Hormonal Balance and Cardiovascular Health: Exploring the Interconnection between Menopause, Body Composition, and Thyroid Function in a Cohort of Hypertensive Women

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript by Pala and colleagues describes an attempt to evaluate several anatomical and physiological changes occurring in two groups of post-menopausal women, those that gained weight since menopause and those that maintained their weight. Menopause involves several physiological changes, mainly hormonal, that change body composition and determine the increase in cardiovascular risk. Several cardiovascular, hormonal and metabolic parameters were compared between both groups. Results clearly showed important differences in body composition, lipid profile, insulin and thyroid hormone levels and arterial augmentation index between these groups.

This study is highly relevant and the manuscript is also well-written and easy to follow. However, there are several major issues that need to be addressed and which may change the results:

·     1. The statistical approach is problematic. First, considering the heterogeneity of the subjects, a larger sample should have likely been used. To support the inclusion of such small samples the authors should disclose how they calculated the sample sizes;

·     2. Considering the small sizes of both samples, and no matter the normality of the sample distribution, non-parametric statistics should have been used (Mann-Whitney test and Spearman coefficient) in order to increase the robustness of the calculation;

This reviewer also raises some minor issues:

·  1. Did the authors also assess the kidney function of the patients? Considering that kidney function indirectly influences cardiovascular risk, it would be interesting to compare for example GFR or plasma creatinine with cardiovascular or hormonal parameters;

· 2. Did the authors also assess the plasma concentration of the proteins that transport T3/T4 in the bloodstream (TBG, transthyretin, etc.)?

33. In English the commas (,) should be written as dots (.) when dividing the unit and decimal digits, including in p values;

44. In Table 4B, how can the HR and T3/T4 ratio be significantly correlated (p=0.03) when the R value suggests no correlation (-0.05)?

 

55. Did the patients need to undergo any preparation for the DXA measurements? For example, water restriction in the hours before?

Comments on the Quality of English Language

English language is fine, although a proofreading by a native speaker could improve the syntax.

Author Response

Rossella Cianci, MD, PhD

Department of Translational Medicine and Surgery, Catholic University of Rome, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy,

e-mail: [email protected],

Telephone number: +39-06-3015-4878                                                                                                                           

Rome, August 17^th 2024

 

Dear Editor,

First, my coauthors and I would like to thank you sincerely for this opportunity to cooperate. We profoundly thank the reviewers for the comments and useful suggestions to improve the paper. We thank You for your constructive critique and hope the review process has improved the manuscript. If additional changes are warranted, we will make them.

We hope that this revised version of our manuscript may now be found suitable for publication.

This is a point-by-point list of changes made in the paper:

Reviewer #1.

This study is highly relevant and the manuscript is also well-written and easy to follow. However, there are several major issues that need to be addressed and which may change the results:

1. The statistical approach is problematic. First, considering the heterogeneity of the subjects, a larger sample should have likely been used. To support the inclusion of such small samples the authors should disclose how they calculated the sample sizes.

RE: Thank you for your suggestion.

We have improved this part in the study limitation section on Page 15, lines 459-467.

 

“Indeed, one of the main limitations of our study is the small sample size and the heterogeneity of the study population. We opted for a smaller sample size because even within this limited cohort, we observed significant differences. We plan to confirm our findings in a larger cohort of patients in the future. Additionally, we did not extract data from a broader database, which could have provided a much larger sample size; instead, we observed the data in a non-selected population of consecutively enrolled patients, making the sample entirely random. We intend to validate our findings in a larger population, using both prospective and retrospective approaches.

Moreover..”

2. Considering the small sizes of both samples, and no matter the normality of the sample distribution, non-parametric statistics should have been used (Mann-Whitney test and Spearman coefficient) in order to increase the robustness of the calculation;

RE: Thank you for your valuable suggestion. Although we initially used the Shapiro-Wilk test to assess the normality of the data distribution, which indicated a normal distribution, we acknowledge that this detail was regrettably omitted from the statistical methods section. We fully understand the limitations posed by the small sample size and agree that caution is necessary when interpreting these results. To address your concern, we have repeated the correlation analysis using non-parametric methods, and the results were consistent with those obtained using Pearson's correlation.

For completeness, we created tables side by side which can make it easier to compare the results of the t-test and Mann-Whitney, as well as the Pearson and Spearman correlations. This layout allows for a clear, direct comparison between the parametric and non-parametric analyses, which could enhance the readability and understanding of results: Table 2a, 3a, 4a1, 4b1 and Supplementary table 1,2,3 (the latter referring to the Supplementary Tables, which we decided not to include in the manuscript, not even as supplementary material, to avoid redundancy with the figures)

 

We have therefore updated the statistical analysis section Page 6, line 196-207 as follows:

“Normality of the data distribution was assessed using the Shapiro-Wilk test. Categorical variables were compared using Fisher’s exact test and the Chi-square test. Continuous variables were presented as either median (interquartile range, IQR) or mean (± standard deviation, SD) based on their distribution. Comparisons between groups were made using either a paired sample t-test for normally distributed data or the Mann-Whitney U test for non-normally distributed data. Specifically, variables with a normal distribution were reported as mean ± SD, and analyses included the t-test and Pearson correlation. For variables that did not follow a normal distribution, the Mann-Whitney U test and Spearman correlation were applied.

To assess significant differences within the MWGG and MWMG groups, t-tests were employed. The Pearson correlation coefficient (denoted as "r") was calculated to evaluate the linear relationship between continuous variables, with correlation values ranging between -1 and 1.”

Moreover, we added in the result section: “We recognized the limitations posed by the small sample size and emphasizing the need for caution in interpreting these findings, we confirmed our results using both the Mann-Whitney U test and Spearman's correlation”.

 

Table 2. Pearson correlation Coefficient.

