Exploring Emerging Trends in Climate Change’s Impacts on the Cardiopulmonary Health of Adults Living in the Canton of Valais, Switzerland: Preliminary Autumn and Winter Results from a Pilot Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This study preliminarily explored the associations between meteorological and air pollution variables and adult cardiopulmonary emergency department admissions in the canton of Valais, Switzerland.  The comments are as follows:

1. In 2.2, the authors need to introduce study period (year and month) at the beginning .
2. In results part, Figure 1 and relevant description can be reloacated to methods part.
3. Line 254-255, please do not cite reference in the results part. This citation can be used in the discussion part.
4. 4.3.3 Regression analysis, please put the part of describing analytical methods (line 332-358) to methods part. The results part should focus on exhibiting study results. Besides the description (line 359-387), please use one or more tables and figures to summarize the results, including possible non-linear association.
5. Reference style should be unified, please check with the cited articles carefully. E.g., try to avoid using "Epub ahead of print",  and add volume and page number. DOIs should be all kept or deleted. Names of journals should be all as full or abbreviated form and do not mix them.   

Comments on the Quality of English Language

The manuscript requires a moderate language correction. 

Author Response

"Please see the attachment."

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors, your article is well written, clearly presented and contributes significantly to the topic and public health field. I recommend its acceptance for publication

Comments for author File: Comments.pdf

Author Response

"Please see the attachment."

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Mayor Comments and Suggestions

1. The introduction could be strengthened by explicitly stating specific research questions or hypotheses, which are optional but commonly included in academic introductions. Presenting specific research questions would provide clarity and focus to the study's objectives.
2. While the description of the meteorological data collection is comprehensive, the methods section lacks detail on the procedures for matching meteorological data with patient data.
3. The decision to aggregate data at the weekly level due to low daily admission counts should be carefully considered, as it may obscure important temporal dynamics. The methods section could benefit from a more detailed justification of this decision and an exploration of alternative modeling strategies that could capture finer temporal variations. There is ample literature that establishes a direct and immediate relationship between high concentrations of pollutants such as ozone or nitrogen oxides, particulate matter, and sudden hospital admissions or cases of mortality due to cardiopulmonary diseases.
4. The methods section lays a robust groundwork for the pilot study; however, there are multiple aspects that could be refined to bolster methodological rigor, particularly concerning the confidence level of the results. Each consideration should be supported by bibliographical references from prior similar research.
5. The Results section starts by detailing the involvement of patients and their sociodemographic characteristics, with the intention of connecting these findings to the study's objectives. Nonetheless, the section does not provide a clear summary that directly links the results to the specific research questions or hypotheses. To enhance this part, the section should begin with a concise introduction that restates the study's objectives and clarifies how the following results align with these aims.
6. The section on data aggregation and longitudinal description of atmospheric pollutants and temperatures is informative but lacks a clear connection to the study's objectives. It would be beneficial to explicitly state how these descriptive analyses contribute to understanding the impact of meteorological conditions on health outcomes.
7. The presentation of atmospheric pollutant data is somewhat disjointed, with numerical values listed without sufficient context. Consider integrating these values into a description that explains their significance in relation to the study's aims.
8. Figure 1 on patient screening is mentioned but not adequately integrated into the narrative. The text should reference this figure more explicitly and explain its relevance to the study's findings. Figures 2, 3, and 4 are used to present data on weekly admissions, atmospheric pollutants, and temperature changes. Yet, the figures are not sufficiently described in the text. Each figure should be accompanied by an explanation and links it to the study's objectives.
9. Table 2 is referenced in relation to participants' sociodemographic and health data, but the text does not provide enough detail about its contents. Why is it important in this study?
10. The Discussion section needs major revisions to improve its conceptual and interpretive profundity. By identified weaknesses and incorporating the recommended enhancements, the authors can more effectively highlight the originality and significance of their findings.
11. The conclusion section does not sufficiently connect back to the original research question or problem. It must be improved using results that are more detailed and discussions.
12. The bibliography provided is quite limited. It would be advisable to broaden it by incorporating the earlier remarks and recommendations.

Comments on the Quality of English Language

Some errors or typos were observed in the English text, such as lines 4, 43, and 330, as well as in the title of Figure 4. Please review the spelling.

Author Response

"Please see the attachment."

Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

Thank you for giving me the opportunity to review this manuscript.

This study aimed to explore the associations between daily variations in meteorological parameters, patients’ demographic and clinical profiles, and the number of adult cardiopulmonary ED admissions in the canton of Valais, Switzerland. It is important to evaluate the health impacts of climate change and air pollution, especially in climate-sensitive alpine regions. Therefore, I agree that the preliminary study in the canton of Valais is meaningful. However, there are several concerns that require the authors to address.

 

Major comments

1. I understand that this is a pilot study and the objective is to provide preliminary results. However, the study period was only 21 weeks in colder season. Because the objective of this study is to explore the effects of climate-related factors, the data from spring and summer, when temperatures and ozone concentrations are high, should be included.
2. In this study, only 91 patients, who were randomized from the 202 participants (Figure 1), were included in the analysis. The sample size is too small, even if this is a pilot study.　Why weren’t all 202 participants included in the analysis?
3. The results section is very long, and the descriptions of the characteristics of the participants, atmospheric pollutants and temperature are redundant. On the other hand, the description of the analysis results is inadequate. The analysis results of the 21 candidate models (line 359) should be explained using Tables.
4. Please describe the explanation of the regression analysis methods (lines 331–358) in the Methods section, not in the Results section.
5. The authors described that ozone exposure showed a consistent positive association (IRR = 1.014) in the Abstract (line 55). Additionally, the association with the mean ozone concentration was to be p <0.1 in the Results (line 372). On the other hand, the authors mentioned that p value =<0.1 was “not statistically significant” (line 374). These descriptions are contradictory. Please specify the criteria for determining significance.
6. In the Discussion section, the authors described that “the effects of PM₁₀, PM_2.5, and NO₂ pollution did not reach statistically significant levels.” However, such results were not provided in the Results section. Please show the analysis results on air pollutants, as mentioned above.

 

Minor comments

1. Figure 3. There are many days when PM2.5 concentrations were higher than PM10 concentrations. This phenomenon seems unnatural, because PM2.5 is included in PM10.
2. Line 355 Although a total of 3 x 7 candidate models was yielded, only 5 meteorological variables were described (lines 355–356). Tmax and Tmin may be also included in the meteorological variables.

Author Response

"Please see the attachment."

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors have revied the manuscript according to the reviewer's comments. Thus, the manuscript can be accepted after proofreading. 

Author Response

We sincerely thank the reviewer for this positive assessment and for acknowledging the revisions made to the manuscript. We appreciate the recommendation for acceptance.

Reviewer 4 Report

Comments and Suggestions for Authors

I appreciate that the authors have revised the manuscript in response to my comments. Especially, Tables 3 and 4 have been added, making the results clearer. However, the description is redundant, and the same results are repeated multiple times. For example, the demographic–clinical risk index “β = 2.315, SE = 0.776, p < 0.01” were repeatedly three times (lines 408, 419, and 426). Please describe the results concisely and clearly, by avoiding such repetitions. Additionally, please explain the data and abbreviations shown in Tables 3 and 4.

In Tables 3 and 4, “***p > .01” should be “***p < .01.”

The explanation of Figure 3 was repeated in lines 343–359 and lines 360–379. The contents of the paragraphs were almost the same.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf