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Thank you for your thorough revision and detailed point-by-point responses. I have carefully reviewed the revised manuscript together with the rebuttal letter, and I am satisfied that all reviewer comments have been fully and appropriately addressed. The authors have provided clear justifications, strengthened methodological explanations, incorporated updated literature, expanded the discussion and limitations, and refined the clinical applicability of the findings.
Both reviewers’ major concerns have now been resolved, and one reviewer has additionally recommended acceptance.
I am pleased to move forward with acceptance.
Thank you for your careful work on this revision, and congratulations.
The manuscript is clearly written, and all previous concerns have been properly addressed. The authors revised the text point-by-point as requested, which I appreciate.
The study design is appropriate, and the authors have responded to all earlier comments in detail. The statistical methods are now clearly described, and the experimental steps provide enough information for replication.
The data are robust and all results are statistically supported. The authors responded to previous concerns and clarified the rationale for including BMI. The conclusions match the data and stay within the scope of the analysis.
The authors have responded sincerely and thoroughly within the limits of what could be revised. They highlight the value of the study while keeping the conclusions appropriately cautious.
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The article hypothesizes that ultrasound-derived tongue metrics correlate with the occurrence of hypoxemia in painless gastroscopy and may facilitate the development of an integrated predictive model through comprehensive evaluation. This is a prospective observational study.
1. Why did the authors include only the patients with ASA class I-II?
2. The cost-effectiveness of the ultrasound-derived tongue metrics was not demonstrated.
Several factors are associated with the outcome of the study. Please discuss these issues.
1. Please review the literature and add more details in the discussion section.
2. What is the new knowledge of the study? Please also clearly explain.
3. From the result of the study, please recommend to the readers “How to apply this knowledge in clinical practice?”.
The manuscript follows the conventional structure of a scientific paper (Abstract, Introduction, Methods, Results, Discussion, and Conclusion). The raw data are provided, and the figures are relevant, well presented, and clearly labeled.
The background information is adequate, placing the study within the broader research context. Relevant literature on the risk of hypoxemia during painless gastroscopy and on ultrasonographic airway assessment has been cited appropriately. However, some of the references are somewhat outdated. Including more recent studies, particularly those addressing predictive models of hypoxemia during sedation or endoscopy, would help strengthen the context and highlight the originality of this work.
The manuscript is overall complete, with all key results presented logically and coherently.
In summary, the paper would benefit from some refinement of expression and the addition of up-to-date references to further enhance its impact.
The research question is well defined and clinically relevant. The authors clearly identify the lack of reliable predictors for hypoxemia during painless gastroscopy and propose tongue ultrasonography as a potential tool.
The study uses a prospective observational design and includes 304 ASA I–II patients. It was conducted using clear inclusion and exclusion criteria and standardized ultrasonographic measurements. The statistical approach is appropriate, employing both univariate and multivariate logistic regression, along with ROC curve, calibration curve, and decision curve analyses.
However, the number of hypoxemia events (n=32) is relatively small, which raises the possibility of overfitting. The study population was restricted to ASA I–II patients, excluding higher-risk groups, which limits generalizability. Sedation was performed only with propofol, so the applicability of the model under alternative sedative agents remains uncertain.
Overall, the study design is rigorous and supports the main conclusions. Nonetheless, expanding the sample to include higher-risk patients and conducting multicenter validation would make the proposed approach of using tongue ultrasonography to predict hypoxemia during painless gastroscopy more convincing and broadly applicable.
These findings are supported by solid statistical analysis. Tongue thickness was identified as an independent risk factor for hypoxemia, and the nomogram incorporating Mallampati score, BMI, and propofol dose demonstrated strong predictive ability (“The area under the ROC curve was 0.833 (95% CI, 0.762–0.904).”).
The conclusions are in line with the presented results. That said, in the multivariate analysis, BMI did not achieve statistical significance, yet it was still incorporated into the nomogram. Since BMI is a well-recognized clinical risk factor for hypoxemia, its inclusion can be justified; however, the authors should explain this choice more explicitly and cite appropriate supporting evidence. Moreover, the discussion of clinical applicability should be tempered. Broader implementation would require multicenter studies and confirmation in higher-risk populations.
The study tackles an important clinical issue and explores a novel application of tongue ultrasonography. Providing clearer justification for some methodological decisions and expanding the discussion of clinical implications would strengthen the manuscript.
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