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Research Article | DOI: https://doi.org/10.31579/2690-4861/942
1Department of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
2Department of Orthopedic Surgery, St. Joseph’s Medical Center, Paterson, NJ, USA.
*Corresponding Author: Sang D. Kim, M.D. Cedars-Sinai Medical Center Department of Orthopedic Surgery.
Citation: Ryan A. Finkel, Christopher Johnson, Paal K. Nilssen, Daniel Farivar, Nakul Narendran, et al, (2025), Perioperative Hyperglycemia Increases Rates of Infection in Lumbar and Cervical Spine Surgery: A Case Control Study, International Journal of Clinical Case Reports and Reviews, 30(4); DOI:10.31579/2690-4861/942
Copyright: © 2025, Sang D. Kim. 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: 05 August 2025 | Accepted: 14 August 2025 | Published: 03 October 2025
Keywords: infection; spine; hyperglycemia; fusion; lumbar; complications
Background/Aim: Hyperglycemic changes can occur after surgery as a response to physiological stress or medication effects. Its association with surgical site infections (SSI) has been studied in other surgical specialties but it has not been looked at in spine surgery. This study aimed to evaluate the correlation of postoperative hyperglycemia with SSI in post-operative spine surgery patients, irrespective of diabetes.
Materials and Methods: We retrospectively reviewed 100 patients at our hospital who underwent spine surgery with SSI and compared them with 111 controls (2010-2020). Independent variables included average postoperative glucose (<100, 100-119, 120-139, ≥140), surgical approach, use of allograft, ASA class, and diabetes mellitus. A multivariate logistic regression analysis using the significant univariate variables was performed to calculate the odds ratio and corresponding 95% confidence intervals to identify patient demographics and surgical characteristics that were associated with development of SSI.
Results: Univariate analysis revealed stand-alone ALIF and lateral transpsoas approach to interbody fusion procedures were associated with a decreased risk of SSI while average serum glucose 120-139 mg/dL and ≥140 mg/dL were at increased risk. Diabetes alone was not a significant risk factor. Multivariant analysis revealed average serum glucose levels ≥140 mg/dL within five days after surgery was found to be a risk factor for SSIs relative to an average serum glucose <100 mg/dL.
Conclusions: Postoperative serum glucose levels ≥140 mg/dL were associated with an increased risk of SSI when compared to glucose levels <100 mg/dL. The role of postoperative hyperglycemia as a risk factor for SSI should be investigated further.
Surgical site infections (SSI) are common postoperative complications with potentially catastrophic consequences in spinal surgery. Previous studies report incidence ranging from 0.2% to 16.7% [1,2]. SSIs after spinal surgery can result in significant morbidity, including pseudoarthrosis, chronic pain, deformity, neurologic deficits, and even death in severe cases [3]. Identification of risk factors for SSIs is essential for developing effective preventative strategies.
In the current literature, there are many patient-related and surgical risk factors for infection, such as prior infection, age, diabetes mellitus, smoking, malnutrition, obesity, prolonged operative time, trauma, hypothermia, blood transfusion, inadequate skin preparation, and hyperglycemia, among others [4,5]. Minimizing risk factors, especially those that are modifiable, has the potential to reduce infection burden. Elevated postoperative glucose levels, irrespective of diabetes mellitus (DM) status, have been associated with an increased risk of SSI across in the orthopedic joint literature [6]. These findings are supported by several studies outside the field of orthopedics [7,8].
The association of hyperglycemia with postoperative infections after spine surgery, irrespective of a DM diagnosis, is not well understood. To our knowledge, there has been minimal examination of immediate postoperative glycemic control to establish an optimal threshold for lowering the incidence of SSIs. The present study aims to understand if postoperative hyperglycemia, irrespective of DM, is an independent risk factor for postoperative infection after spine surgery and to determine a threshold that surgeons should target following spine surgery.
