Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

1. Sample size grossly inadequate for multivariable analysis, only 25 patients with facial paralysis were included, yet the logistic regression model contained 5 predictors (age, sex, CTRP3, CTRP5, NLR). This violates the recommended minimum of 10–15 events per predictor (here only ~5 events per predictor), leading to overfitting and unstable odds ratio estimates.
2. No power calculation, the authors did not provide any a priori sample size calculation. It is unclear whether the study had sufficient power to detect meaningful differences in CTRP3, CTRP5, or NLR between groups.
3. Retrospective design with potential selection bias, the study is retrospective, yet the authors claim to evaluate “diagnostic significance.” No clear description of how consecutive patients were enrolled or how controls were selected; the high control-to-patient ratio (39:25) without justification raises selection bias concerns.
4. Missing key confounding variables, Important confounders such as body mass index (BMI), smoking status, comorbidities (diabetes, hypertension), medication use (steroids, antivirals), and time from symptom onset to blood draw are not reported or adjusted for. CTRP3 levels are known to be influenced by metabolic syndrome and obesity.
5. Incorrect use of p-values for baseline comparability, the authors state gender distribution did not differ significantly (p > 0.05) and conclude groups are homogenous. Failure to prove a difference (p > 0.05) does not prove homogeneity; this is a common misinterpretation.
6. CTRP3 AUC reporting is misleading, the abstract states raw CTRP3 coding yields an AUC below 0.5 (AUC=0.265) but then presents an inverse coding AUC of 0.735. This manipulation is statistically unconventional; researchers should report the raw AUC and explain the inverse relationship clearly without creating an artificially inverted ROC curve.
7. No correction for multiple comparisons, the authors performed numerous univariate tests (age, sex, Hb, albumin, lymphocytes, neutrophils, platelets, CTRP3, CTRP5, NLR, PLR – over 11 comparisons) without any adjustment (e.g., Bonferroni). The significant p-values for CTRP3 (p=0.002) and NLR (p<0.001) may be inflated by multiple testing.
8. CTRP5 data inconsistency, In Table 1, CTRP5 values are reported as mean ± SEM (3.20 ± 0.42 vs 3.93 ± 0.84), but in the text (lines 217-218) median and IQR are used. The reported p-value changes from 0.853 (line 23) to 0.847 (line 218) – a minor discrepancy but reflects poor data consistency.
9. Logistic regression model includes non-significant variables without justification, Age, sex, CTRP3, and CTRP5 were forced into the model despite univariate non-significance or borderline trends. Backward elimination or a more parsimonious model should have been used, especially given the small sample.
10. Over-interpretation of NLR as independent predictor, with only 25 cases, the claim that NLR is an independent predictor is fragile. The confidence interval for NLR OR (1.347–4.802) is wide, and the model’s classification accuracy of 75% is not impressive given the imbalance in group sizes.
11. Correlation coefficient misinterpretation, the authors claim a weak-to-moderate positive correlation between albumin and CTRP3 (ρ = 0.269, p=0.032). With an R² of only 0.072, this is a very weak correlation that may be spurious given multiple testing.
12. No longitudinal or prognostic data, the title and introduction imply interest in diagnostic significance and prognostic indicators, yet the study is purely cross-sectional. No follow-up data on recovery, severity grading (e.g., House-Brackmann scale), or treatment response are provided.
13. Inappropriate reference to C1q complement pathway, Lines 118-124 discuss C1q structure and function in detail, but the study measured CTRP3 and CTRP5, which are not complement proteins. This discussion is largely irrelevant and distracts from the actual findings.
14. Poor reporting of ELISA methods, The ELISA kits are not identified by manufacturer, catalog number, or lot number. The claimed intra-assay CV of 6.43% for CTRP3 is relatively high for a diagnostic study; many journals require CV < 5%.
15. Units and conversions are confusing, in lines 95-99, platelet counts are converted from cells/µL to 10³/µL, and albumin from g/L to g/dL. This increases the risk of transcription errors. The raw data should be reported in standard units without unnecessary conversions.
16. No assessment of assay linearity or spike recovery, for novel biomarkers like CTRP3 in facial paralysis, the authors should have validated the ELISA in their sample matrix, especially given the low levels in patients (median 0.50 ng/mL).
17. Figure 1 is not adequately described, The ROC curves are shown but the figure legend is incomplete (line 304–306). The figure itself is missing from the manuscript draft, making it impossible to verify the AUC claims.
18. Hosmer-Lemeshow test result not reported, in line 332, the authors mention minor limitations in the Hosmer-Lemeshow test likely due to the specific sample size but they do not provide the test statistic or p-value. This suggests model calibration may be poor.
19. The authors claim that a single-unit increase in NLR corresponds to a 2.5-fold higher probability of facial paralysis implying causality. However, cross-sectional data cannot distinguish whether elevated NLR is a cause, consequence, or epiphenomenon of facial paralysis. Clinical utility as a diagnostic tool is questionable because NLR is non-specific and elevated in many inflammatory conditions.

Author Response

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Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Title: Evaluation of the Systemic Inflammatory Landscape and C1q/TNF-Related Protein Profiles in Facial Paralysis.

In this paper, the authors study the diagnostic significance of systemic inflammatory indices and C1q/TNF-related proteins (CTRP3 and CTRP5) in acute facial paralysis. The results show that acute facial paralysis is associated with a systemic inflammatory shift, such as higher neutrophils, NLR/PLR, lower lymphocytes and albumin, and reduced CTRP3 levels. The authors conclude that in multivariate analysis, NLR is the only independent predictor, while CTRP3 exhibits an inverse discriminative pattern but does not maintain independent significance.

This paper seems good to me and brings some novelties to its field, however I have some concerns.

The relationship between MAPK pathways and the C1q/TNF-related proteins (CTRP) family is a central theme in the study of metabolism, inflammation, and cell signaling. Some CTRPs directly activate MAPK, as occurs with CTRP9 which activates ERK1/2. In addition, CTRP3 modulates p38 MAPK causing an anti-inflammatory effect and reduces pro-inflammatory signals induced by TNF. In the light of these concepts, to make this paper more interesting for the readers of this important journal, the authors should expand a bit the discussion (or introduction). Below I report an interesting article that should be studied, incorporate the meaning and report it briefly in the discussion and in the list of references.

Saggini R, Pellegrino R. MAPK is implicated in sepsis, immunity, and inflammation. International Journal of Infection. 2024;8(3):100-104. (www.biolife-publisher.it).

In addition,  activation of PI3K/Akt pathway, link to mTOR. Again, here, we report  an article which has been recently published that should be studied, incorporate the meaning and report briefly in the discussion or introduction, and in the list of the references.

 

Avivar-Valderas A. Inhibition of PI3Kβ and mTOR influence the immune response and the defense mechanism against pathogens. International Journal of Infection. 2023;7(2):46-49. (www.biolife-publisher.it).

The tables and Figure 1 contain only the title and lack a legend, which should be described point by point. This helps the reader to better understand.

I believe these suggestions are important for improving this paper. Without these corrections the paper cannot be published. So I recommend minor revision.

Author Response

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Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Authors answered all my questions and provided revised manuscript. I accept this manuscript in the present form

Author Response

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Author Response File: Author Response.pdf