Review Reports - Magnetic Resonance Enterography Reinvented: Exploring the Potential of a New Natural Beverage as an Alternative to Polyethylene Glycol Solution

Round 1

Reviewer 1 Report

Summary:

This manuscript presents a study that aimed to evaluate the effectiveness of a new oral contrast medium, composed of natural components, for magnetic resonance imaging (MRI) of small bowel diseases. The study included 35 patients with ileo-colic Crohn's disease who underwent two sequential MR enterographies: one with the standard polyethylene glycol (PEG) water solution and another with the new natural beverage developed by the research team. Patient satisfaction was assessed through a survey regarding the palatability of both beverages. Intestinal distention and image quality were evaluated by two expert radiologists for both studies. The results showed that the natural beverage received significantly higher positive judgments from patients in terms of palatability compared to the PEG water solution. The degree of intestinal distention and image quality were comparable between the two contrast media, with high inter-observer agreement. The study concludes that the new natural beverage is a valid alternative to the synthetic standard oral contrast for MRI of small bowel diseases, offering better palatability.

Comments:

The use of a natural beverage as an oral contrast agent in MRE is an interesting approach. Traditional oral contrast agents like PEG can be poorly tolerated by patients due to their unpalatability and potential adverse reactions. Therefore, finding an alternative with better acceptability is valuable for improving patient experience during the procedure. However, it is important to note that the primary purpose of the oral contrast agent in MRE is to distend the bowel loops, allowing for better visualization of the intestinal wall. The contrast agent itself does not need to be magnetic since the MRI machine primarily detects the differences in signal intensity between the surrounding tissues and the bowel wall. The natural beverage in this study aimed to achieve adequate bowel distension, similar to the standard PEG solution, rather than providing magnetic properties. The study's results are promising, showing that the natural beverage achieved comparable bowel distension and image quality to the PEG solution. Additionally, the higher palatability and increased consumption of the natural beverage are positive indicators of improved patient acceptance. However, it is worth noting that this study had a relatively small sample size, and further research with larger cohorts and multi-center studies would be beneficial to validate the findings and assess the long-term safety and efficacy of the natural beverage as an oral contrast agent. Overall, the use of a more palatable and well-tolerated oral contrast agent in MRE has the potential to enhance patient compliance and satisfaction, leading to improved image quality and diagnostic accuracy.

Major points:

1. The title is not ideal; I suggest revising it to "Magnetic Resonance Enterography Reinvented: Exploring the Potential of a Natural Beverage as an Alternative to Polyethylene Glycol Solution."

2. The positioning of tables and figures is incorrect; they need to be redrawn and repositioned accordingly.

3. Do you have any data related to the dosage, timing, and toxicity of this new oral beverage? It is important to consider whether this beverage may have any negative effects on the patients' health.

4. The opinions of only two radiologists may be insufficient to draw statistically significant conclusions. It would be beneficial to involve more participants and evaluators in this study.

The manuscript requires improvement as there are several sentences that are unclear and difficult for readers to understand.

Author Response

Dear Reviewer

Please find enclosed the revised version of our manuscript entitled “MR Enterography after oral administration of a new natural beverage instead of polyethylene glycol solution” which we request to consider for possible publication as a Reasearch Article in Gastroenterology Insights. Thank you for the opportunity to revise and improve our paper according to your helpful comments. We have modified the main text in accordance with your insightful and significant suggestions and we have replied point by point to all requested revisions. We hope that now our manuscript reaches a suitable level for a possible publication in Gastroenterology Insights.

Sincerely,

Nicolò Brandi

Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italia.

REVIEWER 1

Comments:

RE: Dear Reviewer, thank you very much for your insightful comments. Your professionalism and competency surely can help improve the quality of our paper.

Major points:

The title is not ideal; I suggest revising it to "Magnetic Resonance Enterography Reinvented: Exploring the Potential of a Natural Beverage as an Alternative to Polyethylene Glycol Solution."

RE: Dear Reviewer, thank you very much for your helpful suggestion. We agree with you and find the new title more engaging and ideal. We have now changed the title as suggested.

The positioning of tables and figures is incorrect; they need to be redrawn and repositioned accordingly.

RE: Dear Reviewer, thank you very much for your helpful suggestion. We are very sorry for the mispositioning of tables and figures. We have now checked the entire text and repositioned them accordingly.

