AUCTORES
Globalize your Research
Case Report | DOI: https://doi.org/10.31579/2640-1053/165
Professor, Medicine Ad-din Women’s Medical College Hospital, Dhaka Bangladesh.
*Corresponding Author: Richmond Ronald Gomes, Professor, Medicine Ad-din Women’s Medical College Hospital, Dhaka Bangladesh.
Citation: Richmond R. Gomes, (2023), Autoimmune Hemolytic Anemia and Classical Hodgkin Lymphoma: An Often-Overlooked Alliance, J. Cancer Research and Cellular Therapeutics, 7(6); DOI:10.31579/2640-1053/165
Copyright: © 2023, Richmond Ronald Gomes. 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: 30 October 2023 | Accepted: 08 November 2023 | Published: 16 November 2023
Keywords: autoimmune hemolytic anemia; lymphoproliferative disorders; hodgkin’s lymphoma; mixed cellularity
Autoimmune hemolytic anemia (AIHA) is related to an underlying condition in an estimated 50 to 60%, while the remaining is Idiopathic. AIHA is associated with viral infections, autoimmune disorders, immunodeficiencies, lymphoproliferative disorders (LPD), and pregnancy. AIHA has predictive properties and may be a harbinger of future LPD in up to 20% of AIHA cases. AIHA has been associated with LPD particularly chronic lymphocytic leukemia and non-Hodgkin lymphoma. Rarely is it seen in Hodgkin’s lymphoma (HL). HL accounts for ten percent of all lymphomas. AIHA is usually detected at the time of diagnosis when it accompanies Hodgkin's and rarely precedes it. It is a warm immune hemolytic anemia. In the following report, we describe the presentation of AIHA, ultimately resulting in the diagnosis of mixed cellularity Hodgkin lymphoma. From the limited reports and reviews available, it is understood that advanced Hodgkin (stage III or IV) of nodular sclerosis (NS) or mixed cellularity (MC) types portend a stronger affiliation to AIHA. The mainstay of AIHA therapy has been corticosteroids; however, this first line regimen appears to be less effective when treating AIHA in the setting of HL. The exact mechanism of AIHA related to HL is unclear, and it may be thought to be that tumor cell produced autoantibodies. Other hypotheses include paraneoplastic phenomena. Through this paper, the authors intend to remind the medical community about the importance of a prompt and deep study of all AIHA cases found in elderly patients, without overlooking possible malignant causes related to this condition such as a LPD. Thus, before diagnosing a hemolytic anemia as idiopathic, the practitioner must be certain that the condition is not a clinical manifestation of an underlying disease.
Autoimmune hemolytic anemia (AIHA) is a relatively rare disease with an annual incidence of 1 per 75 000 to 80 000 people. The etiology of autoimmune hemolytic anemia (AIHA) is related to an underlying condition in an estimated 50 to 60%, while the remaining is idiopathic, as a result of a combination of immune activation, deficiency, or dysregulation [1]. AIHA is associated with viral infections, autoimmune disorders, immunodeficiencies, lymphoproliferative disorders, and pregnancy. For decades, autoimmune entities such as hemolytic anemia, thrombocytopenic purpura, neutropenia and insulin receptor antibodies have been reported as paraneoplastic manifestations of Hodgkin’s disease (HD) [2,3,4,5]. Autoimmune hemolytic anemia (AIHA) is rarely seen in Hodgkin lymphoma (HL) patients, with a reported incidence of 0.2–4.2%. [3,6,7]. Sporadic case reports and reviews have shown that when AIHA occurs in HL patients, it happens mostly at stages III and IV nodular sclerosis HL (NSHL) or mixed cellularity HL(MCHL).8 The Hodgkin
lymphoma implies alterations in the immune system, which include abnormalities in the cytokine production and increased sensitivity to regulatory T cells, but with an overall decrease in the number and functional capacity of T cells 9,10,11. Thus, during a decrease of cytotoxic T lymphocytes, an increase in autoantibody production may occur; this is currently the most accepted mechanism to explain the appearance of AIHA in some of these patients [12]. HL is usually manifested as lymphadenopathy typically in the cervical (70%), axillary (25%,), mediastinal areas (60%), and in 16-34 % of the cases presents as nodal disease below the diaphragm. HL presenting as AIHA has been reported in very few case reports in literature. We hereby report a case mixed cellularity type HL who presented as AIHA.
A 52 years old Bangladeshi non smoker male not known to have diabetes, hypertension, bronchial asthma or ischemic heart disease presented with low grade fever, malaise, night sweats, exertional dyspnoea, generalized weakness and painless lumps over neck and axilla and weight loss of 10 kg of three months duration. On query, he also complained of pruritus especially at night, anorexia and ten kg weight loss during the past 3 months. On examination, his vital parameters were stable but febrile (axillary temperature 101o F). He had conjunctival pallor but non icteric. Multiple anterior and posterior cervical and axillary nodes were palpable. Nodes were rubbery, non tender, mobile, largest lymph node of 2.5 x 2 cm size. There was no overlying sinus. Systemic examination revealed Hepatosplenomegaly.
