Effects of monosaccharides administration on rat DEHP toxicity

Research Article | DOI: https://doi.org/DOI:10.31579/2693-2156/096

Effects of monosaccharides administration on rat DEHP toxicity

  • Shigeru Suna 1*
  • Masaaki Tokuda 2

1 Private HealthResearch Laboratory, Kagawa,Japan

2 Professor Emeritus,Kagawa University, Kagawa,Japan

*Corresponding Author: Shigeru Suna, Private Health Research Laboratory, 14-22 Shinkita-machi, Takamatsu-shi, Kagawa 760-0001, Japan.

Citation: Shigeru Suna, and Masaaki Tokuda, (2024), Effects of monosaccharides administration on rat DEHP toxicity, J Thoracic Disease and Cardiothoracic Surgery, 5(4); DOI:10.31579/2693-2156/096

Copyright: © 2024, Shigeru Suna. 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: 30 April 2024 | Accepted: 15 May 2024 | Published: 25 May 2024

Keywords: D-glucose; D-fructose; D-allulose; D-allose; allitol; DEHP

Abstract

Di(2-ethylhexyl) phthalate (DEHP), a suspected endocrine disruptor, causes hepatomegaly, testicular damage, and other toxic effects in oral administration experiments using rats. MEHP, a DEHP metabolite, is directly responsible for these toxicities; the potent oxidative stress generated by MEHP is thought to be closely involved.

To elucidate the relationship between the hydroxyl radical scavenging activity of monosaccharides, including rare sugars, and DEHP toxicity, D-glucose, D-fructose, D-allulose, D-allose and allitol were mixed 1.0 w/v% in drinking water and administered to 4-week-old male SD rats for 1 week with 1% w/w DEHP mixed food.

D-Allulose had a strong inhibitory effect on testicular atrophy, and D-Allose had a significant inhibitory effect on hepatomegaly.Furthermore, plasma ALT levels in the D-allulose and D-allose-treated groupswere significantly lowerthan those in the control group and the group treated with DEHP alone. These results may be due to the anti-inflammatory and anti-cell death effects of the monosaccharides through their hydroxyl radical scavenging action. Although allitol did not prevent DEHP-induced hepatomegaly and testicular atrophy, but prevented DEHP-induced reduction in weight gain. MEHP induced oxidative stress can disrupt thyroid hormones, which plays an important role in the process of skeletal muscle formation. The weight loss may be due to MEHP-induced thyroid dysfunction. Allitol may counteract MEHP- induced thyroid dysfunction.

Introduction

Di(2-ethylhexyl) phthalate (DEHP), a suspected endocrine disruptor, is used as a plasticizer in polyvinyl chloride (PVC) in ratios ranging from a few percent to tens of percent [1-3]. DEHP is known to cause hepatic peroxisome proliferation and testicular atrophy in rats as an oral toxicity of DEHP [4-11]. However, recently, toxic effects on the testes have been observed at even lower concentration levels than those conventionally used for detection, and there is growing concernabout the health effects of exposure to low concentrations of DEHP [13].

In oral administration experiments using rats and other animals, DEHP itself is hardly absorbed into the body, but mono(2- ethylhexyl) phthalate (MEHP), which is hydrolyzedby lipase in the digestive tract, is absorbed and distributed in the body, and is thought to be involvedin the development of toxicityin the testes and liver [14-16]. Recently, the involvement of reactive oxygen species (ROS) in the mechanism of germ cell apoptosis induction by MEHP has been clarified [17, 18].

On the other hand, many monosaccharides, including rare sugars, are known to exhibitantioxidant effects basedon hydroxyl radical scavenging [19-24], and may have a protective effect against DEHP-induced testicular toxicity and liver toxicity.

Therefore, the authors investigated the effects of some monosaccharides, including rare sugars on DEHP toxicity in animal experiments.

 

Figure 1. Molecular structures of D-glucose, D-fructose, D-allulose, D-allose and allitol.

Methods

2-1. Experimental Animals and Reagents

Male Charles River Sprague-Dawley (SD) rats were used as experimental animals, and were fed a rat diet made by Oriental Yeast and a diet mixed with DEHP (97% or higher purity). Rare sugars (98% or higher purity) were provided by the Kagawa University Rare Sugar Research Center. Other ingredients were commercial grade reagents.

Oral administration of DEHP and sugars

The experiments were conducted under the conditions of 22-24℃ of temperature and 50-60% relative humidity at the Laboratory Animal Center of Kagawa University. The experiment protocols had the approval by the Kagawa University Animal Committee. D-glucose, D-fructose, D-allulose, D-allose and allitol (Figure 1) were mixed 1.0 w/v% in drinking water and administered to 4- week-oldmale SD rats for 1 week with 1% w/w DEHP mixed food. The administration experiment was repeated in units of 6 rats per group.

