Case Report: Effect of rTMS on urinary incontinence in major vascular neurocognitive disorder

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Repetitive transcranial magnetic stimulation (rTMS) was used in many diseases for its focusing on neural network regulation. However, rTMS on the cortical urination center for acting on urination process remained further study. Case report A 67-year-old female farmer suffered from UI over two weeks. She was diagnosed with major vascular neurocognitive disorder. The patient received rTMS on the bilateral paracentral lobule. Stimulation was administered at 20 Hz with 25 stimulation trains of 30 stimuli each with a 30-second intertrain interval. After a 5-day course of rTMS intervention, the patient reported full awareness of her urination, but her neurocognitive decline had not improved at all. Conclusions In this case of UI with major vascular neurocognitive disorder, rTMS on the bilateral paracentral lobule was applied and therapeutic effect on UI was obvious. 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F1000Research 2024, 12 :1505 ( https://doi.org/10.12688/f1000research.134188.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Case Report Revised Case Report: Effect of rTMS on urinary incontinence in major vascular neurocognitive disorder [version 2; peer review: 1 approved, 1 not approved] Xiaohong Ni 1 , Hongyan Ke 1 , Yu Tian 1 , Lei Zhou 1 , Xin Chen 1 , Yuangao Liao 1 Xiaohong Ni 1 , Hongyan Ke 1 , [...] Yu Tian 1 , Lei Zhou 1 , Xin Chen 1 , Yuangao Liao 1 PUBLISHED 22 May 2024 Author details Author details 1 Department of Neurology, Huanggang Central Hospital of Yangtze University, Yangtze University, Huanggang, Hubei, China Xiaohong Ni Roles: Funding Acquisition, Methodology, Visualization, Writing – Original Draft Preparation Hongyan Ke Roles: Formal Analysis, Methodology, Project Administration, Validation Yu Tian Roles: Data Curation, Methodology Lei Zhou Roles: Investigation, Project Administration, Validation Xin Chen Roles: Methodology, Project Administration, Resources, Validation Yuangao Liao Roles: Conceptualization, Formal Analysis, Funding Acquisition, Supervision, Writing – Original Draft Preparation OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Background Urinary incontinence (UI) was an intractable symptom and many efforts had been made to combat this symptom over the past decades. Repetitive transcranial magnetic stimulation (rTMS) was used in many diseases for its focusing on neural network regulation. However, rTMS on the cortical urination center for acting on urination process remained further study. Case report A 67-year-old female farmer suffered from UI over two weeks. She was diagnosed with major vascular neurocognitive disorder. The patient received rTMS on the bilateral paracentral lobule. Stimulation was administered at 20 Hz with 25 stimulation trains of 30 stimuli each with a 30-second intertrain interval. After a 5-day course of rTMS intervention, the patient reported full awareness of her urination, but her neurocognitive decline had not improved at all. Conclusions In this case of UI with major vascular neurocognitive disorder, rTMS on the bilateral paracentral lobule was applied and therapeutic effect on UI was obvious. READ ALL READ LESS Keywords repetitive transcranial magnetic stimulation, urinary incontinence, vascular neurocognitive disorder Corresponding Author(s) Yuangao Liao ( [email protected] ) Close Corresponding author: Yuangao Liao Competing interests: No competing interests were disclosed. Grant information: This work was financially supported by the Huanggang Science and Technology Bureau (YBXM20230018-3) to Yuangao Liao. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2024 Ni X et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Ni X, Ke H, Tian Y et al. Case Report: Effect of rTMS on urinary incontinence in major vascular neurocognitive disorder [version 2; peer review: 1 approved, 1 not approved] . F1000Research 2024, 12 :1505 ( https://doi.org/10.12688/f1000research.134188.2 ) First published: 27 Nov 2023, 12 :1505 ( https://doi.org/10.12688/f1000research.134188.1 ) Latest published: 22 May 2024, 12 :1505 ( https://doi.org/10.12688/f1000research.134188.2 ) Revised Amendments from Version 1 Firstly, the Abstract has been rewritten in which some statements were rephrased and the last sentence of Background was substituted into the Conclusion. Secondly, almost all of the Introduction has been rewritten. Firstly, the Abstract has been rewritten in which some statements were rephrased and the last sentence of Background was substituted into the Conclusion. Secondly, almost all of the Introduction has been rewritten. See the authors' detailed response to the review by Elizabeta B Mukaetova Ladinska See the authors' detailed response to the review by Penghui Wei READ REVIEWER RESPONSES Introduction UI was one of the most troublesome difficults, especially in ageing and people with dementia. Not only did UI bring a lot of inconvenences to the symptom-bearing family, but also present great challenges to clinicians for its intractable nature. To relieve symptoms of UI, many methods have emerged in past decades, such as physiotherapy, psychological care, manual assistance, behavior therapy, drug therapy, urethral catheterization, and surgical treatment. 1 , 2 Among those invasive methods, pelvic floor muscle training (PFM) was proven to be effective and recommended as the first option, 3 – 5 and series of novel PFM programs were launched. 6 rTMS was also attempted to treat UI in recent years. rTMS was proved to be a safety therapeutic way which was widely used for many kinds of diseases. rTMS effect on disease was depended on the stimulus hotspot, intensity, frequency and pattem. Since rTMS was one of newly emerging therapeutics, more and more explorations about the relationship between rTMS and UI would be accumulated. Here we reported a case of rTMS on UI in a patient suffering probable major vascular neurocognitive disorder for peer discussion. Case report A 67-year-old female Chinese Han farmer suffered from UI over two weeks. She had received intravenous levofloxacin ( Levofloxacin Lactate and Sodium Chloride Injection, Zhejiang Medicine Co., Ltd., 0.4 g qd) and pelvic floor electrical stimulation for a week before her admission, but little therapeutic effect was produced. She was hospitalized in Huanggang Central Hospital of Yangtze University. She had no awareness of her urination. Her caregiver noticed her urination from her soaked clothes and sheets. She was not unconscious and had no paralysis, numbness or ataxia. She did not complain of headache, dizziness, diplopia, or tinnitus and had no difficulty swallowing. She was poor in spirit, appetite and sleep, and her bowel movements required medical assistance. She had no medical records of hypertension, diabetes, heart disease, cerebrovascular disease or head trauma and no substance abuse or mental stimulation. However, over the past several years, she had experienced insidious onset and gradual progression of impaired cognitive function, manifesting