Determinants of stroke among adult hypertension patients in dessie comprehensive specialized hospital and Kombolcha general hospital, Amhara, Ethiopia: A case-control study

Muluken Demile; Molla Kassie Yenesew; Abebe Bekele Jibat; Yohannes Kibret; Dagnachew Melak; Endalew Minwuye Andargie; Yonas Fissha Adem

doi:10.1371/journal.pone.0319016

Peer Review History

Original SubmissionJuly 18, 2024
18 Jul 2024 Author Response https://doi.org/10.1371/journal.pone.0319016.r001
15 Sep 2024 Decision Letter - Denekew Bitew Belay, Editor PONE-D-24-27441Determinants of Stroke among Adult Hypertension Patients in Dessie Comprehensive Specialized Hospital and Kombolcha General Hospital, Amhara, Ethiopia: A Case-Control StudyPLOS ONE Dear Dr. Adem, 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. ============================== ACADEMIC EDITOR (comments) This manuscript requires substantial improvement in clarity, coherence, and conciseness. The methods section needs thorough revision. please see the below details of comments for each section in the study: Introduction � The introduction needs to be revised. The rationale for the study is not well articulated � Some phrases and information are not clearly stated, some are repeated or redundant. � Authors need to ensure that each section flows logically into the next for better readability. � Authors need to provide more actionable recommendations based on their findings. � The entire manuscript writings needs improvement for ease of understanding and authors may need to seek the services of professional English language editors. � Abbreviation is not appropriate used � Some parts contain redundancy or could be better structured to improve readability. � Authors need to ensure each paragraph transitions smoothly to the next. � It would be more effective if the introduction flowed from the background to the specific problem being addressed. Methods � The statistical methods should be rewritten Result section This is not well articulated and needs improvement which needs to be interpreted based on the findings. Conclusion The conclusion lacks clarity and need to be based on the study. Please rewrite this section. ============================== Please submit your revised manuscript by Oct 30 2024 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 . When you're 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. 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). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. 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Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols . We look forward to receiving your revised manuscript. Kind regards, Denekew Bitew Belay, Ph.D Academic Editor PLOS ONE Journal requirements: When submitting your revision, we need you to address these additional requirements. 1. 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 https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. We note that you have indicated that there are restrictions to data sharing for this study. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. 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We notice that your supplementary figures are uploaded with the file type 'Figure'. Please amend the file type to 'Supporting Information'. Please ensure that each Supporting Information file has a legend listed in the manuscript after the references list. 5. We notice that your supplementary tables are included in the manuscript file. Please remove them and upload them with the file type 'Supporting Information'. Please ensure that each Supporting Information file has a legend listed in the manuscript after the references list. [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: Partly Reviewer #3: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know Reviewer #2: Yes Reviewer #3: 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: No Reviewer #2: Yes Reviewer #3: 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 Reviewer #3: 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: Dear Authors, Thank you for your dedication to researching the important topic of "Determinants of Stroke among Adult Hypertension Patients in Dessie Comprehensive Specialized Hospital and Kombolcha General Hospital, Amhara, Ethiopia: A Case-Control Study." While I acknowledge the effort you have put into this study, it is essential to address certain areas that require further attention to enhance the objectivity and precision of the findings. Specifically, I recommend additional quantification of the identified significant factors to reduce subjectivity and enhance the robustness and reliability of the research outcomes. Additionally, I suggest that the conclusions drawn should be firmly rooted in the empirical evidence presented in the study results to uphold the validity and reliability of the research findings. Reviewer #2: 1. Several study is conducted in Ethiopia For example: https://biomedres.us/pdfs/BJSTR.MS.ID.008576.pdf, https://doi.org/10.1186/s40001-023-01192-6, https://doi.org/10.1371/journal.pone.0228650, https://doi.org/10.2147/DNND.S435806. What's new in your research? 2. I would suggest the authors to find a native English speaker for English editing. 3. Please describe why the independent variables you chose are relevant and how they were defined. 4. In the introduction, the authors have pointed out the deficiencies of the previous studies. The authors are expected to explain in what way the findings of this study were different from the previous studies. 