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Review Article | DOI: https://doi.org/10.31579/2690-4861/1011
1 Regional Hospital Center “Shefqet Ndroqi,” Tirana, Albania.
*Corresponding Author: Prof. Perlat. Kapisyzi FCCP, Regional Hospital Center “Shefqet Ndroqi,” Tirana, Albania.
Citation: P. Kapisyzi FCCP., Tashi, E., Karaulli, L., Gjoni, J., Çuko., A., et al, (2026), Innovative Conceptual Framework in Lung Ultrasound: From Morphology to Bedside Spirometry and Perfusion Innovative Conceptual Review, International Journal of Clinical Case Reports and Reviews, 33(5); DOI:10.31579/2690-4861/1011
Copyright: © 2026, Perlat Kapisyzi FCCP. 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: 08 December 2025 | Accepted: 22 December 2025 | Published: 23 January 2026
Keywords: functional lung ultrasound; twinkling white area; merlin space; bat sign; front sight in rear sight; obstructive syndrome; pleural separation; pulmonary embolism
Purpose:
This manuscript synthesizes and integrates a series of previously published innovative sonographic concepts into a unified framework of Functional Lung Ultrasound (FLUS), introducing lung ultrasound as a real-time bedside functional “visual spirometry” tool. Rather than focusing on artefact-based interpretation, it reframes pulmonary sonography as a structural–functional imaging modality. The primary aim is to systematize the diagnostic meaning of novel sonographic entities—namely the Twinkling White Area (TWA), Bat Sign dynamics, vascular echo patterns, and pleural separation—with particular emphasis on lung ultrasound’s role in the bedside functional diagnosis, phenotyping, and monitoring of obstructive lung syndromes, within a coherent physiological and pathophysiological model of peripheral lung function.
Methods:
This work is based on a structured reinterpretation of serial ultrasound examinations previously performed in healthy subjects and in over 600 patients with obstructive, interstitial, infectious, malignant, and vascular lung diseases, as reported across separate original publications. Sonographic features of the Merlin Space—including pleural line behavior, rib-shadow geometry, TWA morphology, and respiratory excursion—are collectively reanalyzed and integrated with their corresponding CT correlations, morphologic substrates, and hemodynamic implications in order to construct a reproducible structure–function continuum.
Results:
The TWA is consolidated as a genuine subpleural reflective interface dynamically linked to peripheral lung density, representing the baseline architectural unit of the aerated lung. The Bat Sign is redefined as a functional continuum rather than a static landmark: the Healthy Bat preserves symmetric TWA geometry, rib-shadow distance, and respiratory motion, whereas the Sick Bat exhibits deformation, asymmetry, and altered dynamics reflecting early parenchymal or obstructive involvement. The Front Sight in Rear Sight sign is confirmed as a dual-vascular echo configuration corresponding to pulmonary infarction supported by bronchial collateral perfusion. Posterior basal pleural separation emerges as a functional marker of chronic, non-exudative, viscerally confined pleural–subpleural remodeling rather than acute inflammatory pleural disease.
Conclusion:
This integrated framework formally establishes Functional Lung Ultrasound (FLUS) as a real-time, bedside “visual spirometry” modality, in which echo morphology, motion analysis, and perfusion patterns translate directly into functional assessment of airflow, density distribution, and peripheral vascular dynamics. By unifying structural and physiological echo phenomena, FLUS positions lung ultrasound as a true functional imaging tool for obstructive, interstitial, infectious, malignant, and vascular lung syndromes.
For decades, lung ultrasound spoke in the language of artefacts — lines, shadows, and reverberations that echoed the limits of imaging the air-filled lung. But within those echoes, something real was always waiting: a geometry that breathed, a structure that pulsed, a pattern that was not illusion but physiology in motion. This marks the beginning of a new understanding — the recognition that the normal lung image is not a random play of reflections but a coherent, structured baseline with measurable features: shape, continuity, proportion, and symmetry. At its heart lies the Twinkling White Area (TWA) — the dynamic subpleural field where peripheral densities interweave in a living biological process. TWA is not an artifact but a signature of organization, a reflection of ventilation–perfusion harmony. When this organized field begins to deform — when continuity fades or geometry fractures — the image evolves into pathology. This transition defines the Sick Bat Sign, where structural distortion replaces the balanced geometry of the Healthy Bat Sign. Disease does not invent new echoes; it alters the architecture of the existing image
Among these transformed patterns, some hold diagnostic precision:
Thus, lung ultrasound transcends the traditional vocabulary of artefacts and becomes a true structural language—a visual grammar of physiology and pathophysiology. Each image reflects a dynamic equilibrium between air, tissue, and blood flow. Within this geometric framework, the lung is no longer an echo chamber but a living morphological, functional map, in which brightness, shadow, and form mirror real-time cardiopulmonary interaction.
