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Age-Specific and Sex-Specific Reference Intervals for Non BMJ Open: first published as 10.1136/bmjopen-2019-030201 on 18 August 2019. Downloaded from PEER REVIEW HISTORY BMJ Open publishes all reviews undertaken for accepted manuscripts. Reviewers are asked to complete a checklist review form (http://bmjopen.bmj.com/site/about/resources/checklist.pdf) and are provided with free text boxes to elaborate on their assessment. These free text comments are reproduced below. ARTICLE DETAILS TITLE (PROVISIONAL) Age- and sex-specific reference intervals for non-fasting lipids and apolipoproteins in 7260 healthy Chinese children and adolescents measured with an Olympus AU5400 analyser: a cross-sectional study AUTHORS Liu, Junjie; Dai, Yanpeng; Yuan, Enwu ; Li, Yushan; Wang, Quanxian; Wang, Linkai; Su, Yanhua VERSION 1 – REVIEW REVIEWER Adagmar Andriolo Escola Paulista de Medicina REVIEW RETURNED 13-Mar-2019 GENERAL COMMENTS Very important topic. These data will be added to the other studies on reference intervals. REVIEWER Martin Frank Strand Høyskolen Kristiania REVIEW RETURNED 25-Mar-2019 http://bmjopen.bmj.com/ GENERAL COMMENTS First, I would like to commend the authors on the scope and importance of the work they present here. They have gathered a unique dataset, with material/data from a large number of healthy pediatric participants, and the establishment of relevant reference intervals is very important both for diagnostics, but also to track population health over time. At the same time there are several improvements the authors can on September 25, 2021 by guest. Protected copyright. do to more clearly present their results, and to get more out of the dataset they have gathered. 4. Are the methods described sufficiently to allow the study to be repeated? There are several elements that need to be addressed in the methods section in order to ensure repeatability. a) The methods lack information about how the participants was recruited b) The methods lack information about where (location/region) the participants were recruited from. This is also important in regards of the use of the reference intervals. c) *How was the non-parametric calculation of the reference intervals performed (software, short description of method)? d) The number of candidates that was excluded due to history with hypertension, DM, coronary heart disease etc. is lacking. e) Reference 11 (Harris Boyd) is not placed correctly in the methods text. 1 BMJ Open: first published as 10.1136/bmjopen-2019-030201 on 18 August 2019. Downloaded from f) Does the laboratory undergo interlaboratory testing schemes to ensure commutability? 7. If statistics are used are they appropriate and described fully? Se above* 10. Are they presented clearly? I marked this as no, but the answer should be yes and no. The reference intervals are clearly defined and presented in a good form in the table that is provided. However, the results provided lack some information that would be valuable to the readers in interpreting the data. This study presents reference intervals based on 7260 participants, but there is very little information about the age and gender distribution of the study population. Figure 1, 2 and 3 repeats the info given in table 2 graphically, but as partitioning by age and gender is an important part of establishing reference intervals, the distribution across age should be visualized with age as a continuous parameter. Thus, the reader will be able to see the changes in lipid levels across age and gender, and this will also increase the ability of readers to compare lipid distribution across age/gender with similar studies in other regions/countries, as this is a common way to present this type of data. The authors could also add information about the prevalence of dyslipidemia based on the data they have gathered. This would be very valuable information as the prevalence of dyslipidemia among healthy children isn’t well known. a) Please add a graph or table that clearly shows/visualizes the number of participants of each age and gender. Examples: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5410076/ figure 1 and https://www.ncbi.nlm.nih.gov/pubmed/26948098 figure 2. b) I highly recommend re-making figure 1-3 as percentile curves (se same references as above) or adding percentile curves in addition to figure 1-3. http://bmjopen.bmj.com/ c) I suggest analyzing and presenting the prevalence of dyslipidemia from the study population. This will add to the aims of the study as they now are stated in the manuscript, but this is very important health information to extract when such a good dataset has been gathered. d) In table 1, the CV-percentages are listed. I suggest adding a sentence under results where you summarize CV-values (give the range). on September 25, 2021 by guest. Protected copyright. 