AUCTORES
Globalize your Research
Review Article | DOI: https://doi.org/10.31579/2690-8808/102
*Corresponding Author: Gian Maria Pacifici, Associate Professor of Pharmacology via Sant’ Andrea 32, 56127 Pisa, Italy.
Citation: Gian Maria Pacifici, (2022) Clinical Pharmacology of Rocuronium in Infants and Children. J, Clinical Case Reports and Studies 3(2); DOI: 10.31579/2690-8808/102
Copyright: © 2022 Gian Maria Pacifici, 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: 16 December 2021 | Accepted: 24 December 2021 | Published: 06 January 2022
Keywords: rocuronium; dosing; effects; metabolism; pharmacokinetics; treatment; placental-transfer; infants; and children
The main clinical use of the neuromuscular blocking agents is an adjuvant in surgical anaesthesia to obtain relaxation of skeletal muscle, particularly of the abdominal wall, to facilitate surgical manipulations. Rocuronium can be used instead of suxamethonium to provide rapid muscle paralysis during tracheal intubation but the recovery is much slower. Rocuronium is administered intravenously to infants and children. In infants, rocuronium is administered at a dose of 450 µg/kg for providing muscle relaxation for laryngeal intubation. To provide sustained paralysis, rocuronium is given at a dose of 600 µg/kg. In children, the neuromuscular blockade is obtained with 600 µg/kg followed by an intravenous infusion of 150 µg/kg per hour. For assisted ventilation in intensive care, rocuronium is administered at a dose of 600 µg/kg followed by an intravenous infusion of 300 to 600 µg/kg per hour. The effects of rocuronium have been extensively studied in infants and children. Rocuronium is converted into 17-desacetyl rocuronium. The pharmacokinetics of rocuronium have been studied in infants and children and the mean residence time is 55.6 and 25.6 min (P-value < 0.01) in infant and children, respectively. Rocuronium interacts with drugs, the treatment of infants and children with rocuronium has been studied, and rocuronium poorly crosses the human placenta. The aim of this study is to review the published data on rocuronium dosing, pharmacokinetics, and treatment in infants and children, and rocuronium metabolism and transfer across the human placenta.
Mechanism of action of neuromuscular blocking agents
Competitive antagonists bind the nicotine acetylcholine receptor in skeletal muscle and thereby competitively block the binding of acetylcholine. The depolarizing agents, such as succinylcholine, depolarize the membrane by opening channels in the same manner as acetylcholine. However, they persist longer at the neuromuscular junction primarily because of their resistance to acetylcholine. The depolarisation is thus longer lasting, resulting in a brief period of repetitive excitation that may elicit transient and repetitive muscle excitation (fasciculations), followed by blocking of neuromuscular transmission and flaccid paralysis (called phase I block). The block arises because, after an initial opening, perjunctional Na+ channels close and will not reopen until the end plate is repolarized. At this point, neural release of acetylcholine results in the binding of acetylcholine to receptors on an already-depolarized end plate. These closed perjunctional channels keep the depolarization signal from effecting downstream channels and effectively shield the rest of the muscle from activity at the motor end plate. This sequence is influenced by such factors as the anaesthetic agent used concurrently, the type of muscle, and the rate of drug administration. Under clinical condition, with increasing concentrations of succinylcholine and over time, the block may convert slowly from a depolarizing phase I block to a non-depolarizing phase II block. While the response to peripheral stimulation during phase II block by administration of anti-acetylcholine agents (e.g., neostigmine) is difficult to predict and should be undertaken cautiously. Many drugs and toxins block neuromuscular transmission by other mechanisms, such as interference with the synthesis or realised acetylcholine, but most of these agents are not employed clinically for neuromuscular blockade. One exception is the group of botulinum toxins, which are administered locally into muscles of the orbit in the management of ocular blepharospasm and strabismus and have been used to control other muscle spasm and to facilitate facial muscle relaxation. This toxin also has been injected into the lower oesophageal sphincter to treat achalasia [1].
