Review for 10.1186/s12876-025-03644-1 (2025)

Title: Efficacy analysis of folic acid in chronic atrophic gastritis with Helicobacter pylori
Infection: a systematic review and meta-analysis
Version: 3 Date: 30 Nov 2024
Reviewer:  Ehsan Amini-Salehi
Reviewer's report:
Dear Editor,
Thank you for inviting me to review the manuscript titled "Efficacy analysis of folic acid in
chronic atrophic gastritis with Helicobacter pylori Infection: a systematic review and meta-
analysis". This manuscript explores the efficacy of folic acid therapy in improving outcomes for
chronic atrophic gastritis (CAG) patients with Helicobacter pylori (H. pylori) infection through
a systematic review and meta-analysis. This is a relevant and timely study, as it addresses a
significant gap in the literature concerning evidence-based treatment for CAG. Below are my
detailed comments.
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General Comments
1. Title and Abstract:
o The title is clear and accurately reflects the scope of the study. However, the abstract could
better highlight the clinical significance of the findings, particularly how they contribute to
current treatment strategies.
o The conclusion section in the abstract should briefly address study limitations.
2. Introduction:
o The introduction effectively sets the stage by highlighting the global burden of CAG and its
link to gastric cancer. However, it could better contextualize the role of folic acid within existing
treatment paradigms for H. pylori eradication.
3. Language and Clarity:
o The manuscript is generally well-written but would benefit from minor grammatical
corrections to improve readability.
4. Figures and Tables:
o The figures and tables are informative but would benefit from clearer legends that explain the
key findings in more detail.
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Clinical Comments
1. Therapeutic Implications:
o While the manuscript demonstrates the efficacy of folic acid therapy, it does not sufficiently
address how these findings could influence clinical guidelines for managing CAG with H. pylori
infection.
2. Patient Subgroups:
o The study includes patients of varying ages and treatment regimens but does not explore
differential outcomes among these subgroups. For instance, how does age or the use of
combination therapies influence the efficacy of folic acid?
3. Safety Profile:
o Although the study reports a lower incidence of adverse events with folic acid therapy, it does
not provide specific details on the types of adverse events observed. This information is critical
for clinical application.
4. Dose Optimization:
o The study mentions variability in folic acid dosage and treatment duration but does not propose
an optimal regimen based on the findings.
5. Integration into Current Therapies:
o Discussing how folic acid therapy could be integrated with other emerging treatments, such
as potassium-competitive acid blockers, would enhance the clinical relevance of the study.
________________________________________
Statistical Comments
1. Heterogeneity:
o The meta-analysis shows moderate heterogeneity for some outcomes. The manuscript
should delve deeper into potential sources of this heterogeneity, such as differences in study
populations, treatment regimens, or diagnostic criteria.
2. Subgroup Analyses:
o While subgroup analyses are reported, the manuscript does not sufficiently discuss their
clinical implications. For example, why do certain subgroups benefit more from folic acid
therapy?
3. Sensitivity Analyses:
o The sensitivity analyses provide reassurance about the robustness of the findings, but their
results are not discussed in sufficient detail.
4. Risk of Bias:
o The Cochrane risk-of-bias assessment is comprehensive. However, the manuscript could
benefit from a brief discussion of how any observed biases might have impacted the results.
5. Effect Sizes:
o The manuscript reports odds ratios and mean differences but does not discuss their clinical
significance. Translating these statistical findings into practical implications would enhance the
manuscript's impact.