At the first week after administration, blood was drawn from the heartunder ether anesthesia, and the testes,liver, and other organs were removed and weighed.

Plasma isolated from rat blood was used to measure the following parameters:

Plasma levels of glucose, aspartate aminotransferase (AST), alanine aminotransferase (ALT), total cholesterol, HDL cholesterol, triglycerides.

The analyzer was a Hitachi Model 7600 Automated Analyzer (Hitachi).

Statistical Analysis

Results were expressed as means ± standard deviations (SD). Statistical analysis was performed by one-way ANOVA test followed by Dunnett's postanalysis test for multiple comparisons. p <0>

Results

Body weight and organweights are shown in Table 1, 2 and 3, and blood biochemical test results are shown in Table 4, 5 and 6. Final body weights of DEHP alone and DEHP plus D-glucose, D- fructose, D-allulose or D-allose, were statistically significantly lower than those of the control group. Significant inhibition of weight suppression was observed in the DEHP plus allitol group. As shown in Table 2, the degreeof testicular atrophyof DEHP in terms of relative testicular weight (testes/body weight %) was DEHP (0.62) ≈ DEHPplus allitol (0.58) > D-glucose (0.75) ≈ D- allose (0.72) > D-allulose (0.82) ≈ control (0.88). D-allulose showed the strongest and statistically significant inhibition of testicular atrophy. As shown in Table 3, the degree of DEHP hepatomegaly in terms of liver weight (relative weight %) was DEHP (7.8) ≈ DEHP+D-allitol (7.7) ≈ D-glucose (7.6) ≥ D- allulose (7.3) > DEHP+D-allose (6.9) versus control (4.8). D- allose significantly suppressed hepatomegaly, while D-allulose showed insignificant suppression (p=0.052).

GroupnInitial body weight (g)Final bodyweight (g)
meanSD meanSD 
Control1897.14.3 159.29.1###
DEHP1894.35.0 141.38.4***
DEHP+Glucose694.04.8 136.25.9***
DEHP+Fruktose699.03.6 145.75.3**
DEHP+Allulose1295.14.5 137.04.6***
DEHP+Allose1296.74.4 135.010.6***
DEHP+Allitol699.03.0 153.96.5##

*p<0.05, **p≤0.01, ***p<0.001, as compared to control. p<0.05, p<0.01, p<0.001, as compared to DEHP alone.

Table 1. Initial and final body weights

 

Group

 

n

Testes (g)Relative testicular weight (%)
meanSD meanSD 
Control181.400.11###0.880.05###
DEHP180.870.20***0.620.15***
DEHP+Glucose61.020.24***0.750.15 
DEHP+Fruktose60.990.20***0.680.13**
DEHP+Allulose121.130.22**, ##0.820.16##
DEHP+Allose120.970.25***0.730.18**
DEHP+Allitol60.890.12***0.580.10***

*p<0.05, **p<0.01, ***p<0.001, as compared to control. #p<0.05, ##p<0.01, ###p<0.001, as compared to DEHP alone.

Table 2: Testicular weights

GroupnLiver (g)Relative liverweight (%)
meanSD meanSD 
Control187.670.64###4.820.24###
DEHP1810.991.25***7.770.69***
DEHP+Glucose610.320.51***7.590.47***
DEHP+Fruktose611.830.66***8.120.30***
DEHP+Allulose1210.000.51***, ###7.310.45***
DEHP+Allose129.370.90***, ###6.950.35***, ###
DEHP+Allitol611.830.66***7.700.54***

*p<0.05, **p<0.01, ***p<0.001, as compared to control. #p<0.05, ##p<0.01, ###p<0.001, as compared to DEHP alone.

Table 3. Liver weights

As shown in Table 4, plasma glucoselevels were significantly

suppressed in the group treated with DEHP alone compared to the control. D-glucose and D-allulose restored plasma glucose levels, while D-allose and allitol did not. DEHP alone and DEHP plus monosaccharide treatments had significantly lower triglycride levelsthan controls. As shown in Table 5, plasma total- cholesterol and HDL-cholesterol in the DEHP alone and DEHP

plus monosaccharide treated groups were significantly lower than controls.

Plasma ALT levels in the DEHP plus D-allulose, or D-allose treated groups were significantly lower than controls and DEHP alone (Table 6).

 

Group

 

n

Glucose (mg/dL)Triglycerides (mg/dL)
meanSD meanSD 
Control18206.256.7#46.221.5###
DEHP18174.227.8*24.89.5***
DEHP+Glucose6185.015.8 19.74.3**
DEHP+Fruktose6-- -- 
DEHP+Allulose12183.823.7 26.08.5**
DEHP+Allose12167.815.1*31.012.9*
DEHP+Allitol6170.511.5*24.89.5**

*p<0.05, **p<0.01, ***p<0.001, as compared to control. #p<0.05, ##p<0.01, ###p<0.001, as compared to DEHP alone.

