Title: Gender Differences in Gastrointestinal, Biopsychosocial and Healthcare-seeking
Behaviors in Chinese Patients with Irritable Bowel Syndrome Predominant with Diarrhea
Version: 1 Date: 30 Nov 2023
Reviewer:  Zipan Lyu
Reviewer's report:
Reviewer Report
Title: More Prominent Psychosocial Disorders Rather Than Intestinal Symptoms in Chinese
Female Patients with Irritable Bowel Syndrome Predominant with Diarrhea Than Male Patients
Authors: Wenjuan Fan, Yang Chen, Xiucai Fang, Liming Zhu, Guijun Fei, Jia Lu, Xiaoqing Li
As a reviewer, I appreciate the comprehensive study comparing the biopsychosocial
characteristics of Chinese patients with irritable bowel syndrome (IBS) predominant with
diarrhea (IBS-D). The manuscript provides valuable insights into the gender differences in this
population. However, to enhance the manuscript's quality, I recommend Major Revision.
Here are some comments for further consideration:
Title and Abstract Clarity:
1. The title could be more specific about the focus on gender differences in Chinese IBS-D
patients.
The abstract is concise but could benefit from more clarity regarding the key findings.
2. Introduction:
The background could be strengthened by providing a brief overview of the existing literature
on gender differences in IBS patients globally, not just in the Chinese population.
Methodology:
Clarify how participants were recruited and whether there were any specific inclusion or
exclusion criteria.
Mention the demographic characteristics of the participants, such as age distribution, to provide
a clearer picture of the study population.
3. Results:
Ensure consistency in reporting statistical values (e.g., P-values) throughout the results section.
When presenting numerical data, consider reporting confidence intervals to indicate the
precision of estimates.
Specify the tools used for evaluating psychological status (HAMD and HAMA scales) for the
benefit of readers unfamiliar with these instruments.
4. Discussion:
Provide a more in-depth discussion of the implications of the observed gender differences,
relating them to existing literature.
Address potential confounding factors that might influence the reported gender differences.
Discuss the clinical relevance of the findings and their implications for the management of IBS-
D in Chinese patients.
5. Conclusion:
Emphasize the main implications and potential applications of the study findings.
Consider mentioning any recommendations for clinical practice or areas for future research.
Language and Style:
Carefully proofread the manuscript for grammatical and typographical errors.
Ensure consistency in the use of terminology and provide clear definitions for any specialized
terms.
Overall, the manuscript is a valuable contribution to the understanding of gender differences in
Chinese IBS-D patients. Addressing these points will strengthen the clarity, rigor, and impact
of the study.
Challenge comments
Method Section
1. Subjects:
a. Clarify whether patients were consecutive or selected through a specific process to address
potential selection bias.
b. Provide details on the number of patients in the database and any potential changes in criteria
over the study period.
c. Could the authors kindly provide an explanation for the decision to use Rome III diagnostic
and subtype criteria for IBS-D in the current study, as opposed to the more recent Rome IV
criteria? Clarifying the rationale for this choice would enhance the understanding of the study
design and its implications.
2. IBS Symptom Questionnaire:
a. Consider providing more information on the reliability and validity of the questionnaire,
especially if modifications were made.
b. Specify the training process for investigators to ensure consistency in data collection.
3. Stress History, Sleep Status, and Psychological Evaluation:
a. Clarify the specific questions or criteria used to assess mental stimulation and abuse history.
b. Describe how the relation of IBS with mental status and sleep disorders was evaluated.
4. Quality of Life Evaluation:
a. Provide more information on the characteristics of the study population in relation to the IBS-
QOL scores.
b. Discuss any potential limitations or biases associated with self-reporting of quality of life.
5. Dietary Habits and Coping Behaviors:
a. Specify the rationale for the choice of dietary questions and how they relate to IBS symptoms.
b. Consider discussing potential cultural influences on dietary habits.
6. Healthcare-Seeking Behaviors:
a. Discuss potential biases related to self-reporting, especially in recalling consultations and
medical costs.
b. Clarify the criteria for patient satisfaction with medical care.
7. Statistical Analysis:
a. Provide additional details on how missing data were handled, especially in the case of any
incomplete responses.
b. Mention whether corrections for multiple comparisons were applied.
Results Section
1. Please clarify the potential implications of age and BMI differences on the study outcomes.
2. The higher prevalence of gastroesophageal reflux in males raises questions about the co-
occurrence of IBS and reflux. It is essential to elaborate on how the study distinguishes between
coexistence and comorbidity. A discussion on the proportion of patients with both conditions
and those with overlapping symptoms would add clarity.