Muscular relaxation of neuromuscular blocking agents
The main clinical use of the neuromuscular blocking agents is an adjuvant in surgical anaesthesia to obtain relaxation of skeletal muscle, particularly of the abdominal wall, to facilitate operative manipulations. With muscle relaxation no longer dependent on the depth of general anaesthesia, a much lighter level of anaesthesia suffices. Thus, the risk of respiratory and cardiovascular depression is minimized, and post-anaesthetic recovery is shortened. Neuromuscular blocking agents of short duration often are used to facilitate endotracheal intubation and have been used to facilitate laryngoscopy, bronchoscopy, and esophagoscopy in combination with a general anaesthetic agent. Neuromuscular blocking agents are administered parenterally, nearly always intravenously. These agents may be administered by continuous infusion in the intensive care setting for improving chest wall compliance and eliminating ventilator dyssynchrony [1].
Clinical use of rocuronium
Rocuronium can be used instead of suxamethonium to provide rapid muscle paralysis during tracheal intubation, but the recovery is much slower. Vecuronium is a similarly long-acting paralytic agent but takes longer to work. Atracurium and mivacurium are useful (but slower acting) alternatives when short-term paralysis is all that is required, but are more likely to trigger histamine release [2]. Rocuronium is used for muscle relaxation/paralysis in patients requiring endotracheal intubation. Rocuronium is an aminosteroid non-depolarizing neuromuscular blocking agent that is an analogue of vecuronium with 10 to 15% of its potency. It has a rapid to intermediate onset depending on the dose and intermediate duration. It acts by competing for cholinergic receptors at the motor end-plate. This action is antagonized by acetylcholinesterase inhibitors, such as neostigmine and edrophonium. The plasma levels of rocuronium follow a three compartment open model following intravenous administration. The rapid distribution half-life is 1 to 2 min and the sower distribution half-life is 14 to 18 min. Onset of clinical effect usually occurs within 2 min and the duration ranges from 20 min to 2 hours. Larger doses (900 to 1,200 µg/kg) lead to more rapid onset and larger duration of clinical effect. It can have differential effects on various muscle groups (e.g., laryngeal versus adductor pollicis versus diaphragm). The onset of laryngeal adductor paralysis is significantly slower with rocuronium compared to succinylcholine. Despite this difference, rocuronium has the fastest onset of any currently available non-depolarizing muscle relaxant. The average half-life in newborns is 1.1 hours. Rocuronium is approximately 30% protein bound, and is primary excreted by the liver [3].
Literature search
The literature search was performed electronically using PubMed database as search engine and the following key words were used: “rocuronium dosing infants, children“, “rocuronium effects infants, children, “rocuronium adverse-effects infants, children”, “rocuronium metabolism”, “rocuronium pharmacokinetics infants, children”, “rocuronium drug interactions”, “rocuronium treatment infants, children”, and “rocuronium placental transfer”. In addition, the books: The Pharmacological Basis of Therapeutics [1], Neonatal Formulary [2], NEOFAX® by Young and Mangum [3], and The British National Formulary for Children [4] have been consulted.
Administration schedules or rocuronium to infants and children
Intravenous administration to infants [2]
Brief use to effect intubation: 450 µg/kg of rocuronium provides the muscle relaxation needed to effect easy laryngeal intubation within a min in infants < 1>
Use to provide sustained paralysis: Start giving 600 µg/kg of rocuronium by intravenous injection. Most infants continue to comply with the imposed ventilator rate as they wake from this first paralysing dose (especially if a moderately fast rate and a relatively short inspiratory time is used) but a few require prolonged paralysis. The standard repeat dose is a quarter to half the initial dose given intravenously every 2 to 4 hours as necessary but some older infants seem to require a higher maintenance dose. Paralysed infants should always be sedated. An infusion of 300 to 600 µg/kg per hour adjusted according to the response is an alternative to intermittent dosing.
Intravenous administration for neuromuscular blockade (intermediate duration) during surgery [4]
Children. Give initially 600 µg/kg, and then (by intravenous injection) 150 µg/kg, repeat the dose if necessary, alternatively (by intravenous infusion) 300 to 600 µg/kg per hour, adjust the dose according to the response.
Intravenous administration for assisted ventilation in intensive care [4]
Children. Give initially 600 µg/kg, initial dose is optimal, and then (by intravenous infusion) give 300 to 600 µg/kg per hour for the first hour, and then (by intravenous infusion) adjust the dose according to the response.
