AUCTORES
Globalize your Research
Case Report
*Corresponding Author: Reham AlGhazo, Al Emadi Hospital Qatar.
Citation: Reham AlGhazo, Khaldown M Alaweneh, Noran K Kofahi, Ali M Ibnian, Ahmad Awad, et al, (2024), Huge and multiple xanthomas misdiagnosed as rheumatoid nodules and mistreated with multiple surgical excisions over 4 years, a case report, International Journal of Clinical Case Reports and Reviews, 19(2); DOI:10.31579/2690-4861/534
Copyright: © 2024, Reham AlGhazo. 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: 29 August 2024 | Accepted: 09 September 2024 | Published: 14 October 2024
Keywords: xanthoma; multiple skin nodules; familial hyperlipidemia; unnecessary surgery; misdiagnosis
Background: Xanthoma is the iceberg of familial hypercholesterolemia; it’s resemblance to other cutaneous lesions such as rheumatoid nodules might lead to misdiagnosis. We emphasize in this case report the importance of comprehensive clinical and investigatory approach to cutaneous lesions as they could be the only manifestation of systemic diseases, and this helps to avoid delayed management and unnecessary interventions.
Aim: Xanthomas as a possible diagnosis for multiple skin nodules, as it can be easily supported by performing simple noninvasive blood tests; the lipid panel.
Case report: Female patient, presented with multiple skin lesions and a strong family history of premature coronary artery disease. She was firstly managed with multiple surgical resections as having benign masses, and later was misdiagnosed as having rheumatoid nodules and referred to rheumatology clinic for evaluation, wherein a clinical suspicion of xanthomas originated, and was supported by the severely elevated serum LDL level and a tissue diagnosis of xanthoma. She has been started on statins with regular clinic.
Conclusion: The purpose of this case study is to explain the importance of including xanthomas within the differential diagnosis of recurrent skin lesions. Whereas the tissue diagnosis is the gold-slandered investigation, simple noninvasive blood test, serum lipid measurement can be the clue for diagnosis of the hidden fatal but easily controllable disease; familial hypercholesterolemia.
Xanthomas are painless slow-growing masses containing lipid-laden macrophages called foam cells [1, 2]. Xanthomas commonly develop at the skin and tendons specifically the extensor surfaces of the elbows, wrists, knees, and ankles; regions exposed to regular mechanical stress [3, 4]. In addition, xanthoma may also appear on other deep connective tissues (e.g., tendon sheath, synovium, and bone), as well as other sites including the stomach, aryepiglottic folds, larynx, and urinary bladder [5-7].
Tendon xanthomas are directly linked to underlying familial hypercholesterolemia (FH) [8]. FH has a large spectrum of genetic mutations and different doses of mutation involvement which impacts the LDL cholesterol level in the blood and the resultant ischemic heart disease (IHD) probability and severity [9-11]; heterozygous FH is more common and has a prevalence of 1 in 200 - 240 individuals [12-14], whereas homozygous FH is very rare and occurs in approximately 1 in 1 million persons, it is associated with more severe myocardial infarctions. It could occur as early as four years of age [15-17].
Xanthomas are sometimes difficult to distinguish from some cutaneous manifestations of certain rheumatological and dermatological diseases [18, 19], this leads to delayed treatment and more patient frustration. Among the known cutaneous manifestations of medical illnesses, rheumatoid nodules can significantly mimic xanthomas [20, 21].
FH continues to be “hidden in plain sight” with a significant number of children and adults remaining undiagnosed and some are misdiagnosed [22]. Here we report an interesting case of a patient who was diagnosed with FH after four years of being initially labeled as having rheumatoid arthritis nodules, for which she has had multiple unnecessary surgical resection procedures.
A 17-year-old female patient was referred to our Rheumatology clinic by her GP for the evaluation of multiple soft and yellow nodular lesions of different sizes, they are painless and distributed over her elbows, knees, ankles, and feet. She reported having these lesions for four years now. They have gradually increased in size, with recurrence after multiple surgical resections.
