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*Corresponding Author: Run Yu, Division of Endocrinology, UCLA David Geffen School of Medicine, Los Angeles, California, USA.
Citation: Jien Shim, Lu Song, Komarova L.E, Run Yu, (2023), Frequency and Clinical Significance of Low or High Sex Hormone Binding Globulin Levels in Patients Suspected of Harboring Abnormal Testosterone Levels, J. Endocrinology and Disorders. 7(3): DOI:10.31579/2640-1045/136
Copyright: © 2023, Run Yu. 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: 17 May 2023 | Accepted: 31 May 2023 | Published: 07 June 2023
Keywords: sex hormone binding globulin; testosterone; sex hormones; comorbidities
Purpose: We aim to examine the frequency of low or high sex hormone binding globulin (SHBG) levels and to investigate whether they are associated with comorbidities and hormonal derangements in patients suspected of harboring abnormal testosterone levels.
Methods: This was a retrospective study of adult patients who underwent SHBG testing as part of a panel for testosterone at UCLA Health between May and July 2019.
Results: A total of 1102 male and 689 female patients underwent SHBG testing; the most common indications of the tests were suspected hypogonadism in male and hyperandrogenism in female patients. Eight male (0.7%, 9.4±1.0 nmol/L) and 66 female patients (9.6%, 21.7±5.2 nmol/L) exhibited low SHBG levels, and 113 male (10.3%, 106.6±29.6 nmol/L) and 118 female (17.1%, 187.1±59.6 nmol/L) patients exhibited high SHBG levels. Patients with low SHBG levels were younger, had higher body mass index, and less commonly receive sex hormone treatments than those with high SHBG levels but they were not different in other assessed clinical parameters. Bioavailable and free testosterone levels were not different in males with low or high SHBG levels but were significantly higher in females with low SHBG levels than in those with high SHBG levels.
Sex hormone binding globulin (SHBG) is a transport protein that selectively binds with steroid hormones, especially androgens [1,2]. SHBG is made by the liver and released into the circulation. The only established clinical significance of SHBG is the regulation of bioavailable testosterone levels [3,4]. As SHBG binds with testosterone tightly, higher SHBG levels could reduce bioavailable testosterone levels while lower SHBG levels could raise bioavailable testosterone levels. Besides this function, SHBG may also play a role in the pathogenesis and pathophysiology of obesity, metabolic syndrome, polycystic ovary syndrome, osteoporosis, breast and prostate cancer, coronary artery disease, and aging [5-12]. SHBG levels are upregulated by estrogen, thyroid hormones, and antiepileptic drugs, in alcoholism, liver disease, HIV infection, and older age, and are downregulated by androgen, obesity, hyperinsulinemia, cortisol excess, progesterone use, growth hormone excess, nephrotic syndrome, and hypothyroidism [1-5,12-28]. It is not clear which of the known factors and what other potential factors are associated with low or high SHBG levels in routine clinical practice.
SHBG levels are commonly measured as a component of the testosterone panel which also includes total, bioavailable, and free testosterone. Thereby, low or high SHBG levels are found in some patients suspected of harboring abnormal testosterone levels, because SHBG results are reported with sex- and age-specific reference ranges. We are often asked by colleagues and patients about the clinical significance of low or high SHBG levels. The frequency and clinical significance of low or high SHBG levels, however, are not known so far. In this study, we aim to examine the frequency of low or high SHBG levels and to investigate whether low or high SHBG levels are associated with comorbidities and hormonal derangements in patients suspected of harboring abnormal testosterone levels.
Patient Eligibility. All patients older than 18 years who were tested for SHBG at UCLA Health laboratory between May and July 2019 were eligible. There are no exclusion criteria. In all patients, SHBG levels were measured as a component of the testosterone panel which also included total, bioavailable, and free testosterone.
Data extraction. The list of patients was obtained from Department of Pathology and Laboratory Medicine, UCLA Health. The patients’ electronic charts were accessed to gather information including demographics, clinical history, laboratory tests, imaging studies, surgical notes, and pathological reports. The patients’ demographics, weight, height, body mass index, clinical presentation, bone density, alcohol drinking history, comorbidities, and laboratory test results were extracted. SHBG was measured by electrochemiluminescence immunoassay on the Roche Cobas e 602 platform. The SHBG reference ranges were 11-80 nmol/L for male and 30-135 nmol/L for female adult patients. Low SHBG levels were defined as values lower than the lower limits of normal reference ranges and high SHBG levels were defined as values higher than the upper limits of reference ranges.
