AUCTORES
Globalize your Research
Case Report | DOI: https://doi.org/10.31579/2578-8965/207
Family Physician & Public Health Consultant Bengaluru.
*Corresponding Author: Suresh K, Family Physician & Public Health Consultant Bengaluru.
Citation: : Suresh K, (2024), Medical Management of Uterine Fibroids-A hope for Fertile Women! J. Obstetrics Gynecology and Reproductive Sciences, 8(3) DOI:10.31579/2578-8965/207
Copyright: © 2024, Suresh K. 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: 01 March 2024 | Accepted: 14 March 2024 | Published: 21 March 2024
Keywords: fibroid; leiomyoma; serm; pbac score; mifepristone; ormeloxifen; pelvic inflammatory diseases (pid); estrogen and progesterone receptors; botanical drug; polyherbal
Uterine fibroids or Myomas or Leiomyoma of uterus are the most common type of benign tumor of uterus and most common pelvic tumour in women with unclear etiology.
Uterine fibroids or Myomas or Leiomyoma of uterus are the most common type of benign tumor of uterus. In India the incidence of fibroids is most common in women of 31- 40 years of age i.e. as more than 1/3 (35%) of them get affected.
Recent understanding of etiology suggests increased number of estrogen and Progesterone Receptors, increased COMT gene expression and TGF-B3. Risk factors for developing fibroids are age, early age at menarche, reduced fertility, frequent caffeine consumption, obesity, hypertension, diabetes mellitus, alcohol consumption and previous pelvic inflammatory disease (PID). Rural women are at a much higher risk of uterine fibroids than urban women in India. (37.65% vs.24%) probably due to multiparty at a young age disturbing Estrogen and Progesterone Receptors.
Treatment options for symptomatic uterine fibroids include medical, surgical, and radiologically guided interventions. Although curative treatment relies on surgical therapies- either myomectomy or hysterectomy, medical treatments are considered the first-line treatment to preserve fertility and avoid or delay surgery. Medical therapy is in nascent stage in India.
Medical treatment must be individualized based on age, signs & symptoms, sustained reduction of the size and sustenance of fertility if desired with minimal side effects.
Materials and Methods: This article is based on a literature review on medical therapy being tried on a case the author is managing now. The initial results are encouraging and need to monitor the reduction of the size or volume of the Fibroid in coming months.
Uterine fibroids or Myomas or Leiomyoma of uterus are the most common type of benign tumor of uterus and most common pelvic tumour in women. Exact etiology is not known but the cause estimated to be is estrogen and progesterone which proliferate tumour growth as fibroid rarely occur before menarche and reduces after menopause. Risk factors for developing fibroids are age, early age at menarche, reduced fertility, frequent caffeine consumption, obesity, hypertension, diabetes mellitus, alcohol consumption and previous pelvic inflammatory disease (PID). The prevalence of uterine fibroids varies with geographical and racial influences and environmental factors.
Globally, the age-standardized incidence of uterine fibroids has been increasing in recent years. In contrast, age-standardized DALY rates have exhibited a decreasing trend. Eastern Europe, Tropical Latin America, Brazil, and India experience the greatest uterine fibroid burden. Uterine fibroids or Myomas or Leiomyoma of uterus are the most common type of benign tumor of uterus and most common pelvic tumour in women. as reflected in the higher incidence rates among these age groups. From 1990 to 2019, the global age-standardized incidence of uterine fibroids increased by 6.87% from 225.67 to 241.18 per 100 women.
In India the incidence of fibroids is most common in women of 31- 40 years of age i.e. as more than 1/3 (35%) of them get affected [1]. There is a difference in incidence in rural and Urban India. Rural women are almost at one and half times risk of uterine fibroids than urban women in India. (37.65% vs.24%) and urban India (24%) women. Incidence in Pakistani women was 78%. The main symptoms are a heavy menstrual flow, abnormal uterine bleeding, pelvic pain, frequent urination, and constipation.