Correlations	Brachial Systolic BP		Brachial Diastolic BP		Heart Rate		Central Systolic BP		Central Diastolic BP		Ai@75		PWA
	r	p	r	p	r	p	r	p	r	p	r	p	r	p
Weight (Kg)	0.18	0.48	0.08	0.75	0.12	0.61	0.15	0.54	0.08	0.72	0.49	0.03	0.08	0.75
BMI (kg/m2)	0.32	0.19	0.28	0.25	0.20	0.41	0.30	0.22	0.29	0.24	0.56	0.01	0.19	0.44
WHR	0.55	0.01	0.47	0.04	-0.01	0.90	0.47	0.04	0.48	0.04	0.17	0.49	0.47	0.04
Total FM (%)	0.20	0.43	0.12	0.62	0.19	0.46	0.19	0.45	0.12	0.63	0.61	0.008	0.13	0.61
Lean/Fat Mass	-0.19	0.44	-0.09	0.74	-0.13	0.61	-0.19	0.46	-0.08	0.75	-0.63	0.006	-0.16	0.53
VAT	0.62	0.01	0.54	0.04	0.17	0.55	0.59	0.02	0.54	0.04	0.26	0.35	0.25	0.37
IMAT	0.21	0.44	0.09	0.71	0.21	0.41	0.19	0.48	0.10	0.71	0.67	0.004	0.16	0.65
ASMI	0.19	0.47	0.14	0.60	0.20	0.45	0.12	0.65	0.16	0.54	0.01	0.95	0.17	0.53

 

Table 2 a. Spearman correlation Coefficient.

 

Correlations	Brachial Systolic BP		Brachial Diastolic BP		Heart Rate		Central Systolic BP		Central Diastolic BP		Ai@75		PWA
	rs	p	rs	p	rs	p	rs	p	rs	p	rs	p	rs	p
Weight (Kg)	0.22	0.43	0.20	0.47	0.18	0.52	0.21	0.46	0.19	0.50	0.51	0.04	0.18	0.53
BMI (kg/m2)	0.27	0.34	0.35	0.20	0.18	0.52	0.24	0.39	0.35	0.21	0.70	0.003	0.29	0.31
WHR	0.52	0.01	0.40	0.02	-0.08	0.76	0.36	0.02	0.40	0.02	0.23	0.41	0.50	0.04
Total FM (%)	0.02	0.93	0.12	0.66	0.23	0.41	0.02	0.93	0.11	0.70	0.58	0.009	0.15	0.61
Lean/Fat Mass	-0.02	0.94	-0.11	0.69	-0.23	0.42	-0.02	0.94	-0.10	0.72	-0.57	0.008	-0.14	0.63
VAT	0.50	0.02	0.52	0.02	0.01	0.95	0.52	0.01	0.50	0.02	0.62	0.20	0.35	0.21
IMAT	0.07	0.79	0.15	0.60	0.30	0.28	0.06	0.82	0.13	0.64	0.57	0.006	0.08	0.76
ASMI	0.09	0.75	0.24	0.39	-0.01	0.96	-0.01	0.96	0.26	0.35	0.22	0.43	0.19	0.50

 

Table 3. Pearson Correlation Coefficient.

 

Correlations	HOMA Index		TyG index		TG/hdl		Ctot/hdl		LDL/HDL		CV Risk: AIP		N/L Ratio
	r	p	r	p	r	p	r	p	r	p	r	p	r	p
B-Systolic BP (mmHg)	0.65	0.004	0.56	0.01	0.42	0.08	0.42	0.08	0.42	0.07	0.51	0.02	0.42	0.08
B-Diastolic BP(mmHg)	0.42	0.07	0.42	0.08	0.37	0.12	0.36	0.16	0.32	0.18	0.37	0.12	0.41	0.09
HR (bpm)	0.50	0.81	0.39	0.19	0.38	0.11	0.30	0.27	0.24	0.32	0.34	0.15	0.05	0.83
C-Systolic BP(mmHg)	0.57	0.01	0.52	0.02	0.39	0.10	0.41	0.08	0.41	0.08	0.48	0.04	0.40	0.06
C-Diastolic BP (mmHg)	0.43	0.07	0.43	0.07	0.37	0.12	0.36	0.13	0.33	0.17	0.37	0.12	0.40	0.09
AI@75	0.46	0.05	0.21	0.39	0.25	0.30	0.23	0.35	0.23	0.35	0.27	0.26	0.28	0.24
PWA	0.49	0.04	0.18	0.47	0.08	0.73	0.15	0.56	0.18	0.45	0.18	0.45	0.54	0.01
Weight (Kg)	0.25	0.29	0.41	0.07	0.41	0.08	0.27	0.25	0.23	0.33	0.38	0.10	0.28	0.23
BMI (Kg/m2)	0.24	0.31	0.43	0.06	0.47	0.03	0.36	0.12	0.32	0.17	0.44	0.05	0.36	0.13
WHR	0.50	0.03	0.37	0.11	0.22	0.36	0.11	0.64	0.08	0.73	0.21	0.38	0.22	0.35
Total FM (%)	0.35	0.15	0.20	0.40	0.27	0.27	0.23	0.35	0.28	0.40	0.24	0.32	0.20	0.42
Lean/Fat Mass	-0.35	0.14	-0.16	0.51	-0.28	0.26	-0.26	0.29	-0.24	0.32	-0.24	0.32	-0.17	0.48
VAT	0.59	0.01	0.44	0.08	0.31	0.24	0.20	0.44	0.16	0.54	0.28	0.28	0.47	0.06
IMAT	0.36	0.14	0.33	0.19	0.31	0.23	0.19	0.44	0.16	0.52	0.29	0.24	0.25	0.32
ASMI	-0.16	0.51	0.32	0.19	0.21	0.40	0.10	0.67	0.10	0.70	0.24	0.35	0.19	0.46

 

Table 3 a. Spearman correlation Coefficient.

 

