Title: Eosinophilic Esophagitis Patients Report Substantial Disease Burden Comparable to
More Systemic Immune-Mediated Diseases
Version: 3 Date: 06 Apr 2025
Reviewer's report:
The aim of this study is a very important one as the impact of disease burden in EoE has long
been under appreciated.  It was a novel approach to compare EoE to that of other disease states,
though, as the authors note,  is difficult to do across disease states.  While the data collected here
is an important first step in bringing to light the significant disease burden of EoE as compared
to other chronic conditions, it is important to ensure that the results are not over stated for this
reason.
Additional comments below:
The EoE survey focuses on dysphagia as primary symptom though includes pediatric patients
who often do not have dysphagia but instead other associated symptoms.   In contrast, survey for
other conditions was more open ended in this questioning, asking “when did you first experience
symptoms related to your diagnosis?”
Please explain what a VAS scale is in the text.
Page 8 lines 212-213: “Consistent with predominantly food-related symptoms, the impact of
EoE on sporting activities, compared to the other investigated diseases, was minimal” - this
phrase makes the assumption that EoE symptoms occur only with the ingestion of food and that
EoE sxs are only feeding related, which is an incorrect assumption.  Does this mean that the
score for EoE in this realm was significantly lower than for other diagnoses?  Please include
statistical values for this statement.
Lines 213-215: “Nonetheless, patients with EoE reported levels of impairment in travel, social,
and work activities that were numerically only slightly lower compared to the other immune-
mediated disease states.”  Please include statistics here - does this mean there was no significant
difference and that patients with EoE were equally affected?
Page 11 line 264-265: “EoE patients reported frequent thoughts, similar to UC patients (median
3, IQR 2-4 vs. median 4, IQR 3-4; p=0.168).”  In looking at the corresponding figure, this does
not seem to illustrate these conclusions.  Fig 5a shows median score of 3 for EoE, whereas all
other conditions show median score of 4.  In looking at this figure alone I would interpret this as
patients with EoE thinking about their condition less often than all other disease states.  Please
rectify this.
Page 11 line 266-268: “Notably, sex differences were more pronounced; female EoE patients
numerically thought about their condition more often than male UC patients (median 2.5, IQR
1-4 vs. median 2, IQR 1-3; p=0.290).”  I’m not sure how much this matters - I would be more
interested to know if there was a difference between males and females with EoE - looking at
fig 5b it looks like there would be since males with EoE had a similar level to males with UC.
While this may not be the case since the N in each group was different, if the difference between
fEoE and mUC is important to highlight would recommend adding p values in the graph to
highlight this.
Page 12 line 278 - was the difference in SLE significant?   If so please add stats, if not would
consider eliminating figure 6 as it does not add any relevant data.
Page 12 line 286 - typo “manifestation”
It would be beneficial to include a table listing the patient characteristics of survey responders
with each disease state - number/percentile in each age category, sex, professional activity -
and to know if there was a significant difference any of the disease groups included as this can
affect interpretation of results.  I would be particularly interested in this information because
you’ve included patients under 10yo in this survey - these patients can have very different
presenting symptoms in EoE.  Are we to assume that for patients under 10yo, parents are the
survey respondent?  If the EoE group as a whole was younger this could greatly influence what
conclusions you can draw from your results and should be addressed in the discussion.
Page 13 lines 303-305: “However, patients with EoE reported a level of impairment in their
travel, social, and work activities, which was numerically only slightly lower compared to their
counterparts with more systemic immune-mediated chronic diseases.”  Is this true?  This seems
to be an oversimplification of your data and in many cases, was not true.  And if numerically
only slightly lower and not significant, would recommend rewriting this statement all together
to state that there was no significant difference between EoE and other disease states.
Page 15 line 359-361: “And patients evidently do not have such a robust methodology in mind
when thinking about crucial aspects to inquire to their community.” This is an odd statement
and sounds disparaging toward patients - would recommend removing.