The medical treatment for uterine fibroids includes i) Gonadotropin-releasing hormone (GnRH) agonists- which reduce fibroids by blocking the body from making the hormones estrogen and progesterone ii) Gonadotropin-releasing hormone (GnRH) antagonists, iii) Progestin-releasing intrauterine device (IUD), iv) Tranexamic acid (Lysteda, Cyklokapron) and v) Other medicines.
This article is based on current experience of trying medical therapy for a case of single posterior submucosal Fibroid. The author is of the opinion the accessibility to Scanning in the last decade more and more women can be diagnosed at early stage and managed medically.
Shilpa, the Youngest Lady with Uterine Fibroids in 2024:
First February 2024 one of my nieces from a mofussil town in Karnataka India approached me for second opinion, sharing an Ultrasound scan of abdomen and Pelvis.
Shilpa is a young lady of 37 years, married about 15 years ago and has a 14-year-old daughter and 6-year-old son. The main complaints were Menorrhagia in the past 6 months, coupled with abdominal pain and weakness. A local gynecologist checked her physically and got her Routine blood laboratory test, which showed her to be anemic with HB=8.5 gm/ Dl and an abdomen and Pelvic report reading “Posterior Submucosal Fibroid size 3.5x3.1 cm. all other abdominal structure were reported to be normal. She was put on Tablet Sevista 60mg (Ormeloxifene-60.0 Mg) tablets basically a contraceptive twice a week, Iron & Folic acid, and Vit B12 supplementation. Ormeloxifene is an excellent drug in controlling dysfunctional uterine bleeding without effecting normal endocrinal and physiological parameters. It leads to a significant reduction in menstrual blood loss and a significant decrease in endometrial thickness without any major side effect. Her periods after use of 15 tablets over 1 month has shown a decrease in menstrual flow by 50%
Uterine leiomyomas are the most common benign uterine tumours affecting around 20-25% women in the fertile age group [1]. They are the most common type of benign tumor of uterus and most common pelvic tumour in women. Exact etiology is not known. In India the incidence of fibroids is most common in women of 31- 40 years of age i.e. as more than 1/3 (35%) of them get affected. Fibroids may be tiny and described as “seedlings” or grow large enough to alter the shape and size of the uterus. Those that grow on the outer wall of the uterus, called the serosa, can develop on a narrow stem that supports the larger growth, called pedunculated fibroids. Fibroids can grow as a single nodule or in a cluster. Clusters of fibroids can range in size from 1 millimeter to more than 20 centimeters (8 inches) in diameter or even larger. For comparison, fibroids can be as small as a seed or as large as a watermelon. The pathogenesis of the tumour is still not well understood. Hence, medical management of this condition is still in its nascent stage. Fibroids can shrink when hormone levels drop as it happens after menopause and therefore, we see symptoms improving for better after menopause. Medical management uses this principle of modifying the hormone levels.
Types of Uterine Fibroids: These growths can develop within the wall of the uterus, inside the main cavity of the uterus or on the outer surface of the uterus. Based on where they grow, there are three major types of uterine fibroids. 1. Intramural fibroids grow within the muscular uterine wall. 2. Submucosal fibroids bulge into the uterine cavity. 3. Sub-serosal fibroids project to the outside of the uterus. 4. Pedunculated fibroids-the least common type, they attach to the uterus with a stalk or stem, often described as mushroom-like. In India Prevalence of submucosal fibroids is around 40%, intramural fibroids 19.3%, submucosal polyp 14.5%, seedling fibroid 13.9% and sub serosal fibroid 10.2% [1]. The size of the fibroids and the manifestations they exhibit decides the course of management. Based on the size i) Small Fibroids can be less than 1 cm to 5 cm, ii) Medium Fibroids range from 5 cm to 10 cm the size of a plum to an orange iii) Large Fibroids can be 10 cm or more, ranging from the size of a grapefruit to a watermelon. Surgical management is advocated for women with fibroids >3 cm in diameter causing significant symptoms, pain or pressure and wishing to retain their uterus may consider myomectomy, and if uterus can be removed hysterectomy are the treatment of choices. Intramural Fibroids of about 4 cm or more, can impact ovum implantation and might block the fallopian tubes, which can cause infertility. Sometimes fibroids can affect the mode of delivery of a baby.
