Hydration Care After Stroke: A Systematic Review of International Clinical Practice Guidelines

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,

the manuscript presents a very interesting topic and is prepared in a reliable and well-structured manner. The content is clear, logically organized, and easy to follow, which makes the article accessible to readers and supports its scientific value. The methodology and presentation of results are appropriate, and the discussion adequately reflects the findings.

I would recommend that the Authors place stronger emphasis on the implications for clinical practice. Highlighting practical recommendations and clearly outlining how the findings can be applied in everyday clinical settings would further enhance the usefulness and impact of the manuscript for clinicians and practitioners.

Author Response

Thank you for your time and expertise in reviewing this manuscript. All reviewer comments prompted discussion and revision, and we appreciate your feedback. 

Please see the attachment for detailed response

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

This paper reports on a systematic review of hydration care in stroke clinical practice guidelines (CPGs) published since 2009. The authors identified 13 eligible CPGs, making 35 relevant recommendations (CPGRs) in total. The authors concluded that while stroke guidelines recognise the importance of hydration care, almost half of the guidelines are of low to moderate quality, and consider hydration in the context of post-stroke complications; whilst routine assessment and management of hydration are broadly endorsed, how to do so remain poorly defined.  

However, there are some issues the authors may wish to address:

1. Lines 2-3 – the guidelines covered seem for ‘national’ than ‘international’
2. Lines 19-29 – I am confused by which refer to CPGs and which to CPGRs – I need to base on the numerator and %. More clarity is needed in the presentation
3. Line 34 – the availability and/or quality of the evidence for hydration was not addressed in the study
4. Lines 35-36 – it may be more appropriate to make a call for guidelines to cover the issues raised by the authors eg who, when and how to assess and monitor hydration, and how to best manage it
5. Table 1 – is the dividing line between sections ‘C’ and ‘A’ missing?
6. Fig 1 – the numbers removed and reasons for doing so need to be stated and placed in a a side box
7. Table 2 – lead author – some are missing eg Singapore (ref 50); is there a reason for highlighting ‘N/A’ for India?
8. Table 3 – the reference number of each study mentioned should be entered
9. Results – the authors need to be clear which refer to CPG and which CPGR
10. Lines 376-337 – this issue was not assessed in this study
11. Line 397 – ‘other pathologies’ – please provide examples and reference
12. Line 401 – ‘invasive and costly’ – I believe osmolality is a calculation based on a blood test, and uses what is usually measured - urea, sodium and glucose
13. Line 458 - ‘specificity’ – as opposed to sensitivity’?
14. References – missing page numbers in many
15. Supplement table 3 – please add the reference of each study mentioned; – lead author – some are missing eg Singapore

Author Response

Thank you for your time and expertise in reviewing this manuscript. All reviewer comments prompted discussion and revision, and we appreciate your feedback. 

Please see the attachment for a detailed response.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

I have finished my review of the manuscript entitled “Hydration care after stroke: A Systematic Review of International Clinical Practice Guidelines.”

The topic is relevant and the manuscript is generally well structured. The authors address an important clinical gap regarding the assessment and management of hydration in patients with acute stroke, and the use of the AGREE II framework adds methodological rigor to the appraisal of existing guidelines.

However, several aspects require clarification and strengthening before the manuscript can be considered for publication. In particular, the transparency of the search strategy, the interpretation of AGREE II findings, and the articulation of the implications for clinical nutrition and hydration management should be improved. Additionally, some inconsistencies in percentages and reporting need verification.

Overall, the manuscript has merit and addresses a clinically meaningful issue, but revisions are necessary to improve methodological clarity and strengthen the discussion of clinical implications. For these reasons, I recommend major revision.

Specific comments.

Introduction. the framing is largely neurological guideline analysis rather than hydration/nutrition science. The authors should better emphasize the nutritional relevance of hydration management. hydration is framed primarily as a complication-management issue rather than a nutrition care domain.

The search strategy is mentioned but insufficiently detailed in the main manuscript.

