AUCTORES
Globalize your Research
Review Article
*Corresponding Author: Shahin Asadi, Medical Genetics Director of the Division of Medical Genetics and Molecular Pathology Research. Division of Medical Genetics and Molecular Pathology Research, Center of Complex Disease, U.S.A
Citation: Shahin Asadi, Zahra Gholizadeh, Hamid Amirabadi, (2024), A Comprehensive Review of the Pathological Mechanism of Evans Syndrome, Clinical Medical Reviews and Reports, 6(4); DOI:10.31579/2690-8794/207
Copyright: © 2024, Shahin Asadi. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 23 March 2024 | Accepted: 01 April 2024 | Published: 09 April 2024
Keywords: evans syndrome; immune system disorder; hemolysis; red blood cell
Evans syndrome is a rare disease in which the immune system produces antibodies that mistakenly destroy red blood cells, platelets, and sometimes some white blood cells called neutrophils. This leads to abnormally low levels of these blood cells in the body (cytopenia). The premature destruction of red blood cells (hemolysis) is known as autoimmune hemolytic anemia, or AIHA. The symptoms and severity of Evans syndrome can be very different from person to person, as can the onset, course and duration of this disorder. Most people show a chronic course with periods of worsening of symptoms (exacerbation) and usually transient improvement with treatment. Most symptoms are caused by low levels of certain blood cells in the body. The exact cause of Evans syndrome is unknown. Evans syndrome is an autoimmune disease. It occurs when the immune system produces antibodies that mistakenly attack healthy tissue, particularly red blood cells, platelets, and sometimes some white blood cells.
Evans syndrome is a rare disease in which the immune system produces antibodies that mistakenly destroy red blood cells, platelets, and sometimes some white blood cells called neutrophils. This leads to abnormally low levels of these blood cells in the body (cytopenia). The premature destruction of red blood cells (hemolysis) is known as autoimmune hemolytic anemia, or AIHA. Thrombocytopenia refers to low levels of platelets (idiopathic thrombocytopenic purpura or ITP in this example). Neutropenia refers to low levels of certain white blood cells known as neutrophils. Evans syndrome is defined as the association between AIHA and ITP. Neutropenia occurs less often. In some cases, autoimmune destruction of these blood cells occurs simultaneously. In most cases, one disease develops first before another condition develops later (sequentially). The symptoms and severity of Evans syndrome can vary greatly from person to person. Evans syndrome can potentially cause serious and life-threatening complications. Evans syndrome can occur alone as a primary disorder (idiopathic) or in association with other autoimmune disorders or lymphoproliferative disorders as a secondary disorder. (Lymphoproliferative disorders are characterized by an overproduction of white blood cells.) The distinction between primary and secondary Evans syndrome is important because it can affect treatment.[1]
Evans syndrome was first described in the medical literature in 1951 by Dr. Robert Evans and colleagues. For many years this disorder was considered a random event of AIHA with thrombocytopenia or neutropenia. However, researchers now believe that this disorder represents a distinct condition characterized by chronic and profound dysfunction (dysregulation) of the immune system (more so than ITP or AIHA alone). [1]
Clinical Signs and Symptoms of Evans Syndrome
The symptoms and severity of Evans syndrome can be very different from person to person, as can the onset, course and duration of this disorder. Most people show a chronic course with periods of worsening of symptoms (exacerbation) and usually transient improvement with treatment. Most symptoms are caused by low levels of certain blood cells in the body. These blood cells perform specific tasks. Red blood cells supply the body with oxygen and remove carbon dioxide, platelets help clot to stop blood loss, and white blood cells help fight infections.[1]
Figure 1: Schematic of the physiological mechanism of the immune system in Evans syndrome.[1]
Some people with Evans syndrome may initially destroy red blood cells faster than the body can replace them. Low levels of circulating red blood cells, known as anemia, can cause a variety of symptoms, including fatigue, pale skin (pallor), dizziness, shortness of breath, dark urine, and palpitations. Some people may experience yellowing of the skin and especially the whites of the eyes (jaundice) .[1-2]
Other people may initially present with low platelet levels, known as thrombocytopenia. Thrombocytopenia can cause tiny reddish or purple spots on the skin (petechiae), a broader purplish discoloration of the skin caused by bleeding from broken blood vessels into the tissue under the skin (ecchymosis), and purpura, a skin rash made up of spots. internal bleeding from the small area of blood vessels. Affected individuals may be more prone to bruising following minor injuries and spontaneous bleeding from the mucous membranes.[1-2]
Low levels of white blood cells, known as neutropenia, are less common in people with Evans syndrome than anemia or thrombocytopenia. People with neutropenia may be prone to frequent infections. General symptoms may include fever, general malaise (malaise), and sores on the mucous membranes of the mouth. [1-2]Additional symptoms that may occur in people with Evans syndrome include swollen lymph nodes, spleen, and liver. These results may come and go or in some cases may only occur in acute periods. In most cases, patients with Evans syndrome may not respond to treatment (resistant Evans syndrome) and can eventually lead to life-threatening complications, including sepsis, severe bleeding (bleeding) episodes, and reversible cardiovascular problems, including l heart failure.[1-2]