Table 4. Plasma levels of glucose and triglycerides

GroupnAST (U/L)ALT (U/L)
meanSD meanSD 
Control18202.6155.3 56.416.0 
DEHP18160.686.9 57.716.8 
DEHP+Glucose6134.841.8 44.05.8 
DEHP+Fruktose6-- -- 
DEHP+Allulose12121.648.5 43.98.6#
DEHP+Allose12138.8107.3 41.57.6*, ##
DEHP+Allitol6116.325.8 44.86.3 

*p<0.05, **p<0.01, ***p<0.001, as compared to control. #p<0.05, ##p<0.01, ###p<0.001, as compared to DEHP alone.

Table 5. Plasma levels of ALT and AST

GroupnTotal-cholesterol (mg/dL)HDL-cholesterol (mg/dL)
meanSD meanSD 
Control1890.114.1###36.44.2###
DEHP1865.25.0***26.43.3***
DEHP+Glucose665.85.2***24.52.2***
DEHP+Fruktose6-- -- 
DEHP+Allulose1266.19.7***26.33.3***
DEHP+Allose1270.88.2***28.34.0***
DEHP+Allitol672.814.4**28.74.7***

*p<0.05, **p<0.01, ***p<0.001, as compared to control. #p<0.05, ##p<0.01, ###p<0.001, as compared to DEHP alone

Table 6. Plasma levels of total cholesterol and HDL cholestero

Discussion

After oral administration, DEHP, distributed in the body primarily as MEHP, stimulates peroxisome proliferator-activated receptors and increases carbohydrate and lipid metabolism. The oxidative stress produced may be closely related to DEHP toxicity, including hepatomegaly and testicular atrophy [4-12]. In the present oral administration experiments of DEHP and monosaccharides, D-Allulose showed the strongest and significant testicular atrophy inhibitory effect, suggesting that D-allose, D- glucose, and D-fructose have a slightinhibitory effect on testicular atrophy. The liver weights of the D-allose-treated groups were significantly lower than those of the group treated with DEHP alone. Furthermore, plasma ALT levels in the D-allulose and D- allose-treated groups were significantly lower than those in the control and the group treatedwith DEHP alone.These results may be attributed to the anti-inflammatory and anti-cell death effects of monosaccharides due to their hydroxyl radical scavenging action. Plasma glucoseconcentrations were significantly lower in the group treated with DEHP alone than in the controlgroup, but not in the D-allulose-treated group. This suggests that D-allulose

inhibits DEHP -induced glycemic suppression; MEHP -induced PPAR-γ can promote lipid metabolism, whilethe reactive oxygen species produced can promote insulin secretion [25-27]. The antioxidant D-allulose may regulate insulin hypersecretion and protect pancreatic function [28, 29].

Allitol did not prevent DEHP-induced hepatomegaly and testicular atrophy, but prevented DEHP-induced reduction in weight gain. MEHP induced oxidative stress can damage thyroid tissue and lower thyroid hormones [30-33] which plays an important role in the process of skeletal muscle formation [34]. The weight loss may be due to MEHP-induced thyroid dysfunction. Allitol may counteract MEHP-induced thyroid dysfunction.

Conclusion

D-Allulose had a stronginhibitory effect on testicular atrophy,and D-Allose had a significant inhibitory effect on hepatomegaly. Furthermore, plasma ALT levels in the D-allulose and D-allose- treated groups were significantly lower than those in the control group and the grouptreated with DEHP alone. These results may be due to the anti-inflammatory and anti-cell death effects of the monosaccharides through their hydroxyl radical scavenging action. Although allitol did not prevent DEHP-induced hepatomegaly and testicular atrophy, but prevented DEHP-

induced reductionin weight gain. MEHP inducedoxidative stress can disruptthyroid hormones, which plays an important role in the process of skeletal muscleformation. The weightloss may be due to MEHP-induced thyroid dysfunction. Allitol may counteract MEHP-induced thyroid dysfunction.

Acknowledgment

This work was supported by a Grants-in-Aid for Rare Sugar Research of Kagawa University. The author appreciates the help of colleagues in the Kagawa University.

Disclosure of conflictof interest

Authors declare that there is no conflict of interests.

References

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.

img

Virginia E. Koenig

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.

img

Delcio G Silva Junior

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.

img

Ziemlé Clément Méda

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.

img

Mina Sherif Soliman Georgy

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.

img

Layla Shojaie

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.

img

Sing-yung Wu

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.

img

Orlando Villarreal

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.

img

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.

img

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.

img

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.

img

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.

img

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.

img

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.

img

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.

img

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.

img

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.

img

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.

img

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!

img

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".

img

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.

img

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.

img

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.

img

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.

img

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.

img

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.

img

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”.

img

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.

img

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.

img

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.

img

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.

img

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.

img

Maria Dolores Gomez Barriga