Review for 10.1186/s12876-024-03193-z (2024)

Title: Characterization of Primary Small Intestinal Lymphoma: A Retrospective Study Based
on Double Balloon Endoscopy
Version: 6 Date: 31 Jan 2024
Reviewer's report:
The authors have made commendable efforts to enhance both the methodology and the quality
of the manuscript. Nevertheless, further refinements are necessary to elevate the scientific rigor.
Below are specific suggestions for improvement:
1. Terminology and Data Collection Methodology:
1.1. It is advisable for the authors to use more precise terminology in Table 1 and throughout
the manuscript. Instead of colloquial verbs such as "smoke" or "drink", terms like "Cigarette
smoking" and "Alcohol drinking" should be employed for scientific accuracy.
1.2. Given the prognostic significance of alcohol consumption in the study results, a detailed
description of the methods used to collect social behavioral information is necessary. This should
be clearly outlined in the Methods section:
1.2.1. The authors need to specify the methodology for collecting data on cigarette smoking and
alcohol consumption. Was this information obtained from chart records, and if so, how complete
and reliable was this data? In cases of missing data, it is important to detail the extent of such
omissions and the strategies employed to address them.
1.2.2. The manuscript should clearly define the criteria used to categorize alcohol consumption
as positive or negative. For instance, was there a specific quantity or frequency of alcohol intake
used as a threshold, akin to the standards set in the 2017 APASL NAFLD guidelines (e.g., 70 g
ethanol per week for women and 140 g ethanol per week for men)? If patient self-reporting was
used, such as inquiring "Do you drink alcohol regularly?", the methodology for incorporating
data on ceased smoking habits should be clarified.
2. Reporting of DBE Findings and Endoscopist Expertise:
2.1. Given the prognostic importance of "deep ulcers" in the study, it is essential for the authors
to provide comprehensive information on the qualifications of the endoscopists performing DBE
and their methodology for describing the lesions, as presented in Table 5. Specifically:
- Clarification is needed on whether all 30 PSIL DBE images were conducted by the same two or
three endoscopists. If this is not the case, it should be stated whether these images were reviewed
by the study authors. A minimum of two or three expert endoscopists should review these images
to ensure consistent and accurate description of the ulcers, including characteristics such as
"longitudinal," "ring-shaped," "irregular," "large," "linear," "small superficial," and "deep." In
instances of expert disagreement, the process of reaching a consensus should be documented
and reflected in the final study results, akin to the CT image review process previously reported.
Alternatively, if a single DBE specialist was responsible for all imaging, this (who and his
experience) should be explicitly stated.
2.2. The "deep ulcers" were described as "a type of ulcer that penetrates through the submucosa
into the deeper layers of the gastrointestinal tract". This should be provided in the Methods
sections, as long as how "longitudinal", "ring-shaped", "irregular", "large"..... was defined in all
30 DBE studies.
2.3. It is recommended that the authors revise Table 5 to eliminate redundant and subjective
descriptors that lack statistical significance. The table should ideally focus on reproducible and
objective descriptions of lesions, backed by expert consensus.
3. The authors' informative response to the previous queries, particularly in point 4, is
appreciated. It is recommended that these discussions, along with the corresponding references,
be incorporated into the main draft of the manuscript. This incorporation should be executed in a
manner that is both clear and concise, ensuring that the added information enhances the overall
coherence and depth of the study.
4. Consistency in Abstract Comparisons:
In the Abstract, the authors have opted for comparisons between 1) DLBCL and indolent B-
cell lymphoma, and 2) DLBCL and indolent T-cell lymphoma. To improve clarity and avoid
confusion, it is suggested that all comparisons be consistently framed with DLBCL as the
reference point. For example, instead of stating, "Compared with DLBCL patients, the body
mass index (BMI) of TCL patients was significantly lower (p = 0.004). Compared with patients
with indolent BCL, the patients with DLBCL had higher levels of C-reactive protein, lactate
dehydrogenase (LDH), fibrinogen and D-Dimer (p = 0.004, p = 0.004, p = 0.006, and p = 0.002,
respectively), and higher proportion okoef thicker intestinal wall and aneurysmal dilation in CT
scan (p = 0.003 and p = 0.020, respectively).", the sentences could be rephrased to maintain
DLBCL as the constant reference across all comparisons, thereby providing a uniform and clear
comparative framework for the reader.
5. Recommendations for Reporting Survival Analysis:
5.1. It is advisable for the authors to adopt a conventional format in presenting the survival
analysis. The section should commence with the total number of cases included, followed by
the median follow-up duration, and the number of events that occurred during this period. These
details are crucial and should be clearly stated in the Results section.
5.2. Regarding the statistical approach, the authors have noted the infrequency of outcome
variable occurrences, necessitating the use of univariable Cox regression models instead of
multiple regression models. This justification and the consequent methodological choice should
be explicitly detailed in the Results section. It is important to ensure that the hazard ratio and
95% confidence interval (CI) are clearly identified as derived from univariate Cox regression
analyses to prevent any confusion. Furthermore, the limitation imposed by the inability to
perform multiple Cox regression due to infrequent outcome events should be acknowledged and
discussed as a significant limitation in the Discussion section, ideally as a key point within the
limitations paragraph.
5.3. The authors should incorporate Table 1 from their response, titled "The detailed
univariate Cox regression results," into the main manuscript, or at least include it as
supplementary material. It would be beneficial for the authors to select and present the most
pertinent information from this table in the manuscript to provide a clear and comprehensive
understanding of the survival analysis results.