3. Given the proximity of females' age to menopausal stages, it's crucial to exclude menopausal
syndrome as a confounding factor. Avoid simplifying the association between IBS and
depressive or anxious states in females. Conducting additional interview-based research to
explore whether anxiety or depression directly results from IBS is recommended. This could
enhance the understanding of the complex interplay between psychological states and IBS
symptoms in females.
4. In Figure 3, the authors employ comorbidity analysis. It's important to verify if mental health
professionals made psychiatric diagnoses regarding patients' anxiety and depression. Relying
solely on scores from two scales may not warrant a definitive diagnosis of illness but rather
suggests anxiety and depression states. Clarify whether psychiatric professionals were involved
in the diagnosis process.
5. In Figure 4, the correlation analysis indicates a negative association between anxiety/
depression states and IBS symptom scores for both males and females. However, the
comparative significance of these correlations needs exploration. Considering the coefficients
(HAMA and HAMD scores) implies that males have stronger correlations, while for IBS
symptom scores and IBS-QOL scores, females have stronger correlations. Conduct a t-test on
the correlation coefficients to ascertain if the gender differences are statistically significant.
6. The response rates, healthcare-seeking behaviors, disease severity, and the relationship
between anxiety and compliance differ between males and females. This contrasts with findings
from clinical studies in Hong Kong. A discussion is needed to explore whether the disparity
in follow-up response rates between males and females in Beijing is influenced by regional or
cultural factors. Investigating these differences may contribute to a more nuanced understanding
of patient behavior in clinical research settings.
Discussion Section
1. The discussion emphasizes gender differences, but a more nuanced exploration of potential
commonalities in symptom experiences and coping mechanisms between genders could enrich
the interpretation.
2. While the discussion on abdominal pain and symptom severity differences aligns with
existing literature, a deeper exploration into the potential mechanisms underlying gender-based
variations in pain perception and cognitive responses would enhance the understanding of
these differences. Additionally, consider acknowledging contrasting findings in recent studies
regarding gender differences in visceral sensitivity.
3. The analysis of defecation-related symptoms is informative, but the inconsistency with a
meta-analysis on constipation-related symptoms warrants discussion. Explain why the focus on
IBS-D patients may contribute to this discrepancy, and consider suggesting avenues for future
research to reconcile these inconsistencies.
4. The disparities in extra-intestinal symptoms between genders are intriguing. However, the
discussion lacks an exploration of the potential impact of these symptoms on the overall quality
of life and daily functioning of male and female IBS-D patients. Considering the broader
implications of these findings could add depth to the interpretation.
5. The discussion on psychological status emphasizes gender-based differences in sleep disorder,
anxiety, and depression. While this is valuable, the role of these psychological factors in
influencing overall symptom experiences and the potential bidirectional relationship between
psychological distress and gastrointestinal symptoms needs more attention.
6. The focus on the lower IBS-QOL scores in females is consistent with existing literature.
However, a more nuanced exploration of the interplay between psychological factors, symptom
severity, and quality of life could enhance the discussion. Consider discussing potential
interventions that address both physical and mental symptoms to improve overall well-being.
7. The higher consultation rates in females are discussed, but the reasons behind this gender
difference remain unexplored. Consider delving into potential sociocultural or healthcare-
seeking behavior factors that may contribute to this gender-based disparity. A discussion on the
implications of these findings for clinical practice and healthcare policy would add value.
8. Acknowledge the retrospective nature of the data collection as a limitation, and consider
discussing potential biases or memory recall issues. Additionally, the study's focus on diagnosed
IBS-D patients from a gastroenterology clinic limits the generalizability of the findings. Discuss
the implications of this limitation and suggest directions for future research to address these
constraints.
Minor comments
Background
1. Original: "The pooled global prevalence of IBS based on Rome IV and Rome III criteria in
Internet survey were 4.1% and 10.1% respectively [1]."
Comment: Consider rephrasing for clarity: "The combined global prevalence of IBS, as
determined by Internet surveys using Rome IV and Rome III criteria, was 4.1% and 10.1%,
respectively [1]."
2. Original: "As the rising of sex or gender-specific medicine which recognized the differences
between males and females in the diagnosis and treatment of diseases, gender was assumed to
be an important factor in the pathogenesis, disease progression and even prognosis of various
diseases [2, 3]."
Comment: Suggested revision: "With the emergence of sex or gender-specific medicine,
recognizing differences in the diagnosis and treatment of diseases between males and females,
gender has been considered a crucial factor in the pathogenesis, disease progression, and
prognosis of various conditions [2, 3]."
3. Original: "It has been noted that IBS was a disease predominantly of women ranging from
2:1 to 4:1 depending on the clinical setting at least in the Western world [5]."
Comment: Consider rephrasing for clarity: "It has been observed that IBS is predominantly
diagnosed in women, with ratios ranging from 2:1 to 4:1, depending on the clinical setting,
especially in the Western world [5]."
