Use of Intravenous Dexamethasone for Cervical Ripening and Labor Induction in Term Pregnancies with Pre-labour Rupture of Membranes: Randomized control trial.

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Research | DOI: https://doi.org/10.31579/2642-9756/048

Use of Intravenous Dexamethasone for Cervical Ripening and Labor Induction in Term Pregnancies with Pre-labour Rupture of Membranes: Randomized control trial.

Sherif H. Hussain ^1*

Amro S. El-Housseiny ²

Wafaa O. Ahmed ³

Mohamed S. Abdel Rahman ⁴

Sarah safwat ⁵

1*Lecturer in Obstetrics and Gynecology, Faculty of Medicine - Ain Shams University; Egypt, address:EL Waha district Nasrcity, Cairo, Egypt. Tel.:01111343606

*Corresponding Author: Sarah Safwat, Lecturer in Obstetrics and Gynecology, Faculty of Medicine - Ain Shams University; Egypt, address:EL Waha district Nasrcity, Cairo, Egypt. Tel.:01111343606

Citation: Sherif H. Hussain, Amro S. El-Housseiny, Wafaa O. Ahmed, Mohamed S. Abdel Rahman, Sarah safwat, (2021) Use of Intravenous Dexamethasone for Cervical Ripening and Labor Induction in Term Pregnancies with Pre-labour Rupture of Membranes: Randomized control trial. J Women Health Care Issues, 4(2); Doi:10.31579/2642-9756/048

Copyright: © 2021 Sarah Safwat, 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: 08 March 2021 | Accepted: 23 March 2021 | Published: 31 March 2021

Keywords: dexamethasone ; cervical ripening

Abstract

Abstract
Background: During the first 36 to 38 weeks of normal gestation, the myometrium is in a preparatory yet unresponsive state. Concurrently, the cervix begins an early stage of remodeling yet maintains structural integrity. Induction of labour is a complex process involving cervical ripening which undergo extensive remodeling and dynamic changes controlled by hormonal, inflammatory changes, and other biological processes.
Aim of the Work: to assess the effect of intravenous administration of dexamethasone on the induction delivery interval in term patients with prelabour rupture of membranes undergoing induction of labor.
Patients and Methods: This randomized control trial was conducted at department of Obstetrics and Gynecology at Ain Shams University Maternity Hospital (ASUMH) in the period between August 2020 and January 2021. Participants of this study were 80 full term pregnant women with pre-labor rupture of membranes attended the labor ward in El Demerdash Maternity Hospital and scheduled for induction of labor by 8 mg dexamethasone IV before starting induction by PGE1, after 4 hours oxytocin was added by 1 IU/hr with the dose increasing by 1 IU every 30 minutes till optimal contractions were reached which were three uterine contractions in 10 minutes and each lasting for 40-50 seconds.
Results: Fetal distress, arrest of delivery and indications of CS delivery were non-significantly less frequent among Dexamethasone group. Induction-active phase and active phase durations were significantly shorter among dexamethasone group than among control group. Second and third stages durations were non-significantly shorter among dexamethasone group than among control group. Total induction-delivery duration was significantly shorter and rate of vaginal delivery was significantly higher among dexamethasone group than among control group. Postpartum hemorrhage (PPH), postpartum endometritis, chorioamnionitis were not reported among the studied groups. No significant difference between Dexamaethasone and Control groups regarding neonatal condition
Conclusion: Intravenous administration of dexamethasone in addition to labor induction protocol shortened the induction - active phase and active phase durations. It shortened the total induction-delivery duration and increased the rate of successful vaginal delivery. It has no effect on second and third stages durations with no increase in incidence of intrapartum, postpartum nor neonatal complications.

