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Research Article | DOI: https://doi.org/10.31579/2692-9406/162
1 Professor in Mansoura Ophthalmic Center, Faculty of Medicine, Mansoura University.
2 Lecture in Mansoura Ophthalmic Center, Faculty of Medicine, Mansoura University.
*Corresponding Author: Mona Abdel kader, Professor in Mansoura Ophthalmic Center, Faculty of Medicine, Mansoura University.
Citation: Mona Abdel kader, Ayman Fawzy, (2023),Triamacinolone Alone Versus Triamacinolone with Laser in Diabetic Macular Odema, J. Biomedical Research and Clinical Reviews. 8(4); DOI:10.31579/2692-9406/162
Copyright: © 2023, Mona Abdel kader. 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: 24 August 2023 | Accepted: 01 September 2023 | Published: 08 September 2023
Keywords: ERG & OCT of DM
Background:Macular oedema is responsible for a significant decrease of vision in this population. Aim of the study is to assess retinal function by multifocal electroretinography (MF-ERG) in eyes with diabetic macular edema (DME) after intravitreal triamcinolone acetonide (IVTA) injection and to compare the effect of IVTA alone and after its combination with argon laser photocoagulation.
Methods: The study included eighty patients (120 eyes), divided into two groups. Group 1 included sixty eyes (60) of forty patients (40) with DME treated with triamcinolone acetonide injection alone, group 2 (laser group) included another sixty eyes (60) of forty patients (40) with DME treated with triamcinolone acetonide injection followed by argon laser photocoagulation (after 3 week). The response to treatment was monitored functionally by visual acuity measurement and MF-ERG and anatomically by foveal thickness measured by optical coherence tomography (OCT). The changes in functional and morphometric parameters were followed at 1 week and 1, 2, 3,6 months.
Results:Visual acuity and MF-ERG values increased after intravitreal triamcinolone acetonide injection. There was statistically significant increase in mean P1 amplitude compared with pretreatment. The mean P1 peak latencies were shortener. There were also statistically significant decreases in the mean foveal thickness after treatment. In group 1, there was deterioration of the initial improvement that started after 2 months from IVTA while in group 2, there was more stability of the initial improvement.
Conclusion: IVTA injection causes transient improvement of macular function and decreases of retinal thickness in diabetic patients. This study suggests the combination of IVTA, and argon laser photocoagulation causes more permanent improvement. Argon laser photocoagulation effectively maintains improvement occurring after IVTA and reduces recurrent DME after IVTA.
Macular oedema affects approximately 29% of diabetic patients with disease duration of 20 years or more and is responsible for a significant decrease of vision in this population [1].
The Early Treatment Diabetic Retinopathy Study (ETDRS) demonstrated a significant benefit of focal laser photocoagulation for the treatment of clinically significant macular oedema [2]. However, eyes with diffuse diabetic macular edema carry a particularly poor prognosis despite laser photocoagulation. In the ETDRS, only 17% of the eyes had an improvement of visual acuity (V.A) and less than 3% had a visual improvement of [3] or more ETDRS lines.2 Laser photocoagulation is at best supportive rather than curative [2-3], prompting interest for alternative therapeutic approaches. Intravitreal administration of triamcinolone acetonide has provided the ophthalmologist with an extra tool for the treatment of eyes with diabetic oedema [4-5].
Triamcinolone acetonide, has been proposed to decrease macular oedema6, the probable mechanisms are increase in tight-junction protein, which diminish vessel leakage by a local vasoconstrictive effect, [7-8] and angiostatic properties through inhibition of vascular endothelial growth factor (VEGF) [9].
IVTA is reported to generate favorable results in the treatment of DME, however the chief limitation of IVTA is the recurrence of DME which develops after a relatively short duration of action. Although repeated administration of IVTA might be an option. Yet, repeated IVTA may potentiate the toxicity of the intraocular corticoid as elevation of intraocular pressure [10], cataractogensis [11] and endophthalmitis [12].
The aims of this study are to assess macular function by MF-ERG and foveal thickness in eyes with diabetic macular oedema after IVTA injection and to determine whether macular argon laser photocoagulation after IVTA might be helpful in the maintenance of improvement after IVTA or not.
Patients and Methods:
This study was carried out on patients attending the outpatient's clinic of Mansoura Ophthalmic Center during the period from December 2012 to February 2014. This study included one hundred and twenty eyes of eighty patients with diabetic macular edema with no sign of vitreo-macular traction on either biomicroscopy or Optical Coherence Tomography (OCT). The patients were divided into two groups :Group 1 included sixty eyes (60) of forty patients (40) with DME treated with triamcinolone acetonide injection alone, group 2 (laser group) included another sixty eyes (60) of forty patients (40) with DME treated with triamcinolone acetonide injection followed by argon laser photocoagulation (after 3 week).The determination of group for the individual was randomized (dependent on last digit of hospital ID number .If it was an even number the patient was located in group 1, if it was an odd number ,the patient was allocated into group 2.
