Review for 10.1186/s12876-023-02703-9 (2023)

Reviewer’s report
Title: 
Food elimination diet is a viable alternative therapy for eosinophilic
esophagitis responsive to proton pump inhibitors
Version: 
0 
Date: 
11 Jan 2023
Reviewer's report:
In this study, the authors retrospectively investigated whether patients with EoE
that responded histologically to PPIs could be maintained in histologic remission
with a food elimination diet. The topic is of interest, as only other small studies
have investigated maintenance of remission with a therapy different from the
therapy used for the induction of remission. However, I do have some major
concerns regarding the methodology of this study and a few other minor issues
to raise. 
MAJOR
Methods
1. The authors define histologic remission as <10 eos/HPF. However, the
established threshold for disease remission in EoE is <15 eos/HPF. Although
several clinical trials on novel drugs are assessing the threshold of <6 eos/HPF,
the threshold of <15 eos/HPF still remains the one that should be used in clinical
practice. To be useful in clinical practice, I believe the analysis should be done
considering remission as <15 eos/HPF.
2. It is unclear how the food elimination diet protocol was performed. Some
patients underwent 2-FED, other 4-FED and so on. However, it is unclear if non-
responders to for eg. A 2-FED underwent all the FEDs up to a 6-FED. 
3. It is unclear why the authors offered to FED responders the possibility to
undergo maintenance with FED+PPI on an as needed basis. What was the reason
for this? 
4. It is unclear if patients were histologically active before FED. If patients were
already in remission, how long after PPI discontinuation did patients undergo
FED monotherapy?
MINOR
1. Despite the affiliation of the authors is from the US, the use of English is often
awkward in the manuscript. I strongly suggest to carefully revise the language. 
2. In the methods section the authors state that they included patients that had
undergone a minimum of 8 weeks of PPI and subsequently FED 
before
histology evaluation. In the following paragraph, they state that a minimum of 6
weeks of treatment was performed. Please clarify. 
3. The questions of the surveys should be reported in a supplementary table 
4. The used episodes of food impaction or urgent visits as a surrogate of
healthcare resources utilization by patients under treatment. Can the authors
exclude that some patients might have be seen in a different centre? How? If not,
this should be mentioned in the limitations
Declaration of competing interests
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No conflicts of interest
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Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
No
Are the methods sufficiently described to allow the study to be repeated?
No
Is the use of statistics and treatment of uncertainties appropriate?
No
Is the presentation of the work clear?
No
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
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No