Correlations	HOMA Index		TyG index		TG/hdl		Ctot/hdl		LDL/HDL		CV Risk: AIP		N/L Ratio
	rs	p	rs	p	rs	p	rs	p	rs	p	rs	p	rs	p
B-Systolic BP (mmHg)	0.58	0.007	0.51	0.01	0.51	0.06	0.38	0.16	0.32	0.25	0.50	0.03	0.43	0.12
B-Diastolic BP(mmHg)	0.52	0.84	0.42	0.13	0.43	0.12	0.43	0.12	0.26	0.35	0.39	0.16	0.38	0.17
HR (bpm)	0.50	0.95	0.39	0.89	0.06	0.81	0.30	0.91	0.00	0.99	0.09	0.74	0.09	0.73
C-Systolic BP(mmHg)	0.51	0.02	0.54	0.02	0.48	0.07	0.37	0.19	0.30	0.28	0.45	0.04	0.38	0.17
C-Diastolic BP (mmHg)	0.47	0.87	0.42	0.13	0.42	0.12	0.26	0.36	0.21	0.46	0.39	0.16	0.38	0.18
AI@75	0.41	0.13	0.31	0.27	0.31	0.27	0.11	0.69	0.12	0.36	0.27	0.33	0.41	0.13
PWA	0.42	0.04	0.26	0.35	0.32	0.25	0.27	0.34	0.24	0.40	0.30	0.29	0.51	0.04
Weight (Kg)	0.66	0.21	0.45	0.09	0.45	0.10	0.27	0.34	0.26	0.36	0.43	0.12	0.21	0.46
BMI (Kg/m2)	0.41	0.14	0.41	0.13	0.41	0.02	0.25	0.38	0.21	0.46	0.40	0.15	0.40	0.15
WHR	0.50	0.02	0.19	0.51	0.08	0.77	0.13	0.65	0.18	0.72	0.04	0.88	0.26	0.35
Total FM (%)	0.35	0.21	0.06	0.83	0.09	0.75	0.00	0.99	0.01	0.94	0.08	0.77	0.03	0.89
Lean/Fat Mass	-0.36	0.20	-0.06	0.81	-0.09	0.73	-0.00	0.97	-0.04	0.88	-0.09	0.74	-0.04	0.88
VAT	0.53	0.01	0.40	0.15	0.28	0.32	0.00	0.98	0.16	0.51	0.24	0.39	0.42	0.12
IMAT	0.43	0.12	0.24	0.39	0.24	0.39	0.18	0.74	0.09	0.75	0.24	0.39	0.17	0.55
ASMI	-0.19	0.50	0.40	0.15	0.35	0.21	0.32	0.25	0.26	0.33	0.34	0.22	0.35	0.21

Table 4 A. Pearson Correlation Coefficient.

 

Correlations	Glicaemia		Insulinemia			TotColesterol		HDL		LDL		TG
	r	p	r	p	r		p	r	p	r	p	r	p
B-Systolic BP (mmHg)	0.46	0.05	0.50	0.03	0.19		0.45	-0.48	0.04	0.36	0.14	0.40	0.09
B-Diastolic BP(mmHg)	0.33	0.18	0.28	0.25	0.33		0.17	-0.30	0.17	0.30	0.21	0.31	0.20
HR (bpm)	0.06	0.80	0.09	0.70	0.42		0.07	-0.25	0.31	0.34	0.16	0.41	0.08
C-Systolic BP (mmHg)	0.44	0.06	0.42	0.08	0.16		0.52	-0.47	0.04	0.32	0.19	0.35	0.16
C-Diastolic BP(mmHg)	0.33	0.17	0.29	0.23	-0.34		0.16	-0.30	0.21	0.31	0.20	0.32	0.18
AI@75	0.14	0.56	0.56	0.01	0.10		0.67	-0.35	0.15	0.09	0.70	0.20	0.40
PWA	0.31	0.20	0.43	0.69	-0.21		0.40	-0.26	0.30	0.01	0.93	0.02	0.92
Weight (Kg)	0.16	0.50	0.23	0.27	0.09		0.69	-0.35	0.12	0.16	0.49	0.47	0.04
BMI (Kg/m2)	0.17	0.47	0.23	0.34	0.10		0.67	-0.46	0.04	0.22	0.36	0.48	0.03
WHR	0.52	0.02	0.30	0.20	-0.00		0.99	-0.18	0.44	0.03	0.91	0.27	0.26
Total FM (%)	0.32	0.18	0.31	0.19	-0.12		0.62	-0.40	0.09	0.07	0.75	0.18	0.46
Lean/Fat Mass	-0.32	0.18	-0.33	0.18	0.18		0.47	0.44	0.06	-0.06	0.79	-0.14	0.57
VAT	0.61	0.01	0.42	0.10	0.04		0.86	-0.24	0.36	0.06	0.82	0.28	0.28
IMAT	0.35	0.17	0.32	0.19	-0.05		0.85	-0.37	0.14	0.11	0.65	0.31	0.21
ASMI	-0.08	0.76	-0.24	0.34	0.35		0.16	-0.05	0.83	0.27	0.27	0.43	0.08

 

Table 4A 1. Spearman correlation Coefficient.

 

Correlations	Glicaemia		Insulinemia			TotColesterol		HDL		LDL		TG
	rs	p	rs	p	rs		p	rs	p	rs	p	rs	p
B-Systolic BP (mmHg)	0.17	0.45	0.48	0.02	0.44		0.11	-0.39	0.02	0.28	0.32	0.39	0.15
B-Diastolic BP(mmHg)	0.09	0.73	0.04	0.88	0.54		0.05	-0.19	0.50	0.26	0.35	0.36	0.19
HR (bpm)	0.00	0.99	0.13	0.63	0.14		0.61	-0.00	0.99	0.18	0.52	0.11	0.95
C-Systolic BP (mmHg)	0.21	0.46	0.12	0.06	0.40		0.14	-0.40	0.04	0.27	0.34	0.33	0.23
C-Diastolic BP(mmHg)	0.33	0.74	0.12	0.66	-0.40		0.14	-0.40	0.15	0.27	0.34	0.33	0.23
AI@75	0.17	0.53	0.51	0.01	0.12		0.66	-0.21	0.45	0.00	0.97	0.31	0.26
PWA	0.39	0.16	0.19	0.51	-0.07		0.80	-0.39	0.15	0.10	0.71	0.16	0.58
Weight (Kg)	0.42	0.13	0.40	0.14	0.12		0.69	-0.38	0.17	0.18	0.53	0.41	0.03
BMI (Kg/m2)	0.34	0.22	0.14	0.61	0.11		0.69	-0.34	0.03	0.11	0.69	0.36	0.02
WHR	0.63	0.02	0.06	0.82	-0.09		0.74	-0.16	0.84	0.20	0.47	0.12	0.66
Total FM (%)	0.36	0.19	0.04	0.88	-0.15		0.58	-0.15	0.59	0.12	0.66	0.02	0.92
Lean/Fat Mass	-0.36	0.19	-0.05	0.86	0.16		0.57	0.16	0.57	-0.11	0.67	-0.03	0.91
VAT	0.71	0.01	0.20	0.48	0.07		0.79	-0.11	0.68	0.06	0.82	0.32	0.26
IMAT	0.31	0.27	0.16	0.56	-0.01		0.95	-0.22	0.43	0.11	0.97	0.22	0.43
ASMI	-0.12	0.68	-0.32	0.26	0.34		0.23	-0.14	0.62	0.26	0.35	0.41	0.14

 

Table 4 B. Pearson Correlation Coefficient.

