AUCTORES
Globalize your Research
Research article
*Corresponding Author: Joel Oster, Tufts University School of Medicine, Department of Neurology, Tufts Medical Center Boston MA, USA.
Citation: Joel Oster, Matthew Tucker, Mohammad Tabaeizadeh, Emma Jost-Price. et al (2022). How Much Propofol is needed when Treating Status Epilepticus? A Case Series. J. Brain and Neurological Disorders. 5(5): DOI:10.31579/2642-973X/041
Copyright: © 2022 Joel Oster. 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: 28 September 2022 | Accepted: 11 October 2022 | Published: 16 December 2022
Keywords: status epilepticus; EEG monitoring; intensive care unit; refractory status epilepticus; propofol
Objective
The objective was to retrospectively review the management of status epilepticus at Tufts Medical Center in patients who failed the initial standard of care benzodiazepine triage of status epilepticus. This article sought to determine the minimal average dose/infusion rate of propofol that was associated with conversion of the EEG long term monitoring (LTM) from status epilepticus to an EEG that was devoid of organized seizure activity.
Background
Literature has not clearly delineated an actual minimal dose or infusion rate of propofol in studies of patients with status epilepticus. Timely and adequate treatment of status epilepticus has treatment implications especially if patients are to be transported from various locations to another center as EEG may not always be readily available. Identifying the minimal dose of propofol required in this setting that allows effective intubation, induction which would also allow treating providers to have confidence that a minimal dose requirement that is associated with converting EEG patterns to patterns devoid of electrographic seizure activity may have clinical utility.
Design/Methods
With IRB approval, a retrospective database was created from 2015-2020 reviewing patients with the clinical diagnosis of status epilepticus at Tufts Medical Center, Boston, MA who failed maximal initial standard of care triage and treatment with benzodiazepines were identified. Multiple clinicopathologic variables were tabulated in a database along with minimal and maximal doses of infused medications and when EEG LTM converted to a pattern devoid of organized seizure activity during treatment. Maximal dose of Propofol was identified daily and dose data was averaged among the patients to report the estimated mean dose.
Results
21 such patients were identified who had real time direct management with both an epileptologist and a neurointensivist during real time assessment as propofol was infused. Treating status epilepticus involved complex decision making with multiple comorbidities and diagnostic variables and considerations as outlined in Table 1. The minimal propofol dose identified that terminated status epilepticus or was associated with EEG conversion to a pattern devoid of such was 42 mcg/kg/min.
Conclusions
Our single center retrospective review of treating status epilepticus identified that propofol at a dose of 42 mcg/kg/min was the minimal effective average dose for converting EEG LTM from status epilepticus to a pattern devoid of organized seizure activity in a small heterogeneous clinical population of patients that failed initial treatment with benzodiazepines.
Status Epilepticus represents a neurologic emergency and literature is evolving regarding optimal management [1-10]. This work retrospectively seeks to identify the minimal dose of propofol that may be helpful when prescribed in an FDA on label fashion as an anesthetic inducing agent prior to intubation during the management of status epilepticus in patients that fail initial triage or treatment with benzodiazepines. The identification of the minimal dose of propofol required that allows effective intubation and induction that is associated with converting EEG patterns to patterns devoid of electrographic seizure activity may have clinical utility. This article seeks to determine the minimal average infusion rate of propofol that was associated with conversion of the EEG during long term monitoring (LTM) from status epilepticus to an EEG that was devoid of organized seizure activity. The minimal propofol dose identified that terminated status epilepticus or was associated with EEG conversion to a pattern devoid of such was 42 mcg/kg/min in a small heterogenous clinical population of patients that failed initial treatment with benzodiazepines
With IRB approval, a retrospective database was created from 2015-2020 reviewing patient charts with the clinical diagnosis of status epilepticus. Various clinicopathologic variables were tabulated (such as age, suspected etiology of status epilepticus, comorbid conditions, whether death occurred, days propofol was infused, and total number of anti-seizure medications) in a database along with minimal and maximal dose of infused medications and other information (Table 1). Propofol was used to provide anesthesia upon intubation while other anti-seizure medications were titrated to ultimately treat the status epilepticus.
Propofol was titrated upwards to achieve both anesthesia and sedation for intubation. Table 1 lists those 21 cases that were identified showing initially status epilepticus by EEG long term monitoring reviewed in real time either with a physically present epileptologist or one reviewing and communicating in real time remotely over an active internet connection.
