Review for 10.1186/s12876-025-03642-3 (2025)

Title: Cardiometabolic Index as a Predictor of Gallstone Incidence in U.S. Adults: Insights from
NHANES 2017-2020
Version: 0 Date: 21 Dec 2024
Reviewer:  Amira A A Othman
Reviewer's report:
First of all
I want to congratulate the authors on their work. In this study, Li and Bai used data from the
2017–2020 National Health and Nutrition Examination Survey (NHANES) for adult Americans,
this research aims to investigate the potential association between the Cardiometabolic Index and
the risk of gallstones in adult US citizens. The paper includes extensive statistical analyses (e.g.,
logistic regression, sensitivity analyses, subgroup analyses), Employing the Cardiometabolic
Index (CMI) as a novel predictor of gallstone disease using data from NHANES.
Gallstone is the most common biliary pathology with a global incidence of 3-21.9%*. In Asia,
it is 4-15%**. In Africa, the prevalence is less than 5%***.  Most of the patients with gallstones
are asymptomatic and are diagnosed incidentally. Symptomatic patients classically present
with biliary colic, usually accompanied by nausea, vomiting, and diaphoresis. Laparoscopic
cholecystectomy is the gold standard treatment. However, about 5.2% of cases convert to open
cholecystectomy for better outcomes due to various reasons****
(*:doi.org/10.33545/surgery.2021.v5.i2e.697, **: doi: 10.5009/gnl.2012.6.2.172, *** doi:
10.29337/ijsp.143, **** DOI: 10.47009/jamp.2024.6.2.161).
The authors handled the reviewer comments satisfactorily, nevertheless, there is an observation
for which sufficient justification must be obtained.
In general:
1. The English writing level is shallow, and it is necessary to seek help from an English language
specialist to correct spelling and grammatical errors in the entire text.
2. Abbreviations must be fully written at their first use.
In Title:
3. I suggest focusing on using the cardiometabolic Index as a novel predictor of gallstone disease,
I would suggest "Cardiometabolic Index as a Predictor of Gallstone Incidence in U.S. Adults:
Insights from NHANES 2017-2020".
In Abstract section
4. The background subsection:
-  Should be the shortest part of the abstract. It should briefly outline the following information:
What is already known about the subject, related to the paper in question. What is not known
about the subject and hence what the study intended to examine (or what the paper seeks to
present). Please reconstruct it properly.
5.  The type of study: a population-based study, cross-sectional study.
6. In method subsection:
- Nothing was mentioned about the participant's age, sex, ethnicity, etc.
- It would help if you described the aim of your statistical analysis. For example, Multivariate
linear regression models were used to examine the linear connection between the lymphocyte-
to-high-density lipoprotein ratio and non-alcoholic fatty liver disease. Fitted smoothing curves
and threshold effect analysis were used to describe the nonlinear relationship, etc.
In the Introduction section:
7. Gallstones are crystallized deposits in the gallbladder or within the biliary tree, composed
of cholesterol, bilirubin, and bile. Try to provide a better identification of gallstones and their
types accordingly.
Try the following: “The primary ingredient in the most prevalent kind of gallstone is cholesterol.
Hemoglobin breaks down to form calcium bilirubinate, which is what causes black stones.
Brown stones, on the other hand, are made of a mixture of calcium substrates, such as calcium
bilirubinate, calcium phosphate or palmitate, cholesterol, and bile, and they develop in the
context of bacterial or parasite illness*. Those with diabetes and other metabolic disorders
frequently develop cholesterol stones. On the other hand, individuals who experience hemolysis
or have an inflammatory disease like Crohn's disease tend to get black stones, whereas people
with biliary strictures and infections from bacteria or parasites tend to get brown-pigmented
stones**.
(*doi: 10.1111/eci.12935, **doi: 10.1016/j.ejphar.2021.174376 ).
8. Try to provide a summarized description of The National Health and Nutrition Examination
Survey (NHANES) in the background section.
You may use the following “NHANES (www.cdc.gov/nchs/nhanes) is designed to assess the
health and nutritional status of adults and children in the United States. The survey is distinctive
in that it incorporates both physical examinations and interviews. Several cross-sectional,
nationally representative health examination surveys are part of the NHANES program.
Questions about demographics, health insurance status, dietary habits, acute and chronic medical
issues, mental health, and prescription drug use are all included in the health interview. Exam
components can change between survey cycles but typically include blood pressure, dental
exams, vision, hearing, dermatology, fitness, balance and strength testing, respiratory testing,
taste and smell, and body measurements (weight, height, skin folds, body composition scans).
Hematology, organ and endocrine function (e.g., thyroid, kidney), environmental exposure,
dietary biomarkers, metabolic and cardiovascular health, and infectious disease are some
laboratory components.”.
9. Explain how the CMI offers advantages over traditional metrics like BMI or waist
circumference in predicting gallstone risk.
In the Methods section:
10. Please provide the participants' sociodemographic data.
11. How the sample size was calculated.
12. Inclusion and exclusion criteria must be provided.
13. How were patients with gallstone disease diagnosed?
14. Are data collections retrospectively on a survey form? Nothing mentioned.
In the Results section:
15. In all tables, please explain the abbreviations under tables.
16. You can title the statistical test column as “Test of significance” and use U= for the Mann–
Whitney U test, T= for the T-test, and #2 = for the Chi-square test, etc., Although the Chi-square
test was used to compare observed and expected results, nothing was mentioned in the statistical
analysis section.
17. What were the patients' complaints?
In the Discussion section:
18. The discussion section is one of the final parts of a research paper, in which an author
describes, analyzes, and interprets their findings. They explain the significance of those results
and tie everything back to the research question(s). In this manuscript, there is confusion
between what should be written in the introduction and discussion sections. Please reconstruct
the discussion section.
19. The discussion should explain how gallstones can be managed.
20. Discuss the novelty of your study.
21. Limitations should be in a dedicated subsection and discuss additional factors like Possible
measurement errors from self-reported gallstone status, Lack of longitudinal data to infer
causation, and Potential confounding variables not accounted for.
In the conclusion section:
22. The conclusion should restate your main points and provide closure. Please reconstruct.
In the References section:
23. Some references are outdated or lack recent studies on CMI.