 

Correlations	TSH		FT3		FT4		FT3/FT4 ratio
	r	p	r	p	r	p	r	p
B-Systolic BP (mmHg)	-0.07	0.77	0.11	0.65	0.09	0.72	0.13	0.62
B-Diastolic BP (mmHg)	-0.11	0.67	-0.04	0.88	0.21	0.40	-0.01	0.96
HR (bpm)	-0.21	0.41	-0.38	0.12	0.37	0.14	- 0.50	0.03
C-Systolic BP (mmHg)	-0.15	0.56	0.16	0.53	0.15	0.57	0.08	0.76
C-Diastolic BP (mmHg)	-0.01	0.68	-0.04	0.90	0.20	0.43	0.00	0.97
AI@75	0.22	0.39	-0.27	0.28	-0.07	0.80	-0.15	0.54
PWA	0.00	0.99	0.17	0.51	-0.25	0.32	0.31	0.21
Weight (Kg)	-0.16	0.52	-0.41	0.08	0.30	0.22	-0.58	0.01
BMI (Kg/m2)	-0.40	0.09	-0.43	0.07	0.33	0.17	-0.59	0.009
WHR	0.02	0.91	-0.05	0.83	0.16	0.51	-0.10	0.68
Total FM (%)	-0.04	0.87	-0.45	0.06	0.23	0.37	-0.63	0.006
Lean/Fat Mass	-0.03	0.90	0.39	0.11	-0.23	0.36	0.61	0.009
VAT	-0.10	0.70	-0.17	0.53	0.31	0.25	-0.32	0.23
IMAT	-0.08	0.74	-0.49	0.05	0.22	0.41	-0.68	0.003
ASMI	-0.62	0.01	-0.00	0.99	-0.05	0.86	0.17	0.53

Table 4 B 1. Spearman correlation Coefficient.

Correlations	TSH		FT3		FT4		FT3/FT4 ratio
	rs	p	rs	p	rs	p	rs	p
B-Systolic BP (mmHg)	0.08	0.77	0.14	0.62	0.09	0.73	0.06	0.83
B-Diastolic BP (mmHg)	-0.11	0.67	-0.04	0.88	0.21	0.40	-0.01	0.96
HR (bpm)	-0.21	0.41	-0.38	0.12	0.37	0.14	- 0.46	0.03
C-Systolic BP (mmHg)	-0.17	0.56	0.08	0.76	0.07	0.79	0.02	0.99
C-Diastolic BP (mmHg)	-0.17	0.55	-0.08	0.76	0.07	0.79	0.00	0.99
AI@75	0.10	0.71	-0.35	0.29	-0.30	0.28	-0.15	0.60
PWA	0.06	0.82	0.06	0.83	-0.38	0.17	0.02	0.92
Weight (Kg)	-0.09	0.74	-0.67	0.08	0.30	0.28	-0.52	0.01
BMI (Kg/m2)	-0.44	0.11	-0.48	0.08	0.08	0.76	-0.49	0.008
WHR	0.22	0.33	-0.08	0.77	0.11	0.70	-0.07	0.80
Total FM (%)	-0.27	0.33	-0.55	0.03	0.23	0.42	-0.55	0.007
Lean/Fat Mass	-0.27	0.33	0.56	0.03	-0.21	0.46	0.57	0.009
VAT	-0.13	0.63	-0.14	0.60	0.33	0.24	-0.06	0.81
IMAT	-0.31	0.26	-0.64	0.05	0.16	0.57	-0.55	0.004
ASMI	-0.71	0.01	-0.19	0.49	-0.22	0.44	0.23	0.42

 

 

Supplementary Table 1.

	MWGG 0	MWMG 1	p-value°	p-value°°
Systolic Blood Pressure (mmHg) (Mean ± SD, range)	125.54 ± 3.83	115.57 ± 4.57	0.11	0.32
Diastolic Blood Pressure (mmHg) (Mean ± SD, range)	80.90 ± 2.96	76.85 ± 3.34	0.38	0.23
Pulse Pressure (mmHg) (Mean ± SD, range)	44.64 ± 2.43	38.71 ± 2.15	0.11	0.21
HR (bpm) (Mean ± SD, range)	73.27 ± 2.56	68.85 ± 2.78	0.27	0.36
C-Systolic Blood Pressure (mmHg) (Mean ± SD, ranhge)	117.09 ± 3.06	109.00 ± 4.36	0.14	0.34
C-Diastolic Blood Pressure (mmHg) (Mean ± SD, range)	82.09 ± 2.97	78.00 ± 3.40	0.38	0.55
C-Pulse Pressure (mmHg) (Mean ± SD, range)	35.00 ± 1.85	31.00 ± 2.12	0.19	0.20
Ai@75 (Mean ± SD, range)	33.90 ± 2.63	22.42 ± 5.27	0.04*	0.04*
PWA (Mean ± SD, range)	8.00 ± 0.22	7.55 ± 0,23	0.20	0.22
°T-test, °° Mann-Whitney ; * p < 0.5, ** p < 0.01; ***p < 0.001

 

Supplementary Table 2.

	MWGG	MWMG	p-value°	p-value°°
BMI (kg/m2) (Mean ± SD, range)	29.00 ± 1.03	23.46 ± 1.16	0.003**	0.005**
Waist-hip ratio (Mean ± SD, range)	0.82 ± 0.02	0,78 ± 0,01	0.23	0.33
Total Fat Mass (kg) (Mean ± SD, range)	28.19 ± 1.56	17,58 ± 2,02	0.0007***	0.0002***
Total Fat Mass (%) (Mean ± SD, range)	38.71 ± 1.24	28,62 ± 2,48	0.0009***	0.0003***
Lean/fat mass (kg)	1.53 ± 0.08	2,52 ± 0,29	0.001**	0.005**
VAT (Mean ± SD, range)	399.90 ± 57.00	241.97 ± 97.19	0.16	0.09
IMAT (Mean ± SD, range)	1.14 ± 0.09	0.62 ± 0.09	0.001**	0.006**
ASMI (Mean ± SD, range)	7.44 ± 0.18	7.34 ± 0.21	0.74	0.92
°T-test, °° Mann-Whitney ; * p < 0.5, ** p < 0.01; ***p < 0.001

 

Supplementary Table 3.

