrome [8].
Most patients had an average of three bowel movements per day. Besides, some patients experienced diarrhea in the absence of respiratory symptoms, which can induce underestimation of cases of COVID-19 [5].
The most common signs and symptoms found were fever, cough, dyspnoea, myalgia, headache, and diarrhea. Also, many of these patients had gastrointestinal syndromes as an initial manifestation of the clinical condition [20,21].
Gastrointestinal manifestations are more frequent in pregnant women and children when compared to adults; however, studies are needed to adequately map which age groups and sex correspond to those with the highest risks for liver involvement [22,23].
A statistically significant association was found between the presence of gastrointestinal symptoms at the presentation - defined as diarrhea, nausea, and vomiting - and a positive result from the COVID-19 test [20-22].
Gastrointestinal symptoms were associated with a 70% increased relative risk of positivity on the test. [24] Other related symptoms were epigastric pain, melena, and constipation [20].
Among patients positive for COVID-19, the presence of gastrointestinal symptoms was associated with longer disease duration, a tendency to lower ICU admission rates, and lower mortality during short-term follow-up [10-12].
These combined findings may suggest that gastrointestinal symptoms are associated with a more indolent form of COVID-19, although the conclusions at this point are preliminary [24,21].
Studies have observed an association between the presence of gastrointestinal manifestations and disease severity, comparing it to patients with milder clinical conditions [14].
The virus is detected through the molecular amplification tests in nasopharyngeal smears, endotracheal aspirates, and bronchoalveolar lavage. It can also be found in feces and blood. [1]
The polymerase chain reaction (PCR) is a method of high sensitivity and specificity, used routinely.[2]. Increasing evidence indicates possible oral-fecal transmission, indicating the need for a rapid and effective modification in the screening and diagnosis algorithms [5,12].
Ozma MA et al. demonstrated that at the beginning of the clinical picture, oral and rectal swabs were positive in 50% and 25% of patients, respectively. After a few days, the values found were 50% for an oral swab and 75% for a rectal swab, suggesting that at the end of the infection, it is more likely to find positivity in the feces [2,7].
In this sense, studies have shown that half of the individuals infected with SARS-CoV-2, who eliminated the respiratory tract infection, showed viral elimination in their fecal samples up to 15 days after the respiratory samples became negative [12,15].
Patients should be stratified according to severity. Those with stable chronic liver disease have a low risk of complications. Patients with decompensated liver cirrhosis have high morbidity and mortality from COVID-19 infection [3,8].
Lleo A et al. suggested that in patients with liver disease and using immunosuppressants, the dose of this medication should be reduced, especially in those with lymphopenia. Besides, patients should be managed in transplant centers in case of liver failure [1-3].
Hepatopaths should avoid access to the hospital, with postponing non-urgent medical appointments until the end of the state of emergency. Invasive procedures, such as paracentesis, should be performed by an experienced professional and preferably in centers that do not care for patients with COVID-19. It is also necessary to reiterate the importance of the vaccine against influenza and pneumococcus [3,17].
In patients with COVID-19 and autoimmune hepatitis, the effects of the administration of glucocorticoids on the prognosis of the disease are still unclear [8-10].
Liver damage in mild cases of COVID-19 is often transient and can return to normal without special treatment. However, when severe liver damage occurs, protective drugs are administered to these patients [5,8,24].
In conclusion, according to the studies analyzed, it is possible to state that COVID-19 is a broad-spectrum disease, with manifestations that go beyond the pulmonary, including liver changes. Patients with abnormal liver function have a worse prognosis and are commonly admitted to the intensive care unit.
The approach towards chronic liver disease is still controversial, especially concerning the reduction of the dose of immunosuppressants. Still, it is a consensus that in these patients, attention should be focused on prevention, with strict control measures. Finally, the exact mechanisms of liver injury by the coronavirus are not yet fully understood, requiring further studies in this line of research.
Acknowledgement
The authors thank the Ph.D. in Health Sciences and Teaching and Research Manager at League Against Cancer, Profa. Dra. Amália Rêgo, for her contribution and relevance to the scientific discussion and supervision of this review, acting as an expert consultant on the bibliographic survey, analysis, and scientific advice. We also thank all the study components for their dedication and effort to build a scientifically validated quality study.
Disclosure of conflict of interest
There are no conflicts of interest to declare by any of the authors of this study.
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
My Testimonial Covering as fellowing: Lin-Show Chin. 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.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