Macular oedema was defined by a zone or zones of retinal thickening one disc area or larger at any part within one disc diameter of the center of the macula on biomicroscopy and, by diffuse fluorescein leakage involving most of the macular area on fluoresein angiography or/ and areas of pooling of flourscein dye within two disc diameters at the center of the macula in cystoid macular edema [13]. Another criterion involved significant reduction in the reflectivity of the outer layer and/ or subfoveal collection on OCT or cavities of low reflectivity in posterior retinal layers or full retinal thickness with tiny walls in cystoid macular edema [13]. Central macular thickness had to be more than 300µm(normal 170±18µm) [13]. Patients were thoroughly informed about the injection procedure, postoperative results and possible complications and written consents were taken from all patients. All tests were carried out in accordance with the tenets of the Declaration Of Helsinki(1989) of the world medical association. The study was approved by Mansoura University Hospital trust ethics committee.
Exclusion Criteria: it included patients who previously received intravitreal injection either triamcinolone or bevacizumab, those with evidence of macular ischaemia, epiretinal membranes or vitreo-retinal traction, patients with past or current history of glaucoma. patients who had undergone cataract surgery or vitre-retinal surgery and patients with renal insufficiency. other ophthalmic disorders associated with macular oedema, such as uveitis and branch or central retinal vein occlusion.
Pre-Injection Evaluation:
Medical history (with special stress on age of onset of diabetes mellitus (DM), condition of metabolic control and presence of associated systemic complication related to DM such as hypertension and renal impairment).
Ophthalmological examination included: best corrected visual acuity (BCVA) determined using Snellen charts in a standardized fashion ,best corrected visual acuity were transformed to logarithmic scale ( log MAR:logarithm of the minimum angle of result), pupillary reaction (direct and consensual), slit lamp examination (with special focus on: presence of any corneal opacities that may affect vision, presence of any lens opacities, intraocular pressure (IOP)(it was measured by slit lamp mounted Goldmann's applanation tonometry), fundus biomicroscopy ( it was done after maximum pupillary dilation by tropicamide 1% and phenylepherine 2.5% using both slit lamp biomicroscopy with non-contact (+90D) Volk lens and Goldman contact lens in order to detect diffuse macular oedema, to evaluate vitreo-retinal interface relationship, to check any pre-retinal membranes and previous macular laser treatment), fundus photography, fundus fluorescein angiography to confirm macular leakage, optical coherence tomography (OCT) to confirm macular thickening, assess vitreoretinal relationship and demonstrate cystoid spaces and multifocal electro-retinagram MF-ERG to assess macular function.
MFERG:
All ERG data were recorded using (Roland Consult, Brandenburg, Germany). Stimulation and recording of MF-ERG responses were performed using the ISCEV guidelines. [6] The stimulus, consisting of (61) hexagons covering a visual field of 30o was presented at a frame rate of 75Hz on a monitor 30cm from the patient’s eye. The luminance (97%) of each hexagon independently alternated between black and white. The amplifier gain was set at 100,000, the lower cutoff frequency were 5 Hz and the upper frequency being 100 Hz. After maximum dilation of the pupil, Dawson Trick litskow (DTL) electrode were applied to topically anaesthetized cornea with one ground electrode in the forehead and two temporal reference electrodes and the opposite eye occluded.
Eyes were optically corrected for near vision in order to see clearly the small fixation spot in the center of the stimulus matrix. and the patients were instructed to fixate at the intersection of the spokes. The recording period was comprised of eight segments of 30 second, providing a total recording time of 4minute. The quality of the recording was controlled by real-time display and contaminated segments were discarded & repeated.
The MF-ERG stimulus location and anatomical areas corresponded roughly to the following: ring 1 to fovea, ring 2 to the parafovea, ring 3 to perifovea, ring 4 to the near periphery and ring 5 to central part of the middle periphery [11].
The response density (amplitude per unit of retinal area (nv/deg2) of each local response and latency were estimated over central ring and four quadrants.
OCT:
OCT was performed on every patient using (Topcon, three dimensional (3D) OCT, -1000, -USA). After dilation of the pupil. Central retinal characteristics were analyzed by optical coherence tomography utilizing 6 radial line scans (6mm) directed on the fovea as determined by simultaneous evaluation of the red-free image on the computer monitor of the OCT scanner. The retinal thickness of the 1mm central retina was obtained using the macular thickness map for calculation.
Triamcinolone Acetonide Injection:
For IVTA injection, topical 1?noxinate was applied to the ocular surface followed by preparation with 5 % povidone Iodine. triamcinolone acetonide (40 mg/ml, 1 ml/both) was drawn into lcc tuberculin syringe after cleaning the top of the bottle with an alcohol wipe. The needle was placed in an upright position to allow the triamcinolone powder to precipitate. The supernatant fluid was then discarded. A separate 27- or 26-gauge needle was placed on to the syringe, which was then inverted to remove the air bubbles. The excess triamcinolone was discarded till 0.1 ml (4 mg) remained in the syring.