Study Design and Population:
Using Deep 6 Artificial Intelligence (AI) software (Pasadena, California, USA), we performed an AI driven search analyzing a complete database of patients at our level 1 trauma medical center since the incorporation of Epic (Epic Systems Corp.) electronic health record software in 2009. A detailed explanation of Deep 6 is described below. A combination of keywords and Current Procedural Terminology (CPT) codes were used to identify all patients, aged 18 years or older, who underwent either a cervical or lumbar spinal laminectomy, discectomy, or spinal arthrodesis from 2010 to 2020 (Supplemental Table 1). A combination of keywords and International Classification of Diseases Ninth (ICD-9) and Tenth Revision (ICD-10) codes were used to exclude patients undergoing operations for intraspinal abscess, osteomyelitis, and surgical site infections (Supplemental Table 1).
| Laminectomy/Discectomy | CPT-63001, CPT-63005, CPT-63012, CPT-63015, CPT-63017, CPT-63020, CPT-63030, CPT-63035, CPT-63040, CPT-63042, CPT-63043, CPT-63044 CPT-63045, CPT-63047, CPT- CPT-63048, CPT-63050, CPT-63075, CPT-63076 |
| Spinal Arthrodesis | CPT-22533, CPT-22534, CPT-22551, CPT-22552, CPT-22554, CPT-22558, CPT-22585, CPT-22600, CPT-22612, CPT-22614, CPT-22630, CPT-22632, CPT-22633, CPT-22634 |
| Intraspinal Abscess | ICD-9-CM-324.1, ICD-10-D-G06.1, ICD-10-D-G06.2 |
| Osteomyelitis | ICD-9-CM-730.08, ICD-9-CM-730.18, ICD-9-CM-730.28, ICD-10-D-M86.18, ICD-10-D-M86.60, ICD-10-D-M86.9 |
| Surgical Site Infection | ICD-9-CM-998.5, ICD-9-CM-998.51, ICD-9-CM-998.59, ICD-10-D-T79.2XXA, ICD-10-D-T81.4XXA |
Legend: CPT, Current Procedural Terminology; ICD-9-CM, International Classification of Diseases Ninth Revision; ICD-10-D, International Classification of Diseases Tenth Revision
Supplemental Table 1: International Classification of Diseases Ninth and Tenth Revision codes and Current Procedural Terminology codes used for inclusion and exclusion criteria.
Eligible surgeries were restricted to those performed by an orthopedic or neurological spine surgeon and patients with at least one year of follow-up. A retrospective chart review was then performed of all patients identified by Deep 6 AI to have had a postoperative SSI (infection cohort). The Center for Disease Control and Prevention definition for SSI was adopted for this study: infection that occurs at or near the surgical incision within 30 days of the procedure (where day 1 is the procedure date) and involves the skin and subcutaneous tissue of the incision [9]. In a similar fashion, a second cohort of patients, over the same period, were identified (controls) by Deep 6 AI and individually matched to the infection cohort based upon age, sex, American Society of Anesthesiologists (ASA) class, DM, and smoking status using propensity score matching
Outcomes Measures
The primary outcome was to evaluate postoperative fasting blood glucose levels as an independent indicator for infection risk irrespective of patient age, sex, diabetes status, steroid use, and operation performed. Blood glucose levels during the perioperative period were obtained via daily morning fasting labs. Of note, several medical societies have published guidelines for perioperative glucose management and provide a general recommendation for patients without diabetes [7,10,11], often defining >140 mg/dL as a risk factor for complications. To identify a stricter threshold at which there is an increased risk for SSIs in patients undergoing spine surgery, we elected to evaluate average blood glucose levels over 5 days after surgery (<100>
In addition to fasting blood glucose levels, the following secondary variables were also measured to evaluate SSI risk: surgical approach, spinal segment operated upon, bone graft use, vancomycin powder use, drain use, ASA class, duration of surgery, pre-incision antibiotics, DM, smoking, sliding scale insulin postoperative, transfusion, and obesity. Lastly, patient demographic information and past medical history were gathered.
Perioperative Management:
A standard perioperative management protocol applied in our institution was followed. All patients fasted overnight 6-8 hours before surgery. In the operating room, patients were placed under a forced air-warming blanket to prevent hypothermia throughout the duration of the surgery. Patients received a single dose of weight-based cefazolin or equivalent antibiotics prior to the skin incision. General anesthesia was administered after orotracheal intubation. No prophylactic antibiotics were prescribed postoperatively. Standard morning fasting labs were obtained for all patients after surgery.