in language, memory and perceptual-motor domains. At admission, she was aware but had little interaction with her surroundings. A significant decline in most cognitive domains was found. She had difficulty making out others’ words, and her sentences were hard to understand. Her recent memory was heavily impaired. She hardly made decisions or planned instrumental activities. She scored seven on the mini-mental state examination (MMSE) test with partially preserved language. Her clock drawing task scored therewith only irregularly rounded shape and several numbers out of circle. Her clinical dementia rating (CDR) test score was two. The routine blood tests were normal. The urine routine test showed no inflammatory variation. Serum liver function, kidney function, electrolytes and homocysteine were normal. Serum triglycerides and total cholesterol were elevated to 4.83 mmol/L and 7.0 mmol/L, respectively. Fasting plasma glucose was normal, while serum glycosylated hemoglobin was increased up to 7.2%. Serum thyroid-stimulating hormone, free triiodothyronine and free tetraiodothyronine were normal. Serum vitamin B12 decreased to 129.0 pg/ml. The serum was negative for antibodies against hepatitis C, syphilis, and AIDS. Electrocardiography showed sinus rhythm with no abnormalities in QRS intervals or QT intervals or ST-T changes. Chest computed tomography examination manifested as chronic bronchitis. Color Doppler ultrasound examination of the heart, digestive system, urinary system, and carotid vertebral artery was normal. Magnetic resonance imaging (MRI) of the brain showed patchy lesions around the lateral ventricle and scattered point lesions in the basal ganglia, corona radiata and frontal and parietal subcortical white matter, with features of hypointensity on T1-weighted images and hyperintensity on T2-weighted images. Mild frontal and temporal atrophy were detected, while the midbrain, pons and medulla were retained. Magnetic resonance angiography (MRA) detected carotid and intracranial atherosclerosis with no significant local stenosis. According to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), we diagnosed the case as probable major vascular neurocognitive disorder. The most pressing issue was urinal incontinence. The patient received treatment with repetitive transcranial magnetic stimulation (rTMS). A B65-type figure-eight coil connected to a MagPro X100 stimulator (Magventure Inc.) was used. Resting motor threshold (RMT) was determined by standard methods and not repeated during the treatment course. Active treatment was delivered at 90% RMT intensity. Stimulation was administered at 20 Hz with 25 stimulation trains of 30 stimuli each with a 30-second intertrain interval. The hot spot of stimulation was located at the bilateral paracentral lobule. In addition, intramuscular injection of vitamin B12 and oral medications to control blood sugar and cholesterol were carried out during the rTMS intervention. The symptom of UI was markedly improved since the third rTMS therapeutic day. After a five-day course of rTMS intervention, the patient reported full awareness of her urination. Another two five-day courses of rTMS were administrated, her UI did not relapse but her neurocognitive decline had not improved at all. The scores of MMSE and CDR were the same as before treatment. Discussion In this case, an elderly female patient suffering from UI had received intravenous antibiotics and pelvic floor electrical stimulation for a week before her admission, but little therapeutic effect was produced. After her admission, high-frequency rTMS on the bilateral paracentral lobule was conducted, and her urination function recovered in one week. During the two weeks of rTMS treatment, the symptom of UI disappeared without any fluctuation. Therefore, we speculated that rTMS in cortical urologic centers is useful for the remission of UI. According to the definitions from International Continence Society Standardization of Terminology reports, 7 the patient was classified into the type of continuous urinary incontinence from her storage symptoms. Multiple factors may contribute to the formation of this patient’s condition. In addition to the normal structure of the bladder and urethral canal, proper function of the detrusor muscle, internal and external urethral sphincters, and nervous system plays important roles during the whole urination process. The cerebral cortex and pontine nucleus coordinate the activities of sympathetic and parasympathetic networks with the somatic nervous system through spinal cord conduction tracts. 8 To relieve symptoms of UI, many methods have emerged in past decades, such as physiotherapy, psychological care, manual assistance, behavior therapy, drug therapy, urethral catheterization, and surgical treatment. 1 , 2 Among those invasive methods, pelvic floor muscle training (PFM) was proven to be effective and recommended as the first option, 3 – 5 and a novel PFM program was launched. 6 Based on a series of clinical trials on intravaginal electrical stimulation, 9 transcutaneous electrical nerve stimulation, 10 neuromuscular electrical stimulation 11 and transcutaneous tibial nerve stimulation, 12 Ali et al. , 4 summarized that electrical stimulation was beneficial for improving the symptoms of urge urinary incontinence among people with multiple sclerosis and those with stroke. To cure voiding dysfunction due to spinal cord lesions, sacral neuromodulation (SNM) system implantation is considered to be a safe and effective method in clinical practice. 13 – 16 Averbeck et al. , reviewed recent literature and regarded SNM as a promising therapy for neurogenic lower urinary tract dysfunction in carefully selected patients with incomplete lesions. 17 rTMS was also attempted to treat UI. Yani et al. , reported that high-frequency rTMS in the supplementary motor area (SMA) of the cortex decreased pelvic floor tone, while low-frequency rTMS in the SMA increased pelvic floor tone. 18 A randomized controlled study was ongoing to explore the effect of posterior tibial nerve stimulation (PTNS) and rTMS on the neurogenic bladder with multiple sclerosis. 19 According to a review by Pericolini et al. , spinal cord stimulation (SCS) and TMS for treating lower tract symptoms in MS patients were effective despite a small number of studies. 20 El-Habashy et al. , saw that cortical as well as sacral magnetic stimulation showed a significant effect on lower urinary tract dysfunction in MS patients with underactive bladder rather than overactive bladder. 21 Vacher et al. , collected data from the literature and found that TMS may have a role in the management of pelvic and perineal disorders. 22 Through administrating a series of impulses at specific intensity and frequency on selected brain cortex, 23 rTMS could generate post stimulation changes that affect the resting membrane potential and action potential of the selected area. Then, rTMS may induce morpho-functional modifications by increasing synaptic connectivity and modulating synaptic plasticity. 