4. Original: "A meta-analysis showed the prevalence of IBS was higher in women than in men
with the odds ratio of 1.46 [6]."
Comment: Suggested revision: "A meta-analysis demonstrated a higher prevalence of IBS in
women compared to men, with an odds ratio of 1.46 [6]."
5. Original: "Actually, many comorbid conditions associated with IBS also had a female
predominance like fibromyalgia, chronic pelvic pain, migraine, and chronic fatigue syndrome
[7]."
Comment: Consider rephrasing for conciseness: "Several comorbid conditions associated with
IBS, including fibromyalgia, chronic pelvic pain, migraine, and chronic fatigue syndrome, also
exhibit a female predominance [7]."
6. Original: "However, in Asia, the distribution seemed to be fairly equal between men and
women [5]."
Comment: Consider rephrasing for precision: "However, in Asia, the distribution appears to be
relatively equal between men and women [5]."
7. Original: "And studies from India and Sri Lanka showed the prevalence of IBS in individuals
seeking medical care was higher in males [9]."
Comment: Suggested revision: "Studies from India and Sri Lanka indicated that the prevalence
of IBS among individuals seeking medical care was higher in males [9]."
8. Original: "As sex-gender differences included a diversity of physiological and psychological
aspects, it can be supposed that the clinical presentation of symptoms and treatment strategies
in women and men with IBS might differ."
Comment: Consider rephrasing for clarity: "Given that sex-gender differences encompass a
variety of physiological and psychological aspects, it can be hypothesized that the clinical
presentation of symptoms and treatment strategies may differ between women and men with
IBS."
9. Original: "Studies compared the differences between male and female IBS showed that
IBS predominant with diarrhea (IBS-D) was more frequently confirmed in men while IBS
predominant with constipation (IBS-C) was more frequent in women and women had a high
prevalence of hard or lumpy stools than males [10]."
Comment: Suggested revision: "Studies comparing differences between male and female IBS
patients revealed a higher frequency of IBS predominant with diarrhea (IBS-D) in men,
while IBS predominant with constipation (IBS-C) was more common in women. Women also
exhibited a higher prevalence of hard or lumpy stools compared to men [10]."
10. Original: "Tang et al compared sex differences in the symptoms and psychological factors of
Chinese male and female IBS patients and showed female patients complained of more severe
abdominal pain/discomfort [11]."
Comment: Suggested revision: "Tang et al. compared the sex differences in symptoms and
psychological factors among Chinese male and female IBS patients, revealing that female
patients reported more severe abdominal pain/discomfort [11]."
11. Original: "In China, the majority of IBS patients were classified as IBS-D [11-13] and the aim
of the current study is to compare the gender difference in the biopsychosocial characteristics
of Chinese patients with IBS-D."
Comment: Consider rephrasing for better flow: "In China, the majority of IBS patients are
classified as IBS-D [11-13]. The current study aims to compare the gender differences in the
biopsychosocial characteristics of Chinese patients with IBS-D."
These suggestions aim to enhance clarity, precision, and overall readability. Feel free to adapt
them to align with your writing style and preferences.
Title: Gender Differences in Gastrointestinal, Biopsychosocial and Healthcare-seeking
Behaviors in Chinese Patients with Irritable Bowel Syndrome Predominant with Diarrhea
Version: 1 Date: 30 Nov 2023
Reviewer:  Zipan Lyu
Reviewer's report:
Reviewer Report
Title: More Prominent Psychosocial Disorders Rather Than Intestinal Symptoms in Chinese
Female Patients with Irritable Bowel Syndrome Predominant with Diarrhea Than Male Patients
Authors: Wenjuan Fan, Yang Chen, Xiucai Fang, Liming Zhu, Guijun Fei, Jia Lu, Xiaoqing Li
As a reviewer, I appreciate the comprehensive study comparing the biopsychosocial
characteristics of Chinese patients with irritable bowel syndrome (IBS) predominant with
diarrhea (IBS-D). The manuscript provides valuable insights into the gender differences in this
population. However, to enhance the manuscript's quality, I recommend Major Revision.
Here are some comments for further consideration:
Title and Abstract Clarity:
1. The title could be more specific about the focus on gender differences in Chinese IBS-D
patients.
The abstract is concise but could benefit from more clarity regarding the key findings.
2. Introduction:
The background could be strengthened by providing a brief overview of the existing literature
on gender differences in IBS patients globally, not just in the Chinese population.
Methodology:
Clarify how participants were recruited and whether there were any specific inclusion or
exclusion criteria.
Mention the demographic characteristics of the participants, such as age distribution, to provide
a clearer picture of the study population.
