Title: The quality of life and body image disturbances of Turner syndrome patients in Malaysia:
a cross-sectional study
Version: 3 Date: 12 Aug 2023
Reviewer's report:
Dear authors,
Thank you very much for your submission. The topic is important in assessing the quality of life
among adults with turner syndrome. This is a two proportionate study involving two different
population.
Following are my suggestion and recommendation for further improvement of the writings:
1) Abstract:
-Results:   "There were no significant differences between TS and control groups’ median scores
of the different WHOQOL-BREF domains" - Kindly state the score value for each groups.
-Results: "However, TS participants were found to score lower than the control group (p<0.05)
in the social relationship domain. Comparatively, body image concerns among TS respondents
were significantly higher in impairment in the mainly social areas of functioning (p<0.05). " -
Kindly state the score value for each groups.
2) Background:
-Authors too much focus on the TS and its medical condition. It is highly recommended for
the authors to discuss more on the topic of QOL. Kindly define QOL and include literature on
previous possible predictive factors of good QOL.
3) Methods
- Authors mentioned about "Two validated, translated questionnaires; World Health
Organization Quality of Life (WHOQOL-BREF) questionnaire and Body Image Disturbances
Questionnaires (BIDQ)".  - Kindly explain more about the questionnaires, what are the domains,
what are the number of items, what are the specificity and sensitivity  and total score / cut off
points for good or poor score.
- Is the questionnaire in English or Malay? What about if patient not understand, are the
researchers assisting or how? Any bias on this and how authors handle if there is.
-Where is the input or notes on sample size? Sample size calculation for two proportions should
be used in order to justify and verify that the study is significant for any findings. Kindly provide
your sample size calculation, which is compulsory.
-Only 24 consented for the data collection. Is this enough?  Kindly refer to the sample size
calculation which should be included.
4) Results:
-Authors mentioned: " Table 2 shows the medical profiles of the TS participants" - Kindly change
the medical profiles to clinical profiles.
-In table I, authors state the ethnicity has statistically significant between the two groups (P value
= 0.045). But this is probably because of zero samples in others group in TS group. I would
suggest avoid others group in calculation of statistical analysis and just compare the Malay and
Chinese ethnicity between the two (as the main difference is because of others subgroup, not
the other groups).
5) Discussion:
-In the section "  Social and Demographic Characteristics" - Authors mentioned "We also
postulate that COVID-19 situation may have contributed to the low employment rate." - Authors
actually not include COVID-19 parameters in the study. Therefore, I would like to suggest not
to include this data in the comments / discussion. Even though it is important, can include this
in your limitation or additional points in recommendation.
- Authors also mentioned " Thus, our TS patients may not have benefited from earlier hormonal
treatment that might have enabled them to achieve an ideal height as they were diagnosed late."
- This is also has not been confirmed yet in this study as authors not included this point in the
study. Therefore, can avoid this comments.
6) Strength and limitations:
- "Our study is the first study in Malaysia and in Southeast Asia " - Preferably not to mentioned
or claimed this in writings, better to be neutral.
7) Conclusion:
- This study should identify the gap and suggest specific measures to increase the QOL, not only
stating that QOL should be focused. Please add some measures to do so.
8) reference No 11 - Year 1989 (quite too long time, probably can revised back the need to
include this reference).