5. Which populations are your sources and studies? Are those patients with hypertension and stroke patients, or just those with hypertension? 6. Delete the passage from lines 259–262 on page 22. 7. How can multicollnarity be tested? 8. The outcome variable needs to be well specified. 9. Did you prepare the table using standard form? Reviewer #3: Thank you for giving me the opportunity to review the manuscript titled “Determinants of Stroke among Adult Hypertension Patients in Dessie Comprehensive Specialized Hospital and Kombolcha General Hospital, Amhara Ethiopia: A Case-Control Study’ I apologize for any inconvenience caused by the delay in my review. The problem raised by the researchers and the hospital data used are impressive and make the work suitable for publication in PLoS ONE. However, the manuscript has several weaknesses that need addressing: Addressing the following issues will enhance the clarity and professionalism of the manuscript, making it more suitable for publication. 1. Language and Editing: The manuscript requires significant improvement in language editing. This includes correcting spelling and typographical errors, as well as grammatical mistakes. 2. Abbreviations: Ensure all abbreviations are properly defined when first introduced. For instance: MRN (line 153), BMI (line 174), HO (line 191), UNICEF (line 194), "Patent" should be corrected to "patient" (line 258) Generally, please make a thorough review of the document to correct these errors and ensure consistency throughout. Introduction The introduction is relatively well written Methods and materials 1. "Study Design, Area, and Period": The subtitle "Study Design, Area, and Period" may not clearly convey the intended content. Consider rephrasing it to better reflect the specifics of your study, such as "Study Design, Geographic Scope, and Time Frame," to make it more descriptive and accurate. 2. Source of Information: Clarify the source of your information, especially regarding the figure of 10 million in the DCSH catchment areas. Verify this number and cite the source accurately. If you cannot provide a source, consider removing this figure from the document to maintain credibility. 3. Source Population vs. Study Population: Define the difference between the source population and the study population. If your intent is to describe a specific group from which the sample is drawn, use "study population" consistently. Avoid confusion by choosing one term and using it throughout the document. 4. Sample Size Determination: The explanation of your sample size determination is unclear. Provide a detailed description and support it with appropriate citations or sources. This will help validate your methodology and ensure that the sample size is justified based on relevant statistical or research standards. 5. Operational Definitions: The operational definitions are well-written and supported with evidence. Ensure that each definition is clearly defined and referenced with appropriate sources to enhance the reliability and validity of your study. These adjustments should help clarify and strengthen the presentation of your study's methodology and findings. Data quality control Is there a specific reason why the pre-test is being conducted at Boru Meda Hospital, which is another hospital included in your study? Data processing and analysis: What exactly does this entail? Are you referring to statistical methods, or something else? Please revise the methodology section, briefly and in detail, to clarify how you could apply bivariable and multivariable logistic regression. Since these methods are used to compare models for calculating your Crude Odds Ratio (COR) and Adjusted Odds Ratio (AOR), please also include the relevant statistical model equations in your explanation. Results: In Table 1, for the "Current Occupation" category, you classify occupations as private, governmental, and NGOs. However, it's unclear where groups like unemployed individuals, farmers, or merchants fall within these classifications. Could you clarify which category they belong to or consider adding additional categories for these occupations? Additionally, please spell out "Non-Governmental Organizations (NGOs)" when first mentioned, and avoid using "gov’tal" as it is not a proper abbreviation. Instead, use "governmental" for clarity. The descriptive statistics provided from Table 1 to Table 4 are insightful, but they require more in-depth explanations. Ensure that each table's findings are clearly explained to highlight the important trends or patterns observed in the data. As for Table 5, which presents the analysis of your logistic regression models, while the presentation is good, it would benefit from more detailed interpretations. Specifically, for the significant variables, please interpret the odds ratios (OR) of each category in relation to their reference groups. For example, explain how an odds ratio above or below 1 indicates increased or decreased likelihood of the outcome compared to the reference category. This will help clarify the real-world implications of the results. Discussion and conclusion The discussion section of the manuscript is relatively well written, providing a good analysis of the findings. However, the conclusion requires improvement to more effectively summarize the key results and their implications. Recommendations: The recommendations should be more specific. Clearly identify the target audience for these recommendations, whether they are intended for national, regional, zonal, or woreda levels, or any other specific bodies. This specificity will help ensure that the recommendations are actionable and relevant to the appropriate stakeholders. ****** 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: No Reviewer #2: Yes: Setegn Muche Fenta Reviewer #3: 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.] 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. 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Revision 1
