Review for 10.1186/s12876-025-03930-y (2025)

Title: Association Between Platelet-to-High-Density Lipoprotein Cholesterol Ratio and
Gallstone Prevalence in the American Adult Population: A Cross-Sectional Study Analysis
Version: 1 Date: 17 Feb 2025
Reviewer:  Erfan Arabpour
Reviewer's report:
Thanks for giving the opportunity to review this manuscript. This study investigate the
association between PHR and gallstones. I have several minor and a major point:
Minor:
- Title: the word "analysis" in the title seems redundant, please remove it.
- Intro: according to new AASLD nomenclature, "NAFLD" us no longer used, and the term
"MASLD" is replaced as a new entity. Please revise it.
- Please change "Method" to "Methods".
- Figure 1: please make the following chabges to make the flowchart more comprehensive: a) at
the end of flow chart, please also add the number of patients with (1441) and without (11722)
gallbladder stones. b) replace studies with participants in "Incorporate the number of the studies".
c) The direction of the arrow indicating the excluded participants should point outward, not
inward. Currently, it appears that these participants have been included in the study rather than
excluded from it.
- The sentence "A detailed flowchart outlining the inclusion and exclusion process is presented
in Figure 1. Ultimately,a total of 13,163 participants were included in the final analysis,of
whom 1,441(10.95%)self-reported a medical history of gallstones." should be mentioned in the
initiation of the results, not the methods section. Also add the exclusion criteria to the methods
in detail.
- Abbreviations are generally defined once upon their first appearance, after which only the
abbreviated form is used, eliminating the need for repetition of the full term or its definition.
However, throughout the text, the full form of "PHR" has been repeatedly mentioned, followed
by its abbreviation in parentheses. The same issue applies to other terms such as "MetS". Please
review and revise the entire text in accordance with the principle stated above.
Major:
The major concern of mine about this study is its clinical implications and how the results should
be utilized in the clinical practice. The authors concluded that "These findings suggest that
monitoring PHR may aid in the early identification of individuals at risk for gallstones,enabling
timely interventions to mitigate disease progression." However, what does this conclusion
exactly mean? Do authors propose a cut-off of PHR that patients with a PHR index more
than it, undergo imaging methods for detection of gallbladder stones? Or just an elevation of
PHR is enough to suggest imaging methods to patients? Moreover, as you know, asymptomatic
gallbladder stones generally do not require any intervention except in specific situations.
Let’s assume that the patient had a high PHR (or PHR increased in monitoring), and upon
recommending an ultrasound, gallbladder stones were diagnosed. What would be the next
step while the patient is asymptomatic? Would you recommend cholecystectomy? I believe
that monitoring this index and subsequent interventions, such as imaging studies, would
only increase healthcare system costs without benefiting either the patient or the healthcare
system. As long as the patient is asymptomatic, there is no need to investigate gallstones.
However, if the patient becomes symptomatic and there is clinical suspicion of biliary issues,
the necessary workups should be performed regardless of PHR, and appropriate actions, such
as cholecystectomy, should be taken.