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Case Report | DOI: https://doi.org/10.31579/2578-8965/275
1Pós-graduação em Endocrinologia, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brasil.
2Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brasil.
3Ricardo A T Castilho Centro de Estudos, Associação Médica de Teresópolis, Teresópolis, Brasil.
4Laboratorio de Endocrinología Experimental - LEEx, Instituto de Ciencias Biomédicas, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brasil
5Departamento de Medicina Interna, Serviço de Diabetes da Maternidade - Escola, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brasil.
6Maternidade Escola da Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brasil.
7Hospital das Clínicas FMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil.
*Corresponding Author: Mirna Sanchez Carvallo, Pós-graduação em Endocrinologia, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brasil.
Citation: Mirna S. Carvallo, Figueiredo Duarte EH, Isabela Alves Saraiva de Sousa, Erika Naliato, Alice Helena Dutra Violante, Leandro Miranda Alves, Lenita Zajdenverg, Marcus Miranda Oliveira and Delmar Muniz Lourenço Jr., (2025), Follow-up and Clinical Management of a Pregnant Woman with Primary Hyperparathyroidism Associated with Multiple Endocrine Neoplasia Type 1: A Case Report, J. Obstetrics Gynecology and Reproductive Sciences, 9(5) DOI:10.31579/2578-8965/275
Copyright: © 2025, Mirna Sanchez Carvallo. 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: 04 July 2025 | Accepted: 25 July 2025 | Published: 31 July 2025
Keywords: multiple endocrine neoplasia type 1; primary hyperparathyroidism; pregnancy; hypercalcemia; fetal growth restriction
Introduction: Studies on clinical implications and management of endocrine tumors in pregnant women with Multiple Endocrine Neoplasia Type 1 (MEN1) are limited to case reports or small series, which challenges individualized treatment decision making. Potential risks of maternal and fetal complications related to MEN1 neoplasms, such as primary hyperparathyroidism (PHPT) and prolactinoma, are primarily known from studies on sporadically occurring tumors.
Case Description: A 38-year-old woman with MEN1 developed mild and sustained hypercalcemia (serum calcium: 10.36 ± 0.32, 9.9-10.8 mg/dL) due to PHPT, throughout her pregnancy, leading to careful periodic laboratory surveillance without specific therapeutic intervention. Progressive intrauterine fetal growth restriction during the third trimester resulted in a cesarean section birth at term (at 38 weeks and 4 days) of a low birth weight for gestational age newborn (< 3rd percentile: 2115 grams).
Conclusions: This case highlights the need for monitoring the progression of intrauterine growth in pregnant women with PHPT associated with MEN1. Since there are no established guidelines for the clinical or surgical management of PHPT in pregnant women with MEN1, treatment decisions should be individualized and made by a specialized multidisciplinary team, based primarily on experience, albeit limited, from sporadic cases of PHPT.
Multiple Endocrine Neoplasia Type 1 (MEN1) is a rare genetic syndrome caused by germline mutations in the MEN1 tumor suppressor gene (chromosome 11q13), which encodes the MENIN nuclear protein, an ubiquitin ligase that regulates transcription, genome stability, and cellular division and proliferation. Germline mutations in the MEN1 gene — deletions, insertions, missense, or nonsense mutations — inactivate this protein, leading to loss of its tumor-suppressing function, and thus predisposing individuals to the development of endocrine tumors that primarily affect pituitary, gastrointestinal tract, and parathyroid glands [1-3].
The estimated prevalence of the syndrome is 3-20 cases per 100,000 individuals, and it affects predominantly women [4]. More than 80% of individuals with a MEN1 germline mutation will present clinical manifestations at the fifth decade of life [5], marking its high penetrance, which is virtually complete at older ages, particularly characterized by primary hyperparathyroidism (PHPT) and non-functioning pancreatic neuroendocrine tumors (NETs). Therefore, these tumors are the most prevalent in MEN1, followed by gastrinoma and prolactinoma. Other pituitary tumors, such as growth hormone-secreting, ACTH-secreting, and non-functioning tumors, as well as other pancreatic NETs, such as insulinomas and glucagonomas, occur less frequently in MEN1. In addition, other endocrine tumors, such as thymic, pulmonary, and gastric NETs, as well as adrenal cortical adenomas, dermal tumors (lipomas, angiofibromas, collagenomas), and other non-endocrine tumors like meningiomas, leiomyomas, and ependymomas, may also develop with variable prevalence [5-7].