Statistical Analysis:
All data was analyzed using IBM SPSS statistics, version 27.0. Descriptive statistics, such as Student’s t test and Chi-Squared analyses, were used to compare patients with an SSI to those without. A multivariable regression model using the significant univariate variables was created to identify associations between preoperative patient demographics and surgical characteristics with the development of SSIs. Odds ratios (OR) with 95% confidence intervals (CI) are reported. The threshold for statistical significance in the model was 0.05.
Deep 6 AI Search Platform
Deep 6 AI platform uses a variety of AI and machine learning to identify both unstructured and structured key terms in a center’s electronic medical database to perform precise matching of search terms rather than relying on a single algorithm. During a search query, over a hundred different clinical ontologies are combined to accurately recognize clinical concepts from unstructured or semi-structured data sources, such as progress notes, consult notes, and operation notes. A set of annotators then parses all source data then it labels and stores clinical concepts in a graph database. At this step, different clinical notes or fields are turned into a multidimensional vector that can represent a patient, which then becomes a node in the network. Machine learning then integrates and helps disambiguate concepts, detect negations and hypotheticals, and reconcile different concepts. The results are then ranked based on a multifactor confidence score. A user can further query the results by creating searches against indexed patient graphs. Once a final query list has been generated, the user can then perform a detailed chart review of each patient queried from the software.
100 infection and 111 control patients were included in the final analysis. There were no differences between cohorts regarding patient age (p=0.45), sex (p=0.63), ASA class (0.13), DM diagnosis (p=0.25), smoking status (p=0.27), and vancomycin powder use (p=0.33) (Table 1). In the infection cohort, 84% (84/100) had a posterior surgery, 10% (10/100) had an Anterior Lumber Interbody Fusion (ALIF) with posterior instrumentation, 4% (4/100) had a stand-alone ALIF, and 2% (2/100) had a lateral transpsoas approach to interbody fusion. In the control cohort, 73% (81/111) had a posterior surgery, 6% (7/111) had an ALIF with posterior instrumentation, 13% (14/111) had a stand-alone ALIF, and 8% (9/111) had a lateral surgery (Table 2).
N (%) | Infection n=100, 47.3 | Control n=111, 52.6 | Total n=211 | P-value |
| Age (year) | 66.5 (±14.5) | 67.9 (±14.0) | 67.3 (±13.9) | 0.45 |
| Sex | 0.63 | |||
| Male | 40 (40) | 48 (43.2) | 88 (41.2) | |
| Female | 60 (60) | 63 (56.8) | 123 (58.3) | |
| BMI | 30.3 (±6.9) | 26.7 (±6.05) | 28.4 (±6.7) | <.001 |
| ASA class | 2.7 (±0.5) | 2.6 (±0.6) | 2.45 (±0.6) | 0.13 |
| DM | 17 (17.0) | 26 (23.4) | 43 (20.4) | 0.25 |
| Smoking | 11 (11.0) | 18 (16.2) | 29 (13.7) | 0.27 |
| Legend: BMI, Body Mass Index; ASA, American Society of Anesthesiologists | ||||
Table 1: Patient Demographic Characteristics
Number of Patients N (%) | Infection (n=100, 47.3) | Control (n=111, 52.6) | Total (n=211) | P value |
| Surgical Approach | ||||
| Posterior | 84 (84.0) | 81 (73.0) | 165 (78.1) | 0.35 |
| Stand-alone ALIF | 4 (4.0) | 14 (6.6) | 18 (8.5) | 0.01 |
| ALIF with posterior instrumentation | 3 (3.0) | 7 (6.3) | 17 (8.0) | 0.14 |
| Lateral transpsoas approach to interbody fusion |
2 (2.0) |
9 (8.1) | 11 (5.2)
|
0.02 |
| Spine Region | ||||
| Lumbar | 84 (84.0) | 100 (90.1) | 184 (87.2) | <.001 |
| Cervical | 16 (16.0) | 11 (5.2) | 27 (12.7) | .46 |
| Revision | 77 (77.0) | 0 (0) | 77 (36.5) | <.001 |
| Vancomycin Powder | 10 (10.0) | 7 (7.2) | 17 (8.1) | 0.33 |