Statistics. Continuous data were expressed as mean±SD in text or mean (range) in tables to provide more details. Student t test was used to determine the significance of the difference between the means of continuous values of two populations. Fisher’s exact test was used to determine the significance of the difference between the rates of two populations.
Frequency of low or high SHBG levels. Between May and July 2019, 1102 male and 689 female adult patients underwent SHBG testing as part of testosterone testing panel. Eight male (0.7%) and 66 female patients (9.6%) exhibited low SHBG levels, and 113 male (10.3%) and 118 (17.1%) female patients exhibited high SHBG levels (Table 1 and Table 2).
| Low SHBG | High SHBG | p | |
| n | 8 | 113 | NA |
| Age (range), yr | 46.0 (28-62) | 63.3 (25-87) | <0> |
| BMI (range), kg/m2 | 31.0 (25.2-37.6) | 25.1 (14.7-41.1) | <0> |
| Testosterone replacement, yes/no, n | 4/4 | 20/87 | 0.0577 |
| Finasteride, yes/no, n | 1/7 | 4/109 | NS |
| Anastrozole, yes/no, n | 0/8 | 1/112 | NS |
| Estradiol, yes/no, n | 0/8 | 3/110 | NS |
| Liver disease, yes/no, n | 0/8 | 5/102 | NS |
| Alcohol drinking, yes/no, n | 3/5 | 37/53 | NS |
| Coronary artery disease, yes/no, n | 1/7 | 9/104 | NS |
| Osteoporosis, yes/no, n | 0/8 | 3/110 | NS |
| TSH (range), µIU/mL | 3.4 (1.4-8.0) (n=6) | 2.4 (0.02-18.5) (n=88) | NS |
| Prostate cancer, yes/no, n | 1/7 | 7/106 | NS |
| SHBG (range), nmol/L | 9.4 (7-10) | 106.6 (81-260) | <0> |
| Total testosterone (range), ng/dL | 226.3 (91-529) | 615.0 (3-1531) | <0> |
| Bioavailable testosterone (range), ng/dL | 208.0 (72-434) (n=6) | 160.2 (1-321) (n=98) | NS |
| Free testosterone (range), pg/mL | 64.8 (25.3-141) | 54.9 (0.6-126.6) (n=110) | NS |
| E2 (range), pg/mL | 25.5 (16-35) (n=2) | 73.8 (12-550) (n=19) | NS |
| LH (range), mIU/mL | 7.5 (2.8-12) (n=2) | 13.6 (0.1-56.1) (n=27) | NS |
| FSH (range), mIU/mL | 7.8 (1.3-16.4) (n=3) | 12.4 (0.1-51.3) (n=22) | NS |
| Prolactin (range), ng/mL | 8.3 (7.3-9.3) (n=2) | 41.0 (5-593) (n=21) | NS |
| AST (range), U/L | 21.4 (16-32) (n=7) | 26.5 (10-174) (n=93) | NS |
| ALT (range), U/L | 27.3 (18-50) (n=7) | 23.6 (7-310) (n=94) | NS |
| AP (range), U/L | 68.1 (2-169) (n=7) | 68.1 (37-135) (n=92) | NS |
| Bilirubin (range), mg/dL | 0.5 (0.3-1) (n=7) | 0.6 (0.2-2.1) (n=92) | NS |
| Albumin (range), g/dL | 4.7 (4.2-5.3) (n=7) | 4.4 (3.4-5.6) (n=92) | NS |
| Globulin (range), g/dL | 2.8 (2.3-3.4) (n=7) | 2.7 (1.8-4.6) (n=91) | NS |
Table 1: Comparison of clinical characteristics of male adult patients with low or high SHBG levels. When data are not available for all patients, the number of patients with available data is indicated. The SHBG reference ranges were 11-80 nmol/L for male adult patients. NA, not applicable; NS, not significant.
