Title: Short and Long-Term Follow-Up and Clinical Outcomes in Patients with Celiac Disease
in a Large Private Practice Setting
Version: 3 Date: 29 Sep 2022
Reviewer:  Anil K Verma
Reviewer's report:
I read the manuscript but I am not sure if I fully understood the concept of the study. If I am right,
the authors have evaluated the GFD adherence guidelines with and without a referral dietician. In
my opinion, the manuscript is not transparent. It must be written in clear way. It confuses me on
multiple occasions. According to me, multiple information provided by the authors is dubious.
I could not understand the actual purpose of the manuscript. Though the authors have written
it. To me it was not clear.  Manuscript preparation has several weaknesses. I have multiple
comments that I am summarizing below.
Major comments
Comment#1: The authors must define ‘registered dietician referral’. What’s the difference
between a ‘referral’ and a normal dietician? Name some of the guidelines they are talking about.
Page no. 2, line no 1.
Comment#2:A lifelong gluten-free diet (GFD) is recommended for patients with CD. Hence, a
long-term follow-up is needed. I am not sure what is a short-term follow-up in a private setting
mean? A celiac follow-up by a dietician includes multiple parameters including nutritional/
micronutrient evaluation. I am not sure which guideline recommends micronutrient evaluation
only. Please justify this. Page no 2, line no. 1-3
Comment#3:I am a little confused here. According to me, tTG enzyme deamidates larger
gluten residue. This deamidated gluten molecule (negatively charged) is recognized by HLA-
DQ molecule that presents it one APC’s surface where T-cell attached to it and produces
inflammatory cytokines (IFN-#) that ultimately cause VA. Antibody against tTG (anti-tTG test)
is used to screen CD patients. Please check if the given explanation needs revision. Page no 3,
line no. 3-4
Comment#4:The authors wrote, ‘patients with poor adherence to a GFD remain at increased risk
of mortality’. This is a strong point please be sure about it. Compliance with GFD causes several
complications including some dangerous situations including malignancy but mortality is the
ultimate situation. Multiple articles have confirmed a relationship between poor compliance to
CD with mortality but all such articles confirm long-term poor GFD compliance. The authors
showed like mortality is frequently seen in CD. In my view, this line should be written in a better
style. Page no 4, line no. 1-3
Comment#5:Please check the ‘Initial and Follow-up Serology and Biopsy’ section; this is very
important data. Please mention the disease status of those four categories of patients. It is
important to know were there patients with positive serology and negative marsh and other
such combinations? This data will also confirm if all the CD cases included in the study were
confirmed CD cases
Comment#6:Table 2: Please provide specific data. ‘Normal, partial, complete’ does not provide
any specific information. Biopsy data must be based on modified marsh criteria (0-3C). For the
serology; mention the test name (tTG, AGA, DGP) cut-off value in the methodology section.
Depending on the cut-off value a negative serology could be a borderline positive and so on.
Comment#7:Please check the section ‘initial and follow-up symptoms’; all these symptoms has
been summarized in the same way. It feels like in the same template the data was inserted.
However, I agree with it but I believe this information can be provided in a table. A table will
increase the reader’s interest.
Comment#8:The ‘conclusions’ is more toward the study findings. Better to write the importance
of referral dietician in light of the study results.
Comment#9:The first two lines of the Study setting and patient section contain results. Please
shift this information to the result section.
Comment#10:The duodenal biopsy is actually the confirmatory test and is considered a ‘Gold
standard test’ for CD diagnosis. This makes it different from serological tests. Hence, this
information should be reflected in the line.  Page no 3, line no. 9
Comment#11:Repeat endoscopic evaluation is actually used for monitoring CD cases already
on GFD. For suspected/dubious cases an HLA -DQ typing is needed. Page no 3, line no. 10-12
Comment#12:How many patients' records were originally explored? Page no 2, line no. 9
Comment#13:If mentioning the symptoms, just do not mention the non-classical symptoms only
also mentioned some of the classical symptoms of CD. Page no 3, line no. 5
Comment#14:In the abstract’s methodology, the authors have written that ‘Fisher’s exact and
Chi-square tests’ have been performed using Microsoft excel software. How these statistical
tests were performed using MS Excel? In the ‘statistical test section,’ the authors have given
opposite information. Please check.  Page no 2, line no. 9
Comment#15:The authors have written the ‘purpose of the study in the abstract and also in the
main body but it was not clear to me.
