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The Concentration Of 25-Hydroxy Vitamin D In Chronic Liver Disease And Its Correlation With Severity

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Research Article

The Concentration Of 25-Hydroxy Vitamin D In Chronic Liver Disease And Its Correlation With Severity

  • Farid Ahmed 1*
  • Pinaki Paul 2
  • Anwarul Kabi 3
  • Rashedul Hasan 4

*Corresponding Author: Farid Ahmed, Assistant Professor, Department of Gastroenterology, Sheikh Russel National Gastroliver Institute & Hospital, Mohakhali, Dhaka, Bangladesh

Citation: Ahmed F., Pinaki Paul, Kabi A. and Hasan R. (2021) The Concentration of 25-Hydroxy Vitamin D in Chronic Liver Disease and Its Correlation with Severity J. Gastroenterology Pancreatology and Hepatobilary Disorders 5(1) DOI:10.31579/2641-5194/018

Copyright: © 2021, Farid Ahmed,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: 26 January 2021 | Accepted: 19 March 2021 | Published: 22 March 2021

Keywords: avitaminosis; parathyroid hormone; p ortal hypertension; gastric varices; child-pugh A; child-pugh B; child-pugh C; 25(OH) D; HCV; CLD

Abstract

Background: Chronic liver disease (CLD is a common disease all over the world and the major cliological factors for the causation of disease are HBV and HCV in this country and Alcoholic liver disease in the western world. With the availability of the modern treatment, the life expectancy is increased now a days. But the long term complications are now evident. One of the complications is hepatic osteodystrophy which is associated with deficiency of vitamin D. Vitamin D undergoes hepatic 25-hydroxylation, but as the hepatic parenchyma is jeopardized so the metabolic activation of this vitamin is impaired. Vitamin D deficiency is highly prevalent in CLD patients and vitamin D level is inversely related to the severity of the disease.

Objective: To assess the concentration of 25-hydroxy vitamin D in chronic liver disease patient in different etiology and to study the relationship of level of 25(OH) D in different stages of the disease according to Child-Pugh classification.

Methods: This cross sectional study was carried out in the Department of Gastroenterology, Bangabandhu Sheikh Mujib Medical University, Dhaka during the period of April 2015 to March 2016. Patient attending the Gastroenterology Department who fulfill the inclusion criteria with cirrhosis of liver were initially be enrolled for the study. Their clinical history, examination and initial investigation report were noted in the standard data sheet. After explaining the study objective, informed consent was taken. The diagnosis of liver cirrhosis was made by combination of clinical features, blood profile and transabdominal ultrasound. Endoscopy of the upper GIT was done to see the presence of oesophageal or gastric varices which is a sign of increase portal pressure. Transabdominal ultrasound demonstrated a shrunken liver with increase echogenicity, with or without splenomegally and presence or absence of ascites. Stages of liver disease were assessed by Child-Pugh scoring system. Level of 25(OH) D was measured from blood with the permission of the Department of Bio-chemistry. Data was collected using a structered data sheet.

Results: Out of 85 patients, male were 61 (71.8%) and female were 24 (28.2%). Mean age was 53.0 ± 10.7 years within tin- range of 25-70 years. More than 90.0% patient* had abates and anorexia. Eighty percent patients had weight loss and 71.8% patients had Jaundice. More than 40.0% patients had abdominal pain and melaena. Sixty (77.9%) patients had history of blood transfusion and 73 (94.8%) patients had previous hospitalization, Most of the patients had anaemia (97.6%) and Splenomegaly (92.9%). More than 50.0% patients had jaundice (61.2%), Leukonychia (61.2%) and hone pain (52.9%). Mean s, vitamin 25(OH) D was 16.29 ± 7.96 in 69 HBV patients and 20.14 ± 9.76 in 16 HCV patients. In this study, 28.2% patients were in child Pugh A, 36.4% in child Pugh B and 32.9% in child Pugh C stages. Mean s. vitamin 25(OH) D were 27.12 ± 6.11, 15.97 ± 5.40 and 9.57 ± J.I5 in Child-pugh A, Child-pugh B and Child-pugh C stages respectively. Mean s. vitamin 25(OH) D was gradually decreased as the changes of stage from lower to higher. Conclusion: Vitamin D deficiency is highly prevalent in patients with CLD and inversely correlated with disease severity. In the case of chronic liver diseases, vitamin D seems to modulate the innate and adaptive immune system, which explains the association. In fact, clinical studies suggest that these parameters may improve with vitamin D supplementation. So, monitoring of S. 25(OH) D is reasonable in CLD patient.