The injection was set to inferior pars-plana to avoid drug deposition in front of the visual axis. The stab was 4mm from the limbus. The bevel of the needle was directed anteriorly (with the needle aimed posteriorly and slightly inferiorly) to avoid direct injection over the macula using a single continuous maneuver, the chemical was injected into the eye. The needle was removed simultaneously with the application of a cotton-tipped applicator over its entry site to prevent regurgitation of the injected material. Indirect ophthalmoscopy was used to confirm proper intravitreal localization of the suspension, perfusion of the optic nerve head and central retinal artery(CRA) pulsation, paracentesis was performed if CRA pulsation was present or if the globe felt very tense.
Patients were asked to sit up immediately after injection and continue maintaining an erect posture for the next six hours at least. This was to ensure that drug assumes a dependant position and does not collect over the macula which would cause a transient visual loss. Patients were given a course of topical antibiotics for 1 week.
Macular Argon Laser Photocoagulation
Macular grid laser photocoagulation was applied 3 weeks after undergoing IVTA in group 2 only. Patients received laser according to ETDRS guide lines.2 All treatment were performed under topical anesthesia with fundus contact lens .Test laser spots were applied in the macular area at a distance of one to two spots from one to another in concentric lines near vascular arcade with argon green ,a duration of 0.2-0.5 second ,diameter of 100 to 200 µ and power increased from 75mv to produce mild gray burn. Based on the finding of fluorescein and OCT, prior IVTA, the grid pattern of macular laser on areas of capillary non perfusion and retinal thickening ,About 50 laser spot were applied to parafoveal region up to the edge of the foveal avascular zone. Direct photocoagulation was applied only to areas in which focally leaking micro aneurysms were observed.
Post-Injection Follows Up
Follow up was scheduled 1 week, 1 month, 2 month ,3 months and 6 months and included: BCVA, slit lamp examination with special attention to (presence of complicated cataract, IOP), fundus biomicroscopy (to determine the presence of any post-injection complication), flourescein angiography , OCT and MF-ERG were done after intravitreal injection.
Outcome Measures
Primary outcomes were monitored anatomically by OCT macular thickness and functionally by visual acuity assessment and MF-ERG. Secondary outcomes were potential corticosteroids and injection related complication (IOP elevation, endophthalmitis, cataract and vitreous hemorrhage). Injection success was judged by: improvement of macular thickening on biomicroscopy, reduction of diffuse leakage on fluorescein angiography, improvement of BCVA, reduction of macular thickness by OCT and improvement of macular function by MF-ERG (tables 1-4, figures 1-4).
Figure 1:MF-ERG over rings before& after IVTA, before IVTA, there is delay in latency and reduction in amplitude, after IVTA, there is increase in amplitude and reduction in latency.
Figure 2: MF-ERG trace array,before injection there is irregular curve, just irregular line ,no apparent peak and trough ,after injection ,appearance of the peak and trough of the curve.
Figure 3: three dimentional MF-ERG.
Table 1: Characteristics of groups.
Table 2: Comparsion of log MAR visual acuity between groups.
Table 3: T changes in OC groups.
Table 4: MF-ERG parameters before and after IVTA over central ring.
The study included one hundred and twenty eyes of eighty patients, forty patients were bilaterally studied (50%) and forty patients were unilaterally studied (50 %). Forty five (45) patients were female (56%) and thirty five (35) patients were male (44%). All procedures were carried out in accordance with the tenets of the Declaration of Helsinki (1989) of the world medical association. The study was approved by Mansoura University Hospital Trust Ethics Committee.
The patients aged from forty (40) years up to sixty – five (65) years with a mean age fifty (50) years. Most of them suffered from type II diabetes (46 patients (57.5%) with mean duration of the disease 10 years (SD±3) (table 1)
Fifty eyes suffered from diffuse maculopathy, fifty eyes suffered from cystoid maculopathy and twenty eyes suffered from mixed maculopathy. Macular edema has been present for 6 month(8±2months) All patients were treated with intra-vitreal injection of 4 mg. triamcinolone acetonide using the same technique. Among (120) eyes: sixteen eyes (13.3%) had marked improvement in visual acuity (3 lines in landolt chart ), 32 eyes (26.6 %) had moderate improvement (2 lines), 60 eyes (50 %) had mild improvement in visual acuity (one line in londolt chart ) and 12 eyes (10 %) had no improvement in visual acuity after one week. The improvement noticed in the first six months is included in table 2.
By OCT studying (table 3,fig 4) ,the study revealed marked improvement ( more than 120 μm ) in 20 eyes (16.6 % )with macular edema depending on the retinal thickness measured from the retinal surface to the retinal pigment epithelium before and after treatment as central retnial thickness ( before treatment ) ranged from 550 micron (μm) to 700 μm with mean thickness 570 μm ±SD 90 μm reduced into mean thickness 400 μm ±SD 50 μm after treatment with mean reduction ( 170 μm ), 36 eyes ( 30 % ) with moderate reduction as central thickness ranged from 450 μm to 350 μm before treatment with mean thickness was 400 μm reduced into mean thickness was 300 μm with mean reduction was 100 μm after treatment , 48 eyes ( 46.6 %) with mild reduction as retinal thickness ranged from 350 to 305 μm with mean thickness was 300 μm reduced into mean thickness 255 μm with mean reduction 45 μm and eight eyes had no improvement after treatment .Although macular thickness was significantly reduced ,values were higher than normal ( less than 200) after injection .This was probably due to chronic edema and high baseline values.
