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Systematic Review of Conductive Hearing Loss Associated With COVID-19 Infection

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Research Article

Systematic Review of Conductive Hearing Loss Associated With COVID-19 Infection

  • Susan Amin

*Corresponding Author: Susan Amin, P.O. Box 15503, Building No. 2441, Road 2835, Busaiteen 228, Bahrain.

Citation: Susan Amin, (2023), Systematic Review of Conductive Hearing Loss Associated With COVID-19 Infection, Clinical Medical Reviews and Reports, 5(7); DOI:10.31579/2690-8794/179

Copyright: © 2023, Susan Amin. 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: 14 August 2023 | Accepted: 23 September 2023 | Published: 31 October 2023

Keywords: sars-cov-2; Conductive hearing loss; Middle ear; coronavirus; covid-19

Abstract

Abstract

Background 

Conductive hearing loss is when sounds to the middle ear are affected. The aim of this study is to identify patients with (COVID-19) with a diagnosis of conductive hearing loss (CHL) with an objective to assaying connected mechanisms. 

Methods

A systematic review was composed using sites including Google Scholar and PubMed. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were adhered to. Studies that followed the inclusion and exclusion criteria were included in the review. Of the ten papers identified in the starting search, eight met the inclusion criteria. The included eight articles consisted of three case reports, a case series, a prospective study, a retrospective cross-sectional study, a retrospective observational analytical study, and a cross sectional observation study. 

Results

All patients were Covid -19 positive and exhibited CHL. In terms of the middle ear effects relating to the hearing loss, abnormalities noted included tympanic membrane disfunction and abnormal tympanometry. In terms of treatment three studies out of the eight reported hearing loss cleared between 6 weeks and 3 months The other studies reported no treatment information of hearing loss. In terms of associated conditions these included tinnitus, Otitis media, hypertension, and mastoiditis. 

Discussion and conclusion

Evidence does point towards a connection between COVID 19 and conductive hearing loss. The current literature describing conductive hearing loss in COVID-19 patients is not enough to elucidate the type of hearing loss or advise about the outcomes. Future research requires a larger sample study with controls.

Introduction

In December 2019, there were news reports of several patients getting pneumonia from the zoonotic transfer of a new virus related to a market in Beijing. [1] Following identical reports, the World Health Organization declared the new coronavirus 2019 (COVID-19) a pandemic on March 11, 2020.2 Frequent symptoms of COVID-19 include fever, cough, and tiredness, but many patients stayed asymptomatic.  Some experience unusual symptoms such as anosmia. Recently, a small population with COVID-19 had symptoms of hearing loss, vertigo, and tinnitus.3 Coronaviruses such as COVID-19 target the immune system,4 the upper respiratory system,5 this relates to the development of ear pathology and hearing loss, hence there is a need for further research in this area. COVID-19 has also been found in the middle ear system of patients infected with the virus. [6]

Hearing loss is often divided into three types: conductive, sensorineural, and mixed.7 mechanics have been described to explain the link with viral infection and sensorineural hearing loss (SNHL), these include viral entrance to the cochlear nerve or fluid area, reactivation of inactive virus within tissues inner ear, or indirect virus antibody triggering.8

Conductive hearing loss includes a pathology from the pinna and the external acoustic meatus (EAM) to the foot of the stapes bone which can affect the mechanical transmission of sound from the EAM to the cochlea.9 There a limited number of studies on the links of covid nineteen with CHL. 

 In this systematic review, we identified COVID-19 patients with both a positive diagnosis of the virus and CHL, with an objective of looking at the mechanisms of aetiology between the two. 


 

 

Figure 1: Prisma diagram for study selection

Methods 

A systematic review was conducted based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines.10 Ethics committee approval was not required for this literature review. Search Strategy We systematically searched literature databases, including PubMed, Scopus, Web of Science, and Embase, using variations of the descriptors for “COVID-19,” “SARS-CoV-2,” “CHL” with AND/OR. Searches were not restricted to studies by date, publication status, or language.

The inclusion criteria determined in our study included: patients having a positive diagnosis of COVID-19 using polymerase chain reaction (PCR) with a diagnosis of CHL at the time of the study and peer-reviewed articles. The exclusion criteria included: patients who did not have COVID-19 confirmed by PCR or patients without CHL. Eight articles were identified by scanning abstracts of papers. Articles that met the inclusion criteria were fully reviewed by their full text versions. Two independent reviewers assayed the abstracts of articles. The following data was collated:  publication year, publication country, study design, age of patient, gender, and CHL diagnosis and which ear and treatment. We also included covid diagnosis method, symptoms, comorbidities, and treatments for covid at the time. 

