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Case report | DOI: https://doi.org/10.31579/2690-4861/782
1Department of Anesthesiology and Pain Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, Netherlands.
2Department of Anesthesiology, Intensive Care and Pain Medicine, St. Antonius Hospital Nieuwegein/Utrecht, Koekoekslaan 1, 3435 CM, Nieuwegein, Netherlands.
*Corresponding Author: Ruben Cornelis Wilhelmus Verdoorn, Anesthesiologist-Painspecialist Department of Anesthesiology and Pain Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, Netherlands.
Citation: Wilhelmus Verdoorn RC, Peter Bruins, (2025), Unexpected Persistent Paralysis Due to Rare Reduced Pseudocholinesterase Activity in Post-Partum Obstetric Hemorrhage Surgery: A Case Report, International Journal of Clinical Case Reports and Reviews, 30(3); DOI:10.31579/2690-4861/782
Copyright: © 2025, Ruben Cornelis Wilhelmus Verdoorn. 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 April 2025 | Accepted: 20 August 2025 | Published: 26 September 2025
Keywords: pseudocholinesterase deficiency; butyrylcholinesterase deficiency; neuromuscular blocker; suxamethonium, pharmacogenetics; obstetric anesthesia
Background
Due to increasing use of non-depolarizing muscle agents (NMBA) and decreased use of depolarizing muscle relaxants as suxamethonium, encountering an unknown genetic predisposition of pseudocholinesterase deficiency in clinical practice may become more exceptional. With a constant prevalence of genetic variants leading to either less active or inactive pseudocholinesterase, continuously raising awareness of this less frequent diagnosis is of considerable importance to avoid misjudgment and to prevent somatic and psychological harm to patients.
Case Report
Our 35-year-old woman of Turkish descent with no known family history of anesthesia-related adverse events, was presented from the maternity ward with excessive blood loss after surgical assisted vaginal birth. Considered general anesthesia was induced, including suxamethonium and a retained placenta was surgically removed. Upon ceasing sevoflurane, the patient did not show any clinical signs of recovery from paralysis which was confirmed with Train of Four (TOF) monitoring. After four hours of monitored continued mechanical ventilation and hypnosis, the patient spontaneously recovered from paralysis and could be extubated. On follow-up, the patient was diagnosed with a heterozygous genetic predisposition for pseudocholinesterase deficiency which, in combination with several different risk factors for delayed metabolization, including pregnancy, sevoflurane and significant blood loss is believed to have led to this clinical presentation.
Conclusions
Heterozygous predisposition for pseudocholinesterase deficiency alone is not explanatory for delayed paralysis induced by depolarizing muscle relaxants for over one hour but in combination with several known risk-factors can certainly lead to significant clinically relevant paralysis.
Pharmacogenetic predisposition regarding genetic diversity in metabolizing commonly used anesthetics is more common than often realized, affecting around 30% of all drugs and accounting for up to 95% of inter individual variability in drug effects [1]. The vast majority of anesthetic agents, 70-80%, are metabolized in the liver by cytochromes P450 [2]. Although, this rarely leads to unexpected adverse events, it is reported to contribute up to 79.7% of anesthesiologic associated deaths after adverse events of anesthetics in therapeutic dose [3, 4]. In addition, anesthesiologic misjudgment or decision making can lead to unnecessary physical and emotional injury to individual patients. For instance, higher levels of pain and distress as well as developing post-traumatic stress disorder (PTSS) or anxiety disorders [5].
Pseudocholinesterase, also referred to as butyrylcholinesterase (BChE), is a plasma enzyme responsible for hydrolyzing choline esters including commonly used neuromuscular blocking agents, either non-depolarizing as mivacurium or depolarizing such as suxamethonium but also local anesthetics, e.g., tetracaine, cocaine, and procaine [6]. Pseudocholinesterase deficiency results in a distinct prolonged paralysis up to six hours after administration.
