AUCTORES
Globalize your Research
Research Article
*Corresponding Author: I Awala, Department of Cardiothoracic surgery, Inkosi Albert Luthuli Central Hospital (IALCH), South Africa. Email: awala009@yahoo.com.
Citation: I Awala, K Maharaj and J Sheehama. (2022). Surgical audit of sternal wound infection following cardiac surgery at Inkosi Albert Luthuli Hospital (IALCH), Durban, South Africa. J Clinical Orthopaedics and Trauma Care, 4(4); DOI:10.31579/2694-0248/033
Copyright: © 2022, Ismael Awala. 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: 10 June 2022 | Accepted: 21 June 2022 | Published: 30 June 2022
Keywords: cardiac surgery; sternal wound infections; prevention; management; patients; IALCH; South Africa
Introduction: Sternal wound infection is a devastating complication following cardiac surgery. It is associated with sternal mal-union, mediastinitis and bacteremia with subsequent infective endocarditis and redo surgery. Although the incidence of sternal wound infections has decreased to 1% - 4% of all cardiac surgery procedures. Sternal wound infection continues to be associated with increased morbidity and mortality, and decrease long term life expectancy. New approaches to open heart surgery, deep and superficial wound infection has a significant impact on patients’ morbidity, length of stay and cost of care. This study was to identify risk factors associated with sternal wound infection and prompt treatments measures to decrease this complication.
Methods: Between January 2016- December 2018, thirty-eight (38) adult patient above 14 years who underwent cardiac surgery developed sternal wound infection at IALCH, KwaZulu Natal Province. Retrospectively reviewed and analyzed patient’s records were evaluated for demographics, risk factors, management and the outcome in relation to hospital stay and cost. The following risk factors shows significant P value<0.05.
Results: The study revealed that, of the 38 patients, 24 were female (63.2%) and 14 male (36.8%), while 26 patients (68.4%) below 60 years, 12 patients (31.6%) above 60 years. 13 patients (34.2%) developed deep sternal wound infection against 25 (65.8%) who developed superficial wound sternal wound infection. Surgical procedure was for valvular heart disease 24 (63.2%), CABG 13 (34.2%) and 1 (2.6%) concomitant CABG and valve replacement. Prolonged ICU stay 3.08 days SD=1.49 was associated with deep sternal wound infection compared to 1.79 days SD=0.723 for superficial, p=0.0001.
Conclusion: This study showed that sternal wound infection increases overall hospital stay and is associated with increased overall treatment cost therefore, it is imperative to address known risk factors by adhering to and implementing preventative programs.
Sternal wound infection is a devastating complication following cardiac surgery. It is associated with sternal malaunion, mediastinitis and bacteremia with subsequent infective endocarditis and redo surgery. Although the incidence of sternal wound infections has decreased to 1% to 4% of all cardiac surgery procedures, they continue to be associated with increased morbidity and mortality, and decrease long term life expectancy [1].
In spite of recent advances in coronary revascularization, new topical antibacterial agents, new approaches to open heart surgery, deep and superficial wound infection has a significant impact on patients morbidity, length of stay and cost of care [2]. Despite the significant clinical and economic consequences of sternal wound infections, there are currently no specific guidelines in cardiac surgery for the prevention and treatment of sternal wound infections [1]. Various recommendations for the prevention of wound infections during the preoperative, intraoperative, and postoperative periods, as well as principles for the most effective methods and techniques to treat sternal wound infections to obtain good outcomes are used in various hospitals. The adherence and implementations of these guidelines has never been strictly tested one by one to have a sequence of events that everyone involved with the care of cardiac patients must follow.
The cost of hospital stays and treatment of cardiac patient is enormous and it increases the budget of hospitals with a cardiac center. AT IALCH cardiac center, it has been observed that patients stay an average of 1 day to a week pre operatively and minimum of one week post-operatively depending on the type of surgery performed. The cost of patients with sternal wound complications is estimated to be twice that of patients with uncomplicated postoperative courses [3].
The treatment of superficial and deep wound infections varies, with deep sternal wound infections more costly and sometimes requiring other disciplines to be involved to manage this patients. Plastic surgery has been of paramount importance in managing deep sternal wound infection (DSWI). Plastic surgery and reconstructive materials used are costly, therefore patients who require this service on top of a cardiac procedure has significantly cost the department of health. Superficial sternal wound infection (SSWI) requires a minimum of 5 days antibiotics treatment and depending on the outcome further management may follow.
There are a number of known patient-related pre-operative, intra-operative and post-operative risk factors associated with increased risk of developing sternal wound infection (SWI) after cardiac surgery which have been studied extensively. Accordingly, major attempts have been made to decrease the incidence of SWI. It is reasonable to believe that adhering and implementing certain affordable recommendations will help reduce SWI [4].