Title: Eosinophilic Esophagitis Patients Report Substantial Disease Burden Comparable to
More Systemic Immune-Mediated Diseases
Version: 3 Date: 06 Apr 2025
Reviewer's report:
The aim of this study is a very important one as the impact of disease burden in EoE has long
been under appreciated.  It was a novel approach to compare EoE to that of other disease states,
though, as the authors note,  is difficult to do across disease states.  While the data collected here
is an important first step in bringing to light the significant disease burden of EoE as compared
to other chronic conditions, it is important to ensure that the results are not over stated for this
reason.
Additional comments below:
The EoE survey focuses on dysphagia as primary symptom though includes pediatric patients
who often do not have dysphagia but instead other associated symptoms.   In contrast, survey for
other conditions was more open ended in this questioning, asking “when did you first experience
symptoms related to your diagnosis?”
Please explain what a VAS scale is in the text.
Page 8 lines 212-213: “Consistent with predominantly food-related symptoms, the impact of
EoE on sporting activities, compared to the other investigated diseases, was minimal” - this
phrase makes the assumption that EoE symptoms occur only with the ingestion of food and that
EoE sxs are only feeding related, which is an incorrect assumption.  Does this mean that the
score for EoE in this realm was significantly lower than for other diagnoses?  Please include
statistical values for this statement.
Lines 213-215: “Nonetheless, patients with EoE reported levels of impairment in travel, social,
and work activities that were numerically only slightly lower compared to the other immune-
mediated disease states.”  Please include statistics here - does this mean there was no significant
difference and that patients with EoE were equally affected?
Page 11 line 264-265: “EoE patients reported frequent thoughts, similar to UC patients (median
3, IQR 2-4 vs. median 4, IQR 3-4; p=0.168).”  In looking at the corresponding figure, this does
not seem to illustrate these conclusions.  Fig 5a shows median score of 3 for EoE, whereas all
other conditions show median score of 4.  In looking at this figure alone I would interpret this as
patients with EoE thinking about their condition less often than all other disease states.  Please
rectify this.
Page 11 line 266-268: “Notably, sex differences were more pronounced; female EoE patients
numerically thought about their condition more often than male UC patients (median 2.5, IQR
1-4 vs. median 2, IQR 1-3; p=0.290).”  I’m not sure how much this matters - I would be more
interested to know if there was a difference between males and females with EoE - looking at
fig 5b it looks like there would be since males with EoE had a similar level to males with UC.
While this may not be the case since the N in each group was different, if the difference between
fEoE and mUC is important to highlight would recommend adding p values in the graph to
highlight this.
Page 12 line 278 - was the difference in SLE significant?   If so please add stats, if not would
consider eliminating figure 6 as it does not add any relevant data.
Page 12 line 286 - typo “manifestation”
It would be beneficial to include a table listing the patient characteristics of survey responders
with each disease state - number/percentile in each age category, sex, professional activity -
and to know if there was a significant difference any of the disease groups included as this can
affect interpretation of results.  I would be particularly interested in this information because
you’ve included patients under 10yo in this survey - these patients can have very different
presenting symptoms in EoE.  Are we to assume that for patients under 10yo, parents are the
survey respondent?  If the EoE group as a whole was younger this could greatly influence what
conclusions you can draw from your results and should be addressed in the discussion.
Page 13 lines 303-305: “However, patients with EoE reported a level of impairment in their
travel, social, and work activities, which was numerically only slightly lower compared to their
counterparts with more systemic immune-mediated chronic diseases.”  Is this true?  This seems
to be an oversimplification of your data and in many cases, was not true.  And if numerically
only slightly lower and not significant, would recommend rewriting this statement all together
to state that there was no significant difference between EoE and other disease states.
Page 15 line 359-361: “And patients evidently do not have such a robust methodology in mind
when thinking about crucial aspects to inquire to their community.” This is an odd statement
and sounds disparaging toward patients - would recommend removing.
