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Case Report | DOI: https://doi.org/10.31579/2690-4861/1060
1Climatic Health,
2Department of Medicine, Duke University,
3The Human Integrative and Environmental Physiology Laboratory, Mayo Clinic.
*Corresponding Author: Dale J. Christensen, Climatic Health and Department of Medicine, Duke University.
Citation: Dale J. Christensen, Annabelle McNeill, Christie M. Hudson, Allison Melnick, Nicholas Haft, et al., (2026), Effect of Enhanced Lung Cleansing on Observed Changes in Performance of Endurance Athletes with Breathing Limitations: An Exploratory Case Series, International Journal of Clinical Case Reports and Reviews, 35(1); DOI:10.31579/2690-4861/1060
Copyright: © 2026, Dale J. Christensen. 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 February 2026 | Accepted: 31 March 2026 | Published: 09 April 2026
Keywords: inhaled lung cleansing agent; athletic performance; heart rate variability
This exploratory case series describes changes in athletic performance, respiratory measures (peak flow), and heart rate variability (HRV) in four endurance athletes with reported breathing limitations (e.g., diagnosed Exercise Induced Asthma or self-reported limitations) following four weeks of utilization of an inhaled lung cleansing agent. Athletes completed a one-week baseline period with physiological parameters monitored daily, and routine training efforts were monitored prior to initiation of the lung cleansing agent with four weeks of monitoring of physiological parameters and continued training. Athletic performance assessments were conducted at baseline, Week 2, and Week 4. Athletic performance was measured using a fixed distance time-trial and physiological parameters measured included peak expiratory flow, nightly HRV, and participant-reported perceptions of exercise effort and breathing performance. Time-trial performance improved by 5.75% ± 8.42%, with three of four athletes recording faster times. Peak expiratory flow increased by 11.25% ± 32.68%, with mixed individual responses. HRV increased during the first two weeks (+2.75% ± 22.78%) and then stabilized. Individual HRV increases of 10–13 ms were observed. These findings support a potential benefit of an over-the-counter lung hygiene product in athletes with a history of asthma or reported respiratory limitation and further support the feasibility of essentially a longitudinal monitoring field study in athletes with breathing limitations.
Breathing efficiency plays an important role in endurance performance. Athletes with asthma or exercise-related breathing limitations often report symptoms that affect training tolerance, recovery, and perceived effort, even when clinical measures appear stable [1]. While spirometry and symptom reporting are commonly used measures to identify factors that influence performance, they may not fully capture how breathing limitations relate to day-to-day performance and recovery [2]. Frequently, inhaled pollutants, pollen, and other particulates create conditions that impair athletic performance due to these inhaled agents causing mucus to thicken and become dehydrated with the impaired mucociliary clearance [3]. Impaired mucociliary cleansing allows for inflammation and other adverse conditions to exist that can hinder athletic performance. In recent years, heart rate variability (HRV) has become a widely used parameter in athletic settings to track recovery and physiological stress., Emerging data describe how HRV changes when measured alongside performance and respiratory measurements in athletes who experience breathing limitations can be used as a surrogate for recovery. Notably, fine particulate matter (PM2.5) has been associated with significant reductions in HRV [4]. This case series study was conducted to determine if an agent previously show to enhance mucociliary clearance would affect athletic performance, respiratory measures, overnight HRV, and participant-reported experience over four weeks in endurance athletes with breathing limitations.
Participants
Four U.S.-based endurance athletes that were following a scheduled training program participated. Athletes were training for cycling, running or triathlon. Each athlete reported recurring breathing-related limitations during moderate-to-high intensity training, and some had a diagnosis of asthma or exercise-induced asthma. Baseline characteristics were collected via an intake survey.
Participation consisted of five weeks of performing assessments and reporting, beginning with a one-week baseline period where training and monitoring was completed with no intervention followed by four weeks of training and monitoring while using the L Max lung cleansing agent. Athletic performance was completed at baseline prior to starting L Max and at two and four weeks after twice daily use of L Max.