Comment#16:The provided reference for CD prevalence in the USA is outdated (10 years old).
Is it possible to provide an updated CD prevalence and reference? Page no 3, line no. 2
Comment#17:In the abstract and the main body (Study setting and patients) please mention
when the study was conducted.
Minor comments
Comment#1:Suspected CD patients should follow a normal diet. No need to emphasize that a
suspected CD patient needs to be on a gluten-containing diet. Page no 3, line no. 9-10
Comment#2:A dietician first checks for adherence to GFD. I am not sure why the authors are
emphasizing nutritional deficiency only.  Page no 4, line no. 6-8
Comment#3:Please mention the full form of SPSS software, its version, and the manufacture’s
location.
Comment#4:What diagnosis patients had from 1/2014 through 12/2018? Page no 2, line no. 7
Comment#5:Please add lifelong adherence. Page no 3, line no. 13
Comment#6:Follow-up visits section: Please write ‘101’ in words
Comment#7:Please mention the full form of AGA and NIH.
Comment#8:There are a few grammatical errors. Please check for those.
-Creates should be produced. Page no 3, line no. 3
-Were taking should be Takes care. Page no 4, line no. 13
-Patients in this study ‘are’ should be ‘were’ followed at Rockford Gastroenterology Associates.
Page 2, line no. 6
Title: Short and Long-Term Follow-Up and Clinical Outcomes in Patients with Celiac Disease
in a Large Private Practice Setting
Version: 3 Date: 29 Sep 2022
Reviewer:  Anil K Verma
Reviewer's report:
I read the manuscript but I am not sure if I fully understood the concept of the study. If I am right,
the authors have evaluated the GFD adherence guidelines with and without a referral dietician. In
my opinion, the manuscript is not transparent. It must be written in clear way. It confuses me on
multiple occasions. According to me, multiple information provided by the authors is dubious.
I could not understand the actual purpose of the manuscript. Though the authors have written
it. To me it was not clear.  Manuscript preparation has several weaknesses. I have multiple
comments that I am summarizing below.
Major comments
Comment#1: The authors must define ‘registered dietician referral’. What’s the difference
between a ‘referral’ and a normal dietician? Name some of the guidelines they are talking about.
Page no. 2, line no 1.
Comment#2:A lifelong gluten-free diet (GFD) is recommended for patients with CD. Hence, a
long-term follow-up is needed. I am not sure what is a short-term follow-up in a private setting
mean? A celiac follow-up by a dietician includes multiple parameters including nutritional/
micronutrient evaluation. I am not sure which guideline recommends micronutrient evaluation
only. Please justify this. Page no 2, line no. 1-3
Comment#3:I am a little confused here. According to me, tTG enzyme deamidates larger
gluten residue. This deamidated gluten molecule (negatively charged) is recognized by HLA-
DQ molecule that presents it one APC’s surface where T-cell attached to it and produces
inflammatory cytokines (IFN-#) that ultimately cause VA. Antibody against tTG (anti-tTG test)
is used to screen CD patients. Please check if the given explanation needs revision. Page no 3,
line no. 3-4
Comment#4:The authors wrote, ‘patients with poor adherence to a GFD remain at increased risk
of mortality’. This is a strong point please be sure about it. Compliance with GFD causes several
complications including some dangerous situations including malignancy but mortality is the
ultimate situation. Multiple articles have confirmed a relationship between poor compliance to
CD with mortality but all such articles confirm long-term poor GFD compliance. The authors
showed like mortality is frequently seen in CD. In my view, this line should be written in a better
style. Page no 4, line no. 1-3
Comment#5:Please check the ‘Initial and Follow-up Serology and Biopsy’ section; this is very
important data. Please mention the disease status of those four categories of patients. It is
important to know were there patients with positive serology and negative marsh and other
such combinations? This data will also confirm if all the CD cases included in the study were
confirmed CD cases
Comment#6:Table 2: Please provide specific data. ‘Normal, partial, complete’ does not provide
any specific information. Biopsy data must be based on modified marsh criteria (0-3C). For the
serology; mention the test name (tTG, AGA, DGP) cut-off value in the methodology section.
Depending on the cut-off value a negative serology could be a borderline positive and so on.