24 – 27 Cirillo et al. , 28 reported that brain rTMS was a valuable tool for cognitive rehabilitation of mild cognitive impairment through the long-term modulation of the metalloprotease- and metalloprotease-related tissue inhibitor 1 system. In this case of UI in a patient with major vascular neurocognitive disorder, we administered high-frequency rTMS to the bilateral paracentral lobule, and the symptom of UI disappeared quickly. We speculated that the therapeutic mechanism was in line with the effect of rTMS on morpho-functional modifications of neural cells and brain networks. After all, there were several factors that could be attributed to the recovery of the patient’s UI. Firstly, that vitamin B12 supplementation and professional nursing care might help to improve the patient’s urinal symptom. Secondly, the clinical manifestation of vascular neurocognitive disorder tends to fluctuate, so, the urinal incontinence symptom may disappear along with the temporarily relief of vascular neurocognitive disorder. Thirdly, intravenous levofloxacin and pelvic floor electrical stimulation before admission might have an effect on the mitigation of urinal symptoms. Whatever, the patient’s UI began to recover and disappeared just after rTMS treatment was added. For rTMS we focused on the bilateral paracentral lobule, which is the cortical center of urination. So we regarded that rTMS being applied to the bilateral paracentral lobule could be used for treating UI in patients with major vascular neurocognitive disorder. More clinical case collections and controlled trials are needed to verify this result. Informed consent Written informed consent for publication of their clinical details was obtained from the daughter of the patient. Data availability All data underlying the results are available as part of the article and no additional source data are required. Acknowledgments We thank AJE ( https://china.aje.com/ ) for linguistic assistance during the preparation of this manuscript. References 1. Abrams P, et al. : The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Am. J. Obstet. Gynecol. 2002; 187 (1): 116–126. PubMed Abstract | Publisher Full Text 2. Leslie SW, Tadi P, Tayyeb M: Neurogenic Bladder and Neurogenic Lower Urinary Tract Dysfunction. StatPearls. Treasure Island (FL): 2022. 3. Xiang L, et al. : Rehabilitation care of patients with neurogenic bladder after spinal cord injury: A literature review. World J. Clin. Cases. 2023; 11 (1): 57–64. PubMed Abstract | Publisher Full Text | Free Full Text 4. 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PubMed Abstract | Publisher Full Text | Free Full Text 12. Araujo TG, et al. : Transcutaneous tibial nerve home stimulation for overactive bladder in women with Parkinson’s disease: A randomized clinical trial. Neurourol. Urodyn. 2021; 40 (1): 538–548. PubMed Abstract | Publisher Full Text 13. Wang XH, et al. : Application of the first rechargeable sacral neuromodulation system for treatment of neurogenic lower urinary tract dysfunction in China: a case report. Am. J. Transl. Res. 2023; 15 (1): 324–329. PubMed Abstract 14. Chen G, et al. : Effectiveness and safety of sacral neuromodulation on neurogenic bladder and bowel dysfunction in patients with spina bifida. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2021; 35 (11): 1374–1379. PubMed Abstract | Publisher Full Text 15. Shan S, et al. : Video-urodynamics efficacy of sacral neuromodulation for neurogenic bladder guided by three-dimensional imaging CT and C-arm fluoroscopy: a single-center prospective study. Sci. 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Atak Cakir P, et al. : Effect of transcutaneous posterior tibial nerve stimulation and repetitive transcranial magnetic stimulation on neurogenic overactive bladder symptoms in female patients with multiple sclerosis: The study protocol of a randomized controlled study. Front. Neurol. 2022; 13 : 1011502. PubMed Abstract | Publisher Full Text | Free Full Text 20. Pericolini M, et al. : Cortical, Spinal, Sacral, and Peripheral Neuromodulations as Therapeutic Approaches for the Treatment of Lower Urinary Tract Symptoms in Multiple Sclerosis Patients: A Review. Neuromodulation. 2022; 25 (8): 1065–1075. PubMed Abstract | Publisher Full Text 21. El-Habashy H, et al. : The effect of cortical versus sacral repetitive magnetic stimulation on lower urinary tract dysfunction in patients with multiple sclerosis. Acta Neurol. Belg. 2020; 120 (1): 141–147. PubMed Abstract | Publisher Full Text 22. Vacher P, et al. : Interest of transcranial stimulation in pelvic and perineal disorders. Prog. Urol. 2019; 29 (7): 349–359. PubMed Abstract | Publisher Full Text 23. Chou YH, Ton That V, Sundman M: A systematic review and meta-analysis of rTMS effects on cognitive enhancement in mild cognitive impairment and Alzheimer’s disease. Neurobiol. Aging. 2020; 86 : 1–10. PubMed Abstract | Publisher Full Text | Free Full Text 24. Cirillo G, et al. : Neurobiological after-effects of non-invasive brain stimulation. Brain Stimul. 2017; 10 (1): 1–18. PubMed Abstract | Publisher Full Text 25. Esposito S, et al. : Repetitive Transcranial Magnetic Stimulation (rTMS) of Dorsolateral Prefrontal Cortex May Influence Semantic Fluency and Functional Connectivity in Fronto-Parietal Network in Mild Cognitive Impairment (MCI). Biomedicines. 2022; 10 (5). PubMed Abstract | Publisher Full Text | Free Full Text 26. Nagerl UV, et al. : Bidirectional activity-dependent morphological plasticity in hippocampal neurons. Neuron. 2004; 44 (5): 759–767. PubMed Abstract | Publisher Full Text 27. 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PubMed Abstract | Publisher Full Text | Free Full Text Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 27 Nov 2023 ADD YOUR COMMENT Comment Author details Author details 1 Department of Neurology, Huanggang Central Hospital of Yangtze University, Yangtze University, Huanggang, Hubei, China Xiaohong Ni Roles: Funding Acquisition, Methodology, Visualization, Writing – Original Draft Preparation Hongyan Ke Roles: Formal Analysis, Methodology, Project Administration, Validation Yu Tian Roles: Data Curation, Methodology Lei Zhou Roles: Investigation, Project Administration, Validation Xin Chen Roles: Methodology, Project Administration, Resources, Validation Yuangao Liao Roles: Conceptualization, Formal Analysis, Funding Acquisition, Supervision, Writing – Original Draft Preparation Competing interests No competing interests were disclosed. Grant information This work was financially supported by the Huanggang Science and Technology Bureau (YBXM20230018-3) to Yuangao Liao. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (2) version 2 Revised Published: 22 May 2024, 12:1505 https://doi.org/10.12688/f1000research.134188.2 version 1 Published: 27 Nov 2023, 12:1505 https://doi.org/10.12688/f1000research.134188.1 Copyright © 2024 Ni X et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Ni X, Ke H, Tian Y et al. Case Report: Effect of rTMS on urinary incontinence in major vascular neurocognitive disorder [version 2; peer review: 1 approved, 1 not approved] . F1000Research 2024, 12 :1505 ( https://doi.org/10.12688/f1000research.134188.