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Research Article | DOI: https://doi.org/10.31579/2690-4861/954
*Faculty of Medicine. Tirana Albania; #University Hospital “Shefqet Ndroqi” Tirana, Albania.
*Corresponding Author: Perlat Kapisyzi FCCP, University of Medicine Tirana Albania.
Citation: Perlat Kapisyzi, Elona Xhardo, Ornela Nuredini, Holta Tafa, Loreta Karaulli, et al, (2025), Lung Ultrasound: An Initial Bedside 'Spirometry' Tool in Diagnosing Obstructive Syndrome, International Journal of Clinical Case Reports and Reviews, 29(1); DOI:10.31579/2690-4861/954
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: 20 August 2025 | Accepted: 26 August 2025 | Published: 03 September 2025
Keywords: lung ultrasound; copd; emphysema; chronic bronchitis; twinkling white area; rib shadow; merlin space; spirometry surrogate; subpleural morphology; pca; roc analysis
Introduction
Chronic obstructive pulmonary disease (COPD), composed of emphysema and chronic bronchitis, is a leading global health burden. Differentiating these phenotypes at the bedside is essential, as emphysema management focuses on relieving hyperinflation and cautious oxygen titration, while chronic bronchitis requires secretion clearance, infection control, and tailored oxygen therapy. Conventional bedside tools lack accuracy for this purpose. Lung ultrasound (LUS), with novel pleural, sub pleural markers such as the Twinkling White Area (TWA) and rib shadow geometry, offers a potential solution. To our knowledge, this is the first study to investigate the role of LUS in phenotyping COPD.
Aim:
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. The current manuscript presents the lung ultrasound findings in emphysema.
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 and discussion
PCA revealed three major components explaining 61.6% of variance; the dominant contributor was TWA length during inspiration and expiration. ANOVA showed significant regional differences, with high expiration rib (F = 60.77, p < 0.0001) and TWA length expiration (up to −40% in Region 1) as leading discriminators. The best single variable was TWA length during expiration (cut-off: −50.2), with sensitivity 78.8%, specificity 85.1%, and AUC = 0.743. A five-variable logistic regression model achieved AUC = 0.728 (train), 0.716 (10-fold CV), with length TWA and W2 rib shadow as key predictors.
Conclusion:
Lung ultrasound enables accurate bedside identification of emphysematous remodeling, particularly through expiratory shortening and widening of TWA, rib shadow distortion, and pleural-rib distance reduction. These sonographic patterns are storytellers that reflect regional and phenotypic heterogeneity and may serve as real-time, non-invasive surrogates for spirometry in the evaluation of obstructive syndromes.
Peripheral pulmonary diseases often present with subtle or absent clinical signs, limiting the sensitivity of auscultation and conventional imaging. Among obstructive syndromes, emphysema and chronic bronchitis may evolve insidiously and remain difficult to differentiate at the bedside. In this context, lung ultrasound (LUS) has emerged as a reliable, non-invasive technique capable of revealing pleural and subpleural abnormalities with clarity. Chronic Obstructive Pulmonary Disease (COPD) is a major global cause of morbidity and mortality [1], defined predominantly by two phenotypes: chronic bronchitis and emphysema. While chronic bronchitis is characterized by airway inflammation, mucus hypersecretion, glandular hypertrophy, and fibrotic remodeling, emphysema involves destruction of alveolar architecture and distal air trapping. Differentiating between these entities is clinically essential, as emphysema requires strategies directed at relieving hyperinflation and cautious oxygen titration, whereas chronic bronchitis demands urgent secretion clearance, infection control, and tailored oxygen therapy to prevent CO₂ retention. However, current bedside tools are limited in their ability to provide accurate phenotyping. Recent advances suggest LUS can extend diagnostic capabilities to the peripheral lung. Among novel markers, the Twinkling White Area (TWA) — reflecting pleural–subpleural 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.
This study aims to quantitatively assess sonographic markers—TWA length, width, density, rib shadow width (W, W2), rib-to-pleural line distance (“high of ribs”)—during rest, forced inspiration and expiration, across three groups: normal individuals, patients with emphysema, and those with chronic bronchitis. The goal is to identify specific sonographic features and their regional distribution that reliably differentiate COPD phenotypes. The current manuscript presents the lung ultrasound findings in emphysema.
In this prospective observational study, 105 subjects (25 controls, 40 with emphysema, 40 with chronic bronchitis) underwent LUS in four thoracic regions using a handheld Clarius scanner. Quantitative measurements were obtained during three respiratory phases. Statistical analysis included Principal Component Analysis (PCA), ANOVA, and multivariable logistic regression to identify the most discriminative variables.
Equipment
Lung ultrasound examinations were performed using a handheld curved-array transducer (Clarius) with a frequency range of 2–5 MHz. The device was operated in lung preset mode, with an imaging depth of 18 to 20 cm.
Scanning Regions
Four lung zones were evaluated in each subject: two anterior regions, the posterior apical zone, and the lower posterior zone of the right lung, corresponding to regions 1, 2, 5, and 6 as defined by the BLUE protocol.