11 Dec 2024 Author Response Date: 10 /10/2024 Denekew Bitew Belay PLOS ONE Dear… Denekew Bitew Belay Thank you for giving us the opportunity to submit a revised draft of our manuscript titled “Determinants of Stroke among Adult Hypertension Patients in Dessie Comprehensive Specialized Hospital and Kombolcha General Hospital, Amhara, Ethiopia: A Case-Control Study” to the PLOS ONE. We appreciate the time and effort that you and the reviewers have dedicated to providing your valuable feedback on our manuscript. We are grateful to the reviewers for their insightful comments on our paper. We have been able to incorporate changes to reflect most of the suggestions provided by the reviewers. We have highlighted the changes within the manuscript. Please let us know if you still have any questions or concerns about the manuscript. We will be happy to address them, now in a timely manner. Sincerely, Yonas Fissha Adem Point by Point Response to - Editor Point by Point Response to – Reviewers Academic Editor This manuscript requires substantial improvement in clarity, coherence, and conciseness. The methods section needs thorough revision. please see the below details of comments for each section in the study: Introduction � The introduction needs to be revised. The rationale for the study is not well articulated � Some phrases and information are not clearly stated, some are repeated or redundant. � Authors need to ensure that each section flows logically into the next for better readability. � Authors need to provide more actionable recommendations based on their findings. � The entire manuscript writings needs improvement for ease of understanding and authors may need to seek the services of professional English language editors. � Abbreviation is not appropriate used � Some parts contain redundancy or could be better structured to improve readability. � Authors need to ensure each paragraph transitions smoothly to the next. � It would be more effective if the introduction flowed from the background to the specific problem being addressed. Response: We would like to thank the dear editorial for your frank comment. We reviewed and made extensive adjustments in the revised manuscript. Methods � The statistical methods should be rewritten Response: We appreciate the suggestion. Changes were made to the method part of revised manuscript. Result section This is not well articulated and needs improvement which needs to be interpreted based on the findings. Response: We appreciate your valuable suggestion. We have made improvement in the revised manuscript as per your expectations. Conclusion The conclusion lacks clarity and need to be based on the study. Please rewrite this section. ============================== Response: We appreciate your thoughtful observation regarding this issue. We've made changes to this section based on your comments. Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #1: Dear Authors, Thank you for your dedication to researching the important topic of "Determinants of Stroke among Adult Hypertension Patients in Dessie Comprehensive Specialized Hospital and Kombolcha General Hospital, Amhara, Ethiopia: A Case-Control Study." While I acknowledge the effort you have put into this study, it is essential to address certain areas that require further attention to enhance the objectivity and precision of the findings. Specifically, I recommend additional quantification of the identified significant factors to reduce subjectivity and enhance the robustness and reliability of the research outcomes. Additionally, I suggest that the conclusions drawn should be firmly rooted in the empirical evidence presented in the study results to uphold the validity and reliability of the research findings. Response: Thank you for this important observation. As much as possible we have tried to improve and update the content of the manuscript as per your recommendation. Reviewer #2: 1. Several study is conducted in Ethiopia For example: https://biomedres.us/pdfs/BJSTR.MS.ID.008576.pdf, https://doi.org/10.1186/s40001-023-01192-6, https://doi.org/10.1371/journal.pone.0228650, https://doi.org/10.2147/DNND.S435806. What's new in your research? Response: dear reviewer, thanks for your valuable comment. while the number of stroke patients being admitted to hospitals as a result of hypertension is rising, few results attempt to investigate those factors through case-control studies since these few studies concentrate more on the magnitude not for the factors. Furthermore, there is no similar study conducted in the study area, that accounts for differences in socioeconomic status, and access to treatment and it is useful for designing contextual interventions. 2. I would suggest the authors to find a native English speaker for English editing. Response: Thank you for your careful inspection. Done as requested. 