Effects of rocuronium in infants and children
Rocuronium facilitates successful intubation and provided clinical paralysis quickly in term and preterm infants [5]. Six-hundred μg/kg of rocuronium has a rapid onset of effect in infants and prolonged duration of action in infants compared to children [6]. Neuromuscular blockade induced by rocuronium can be effectively reversed with sugammadex 2 mg/kg in children aged 1 to 12 years [7]. A dose of 450 µg/kg rocuronium results in rapid relaxation and safe ventilation in paediatric patents undergoing rigid bronchoscopy [8]. Rocuronium at intubating doses of 450, 600 or 1,000 µg/kg is effective in producing rapid-onset neuromuscular blockade with an intermediate duration of action in paediatric patients during sevoflurane induction/isoflurane maintenance anaesthesia [9]. Intramuscular rocuronium does not consistently provide satisfactory tracheal intubating conditions in infants and children and is not an adequate alternative to intramuscular succinylcholine when rapid intubation is necessary [10]. Deltoid injections of rocuronium at a dose of 1,000 µg/kg in infants and 1,800 µg/kg in children rapidly permit tracheal intubation in infants and children, despite a light plane of anaesthesia [11]. The emergency recovery following an average 94.5+4.8% neuromuscular blockade established by rocuronium is roughly similar in infants and children. Thus, one ED95 dose of rocuronium, unlike vecuronium, acts as an intermediate-acting agent in infants and children [12]. Rocuronium has a rapid onset and intermediate duration of action in children aged 4 to 12 years and appears to devoid significant adverse-effects [13]. Rocuronium reduces the frequency of oculocardiac reflex mainly by reducing the incidence of supraventricular and ventricular premature beats [14]. Rocuronium given at a dose of 300 µg/kg during halothane anaesthesia causes neuromuscular depression and has a longer duration of action in infants than in children older than 2 years [15].
Adverse-effects caused by rocuronium in infants and children [4]
Uncommon adverse-effects
Procedural complications and tachycardia.
Rare or very rare adverse-effects
Angioedema, circulatory collapse, face oedema, malignant hyperthermia, paralysis, and shock.
Metabolism of rocuronium
In literature there is only one study on rocuronium metabolism and it has been reported by Proost et al. [16]. In samples of human urine, bile, and faeces only small amounts of rocuronium metabolite 17-desacetyl-rocuronium have been found.
Pharmacokinetics of rocuronium in infants and children
Wierda et al. [17] studied the pharmacokinetics of rocuronium in 5 infants aged 0.1 to 0.8 years and in 5 children aged 2.3 to 8 years. Rocuronium was intravenously infused at a dose of 600 µg/kg per min to infants and at a dose of 900 µg/kg per min to children. Table 1 provides the surgical procedures and subject’s demographic characteristics and table 2 summarizes the pharmacokinetics of rocuronium.
Clpl = plasma clearance. Cl12 and Cl13 = distribution clearance to the second and third compartment, respectively. V1, V2, and V3 = volume of the central, second and third compartments, respectively. Vss = distribution volume at steady-state. MRT = mean residence time after an intravenous bolus dose. Keo = rate constant of equilibration between central and peripheral compartments. EC50 = the concentration in the effect compartment at 50% neuromuscular block. γ = slope of the concentration-effect relationship in the effect compartment. ED50 = calculated bolus dose resulting in 90% block. NS = not significant. *Mann-Whitney U test.
This table shows that the plasma clearance is greater in children than in infants, the volume of the second compartment is lower in children, the distribution volume at the steady state and the mean residence time are lower in children, and the concentration in the peripheral compartment at 50% neuromuscular block is greater in children, the slope of the concentration-effect relationship in the effect compartment is lower in children.