Introduction

Cirrhosis may be defined us a phase of chronic liver disease or insult leads to the diffuse destruction of hepatic parenchymal cell by fibrosis and the formation of nodules, which results in disorganization of the liver’s lobular and vascular architecture. In western countries, common causes are alcohol. Where as in developing countries, common CHUM'S arc chronic hepatitis B or C virus infection [1]. Cirrhosis may be compensated or decompensated when complicated by jaundice, ascites, and hepatic encephalopathy or raised prothrombin time. It is insidious. Initially asymptomatic later present \\iih over! Complication [2]. The final stage of chronic inflammation in the liver is cirrhosis. Liver cirrhosis gives rise to portal hypertension and complications such as bleeding esophageal varices, ascites and encephalopathy. Hepato-cellular failure results in hyperbilirubinemia, hypoalbuminemia and prolonged prothrombin time. Child's grade is used to assess hepato-cellular function in cirrhosis based on these factors [3]. Though the disease is progressive, indolent and having many complications, but with the development of modern treatment modalities of cirrhosis of liver life span is increased. With the effective treatment long term complications are now commonly encountered. Metabolic bone disease occuring in patients with cirrhosis, known as hepatic osteodystrophy, covers both osteomalacia and osteoporosis [4]. It is a common complication among individuals with long standing hepatic disease. Various studies were conducted in different countries in the world to assess the prevalence of vitamin D deficiency in cirrhosis patient. One study was conducted in the University of Tennessee Hepatology clinic. Where one hundred and eighteen cirrhosis patients with different aetiology were included and their 25-hydroxy vitamin D level were measured. Severity was graded as mild (20-32 ng/ml), moderate (7-19 ng/ml) or severe (<7> 32 ng/ml [5]. Of patients one hundred eighteen, one hundred and nine had some degree of vitamin D deficiency. The result showed vitamin D deficiency is universal (92 %) among patients with cirrhosis and at least one third of them suffered from severe vitamin D deficiency [6]. Miroliace el al. of Iran, works with CLD patient where HBV (n=26), HCV (n=28), AIH (n=19), Cryptogenic (n=17) with 40 healthy controls [9]. Among the study population CM) group 56% male and Control group 60% male. The main outcome is significantly higher prevalence of vitamin D deficiency in cirrhotic versus non-cirrhotic patient (76% vs 17.9%, P < 0 xss=removed xss=removed xss=removed>

General Objective:

  1. To assess the concentrations of 25-Hydroxy Vitamin D in chronic liver disease patient.

Specific Objectives:

  1. To assess 25(OH) D in relation to etiology of cirrhosis.
  2. To study the relationship of level of 25(OH) D with different stage of cirrhosis according to Child-Pugh score.

Material and Methods

This cross sectional study was carried out in the Department of Gastroenterology, Bangabandhu Sheikh Mujib Medical University, Dhaka during the period of April 2015 to March 2016. 85 patients attending the Gastroenterology Department who fulfill the inclusion criteria with cirrhosis of liver were initially be enrolled for the study. Their clinical history, examination and initial investigation report were noted in the standard data sheet. After explaining the study objective, informed consent was taken. The diagnosis of liver cirrhosis was made by combination of clinical features, blood profile and transabdominal ultrasound. Endoscopy of the upper GIT was done to see the presence of oesophageal or gastric varices which is a sign of increase portal pressure. Transabdominal ultrasound demonstrated a shrunken liver with increase echogenicity, with or without splenomegally and presence or absence of ascites. Stages of liver disease were assessed by Child-Pugh scoring system. Level of 25(OH) D was measured from blood with the permission of the Department of Bio-chemistry. Data was collected using a structered data sheet.