Figure 2: Types of Uterine Fibroids
International Federation of Obstetrics & Gynecology (FIGO) subclassified fibroids as:
1. Sub-mucosal: i) 0= Pedunculated intracavity, 1=<50 xss=removed>50% intramural.
2. Others: 3=contacts endometrium-100% intramural,4=Intramural, 5=Sub serosal >50% intramural, 6= Sub serosal <50 xss=removed>
Etiology: Though exact etiology is not known, i) Estrogen has been implicated as Fibroids contain higher estrogen receptors than surrounding myometrium, as their size increases in pregnancy and estrogen therapy, they are not seen before menarche and regress after menopause ii) Progesterone as they increase mitotic activity and reduce apoptosis iii) Fibroids are monoclonal and about 40% have chromosomal abnormality- translocations between chromosomes 12 &14. Overall Fibroids overexpress Estrogens and Progesterone. iv) An analysis of the variability of the COMT gene in 44 patients by PCR-sequencing, showed that the Val158Met polymorphism
(rs4680) is the main cause of variation in COMT activity. This polymorphism is a causal factor in the incidence of uterine fibroids by allowing a higher estrogenic activity in myometrial cells [8].
Pathophysiology of Fibroids: Although Fibroids are benign, can significantly impact on the everyday physical and mental well-being of women. Fibroids are a result of the inappropriate growth of uterine smooth muscle tissue or myometrium. Their growth is dependent on estrogen and progesterone levels. Recent studies indicate involvement of the COMT gene in the occurrence of uterine fibroids.
Diagnosis: Transvaginal ultrasound (TSV) is the gold standard for imaging uterine fibroids with a sensitivity of around 90 to 99%. Saline-infused sonography Ultrasound increases the sensitivity for the detection of subserosa and intramural fibromas. Fibroid appearance is as a firm, well-circumscribed, hypoechoic mass. A simple ultrasound was sufficient in our case.[3]
Hysteroscopy: A hysteroscope is used to visualize the inside of the uterus, allows for better visualization of fibroids inside the uterine cavity and allows for the direct removal of intrauterine growths during the procedure.
Magnetic Resonance Imaging MRI: MRI has the benefit of providing a better picture of the number, size, vascular supply, and boundaries of the fibroids as they relate to the pelvis. It may not be needed routinely on the suspicion of the fibroids are. It has not been shown to differentiate leiomyosarcoma from leiomyoma.
Treatment: Treatment options for symptomatic uterine fibroids include medical, surgical, and radiologically guided interventions. Although curative treatment of this tumor relies on surgical therapies, medical treatments are considered the first-line treatment to preserve fertility and avoid or delay surgery. Treatment for patients must begin with trials of NSAIDs and hormonal therapy, and escalated only when symptoms are refractory, or unmanageable by medication. Minimally invasive treatment (hysteroscopic Myomectomy) options performed by gynaecologists or interventional radiologists can be an option if there is a need to preserve uterus. Hysterectomy is the definitive treatment for leiomyomas and must be opted for patients with high severity of symptoms, who do not mind infertility.
Currently among medical therapy tow possibilities are there, 1) Hormonal therapy consists of gonadotrophin-releasing hormone (GnRH) {GnRH agonists, GnRH antagonists}, Androgens (Danazol), Levonorgestrel releasing intrauterine system and selective progesterone receptor modulators (SPRMs- Ulipristal Acetate and Mifepristone) and 2) non-hormonal therapy Tripterygium Wilfordii, Epigallocatechin gallate (EGCG) and Vitamin D are the most effective medical therapies. Medical treatment needs repeated consultations and interventions.