Innovative Conceptual Framework in Lung Ultrasound
A Dynamic Subpleural Morphologic–Functional Tissue–Air Interface
TWA represents the true subpleural reflective interface, an area where peripheral tissue densities interweave dynamically in an active biological process, rather than an acoustic artifact. It belongs to the Merlin Space, a structured reflective corridor bounded by the pleural line and rib shadows, whose dimensions and echo patterns vary with physiology and pathology. This defines the structural baseline for normal lung imaging (figure 1) [1].
Figure 1: Merlin space, twinkling white area. Kapisyzi, P. ©
Therefore, we defined the Merlin space as follows: The Merlin space is the hyper-echoic twinkling white area below the pleural line, delimited laterally by rib shadows and inferiorly by the hypo-echoic twinkling black area extending to the bottom of the screen. This definition more accurately reflects the real presentation of the Merlin space and helps in understanding the changes it undergoes in abnormal lung conditions (Figure 1).
Evaluating the structural and functional components of Merlin’s space provides a holistic understanding of lung ultrasound findings: Twinkling White Area: Analyze its configuration, density, homogeneity, and border regularity. Grey Area Inside Black Region: Assess its relationship with surrounding structures. Rib Shadows: Evaluate their width, length, and distance from the pleural line. This systematic approach helps identify the healthy bat sign, a hallmark of normal lung ultrasound findings. Deviations from this pattern may indicate the “sick bat sign,” associated with underlying pathologies.
Morphologic Integrity versus Structural Distortion of the Peripheral Lung
According to Lichtenstein and other authors, the “bat sign” is a configuration composed of the ribs and their shadows, standing for the bat’s wings, and the pleural line, representing its body. When examining the bat’s wings from beginning to end (where the beginning is the ribs and the extension are the shadows of the ribs), the body cannot be depicted as a simple line but rather as a truncated cone with its base at the pleural line. Thus, the bat’s body aligns with the hyper-echoic, twinkling area in the Merlin space. Therefore, it is crucial not only to see the bat’s wings but also its body. Recognizing the normal appearance of the bat’s body (hyper echoic twinkling white area) along with the bat sign (ribs’s line and shadow, pleural line) is essential for early detection of injuries, known as “sick bat,” in the lungs [2]. The Bat Sign evolves from a static anatomical landmark to a functional morphologic continuum. Healthy Bat: preserved TWA geometry, harmonious rib shadows, and homogeneous echotexture. Sick Bat: deformation of TWA dimensions (width, length, contour) and irregular rib-shadow dynamics, revealing early parenchymal or obstructive pathology. This model replaces the concept of 'artefactual patterns' with real structural descriptors (Figure 2), [2].
Figure 2: Healthy bat sign versus sick Chiroptera sign. Kapisyzi, P. ©
Knowing this normal structure which to our knowledge has not been described in this way in details but Merlin’s space has been considered homogeneous—allows us to use ultrasound to discern when “something” is not normal at the lung periphery. If we are not familiar with the “healthy bat” image, it will not be easy to recognize the “sick bat’s” images with various diseases, especially in the initial stages [2].
Sick Bat sign refers to any ultrasound image in which one or more of the following components are observed, either together or separately:
A Geometric–Functional Hemodynamic Signature of Pulmonary Infarction
The Front Sight in Rear Sight Sign represents a distinct hemodynamic and geometric echo-phenotype of pulmonary infarction, appearing within the Sick Bat progression.
It is defined by two symmetric hypoechoic zones (A)—corresponding to infarcted, non-perfused pulmonary segments—flanking a central preserved region (B) that remains perfused through bronchial arterial collateral flow.
This configuration creates a triphasic geometric pattern in which:
Functionally, this sign establishes one of the clearest direct visual correspondences in lung ultrasound: echo morphology mirroring dual vascular supply (pulmonary vs. bronchial artery).