Introduction

During 36 to 38 weeks of normal gestation, the uterus is in a silent unresponsive state. While, the cervix starts remodelingand structural changes. Following this stage, the cervix undergoes ripening, effacement, and loss of structural adhesions under effect of prostaglandins, produced in the cervix, uterus and fetal membranes [1,2].
Induction of labor is the process by which artificial stimulation of uterine contractions leads to progressive cervical effacement and dilatation, then active labor and birth [3].
Steroid substances secreted by fetal adrenal glands cause uterine contractions. The placenta may have a role by producing CRH (Corticotropin releasing hormone). During the last weeks of pregnancy, cortisol and DHEA-S (Dehydroepiandrosterone sulfate), CRH in the fetus increase, also maternal estrogens.Th. This results in modification of the contractility of the uterus [4].
Studies have shown that corticosteroids analogues as dexamethasone could improve the Bishop score of the cervix and thus causes softening of the cervix and reduces the length of time between labor induction and delivery but further studies in that field is still needed & no studies in prelabour rupture of membranes were done [4].
This study aims to assess the effect of intravenous administration of dexamethasone on the induction delivery interval in term patients with prelabour rupture of membranes undergoing induction of labor.
Patients and Methods
This randomized control, double blinded study was conducted during the period during the period from August 2020 to January 2021 on 80 pregnant patients with pre-labor rupture of membranes attended the labor ward in El Demerdash Maternity Hospital and scheduled for induction of labor by 8 mg dexamethasone IV under cover of broad spectrum antibiotics (3 gm ampicillin-sulbactum I.V. every 6 hours) to decrease the risk of infection according to inclusion and exclusion criteria.
The study included primipara patients with gestational age (> or equal 37 weeks) according to Naegles rule and a first-trimester ultrasound evaluation, vertex presentation, singleton fetus, prelabor Rupture of fetal membranes, cervix with a Bishop score (5-6), reactive CTG, clear liquor who are not in labor.
While patients with indication for cesarean section e.g. CPD (obstructed labour), placenta previa (Antepartum hemorrhage), IUGR (fetal distress), non-vertex presentation (failed induction) and previous cesarean section (rupture uterus), maternal medical disorders as diabetes mellitus and severe preeclampsia as dexamethasone increases the blood pressure and blood sugar and may cause DKA), active phase of labor (cervical dilatation of 4 cm plus 3 forceful contractions over a ten minute span) (no role for induction), multiparous women, significant vaginal bleeding as Placenta Previa, probable placental abruption, (fetal distress), fetal macrosomia > 4.5 kg estimated by U/S (may cause shoulder dystocia) and Fetal distress and non-reactive CTG (it may lead to prenatal mortality) were excluded from the study.

Ethical considerations

The study was approved from the Ethical Committee of the Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University. Informed written consents will be taken from all women before recruitment in the study, and after extensive explanation and clear discussion of risks and benefits.
Eighty patients were distributed into two groups: Group C (control group): 40 patients undergoing induction of labor received 2 ml of normal saline intravenous one hour before the initiation of labor induction, and labor induction was performed according to the American College of Obstetricians and Gynecologists protocol, i.e., starting by 25 mcg of PGE1 vaginally, in the form of Vagiprost®,. After 4 hours oxytocin was added by 1 IU/hr with the dose increasing by 1 IU every 30 minutes till optimal contractions were reached which were three uterine contractions in 10 minutes and each lasting for 40-50 seconds. Group D (intervention group Dexamethasone group): 40 patients undergoing induction of labor received 8 mg (2 ml) of the product dexamethasone sodium phosphate intravenous one hour before the initiation of labor induction in the form of Epidrone® ampoules which is a dexamethasone product from Epico-Egypt, and labor induction was performed according to the American College of Obstetricians and Gynecologists protocol, i.e., starting by 25 mcg of PGE1 vaginally, in the form of Vagiprost®,. After 4 hours oxytocin was added by 1 IU/hr with the dose increasing by 1 IU every 30 minutes till optimal contractions were reached which were three uterine contractions in 10 minutes and each lasting for 40-50 seconds
Blinding: Staff members responsible for process of induction of labor (whether giving doses or follow up progression of labour) were blinded to which group the patients belonged either received intravenous dexamethasone, or saline.
Randomization & Allocation: b randomized numbers table designed by random allocation software (SPSS® for Windows® version 24.0).
Every patient was subjected to: Written consent. Complete history to determine the last menstrual period (LMP) to calculate the gestational age (GA) and to exclude systemic disorders, congenital fetal malformation and contraindications for vaginal delivery. General examination of the patients including pulse, blood pressure and temperature. Abdominal examination including presentation, station of fetal head, fetal heart rate, uterine contractions and exclusion of multiple pregnancy Local examination to determine cervical dilatation at the beginning of intervention, presenting part, station of fetal head, pelvis adequacy and Bishop scoring.