Interaction of rocuronium with drugs
The co-administration of rocuronium with cisatracurium results in a synergic effect [18]. Rocuronium inhibits the formation-rate of temazepam and desmethyldiazepam by 20% and 15%, respectively, in human liver microsomes [19]. Magnesium potentiates the neuromuscular effect of rocuronium and shifts the concentration-response curve to the left [20]. The calculated doses producing 50
The main clinical use of the neuromuscular blocking agents is an adjuvant in surgical anaesthesia to obtain relaxation of skeletal muscle, particularly of the abdominal wall, to facilitate surgical manipulations. Neuromuscular blocking agents of short duration often are used to facilitate endotracheal intubation and have been used to facilitate laryngoscopy, bronchoscopy, and esophagoscopy in combination with a general anaesthetic agent [1]. Rocuronium can be used instead of suxamethonium to provide rapid muscle paralysis during tracheal intubation, but the recovery is much slower. Vecuronium is a similarly long-acting paralytic agent but takes longer time to work. Atracurium and mivacurium are useful (but slower acting) alternatives when short-term paralysis is all that is required, but are more likely to trigger histamine release [2]. Rocuronium is used for muscle relaxation/paralysis in patients requiring endotracheal intubation. Rocuronium is an aminosteroid non-depolarizing neuromuscular blocking agent that is an analogue of vecuronium with 10 to 15% of its potency. It has a rapid to intermediate onset depending on dose and intermediate duration. Rocuronium acts by competing for cholinergic receptors at the motor end-plate. Rocuronium can have differential effects on various muscle groups (e.g., laryngeal versus adductor pollicis versus diaphragm). The onset of laryngeal adductor paralysis is significantly slower with rocuronium compared to succinylcholine. Despite this difference, rocuronium has the fastest onset of any currently available non-depolarizing muscle relaxant [3]. Rocuronium is administered intravenously to infants and children. In infants, the dose to produce a brief effect for intubation is 450 µg/kg and the dose for providing a sustained paralysis is 600 µg/kg [2]. In children, the dose for neuromuscular blockade is 600 µg/kg followed by 150 µg/kg [4]. The effects caused by rocuronium have been extensively studied in infants and children [5-15]. Rocuronium is used to provides clinical paralysis to facilitates intubation in term and preterm infants [5], a dose of 600 µg/kg rocuronium has a more prolonged onset of effect in infants than in children [6], the neuromuscular blockade induced by rocuronium is reversed by 2 mg/kg sugammadex [7], a dose of 450 µg/kg results in a rapid relaxation in paediatric patients undergoing rigid bronchoscopy [8], rocuronium at a dose of 450, 600, or 1,000 µg/kg produces neuromuscular blockade in paediatric patients during anaesthesia [9], intramuscular rocuronium does not provide satisfactory tracheal intubation conditions in infants and children and is not alternative to succinylcholine [10], deltoid injections of rocuronium at a dose of 1,000 µg/kg to infants and 1,800 µg/kg to children permit tracheal intubation [11], the emergency recovery of neuromuscular blockade established by rocuronium is similar in infants and children [12], rocuronium produces neuromuscular blockade in children without producing adverse-effects [13], rocuronium reduces the frequency of oculocardiac reflex in children [14], and a rocuronium dose of 300 µg/kg causes neuromuscular depression in infants and children undergoing anaesthesia [15]. Rocuronium is converted into 17-desacetyl rocuronium and this metabolite appears in small amounts in urine, bile, and faeces [16]. The pharmacokinetics of rocuronium have been studied in infants and children and the mean residence time of rocuronium is 55.6 and 25.6 hours (P-values < 0>
In conclusion, rocuronium is a neuromuscular agent and is used in surgical anaesthesia to reduce the relaxation of skeletal muscle, particularly of the abdominal wall, to facilitate surgical manipulations. Rocuronium is administered intravenously to infants and children. In infants, the muscular relaxation necessary for easy laryngeal intubation is obtained with 450 µg/kg and a dose of 600 µg/kg is necessary for surgery. In children, the neuromuscular blockade is obtained with 600 µg/kg followed by 150 µg/kg. The effects caused by rocuronium in infants and children have been extensively studied. Rocuronium is converted into 17-desacetyl rocuronium. The pharmacokinetics of rocuronium have been studied in infants and children and the mean residence time of rocuronium is 55.6 and 25.6 hours (P-value <0>
The authors declare no conflicts of financial interest in any product or service mentioned in the manuscript, including grants, equipment, medications, employments, gifts, and honoraria.
This article is a review and drugs have not been administered to men or animals.
The author thanks Dr. Patrizia Ciucci and Dr. Francesco Varricchio, of the Medical Library of the University of Pisa, for retrieving the scientific literature.
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.