Inclusion criteria:

  1. Patients with age greater or equal to 18 years.
  2. Patients with liver cirrhosis evidence by clinical, biochemical & ultrasonography of hepatobiliary system.
  3. Patients given informed consent.

Exclusion criteria:

  1. Patients with hepatocellular carcinoma.
  2. Patients with evidence of ongoing pregnancy.
  3. Patients with severe life threatening infection.
  4. Patients who have Deformity or fracture in any part of body.
  5. Female patients on hormonal contraception or in postmenopausal periods.
  6. Patients who had any secondary cause associated with osteoporosis or affect BMD
  7. Patients with chronic kidney disease, diabetes mellitus, history of endocrinal disease, metastatic bone disease or other malignancies.
  8. Patients receiving vitamin D or calcium supplements, hormone replacement therapy, corticosteroids or any drug known to affect bone density.

Operational Definition:

Cirrhosis of Liver: Cirrhosis is a diffuse process characterized by replacement of normal liver tissue by fibrosis and regenerative nodule formation [1]. The development of cirrhosis is usually an irreversible process. The term cirrhosis is a histologic diagnosis and has its own unique constellation of clinical manifestations such that a clinical diagnosis of cirrhosis can be made with confidence most of the time. The diagnosis of cirrhosis in clinical practice is based on risk factors, history and clinical findings, biochemical tests, imaging, endoscopic and histologic findings. The diagnosis of cirrhosis is not based on a single clinical parameter but a combination of above parameters and the identification and interpretation of these findings. The most common complication of cirrhosis of liver is ascites, hepatic encephalopathy, esophageal varices, splenomegaly, hematemesis and melaena.

Vitamin D: This is a water soluble vitamin which main function is to maintain the normal skeletal architecture and also plays an important role in cardiovascular and nervous system, cellular proliferation and differentiation. Vitamin D3 is primarily acquired through the photochemical conversion of 7- dehydrocholesterol to provitamin D3 in the skin. Vitamin D2 differs in that it is incorporated into micelle then further amalgamated into chylomicron via enterocyte absorption and reaches the liver from the venous circulation for hydroxylation. The serum concentration of 25(OH)D is the most commonly used biomarker for vitamin D status.

Endoscopy: Upper gastrointestinal endoscopy will be done using a standard forward viewing endoscope. In order to prevent contamination from another patient, after each procedure endoscope and biopsy forceps will be disinfected using glutaraldehyde 2% (CIDEX) solution. Instruments will be immersed in solution and kept for 15 minutes. Side channels will also be rinsed.

Data Collect Ion Method: Prior to data collection both verbal and written consent was taken from the respondents. Data ^recollected using a preformed data collection sheet (questionnaire). Base line information was collected from the patient after exploration of different complaints. All information regarding clinical features were recorded in a data collection sheet. S. 25-hydroxy vitamin D wow done in the Department of Bio-chemistry, Bangabandhu Sheikh Mujib Medical University Dhaka Bangladesh.

Data processing and analysis: After collection of data, all data will be checked and cleaned. After cleaning, the data will be entered into computer and statistical analysis of the results being obtained by using windows based computer software devised with Statistical Packages for Social Sciences. Numerical variables will be expressed as mean and standard deviation, whereas categorical variables are count with percentage. Continuous variables will be compared using Student's t test; categorical variables will be analyzed by Chi-square test. A p-value <0>

Liver failure and the Child-Pugh classification: The final stage of chronic inflammation in the liver is cirrhosis. Liver cirrhosis gives rise to portal hypertension and complications such as bleeding esophageal varices, ascites and encephalopathy. Hepato-cellular failure results in hyperbilirubinemia, hypoalbuminemia and prolonged prothrombin time. The Child-Pugh classification is a scoring system used to assess the prognosis of cirrhosis.