The CBC revealed normal white cell count, hemoglobin 6.9 gm/dL, hematocrit of 19.6 gm/dL, and platelets of 234,000 gm/dL, MCV 113fL, and MCH 33.5pg. Peripheral blood film showed moderate anisocytosis and poikilocytosis with spherocytes, polychromatic cells (Figure 1). Lactate dehydrogenase was elevated at 624 gm/dL, reticulocytes count 6.6%. Total bilirubin was 4.3 mg/dL with most of it being indirect; the rest of the liver function test was normal. Direct Coomb's test was positive, consistent with the diagnosis of AIHA. ANA was negative. His ultrasound abdomen showed paraaortic lymphnodes with mild hepatosplenomegaly and no abnormalities were seen on his chest radiography. CT scan of the thorax, abdomen, and revealed multiple symmetrically enlarged lymph nodes in the mediastinum and abdomen with hepatosplenomegaly (figure 2).
Figure 1 and 2: Peripheral blood film showing spherocytes, polychromatic cells and CT abdomen showing multiple enlarged intra-abdominal lymph nodes respectively.
His lymph node biopsy showed polymorphous population of lymphocytes, plasma cells, eosinophils and scattered mononuclear and binuclear variants of Reed Sternberg (RS) cells (figure 3). The immuno histochemistry on the lymph node biopsy revealed all the RS like cells stained strongly positively with CD 30 (figure 4). Few RS cells stain positively with CD 15. These cells stained negatively for CD45, CD 20 and Oct- 2. Bone marrow examination revealed reactive hyperplasia. A diagnosis of autoimmune hemolytic anemia with Hodgkin's lymphoma was made. Our patient had stage III disease with 'B' symptoms.
Figure 3 and 4: Photomicrograph of lymph node biopsy showing Reed-Sternberg cells and its cellular environment and Reed-Sternberg cells staining strongly positive for CD 30
Patient improved symptomatically on treatment with oral prednisolone 1 mg/kg/day. Patient was started on chemotherapy cycles with inj Adriamycin, inj Bleomycin, inj Vinblastine, inj Dacarbazine and inj dexamethasone at referral oncology centre. After completing two cycles with ABVD of a planned six cycles, the CT scan of chest and pelvis showed good response to treatment with a marked decrease in lymph node size No new site of disease was seen. With chemotherapy patient’s hemolysis resolved, steroids were tapered and discontinued. At this time, the patient has completed six cycles of ABVD. He is planned for ongoing surveillance.
Hodgkin's lymphoma (HL) is a solid tumor that arises from B lymphocytes. It was first described in 1832 [13,14]. Since that time, this neoplasm has been extensively studied; currently, it is classified into classic Hodgkin lymphoma (cHL) and lymphocyte predominant variant. cHL is further divided into four categories-nodular sclerosis, mixed cellularity, lymphocyte rich, and lymphocyte depleted [13,15,16]; other lymphomas, especially primary mediastinal large B-cell lymphoma, show borderline histological features similar cHL.
In the developed countries, HL roughly accounts for ten percent of all diagnosed lymphomas. This neoplasm follows a bimodal age distribution having a peak in early adulthood and then in the seventh decade. It has male predominance. The classical Reed-Sternberg (RS) cells have been identified in every subclass of cHL. They originate from germinal center B cells that have lost their genetic regulation for normal development and maturation; Epstein-Barr virus (EBV) or its remnants have identified in Sternberg-Reed cells. This supports the hypothesis that EBV is associated with HL; however, it is not clear whether its presence is necessary for oncogenesis, since 40%–60% of HL is EBV negative [13,15,16,17].
cHL presents with B symptoms (night sweat, fever, and weight lost) which are encountered in about twenty percent of patients with early stages and as much as in fifty percent of those with advance disease. Unexplained weight loss of more than 10% of body weight is one of the most frequent presenting complaints. Pel-Ebstein fever, although less common, is also associated with this illness. It usually happens at irregular intervals of several days or weeks before it finally disappears. Seldom symptoms such as pruritus, which may precede the diagnosis of cHL for months, cholestatic liver disease, skin lesions such as ichthyosis, acrokeratosis, and hyperpigmentation, neurological symptoms secondary to central nerve system malignant cells infiltration, and nephrotic syndromes resulting from hypersecretion of toxic lymphokines can be observed at onset of clinical disease. Fatigue is almost universally seen at the time of diagnosis; it results from anemia. The mechanism of anemia varies; it could be secondary to chronic disease reflecting the underlying malignant process. In advanced, disease anemia occurs from bone marrow infiltration by malignant cells. It can also be iatrogenic due bone marrow suppression by chemotherapeutic agents. Rarely, it results from hemolysis. Autoimmune hemolytic anemia is known for its link to B-cell non-Hodgkin's lymphoma, suggesting a relationship between the two. Here, we discuss a case of MCHL which presented with AIHA. Typically, the Hodgkin/Reed-Sternberg cells stain positively for CD30 (80-100% of cases), CD15 (75-85% of cases), and B-cell specific activating protein (BSAP), which is the product of the PAX5 gene (>90% of cases). CD20, a generally reliable marker of B-cell lineage, is positive in about 40% of cases of classic Hodgkin's lymphoma but the staining can be weak.