There was good correlation between retinal thickness and visual acuity (R=-5.00, P=0.01). The reduction in retinal thickness was associated with improvement of visual acuity.
Flourescein Angiography showed leakage from macular area in all cases before IVTA. After IVIA, there was reduction of the macular leakage in most of the cases (116 eyes) (96.6 %).
The retinal response density of MF-ERG in affected eyes before treatment ranged from 15 nv/deg2 to 2 nv/deg2 (mean value ± SD 7.4 ±5.5 nv/deg). After treatment, the response density ranged from 22 to 17 (mean value ±SD 15.3 ± 6.4). Table 4 (Fig.1-3).
The latency of MF-ERG in eyes before treatment ranged from 70 millisecond (ms ) to 59 ms ( mean value ±SD 65 ±2 ms).
After treatment the latency ranged from 54 to 58 ms (mean ± SD 55± 3.1 ms ).
There was good correlation between increased amplitude of MF-ERG and decreased macular thickness by OCT ( R=0.54 , P=0.008 ).
The IVTA effect (OCT improvement, MFERG changes and visual acuity improvement) regressed 2 months after injection in group 1 while in group 2, there were more stabilization of improvement.
Post-Treatment Complication:
Intra-ocular pressure: The mean pre-injection IOP was 15 ± 2.2.
The mean post injection IOP was 17 ±3.5 . There was only four cases (3.3%) develop mild increase in IOP (It was 26 mm Hg) and was controlled with B-blocker.
Minor local adverse events related to the treatment procedure (conjunctiva hyperemia and subconjuctival haemorrhage) were presented in 6 cases only (5% ) during the first week.
Lens status: The lens was clear in all patient before treatment. At the end of follow up, none of the eyes displayed any cataract.
There were no cases of endophthalmitis, clinically evident inflammation, retinal tear, retinal detachment or thrombi embolic.
Diabetic macular edema is a major complication of diabetic retinopathy that faces a challenge in its management . Although several treatment modalities have been tried for the management of diabetic macular edema, these modalities have many limitations. Focal and grid laser photocoagulation have remained the primary treatment option for diabetic macular edema for several years. However most eyes treated with laser photocoagulation do not have an improvement in visual acuity. Although ETDRs,[2] demonstrated that immediate focal photocoagulation reduced moderate visual loss by 50%, 12% of treated eyes still lost vision at the 3-year follow up interval and 24%of immediately treated eyes had thickening involving the center of the macula at 36 months .In addition , laser treatment of eyes with diffuse macular edema has been disappointing [15,16].
In the past years, attempts to understand the pathogenesis of diabetic retinopathy had led to other strategies in the management of diabetic macular edema . The development of diabetic retinopathy is a multifactorial process. Much of retinal damage that characterizes the disease is now understood to result from retinal vascular leakage and non perfusion mediated by numerous growth factors [17,18]. The up regulation of growth factors is associated with breakdown of the blood – retinal barrier with increased vascular permeability resulting in retinal oedema, stimulation of endothelial cell growth and neovasculization [19].
For years, corticosteroids have been used in ophthalmology to suppress intraocular inflammation and reduce leakage from retinal blood vessels . Local application of cortisone was used to decrease the adverse side effects of systemic cortisone and at the same time achieve a higher concentration at the site of action . The use of intraocular corticosteroids for diabetic macular oedema started after the significant observations of McCuen et al , [20] and Young et al, [21] on the lack of toxicity of intra-vitreal triamcinolaone (9-fluoro – 16 – hydroxyl prednisolone ) . Subsequently , there have been several studies documenting the antiangiogenic , anti proliferative and antiedematous effects of IVTA. The landmark study by Martidis et al [22] involved sixteen eyes with clinically significant macular oedema that failed to respond to at least two previous sessions of laser photocoagulation at least 6 months after laser therapy, the response was measured by clinical examination and OCT. Eyes with residual central macular thickness more than 300 µm. were administered an intravitreal injection of 4mg in 0.1 ml of trimacinolone acetonide. The central macular thickness deceased after injection by 55%, 57?ter lst and 3rd month respectively as measured by OCT. Aurder et al 27 characterized the pharmacodynamic profile of the IVTA on macular thickness as 3-phase curve (fast decrease , steady state and a relapse) The maximum effect duration was 140 day. [23] Massin et al. too, [24] have found transient improvement of macular thickness that necessitate repeated injection However, Jonas et al,21 have found an impressive improvement in visual acuity after IVTA injection. but 25 mg of the drug was used. There was significant transient increase in the intraocular pressure [25].
In this study, there was decrease in retinal thickness with improvement of visual acuity after IVTA for 2 months. Then begin to relapse in group 1 . There was improvement in retinal function after IVTA after one week that continued to improve for 1month then begin to decrease after 2 month in group 1. There was increase in the amplitude of P1 wave and decrease in latency of P1 wave for 2 months. The visual benefit of argon laser photocoagulation subsequent to IVTA for DME became apparent months afterwards .In contrast to IVTA only ,this combination therapy appears to maintain reduced central macular thickness at least for 6 months follow up .Central macular thickness was minimal and visual acuity was improved at examination performed 1week and 1month after IVTA.
