Study on the Missed Detection of Unexpected anti-E by MGT and Polybere Method

Research Article | DOI: https://doi.org/10.31579/2690-4861/891

Study on the Missed Detection of Unexpected anti-E by MGT and Polybere Method

  • He Ziyi *
  • Hu Yingming
  • Bei Menghui
  • Jie Xiaomei

Department of Transfusion Research, Dongguan Blood Center, Guangdong 523000, China.

*Corresponding Author: He Ziyi, Department of Transfusion Research, Dongguan Blood Center, Guangdong 523000, China.

Citation: He Ziyi, Hu Yingming, Bei Menghui, Jie Xiaomei, (2025), The Role of Mitogen-Activated Protein Kinase Kinase (MEK) in Hepatocellular Carcinoma, International Journal of Clinical Case Reports and Reviews, 30(1); DOI:10.31579/2690-4861/891

Copyright: © 2025, He Ziyi. 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: 18 June 2025 | Accepted: 16 July 2025 | Published: 22 September 2025

Keywords: institutional-normative factors, social norms covid-19, personal protective behaviour, mazandaran province

Abstract

The mitogen-activated protein kinase kinase (MEK) pathway is a key regulator of cell proliferation, survival, and differentiation, and its dysregulation is closely linked to hepatocellular carcinoma (HCC) development. This retrospective study aimed to investigate the expression of MEK in HCC, its association with clinicopathological features, and prognostic significance. A total of 260 HCC patients who underwent surgical resection at our institution from 2016 - 2021 were included. MEK expression in tumor and adjacent non-tumor tissues was detected by immunohistochemistry. High MEK expression in tumor tissues was significantly associated with larger tumor size (p = 0.003), higher histological grade (p = 0.01), microvascular invasion (p = 0.001), and elevated alpha-fetoprotein (AFP) levels (p = 0.005). Multivariate Cox regression analysis identified high MEK expression as an independent predictor of poor overall survival (hazard ratio [HR] = 2.2, 95% confidence interval [CI]: 1.4 - 3.5, p < 0.001) and recurrence-free survival (HR = 2.1, 95% CI: 1.3 - 3.3, p = 0.002). These findings highlight the critical role of MEK in HCC progression and suggest its potential as a prognostic biomarker and therapeutic target.

Introduction

With the rapid development of blood transfusion technology, automatic blood group analyzer based on MGT has been widely used in blood group serological detection, almost replacing the traditional blood group serological technology such as saline method, polybrene method and antiglobulin method. MGT has high sensitivity and specificity in crossmatching [1], and compared with polybrene method, MGT can significantly improve the detection rate of unexpected antibodies [2]. Wang Wenting et al reported[3] that 164,838 cases of cross-matching blood by MGT were negative, and 35 cases of positive blood were detected by cross-matching by saline method and polybrene method. The reason was analyzed that the laboratory over-relied on a single MGT for cross-matching and missed the detection of saline-reactive antibodies, but the report did not find unexpected anti-E missed during cross-matching by MGT. There were no reports of anti-E missed by the MGT when searching the literature on the "China National Knowledge Network", but there were more reports of anti-E detected by the MGT after the missed detection by the polybrene method [4], and the detection rate of anti-E by the MGT (37 cases) was higher than that by the polybrene method (20 cases) [5]. In the routine work of our laboratory, we found that there are two serological reaction characteristics of anti-E from human sources, one is missed by MGT and detected by polybrene method, and the other is detected by MGT and polybrene method. We speculated that there might be two kinds of anti-E immunoglobulins with high and low charges, and designed low ion and strong ion reaction system to verify the experiment, as reported below.

1. Materials and methods

1.1 General Information Case 1: The patient was a 77-year-old female with 3 pregnancies and 2 pregnancies and a history of transfusion. She developed fever and adverse transfusion reactions during transfusion of white suspended RBC. She was clinically diagnosed with hemorrhagic anemia, RBC:1.47×1012/L, Hb 47g/L, hematocrit 14.8%, blood group:O, RhD(+), and applied for transfusion of washed RBC. Case 2: A 32-year-old female patient with 4 pregnancies and 2 births, unknown transfusion history, clinically diagnosed hemolytic anemia, applied for infusion of washed RBC 4U.