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 2 VERSION 2 PUBLISHED 22 May 2024 Revised Views 0 Cite How to cite this report: Mukaetova Ladinska EB. Reviewer Report For: Case Report: Effect of rTMS on urinary incontinence in major vascular neurocognitive disorder [version 2; peer review: 1 approved, 1 not approved] . F1000Research 2024, 12 :1505 ( https://doi.org/10.5256/f1000research.166609.r281453 ) The direct URL for this report is: https://f1000research.com/articles/12-1505/v2#referee-response-281453 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 19 Jul 2024 Elizabeta B Mukaetova Ladinska , University of Leicester, Leicester,, UK Not Approved VIEWS 0 https://doi.org/10.5256/f1000research.166609.r281453 General comments: I appreciate the additional work the authors have done to the case report. However, the serious issues raised in the first submission remain unattended. The following are listed below: 1) Whether the ... Continue reading READ ALL General comments: I appreciate the additional work the authors have done to the case report. However, the serious issues raised in the first submission remain unattended. The following are listed below: 1) Whether the improvement of UTI was due to the previous UTI treatment one week prior hospitalisation, or the rTMS alone? 2) What does the case report add new to the literature in the field? 3) Was delirium being considered? 4) The English needs attention, i.e. in the abstract…. Introduction section: ‘UI was one of the…’ - this implies that UI was a problem in the past and but not now – is this the case? It is customary to refer to urinary incontinence as urinary tract incontinence, and the abbreviation used is UTI. 5) The Authors need to pay attention to sequence of tenses, and the whole text will benefit from being edited by a specialist in the field, i.e. psychogeriatrician etc. to help with rephrasing some of the statements in relation to the mental state, cognitive and neuroradiological assessments discussed. 6) Addressing delirium would be beneficial (Please refer to comments below). More specific comments: Abstract: From the abstract it is not clear that the case report addresses UI in a person with vascular dementia. The case report description is not sufficient to provide information to the reader. Similarly the conclusion does not read as a conclusion, and it needs to be rewritten to strengthen the case for use of rTMS in people with UI and dementia highlighting the need for further studies in the field, including RCT. The abstract needs to reflect the content of the paper. Introduction: Please explain the abbreviations when it appears first, i.e. Urinary Incontinence (UI). Avoid colloquialisms, i.e. ‘more and more’ – attention to Academic English needs to be improved. Case report: Needs further work and better structuring of the case report. I appreciate that the authors pay attention to the physical state, whereas the cognitive state is commented very vaguely (with MMSE 7/30 and CDR 2), and MRI brain scan comments, but no MRI brain scan added. Was delirium being excluded/considered? The clinical presentation would suggest that the patient may well have had a hypoactive delirium (‘...At admission, she was aware but had little interaction with her surroundings. A significant decline in most cognitive domains was found. She had difficulty making out others’ words, and her sentences were hard to understand. Her recent memory was heavily impaired. She hardly made decisions or planned instrumental activities.’). Has this been considered? Was her cognitive functioning different to her usual behaviour/cognition? This has been also raised in the first review. In conclusion, I would like to say that although the authors have addressed some of my comments like the re-structuring of the text, one of the major concerns raised, that of hypoactive delirium, use of academic terminology, has not been addressed. I personally based on the case report am not convinced about the rTMS efficacy in treating urine incontinence. Although the authors have continued to use 'empty' phrases like 'more and more' etc. that do not add much to the academic presentation/language. I feel that the case report, as it stands, is of a substandard and speculative value. Competing Interests: No competing interests were disclosed. Reviewer Expertise: dementia, Alzheiemr's disease, treatment, diagnosis I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Mukaetova Ladinska EB. Reviewer Report For: Case Report: Effect of rTMS on urinary incontinence in major vascular neurocognitive disorder [version 2; peer review: 1 approved, 1 not approved] . F1000Research 2024, 12 :1505 ( https://doi.org/10.5256/f1000research.166609.r281453 ) The direct URL for this report is: https://f1000research.com/articles/12-1505/v2#referee-response-281453 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Wei P. Reviewer Report For: Case Report: Effect of rTMS on urinary incontinence in major vascular neurocognitive disorder [version 2; peer review: 1 approved, 1 not approved] . F1000Research 2024, 12 :1505 ( https://doi.org/10.5256/f1000research.166609.r281454 ) The direct URL for this report is: https://f1000research.com/articles/12-1505/v2#referee-response-281454 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 27 Jun 2024 Penghui Wei , Shandong University, Qingdao, Shandong, China Approved VIEWS 0 https://doi.org/10.5256/f1000research.166609.r281454 Thanks for the authors' response. They ... Continue reading READ ALL Thanks for the authors' response. They have adequately addressed my all concerns Competing Interests: No competing interests were disclosed. Reviewer Expertise: perioperative neurocognitive disorders; surgery; tDCS; elderly patients; postoperative delirium I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Wei P. Reviewer Report For: Case Report: Effect of rTMS on urinary incontinence in major vascular neurocognitive disorder [version 2; peer review: 1 approved, 1 not approved] . F1000Research 2024, 12 :1505 ( https://doi.org/10.5256/f1000research.166609.r281454 ) The direct URL for this report is: https://f1000research.com/articles/12-1505/v2#referee-response-281454 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 27 Nov 2023 Views 0 Cite How to cite this report: Wei P. Reviewer Report For: Case Report: Effect of rTMS on urinary incontinence in major vascular neurocognitive disorder [version 2; peer review: 1 approved, 1 not approved] . F1000Research 2024, 12 :1505 ( https://doi.org/10.5256/f1000research.147220.r233454 ) The direct URL for this report is: https://f1000research.com/articles/12-1505/v1#referee-response-233454 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 17 Apr 2024 Penghui Wei , Shandong University, Qingdao, Shandong, China Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.147220.r233454 Thank you for inviting me to review the case. The authors introduced an interesting case for resolving the urinary incontinence in major vascular neurocognitive disorder by the repetitive transcranial magnetic stimulation (rTMS). The case actually provided a new idea and method ... Continue reading READ ALL Thank you for inviting me to review the case. The authors introduced an interesting case for resolving the urinary incontinence in major vascular neurocognitive disorder by the repetitive transcranial magnetic stimulation (rTMS). The case actually provided a new idea and method for the major clinical issue. Authors need to address the following concerns before acceptance for indexing. Major concern : did the authors not obtain ethical or family consent before starting the rTMS? As rTMS is a new method uncommonly used for urinary incontinence in clinical practice, it is essential for obtaining the ethical consent. Minor concerns : 1) Abstract: "Many efforts had been made to combat the symptoms of incontinence over the past decades, yet difficulties still remain", the incontinence should be clarified as urinary incontinence; 2) Abstract: there are a lack of treatments before rTMS; 3) Abstract: the conclusion was too absolute since a case was obviously not for a clear result and further studies are still needed. 