AUCTORES
Globalize your Research
Chat with us
Case Reports | DOI: https://doi.org/10.31579/2692-9392/002
*Corresponding Author: J. M. Keppel Hesselink, Institute Neuropathic Pain, 4Spoorlaan 2a, 3735 MV Bosch en Duin, the Netherlands
Citation: J. M. Keppel Hesselink, Topical phenytoin in a case of severe fibromyalgia: ex juvantibus proof for fibromyalgia as a localized non-length dependent small fiber neuropathy. J Archives of Medical Case Reports and Case Study. Doi: 10.31579/2692-9392/002
Copyright: © 2019 J. M. Keppel Hesselink. 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: 26 January 2019 | Accepted: 26 February 2019 | Published: 04 May 2019
Keywords: Neuropathic; treatment; formulation; pain; SFN
We present a case of a 52-year old woman suffering from severe fibromyalgia, unable to manage even the lightest of housework, she gradually became crippled and her life became a ‘couch potato’ in patient’s own words. Treatment with topical phenytoin (5% titrated up to 15%) transformed her life, pain nearly vanished, and she became active, looking for a job, doing housework and she can walk rapidly. One explanation of this phenomenon could be that a number of patients suffering from fibromyalgia and having tender points suffer from localized length non-dependent small fiber neuropathy, and this pathology can be found in the skin above the tender points.
The patient we present to you, a 52-year old woman seen first in November 2013 suffering from chronic fibromyalgic pain during many years, used to take 4 or 5 minutes just to walk down the corridor to the physician’s office, her clothes were always loose, she never wore a bra due to the severe pain of putting it on, her husband helped with most of the housework, and even light housework for her was too much. Many different analgesics where tried, but none helped. After starting treatment with topical phenytoin, she now is a new woman, looking for a job, doing housework, walks rapidly, and the impression is that her ‘new body and life’ results in her exploding with joy.
The patient was first seen in November 2013 at the age of 52 upon referral regarding a narrow band of pain across her chest and back at the D4-5 level. The pain and sensitivity had gradually increased after a very minor back bump in the course of her housework. This has been extremely well investigated with a number of MRIs, neurological consultations but with no resolution. The pain was of such severity that she was unable to work, wear tight clothing particularly a bra. From working full-time at a heavy job, she was unable to manage even the lightest of housework and gradually became crippled. Following the above-mentioned pain, she developed symptoms suggestive of Fibromyalgia which gradually escalated in intensity and became intrusive to her health and lifestyle.
Examination revealed a pleasant woman who even needed help getting out of the chair as the pain in her back was so intrusive score 8-9 on an 11-point NRS. Her pain tolerance using a Fischer Probe (figure 1) was reduced in her arms and to a lesser extent in her legs. Even applying the probe without pressure on the piston produced considerable pain. The area of pain corresponded to an area of hyperesthesia running from D4-5 like a band around her body. The skin over the area showed very significant hyperesthesia, with cotton wool producing significant pain. Tender point count was 18/18 on a A.R.C. scale. Her mood was quiet and debilitated. The pain inhibited her sexual life and greatly her sense of well-being. In the past she had taken a wide range of analgesics, neuroleptics, anti-depressants, and pure analgesics to no effect.
Her medical treatment at that time consisted of amitriptyline 50 mg at night, gabapentin 600 mg five times per day, which provided minimal help. Progress – over the years, a full spectrum of supportive vitamin therapies was tried, oxycodone, trigger point therapy. The use of a topical mixtures of NSAIDS, with lidocaine were somewhat helpful but transient and over time seemed to lose its effectiveness. During this time, her health stabilized but she was still quite incapacitated. The use of cannabinoids provided no significant change and was abandoned. A further neurological investigation and consultation provided no cause for the band of chest pain. She was grateful for the attempt to help the pain, but we were making no significant improvement. Wishing to leave no stone unturned, she was even started on micro-dose lithium up to 1mg, again without any significant change.
The authors are grateful for the research assistance provided by Janice Thompson, Librarian at William Osler Health System.
