AUCTORES
Globalize your Research
Research Article | DOI: https://doi.org/10.31579/2834-5142/050
1 Department of Urology, Yale University School of Medicine, New Haven, CT, United States.
2 Touro College of Medicine, Harlem, NY, United States.
*Corresponding Author: Syed N. Rahman, Department of Urology, Yale School of Medicine.
Citation: Syed N. Rahman, Mursal Gardezi, Jonathan Coronado, Katelyn Johnson, Jamil Syed, et all (2023), Retrospective Evaluation of a Novel Perioperative Opioid Sparing Protocol for Patients Undergoing Robotic Assisted Laparoscopic Radical Prostatectomy or Partial/Total Nephrectomy: A Case Control Study. International Journal of Clinical Nephrology. 5(1); DOI:10.31579/2834-5142/050
Copyright: © 2023 Syed N. Rahman. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 17 January 2023 | Accepted: 30 January 2023 | Published: 03 February 2023
Keywords: opioids; opioid sparing; robotic surgery; eras
Background/Aim: We aimed to evaluate the clinical effect and outcomes of an opioid-sparing perioperative regimen among patients treated with minimally invasive abdominal urologic surgery.
Materials and Methods: We conducted a retrospective study to evaluate the efficacy of a perioperative opioid sparing protocol. Patients enrolled in the treatment group received a pre-specified regimen of meloxicam, gabapentin, omeprazole, oxybutynin, and acetaminophen. Average length of stay, numeric pain scores, amount of opioids utilized in the inpatient post-operative period, the necessity of an opioid prescription at discharge, and outpatient 7-day post-operative phone calls were collected. Descriptive statistics were utilized to measure significant differences between cohorts.
Results: The study consisted of 197 patients enrolled between 2018-2020, including 70 (35.5%) who received the intervention and 127 (64.5%) controls. 106 patients out of 127 (83.5%) patients in the control group were discharged with an opioid prescription as compared to 2 of 70 (2.9%) patients in the treatment group (p< 0.01). There were also significant differences in total inpatient oral milligram morphine equivalents (44.14 mg vs 17.38 mg, p=0.01) in patients with no history of chronic opioid use, inpatient pain score at post-operative days 2-3 (3.84 vs 2.75, p<0.01) and average outpatient pain scores seven days after discharge (3.73 vs 1.67, p<0.01). No difference was observed regarding length of stay (1.74 vs 1.49, p=0.17)
Conclusion: A non-opioid perioperative regimen can result in similar post-operative pain control and length of stay while leading to fewer opioid prescriptions being written at discharge. By decreasing the number of patients requiring opioids post operatively, there is the potential to have a positive impact on the opioid epidemic.
Worldwide the use of post-operative opioid analgesia has resulted in numerous harms including opioid overuse, increased incidence of opioid dependence and opioid use disorder, and opioid diversion [1]. Such outcomes can be linked to the growing opioid epidemic in the United
States resulting in up to 120 deaths per day as a result of both non-synthetic and synthetic opioids [2]. Given the development of such deleterious outcomes from excess opioid prescriptions, a growing amount of research has started to investigate patterns in opioid prescriptions.
It has previously been demonstrated that there exists high variability in outpatient surgery opioid prescriptions even amongst the same procedure [3]. Additionally, longitudinal data has demonstrated that opioid prescriptions for both low risk and high risk surgery have increased steadily [4]. Given this increase there has been growing interest and research into adopting different approaches to treat pain while reserving the use of opioid analgesics as a last resort. Some of these different approaches include novel surgical techniques and procedures as well as the implementation of multimodal analgesia, defined as using medications to target multiple areas in which pain originates in order to provide a more synergistic effect than using any one agent alone [5].
An opioid-sparing regimen was originally developed at our institution to reduce the amount of pain medications utilized by patients in orthopedic surgeries. Slight modifications to the regimen given to the orthopedic patients were made to tailor the regimen to patients undergoing robotic-assisted laparoscopic radical prostatectomy or partial/total nephrectomy. These minimally invasive procedures allow a surgeon to perform a prostatectomy or nephrectomy with decreased blood loss and typically result in better pain control as well as shorter lengths of stay [6]. The purpose of this study is to investigate the effectiveness of a pre-defined opioid sparing pathway by observing a reduction in the amount of prescriptions written at discharge by targeting multiple pathways of pain for patients undergoing a robotic-assisted laparoscopic radical prostatectomy or partial/total nephrectomy.
Patient Selection and Cohort Design
A retrospective cohort study was conducted to determine if there is a significant impact in the prescribing of opioid analgesics in both the inpatient and outpatient setting while still maintaining adequate pain control. Data was collected from the medical records of 97 consecutive patients who had a robotic-assisted laparoscopic radical prostatectomy or partial/total nephrectomy performed by the same surgeon at the same facility.
