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Research Article | DOI: https://doi.org/10.31579/2690-4861/982
1 University of Medicine Tirana Albania.
2 Regional Hospital Center “Shefqet Ndroqi” Tirana, Albania.
*Corresponding Author: Prof. Perlat Kapisyzi FCCP, University of Medicine Tirana Albania.
Citation: Perlat Kapisyzi, Eritjan Tashi, Ornela Nuredini, Loreta Karaulli, Juliana Gjoni, et al, (2025), Lung Ultrasound: An Initial Bedside 'Spirometry' Tool in Diagnosing Obstructive Syndrome, International Journal of Clinical Case Reports and Reviews, 31(2); DOI:10.31579/2690-4861/982
Copyright: © 2025, Perlat Kapisyzi. 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: 07 October 2025 | Accepted: 21 October 2025 | Published: 01 November 2025
Keywords: lung ultrasound; COPD; chronic bronchitis; emphysema; twinkling white area; rib shadows
Background: Chronic obstructive pulmonary disease (COPD) includes two key phenotypes—chronic bronchitis and emphysema—whose differentiation is essential for targeted therapy. Traditional diagnostics like spirometry and imaging often lack bedside applicability and regional specificity. Lung ultrasound (LUS), particularly through assessment of the Merlin space, Twinkling White Area (TWA), offers a novel non-invasive method for real-time evaluation of pleural and subpleural, peripheral abnormalities.
Objective: To assess the diagnostic utility of TWA morphology (length, width, density), rib shadow characteristics (W, W2), and rib-to-pleural line distance (“high of ribs”) during rest, inspiration, and expiration, in distinguishing normal lungs from emphysema and chronic bronchitis.
This study is first of three approaches: the first examines the echographic characteristics of emphysema compared to normal subjects; the second compares chronic bronchitis with normal subjects; and the third focuses on the echographic features that differentiate emphysema from chronic bronchitis.
Methods: A prospective observational study was conducted on 105 individuals (25 controls, 40 emphysemas, 40 bronchitis), using a 2–5 MHz handheld Clarius ultrasound probe. Four thoracic regions were scanned. Quantitative measurements were analyzed via PCA, ANOVA, ROC analysis, and logistic regression.
Results: ANOVA identified five ultrasound variables—Length TWA inspiration, Length TWA, Length TWA expiration, width of TWA, W2 ribs shadow inspiration as the most significant discriminators between Bronchitis and Normal groups (all FDR‑adjusted p < 0.001), with Length TWA inspiration showing the largest effect size (Cohen’s d = 0.86, η² = 0.15). PCA explained 71.0% of the total variance (PC1 37.0%, PC2 17.7%, PC3 16.3%). Heatmap loadings indicated that positive loadings (red) reflect parameters increased in Bronchitis, while negative loadings (blue) identify reduced parameters characteristic of the disease. Youden analysis ranked Length TWA inspiration (AUC 0.706, >54.5 mm) and Length TWA (>61.5 mm) as top performers (specificity >95%). A logistic model combining the five Youden‑selected variables achieved a training AUC of 0.769 (10‑fold CV AUC = 0.755) with specificity 95.8% and sensitivity 61.4% at the optimal threshold.
Discussion: Findings converge on a coherent, phase‑sensitive sonographic pattern: inspiratory TWA length and rib‑shadow geometry show positive associations with bronchitis, whereas selected widths—particularly TWA width and expiratory TWA width —are reduced, yielding the bidirectional loading structure seen in PCA/heatmap, ANOVA and Youden index.
Conclusion: Chronic bronchitis shows a consistent sonographic pattern characterized by increased Length of TWA (quiet breathing and inspiration) and rib-shadow width, together with reduced Width of TWA and Width of TWA expiration. This bidirectional, phase-dependent signature supports a practical phase-aware scanning protocol, offering high rule-in specificity and improved diagn+ostic discrimination at the bedside.