1.2 Specific identification: Anti-E by MGT or polybrene method, unexpected antibodies were identified as anti-E, no autoantibodies or other unexpected antibodies, no lipids, no hemolysis.

1.3 Instruments and reagents:  Diana microcolumn gel card incubator and special centrifuge, KA-2200 Kubota centrifuge. MGT provided by Diana Company; Polybrene reagents, screening cells, Pannel cells, monoclonal anti-A, anti-B blood group reagents, monoclonal anti-E are provided by Shanghai Blood Biomedicine Co., LTD. Pannel cell 2 was produced in Hungary (Lot: 732209); IgG monoclonal anti-D,IgG monoclonal anti-AB, and anti-globulin reagents are manufactured by DIAGNOSTICS SCOTLAND. ABO reverse reagent for RBC was made by our laboratory.

1.2 Methods

1.2.1 Blood group ABO/RhD blood group was performed using the saline test.

1.2.2 Screening and identification of unexpected antibodies The routine method is to first detect IgM unexpected antibodies by saline method, and then to screen IgG unexpected antibodies by MGT. If the unexpected antibodies are positive, Pannel cells are used for antibody specific identification. MGT and Polybrene method were used for screening and identification of IgG unexpected antibodies.

1.2.3 Cross-matching: Primary and secondary cross matching, the saline test method was used, and then the MGT and the Polybrene method were used for cross-matching.

1.2.4 Comparison between low ion reaction system and high ion reaction system   

RhE positive RBC were selected, washed with 0.9%NaCl for 3 times, hematocrit was taken and Liss solution was used to prepare 4% and 1% RBC suspensions as low ion salt suspension RBC, and 0.9% NaCl was used to prepare 4% and 1% RBC suspensions as high ion salt suspension RBC. Human anti-E was diluted 1:4 with Liss solution and 0.9%NaCl, respectively. The suspended RBC and diluted human anti-E were detected by MGT and Polybrene method.

2.Results

2.1 Blood group identification ABO group: O, RhD(+).

2.2 Unexpected Antibody screening The sample 1 was negative in saline medium and MGT, and strongly positive "3+" in Polybrene method. Sample 2 did not agglutinate in saline medium, and the agglutination strength of cells screened by MGT was "2+", which was significantly higher than that by Polybrene method (see Table 1).

MethodsSamples 1Samples 2
O1O2O3ControlO1O2O3Control
saline medium--------
MGT----2+-2+-
Polybrene3+-3+-±-±-

Table 1: Results of unexpected antibody screening by three serological methods

2.3 Unexpected Antibody identification In sample 1, unexpected antibody identification was performed by MGT, and cells Ⅰ to X were negative (see Figure 1); Unexpected antibody identification was performed by Polybrene method, and cells II, IV and IX were positive (see Figure 2), and the reaction pattern was completely consistent with that of anti-E. The anti-E in sample 1 was missed by MGT. Sample 2 was unexpectedly identified by MGT. Cells II, VI, VII, Ⅷ and X of the Pannel cells were positive (see Figure 3). Cells I - X of the Pannel cells were negative by Polybrene method. The RBC E antigen of the two patients was identified by monoclonal anti-E, and the presence of anti-E in the plasma of the patients was determined with titers of 1:8 and 1:4, respectively.

Figure 1: Unexpected antibody identification by MGT

Figure 2: Unexpected antibody identification by Polybrene method

Figure 3: Results of unexpected antibody identification in sample 2

2.4 Cross matching O, RhD(+)Ec (-) RBC were selected for cross matching, and there was no agglutination or hemolysis in saline medium, 

MGT and polybrene method. RBC from Rh Ec(+) simulated donors were selected to exhibit agglutination reaction on the main cross-matching with the polybrene (see Table 2).

 
 ABORhSample 1 main cross matching Sample 2 main cross matching 
N.SMGTPolybreneN.SMGTPolybrene
Donor 1OD (+),Ec(-)------
Donor 2OD (+),Ec(-)------
Simulated donorOD(+),Ec(+)--3+-2+±

Table 2: Results of cross-matching between donor and simulated donor

2.5 Comparison between Liss liquid (low ion) and 0.9% NaCl (strong ion) reaction system. The concentration of 4% Liss liquid suspended RBC and 0.9% NaCl suspended RBC were reacted with 1:4 diluted plasma containing anti-E, respectively. Sample 1 was negative by MGT and positive by polybrene method. Sample 2 was positive by MGT and stronger than polybrene method, especially negative in 0.9% saline medium after dilution (see Table 3).