3. Please describe why the independent variables you chose are relevant and how they were defined. Response: dear reviewer, thank you for pointing this out. The independent variables were taken from different literature which might be a factor for outcome variable. Some independent variables were defined in the operational definition of this study. 4. In the introduction, the authors have pointed out the deficiencies of the previous studies. The authors are expected to explain in what way the findings of this study were different from the previous studies. Response: Thank you for your thoughtful comment. We have already explained it above. 5. Which populations are your sources and studies? Are those patients with hypertension and stroke patients, or just those with hypertension? Response: We appreciate the reviewer’s important opinion. All adult (>18 years of age) hypertensive patients who were on follow-up in DCSH and Kombolcha General Hospital visit during the data collection period were the study population which were the actual sample size was drawn, this population is called sample population. But All adult hypertensive patients and stroke patients from hypertension backgrounds in DCSH and Kombolcha General Hospital visit the facilities were the source population which finally this study result was generalized. We have made it short and precise in the revised manuscript. 6. Delete the passage from lines 259–262 on page 22. Response: Thank you very much for your comments. But this passage is important because this passage talk about how bivariable logistic analysis was done then the candidate is chosen for final multivariable logistic analysis. So, we considered this passage is essential but if it is mandatory, it’s easy to delete it. 7. How can multicollinearity be tested? Response: Thank you for your insightful comment. We have incorporated your idea in the data analysis part of a revised manuscript. 8. The outcome variable needs to be well specified. Response: We thank you for your valuable opinion. Our outcome variable is all sampled adult stroke patients older than eighteen years were from a hypertension background diagnosed by the neurologist (consultant internist) as cases and all adult hypertension patients older than eighteen years who did not exhibit clinical signs of stroke or a history of stroke as controls. It’s placed in short in the revised manuscript. 9. Did you prepare the table using standard form? Response: Thank you for the comments. We have made adjustments accordingly. Reviewer #3: Thank you for giving me the opportunity to review the manuscript titled “Determinants of Stroke among Adult Hypertension Patients in Dessie Comprehensive Specialized Hospital and Kombolcha General Hospital, Amhara Ethiopia: A Case-Control Study’ I apologize for any inconvenience caused by the delay in my review. The problem raised by the researchers and the hospital data used are impressive and make the work suitable for publication in PLoS ONE. However, the manuscript has several weaknesses that need addressing: Addressing the following issues will enhance the clarity and professionalism of the manuscript, making it more suitable for publication. 1. Language and Editing: The manuscript requires significant improvement in language editing. This includes correcting spelling and typographical errors, as well as grammatical mistakes. Response: dear reviewer, we agreed with the reviewer's comment. Done as requested. 2. Abbreviations: Ensure all abbreviations are properly defined when first introduced. For instance: MRN (line 153), BMI (line 174), HO (line 191), UNICEF (line 194), "Patent" should be corrected to "patient" (line 258) Generally, please make a thorough review of the document to correct these errors and ensure consistency throughout. Response: dear reviewer, thank you for your valuable feedback. We have corrected it accordingly in the revised manuscript. Introduction The introduction is relatively well written Response: dear reviewer, thank you very much for your motivational comment. Methods and materials 1. "Study Design, Area, and Period": The subtitle "Study Design, Area, and Period" may not clearly convey the intended content. Consider rephrasing it to better reflect the specifics of your study, such as "Study Design, Geographic Scope, and Time Frame," to make it more descriptive and accurate. Response: dear reviewer, thank you for spotting this. It has been rewritten to give clarity in the revised manuscript. 2. Source of Information: Clarify the source of your information, especially regarding the figure of 10 million in the DCSH catchment areas. Verify this number and cite the source accurately. If you cannot provide a source, consider removing this figure from the document to maintain credibility. Response: Thank you for your thoughtful concern of our study. We had removed this figure from the revised manuscript. 3. Source Population vs. Study Population: Define the difference between the source population and the study population. If your intent is to describe a specific group from which the sample is drawn, use "study population" consistently. Avoid confusion by choosing one term and using it throughout the document. Response: Thank you for your detailed comments. We have revised the manuscript according to your comments. 