Intervention
All participants self-administered a 27 mg capsule dose of L Max powder that was delivered using a Plastiape RS-01 high-resistance capsule-based dry powder inhaler twice daily. One dose was administered 15-30 min prior to exercise. If an athlete trained in the evening, then a second dose was administered within an hour of waking in the morning. For athletes that trained in the morning, a second dose was administered within an hour of bedtime. The L Max product is a powder that has been demonstrated to accelerate the mucociliary clearance process in cell-based assays and in an ovine model of mucus clearance [5].
Procedures and Measures
Athletes were instructed to maintain their scheduled training plans provided by an individual coach while adding time trials at the end of the baseline period and after two and four weeks. For each participant, time trials consisted of either a 5 km run or a 5- or 10-mile cycling session at race pace. In order to reduce course, temperature or time of day variations on the measured athletic performance results, the time trials were conducted on the same course and at the same time of day, whenever possible. Subjects were allowed to perform the time trial ±1 day from the schedule to ensure that the weather was similar to prior test efforts. Time trials were chosen as they represent a reliable method to assess athletic performance [6]. Daily respiratory function assessments were performed using a peak expiratory flow (PEF) meter from Nascool with two efforts each morning and 1Xaiogy 5 min after administering L Max. Peak flow was measured according to the device manufacturers directions and was utilized to determine if the L Max product had measurable effects on respiratory function using a device that is easily accessible to consumers. These devices have been well characterized for use [7]. Physiological measurements of health including overnight sleep duration, blood oxygenation, heart rate, temperature difference from mean, and HRV were monitored using an Oura ring [8]. Participants also completed subjective surveys related to breathing comfort, recovery, training tolerance and other observations. Athletes with a diagnosis of exercise induced asthma and prescribed a short acting bronchodilator were allowed to use medication as needed and not limited. Use of bronchodilators was recorded by participants when used.
Ethics
All participants provided voluntary consent to participate in the study and for use of the data for research purposes.
Comparative Outcomes
A total of four athletes were included in preliminary testing to identify if the mucociliary clearance enhancement provided by L Max, resulting in enhanced clearance of particulate matter from the lungs. Participant demographics and athletic characteristics are shown in Table 1.
| Table 1: Participant Characteristics | |||
| Participant | Sex | Time Trial Activity | Medical Diagnosis |
| 1 | M | Running | Exercise Induced Asthma (EIA) |
| 2 | M | Cycling | EIA, Asthma |
| 3 | F | Cycling | EIA, Asthma |
| 4 | M | Running | None |
Athletic Performance
Time trial results from each athlete were measured for a running or cycling time trial at race pace. Time trial results for each athlete are shown in Table 2. Most athletes showed improvement from baseline at 2 and 4 weeks with mean time-trial performance improving by 5.75% ± 8.42%. Three of four athletes recorded faster completion times compared with baseline. One athlete showed no improvement.
