Reviewer ’s report  
 
Title: Biologic Treatment of Japanese Patients with Inflammatory Bowel Disease  
 
Version: 0 Date: 23 Apr 2018  
 
Reviewer: Valerie Pittet  
 
Reviewer's report:  
 
In this manuscript, Mahlich et al. described results of a cross -sectional survey performed among 
the Japanese population. Data was collected from 1035 patients w ith IBD. The goal of the study 
was to assess factors associated with the use of biologics.  
 
 
The manuscript provides interesting results and interpretations. There are however many points 
that would require further clarification.  
 
 
 
MAJOR COMMENTS.  
 
The major li mitation of the study is the use of patient -reported data to assess the use of biological 
treatment instead of data from medical reports. Therefore, details regarding clinical presentations 
and initiation of treatment are missing, although the authors seve ral times interpreted their results 
as if those data were present (talking about "initiation", "switch", "severe patients").  
 
 
 
INTRODUCTION.  
 
- P.4, L.19 -20: Why should the fact that biologicals were first administered to patients with 
a severe disease presen tation affect its long -term efficacy? The efficacy is assessed by 
indication not for a whole set of disease presentation. Did you refer to the generalizability 
of efficacy results for other clinical presentations? Please explain.  
 
 
- P.4, L.289: the most imp ortant factor for the optimization of therapy is THE 
ASCERTAINMENT of active IBD inflammation. Please update.  
 
 
- P.4, L29 -34: the sentence is unclear and difficult to read. It gives the impression that 
active inflammation only causes symptoms once during di sease course and this until 
biologics are given. I suppose "recipients" referred to patients.  
 
 
- P.4, L.39: previous studies identified factors (or determinants) that were associated with 
the prescription. Please correct the wording.  
 
 
- P.4, L.53 -59: "althou gh we are not aware […] in Japanese culture" is an interpretation 
that should be moved in the discussion section. Moreover, it was not clear to me why the 
authors tried to explain results obtained from studies conducted outside Japan (refs 15 to 
17. Hungar y, Sweden, US) by cultural aspects of Japanese people.  
 
 
- P.5, L.17 -22: "This study assessed the factors associated with the treatment of IBD in 
Japan by biologic agents using a survey of Japanese IBD patients all over Japan." 
Sentence difficult to read and  repetitive. Please reword.  
 
 
- P.5, L.22 -26. The conclusions and perspectives based on study findings should be moved 
at the end of the discussion section.  
 
 
 
METHODS.  
 
The description of the methods did not completely fit with the present manuscript, but rathe r 
with the Morishige (ref 25). The Baars' questionnaire was developed to assess patient's 
preferences about their involvement in decision -making. I did not understand the link with the 
present study, and I did not see any results from data collected using this questionnaire in the 
tables provided. Those were indeed used, but only in the manuscript ref 25.  
 
 
Therefore, I would highly suggest the authors to remove all information regarding this specific 
questionnaire and the description of its back and forth tr anslation, and keep only what was used 
for the present analyses.  
 
 
The authors noted in their response to a previous reviewer's comment that this study was a 
secondary data analysis of the Morishige et al. study. This should be mentioned explicitly in the 
methods section. In addition, ref 25 indicated that the database used was a "consumer panel 
database where all persons registered in the database have opted into accept research survey". 
This contradicts the information reported in the present manuscript tha t the database is 
containing Japanese patients of all indications. There is a major difference between patients and 
persons (individuals). This should be corrected This point is important in terms of potential 
generalization of the findings.  
 
 
 
 
- P.5, L. 53: "work status"/"occupation" is missing in the list of variables  
 
 
- P.5, L.56: the treatment referred to the "current treatment", and the duration to "frequency of 
visits". Please update in the text.  
 
 
Regarding the occupation variable, could you please explain why there was a special category 
for women only, called "house wife"? How does this differ from either being unemployed or 
being full/part -time employed?  
 
 
 
Statistical analysis.  
 
- P.6, L24: The out come seemed to have been defined as "the initiation of a treatment with 
biologics or a switch between different biologics". This detail appeared neither in the tables, nor 
in the methods. How was the question formulated to collect this information? If this  only refers 
to the current use of biologics, the sentence should be updated accordingly.  
 
 
 
RESULTS.  
 
- P.6, L.53 -56. "The majority […]. 30's and 40's[24]" is an interpretation of the results and 
should be moved in the discussion section.  
 
 
- P.6, L.53. The au thors confirmed a male predominance, which is the opposite of what is 
observed in epidemiological surveys. i.e., women usually respond more frequently than men. 
However, if this reflects usual surveys' findings in Japan, it should be reported more accurate ly.   
 