The exact mechanism underlying the maintenance of improved vision, increase MFERG amplitude and decreased central macular thickness due to grid laser photocoagulation was not identified, but several factors may be involved. First, decreased foveal thickness after IVTA may enhance the effects of grid laser photocoagulation. Without IVTA, markedly increased foveal thickness, subfoveal fluid and retinal opacity due to edema might interfere with adequate laser burning of the retinal pigment epithelium and photoreceptor layers. However, after IVTA, decreased foveal thickness and restoration of retinal transparency achieved by the treatment would facilitate the delivery of the laser energy selectively to retinal pigment epithelium and photoreceptor layers. Second, the possibility exists that steroid might act beneficially in the process of mature laser scar formation. It has been established that 2 or 3 weeks should elapse for the formation of mature laser scar and laser treatment itself frequently induces aggravation of macular edema or inflammation during this period .The presence of intravitreal steroids might exert certain protective effects against the initial deleterious events that follow grid laser treatment and might also modulate retinal pigment epithelium remodeling after laser photocoagulation.
Karacorlu et al, found significant increase in mean P1, response amplitude at all examinations compared with pretreatment. The mean p1, peak latencies were shorter [22].
Similarily, Koutsandrea et al, observed increase in MF-ERG amplitude after triamcinolone acetonide injections [28].
The interval 3 weeks for the separation of laser photocoagulation was chosen because therapeutic effects of IVTA were found to reach maximum values in most cases [24].
The rational for the use of corticosteroids in the treatment of diabetic macular edema follows from the observation that the breakdown of the blood retinal barrier leads to the edeme and is in past mediated by vascular endothelial growth factor VEGF[23]. Corticosteroids have been shown to inhibit (VEGF), other cytokines and other growth factors, thereby regulating endothelial cell tight Junctions. In addition, corticosteroids inhibit prostaglandin and leukotriene synthesis, which results in local reduction of inflammatory mediators. The resultant anti-inflammatory effect contributes to the reduction of oedema [24]. Increased diffusion by modulation of calcium channels could also account for the efficacy of the corticosteroids in reducing macular edema [25]. The two main complication of IVTA are the intra ocular pressure rise and the development of cataract furthermore, the effects of intravitreal injections are short lasting requiring repeated injections which would further increase the risk of complications. It sounds prudent to think that this treatment modality could replace or complement focal/grid laser photo coagulation Further -more focal grid laser photo coagulation could be used to consolidate the results obtained with one intravitreal injection and decrease the need for re-injection [26].
There was inverse significant correlation between central macular thickness and visual acuity. In this study, the incidence of complications between the two groups were similar and there were only four eyes (2 in group 1, 2 in group 2) that had increased intra ocular pressure after IVTA within one week . The rates were consistent with previous studies [10,29].
Thus, the all complications appeared to be attributable to IVTA and laser photocoagulation appears not to cause significant additional complications. Also, Martidis, et al, [4] and sutler et al [5] found significant increase in intraocular pressure after IVTA. [4,5] Similarly, paccola, et al, [29] observed significant IOP increase from baseline at 4 weeks after IVTA.
In summary, the results seen in this study after IVTA are encouraging. IVTA resulted in statistically significant improvement of best corrected visual acuity, central macular thickness and macular function with little complication (mild increase in IOP that controlled with B-blocker, transient conjunctival hyperemia and subconjuctival haemorrhage).
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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.
I would like to offer my testimony in the support. I have received through the peer review process and support the editorial office where they are to support young authors like me, encourage them to publish their work in your esteemed journals, and globalize and share knowledge globally. I really appreciate your journal, peer review, and editorial office.
Dear Agrippa Hilda- Editorial Coordinator of Journal of Neuroscience and Neurological Surgery, "The peer review process was very quick and of high quality, which can also be seen in the articles in the journal. The collaboration with the editorial office was very good."
I would like to express my sincere gratitude for the support and efficiency provided by the editorial office throughout the publication process of my article, “Delayed Vulvar Metastases from Rectal Carcinoma: A Case Report.” I greatly appreciate the assistance and guidance I received from your team, which made the entire process smooth and efficient. The peer review process was thorough and constructive, contributing to the overall quality of the final article. I am very grateful for the high level of professionalism and commitment shown by the editorial staff, and I look forward to maintaining a long-term collaboration with the International Journal of Clinical Case Reports and Reviews.
To Dear Erin Aust, I would like to express my heartfelt appreciation for the opportunity to have my work published in this esteemed journal. The entire publication process was smooth and well-organized, and I am extremely satisfied with the final result. The Editorial Team demonstrated the utmost professionalism, providing prompt and insightful feedback throughout the review process. Their clear communication and constructive suggestions were invaluable in enhancing my manuscript, and their meticulous attention to detail and dedication to quality are truly commendable. Additionally, the support from the Editorial Office was exceptional. From the initial submission to the final publication, I was guided through every step of the process with great care and professionalism. The team's responsiveness and assistance made the entire experience both easy and stress-free. I am also deeply impressed by the quality and reputation of the journal. It is an honor to have my research featured in such a respected publication, and I am confident that it will make a meaningful contribution to the field.