| Table 2: Athletic performance results | |||||
| Participant | Baseline | 2 Week | 4 Week | 2 Week Time Differential Absolute (%) a | 4 Week Time Differential Absolute (%) b |
| 1 - Running 10k | 44:02 | 43:11 | 43:10 | 0:51 (1.9%) | 0:52 (2.0%) |
| 2 - Cycling 5mi | 9:38 | 9:11 | 9:13 | 0:27 (4.7%) | 0:25 (4.3%) |
| 3 - Cycling 5mi | 20:01 | 16:38 | 16:22 | 3:23 (16.9%) | 3:39 (18.2%) |
| 4 - Running 5k | 18:23 | 18:25 | 18:32 | -0:02 (-0.2%) | -0:09 (-0.8%) |
a Difference between baseline and 2-week time trial completion times b Difference between baseline and 4-week time trial completion times | |||||
| Table 3: Peak Flow Measurements 15 Minutes After L Max Administration | ||||
| Participant | Baseline Average (± stdev) | PEF Average on L Max (± stdev) | 2 Week Differential Absolute (%) | Paired T-test P value (Baseline to PEF average) |
| 1 | 348 ± 72 L/min | 554 ± 62 L/min | +206 L/min (59.2%) | <0> |
| 2 | 485 ± 25 L/min | 497 ± 26 L/min | +12 L/min (2.5%) | 0.3207 |
| 3 | 403 ± 19 L/min | 398 ± 23 L/min | -5 L/min (-1.2%) | 0.5997 |
| 4 | 613 ± 13 L/min | 523 ± 59 L/min | -90 L/min (-14.7%) | 0.0004 |
Respiratory Measures
To determine if any changes, either positive or negative, in lung function, peak flow was used as a surrogate for respiratory function. While not diagnostic, the induction of bronchospasm by L Max would be expected to reduce peak flow. Overall, peak expiratory flow increased by 11.25% ± 32.68?ross the study period. Two athletes demonstrated improved peak flow relative to baseline, while two showed little change or minimal decline. However, no substantial declines in PEF were noted that would indicate bronchospasm had occurred and no participants utilized rescue inhalers due to shortness of breath that they associated with bronchospasm.
Biometric Analysis
Nightly average heartrate and low heart rate, blood oxygen levels, average HRV, and other measures monitored by the Oura ring were recorded each day and analyzed for change from baseline established during the week prior to L Max use. Of the parameters recorded by the Oura ring, HRV was the only parameter that showed a notable change that followed a two-phase pattern. During the first two weeks, mean nightly HRV increased by 2.75% ± 22.78%, with three of four athletes showing higher values compared with baseline. During the latter part of the study, HRV stabilized rather than continuing to increase, corresponding to a mean absolute change of +0.03 ± 0.13 ms from baseline to the final two weeks as shown in Table 4.
| Table 4: Overnight HRV Measurements Prior to and During L Max Administration | |||||
| Participant | Baseline | 2 Week | 4 Week | 2 Week Differential Absolute (%) | 4 Week Differential Absolute (%) |
| 1 | 39 ms | 43 ms | 41 ms | +4 (10.3%) | +2 (5.1%) |
| 2 | 41 ms | 48 ms | 46 ms | +7 (17.1%) | +5 (12.2%) |
| 3 | 48 ms | 33 ms | 40 ms | -15 (-31.3%) | -8 (-16.7%) |
| 4 | 71 ms | 83 ms | 79 ms | +12 (16.9%) | +8 (11.3%) |
At the individual level, HRV responses varied with most gains being recorded at 2 weeks. Athlete 4 showed an increase of 12 ms with 2 weeks of L Max use, while athlete 2 showed an increase of 7 ms and athlete 1 experienced a 4 ms change with athlete 3 showing a decrease of 15 ms at 2 weeks. Absolute increases of 10–13 ms are commonly considered meaningful in endurance training and recovery monitoring [9].
In this case series, most athletes demonstrated improved time-trial performance during their benchmark studies. Respiratory assessment by PEF as well as HRV responses varied between individuals during the study period.
While it was anticipated that improved airway clearance could improve many parameters, analysis of physiological outcomes from those captured by the wearable ring, in these subjects no consistent changes in sleep duration, heart rate, or other parameters were observed, with the exception of HRV. For HRV a clear pattern among the physiological parameters evaluated was demonstrated with modest individual HRV increases of 4–12 ms were observed in multiple athletes. Magnitudes greater than 8 ms are commonly viewed as meaningful in applied endurance settings as signals of increased recovery [9]. The pattern of early increase followed by stabilization is consistent with an initial adaptation rather than continuous linear change. This is consistent with cleansing of particulate matter from the lung given that inhalation of PM2.5 has been associated with decreased HRV [4]. Changes in HRV did not consistently mirror performance outcomes and dissociation between HRV and athletic performance is common and reflects the influence of multiple factors on performance beyond physiological recovery alone [10].