 
- P.11, L.12 -19. The sentence should be written the other way around. What was observed was a 
higher probability with longer disease duration, as compared to the reference (disease duration 
less than 2 y).  
 
 
- Table 1: the title should be "with or with out" biologic treatment instead of "by"  
 
 
- Table 1: The line "biologic agents" should be reported into columns on biologics users.  If I 
read correctly the current treatments, it comes that 27% of CD patients and 43% of UC patients 
were under a combination  therapy (Biologic + immunomodulator). Is that correct.  
 
 
Unfortunately, findings regarding co -current treatments were not discussed at all.  
 
This globally led to the question on how information on drug therapies were collected.  
 
Indeed, it was not clearly me ntioned if the current therapy corresponded to all current 
concomitant therapies reported by the patient. And how valid this data may be for a study like 
this. Patient -reported treatment data primarily provide information on compliance with 
prescribed trea tments, not directly on the prescription itself.  
 
 
 
 
DISCUSSION.  
 
- P.13, L.43 -50. The 2 last sentences of the paragraph did not refer to findings from the 
present study, but to those from the reference 25. Patient's preferences and satisfaction 
were not asse ssed here.  
 
 
- P.14. L.39: "nanbyo" disease. Please add a reference.  
 
 
- P.16. L1 -5: "Our results suggest that the only co -medication that increased the likelihood 
of being treated with a biologic is the use of immunomodulators in the overall and UC 
population ." What about the nutritional treatment, which was also associated with the use 
of biologics? (Table 2)  
 
 
- P.6, L.30 -35. The link between the results and the launch of new product is difficult to 
assess/discuss because no information was provided on the var ious biologicals. In 
addition, as the authors stated, this was a cross -sectional study collecting information in 
2016. The data collection period was very short. Therefore, the cited reason is one of the 
many potential reasons, but it makes no sense here. Rather, it would have been interesting 
to discuss the reliability of patient -reported data for this type of study.  
 
 
 
MINOR COMMENTS.  
 
- P.6, L.24: please add the word "adjusted" to the linear regressions performed.  
 
 
- P.13, L.53: "predictor" should be replac ed by "associated factor" or "determinants", as no 
predictive model was constructed  
 
 
- P.6, L.30: "[…], which was carried out at one time point". Can be deleted because 
corresponds to the definition of a cross -sectional study.  
 
 
- P.6, L. 42 -45: these are pat ient-reported data (not patients' perspectives)  
 
 
 
 
Are the methods appropriate and well described?  
If not, please spe cify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional s tatistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some la nguage corrections before being published  
 
 
 
 
 
 
 
 
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary fro m an 
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation t hat may in any way gain or lose 
financially from the publication of  this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds or has appl ied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
I agree to the open peer review policy of the journal . I understan d that my name will be included 
on my report to the authors and, if the manuscript is accepted f or publication, my named report 
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be in cluded as confidential comments 
to the editor s, which will not be publis hed. 
 
I agree to the open peer review policy of the journal  
Reviewer ’s report  
 
Title: Biologic Treatment of Japanese Patients with Inflammatory Bowel Disease  
 
Version: 0 Date: 23 Apr 2018  
 
Reviewer: Valerie Pittet  
 
Reviewer's report:  
 
In this manuscript, Mahlich et al. described results of a cross -sectional survey performed among 
the Japanese population. Data was collected from 1035 patients w ith IBD. The goal of the study 
was to assess factors associated with the use of biologics.  
 
 
The manuscript provides interesting results and interpretations. There are however many points 
that would require further clarification.  
 
 
 
MAJOR COMMENTS.  
 
The major li mitation of the study is the use of patient -reported data to assess the use of biological 
treatment instead of data from medical reports. Therefore, details regarding clinical presentations 
and initiation of treatment are missing, although the authors seve ral times interpreted their results 
as if those data were present (talking about "initiation", "switch", "severe patients").  
 
 
 
INTRODUCTION.  
 
- P.4, L.19 -20: Why should the fact that biologicals were first administered to patients with 
a severe disease presen tation affect its long -term efficacy? The efficacy is assessed by 
indication not for a whole set of disease presentation. Did you refer to the generalizability 
of efficacy results for other clinical presentations? Please explain.  
 
 
- P.4, L.289: the most imp ortant factor for the optimization of therapy is THE 
ASCERTAINMENT of active IBD inflammation. Please update.  
 
 
- P.4, L29 -34: the sentence is unclear and difficult to read. It gives the impression that 
active inflammation only causes symptoms once during di sease course and this until 
biologics are given. I suppose "recipients" referred to patients.  
 
