AUCTORES
Globalize your Research
Research Article
*Corresponding Author: Joy C. Ekezie, Department of Pediatrics, Red Oaks Medical Group, Red Bluff, California, USA.
Citation: Citation: Joy C. Ekezie, Adetokunbo O. Joacquima, Funmilayo O. Babatundea, Adeseye M. Akinseteb, et al, (2024), Misdiagnosis of Sickle Cell Trait contributes to increased burden of Sickle Cell Disease in Sub-Saharan Africa, J. Women Health Care and Issues, 7(7); DOI:10.31579/2642-9756/201
Copyright: Copyright: © 2024, Joy C. Ekezie. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 02 September 2024 | Accepted: 10 September 2024 | Published: 24 September 2024
Keywords: black women; depression; somatic symptoms; cultural competence; mental health; systemic barriers; community support; holistic health; misdiagnosis; healthcare access
Background: Sickle cell trait is a heterozygous non-disease condition in which an individual inherits sickle haemoglobin (HbS) with normal haemoglobin A (HbA). Despite increased awareness and testing in Nigeria, it has been observed that the prevalence of sickle cell disease is not decreasing. The aim of the study was to document the burden of misdiagnosis of sickle cell trait in a sample from the most populous country in Sub-Saharan Africa.
Methods: A cross-sectional study of 264 biologic parents of children with sickle cell disease accessing haematology services between January 2019 and December 2019.
Results: The mean ages were 44.2 ± 7.4 years and 37.7 ± 6.4 years for males and females respectively with most having tertiary education. One hundred and forty-four (54.5%) biologic parents of children with sickle cell anaemia had premarital haemoglobin genotype testing done for both parents at least. The prevalence of misdiagnosis was 28.4% and 17.8% in fathers and mothers respectively; 6.7% and 12.7% of fathers and mothers respectively were misdiagnosed twice. Of the children of respondents with sickle cell anaemia, 19.0% were misdiagnosed at least once during genotype testing. Privately owned laboratories and laboratories in private hospitals were identified as the most common facilities for genotype testing (33.3 – 51.1% and 33.3 – 34.8% respectively) and gave the highest rates of misdiagnoses (up to 43.0% and 31.9% respectively).
Conclusion: A national policy is needed to regulate the framework of laboratory testing in Sub-Saharan countries to improve the awareness generated and reduce the scourge of misdiagnosis.
Sickle cell trait is a heterozygous non-disease condition in which an individual inherits sickle haemoglobin (HbS) with normal haemoglobin A (HbA). The sickle haemoglobin results from the substitution of the amino acid valine for the amino acid glutamic acid at the sixth position of the β-globin chain of the haemoglobin.[1] Affected individuals do not manifest with symptoms or complications of sickle cell disease except in unusual or extreme conditions like severe dehydration in athletes or hypoxia in high altitude.[2] Generally, individuals with sickle cell trait have a normal life expectancy.
The sickle cell gene is seen predominantly in Africans but can also affect people of other races like Hispanics, Asians, and Caucasians. Globally, more than 100 million people have the sickle cell trait.[2] In Africa, the prevalence of the sickle cell trait varies in different countries, and in these countries, prevalence varies amongst different geographic locations. An important variable is Plasmodium falciparum malaria endemicity which has a direct relationship with the sickle cell gene.[3] The highest prevalence in Africa and probably worldwide was found in the Bundibugyo district of Western Uganda with a rate of 45%,[4] though a more recent study found a prevalence of 13.4%.[5] In Nigeria, which is the most populous country in Africa, the prevalence of the sickle cell trait ranges from 24 – 25%.[6] This is similar to Benin with a prevalence rate of 25%, [7] as both countries have a similar climate and are holoendemic for malaria.
The most common form of sickle cell disease in Sub-Saharan Africa is the homozygous haemoglobin S gene.[8] Sickle cell disease affects up to 3% of births in some parts of Africa.[8] About 200, 000 newborns with sickle cell anaemia are delivered yearly in Africa [9] and this constitutes approximately 66.6% of the children born with haemoglobinopathies worldwide.[5]
Sickle cell anaemia is a multi-organ disease associated with high morbidity and mortality with the attendant health burden comparable to that of communicable diseases. [10,11] It is estimated that 50 – 80% of children with sickle cell anaemia in Africa will die before their fifth birthday.[12]
Various laboratory diagnostic methods have been developed to promote early diagnosis of sickle cell trait and disease from the fetal to the newborn period, and also for the screening of older children and adults. These tests demonstrate the presence of haemoglobin S, significant reductions in haemoglobin A and variations in the percentages of hemoglobin F and A2 in red blood cells. The screening tests commonly used in Africa are sickling test using sodium metabisulphite and sickle solubility test. The confirmatory tests are hemoglobin electrophoresis (HBE), isoelectric focusing (IEF) and high-performance liquid chromatography (HPLC).[1] These tests are very specific and are used to confirm the sickle phenotype (AS/SS/SC/Sβ-thalassaemia). In addition, HPLC can quantify hemoglobin fractions.
