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Your manuscript has been Accepted for publication. Congratulations!
Dear authors,
Thank you for submitting the revised version of your manuscript. After reviewing the feedback from both reviewers, I concur with their assessments that while the manuscript has improved, it requires a minor revision to meet the necessary level of scientific rigor for publication.
To ensure the study achieves the highest standards of quality and clarity, I kindly request that you address the reviewers' remaining comments in detail. Their recommendations focus on consider reviewing the English language throughout the manuscript. The repetitive information in the introduction and discussion sections should be streamlined for clarity and conciseness. The objectives, which Reviewer 1 identified as overly ambitious, must be revised accordingly. Additionally, the explanations of correlation analysis and multiple regression in the Statistical Analysis section require further refinement. Ensure that all other recommendations from both reviewers are thoroughly addressed, which are essential to strengthen the manuscript.
Best regards,
Ana María Jimenez Cebrian
Dear authors, thanks for your response to my review.
The use of English has significantly improved in this revised version, although there are still few corrections that I recommend you to consider.
In line 49, beginning the document with "With rapid economic..." is too direct, please consider using something similar to "In the context of..." or "Lifestyle changes..."
The Introduction section is still too extensive. Even with the content being appropriate, some of it is not essential as a context for your specific project. Please consider removing from the text reiterative information.
The objectives section is pretentious in lines 103-106. Please consider aims that you will be able to fulfil with your results. Might be more adequate to mention this in your discussion section.
In the discussion section, the section on age addresses physiological and psychological factors that affect PSF in middle-aged groups, which is relevant. However, you could condense this information to improve flow. It would be beneficial to include some mention of how specific approaches for different age groups could enhance rehabilitation, linking these data with practical clinical recommendations.
If findings are mentioned repeatedly from the results section, please remove it of simplify on the discussion to avoid redundance.
The analysis of the impact of income is solid, but you could include a more explicit recommendation on how public health policies or community support services could help mitigate the burden of PSF in low-income individuals. This would strengthen the clinical relevance of the findings.
The discussion on the relationship between depression and PSF is comprehensive and well-supported by the literature. To improve cohesion, you could integrate how early psychological intervention might positively influence PSF, highlighting the importance of early and continuous mental health assessment in stroke survivors.
I have reviewed the authors' responses to my previous comments and the revised manuscript. The authors sincerely addressed many of my concerns, but there are still a few areas that need revision.
1. Novelty of the Study
While this journal does not include research impact and novelty in its acceptance criteria, please consider the following points to improve the manuscript.
(1) Introduction section:
If the focus on younger and middle-aged stroke survivors who are ambulatory is a novel aspect, this should be highlighted.
(2) Discussion section:
The authors should emphasize any new findings that differ from or extend beyond previous research.
2. Statistical Analysis
I appreciate the authors' explanation of their choice of correlation and multiple regression analyses.
To avoid confusion among readers, I recommend revising the explanations of correlation analysis and multiple regression analysis in the Statistical Analysis section. Specifically, for the correlation analysis, replace "PSF" with "the severity of fatigue". For the multiple regression analysis, replace "contributing to the incidence of PSF" with "related to the severity of fatigue".
Similarly, please ensure consistent and accurate terminology throughout the Results and Discussion sections when describing correlation and regression analyses to prevent any misunderstanding among readers.
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Dear Authors,
One of the most significant issues with the manuscript is the use of language. It is essential to adopt an academic tone and avoid casual expressions, ensuring the writing is impersonal and maintains a formal style.
Please ensure that you address all the points raised by the reviewers, as doing so will greatly enhance the scientific quality of the manuscript. I agree with the reviewers for the most part, and I concur that major revisions are necessary to improve the overall clarity and rigor of the work.
In addition, please clarify any that you think should not be addressed, providing a clear rationale for your decisions.
Thank you for your cooperation.
Best regards,
Ana María Jiménez-Cebrián
The entire document needs to be reviewed again to ensure a more appropriate and academic use of English, employing an impersonal style. In the introduction, the content is correct, although the epidemiological data should be summarized; some data do not provide relevant information to achieve the objectives. The repetition of acronyms should be avoided, and their usage should remain consistent once defined (e.g., PSF). All the raw data, tables and figures are appropriate. Discussion section should be re-written as not all of the content is necessary to justify the findings.
Aims & Scope of the journal is consistent with this paper. Research question is well defined, relevant & meaningful. It is stated how research fills an identified knowledge gap. Rigorous investigation performed to a high technical & ethical standard. Methods described with sufficient detail & information to replicate.
In the paragraph from lines 107-110, it would be beneficial to include references from similar studies that have obtained the same demographic data. Please consider moving the content from lines 118, 124, 132, and 138 (internal consistency results) to the Results section.
In the discussion, lines 233-249 should be reconsidered, as income data alone cannot lead to such profound conclusions, especially considering that a properly validated tool to measure wealth among the Chinese population was not used. Instead, only two income groups were presented without sufficient justification.
As this is mentioned in the discussion section "The impact of gender on post-stroke fatigue lacks consensus, necessitating further clarification in future investigations", please do not include "gender" as a predictor of PSF in the conclusions section.
In lines 322-323 it is mentioned that "the study used self-administered questionnaires, potentially biased by subjective participant factors". Please note that this should not be a limitation itself as far as the questionnaire is valid and reliable enough.
No comments.