Lung ultrasound (LU) has recently gained recognition as a widely adopted imaging modality in emergency and critical care medicine. Its use in the point-of-care setting allows rapid, bedside diagnosis or exclusion of several pulmonary conditions, including pulmonary edema, acute interstitial syndrome, pleural effusion, pneumonia, pulmonary embolism, and other pathologies predominantly affecting the peripheral lung regions. Despite this growing clinical utility, no studies to date have specifically investigated the role of LU in the diagnosis and differential diagnosis between emphysema and chronic bronchitis—two major phenotypes of chronic obstructive pulmonary disease (COPD) whose distinction carries significant implications for patient management and prognosis [1]. Therefore, the present study aims to evaluate the diagnostic performance of LU in chronic bronchitis in patients with obstructive lung disease. Recent advances suggest LUS can extend diagnostic capabilities to the peripheral lung. Among novel markers, the Twinkling White Area (TWA) — reflecting pleural–sub pleural dynamics [2,3] — together with rib shadow geometry (W, W2), rib-to-pleural distance (“high of rib”), and their inspiratory–expiratory variations, may offer critical diagnostic insights. To date, ultrasonography has explored diaphragm motion, A-lines, and air trapping [4–16], but no study has evaluated the diagnostic utility of LUS through targeted assessment of Merlin space dimensions. To our knowledge, this is the first investigation addressing that gap.
Objective:
To assess the diagnostic utility of TWA morphology (length, width, density), rib shadow characteristics (W, W2), and rib-to-pleural line distance (“high of ribs”) during rest, inspiration, and expiration, in distinguishing normal lungs from chronic bronchitis.
This study is second of three approaches: the first examines the echographic characteristics of emphysema compared to normal subjects; the second compares chronic bronchitis with normal subjects; and the third focuses on the echographic features that differentiate emphysema from chronic bronchitis.
Study Design and Population
This was a prospective observational study including 105 individuals: 25 controls, 40 patients with emphysema, and 40 with chronic bronchitis. All underwent standardized LUS examinations performed with a handheld curved-array Clarius transducer (2–5 MHz, lung preset mode, imaging depth 18–20 cm). Four thoracic regions were scanned in each subject: two anterior and two posterior (apical and lower posterior right lung), corresponding to regions 1, 2, 5, and 6 defined by the BLUE protocol.
Ultrasound Protocol
In each region, the pleural line was examined for morphology and continuity, and the Twinkling White Area (TWA) was assessed for length, width, and density. Rib shadow geometry was evaluated, including width at the level of the pleura (W) and at the distal end of the TWA (W2), as well as the vertical distance from the lower rib margin to the pleural line (“rib height”). All measurements were obtained during three respiratory states: quiet breathing, deep inspiration, and deep expiration, allowing assessment of dynamic changes across phases. All examinations were performed by a single experienced sonographer to minimize inter-operator variability. Images were analyzed using standardized LUS software to ensure consistent quantification of echographic variables. Quantitative data, including TWA dimensions, rib shadow widths, and pleural distances, were expressed as means ± standard deviations.
Data analysis was performed using the Python environment. Statistical approaches included principal component analysis (PCA) to reduce dimensionality, ANOVA to identify discriminative variables, ROC analysis with Youden index to determine optimal thresholds, and multivariable logistic regression to assess combined diagnostic performance.
Study Structure
The overall project is structured in three complementary parts: (1) echographic features of emphysema compared with normal subjects, (2) chronic bronchitis compared with normal subjects (the focus of the present manuscript), and (3) emphysema versus chronic bronchitis. Representative examples of measurements by region, together with pictograms, are presented to illustrate the methodology.
The methodology for quantifying regional variables in normal subjects and bronchitis patients is illustrated with pictograms and representative examples
Across analyses, rib shadow and Twinkling White Area (TWA) measurements—particularly during inspiration—emerged as the most informative ultrasound parameters distinguishing Bronchitis from Normal subjects.