Table 1: Patient characteristics of the study population are noted. Age, Sex, Underlying diagnosis thought to be the cause of status epilepticus along with outcome, starting dose of propofol, minimal, maximal and average dose of propofol used along with days used, and line of therapy among the total number of anti-seizure medication therapies tried on each patient are tabulated.
Propofol was administered at the discretion of the Neurointensivists after deemed benzodiazepine failure. Hemodynamic responses and side effects were closely monitored and treated with either intravenous fluids or vasopressors (e.g., norepinephrine) as needed during the treatment course in a neurologic ICU. Epileptologist and Neurointensivist communications were essential in the effective management of each case and discussion and documentation regarding whether or not seizure activity was or was not present occurred at minimum once daily and more frequently in the acute setting. Exactly when the EEG converted to a pattern devoid of organized seizure activity during treatment was determined through clinical and electrographic evaluation in real time for clinical management and verified retrospectively for analysis of this dataset. Patients whose EEG patterns either did not identify seizures or at any point identified ictal continuum at any time were excluded from this analysis. Dose of effective seizure eradication was determined by the highest propofol dose or infusion rate associated with electrographic and or clinical timepoints when no further seizures on EEG were identified. This data set did not include patients who had readmissions. This dataset did not have multiple EEG readers or a committee in real time delineating protocolled review of the EEGs or protocolled determination of any particular treatment strategy. American Clinical Neurophysiology Society (ACNS) criteria for identifying electrographic seizure activity and other activities were used by the epileptologists in determining the presence or absence of electrographic seizure activity for this study both prospectively during the treatment phases and in retrospective review for determining the presence or absence of electrographic seizure activity in the data analysis. [11] Patients with psychogenic non epileptic seizures were excluded. Patients were deemed to have had benzodiazepine failure when either 8 mg lorazepam was administered, 10 mg of diazepam was administered, or further administration of benzodiazepines at any dose regimen would require further critical care.
Of 73 patients that were identified to exhibit Status Epilepticus at Tufts Medical Center from 2015-2020, 21 of these patients had induction of anesthesia and intubation with propofol while under VEEG/as described. The average propofol dose that was identified that terminated status epilepticus was approximately 42 mcg/kg/min. Propofol was administered for an average of 3.7 days, excluding a notable outlier that required sedation for 17 days.
Status epilepticus (SE) is a neurological emergency defined by the occurrence of five minutes of consecutive seizure activity or with seizure activity occurring to such an extent that the recurrence precludes return to baseline. [1-7] The condition is associated with significant mortality and morbidity and is estimated to occur between 1.29-73.1/100,000. [1] Timely and adequate treatment of status epilepticus can have lasting implications. [1-10] Early seizure termination decreases the risk of cardiac and respiratory complications and effective and efficient treatment of status epilepticus is associated with reduced risks in such patients [1-7].
Current published guidelines and treatment protocols recommend the initial use of benzodiazepines, followed by intravenous antiepileptic drugs, and if necessary, anesthetics to provide effective anesthesia upon intubation for further management as anti -seizure medications are administered [3-8] Although this treatment paradigm is widely used, authoritative dosing for the anesthetics and sedatives are based on limited evidence [3-8]. If seizures fail to response to first and second-line treatments using common anti-seizure medications and benzodiazepines, it is considered Refractory Status Epilepticus (RSE) and ICU care may be required with subsequent intubation and administration of an anesthetic agent for such patients [3-8]. Seizures that continue 24 hours or more after onset of anesthetics are administered are considered Super Refractory Status Epilepticus (SRSE). [5-7] Approximately 12–43% of those presenting to the hospital with SE progress to having RSE and 10–15% of patients develop super-refractory status epilepticus [5-7].
In the context of benzodiazepine-refractory status epilepticus, the anticonvulsant drugs levetiracetam, fosphenytoin, and valproate in a recent literature review each led to seizure cessation and improved alertness by 60 minutes in approximately half of patients in the literature, and the three drugs were associated with similar incidences of adverse events[8] However, many cases require ICU level of care with intubating such patients and a number of intravenous anesthetic drugs are often used in this setting of treating RSE, such as barbiturates, midazolam, ketamine, and propofol concomitantly [5-7].