Clinical diagnosis of MEN1 is established by the presence of tumors affecting at least two of the three main endocrine glands associated with MEN1: parathyroid, pituitary, and pancreatic/duodenal endocrine tissue. The diagnosis of familial MEN1 can be established when a first-degree relative of a confirmed MEN1 patient also presents at least one endocrine tumor affecting one of these tissues/glands. Molecular diagnosis is made by identifying a MEN1 germline mutation in an individual, regardless of phenotype [4-8].
The scarcity of studies and specific guidelines for the management of pregnant women with MEN1 significantly challenges follow-up and treatment. The rarity of MEN1, combined with the multiplicity of tumor manifestations, requires individualized and multidisciplinary approach.
Hogg et al. identified an increased risk of maternal and fetal complications in 26 women with MEN1 throughout 96 pregnancies, as they were more prone to hypertensive disorders, gestational diabetes, premature birth, and low birth weight offspring [9].
The risk of complications during pregnancy varies according to the clinical manifestations of the syndrome. The presence of PHPT has been associated with higher risk of hypertensive disorders, hyperemesis gravidarum, nephrolithiasis, and pancreatitis, as well as intrauterine growth restriction and neonatal hypocalcemia [10]. Pregnant women with prolactinoma are at a higher risk of pituitary adenoma enlargement and, consequently, pituitary apoplexy and visual disturbances [11]. Given this complexity, pre- and perinatal follow-up of pregnant women with MEN1 by an experienced and multidisciplinary team is crucial to ensure the well-being of both mother and child, as more than one endocrine tumor with potential risks to both may synchronously occur.
We present the case of a pregnant woman with MEN1, highlighting the endocrine manifestations of the syndrome during pregnancy and the strategies employed to optimize maternal and fetal outcomes.
At 23 years of age, following an endocrine investigation due to menstrual irregularity, a female patient was diagnosed with a microprolactinoma and started on dopamine agonist treatment (cabergoline), exhibiting an excellent response, with normalization of serum prolactin levels and involution of the tumor lesion at pituitary magnetic resonance imaging (MRI).
Four years later, the patient and her brother were referred to the Endocrinology Outpatient Clinic at the Clementino Fraga Filho University Hospital (HUCFF) for genetic counseling, since their mother had been clinically diagnosed with MEN1 (Table 1).
| Cases | Age at clinical / molecular diagnosis (years) | Morbidities |
| Proband (mother) | 46 / 52 | Prolactinoma PHPT Adrenocortical tumor (NF) Insulinoma |
| Brother | 34 / 38 | PHPT Metastatic thymic NET |
| Pregnant (present case) | 23 / 28 | Prolactinoma PHPT Bronchial NET Adrenocortical tumor (NF) |
Table 1: Clinical features of a pregnant woman with MEN1 and her affected family members harboring the nonsense germline pathogenic variant c.1177C>T (p.Q393).
PHPT: primary hyperparathyroidism; NF: non-functioning
Molecular analysis of these three family members, performed at the Faculty of Medicine of the University of São Paulo (FMUSP), revealed a pathogenic germline variant, in heterozygosity, nonsense (c.1177C>T; p.Q393) in exon 8 of the MEN1 gene (Figure 1).
Figure 1: A pathogenic variant was initially found in the proband and her two siblings, including her pregnant daughter with primary hyperparathyroidism and prolactinoma. The normal MEN1 reference sequence, as well as the forward and reverse sequences amplified from the proband (mother), are illustrated, revealing a change from cytosine to thymine at position 1177 of the complementary DNA (c.1177C>T) located in exon 8 of the MEN1 gene, resulting in a stop codon corresponding to codon 393 of the MENIN protein, which encodes the amino acid glutamine, generating a truncated protein with 392 amino acids.