4) Introduction: the paragraph 1 of the section was almost Duplicated with Abstract. The therapeutic effect was not discussed in the INTRODUCTION. The authors should introduce the conventional method for treating urinary incontinence and emphasized the necessity of rTMS; 5) ethical consent should be added in the section of case report. Is the background of the case’s history and progression described in sufficient detail? No Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: perioperative neurocognitive disorders; surgery; tDCS; elderly patients; postoperative delirium I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Wei P. Reviewer Report For: Case Report: Effect of rTMS on urinary incontinence in major vascular neurocognitive disorder [version 2; peer review: 1 approved, 1 not approved] . F1000Research 2024, 12 :1505 ( https://doi.org/10.5256/f1000research.147220.r233454 ) The direct URL for this report is: https://f1000research.com/articles/12-1505/v1#referee-response-233454 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 26 Jun 2024 yuangao liao , Huanggang Central Hospital of Yangtze University, China 26 Jun 2024 Author Response Dear Penghui Wei, We would sincerely thank you for your time and effort that you have put into reviewing the previous version of this manuscript. Your suggestions have enabled ... Continue reading Dear Penghui Wei, We would sincerely thank you for your time and effort that you have put into reviewing the previous version of this manuscript. Your suggestions have enabled us to improve our work. According to your nice suggestions, we have made extensive corrections to our previous draft and the detailed corrections are labeled on the new version of the manuscript which we hope to meet with approval. For details about the corrections according to your suggestions, here we list them as follows. 1) Firstly, as a matter of fact, we did not obtain ethical consent before starting the rTMS. However, we did all of the treatment on patient according to our clinical team decision and oral consent from the patient’s family. Since rTMS were used in patients of almost all kinds of disease and were proven to be a safe therapeutic way in the past decades, we were not asked to obtain ethical consent before starting rTMS from Ethic Committee of our hospital. Hope you accept our irretrievable deficiency. 2) Secondly, the ABSTRACT and INTRODUCTION have been rewritten that would be matched to the criterion of medical thesis in our perspective. 3) Thirdly, we have rephrased some sentences adopting your sensible suggestion. Thank you a lot for your sincerely instructions which would help us to improve our abilities in clinical practice and research work. Hope you kindly accept our new version. Yours sincerely, Yuangao Liao. Department of neurology, Huanggang Center Hospital, Huanggang, Hubei, China. [email protected] . Dear Penghui Wei, We would sincerely thank you for your time and effort that you have put into reviewing the previous version of this manuscript. Your suggestions have enabled us to improve our work. According to your nice suggestions, we have made extensive corrections to our previous draft and the detailed corrections are labeled on the new version of the manuscript which we hope to meet with approval. For details about the corrections according to your suggestions, here we list them as follows. 1) Firstly, as a matter of fact, we did not obtain ethical consent before starting the rTMS. However, we did all of the treatment on patient according to our clinical team decision and oral consent from the patient’s family. Since rTMS were used in patients of almost all kinds of disease and were proven to be a safe therapeutic way in the past decades, we were not asked to obtain ethical consent before starting rTMS from Ethic Committee of our hospital. Hope you accept our irretrievable deficiency. 2) Secondly, the ABSTRACT and INTRODUCTION have been rewritten that would be matched to the criterion of medical thesis in our perspective. 3) Thirdly, we have rephrased some sentences adopting your sensible suggestion. Thank you a lot for your sincerely instructions which would help us to improve our abilities in clinical practice and research work. Hope you kindly accept our new version. Yours sincerely, Yuangao Liao. Department of neurology, Huanggang Center Hospital, Huanggang, Hubei, China. [email protected] . Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 26 Jun 2024 yuangao liao , Huanggang Central Hospital of Yangtze University, China 26 Jun 2024 Author Response Dear Penghui Wei, We would sincerely thank you for your time and effort that you have put into reviewing the previous version of this manuscript. Your suggestions have enabled ... Continue reading Dear Penghui Wei, We would sincerely thank you for your time and effort that you have put into reviewing the previous version of this manuscript. Your suggestions have enabled us to improve our work. According to your nice suggestions, we have made extensive corrections to our previous draft and the detailed corrections are labeled on the new version of the manuscript which we hope to meet with approval. For details about the corrections according to your suggestions, here we list them as follows. 1) Firstly, as a matter of fact, we did not obtain ethical consent before starting the rTMS. However, we did all of the treatment on patient according to our clinical team decision and oral consent from the patient’s family. Since rTMS were used in patients of almost all kinds of disease and were proven to be a safe therapeutic way in the past decades, we were not asked to obtain ethical consent before starting rTMS from Ethic Committee of our hospital. Hope you accept our irretrievable deficiency. 2) Secondly, the ABSTRACT and INTRODUCTION have been rewritten that would be matched to the criterion of medical thesis in our perspective. 