Reaction systemSample 1Sample 2
MGTPolybreneMGTPolybrene
0.9% NaCl suspended red blood cells + human anti-E serum-2+2++
Liss liquid suspension Red Blood cells +Liss diluted plasma (1:4)-2+s3+1+
0.9% NaCl suspended red blood cells +0.9% NaCl diluted plasma (1:4)-+s1+-

Table 3: Comparison of Liss liquid (low ion) and 0.9% NaCl (strong ion) reaction system detection

3.Discussion

The commonly methods for detecting IgG antibodiesinclude polybere method, antiglobulin method, MGT and enzyme medium method. The saline method is mainly used to detect IgM antibodies, which is an indispensable step in cross-matching. This method can find IgM unexpected antibodies, Group errors or determine whether hemolysis occurs, but cannot detect IgG unexpected antibodies. The process of polybere method is quick, simple and manual operation, but it is not sensitive to the antibodies of  Kell group system, and K antigen in Chinese is almost 100% negative, so this method is widely used in primary medical institutions. Antiglobulin method is recognized as the "gold standard", but its operation time is long, there are many steps, many influencing factors, and it needs manual operation. Based on the gel filtration technology and the specific reaction principle of immunochemical antigen and antibody, the MGT controls the size of the gel gap by adjusting the concentration of the gel, so that the gap can only allow free RBC to pass through, so that free RBC and agglutinated RBC can be separated. This method has high sensitivity, simple operation, clear, and easy automation. And there is no need to worry about the false negative caused by the neutralization of anti-globulin antibodies, so this method has been widely used, and even will completely replace the saline method, polybere method and other methods.

Unexpected antibodies are a major cause of cross mismatch, most commonly in the Rh system. It was reported that the cross mismatch caused by unexpected antibodies accounted for 80.9% of the total cross mismatch [6], among which 25.9% (14/54) was caused by anti-E in the Rh group system [7], and there were more reports of hemolytic transfusion reactions caused by anti-E [8-13]. It is generally believed that the sensitivity of MGT to detect unexpected antibodies is higher than that of the ploybere method, but there are few reports of missing anti-E detection by MGT in China. Wang Wenting et al. [3] reported that 164,838 cases of cross-matching blood with MGT were detected by MGT, and no missed anti-E was found, and 35 cases of missed antibodies were all IgM unexpected antibodies. The anti-E found in this study was missed in antibody screening and antibody identification by MGT, but showed obvious positive reaction by polybere method. There was no positive reaction when Ec (+) RBC were cross-matched by MGT, but there was agglutination reaction when the main side was cross-matched by polybere method. In this case, if only the MGT is used for cross-matching, the RBC of E (+) may be mistakenly sent to the clinic, which may lead to delayed hemolytic transfusion adverse reactions. It has been reported that the sensitivity and specificity of polybere method used in cross-matching and screening of incomplete antibodies are 1-250 times higher than other media [14,15]. Polybere is more sensitive in the determination of most antibodies (such as Rh system antibodies, Kidd system) than enzymatic method and traditional antiglobulin method [16]. The anti-E sensitivity of sample 1 was better than that of the MGT. On the contrary, the reaction strength of sample 2 was stronger than that of the MGT. When the original plasma was diluted to 1:4, the polybere rule was missed. It is speculated that the amount of charge carried by the anti-E immunoglobulins produced by different individuals in the RBC is different, thus affecting the affinity between the anti-E immunoglobulins and the corresponding antigens. In the strong ionic medium, the anti-E immunoglobulins carrying more negative charges have a strong charge rejection effect on the RBC, so the antigen-antibody reaction cannot be well completed in the low ionic medium. The amount of charge of immunoglobulin is reduced, the rejection is weakened, but it is more prone to antigen-antibody reaction, which shows a positive reaction in the polybere method, and a negative reaction in the MGT. However, the charge repulsion of RBC with low charge of anti-E immunoglobulins and corresponding antigen is weak, and they are more sensitive in MGT. Experiments confirmed that the amount of charge carried by anti-E immunoglobulin and RBC was reduced in the low-ion solution system, and the decrease of charge repulsion made it easier for the RBC antigen and immunoglobulin antibody to bind to the immune antigen and antibody, showing the enhanced reaction in the low-ion salt solution, which also explained the reason for the missed detection by MGT method in the high-ion reaction system. In this report, it is speculated that there are two types of anti-E immunoglobulins derived from human sources, one of which carries a high negative charge, such as the anti-E derived from sample 1, and the other carries a weak negative charge, such as sample 2. The detection sensitivity of MGT is higher than that of polybere, which is consistent with most literature reports that such antibodies are easily missed by polybere [4,5]. Therefore, there is no single method that can detect all antibodies at the same time, and cross-matching methods with different sensitivity and specificity should be selected for different patients or antibodies[17]. At present, there is a lack of direct evidence for this speculation, such as detecting the amount of charge carried by immunoglobulins.