	MWGG	MWMG	p-value°	p-value°°
Haemoglobin (g/dL) (Mean ± SD, range)	13.12 ± 0.24	13.24 ± 0.28	0.74	0.61
Haematocrit (%) (Mean ± SD, range)	39.6 ± 0.65	41.51 ± 1.21	0.14	0.27
Glicaemia (mg/dL) (Mean ± SD, range)	99.17 ± 3.96	87.57 ± 4.05	0.07	0.06
Insulinemia (mg/dL) (Mean ± SD, range)	9.21 ± 0.38	6.86 ± 0.79	0.007**	0.003**
Uric Acid (mg/dL) (Mean ± SD, range)	4.63 ± 0.31	4.75 ± 0.42	0.80	0.76
TOT-C (mg/dL) (Mean ± SD, range)	221.75 ± 7.73	206.71 ± 13.29	0.3	0.21
HDL-C (mg/dL) (Mean ± SD, range)	48.15 ± 5.26	81.85 ± 3.81	0.000***	0.0005***
LDL-C (mg/dL) (Mean ± SD, range)	146.41 ± 7.43	109.74 ± 10.38	0.001**	0.001**
Triglycerides (mg/dL) (Mean ± SD, range)	137.08 ± 16.31	85.14 ± 13.73	0.04*	0.03*
Lipoprotein a (mg/dL) (Mean ± SD, range)	45.40 ± 6.36	24.34 ± 8.83	0.05	0.05
TSH (mg/dL) (Mean ± SD, range)	2.45 ± 0.23	2.48 ± 0.55	0.96	0.39
FT3 pg/mL (Mean ± SD, range)	2.62 ± 0.27	5.80 ± 1.29	0.004**	0.006**
Ft4 ng/mL (Mean ± SD, range)	1.66 ± 0.32	1.66 ± 0.49	0.99	0.17
FT3/FT4 ratio (Mean ± SD, range)	2.29 ± 0.37	3.70 ± 0.25	0.02*	0.005**
HOMA Index (Mean ± SD, range)	2.28 ± 0.17	1.46 ± 0.14	0.005**	0.003**
TyG Index (Mean ± SD, range)	8.73 ± 0.11	8.14 ± 0.15	0.007**	0.007**
Chol Tot/HDL (Mean ± SD, range)	5.46 ± 0.74	2.54 ± 0.17	0.009**	0.001**
LDL/HDL (Mean ± SD, range)	3.71 ± 0.58	1.36 ± 0.14	0.008**	0.001**
TG/HDL (Mean ± SD, range)	3.60 ± 0.71	1.04 ± 1.75	0.01*	0.02*
AIP (Mean ± SD, range)	0.45 ± 0.09	0.12 ± 0.18	0.09	0.006
PRL (Mean ± SD, range)	197.87 ± 72.88	123.16 ± 8.28	0.45	0.55
NRL (Mean ± SD, range)	1.73 ± 0.12	1.51 ± 0.24	0.38	0.35
Azotemia (mg/dL) (Mean ± SD, range)	25.71 ± 2.80	24.14 ± 4.09	0.75	0.64
Creatinine(mg/dL) (Mean ± SD, range)	0.75 ± 0.03	0.80 ± 0.03	0.09	0.05
Estimated glomerular filtration rate (mL/min) (Mean ± SD, range)	100.00 ± 19.02	75.46 ± 11.0	0.26	0.31
GOT (u/L) (Mean ± SD, range)	25.21 ± 2.59	22.14 ± 2.29	0.42	0.67
GPT (u/L) (Mean ± SD, range)	22.18 ± 2.00	22.14 ± 1.05	0.98	0.86
°T-test, °° Mann-Whitney ; * p < 0.5, ** p < 0.01; ***p < 0.001

 

This reviewer also raises some minor issues:

1. Did the authors also assess the kidney function of the patients? Considering that kidney function indirectly influences cardiovascular risk, it would be interesting to compare for example GFR or plasma creatinine with cardiovascular or hormonal parameters;

RE: Thank you for your observation. We did assess renal function in our patients, as shown in Figure 3 and in the supplementary table 3 included in this revision. Our analysis showed no significant differences between the two groups, with both maintaining normal renal function: the mean eGFR for the MWGG was 100 ± 19.2, while for the MWMG it was 75.46 ± 11.9; with p-value 0,26. Similarly, the mean creatinine levels were 0.75 ± 0.03 in the MWGG and 0.80 ± 0.03 in the MWMG, with a p-value of 0.09.

Additionally, although there was a weak negative correlation (r = -0.3) between systolic blood pressure (both brachial and central) and eGFR, it did not reach statistical significance, as shown in the tables attached. There was no significant correlation to the other cardiovascular or hormonal parameters.

2. Did the authors also assess the plasma concentration of the proteins that transport T3/T4 in the bloodstream (TBG, transthyretin, etc.)?

      RE: Thank you for bringing this important point to our attention. We did not evaluate these specific parameters in our study, as they were not among our study's objectives. We acknowledge that assessing the plasma concentration of proteins such as TBG and transthyretin could provide valuable additional insights. This limitation will be noted in our limitation section. We added in the text page 15, lines 470-472.

3. In English the commas (,) should be written as dots (.) when dividing the unit and decimal digits, including in p values;

      RE: We agree with this observation. Accordingly, we have revised the entire manuscript to correct this issue.

4. In Table 4B, how can the HR and T3/T4 ratio be significantly correlated (p=0.03) when the R value suggests no correlation (-0.05)?

      RE: Thank you for bringing this to our attention. It was a typographical error, and we acknowledge our mistake. Upon reanalyzing the data, we found that the correct correlation coefficient is -0.50, not -0.05, which indicates a negative correlation.

5. Did the patients need to undergo any preparation for the DXA measurements? For example, water restriction in the hours before?

RE: The authors thank the Reviewer. The paragraph was revised accordingly, as follows in Page 5 line 174-178: “After a 8-hour overnight fast, all subjects underwent whole-body and segmental fat mass (measured in kilograms) assessment, employing Dual-Energy X-ray Absorptiometry (DXA) scans, Primus X-ray densitometer and software version 1.2.2 (Osteosys Co). All individuals were instructed to remove their clothes (except underwear), shoes, and any metal object before being measured.

The total fat mass percentage (%FM) was determined by dividing the total body fat mass (Total FM) by the combined mass of all tissues, including the total body bone (TBBone). The formula used for this calculation is as follows: %FM = (Total FM/(Total FM + Total Lean Mass (LM) + TBBone)) × 100 (17).”

 

We thank You for your constructive critique and hope the review process has improved the manuscript.

If additional changes are warranted, we will make them.

We hope that this revised version of our manuscript may now be found suitable for publication.