The control group consisted of patients undergoing one of these procedures from the beginning of June 2018 to the end of January 2020 and did not receive an opioid-sparing packet. The treatment group consisted of patients undergoing one of these procedures from September 2018 to November 2019 that received a blister-pack of medications containing three days of meloxicam 7.5mg daily and gabapentin 300mg at bedtime as well as omeprazole 40mg, oxybutynin ER 5mg, and acetaminophen 1000mg the morning of the procedure. These medications were continued immediately after the surgery and during the rest of the hospitalization. Patients were then discharged with these medications for seven days post-operatively.
Outcomes
The primary outcomes were opioid prescriptions needed at time of discharge and average inpatient MME in the control group vs the treatment group. Secondary outcomes included average length of stay, average daily numeric pain scores, number of opioid medications utilized in the inpatient post-operative period and outpatient 7-day post-operative pain scores. Average length of stay was calculated by using the number of midnights spent in the institution. Average daily numeric pain scores were collected via nursing assessment on a scale from 0-10 (0 = no pain, 10 = worst pain). The amount of opioids utilized in the post-operative period was converted to oral milligram morphine equivalents (MME) to account for different type of opioids used, see Table 1 for conversions. Outpatient 7-day post-operative pain scores were collected via telephone interview.
| Oral (mg) | IV (mg) | |
| Buprenorphine | 0.4 (SL) | N/A |
| Hydrocodone | 30 | N/A |
| Hydromorphone | 7.5 | 1.5 |
| Fentanyl | N/A | 0.1 |
| Meperidine | N/A | 100 |
| Methadone* | 10 | N/A |
| Morphine | 30 | 10 |
| Oxycodone | 20 | N/A |
*While some sources use a conversion of 1:4.7, 1:3 is an appropriate conservative conversion.
Table 1: Milligram Morphine Equivalents
All patients that underwent surgery from June 2018 to November 2019 were included in the study. If a patient was non-compliant with the opioid-sparing pathway before and after the surgery, they were automatically placed into the control group. Patients were only excluded if they did not undergo the surgical procedure. If a patient in the opioid sparing group had an allergy to any component to the opioid-sparing packet, that component was removed and they received the other medications. No regional blocks were utilized for these procedures. It was documented if patients chronically took opioids or had a history of any kind of alcohol or drug abuse, but they were not excluded if they did use chronic opioids. The baseline characteristics are listed in Table 2.
| No Opioid Sparing Pathway/ Control Group (n=127) | Opioid Sparing Pathway/ Treatment Group (n=70) | |
| Age | 63 [55-73] | 65 [56-78] |
| Gender | ||
| Male (#) | 124 | 66 |
| Female (#) | 3 | 4 |
| Allergy to Opioid-Sparing Regimen | 0% (0/127) | 3% (2/70) |
| Chronic Use of Opioids | 5% (7/127) | 4% (3/70) |
| Prior History of Any Substance Abuse (including marijuana) | 8% (10/127) | 11% (8/70) |
| Alcohol Usage | 35% (45/127) | 40% (28/70) |
| Type of Surgery | ||
| Prostatectomy (#) | 90% (116/127) | 83% (58/70) |
| Nephrectomy (#) | 10% (11/127) | 17% (12/70) |
Table 2: Baseline Characteristics
The protocol was reviewed and approved by the Institutional Review Board of South County Hospital and the research was conducted according to the principles of the Declaration of Helsinki, seventh revision (JAMA. 2013; 310:2191-4).
Statistical analysis was performed using Microsoft Excel 2010 software. The statistical significance threshold was set at p-value 
0.05 using 95% confidence intervals (CIs). An unpaired t-test assuming equal variances was used to compare the differences in length of stay, average pain scores on post-op days 0, 1 and 2, pain scores 7 days post-op, average oral milligram morphine equivalents utilized inpatient and number of opioid prescriptions at discharge (given independent groups).
Results
Baseline characteristics
From 2018 to 2020, 197 patients were ultimately eligible for analysis, including 127 patients in the control cohort and 70 patients in the opioid sparing cohort (Table 2). The majority of patients enrolled were men (97.6% in control cohort and 94.2% in opioid sparing cohort) and underwent prostatectomy (90% and 83% respectively). No significant differences in terms of chronic opioid use or prior substance use were identified between cohorts (5% vs. 4% p=0.87, 8% vs. 11% p=0.46).
Pain Score and Length of Stay
The average length of stay did not significantly differ between both cohorts (1.74 days compared to 1.49 days in the non-opioid sparing cohort and opioid sparing cohort respectively, p=0.17). Pain scores did not significantly differ between the non-opioid sparing and opioid sparing cohort on POD1 (2.90 vs. 2.58, p=0.28). However, pain scores were significantly reduced in the opioid sparing cohort compared to the non-opioid sparing cohort on POD2 and POD3 (3.84 vs. 2.75 p<0 p=0.03>
Opioid Utilization
Overall, 106 patients out of 127 (83.5%) in the control group were discharged with an opioid prescription as compared to 2 of 70 (2.9%) patients in the opioid sparing cohort (p< 0 xss=removed p=0.01).>Table 3 for a complete list of all results.