3. Results:
Ensure consistency in reporting statistical values (e.g., P-values) throughout the results section.
When presenting numerical data, consider reporting confidence intervals to indicate the
precision of estimates.
Specify the tools used for evaluating psychological status (HAMD and HAMA scales) for the
benefit of readers unfamiliar with these instruments.
4. Discussion:
Provide a more in-depth discussion of the implications of the observed gender differences,
relating them to existing literature.
Address potential confounding factors that might influence the reported gender differences.
Discuss the clinical relevance of the findings and their implications for the management of IBS-
D in Chinese patients.
5. Conclusion:
Emphasize the main implications and potential applications of the study findings.
Consider mentioning any recommendations for clinical practice or areas for future research.
Language and Style:
Carefully proofread the manuscript for grammatical and typographical errors.
Ensure consistency in the use of terminology and provide clear definitions for any specialized
terms.
Overall, the manuscript is a valuable contribution to the understanding of gender differences in
Chinese IBS-D patients. Addressing these points will strengthen the clarity, rigor, and impact
of the study.
Challenge comments
Method Section
1. Subjects:
a. Clarify whether patients were consecutive or selected through a specific process to address
potential selection bias.
b. Provide details on the number of patients in the database and any potential changes in criteria
over the study period.
c. Could the authors kindly provide an explanation for the decision to use Rome III diagnostic
and subtype criteria for IBS-D in the current study, as opposed to the more recent Rome IV
criteria? Clarifying the rationale for this choice would enhance the understanding of the study
design and its implications.
2. IBS Symptom Questionnaire:
a. Consider providing more information on the reliability and validity of the questionnaire,
especially if modifications were made.
b. Specify the training process for investigators to ensure consistency in data collection.
3. Stress History, Sleep Status, and Psychological Evaluation:
a. Clarify the specific questions or criteria used to assess mental stimulation and abuse history.
b. Describe how the relation of IBS with mental status and sleep disorders was evaluated.
4. Quality of Life Evaluation:
a. Provide more information on the characteristics of the study population in relation to the IBS-
QOL scores.
b. Discuss any potential limitations or biases associated with self-reporting of quality of life.
5. Dietary Habits and Coping Behaviors:
a. Specify the rationale for the choice of dietary questions and how they relate to IBS symptoms.
b. Consider discussing potential cultural influences on dietary habits.
6. Healthcare-Seeking Behaviors:
a. Discuss potential biases related to self-reporting, especially in recalling consultations and
medical costs.
b. Clarify the criteria for patient satisfaction with medical care.
7. Statistical Analysis:
a. Provide additional details on how missing data were handled, especially in the case of any
incomplete responses.
b. Mention whether corrections for multiple comparisons were applied.
Results Section
1. Please clarify the potential implications of age and BMI differences on the study outcomes.
2. The higher prevalence of gastroesophageal reflux in males raises questions about the co-
occurrence of IBS and reflux. It is essential to elaborate on how the study distinguishes between
coexistence and comorbidity. A discussion on the proportion of patients with both conditions
and those with overlapping symptoms would add clarity.
3. Given the proximity of females' age to menopausal stages, it's crucial to exclude menopausal
syndrome as a confounding factor. Avoid simplifying the association between IBS and
depressive or anxious states in females. Conducting additional interview-based research to
explore whether anxiety or depression directly results from IBS is recommended. This could
enhance the understanding of the complex interplay between psychological states and IBS
symptoms in females.
4. In Figure 3, the authors employ comorbidity analysis. It's important to verify if mental health
professionals made psychiatric diagnoses regarding patients' anxiety and depression. Relying
solely on scores from two scales may not warrant a definitive diagnosis of illness but rather
suggests anxiety and depression states. Clarify whether psychiatric professionals were involved
in the diagnosis process.
5. In Figure 4, the correlation analysis indicates a negative association between anxiety/
depression states and IBS symptom scores for both males and females. However, the
comparative significance of these correlations needs exploration. Considering the coefficients
(HAMA and HAMD scores) implies that males have stronger correlations, while for IBS
symptom scores and IBS-QOL scores, females have stronger correlations. Conduct a t-test on
the correlation coefficients to ascertain if the gender differences are statistically significant.
6. The response rates, healthcare-seeking behaviors, disease severity, and the relationship
between anxiety and compliance differ between males and females. This contrasts with findings
from clinical studies in Hong Kong. A discussion is needed to explore whether the disparity
in follow-up response rates between males and females in Beijing is influenced by regional or
cultural factors. Investigating these differences may contribute to a more nuanced understanding
of patient behavior in clinical research settings.
Discussion Section
1. The discussion emphasizes gender differences, but a more nuanced exploration of potential
commonalities in symptom experiences and coping mechanisms between genders could enrich
the interpretation.