Of the fourteen articles reviewed, ten articles matched the inclusion criteria. Of those, eight papers were included in the study (Figure 1). Six articles were rejected as two were on practicalities of conductive hearing loss testing, two reported hearing loss in general and did not go into details and two were on pathology. All the patients were between the ages of seventeen and sixty-eight years. All patients exhibited CHL, either unilateral or bilateral. The number of participants ranged from one to six hundred and twenty (Table 1). 

Results 

Type of study

The eight articles selected consisted of three case reports, a case series, a prospective study, a retrospective cross-sectional study, a retrospective observational analytical study, and a cross sectional observation study (table 1). 

Place of study 

Two studies came from India, two studies came from Iran. Other countries included Spain, Italy Turkey, and Tanzania (Table 1).

Middle ear pathology

In terms of the middle ear effects relating to the hearing loss, two papers report on tympanic membrane disfunction, two papers report on abnormal tympanometry with abnormal peaks of type B or C, one paper reports on ossicular chain disruption. Three reported changes in audiological assessments such as middle ear pressure that was negative as well as ear fullness (Table 1). 

Treatment of hearing loss

Three studies reported hearing loss cleared between six weeks to three months. The other studies reported no information (Table 1). 

Comorbidities

Two papers reported associated conditions of tinnitus. Three papers reported a comorbidity of OM. One reported mastoiditis and one hypertension. There were no comorbidities mentioned with one paper (Table 2).

Covid 19 diagnosis 

All diagnosis of COVID 19 was confirmed using PCR. In terms of symptoms four papers reported no symptoms and four noted symptoms including non-productive cough, mild dyspnoea, anosmia, fever, hypertension, asthenia, vomiting, diarrhoea, rhinorrhoea, sore throat, cough, rash, and hyposmia (Table 2). 

Covid 19 treatment

Sadiq et al, 2022 reported treatments of (Table 2) oxygen and a multitude of medications over 5 days consisting of intravenous dexamethasone 8mg qd, intravenous ceftriaxone 1 g qd, subcutaneous enoxaparin 40mg qd, oral azithromycin 500mg qd, oral ivermectin 12mg qd, oral colchicine 0.5mg qd, oral vitamin C 1 g qd, oral vitamin D 5000 IU qd, and oral zinc 40mg qd.11 Fidan, 2020 reported antiviral treatment (75 mg of oseltamivir taken orally every 12 h, 7 days). The patient was kept at her home to continue the quarantine protocol for 14 days.12 Malesci et al, 2022 reported non-ototoxic antibiotics, paracetamol, steroids, immunosuppressants, and heparin for treatment.13 Dharmarajan et al, 2021 reported treatment with intravenous steroid.14 Raad et al, 2019 and Bhatta et al, 2021 reported clearing of symptoms in two to three months. 15,16 Two studies, Boroujeni et al, 2021 and Enrique et al, 2021 reported no treatments for COVID (Table 2). 17,18

 

Author, year Country Type of study Number of patientsAge rangeSexConductive hearing loss symptoms percentage and diagnosisDescription of loss Treatment of hearing loss
Raad et al, 2019IranCase series 8 20-45I m and 7 F 

Left sided audiogram.

Four out of eight

 

otalgia, ear fullness and hearing loss. 

Opacification of the left middle air cavity, indicative of otitis media. central tympanic membrane perforation with purulent otorrheaHearing loss resolved from a few days to six weeks. 
Sadiq et al, 2022Tanzania Case report 168 F 

A repeat audiological assessment revealed bilateral hearing loss. 

 

Middle ear effusion and negative pressure or tympanic membrane retraction.Resolution after 2 months. 
Boroujeni et al, 2021Iran Case report 139F 

Tympanometry

Earache and fullness. 

In the left ear hearing tests, type B tympanometry was still present.n/a 
Bhatta et al, 2021India and Nepal Prospective study 33132 ± 4.3 years66.7% males and 33.3

Discussion

The aim of this study was to determine if there is connection between COVID-19 and CHL with a link to possible mechanics.

COVID-19 is presented in many ways which delays diagnosis. In our study the patients presented with conductive hearing loss as well as other associated conditions including earache and tinnitus. Tinnitus and Otitis media were two conditions presented with conductive hearing loss and no associated symptoms of covid. In terms of tinnitus a recent review found 60.9% patients with covid related hearing loss had tinnitus symptoms.19

CHL, OM and Covid 19. 