Table 1: Bishop scoring system [1]

Modified Bishop Score
Subtract 1 point of overall score do postdate pregnancy, no prior births, premature or prolonged rupture of membranes (water breaking). Sonographic examination including assessment of fetal well-being by biophysical profile and cardiotocography (CTG). Partographic representation of labor. The induction delivery interval, induction active phase interval and the duration of 2nd and 3rd stages of labor were determined. Follow up for 6 hours after delivery to detect postpartum hemorrhage.
The study assessed the rate of vaginal delivery in dexamethasone and prostaglandins group in comparison to prostaglandins group as primary outcome, while the secondary outcome measures were: Induction active phase interval, duration of second stage of labor, duration of third stage of labor, neonatal Outcome, occurrence of Postpartum haemorrhage or sepsis, occurrence of chorioamnionitis.
Statistical analysis:
Descriptive statistics for measured variables were expressed as range, mean and standard deviation (for metric data); range, median and interquartile range (for discrete data); and number and proportions (for categorical data). Demographic data, and primary and secondary outcomes of both groups were compared using t-test (for quantitative parametric measures), Mann-Whitneys U-test (for quantitative non-parametric measures) and Chi-squared and Fischers Exact tests (for categorical measures). Pearsons correlation coefficient (for metric variables) and Spearmans correlation coefficient (for rank variables) were used to estimate association between variables. Microsoft® Excel® (version 2007) and SPSS® for Windows® version 24.0 were used for data presentation and statistical analysis.
Sample size justification:
Assuming an effect size of 0.9 for induction of labour between the 2 groups, a sample size of 39 patients in each group would be enough to detect such effect if true at 0.01 2 sided alpha error & 0.90 power of the test

Results

Figure 1: Flow chart of the studied cases

Table (2) shows that: No significant difference between Dexamaethasone and Control groups regarding age, BMI, gestational age and BISHOP score.

Table 2: Baseline characteristics among the studied groups

Table (3) shows that: Fetal distress, arrest of delivery and CS delivery were non-signifciantly less frequent among Dexamethasone group

Table 3: Mode of delivery and indications of ceasarean section among the studied groups

Table (4) shows that: Induction-Active phase duration was significantly shorter among Dexamethasone group than among Control group.

Table 4: Induction-Active phase duration (hours) among the studied groups

Table (5) shows that: Active phase duration was significantly shorter among Dexamethasone group than among Control group.

Table 5: Active phase duration (hours) among the studied groups

Table (6) shows that: Second stage duration was non-significantly shorter among Dexamethasone group than among Control group.

Table 6: Second stage duration (minutes) among the studied groups

Table (7) shows that: Third stage duration was non-significantly shorter among Dexamethasone group than among Control group.

Table 7: Third sage duration (minutes) among the studied groups

Table (8) shows that: Total Induction-delivery duration was significantly shorter among Dexamethasone group than among Control group.

Table 8: Total induction-delivery duration (hours) among the studied groups

Figure (2) shows that: Rate of delivery was significantly higher among Dexamethasone group than among Control group.

Figure 2: Kaplan meier curve for vaginal delivery since induction among the studied groups

Table (9) shows that: No significant difference between Dexamaethasone and Control groups regarding neonatal condition

Table 9: Neonatal condition among the studied groups

Table (10) shows that: Post partum hemorrhage (PPH) and endometritis were not reported among the studied groups.

