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*Corresponding Author: Avra S. Laarakker, Division of Plastics, Hand, and Burn Surgery, University of New Mexico, UNM School of Medicine MSC 10 5610, 1 University of New Mexico Albuquerque, New Mexico 87131
Citation: Ronald Orozco, Avra S. Laarakker, Brian Castlemain (2021) Intracardiac Self Insertion of a Darning Needle in a Psychiatric Patient. J. Clinical Cardiology and Cardiovascular Interventions, 4(5); Doi:10.31579/2641-0419/127
Copyright: © 2021 Avra S. Laarakker, 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: 12 January 2021 | Accepted: 19 February 2021 | Published: 25 February 2021
Keywords: intracardiac needle; self-insertion; acupuncture; darning needle
Objective: We report a case of self inserted needle into the left ventricle of the heart and a description of our surgical intervention in a psychiatric patient without decision-making capacity. We discuss issues regarding obtaining consent in this patient with a sub-acute presentation, report our operative approach, and summarize a treatment approach based on a review of current literature.
Methods: A PubMed search using terms “needle, “heart”, “insertion”, “intracardiac foreign object”, yielded 69 relevant papers. 67 of these were case reports yielding 72 individual cases. Age, gender, cause of the needle entry (Accidental Plus (A+), Intravenous Drug User [IVDU], Self-inflicted (SI)), type of needle, location in heart, neuropsychiatric history, treatment, and outcome were documented.
Results: Within the SI category, there were a total of 28 cases, 89.3% had a neuropsychiatric history whereas only there were only 2 such patients in both the IVDU and A+ group. The location of the needle in the heart in all 72 cases was as follows: right ventricle 40.3%, other 20.8%, left ventricle 19.4 %, ventricle and interventricular septum 16.7% and the right and left atrium were each 1.4 %. In all three groups (n=72), 77.8% of patients underwent surgery, with 92.9% having a stable outcome.
Conclusion: Our case and review demonstrates that management of such cases, particularly when active mental health issues are present, requires a case-by-case evaluation and treatment as a specific standard of care has not been established. Surgical intervention appears to be the preferred management regardless of presentation with good outcomes.
Running Title: Intracardiac Self Insertion of a Darning Needle in a Psychiatric Patient
Cases of needle self-insertion are not uncommon, and while common causes of chest pain should be considered, in patients with self-injurious or psychiatric history, this pathology should not be excluded. Currently there is no standard of care or guidelines for the management or treatment of needles within the heart. Our review finds that most cases undergo surgical intervention to remove the needle.
We report a case of needle self-insertion into the left ventricle of the heart in a patient with psychiatric illness. We describe our treatment approach by sternotomy and left ventriculotomy, and outline the difficulties encountered with this particular patient. Additionally, we present a review of the literature regarding all published cases, management of intracardiac needles, and specifics of this complex patient population and their presentation.
Case Description:
A 35 year old male with a history of schizophrenia, bipolar disorder, and methamphetamine abuse presented to the emergency department at our institution. He had been transferred from an inpatient psychiatric facility with complaints of sharp and persistent chest pain in the left anterior chest. The patient stated he was having a “heart attack.” He also stated that he had inserted a six centimeter sewing needle into his left anterior chest days prior to relieve the pain and “heal himself.” He had a long history of needle insertion into various areas of his body, believing this practice would improve his health. He was initially evaluated by the general surgery service for a number of needles in the epigastric area, noted on abdominal radiography. These were noted to be extraperitoneal and conservative measures were advised. A CT scan of the chest demonstrated a metallic foreign within the left ventricle, and the cardiothoracic surgical service was consulted (Figure 1).
Notable findings on his evaluation included a troponin of 0.73 ng/cc, an unremarkable ECG, and a transthoracic echocardiogram that revealed a needle completely within the left ventricle, not involving left-sided valves and with no evidence of pericardial effusion. From the time of his arrival in the emergency department, and throughout his pre-surgical course, the patient was asymptomatic. He was admitted for observation and surgical planning. The patient was evaluated by the psychiatry service and deemed incapable of giving his own consent for surgery. Obtaining power of attorney required several days, but eventually consent was obtained, and the patient was taken to the operating room. Repeat echocardiography prior to operation revealed evidence of thrombus involving the needle and seemed to demonstrate migration of the needle anteriorly in the left ventricle (Figure 2).
The patient underwent median sternotomy with cardiopulmonary bypass and cardiac arrest to retrieve the needle via a left ventriculotomy due to needle location (Figure 3).