ANOVA highlighted five variables with robust between‑group differences after false discovery rate correction (all adjusted p < 0>
Length TWA inspiration demonstrated the largest effect (Cohen’s d = 0.86; η² = 0.15), with the remaining variables—Length TWA, Length TWA expiration, W2 ribs shadow inspiration, and High inspiration—showing moderate effects (Cohen’s d ≈ 0.36–0.59). For all five variables, mean values were higher in the Bronchitis group, supporting a consistent directional pattern [Table 1].
| Variable | Mean (Bronchitis) | Mean (Normal) | Mean difference (B–N) | Cohen’s d | ANOVA F-value | p-value | Eta squared(η²) | Direction (by mean) | p-FDR adjusted | Significant after FDR |
| Length TWA inspiration | 63.84 | 44.25 | 19.59 | 0.862 | 89.06 | <0> | 0.149 | Positive (Bronchitis > Norma) | <0> | True |
| Length TWA | 67.98 | 55.44 | 12.54 | 0.594 | 39.92 | <0> | 0.075 | Positive (Bronchitis > Norma) | <0> | True |
| Length TWA expiration | 66.15 | 53.85 | 12.30 | 0.468 | 26.99 | <0> | 0.049 | Positive (Bronchitis > Norma) | 0.000001 | True |
| W2 ribs shadow inspiration | 25.80 | 22.51 | 3.28 | 0.450 | 25.06 | 0.000001 | 0.046 | Positive (Bronchitis > Norma) | 0.000003 | True |
| High INSPIRATION | 7.74 | 6.93 | 0.81 | 0.365 | 16.50 | 0.000056 | 0.031 | Positive (Bronchitis > Norma) | 0.000168 | True |
Table 1: ANOVA – Top 5 discriminative variable
Principal Component Analysis (PCA) explained 71.0% of the total variance (PC1 37.0%, PC2 17.7%, PC3 16.3%). PC1 was driven primarily by W2 ribs shadow inspiration and TWA length metrics (positive loadings), alongside negative loadings for Width TWA measures—indicating that increases in TWA length and decreases in specific TWA widths jointly characterize Bronchitis. PC2 captured rib height dynamics (positive loadings for inspiratory and expiratory rib height; negative for resting height), while PC3 reflected phase‑dependent rib shadow width patterns (positive in rest/inspiration, negative in expiration). [Table 2]
| Principal Component | Explained Variance | Top variables (sign) |
| PC1 | 37.0% | W2 ribs shadow inspiration (+); Length TWA inspiration (+); Width TWA inspiration (–); Width TWA (–); Length TWA expiration (+) |
| PC2 | 17.7% | High of rib (–); High of rib inspiration (+); High of rib expiration (+); Width of rib shadow (+); Length TWA inspiration (+) |
| PC3 | 16.3% | Width of rib shadow (+); Width of rib shadow inspiration (+); Width of rib shadow expiration (–); Width TWA expiration (–); W2 of rib shadow (+) |
Table 2: PCA summary (PC1–PC3)
Heatmap interpretation aligned with this structure: red (positive) loadings denoted parameters increased in Bronchitis, whereas blue (negative) loadings marked parameters reduced in Bronchitis—i.e., characteristic narrowing in selected respiratory phases. Overall, inspiratory measurements contributed most strongly to group separation.
Figure 1: PCA loadings heatmap
Note: Red = positive loading (increased in Bronchitis); Blue = negative loading (reduced in Bronchitis).
Receiver‑operating analysis using the Youden Index identified practical thresholds with high rule‑in performance. Length TWA (>61.5 mm) yielded the highest Youden value (0.482; specificity 97.1%), and Length TWA inspiration (>54.5 mm) achieved the highest AUC (0.706;
specificity 95.3%). Width TWA expiration (<20>14.62 mm) each reached specificity 95.5%, while Width TWA (<21>
| Variable | AUC | Youden | Threshold | Decision rule | Sensitivity | Specificity |
| Length TWA | 0.586 | 0.482 | 61.500 | Bronchitis if value > 61.5 | 0.511 | 0.971 |
| Length TWA inspiration | 0.706 | 0.473 | 54.500 | Bronchitis if value > 54.5 | 0.520 | 0.953 |
| Width TWA expiration | 0.594 | 0.318 | 20.330 | Bronchitis if value < 20> | 0.362 | 0.955 |
| Width of ribs shadow | 0.617 | 0.310 | 14.620 | Bronchitis if value > 14.62 | 0.354 | 0.955 |
| Width TWA | 0.552 | 0.298 | 21.670 | Bronchitis if value < 21> | 0.397 | 0.900 |
Table 3: Youden Index – Top 5 variables and thresholds
Bar Plot of Top Discriminative Variables
The bar plot below shows the top five discriminative variables for distinguishing bronchitis from normal cases. Positive values indicate variables that increase in size in bronchitis, while negative values indicate which variables decrease in size in bronchitis:
Variables with positive signs reflect increased structural alterations linked to chronic inflammation, whereas negative values indicate dimensional reductions suggestive of airflow obstruction. Together, these markers provide complementary discriminatory power across thoracic regions. [Figure 2]:
The cut-off values for Length TWA show regional variation. The highest positive threshold is observed in region 4, while the lowest positive threshold is observed in region 3 [Table 4, Figure 3].