Etiology of Evans Syndrome
The exact cause of Evans syndrome is unknown. Evans syndrome is an autoimmune disease. It occurs when the immune system produces antibodies that mistakenly attack healthy tissue, particularly red blood cells, platelets, and sometimes some white blood cells. [1-3] The immune system usually responds to foreign substances by producing specialized proteins called antibodies. Antibodies work by directly destroying foreign substances or by coating them with substances that mark them for destruction by white blood cells. When antibodies target healthy tissue, they may be called autoantibodies. Researchers believe that a trigger event (such as an infection or underlying disorder) may cause the immune system to produce autoantibodies in Evans syndrome. [1-3]
Figure 2: Schematic of the pathway, biochemical mechanism, and pathogenesis of Evans syndrome.[1]
Evans syndrome can occur with another disorder as a secondary disease. Secondary Evans syndrome may be associated with other disorders such as autoimmune lymphoproliferative syndrome (ALPS), lupus, antiphospholipid syndrome, Sjogren's syndrome, common variable immunodeficiency, IgA deficiency, specific lymphoma, and chronic lymphocytic leukemia.[1-3]
Frequency of Evans Syndrome
The incidence and prevalence of Evans syndrome are unknown. This disorder can affect children or adults. [1-4]
Disorders Associated with Evans Syndrome
Symptoms of the following disorders may be similar to the symptoms of Evans syndrome. The comparison can be useful for differential diagnosis:
Several disorders can be characterized by the presence of hemolytic anemia and thrombocytopenia. These disorders include paroxysmal nocturnal hemoglobinuria (PNH), acquired thrombotic thrombocytopenic purpura, hemolytic uremic syndrome, and Kasabach-Merritt syndrome. [1-4] Autoimmune lymphoproliferative syndrome (ALPS) is a rare genetic disorder that overlaps with Evans syndrome. A characteristic finding of ALPS is the presence of abnormally high numbers of white blood cells called lymphocytes, which can accumulate in the lymph nodes, liver, and spleen and cause enlargement of these organs. ALPS can lead to symptoms similar to Evans syndrome, particularly anemia, thrombocytopenia, and neutropenia. Most people with ALPS have a mutation in the tumor necrosis factor receptor superfamily member gene (TNFRSF6), also called CD95 or Fas. The exact relationship, if any, between these disorders is not fully understood. It is believed that approximately half of children diagnosed with Evans syndrome may have an underlying ALPS cause because autoreactive cells do not undergo normal programmed cell death (apoptosis). The intersection of ALPS and Evans syndrome in adults is less clear. [1-4]
Diagnosis of Evans Syndrome
The diagnosis of Evans syndrome is based on the identification of characteristic symptoms, a detailed patient history, a comprehensive clinical evaluation and a series of specialized tests. There is no specific test for Evans syndrome and it is diagnosed after other possible diagnoses have been ruled out. Specifically, a diagnosis of Evans syndrome can be made when autoimmune hemolytic anemia (with positive direct Coombs test) and thrombocytopenia (ITP) occur in the same patient, even if they are not concurrent. [1-4] Laboratory studies include a complete blood count (CBC), which may show low levels of red blood cells, platelets, and white blood cells. Another blood test, known as a direct antiglobulin test, or DAT, is used to determine whether the amount of certain antibodies is higher than normal. A series of tests can be performed to rule out other conditions. Such tests may include bone marrow biopsy, additional antibody tests, and CT scans of the chest, abdomen, and pelvis [1-4]Some doctors recommend that children with Evans syndrome be screened for ALPS because the prevalence of these two disorders is high. Screening includes testing for the presence of double negative T cells (DNT) by flow cytometry, the presence of which indicates ALPS. [1-5]
There is no cure for Evans syndrome, and treatment is often challenging. Treatment is directed at specific symptoms evident in each individual. Treatment may require the coordinated effort of a team of specialists. Pediatricians, surgeons, hematologists, pediatric hematologists, immunologists, rheumatologists and other healthcare professionals may need to systematically and comprehensively plan an effective treatment for a child [1-5] Most affected individuals require treatment, although spontaneous recovery has been reported in rare cases. Several different types of treatments have been used to treat people with Evans syndrome, and their effectiveness has varied greatly among affected people. Some people have long-term recovery from this disorder. Others experience chronic problems without improvement. [1-6] As a result, treatment procedures and specific interventions may vary based on several factors, including the severity of the disease. blood cell count level; presence or absence of specific symptoms; the person's age and general health; and/or other elements Decisions regarding the use of specific drug regimens or other treatments should be made by physicians and other members of the healthcare team in careful consultation with the patient based on the characteristics of his or her case. [1-6]