Operative findings included the intracavitary needle covered with thrombus, no pericardial effusion, and fibrosis in the area where the needle penetrated the pericardium into the heart. These findings were consistent with needle entry at an earlier time. The patient’s postoperative course was uneventful. During his postoperative psychiatric evaluation, the patient reported his desire to continue his self-insertion of needles, and he was transferred back to an inpatient psychiatric facility for further evaluation and treatment.
Materials and Methods:
To perform our literature review, a thorough search of PubMed using search terms “needle, “heart”, “insertion”, “intracardiac foreign object”, yielded 69 relevant papers. 67 of these were case reports yielding 72 individual cases. We included only papers describing “needles” as the intracardiac foreign body.
For each case, age, gender, cause of the needle entry (Accidental Plus, Intravenous Drug User [IVDU], Self-inflicted), type of needle, location in heart, neurologic or cognitive/psychiatric history (denoted as NeuroPsych in tables), treatment, and outcome, were documented. The category “Accidental Plus” was used for patients who were not IVDUs nor needle self-inserters. However, this did include trauma or intentional injury by another person. Patients who were IVDUs were categorized separately as these accounts were not purely accidental nor were they intentionally self-inflicted. When categorizing the location of the needle, we looked at all chambers of the heart and other locations, but defined needles involving the intraventricular septum as either left or right ventricle or both. We defined “other” location as extracavitary or not specified.
Our review included 72 cases from 67 case reports [1-67]. For the “Accidental Plus” category there were a total of 34 cases. Of note, 17.6 percent, (6 out of 34) of these cases were acupuncture needles. It appears that in these acupuncture cases, the provider was an unlicensed acupuncturist. In the “Accidental Plus” category, 2.9% (1 of 34) had a neurologic or cognitive/psychiatric history. Among the IVDU category there were a total of 10 cases where only 10% (1 of 10) of these patients had a neurocognitive/psychiatric history. Within the Self-Inflicted category, there were a total of 28 cases, 89.3% (25 of 28) had a neuropsychiatric history. In order of decreasing frequency, the location of the needle in the heart was as follows: right ventricle 40.3% (29 of 72), other 20.8% (15 of 72), left ventricle 19.4 % (14 of 72), ventricle and interventricular septum 16.7% (12 of 72) and the right and left atrium were each 1.4 % (1 of 72). Of note, in IVDUs the needle location was in the right ventricle in all cases. In all instances the atria were unlikely to be involved. In all three groups, treatment favoured surgical intervention with 77.8% (56 of 72) undergoing surgery with 92.9% (52 of 56) having a stable outcome. The missing patients here were either lost to follow up or outcome was not specified. There was one death in the Accidental Plus category, however the treatment of the patient was not specified. In the Self-Inflicted group, there were three deaths, however these patients were managed conservatively or the treatment was not specified. There did not appear to be a gender predominance in the individual categories or when looking at all three groups together. However, all the patients in the Acupuncture group were female. A summary of the Appendices can be seen in Table 1.
Table 1:
Accidental Plus: 34 Reports
IVDU: 10 Reports
Self-Inflicted: 28 Reports
Totals: 72 reports
Please see individual categories and details in Appendices A-E.
Appendices: A.