GnRH agonists drugs include Leuprolide, goserelin, triptorelin and histrelin, they are synthetic GnRH products structurally analogous to natural GnRH, reduce Fibroid size by 30-40%. However, they have side effects of exacerbation of symptoms, development of vasomotor symptoms, and decreased Bone density.
The predominant GnRH antagonist is Degarelix.
Evidence is split as far as their ability of reduction of fibroid volume /size, but there in agreement on its effectiveness in preventing further growth of the tumour and menstrual bleeding significantly [3,4]
Incidence of fibroids is most common in 31-40 years of age i.e. 34.9%. Commonly observed symptoms were abdominal lump (41%) and abnormal uterine bleeding (24.1%).
In a prospective clinical observation to evaluate the efficacy of Ormeloxifene in uterine fibroid in reproductive age group were studied for primary outcomes of i) fibroid size, ii) uterine size, and iii) delta size and secondary outcomes of Secondary outcomes i) menstrual blood loss using the PBAC score, ii) hemoglobin concentration and iii) endometrial thickness. Forty-four (44) women aged 20–50-year age group diagnosed with fibroid uterus as outpatient cases. Both symptomatic and asymptomatic were given Ormeloxifene 60 mg was given orally twice a week for 6 months. Follow up after 6 months clinically and by USG. The Results showed i. No significant changes in the leiomyoma, uterine and delta size, ii) 91% fibroids remained unchanged at the end of 6 months. The difference in mean hemoglobin concentration, PBAC scores and endometrial thickness were reduced statistically significant (p<0>
Another study compared the effect of mifepristone and Ormeloxifen on symptomatology, size, and vascularity of fibroid and to compare the compliance and side effects of both these drugs in Allahabad, India, over a period of one year between 2016-2017 in 90 fibroid patients. Group A included 44 fibroid patients who were given mifepristone and Group B included 46 fibroid patients who were given Ormeloxifen by choice of the patients. Assessment of heavy menstrual bleeding by pictorial blood loss assessment chart, dysmenorrhea and dyspareunia by visual analogue scale, estimation of hemoglobin and repeat imaging to assess size, number, endometrial thickness, Doppler velocimetry of fibroid was done. Results showed that 97.7% patients in group A and 95.6% patients in group B were compliant towards treatment. Mifepristone and Ormeloxifen were equally effective for symptomatic relief in fibroid patients. Myoma size was significantly reduced by mifepristone only, with notable endometrial hyperplasia whereas Ormeloxifen causes significant reduction in endometrial thickness. No major side effects observed with any of them.
Non-hormonal Therapy: Tripttergium wilfordii decreases numbers and expressions of Progesterone and estrogen Receptors and decreases Aromatase Enzyme. It may be an effective therapy with few side effects.
EGCG (45%) decreases severity of symptoms and health related quality of Life Index
Vit D3 with EGCG have shown reduction of volume after 4 months of treatment.
Botanical drugs are gaining attention in this era due to their cost effectiveness with a comparable and more potent therapeutic efficacy while demonstrating lesser adverse effects. A total of five botanical drugs and three polyherbal formulations have been reviewed which have potentials of becoming an alternative treatment choice for uterine fibroids. However, a validated testing protocol is needed to standardize the active constituents in botanical drug products for use as a uterine fibroid treatment in ensuring a reproducible therapeutic effect [9].
Conclusion:
Uterine Fibromas are commonest benign tumours of muscles and fibrous tissue in the walls of the Uterus affecting one third of the fertile women.
In India the incidence of fibroids is most common in women of 31- 40 years of age
Recent understanding of etiology suggests increased number of estrogen and Progesterone Receptors, increased COMT gene expression and TGF-B3
Treatment must be individualized based on age, signs & symptoms, sustained reduction of the size and sustenance of fertility if desired with minimal side effects.
Medical Therapies are both hormonal and non-hormonal and in near future some botanical drugs.
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.