The subsequent case describes an unexpected case of an unexpected pseudocholinesterase deficiency in a 34-year-old postpartum woman (following CARE Guidelines [7] and uniform requirements for manuscripts [8]). The aim of this case report focusses on the unexpected presentation of heterozygous pseudocholinesterase deficiency, the direct clinical consequences in order to elaborate on the direct clinical management and patient follow-up, emphasizing early recognition within a simple decision-making tool. With the steep rise of the usage of sugammadex, clinical properties of non-depolarizing neuromuscular blocking agents (NMBA’s), especially rocuronium widened, making it very suitable for rapid-sequence induction. Therefore, the administration of either suxamethonium or mivacurium is significantly reduced, most certainly considering the significantly reduced costs of sugammadex in recent years. As the prevalence of the genetic disorder is unchanged within the population, the reduced use of suxamethonium will make this specific finding much rarer including the awareness.
A 35-year-old woman (G3P1) of Turkish descent with BMI of 27 was announced from our maternity ward with excessive postpartum blood loss estimated at 1300mL due to a retained placenta. Her first pregnancy ended in miscarriage and consecutively this second pregnancy resulted in a vaginal birth, requiring vacuum extraction but no other maternal complications requiring any surgical nor radiological intervention. Epidural anesthesia was performed successfully to relieve pain during labor and birth, with the catheter still in place upon presentation. Due to hypotonic labor, the spontaneous started labor needed additional stimulation using intravenous oxytocin to a maximum of 4,5mL/h of a 0.4IU/mL solution. Giving birth was complicated by maternal exhaustion and fetal distress, as derived by maternal irritability, and measured with an abnormal cardiotocography (consisting of an increased base heartrate of 160bpm with decreased variability) and with pre-acidotic blood gas results using micro blood sampling technology (pH 7.21). Vacuum extraction was performed which was then complicated by shoulder dystocia. A full-term baby girl was born with a normal weight of approximately 3550 grams but in need of respiratory support for which immediate care was provided by the pediatrician. Meconium in the amniotic fluid confirmed the fetal distress, which had resulted in meconium aspiration leading to respiratory failure. The attending pediatrician was able to stabilize the newborn utilizing positive airway pressure.
Patient’s condition was considered hemodynamically stable when arriving at the operating complex, having a stable sinus tachycardia of 130 beats/minute and consequent mean arterial pressure well above 70mmHg. Her medical history only included limited excision of a pilonidal sinus under spinal anesthesia and today’s mentioned vaginal birth. When conducting a limited preoperative assessment, patient reported no allergies, no medication, nor any anesthesia-related complications or known familial genetic disorders. Laboratory results at admission showed a Hemoglobin level of 7.0 mmol/L (11.3 g/dL), no irregular antibodies and a normal renal function. In the operating room, after standard protocol time-out procedure, confirming a free flow of NaCl 0,9% IV, general anesthesia was induced using 160mg of propofol, 100mcg of fentanyl and 100mg of suxamethonium. Intubation conditions were optimized putting patient in sniffing position and successful first-time endotracheal intubation was obtained utilizing a video laryngoscope. Anesthesia was maintained with 3% in sevoflurane (O2/air mixture of 40%).
After a 14-minute obstetric procedure, a small retained placental part was manually removed and total blood loss was estimated just above 2000mL, including the preoperative loss. During wash-out of sevoflurane to approximately end-tidal concentration below ETsev of 0.5%, the patient remained unresponsive and without any clinical sign of paralytic recovery. A neuromuscular transmission monitor (NMT) was then applied on the m. adductor pollicis on the right wrist, stimulating the ulnar nerve, which did not show any muscle contractions. Post-tetanic count (PTC) was not measured. In absence of other obvious explanations, a prolonged neuromuscular blockade due to a hydrolyzation deficiency of the administered choline ester molecules was expected. Patient was informed of prolonged paralysis and reassured while sevoflurane was restarted. Persistent patient paralysis was confirmed by a negative NMT on the contralateral side and verifying there were no instrumental or technical defects.
After consulting a colleague, anesthesia maintenance was exchanged for propofol and Bispectral index (BIS) monitoring was then applied, measuring a BIS of 46. The patient was transferred to the Intensive Care Unit for ventilation support. Three and a half hours after induction she first displayed return of spontaneous breathing. Propofol was stopped, and after careful evaluation, patient was extubated without any respiratory complications. Although, a period of approximately four and half minutes of solely light sedation during paralysis, she did not have any awareness with recall.