By making the dual-circulation physiology visible at the bedside, the Front Sight in Rear Sight Sign elevates pulmonary infarction from a non-specific “wedge-shaped hypoechoic area” to a structured hemodynamic signature, advancing the geometric-functional paradigm of this new framework. A hemodynamic echo-sign of pulmonary infarction, characterized by two hypoechoic zones (A) flanking a central preserved region (B) sustained by bronchial collateral perfusion. It establishes a direct visual correlation between echo morphology and dual vascular supply, contributing to functional interpretation of vascular injuries (Figure 3), [2].
A Pathology-Oriented Approach
Lung ultrasound interpretation can benefit from adopting a descriptive, pathology-focused terminology, akin to approaches used in advanced imaging techniques like CT or MRI. These modalities emphasize anatomical and pathological findings over the technical processes that generate the images. For example: CT reports describe “ground-glass opacities” or “hyperdense masses,” without referring to imaging mechanisms like iterative reconstruction. Similarly, LU should prioritize findings' clinical relevance over their physical origins. Proposed Terminological Changes: A-Lines: Describe as horizontal hyper-echoic lines (not as artifact) indicating (except normal lung) increased air/fluid ratios, observed in conditions like COPD, asthma, or pulmonary embolism. B-Lines more than three refer to as vertical streaky hyper-echoic densities (not as artifact), reflecting interstitial fluid accumulation. C-Lines: Describe as pleural thickening, irregularities without hypo or hyper echoic densities with pleural interruptions to improve precision.
This conceptual shift reshapes the fundamental interpretive framework of lung ultrasound, advancing beyond the reductionist artifact terminology of A- and B-lines. LUS is viewed as real tissue-interface imaging, where each echo expresses a structural or physiological interaction within the lung parenchyma (Figure 4,5,6), [3].
Innovative Conceptual Framework in Functional Lung Ultrasound
As we have emphasized throughout this innovative framework, mastering
the geometry and functional behavior of the healthy Merlin Space—particularly the morphology, proportionality, and coherence of the Twinkling White Area (TWA)—is fundamental for high-precision functional lung ultrasound.
This knowledge serves as more than a reference point; it forms an internal cognitive model against which the brain rapidly compares every new ultrasound pattern.
Importantly, this rapid pattern recognition is often mislabeled as “intuition.” Yet we must distinguish sharply between expert intuition—a high-speed perceptual judgment grounded in deep internalized knowledge—and the superficial optimism of ignorance, an illusion of understanding arising from lack of expertise. Here, intuition is not mystical guesswork but the end result of knowing the normal geometry–function relationship so well that deviations become instantly visible.
Much like looking through a window and immediately sensing both the weather and the time of day—not through speculation, but through decoding known atmospheric cues—the clinician who understands normal TWA geometry can instantly distinguish whether an image represents a healthy state or a Sick Bat Sign.
Through this conceptual lens, the three peripheral lung phenotypes emerge as distinct “atmospheric” signatures, each expressing a unique harmony—and disharmony—between geometry and function.
Emphysema – Geometric Compression and Black-Dominant Atmosphere (“Nightfall Pattern”)
In emphysema, hyperinflation generates deep, uninterrupted black aeration that overtakes the sonographic field.
The subpleural functional architecture collapses in its vertical dimension:
This geometric distortion is a direct expression of functional decline: alveolar overdistension, loss of elastic recoil, and destruction of the peripheral capillary–interstitial network, which normally generates micro-reflections and structural depth.
Visually, this creates the nightfall atmosphere, where brightness collapses into a low, horizontal band, while the image above and below it becomes dominated by darkness—an immediate geometric signature of emphysematous hyperinflation. (Figure 7: Nightfall pattern)
Chronic Bronchitis – Geometric Elongation and Diffuse Subpleural Brightness (“Foggy Dawn Pattern”)
Chronic bronchitis produces a diametrically different transformation.
Here, the TWA becomes elongated, extending downwards along its vertical axis:
This elongation is a geometric expression of functional obstruction without hyperinflation. The reflective interface gains depth but loses crispness, resembling a foggy dawn where light is present but softened through suspended density.
The rib shadows remain structurally preserved but appear visually longer relative to the expanded TWA, reinforcing the impression of an extended, thickened subpleural interface.
(Figure 8: Foggy dawn pattern)
Normal Lung – Geometric Equilibrium and Stable Reflective Pattern (“Cloud in a Clear Sky Pattern”)
The normal lung sets the archetype for comparison. Its TWA demonstrates:
This appearance is neither exaggerated nor attenuated; it is structurally harmonious, representing the healthy interaction between the pleural layers and the subpleural microarchitecture.