The majority of subjects in this study demonstrated positive outcomes in athletic performance and improved overnight HRV. The small sample size that prevents conclusion that the use of the lung cleansing agent is responsible for improved performance, but served the purpose of demonstrating that it is possible to collect athletic performance and physiological parameters in a randomized placebo-controlled study for a more in depth study.
In four endurance athletes with breathing limitations, twice daily utilization of a lung cleansing agent resulted in improved time-trial performance in three participants over four weeks, while respiratory responses were mixed. HRV increased early with individual improvements of up to 12 ms by 2 weeks and then stabilized for the final two weeks of L Max use. These findings support the use of HRV as a sensitive physiological marker in this population and demonstrate the feasibility of multimodal longitudinal monitoring.
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Dear Jessica, and the super professional team of the ‘Clinical Cardiology and Cardiovascular Interventions’ I am sincerely grateful to the coordinated work of the journal team for the no problem with the submission of my manuscript: “Cardiometabolic Disorders in A Pregnant Woman with Severe Preeclampsia on the Background of Morbid Obesity (Case Report).” The review process by 5 experts was fast, and the comments were professional, which made it more specific and academic, and the process of publication and presentation of the article was excellent. I recommend that my colleagues publish articles in this journal, and I am interested in further scientific cooperation. Sincerely and best wishes, Dr. Oleg Golyanovskiy.
Dear Ashley Rosa, Editorial Coordinator of the journal - Psychology and Mental Health Care. " The process of obtaining publication of my article in the Psychology and Mental Health Journal was positive in all areas. The peer review process resulted in a number of valuable comments, the editorial process was collaborative and timely, and the quality of this journal has been quickly noticed, resulting in alternative journals contacting me to publish with them." Warm regards, Susan Anne Smith, PhD. Australian Breastfeeding Association.
Dear Jessica Magne, Editorial Coordinator, Clinical Cardiology and Cardiovascular Interventions, Auctores Publishing LLC. I appreciate the journal (JCCI) editorial office support, the entire team leads were always ready to help, not only on technical front but also on thorough process. Also, I should thank dear reviewers’ attention to detail and creative approach to teach me and bring new insights by their comments. Surely, more discussions and introduction of other hemodynamic devices would provide better prevention and management of shock states. Your efforts and dedication in presenting educational materials in this journal are commendable. Best wishes from, Farahnaz Fallahian.
Dear Maria Emerson, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews, Auctores Publishing LLC. I am delighted to have published our manuscript, "Acute Colonic Pseudo-Obstruction (ACPO): A rare but serious complication following caesarean section." I want to thank the editorial team, especially Maria Emerson, for their prompt review of the manuscript, quick responses to queries, and overall support. Yours sincerely Dr. Victor Olagundoye.
Dear Ashley Rosa, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews. Many thanks for publishing this manuscript after I lost confidence the editors were most helpful, more than other journals Best wishes from, Susan Anne Smith, PhD. Australian Breastfeeding Association.
Dear Agrippa Hilda, Editorial Coordinator, Journal of Neuroscience and Neurological Surgery. The entire process including article submission, review, revision, and publication was extremely easy. The journal editor was prompt and helpful, and the reviewers contributed to the quality of the paper. Thank you so much! Eric Nussbaum, MD
Dr Hala Al Shaikh This is to acknowledge that the peer review process for the article ’ A Novel Gnrh1 Gene Mutation in Four Omani Male Siblings, Presentation and Management ’ sent to the International Journal of Clinical Case Reports and Reviews was quick and smooth. The editorial office was prompt with easy communication.
Dear Erin Aust, Editorial Coordinator, Journal of General Medicine and Clinical Practice. We are pleased to share our experience with the “Journal of General Medicine and Clinical Practice”, following the successful publication of our article. The peer review process was thorough and constructive, helping to improve the clarity and quality of the manuscript. We are especially thankful to Ms. Erin Aust, the Editorial Coordinator, for her prompt communication and continuous support throughout the process. Her professionalism ensured a smooth and efficient publication experience. The journal upholds high editorial standards, and we highly recommend it to fellow researchers seeking a credible platform for their work. Best wishes By, Dr. Rakhi Mishra.