Accidental Plus | ||||||||
| Gender | Age | Needle Type | Cause | Neuropsych | Location | Treatment | Outcome |
Actis Dato, Arslanian, Di Marzio, Filosso, Ruffini 32 | M | 2.5 Years | Not Specified | Accidental | None Reported | Left Ventricle | Left anterior thoracotomy | Stable |
M | 9 Years | Not Specified | Accidental | None Reported | Left Atrium | Left thoracotomy | Not Specified | |
M | 51 Years | Not Specified | Accidental | None Reported | Pulmonary artery | Conservative Treatment | Death: Cancer | |
Affronti, Di Bella, Di Lazzaro, Capozzi, Scarnecchia, Ragni 33 | M | 30 Years | Sewing | Accidental | None Reported | Left Ventricle lateral wall | Sternotomy and heart dissection | Stable |
Akpinar, Sayin, Karabag, Dogan, Aydin 34 | - | 34 Years | Safety Pin | Accidental | None Reported | Left ventricle anterolateral wall | Conservative management | Stable |
Choudhary, Pujar Venkateshacharya, Reddy 35 | M | 3 Years | Sewing | Accidental | None Reported | Right heart across tricuspid | Sternotomy and heart dissection | Stable |
Darmawan 36 | M | 14 Years | Sewing | Accidental | None Reported | Right Ventricle | Sternotomy did not incise heart | Stable |
Dong, Zhai, Li, Cui, Chen, Wang 37 | F | 13 Months | Sewing | Accidental | None Reported | Right ventricle and interventricular septum | Sternotomy and heart dissection | Stable |
Ernst 38 | F | 44 Years | Acupuncture | Acupuncture | None Reported | Right Ventricle | Not Specified | Death |
Honikman, Chikwe, Tokita, Mittnacht 39 | M | 55 Years | 14-gauge all metal hemodialysis cannulation needle, | hemodialysis access needle | None Reported | Lateral Right ventricular wall, below tricuspid | Ministernotomy and heart dissection | Stable |
Hsia, Mahadevan, Brundage 40 | F | 54 Years | Wooden knitting needle | Accidental | None Reported | Right Ventricle | Sternotomy did not incise heart | Stable |
Irdem, Baspinar, Gokaslan 41 | M | 3 Years | Not Specified | Accidental | None Reported | Right Ventricle | Anterior thoracotomy | Stable |
Kataoka 42 | F | 69 Years | Acupuncture | Acupuncture | None Reported | Right Ventricle | Sternotomy did not incise heart | Stable |
Kim, Yang, Choi, Seo, Chun, Lee, Hong, Joo, Choi 31 | F | 61 Years | Acupuncture | Acupuncture | None Reported | Not Specified | Not Specified | Not Specified |
Kobayashi, Hayashi, Sakata, Kobayashi 43 | F | 55 | Needle like | Unknown | None | Tricuspid | Sternotomy | Not |
|
| Years | foreign body |
| Reported | anterior leaflet | and heart dissection | Specified |
Lake, Puleston, Farquharson 44 | M | 53 Years | Endoscopic | Accidental | None Reported | Left Ventricle into aortic arch | Percutaneous | Stable |
Linard, Marques, Bezon, Delaperriere, Germouty, Fenoll, de Vries 1 | M | 14 Years | Sewing | Accidental | congenital mental retardation | Posterior pericardial side below 4 pulmonary veins | Thoracotomy | Stable |
Liu, Gilkeson, Markowitz, Schroder 45 | M | 46 Years | Suture | Surgical error | None Reported | Under pericardium | Sternotomy did not incise heart | Stable |
Mandegar, Ali Yousefnia, Rayatzadeh, Roshanali 46 | M | 36 Years | Sewing | Domestic abuse | None Reported | Left Ventricle | Sternotomy and heart dissection | Stable |
Murakami, Okada, Nishida, Hamano 47 | M | 14 Years | Sewing | Accidental | None Reported | Intraventricular Septum | Sternotomy and heart dissection | Stable |
Papadopoulos, Kouerinis, Giannakopoulou, Eleftherakis, Andreou, Azariades 48 | M | 3 Years | Tropical plant needle | Accidental | None Reported | Right Atrium | Thoracotomy | Stable |
Park, Shin, Choo, Song, Kim 49 | F | 49 Years | Acupuncture | Acupuncture | None Reported | Right ventricular wall and interventricular septum | Sternotomy and heart dissection | Stable |
Potek, Wright 50 | F | 61 Years | Darning needle | Accidental | None Reported | Left Ventricle | Sternotomy and heart dissection | Stable |
Sanchez, Bradfield, Traina, Wachsner 51 | F | 57 Years | Acupuncture | Acupuncture | None Reported | Right Ventricle | Heart dissection | Lost to f/u |
Sbokos, Azariades, Chlapoutakis, Vomvogiannis, Nomikos, Andritsakis 52 | - | 6 weeks | Sewing | Accidental | None Reported | Left Ventricle through Intraventricular septum into Right Ventricle | Median Sternotomy | Stable |
- | 2 Years | Not Specified | Accidental | None Reported | Lateral side of Left chest wall | Median sternotomy under ECC | Not Specified | |