"I am grateful for the opportunity of contributing to [International Journal of Clinical Case Reports and Reviews] and for the rigorous review process that enhances the quality of research published in your esteemed journal. I sincerely appreciate the time and effort of your team who have dedicatedly helped me in improvising changes and modifying my manuscript. The insightful comments and constructive feedback provided have been invaluable in refining and strengthening my work".
I thank the ‘Journal of Clinical Research and Reports’ for accepting this article for publication. This is a rigorously peer reviewed journal which is on all major global scientific data bases. I note the review process was prompt, thorough and professionally critical. It gave us an insight into a number of important scientific/statistical issues. The review prompted us to review the relevant literature again and look at the limitations of the study. The peer reviewers were open, clear in the instructions and the editorial team was very prompt in their communication. This journal certainly publishes quality research articles. I would recommend the journal for any future publications.
Dear Jessica Magne, with gratitude for the joint work. Fast process of receiving and processing the submitted scientific materials in “Clinical Cardiology and Cardiovascular Interventions”. High level of competence of the editors with clear and correct recommendations and ideas for enriching the article.
We found the peer review process quick and positive in its input. The support from the editorial officer has been very agile, always with the intention of improving the article and taking into account our subsequent corrections.
My article, titled 'No Way Out of the Smartphone Epidemic Without Considering the Insights of Brain Research,' has been republished in the International Journal of Clinical Case Reports and Reviews. The review process was seamless and professional, with the editors being both friendly and supportive. I am deeply grateful for their efforts.
To Dear Erin Aust – Editorial Coordinator of Journal of General Medicine and Clinical Practice! I declare that I am absolutely satisfied with your work carried out with great competence in following the manuscript during the various stages from its receipt, during the revision process to the final acceptance for publication. Thank Prof. Elvira Farina
Dear Jessica, and the super professional team of the ‘Clinical Cardiology and Cardiovascular Interventions’ I am sincerely grateful to the coordinated work of the journal team for the no problem with the submission of my manuscript: “Cardiometabolic Disorders in A Pregnant Woman with Severe Preeclampsia on the Background of Morbid Obesity (Case Report).” The review process by 5 experts was fast, and the comments were professional, which made it more specific and academic, and the process of publication and presentation of the article was excellent. I recommend that my colleagues publish articles in this journal, and I am interested in further scientific cooperation. Sincerely and best wishes, Dr. Oleg Golyanovskiy.
Dear Ashley Rosa, Editorial Coordinator of the journal - Psychology and Mental Health Care. " The process of obtaining publication of my article in the Psychology and Mental Health Journal was positive in all areas. The peer review process resulted in a number of valuable comments, the editorial process was collaborative and timely, and the quality of this journal has been quickly noticed, resulting in alternative journals contacting me to publish with them." Warm regards, Susan Anne Smith, PhD. Australian Breastfeeding Association.
Dear Jessica Magne, Editorial Coordinator, Clinical Cardiology and Cardiovascular Interventions, Auctores Publishing LLC. I appreciate the journal (JCCI) editorial office support, the entire team leads were always ready to help, not only on technical front but also on thorough process. Also, I should thank dear reviewers’ attention to detail and creative approach to teach me and bring new insights by their comments. Surely, more discussions and introduction of other hemodynamic devices would provide better prevention and management of shock states. Your efforts and dedication in presenting educational materials in this journal are commendable. Best wishes from, Farahnaz Fallahian.
Dear Maria Emerson, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews, Auctores Publishing LLC. I am delighted to have published our manuscript, "Acute Colonic Pseudo-Obstruction (ACPO): A rare but serious complication following caesarean section." I want to thank the editorial team, especially Maria Emerson, for their prompt review of the manuscript, quick responses to queries, and overall support. Yours sincerely Dr. Victor Olagundoye.
Dear Ashley Rosa, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews. Many thanks for publishing this manuscript after I lost confidence the editors were most helpful, more than other journals Best wishes from, Susan Anne Smith, PhD. Australian Breastfeeding Association.
Dear Agrippa Hilda, Editorial Coordinator, Journal of Neuroscience and Neurological Surgery. The entire process including article submission, review, revision, and publication was extremely easy. The journal editor was prompt and helpful, and the reviewers contributed to the quality of the paper. Thank you so much! Eric Nussbaum, MD
Dr Hala Al Shaikh This is to acknowledge that the peer review process for the article ’ A Novel Gnrh1 Gene Mutation in Four Omani Male Siblings, Presentation and Management ’ sent to the International Journal of Clinical Case Reports and Reviews was quick and smooth. The editorial office was prompt with easy communication.
Dear Erin Aust, Editorial Coordinator, Journal of General Medicine and Clinical Practice. We are pleased to share our experience with the “Journal of General Medicine and Clinical Practice”, following the successful publication of our article. The peer review process was thorough and constructive, helping to improve the clarity and quality of the manuscript. We are especially thankful to Ms. Erin Aust, the Editorial Coordinator, for her prompt communication and continuous support throughout the process. Her professionalism ensured a smooth and efficient publication experience. The journal upholds high editorial standards, and we highly recommend it to fellow researchers seeking a credible platform for their work. Best wishes By, Dr. Rakhi Mishra.