 
- P.4, L.39: previous studies identified factors (or determinants) that were associated with 
the prescription. Please correct the wording.  
 
 
- P.4, L.53 -59: "althou gh we are not aware […] in Japanese culture" is an interpretation 
that should be moved in the discussion section. Moreover, it was not clear to me why the 
authors tried to explain results obtained from studies conducted outside Japan (refs 15 to 
17. Hungar y, Sweden, US) by cultural aspects of Japanese people.  
 
 
- P.5, L.17 -22: "This study assessed the factors associated with the treatment of IBD in 
Japan by biologic agents using a survey of Japanese IBD patients all over Japan." 
Sentence difficult to read and  repetitive. Please reword.  
 
 
- P.5, L.22 -26. The conclusions and perspectives based on study findings should be moved 
at the end of the discussion section.  
 
 
 
METHODS.  
 
The description of the methods did not completely fit with the present manuscript, but rathe r 
with the Morishige (ref 25). The Baars' questionnaire was developed to assess patient's 
preferences about their involvement in decision -making. I did not understand the link with the 
present study, and I did not see any results from data collected using this questionnaire in the 
tables provided. Those were indeed used, but only in the manuscript ref 25.  
 
 
Therefore, I would highly suggest the authors to remove all information regarding this specific 
questionnaire and the description of its back and forth tr anslation, and keep only what was used 
for the present analyses.  
 
 
The authors noted in their response to a previous reviewer's comment that this study was a 
secondary data analysis of the Morishige et al. study. This should be mentioned explicitly in the 
methods section. In addition, ref 25 indicated that the database used was a "consumer panel 
database where all persons registered in the database have opted into accept research survey". 
This contradicts the information reported in the present manuscript tha t the database is 
containing Japanese patients of all indications. There is a major difference between patients and 
persons (individuals). This should be corrected This point is important in terms of potential 
generalization of the findings.  
 
 
 
 
- P.5, L. 53: "work status"/"occupation" is missing in the list of variables  
 
 
- P.5, L.56: the treatment referred to the "current treatment", and the duration to "frequency of 
visits". Please update in the text.  
 
 
Regarding the occupation variable, could you please explain why there was a special category 
for women only, called "house wife"? How does this differ from either being unemployed or 
being full/part -time employed?  
 
 
 
Statistical analysis.  
 
- P.6, L24: The out come seemed to have been defined as "the initiation of a treatment with 
biologics or a switch between different biologics". This detail appeared neither in the tables, nor 
in the methods. How was the question formulated to collect this information? If this  only refers 
to the current use of biologics, the sentence should be updated accordingly.  
 
 
 
RESULTS.  
 
- P.6, L.53 -56. "The majority […]. 30's and 40's[24]" is an interpretation of the results and 
should be moved in the discussion section.  
 
 
- P.6, L.53. The au thors confirmed a male predominance, which is the opposite of what is 
observed in epidemiological surveys. i.e., women usually respond more frequently than men. 
However, if this reflects usual surveys' findings in Japan, it should be reported more accurate ly.   
 
 
- P.11, L.12 -19. The sentence should be written the other way around. What was observed was a 
higher probability with longer disease duration, as compared to the reference (disease duration 
less than 2 y).  
 
 
- Table 1: the title should be "with or with out" biologic treatment instead of "by"  
 
 
- Table 1: The line "biologic agents" should be reported into columns on biologics users.  If I 
read correctly the current treatments, it comes that 27% of CD patients and 43% of UC patients 
were under a combination  therapy (Biologic + immunomodulator). Is that correct.  
 
 
Unfortunately, findings regarding co -current treatments were not discussed at all.  
 
This globally led to the question on how information on drug therapies were collected.  
 
Indeed, it was not clearly me ntioned if the current therapy corresponded to all current 
concomitant therapies reported by the patient. And how valid this data may be for a study like 
this. Patient -reported treatment data primarily provide information on compliance with 
prescribed trea tments, not directly on the prescription itself.  
 
 
 
 
DISCUSSION.  
 
- P.13, L.43 -50. The 2 last sentences of the paragraph did not refer to findings from the 
present study, but to those from the reference 25. Patient's preferences and satisfaction 
were not asse ssed here.  
 
 
- P.14. L.39: "nanbyo" disease. Please add a reference.  
 