2. While the discussion on abdominal pain and symptom severity differences aligns with
existing literature, a deeper exploration into the potential mechanisms underlying gender-based
variations in pain perception and cognitive responses would enhance the understanding of
these differences. Additionally, consider acknowledging contrasting findings in recent studies
regarding gender differences in visceral sensitivity.
3. The analysis of defecation-related symptoms is informative, but the inconsistency with a
meta-analysis on constipation-related symptoms warrants discussion. Explain why the focus on
IBS-D patients may contribute to this discrepancy, and consider suggesting avenues for future
research to reconcile these inconsistencies.
4. The disparities in extra-intestinal symptoms between genders are intriguing. However, the
discussion lacks an exploration of the potential impact of these symptoms on the overall quality
of life and daily functioning of male and female IBS-D patients. Considering the broader
implications of these findings could add depth to the interpretation.
5. The discussion on psychological status emphasizes gender-based differences in sleep disorder,
anxiety, and depression. While this is valuable, the role of these psychological factors in
influencing overall symptom experiences and the potential bidirectional relationship between
psychological distress and gastrointestinal symptoms needs more attention.
6. The focus on the lower IBS-QOL scores in females is consistent with existing literature.
However, a more nuanced exploration of the interplay between psychological factors, symptom
severity, and quality of life could enhance the discussion. Consider discussing potential
interventions that address both physical and mental symptoms to improve overall well-being.
7. The higher consultation rates in females are discussed, but the reasons behind this gender
difference remain unexplored. Consider delving into potential sociocultural or healthcare-
seeking behavior factors that may contribute to this gender-based disparity. A discussion on the
implications of these findings for clinical practice and healthcare policy would add value.
8. Acknowledge the retrospective nature of the data collection as a limitation, and consider
discussing potential biases or memory recall issues. Additionally, the study's focus on diagnosed
IBS-D patients from a gastroenterology clinic limits the generalizability of the findings. Discuss
the implications of this limitation and suggest directions for future research to address these
constraints.
Minor comments
Background
1. Original: "The pooled global prevalence of IBS based on Rome IV and Rome III criteria in
Internet survey were 4.1% and 10.1% respectively [1]."
Comment: Consider rephrasing for clarity: "The combined global prevalence of IBS, as
determined by Internet surveys using Rome IV and Rome III criteria, was 4.1% and 10.1%,
respectively [1]."
2. Original: "As the rising of sex or gender-specific medicine which recognized the differences
between males and females in the diagnosis and treatment of diseases, gender was assumed to
be an important factor in the pathogenesis, disease progression and even prognosis of various
diseases [2, 3]."
Comment: Suggested revision: "With the emergence of sex or gender-specific medicine,
recognizing differences in the diagnosis and treatment of diseases between males and females,
gender has been considered a crucial factor in the pathogenesis, disease progression, and
prognosis of various conditions [2, 3]."
3. Original: "It has been noted that IBS was a disease predominantly of women ranging from
2:1 to 4:1 depending on the clinical setting at least in the Western world [5]."
Comment: Consider rephrasing for clarity: "It has been observed that IBS is predominantly
diagnosed in women, with ratios ranging from 2:1 to 4:1, depending on the clinical setting,
especially in the Western world [5]."
4. Original: "A meta-analysis showed the prevalence of IBS was higher in women than in men
with the odds ratio of 1.46 [6]."
Comment: Suggested revision: "A meta-analysis demonstrated a higher prevalence of IBS in
women compared to men, with an odds ratio of 1.46 [6]."
5. Original: "Actually, many comorbid conditions associated with IBS also had a female
predominance like fibromyalgia, chronic pelvic pain, migraine, and chronic fatigue syndrome
[7]."
Comment: Consider rephrasing for conciseness: "Several comorbid conditions associated with
IBS, including fibromyalgia, chronic pelvic pain, migraine, and chronic fatigue syndrome, also
exhibit a female predominance [7]."
6. Original: "However, in Asia, the distribution seemed to be fairly equal between men and
women [5]."
Comment: Consider rephrasing for precision: "However, in Asia, the distribution appears to be
relatively equal between men and women [5]."
7. Original: "And studies from India and Sri Lanka showed the prevalence of IBS in individuals
seeking medical care was higher in males [9]."
Comment: Suggested revision: "Studies from India and Sri Lanka indicated that the prevalence
of IBS among individuals seeking medical care was higher in males [9]."
8. Original: "As sex-gender differences included a diversity of physiological and psychological
aspects, it can be supposed that the clinical presentation of symptoms and treatment strategies
in women and men with IBS might differ."
Comment: Consider rephrasing for clarity: "Given that sex-gender differences encompass a
variety of physiological and psychological aspects, it can be hypothesized that the clinical
presentation of symptoms and treatment strategies may differ between women and men with
IBS."