Due to the diagnosis of familial MEN1, active laboratory surveillance of calcium, phosphate, and parathyroid hormone levels was initiated. Over the first 11 years of follow-up, her serum calcium levels remained at the upper normal limit with concomitant inappropriately normal or non-suppressible PTH levels - characterizing mild primary hyperparathyroidism (PHPT). The patient subsequently developed sustained mild hypercalcemia and elevated PTH levels (Table 2). Bone densitometry was performed, showing a 4% decrease in femoral neck bone density over a 7-year period.
| Year | Calcium (mg/dL) | Phosphorus (mg/dL) | PTH (pg/mL) |
| 2007 | 9.7 | 3.6 | 47.7 |
| 2008 | 9.6 | 3.5 | 43.3 |
| 2009 | 10.1 | 3.6 | 51.4 |
| 2010 | 9.6 | 3.3 | - |
| 2011 | - | - | - |
| 2012 | - | - | - |
| 2013 | 10.1 | 3.8 | 66.4 |
| 2014 | 10.1 | 3.6 | 50.3 |
| 2015 | 9.3 | 2.7 | 36.0 |
| 2016 | 9.9 | 3.4 | 62.3 |
| 2017 | 10.0 | 3.0 | 76.3 |
| 2018 | 10.5 | 3.5 | 94.4 |
Table 2: Calcium, phosphorus and PTH levels (2007-2018)
Reference values: Calcium = 8.5 -10.2 mg/dL; Phosphorus = 2.5 - 4.5 mg/dL; PTH = 12 - 65pg/mL
Given these persistent changes, parathyroid scintigraphy was performed and detected persistent 3h-uptake of sestamibi by the lower right cervical region, suggesting the presence of a parathyroid adenoma. The patient was referred to a parathyroidectomy. However, surgery was not performed, since the patient returned to the outpatient clinic reporting an ongoing pregnancy. At that moment, dopamine agonist treatment was discontinued and the 38-year-old patient was subsequently referred to the Maternity School of the Federal University of Rio de Janeiro (UFRJ) for prenatal follow-up by a multidisciplinary team at 7 weeks and 3 days of gestation. During the first consultation, she was counseled about the possibility of parathyroidectomy during the second trimester of pregnancy.
In the first trimester of pregnancy, daily treatment with levothyroxine 88 mcg was initiated following the diagnosis of subclinical hypothyroidism [thyroid-stimulating hormone (TSH) = 5.29 mU/L, (reference range: 0.1 – 2.5 mU/L); free T4 = 0.9 ng/dL (reference range: 0.7-1.9 ng/dL); negative anti-thyroid peroxidase (TPO) antibody]. Daily vitamin D supplementation of 2000 IU was initiated, with dose adjustments throughout pregnancy based on serum levels of 25-OH vitamin D (Table 3). Starting at the 12th week of pregnancy, acetylsalicylic acid (ASA) was initiated at a dose of 100 mg/day for preeclampsia prophylaxis.
She progressed without complications associated with PHPT, maintaining mild hypercalcemia without hypercalciuria or nephrolithiasis (Table 3). Blood pressure remained normal throughout the prenatal follow-up.
| Gestational age | 7W3D | 11W | 13W | 14W6D | 17W5D | 21W4D | 26W6D | 30W2D | 36W | 37W6D |
Calcium (mg/dL) | 10.6 | 10.6 | 10.8 | 10.5 | 10.1 | 10.2 | 9.9 | 10.0 | 10.6 | - |
Ionized calcium (mg/dL) | - | 5.3 | 5.5 | - | 5.3 | 5.4 | 5.6 | 5.65 | 5.97 | - |
| Phosphorus (mg/dL) | 3.1 | 2.9 | 3.5 | - | 3.6 | 2.7 | 3.9 | 3.6 | 3.2 | - |
| PTH (pg/mL) | 68 | 72 | 58 | 79 | - | 61 | 61 | 57 | 65 | - |
25-OH vitamin D (ng/mL) | 16.3 | 21.2 | 21.2 | 16.5 | - | 22.1 | 14.5 | 19.2 | 19.5 | - |
| Glucose (mg/dL) | 94 | 82.6 | 83 | - | - | 76 | 77.8 | - | - | |
| OGTT (mg/dL) | - | - | - | - | - | - | 1h: 124 2h:123 | - | - | - |
| 24 h-urinary calcium (mg/24h) | 173.5 | - | - | - | 248.6 | - | - | - | - | - |
| Proteinuria (mg/24h) | - | - | - | - | - | - | - | - | - | 300 |
| Albumin (g/dL) | 4.9 | 4.2 | 4.2 | 4.0 | 3.9 | 3.8 | 3.3 | 3.4 | 3.3 | - |
| TSH (mU/L) | 5.29 | - | - | 0.918 | 0.918 | 1.87 | 0.896 | 0.991 | 1.26 | - |
| TPO (U/mL) | - | - | - | 19 | - | - | - | - | - | - |
Table 3: Laboratory exams assessed during pregnancy.