Table 10: Post partum complications hemorrhage among the studied groups

Induction of labor represents a chance to control pregnancy as regards delivery timing for either maternal or fetal benefit. Much literature has been published and continues to be published on both the maternal and fetal safety of induction of labor, especially if related to decrease the incidence of cesarean section rates [5].
This randomized control trial was conducted at department of obstetrics and gynecology at Ain Shams University Maternity Hospital (ASUMH) in the period between August 2020 and January 2021.
This study assessed the effect of intravenous administration of dexamethasone on the induction delivery interval in term patients with prelabour rupture of membranes undergoing induction of labor.
Statistical analysis of current study showed that there were no significant differences between women of both groups regarding age, BMI, gestational age and BISHOP score.
Pahlavan et al studied total 121 nulliparrous women in Iran with a singleton pregnancy and cephalic presentation at 4042 gestational weeks in prolonged latent phase were randomly assigned to receive 2 ml ampoule dexamethasone 4 mg/mL (the intervention group) and 2 ml ampoule of sterile water for injections (the control group), which were both intramuscularly administered. Then, the augmentation of labor with the use of intravenous oxytocin infusion (2.5 m units/ per minute) began in both groups. They agreed with current study and stated that there were no significant differences were seen in the mean age, body mass index, the gestational age and the Bishop score at the baseline in both groups. He found the duration of time between the onset of augmentation and the second stage of labor was 5.6 ± 1.9 in the study group, whereas it was 7.7 ± 1.5 in controls with a significant difference (p ≤ <0 xss=removed>
Laloha et al determined the effect of intravenous Dexamethasone on preparing the cervix and on labor induction. A randomized, clinical, double blind trial was conductedon 172 women divided into a control and an experimental group., each woman was intravenously injected with eight milligrams of Dexamethasone or eight milligrams of distilled water.. They agreed with current results and stated that there were no statistically significant differences between the two groups in terms of their age, period of pregnancy, and Bishop score. at the start of the study. Following our results, stated that the interval between the start of induction and the beginning of the active phase in case and control groups was different significantly (P<0>
Elmaraghy et al evaluated the efficacy of intramuscular dexamethasone injection prior to induction in improving progression and duration of labor phases. 100 Nulliparous Pregnant women who were conducted at the labor wards of Ain Shams Maternity Hospital. He stated that use of dexamethasone intramuscularly prior to induction significantly shortens duration of normal labor with minimal complications [7].
This study differs from ours that there was no change on rate of normal vaginal delivery as ours which showed that the rate of normal delivery was significantly higher among Dexamethasone group than among
control group, this difference may be due to use of dexamethasone intramuscular, induction of labor was in term pregnancies (GA 40-42 weeks) with intact membranes [7].
Ahmed et al conducted case-controlled trial study was conducted in the labor ward of El Hussein University Hospital and El-Shiekh Zaid Specialized Hospital to evaluate the effect of dexamethasone infusion administration on the duration of induction of labor on 100 pregnant women with full term pregnancy. They agreed with current results and showed no significant difference between dexamethasone and saline groups regarding basal maternal and fetal characteristics as age, BMI, GA, also induction-active, active-second and induction-second durations were shorter among dexamethasone group than among saline group, but the differences were statistically significant only in induction- active and induction-second durations. Rate of normal delivery was significantly higher among dexamethasone group than among saline group [8].
Elsayed et al assessed the efficacy of intramuscular administration of dexamethasone on the induction delivery-interval in full term women undergoing induction of labor. This study was carried out between July 2018 and January 2019, at the labor ward of Ain Shams university maternity hospital, they stated that there was significant statistical difference between the two groups as regard induction-delivery interval (P<0>
Statistical analysis of current study showed that second and third stages durations were non-significantly shorter among dexamethasone group than among control group [9].
Statistical analysis of current study showed that fetal distress, arrest of delivery and indications of CS delivery were non-significantly less frequent among Dexamethasone group. The reasons for cesarean section in the 5 women in the study group included two arrest of labour, three fetal distress. Among 8 women who had cesarean sections in control group, the reason for the cesarean sections included six arrest of labour, two fetal distress.
Pahlavan et al stated that 50 cases (82.0%) in the study group and 47 cases (78.3%) in the control group had vaginal delivery. The reasons for the caesarean section in the 11 women in the study group included four fetal distress, three meconium liquor cases, and four labour arrest cases. Among 13 women who had caesarean section in the control group, the reasons for the cesarean section included five cases of arrest in the labor stages, four cases not responding to augmentation of labor, two meconium cases, and two fetal distresses with no significant difference [6].
Laloha et al stated that the frequency of C/S (Caesarian Section) in case and control group was 9.9% and 8.1%, respectively with no significance, this follows our results [4].
Kavanagh et al aimed to determine the effects of corticosteroids for third trimester cervical ripening or induction of labor in comparison with other methods. They disagreed with us and stated that the primary outcome vaginal birth within 24 hours was not reported. No benefit of intramuscular administration of corticosteroids with intravenous oxytocin was found when compared with oxytocin alone. However, given the small size of this trial this result should be interpreted cautiously. This method of induction of labor is not commonly used [10].
In contrast to our study, Pahlavan et al mentioned that the duration of the second stage of labor (p <0>
Similar to current study, Elsayed et al stated that there were no statistically significant differences between the two groups as regard duration of 2nd and 3rd stages of labor [9].
Statistical analysis of current study showed that there were no significant differences between dexamethasone and control groups regarding neonatal condition as birth weight, APGAR 1 and 5 minutes and need for NICU admission. Postpartum hemorrhage (PPH), also postpartum endometritis, chorioamnionitis were not reported among the studied groups.
While Pahlavan et al stated that the fetal complications in the study group included one infant admitted in the neonatal intensive care unit (NICU) for respiratory distress and one infant for fetal heart rate variation. Also, in the control group, two infants were admitted in the NICU for respiratory problems. Regarding maternal complications, 4 (6.5%) women with nausea were observed in the dexamethasone group, while there were 3 (5.0) cases of nausea in the control group, all non significant statistically [6].
Laloha et al agreed with us and stated that there was no significant difference in the first and fifth minute Apgar score between case and control groups (P<0>
Elmaraghy et al stated that there were no significant statistical differences between the two studied groups as regards fetal heart rate [7].
Ahmed et al goes with our results and stated that there was no significant difference between dexamethasone and saline groups regarding neonatal condition as birth weight, APGAR 1 and 5 minutes and need for NICU admission [8].
Points of strength of the study:
Double blinded RCT study, randomization, allocation and concealment of study population were done.
Assessment of study outcomes was done by the same observer, the study included women with term pregnancies with pre-labour rupture of membranes with no studies done before in this area.
Limitations of the study:
Exclude women with medical disorder and Great variation in Gestational age and Bishop score.