Propofol has been proposed as a first line treatment as an anesthetic agent for RSE and literature is evolving supporting its use as a first-line anesthetic given its pharmacokinetic characteristics of rapid onset and short half-life [5-7]. Approximately 20 years ago caution was advised in scattered case reports identifying risks of increased mortality with use of anesthetic agents in treating status epilepticus, although some articles as cited indicate that propofol may be associated with faster onsets of anesthetic effect and less hypotension compared to other agents [5,9,10]. Propofol carries risks of adverse reactions, such as hypotension, severe metabolic acidosis, and rhabdomyolysis. [5,9,10] The risks of developing propofol-related infusion syndrome especially at higher doses and in regimens that involve prolonged administration has been noted and therefore determining minimally effective dosing would prove helpful [5-8]. Studies have yet to determine what other anti-seizure medication regimens should be administered concomitantly and how durable a treatment regimen might be, i.e., to what extent seizures might re-emerge clinically or electrographically upon down titration of propofol. Of note Propofol’s FDA approved indication and use as an anesthetic has been studied in various settings including continuation of sedation and anesthesia for neurologic indications in pivotal trials involving intensive care unit settings, and may be dosed up to 100-200 mcg/kg/minute over multiple days, and therefore no off-label use or other off label dosing regimens outside of these parameters occurred within the context of this study. [12]
The dose of propofol that constitutes a therapeutic window between induction of effective anesthesia for intubation and adequate treatment in suppressing the EEG or changing the EEG to a pattern devoid of seizures while potentially minimizing side effects from starting with low doses and escalating to a minimally effective clinical dose regimen is not currently known authoritatively in the literature- and retrospectively determining this dose was the rationale for proceeding with this study. A minimum dose for propofol titration is therefore a potentially useful metric that would allow clinicians to reach therapeutic anesthesia and suppressing seizures on EEG in a timely manner and additionally potentially avoiding risks of negative outcomes associated with untreated seizures as patients are intubated. Moreover, this minimal propofol dose would also serve as a baseline that may offset the side effect risks associated with an over aggressive up-titration of anesthetic which may be associated with the previously noted risks of such agents as other anti-seizure medications are administered and titrated. The findings from this retrospective case series may inform future prospective status epilepticus trials and allow treating providers to have confidence in identifying a minimal dose requirement for propofol for providing effective anesthesia for intubation while to effectively terminating clinical and electrographic seizure activity.
Limitations of the current study include that this study represents a small number of cases with potentially significant heterogeneity and confounding in clinical variables and real-time decision making was done without a specific protocolled treatment plan as would occur in a prospective randomized clinical trial. The current case series includes various cases with either unknown durations of status epilepticus or had a heterogeneous timing or timeline of therapy which may be impacting clinical outcome. It may be stated that there may have been arbitrary implementation of propofol as a first line anesthetic agent as opposed to other anesthetics without further rationale or indication specified. The lack of standardization for continuing such therapy for a certain duration among dosing regimens and infusion rates remain without guidelines and is overall not studied, and follow up was limited to status epilepticus being treated in a solitary admission on a case-by-case basis so timelines and comorbid clinical courses, concomitant medications and comorbidities varied from case to case. Additionally, lack of analyses of the cases in a comparison which either had resolution with another anesthetic or did not have successful treatment of status epilepticus compared to the current dataset that were treated as noted remain additional limitations or undefined elements in the current study. Although there was agreement retrospectively among the EEGs between the two involved interpreters retrospectively in this analysis (JO and KP), verification with multiple readers was not performed in real time during a protocoled approach to treatment strategy as noted which may also confound the data analysis and discussion. No study of long-term clinical outcome beyond termination of seizure activity or death as indicated was made with this dataset. No claim is being made that propofol actually represents a short term or a long-term option or has long term potential to be used as an anti-seizure medication to treat seizure disorders.
Although successful management of the small number of patients in this current study is noted, determining what multiple complex medication regimens are recommended in diverse clinical scenarios remains largely unknown. Additionally, to what extent propofol infusions must be maintained or what degree of burst suppression is required remain unknown. Cases involving titration of the EEG monitoring to a state devoid of seizure activity and or burst suppression were included in this heterogenous population and such dataset was not further analyzed for this study other than as noted above.
Despite the confounding issues discussed, the data derived from this study indicate that Propofol used as its FDA approved indication as an anesthetic during intubation and for maintenance of mechanical ventilation or induction during treatment of status epilepticus eradicated status epilepticus on EEG long term monitoring at approximately 42 mcg/kg/min in this series of patients who failed initial treatment with benzodiazepines. Further analysis of such a study population may be useful in guiding future research.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
