Title: U-shaped association of the stress hyperglycemia ratio for all-cause and cardiovascular
mortality in patients with NAFLD: results from the NHANES database prospective cohort study
Version: 0 Date: 22 May 2025
Reviewer's report:
This manuscript investigates the association between the stress hyperglycemia ratio (SHR)
and all-cause as well as cardiovascular mortality in NAFLD patients using NHANES data.
While the topic is of clinical relevance and the dataset is robust, several major issues—ranging
from methodological weaknesses and unclear statistical presentation to extensive language and
formatting problems—limit the clarity, rigor, and interpretability of the study.
If you believe any comment is based on a misunderstanding or you choose not to implement a
suggested change, please state your reasoning clearly rather than simply agreeing. A thoughtful,
critical response is always appreciated.
Comments
1. The use of causal terms such as "effect," "leads to," and “impact” is inappropriate for an
observational study and needs to be revised throughout the manuscript. Use association-based
phrasing like “linked to” or “associated with.”
2. Proportional Hazards Assumption: There is no assessment or reporting of the proportional
hazards (PH) assumption in the Cox regression models. Please check this assumption (e.g., using
PH test or Schoenfeld residuals) and report the results.
3. Add a dashed or solid horizontal line at HR = 1.0 to clearly demarcate the reference risk level
across the SHR spectrum.
4. You have chosen restricted cubic splines (RCS) to model the non-linear association between
SHR and mortality, which is appropriate for exploratory dose–response analysis. However, you
did not mention whether other non-linear modeling strategies were considered, such as piecewise
linear regression. Please clarify whether alternative models were tested (e.g., piecewise or
segmented regression), and if so, how the RCS was selected as the final approach.
5. Use the term p-value for linear trend. Additionally, compare and discuss the results of the p-
value for linear trend and the non-linearity value.
6. The U-shaped association is mentioned repeatedly, but its clinical implication is unclear. For
example, the discussion implies that SHR < 0.88 is protective but also associates it with increased
mortality. This contradiction needs clearer interpretation and discussion.
7. Although many covariates are included, some relevant confounders such as socioeconomic
status, diet, and medication history are missing. Acknowledge this more explicitly in the
limitations.
8. The manuscript contains numerous grammatical errors, typos, and awkward phrases.
Professional English editing is essential before resubmission.
9. Inconsistent formatting and citation style; please adhere to journal-specific reference
guidelines.
10. Please revise all figures for clarity, consistency, and standalone interpretability. Use
uniform color schemes, standard hazard ratio axes, and ensure all annotations are readable and
informative.
Title: U-shaped association of the stress hyperglycemia ratio for all-cause and cardiovascular
mortality in patients with NAFLD: results from the NHANES database prospective cohort study
Version: 0 Date: 22 May 2025
Reviewer's report:
This manuscript investigates the association between the stress hyperglycemia ratio (SHR)
and all-cause as well as cardiovascular mortality in NAFLD patients using NHANES data.
While the topic is of clinical relevance and the dataset is robust, several major issues—ranging
from methodological weaknesses and unclear statistical presentation to extensive language and
formatting problems—limit the clarity, rigor, and interpretability of the study.
If you believe any comment is based on a misunderstanding or you choose not to implement a
suggested change, please state your reasoning clearly rather than simply agreeing. A thoughtful,
critical response is always appreciated.
Comments
1. The use of causal terms such as "effect," "leads to," and “impact” is inappropriate for an
observational study and needs to be revised throughout the manuscript. Use association-based
phrasing like “linked to” or “associated with.”
2. Proportional Hazards Assumption: There is no assessment or reporting of the proportional
hazards (PH) assumption in the Cox regression models. Please check this assumption (e.g., using
PH test or Schoenfeld residuals) and report the results.
3. Add a dashed or solid horizontal line at HR = 1.0 to clearly demarcate the reference risk level
across the SHR spectrum.
4. You have chosen restricted cubic splines (RCS) to model the non-linear association between
SHR and mortality, which is appropriate for exploratory dose–response analysis. However, you
did not mention whether other non-linear modeling strategies were considered, such as piecewise
linear regression. Please clarify whether alternative models were tested (e.g., piecewise or
segmented regression), and if so, how the RCS was selected as the final approach.
5. Use the term p-value for linear trend. Additionally, compare and discuss the results of the p-
value for linear trend and the non-linearity value.
6. The U-shaped association is mentioned repeatedly, but its clinical implication is unclear. For
example, the discussion implies that SHR < 0.88 is protective but also associates it with increased
mortality. This contradiction needs clearer interpretation and discussion.
7. Although many covariates are included, some relevant confounders such as socioeconomic
status, diet, and medication history are missing. Acknowledge this more explicitly in the
limitations.
8. The manuscript contains numerous grammatical errors, typos, and awkward phrases.
Professional English editing is essential before resubmission.
9. Inconsistent formatting and citation style; please adhere to journal-specific reference
guidelines.
10. Please revise all figures for clarity, consistency, and standalone interpretability. Use
uniform color schemes, standard hazard ratio axes, and ensure all annotations are readable and
informative.
Please review this paper.
user
Title: U-shaped association of the stress hyperglycemia ratio for all-cause and cardiovascular
mortality in patients with NAFLD: results from the NHANES database prospective cohort study
Version: 0 Date: 22 May 2025
Reviewer's report:
This manuscript investigates the association between the stress hyperglycemia ratio (SHR)
and all-cause as well as cardiovascular mortality in NAFLD patients using NHANES data.
While the topic is of clinical relevance and the dataset is robust, several major issues—ranging
from methodological weaknesses and unclear statistical presentation to extensive language and
formatting problems—limit the clarity, rigor, and interpretability of the study.
If you believe any comment is based on a misunderstanding or you choose not to implement a
suggested change, please state your reasoning clearly rather than simply agreeing. A thoughtful,
critical response is always appreciated.
Comments
1. The use of causal terms such as "effect," "leads to," and “impact” is inappropriate for an
observational study and needs to be revised throughout the manuscript. Use association-based
phrasing like “linked to” or “associated with.”
2. Proportional Hazards Assumption: There is no assessment or reporting of the proportional
hazards (PH) assumption in the Cox regression models. Please check this assumption (e.g., using
PH test or Schoenfeld residuals) and report the results.
3. Add a dashed or solid horizontal line at HR = 1.0 to clearly demarcate the reference risk level
across the SHR spectrum.
4. You have chosen restricted cubic splines (RCS) to model the non-linear association between
SHR and mortality, which is appropriate for exploratory dose–response analysis. However, you
did not mention whether other non-linear modeling strategies were considered, such as piecewise
linear regression. Please clarify whether alternative models were tested (e.g., piecewise or
segmented regression), and if so, how the RCS was selected as the final approach.
5. Use the term p-value for linear trend. Additionally, compare and discuss the results of the p-
value for linear trend and the non-linearity value.
6. The U-shaped association is mentioned repeatedly, but its clinical implication is unclear. For
example, the discussion implies that SHR < 0.88 is protective but also associates it with increased
mortality. This contradiction needs clearer interpretation and discussion.
7. Although many covariates are included, some relevant confounders such as socioeconomic
status, diet, and medication history are missing. Acknowledge this more explicitly in the
limitations.
8. The manuscript contains numerous grammatical errors, typos, and awkward phrases.
Professional English editing is essential before resubmission.
9. Inconsistent formatting and citation style; please adhere to journal-specific reference
guidelines.
10. Please revise all figures for clarity, consistency, and standalone interpretability. Use
uniform color schemes, standard hazard ratio axes, and ensure all annotations are readable and
informative.
assistant