Conclusion

From the results of current study we can conclude that: Intravenous administration of dexamethasone in addition to labor induction according to the American College of Obstetricians and Gynecologists protocol shortened the induction - active phase and active phase durations. It shortened the total induction-delivery duration and increased the rate of successful vaginal delivery, but has no effect on second and third stages´ durations, incidence of intrapartum complications as fetal distress, arrest of delivery process, rate of emergency CS, chorioamniotis.Use of dexamethasone didnt alter neonatal condition as regards birth weight, APGAR 1 and 5 minutes and need for NICU admission, also didnt increase the incidence of postpartum complication as postpartum hemorrhage or postpartum endometritis.
Disclosure statement
No potential conflict of interest was reported by the authors.
Informed consent: Informed consent was obtained from all individual participants included in the study.
Ethical approval: All procedures performed in studies involving human participants were in accordance with ethical standards of the Ethical committee of the department of obstetrics and gynecology faculty of medicine, Ain Shams University.

References

Cunningham, F. G., Leveno, K. J., Bloom, S. L., Spong, C. Y., Dashe, J. $., Hoffman, B. L., Sheffield, J. S. (2016). Williams Obstetrics (25th edition). New York: McGraw-Hill Education, 408-410: 526.
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Bakker, R., Pierce, S., & Myers, D. (2017). The role of prostaglandins El and E2, dinoprostone, and misoprostol in cervical ripening and the induction of labor: a mechanistic approach. Archives of gynecology and obstetrics, 296(2), 167-179.
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Luesley, D. and Kilby, M. (2016). Obstetrics & Gynaecology; an Evidence-based text for the MRCOG. (3rd edition). Boca & Raton: CRC Press, 373.
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Laloha, F., Asiabar, N.M., Barikani, A., Movahed, F., & Javadi, E.H. (2015). Effect fo intravenous dexamethasone on preparing the cervix and labor induction. Acta Medica Iranica, 53(9): 568.
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Gill P, Lende MN, Van Hook JW. Induction of Labor. [Updated 2020 Jun 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.
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Pahlavan Z, Barat S, Esmaeilzadeh S, Ghanbarpour A, Naeimirad M, Golsorkhtabaramiri M. The effect of dexamethasone therapy on prolonged latent phase of labor: a randomized double-blind clinical trial. Caspian Journal of Reproductive Medicine. 2017 Apr 10;3(1):33-38.
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“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”.

George Varvatsoulias

Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.

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.

Khurram Arshad

Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.

Gomez Barriga Maria Dolores

The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.

Lin Shaw Chin

Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.

Maria Dolores Gomez Barriga

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.

Dr Maria Dolores Gomez Barriga

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¨.

Dr Maria Regina Penchyna Nieto

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.

Dr Marcelo Flavio Gomes Jardim Filho

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!”

Zsuzsanna Bene

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

Dr 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.

Lin-Show Chin

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.

Sonila Qirko

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.

Luiz Sellmann

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.

Zhao Jia

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."

Thomas Urban

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.

Cristina Berriozabal

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.

Dr Tewodros Kassahun Tarekegn

"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".

Dr Shweta Tiwari

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.

Dr Farooq Wandroo

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.

Dr Anyuta Ivanova

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.

Dr David Vinyes

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.

Gertraud Teuchert-Noodt

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

Dr Elvira Farina

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.

Virginia E. Koenig

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