W: weeks; D: Days
Reference values: Calcium = 8.5 -10.2 mg/dL; Ionized calcium = 4.0 - 5.0 mg/dL; Phosphorus = 2.5 - 4.5 mg/dL; PTH = 12 - 65pg/mL; 25-OH vitamin D = 30 - 60 ng/mL; Fasting glucose= 92 mg/dL; OGTT: 1h< 180 mg/dL, 2h< 153 mg/dL; 24h-urinary calcium< 300 mg/24h; Proteinuria < 300 mg/24h; Albumin = 3.5 - 4.7 g/dL; TSH 1st trimester = 0.1 - 2.5, 2nd trimester = 0.2 - 3.0; 3rd trimester = 0.3 - 3.0 mU/L; TPO < 34 U/mL.
A fetal ultrasonography (USG) performed at 32 weeks and 3 days of gestation showed fetal weight of 1,652 g (10.6th percentile). Five weeks later, fetal weight was 2,387 g (4.9th percentile) and a cardiotocography showed a reactive pattern, consistent with good fetal vitality.
At 38 weeks and 2 days of gestation, the patient was admitted to the maternity ward for labor induction. After 2.5 days of induction, despite good progression of uterine contractions and adequate cervical effacement, there was a halt in fetal descent and elective cesarean section was indicated. The female neonate was small for gestational age (weight= 2115 g, below the 3rd percentile) with Apgar scores of 8 and 9 at the first and fifth minutes, respectively. The baby was in good clinical condition at birth without neonatal hypocalcemia. During the puerperal period, no signs of post-partum hyperparathyroid crisis were observed. Breastfeeding occurred on demand and hospital discharge occurred 48 hours after birth.
Clinical conditions frequently associated with intrauterine growth restriction, such as gestational hypertension, placental insertion defects, smoking, malnutrition, congenital infectious diseases, such as toxoplasmosis, syphilis, cytomegalovirus, rubella, HIV, hepatitis, genetic dysmorphisms or inborn metabolic errors were excluded.
Two years after delivery, the patient returned to the endocrinology outpatient clinic with laboratory tests revealing mild PHPT (Calcium = 10.8 mg/dL; PTH = 86 pg/mL). Despite remaining out of dopamine agonist treatment since the detection of pregnancy, normal prolactin levels and a pituitary magnetic resonance imaging revealing a stable pituitary adenoma measuring 0.6 cm x 0.4 cm were obtained. During preoperative evaluation for parathyroidectomy, she was diagnosed with a neuroendocrine bronchial tumor greater than 2 cm and treated with octreotide LAR and parathyroidectomy was once again suspended. Four years after her pregnancy, a computed tomography scan revealed the presence of a non-functioning adrenal adenoma measuring 1.6 cm.
Presently, although parathyroidectomy was not performed due to the significant morbidity of the other manifestations, the patient remains asymptomatic without bone or renal complications.
Women with MEN1 germline mutations are at high risk of developing various types of tumors, which in their sporadic form could interfere with both fertility and pregnancy. However, studies on pregnant women with MEN1 are limited, consisting mostly of case reports and two large retrospective Australian studies [9,12-17].
Turner et al. highlighted the crucial role of family history on MEN1 detection and suggested that even individuals without evident clinical manifestations must be considered for diagnostic scrutinization of MEN1 when specific endocrine tumors are identified in another family member. The goal of follow-up is to detect early manifestations of the syndrome and implement appropriate preventive and therapeutic measures [8].