| Low SHBG | High SHBG | p | |
| n | 66 | 118 | NA |
| Age (range), yr | 34.5 (18-74) | 41.8 (18-75) | <0> |
| BMI (range), kg/m2 | 35.1 (21.3-53.4) | 24.4 (16.6-38.6) | <0> |
| Hormone replacement therapy, yes/no, n | 4/62 | 22/96 | 0.0258 |
| Hormonal contraception, yes/no, n | 2/64 | 31/87 | <0> |
| Liver disease, yes/no, n | 4/62 | 8/110 | NS |
| Alcohol drinking, yes/no, n | 25/29 | 53/45 | NS |
| Polycystic ovary syndrome, yes/no, n | 18/48 | 16/102 | 0.029 |
| Coronary artery disease, yes/no, n | 1/65 | 0/118 | NS |
| Osteoporosis, yes/no, n | 0/68 | 5/113 | NS |
| TSH (range), µIU/mL | 2.1 (0.2-10.7) (n=59) | 2.1 (0.04-12.3) (n=97) | NS |
| Breast cancer, yes/no, n | 0/66 | 1/117 | NS |
| SHBG (range), nmol/L | 21.7 (9-29) | 187.1 (136-458) | <0> |
| Total testosterone (range), ng/dL | 31.8 (7-362) | 42.1 (2-639) (n=114) | NS |
| Bioavailable testosterone (range), ng/dL | 25.4 (3.6-207) (n=27) | 4.0 (0.1-13.5) (n=31) | 0.004 |
| Free testosterone (range), pg/mL | 6.8 (1.2-71) | 2.1 (0.1-23.6) (n=113) | <0> |
| E2 (range), pg/mL | 57.5 (0-319) (n=28) | 94.3 (0-820) (n=76) | NS |
| LH (range), mIU/mL | 14.8 (2.1-64.7) (n=33) | 14.6 (0-80.5) (n=47) | NS |
| FSH (range), mIU/mL | 10.1 (2.8-108) (n=36) | 23.7 (0-127) (n=65) | 0.028 |
| Prolactin (range), ng/mL | 18.3 (6.6-53.1) (n=30) | 16.0 (0-54.0) (n=36) | NS |
| AST (range), U/L | 23.7 (10-57) (n=46) | 56.7 (10-2661) (n=79) | NS |
| ALT (range), U/L | 30.4 (11-143) (n=46) | 44.2 (8-1819) (n=80) | NS |
| AP (range), U/L | 75.1 (49-160) (n=46) | 64.7 (25-255) (n=78) | NS |
| Bilirubin (range), mg/dL | 0.42 (0.2-1.1) (n=44) | 0.45 (0.2-2) (n=77) | NS |
| Albumin (range), g/dL | 4.6 (4-5.3) (n=46) | 4.5 (3.2-5.3) (n=76) | NS |
| Globulin (range), g/dL | 3.0 (1.7-4.0) (n=45) | 2.7 (1.7-4.0) (n=78) | 0.001 |
Table 2: Comparison of clinical characteristics of female adult patients with low or high SHBG levels. When data are not available for all patients, the number of patients with available data is indicated. The SHBG reference ranges were 30-135 nmol/L for female adult patients. NA, not applicable; NS, not significant.
Characteristics of patients with low or high SHBG levels.The mean SHBG level of male patients with low SHBG levels was 9.4±1.0 nmol/L and that with high SHBG levels was 106.6±29.6 nmol/L. The mean SHBG level of female patients with low SHBG levels was 21.7±5.2 nmol/L and that with high SHBG levels was 187.1±59.6 nmol/L (Table 1 and Table 2). In both male and female patients, those with low SHBG levels were younger (mean age 46.0 versus 63.3 in male patients, p<0>p<0>p<0>p<0>p<0>p=0.004 and 6.8 versus 2.1 pg/mL, p<0>
Hypogonadism and erectile dysfunction were the most common conditions in male patients with SHBG tests (Table 3 and Table 4). Because only 8 males had low SHBG levels, it was impossible to derive medical factors within this group that are associated with low SHBG levels. In male patients with high SHBG levels, 3 treated with estrogen for transgender purposes had the highest SHBG as a group (Table 4). Male patients with prostate cancer who were undergoing androgen ablation therapy had higher SHBG levels than those who were not but the difference was not significant, likely due to small sample size (Table 4).