Dear Jessica Magne, Editorial Coordinator, Clinical Cardiology and Cardiovascular Interventions, Auctores Publishing LLC. The peer review process of the journal of Clinical Cardiology and Cardiovascular Interventions was excellent and fast, as was the support of the editorial office and the quality of the journal. Kind regards Walter F. Riesen Prof. Dr. Dr. h.c. Walter F. Riesen.
Dear Ashley Rosa, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews, Auctores Publishing LLC. Thank you for publishing our article, Exploring Clozapine's Efficacy in Managing Aggression: A Multiple Single-Case Study in Forensic Psychiatry in the international journal of clinical case reports and reviews. We found the peer review process very professional and efficient. The comments were constructive, and the whole process was efficient. On behalf of the co-authors, I would like to thank you for publishing this article. With regards, Dr. Jelle R. Lettinga.
Dear Clarissa Eric, Editorial Coordinator, Journal of Clinical Case Reports and Studies, I would like to express my deep admiration for the exceptional professionalism demonstrated by your journal. I am thoroughly impressed by the speed of the editorial process, the substantive and insightful reviews, and the meticulous preparation of the manuscript for publication. Additionally, I greatly appreciate the courteous and immediate responses from your editorial office to all my inquiries. Best Regards, Dariusz Ziora
Dear Chrystine Mejia, Editorial Coordinator, Journal of Neurodegeneration and Neurorehabilitation, Auctores Publishing LLC, We would like to thank the editorial team for the smooth and high-quality communication leading up to the publication of our article in the Journal of Neurodegeneration and Neurorehabilitation. The reviewers have extensive knowledge in the field, and their relevant questions helped to add value to our publication. Kind regards, Dr. Ravi Shrivastava.
Dear Clarissa Eric, Editorial Coordinator, Journal of Clinical Case Reports and Studies, Auctores Publishing LLC, USA Office: +1-(302)-520-2644. I would like to express my sincere appreciation for the efficient and professional handling of my case report by the ‘Journal of Clinical Case Reports and Studies’. The peer review process was not only fast but also highly constructive—the reviewers’ comments were clear, relevant, and greatly helped me improve the quality and clarity of my manuscript. I also received excellent support from the editorial office throughout the process. Communication was smooth and timely, and I felt well guided at every stage, from submission to publication. The overall quality and rigor of the journal are truly commendable. I am pleased to have published my work with Journal of Clinical Case Reports and Studies, and I look forward to future opportunities for collaboration. Sincerely, Aline Tollet, UCLouvain.
Dear Ms. Mayra Duenas, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews. “The International Journal of Clinical Case Reports and Reviews represented the “ideal house” to share with the research community a first experience with the use of the Simeox device for speech rehabilitation. High scientific reputation and attractive website communication were first determinants for the selection of this Journal, and the following submission process exceeded expectations: fast but highly professional peer review, great support by the editorial office, elegant graphic layout. Exactly what a dynamic research team - also composed by allied professionals - needs!" From, Chiara Beccaluva, PT - Italy.
Dear Maria Emerson, Editorial Coordinator, we have deeply appreciated the professionalism demonstrated by the International Journal of Clinical Case Reports and Reviews. The reviewers have extensive knowledge of our field and have been very efficient and fast in supporting the process. I am really looking forward to further collaboration. Thanks. Best regards, Dr. Claudio Ligresti
Dear Chrystine Mejia, Editorial Coordinator, Journal of Neurodegeneration and Neurorehabilitation. “The peer review process was efficient and constructive, and the editorial office provided excellent communication and support throughout. The journal ensures scientific rigor and high editorial standards, while also offering a smooth and timely publication process. We sincerely appreciate the work of the editorial team in facilitating the dissemination of innovative approaches such as the Bonori Method.” Best regards, Dr. Matteo Bonori.
I recommend without hesitation submitting relevant papers on medical decision making to the International Journal of Clinical Case Reports and Reviews. I am very grateful to the editorial staff. Maria Emerson was a pleasure to communicate with. The time from submission to publication was an extremely short 3 weeks. The editorial staff submitted the paper to three reviewers. Two of the reviewers commented positively on the value of publishing the paper. The editorial staff quickly recognized the third reviewer’s comments as an unjust attempt to reject the paper. I revised the paper as recommended by the first two reviewers.