In summary, this study confirmed that there are two types of human anti-E, one missed by MGT and the other missed by polybere method. It is speculated that these two types of human immunoglobulins have the same immune reactivity, but the amount of charge they carry is different. Different media may have differences in different blood group systems or different specific antibodies, and a single method may cause unexpected antibody missed detection. It is advisable to use more than two media methods, and take advantage of the advantages of the two methods, such as low-ion medium micro-gel method, to better ensure the safety of clinic.

References

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Thomas Urban

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.

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Cristina Berriozabal

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.

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Dr Tewodros Kassahun Tarekegn

"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".

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Dr Shweta Tiwari

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.

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Dr Farooq Wandroo

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.

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Dr Anyuta Ivanova

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.

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Dr David Vinyes

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.

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Gertraud Teuchert-Noodt

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

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Dr 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.

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Dr Oleg Golyanovski

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.

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Dr Susan Anne Smith

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.

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Dr 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.

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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.

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Dr Susan Anne Smith

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

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Dr Eric S Nussbaum

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.

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Hala Al Shaikh

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.

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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.

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Dr 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.

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Dr Jelle 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

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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.

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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.

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Dr Aline Tollet

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.

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Dr Chiara Giuseppina Beccaluva

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

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Dr Claudio Ligresti

Dear Chrystine Mejia, Editorial Coordinator, Journal of Neurodegeneration and Neurorehabilitation. “The peer review process was efficient and constructive, and the editorial office provided excellent communication and support throughout. The journal ensures scientific rigor and high editorial standards, while also offering a smooth and timely publication process. We sincerely appreciate the work of the editorial team in facilitating the dissemination of innovative approaches such as the Bonori Method.” Best regards, Dr. Matteo Bonori.

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Dr Matteo Bonori

I recommend without hesitation submitting relevant papers on medical decision making to the International Journal of Clinical Case Reports and Reviews. I am very grateful to the editorial staff. Maria Emerson was a pleasure to communicate with. The time from submission to publication was an extremely short 3 weeks. The editorial staff submitted the paper to three reviewers. Two of the reviewers commented positively on the value of publishing the paper. The editorial staff quickly recognized the third reviewer’s comments as an unjust attempt to reject the paper. I revised the paper as recommended by the first two reviewers.

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Edouard Kujawski

Dear Maria Emerson, Editorial Coordinator, Journal of Clinical Research and Reports. Thank you for publishing our case report: "Clinical Case of Effective Fetal Stem Cells Treatment in a Patient with Autism Spectrum Disorder" within the "Journal of Clinical Research and Reports" being submitted by the team of EmCell doctors from Kyiv, Ukraine. We much appreciate a professional and transparent peer-review process from Auctores. All research Doctors are so grateful to your Editorial Office and Auctores Publishing support! I amiably wish our article publication maintained a top quality of your International Scientific Journal. My best wishes for a prosperity of the Journal of Clinical Research and Reports. Hope our scientific relationship and cooperation will remain long lasting. Thank you very much indeed. Kind regards, Dr. Andriy Sinelnyk Cell Therapy Center EmCell

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Dr Andriy Sinelnyk