| Indication | n (%) | Age, mean (range), yr* | SHBG, mean (range), nmol/L* |
| Hypogonadism | 7 (87.5) | 46.9 (28-62) | 9.3 (7-10) |
| Erectile dysfunction | 1 (12.5) | 40 | 10 |
Table 3: Clinical characteristics of male patients with low SHBG levels. *When an indication only applies to 1 patient, the individual values are listed.
| Indication | n (%) | Age, mean (range), yr* | SHBG, mean (range), nmol/L* |
| Hypogonadism | 33 (29.2) | 64.3 (29-87) | 102.6 (82-175) |
| Erectile dysfunction | 15 (13.2) | 61.8 (35-84) | 109.3 (85-260) |
| Health maintenance | 13 (11.5) | 57.8 (30-78) | 118.4 (82-186) |
| Prostate cancer | 9 (8.0) | 74.6 (54-84) | 98.0 (81-140) |
| Prostate cancer without androgen ablation | 5 (4.4) | 70.6 (54-80) | 93.2 (81-105) |
| Prostate cancer with androgen ablation | 4 (3.5) | 79.5 (73-84) | 104.0 (81-140) |
| Fatigue | 8 (7.1) | 49.9 (38-76) | 100.4 (82-122) |
| Osteoporosis | 7 (6.0) | 68.7 (55-78) | 114.1 (86-144) |
| Benign prostate hypertrophy | 6 (6.2) | 72.2 (62-80) | 92.3 (86-106) |
| Low libido | 4 (3.5) | 64.5 (59-67) | 95.3 (84-113) |
| Gynecomastia | 3 (2.7) | 58.3 (25-80) | 96.7 (84-106) |
| Male-to-female transgender | 3 (2.7) | 56.0 (47-65) | 182.3 (166-191) |
| Pituitary tumor | 3 (2.7) | 60.3 (44-74) | 106.0 (86-131) |
| Anemia | 2 (1.8) | 66, 69 | 83, 103 |
| Family history of high testosterone | 1 (0.9) | 82 | 83 |
| Alopecia | 1 (0.9) | 56 | 87 |
| Adrenal cortical carcinoma | 1 (0.9) | 53 | 89 |
| Not described | 4 (3.5) | 63 (57-69) | 111.8 (88-156) |
Table 4: Clinical characteristics of male patients with high SHBG levels. *When an indication only applies to 1 or 2 patients, the individual values are listed.
Polycystic ovary syndrome, irregular menses, and hirsutism were the most common conditions in female patients with low SHBG levels (Table 5). The SHBG levels were remarkably similar regardless of the clinical conditions in female patients with low SHBG levels. Menopause, irregular menses, and polycystic ovary syndrome were the most common conditions in female patients with high SHBG levels (Table 6). The 17 patients with polycystic ovary syndrome had the highest SHBG levels as a group but the difference between the SHBG levels in female patients with polycystic ovary syndrome and those in other groups was small.
| Indication | N (%) | Age, mean (range), yr* | SHBG, mean (range), nmol/L* |
| Polycystic ovary syndrome | 29 (43.9) | 28.5 (18-54) | 20.7 (9-29) |
| Irregular menses | 8 (12.1) | 33.3 (22-39) | 21.4 (16-25) |
| Hirsutism | 6 (9.1) | 35.7 (19-58) | 23.0 (16-29) |
| Amenorrhea | 5 (7.6) | 27.0 (20-44) | 20.4 (14-29) |
| Menopause | 5 (7.6) | 49.8 (41-47) | 24.2 (21-29) |
| Hyperandrogenism | 4 (6.1) | 63.5 (54-74) | 22.3 (14-28) |
| Alopecia | 3 (4.5) | 30.3 (19-41) | 22.7 (19-25) |
| Female-to-male transgender | 1 (1.5) | 47 | 27 |
| Infertility | 1 (1.5) | 39 | 24 |
| Not described | 4 (6.1) | 38.5 (20-63) | 22.3 (9-29) |
Table 5: Clinical characteristics of female patients with low SHBG levels. *When an indication only applies to 1 or 2 patients, the individual values are listed.