The patient we present to you, a 52-year old woman seen first in November 2013 suffering from chronic fibromyalgic pain during many years, used to take 4 or 5 minutes just to walk down the corridor to the physician’s office, her clothes were always loose, she never wore a bra due to the severe pain of putting it on, her husband helped with most of the housework, and even light housework for her was too much. Many different analgesics where tried, but none helped. After starting treatment with topical phenytoin, she now is a new woman, looking for a job, doing housework, walks rapidly, and the impression is that her ‘new body and life’ results in her exploding with joy.
The patient was first seen in November 2013 at the age of 52 upon referral regarding a narrow band of pain across her chest and back at the D4-5 level. The pain and sensitivity had gradually increased after a very minor back bump in the course of her housework. This has been extremely well investigated with a number of MRIs, neurological consultations but with no resolution. The pain was of such severity that she was unable to work, wear tight clothing particularly a bra. From working full-time at a heavy job, she was unable to manage even the lightest of housework and gradually became crippled. Following the above-mentioned pain, she developed symptoms suggestive of Fibromyalgia which gradually escalated in intensity and became intrusive to her health and lifestyle.
Examination revealed a pleasant woman who even needed help getting out of the chair as the pain in her back was so intrusive score 8-9 on an 11-point NRS. Her pain tolerance using a Fischer Probe (figure 1) was reduced in her arms and to a lesser extent in her legs. Even applying the probe without pressure on the piston produced considerable pain. The area of pain corresponded to an area of hyperesthesia running from D4-5 like a band around her body. The skin over the area showed very significant hyperesthesia, with cotton wool producing significant pain. Tender point count was 18/18 on a A.R.C. scale. Her mood was quiet and debilitated. The pain inhibited her sexual life and greatly her sense of well-being. In the past she had taken a wide range of analgesics, neuroleptics, anti-depressants, and pure analgesics to no effect.
Her medical treatment at that time consisted of amitriptyline 50 mg at night, gabapentin 600 mg five times per day, which provided minimal help. Progress – over the years, a full spectrum of supportive vitamin therapies was tried, oxycodone, trigger point therapy. The use of a topical mixtures of NSAIDS, with lidocaine were somewhat helpful but transient and over time seemed to lose its effectiveness. During this time, her health stabilized but she was still quite incapacitated. The use of cannabinoids provided no significant change and was abandoned. A further neurological investigation and consultation provided no cause for the band of chest pain. She was grateful for the attempt to help the pain, but we were making no significant improvement. Wishing to leave no stone unturned, she was even started on micro-dose lithium up to 1mg, again without any significant change.
In January 2018, we started treatment with topical phenytoin, 5%, titrating up to 15%. Her improvement was in a straight line and gradually over the ensuing few months, the pain decreased significantly. She was able to walk at speed, carry out housework, and wear clothes that touched her skin with total relief of pain. Over the next few months, the pain over her tender points became less and less as measured by a Fischer Probe (a tonometer or pressure gauge) reading 5-6 which is a normal value in these areas demonstrating a return to normality. Her sensitivity was so great that the slightest pressure from the rubber piston of the probe initially would produce pain and after treatment there was very little sensitivity to the probe pressure.
With her positive response, the physician and patient both agreed that the high dose of gabapentin would be slowly reduced, and this is now at 550 mg/daily rather than the previous 3000 mg/daily. With the gradual reduction of gabapentin, she was started on phenytoin low-dose 50 mg once per day. The most impressive improvement of her health has been in the control of her back pain and the tender point pain. The reduction of high doses of gabapentin and the addition of phenytoin subsequently also has helped and added quality of life.
In order to add some extra perspective to this case we briefly present a second patient: The second case was a woman, 42 years-old with many medical conditions including a spectrum of autoimmune disorders including Multiple Sclerosis and Rheumatoid. After a number of years, she developed fibromyalgia increasing in intensity with the onset of her other disorders. The pain increased in intensity and spread. We failed to produce controllable levels even with the addition of narcotics in a hospital setting. She was started on topical phenytoin 5% and then 10% which produced a remarkable contraction of the painful area around the tender points which occurred within a few days. These decreased in sensitivity as measured by a Fischer Probe. She was subsequently started on oral phenytoin, 20 mg b.i.d.