Hours after recovery, patient called her parents to ask if there have been apparent incidents with general anesthesia running in the family. She reported that it took her mother hours before she ‘woke up’ from general anesthesia and only after transfusion of ‘fresh blood’. No additional diagnostics were performed at that time due to a lack of resources in this particular rural area in Turkey.
The following morning, we assessed the possibility of presence of awareness utilizing the modified version of the Brice questionnaire [9] (Table 1). She did not meet any of the criteria and thus did not have any awareness with recall. Patient was particularly satisfied with the extensive explanation and thorough information she and her husband were presented with. She emphasized, having had a very emotional, exhausting labor and fearing a bad outcome of her newborn, a third hit by experiencing paralysis while being awake would have devastated her.
Table 1. Brice Questionnaire [8]
1. What is the last thing you remember before going to sleep?
2. What is the first thing you remember after waking up?
3. Do you remember anything between going to sleep and waking?
4. Did you dream during your procedure?
5. What was the worst thing about your operation?
Patient was referred to a nearby university hospital for extensive genetic and neurological analysis. Thorough anamnesis and neurological examination showed no indications for a possible underlying neurological condition. Based on BChE genotyping on a EDTA plasma sample, patient appeared heterozygous for the abnormal genetic inactive haplotype AK “atypical” and “Kalow” (A 209A>G; rs1799807 and K 1615G>A; rs1803274), in combination with a normal and active “usual variant” U. This makes our patient a carrier of pseudocholinesterase deficiency. This genetic variant could account for approximately a 50% up to a 100% prolongation of paralysis due to reduction of pseudocholinesterase activity, but never more than one hour [10]. In this case, there must be a combination of non-genetic factors contributing to a more severe clinical presentation. Given the fact that the complete DNA sequence and amino acid structure of the normal pseudocholinesterase protein, as well as most common abnormal variants are known, and the availability of genetic analysis, running once every week, other diagnostic methods such as dibucaine and fluoride numbers, as well as the more simplified screening Acholest test, were not reported [11].
This case presents an unexpected finding in a young, Turkish woman after a complicated delivery who experienced a persistent paralysis after administration of a normal dosage of suxamethonium for general anesthesia for manual removal of a retained placenta. She was mechanically ventilated for 4 hours until she recovered from paralysis and could be extubated. Genetic analysis demonstrated that our patient appeared to be heterozygous (intermediate) for pseudocholinesterase deficiency. Although this would not fully account for the described clinical course, a total sum of additional risk factors is believed to be enough explanation to suffice for an exceptionally long recovery from paralysis induced by this depolarizing neuromuscular blocking agent. (Table 2)
| Metabolic factors | Liver failure | |||||
| Renal failure | ||||||
| Major Burns | ||||||
| Advanced age | ||||||
| Pregnancy/ postpartum state | ||||||
| Decrease in pseudocholinesterase activity | Oral contraceptive pill | |||||
| Cholinesterase inhibitors (neostigmine, pyrodostigmine) | ||||||
| Cyclophosfamide | ||||||
| Echothiopate iodide for ophthalmic solution | ||||||
| Potentiating agents | Antibiotics (clindamycin, tetracyclin) | |||||
| Antiarrhythmic drugs (procainamide, calcium channel blockers | ||||||
| and magnesium sulphate) | ||||||
| Local anesthetics | ||||||
| Diuretics (furosemide) | ||||||
| Inhalational anesthetics | ||||||
| Lithium | ||||||
| Substantial increase in sensitivity | Myasthenia syndrome | |||||
| Autoimmune disorders (systemic lupus erythematosis) | ||||||
Table 2: Synopsis of the most significant risk factors which may contribute to clinically relevant prolongation of depolarizing muscle relaxant induced paralysis. Factors present in the patient described are highlighted (Italic).
Table 3: Causes of delayed emergence from anesthesia [15]
Table 4: Causes of delayed recovery from paralysis [11]
General synopsis of factors contributing to delayed emergence from general anesthesia. Factors present in the patient described are highlighted (Italic).