4. Sample Size Determination: The explanation of your sample size determination is unclear. Provide a detailed description and support it with appropriate citations or sources. This will help validate your methodology and ensure that the sample size is justified based on relevant statistical or research standards. Response: Thank you so much for your careful check. But we have already explained it as much as possible even by putting a reference from previous study. But if you have a specific comments, we are happy to modify it. 5. Operational Definitions: The operational definitions are well-written and supported with evidence. Ensure that each definition is clearly defined and referenced with appropriate sources to enhance the reliability and validity of your study. These adjustments should help clarify and strengthen the presentation of your study's methodology and findings. Response: Thank you very much for your good comment. Data quality control Is there a specific reason why the pre-test is being conducted at Boru Meda Hospital, which is another hospital included in your study? Response: Thank you for your rigorous comment. pretesting is designed to make sure that people understand the questions, and that there isn’t anything in the data that indicates that the information is inaccurate. Pretest is also important for budget allocation. But pretest is done for primary data in different facility other than the study area. Because if pretest is done on same area for primary data the information linkage is high so finally we have got biased information from respondents. But for secondary data we can done pretest on the same area. Data processing and analysis: What exactly does this entail? Are you referring to statistical methods, or something else? Please revise the methodology section, briefly and in detail, to clarify how you could apply bivariable and multivariable logistic regression. Since these methods are used to compare models for calculating your Crude Odds Ratio (COR) and Adjusted Odds Ratio (AOR), please also include the relevant statistical model equations in your explanation. Response: Thank you for your valuable input. We modified it accordingly in the revised manuscript. Results: In Table 1, for the "Current Occupation" category, you classify occupations as private, governmental, and NGOs. However, it's unclear where groups like unemployed individuals, farmers, or merchants fall within these classifications. Could you clarify which category they belong to or consider adding additional categories for these occupations? Response: Thank you for your reminder. Sorry for making us a mistake here and we have improved the contents in the revised manuscript. In this study we were consider private (self-employed) consists merchant and farmers. We have also forgotten “Other” options. We have made correct all this issue. Also we have done Bivariable analysis again and p-value became above 0.25 so it’s not a candidate for multivariable analysis as shown below. Variables in the Equation B S.E. Wald df Sig. Exp(B) 95% C.I.for EXP(B) Lower Upper Step 1a Occupation? .346 4 .987 Occupation?(1) .022 .415 .003 1 .958 1.022 .453 2.305 Occupation?(2) .313 .600 .272 1 .602 1.367 .422 4.430 Occupation?(3) .138 .441 .097 1 .755 1.148 .483 2.726 Occupation?(4) .130 .609 .046 1 .831 1.139 .345 3.759 Constant 1.191 .233 26.128 1 .000 3.292 a. Variable(s) entered on step 1: Occupation?. Additionally, please spell out "Non-Governmental Organizations (NGOs)" when first mentioned, and avoid using "gov’tal" as it is not a proper abbreviation. Instead, use "governmental" for clarity. Response: Thank you for your reminder. We have implemented the necessary modifications in the revised manuscript. The descriptive statistics provided from Table 1 to Table 4 are insightful, but they require more in-depth explanations. Ensure that each table's findings are clearly explained to highlight the important trends or patterns observed in the data. Response: Thank you for raising this important point. We have added the in-depth explanation based on your comment in the revised manuscript. As for Table 5, which presents the analysis of your logistic regression models, while the presentation is good, it would benefit from more detailed interpretations. Specifically, for the significant variables, please interpret the odds ratios (OR) of each category in relation to their reference groups. For example, explain how an odds ratio above or below 1 indicates increased or decreased likelihood of the outcome compared to the reference category. This will help clarify the real-world implications of the results. Response: Thank you for your suggestions. We have included the exact number of odds ratios in the revised manuscript. Discussion and conclusion The discussion section of the manuscript is relatively well written, providing a good analysis of the findings. However, the conclusion requires improvement to more effectively summarize the key results and their implications. Response: We would like to thank the reviewer for her/his kind words regarding our paper. We have revised in the manuscript based on your comment, Recommendations: The recommendations should be more specific. Clearly identify the target audience for these recommendations, whether they are intended for national, regional, zonal, or woreda levels, or any other specific bodies. This specificity will help ensure that the recommendations are actionable and relevant to the appropriate stakeholders. Response: Thank you. We reviewed the recommendation and made it rewrite. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0319016.r003