In a 10-year retrospective study, Lourenço Jr et al. demonstrated the impact of genetic testing family members at risk for MEN1 on appropriate clinical management of the syndrome, observing that asymptomatic young individuals carrying the MEN1 mutation benefited from early detection of endocrine tumors [18]. Early diagnosis of tumors is possible through periodic hormonal and radiological screening suggested by guidelines for carriers of the MEN1 germline mutation [4-7].
Tumors that manifest during pregnancy have been associated with complications, such as miscarriage, prematurity, and increase both maternal and fetal mortality [9]. Therefore, counseling aimed at planning the best timing for conception and implementation of appropriate preventive and therapeutic measures is essential for women with MEN1 who wish to conceive.
Studies on the management of PHPT and prolactinoma in MEN1 during pregnancy are scarce [4-7,9,12-17,19] and no clinical guideline has addressed this subject.
In women with MEN1, the incidence of pituitary tumors is high (15% to 50%) with prolactinoma being the most common (approximately 65%) and not rarely the first manifestation of the syndrome [4-8]. Symptoms of hyperprolactinemia in MEN1 do not differ from those observed in sporadic prolactinomas [20]. During pregnancy, increased estrogen levels can stimulate the growth of prolactinomas in 2-3% of micro- and 31% of previously untreated macroprolactinomas [21,22]. During her pregnancy follow-up, our patient was monitored for tumoral growth with no need for dopaminergic agonist therapy.
PHPT is the most frequent endocrine manifestation in MEN1, with a prevalence of 90%. Symptoms include hypercalcemia, nephrolithiasis, polydipsia, polyuria, constipation, osteoporosis, fractures, and impaired quality of life [4-8,23-25]. Parathyroidectomy is the cornerstone of PHPT treatment and generally curative, leading to normalization of calcium levels and resolution of symptoms in sporadic forms. However, in cases with multiglandular disease, such as in MEN1, recurrence and persistence rates are high, even after more extensive surgeries [4-8,23]. During pregnancy, calcium homeostasis changes, resulting in relative fetal hypercalcemia. Maternal serum calcium increases due to a higher production of active vitamin D, increased intestinal calcium absorption, and placental parathyroid hormone-related peptide released in response to estradiol, placental lactogen, and prolactin [26,27]. PHPT may result in maternal hypertensive disorders, hyperemesis gravidarum, nephrolithiasis, pancreatitis, and osteoporosis, fetal death, intrauterine growth restriction and neonatal hypocalcemia [10,14].
Mistry et al. reported the case of a 31-year-old primigravida with MEN1 (macroprolactinoma, PHPT, pancreatic gastrinoma, non-functioning adrenal adenoma, and secondary hypothyroidism). During pregnancy, she developed hypercalcemia, requiring an early cesarean section at 35 weeks due to intrauterine growth restriction (IUGR). The fetus had adequate Apgar score, but developed hypocalcemia, requiring intravenous calcium replacement with good recovery and hospital discharge [12].
McCarthy et al. described three pregnant women with PHPT who underwent surgery in the second trimester, including a 20-year-old patient with MEN1, who had an uneventful pregnancy and delivery [19].
Hogg et al. studied 26 pregnant women with MEN1; 30% with PHPT and peak serum calcium levels observed during the second trimester. They also identified high rates of gestational diabetes mellitus (56%), hypertensive disorders (25.9%) and low birth weight (30.1%) [9].
During pregnancy, 25-OH vitamin D levels tend to decrease due to its role in fetal development, increasing the risk of complications such as preeclampsia, gestational diabetes, prematurity, IUGR, and low birth weight [28,29]. The establishment of target levels of 25-OH vitamin D above 40 ng/mL has been suggested for pregnancy [30]. Daily supplementation of 2000 IU of 25-OH vitamin D was prescribed to our patient, resulting in a peak level of 22.1 ng/mL, at 21 weeks and 4 days of gestation. Low adherence to 25-OH vitamin supplementation might explain the suboptimal levels obtained during this pregnancy follow-up, since by that time the referred medication was not provided by the Brazilian public health system [31].