Pseudocholinesterase, synonymous with serum cholinesterase, plasma cholinesterase, nonspecific cholinesterase, butyrylcholinesterase or S-type cholinesterase, is a complex molecule made up of four identical subunits each weighing 85kD and synthesized in the liver [12]. Deficiency may be inherited as an autosomal recessive condition with prevalence varying from 1:3200 to 1:5000 people. Male-to-female incidence ratio approximately 2:1 and prevalence is higher in Caucasian males, Alaska Natives and the Persian community [6,10-13]. The accountable gene is known and located on the long arm (E1 locus) of chromosome 3 (3q26.1-q26.2). Just over 96% of the total population are homozygous for a normal gene type and 3.9% is heterozygous for an atypical allele. Practically this will, depending on the variant, cause a 5 minute to a maximum of 1 hour prolongation of paralysis, whilst in a homozygous individual this could stretch up to 6 hours.
Remarkably, there is one very rare variant allele known that results in a significantly higher enzyme activity, making these individuals relatively resistant to the paralytic effects of suxamethonium. Approximately half
to 80% of patients with a (partly) deficient pseudocholinesterase, a homozygote mutation of the BChE gene is found [14,15]. When encountering a case of suspected persistent paralysis, we can revert to a concise and structured differential diagnosis, also accounting for possible contributing factors [10] (Tables 3 and 4).
There is no specific treatment for pseudocholinesterase deficient patients, and the most safe and acceptable management is to continue sedation and ventilator support until passive diffusion of succinylcholine away from the neuromuscular junction and respiratory muscle paralysis spontaneously resolves [16]. If more rapid recovery is necessary, for example if neurological assessment is required, it may be considered to administer donor plasma, as this contains small variable amounts of pseudocholinesterase, in concentrates of fresh frozen plasma (FFP), omniplasma (OP) or enzyme concentrate. Several cases report that one to two units of FFP would be sufficient to recover a paralyzed patient within minutes [18].
In this particular case the patient had a sufficiently working epidural catheter. In addition to birthweight, maternal diabetes, excessive maternal weight or weight gain, operative vaginal delivery, oxytocin use, multiparity and prior occurrence, epidural anesthesia is also a purported risk factor for shoulder dystocia. Recently this became more questionable considering a persistent increase in the rate of epidural use for pain relief in labor in the United States with an essentially constant rate of shoulder dystocia, occurring in around 1% of all deliveries [19]. Utilizing this for epidural anesthesia during the surgical procedure was considered and, in retrospect, would have prevented this clinical outcome. Considering the ongoing blood loss, the amount of extra time until surgical block would
be sufficient after administering extra epidural local anesthetic and the impending hemodynamic instability, we opted for general anesthesia, despite a possibly more challenging airway management and possible respiratory complications.
Soliday et al. and Andersson et al. demonstrated that, next to genetic predisposition, many different metabolic factors, enzyme-inhibiting agents, depolarizing muscle relaxant potentiating drugs and disorders influence the clinical outcome when administering depolarizing muscle relaxants. In this case the combination of heterozygous pseudocholinesterase deficiency, postpartum state, administration of inhalational anesthetics, possible impaired metabolism/elimination and altered distribution due to large fluid shifts and dilution during acute major blood loss, caused a significant prolongation of drug induced paralysis of 4 hours [6, 20].
Heterozygous pseudocholinesterase deficiency has a constant prevalence but will be encountered less frequent with the increasing use of other neuromuscular blocking agents, e.g., rocuronium which after the introduction of sugammadex has become more popular taking into account the added value of being able to antagonize quickly in the context of patient safety, efficacy and efficiency. In addition to other risk factors, heterozygous pseudocholinesterase deficiency may lead to a significant prolonged paralysis when using depolarizing muscle relaxants, inducing the possible risk of a potential traumatic awareness for the patient when prolonged paralysis is not noticed in time. To prevent this, timely recognition should lead to (re-)start of mechanical ventilation, open communication and reassuring the patient followed by restart of sedation. The prolonged paralysis caused by pseudocholinesterase deficiency is safely managed by continued mechanical ventilation and in some cases may be treated with plasma transfusion but should never be counteracted with neostigmine.