Schechter, Gilbert 23 | M | 34 Years | Not Specified | Accidental | None Reported | Right ventricle and interventricular septum | Left anterior thoracotomy | Stable |
Schultz, Post, Plumley, O'Brien, DeCampli 53 | M | 10 Years | Sewing | Accidental | None Reported | Right Ventricle | Sternotomy and heart dissection | Stable |
Sola, Cateriano, Thompson, Neville 54 | F | 3 Months | Sewing | Intentional parent abuse | None Reported | Not Specified | Subxyphoid incision and removal | Stable |
Talwar, Subramaniam, Subramanian, Kothari, Kumar 55 | M | 4 Years | Sewing | Accidental | None Reported | Right ventricle and interventricular septum | Thoracotomy | Stable |
Tan, Azzi, Sharma 56 | - | None Reported | hemodialysis cannulation needle | None Reported | None Reported | Not Specified | Not Specified | Not Specified |
Vazquez, Tapia, Revilla, San Roman 57 | M | 62 Years | Sewing | Accidental | None Reported | Left Ventricle | Not specified | Not Specified |
Wigger, Stortecky, Most, Englberger 58 | F | 51 Years | Acupuncture | Acupuncture | None Reported | Left Ventricle | Sternotomy and heart dissection | Stable |
Yanar, Aksoy, Taviloglu, Unal, Kurtoglu, Nisli 59 | F | 5 Years | Hooked knitting needle | Accidental | None Reported | Right Ventricle | Thoracotomy | Asymptomatic VSD |
B
Intravenous drug use | ||||||||
| Gender | Age | Needle Type | Cause | Neuropsych | Location | Treatment | Outcome |
Al-Sahaf, Harling, Harrison-Phipps, Bille 60 | M | 39 Years | Hypodermic | IVDU needle | None Reported | Right Ventricle septal wall into mediastinum | Thoracotomy | Stable |
Bompotis, Karkanis, Chatziavramidis, Konstantinidis, Dokopoulos, Lazaridis, Pyriochos 30 | M | 47 Years | insulin needle | IVDU needle | None Reported | Apex of Right Ventricle | Percutaneous | Stable |
Danek, Kuchynka, Palecek, Cerny, Hlavacek, Lambert, Nemecek, Podzimkova, Linhart 61 | M | 27 Years | Not Specified | IVDU needle | None Reported | Apex of Right Ventricle | Conservative management, needle left in place | Stable |
Fu, Chen, Liao, Shen 62 | M | 40 Years | Not Specified | IVDU needle | None Reported | Right Ventricle | Sternotomy did not incise heart | Stable |
Gyrtrup, Andreassen, Pedersen, Mortensen 63 | M | 32 Years | Hypodermic Needle | IVDU needle | None Reported | Right Ventricle | Thoracotomy | Lost to follow up |
LeMaire, Wall, Mattox 64 | F | 31 Years | 27g hollow needle | IVDU needle | None Reported | Apex of Right Ventricle | Sternotomy did not incise heart | Stable |
Low, Jenkins, Prendergast 65 | M | 28 Years | Not Specified | IVDU needle | None Reported | Right Ventricle | Conservative management | Stable |
Ngaage, Cowen 2 | F | 22 Years | Not Specified | IVDU needle | Depression, attempted suicide | Right Ventricle | Conservative management, patient refused surgery | Stable |
Steiner, Dhingra, Devries 66 | M | 24 Years | Not Specified | IVDU needle | None Reported | Right Ventricle | Percutaneous | stable |
Thanavaro, Shafi, Roberts, Cowley, Arrowood, Cassano, Abbate 67 | F | 49 Years | Not Specified | IVDU needle | None Reported | Right Ventricle | Surgery: Sternotomy did not incise heart | Stable |
C
Self inflicted | |||||||||
| Gender | Age | Needle Type | Cause | Neuropsych | Location | Treatment | Outcome | |
Arslan, Colkesen, Akcan, Hilal, Meral 3 | M | 46 Years | Tapestry needle | Self Inflicted | Depression | Apex to Left Ventricle | Not specified | Death, suicide | |
Chand, Sarju, Kumar, Singh 4 | M | 20 Years | Not Specified | Self Inflicted | History of suicidal tendencies | Apex | Sternotomy did not incise heart | Stable | |
Dwivedi, Gupta, Narain 5 | M | 40 Years | Not Specified | Self Inflicted | Hebephrenic-schizophrenic | Right Ventricle though interventricular septum into Left Ventricle | Median sternotomy under ECC | Not Specified | |
Gallerani, Ferrari, Magenta, Barboso, Antonelli, Manfredini 6 | M | 34 Years | Darning needle | Self Inflicted | Borderline personality disorder | Right Ventricle | Median sternotomy without ECC | Stable | |
Gungor, Duygu, Yildiz, Gul, Zoghi, Ozerkan 7 | M | 32 Years | Sewing | Self Inflicted | depression | Right Ventricle | Sternotomy bypass | Stable | |
Inoue, Iemura, Saga 8 | F | 47 Years | Not Specified | Self Inflicted | Depressive Psychosis | Left Ventricle and Right Ventricle | Median sternotomy without ECC | Not Specified | |