Dear Maria Emerson, Editorial Coordinator, Journal of Clinical Research and Reports. Thank you for publishing our case report: "Clinical Case of Effective Fetal Stem Cells Treatment in a Patient with Autism Spectrum Disorder" within the "Journal of Clinical Research and Reports" being submitted by the team of EmCell doctors from Kyiv, Ukraine. We much appreciate a professional and transparent peer-review process from Auctores. All research Doctors are so grateful to your Editorial Office and Auctores Publishing support! I amiably wish our article publication maintained a top quality of your International Scientific Journal. My best wishes for a prosperity of the Journal of Clinical Research and Reports. Hope our scientific relationship and cooperation will remain long lasting. Thank you very much indeed. Kind regards, Dr. Andriy Sinelnyk Cell Therapy Center EmCell
Dear Editorial Team, Clinical Cardiology and Cardiovascular Interventions. It was truly a rewarding experience to work with the journal “Clinical Cardiology and Cardiovascular Interventions”. The peer review process was insightful and encouraging, helping us refine our work to a higher standard. The editorial office offered exceptional support with prompt and thoughtful communication. I highly value the journal’s role in promoting scientific advancement and am honored to be part of it. Best regards, Meng-Jou Lee, MD, Department of Anesthesiology, National Taiwan University Hospital.
Dear Editorial Team, Journal-Clinical Cardiology and Cardiovascular Interventions, “Publishing my article with Clinical Cardiology and Cardiovascular Interventions has been a highly positive experience. The peer-review process was rigorous yet supportive, offering valuable feedback that strengthened my work. The editorial team demonstrated exceptional professionalism, prompt communication, and a genuine commitment to maintaining the highest scientific standards. I am very pleased with the publication quality and proud to be associated with such a reputable journal.” Warm regards, Dr. Mahmoud Kamal Moustafa Ahmed
Dear Maria Emerson, Editorial Coordinator of ‘International Journal of Clinical Case Reports and Reviews’, I appreciate the opportunity to publish my article with your journal. The editorial office provided clear communication during the submission and review process, and I found the overall experience professional and constructive. Best regards, Elena Salvatore.
Dear Mayra Duenas, Editorial Coordinator of ‘International Journal of Clinical Case Reports and Reviews Herewith I confirm an optimal peer review process and a great support of the editorial office of the present journal
Dear Editorial Team, Clinical Cardiology and Cardiovascular Interventions. I am really grateful for the peers review; their feedback gave me the opportunity to reflect on the message and impact of my work and to ameliorate the article. The editors did a great job in addition by encouraging me to continue with the process of publishing.
Dear Cecilia Lilly, Editorial Coordinator, Endocrinology and Disorders, Thank you so much for your quick response regarding reviewing and all process till publishing our manuscript entitled: Prevalence of Pre-Diabetes and its Associated Risk Factors Among Nile College Students, Sudan. Best regards, Dr Mamoun Magzoub.
International Journal of Clinical Case Reports and Reviews is a high quality journal that has a clear and concise submission process. The peer review process was comprehensive and constructive. Support from the editorial office was excellent, since the administrative staff were responsive. The journal provides a fast and timely publication timeline.
Dear Maria Emerson, Editorial Coordinator of International Journal of Clinical Case Reports and Reviews, What distinguishes International Journal of Clinical Case Report and Review is not only the scientific rigor of its publications, but the intellectual climate in which research is evaluated. The submission process is refreshingly free of unnecessary formal barriers and bureaucratic rituals that often complicate academic publishing without adding real value. The peer-review system is demanding yet constructive, guided by genuine scientific dialogue rather than hierarchical or authoritarian attitudes. Reviewers act as collaborators in improving the manuscript, not as gatekeepers imposing arbitrary standards. This journal offers a rare balance: high methodological standards combined with a respectful, transparent, and supportive editorial approach. In an era where publishing can feel more burdensome than research itself, this platform restores the original purpose of peer review — to refine ideas, not to obstruct them Prof. Perlat Kapisyzi, FCCP PULMONOLOGIST AND THORACIC IMAGING.
Dear Grace Pierce, International Journal of Clinical Case Reports and Reviews I appreciate the opportunity to review for Auctore Journal, as the overall editorial process was smooth, transparent and professionally managed. This journal maintains high scientific standards and ensures timely communications with authors, which is truly commendable. I would like to express my special thanks to editor Grace Pierce for his constant guidance, promt responses, and supportive coordination throughout the review process. I am also greatful to Eleanor Bailey from the finance department for her clear communication and efficient handling of all administrative matters. Overall, my experience with Auctore Journal has been highly positive and rewarding. Best regards, Sabita sinha
Dear Mayra Duenas, Editorial Coordinator of the journal IJCCR, I write here a little on my experience as an author submitting to the International Journal of Clinical Case Reports and Reviews (IJCCR). This was my first submission to IJCCR and my manuscript was inherently an outsider’s effort. It attempted to broadly identify and then make some sense of life’s under-appreciated mysteries. I initially had responded to a request for possible submissions. I then contacted IJCCR with a tentative topic for a manuscript. They quickly got back with an approval for the submission, but with a particular requirement that it be medically relevant. I then put together a manuscript and submitted it. After the usual back-and-forth over forms and formality, the manuscript was sent off for reviews. Within 2 weeks I got back 4 reviews which were both helpful and also surprising. Surprising in that the topic was somewhat foreign to medical literature. My subsequent updates in response to the reviewer comments went smoothly and in short order I had a series of proofs to evaluate. All in all, the whole publication process seemed outstanding. It was both helpful in terms of the paper’s content and also in terms of its efficient and friendly communications. Thank you all very much. Sincerely, Ted Christopher, Rochester, NY.
