Prevalence and Outcome of Asthma in Adult Patients Admitted to the Emergency Department for COVID-19: A Case-Control Study

Round 1

Reviewer 1 Report

No comments

Author Response

Thank you very much for your favourable opinion on our paper.

We made a minor editing of English language, as suggested by the reviewer.

Reviewer 2 Report

This manuscript is clear and well organized. However, I may require some comments on the following issues.
Title: The title is easy to follow and understand.

Abstract: This section was well-written and easy to understand. In addition, the objective of the study and the state of the art of the study are clear. Furthermore, the keywords should be represented the study. Please match the keywords with the mesh.

Introduction: Based on my review, I recommend that the authors should add various improvements, such as:
- Hypothesis and objectives.
- Add a statement or sentence about whether there are any similar studies that have been done before.
- Add the important issues.

Material and Methods: This section was well-written

Results: Many tables and figures have been used. It is suggested that some ‎of them be explained in the text or presented as supplementary file.

Discussion: The discussion of the study is very comprehensive.
Conclusion: In this part of the manuscript, the authors have been successfully established the conclusion of this research. However, it might be useful if the authors mention the suggestion for forthcoming research.

References: The core references are acceptable, but I think the authors should add the latest references in this manuscript. Please mentioned many high-quality COVID-19 related papers, such as:
https://pubmed.ncbi.nlm.nih.gov/33200716/

https://pubmed.ncbi.nlm.nih.gov/34904379/

https://pubmed.ncbi.nlm.nih.gov/34554905/

Author Response

• “… Furthermore, the keywords should be represented the study. Please match the keywords with the mesh”.

As suggested by the reviewer, we matched the keywords with the MESH.

• Introduction: Based on my review, I recommend that the authors should add various improvements, such as: - Hypothesis and objectives. - Add a statement or sentence about whether there are any similar studies that have been done before. - Add the important issues.

We improved the introduction as suggested by the reviewer.

• Results: Many tables and figures have been used. It is suggested that some ‎of them be explained in the text or presented as supplementary file.

As suggested by the reviewer, we modified the Results section, eliminating 1 table and presenting results in the text.

• Conclusion: In this part of the manuscript, the authors have been successfully established the conclusion of this research. However, it might be useful if the authors mention the suggestion for forthcoming research.

In the Conclusion section, we added suggestion for forthcoming research, as suggested by the referee.

• References: The core references are acceptable, but I think the authors should add the latest references in this manuscript. Please mentioned many high-quality COVID-19 related papers, such as: https://pubmed.ncbi.nlm.nih.gov/33200716/ https://pubmed.ncbi.nlm.nih.gov/34904379/ https://pubmed.ncbi.nlm.nih.gov/34554905/.

We added the suggested references in the References section.

Reviewer 3 Report

I understand the need to fill the gap and define the role that pre-existing asthma has for risk of developing severe COVID-19 disease.  Despite the small sample size for this retrospective study, the study had included a valid control group that were matched for other confounders to eliminate selection bias.  I do however think that maybe a 3:1 ratio of Controls:Case may have been possible given that they had 935 individuals after triage and this increased controls to case ration would havemade the findings more robust. Despite the small sample size the study does show that asthma does not increase the risk for developing severe COVID-19 disease unlike diabetes and hypertension or cardiovascular disease. 

Two minor edits that are required:

Line 59- maybe paint is an inapproprtiate term here, not scientific so I would suggest changing this to ascribe or attribute

Line 278- it is not a thunderstorm- please replace with cytokine "storm"- the thunderstorm is not scientific.

I understand that English is not the authors first language so minor editing is required.

Author Response

• I understand the need to fill the gap and define the role that pre-existing asthma has for risk of developing severe COVID-19 disease. Despite the small sample size for this retrospective study, the study had included a valid control group that were matched for other confounders to eliminate selection bias. I do however think that maybe a 3:1 ratio of Controls: Case may have been possible given that they had 935 individuals after triage and this increased controls to case ration would have made the findings more robust. Despite the small sample size, the study does show that asthma does not increase the risk for developing severe COVID-19 disease unlike diabetes and hypertension or cardiovascular disease.

The reviewer's observation is absolutely correct and to the point. However, we preferred to reduce the number of controls but match them very strictly to cases regarding not only age, sex and race, but also the enrolment period. This, in fact, could have influenced the results, as is known, from many points of view.

• Line 59 - maybe paint is an inappropriate term here, not scientific so I would suggest changing this to ascribe or attribute.

We changed the sentence, modifying the term also as suggested by the reviewer.

• Line 278- it is not a thunderstorm- please replace with cytokine "storm"- the thunderstorm is not scientific.

We have made the change suggested by the reviewer.

• I understand that English is not the authors first language so minor editing is required.

We made a minor editing of English language, as suggested by the reviewer.

Reviewer 4 Report

This work by Maurizio Gabrielli et al tried to assess the prevalence and outcome of patients with asthma admitted to the ED for COVID-19. However, some issues need to be clarified, which strengthens their conclusions.

1.     The manuscript mentions that the available cases are 935, and only 83 patients with asthma were identified (prevalence 8.9%). A smaller percentage of asthma patients, does this affect the judgment?

2.     It’s better to show us the exact age distribution of these 83 asthma patients and the other patients.

3.     In addition, there are some grammar mistakes in the manuscript, please edit the article by a native speaker. 

Author Response

1. The manuscript mentions that the available cases are 935, and only 83 patients with asthma were identified (prevalence 8.9%). A smaller percentage of asthma patients, does this affect the judgment?

We agree with the reviewer that the number of patients with asthma in our population was limited and this issue was also highlighted in the discussion section (limitations of the study). The proportion of patients with asthma in other literature cohorts is similar or sometimes lower. The percentage we found in our cohort was similar to the prevalence of asthma in the general Italian population (see discussion section). Furthermore, the fact that asthma has not shown a higher prevalence in COVID-19 patients admitted to the emergency department suggests that asthmatics do not appear to be at risk of severe forms of SARS-CoV2 infection.

2. It’s better to show us the exact age distribution of these 83 asthma patients and the other patients.

The exact age distribution of patients and controls was the same due to matching. It was showed as suggested by the reviewer in a supplementary file.

3. In addition, there are some grammar mistakes in the manuscript, please edit the article by a native speaker.

We have edited the manuscript by a native English speaker, as suggested by the reviewer.

Round 2

Reviewer 4 Report

The manuscript was adequately modified by the authors. I thought that it can be accepted in current form.