 

Sincerely,

Barbara Pala and Rossella Cianci 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

I have read the manuscript with great interest. I have thoroughly assessed the original research paper and have identified specific areas that necessitate improvement. While the manuscript delivers valuable insights into the interactions between thyroid function, body composition, and cardiovascular health in post-menopausal women, it unequivocally requires significant enhancements.

ABSTRACT

1.“We included 12 cases (MWGG) and 8 control (MWMG) women.” – Please consider moving this sentence higher into the Material and Methods section from the Results section.

Please make the following changes to the MATERIAL AND METHODS section:

1. I think that, in the MATERIAL AND METHODS section, the first paragraph should not be unnamed. I recommended call it Participants and Study Design.

2. The first paragraph of this section seems a bit overwhelming with all the important information packed into a single lengthy sentence. It's crucial to clearly mention the specific dates when the clinical study took place, from [start date] to [end date].

3. Please provide details on how the study participants were recruited, such as whether they were patients at a hypertension unit or volunteers recruited through advertisements.

4. Please include a sentence stating that the study participants were post-menopausal women (n=20) who were divided into two groups. The detailed characteristics of the study participants are included in Table 1.

5. In the Materials and Methodology section. Line 115- What were the criteria used to assess CV risk (according to which guidelines/guidelines of which organization)? Did people with cardiovascular disease participate in the study? Please refer to this in the description of the participants.

6. It is important to provide the consent number for the research and the organization from which the consent was issued.

7. In line 143, please provide the name of the apparatus used to perform the ECG in parentheses.

8. Please include a more detailed description of the study procedures, specifying the tubes and anticoagulant used for blood drawing, as well as the methods and equipment used to measure morphological and biochemical parameters.

9. Why the ejection fraction was not assessed?

10. Please provide information regarding the pharmacological treatment administered to the participants, and specify the medications utilized. Additionally, clarify whether these medications have an impact on the assessed parameters.

RESULTS

1. Figure 2: Do the IMAT and VAT values have any unit? If so, please include.

2. It is not clear how the results are presented in figure 2, particularly the Y and X axes. Consider using a larger font for better visibility.

Author Response

Rossella Cianci, MD, PhD

Department of Translational Medicine and Surgery, Catholic University of Rome, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy,

e-mail: [email protected],

Telephone number: +39-06-3015-4878                                                                                                                           

Rome, August 17^th 2024

 

Dear Editor,

First, my coauthors and I would like to thank you sincerely for this opportunity to cooperate. We profoundly thank the reviewers for the comments and useful suggestions to improve the paper. We thank You for your constructive critique and hope the review process has improved the manuscript. If additional changes are warranted, we will make them.

We hope that this revised version of our manuscript may now be found suitable for publication.

This is a point-by-point list of changes made in the paper:

 

 

 

Reviewer #2.

ABSTRACT

1.“We included 12 cases (MWGG) and 8 control (MWMG) women.” – Please consider moving this sentence higher into the Material and Methods section from the Results section.

RE: We agree with this suggestion. Accordingly, we have revised the manuscript, moving the mentioned sentence to the appropriate section in the Materials and Methods, page 3 line 58.

Please make the following changes to the MATERIAL AND METHODS section:

1. I think that, in the MATERIAL AND METHODS section, the first paragraph should not be unnamed. I recommended call it Participants and Study Design.

RE: We have implemented your suggestion and titled the first paragraph Participants and Study Design. Page 5 line 130.

2. The first paragraph of this section seems a bit overwhelming with all the important information packed into a single lengthy sentence. It's crucial to clearly mention the specific dates when the clinical study took place, from [start date] to [end date].

RE: We have revised the first paragraph to improve clarity, ensuring that the specific dates of the clinical study are clearly mentioned. Page 5 line 135.

3. Please provide details on how the study participants were recruited, such as whether they were patients at a hypertension unit or volunteers recruited through advertisements.

RE:  The participants were patients from a hypertension unit, all of whom were under consistent medical supervision, with complete cardiological documentation available for review. We have added the following information to the manuscript Page 5 line 137-140: “the study participants were post-menopausal women (n=20), who were consistently followed at our hypertension unit at the Division of Cardiology, Sant’Andrea Hospital, Sapienza University of Rome. The participants were divided into two groups. The detailed characteristics of the study participants are included in Table 1”.

4. Please include a sentence stating that the study participants were post-menopausal women (n=20) who were divided into two groups. The detailed characteristics of the study participants are included in Table 1.

RE: See the answer before.

5. In the Materials and Methodology section. Line 115 - What were the criteria used to assess CV risk (according to which guidelines/guidelines of which organization)? Did people with cardiovascular disease participate in the study? Please refer to this in the description of the participants.

RE: No, the participants did not have a history of major cardiovascular events. They were patients with arterial hypertension, as defined by the inclusion criteria. The most commonly cited reference for indicating that a waist-to-hip ratio (WHR) greater than 0.85 increases cardiovascular risk is derived from guidelines and epidemiological studies that have underscored the link between fat distribution and cardiovascular disease risk. A key authoritative source is the World Health Organization (WHO), which has published reports stating that a WHR greater than 0.85 in women (and greater than 1.0 in men) is associated with an increased risk of cardiovascular diseases and other metabolic disorders. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser. 2000 which is reference number 12.

6. It is important to provide the consent number for the research and the organization from which the consent was issued.

RE: The informations requested are in the section ethics approval at the end of the paper. Calabria region ethics committee approval n. 97 april 20^th, 2023.

7. In line 143, please provide the name of the apparatus used to perform the ECG in parentheses.

RE: Thank you for highlighting this point. We have optimized the text and included the name of the apparatus as follows page 5, line 165-169. “All participants underwent a resting 12-lead electrocardiogram (ECG) while in the supine position, utilizing a Mortara Eli 350 ECG device (Milwaukee, Wisconsin, USA). The ECGs were recorded with a paper speed of 25 mm/s and a calibration of 1 mV/cm. Each ECG was then scanned at 600 dpi, allowing for both conventional and novel ECG parameters to be analyzed on a high-resolution computer monitor.”

8. Please include a more detailed description of the study procedures, specifying the tubes and anticoagulant used for blood drawing, as well as the methods and equipment used to measure morphological and biochemical parameters.

RE: Thank you for underlining this point. We have improved the text as follows page 6, lines 189-192: “For each patient, blood samples were drawn in the morning between 8:00 and 10:00 AM from the antecubital vein while the patient was seated and in a fasting state. Samples were collected using BD Vacutainer tubes (Franklin Lakes, NJ, USA), either without anticoagulants or with anticoagulants (trisodium citrate, 3.8%, 1/10 (v/v) or 7.2 EDTA).”