Three studies note a link with conductive hearing loss, otitis media and Covid 19.15,17,14 Otitis media (OM) refers to infection of the middle ear, swelling, redness and the build-up of fluid in the ear drum/ middle ear space, otitis media with effusion (OME) and has the inclusion of both the adaptive and innate immune systems, eustachian tube dysfunction, and other related factors. Otopathogens, commonly Streptococcus pneumoniae, Haemophilus influenzae and/or respiratory viruses, colonize and proliferate in the nasopharynx (NP), and eventually infect the middle ear and cause OM.20 

Otitis media with effusion (OME) is one of the biggest causes of (CHL).21 The angiotensin-converting enzyme-2 (ACE2) receptor, which is an entry point for COVID has a high expression the ciliated cell area of the Eustachian tube and this could promote the passage of infection to the components of the middle ear. This is dependent on the interaction between its spike protein to a cellular receptor named angiotensin-converting enzyme 2 (ACE2) and depends on Furin-mediated spike protein cleavage and spike protein priming by host cell proteases such as transmembrane protease serine 2 (TMPRSS2) for viral entry. An immunohistochemical study showed that Ace2, Tmprss2, and Furin were collectively expressed in the epithelium mucosa lining of the Eustachian tube, middle ear spaces and the organ of Corti, lateral wall, and spiral ganglion cells in the cochlea.22 

CHL, Tympanic membrane dysfunction and Covid 19. 

In this review, Dharmarajan et al., 2021 and Fidan et al., 2020 reported on changes in the structure of the tympanic membranes, in COVID-19 patients.12,14 Fidan et al. (2020) noted tympanic membrane swelling and increased blood flow,12 Dharmarajan. et al. (2021), noted patients that presented with tympanic membrane retraction and some with dull membranes.14 Perforation of the tympanic membrane can also cause a conductive hearing loss. 23 Tympanic membrane shape changes can be a result of long-standing ear conditions that could have been left untreated that are difficult to connect to covid nineteen. Despite this, COVID-19 seems to contribute to middle ear conditions that affect the tympanic membrane especially with an OME association as Dharmarajan et al., 2021.14 This entails a requirement for hearing professionals to be observant of the chances of structural changes of the   tympanic membrane because of middle ear pathologies in patients with COVID 19 that if left could become long lasting, causing speech issues later.24 One study Enrique,2021, reported a patient with ossicular disruption and covid nineteen. A defect in the ossicles will also give a conductive hearing loss. This could be due to head trauma resulting in ossicle discontinuity, or it could be due to a disease process such as otosclerosis.18 Otosclerosis is an osseous dyscrasia within the temporal bone.25 The ossicular disfunction may be linked to tympanic membrane damage. More studies are needed to confirm these findings. 

CHL, hypertension and Covid 19. 

One study (Sadiq et al, 2022) reported on hypertension, with covid nineteen and CHL.11 In terms of covid nineteen and hypertension the link is the renin angiotensin system function and the expression of ACE2, which allows entry of virus. Renin is made in the kidneys by the juxtaglomerular cells and released into the circulation. Renin catalyses the splitting of the protein angiotensinogen producing Angiotensin I. Angiotensin I is then converted by angiotensin converting enzyme to form angiotensin II, this binds to receptors of angiotensin II triggering aldosterone synthesis which causes increased sodium and water reabsorption and hence pressure of blood.26

A few mechanisms have been proposed linking hypertension with auditory system, increasing blood stickiness leading to increased resistance and deprivation of oxygen to the systems.27 Another way is the high blood pressure in the systemic arteries producing haemorrhage within the cochlea, thus disrupting its integrity, and leading to hearing loss.28 A majority of the studies link hypertension with sensorineural hearing loss. Larger scale studies are needed to review the effect of hypertension on CHL. 

CHL, mastoiditis and Covid 19 

In this review one study Enrique,2021 reported mastoiditis with one person.18 The link with covid nineteen is the so called “cytokine storm.” This is when there is a pro-inflammatory cytokine surge or a higher concentration of cytokines such as interleukin IL-2R, IL-6, IL-10, and tumour necrosis factor α detected among the group of severe COVID-19 patients. A similar thing could be happening in this patient where exposure to the virus generates a more intense inflammation response and aggravates the infection. Mastoiditis has been linked to CHL and this may be related to the movement of infection as in the case with OME.29 One study Sadiq et al, 2022 reported a link with negative pressure and hearing loss.11 This can be related to tympanic membrane dysfunction and negative pressure changes. 30

Abnormal tympanograms and CHL.