Measured Parameters
In each region, the following echographic features were assessed:
Dynamic Assessment
All parameters were measured during three distinct respiratory states:
This allowed assessment of dynamic changes in TWA size, rib shadow width, and rib-to-pleura distances across different phases of respiration.
Image Acquisition and Analysis
The ultrasound scanning was performed by a single experienced sonographer to ensure inter-operator consistency. All images were analyzed using standardized Lung Ultrasound (LUS) software, enabling consistent quantification of echographic variables.
Data Collection and Statistical Analysis
Quantitative variables—including TWA dimensions, rib shadow widths, and pleural line distances—were recorded and expressed as means ± standard deviations.
Statistical analysis was conducted using the Python programming environment, applying appropriate inferential tests based on the distribution and nature of the data.
Study Structure
The study is structured into three main parts:
The methodology for quantifying regional variables in normal subjects and bronchitis patients is illustrated with pictograms and representative examples
Principal Component Analysis identified three main components explaining a cumulative 61.6% of the variance across the dataset. PC1, accounting for 25.6% of the total variance, was primarily driven by variables related to the Twinkling White Area (TWA), including its length
and width during inspiration. PC2 (21.5%) captured variations in rib height during respiratory phases, while PC3 (14.5%) reflected structural parameters such as W2 ribs during inspiration/expiration and rib shadow dimensions. (Table 1)
| Principal Component | Explained variance | Top varibles |
| Length TWA inspiration | ||
| Length TWA | ||
| PC1 | 25.60% | Width TWA |
| Width TWA inspiration | ||
| W2 ribs expiration | ||
| High rib expiration | ||
| High rib inspiration | ||
| PC2 | 21.50% | High of rib |
| Width TWA | ||
| Width TWA expiration | ||
| W2 ribs expiration | ||
| W2 ribs inspiration | ||
| PC3 | 14.50% | High of rib |
| W2 ribs shadow | ||
| High of rib expression |
Table 1: Principal Components Analysis
The percent change heatmap (emphysema vs. normal) revealed significant regional alterations. The length of TWA during expiration showed the most pronounced reduction in emphysematous subjects, especially in Region 1 (up to −40%), suggesting localized expiratory collapse. In contrast, increases in width of TWA and rib shadow width were observed, particularly in Regions 3 and 4, indicating possible compensatory widening or distortion of intercostal spaces. (Heatmap)
One-way ANOVA supported these findings, with several variables showing statistically significant inter-regional differences. High expiration rib (F = 60.77, p 0.0001), high of ribs (F = 42.91, p < 0 xss=removed>
Bar plot analyses of the top discriminative variables across thoracic regions revealed consistent and marked differences between subjects with emphysema and normal controls. The most significant divergence occurred in the length of TWA during expiration, which emerged as the leading differentiator in all four regions, with the greatest absolute difference in Region 1. Region 1 also showed strong separation based on TWA width, rib shadow width, and height of ribs, suggesting early upper-anterior morphological distortion. In Region 2, a similar trend was observed, with additional emphasis on W2 ribs shadow and TWA width during expiration, indicating expiratory dysfunction and structural widening. Regions 3 and 4 exhibited distinct patterns, with Region 3 highlighting rib shadow width and TWA width during expiration as dominant variables, and Region 4 showing a substantial increase in W2 ribs shadow, suggesting posterior-lateral remodeling. Across all regions, rib height and TWA configuration metrics consistently distinguished emphysematous from normal morphology, underscoring their diagnostic value. [Regions-1,2,3,4]
Using Youden’s J index, we identified the top-performing variables based on either sensitivity or specificity for distinguishing emphysema from normal subjects. The three most sensitive variables were:
Conversely, variables selected for maximal specificity included:
Figure 2
These findings suggest that variables related to expiratory morphology (especially TWA length) are more balanced in terms of diagnostic performance, while highly specific variables may be useful in ruling in emphysema when present (Table 3 and 4)
A logistic regression model was constructed to differentiate emphysema from normal subjects using five ultrasound-based variables. The trained model achieved an Area Under the Curve (AUC) of 0.728, and 0.716 under 10-fold cross-validation, showing both good discrimination and internal validity.
Cut-off thresholds were determined via the Youden Index, balancing sensitivity and specificity. Among the features, length_twa demonstrated the highest individual AUC (0.738) and Youden Index (0.592), followed by w2_ribs_shadow. While width_twa_expiration showed limited sensitivity (0.229), its high specificity (0.976) made it clinically valuable in confirming true-negative cases.