Jamilla, Casey 9 | M | 42 Years | Sewing | Self Inflicted | History of depression, suicide attempts, self harm | Left Ventricle | Surgery not indicated | Lost to f/u | |
Keogh, Oakley, Taylor 10 | F | 34 Years | Sewing | Self Inflicted | Depressive psychosis | Pericardium, Adventitia of ascending aorta | Median sternotomy, pericardiectomy | Not Specified | |
Keskin, Sen, Baysal, Kahraman 11 | M | 49 Years | Sewing | Self Inflicted | Schizophrenia | Apex to Left Ventricle | Sternotomy did not incise heart | Stable | |
Kishon, Pauzner, Dalith, Neufeld 12 | F | 32 Years | Not Specified | Self Inflicted | Suicide Attempt | Right Ventricle | Median sternotomy, pericardiectomy | Stable | |
F | 32 Years | Not Specified | Self Inflicted | Suicide Attempt | Right Ventricle | Median sternotomy, pericardiectomy | Stable | ||
Lin, Yoneyama, Takahashi-Igari, Ohto, Sakamoto 13 | F | 14 Years | Not Specified | Self Inflicted | Tuberous Sclerosis Complex- TAND | Right ventricle and interventricular septum | Sternotomy and heart dissection | Moderate left ventricular dysfunction | |
Mihmanli, Kurugoglu, Kantarci, Atakir, Akman 14 | F | 12 Years | Sewing | Self Inflicted | Attempted Suicide | Lateral wall of Left Ventricle | Median Sternotomy without ECC | Stable | |
Mochizuki, Sugita, Okamura, Iida, Mori, Shimada 15 | F | 17 Years | Not Specified | Self Inflicted | History of self harm | Right Ventricle | ECC and Fluoroscopy | Not Specified | |
Moon, Jo, Song, Kim 16 | F | 59 Years | Sewing | Self Inflicted | MDD, history of self injury | Right ventricle and interventricular septum | Sternotomy and heart dissection | stable to psych unit | |
Morrison, Heyworth 17 | M | 22 Years | Sewing | Self Inflicted | Personality disorder and depression | Through LAD into LV | Median sternotomy under ECC | Stable | |
Neely, Jeganathan, Campalani 18 | M | 30 Years | acupuncture | Self Inflicted | History of self harm | Right Ventricle | Sternotomy and heart dissection | Stable | |
Nishida, Tomita, Watanabe, Yasuda, Iino, Arai 19 | F | 72 Years | Not Specified | Self Inflicted | History of Dementia | Left Ventricle and Right Ventricle through the interventricular septum | Median sternotomy under ECC | Not Specified | |
Park, Jeong, Lee, Jeong 20 | F | 54 Years | Not Specified | Swallowed needle, self inflicted | None Reported | R Ventricle into septal leaflet | Sternotomy did not incise heart | Mild tricuspid regurgitation | |
Qian, Song, Li, Jiang 21 | M | 34 Years | Sewing | Self Inflicted | History of depression, self harm | Left Ventricle | Thoracotomy | Stable | |
F | 62 Years | Sewing | Self Inflicted | Depression, suicide attempt | Right Ventricle | Thoracotomy | stable to psych unit | ||
Sayin, Besirli, Arslan, Canturk 22 | F | 13 Years | Sewing | Self Inflicted | Prepsychotic episode and depression | Left Ventricle across interventricular septum | Median sternotomy without ECC | Not Specified | |
Schechter, Gilbert 23 | F | 34 Years | Not Specified | Self Inflicted | Depression | Anterior surface of Right Ventricle | Left anterior thoracotomy | Stable | |
F | 29 Years | Sewing | Self Inflicted | None Reported | Pericardial fat over Right Ventricle | Left anterior thoracotomy | Stable | ||
Sobnach S, Castillo F, Blanco Vinent R, Kahn D, Bhyat A 24 | M | 19 Years | Sewing needle | Swallowed needle, self inflicted | None Reported | Left Ventricle | Sternotomy did not incise heart | Stable | |
Tan, Brunswicker, Abdelraheem, Sheehan 25 | F | 39 Years | Sewing | Self Inflicted | Cerebral Palsy | Needle tip at myocardium | Palliative | Death: hypoxic brain injury | |
Ulas, Kocabeyoglu, Diken, Lafci, Yalcinkaya 26 | F | 25 Years | Sewing | Self Inflicted | Under antipsychotic treatment | Right Ventricle | Sternotomy and heart dissection | Stable | |
Vesna, Tatjana, Slobodan, Slobodan 27 | F | 20 Years | Sewing | Self Inflicted | Acute Psychosis | Left Ventricle across interventricular septum | Misdiagnosis | Death |
|
D
Acupuncture | ||||||||
| Gender | Age | Needle Type | Cause | Neuropsych | Location | Treatment | Outcome |
Ernst 38 | F | 44 Years | Acupuncture | Acupuncture | None Reported | Right Ventricle | Not Specified | Death |
Kataoka 42 | F | 69 Years | Acupuncture | Acupuncture | None Reported | Right Ventricle | Sternotomy did not incise heart | Stable |