The cut-off values for Width TWA show regional variation. The highest negative threshold is observed in region 2, while the lowest negative threshold is observed in region 1 [Table 5, Figure 4].
The cut-off values for Width TWA expiration show regional variation. The highest negative threshold is observed in region 3, while the lowest negative threshold is observed in region 1 [Table 6, Figure 5].
The cut-off values for Length TWA inspiration show regional variation with highest positive threshold in region 2, while the lowest positive threshold is observed in region 4 [Table 7, Figure 6].
The cut-off values for Width of ribs shadow show regional variation. The highest threshold is observed in region 3, while the lowest threshold is observed in region 1[Table 8, Figure 7].
The cut off values of top five variables indicates that diagnostic performance may depend on regional lung characteristics in normal and diseased conditions [Figure 3-8].
Table 4
Table 5
Figure 3
Figure 4
Table 6
Table 7
Figure 5
Figure 6
Table 8
Figure 7
Figure 8
Table 8, Figure 70A multivariable logistic model combining these five Youden‑selected parameters provided improved discrimination: AUC (train) 0.769 and 10‑fold cross‑validated AUC 0.755. At the optimal probability threshold (0.651), sensitivity and specificity were 0.614 and 0.958, respectively (Youden 0.572), indicating excellent rule‑in capability with moderate sensitivity.
Figure 9: ROC curve – Logistic regression (top 5 Youden variables)
Model performance: AUC (train) = 0.769; AUC (10‑fold CV) = 0.755; Optimal threshold = 0.651; Sensitivity = 0.614; Specificity = 0.958; Youden = 0.572.
The integrated analysis delineates a coherent sonographic signature of chronic bronchitis. Across complementary statistical and comparative methods, two recurring features emerge: (i) inspiratory TWA length and rib-shadow metrics show positive loadings and higher means in bronchitis, while (ii) selected widths—especially TWA width and expiratory rib-shadow widths—exhibit negative loadings, indicating a phase-dependent narrowing pattern.
Ultrasound markers and discriminative value
The comparative bar-plot analysis underscores the discriminative performance of top ultrasound-derived variables across thoracic regions. Width of TWA (expiration) and Width of TWA (quite breathing) consistently demonstrate negative contributions, reflecting their reduction in bronchitis compared with normal subjects. Conversely, Length of TWA during quiet breathing displays a strong positive contribution, aligning with the structural elongation of the twinkling white area in bronchitic patients. Rib-shadow width variables reveal region-specific behaviors, mirroring the interplay between hyperinflation and rib spacing.
Together, these findings confirm that dimensional changes of the TWA and rib-related measurements offer complementary diagnostic information. Particularly, the inclusion of quiet-breathing TWA length emphasizes the sensitivity of bronchitic lungs to subtle inspiratory mechanics, providing a practical, reproducible bedside marker [17].
Pathophysiological underpinnings and imaging correlates
Chronic bronchitis involves peribronchial inflammatory processes that progressively extend into the subpleural and interlobular interstitium via lympho-vascular conduits, longitudinal spread along bronchovascular bundles, extracellular-matrix remodeling with perifocal fibrosis, and cytokine/chemokine-driven recruitment. The cumulative effect is pleural interface thickening and increased subpleural density [18,19,20,21].