Patients and Methods
This was a retrospective observational study done on all adult patients who developed sternal wound infection following open cardiac surgery. All adult patients, 14 years and above who underwent cardiac surgery at IALCH from January 2016 to December 2018 and developed documented sternal wound infection were included.
The principal investigator and supervisor have physically examined and took part in the treatment of the indexed patient. All the pre, intra, post-operative characteristics, outcome and costs were obtained from the patients charts. Treatment and management were done primarily based on institutional protocol and monitored by the operating surgeon. Treatment ranged from simple wound dressing, dressing with oral/ intravenous antibiotics, vacuum assisted dressing, wound debridement with sternal fixation and different plastic surgery procedures.
Statistical analysis
Data were collected and captured in excel and analyzed using the SPSS 25 statistical program for windows. Chi-square tests were conducted using custom tables for Pre, intra, postoperative characteristics, Type of surgery vs type of wound, In all cases, the results were analyzed and considered statistically significant when P< 0>
Statistical Results
In total 38 patients were included, 24 were female (63.2%) and 14 male (36.8%). 26 patients (68.4%) aged below 60 years; 12 patients (31.6%) aged above 60 years. 13 patients (34.2%) developed deep sternal wound infection against 25 (65.8%) who developed superficial sternal wound infection. Surgical procedure performed was for valvular heart disease 24 patients (63.2%), coronary artery bypass grafting (CABG) 13 (34.2%) and 1 (2.6%) concomitant CABG and valve replacement. 14 patients (36.8%) developed infections within 7 days post-operatively, 21 (55.3%) between 7-30 days and 3 (7.9%) after 30 days.
Except clinical presentation (fever, wound erythema, drainage and sternal dehiscence) , infection was also confirmed on laboratory testing. A total of 32 (84.2%) patients had increased infective markers as compared to 6 (15.8%) patients without raised infective markers. Infective organisms were isolated in 28 (73.7%) of patients and no organism were isolated in 10 (26.3%) patients. Clinical characteristics of patients are given in table 1. Type of surgical procedure is shown in table 2. The incidence of superficial and deep sternal wound infection is shown in table 3. Risk factor analysis was divided into pre-operative, intra-operative and post-operative factors. A total of 19 factors were evaluated. 1. Age 2. Sex 3. Type of operation 4. Diabetes 5. Body mass index (BMI) 6. Chronic obstructive pulmonary disease (COPD) 7. Retro-viral disease (RVD) status 8. Pre op albumin 10. Remote infection 11. New York heart association (NYHA) 12. Duration of cardiopulmonary bypass (CPB) 13. Use of bone wax 14. Antibiotics prophylactics, re dosing and duration of use 15. Deep hypothermic arrest 16. Massive transfusion 17. Use of intra-aortic balloon pump (IABP) 18. Low cardiac output state 19. Length of ICU stay. The following factors were shown to be independent predictor of increased wound infection in this study. 1. Advanced age, 2. Obesity, 3. Smoking, 4. COPD 5. Massive transfusion, 6. Low cardiac output state (LOCS), 7. Increased length of intensive care unit (ICU) stay.
| Mean Age | 48.53 ± 16.196 |
| Male/female | 14/24 |
| Obesity (BMI ≥ 30) | 50% |
| Diabetes | 39.50% |
| Deep/Superficial wound | 34.2%/65.8% |
| Smoker (existing/ previous) | 65.80% |
| COPD | 36.80% |
| Elevated Infective markers | 84.20% |
| Pairilero (Hospital/Community) | 92.1%/7.9% |
| Pairilero <7> | 36.80% |
| Pairilero > 7-30 days – Hospital | 55.30% |
| Pairilero > 30 days - Community Acquired | 7.90% |
| Albumin > 31 | 94.70% |
| Remote infection | 26.30% |
| Heart failure | 50% |
| HIV Positive | 39.50% |
| Surgery: Valve | 63.20% |
| Surgery: CABG | 34.20% |
| Surgery: CABG & Valve | 2.60% |
| Cardiopulmonary bypass (Mean, mins) | 132.68 ± 57.649 |
| Prophylactic antibiotics | 94.70% |
| Massive transfusion | 23.70% |
| LCOS | 31.60% |
| Average length of stay in ICU (days) | 2.21 ± 1.212 |
| Average length of stay (days) | 55.76 ± 41.761 |
| Intra-aortic balloon pump | 13.20% |
| Isolated Organism | 73.70% |
| Treatment | 57.90% |
| Total Cost (Mean in Rands) | 118552.47 ± 88783.588 |
| Use of Bone Wax | 100% |
Table 1. Clinical characteristics of the 38 patients.