Kim, Yang, Choi, Seo, Chun, Lee, Hong, Joo, Choi 31 | F | 61 Years | Acupuncture | Acupuncture | None Reported | Not Specified | Not Specified | Not Specified |
Park, Shin, Choo, Song, Kim 49 | F | 49 Years | Acupuncture | Acupuncture | None Reported | Right ventricular wall and interventricular septum | Sternotomy and heart dissection | Stable |
Sanchez, Bradfield, Traina, Wachsner 51 | F | 57 Years | Acupuncture | Acupuncture | None Reported | Right Ventricle | Heart dissection | Lost to follow up |
Wigger, Stortecky, Most, Englberger 58 | F | 51 Years | Acupuncture | Acupuncture | None Reported | Left Ventricle | Sternotomy and heart dissection | Stable |
Self-insertion of needles into the heart, particularly among neuropsychiatric patients, has been frequently reported in the literature, as described above [1-27]. Our patient’s subacute presentation, the apparent needle migration within the ventricle, and the difficulty in obtaining consent, all presented challenging aspects of this particular case. The potential risks of a needle within the heart of pericardium are protean. These include acute or delayed cardiac tamponade, pericarditis, endocarditis, acute thrombus formation, thromboembolism, and recurrent local and systemic infection [22]. The heart may be more vulnerable to serious injury, when the foreign body is extraventricular rather than completely intraventricular per Perotta et al [28]. They posit that the repetitive wall motion of the heart against a fixed foreign body has the potential for bleeding and/or infection with subsequent tamponade. They also suggest that less symptomatic patients or those with delayed presentation and evidence of fibrosed or non-mobile foreign bodies within the cardiac space could possibly be managed conservatively [5].
As far as diagnosis of this pathology, initial patient history and chest plain film should suffice. The patients’ clinical presentation, like in our case, could be delayed, in which asymptomatic patients could suffer sequelae mentioned. We found that in recent reports management of foreign bodies, specifically needles within the heart, still requires a case by case evaluation and treatment. Depending on location and accessibility, endovascular, percutaneous, thoracoscopic, or thoracotomy approaches might be utilized. Alternatively, with any evidence of intracardiac penetration, the safest approach involves sternotomy with or without the use of cardiopulmonary bypass [29-31]. From the literature, there are general guidelines regarding indications for surgical intervention.
Size of needle was not a criteria-determining intervention within the literature reviewed, however, our opinion left ventricular needles should be treated urgently or emergently because of the possibility of embolization to vital structures. Any intracavitary needle regardless of size should be considered for removal. Symptomatic needles (foreign bodies) manifesting with infection, arrhythmia, bleeding, or neurologic findings, should be removed [22]. As Perrota et al concludes in their review, intracardiac needles should be promptly taken for intraoperative removal, especially if the needle is within the myocardium.
Asymptomatic foreign bodies discovered soon after injury with associated risk of infection, embolization, or erosion should be removed. Asymptomatic foreign bodies demonstrating fibrosis or fixation within the myocardium, pericardium, or pericardial space, may be able to be treated conservatively with some form of serial examination going forward [28,32]. Our results also demonstrate that acupuncture under an unlicensed acupuncturist is not benign. Our review demonstrates the safety of surgical intervention with favorable and predictable outcomes; it may be the preferred management approach regardless of presentation.
Limitations of our study revolve around the difficulty of drawing conclusions from a vast collection of case reports with varying levels of detail regarding both the presentation and management.
In conclusion, patients with neuropsychiatric illness and history of needle self-insertion, particularly into the cardiac space, invariably produce a challenging treatment problem involving psychosocial, physiologic, and follow-up dilemmas. These patients may be best served with an operative approach for needle extraction.
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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.