| Legend: ASA, American Society of Anesthesiology; BMI, Body Mass Index; DM, diabetes mellitus; ALIF, Anterior Lumbar Interbody Fusion | ||||
Table 2: Baseline Clinical and Surgical Characteristics
Univariate analysis showed that stand-alone ALIF procedures (OR 0.28, 95% CI 0.08-0.81, p=0.03) and lateral transpsoas approaches to interbody fusion (OR 0.21, 95% CI 0.03-0.86, p=0.05) were associated with a significantly decreased risk for surgical site infections (Table 3). On the other hand, average serum glucose levels between 120-139 mg/dL (OR 3.29, 95% CI 1.07-11.55, p=0.05) and ≥140 mg/dL (OR 8.12, 95% CI 2.67-28.21, p<0> OR (95% CI) P-Values Average Post-Op Glucose (mg/dL) <100> NA NA 100-119 1.34 (0.46-4.49) 0.60 120-139 3.29 (1.07-11.55) 0.05 ≥140 8.12 (2.70-28.22) <0> Surgical Approach Posterior NA NA Stand-alone ALIF 0.28 (0.08-0.81) 0.03 ALIF with posterior instrumentation 1.38 (0.50-3.96) 0.54 Lateral transpsoas approach to interbody fusion 0.21 (0.03-0.86) 0.05 Use of Allograft 1.08 (0.60-1.96) 0.80 ASA Class ASA 1 NA NA ASA 2 3.41 (0.55-66.11) 0.27 ASA 3 7.85 (1.29-150.61) 0.06 ASA 4 6.00 (0.38-182.92) 0.22 DM 1.94 (0.99-3.90) 0.06 Smoking 2.00 (0.90-4.59) 0.09 pRBC Transfusion 1.13 (0.48-2.66) 0.79 Legend: OR, odds ratio; CI, confidence interval; mg, milligram; dL, deciliter; ASA, American Society of Anesthesiology; DM, diabetes mellitus; pRBC Transfusion, packed red blood cell transfusion; ALIF, Anterior Lumber Interbody Fusion
Table 3: Odds ratios with 95% confidence intervals comparing clinical and surgical Characteristics and risk of surgical site infection.
Multivariate logistic regression analysis using the significant univariate variables showed that average serum glucose levels ≥140 mg/dL within five days after the operation were found to be most predictive of surgical site infections (OR 7.68, 95% CI 1.85-37.76, p=0.01). A diagnosis of DM alone was not a significant risk factor (OR 0.63, 95% CI 0.25-1.56, p=0.32), as well as stand-alone anterior and lateral transpsoas approaches to interbody fusion (Table 4).
| n (%) | Control (N = 111) | Infection (N = 100) | Adjusted OR (95% CI) | Adjusted P Values |
| Average Post-Op Glucose* (mg/dL) | ||||
| <100> | 17 (15.5%) | 5 (5.0%) | NA | NA |
| 100-119 | 56 (50.5%) | 27 (27.0%) | 1.02 (0.27-4.42) | 0.97 |
| 120-139 | 21 (18.9%) | 23 (23.0%) | 2.83 (0.69-13.43) | 0.16 |
| ≥140 | 17 (15.3%) | 45 (45.0%) | 7.68 (1.85-37.79) | 0.01 |
| Surgical Approach** | ||||
| Posterior | 81 (72.9%) | 84 (84.0%) | NA | NA |
| Stand-alone ALIF | 14 (12.6%) | 4 (4.0%) | 0.37 (0.08-1.34) | 0.15 |
| ALIF with Posterior Instrumentation | 7 (6.3%) | 10 (10.0%) | 2.45 (0.68-9.31) | 0.18 |
| Lateral transpsoas approach to interbody fusion | 9 (8.1%) | 2 (2.0%) | 0.23 (0.03-1.12) | 0.10 |
| Use of Allograft | 84 (76.6%) | 66 (66.0%) | 2.31 (0.74-8.01) | 0.16 |
| ASA Class*** | ||||
| ASA 1 | 6 (5.4%) | 1 (1.0%) | NA | NA |
| ASA 2 | 51 (45.9%) | 29 (29.0%) | 1.48 (0.20-31.13) | 0.73 |
| ASA 3 | 52 (46.8%) | 68 (68.0%) | 4.83 (0.69-99.39) | 0.17 |
| ASA 4 | 2 (1.8%) | 2 (2.0%) | 1.80 (0.07-75.55) | 0.73 |
| DM | 17 (15.3%) | 26 (26.0%) | 0.63 (0.25-1.56) | 0.32 |
| Smoking | 11 (9.9%) | 18 (18.0%) | 2.48 (0.90-7.17) | 0.08 |
| pRBC Transfusion | 16 (14.4%) | 24 (24.0%) | 1.57 (0.64-3.88) | 0.32 |
Legend: OR, odds ratio; CI, confidence interval; mg, milligram; dL, deciliter; ASA, American Society of Anesthesiology; DM, diabetes mellitus; pRBC Transfusion, packed red blood cell transfusion; ALIF, Anterior Lumber Interbody Fusion *OR relative to blood glucose < 100> ** OR relative to posterior approach. *** OR relative to ASA 1. | ||||
Table 4: Adjusted odds ratios with 95% confidence intervals comparing clinical and surgical Characteristics and risk of surgical site infection.