In Africa, the predominant screening method is sickling test using sodium metabisulphite which creates a hypoxic environment that deforms the red blood cells containing haemoglobin S. Confirmatory testing, though mandatory, is not done in many parts of Sub-Saharan Africa because of cost and the weak support infrastructure. In developed countries, HPLC is the predominant diagnostic method.[1]
In Nigeria, there are many laboratories and most, if not all, do hemoglobin genotype testing. The laboratories range from privately owned to laboratories that are part of a primary, secondary, or tertiary health institution. Most adults in Nigeria go for premarital genotype testing on account of the increasing awareness of sickle cell disease and its complications. This is to prevent the couple from having children with sickle cell anaemia and the attendant physical, emotional, psychosocial, and financial burden. Despite the increased awareness and testing, it has been observed that the prevalence of the disease is not decreasing. [13, 14] This study, therefore, aimed to document the burden of misdiagnosis of sickle cell trait in one of the largest tertiary health institutions in Nigeria, and identify which groups of laboratories were associated with the misdiagnosis of the sickle cell trait.
The study was conducted at the Lagos University Teaching Hospital (LUTH), Lagos State, Nigeria. Lagos State is in the South-Western part of Nigeria and is the center of commerce in the country. The population as of 2016 was estimated to be over 21 million. [15]
The study was cross-sectional in design. The study population included the biologic parents of children with sickle cell disease attending the Pediatric Hematology Clinic and those admitted into the pediatric wards between January 2019 and December 2019.
Ethical approval was obtained from the Health Research Ethics Committee of LUTH prior to the commencement of the study. Informed consent was obtained from the parent of each child after thoroughly explaining the scope, nature, and objectives of the study. Interviewer-administered questionnaires were used to collect the information from each consecutive parent that consented to participate in the study.
The minimum sample size was determined using the formula;
n = z2 pq
d2
Where n = sample size
p = expected proportion of misdiagnosis in the population, assumed to be 20%
q = 1-p
z = standard normal distribution at α level of 0.05 = 1.96 at 95% confidence interval
Sample size, n = 1.962 x 0.2 (0.8)
0.052
= 3.8416 x 0.16
0.0025
= 245.8 ~ 246
Using a 5% attrition rate (12.3) to make up for incomplete data, total sample size was:
n = 246 + 12.3 = 258.3; this was rounded up to 264.
Therefore, a total number of 264 biological parents were recruited into the study.
Data collected was analyzed using the Statistical Package for Social Sciences (SPSS) software (version 20.0). Results were presented in frequency tables, graphs, and figures. Proportions were used to summarize categorical variables. Pattern of misdiagnosis in each type of laboratory was calculated as the number of misdiagnoses in that center divided by the number of hemoglobin genotype testing done in the center. Level of significance was set at a P value of <0>
A total of two hundred and sixty-four biological parents of children with sickle cell disease were included in the study. The mean age of fathers and mothers was 44.2 ± 7.4 years and 37.7 ± 6.4 years respectively [Table 1]. Majority of the parents (62.9% and 59.1% of fathers and mothers respectively) had at least tertiary level of education and were professionals [Table 1].
Among the biologic parents of children with sickle cell anaemia, 144 (54.5%) had premarital haemoglobin genotype testing done for both parents at least once.
The prevalence of misdiagnosis was 28.4% and 17.8% in fathers and mothers respectively; 6.7% and 12.7% of fathers and mothers respectively were misdiagnosed twice [Table 2]. Of the children of respondents with sickle cell anaemia, 19.0% were misdiagnosed at least once during genotype testing [Table 2].
Privately owned laboratories and laboratories in private hospitals gave the highest rates of misdiagnoses (up to 43.0% and 31.9% respectively) [Table 3].
The global burden of sickle cell anemia is still largely borne by countries in Sub-Saharan Africa.[14] Currently, Nigeria alone harbors about one-third of all cases of sickle cell disease.[16] Over the years, several studies have proposed different factors responsible for the continued endemicity of sickle cell disease in Sub-Saharan Africa.[16] Worldwide, innovations and breakthroughs in the field of hemopoietic stem cell transplantation have resulted in creation of a definitive cure for the disease, while several interventions such as prophylactic antimalarial and antibiotics administration, newborn screening, transcranial doppler screening and exchange blood transfusions have resulted in increased life expectancy of those with sickle cell anaemia. However, a lot of these interventions are not readily available in resource-constrained settings.[17] Since the goal of eradicating the disease is careful haemoglobin selection by pairing of genotypically compatible pairs, every potential parent with sickle cell trait misdiagnosed as being free of the sickle gene can result in dire consequences.