Do you have any data related to the dosage, timing, and toxicity of this new oral beverage? It is important to consider whether this beverage may have any negative effects on the patients' health.

RE: Dear Reviewer, thank you very much for your comments. The data related to the dosage, timing and toxicity are presented in the text. First of all, in the first experimental phase of the protocol, the new natural beverage was successfully tested in 20 healthy volunteers who underwent a standard MRE in order to test its safety as well to optimize its final composition (in terms of concentration, quantity and palatability). After identifying the correct concentration for the adequate distension of the bowel loops and the absence of adverse events related to the natural beverage, the second phase of the study began, and the new beverage was administrated to 35 patients affected by ileo-colic CD. The results of the present study (in terms of effectiveness and palatability) derived from the analysis of the MRE examinations of these latter patients. The timing and the dosage in which the new beverage was administrated to these patients were similar to those used with PEG water solution (a maximum of 1500 ml, starting the administration about 45 minutes before the examination) [doi: 10.1007/s11604-019-00838-y]. The specific recipe of the tested new natural beverage has been deposited as a Patent and we are waiting for the approval of its commercial license, thus we are not allowed to give the precise concentration of every single component at the moment.

The opinions of only two radiologists may be insufficient to draw statistically significant conclusions. It would be beneficial to involve more participants and evaluators in this study.

RE: Dear Reviewer, thank you very much for your helpful suggestion. We agree with you and, partially due to the difficulties in the enrolment process (patients willing to undergo two different MRI examinations only 1 week apart), this study has indeed a relatively small sample size. However, this limited number was sufficient to reach statistical significance. Moreover, the interreader agreement between the two radiologists is a reliable and valid result, as it was properly obtained and calculated as in other studies in the literature. Nonetheless, as you correctly stated, we hope that further research with larger cohorts and involving different centers would be beneficial to validate our initial findings and assess the long-term safety and efficacy of this new natural beverage as an oral contrast agent. We have now stressed this limitation in the text.

The manuscript requires improvement as there are several sentences that are unclear and difficult for readers to understand.

RE: Dear Reviewer, thank you very much for your comment. The paper has been checked and revised by a professor of English specialized in scientific translations.

Reviewer 2 Report

The paper is very interesting and fit for the publication in the journal but I have some observations:

- At page 3, line 135 the authors should change "the same maximum......." with the dosage of natural beverage and should, if it is possible, give tge concentration of every single component

- At page 4, line 174, I kindly ask to explain better the role of number 175, 176, 177

Author Response

Dear Reviewer

Sincerely,

Nicolò Brandi

Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italia.

REVIEWER 2

The paper is very interesting and fit for the publication in the journal but I have some observations:

- At page 3, line 135 the authors should change "the same maximum......." with the dosage of natural beverage and should, if it is possible, give tge concentration of every single component

RE: Dear Reviewer, thank you very much for your comments. In the present study, each patient was asked to drink the PEG water solution to a maximum of 1500 ml (as reported in the literature [doi: 10.1007/s11604-019-00838-y]). After one week, the same patients were asked to drink the new water solution, to a maximum of 1500 ml in a similar way. After the administration of each beverage, the quantity of contrast medium really assumed by each patient before the MRE was recorded on a dedicated database. The specific recipe of the tested new natural beverage has been deposited as a Patent and we are waiting for the approval of its commercial license, thus we are not allowed to give the precise concentration of every single component at the moment.

- At page 4, line 174, I kindly ask to explain better the role of number 175, 176, 177

RE: Dear Reviewer, thank you very much for your helpful suggestion. As suggested by the other Reviewer, we have now checked the entire text and repositioned both tables and figures accordingly. Moreover, we have now specified in Tables 1 and 2 that “N” is referring to the number of patients.

Round 2

Reviewer 1 Report

Minor editing of the English language is required, and please use better phrasing in the manuscript to describe if the evaluation of your New Natural Beverage by two Radiologists is sufficient.

Minor editing of English language required,

Author Response

Dear Reviewer,

Thank you very much for your insightful comments.

The paper has been checked and revised by a professor of English specialized in scientific translations and a certificate of this revision has been uploaded with the revised manuscript. Furthermore, we have used better phrasing to describe how two radiologists are statistical sufficiency for a reliable evaluation of our new natural beverage.

We hope that now our manuscript reaches a suitable level for a possible publication in Gastroenterology Insights.

Kind regards,