 
- P.16. L1 -5: "Our results suggest that the only co -medication that increased the likelihood 
of being treated with a biologic is the use of immunomodulators in the overall and UC 
population ." What about the nutritional treatment, which was also associated with the use 
of biologics? (Table 2)  
 
 
- P.6, L.30 -35. The link between the results and the launch of new product is difficult to 
assess/discuss because no information was provided on the var ious biologicals. In 
addition, as the authors stated, this was a cross -sectional study collecting information in 
2016. The data collection period was very short. Therefore, the cited reason is one of the 
many potential reasons, but it makes no sense here. Rather, it would have been interesting 
to discuss the reliability of patient -reported data for this type of study.  
 
 
 
MINOR COMMENTS.  
 
- P.6, L.24: please add the word "adjusted" to the linear regressions performed.  
 
 
- P.13, L.53: "predictor" should be replac ed by "associated factor" or "determinants", as no 
predictive model was constructed  
 
 
- P.6, L.30: "[…], which was carried out at one time point". Can be deleted because 
corresponds to the definition of a cross -sectional study.  
 
 
- P.6, L. 42 -45: these are pat ient-reported data (not patients' perspectives)  
 
 
 
 
Are the methods appropriate and well described?  
If not, please spe cify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional s tatistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some la nguage corrections before being published  
 
 
 
 
 
 
 
 
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary fro m an 
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation t hat may in any way gain or lose 
financially from the publication of  this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds or has appl ied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
I agree to the open peer review policy of the journal . I understan d that my name will be included 
on my report to the authors and, if the manuscript is accepted f or publication, my named report 
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be in cluded as confidential comments 
to the editor s, which will not be publis hed. 
 
I agree to the open peer review policy of the journal  
Please review this paper.
user
Reviewer ’s report  
 
Title: Biologic Treatment of Japanese Patients with Inflammatory Bowel Disease  
 
Version: 0 Date: 23 Apr 2018  
 
Reviewer: Valerie Pittet  
 
Reviewer's report:  
 
In this manuscript, Mahlich et al. described results of a cross -sectional survey performed among 
the Japanese population. Data was collected from 1035 patients w ith IBD. The goal of the study 
was to assess factors associated with the use of biologics.  
 
 
The manuscript provides interesting results and interpretations. There are however many points 
that would require further clarification.  
 
 
 
MAJOR COMMENTS.  
 
The major li mitation of the study is the use of patient -reported data to assess the use of biological 
treatment instead of data from medical reports. Therefore, details regarding clinical presentations 
and initiation of treatment are missing, although the authors seve ral times interpreted their results 
as if those data were present (talking about "initiation", "switch", "severe patients").  
 
 
 
INTRODUCTION.  
 
- P.4, L.19 -20: Why should the fact that biologicals were first administered to patients with 
a severe disease presen tation affect its long -term efficacy? The efficacy is assessed by 
indication not for a whole set of disease presentation. Did you refer to the generalizability 
of efficacy results for other clinical presentations? Please explain.  
 
 
- P.4, L.289: the most imp ortant factor for the optimization of therapy is THE 
ASCERTAINMENT of active IBD inflammation. Please update.  
 
 
- P.4, L29 -34: the sentence is unclear and difficult to read. It gives the impression that 
active inflammation only causes symptoms once during di sease course and this until 
biologics are given. I suppose "recipients" referred to patients.  
 
 
- P.4, L.39: previous studies identified factors (or determinants) that were associated with 
the prescription. Please correct the wording.  
 
 
- P.4, L.53 -59: "althou gh we are not aware […] in Japanese culture" is an interpretation 
that should be moved in the discussion section. Moreover, it was not clear to me why the 
authors tried to explain results obtained from studies conducted outside Japan (refs 15 to 
17. Hungar y, Sweden, US) by cultural aspects of Japanese people.  
 
 
- P.5, L.17 -22: "This study assessed the factors associated with the treatment of IBD in 
Japan by biologic agents using a survey of Japanese IBD patients all over Japan." 
Sentence difficult to read and  repetitive. Please reword.  
 
 
- P.5, L.22 -26. The conclusions and perspectives based on study findings should be moved 
at the end of the discussion section.  
 
 
 
METHODS.  
 
The description of the methods did not completely fit with the present manuscript, but rathe r 
with the Morishige (ref 25). The Baars' questionnaire was developed to assess patient's 
preferences about their involvement in decision -making. I did not understand the link with the 
present study, and I did not see any results from data collected using this questionnaire in the 
tables provided. Those were indeed used, but only in the manuscript ref 25.  
 
 
Therefore, I would highly suggest the authors to remove all information regarding this specific 
questionnaire and the description of its back and forth tr anslation, and keep only what was used 
for the present analyses.  
 