Three of the studies assessed (Bhatta et al., 2021; Boroujeni et al., 2021; Fidan, 2020) calculated acoustic immittance to diagnose middle ear disruption if any.16,17,12 All these works also reported tympanometry, while Boroujeni et al., 2021 reported on acoustic reflex thresholds, in addition.17 Type B tympanogram was frequently found in the studies with three studies indicating its presence in connection with COVID-19. 16,17,12 Bhatta et al. (2021) reported a presence of 5.1% for Type B and 1.15% for type C tympanograms.16 These studies link middle ear dysfunction with tympanic membrane rigidity. Certain health professionals do not routinely include tympanometry in their testing of patients,30 this review shows that this is an important outcome to measure. This coincides with another study that found in a rat model of diabetes type I, type B tympanograms were present and in the control group type A tympanograms were present. Type A tympanograms are associated with a compliant and fully functionable middle ear connection whereas the Type B tympanograms indicate fluid or infection in the region.32 This infection could be the COVID 19.

Future studies could also include sensitive instruments of conductive compliance such as the wideband acoustic immittance (WAI).30

CHL and Covid 19 presence.

Eight studies indicated a conductive element to the hearing loss.16,17,14,12,13,15,11,18 Bhatta et al. (2021) reported an incidence of  CHL with COVID 19 of 3.2%.16 While the other studies reported the incidence of CHL, two of those studies did not report on the severity of the CHL. Boroujeni et al. (2021)  indicated the severity of CHL in a participant infected with COVID-19 was mild to moderately severe.17 The presence of CHL in these studies is connected to the middle ear disruption. Three of the studies reviewed were case series which involved only one participant. Despite the lack of data from the studies, the evidence presented does present the occurrence of CHL in this group. A much larger study with a group without COVID 19 is needed for a better comparison and to verify these results. 

CHL and treatment 

Three studies mentioned that hearing loss resolved from a few weeks to three months.16,15,11 Five studies did not provide details on the duration of the conductive hearing loss and if it was resolved.12,13,14,17,18 There was limited information on treatments given for COVID 19 being used for treating CHL. Although there are studies linking pharmacological treatments of covid nineteen such as hydroxychloroquine with SNHL, tinnitus and vertigo.33 Steroids,34 Dexomethosone,35 Enoxaparin, 36 Ceftriaxone,37 and Colchicine38 have been used in the treatment of sensorineural hearing loss. This is also an avenue to explore in future work. Azithromycin, 39 Ivermectin, 11 and Oseltamivir, 40 in combinations with other drugs may lead to ototoxicity as a side effect. Ototoxicity may be manifested by hearing loss, tinnitus, imbalance, and cochlear-mandibular symptoms. 41

This review provided some crucial information about conductive hearing loss in patients infected with COVID-19. The study suggests a need for audiological evaluation and periodic monitoring for patients infected with COVID-19 that is continuous. Hearing professionals in healthcare need to be aware of the risks of COVID-19 on middle ear function to implement effective preventive care, and to provide education and counselling to patients and their families. Larger scale studies are needed to better measure the outcomes of COVID 19 and hearing loss. 

Conclusions 

This review found a link with CHL and covid 19, However studies are limited. COVID-19 has been noted in the middle ear tissues of patients infected with the virus.6 As well as causing infections of the upper respiratory tract,5 which will link to middle ear diseases. Results of this study raise expectations for future studies to use correct methodologies, include a control sample, as well as more diagnostic methods and participants. 

Acknowledgements 

Competing interests

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in authoring this article. Authors’ contributions

S.A co-conceptualised the study and the methodology, collected the initial data, screened, and analysed the data with a colleague.

Data availability

Data are available from the first author upon a reasonable request. 

Disclaimer

 The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.

 

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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.

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Katarzyna Byczkowska

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.

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Anthony Kodzo-Grey Venyo

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.

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Pedro Marques Gomes

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.

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Bernard Terkimbi Utoo

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.

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Prof Sherif W Mansour

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.

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Hao Jiang

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.

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Dr Shiming Tang

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.

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Raed Mualem

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.

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Andreas Filippaios

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.

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Dr Suramya Dhamija

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.

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Bruno Chauffert

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!

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Baheci Selen

"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".

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Jesus Simal-Gandara

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.

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Douglas Miyazaki

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.

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Dr Griffith

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.

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Dr Tong Ming Liu

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.

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Husain Taha Radhi

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.

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S Munshi

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.

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Tania Munoz

“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”.

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George Varvatsoulias

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.

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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.

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Khurram Arshad

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.

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Gomez Barriga Maria Dolores

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.

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Lin Shaw Chin

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.

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Maria Dolores Gomez Barriga

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.

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Dr Maria Dolores Gomez Barriga

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¨.

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Dr Maria Regina Penchyna Nieto

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.

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Dr Marcelo Flavio Gomes Jardim Filho

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!”

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Zsuzsanna Bene

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

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Dr 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.

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Lin-Show Chin

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.

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Sonila Qirko

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.

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Luiz Sellmann