PONE-D-19-21883

The validation of the Beijing version of the Montreal Cognitive Assessment in Chinese patients undergoing hemodialysis

PLOS ONE

Dear Dr. Luo,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

We would appreciate receiving your revised manuscript by Dec 14 2019 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Jeannie-Marie Sheppard Leoutsakos, PhD

Academic Editor

PLOS ONE

Journal Requirements:

1. When submitting your revision, we need you to address these additional requirements. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at http://www.journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and http://www.journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2.  Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

3. There are several cases where P-values are reported as being equal to 0. Please correct and clarify.

4.  We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The ms. is focused on a contribution to the validation of the Beijing version of the MoCA (MoCA-BJ) for detecting Cognitive Impairments among a group of haemodialysis patients.

I have some concerns with the ms. In particular:

• Review the Abstract

Please revise the English

• Review the Introduction:

I suggest to improve this section, it is very gaunt, providing scarce information. First of all, it is not clear which kind of cognitive impairment the authors are talking about. Moreover, before starting to investigate the prevalence of the disorder in the hemodialysis population, it’d be good to do a general overview of the disorder, also in other populations, citing recent articles published on the same topic such as Bosco et al., 2017; Siciliano et al., 2019; Huang et al., 2018.

• Review the Subjects and Methods section:

Rename the section “method”;

Move the subsection “ethics statement” before the “statistical analysis”;

Rename the subsection “Study participants” in “participants”. Add in the text some demographic information such as means and standard deviation about age and level of education, and gender composition, as well. the paragraph needs to be rewrite taking into account English grammar and syntactic rules.

Au.s should clarify in the subsection “Classification of cognitive function” what they intend for “cognitive impairment”, specifying better also the criteria of DSM-5 used to diagnose the impairment. Reading is not easy.

Add references after Roc Curves and Youden Index in the statistical analysis section.

• Review the Results section and Discussion

In table 1 substitute the label p-value with Test

Add references after this sentence: “Previous studies have evaluated the efficacy of the MoCA and the MMSE in screening cognitive impairment in a variety of populations”

It is necessary to check some typos and errors, and, again, to revise the English in order to make the ms. easily legible.

• Notwithstanding the scarce literature about haemodialysis patients affected by “cognitive impairment” it is necessary to integrate the bibliographical apparatus with more recent research.

Reviewer #2: This study details the use of the MoCA-Beijing (BJ) in hemodialysis patients. The authors report on the MoCA-BJ’s correlation with the MMSE as well as with neuropsychological tests. Diagnostic accuracy of the MoCA-BJ is also assessed and the authors find that the optimal cutoff for cognitive impairment is 24, which is consistent with several previously published studies of the English version of the MoCA. Below are my comments.

General Comments

1. Although the English is generally good, there are several instances where the text is grammatically incorrect.

2. Throughout the manuscript, the authors refer to their subjects as cognitive impairment and non-cognitive impairment. The preferred term for non-cognitive impairment is “cognitively unimpaired” (Jack CR, et al. NIA-AA Research Framework: toward a biological definition of Alzheimer’s disease. Alzheimers Dementia. 2018;14.4:535–62.)

Statistical Analysis

1. When describing the analysis of categorical variables, please spell out Chi-square and only use the Greek symbol for Chi when reporting the results from statistical tests.

Results

1. In the bivariate linear regression model, were any demographic variables such as age, sex, and education adjusted for? This is particularly relevant on page 13 where the authors report the amount of variance explained. Perhaps they could report R-squared values from adjusted and unadjusted models.

2. Throughout the text and in the tables, p-values of 0.000 are reported. Although this is the default output for small p-values in SPSS, this is not the way they should be reported. For all cases where the p-value is 0.000, please replace with <0.001.

3. For the measures of diagnostic accuracy, the authors report 95% CIs for the AUC values but not for sensitivity and specificity. 95% CIs for sensitivity and specificity should be reported as well. If these are not given by SPSS, the equation for their calculation is relatively simple and is easily available on a number of reputable websites.

Discussion

1. The authors’ finding that 24 is the optimal cutoff for the identifying cognitive impairment is similar to other findings and these studies should be cited and briefly discussed:

Damian, A.M., Jacobson, S.A., Hentz, J.G., Belden, C.M., Shill, H.A., Sabbagh, M.N., et. al (2011). The Montreal Cognitive Assessment and the Mini-Mental State Examination as screening instruments for cognitive impairment: Item analyses and threshold scores. Dementia and Geriatric Cognitive Disorders, 31, 126-131.

Coen, R.F., Cahill, R., & Lawlor, B.A. (2011). Things to watch out for when using the Montreal Cognitive Assessment (MoCA). International Journal of Geriatric Psychiatry, 26, 106- 108.

Luis CA, Keegan PA, & Mullan M. (2009). Cross validation of the Montreal Cognitive

Assessment in community dwelling older adults residing in the Southeastern US. International Journal of Geriatric Psychiatry, 24, 197-201.

Gluhm, S., Goldstein, J., Loc, K., Colt, A., Van Liew, C., & Corey-Bloom, J. (2013). Cognitive performance on the Mini-Mental State Examination and the Montreal Cognitive Assessment across the healthy adult lifespan. Cognitive and Behavioral Neurology, 26, 1-5.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Prof. Andrea Bosco PhD

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.

The validation of the Beijing version of the Montreal Cognitive Assessment in Chinese patients undergoing hemodialysis

PONE-D-19-21883R1

Dear Dr. Luo,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication.

Shortly after the formal acceptance letter is sent, an invoice for payment will follow. To ensure an efficient production and billing process, please log into Editorial Manager at https://www.editorialmanager.com/pone/, click the "Update My Information" link at the top of the page, and update your user information. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, you must inform our press team as soon as possible and no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

With kind regards,

Jeannie-Marie Sheppard Leoutsakos, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: It seems to me that authors have made all the requested revisions.

Minor concers

In the list of references I found after some authors' names, the fragment "AUID- Oho", please identify it and delete.

Reviewer #2: The authors have responded sufficiently to my comments. No additional revisions are needed for this manuscript.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Prof. Andrea Bosco

Reviewer #2: Yes: Michael Malek-Ahmadi