Visually, it resembles a white cloud in a clear sky—defined, bright, and suspended in a stable environment.
This equilibrium becomes the baseline atmospheric state from which deviations toward nightfall (compression) or foggy dawn (elongation) are immediately perceivable to the informed eye. (Figure 9: Cloud in a clear sky pattern)
Integrating TWA motion, rib-shadow displacement, and pleural kinetics allows the quantification of airflow changes and obstruction patterns at the bedside. This approach inaugurates Functional Sonopulmonology, transforming lung ultrasound into a visual spirometer for obstructive syndromes [4,5].
Figure 7: Nightfall pattern.
Figure 8: Foggy dawn pattern.
Figure 9: Cloud in a clear sky pattern.
A New Geometric Marker of Chronic Visceral Pleuritis and Vascular Chronicity
The pleural separation sign represents a novel geometric–functional observation in lung ultrasound: the distinct visualization of the parietal and visceral pleura as two clearly separated echogenic lines, rather than as a single fused pleural complex.
This uncommon appearance emerged through systematic imaging with 2.5–5 MHz Clarius transducers, which allow the discrimination of pleural micro-geometry.
Importantly, the sign does not suggest acute exudative pleuritis. Instead, the pattern—subtle yet disproportionate separation between the pleural layers—combined with consecutive pleural interruptions, is far more compatible with chronic remodeling of the visceral pleura.
Such remodeling may include:
In this framework, pleural separation becomes a functional signature: a marker of chronic, non-exudative, viscerally confined inflammatory processes rather than acute pleural disease.
Crucially, in the vascular context, this geometry acquires additional diagnostic value.
When present alongside hypo perfused subpleural territories, pleural separation may offer a non-invasive sonographic clue for differentiating chronic from acute pulmonary embolism, reflecting the chronicity of pleural–subpleural interaction in long-standing vascular obstruction. (Figure 10,11,12)
Thus, the pleural separation sign contributes to the emerging ecosystem of functional, geometry-based markers in lung ultrasound, reinforcing the paradigm that structural geometry mirrors underlying physiology, chronicity, and vascular history.[6].
Figure 10: Pleural separation
Figure 11: Pleural separations.<> > >
This integrated framework formally establishes Functional Lung Ultrasound (FLUS) as a real-time, bedside “functional imaging” modality, in which echo morphology, motion analysis, and perfusion patterns translate directly into functional assessment of airflow, density distribution, and peripheral vascular dynamics. By unifying structural and physiological echo phenomena, FLUS positions lung ultrasound as a true functional imaging tool for obstructive, interstitial, infectious, malignant, and vascular lung syndromes.
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"I am grateful for the opportunity of contributing to [International Journal of Clinical Case Reports and Reviews] and for the rigorous review process that enhances the quality of research published in your esteemed journal. I sincerely appreciate the time and effort of your team who have dedicatedly helped me in improvising changes and modifying my manuscript. The insightful comments and constructive feedback provided have been invaluable in refining and strengthening my work".
I thank the ‘Journal of Clinical Research and Reports’ for accepting this article for publication. This is a rigorously peer reviewed journal which is on all major global scientific data bases. I note the review process was prompt, thorough and professionally critical. It gave us an insight into a number of important scientific/statistical issues. The review prompted us to review the relevant literature again and look at the limitations of the study. The peer reviewers were open, clear in the instructions and the editorial team was very prompt in their communication. This journal certainly publishes quality research articles. I would recommend the journal for any future publications.
Dear Jessica Magne, with gratitude for the joint work. Fast process of receiving and processing the submitted scientific materials in “Clinical Cardiology and Cardiovascular Interventions”. High level of competence of the editors with clear and correct recommendations and ideas for enriching the article.
We found the peer review process quick and positive in its input. The support from the editorial officer has been very agile, always with the intention of improving the article and taking into account our subsequent corrections.
My article, titled 'No Way Out of the Smartphone Epidemic Without Considering the Insights of Brain Research,' has been republished in the International Journal of Clinical Case Reports and Reviews. The review process was seamless and professional, with the editors being both friendly and supportive. I am deeply grateful for their efforts.
To Dear Erin Aust – Editorial Coordinator of Journal of General Medicine and Clinical Practice! I declare that I am absolutely satisfied with your work carried out with great competence in following the manuscript during the various stages from its receipt, during the revision process to the final acceptance for publication. Thank Prof. Elvira Farina
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.
