Neutrophil-to-lymphocyte ratio may predict clinical relapse in ulcerative colitis patients with mucosal healing

Noriyuki Kurimoto; Yu Nishida; Shuhei Hosomi; Shigehiro Itani; Yumie Kobayashi; Rieko Nakata; Masaki Ominami; Yuji Nadatani; Shusei Fukunaga; Koji Otani; Fumio Tanaka; Yasuaki Nagami; Koichi Taira; Noriko Kamata; Yasuhiro Fujiwara

doi:10.1371/journal.pone.0280252

Peer Review History

Original SubmissionJune 5, 2022
14 Sep 2022 Decision Letter - Senthilnathan Palaniyandi, Editor PONE-D-22-16251Neutrophil-to-lymphocyte ratio may predict clinical relapse in ulcerative colitis patients with mucosal healingPLOS ONE Dear Dr. Hosomi 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 have now received comments from the referee of your manuscript, we invite you to submit a revised version of the manuscript. Please consider and address each of the comments raised by the reviewer. Please submit your revised manuscript by Oct 26 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. 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Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 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 manuscript is well written, however still a novel score but available to every patient, but we don't really know if it will be used in the clinical context. In addition, this is a single center study and additional studies are needed. Reviewer #2: Dear Authors these are my comments; 1.The authors posit that NLR can be used to determine treatment option. Can you please further elaborate how NLR can provide insight into the selection of agents for UC 2. Sample Size calculation- The authors have not depicted their sample size calculation to ensure that the number of subjects (n) is enough for a statistically well powered study. 3.Patient subsection of materials and methods section: It will be interesting to know how many of the 129 subjects have been maintaining remission and for how long or was remission only received in the past few months. This can provide insight if NLR can also predict durable remission. 4.Can you please clarify if selected patients had been screened for any other comorbidities such as an ongoing infection that may affect the NLR. This is a major limitation to the use of NLR as it can easily be affected by infections or sometimes even states of inflammation. Practically, IBD patients will be on corticosteroids as well and this again may hamper the use of NLR. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). 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Revision 1
2 Nov 2022 Author Response Response to the Reviewer #1 comments: We appreciate your constructive comments and valuable suggestions as they helped us to revise and improve this manuscript. As indicated in the responses that follow, we have considered these comments and suggestions in the revised version of our manuscript. All changes in the manuscript in response to the critiques are indicated with yellow highlights. Reviewer #1: The manuscript is well written, however still a novel score but available to every patient, but we don't really know if it will be used in the clinical context. In addition, this is a single center study and additional studies are needed. Thank you for your valuable remarks. We are in full agreement that this study is a retrospective and whether it would be would be used in clinical context. Actually, the number of elderly UC patients is increasing, and it is likely that more cases will be affected by underlying diseases and medications that affect NLR values. In the future, it is desirable to conduct prospective multicenter studies to confirm the usefulness of NLR in the real world, however; this would be beyond the scope of the present study. The following text was added to Discussion: "As the number of elderly UC patients is increasing [41], the number of patients with comorbidities, immune dysfunction, polypharmacy, and other factors affecting NLR values is also increasing. Prospective multicenter studies seem necessary to confirm the usefulness of NLR in the real world." (line 228-231) "Therefore, a multicenter prospective study with a larger sample size may help verify our results and confirm whether NLR is a predictor of clinical relapse after MH." (line 235-237) Response to the Reviewer #2 comments: We appreciate your constructive comments and valuable suggestions that have helped improve this manuscript. As indicated in the responses that follow, we have considered these comments and suggestions, which are reflected in our revised manuscript. All changes in the manuscript made in response to the comments are highlighted in yellow. 1.The authors posit that NLR can be used to determine treatment option. Can you please further elaborate how NLR can provide insight into the selection of agents for UC Thank you for your valuable suggestions. There have been several reports on the association between therapeutic agents for ulcerative colitis and NLR. To the best of our knowledge, there are reports that NLR can be a biomarker for predicting the therapeutic outcome of systemic corticosteroid therapy (univariate analysis only) [Endo K, et al. Inflamm Intest Dis. 2021 Nov 16;6(4):218-24] and that NLR can be an early predictor of therapeutic response to anti-TNF therapy [Bertani L, et al. Inflamm Bowel Dis. 2020 Sep 18;26(10):1579-87]. This study describes the significance of NLR in patients who achieved mucosal healing with no medication or with 5-ASA/SASP formulations alone. Therefore, the results of this study can be used as criteria for increasing or decreasing the dose of 5-ASA/SASP formulations, but not for changing to other UC treatments. Treatment attenuation might be considered for patients with mucosal healing with low NLR. We paraphrased the manuscript as follows: "There have been reports on the association of NLR with therapeutic agents for UC, including reports that NLR may be a biomarker for predicting the outcome of systemic corticosteroid therapy [20] and that NLR is an early predictor of therapeutic response to TNF-α antibody therapy [21]. However, to the best of our knowledge, the prediction of clinical relapse in UC patients with MH using NLR has not been investigated previously. In this study, we described the significance of NLR in patients who achieve MH with no medication or with 5-ASA/SASP preparations alone. Therefore, the present results can be used as criteria for increasing or decreasing the dose of the 5-ASA/SASP formulation, but not as criteria for switching to other UC therapies. We believe that if remission is maintained and the NLR is low, reducing the dose of the therapeutic agent can be considered. Conversely, if remission is maintained but the NLR is high, it can be used as a criterion for increasing the dose of the therapeutic agent." (line 161-172) 2. Sample