Review for 10.1186/s12876-025-03730-4 (2025)

Title: Effect of L-carnitine Supplementation on Muscle Cramps in Liver Cirrhosis: Results from
a Retrospective Cohort Study
Version: 1 Date: 07 Dec 2024
Reviewer's report:
I would like to thank the journal for considering me as a reviewer for this manuscript. After a
thorough review, I have identified several areas where the manuscript could be improved.
Abstract
The abstract does not sufficiently detail the study's quantitative findings, particularly in the
conclusion. Including specific data points, such as the percentage reduction in cramp severity
or duration, would make the findings more impactful and informative for potential readers.
Study Design and Cohort Description
While the retrospective cohort design is acknowledged as a limitation in the discussion, it
should be justified earlier in the methodology section. The rationale for choosing a retrospective
approach over a randomized or prospective design is unclear and could raise questions about
the robustness of the findings. Additionally, the manuscript does not address the potential for
selection bias due to the retrospective nature of the study. For instance, it is not clear if patients
with incomplete records were systematically different from those included in the analysis.
Novelty and Clinical Implications
The manuscript mentions the need for further research but does not adequately position this
study in the context of existing literature. While prior studies on L-carnitine are referenced, the
specific novelty or unique contributions of these findings are not well-highlighted. For example,
the manuscript could discuss in more depth how demographic or response trends in this cohort
contribute to the existing body of knowledge. Additionally, the practical application of the
findings, such as their potential influence on treatment guidelines or clinical practice, is not
sufficiently explored.
Statistical Reporting
Although the statistical analysis is generally robust, key findings would benefit from the
inclusion of confidence intervals alongside p-values to provide a fuller context for the results.
The study also lacks a discussion on its statistical power, which is particularly important given
the relatively small final sample size.
Tables and Figures
The tables, while informative, could be improved for readability and presentation. For example,
tables summarizing cramp indices before and after treatment could combine summary statistics
with graphical elements, such as bar or line charts, to visually demonstrate the changes. Including
a flowchart to clarify the patient selection process would also enhance transparency in the
methodology.
Results Presentation
The results section is clear but could better integrate findings across tables to provide a cohesive
narrative. For instance, the significant correlations between BMI and cramp indices could be
discussed more comprehensively, linking them directly to potential clinical implications.
Language and Clarity
The manuscript is generally well-written but could benefit from simplification of overly complex
sentences, particularly in the discussion of BMI and treatment response. Some technical terms,
such as "relative change in cramp indices," should be explicitly defined to improve accessibility
for readers.
Limitations
The limitations section is too brief and could benefit from further critical reflection. The absence
of a control group is a major limitation that requires a more thorough discussion, particularly
regarding its potential impact on the observed results. Additionally, confounding factors such as
diet, physical activity, or concurrent medications are not addressed and should be considered.
Ethical and Practical Considerations
Although ethical approval and informed consent are mentioned, the manuscript does not
elaborate on how retrospective data collection adhered to ethical guidelines. Clarifying how
patient confidentiality and data security were maintained would strengthen the study's ethical
rigor.
Future Research Directions
The manuscript concludes by mentioning the need for further studies but does not provide
specific recommendations. Suggestions could include conducting randomized controlled trials,
exploring higher doses of L-carnitine, or investigating subgroups with specific characteristics,
such as high BMI or severe cirrhosis, who might benefit differently from supplementation.