3) Thirdly, we have rephrased some sentences adopting your sensible suggestion. Thank you a lot for your sincerely instructions which would help us to improve our abilities in clinical practice and research work. Hope you kindly accept our new version. Yours sincerely, Yuangao Liao. Department of neurology, Huanggang Center Hospital, Huanggang, Hubei, China. [email protected] . Dear Penghui Wei, We would sincerely thank you for your time and effort that you have put into reviewing the previous version of this manuscript. Your suggestions have enabled us to improve our work. According to your nice suggestions, we have made extensive corrections to our previous draft and the detailed corrections are labeled on the new version of the manuscript which we hope to meet with approval. For details about the corrections according to your suggestions, here we list them as follows. 1) Firstly, as a matter of fact, we did not obtain ethical consent before starting the rTMS. However, we did all of the treatment on patient according to our clinical team decision and oral consent from the patient’s family. Since rTMS were used in patients of almost all kinds of disease and were proven to be a safe therapeutic way in the past decades, we were not asked to obtain ethical consent before starting rTMS from Ethic Committee of our hospital. Hope you accept our irretrievable deficiency. 2) Secondly, the ABSTRACT and INTRODUCTION have been rewritten that would be matched to the criterion of medical thesis in our perspective. 3) Thirdly, we have rephrased some sentences adopting your sensible suggestion. Thank you a lot for your sincerely instructions which would help us to improve our abilities in clinical practice and research work. Hope you kindly accept our new version. Yours sincerely, Yuangao Liao. Department of neurology, Huanggang Center Hospital, Huanggang, Hubei, China. [email protected] . Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Mukaetova Ladinska EB. Reviewer Report For: Case Report: Effect of rTMS on urinary incontinence in major vascular neurocognitive disorder [version 2; peer review: 1 approved, 1 not approved] . F1000Research 2024, 12 :1505 ( https://doi.org/10.5256/f1000research.147220.r239435 ) The direct URL for this report is: https://f1000research.com/articles/12-1505/v1#referee-response-239435 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 26 Feb 2024 Elizabeta B Mukaetova Ladinska , University of Leicester, Leicester,, UK Not Approved VIEWS 0 https://doi.org/10.5256/f1000research.147220.r239435 Abstract is not connected to the case report. Especially the introduction requires rephrasing of some statements required. i.e. ‘To stimulate the cortical urination centre might theoretically be useful for regulating urination process.’ The background last sentence. In this case of ... Continue reading READ ALL Abstract is not connected to the case report. Especially the introduction requires rephrasing of some statements required. i.e. ‘To stimulate the cortical urination centre might theoretically be useful for regulating urination process.’ The background last sentence. In this case of urinary incontinence with major vascular neurocognitive disorder, repetitive transcranial magnetic stimulation (rTMS) on the bilateral paracentral lobule was applied and therapeutic effect was obvious.’ is best suited to conclusion. Case report: Introduction needs rewriting, raising the importance of addressing incontinence in both ageing and people with dementia. This needs to be better documented, and concentrating on introducing the importance of the topic, and therapeutic issues around it. I would suggest the authors to avoid sentences that do not add much to the text, i.e. ‘Efforts to combat the symptoms of incontinence have been made over the past decades, yet difficulties still remain.’ If using such statements, please rephrase it and document it. The second part of the introduction is part of the discussion/conclusion, and not introduction. The case report needs to be better structured I wonder why authors did not exclude hypoactive delirium as one of he differential diagnosis? Vitamin B12 deficiency can lead to delirium and authors’ discussion points towards its regulation contributing to improvement in both physical and mental state. There is not documentation of CRP, or the reasons why patients required inpatient admission (the latter points towards seriousness of patient’s physical state), or when the Vitamin B12 blood levels were normalised, i.e. whether this coincided with regulation of urine incontinence. Also, why implementing rTMS before physical state is normalised? Was the patient assessed for delirium with CAM or AT4? The case presentation and discussion indicate that the use of rTMS in this case are highly speculative, with other studies conducted in this areas requiring further confirmation. Is the background of the case’s history and progression described in sufficient detail? No Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? No Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? No Is the case presented with sufficient detail to be useful for other practitioners? No Competing Interests: No competing interests were disclosed. Reviewer Expertise: dementia, Alzheiemr's disease, treatment, diagnosis I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Mukaetova Ladinska EB. Reviewer Report For: Case Report: Effect of rTMS on urinary incontinence in major vascular neurocognitive disorder [version 2; peer review: 1 approved, 1 not approved] . F1000Research 2024, 12 :1505 ( https://doi.org/10.5256/f1000research.147220.r239435 ) The direct URL for this report is: https://f1000research.com/articles/12-1505/v1#referee-response-239435 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 26 Jun 2024 yuangao liao , Huanggang Central Hospital of Yangtze University, China 26 Jun 2024 Author Response Dear Elizabeta B Mukaetova Ladinska, We would sincerely thank you for your time and effort that you have put into reviewing the previous version of this manuscript. Your suggestions ... Continue reading Dear Elizabeta B Mukaetova Ladinska, We would sincerely thank you for your time and effort that you have put into reviewing the previous version of this manuscript. Your suggestions have enabled us to improve our work. According to your nice suggestions, we have made extensive corrections to our previous draft and the detailed corrections are labeled on the new version of the manuscript which we hope to meet with approval. For details about the corrections according to your suggestions, here we list them as follows. 1) Firstly, the ABSTRACT have been rewritten in which some statements was rephrased and the last sentence of BACKGROUND was been substituted into CONCLUSION. 2) Secondly, almost all of the INTRODUCTION have been rewritten that would be matched to the criterion of introduction in our perspective. 3) Thirdly, that we did not make differential diagnosis about hypoactive delirium in part of CASE REPORT was an irreparable deficiency. The reason that we did not assess the patient with CAM or AT4 was that we had experientially excluded the diagnosis of delirium at our first glance. In fact, we might do more to improve our scientific strictness when preparing an academic report. 