The presence of these lesions along with some mild and non-specific joint pains misled her primary physician at that time to presume a diagnosis of rheumatoid arthritis with associated rheumatoid nodules. Furthermore, she was also evaluated by a surgeon as having some benign masses managed with multiple surgical resections where no tissue diagnosis attempts were made. The procedures involved the lesions over her elbows and left Achilles’s tendon with recurrence requiring a total of 4 resections over the past 4 years. Unfortunately, no clear details could be obtained regarding her previous treatments and investigations apart from this as her family denied being counseled or taught about their daughter’s exact problem.
Upon primary evaluation at our clinic, the patient reported mild non-specific arthralgia but no joint swelling or morning stiffness. She has never complained of chest pain, or shortness of breath and has no other previous or current medical illnesses including diabetes, hypertension, or any thyroid disorder. The patient is a daughter of consanguineous healthy parents; she has four healthy siblings with no similar conditions among her family members. However, family history was significant for early sudden deaths and premature coronary artery disease; one of her paternal uncles passed away suddenly at the age of 39, and an elder one has a history of coronary artery disease and had a myocardial infarction when he was 33.
Physical examination showed a patient with well body build and normal vital signs. It revealed multiple non-tenders, yellow-colored masses of varying sizes ranging from 1 to 6 cm, located mainly at the extensor surfaces of her elbows, left wrists, both knees, feet, and Achilles’s tendons bilaterally (Figure 1).
The lesions were firm, locally mobile, and not tethered to the overlying skin; their proximity to the joints caused minimal limitation of movement. Arcus lipoides juveniles have also been noticed (Figure 2).
Figure 1 (A): Right elbow
Figure 1(B): Left elbow
Figure 2(A): Left wrist
Figure 2(B): Both knees
Figure 2(C): Both knees
Laboratory investigations were unremarkable except for hypercholesterolemia; LDL was found to be 17 mmol/l (table 1).
| Laboratory (reference range) | Result |
| CBC | |
| Hb level (11.5-14) | 11.7 |
| WBCs (4000-11000) | 7.3 103/mm3 |
| Platelet (150-400) 103/mm3 | 279 103/mm3 |
| Lipid Panel | |
| Total cholesterol (0-5.2 mmol/l) | 19.55 mmol/l |
| Triglycerides (0-1.7 mmol/l) | 2.57 mmol/l |
| LDL (0-4.4 mmol/l) | 17.52 mmol/l |
| HDL (1.1-1.5 mmol/l) | 0.86 mmol/l |
| Liver Enzymes | |
| AST (4-44 iu/l) | 13 IU/L |
| ALT (4-44 iu/l) | 7 IU/L |
| Thyroid panel | |
| TSH (0.3-4.8 μIU/mL) | 0.949 μIU/mL |
| T4 (0.3-4.8 μIU/mL) | 13.9 |
| T3 (0.3-4.8 μIU/mL) | 4.22 |
| Inflammatory markers | |
| ESR | 35 |
| CRP (<5> | Negative |
| Rheumatoid factor | Negative |
| ACCP | Negative |
| ANA | Negative |
Table 1: Biochemical findings of the presented case
The overall clinical description along with the very high levels of LDL and the presence of lipid-laden histiocytes located in the dermis and subcutis on biopsy (Figure 3) confirmed the diagnosis of tendinous and tuberous xanthomas.
Figure 3(A): Medial aspect of both feet
Figure 3(B): Lateral aspect of the foot and Achilles tendon
Subsequently, the diagnosis of familial hypercholesterolemia was made based on high LDL levels, xanthomas, and a family history of early cardiovascular disease and early death. Therefore, the patient has been advised towards lifestyle modification and treatment started with statins with gradual dose increments aiming to reach the highest tolerated dose. The patient was counseled about possible future surgical interventions. Screening lipid profile was recommended to all family members (Figure 4 and 5).