Discussion:
The present study demonstrated that an elevated postoperative serum glucose ≥140 mg/dL was associated with an increased risk of SSI compared to patients with serum glucose less than 100 mg/dL. Postoperative serum glucose levels between 100-119 mg/dL and 120-129 were not associated with increased risk of infection compared to patients under 100 mg/dL. Additionally, we found that DM alone was not a significant risk factor for SSI on univariate analysis. The present study adds to the body of literature of perioperative glycemic control and gives a unique perspective on the importance of glucose control in patients undergoing spine surgery, irrespective of DM status [6,12–15].
Historically, orthopaedic literature has focused on DM as a risk factor for SSI, using glycosylated hemoglobin (HbA1c) as a biomarker to assess glycemic control in the preoperative setting [16-18]. Yet, studies found that using diabetes status alone or HbA1c thresholds, as a proxy to predict hyperglycemia, are of poor predictive value [19–22]. Instead, it has been suggested that hyperglycemia, and a postoperative measure, may be a stronger predictor of SSIs than DM itself or HbA1c levels, especially when other factors are considered in multivariable analyses [23]. Furthermore, in patients without DM, HBA1c levels are infrequently checked, which hinders the utility of these studies to the average spine patients undergoing surgery. The role of postoperative fasting blood glucose levels has gained attention across other surgical subspecialties. In the joint arthroplasty, general surgery, and cardiothoracic surgery literature, hyperglycemia has been shown to be associated with an increased risk for perioperative infection, with postoperative values being more closely related to infection risk than preoperative values [6,8,24,25].
In this study, we found that elevated serum glucose in the postoperative setting increased the risk of SSI. Considering the impact of SSI on patient morbidity and healthcare costs, it is critical to understand and describe a safe target range of glucose levels for those undergoing spine surgery. Kheir et al. [6] performed a retrospective review of 24,857 primary total joint arthroplasties between 2001 and 2015 and found that the relationship between postoperative blood glucose levels and periprosthetic joint infections increased linearly, with an optimal cutoff of 137 mg/dL. In this study, our cutoff was identified to be ≥140 mg/dL. Similarly, Upadhyaya et al. identified glucose levels ≥140 mg/dL placed patients at a more than two-fold increase (OR 2.19; 95 % CI 1.13, 4.25) in the likelihood of revision surgery for infection [26], however the study did not stratify glucose levels in greater detail.
Our findings, and those from the joint arthroplasty literature [6], suggest that immediate and strict postoperative glycemic control may play an important role in reducing postoperative SSIs after orthopaedic procedures, irrespective of DM status. However, despite our findings, target glucose ranges can depend upon the patient and their comorbidities in the context of their operation and the implications of overtreating glycemic levels. Many studies have reported that anterior approaches are at lower risk for SSI [27]. A recent systematic review and meta-analyses found that the incidence of SSI in posterior approach surgery was more than twice anterior approach surgery (5.0% vs. 2.3%) [27]. In this study, we found that anterior and lateral approaches had a lower risk for SSI in the univariant analysis but lost statistical significance in the multivariant analysis. Additionally, previous studies have investigated the efficacy of adjunctive vancomycin powder and found that it lowers the risk of SSI [27,28]. In this study, no difference between groups was found. Notably the use of vancomycin powder was infrequent (overall incidence: 8.1%), significantly underpowering our findings. Future well-designed randomized controlled trials are warranted to investigate the effect of implementing various postoperative glucose strategies post spine surgery.