9. Why the ejection fraction was not assessed?

RE: Thank you for the correct observation. However, the ejection fraction was not assessed because an echocardiogram was not performed. Due to time constraints of the study, we decided not to include the echocardiogram in our protocol. Nevertheless, future studies with a more specific focus could evaluate changes in echocardiographic function in relation to body composition.

10. Please provide information regarding the pharmacological treatment administered to the participants, and specify the medications utilized. Additionally, clarify whether these medications have an impact on the assessed parameters.

RE: The therapy regimen was consistent among the patients, with the majority being treated with ACE inhibitors and amlodipine. Only one patient was using a diuretic, which could potentially influence the assessment of body composition. However, before the start of the study, we adjusted this patient’s baseline therapy due to poorly controlled blood pressure, switching her to an ACE inhibitor and a beta-blocker. Therefore, we do not believe that any significant influence from the diuretic occurred. All medications were taken consistently every day without any changes before the diagnostic tests.

Additionally, we have specified in the text page 6, lines 193-194: “all patients consistently adhered to their baseline antihypertensive therapy without any modifications prior to the diagnostic tests”

RESULTS

1. Figure 2: Do the IMAT and VAT values have any unit? If so, please include.

RE: Thank you for your observation. Yes, both IMAT (Intramuscular Adipose Tissue) and VAT (Visceral Adipose Tissue) values are measured in grams (g). We have included these units in the figure legend for clarity.

2. It is not clear how the results are presented in figure 2, particularly the Y and X axes. Consider using a larger font for better visibility.

RE: We appreciate your suggestion. We have improved the figure by increasing the font size to enhance visibility and ensure clarity in the presentation of results.

 

We thank You for your constructive critique and hope the review process has improved the manuscript.

If additional changes are warranted, we will make them.

We hope that this revised version of our manuscript may now be found suitable for publication.

 

Sincerely,

Barbara Pala and Rossella Cianci

Author Response File: Author Response.docx

Reviewer 3 Report

Comments and Suggestions for Authors

All of my suggestions and questions are available throughout the text.

Comments for author File: Comments.pdf

Comments on the Quality of English Language

All of my suggestions and questions are available throughout the text.

Author Response

Rossella Cianci, MD, PhD

Department of Translational Medicine and Surgery, Catholic University of Rome, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy,

e-mail: [email protected],

Telephone number: +39-06-3015-4878                                                                                                                           

Rome, August 17^th 2024

 

Dear Editor,

First, my coauthors and I would like to thank you sincerely for this opportunity to cooperate. We profoundly thank the reviewers for the comments and useful suggestions to improve the paper. We thank You for your constructive critique and hope the review process has improved the manuscript. If additional changes are warranted, we will make them.

We hope that this revised version of our manuscript may now be found suitable for publication.

This is a point-by-point list of changes made in the paper:

 

Reviewer #3.

 

1.Please author, look at the significance of type of the color green, red and so on.

 

The colors were chosen arbitrarily; however, we consistently linked the green color with the MWGG (Menopausal Weight Gain Group) and the red color with the MWMG (Menopausal Weight Maintenance Group) throughout the graphical abstract.

We have nevertheless optimized the legend of the graphical abstract as follows:

 

“Our patients were stratified into two groups based on weight changes after menopause: The Menopausal Weight Gain Group (MWGG) and the Menopausal Weight Maintenance Group (MWMG). Significant increases in total fat mass, both in percentage and kilograms (but not in Visceral Adipose Tissue, VAT), Intramuscular Adipose Tissue (IMAT), and arterial stiffness (evaluated as Augmentation Index at 75 bpm, AI@75) were observed in the MWGG (dashed green line) compared with the MWMG. A significant decrease in the Free Triiodothyronine to Free Thyroxine (FT3/FT4) ratio was observed between the MWGG and MWMG (dashed green line). A correlation between VAT and blood pressure levels was reported (dashed red line). A novel correlation was found between IMAT and AI@75; moreover, a negative correlation was observed between the FT3/FT4 ratio and heart rate, VAT, and IMAT (dashed red line). Additionally, in the blood samples of the patients, a significant difference favoring the MWMG was detected in terms of free FT3 levels, which were lower in the MWGG. Higher levels of cardiovascular risk indices and Low-Density Lipoprotein (LDL) were notably present in the MWGG (dashed green words). Created with Biorender.com.”

 

2. Please author, you can do the representation using a line.

 

RE: Thank you for your suggestion. The use of color in the graphical abstract was chosen to consistently differentiate between the two groups: green represents the Menopausal Weight Gain Group (MWGG), and red represents the Menopausal Weight Maintenance Group (MWMG). This color coding is used throughout the figure to maintain consistency and clarity. The arrows and icons are intended to visually summarize the key findings, making it easy to distinguish the changes and correlations between the two groups.

 

3. Please authors, ameliorate your abstract conclusion from your principal findings.

 

RE: Thank you for your suggestion. We have revised the conclusion in the abstract to better reflect our principal findings, as follows Page 2, line 73-76:

“MWGG presented a higher BMI, greater total fat mass (kg) and a higher percentage of total fat mass compared to the MWMG. Interestingly, we reported a significant difference in intramuscular adipose tissue between groups….”

 

4. Please authors, look for other keywords different from the title.

 

RE: Thank you for your suggestion. In accordance with the reviewer’s recommendation, we have updated the keywords. The new keywords are: Adipose Tissue Distribution, Cardiovascular Risk, Metabolic Health, Arterial Stiffness, Gender Medicine, Cardiovascular Prevention.

 

5. Please author present the categorization and add the reference on page 4, line 153-155

 

RE: Thank you for your comment. We added the categorization of Body Mass Index (BMI) on page 5, line 154. The authoritative source is the World Health Organization (WHO) (Report of a WHO consultation. World Health Organ Tech Rep Ser. 2000 which is the reference number 12).

 

6. Please author write the formula alone from the line test (line 152, page 4).

RE: We made this in page 6, line 184.

 

7. Check the acronyms on the result section.

RE: Thank you for your suggestion. We have made the necessary adjustments to ensure the correct usage of acronyms throughout the results section.

 

8. Modify the layout of Table 1 and update the legends.

RE: We appreciate your feedback. We have modified the layout of Table 1 in accordance with your suggestions. The legends have been updated as follows: r = Pearson’s correlation coefficient; p = P value; p < 0.05, p < 0.01, p < 0.001.