Table 1. Child Pugh Score (Sherlock & Dooley, 2011) [1]

Although it was originally used to predict mortality during surgery, it is now used to determine the prognosis, as well as the required strength of treatment and the necessity of liver transplantation. Scoring is based upon several factors: albumin, ascites, total bilirubin, prothrombin time, and encephalopathy.

Table 2. Survival in cirrhosis (Colledge et al. 2010) [18]

Results and observations

This cross sectional study was carried out in the Department of Gastroenterology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka from April 2015 to March 2016 for a period of 1 year. A total of 85 patients with chronic liver disease were included in this study. The results were as follows:

Table 1. Distribution of patients with CLD according to age (n=85)

 
Table-1 Distribution of patients with CLD according to age. Maximum 36.5% patients were in age group 51-60 years followed by 23(27.1%), 16(18.8%) and 15 (17.6%) in >60, 41-50 and ≤ 40 years age group respectively. Mean age was 53.0 ± 10.7 years within the range of 25-70 years.

Figure-1: Bar diagram showing distribution of patients with CLD according to age.

 

Table 2: Distribution of patients with CLD according to gender (n=85)

Table-2 shows distribution of patients according to gender. Male was predominant in this study. Male female ratio was 2.54:1

Figure-2:  Shows distribution of patients according to gender.

 

Table 3. Presenting complain of the patients with CLD (n=85)

Table 3 show presenting complains of the CLD patients. More than 90.0% patients had ascites and anorexia. Eighty percent patients had weight loss and 71.8% patients had Jaundice. More than 40.0% patients had abdominal pain and melaena.

Table 4: History of past illness of the patients with CLD (n=85)

Table-4 shows history of past illness. Sixty (77.9%) patients had history of blood transfusion and 73 (94.8%) patients had previous hospitalization.

Table 5: Clinical features of the patients with CLD (n=85)
Table 6: Laboratory investigations of the patients with CLD (n=85)

 

Figure-4: Bar chart showing mean S.vitamin 25(OH) D in different aetiology stages of CLD.

 

Table 7: S. vitamin 25(OH) D in different stages of CLD (n=85)

Table 7 shows level of s. vitamin 25(OH)D in different stages of CLD. Mean s. vitamin 25(OH)D was gradually decreased as the changes of stage from lower to higher. There was statistical significant difference in s. vitamin 25(OH)D among the different stages of CLD.

Discussion

Vitamin D has pleiotropic functions. It is widely recognized to have a central role in calcium metabolism and bone mineralization. A vitamin D deficiency is causally related to rickets in children and osteomalacia in adults, but vitamin D is also physiologically important for the proper function of other organs such as skeletal muscle, heart, brain, and pancreas. Vitamin D deficiency is extremely common in chronic liver disease patients. Up to 93% of these patients have some degree of vitamin insufficiency [6, 19]. Even patients with mild liver disease are affected, although liver cirrhosis patients more commonly suffer from severe deficiency. In this study, males were predominant. Male female ratio was 2.54:1. Males were predominant and male female ratio was 2.70:1 [20]. The male female ratio was in the range of 2.3:1 to 2.6:1 among the patients with cirrhosis and HCC [21]. All these results are similar to this study result. Male female ratio of patients with CLD in Malayasia was 4.4:1 [22]. Maximum 36.5% patients were in age group 51-60 years followed by 23(27.1%), 16(18.8%) and 15(17.6%) in >60, 41-50 and <40>

Conclusion

In this study, 85 patients were enrolled and the mean S. 25(OH)D was 17.03 which was in the lower limit. The patient was also categorized according to severity with Child-Pugh classification and showed the level of vitamin D is inversely related to the severity of the disease.

Limitations and Recommendation

  1. No control.
  2. Sample size is small.
  3. Study was carried out in BSMMU and it is not the actual reflection of total population.
  4. A multicenter, population based with control and having a larger sample size study should be done. So that, it can be properly evaluated and will be more correct.

