White Nail as a Static Physical Finding: Revitalization of Physical Examination
Round 1
Reviewer 1 Report
The new version of the manuscript has now been considerably improved although there are still some minor issues to be dealt with at the authors' discretion.
"This case series shows two reports the cases of two older patients ..." Case "series" is a bold statement for just two cases.
It is generally said that long-term hypoalbuminemia causes the white nails. However, you observed the white nails at admission when the serum albumin was still within the normal range. So what are these nails: Terry's or Lindsay's? You also fail to approximate the percentage of white : brown.
Line 135: "... the disappearance of the lunula of a white nail can contribute ..." The lunula is normally white. When the nail becomes white and intransparent the lunula is no longer visible, but does this mean the lunula disappears? Not visible and disappearance are two fundamentally different processes.
Author Response
The new version of the manuscript has now been considerably improved although there are still some minor issues to be dealt with at the authors' discretion.
"This case series shows two reports the cases of two older patients ..." Case "series" is a bold statement for just two cases.
Response:
We appreciate your pertinent observations, and have accordingly deleted the term “series.” We have mentioned “case report” instead.
It is generally said that long-term hypoalbuminemia causes the white nails. However, you observed the white nails at admission when the serum albumin was still within the normal range. So what are these nails: Terry's or Lindsay's? You also fail to approximate the percentage of white : brown.
Response:
We appreciate your pertinent observations and question. In order to ensure clarity, we have additionally mentioned that we diagnosed Lindsay’s nails; the proportion of white : brown has also been mentioned in the case description.
Line 135: "... the disappearance of the lunula of a white nail can contribute ..." The lunula is normally white. When the nail becomes white and intransparent the lunula is no longer visible, but does this mean the lunula disappears? Not visible and disappearance are two fundamentally different processes.
Response:
We appreciate your pertinent observations, and have accordingly revised the description of the lunula; we have now mentioned that it was indistinguishable.
Reviewer 2 Report
Your case report is interesting and you make several good points. Muehrcke’s lines is the classic nail finding associated with hypoalbuminemia and should be acknowledged somewhere in the text. A discussion about leukonychia in general including true leukonychia vs apparent leukonychia would be helpful for the reader. Additional and sharper clinical images of multiple digits would more clearly illustrate your points, especially in case 2, and would make your results more compelling. It is unusual to see nail findings due to a systemic disease present only in a solitary nail.
Author Response
Your case report is interesting and you make several good points. Muehrcke’s lines is the classic nail finding associated with hypoalbuminemia and should be acknowledged somewhere in the text. A discussion about leukonychia in general including true leukonychia vs apparent leukonychia would be helpful for the reader. Additional and sharper clinical images of multiple digits would more clearly illustrate your points, especially in case 2, and would make your results more compelling. It is unusual to see nail findings due to a systemic disease present only in a solitary nail.
Response:
We appreciate your pertinent observations. We have added a description of Muehrcke’s lines in the discussion section; the difference between leukonychia and pseudoleukonychia has also been discussed.
Reviewer 3 Report
There is no doubt that nail alterations are clinical markers that function as controls both for the early diagnosis or debut of a disease and as markers of the evolution of multitudud of systemic pathologies, its backed by a multitude of bibliographic references. The work entitled " White Nail as a Static Physical Finding: Revitalization of Physical Examination” has main objective is to corroborate these premises through the report of two clinical cases.
The symptomatology of nail pathology is quite nonspecific, making its manifestations concomitant……. as it happens in the white nails, and so the authors state it: “The typical static findings seen in nails are Terry’s and Lindsay's nails, indicative of hypoalbuminemia, cirrhosis, heart failure, or renal dysfunction”. In the anamnesis of exposed patients it is reflected that they have several of these pathologies, making it impossible to know which one may be causing said manifestations nails.
In addition, the authors do not make references about the treatments of the underlying diseases that these patients present, and these are some factors to take into consideration because they can also be the cause of these pathologies.
For these reason, and in my opinion, it does not provide sufficient data to be able to associate that white nails are exclusively due to hypoalbuminemia. And in short, these reflections lead I to consider that the work presented should not be accepted for publication in Clinics and Practice.
Author Response
There is no doubt that nail alterations are clinical markers that function as controls both for the early diagnosis or debut of a disease and as markers of the evolution of multitudud of systemic pathologies, its backed by a multitude of bibliographic references. The work entitled " White Nail as a Static Physical Finding: Revitalization of Physical Examination” has main objective is to corroborate these premises through the report of two clinical cases.