2 Jan 2025 Decision Letter - Denekew Bitew Belay, Editor PONE-D-24-27441R1Determinants of Stroke among Adult Hypertension Patients in Dessie Comprehensive Specialized Hospital and Kombolcha General Hospital, Amhara, Ethiopia: A Case-Control StudyPLOS ONE Dear Dr. Adem, 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. Please submit your revised manuscript by Feb 16 2025 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 . When you're 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. 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). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols . We look forward to receiving your revised manuscript. Kind regards, Denekew Bitew Belay, Ph.D Academic Editor PLOS ONE Additional Editor Comments: The manuscript still needs substantial improvements. Please pay attention and make the required revisions. The Sample size determination still needs improvements. [Note: HTML markup is below. Please do not edit.] 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 #2: All comments have been addressed Reviewer #3: (No Response) ******** 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 #2: Yes Reviewer #3: Partly ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: Yes Reviewer #3: No ****** 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 #2: Yes Reviewer #3: 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 #2: Yes Reviewer #3: 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 #2: I appreciate the editor giving me the opportunity to assess this work, and the authors answered all of my questions. Reviewer #3: Dear Author/s Thank you for addressing many of the comments and making improvements in the manuscript. However, there are still some concerns that were not adequately addressed in this round of revisions. 1. The abbreviations are not correctly abbreviated eg. Medical Record Number (MRN) mentioned two times on page 8 and 9. 2. Some of my questions are not replied, for example a. my suggestions on sample size determination “Sample Size Determination: The explanation of your sample size determination is unclear. Provide a detailed description and support it with appropriate citations or sources. This will help validate your methodology and ensure that the sample size is justified based on relevant statistical or research standards. “ The Response is “Thank you so much for your careful check. But we have already explained it as much as possible even by putting a reference from previous study. But if you have a specific comment, we are happy to modify it.” Now I can ask more questions as What is sample size determinations and what is it is purpose? Sample size determination is the process of calculating the number of participants or observations needed in a study to achieve reliable and valid results. Therefore, where is your sample size calculations? how can you determine the sample size? Your readers need clarity about your sample size determination? If your sample size determination is wrong then what will happen about work? b. My question “Data processing and analysis: What exactly does this entail? Are you referring to statistical methods, or something else? Please revise the methodology section, briefly and in detail, to clarify how you could apply bivariable and multivariable logistic regression. Since these methods are used to compare models for calculating your Crude Odds Ratio (COR) and Adjusted Odds Ratio (AOR), please also include the relevant statistical model equations in your explanation.” The response is: “Thank you for your valuable input. We modified it accordingly in the revised manuscript.” But I could not find the modified methods in the revised manuscript. 3. Under section: Study Design, Geographic Scope, and Time Frame There is no clear evidence for your information, please put the references where did you get this information 4. In general, I could not identify where the responses to the comments are located, as there are no page or line numbers provided. Many answers are vague, using phrases like “we have done based on the comments” or “modified as per the comments,” without offering concrete evidence or detailed justifications. This lack of clarity makes it difficult to understand the rebuttals or acceptances in the manuscript. Therefore, I strongly recommend providing clearer and more detailed explanations for the questions, including the specific page and line numbers where your responses can be found. ****** 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? 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Revision 2
18 Jan 2025 Author Response Date: 03 /01/2025 Denekew Bitew Belay PLOS ONE Dear… Denekew Bitew Belay Thank you for giving us the opportunity to submit a revised draft of our manuscript titled “Determinants of Stroke among Adult Hypertension Patients in Dessie Comprehensive Specialized Hospital and Kombolcha General Hospital, Amhara, Ethiopia: A Case-Control Study” to the PLOS ONE. We appreciate the time and effort that you and the reviewers have dedicated to providing your valuable feedback on our manuscript. We are grateful to the reviewers for their insightful comments on our paper. We have been able to incorporate changes to reflect most of the suggestions provided by the reviewers. We have highlighted the changes within the manuscript. Please let us know if you still have any questions or concerns about the manuscript. We will be happy to address them, now in a timely manner. Sincerely, Yonas Fissha Adem Point by Point Response to - Editor Point by Point Response to – Reviewers Additional Editor Comments: The manuscript still needs substantial improvements. Please pay attention and make the required revisions. The Sample size determination still needs improvements. Response: Thank you for your suggestions. We will improve it as per your recommendations. Reviewer #3: Dear Author/s Thank you for addressing many of the comments and making improvements in the manuscript. However, there are still some concerns that were not adequately addressed in this round of revisions. 