4) Fourthly, it was about the effect of vitamin B12 supplement on patient’s psychiatric status. We had mentioned in the last paragraph of DISCUSSION that all other symptoms except for urinary incontinence did not alleviate at all. Based on this, we speculated that vitamin B12 supplement did not effect on urinary incontinence improvement in our observational period. 5) Lastly, there were others questions in part of CASE REPORT such as documentation of CRP, reasons of inpatient admission and implementing rTMS before physical state normalized. We hardly make comprehensive explanations to them, but we declare that we did those clinical practices according to our team decision and oral consent from the patient’s family. Thank you a lot for your sincerely instructions which would help us to improve our abilities in clinical practice and research work. Hope you kindly accept our new version. Yours sincerely, Yuangao Liao. Department of neurology, Huanggang Center Hospital, Huanggang, Hubei, China. [email protected] . Dear Elizabeta B Mukaetova Ladinska, We would sincerely thank you for your time and effort that you have put into reviewing the previous version of this manuscript. Your suggestions have enabled us to improve our work. According to your nice suggestions, we have made extensive corrections to our previous draft and the detailed corrections are labeled on the new version of the manuscript which we hope to meet with approval. For details about the corrections according to your suggestions, here we list them as follows. 1) Firstly, the ABSTRACT have been rewritten in which some statements was rephrased and the last sentence of BACKGROUND was been substituted into CONCLUSION. 2) Secondly, almost all of the INTRODUCTION have been rewritten that would be matched to the criterion of introduction in our perspective. 3) Thirdly, that we did not make differential diagnosis about hypoactive delirium in part of CASE REPORT was an irreparable deficiency. The reason that we did not assess the patient with CAM or AT4 was that we had experientially excluded the diagnosis of delirium at our first glance. In fact, we might do more to improve our scientific strictness when preparing an academic report. 4) Fourthly, it was about the effect of vitamin B12 supplement on patient’s psychiatric status. We had mentioned in the last paragraph of DISCUSSION that all other symptoms except for urinary incontinence did not alleviate at all. Based on this, we speculated that vitamin B12 supplement did not effect on urinary incontinence improvement in our observational period. 5) Lastly, there were others questions in part of CASE REPORT such as documentation of CRP, reasons of inpatient admission and implementing rTMS before physical state normalized. We hardly make comprehensive explanations to them, but we declare that we did those clinical practices according to our team decision and oral consent from the patient’s family. Thank you a lot for your sincerely instructions which would help us to improve our abilities in clinical practice and research work. Hope you kindly accept our new version. Yours sincerely, Yuangao Liao. Department of neurology, Huanggang Center Hospital, Huanggang, Hubei, China. [email protected] . Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 26 Jun 2024 yuangao liao , Huanggang Central Hospital of Yangtze University, China 26 Jun 2024 Author Response Dear Elizabeta B Mukaetova Ladinska, We would sincerely thank you for your time and effort that you have put into reviewing the previous version of this manuscript. Your suggestions ... Continue reading Dear Elizabeta B Mukaetova Ladinska, We would sincerely thank you for your time and effort that you have put into reviewing the previous version of this manuscript. Your suggestions have enabled us to improve our work. According to your nice suggestions, we have made extensive corrections to our previous draft and the detailed corrections are labeled on the new version of the manuscript which we hope to meet with approval. For details about the corrections according to your suggestions, here we list them as follows. 1) Firstly, the ABSTRACT have been rewritten in which some statements was rephrased and the last sentence of BACKGROUND was been substituted into CONCLUSION. 2) Secondly, almost all of the INTRODUCTION have been rewritten that would be matched to the criterion of introduction in our perspective. 3) Thirdly, that we did not make differential diagnosis about hypoactive delirium in part of CASE REPORT was an irreparable deficiency. The reason that we did not assess the patient with CAM or AT4 was that we had experientially excluded the diagnosis of delirium at our first glance. In fact, we might do more to improve our scientific strictness when preparing an academic report. 4) Fourthly, it was about the effect of vitamin B12 supplement on patient’s psychiatric status. We had mentioned in the last paragraph of DISCUSSION that all other symptoms except for urinary incontinence did not alleviate at all. Based on this, we speculated that vitamin B12 supplement did not effect on urinary incontinence improvement in our observational period. 5) Lastly, there were others questions in part of CASE REPORT such as documentation of CRP, reasons of inpatient admission and implementing rTMS before physical state normalized. We hardly make comprehensive explanations to them, but we declare that we did those clinical practices according to our team decision and oral consent from the patient’s family. Thank you a lot for your sincerely instructions which would help us to improve our abilities in clinical practice and research work. Hope you kindly accept our new version. Yours sincerely, Yuangao Liao. Department of neurology, Huanggang Center Hospital, Huanggang, Hubei, China. [email protected] . Dear Elizabeta B Mukaetova Ladinska, We would sincerely thank you for your time and effort that you have put into reviewing the previous version of this manuscript. Your suggestions have enabled us to improve our work. According to your nice suggestions, we have made extensive corrections to our previous draft and the detailed corrections are labeled on the new version of the manuscript which we hope to meet with approval. For details about the corrections according to your suggestions, here we list them as follows. 1) Firstly, the ABSTRACT have been rewritten in which some statements was rephrased and the last sentence of BACKGROUND was been substituted into CONCLUSION. 2) Secondly, almost all of the INTRODUCTION have been rewritten that would be matched to the criterion of introduction in our perspective. 3) Thirdly, that we did not make differential diagnosis about hypoactive delirium in part of CASE REPORT was an irreparable deficiency. The reason that we did not assess the patient with CAM or AT4 was that we had experientially excluded the diagnosis of delirium at our first glance. In fact, we might do more to improve our scientific strictness when preparing an academic report. 