| Frequency | Percent | Valid Percent | Cumulative Percent | |
| 1 Valve | 24 | 63.2 | 63.2 | 63.2 |
| 2 CABG + Valve | 1 | 2.6 | 2.6 | 65.8 |
| 3 CABG | 13 | 34.2 | 34.2 | 100.0 |
| Total | 38 | 100.0 | 100.0 |
Table 2. Shows the type of surgical procedure performed.
| Frequency | Percent | Valid Percent | Cumulative Percent | |
| 1 Deep | 13 | 34.2 | 34.2 | 34.2 |
| 2 Superficial | 25 | 65.8 | 65.8 | 100.0 |
| Total | 38 | 100.0 | 100.0 |
Table 3. The incidence of superficial and deep sternal wound infection.
Advanced age over 60 years is a predictor of increased deep sternal wound infection, n-12, 7 patient developed deep sternal wound infection as compared to 5 who developed superficial wound infection with a p=0.04. There was also a significant association between LCOS and deep sternal wound infection with a p=0.007. In this study we found out that the use of IABP intra operatively is a major risk factor for sternal wound infection with all the patient n=5 where IABP was used developed sternal wound infection. Most diabetic patient n=15 developed sternal wound infection. There were 8 deep and 7 superficial wound infections. This shows a significant association between diabetes mellitus and wound type, p=0.049 as indicated in table 4.
| 1 Deep | 2 Superficial | Total | ||
| Pre op diabetes | 1 Yes | 8 | 7 | 15 |
| 2 No | 5 | 18 | 23 | |
| Total | 13 | 25 | 38 | |
Table 4. Association between diabetes and wound type.
Although duration of CPB is shown to increase SWI especially beyond 150 min in most studies, there was no significant association between the duration of CPB and SWI in this study as shown in table 5.
| CPB min (Binned) | Total | |||
| 1 < 150> | 2 150+ | |||
| WOUND TYPE | 1 Deep | 6 | 7 | 13 |
| 2Superficial | 15 | 10 | 25 | |
| Total | 21 | 17 | 38 | |
Table 5. Shows the relationship between wound type and the duration of CPB (min).
This study showed (table 6) an average ICU stay of 3.08 days SD=1.49 for deep sternal wound infection compared to 1.79 days SD=0.723 for superficial, p=0.0001. Average days in hospital was 92.31 SD=46.9 for deep and 36.76 days SD=22.17 for superficial wound infection, p=0.0001. Cost of treatment was significantly higher for deep sternal wound infection when compared to superficial p<0>Wound type N Mean Std. Deviation Std. Error Mean POSTOP ICU day 1 Deep 13 3.08 1.498 0.415 2 Superficial 25 1.76 0.723 0.145 Days in Hospital 1 Deep 13 92.31 46.855 12.995 2 Superficial 25 36.76 22.167 4.433 Total cost 1 Deep 13 196246.15 99613.875 27627.918 2 Superficial 25 78151.76 47126.120 9425.224
Table 5: Wound type vs length of stay and cost
The current study shows that SWI is associated with prolonged hospital stay and increased hospital cost. This is in keeping with other studies that indicates that patients with sternal wound complications accumulate an average of 20 additional hospital days and incur an estimated 2.8 times the cost of that for patients with uncomplicated postoperative courses[5]. Average days in hospital was 92.31 SD=46.9 for deep and 36.76 days SD=22.17 for superficial wound infection, p=0.0001. Cost of treatment was significantly higher for deep sternal wound infection when compared to superficial p<0>
The Pairolero classification of infected median sternotomies divides wounds into three types based on duration and clinical findings [6, 7]. The majority of cases are type II infections, which occur during the second to fourth weeks after Costochondritis is rare, but osteomyelitis is frequent. This study also indicated that most wounds occur between 7-30 days n-21 (55.3%).
It is important to distinguish DSWIs from superficial sternal wound infections (SSWIs). SSWI involves the skin, subcutaneous tissue, and pectoralis fascia only. The incidence of SSWIs is 0.5 to 8% with an associated morbidity and mortality rate ranging from 0.5 to 9%[8]. The diagnosis may be made clinically by the presence of erythema, drainage, fever, and sternal instability but is often occult with a low-grade fever as its only presentation. SSWIs are often completely eradicated with intravenous antibiotics and local wound care if necessary without long-term sequelae[9]. The main presentation in our study was fever, erythema and wound drainage.