The final regression model included five variables for several methodological and clinical reasons: complementary value of individually weaker variables (e.g., width_twa_expiration), maximal specificity gain, better multidimensional representation of sonographic pathology, and improved cross-validation performance. For instance, despite its lower individual AUC, width twa expiration added discriminative power in combination with other variables. [Table 5, figure 3]
| Variable | Cut-off (Youden) | Sensitivity (Emphysema) | Specificity (Normal) | AUC (Individual) |
| width_twa | 26,7 | 0,43 | 0,964 | 0,606 |
| width_twa_expiration | 29,5 | 0,229 | 0,976 | 0,494 |
| w2_ribs_shadow | -23,41 | 0,627 | 0,793 | 0,643 |
| length_twa | -50,4 | 0,627 | 0,964 | 0,738 |
| length_twa_expiration | -50,2 | 0,788 | 0,851 | 0,743 |
Figure 3
General Diagnostic Insights from LUS
This study demonstrates that emphysema is characterized by distinct and regionally specific morphological changes detectable through lung ultrasound. A consistent and pronounced reduction in the length of the Twinkling White Area (TWA) during expiration—particularly in anterior upper regions—emerges as a hallmark of early loss of elastic recoil and dynamic airway collapse. These features align with previously described pathophysiological patterns of emphysema, where premature airway closure during forced expiration is a key mechanism [17]. In contrast to TWA shortening, a concomitant increase in TWA width and rib shadow width was observed, especially in posterior regions. This may reflect compensatory remodeling of the thoracic cage due to hyperinflation [18]. Changes in rib height and the rib-to-pleural line distance also proved discriminative, possibly reflecting altered intrathoracic pressure dynamics and parenchymal integrity. Notably, expiratory-phase variables, particularly TWA length, offered the most favorable balance of sensitivity and specificity. Meanwhile, variables measured at rest or during inspiration showed very high specificity but low sensitivity, supporting their role in phenotype confirmation rather than screening. Multivariable logistic regression demonstrated that a combination of five variables improved predictive performance and diagnostic reliability. The regional heterogeneity of ultrasound findings mirrors CT-based descriptions of emphysema's topographic variability [19]. This supports the concept that numeric cut-offs for ultrasound variables may have diagnostic value only when interpreted within their anatomical context. Importantly, this is the first study to evaluate the diagnostic and phenotypic potential of Merlin space components—specifically TWA and rib shadow parameters—using lung ultrasound in obstructive pulmonary syndromes. The approach used here demonstrates that lung ultrasound may serve not only as a detection tool but also as a bedside surrogate for functional phenotyping of COPD.
Pathophysiological Differentiation Between Emphysema and Chronic Bronchitis
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]. This explains the characteristic shortening of the TWA during expiration, increase in width of TWA, as well as the increased distance between the ribs and the pleural line. Rib shadows become shorter, wider or nerrower according the regions, likely reflecting changes in intercostal spacing due to altered chest wall and lung compliance. Ultrasound patterns also varied according to emphysema subtype. In panacinar emphysema, there was global shortening of the TWA and loss of definition of its borders. In centriacinar emphysema, pleural distortion and irregular rib shadows were more prominent, while in periacinar emphysema, changes were subtle and localized, often limited to posterior-lateral zones.
Several control subjects displayed localized sonographic signs of small airway obstruction—such as paradoxical shortening of TWA during expiration and increased width—despite having normal spirometry but not normal curve configuration. These findings align with known limitations of spirometry in detecting early airway disease and support the emerging role of ultrasound in screening for latent dysfunction [24,25]. Furthermore, coexisting patterns of emphysema and chronic bronchitis were observed in several regions within individual patients, reinforcing the heterogeneity of COPD. This highlights the clinical relevance of regional LUS, which may help identify not only the presence but also the distribution and subtype of disease involvement. Taken together, these findings suggest that lung ultrasound, when applied with dimensional and phase-specific metrics, offers a dynamic, region sensitive, and non-invasive method to classify obstructive phenotypes. The ability to detect expiratory collapse, pleural, twinkling white area and rib’s shadow distortion, or inflammatory thickening at the bedside opens new perspectives for COPD diagnosis and management.
Lung ultrasound enables accurate bedside identification of emphysematous remodeling, particularly through expiratory shortening and widening of TWA, rib shadow distortion, and pleural-rib distance reduction. These sonographic patterns are storytellers that reflect regional and phenotypic heterogeneity and may serve as real-time, non-invasive surrogates for spirometry in the evaluation of obstructive syndromes and specifically emphysema phenotype.
Clinical Application
This study highlights a consistent sonographic pattern for emphysema within the Merlin space. The most discriminative variables were reduced TWA length, decreased rib-shadow width (W2), and increased TWA width, particularly in expiration. Among these, TWA length showed the best diagnostic performance (AUC ~0.74), while rib-shadow width and TWA width provided complementary value. These phase-dependent reductions reflect pleural– sub pleural remodeling and distal air trapping characteristic of emphysema. Although preliminary, integrating these markers into bedside scanning may support recognition of hyperinflation and guide clinical management when spirometry is unavailable.
Strengths, Limitations, and Conclusion
This study is among the first to systematically characterize emphysema 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 negativ markers (TWA length in quiet breathing and inspiration, W2 rib-shadow width) and positive 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.
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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. Giselle Pentón-Rol.