 

9. The reviewer suggests changing "notably" to "however."

 

RE: Thank you for your suggestion. However, we rewrite this part according to your suggestion. Please see the next answer.

 

10. The reviewer suggests grouping the data into two categories: significant and non-significant results, without including the specific values. (page 10, line 276).

 

RE: Thank you for the proposal. we rewrite as follows: (Page 10, line 2276)

“there were some significant correlations observed. Waist-Hip Ratio (WHR) showed a significant correlation with brachial systolic and diastolic blood pressure, central systolic and diastolic blood pressure, and arterial stiffness as measured by AI@75. Additionally, visceral adipose tissue (VAT) had significant correlations with brachial and central systolic blood pressure, brachial diastolic blood pressure, and AI@75. AI@75 was also significantly correlated with total fat mass, lean/fat mass ratio, and IMAT.

In contrast, several correlations did not reach statistical significance. Specifically, weight, BMI, and total fat mass (FM) did not show significant correlations with most of the cardiovascular parameters, including brachial systolic and diastolic blood pressure, heart rate, central systolic and diastolic blood pressure, and pulse wave analysis (PWA). Similarly, lean/fat mass ratio and intramuscular adipose tissue (IMAT) also had mostly non-significant correlations with the cardiovascular parameters”

 

10. The reviewer suggests moving lines from the discussion section to the study limitations section.

 

RE: Thank you for the suggestion. Please see the updated text.

 

11. The reviewer suggests specifying what is referred to in lines 404 by the phrase, “This emphasizes the necessity for targeted prevention efforts during this vulnerable phase of women's lives.”

RE: We thank the reviewer for this valuable suggestion. We clarify that this refers to the transition phase to menopause, which is crucial for cardiovascular prevention. During menopause transition, several hormonal changes occur that significantly influence body composition and alterations in cardiovascular risk. Our findings suggest that women who experience this transition towards a phenotype characterized by increased fat mass percentage, changes in body composition, and alterations in lipid profiles may develop cardiovascular changes, such as vascular stiffness and increased blood pressure. This highlights the importance of closely monitoring women at the onset of menopause to prevent these sequelae.

We added this in page line 405: “This emphasizes the necessity for targeted prevention efforts during this vulnerable phase of women's lives (menopause transition), when a closely monitoring is important to prevent these sequelae.”

 

12. Acronyms and references on page 12.

RE: We have updated and added references and, where possible, the acronyms on page 12.

 

13: Make the conclusions more focused.

RE: We thank you for helping us focus and improve the article. We have made the necessary changes to the conclusions in the text

We modified as follows: “In conclusion, our findings highlight the complex relationship between menopausal weight gain, body composition, and cardiometabolic health: The MWGG group exhibited a higher BMI, along with greater total fat mass in kilograms and a higher percentage of total fat mass, compared to the MWMG group. Notably, we also observed a significant difference in the amount of intramuscular adipose tissue between the two groups. Integrating measurements of body composition with routine BP assessments may enhance our understanding of the pathophysiology underlying cardiovascular diseases and facilitate the development of more personalized preventive and therapeutic strategies. This approach could foster increased awareness and encourage the adaptation of clinical practices aimed at identifying and managing patients at risk of cardiovascular diseases, thereby enhancing preventive healthcare measures for menopausal women.”

We thank You for your constructive critique and hope the review process has improved the manuscript.

If additional changes are warranted, we will make them.

We hope that this revised version of our manuscript may now be found suitable for publication.

 

Sincerely,

Barbara Pala and Rossella Cianci

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors have made significant improvements to the manuscript, namely the revision of the statistical analysis. Also, typographic errors were corrected and the limitations were extended. Overall, their responses to this reviewer's issues were satisfactory and no further issues need clarification.

Author Response

Rome, 27^th August 2024

 

Dear Editor-in-Chief,

First, my coauthors and I sincerely thank you for this cooperation opportunity.

We profoundly thank the Reviewers for the comments and useful suggestions aimed at improving the paper. We thank You for your constructive critique.

Reviewer 1

The authors have made significant improvements to the manuscript, namely the revision of the statistical analysis. Also, typographic errors were corrected and the limitations were extended. Overall, their responses to this reviewer's issues were satisfactory and no further issues need clarification.

We thank the reviewer.

We confirm that this manuscript describes original work and is not under consideration by any other journal. All authors approved the manuscript and this submission.

We declare no conflict of interest.

We look forward to hearing from you at your earliest convenience.

Yours sincerely,

Rossella Cianci

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for the thorough responses and the corrections.

Please ensure consistent completion of the IMAT and VAT units throughout the manuscript prior to publication, for example, in Figure 2's second graph and Table 2.

Author Response

Rome, 27^th August 2024

 

Dear Editor-in-Chief,

First, my coauthors and I sincerely thank you for this cooperation opportunity.

We profoundly thank the Reviewers for the comments and useful suggestions aimed at improving the paper. We thank You for your constructive critique.

Reviewer #2.

 

1. Please ensure consistent completion of the IMAT and VAT units throughout the manuscript prior to publication, for example, in Figure 2's second graph and Table 2.

 

RE: Thank you for your valuable feedback. We have carefully reviewed the manuscript and have corrected the inconsistencies in the IMAT and VAT units throughout the text, as well as in the relevant tables and figures. We appreciate your guidance in ensuring the accuracy of our submission.

We confirm that this manuscript describes original work and is not under consideration by any other journal. All authors approved the manuscript and this submission.

We declare no conflict of interest.

We look forward to hearing from you at your earliest convenience.

Yours sincerely,

Rossella Cianci

Reviewer 3 Report

Comments and Suggestions for Authors

The authors answered all of my suggestions and questions and improved their manuscript.

Comments for author File: Comments.pdf

Author Response

Rome, 27^th August 2024

 

Dear Editor-in-Chief,

First, my coauthors and I sincerely thank you for this cooperation opportunity.

We profoundly thank the Reviewers for the comments and useful suggestions aimed at improving the paper. We thank You for your constructive critique.

Reviewer 3

The authors answered all of my suggestions and questions and improved their manuscript.

We thank the reviewer.

We confirm that this manuscript describes original work and is not under consideration by any other journal. All authors approved the manuscript and this submission.

We declare no conflict of interest.

We look forward to hearing from you at your earliest convenience.

Yours sincerely,

Rossella Cianci