The inclusion criteria require guidelines to be “endorsed by a national or international organisation” (page 3) but no detail is provided about how endorsement was verified, if a consensus statements or society recommendations were considered equivalent to formal guidelines or if any methodological standards or guidelines were required

Table 3. Stakeholder involvement scored lowest across guidelines (31%) and applicability median score only 13% These findings are clinically significant and suggest systematic weaknesses in guideline development, therefore, the discussion should explore these aspects.

authors could strengthen the study by including frequency of specific hydration recommendations, comparison of high vs low quality guidelines and perhaps a geographical patterns

The conclusions correctly state that recommendations are vague and poorly standardized (page 15). However, the manuscript stops short of proposing practical solutions and I encourage authors to kindly do so.

Other aspects.

Keep terminology consistent, You use either hydration care; hydration management; fluid therapy, hydration assessment, please choose and use consistently.

On page 10, the manuscript states that 9 CPGs correspond to 26%, but if 13 guidelines are included, 9 would represent 69%, not 26%. Please check and correct accordingly

Table 2 could be simplified by grouping guidelines over a relevant variable.

Author Response

Thank you for your time and expertise in reviewing this manuscript. All reviewer comments prompted discussion and revision, and we appreciate your feedback.

Please see the attachment for a detailed response.

 

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

This paper is a revised submission of a report on a systematic review of hydration care in stroke clinical practice guidelines (CPGs) published since 2009.

I thank the authors for addressing my queries

However, there are some issues the authors may wish to address:

1. Lines 2-3, 14, 15, 31, and elsewhere in the paper – I thank the authors for their comment but I maintain that the guidelines covered seem for ‘national’ than ‘international’ use. I suggest that the word ‘international’ be omitted from the title. But perhaps the journal Editor may be best placed to advise if ‘international’ is appropriate
2. Line 34-35 – I thank the authors for their comment, but I maintain the availability and/or quality of the evidence for hydration was not addressed in the study. I suggest this sentence be deleted
3. Lines 35-36 – again, as the paper is not about where the research gaps are, I maintain it would be more appropriate to make a call for guidelines to cover the issues raised by the authors eg who, when and how to assess and monitor hydration, and how to best manage it. Amending ‘research’ to ‘guidelines’ in line 35 would be just right
4. Table 1 – is the dividing line between sections ‘C’ and ‘A’ is still missing in the version I received
5. Fig 1 – I maintain that the numbers removed and reasons for doing so need to be stated and placed in a side box. Please see https://www.prisma-statement.org/prisma-2020-flow-diagram
6. Table 2 – lead author is still missing for Singapore (ref 55), it is incorrect to say that it was not stated in the reference; ‘Venketasubramanian, N.; Pwee, K. H.; Chen, C. P. L. Singapore Ministry of Health Clinical Practice Guidelines on Stroke and 720 Transient Ischemic Attacks. Int J Stroke 2011, 6 (3), 251–258. [CrossRef]’ – this is taken directly from the authors’ reference list….
7. Line 440 – ‘invasive’ – I doubt most clinicians would consider a blood draw as ‘invasive’. I suggest a rephrase ‘is invasive and costly’ to ‘requires blood taking and may be costly’ would be more appropriate
8. Supplement table 3 – as mentioned before, lead author missing for Singapore (ref 55) ‘Venketasubramanian, N.; Pwee, K. H.; Chen, C. P. L. Singapore Ministry of Health Clinical Practice Guidelines on Stroke and 720 Transient Ischemic Attacks. Int J Stroke 2011, 6 (3), 251–258. [CrossRef]’ – this is taken directly from the authors’ reference list….

Author Response

Thank you for your time and expertise, your feedback is appreciated in improving and strengthening the manuscript. Please see the attachment for detailed response. 

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

The revised version shows a clear and meaningful improvement, particularly in its alignment with the nutritional perspective of the journal and in the depth and coherence of the discussion. The manuscript now better frames hydration as a fundamental component of clinical nutrition, which strengthens its relevance for Nutrients.

However, important issues remain. There are several formal and typographical errors that require careful correction, and some methodological aspects still need clarification. Rephrase and strenghten clinical implications and search strategy to provide more actionable insights for practice.

Author Response

Thank you for your time and expertise, your feedback is appreciated in improving and strengthening the manuscript. Please see the attachment for detailed response. 

Author Response File: Author Response.pdf