Review for 10.1186/s12876-025-03641-4 (2025)

Title: TITLE: The Association Between Blood Pressure and Gallstones and the Age of First
Cholecystectomy in U.S. Adults: Results from a Cross-Sectional Study
Version: 1 Date: 09 Dec 2024
Reviewer:  Sandeep S. Nayak
Reviewer's report:
The manuscript explores the relationship between hypertension (HTN), gallstone disease (GD),
and the age at first cholecystectomy using NHANES data. The revisions enhance the paper’s
rigor by:
Clarifying the exclusion criteria and covariate selection.
Expanding the Discussion to incorporate biological plausibility and implications for public
health.
Simplifying tables and figures to improve readability.
While the changes strengthen the study, there are areas where further improvements are
necessary.
Title and Abstract:
Title: The revised title is concise and reflects the study's objectives accurately.
Abstract: While improved, the Abstract still lacks accessibility for a broader audience. For
example:
Clarify technical terms such as "threshold effect" and "nonlinear relationship."
Add numerical results for subgroup analyses to strengthen the summary.
Introduction:
Strengths:
The revisions focus on research gaps, particularly the novel association between systolic blood
pressure (SBP) and cholecystectomy age.
Suggestions:
Avoid redundancy by omitting global prevalence statistics that do not directly support the study's
objectives.
Methods:
Study Design and Data Collection:
The justification for excluding participants with missing SBP or GD data is sound. However,
imputation methods for missing covariates require more detail to ensure reproducibility.
The NHANES dataset’s cross-sectional nature limits causal inferences. This limitation is
acknowledged but should be emphasized upfront in the Statistical Methods section.
Covariates:
Improvements: The authors justified education and marital status as covariates.
Remaining Issues: Variables such as dietary intake and physical activity, which significantly
influence both BP and GD, were excluded due to missing data. Future work should address these
gaps to provide a more holistic model.
Statistical Analyses:
Generalized Additive Models (GAM) and two-piecewise linear regression are well-described
and appropriate. However, the explanation of threshold effects should include biological
plausibility.
Clarify the basis for selecting 170 mmHg as the inflection point. Was it data-driven or informed
by prior literature?
Results:
Baseline Characteristics:
The summary in Table 1 is well-structured but retains excessive detail (e.g., PIR, education
level). Focus on statistically significant variables such as SBP, HTN, and GD.
Key Findings:
The relationship between HTN and GD is significant only in individuals aged >48 years, with
an odds ratio of 1.39 (95% CI: 1.03–1.88).
The dose-response analysis reveals that each unit increase in SBP corresponds to a 0.20-year
delay in cholecystectomy age, with a threshold effect at 170 mmHg.
Figures and Tables:
While clearer, Figure 3’s nonlinear relationship needs additional annotations for accessibility.
Discussion:
Interpretation:
The Discussion effectively highlights the potential implications of BP management in reducing
GD risk.
Avoid overgeneralizing the findings. For example, the biological mechanism linking SBP and
GD remains speculative and warrants longitudinal studies.
Strengths and Limitations:
The authors appropriately discuss recall bias and the absence of dietary data as limitations.
However, they could further elaborate on the implications of using self-reported variables.
Comparison with Literature:
The manuscript now includes comparisons with prior studies but could benefit from additional
insights into why the associations were stronger in older individuals.
Conclusion:
The conclusion is concise and aligns with the study's findings. However, avoid implying
causality given the cross-sectional design.