1. The abbreviations are not correctly abbreviated eg. Medical Record Number (MRN) mentioned two times on page 8 and 9. Response: Thank you for your suggestions. But in our health facility setting MRN stands for medical record number. If you have other idea for MRN abbreviation. Give us your idea and we can modify according to your comments. 2. some of my questions are not replied, for example A. my suggestions on sample size determination “Sample Size Determination: The explanation of your sample size determination is unclear. Provide a detailed description and support it with appropriate citations or sources. This will help validate your methodology and ensure that the sample size is justified based on relevant statistical or research standards. “ The Response is “Thank you so much for your careful check. But we have already explained it as much as possible even by putting a reference from previous study. But if you have a specific comment, we are happy to modify it.” Now I can ask more questions as What is sample size determinations and what is it is purpose? Sample size determination is the process of calculating the number of participants or observations needed in a study to achieve reliable and valid results. Therefore, where is your sample size calculations? How can you determine the sample size? Your readers need clarity about your sample size determination? If your sample size determination is wrong then what will happen about work? Response: Thank you very much dear reviewer, we have calculated the required sample size by using double population proportion formula using Epi Info 7 Software version 2.1.1. We didn’t use single population formula to get the largest sample size because this study isn’t cross-sectional study rather it’s a case control study so we calculate the sample size using factors associated with stroke from previous studies. We will show these factors using a table in the revised manuscript. You can check these using Epi info 7 software versions. Page 8 and line number 138-149 B. My question “Data processing and analysis: What exactly does this entail? Are you referring to statistical methods, or something else? Please revise the methodology section, briefly and in detail, to clarify how you could apply bivariable and multivariable logistic regression. Since these methods are used to compare models for calculating your Crude Odds Ratio (COR) and Adjusted Odds Ratio (AOR), please also include the relevant statistical model equations in your explanation.” The response is: “Thank you for your valuable input. We modified it accordingly in the revised manuscript.” But I could not find the modified methods in the revised manuscript. Response: Thank you for your suggestions. Dear, l seems that l have changed very well the “Data processing and analysis part” in previous revised manuscript as per your recommendation. But you are not satisfied. I will revise again as much as I can but l am stressed how I satisfied you. Because l considered that l was write all things about logistic regression. Page 11 and line number 218-223. 3. Under section: Study Design, Geographic Scope, and Time Frame There is no clear evidence for your information, please put the references where did you get this information Response: Thank you for your suggestions. We incorporated the reference for the information. page 6, line number 118 4. In general, I could not identify where the responses to the comments are located, as there are no page or line numbers provided. Many answers are vague, using phrases like “we have done based on the comments” or “modified as per the comments,” without offering concrete evidence or detailed justifications. This lack of clarity makes it difficult to understand the rebuttals or acceptances in the manuscript. Therefore, I strongly recommend providing clearer and more detailed explanations for the questions, including the specific page and line numbers where your responses can be found. Response: Thank you for your suggestions. We incorporated the page number and line numbers for each comments. Attachments Attachment Submitted filename: Response_to_Reviewers_auresp_2.docx https://doi.org/10.1371/journal.pone.0319016.r005
27 Jan 2025 Decision Letter - Denekew Bitew Belay, Editor Determinants of Stroke among Adult Hypertension Patients in Dessie Comprehensive Specialized Hospital and Kombolcha General Hospital, Amhara, Ethiopia: A Case-Control Study PONE-D-24-27441R2 Dear Dr. Adem, 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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, 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, Denekew Bitew Belay, Ph.D Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0319016.r006
Formally Accepted
Acceptance Letter - Denekew Bitew Belay, Editor PONE-D-24-27441R2 PLOS ONE Dear Dr. Adem, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, 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 customercare@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. Denekew Bitew Belay Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0319016.r007

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