11. Are the discussion and conclusions justified by the results The discussion is a bit thin given the data presented. How does the reference intervals you have found compare to reference values in use now? How do they compare to published reference intervals in similar studies in other countries? The take home messages listed t the start of the manuscript could be addressed in greater detail in the discussion. Do you find evidence to support the first point listed under the take home messages when you compare your results to others? 12. Are the study limitations discussed adequately? Some strengths/limitations are briefly listed after the abstract but is not discussed adequately in the discussion section. The elements listed after the abstract should be elaborated on more clearly in the discussion. Information about recruitment method, location, age 2 BMJ Open: first published as 10.1136/bmjopen-2019-030201 on 18 August 2019. Downloaded from and gender distribution etc. is lacking from methods, and possible limitations to the study population are not addressed. Corrections: Sentence 22, page 7: “lipids levels”. Normally when using two nouns in a row; only the lat is given the plural form: “lipid levels”. Conclusion: I recommend a minor revision of the manuscript; with some more work on/additions to the text in the methods, results and discussion sections. I also recommend some work on additional figures in order to present the gathered data in a more useful form. REVIEWER Tenna Ruest Haarmark Nielsen Department of Pediatrics, Copenhagen University Hospital Rigshospitalet, Denmark REVIEW RETURNED 17-Apr-2019 GENERAL COMMENTS This is a very nice study, with a large number of participants. However, I have som general and som specific comments listed below: Title: Apparently – are they considered healthy or not? Consider eliminating that word, and instead list the number, which is very impressive for such a cohort. P 2: Abstract – aim: Ethnic more than geographic factors influence lipids. P2 line 30: ”Outliers were removed” – this seems too detailed for an abstract. Should be kept in the main text. P 2 Results: Very short. Would be preferable, if the references were a bit described. Were there age differences? Were there http://bmjopen.bmj.com/ gender differences? P 2: Conclusions: This could be more to the point if taking into account which reference values have been used previously for Chinese children – how does this change with the new references? What does this study really bring to the world of new knowledge. Introduction: Obesity is a considerable factor in terms of dyslipidemia in children on September 25, 2021 by guest. Protected copyright. and adolescents. This should be touched upon, also in a context that takes into account the prevalence and development of obesity in China or at least in the world. Also, the level of lipids that seems to cause CVD may be different among ethnicities (I.e. In Chinese adults, variations, even within levels usually regarded as low concentrations of TC (3.8−4.7 mmol/L), are associated with increased mortality from coronary heart disease) (Chen Z, Peto R, Collins R, MacMahon S, Lu J, Li W. Serum cholesterol concentration and coronary heart disease in population with low cholesterol concentrations. BMJ. 1991;303(6797):276-282.) Subjects and methods: How were participants enrolled? From where? What type of community? Can they be considered representative of the specific community/region/country? The cohort should be described in detail when the aim as stated is to generate reference values. Otherwise the reader can not decide 3 BMJ Open: first published as 10.1136/bmjopen-2019-030201 on 18 August 2019. Downloaded from whether the population in the study can be compared to any other given population where the references may be used How were exclusions made – based on journals – or based on interview? How were weight and height measured? (Types of equipment? With/without shoes= With/without clothes?) P 5 ln 6pp: How many participants were excluded based on diagnoses listed in this section? P 5 ln 17pp: Seems to be very low numbers for use of medication and especially for obesity? How were these individuals recruited? Have you considered whether the cohort is representative for the Chinese population in general? According this report from Unicef it seems that 5-10% of children/adolescents have obesity in China – depending on rural or urban geography (http://www.unicef.cn/en/uploadfile/2018/0423/2018042311440016 5.pdf) P 5 ln 20: What acute clinical symptoms were causes for exclusion? P 5 ln 35: Non-fasting values – although HDL and total cholesterol are little affected by whether samples are drawn in the fasting or non-fasting state, triglycerides are on average 20% higher in the non-fasting state, and presents with great variability. This will also affect LDL concentrations, if they are calculated by i.e. the Friedewald equation. How is the LDL concentration extracted from the Olympus AU5400? It seems the LDL is directly measured by clearance though.
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