PONE-D-23-00740Sex-based differences in long-term outcomes after stroke: a meta-analysisPLOS ONE

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PLOS ONE

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Reviewers' comments:

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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: No

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

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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: No

Reviewer #2: Yes

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

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Reviewer #1: Yes

Reviewer #2: Yes

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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 authors address the important topic of gender differences in long-term outcome after stroke. They identified twenty-two cohort studies and analysed 84538 patients, of whom with 49.8% were women.

Their results showed that women had a higher mortality after 1 and 5 years, higher rate of recurrent strokes and less favourable 1-year outcome.

The results are very important and strengthen the need for further investigations in this area of stroke medicine. The results are a basis for the development of interventional studies aiming at gender equity.

The analysis is seems well conducted however, I cannot fully review the manuscript. I was not able to read Figure 1, which shows the main results. The image quality is too poor and the figure appears too blurry. Nothing can be identified. Same for Figure 4. It was not possible to review most of the results.

I have the following comments to the introduction and methods:

Introduction:

I suggest to omit the "general" sentence that stroke is a leading cause of death and disability. This Is well known and it would be much more attracting for readers to start with the topic, e.g. start with sentence two.

The authors describe that they used the "Cochrane risk bias assessment tool was used to assess the bias in randomized controlled studies". Was this the "Cochrane risk-of-bias tool for randomized trials (RoB 2)" tool? If so, it would be easier for the reader if this was indicated in the sentence in detail.

Just out of curiosity, what was the reason to not use the ROBINS-I tool for observational studies?

From the text, I do not understand whether the sensitivity analysis for mortality was performed for 1 year and 5 years? On Page 10, lines 200-203 only one results is presented.

In the paragraph addressing the secondary outcomes depression and health related quality of live, the authors describe that there was no significant difference between men and women. This is also discussed on page 12. Considering the serious heterogeneity of the studies with I2 between 68 and 97%, the conclusion should be that there is not enough evidence to answer this question.

Is any analysis available comparing data from men and women of the same age-group and disease severity?

Reviewer #2: Dear Authors

I congratulate you on a well-written article which attempts to highlight an important yet less addressed issue in stroke. I would like to however point out few discrepancies and urge you to correct these.

1. While the results clearly state that the mortality rates were higher for women at 1 year and 10 years, repeatedly in the paper (abstract, body and conclusion) it is mentioned at 1 and 5 year significant mortality rates. I believe this is a mistake and needs to be edited.

2. Again in the results HRQoL shows no difference between males and females, however in the discussion authors have highlighted and discussed a difference in the poorer mental and physical QOL in women.

3. The consort figure also has discrepancies. The number of excluded articles with reasons do not tally together and some information is either missing or incorrect.

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Reviewer #1: No

Reviewer #2: Yes: Ivy Anne Sebastian

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Attachments

Attachment

Submitted filename: PONE-D-23-00740_reviewer_IS.pdf

Sex-based differences in long-term outcomes after stroke: a meta-analysis

PONE-D-23-00740R1

Dear Dr. Zheng,

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.

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Kind regards,

Ahmed Nasreldein, MD

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

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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

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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: Yes

Reviewer #2: Yes

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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

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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: (No Response)

Reviewer #2: The authors have addressed all the suggested comments. Congratulations on a Well written article on an important topic.

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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

Reviewer #2: No

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