9. Original: "Studies compared the differences between male and female IBS showed that
IBS predominant with diarrhea (IBS-D) was more frequently confirmed in men while IBS
predominant with constipation (IBS-C) was more frequent in women and women had a high
prevalence of hard or lumpy stools than males [10]."
Comment: Suggested revision: "Studies comparing differences between male and female IBS
patients revealed a higher frequency of IBS predominant with diarrhea (IBS-D) in men,
while IBS predominant with constipation (IBS-C) was more common in women. Women also
exhibited a higher prevalence of hard or lumpy stools compared to men [10]."
10. Original: "Tang et al compared sex differences in the symptoms and psychological factors of
Chinese male and female IBS patients and showed female patients complained of more severe
abdominal pain/discomfort [11]."
Comment: Suggested revision: "Tang et al. compared the sex differences in symptoms and
psychological factors among Chinese male and female IBS patients, revealing that female
patients reported more severe abdominal pain/discomfort [11]."
11. Original: "In China, the majority of IBS patients were classified as IBS-D [11-13] and the aim
of the current study is to compare the gender difference in the biopsychosocial characteristics
of Chinese patients with IBS-D."
Comment: Consider rephrasing for better flow: "In China, the majority of IBS patients are
classified as IBS-D [11-13]. The current study aims to compare the gender differences in the
biopsychosocial characteristics of Chinese patients with IBS-D."
These suggestions aim to enhance clarity, precision, and overall readability. Feel free to adapt
them to align with your writing style and preferences.
Please review this paper.
user
Title: Gender Differences in Gastrointestinal, Biopsychosocial and Healthcare-seeking
Behaviors in Chinese Patients with Irritable Bowel Syndrome Predominant with Diarrhea
Version: 1 Date: 30 Nov 2023
Reviewer:  Zipan Lyu
Reviewer's report:
Reviewer Report
Title: More Prominent Psychosocial Disorders Rather Than Intestinal Symptoms in Chinese
Female Patients with Irritable Bowel Syndrome Predominant with Diarrhea Than Male Patients
Authors: Wenjuan Fan, Yang Chen, Xiucai Fang, Liming Zhu, Guijun Fei, Jia Lu, Xiaoqing Li
As a reviewer, I appreciate the comprehensive study comparing the biopsychosocial
characteristics of Chinese patients with irritable bowel syndrome (IBS) predominant with
diarrhea (IBS-D). The manuscript provides valuable insights into the gender differences in this
population. However, to enhance the manuscript's quality, I recommend Major Revision.
Here are some comments for further consideration:
Title and Abstract Clarity:
1. The title could be more specific about the focus on gender differences in Chinese IBS-D
patients.
The abstract is concise but could benefit from more clarity regarding the key findings.
2. Introduction:
The background could be strengthened by providing a brief overview of the existing literature
on gender differences in IBS patients globally, not just in the Chinese population.
Methodology:
Clarify how participants were recruited and whether there were any specific inclusion or
exclusion criteria.
Mention the demographic characteristics of the participants, such as age distribution, to provide
a clearer picture of the study population.
3. Results:
Ensure consistency in reporting statistical values (e.g., P-values) throughout the results section.
When presenting numerical data, consider reporting confidence intervals to indicate the
precision of estimates.
Specify the tools used for evaluating psychological status (HAMD and HAMA scales) for the
benefit of readers unfamiliar with these instruments.
4. Discussion:
Provide a more in-depth discussion of the implications of the observed gender differences,
relating them to existing literature.
Address potential confounding factors that might influence the reported gender differences.
Discuss the clinical relevance of the findings and their implications for the management of IBS-
D in Chinese patients.
5. Conclusion:
Emphasize the main implications and potential applications of the study findings.
Consider mentioning any recommendations for clinical practice or areas for future research.
Language and Style:
Carefully proofread the manuscript for grammatical and typographical errors.
Ensure consistency in the use of terminology and provide clear definitions for any specialized
terms.
Overall, the manuscript is a valuable contribution to the understanding of gender differences in
Chinese IBS-D patients. Addressing these points will strengthen the clarity, rigor, and impact
of the study.
Challenge comments
Method Section
1. Subjects:
a. Clarify whether patients were consecutive or selected through a specific process to address
potential selection bias.
b. Provide details on the number of patients in the database and any potential changes in criteria
over the study period.
c. Could the authors kindly provide an explanation for the decision to use Rome III diagnostic
and subtype criteria for IBS-D in the current study, as opposed to the more recent Rome IV
criteria? Clarifying the rationale for this choice would enhance the understanding of the study
design and its implications.