 
The authors noted in their response to a previous reviewer's comment that this study was a 
secondary data analysis of the Morishige et al. study. This should be mentioned explicitly in the 
methods section. In addition, ref 25 indicated that the database used was a "consumer panel 
database where all persons registered in the database have opted into accept research survey". 
This contradicts the information reported in the present manuscript tha t the database is 
containing Japanese patients of all indications. There is a major difference between patients and 
persons (individuals). This should be corrected This point is important in terms of potential 
generalization of the findings.  
 
 
 
 
- P.5, L. 53: "work status"/"occupation" is missing in the list of variables  
 
 
- P.5, L.56: the treatment referred to the "current treatment", and the duration to "frequency of 
visits". Please update in the text.  
 
 
Regarding the occupation variable, could you please explain why there was a special category 
for women only, called "house wife"? How does this differ from either being unemployed or 
being full/part -time employed?  
 
 
 
Statistical analysis.  
 
- P.6, L24: The out come seemed to have been defined as "the initiation of a treatment with 
biologics or a switch between different biologics". This detail appeared neither in the tables, nor 
in the methods. How was the question formulated to collect this information? If this  only refers 
to the current use of biologics, the sentence should be updated accordingly.  
 
 
 
RESULTS.  
 
- P.6, L.53 -56. "The majority […]. 30's and 40's[24]" is an interpretation of the results and 
should be moved in the discussion section.  
 
 
- P.6, L.53. The au thors confirmed a male predominance, which is the opposite of what is 
observed in epidemiological surveys. i.e., women usually respond more frequently than men. 
However, if this reflects usual surveys' findings in Japan, it should be reported more accurate ly.   
 
 
- P.11, L.12 -19. The sentence should be written the other way around. What was observed was a 
higher probability with longer disease duration, as compared to the reference (disease duration 
less than 2 y).  
 
 
- Table 1: the title should be "with or with out" biologic treatment instead of "by"  
 
 
- Table 1: The line "biologic agents" should be reported into columns on biologics users.  If I 
read correctly the current treatments, it comes that 27% of CD patients and 43% of UC patients 
were under a combination  therapy (Biologic + immunomodulator). Is that correct.  
 
 
Unfortunately, findings regarding co -current treatments were not discussed at all.  
 
This globally led to the question on how information on drug therapies were collected.  
 
Indeed, it was not clearly me ntioned if the current therapy corresponded to all current 
concomitant therapies reported by the patient. And how valid this data may be for a study like 
this. Patient -reported treatment data primarily provide information on compliance with 
prescribed trea tments, not directly on the prescription itself.  
 
 
 
 
DISCUSSION.  
 
- P.13, L.43 -50. The 2 last sentences of the paragraph did not refer to findings from the 
present study, but to those from the reference 25. Patient's preferences and satisfaction 
were not asse ssed here.  
 
 
- P.14. L.39: "nanbyo" disease. Please add a reference.  
 
 
- P.16. L1 -5: "Our results suggest that the only co -medication that increased the likelihood 
of being treated with a biologic is the use of immunomodulators in the overall and UC 
population ." What about the nutritional treatment, which was also associated with the use 
of biologics? (Table 2)  
 
 
- P.6, L.30 -35. The link between the results and the launch of new product is difficult to 
assess/discuss because no information was provided on the var ious biologicals. In 
addition, as the authors stated, this was a cross -sectional study collecting information in 
2016. The data collection period was very short. Therefore, the cited reason is one of the 
many potential reasons, but it makes no sense here. Rather, it would have been interesting 
to discuss the reliability of patient -reported data for this type of study.  
 
 
 
MINOR COMMENTS.  
 
- P.6, L.24: please add the word "adjusted" to the linear regressions performed.  
 
 
- P.13, L.53: "predictor" should be replac ed by "associated factor" or "determinants", as no 
predictive model was constructed  
 
 
- P.6, L.30: "[…], which was carried out at one time point". Can be deleted because 
corresponds to the definition of a cross -sectional study.  
 
 
- P.6, L. 42 -45: these are pat ient-reported data (not patients' perspectives)  
 
 
 
 
Are the methods appropriate and well described?  
If not, please spe cify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional s tatistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some la nguage corrections before being published  
 
 
 
 
 
 
 
 
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary fro m an 
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation t hat may in any way gain or lose 
financially from the publication of  this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds or has appl ied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
I agree to the open peer review policy of the journal . I understan d that my name will be included 
on my report to the authors and, if the manuscript is accepted f or publication, my named report 
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be in cluded as confidential comments 
to the editor s, which will not be publis hed. 
 
I agree to the open peer review policy of the journal  
assistant