First-line treatment for Evans syndrome often includes corticosteroids such as prednisolone. Corticosteroids help suppress the immune system and reduce the production of autoantibodies. The first results are often effective. Intravenous immunoglobulin (IVIg) therapy has also been used to treat people with Evans syndrome. IVIg treatment modifies the activity of the immune system. IVIg is a solution containing antibodies donated by healthy people and injected directly into the vein. [1-7] Surgical removal of the spleen (splenectomy) has been used to treat some people with Evans syndrome. Most reports are non-definitive and anecdotal, and it is difficult to determine the effectiveness of this method due to the simultaneous use of other treatments such as medications. Splenectomy is generally reserved for people who do not respond to other treatment options (refractory Evans syndrome). In children, splenectomy rarely results in long-term improvement in symptoms. In adults, effectiveness varies and symptoms usually return at some point. Therefore, it is usually delayed as much as possible and every effort is made not to do so. [1-7]During an acute episode, blood or platelet transfusions may be needed to relieve symptoms. However, the use of blood or platelet transfusions should be avoided as much as possible. [1-7] New treatments for Evans syndrome are being studied. Rituximab appears to be a very effective treatment for patients with Evans syndrome. Rituximab is classified as a monoclonal antibody or biologic therapy, drugs that act like antibodies but are created artificially in a laboratory. Preliminary studies have shown this drug to be generally safe and effective. The advantages of rituximab are to avoid severe immunosuppression and side effects associated with other immunosuppressive agents. The disadvantage is that in cases of Evans syndrome caused by underlying ALPS, hypogammaglobulinemia appears to develop which may persist in patients treated with rituximab. Hypogammaglobulinemia is a condition in which the body's immune system does not produce enough antibodies and potentially makes those affected susceptible to bacterial infections and, to some extent, some viral infections. [1-7] Additional drugs have been studied in a small number of people with Evans syndrome. The second factor that appears to be relatively effective in this disorder is mycophenolate mofetil. These drugs can be used alone or in combination (multi-agent therapy) as second-line treatments for people with Evans syndrome who do not respond to corticosteroids or IVIg therapy. More research is needed to determine the long-term safety and effectiveness of these potential treatments for people with Evans syndrome. [1-7]
Research treatments
Some people with Evans syndrome have been treated with allogeneic or autologous stem cell transplantation. Stem cells are special cells that are found in the bone marrow and produce different types of blood cells (ie red blood cells, white blood cells and platelets). In an autologous stem cell transplant, the patient's stem cells are removed after previous treatment, usually with drugs. These healthy stem cells are re-injected into the bone marrow after the progression of the disorder. In an allogeneic stem cell transplant, stem cells are donated from another person, usually a close family member. These methods are usually used as a last resort for people who have failed to respond to other forms of treatment. They have produced mixed results, and more experience is necessary to determine their potential effectiveness as a treatment for Evans syndrome. [1-7]
Evans syndrome was first described in the medical literature in 1951 by Dr. Robert Evans and colleagues. For many years this disorder was considered a random event of AIHA with thrombocytopenia or neutropenia. However, researchers now believe that this disorder represents a distinct condition characterized by chronic and profound dysfunction (dysregulation) of the immune system (more so than ITP or AIHA alone). Additional symptoms that may occur in people with Evans syndrome include swollen lymph nodes, spleen, and liver. These results may come and go or in some cases may only occur in acute periods. In most cases, patients with Evans syndrome may not respond to treatment (resistant Evans syndrome) and can eventually lead to life-threatening complications, including sepsis, severe bleeding (bleeding) episodes, and reversible cardiovascular problems, including l heart failure. Some doctors recommend that children with Evans syndrome be screened for ALPS because the prevalence of these two disorders is high. Screening includes testing for the presence of double negative T cells (DNT) by flow cytometry, the presence of which indicates ALPS. New treatments for Evans syndrome are being studied. Rituximab appears to be a very effective treatment for patients with Evans syndrome. Rituximab is classified as a monoclonal antibody or biologic therapy, drugs that act like antibodies but are created artificially in a laboratory. Preliminary studies have shown this drug to be generally safe and effective. The advantages of rituximab are to avoid severe immunosuppression and side effects associated with other immunosuppressive agents. The disadvantage is that in cases of Evans syndrome caused by underlying ALPS, hypogammaglobulinemia appears to develop which may persist in patients treated with rituximab. Hypogammaglobulinemia is a condition in which the body's immune system does not produce enough antibodies and potentially makes those affected susceptible to bacterial infections and, to some extent, some viral infections. [1-7]
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