2. IBS Symptom Questionnaire:
a. Consider providing more information on the reliability and validity of the questionnaire,
especially if modifications were made.
b. Specify the training process for investigators to ensure consistency in data collection.
3. Stress History, Sleep Status, and Psychological Evaluation:
a. Clarify the specific questions or criteria used to assess mental stimulation and abuse history.
b. Describe how the relation of IBS with mental status and sleep disorders was evaluated.
4. Quality of Life Evaluation:
a. Provide more information on the characteristics of the study population in relation to the IBS-
QOL scores.
b. Discuss any potential limitations or biases associated with self-reporting of quality of life.
5. Dietary Habits and Coping Behaviors:
a. Specify the rationale for the choice of dietary questions and how they relate to IBS symptoms.
b. Consider discussing potential cultural influences on dietary habits.
6. Healthcare-Seeking Behaviors:
a. Discuss potential biases related to self-reporting, especially in recalling consultations and
medical costs.
b. Clarify the criteria for patient satisfaction with medical care.
7. Statistical Analysis:
a. Provide additional details on how missing data were handled, especially in the case of any
incomplete responses.
b. Mention whether corrections for multiple comparisons were applied.
Results Section
1. Please clarify the potential implications of age and BMI differences on the study outcomes.
2. The higher prevalence of gastroesophageal reflux in males raises questions about the co-
occurrence of IBS and reflux. It is essential to elaborate on how the study distinguishes between
coexistence and comorbidity. A discussion on the proportion of patients with both conditions
and those with overlapping symptoms would add clarity.
3. Given the proximity of females' age to menopausal stages, it's crucial to exclude menopausal
syndrome as a confounding factor. Avoid simplifying the association between IBS and
depressive or anxious states in females. Conducting additional interview-based research to
explore whether anxiety or depression directly results from IBS is recommended. This could
enhance the understanding of the complex interplay between psychological states and IBS
symptoms in females.
4. In Figure 3, the authors employ comorbidity analysis. It's important to verify if mental health
professionals made psychiatric diagnoses regarding patients' anxiety and depression. Relying
solely on scores from two scales may not warrant a definitive diagnosis of illness but rather
suggests anxiety and depression states. Clarify whether psychiatric professionals were involved
in the diagnosis process.
5. In Figure 4, the correlation analysis indicates a negative association between anxiety/
depression states and IBS symptom scores for both males and females. However, the
comparative significance of these correlations needs exploration. Considering the coefficients
(HAMA and HAMD scores) implies that males have stronger correlations, while for IBS
symptom scores and IBS-QOL scores, females have stronger correlations. Conduct a t-test on
the correlation coefficients to ascertain if the gender differences are statistically significant.
6. The response rates, healthcare-seeking behaviors, disease severity, and the relationship
between anxiety and compliance differ between males and females. This contrasts with findings
from clinical studies in Hong Kong. A discussion is needed to explore whether the disparity
in follow-up response rates between males and females in Beijing is influenced by regional or
cultural factors. Investigating these differences may contribute to a more nuanced understanding
of patient behavior in clinical research settings.
Discussion Section
1. The discussion emphasizes gender differences, but a more nuanced exploration of potential
commonalities in symptom experiences and coping mechanisms between genders could enrich
the interpretation.
2. While the discussion on abdominal pain and symptom severity differences aligns with
existing literature, a deeper exploration into the potential mechanisms underlying gender-based
variations in pain perception and cognitive responses would enhance the understanding of
these differences. Additionally, consider acknowledging contrasting findings in recent studies
regarding gender differences in visceral sensitivity.
3. The analysis of defecation-related symptoms is informative, but the inconsistency with a
meta-analysis on constipation-related symptoms warrants discussion. Explain why the focus on
IBS-D patients may contribute to this discrepancy, and consider suggesting avenues for future
research to reconcile these inconsistencies.
4. The disparities in extra-intestinal symptoms between genders are intriguing. However, the
discussion lacks an exploration of the potential impact of these symptoms on the overall quality
of life and daily functioning of male and female IBS-D patients. Considering the broader
implications of these findings could add depth to the interpretation.
5. The discussion on psychological status emphasizes gender-based differences in sleep disorder,
anxiety, and depression. While this is valuable, the role of these psychological factors in
influencing overall symptom experiences and the potential bidirectional relationship between
psychological distress and gastrointestinal symptoms needs more attention.
6. The focus on the lower IBS-QOL scores in females is consistent with existing literature.
However, a more nuanced exploration of the interplay between psychological factors, symptom
severity, and quality of life could enhance the discussion. Consider discussing potential
interventions that address both physical and mental symptoms to improve overall well-being.
7. The higher consultation rates in females are discussed, but the reasons behind this gender
difference remain unexplored. Consider delving into potential sociocultural or healthcare-
seeking behavior factors that may contribute to this gender-based disparity. A discussion on the
implications of these findings for clinical practice and healthcare policy would add value.