| No Opioid Sparing Pathway (n=127) | Opioid Sparing Pathway (n=70) | P value | |
| Percent Discharged with Opioid Prescription | 83.5% (106/127) | 2.9% (2/70) | <0> |
| Average Length of Stay (days) | 1.74 (CI = 1.46–2.14) (n=127) | 1.49 (CI = 1.24–1.73) (n=70) | 0.17 |
| Average Pain Score Post-Op Day 0 | 2.90 (CI = 2.34-3.26) (n=127) | 2.58 (CI = 2.20–2.97) (n=70) | 0.28 |
| Average Pain Score Post-Op Day 1 | 3.84 (CI = 3.52–4.18) (n=127) | 2.75 (CI = 2.32–3.15) (n=70) | <0> |
| Average Pain Score Post-Op Day 2 | 4.45 (CI = 4.01–5.07) (n=20) | 3.18 (CI = 2.37–3.99) (n=7) | 0.03 |
| Average Inpatient Total Oral MME (mg) | 34.40 (CI = 22.29–41.93) (n=127) | 1.92 (CI = 0.15–3.43) (n=70) | <0> |
| Average Inpatient Total Oral MME (for those that utilized opioids) (mg) | 44.64 (CI = 38.81–101.34) (n=127)
| 71.91 (CI = 8.63–135.19) (n=11)
| 0.74 |
| Average Inpatient Total Oral MME Excluding those with Chronic Opioid Use history (for those that utilized opioids) | 44.14 (CI = 36.14–52.26) (n=126) | 17.38 (CI = 4.27–30.29) (n=8) | <0> |
| Average Pain Score at Home 7 Days Post-Op | 3.73 (CI = 3.32–4.15) (n=15) | 1.67 (CI = 1.26–2.09) (n=61) | <0> |
Table 3: Results
This retrospective analysis revealed a non-opioid perioperative regimen can result in the equivalent length of stay, improved pain control POD1 onwards and lead to fewer opioid prescriptions being written at the time of discharge. The amount of opioid prescriptions written at discharge had an absolute reduction of 80.6%. The amount of opioids required in the post-operative period for patients who do not chronically use opioids was reduced by more than 50%.
However, the notable takeaway from our results is that a reduction in opioid prescriptions and inpatient use of opioids with our opioid sparing pathway led to similar pain scores in POD0 and actually improved pain scores POD1 and beyond. Length of stay was noted to be decreased in the opioid sparing group, although not a statistically significant reduction. Additionally, pain scores remained improved until postoperative day 7 in the opioid sparing cohort. The overall sample size across both cohorts remained low preventing further generalizability of such results.
To our knowledge this is the first study focused on achieving a profound reduction in opioid prescriptions and leading to improved pain control with an opioid-sparing regimen in patients undergoing urologic procedures. Multiple studies have investigated opioid prescriptions being filled after robotic assisted laparoscopic urologic procedures. Studies have identified that in certain cohorts over 50% of patients following radical prostatectomy fill a prescription for opioids [6-7]. However, it has become evident now that in those cohorts over 70% of prescriptions ultimately remain unused and add potential opioids to the community that may subsequently contribute to the growing opioid epidemic [8]. Although prior trials aimed at developing and testing opioid-sparing regimens had different results based on the time of procedure, our results demonstrate the need for a randomized prospective trial comparing an opioid sparing pathway to the traditional opioid pain regimen. Modifications to the existing pain regimen identified in our study, such as the utilization of Toradol inpatient and incorporating regional blocks, should additionally be investigated. Additionally, proper patient educations regarding medication administration, such as discussing each element of the blister pack given to the patient in our study, may lead to improved patient satisfaction and post-operative pain scores that may directly affect opioid requirements.
There are a few notable strengths to this study. All surgeries were performed by the same two surgeons at the same institution. Since the same surgeons performed these procedures, the outcomes are more likely to reflect differences in the medical management rather than differences in the surgical techniques. In addition, all patients that received the surgery in the specified timeframe were included in the study. Lastly, all patients received the same preoperative and post-operative regimen, except for two patients, both of which reported an allergy to non-steroidal anti-inflammatory drugs.
The greatest limitation to this study was the retrospective nature and small sample size of patients as it relates to average pain scores at seven days after discharge. Since pain scores were recorded via telephone interview, we were unable to include pain scores for patients that were unable to be reached after discharge. Additionally, it is important to note that this is a descriptive study and that further refined statistical analyses with larger sample sizes will be required to understand optimal combinations of perioperative pain regimens. Future randomized controlled trials investigating opioid sparing protocols are warranted.
A non-opioid perioperative regimen can result in equivalent length of stay, similar or even improved post-operative pain control and fewer opioid prescriptions being written at the time of discharge. By decreasing the number of opioids required in the post-operative recovery period and the number of patients requiring opioids at discharge, the utilization of an opioid-sparing regimen has the potential to have a substantial impact on the opioid epidemic by reducing drug availability.
All authors have no financial interests to disclose
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