Dear Jessica Magne, Editorial Coordinator, Clinical Cardiology and Cardiovascular Interventions, Auctores Publishing LLC. The peer review process of the journal of Clinical Cardiology and Cardiovascular Interventions was excellent and fast, as was the support of the editorial office and the quality of the journal. Kind regards Walter F. Riesen Prof. Dr. Dr. h.c. Walter F. Riesen.
Dear Ashley Rosa, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews, Auctores Publishing LLC. Thank you for publishing our article, Exploring Clozapine's Efficacy in Managing Aggression: A Multiple Single-Case Study in Forensic Psychiatry in the international journal of clinical case reports and reviews. We found the peer review process very professional and efficient. The comments were constructive, and the whole process was efficient. On behalf of the co-authors, I would like to thank you for publishing this article. With regards, Dr. Jelle R. Lettinga.
Dear Clarissa Eric, Editorial Coordinator, Journal of Clinical Case Reports and Studies, I would like to express my deep admiration for the exceptional professionalism demonstrated by your journal. I am thoroughly impressed by the speed of the editorial process, the substantive and insightful reviews, and the meticulous preparation of the manuscript for publication. Additionally, I greatly appreciate the courteous and immediate responses from your editorial office to all my inquiries. Best Regards, Dariusz Ziora
Dear Chrystine Mejia, Editorial Coordinator, Journal of Neurodegeneration and Neurorehabilitation, Auctores Publishing LLC, We would like to thank the editorial team for the smooth and high-quality communication leading up to the publication of our article in the Journal of Neurodegeneration and Neurorehabilitation. The reviewers have extensive knowledge in the field, and their relevant questions helped to add value to our publication. Kind regards, Dr. Ravi Shrivastava.
Dear Clarissa Eric, Editorial Coordinator, Journal of Clinical Case Reports and Studies, Auctores Publishing LLC, USA Office: +1-(302)-520-2644. I would like to express my sincere appreciation for the efficient and professional handling of my case report by the ‘Journal of Clinical Case Reports and Studies’. The peer review process was not only fast but also highly constructive—the reviewers’ comments were clear, relevant, and greatly helped me improve the quality and clarity of my manuscript. I also received excellent support from the editorial office throughout the process. Communication was smooth and timely, and I felt well guided at every stage, from submission to publication. The overall quality and rigor of the journal are truly commendable. I am pleased to have published my work with Journal of Clinical Case Reports and Studies, and I look forward to future opportunities for collaboration. Sincerely, Aline Tollet, UCLouvain.
Dear Ms. Mayra Duenas, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews. “The International Journal of Clinical Case Reports and Reviews represented the “ideal house” to share with the research community a first experience with the use of the Simeox device for speech rehabilitation. High scientific reputation and attractive website communication were first determinants for the selection of this Journal, and the following submission process exceeded expectations: fast but highly professional peer review, great support by the editorial office, elegant graphic layout. Exactly what a dynamic research team - also composed by allied professionals - needs!" From, Chiara Beccaluva, PT - Italy.
Dear Maria Emerson, Editorial Coordinator, we have deeply appreciated the professionalism demonstrated by the International Journal of Clinical Case Reports and Reviews. The reviewers have extensive knowledge of our field and have been very efficient and fast in supporting the process. I am really looking forward to further collaboration. Thanks. Best regards, Dr. Claudio Ligresti
Dear Chrystine Mejia, Editorial Coordinator, Journal of Neurodegeneration and Neurorehabilitation. “The peer review process was efficient and constructive, and the editorial office provided excellent communication and support throughout. The journal ensures scientific rigor and high editorial standards, while also offering a smooth and timely publication process. We sincerely appreciate the work of the editorial team in facilitating the dissemination of innovative approaches such as the Bonori Method.” Best regards, Dr. Matteo Bonori.