8. Acknowledge the retrospective nature of the data collection as a limitation, and consider
discussing potential biases or memory recall issues. Additionally, the study's focus on diagnosed
IBS-D patients from a gastroenterology clinic limits the generalizability of the findings. Discuss
the implications of this limitation and suggest directions for future research to address these
constraints.
Minor comments
Background
1. Original: "The pooled global prevalence of IBS based on Rome IV and Rome III criteria in
Internet survey were 4.1% and 10.1% respectively [1]."
Comment: Consider rephrasing for clarity: "The combined global prevalence of IBS, as
determined by Internet surveys using Rome IV and Rome III criteria, was 4.1% and 10.1%,
respectively [1]."
2. Original: "As the rising of sex or gender-specific medicine which recognized the differences
between males and females in the diagnosis and treatment of diseases, gender was assumed to
be an important factor in the pathogenesis, disease progression and even prognosis of various
diseases [2, 3]."
Comment: Suggested revision: "With the emergence of sex or gender-specific medicine,
recognizing differences in the diagnosis and treatment of diseases between males and females,
gender has been considered a crucial factor in the pathogenesis, disease progression, and
prognosis of various conditions [2, 3]."
3. Original: "It has been noted that IBS was a disease predominantly of women ranging from
2:1 to 4:1 depending on the clinical setting at least in the Western world [5]."
Comment: Consider rephrasing for clarity: "It has been observed that IBS is predominantly
diagnosed in women, with ratios ranging from 2:1 to 4:1, depending on the clinical setting,
especially in the Western world [5]."
4. Original: "A meta-analysis showed the prevalence of IBS was higher in women than in men
with the odds ratio of 1.46 [6]."
Comment: Suggested revision: "A meta-analysis demonstrated a higher prevalence of IBS in
women compared to men, with an odds ratio of 1.46 [6]."
5. Original: "Actually, many comorbid conditions associated with IBS also had a female
predominance like fibromyalgia, chronic pelvic pain, migraine, and chronic fatigue syndrome
[7]."
Comment: Consider rephrasing for conciseness: "Several comorbid conditions associated with
IBS, including fibromyalgia, chronic pelvic pain, migraine, and chronic fatigue syndrome, also
exhibit a female predominance [7]."
6. Original: "However, in Asia, the distribution seemed to be fairly equal between men and
women [5]."
Comment: Consider rephrasing for precision: "However, in Asia, the distribution appears to be
relatively equal between men and women [5]."
7. Original: "And studies from India and Sri Lanka showed the prevalence of IBS in individuals
seeking medical care was higher in males [9]."
Comment: Suggested revision: "Studies from India and Sri Lanka indicated that the prevalence
of IBS among individuals seeking medical care was higher in males [9]."
8. Original: "As sex-gender differences included a diversity of physiological and psychological
aspects, it can be supposed that the clinical presentation of symptoms and treatment strategies
in women and men with IBS might differ."
Comment: Consider rephrasing for clarity: "Given that sex-gender differences encompass a
variety of physiological and psychological aspects, it can be hypothesized that the clinical
presentation of symptoms and treatment strategies may differ between women and men with
IBS."
9. Original: "Studies compared the differences between male and female IBS showed that
IBS predominant with diarrhea (IBS-D) was more frequently confirmed in men while IBS
predominant with constipation (IBS-C) was more frequent in women and women had a high
prevalence of hard or lumpy stools than males [10]."
Comment: Suggested revision: "Studies comparing differences between male and female IBS
patients revealed a higher frequency of IBS predominant with diarrhea (IBS-D) in men,
while IBS predominant with constipation (IBS-C) was more common in women. Women also
exhibited a higher prevalence of hard or lumpy stools compared to men [10]."
10. Original: "Tang et al compared sex differences in the symptoms and psychological factors of
Chinese male and female IBS patients and showed female patients complained of more severe
abdominal pain/discomfort [11]."
Comment: Suggested revision: "Tang et al. compared the sex differences in symptoms and
psychological factors among Chinese male and female IBS patients, revealing that female
patients reported more severe abdominal pain/discomfort [11]."
11. Original: "In China, the majority of IBS patients were classified as IBS-D [11-13] and the aim
of the current study is to compare the gender difference in the biopsychosocial characteristics
of Chinese patients with IBS-D."
Comment: Consider rephrasing for better flow: "In China, the majority of IBS patients are
classified as IBS-D [11-13]. The current study aims to compare the gender differences in the
biopsychosocial characteristics of Chinese patients with IBS-D."
These suggestions aim to enhance clarity, precision, and overall readability. Feel free to adapt
them to align with your writing style and preferences.
assistant