The Role of Human Microbiota in Myasthenia Gravis: A Narrative Review
Round 1
Reviewer 1 Report
In this review, Schiro et al. reported that the alterations of oral and gut microbiota are intriguing factors in MG pathogenesis and disease severity. This review article is well written and carries novel findings.
Only a few minor concerns:
Line 45, obesity should be associated with an increase of F/B ration instead of decrease.
In Table 1, what is category of the bacteria mentioned, class or genus?
Bacteria should be written in italic font.
Acronyms should be used correctly, such as TNF in line 171 and PPI in line 183.
In line 225, be Rinaldi et al. instead of Rinaldi E.
Author Response
Dear respectable reviewer
Thank you for your comments.
We updated the manuscript according your precious suggestions. All the changes are highlighted in red.
The relationship between obesity and F/B ratio has been clarified.
Table 1: phyla are highlighted in bold while genus are listed under the phyla level (*see description under table 1)
Bacteria are now written in Italic font.
Acronyms have been checked.
Thank you
Kind regards
Reviewer 2 Report
The authors have completed a brief review covering the potential role of oral and gut microbiota in the pathogenesis of myasthenia gravis (MG). The subject matter is of interest and topical so the review is suitable for publication. However, I would suggest the authors address the following points:
Table 1, not clear why tenses are mixed, reduced, reduction, increase – so either all the same or just use arrows to indicate increase or decrease. Secondly, Table 1 would benefit if the authors included more details about the study populations and whether the results were deemed significant. Hence, expand the Table to include details of the study populations (male/female; ages of the participants; study size (number of participants); control and test group; and the statistical significance of the results (where available).
Figure 1, TNF-alpha is spelt incorrectly, and AChRs should have a capital C in the Figure Legend. There are other examples of typos/grammatical errors within the text that will also need to be rectified.
Section 3.1 first sentence, I would suggest a change of wording to may help to restore…
Lastly, can the authors provide any concluding statement or details regarding whether some of the changes in the microbiota reflect a response to the disease itself rather than being involved in the pathogenesis of the disease, how could this be dissected?
Author Response
Dear respectable reviewer
We appreciated your comments that help us to improve our manuscript.
Table 1 has been updated including number of patients enrolled, control group and statistically significance.
Figure1: is has been replaced with a correct figure (TNF alpha). Legend has been updated.
We agree with the reviewer on the fact that some of the changes in the microbiota reflect a response to the disease itself rather than being involved in the pathogenesis therefore we stated among the conclusion:
"We supposed that microbiota may share a role in the pathogenesis of MG although, it is also reasonable that oral and gut microbiota alterations may be an indirect effect of MG because patients take a higher number of medications such as PPI immunosuppressants, pyridostigmine and corticosteroids which overall may alter microbiota composition. Also, the alteration of nutritional lifestyle and physical activity in patients with MG may have a further role in the microbiota perturbation. Thus, further studies are needed to clarify the direction of this close relationship between MG and microbiota alteration"
Thank you for your evaluable comments that help us to improve the manuscript.
Kind regards
Reviewer 3 Report
Your paper presented in the form of a narrative review addresses an interesting and important theme. This work contributes to the increasing data on the role and dysbiosis of oral and intestinal microbiota on autoimmune disorders, in this case Myasthenia Gravis. This reviewer provides a minor observation and raises a question. (1) In the segment discussing herbal-based food-supplement therapy, described as Traditional Chinese medicine, which I agree remains as anecdotal therapy, this option is worldwide non-based-on evidence utilized, not "accepted'. (2) The reader would be interested in the paper discussing as well Mediterranean and other diet modalities mot just the excellent figure you used to illustrate Western Diet.
Author Response
Dear respectable reviewer, we thank for your evaluable comments.
To date, many patients with neurological disease rely improperly on alternative medicine (food supplements-herbal based), therefore we found useful describing briefly the TCM approach. We stated its not-evidence based nature and its anectodal role in MG. Thank you.
Mediterranean diet section has been expanded, reporting the role of MD in modulating chronic inflammation. We added, also a new reference about the use of whole plant based diet in MG.
Your comments helped us to improve the manuscript. We hope that all the concerns have been clarified.
Thank you
Kind regards