I recommend without hesitation submitting relevant papers on medical decision making to the International Journal of Clinical Case Reports and Reviews. I am very grateful to the editorial staff. Maria Emerson was a pleasure to communicate with. The time from submission to publication was an extremely short 3 weeks. The editorial staff submitted the paper to three reviewers. Two of the reviewers commented positively on the value of publishing the paper. The editorial staff quickly recognized the third reviewer’s comments as an unjust attempt to reject the paper. I revised the paper as recommended by the first two reviewers.
Dear Maria Emerson, Editorial Coordinator, Journal of Clinical Research and Reports. Thank you for publishing our case report: "Clinical Case of Effective Fetal Stem Cells Treatment in a Patient with Autism Spectrum Disorder" within the "Journal of Clinical Research and Reports" being submitted by the team of EmCell doctors from Kyiv, Ukraine. We much appreciate a professional and transparent peer-review process from Auctores. All research Doctors are so grateful to your Editorial Office and Auctores Publishing support! I amiably wish our article publication maintained a top quality of your International Scientific Journal. My best wishes for a prosperity of the Journal of Clinical Research and Reports. Hope our scientific relationship and cooperation will remain long lasting. Thank you very much indeed. Kind regards, Dr. Andriy Sinelnyk Cell Therapy Center EmCell
Dear Editorial Team, Clinical Cardiology and Cardiovascular Interventions. It was truly a rewarding experience to work with the journal “Clinical Cardiology and Cardiovascular Interventions”. The peer review process was insightful and encouraging, helping us refine our work to a higher standard. The editorial office offered exceptional support with prompt and thoughtful communication. I highly value the journal’s role in promoting scientific advancement and am honored to be part of it. Best regards, Meng-Jou Lee, MD, Department of Anesthesiology, National Taiwan University Hospital.
Dear Editorial Team, Journal-Clinical Cardiology and Cardiovascular Interventions, “Publishing my article with Clinical Cardiology and Cardiovascular Interventions has been a highly positive experience. The peer-review process was rigorous yet supportive, offering valuable feedback that strengthened my work. The editorial team demonstrated exceptional professionalism, prompt communication, and a genuine commitment to maintaining the highest scientific standards. I am very pleased with the publication quality and proud to be associated with such a reputable journal.” Warm regards, Dr. Mahmoud Kamal Moustafa Ahmed
Dear Maria Emerson, Editorial Coordinator of ‘International Journal of Clinical Case Reports and Reviews’, I appreciate the opportunity to publish my article with your journal. The editorial office provided clear communication during the submission and review process, and I found the overall experience professional and constructive. Best regards, Elena Salvatore.
Dear Mayra Duenas, Editorial Coordinator of ‘International Journal of Clinical Case Reports and Reviews Herewith I confirm an optimal peer review process and a great support of the editorial office of the present journal
Dear Editorial Team, Clinical Cardiology and Cardiovascular Interventions. I am really grateful for the peers review; their feedback gave me the opportunity to reflect on the message and impact of my work and to ameliorate the article. The editors did a great job in addition by encouraging me to continue with the process of publishing.
Dear Cecilia Lilly, Editorial Coordinator, Endocrinology and Disorders, Thank you so much for your quick response regarding reviewing and all process till publishing our manuscript entitled: Prevalence of Pre-Diabetes and its Associated Risk Factors Among Nile College Students, Sudan. Best regards, Dr Mamoun Magzoub.
International Journal of Clinical Case Reports and Reviews is a high quality journal that has a clear and concise submission process. The peer review process was comprehensive and constructive. Support from the editorial office was excellent, since the administrative staff were responsive. The journal provides a fast and timely publication timeline.