Please review this paper.
user
Title: Eosinophilic Esophagitis Patients Report Substantial Disease Burden Comparable to
More Systemic Immune-Mediated Diseases
Version: 3 Date: 06 Apr 2025
Reviewer's report:
The aim of this study is a very important one as the impact of disease burden in EoE has long
been under appreciated.  It was a novel approach to compare EoE to that of other disease states,
though, as the authors note,  is difficult to do across disease states.  While the data collected here
is an important first step in bringing to light the significant disease burden of EoE as compared
to other chronic conditions, it is important to ensure that the results are not over stated for this
reason.
Additional comments below:
The EoE survey focuses on dysphagia as primary symptom though includes pediatric patients
who often do not have dysphagia but instead other associated symptoms.   In contrast, survey for
other conditions was more open ended in this questioning, asking “when did you first experience
symptoms related to your diagnosis?”
Please explain what a VAS scale is in the text.
Page 8 lines 212-213: “Consistent with predominantly food-related symptoms, the impact of
EoE on sporting activities, compared to the other investigated diseases, was minimal” - this
phrase makes the assumption that EoE symptoms occur only with the ingestion of food and that
EoE sxs are only feeding related, which is an incorrect assumption.  Does this mean that the
score for EoE in this realm was significantly lower than for other diagnoses?  Please include
statistical values for this statement.
Lines 213-215: “Nonetheless, patients with EoE reported levels of impairment in travel, social,
and work activities that were numerically only slightly lower compared to the other immune-
mediated disease states.”  Please include statistics here - does this mean there was no significant
difference and that patients with EoE were equally affected?
Page 11 line 264-265: “EoE patients reported frequent thoughts, similar to UC patients (median
3, IQR 2-4 vs. median 4, IQR 3-4; p=0.168).”  In looking at the corresponding figure, this does
not seem to illustrate these conclusions.  Fig 5a shows median score of 3 for EoE, whereas all
other conditions show median score of 4.  In looking at this figure alone I would interpret this as
patients with EoE thinking about their condition less often than all other disease states.  Please
rectify this.
Page 11 line 266-268: “Notably, sex differences were more pronounced; female EoE patients
numerically thought about their condition more often than male UC patients (median 2.5, IQR
1-4 vs. median 2, IQR 1-3; p=0.290).”  I’m not sure how much this matters - I would be more
interested to know if there was a difference between males and females with EoE - looking at
fig 5b it looks like there would be since males with EoE had a similar level to males with UC.
While this may not be the case since the N in each group was different, if the difference between
fEoE and mUC is important to highlight would recommend adding p values in the graph to
highlight this.
Page 12 line 278 - was the difference in SLE significant?   If so please add stats, if not would
consider eliminating figure 6 as it does not add any relevant data.
Page 12 line 286 - typo “manifestation”
It would be beneficial to include a table listing the patient characteristics of survey responders
with each disease state - number/percentile in each age category, sex, professional activity -
and to know if there was a significant difference any of the disease groups included as this can
affect interpretation of results.  I would be particularly interested in this information because
you’ve included patients under 10yo in this survey - these patients can have very different
presenting symptoms in EoE.  Are we to assume that for patients under 10yo, parents are the
survey respondent?  If the EoE group as a whole was younger this could greatly influence what
conclusions you can draw from your results and should be addressed in the discussion.
Page 13 lines 303-305: “However, patients with EoE reported a level of impairment in their
travel, social, and work activities, which was numerically only slightly lower compared to their
counterparts with more systemic immune-mediated chronic diseases.”  Is this true?  This seems
to be an oversimplification of your data and in many cases, was not true.  And if numerically
only slightly lower and not significant, would recommend rewriting this statement all together
to state that there was no significant difference between EoE and other disease states.
Page 15 line 359-361: “And patients evidently do not have such a robust methodology in mind
when thinking about crucial aspects to inquire to their community.” This is an odd statement
and sounds disparaging toward patients - would recommend removing.
assistant