This study has inherent limitations, which should be considered in the context of our findings. First, the present study is a single-center retrospective study, which not only depends on the quality, availability, and accuracy of existing medical records, but also carries its own inherent biases that may not be generalizable to the general population. Second, it is important to realize that glucose measurements represent a snapshot in time in the perioperative setting, rather than the course of the patient’s inpatient stay. However, glucose values in this study were obtained via routine fasting blood chemistry each morning at 0600. Third, preoperative HbA1c data was not included in our analyses because values were only available in patients with DM and the focus of this study was on postoperative hyperglycemia irrespective of DM diagnosis. Lastly, while propensity score matching can control for measured confounding variables, it cannot adjust for unmeasured variables, which may bias the estimated outcome. Using larger matched cohorts could increase the statistical power of our study, potentially improving the robustness of our findings. While our study was designed to have adequate power to detect small to medium effect sizes, it may lack the sensitivity to detect larger treatment effects. Nonetheless, we believe our findings are strengthened by the fact that cohorts are similar in terms of age, sex, ASA score, DM diagnosis, and smoking status. Furthermore, the strength of our study is its applicability to the average patient undergoing spine surgery. It does not require any additional preoperative testing. With our findings, actionable changes can be implemented to reduce one potential risk factor for surgical site infections.
Postoperative blood glucose levels ≥140 mg/dL increased the risk of SSI compared to those with postoperative blood glucose <100>
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
I would like to offer my testimony in the support. I have received through the peer review process and support the editorial office where they are to support young authors like me, encourage them to publish their work in your esteemed journals, and globalize and share knowledge globally. I really appreciate your journal, peer review, and editorial office.
Dear Agrippa Hilda- Editorial Coordinator of Journal of Neuroscience and Neurological Surgery, "The peer review process was very quick and of high quality, which can also be seen in the articles in the journal. The collaboration with the editorial office was very good."
I would like to express my sincere gratitude for the support and efficiency provided by the editorial office throughout the publication process of my article, “Delayed Vulvar Metastases from Rectal Carcinoma: A Case Report.” I greatly appreciate the assistance and guidance I received from your team, which made the entire process smooth and efficient. The peer review process was thorough and constructive, contributing to the overall quality of the final article. I am very grateful for the high level of professionalism and commitment shown by the editorial staff, and I look forward to maintaining a long-term collaboration with the International Journal of Clinical Case Reports and Reviews.
To Dear Erin Aust, I would like to express my heartfelt appreciation for the opportunity to have my work published in this esteemed journal. The entire publication process was smooth and well-organized, and I am extremely satisfied with the final result. The Editorial Team demonstrated the utmost professionalism, providing prompt and insightful feedback throughout the review process. Their clear communication and constructive suggestions were invaluable in enhancing my manuscript, and their meticulous attention to detail and dedication to quality are truly commendable. Additionally, the support from the Editorial Office was exceptional. From the initial submission to the final publication, I was guided through every step of the process with great care and professionalism. The team's responsiveness and assistance made the entire experience both easy and stress-free. I am also deeply impressed by the quality and reputation of the journal. It is an honor to have my research featured in such a respected publication, and I am confident that it will make a meaningful contribution to the field.
"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 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.
Dear Grace Pierce, International Journal of Clinical Case Reports and Reviews I appreciate the opportunity to review for Auctore Journal, as the overall editorial process was smooth, transparent and professionally managed. This journal maintains high scientific standards and ensures timely communications with authors, which is truly commendable. I would like to express my special thanks to editor Grace Pierce for his constant guidance, promt responses, and supportive coordination throughout the review process. I am also greatful to Eleanor Bailey from the finance department for her clear communication and efficient handling of all administrative matters. Overall, my experience with Auctore Journal has been highly positive and rewarding. Best regards, Sabita sinha
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).