Autoimmune hemolytic anemia occurs when a patient produces pathologic antibodies that attach to and lead to the destruction of red blood cells causing anaemia. Warm antibodies are typically of the IgG variety, may or may not fix complement, and primarily lead to RBC loss by splenic removal of sensitized cells. Acquired AIHA has been described to be associated with an underlying disease in more than fifty percent of cases. The majority of AIHA is related to an underlying etiology that alters immune system activity such infectious, autoimmune disorders, immunodeficiencies, lymphoproliferative disorders, and pregnancy. The lymphoproliferative disorders are comprised of diseases such as autoimmune lymphoproliferative syndrome (ALPS), CLL, non-Hodgkin lymphoma, and Hodgkin lymphoma [12,18,19,20]. While AIHA has well-known associations with non-Hodgkin lymphoma and CLL, its relationship to Hodgkin lymphoma is rarer and potentially less well recognized. The relationship of autoimmune hemolytic anemia with cHL has been recognized for more than forty years. Previously, prevalence of autoimmune hemolytic anemia has been reported in patients with Hodgkin’s disease ranging between 0.2% and 2.7% [3,21]. When it occurs, it is usually seen in adults rather than children. Autoimmune hemolytic anemia may be present at any stage of Hodgkin’s disease; although it is usually associated with the active or advanced disease, it can precede the diagnosis or be present in a relapse episode [2,7]. A positive Coombs test can be an indicator to suspect possible relapses in patients with a history of HD in remission with or without AHA 7,9. Immune-mediated hemolytic anemia is mostly seen in the nodular sclerosing subtype and in mixed cellularity subtypes, as in this case. It was reported that 90–100% of Hodgkin’s disease patients with immune hemolytic anemia were in stages 3 or 4 [22].
In very rare cases, HL-related AIHA may be direct antiglobulin test negative which may be attributed to undetectably low levels of IgG, low-affinity bound IgG antibodies are washed away during pretest processing, or non-IgG antibodies are the cause of the AIHA (e.g., IgA and IgM) [23].
The mainstay of AIHA has been corticosteroids; however, this first-line regimen appears to be less effective when treating AIHA in the setting of HL [10, 16]. In one single center study, the use of rituximab, traditionally a second-line therapy, had significantly improved mortality rates compared to corticosteroids in those with warm AIHA and lymphoproliferative disease [24]. As seen in this case, treatment of the primary disease with combination chemotherapy led to treatment of AIHA. In very rare cases, splenectomy may be advocated as an effective therapy [25].
Currently, there are no studies of sufficient quality to establish appropriate protocols for the management of AIHA, nor a consensus on what complete remission or partial remission of the diseasemeans [8], therefore, the management of hemolytic autoimmune anemia is based on experience and individual clinical decisions. It should be noted that the effectiveness of therapies for AIHA is low when it is secondary to an underlying disease, this being especially true for autoimmune hemolytic anemias secondary to lymphoproliferative syndromes [9,26].
The above statement was evident in the case reported here, in which no adequate response to treatment with corticosteroids was obtained. Definitive therapy for autoimmune hemolytic anemia associated with Hodgkin’s disease is the treatment of the underlying disease, through which there is a progressive decrease of antibody titers until reaching the eventual negativization of the Coombs test [27], the recovery of Hb values and the disappearance of hemolysis signs.
AIHA although unusual, can be a paraneoplastic manifestation of a LPD, especially chronic lymphocytic leukemia. HL however is rarely associated with AIHA. Clinicians should consider the differential diagnosis of this malignancy in patients affected by seemingly idiopathic AIHA. Although the initial treatment of AIHA is steroids, immune hemolysis associated with Hodgkin’s disease requires definitive treatment with systemic chemotherapy. While there is much to be elucidated about the relationship between AIHA and HL, it is clear that further study must be done into the interactions of lymphoproliferative diseases, their effects on the immune system, and the development of autoimmune disorders. As we continue to develop foundational knowledge of these interactions, greater understanding of best treatments for AIHA in the setting of HL will aid in management of this complication and potentially reveal further mechanisms to research
Conflict of interest: None declared
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.