Comment#7:Please check the section ‘initial and follow-up symptoms’; all these symptoms has
been summarized in the same way. It feels like in the same template the data was inserted.
However, I agree with it but I believe this information can be provided in a table. A table will
increase the reader’s interest.
Comment#8:The ‘conclusions’ is more toward the study findings. Better to write the importance
of referral dietician in light of the study results.
Comment#9:The first two lines of the Study setting and patient section contain results. Please
shift this information to the result section.
Comment#10:The duodenal biopsy is actually the confirmatory test and is considered a ‘Gold
standard test’ for CD diagnosis. This makes it different from serological tests. Hence, this
information should be reflected in the line.  Page no 3, line no. 9
Comment#11:Repeat endoscopic evaluation is actually used for monitoring CD cases already
on GFD. For suspected/dubious cases an HLA -DQ typing is needed. Page no 3, line no. 10-12
Comment#12:How many patients' records were originally explored? Page no 2, line no. 9
Comment#13:If mentioning the symptoms, just do not mention the non-classical symptoms only
also mentioned some of the classical symptoms of CD. Page no 3, line no. 5
Comment#14:In the abstract’s methodology, the authors have written that ‘Fisher’s exact and
Chi-square tests’ have been performed using Microsoft excel software. How these statistical
tests were performed using MS Excel? In the ‘statistical test section,’ the authors have given
opposite information. Please check.  Page no 2, line no. 9
Comment#15:The authors have written the ‘purpose of the study in the abstract and also in the
main body but it was not clear to me.
Comment#16:The provided reference for CD prevalence in the USA is outdated (10 years old).
Is it possible to provide an updated CD prevalence and reference? Page no 3, line no. 2
Comment#17:In the abstract and the main body (Study setting and patients) please mention
when the study was conducted.
Minor comments
Comment#1:Suspected CD patients should follow a normal diet. No need to emphasize that a
suspected CD patient needs to be on a gluten-containing diet. Page no 3, line no. 9-10
Comment#2:A dietician first checks for adherence to GFD. I am not sure why the authors are
emphasizing nutritional deficiency only.  Page no 4, line no. 6-8
Comment#3:Please mention the full form of SPSS software, its version, and the manufacture’s
location.
Comment#4:What diagnosis patients had from 1/2014 through 12/2018? Page no 2, line no. 7
Comment#5:Please add lifelong adherence. Page no 3, line no. 13
Comment#6:Follow-up visits section: Please write ‘101’ in words
Comment#7:Please mention the full form of AGA and NIH.
Comment#8:There are a few grammatical errors. Please check for those.
-Creates should be produced. Page no 3, line no. 3
-Were taking should be Takes care. Page no 4, line no. 13
-Patients in this study ‘are’ should be ‘were’ followed at Rockford Gastroenterology Associates.
Page 2, line no. 6
Please review this paper.
user
Title: Short and Long-Term Follow-Up and Clinical Outcomes in Patients with Celiac Disease
in a Large Private Practice Setting
Version: 3 Date: 29 Sep 2022
Reviewer:  Anil K Verma
Reviewer's report:
I read the manuscript but I am not sure if I fully understood the concept of the study. If I am right,
the authors have evaluated the GFD adherence guidelines with and without a referral dietician. In
my opinion, the manuscript is not transparent. It must be written in clear way. It confuses me on
multiple occasions. According to me, multiple information provided by the authors is dubious.
I could not understand the actual purpose of the manuscript. Though the authors have written
it. To me it was not clear.  Manuscript preparation has several weaknesses. I have multiple
comments that I am summarizing below.
Major comments
Comment#1: The authors must define ‘registered dietician referral’. What’s the difference
between a ‘referral’ and a normal dietician? Name some of the guidelines they are talking about.
Page no. 2, line no 1.