The sonographic features that distinguish emphysema from chronic bronchitis reflect their fundamental pathophysiological differences. In chronic bronchitis, increased echogenicity of the pleural line and subpleural structures, particularly during expiration, likely corresponds to peribronchial and interstitial inflammation [20]. Histological studies have shown that inflammation in chronic bronchitis can spread from peribronchial regions to subpleural areas via vascular and lymphatic pathways [21], leading to increased tissue density and thickening of the pleural line visible on ultrasound [22].
In emphysema, however, the dominant mechanism is destruction of the alveolar-capillary membrane and elastic fibers, resulting in air trapping and hyperinflation [17,23].
These histopathological alterations provide a coherent rationale for the sonographic signature observed. Inspiratory elongation of the TWA (positive loadings, higher means in bronchitis) is consistent with enhanced acoustic backscatter from a roughened pleural–subpleural interface affected by airway wall edema, mucus accumulation, and small airway inflammation. Conversely, the reduction in TWA width and expiratory rib-shadow widths (negative loadings) likely reflects phase dependent airway narrowing/closure and altered impedance, generating elongated, slender echogenic densities rather than broadening.
Rib-to-pleura distances and rib-shadow geometry further indicate subtle modifications in chest-wall/pleural mechanics. Prolonged inspiratory effort and early expiratory flow limitation alter acoustic angles and window thickness, amplifying inspiratory length signals while attenuating expiratory widths. These mechanisms explain the bidirectional loading pattern captured by PCA/heatmaps and support the phase-aware acquisition strategy proposed here.
Some control subjects showed localized sonographic signs of small airway obstruction—paradoxical TWA shortening during expiration and increased width—despite normal spirometry but abnormal flow–volume curves. These findings highlight spirometry’s limitations in detecting early disease and support ultrasound as a screening tool for latent dysfunction [24,25]. In addition, overlapping emphysema and bronchitis patterns were detected within individual patients, underscoring COPD’s heterogeneity and the clinical value of regional LUS in identifying both distribution and subtype of disease involvement.
Clinical implications
Clinically, single cut-off thresholds (e.g., Length TWA inspiration > 54.5 mm; Length TWA > 61.5 mm; length TWA expiration > 66.5mm) demonstrate high specificity, favoring a rule-in role. The multivariable model (AUC = 0.769; CV-AUC = 0.755) preserves high specificity (0.958) while achieving moderate sensitivity, strengthening discrimination between bronchitis and normal lungs. A phase-aware scanning protocol—leveraging inspiratory frames for TWA length and rib-shadow geometry, and expiratory frames for width reductions—offers a pragmatic diagnostic workflow.
Future research should address inter-rater reliability, probe/device variability, and integration with spirometry and clinical indices in prospective diagnostic pathways. Validating these sonographic features in multicenter cohorts would consolidate their role as rapid, bedside markers for obstructive lung disease.
This study is among the first to systematically characterize chronic bronchitis using quantitative lung ultrasound. Its strengths include a prospective design, standardized multi-region scanning, and integration of robust statistical methods. Limitations include operator dependence of ultrasound measurements, variability in breathing effort, and age imbalance between groups, though these factors are unlikely to bias intergroup comparisons. The consistent identification of positive markers (TWA length in quiet breathing and inspiration, rib-shadow width) and negative markers (TWA width and TWA width in expiration) establishes a phase-dependent diagnostic framework. This bidirectional signature supports a phase-aware scanning protocol with high specificity, and, with further validation and dedicated software for TWA density quantification, lung ultrasound may serve as a reliable bedside surrogate for spirometry in COPD phenotyping.
Chronic bronchitis shows a consistent sonographic pattern characterized by increased Length of TWA quiet breathing expiration and inspiration) and rib-shadow width, together with reduced Width of TWA and Width of TWA expiration. This bidirectional, phase-dependent signature supports a practical phase-aware scanning protocol, offering high rule-in specificity and improved diagnostic discrimination at the bedside. Lung ultrasound no longer describes illusions; it translates function. It speaks of air where air moves, of tissue where life circulates. It measures obstruction not by breath alone, but by geometry. It is the moment when sound becomes structure, the image begins to breathe and a visual physiology.
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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).