Acknowledgements
Not applicable
Abbreviations
NMBA’s: non-depolarizing neuromuscular blocking agents; TOF: Train of Four; BChE: butyrylcholinesterase; PTSS: post-traumatic stress disorder; BMI: body-mass index; ETsev: end-tidal sevoflurane; NMT: neuromuscular transmission monitoring; PTC: post-tetanic count; BIS: Bispectral Index; FFP: fresh frozen plasma; OP: omniplasma
Conflict of interests
The authors declare that they have no competing interests.
Availability of data and materials
Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.
Conflict of interests
The authors declare that they have no competing interests.
Funding
This study was not supported by any funding.
Authors’ contributions
RV: Writing, editing. PB: editing, revision. Both authors read and approved the final manuscript.
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My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
I would like to offer my testimony in the support. I have received through the peer review process and support the editorial office where they are to support young authors like me, encourage them to publish their work in your esteemed journals, and globalize and share knowledge globally. I really appreciate your journal, peer review, and editorial office.
Dear Agrippa Hilda- Editorial Coordinator of Journal of Neuroscience and Neurological Surgery, "The peer review process was very quick and of high quality, which can also be seen in the articles in the journal. The collaboration with the editorial office was very good."
I would like to express my sincere gratitude for the support and efficiency provided by the editorial office throughout the publication process of my article, “Delayed Vulvar Metastases from Rectal Carcinoma: A Case Report.” I greatly appreciate the assistance and guidance I received from your team, which made the entire process smooth and efficient. The peer review process was thorough and constructive, contributing to the overall quality of the final article. I am very grateful for the high level of professionalism and commitment shown by the editorial staff, and I look forward to maintaining a long-term collaboration with the International Journal of Clinical Case Reports and Reviews.
To Dear Erin Aust, I would like to express my heartfelt appreciation for the opportunity to have my work published in this esteemed journal. The entire publication process was smooth and well-organized, and I am extremely satisfied with the final result. The Editorial Team demonstrated the utmost professionalism, providing prompt and insightful feedback throughout the review process. Their clear communication and constructive suggestions were invaluable in enhancing my manuscript, and their meticulous attention to detail and dedication to quality are truly commendable. Additionally, the support from the Editorial Office was exceptional. From the initial submission to the final publication, I was guided through every step of the process with great care and professionalism. The team's responsiveness and assistance made the entire experience both easy and stress-free. I am also deeply impressed by the quality and reputation of the journal. It is an honor to have my research featured in such a respected publication, and I am confident that it will make a meaningful contribution to the field.
"I am grateful for the opportunity of contributing to [International Journal of Clinical Case Reports and Reviews] and for the rigorous review process that enhances the quality of research published in your esteemed journal. I sincerely appreciate the time and effort of your team who have dedicatedly helped me in improvising changes and modifying my manuscript. The insightful comments and constructive feedback provided have been invaluable in refining and strengthening my work".
I thank the ‘Journal of Clinical Research and Reports’ for accepting this article for publication. This is a rigorously peer reviewed journal which is on all major global scientific data bases. I note the review process was prompt, thorough and professionally critical. It gave us an insight into a number of important scientific/statistical issues. The review prompted us to review the relevant literature again and look at the limitations of the study. The peer reviewers were open, clear in the instructions and the editorial team was very prompt in their communication. This journal certainly publishes quality research articles. I would recommend the journal for any future publications.
Dear Jessica Magne, with gratitude for the joint work. Fast process of receiving and processing the submitted scientific materials in “Clinical Cardiology and Cardiovascular Interventions”. High level of competence of the editors with clear and correct recommendations and ideas for enriching the article.
We found the peer review process quick and positive in its input. The support from the editorial officer has been very agile, always with the intention of improving the article and taking into account our subsequent corrections.
My article, titled 'No Way Out of the Smartphone Epidemic Without Considering the Insights of Brain Research,' has been republished in the International Journal of Clinical Case Reports and Reviews. The review process was seamless and professional, with the editors being both friendly and supportive. I am deeply grateful for their efforts.