| Indication | n (%) | Age, mean (range), yr* | SHBG, mean (range), nmol/L* |
| Menopause | 34 (28.8) | 52.4 (40-75) | 175.6 (136-312) |
| Irregular menses | 17 (14.4) | 33.3 (18-63) | 171.8 (137-251) |
| Polycystic ovary syndrome | 17 (14.4) | 28.4 (19-39) | 214.8 (138-358) |
| Alopecia | 7 (5.9) | 46.4 (27-67) | 194.1 (141-385) |
| Low libido | 5 (4.2) | 47.2 (36-57) | 191.2 (142-292) |
| Amenorrhea | 4 (3.4) | 35.0 (28-39) | 170.5 (160-178) |
| Hirsutism | 3 (2.5) | 34.3 (25-44) | 159.3 (143-170) |
| Acne | 3 (2.5) | 42.7 (25-61) | 151.0 (142-168) |
| Hormone imbalance | 3 (2.5) | 39.0 (31-47) | 198.7 (143-281) |
| Healthcare maintenance | 2 (1.7) | 27, 31 | 161, 236 |
| Hyperandrogenism | 2 (1.7) | 29, 43 | 168, 173 |
| Fatigue | 2 (1.7) | 39, 56 | 164, 456 |
| Pelvic pain | 1 (0.8) | 50 | 139 |
| Pregnancy | 1 (0.8) | 36 | 380 |
| Premenstrual syndrome | 1 (0.8) | 42 | 151 |
| Female-to-male transgender | 1 (0.8) | 25 | 140 |
| Low testosterone | 1 (0.8) | 39 | 169 |
| Ovarian cyst | 1 (0.8) | 51 | 178 |
| Dyspareunia | 1 (0.8) | 31 | 197 |
| Endometriosis | 1 (0.8) | 34 | 186 |
| Cushing disease | 1 (0.8) | 23 | 331 |
| Anovulation | 1 (0.8) | 34 | 145 |
| Adrenal mass | 1 (0.8) | 71 | 214 |
| Chest pain | 1 (0.8) | 56 | 259 |
| Headache | 1 (0.8) | 38 | 165 |
| Not described | 6 (5.1) | 50.3 (25-63) | 166.7 (148-183) |
Table 6: Clinical characteristics of female patients with high SHBG levels. *When an indication only applies to 1 or 2 patients, the individual values are listed.
Whenever an abnormal test result is reported, its clinical significance becomes the key issue. After sex hormone binding globulin (SHBG) was routinely reported as part of a testosterone panel in our institution, we began to encounter low or high SHBG levels defined by the clinical laboratory. We were also asked by patients on why their SHBG levels were low or high and how to make the SHBG levels normal. Our current study gives us useful information on the clinical significance of low or high SHBG levels in patients suspected of harboring abnormal testosterone levels.
Most studies classify SHBG levels into tertiles or quartiles, implying that no abnormal SHBG levels are defined [18,27,28]. In a clinical setting, all laboratory tests, including SHBG, must have a reference range. To our knowledge, the frequency of low or high SHBG levels in a clinical setting has not been reported before. We first show that in patients with suspected testosterone abnormalities, mostly hypogonadism in males and hyperandrogenism in females, low SHBG levels are rare in males but quite common in females (about 10%) and high SHBG levels are quite common in both males (about 10%) and females (about 17%). Thus overall, over 10% of males with suspected hypogonadism and over 25% of females with suspected hyperandrogenism have “abnormal” SHBG levels, making SHBG result interpretation a significant issue for those patients in clinical practice. It is worthwhile to point out that our results on frequency of low or high SHBG levels in our study subjects were limited to patients suspected of harboring abnormal testosterone levels and should not be extrapolated to other population without further studies.