Dear Mayra Duenas, Editorial Coordinator of the journal IJCCR, I write here a little on my experience as an author submitting to the International Journal of Clinical Case Reports and Reviews (IJCCR). This was my first submission to IJCCR and my manuscript was inherently an outsider’s effort. It attempted to broadly identify and then make some sense of life’s under-appreciated mysteries. I initially had responded to a request for possible submissions. I then contacted IJCCR with a tentative topic for a manuscript. They quickly got back with an approval for the submission, but with a particular requirement that it be medically relevant. I then put together a manuscript and submitted it. After the usual back-and-forth over forms and formality, the manuscript was sent off for reviews. Within 2 weeks I got back 4 reviews which were both helpful and also surprising. Surprising in that the topic was somewhat foreign to medical literature. My subsequent updates in response to the reviewer comments went smoothly and in short order I had a series of proofs to evaluate. All in all, the whole publication process seemed outstanding. It was both helpful in terms of the paper’s content and also in terms of its efficient and friendly communications. Thank you all very much. Sincerely, Ted Christopher, Rochester, NY.
Dear Grace Pierce, Editorial Coordinator of the journal IJCCR, I had a very positive experience with Auctores - Journal throughout the publication process. The Editorial Team was highly responsive, professional, and supportive at every stage. I would like to extend my sincere thanks to the Editor: Grace Pierce, for her guidance and assistance. The peer-review process was smooth and constructive, helping improve the quality of my work. I would gladly recommend Auctores Journal to fellow researchers and authors. Dr. SABITA SINHA, Medical Oncologist, MD (Electro Homeopathy).
Dear Maria Emerson, Editorial Coordinator of - Journal of Clinical Research and Reports. ''I am pleased to provide this testimonial following the publication of our recent case report in this journal. The peer review process was rigorous, constructive, thorough, and conducted in a timely manner. The reviewers’ comments were thoughtful, detailed, and highly constructive, contributing substantially to the refinement, clarity, and scientific robustness of our manuscript. The process was conducted with professionalism and academic integrity throughout. The support provided by the editorial office was exemplary. Communication was consistently prompt, clear, and courteous at all stages of the submission and publication process. The editorial team demonstrated a high level of organization and responsiveness, ensuring that all queries were addressed efficiently and that the process remained transparent and well-coordinated. The overall quality of the journal is reflected in its strong editorial standards, commitment to scientific excellence, and dedication to publishing clinically meaningful research. It has been a privilege to publish our work in this journal, and we would welcome the opportunity to contribute further in the future.'' Best wishes from, Dr. Efstratios Trogkanis, Cardiologist.
Dear Reader: We have published several articles in the Auctores Publishing, LLC, journal, Clinical Medical Reviews and Reports in recent years (CMRR). This is an ‘open access’ journal and the following are our observations. From the initial invitation to submit an article, to the final edits of galley proofs, we have found CMRR personnel to be professional, responsive, rapid and thorough. This entire process begins with Catherine Mitchell, Editorial Coordinator. She is simply outstanding, and, I believe, unparalleled in her capacity. I cannot imagine a more responsive and dedicated Editorial Coordinator. As I read the dates and timing of her correspondence with us, it seems that she never sleeps. I hope Auctores Publishing, LLC, appreciates her efforts as much as these authors do. Thank you to Auctores Publishing, LLC, to the Editorial Staff/Board, and to Catherine Mitchell from a grateful author(s).
Dear Maria Emerson, Editorial Coordinator of International Journal of Clinical Case Reports and Reviews, What distinguishes International Journal of Clinical Case Report and Review is not only the scientific rigor of its publications, but the intellectual climate in which research is evaluated. The submission process is refreshingly free of unnecessary formal barriers and bureaucratic rituals that often complicate academic publishing without adding real value. The peer-review system is demanding yet constructive, guided by genuine scientific dialogue rather than hierarchical or authoritarian attitudes. Reviewers act as collaborators in improving the manuscript, not as gatekeepers imposing arbitrary standards. This journal offers a rare balance: high methodological standards combined with a respectful, transparent, and supportive editorial approach. In an era where publishing can feel more burdensome than research itself, this platform restores the original purpose of peer review — to refine ideas, not to obstruct them Prof. Perlat Kapisyzi, FCCP PULMONOLOGIST AND THORACIC IMAGING.