Previously in Nigeria, poor knowledge and attitude towards premarital hemoglobin genotype testing and counseling resulted in couples giving birth to children with sickle cell anaemia and a resulting high prevalence of the disorder. This was corroborated in 2015 by Adewoyin et al, [18] in Benin City in Southern Nigeria, who reported that the prevalence of premarital genotype testing was 13.2% and although 98.4% of the respondents knew that sickle cell anaemia was a disease, only 17.8% of respondents had good knowledge of the disease. In Jos, North-Central Nigeria, Oyedele et al,[13] recorded improved awareness of premarital genotype screening (50.7%) and actual screening (52.7%). This improved awareness and screening is as a result of several interventions such as community education programs and outreaches with the participation of religious bodies.[13]
Despite this improvement, there has been no steady decline in the prevalence of sickle cell disease in Nigeria. This implies that there are other factors responsible for this inconsistency. Individuals who had premarital hemoglobin genotype testing at least once before marriage and have been deemed genotypically compatible still give birth to children with sickle cell anaemia.
The study found that slightly over half (54.5%) of couples underwent premarital genotype testing and counselling before marriage which was similar to what was reported by Oyedele et al. [13] In spite of this increased awareness, high prevalence rates of misdiagnosis of sickle cell trait in parents of children with sickle cell disease were noted with rates of 28.4% and 17.8% in fathers and mothers respectively. These parents reported misdiagnosis of the genotype at least once with most misdiagnosed as having genotype AA. With the assurance of a compatible genotype, these individuals got married and unexpectedly had children with sickle cell anaemia with the attendant medical, psychosocial, financial and socioeconomic consequences. This finding was similar to another study in Enugu, South-East Nigeria where all the parents sampled had premarital genotype testing, however 39.1% of the couples ended up with children with sickle cell anaemia.[19]
Misdiagnosis of sickle cell trait was highest in private laboratories and lowest in laboratories situated in tertiary hospitals and the National Sickle Cell Foundation. This is not unexpected as these larger facilities have the capacity to install equipment with better accuracy/precision such as high-performance liquid chromatography, and also to employ trained and experienced professionals to work in the laboratories unlike the smaller facilities with limited resources. Furthermore, factors such as on-specificity of experimental assay, inappropriate allele calling, or random assay instability could also have contributed to the disparity in results between the various laboratories. [20,21] Perhaps, the approach to genotype testing in these laboratories including the use of less efficient methods could account for the high disparity rates observed. In many laboratories, genotype testing is done by haemoglobin electrophoresis and although it has a fairly high accuracy rate, it does not compare in sensitivity and specificity to liquid chromatographic methods which are not widely available.[21]
Even in the children with sickle cell disease, treatment was delayed in 19
The study shows that misdiagnosis of sickle cell trait constitutes a significant problem in Sub-Saharan Africa with 28.4% of fathers and 17.8% of mothers of children with sickle cell anaemia affected, and 19% of children with sickle cell anaemia initially misdiagnosed. The results of this study, although conducted in Nigeria, may be generalizable to most countries in Sub-Saharan Africa because of similar sociodemographic and economic characteristics. The major limitation of this study is that we did not explore the methods of haemoglobin genotype testing in the laboratories to identify which one(s) is (are) associated with errors, or other factors which might contribute towards misdiagnosis of sickle cell trait in laboratories. We therefore recommend increased awareness about its prevalence and counselling of potential parents on the need for confirmatory premarital haemoglobin genotype testing to ensure there are no errors, as well as the development of a national algorithm to testing. We further recommend routine quality improvement checks of laboratories to minimize errors.
What is already known
Increased awareness of a disease leads to disease modifying behaviours and reduced prevalence.
What this study adds
Increased awareness does not translate to a reduced burden in the setting of poor regulation of laboratories, absence of national guidelines and poor laboratory quality management systems.
All the parents and children who access services at the paediatric haematology unit of the Lagos University Teaching hospital, Lagos, Nigeria.
i. Funding: Not applicable
ii.Conflict of interest/Competing interests: None
iii. Ethics approval: Obtained from the Health Research Ethics Committee of LUTH prior to the commencement of the study.
iv. Consent to participate: Obtained from parent(s) prior to administration of the questionnaires.
v. Consent for publication: Respondents were informed that research findings will be published and their consent was obtained prior to administration of the questionnaires.
vi. Availability of data and material (data transparency): Yes
vii. Code availability (software application or custom code): Statistical Package for Social Sciences (SPSS) software (version 20.0)
viii. Authors’ contributions:
a. Study Design: JE, AA
b. Literature Search: JE, AJ, FB, AA
c. Data Collection: JE, AJ, FB
d. Data Analysis: AJ, FB, AA
e. Manuscript Preparation, Editing & Review: JE, AJ, FB, AA
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.