The biological functions of SHBG are complex and appear to be involved in many metabolic processes such as sex hormone function, obesity, metabolic syndrome, polycystic ovary syndrome, osteoporosis, breast and prostate cancer, coronary artery disease, and aging [1-12]. The diverse functions of SHBG are either mediated through modulation of sex hormone function or through direct SHBG interaction with its target cells [1-4,29]. Having “abnormal” SHBG levels is therefore a potentially large health hazard. Our data, however, show that “abnormal” SHBG levels have limited health effects. Male and female patients appear to have a somewhat different response to low or high SHBG levels. In male patients, even though total testosterone levels are higher in those with high SHBG levels, bioavailable and free testosterone levels are not different between those with low or high SHBG levels. Our data suggest that male patients with high SHBG levels may be more likely to received testosterone treatment, which increase the bioavailable and free testosterone levels in those patients as a group. In female patients, however, bioavailable and free testosterone levels are higher in those with low SHBG levels. Although we don’t have clear evidence indicating a specific mechanism for the difference in androgen response to SHBG levels in male and female patients, the higher gonadotropin levels in male patients with high SHBG levels suggests that male patients could compensate for the high SHBG levels by raising gonadotropin levels to stimulate testosterone production. This hypothesis needs to be tested in future studies. The very similar LH levels in female patients with low or high SHBG levels suggests that the higher FSH levels in female patients with high SHBG levels are probably due to the older age. Apart from testosterone levels, we did not find any difference in the association of low or high SHBG levels with polycystic ovary syndrome, osteoporosis, breast and prostate cancer, or coronary artery disease.
The regulation of SHBG levels is not very well understood [1-4,30,31]. Our study confirms that high SHBG levels are associated with older age and low SHBG levels with obesity in both male and female patients [5-12]. Our results are also generally consistent with the well-established observations that estrogen raises, and androgen suppresses, SHBG levels. Our data clearly showed that female patients with high SHBG levels more frequently were on hormone replacement therapy or hormonal contraception than those with low SHBG levels. The statistical trend of more frequent testosterone replacement in male patients with high SHBG than those with low SHBG levels is more plausibly explained by that the male patients with high SHBG levels tend to harbor lower bioavailable and free testosterone levels thus were more likely to require testosterone replacement. Alcohol drinking and withdrawal are associated with high SHBG levels [15, 16]. In our patient population, however, the percentage of patients with alcohol drinking history is not different between male and female patients with low or high SHBG levels, implying that alcohol drinking is not a major factor influencing SHBG levels in clinical practice. High SHBG levels are also associated with liver diseases such as iron overload and nonalcoholic fatty liver disease [17,18]. Liver functions and established liver diseases were remarkably similar in both male and female patients with low or high SHBG levels in our study, arguing against that liver disease is a major factor influencing SHBG levels in clinical practice. Although thyroid hormones regulate SHBG levels [13-26], the differences in SHBG levels in our patients were not explained by differences in the thyroid status as TSH levels were similar in both male and female patients with low or high SHBG levels. We did not have systemic data on seizure, antiepileptic medications, corticosteroid use, HIV infection, nephrotic syndrome, insulin levels, or growth hormone status which regulate SHBG levels [14,19-25]; case studies, however, did not find any of the factors we did not systemically study were present in those patients with the lowest or highest SHBG levels (data not shown). The major factors determining SHBG levels may be heterogeneous and remain unclear.
Our study had several limits. It was descriptive and correlative based on available clinical, laboratory, and imaging data. We could not derive convincing causal-effective relationship between the studied parameters and SHBG levels. Missing data prevented us from doing multivariate analysis of the numerous factors potentially correlated with SHBG levels. Our study did not collect data on patients with normal SHBG levels because we reasoned that if SHBG levels are associated with a particular disease, it is mostly likely to be differentially present in patients with low or high SHBG levels. Nonetheless, lack of data of patients with normal SHBG levels was still a limit of our study. Lastly, we could only study factors that we suspect may be correlated with SHBG levels or that we had data on so that we could miss factors that are significantly correlated with SHBG levels.
In summary, our study shows that low or high SHBG levels are common in patients suspected of harboring abnormal testosterone levels, especially in female patients. Besides age, body mass index, and sex hormone treatment, no other clinical characteristics are found to be correlated with SHBG levels in patients suspected of harboring abnormal testosterone levels. SHBG levels are not significantly associated with bioavailable and free testosterone levels in males but are inversely associated with bioavailable and free testosterone levels in females. Regardless of the causes, low or high SHBG levels per se do not appear to be a health hazard.
Conflicts of interests:
The authors have no relevant financial or non-financial interests to disclose.
Ethics approval:
The study has been approved by the UCLA Institution Review Board (#20-000631).
Informed Consent:
Informed Consent was waived by the UCLA Institution Review Board.
Low or high SHBG levels are common in patients suspected of harboring abnormal testosterone levels. Besides age, body mass index, and sex hormone treatments, no other clinical characteristics are found to be correlated with SHBG levels in this patient population.
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As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
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