Early recognition and strict monitoring of PHPT during pregnancy are essential, and management depends on the severity of symptoms, maternal complications, and potential risks to fetal development. Therapeutic options may include hydration, discontinuation of thiazide diuretics, and supplementation of calcium and vitamin D to prevent bone demineralization. Bisphosphonates and denosumab cross the placental barrier, are associated with adverse fetal skeletal effects, and should be avoided [10]. Calcitonin and calcimimetics have been used to control moderate and severe hypercalcemia during pregnancy, despite uncertain evidence on maternal and fetal repercussion, requiring strict monitoring due to potential side effects. Calcitonin reduces calcemia, while cinacalcet decreases both PTH and calcium. [10,32].
During pregnancy, parathyroidectomy is generally considered as a treatment option for PHPT with moderate to severe hypercalcemia (calcium>12 mg/dL) and is performed in the second trimester, when maternal and fetal risk of untreated hyperparathyroidism outweighs the risks of a surgery [10,32].
Based on data from a tertiary center with expertise on endocrine surgery, DiMarco et al. studied a cohort of 17 pregnant women with PHPT in which 15 were submitted to a parathyroidectomy and two did not undergo surgery. The parathyroidectomy subgroup had no cases of fetal distress or miscarriage. Deliveries occurred without complications, except for one membrane rupture at 39 weeks of gestation that resulted in a healthy cesarean section-delivered baby. The two patients who did not undergo surgery, on the other hand, experienced perinatal complications: one developed preeclampsia and delivered an IUGR baby, while the other progressed to a miscarriage [33].
Thompson et al. pointed that neonates of mothers with MEN1 had a higher prevalence of IUGR (MEN1: 28.9% vs. No MEN1: 6.7%). In addition, postnatal mortality was higher in offsprings of MEN1 (HR 4.6; p = 0.046 at 6 months of age). However, increased mortality and IUGR rates could not be solely explained by neonatal or maternal hypercalcemia [16].
In the present case report, progressive IUGR started at the 32nd week of gestation, with fetal weight decreasing from the 10.6th to the 4.9th, at week 36, and dropping below the 3rd percentile, at birth. Besides PHPT with sustained maternal hypercalcemia and no spikes, no other maternal condition could be related to the severity of IUGR. The subclinical hypothyroidism diagnosed at the 7th week of pregnancy was promptly treated and remained well-controlled throughout the pregnancy, minimizing its potential impact on the development of IUGR.
This case report has some limitations. First, being limited to a single patient, the report inherently limits the generalizability of the findings. While the patient’s favorable maternal and neonatal outcomes are encouraging, these results may not be extrapolated to all women with MEN1, especially those presenting with more severe or multisystemic manifestations. Second, the absence of postnatal neurodevelopmental follow-up to assess the impact of IUGR potentially associated with sustained maternal hypercalcemia. Third, the lack of consensus on when to surgically manage PHPT during pregnancy, particularly in cases of mild hypercalcemia, further complicates clinical decisions. Future studies, including prospective registries and comparative cohorts, are essential to guide management and establish standardized care protocols for pregnant women with MEN1.
Pregnant women with MEN1 are prone to developing numerous maternal-fetal complications. Those with PHPT require proper control of calcium, PTH, and vitamin D to reduce the risk of peri- and prenatal complications. More studies on the association between IUGR and MEN1 are necessary to assess the potential impact of MEN1 on fetal growth, including the subset of patients with PHPT and mild hypercalcemia. Significant IUGR development could be used as an additional indication for surgical treatment in the second trimester of pregnancy. This case highlights the importance of extending knowledge regarding the clinical impact of endocrine tumors in pregnant women with MEN1. Due to the rarity of the disease, there is no consensus on the optimal management of these cases. Consequently, definition of management strategies should be individualized, based on the data originated from the treatment of corresponding sporadic endocrine tumors and involve a specialized multidisciplinary team.
Conception and Design: M.S.C. and A.H.D.V
Data Collection: M.S.C., E.H.F.D. and I.A.S.S. were responsible to data collection
Drafting and Revising the Manuscript: M.S.C., E.H.F.D., I.A.S.S. and D.M.L.J were responsible for drafting the Manuscript. A.H.D.V., L.Z., L.M.A., D.M.L.J, M.M.O and E.N. were responsible to revise the manuscript.
D.M.L.J was responsible for the molecular sequencing.
Supervision: A.H.D.V. and D.M.L.J. were responsible to supervise.
Acknowledgements: The authors have nothing to report.
The authors declare no conflicts of interest.
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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
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.