The treating physician, ALR, based on 50 years of medical practice had never seen such a transformation from couch potato (patient’s own words) to an active woman looking for a job. Topical phenytoin has been selected as a broad acting sodium channel blocker for the development of a compounded formulation in 2015. [1] It has been tested in open and single blind test paradigms in a number of peripheral neuropathic pain states. [2-4] Its mechanism of action is intradermally, plasma levels could not be measured 2 hours after application. [5] What could be the reason of this positive reaction of fibromyalgic pain after treatment with phenytoin cream? Ex juvantibus refers to the process of identifying the cause (in this case the pathogenesis) of a disease based an observed response of a patient to a specific treatment. In our case the fact that this patient responded so clearly after the treatment with topical phenytoin suggests that the pathogenesis, at least in this case, also resides in the skin, as we have demonstrated the absence of systemic effects.
Fibromyalgia and trigger points perhaps to a lesser degree have been one of the failures of medical science. Fibromyalgia first entered the literature over 200 years ago and has been certainly aggressively investigated over the past 100 years to little avail. It is a worldwide dysfunction although the tender points have different calculations, it is the same illness. Like many disorders in medicine, it has gone through various cycles of etiology and certainly without being able to be reproduced in the lab, diagnosed accurately or treated, it has sometimes been labelled psychosomatic. To this day, we still do not have a definitive and effective treatment.
Trigger points were in a similar dilemma, the work of Janet Travell and her famous patient, President Kennedy, put this subject on the map. There is little doubt that trigger point therapy is effective in many cases with the injection of local anesthetic, why they happen in recurrence has been a puzzle. Having treated trigger points for the last 30 years one is impressed by their response to local anesthetics, often repeated to the next cycle of trigger points appear. The question of why has not been defined. Like most things that are not well defined or understood, various treatments have been tried extensively on Fibromyalgia to little effect. The importance of sleep has led to a considerable number of trials using a range of sedatives to antidepressants. Whether disrupted sleep is cause or effect is still somewhat uncertain although early studies of waking healthy students every hour developed a pattern similar to Fibromyalgia.
Over the years, treating trigger points in patients with a fair degree of success has been very satisfying. Fibromyalgia on the other hand has been depressing to manage, a percentage of cases seem to spin out of control with pain, spasms, insomnia, depression, and a sense of hopelessness in some cases as doctors try one favorite drug after another. Trigger point therapy is only partially effective and temporary. Why the pattern which is very definite is another failure of medical science.
From numerous clinical observations and papers, it is obviously a cycle of dysfunction between the periphery and the central nervous control. The question is why? How can this cycle be broken?
Our work on the treatment of diabetic and other causes of peripheral neuropathies using topical 5-10% phenytoin cream helped us to define the pathogenesis of many peripheral neuropathic pain states to reside in the skin. Together with Professor Notermans, from the Utrecht Academic Medical Centre in the Netherlands, we discussed the pathogenesis of a number of small fiber neuropathic pain states, and linked this pathogenesis to the pain reduction in these patients after applying a broad acting sodium channel blocker such as phenytoin.[6] Recently it was found that more than half of the patients presenting with neuropathic pain and who met diagnostic criteria for fibromyalgia had small fiber neuropathy, detected by skin biopsy testing. [7]
Our fibromyalgia patient was so helped by topical phenytoin, that she also commented on her husband using it for arthritis and her mother-in-law for cancer pain. Topical phenytoin has been reported to be of use in the treatment of various peripheral neuropathic pain states. [5] This however is the first report where topical phenytoin seems to reduce pain in fibromyalgia, and the reported effects might be related to the existence of small fiber neuropathy in this fibromyalgia patient. A significant number of fibromyalgia patients with positive trigger points might actually be suffering from a wide spread non-length dependent small fiber neuropathy. This is the first time this hypothesis has been launched as far as we know.
JMKH is holder of two patents: topical phenytoin for use in the treatment of peripheral neuropathic pain and topical pharmaceutical composition containing phenytoin and a (co- )analgesic for the treatment of chronic pain.
The authors are grateful for the research assistance provided by Janice Thompson, Librarian at William Osler Health System.
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.