To Dear Erin Aust – Editorial Coordinator of Journal of General Medicine and Clinical Practice! I declare that I am absolutely satisfied with your work carried out with great competence in following the manuscript during the various stages from its receipt, during the revision process to the final acceptance for publication. Thank Prof. Elvira Farina
Dear Jessica, and the super professional team of the ‘Clinical Cardiology and Cardiovascular Interventions’ I am sincerely grateful to the coordinated work of the journal team for the no problem with the submission of my manuscript: “Cardiometabolic Disorders in A Pregnant Woman with Severe Preeclampsia on the Background of Morbid Obesity (Case Report).” The review process by 5 experts was fast, and the comments were professional, which made it more specific and academic, and the process of publication and presentation of the article was excellent. I recommend that my colleagues publish articles in this journal, and I am interested in further scientific cooperation. Sincerely and best wishes, Dr. Oleg Golyanovskiy.
Dear Ashley Rosa, Editorial Coordinator of the journal - Psychology and Mental Health Care. " The process of obtaining publication of my article in the Psychology and Mental Health Journal was positive in all areas. The peer review process resulted in a number of valuable comments, the editorial process was collaborative and timely, and the quality of this journal has been quickly noticed, resulting in alternative journals contacting me to publish with them." Warm regards, Susan Anne Smith, PhD. Australian Breastfeeding Association.
Dear Jessica Magne, Editorial Coordinator, Clinical Cardiology and Cardiovascular Interventions, Auctores Publishing LLC. I appreciate the journal (JCCI) editorial office support, the entire team leads were always ready to help, not only on technical front but also on thorough process. Also, I should thank dear reviewers’ attention to detail and creative approach to teach me and bring new insights by their comments. Surely, more discussions and introduction of other hemodynamic devices would provide better prevention and management of shock states. Your efforts and dedication in presenting educational materials in this journal are commendable. Best wishes from, Farahnaz Fallahian.
Dear Maria Emerson, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews, Auctores Publishing LLC. I am delighted to have published our manuscript, "Acute Colonic Pseudo-Obstruction (ACPO): A rare but serious complication following caesarean section." I want to thank the editorial team, especially Maria Emerson, for their prompt review of the manuscript, quick responses to queries, and overall support. Yours sincerely Dr. Victor Olagundoye.
Dear Ashley Rosa, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews. Many thanks for publishing this manuscript after I lost confidence the editors were most helpful, more than other journals Best wishes from, Susan Anne Smith, PhD. Australian Breastfeeding Association.
Dear Agrippa Hilda, Editorial Coordinator, Journal of Neuroscience and Neurological Surgery. The entire process including article submission, review, revision, and publication was extremely easy. The journal editor was prompt and helpful, and the reviewers contributed to the quality of the paper. Thank you so much! Eric Nussbaum, MD
Dr Hala Al Shaikh This is to acknowledge that the peer review process for the article ’ A Novel Gnrh1 Gene Mutation in Four Omani Male Siblings, Presentation and Management ’ sent to the International Journal of Clinical Case Reports and Reviews was quick and smooth. The editorial office was prompt with easy communication.
Dear Erin Aust, Editorial Coordinator, Journal of General Medicine and Clinical Practice. We are pleased to share our experience with the “Journal of General Medicine and Clinical Practice”, following the successful publication of our article. The peer review process was thorough and constructive, helping to improve the clarity and quality of the manuscript. We are especially thankful to Ms. Erin Aust, the Editorial Coordinator, for her prompt communication and continuous support throughout the process. Her professionalism ensured a smooth and efficient publication experience. The journal upholds high editorial standards, and we highly recommend it to fellow researchers seeking a credible platform for their work. Best wishes By, Dr. Rakhi Mishra.
Dear Jessica Magne, Editorial Coordinator, Clinical Cardiology and Cardiovascular Interventions, Auctores Publishing LLC. The peer review process of the journal of Clinical Cardiology and Cardiovascular Interventions was excellent and fast, as was the support of the editorial office and the quality of the journal. Kind regards Walter F. Riesen Prof. Dr. Dr. h.c. Walter F. Riesen.
Dear Ashley Rosa, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews, Auctores Publishing LLC. Thank you for publishing our article, Exploring Clozapine's Efficacy in Managing Aggression: A Multiple Single-Case Study in Forensic Psychiatry in the international journal of clinical case reports and reviews. We found the peer review process very professional and efficient. The comments were constructive, and the whole process was efficient. On behalf of the co-authors, I would like to thank you for publishing this article. With regards, Dr. Jelle R. Lettinga.
