Title: The Reflux Symptom Score has good screening value for Laryngopharyngeal Reflux
Version: 1 Date: 08 Jul 2024
Reviewer's report:
Thank you for the opportunity to review this well-written article. The authors sought to explore
the agreement between RSS and Pepsin test, and to investigate the screening value of the RSS for
LPR by receiver operating characteristic (ROC) analysis using Pepsin test as diagnostic standard.
However, there are some issues that need further addressed by the authors:
1. The salivary pepsin test is generally accepted to be a first-line screening test (doi: 10.1016/
j.bjorl.2022.10.050.). A positive pepsin test can be regarded as direct evidence of the presence
of reflux to the larynx. But referring it as diagnosis for LPR seems to be somewhat overreaching.
As mentioned as a limitation, I think the authors could elaborate more on the pros and cons of
24-h MII-pH monitoring and the reasoning why it is not incorporated in the current study. Also,
the authors might reflect on the title “The Reflux Symptom Score has good screening value for
Laryngopharyngeal Reflux”. Again, it seems overreaching. I do believe the idea of concurrent
with a structured questionnaire and Pepsin test for better screening /diagnostic accuracy. And
it is interesting and of importance that these two screening tools with different aspect had good
agreement. But using Pepsin test as gold standard may not be optimal.
2. Although it had been shown that a single detection of salivary pepsin in the morning is more
economical, the sensitivity is too low, and it is necessary to detect it multiple times a day.
As explained in the Method section: All subjects underwent multiple time-point saliva pepsin
detection within a single day (the first sample was collected in the morning before brushing teeth
and eating, followed by hourly collections starting at 8 a.m. until 6 p.m., totaling 12 times), and
saliva sample collection was conducted in the hospital. Were the participant in-hospital patient or
recruited from out-patient clinic? Did the participant report to the hospital hourly for performing/
submitting the test? The process is confusing and undermine the applicability of generalizing
the results. Also, study had showed that when the number of tests were further increased beyond
combining with the waking, 1 and 2 h after breakfast and lunch, and 1 h after dinner tests, the
diagnostic value did not improve significantly.( doi: 10.1002/lary.30408.)
3. Was Salivary pepsin detected on the day of RSS?
4. For inclusion, the definition of ”longterm” should be further delineated.
Title: The Reflux Symptom Score has good screening value for Laryngopharyngeal Reflux
Version: 1 Date: 08 Jul 2024
Reviewer's report:
Thank you for the opportunity to review this well-written article. The authors sought to explore
the agreement between RSS and Pepsin test, and to investigate the screening value of the RSS for
LPR by receiver operating characteristic (ROC) analysis using Pepsin test as diagnostic standard.
However, there are some issues that need further addressed by the authors:
1. The salivary pepsin test is generally accepted to be a first-line screening test (doi: 10.1016/
j.bjorl.2022.10.050.). A positive pepsin test can be regarded as direct evidence of the presence
of reflux to the larynx. But referring it as diagnosis for LPR seems to be somewhat overreaching.
As mentioned as a limitation, I think the authors could elaborate more on the pros and cons of
24-h MII-pH monitoring and the reasoning why it is not incorporated in the current study. Also,
the authors might reflect on the title “The Reflux Symptom Score has good screening value for
Laryngopharyngeal Reflux”. Again, it seems overreaching. I do believe the idea of concurrent
with a structured questionnaire and Pepsin test for better screening /diagnostic accuracy. And
it is interesting and of importance that these two screening tools with different aspect had good
agreement. But using Pepsin test as gold standard may not be optimal.
2. Although it had been shown that a single detection of salivary pepsin in the morning is more
economical, the sensitivity is too low, and it is necessary to detect it multiple times a day.
As explained in the Method section: All subjects underwent multiple time-point saliva pepsin
detection within a single day (the first sample was collected in the morning before brushing teeth
and eating, followed by hourly collections starting at 8 a.m. until 6 p.m., totaling 12 times), and
saliva sample collection was conducted in the hospital. Were the participant in-hospital patient or
recruited from out-patient clinic? Did the participant report to the hospital hourly for performing/
submitting the test? The process is confusing and undermine the applicability of generalizing
the results. Also, study had showed that when the number of tests were further increased beyond
combining with the waking, 1 and 2 h after breakfast and lunch, and 1 h after dinner tests, the
diagnostic value did not improve significantly.( doi: 10.1002/lary.30408.)
3. Was Salivary pepsin detected on the day of RSS?
4. For inclusion, the definition of ”longterm” should be further delineated.
Please review this paper.
user
Title: The Reflux Symptom Score has good screening value for Laryngopharyngeal Reflux
Version: 1 Date: 08 Jul 2024
Reviewer's report:
Thank you for the opportunity to review this well-written article. The authors sought to explore
the agreement between RSS and Pepsin test, and to investigate the screening value of the RSS for
LPR by receiver operating characteristic (ROC) analysis using Pepsin test as diagnostic standard.
However, there are some issues that need further addressed by the authors:
1. The salivary pepsin test is generally accepted to be a first-line screening test (doi: 10.1016/
j.bjorl.2022.10.050.). A positive pepsin test can be regarded as direct evidence of the presence
of reflux to the larynx. But referring it as diagnosis for LPR seems to be somewhat overreaching.
As mentioned as a limitation, I think the authors could elaborate more on the pros and cons of
24-h MII-pH monitoring and the reasoning why it is not incorporated in the current study. Also,
the authors might reflect on the title “The Reflux Symptom Score has good screening value for
Laryngopharyngeal Reflux”. Again, it seems overreaching. I do believe the idea of concurrent
with a structured questionnaire and Pepsin test for better screening /diagnostic accuracy. And
it is interesting and of importance that these two screening tools with different aspect had good
agreement. But using Pepsin test as gold standard may not be optimal.
2. Although it had been shown that a single detection of salivary pepsin in the morning is more
economical, the sensitivity is too low, and it is necessary to detect it multiple times a day.
As explained in the Method section: All subjects underwent multiple time-point saliva pepsin
detection within a single day (the first sample was collected in the morning before brushing teeth
and eating, followed by hourly collections starting at 8 a.m. until 6 p.m., totaling 12 times), and
saliva sample collection was conducted in the hospital. Were the participant in-hospital patient or
recruited from out-patient clinic? Did the participant report to the hospital hourly for performing/
submitting the test? The process is confusing and undermine the applicability of generalizing
the results. Also, study had showed that when the number of tests were further increased beyond
combining with the waking, 1 and 2 h after breakfast and lunch, and 1 h after dinner tests, the
diagnostic value did not improve significantly.( doi: 10.1002/lary.30408.)
3. Was Salivary pepsin detected on the day of RSS?
4. For inclusion, the definition of ”longterm” should be further delineated.
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