The cross-sectional study's authors discussed the variables affecting stroke survivors' post-stroke fatigue.
According to data from the literature, changes in the frontothalamostriatal system and/or inflammatory processes may be the cause of post-stroke weariness.
Methods are well described and clear.
Strobe checklist is included in the supplemental material.
Ethical considerations are reported.
Prestroke exhaustion, pain, and sleep issues also seemed to be connected to PSF s reported in an appropriate systematic review (10.1155/2015/347920).
https://pubmed.ncbi.nlm.nih.gov/26101691/
A more recent meta-analysis reported the importance of comorbidities and psychological factors (10.1007/s10072-020-04633-w).
https://pubmed.ncbi.nlm.nih.gov/32813167/
Moreover, a very recent RCT reported the crucial role of nutritional supplements on PSF (10.1016/j.jnha.2024.100256).
https://pubmed.ncbi.nlm.nih.gov/38696891/
Muscle activation should be considered relevant (10.1016/j.clinph.2020.04.158) with a particular perspective of rehabilitation.
https://pubmed.ncbi.nlm.nih.gov/32506008/
[# PeerJ Staff Note: It is PeerJ policy that additional references suggested during the peer-review process should *only* be included if the authors are in agreement that they are relevant and useful #]
A minor revision considering muscle activation, rehabilitation, and nutrition.
1. Throughout the manuscript, expressions suggesting causal relationships such as 'influencing', 'contributing to', and 'affect' are frequently used when explaining the relationship between post-stroke fatigue and various variables. However, as this study employs a cross-sectional observational design, such expressions suggesting causal relationships should not be used as they may mislead readers.
Please revise these expressions throughout the entire paper. Instead of causal language, I recommend using phrases such as 'associated with' or 'correlated with' to more accurately reflect the nature of the relationships observed in this cross-sectional study.
Additionally, I strongly advise adding a statement in the limitations section acknowledging that the cross-sectional design of this study precludes drawing causal inferences. This will help readers interpret the findings appropriately within the context of the study design.
2. Lines 76-78 state: 'Furthermore, PSF patients were at a higher risk for experiencing adverse effects like depression, mobility impairments, and cognitive decline compared to stroke patients who had not experienced fatigue.' While I can understand that PSF might increase the risk of developing depressive symptoms, I believe that motor impairments and cognitive decline are primarily due to stroke-induced damage, rather than PSF increasing the risk of these conditions.
Please provide an explanation for how PSF might increase the risk of motor impairments and cognitive decline. It's possible that PSF is not increasing the risk of these adverse events, but rather is simply correlated with them.
3. Lines 79-82: There are already numerous studies examining factors associated with PSF (for example, please refer to: DOI: 10.1161/STR.0000000000000132). Please clearly explain the necessity of this study.
4. Lines 83-86: Please explicitly state the primary objective and secondary objectives. Also, please include your hypotheses.
5. Line 109: Please cite the 'Previous studies' mentioned.
No comment.
1. Line 94: This study is limited to subjects aged 18 to 59 years and who are ambulatory. Please include in the discussion section the reasons for setting these inclusion criteria and their potential impact on the results.
Additionally, this study includes patients within 3 months post-stroke. It has been suggested that factors associated with PSF may change depending on the time since stroke onset (DOI: 10.1161/STROKEAHA.114.006647). Please also discuss the potential impact on the results of including only relatively early post-stroke patients.
2. Lines 98-99: In the Introduction, it is explained that the prevalence of PSF is 42% to 53% according to meta-analysis, and 40% to 59% in China. However, in the sample size calculation, the prevalence is set at 20%, which is inconsistent.
Please explain this discrepancy. If 20% is not an accurate estimate of PSF prevalence based on previous literature, the sample size calculation should be revised using a more appropriate prevalence estimate. If there is a specific reason for using 20%, please provide a justification.
Additionally, please discuss how this lower prevalence estimate in your sample size calculation might affect the power of your study and the reliability of your results. If the actual prevalence in your sample was higher than 20%, how might this impact your findings?
3. Line 107: In this study, the Barthel Index is scored based on self-reporting by the subjects. Originally, the Barthel Index should be objectively evaluated by healthcare professionals observing the patient's actions. Please add an explanation about the reliability of the Barthel Index results that were evaluated based on self-reporting by the subjects. Please discuss any existing literature on the validity and reliability of self-reported Barthel Index scores compared to those obtained through standard administration by healthcare professionals.
4. Lines 153-156: In the Study instruments section, the authors explain that they divided the subjects into two groups based on the presence or absence of PSF according to FSS scores. Therefore, shouldn't t-tests or Fisher's exact tests be used instead of Pearson's correlation analysis to evaluate the relationship between PSF and variables? Also, for multivariate analysis, shouldn't logistic regression analysis with the presence or absence of PSF as the dependent variable be used instead of multiple regression analysis? Please revise the results and discussion sections accordingly if the statistical methods are modified.
5. Line 157: The criterion for determining that there is little suspicion of multicollinearity seems more appropriate to set the VIF value to less than 5 rather than less than 10. The following paper is often cited as the basis for this. Please consider:
Kim JH. Multicollinearity and misleading statistical results. Korean J Anesthesiol. 2019 Dec;72(6):558-569. doi: 10.4097/kja.19087. Epub 2019 Jul 15. PMID: 31304696; PMCID: PMC6900425.
No comment.
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