Size calculation- The authors have not depicted their sample size calculation to ensure that the number of subjects (n) is enough for a statistically well powered study. We are in full agreement that we should have mentioned whether the sample size is sufficient because the sample size in this study was rather small. We calculated the required sample size. Sample size calculation as a post-hoc analysis indicated that a total of 118 patients were required to detect a significant association between low NLR and the development of non-clinical relapse with the following assumption: an α level of 0.05, a β level of 0.20, half of the patients were allocated to the high NLR group, the incidences of non-clinical relapse in patients with high and low NLR group were 35.8% and 53.4%, and the follow-up period was 8 years. Therefore, the sample size in this study was satisfied to examine the association between NLR and the development of clinical relapse. We have added the following sentences in the Discussion: "Because the sample size of this study was relatively small, the general formula for calculating the total sample size was used to calculate the required sample size [27]. Sample size calculation indicated that a total of 118 patients were required to detect a significant association between NLR and clinical relapse with the following assumptions: an α level of 0.05 and a β level of 0.20; half of the patients were allocated to the high NLR group, the incidences of non-clinical relapse in patients with high and low NLR group were 35.8% and 53.4%, and the follow-up period was 8 years. Therefore, the sample size in this study was sufficient to examine the association between NLR and the development of clinical relapse." (lines 189-196) 3.Patient subsection of materials and methods section: It will be interesting to know how many of the 129 subjects have been maintaining remission and for how long or was remission only received in the past few months. This can provide insight if NLR can also predict durable remission. Thank you very much for your valuable remarks. We fully agree with you that you should have mentioned the details of the duration of remission in patients who have achieved mucosal healing. As noted in the text, 71 of 129 patients remained in remission. The median duration of remission during the observation period was 70.87 months (IQR: 12.32-125.75 months). The 58 patients who relapsed had a median duration of remission of 28.97 months (IQR: 6.5-65.49 months). The study excluded patients within 6 months of treatment intensification when enrolling them. Therefore, all patients were checked for symptoms and treatment up to 6 months prior to the date of enrollment to assure that they were in remission. However, maintenance of remission prior to 6 months before the date of enrollment could not be confirmed in this study. The following text was added to the Result: "The median duration of remission for the 79 patients who remained in remission was 70.9 months (IQR: 12.3–125.8 months). The median duration of remission for the 58 patients who relapsed was 29.0 months (IQR: 6.5–65.5 months)." (line 116-118) 4.Can you please clarify if selected patients had been screened for any other comorbidities such as an ongoing infection that may affect the NLR. This is a major limitation to the use of NLR as it can easily be affected by infections or sometimes even states of inflammation. Practically, IBD patients will be on corticosteroids as well and this again may hamper the use of NLR. Thank you very much for your valuable remarks. We have excluded cases that are on oral medications that may affect NLR values, such as corticosteroids or IM, as stated in the paper. We checked the medical records for underlying diseases other than UC and excluded cases with complications such as Sjögren's syndrome, for example. In addition, there were no cases that had been diagnosed with any infectious diseases shortly before enrollment, as far as we could ascertain from the medical records. However, we cannot completely rule out the possibility that the patient had been treated for other diseases, such as the common cold or some other infectious disease or taking drugs prescribed in other hospitals. It is also possible that the patient's UC symptoms flared up during the observation period due to some infection or worsening of other comorbidities, and the observation period ended. The following text was added to Discussion: "We checked the medical records for underlying diseases other than UC and excluded cases with complications such as Sjögren's syndrome. In addition, there were no cases of infectious disease immediately before enrollment based on our review of the medical records. However, we cannot completely rule out the possibility that patients were treated for colds or other infectious diseases at the hospital they were visiting for other underlying diseases. It is also possible that the patients' UC symptoms flared up during the observation period due to some infection or worsening of other comorbidities." (line 218-224) https://doi.org/10.1371/journal.pone.0280252.r002
27 Dec 2022 Decision Letter - Senthilnathan Palaniyandi, Editor Neutrophil-to-lymphocyte ratio may predict clinical relapse in ulcerative colitis patients with mucosal healing PONE-D-22-16251R1 Dear Dr. Hosomi, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. 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 help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- 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. Kind regards, Senthilnathan Palaniyandi, Ph.D 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 ******** 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 ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know ****** 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: 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 ****** 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: The manuscript was improved after the revision. The points raised were addressed. In the future additional studies are needed due to the limitations of the study. Now the manuscript is well written, and all section are well described. ****** 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: No ******** https://doi.org/10.1371/journal.pone.0280252.r003
Formally Accepted
2 Jan 2023 Acceptance Letter - Senthilnathan Palaniyandi, Editor PONE-D-22-16251R1 Neutrophil-to-lymphocyte ratio may predict clinical relapse in ulcerative colitis patients with mucosal healing Dear Dr. Hosomi: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. 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. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Senthilnathan Palaniyandi Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0280252.r004

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