References

  1. Sherlock S. and Dooley J. (11th edn) (2002). 'Diseases of the Liver and Biliary System', Blackwell Scientific Publications, Oxford.
    View at Publisher | View at Google Scholar
  2. AGA Clinical Practice Committee. (2003), 'AGA technical review on osteoporosis in hepatic disorders’. Gasfwwrttero/ogy, vol. 125, pp. 941-66.
    View at Publisher | View at Google Scholar
  3. Pugh RNH, Dawson JL, and William R. (1977). Transection of the oesophagus for bleeding oesophageal varices', British Journal of Surgery, vol. 60, pp. 646-49.
    View at Publisher | View at Google Scholar
  4. Compston JE. (1986) ‘Hepatic osteodystrophy: Vitamin D metabolism in patients with liver disease’ Gut, vol. 27, pp. 1073-90.
    View at Publisher | View at Google Scholar
  5. Hollick MF. (2005). ‘Variations in 25-hydroxyvitamin I) assay results’. Journal of Clinical Endocrynology and Metabolism, vol. 90(5). pp. 210-15.
    View at Publisher | View at Google Scholar
  6. Aneh J. Narra S. and Nair S. (2010). 'Prevalence of vitamin D deficiency in chronic liver disease', Djgextive Disease Science, vol. 55, pp. 2624-28.
    View at Publisher | View at Google Scholar
  7. Petta S, Camma C Scazzone C, Tripodo C, Di Marco V, Bono A, Cabibi D, Licata G, Porcasi R, Marchesini G and Craxi A. (2010),' Low vitamin D serum level is related to severe fibrosis and ••» responsiveness to interferon-based therapy in genotype 1 chronic hepatitis C', H^ology. Vo1-51, pp. 1158-67.
    View at Publisher | View at Google Scholar
  8. Rose J, Compston JE, and Evans W. (1991). 'Osteoporosis associated with chronic liver disease', European Journal of Gastroenterology and Hepatology, vol. 3, pp. 63-69.
    View at Publisher | View at Google Scholar
  9. Matsumura T, Kato T. Tasaka-Fujita M, Murayama A, Masaki T, and Wakita T. (2006). '25hydroxyvitamin D inhibits hepatitis C virus replication and production of the infectious viruses', Hepatology, vol. 54, pp. 54-67.
    View at Publisher | View at Google Scholar
  10. Diamond TH, Stiel D, Lunzcr M, McDowall D, Eckstein RP, and Posen S. (1989). ‘Hepatic osteodyslrophy. Static and dynamic bone histomorphometry and bone Gla-protein in 80 patients with chronic liver disease' Gastroenterology\ vol. 96, pp.213-21.
    View at Publisher | View at Google Scholar
  11. Diamond TH, Stiel D, Lunzer M, Wilkinson M, and Roche J. (1990). ‘Osteoporosis and skeletal fractures in chronic liver disease’, Gut, vol. 31, pp. 82-87.
    View at Publisher | View at Google Scholar
  12. Monegal A, Navasa M, and Ouanabcns. (1997), ‘Osteoporosis and bone mineral metabolism disorders in cinhotic patients referred for orthotopic liver transplantation', Calcified Tissue International, vol. 60, pp. 148-54.
    View at Publisher | View at Google Scholar
  13. Kilson MT, Sarrazin C, Toniutto P, Eslick DG, and Roberts SK. (2012). ‘The importance of vitamin D status in chronic liver disease’. Journal of Hepatology, vol. 57, pp. 897-09.
    View at Publisher | View at Google Scholar
  14. Farnik H, Bojunga J, Berger A, Allwinn R, Waidmann O, Kronenberger B, Keppler TO, Zeuzem S, Sarrazin C, and Lange CM. (2013). ‘Low vitamin D serum concentration is associated with high levels of hepatitis B virus replication in chronically infected patients' Hepatology, vol. 58, pp. 1270-76.
    View at Publisher | View at Google Scholar
  15. Demir C and Demir M. (2013). ‘Vitamin D levels in patients with chronic hepatitis B virus infection and naturally immunized individuals’ Internal Medicine Inside, vol. 1(1), pp. 2-6.
    View at Publisher | View at Google Scholar