Dear Clarissa Eric, Editorial Coordinator, Journal of Clinical Case Reports and Studies, I would like to express my deep admiration for the exceptional professionalism demonstrated by your journal. I am thoroughly impressed by the speed of the editorial process, the substantive and insightful reviews, and the meticulous preparation of the manuscript for publication. Additionally, I greatly appreciate the courteous and immediate responses from your editorial office to all my inquiries. Best Regards, Dariusz Ziora
Dear Chrystine Mejia, Editorial Coordinator, Journal of Neurodegeneration and Neurorehabilitation, Auctores Publishing LLC, We would like to thank the editorial team for the smooth and high-quality communication leading up to the publication of our article in the Journal of Neurodegeneration and Neurorehabilitation. The reviewers have extensive knowledge in the field, and their relevant questions helped to add value to our publication. Kind regards, Dr. Ravi Shrivastava.
Dear Clarissa Eric, Editorial Coordinator, Journal of Clinical Case Reports and Studies, Auctores Publishing LLC, USA Office: +1-(302)-520-2644. I would like to express my sincere appreciation for the efficient and professional handling of my case report by the ‘Journal of Clinical Case Reports and Studies’. The peer review process was not only fast but also highly constructive—the reviewers’ comments were clear, relevant, and greatly helped me improve the quality and clarity of my manuscript. I also received excellent support from the editorial office throughout the process. Communication was smooth and timely, and I felt well guided at every stage, from submission to publication. The overall quality and rigor of the journal are truly commendable. I am pleased to have published my work with Journal of Clinical Case Reports and Studies, and I look forward to future opportunities for collaboration. Sincerely, Aline Tollet, UCLouvain.
Dear Ms. Mayra Duenas, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews. “The International Journal of Clinical Case Reports and Reviews represented the “ideal house” to share with the research community a first experience with the use of the Simeox device for speech rehabilitation. High scientific reputation and attractive website communication were first determinants for the selection of this Journal, and the following submission process exceeded expectations: fast but highly professional peer review, great support by the editorial office, elegant graphic layout. Exactly what a dynamic research team - also composed by allied professionals - needs!" From, Chiara Beccaluva, PT - Italy.
Dear Maria Emerson, Editorial Coordinator, we have deeply appreciated the professionalism demonstrated by the International Journal of Clinical Case Reports and Reviews. The reviewers have extensive knowledge of our field and have been very efficient and fast in supporting the process. I am really looking forward to further collaboration. Thanks. Best regards, Dr. Claudio Ligresti
Dear Chrystine Mejia, Editorial Coordinator, Journal of Neurodegeneration and Neurorehabilitation. “The peer review process was efficient and constructive, and the editorial office provided excellent communication and support throughout. The journal ensures scientific rigor and high editorial standards, while also offering a smooth and timely publication process. We sincerely appreciate the work of the editorial team in facilitating the dissemination of innovative approaches such as the Bonori Method.” Best regards, Dr. Matteo Bonori.
I recommend without hesitation submitting relevant papers on medical decision making to the International Journal of Clinical Case Reports and Reviews. I am very grateful to the editorial staff. Maria Emerson was a pleasure to communicate with. The time from submission to publication was an extremely short 3 weeks. The editorial staff submitted the paper to three reviewers. Two of the reviewers commented positively on the value of publishing the paper. The editorial staff quickly recognized the third reviewer’s comments as an unjust attempt to reject the paper. I revised the paper as recommended by the first two reviewers.
Dear Maria Emerson, Editorial Coordinator, Journal of Clinical Research and Reports. Thank you for publishing our case report: "Clinical Case of Effective Fetal Stem Cells Treatment in a Patient with Autism Spectrum Disorder" within the "Journal of Clinical Research and Reports" being submitted by the team of EmCell doctors from Kyiv, Ukraine. We much appreciate a professional and transparent peer-review process from Auctores. All research Doctors are so grateful to your Editorial Office and Auctores Publishing support! I amiably wish our article publication maintained a top quality of your International Scientific Journal. My best wishes for a prosperity of the Journal of Clinical Research and Reports. Hope our scientific relationship and cooperation will remain long lasting. Thank you very much indeed. Kind regards, Dr. Andriy Sinelnyk Cell Therapy Center EmCell