The symptomatology of nail pathology is quite nonspecific, making its manifestations concomitant……. as it happens in the white nails, and so the authors state it: “The typical static findings seen in nails are Terry’s and Lindsay's nails, indicative of hypoalbuminemia, cirrhosis, heart failure, or renal dysfunction”. In the anamnesis of exposed patients it is reflected that they have several of these pathologies, making it impossible to know which one may be causing said manifestations nails.
Response:
We appreciate your pertinent observations. Based on your observations, we have revised the discussion focusing on the importance of nail findings; in particular, we have mentioned that these findings provide opportunities to investigate undiagnosed chronic diseases that impair the clinical condition. We have also revised the background and discussion sections based on the comments from the other reviewers.
In addition, the authors do not make references about the treatments of the underlying diseases that these patients present, and these are some factors to take into consideration because they can also be the cause of these pathologies.
Response:
We appreciate your pertinent observations. Based on your observations, we have added precise descriptions of the two cases; the risk factors related to the development of white nails and related treatments have been discussed in depth considering the pathophysiology causing white nails in each case.
For these reason, and in my opinion, it does not provide sufficient data to be able to associate that white nails are exclusively due to hypoalbuminemia. And in short, these reflections lead I to consider that the work presented should not be accepted for publication in Clinics and Practice.
Response:
We appreciate your pertinent observations. We have revised the manuscript extensively based on your observations. In particular, the text pertaining to the findings of white nails, associated risk factors, descriptions of the cases in relation to the treatment of risk factors, and most parts of the discussion have been revised. We believe that the concerns raised have been addressed during revision, and would be grateful if the manuscript could be considered for publication.
Round 2
Reviewer 2 Report
Your manuscript is much improved
with your additional description of types
of leukonychia.
Reviewer 3 Report
I thank the authors for all the work done to improve the work entitled " White Nail as a Static Physical Finding: Revitalization of Physical Examination”, but I still consider that it does not provide sufficient data to be able to diagnosis that white nails origin. On the other hand, the data collected and the results provided by the authors are not sufficiently innovative and relevant. And in short, these reflections lead I still consider that the work presented should not be accepted for publication in Clinics and Practice.
This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.
Round 1
Reviewer 1 Report
The authors describe two patients in their 80s with white nails. One had pyuria and was treated with a cephalosporin, the other was diagnosed as having had viral myositis with no further proof given for the diagnosis. The first patient hat opaque white nails of all fingers, the second patient's thumb nails were spared. No information on the course of the condition over a bit longer time was given.
Terry published the results of his observations in 100 consecutive patients with liver disease, 82 of whom had white nails.
The manuscript has serious flaws. The authors apparently cannot distinguish between nail (plate) and nail bed when they speak of "nail bed opacity". This is not the case, it is the nail plate that turns "ground-glass" white and thus opaque, which means you cannot see the nail bed and lunula.
Please give an explanation of Terry’s and Lindsay’s nails in the beginning of your manuscript and their differences.
“White discoloration of the fingernails, such as in Terry's and Lindsay's nails, can be related to chronic inflammation leading to malnutrition.”
You state that “nail bed opacity” makes the nails look white. This is not true for Terry’s or Lindsay’s nails!
“Her nail findings were specific, and …” What do you mean by this statement?
“… nail plate findings can show patients' nutritional status before the acute condition.”
“… serum albumin levels can indicate patients' nutritional conditions within several months,”
Why were the serum albumin levels almost normal at hospital admission and dropped within a few days despite good care (I presume) in the hospital? Only an effect of iv rehydration?
“Nail plates and beds change gradually, and deformation and changes in color occur over several months; these can be referred to as vascular changes in nail beds [17]. Even in acute conditions, nail color can be used to assess nutritional status.” Pls make clear what you really mean: you write in the beginning of “nail bed opacity” and now you speak of nail beds.
“… the disappearance of the lunula of a white nail can contribute to proper nutritional assessment.” Actually, the lunula is not visible through a ground-glass white opaque nail!
“White nail can be useful for the evaluation of nutritional conditions in patients with acute diseases.” However, this is also seen in congestive heart failure and chronic renal failure, in patients with type 2 diabetes mellitus, chronic allograft nephropathy, acute viral hepatitis, vitiligo, and tuberculoid leprosy. What have congestive heart failure, vitiligo and chronic renal failure to do with the nutritional status?
Reviewer 2 Report
even though the authors had thei rbest intentions to underline the needs to rely on physical examination as much as leb test to find an appropriate diagnosis and therapy, I do not find the cases novel or with high importance or rarity. Therefore I reccomend the rejection. Maybe a review on the importance of the medical examination would be more appropriate.