  16. WHO   (2014)   Fact   sheet   N°164.   [Updated   2014   April].   
    View at Publisher | View at Google Scholar
  17. Stokes CS, Volmer DA, Grunhage F, and Lammert F. (2013). 'Vitamin D in chronic liver disease, Liver International, vol. 33, pp. 338-52.
    View at Publisher | View at Google Scholar
  18. Carey J, Halan V, Krcmcrs, and Hay WK. (2003). ‘Osleopenia and osteoporosis in patients with end-stage liver disease caused by hepatitis C and alcoholic liver disease: Not just a cholestatic problem’, Liver Transportation, vol. 9(11), pp. ] 166-73
    View at Publisher | View at Google Scholar
  19. Fisher L, and Fisher A. (2007). ‘Vitamin D and parathyroid hormone in outpatients with noncholestatic chronic liver disease’, Clinical Gastroenterology and Hepatology, vol. 5, pp. 513-20.
    View at Publisher | View at Google Scholar
  20. Hossain SF, Islam QT, Siddiqui MR, Hossain A, Jahan N, Rahman N, and Iqbal MJ. (201 1). ‘A study of hypoalbuminemia in chronic liver disease and its correlation with development of csophageal variccs’ Bangladesh Journal of Medicine, vol. 22, pp. 17-20.
    View at Publisher | View at Google Scholar
  21. Shimizu I, Inoue H, Yano M, Shinomiya H, Wada S andTsuji Y. (2001). 'Estrogen receptor levels and lipid peroxidation in hepatocellular carcinoma with hepatitis C virus infection', Liver, (2001). Vol. 21, pp. 342-49.
    View at Publisher | View at Google Scholar
  22. Kudva MV, and Zawawi MM. (1990). ‘Chronic liver disease in Kualalumpur, Malaysia: A c'inical study’. Singapore Medicine Journal, vol. 31, pp. 368-73.
    View at Publisher | View at Google Scholar
  23. Sachin Devidas Dhole, Archana S Kher, Radha G Ghildiyal, Manjusha P Tambse (2015) Chronic Liver Diseases in Children: Clinical Profile and Histology. J Clin Diagn Res. 9(7):SC04-7.
    View at Publisher | View at Google Scholar
  24. Putz-Bankuti C, Pilz S, Stojakovic T, Scharnagl H, Pieber TR, Trauner M, Obermeyer-Pietsch B, and Stauber RE. (2012), 'Association of 25-hydroxyvitamin D levels with liver dysfunction and mortality in chronic liver disease' Liver international, vol. 32(5), pp. 845-51.
    View at Publisher | View at Google Scholar
  25. Chen CC, Wang SS, Jcng FS, and Lee SD. (1996). ‘Metabolic bone disease of liver cirrhosis: Is it parallel to the clinical severity of cirrhosis?’ Journal of Gastroenterology and Hepatology, vol. 11, pp.4l7-21.
    View at Publisher | View at Google Scholar
  26. Crawford BA, Labio ED, Strasser SI, and McCaughan GW. (2006) ‘Vitamin D replacement for cirrhosis- related bone disease’, Nature clinical practice, Gastroenterology and Hepatology, vol. 3(12), pp. 689-99.
    View at Publisher | View at Google Scholar
  27. Clark PJ, Thompson AJ, Vock DM, Kratz LE, Tolun AA, Muir AJ, McHutchison JG, Subramanian M, Millington DM, Kelley RI, and Patel K. (2012), ‘Hepatitis C virus selectively perturbs the distal cholesterol synthesis pathway in a genotype-specific manner.’ Hepatology 2012.
    View at Publisher | View at Google Scholar
  28. Bellecave P, Sarasin-Filipowic/. M. Don/e O, Kennel A, Gouuenoirc J, Mcylan E, Terracciano L, Tschopp J, Sarrazin C, Berg T, Moradpour D, and l-leim MH. (2010), ‘Cleavage of mitochondrial antiviral signaling protein in the liver of patients with chronic hepatitis C correlates with a reduced activation of the endogenous interferon system, Hepatology, vol. 51, pp.1127-36.
    View at Publisher | View at Google Scholar

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"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