Figure 4: Arcus Lipoides Juvenalis
Figure 5: Histopathology shows lipid-laden histiocytes located in dermis and subcutis
Figure 5(A): Microscopic view lipid-laden histiocytes located in dermis and subcutis
Figure 5(B): Closer view lipid-laden histiocytes located in dermis and subcutis
Rheumatoid arthritis (RA) is an inflammatory disease that affects synovial tissues of the peripheral joints, it is characterized by bilateral and symmetrical joint involvement; mainly joints of the hands and feet [23]. Tendons, ligaments, and other extra-articular structures such as the skin, lungs, and kidneys may also be involved in the disease activity [24]. The prevalence of rheumatoid arthritis (RA) is variable and is affected by race, gender, socioeconomic status, and age and it ranges from 0.3%-4%, however; it’s reported to be as high as 9.3% among non-Hispanic African American women [24, 25].
Rheumatoid nodules are the most common cutaneous manifestation of rheumatoid arthritis (RA), they may occur at any site including internal body organs but mainly affect areas exposed to repeated pressure and mechanical stress such as the olecranon processes. They are mainly detected among seropositive patients and are associated with a more severe and aggressive inflammatory process. Multiple nodules have been reported at initial presentation in 7 percent of patients with rheumatoid arthritis (RA) and are found at some time during the disease course in 20 to 40 percent of patients [26, 27]. The accelerated formation of multiple rheumatoid nodules may also occur in association with the use of certain medications, particularly methotrexate [28]. The presence of rheumatoid nodules can infrequently be seen with only mild or no systemic manifestations of RA; a condition termed rheumatoid nodulosis [29].
Some cases of rheumatoid nodules were reported to be misinterpreted as xanthomas, and the other way around [30]. Tendinous xanthomas and rheumatoid nodules share some characteristics that may lead to confusion between the two entities and end with wrong diagnoses and delayed management; the most important of which is their similar distribution over extensor surfaces of the arms and legs, and this was what directed our patient’s general practitioner towards a wrong diagnosis of rheumatoid arthritis [31]. Furthermore, the possibility of the presence of cholesterol crystals in both xanthomas and rheumatoid nodules on FNA may add more confusion [32] and necessitate performing a tissue biopsy [33]. It is worth mentioning that both conditions have an increased risk of cardiovascular disease and indicate poor prognosis for the primary disorder [34].
Skin and tendon xanthomas are extremely important manifestations of familial hypercholesterolemia (FH), and their presence is linked to severe early ischemic events [30]. Even in the absence of apparent xanthomas, Achilles’ tenosynovitis presenting merely as tendon pain is observed in patients with FH [35]. So, serum cholesterol measurement in young patients presenting with a painful Achilles tendon is mandatory as it could allow early diagnosis of FH [36].
Management of xanthomas starts with the early diagnosis especially when it is associated with familial hypercholesterolemia. Successful Surgical resection of large xanthomas in conjugation with aggressive lipid-lowering therapy has been reported, but not as monotherapy [37].
Gradual escalation of lipid-lowering therapy should always be taken into account, and exacerbations of Achilles tendinopathy should be anticipated; it is attributable to the effect of statins in lowering cholesterol levels rapidly, this is similar to the worsening of rheumatoid nodules when commencing treatment for RA [38].
Based on our patient’s clinical presentation including the absence of significant signs of inflammatory arthritis and the positive family history of premature coronary artery disease, along with her negative inflammatory markers, very high titers of LDL level, and the true cut biopsy results confirming xanthomas; a diagnosis of familial hypercholesterolemia has been made and she has been started on statin therapy and ezeteimibe with gradual dose increments and regular endocrinology follow up, Endocrinology team decided to start novel lipid-lowering agent like evolocumab.
The case report emphasizes that Xanthomas should be considered within the differential diagnoses for any multiple skin nodules, as it can be easily supported by performing simple noninvasive blood tests (Lipid panel). It also highlights the importance of attaining a histopathology diagnosis for ambiguous cutaneous lesions before proceeding with any treatment and not only relying on clinical diagnosis.
All figures submitted have been created by the authors who confirm that the images are original with no duplication and have not been previously published in whole or in part, after obtaining consent form patient’s parent.
The patient and her family were consented and informed about subject of the study.
There are no conflicts of interest.
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
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.