Comment#2:A lifelong gluten-free diet (GFD) is recommended for patients with CD. Hence, a
long-term follow-up is needed. I am not sure what is a short-term follow-up in a private setting
mean? A celiac follow-up by a dietician includes multiple parameters including nutritional/
micronutrient evaluation. I am not sure which guideline recommends micronutrient evaluation
only. Please justify this. Page no 2, line no. 1-3
Comment#3:I am a little confused here. According to me, tTG enzyme deamidates larger
gluten residue. This deamidated gluten molecule (negatively charged) is recognized by HLA-
DQ molecule that presents it one APC’s surface where T-cell attached to it and produces
inflammatory cytokines (IFN-#) that ultimately cause VA. Antibody against tTG (anti-tTG test)
is used to screen CD patients. Please check if the given explanation needs revision. Page no 3,
line no. 3-4
Comment#4:The authors wrote, ‘patients with poor adherence to a GFD remain at increased risk
of mortality’. This is a strong point please be sure about it. Compliance with GFD causes several
complications including some dangerous situations including malignancy but mortality is the
ultimate situation. Multiple articles have confirmed a relationship between poor compliance to
CD with mortality but all such articles confirm long-term poor GFD compliance. The authors
showed like mortality is frequently seen in CD. In my view, this line should be written in a better
style. Page no 4, line no. 1-3
Comment#5:Please check the ‘Initial and Follow-up Serology and Biopsy’ section; this is very
important data. Please mention the disease status of those four categories of patients. It is
important to know were there patients with positive serology and negative marsh and other
such combinations? This data will also confirm if all the CD cases included in the study were
confirmed CD cases
Comment#6:Table 2: Please provide specific data. ‘Normal, partial, complete’ does not provide
any specific information. Biopsy data must be based on modified marsh criteria (0-3C). For the
serology; mention the test name (tTG, AGA, DGP) cut-off value in the methodology section.
Depending on the cut-off value a negative serology could be a borderline positive and so on.
Comment#7:Please check the section ‘initial and follow-up symptoms’; all these symptoms has
been summarized in the same way. It feels like in the same template the data was inserted.
However, I agree with it but I believe this information can be provided in a table. A table will
increase the reader’s interest.
Comment#8:The ‘conclusions’ is more toward the study findings. Better to write the importance
of referral dietician in light of the study results.
Comment#9:The first two lines of the Study setting and patient section contain results. Please
shift this information to the result section.
Comment#10:The duodenal biopsy is actually the confirmatory test and is considered a ‘Gold
standard test’ for CD diagnosis. This makes it different from serological tests. Hence, this
information should be reflected in the line.  Page no 3, line no. 9
Comment#11:Repeat endoscopic evaluation is actually used for monitoring CD cases already
on GFD. For suspected/dubious cases an HLA -DQ typing is needed. Page no 3, line no. 10-12
Comment#12:How many patients' records were originally explored? Page no 2, line no. 9
Comment#13:If mentioning the symptoms, just do not mention the non-classical symptoms only
also mentioned some of the classical symptoms of CD. Page no 3, line no. 5
Comment#14:In the abstract’s methodology, the authors have written that ‘Fisher’s exact and
Chi-square tests’ have been performed using Microsoft excel software. How these statistical
tests were performed using MS Excel? In the ‘statistical test section,’ the authors have given
opposite information. Please check.  Page no 2, line no. 9
Comment#15:The authors have written the ‘purpose of the study in the abstract and also in the
main body but it was not clear to me.
Comment#16:The provided reference for CD prevalence in the USA is outdated (10 years old).
Is it possible to provide an updated CD prevalence and reference? Page no 3, line no. 2
Comment#17:In the abstract and the main body (Study setting and patients) please mention
when the study was conducted.
Minor comments
Comment#1:Suspected CD patients should follow a normal diet. No need to emphasize that a
suspected CD patient needs to be on a gluten-containing diet. Page no 3, line no. 9-10
Comment#2:A dietician first checks for adherence to GFD. I am not sure why the authors are
emphasizing nutritional deficiency only.  Page no 4, line no. 6-8
Comment#3:Please mention the full form of SPSS software, its version, and the manufacture’s
location.
Comment#4:What diagnosis patients had from 1/2014 through 12/2018? Page no 2, line no. 7
Comment#5:Please add lifelong adherence. Page no 3, line no. 13
Comment#6:Follow-up visits section: Please write ‘101’ in words
Comment#7:Please mention the full form of AGA and NIH.
Comment#8:There are a few grammatical errors. Please check for those.
-Creates should be produced. Page no 3, line no. 3
-Were taking should be Takes care. Page no 4, line no. 13
-Patients in this study ‘are’ should be ‘were’ followed at Rockford Gastroenterology Associates.
Page 2, line no. 6
assistant