As defined by the Centers for Disease Control and Prevention, DSWIs require the presence of one of the following criteria: (1) an organism isolated from culture of mediastinal tissue or fluid; (2) evidence of mediastinitis seen during operation; or (3) presence of either chest pain, sternal instability, or fever (> 38°C), and either purulent drainage from the mediastinum, isolation of an organism present in a blood culture, or culture of the mediastinal area[2]. These patients require a much more aggressive treatment regimen consisting of early surgical debridement with subsequent autologous tissue coverage and long-term intravenous antibiotics. Treatment and management of our patients was done primarily based on institutional protocol and monitored by the operating surgeon. SWI treatment ranged from simple wound dressing, dressing with oral/ intravenous antibiotics while DSW was treated with vacuum assisted dressing, wound debridement with delayed sternal fixation and other different plastic surgical procedures.
Risk factor stratification and patients characteristics was done in correlation with the new guideline for the prevention and management of sternal wound infections presented by Harold L. Lazar in the European journal of Thoracic and cardiovascular surgery in 2016- Expert Consensus Review. A total of 19 factors were evaluated. 1. Age 2. Sex 3. Type of operation 4. Diabetes 5.BMI 6. COPD 7. RVD status 8. Pre op albumin 10. Remote infection 11. NYHA 12. Duration of CPB 13. Use of bone wax 14. Antibiotics prophylactics, re dosing and duration of use 15. Deep hypothermic arrest 16. Massive transfusion 17. Use of IABP 18. Low cardiac output state 19. Length of ICU stay. The following factors were shown to be independent predictor of increased wound infection in this study. 1. Advanced age, 2. Obesity, 3. Smoking, 4. COPD 5. Massive transfusion, 6. LOCS, 7. Increased length of ICU stay.
Most studies have identified the following as key contributors to the development of sternal wound infections. 1. Nasal staphylococcus carries, incorrect pre surgical preparation, poor nutritional status, remote infections, poorly controlled glycemic, smoking till surgery, incorrect use and dosage of antibiotics, use of bone wax, type of surgery, technique, duration , ICU stay and blood transfusion[1]. Additionally, to the above-described well-known risk factors to augment the risk of SWI after cardiac surgery, deep hypothermia and usage of synthetic graft may worsen the result of SWI related to aortic surgery [10]
As per Expert Consensus Review 2016 the use of bone wax is shown to increase sternal SWI. In this study all 38 patients had bone wax applied to the sternotomy wound, no nasal mupirocin was used. Antibiotics prophylaxis was administered in all patient accept those already on treatment however timing, re dosing and duration of use was not accurate or probably not properly recorded. Electrocautery was also used in all of our patients. This indicates on areas that we think we need institutional protocol review to pare with Expert Consensus Review.
Patients with DSWI die at a rate that is twice that of those without. The associated mortality rate in the literature ranges from 10 to 47%. Risk factors for the development of DSWIs after median sternotomy include diabetes, obesity, chronic obstructive pulmonary disease, osteoporosis, tobacco use, reoperation, prolonged intensive care unit stays, and use of assist devices. Treatment begins with exploration and debridement of all necrotic tissues with removal of all foreign materials and exposed cartilage[11]. A study by Daya. M et al in 2009 at IALCH concluded that the use of VAC dressing and definitive wound closure using sternal plating is an effective method for managing sternotomy wound dehiscence. Most of our patients with DSWI underwent a similar treatment and had favorable outcome.
Due to budget constraint and necessity of state cardiac service particularly KNZ province that is densely populated and this service also caters for other provinces especially eastern cape, I believe adherence and implementing basic evidence based recommendation is of paramount importance to save cost and continue with state cardiac service. The aim of this audit was not merely to identify risk factors as this is already done extensively in other studies but mainly to pin point certain critical area we believe are not part of our institutional protocol.
The strength of this audit is that it is the first in our department about sternotomy infection and hopefully would sensitize surgeons, nurses and all members responsible for the patients on the current consensus on preventing SWI. The limitations are its retrospective nature, short duration and few patients, not reporting on mortality. A large similar study is required to validate the findings.
This study shows that sternal wound infection increases overall hospital stay and is associated with increased overall treatment cost. In addition to pre-operative optimization of patient related factors and procedure related factors. The research team recommend nasal mupirocin prophylaxis to be implemented, discontinue the universal use of bone wax, minimize unnecessary use of diathermy, standardize and monitor pre-operative skin preparation, adhere to appropriate antibiotic prophylactic timing and duration of use.
The authors would like to thank the surgeons and nursing team from the department of cardiothoracic surgery at IALCH for the assistance in managing this patient and data collection.
None.
The authors declare that they all have no conflict of interest.
IA: Study conception and design, Developed the initial draft, Data acquisition, analysis, interpretation, and manuscript. KM: Reviewed every draft and assisted with writing and editing.
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.