4) Fourthly, it was about the effect of vitamin B12 supplement on patient’s psychiatric status. We had mentioned in the last paragraph of DISCUSSION that all other symptoms except for urinary incontinence did not alleviate at all. Based on this, we speculated that vitamin B12 supplement did not effect on urinary incontinence improvement in our observational period. 5) Lastly, there were others questions in part of CASE REPORT such as documentation of CRP, reasons of inpatient admission and implementing rTMS before physical state normalized. We hardly make comprehensive explanations to them, but we declare that we did those clinical practices according to our team decision and oral consent from the patient’s family. Thank you a lot for your sincerely instructions which would help us to improve our abilities in clinical practice and research work. Hope you kindly accept our new version. Yours sincerely, Yuangao Liao. Department of neurology, Huanggang Center Hospital, Huanggang, Hubei, China. [email protected] . Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 27 Nov 2023 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 2 (revision) 22 May 24 read read Version 1 27 Nov 23 read read Elizabeta B Mukaetova Ladinska , University of Leicester, Leicester,, UK Penghui Wei , Shandong University, Qingdao, China Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Mukaetova Ladinska E. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 19 Jul 2024 | for Version 2 Elizabeta B Mukaetova Ladinska , University of Leicester, Leicester,, UK 0 Views copyright © 2024 Mukaetova Ladinska E. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions General comments: I appreciate the additional work the authors have done to the case report. However, the serious issues raised in the first submission remain unattended. The following are listed below: 1) Whether the improvement of UTI was due to the previous UTI treatment one week prior hospitalisation, or the rTMS alone? 2) What does the case report add new to the literature in the field? 3) Was delirium being considered? 4) The English needs attention, i.e. in the abstract…. Introduction section: ‘UI was one of the…’ - this implies that UI was a problem in the past and but not now – is this the case? It is customary to refer to urinary incontinence as urinary tract incontinence, and the abbreviation used is UTI. 5) The Authors need to pay attention to sequence of tenses, and the whole text will benefit from being edited by a specialist in the field, i.e. psychogeriatrician etc. to help with rephrasing some of the statements in relation to the mental state, cognitive and neuroradiological assessments discussed. 6) Addressing delirium would be beneficial (Please refer to comments below). More specific comments: Abstract: From the abstract it is not clear that the case report addresses UI in a person with vascular dementia. The case report description is not sufficient to provide information to the reader. Similarly the conclusion does not read as a conclusion, and it needs to be rewritten to strengthen the case for use of rTMS in people with UI and dementia highlighting the need for further studies in the field, including RCT. The abstract needs to reflect the content of the paper. Introduction: Please explain the abbreviations when it appears first, i.e. Urinary Incontinence (UI). Avoid colloquialisms, i.e. ‘more and more’ – attention to Academic English needs to be improved. Case report: Needs further work and better structuring of the case report. I appreciate that the authors pay attention to the physical state, whereas the cognitive state is commented very vaguely (with MMSE 7/30 and CDR 2), and MRI brain scan comments, but no MRI brain scan added. Was delirium being excluded/considered? The clinical presentation would suggest that the patient may well have had a hypoactive delirium (‘...At admission, she was aware but had little interaction with her surroundings. A significant decline in most cognitive domains was found. She had difficulty making out others’ words, and her sentences were hard to understand. Her recent memory was heavily impaired. She hardly made decisions or planned instrumental activities.’). Has this been considered? Was her cognitive functioning different to her usual behaviour/cognition? This has been also raised in the first review. In conclusion, I would like to say that although the authors have addressed some of my comments like the re-structuring of the text, one of the major concerns raised, that of hypoactive delirium, use of academic terminology, has not been addressed. I personally based on the case report am not convinced about the rTMS efficacy in treating urine incontinence. Although the authors have continued to use 'empty' phrases like 'more and more' etc. that do not add much to the academic presentation/language. I feel that the case report, as it stands, is of a substandard and speculative value. Competing Interests No competing interests were disclosed. Reviewer Expertise dementia, Alzheiemr's disease, treatment, diagnosis I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. reply Respond to this report Responses (0) Mukaetova Ladinska EB. Peer Review Report For: Case Report: Effect of rTMS on urinary incontinence in major vascular neurocognitive disorder [version 2; peer review: 1 approved, 1 not approved] . F1000Research 2024, 12 :1505 ( https://doi.org/10.5256/f1000research.166609.r281453) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-1505/v2#referee-response-281453 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Wei P. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 27 Jun 2024 | for Version 2 Penghui Wei , Shandong University, Qingdao, Shandong, China 0 Views copyright © 2024 Wei P. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Thanks for the authors' response. They have adequately addressed my all concerns Competing Interests No competing interests were disclosed. Reviewer Expertise perioperative neurocognitive disorders; surgery; tDCS; elderly patients; postoperative delirium I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Wei P. Peer Review Report For: Case Report: Effect of rTMS on urinary incontinence in major vascular neurocognitive disorder [version 2; peer review: 1 approved, 1 not approved] . F1000Research 2024, 12 :1505 ( https://doi.org/10.5256/f1000research.166609.r281454) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-1505/v2#referee-response-281454 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Wei P. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 17 Apr 2024 | for Version 1 Penghui Wei , Shandong University, Qingdao, Shandong, China 0 Views copyright © 2024 Wei P. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Thank you for inviting me to review the case. The authors introduced an interesting case for resolving the urinary incontinence in major vascular neurocognitive disorder by the repetitive transcranial magnetic stimulation (rTMS). The case actually provided a new idea and method for the major clinical issue. Authors need to address the following concerns before acceptance for indexing. Major concern : did the authors not obtain ethical or family consent before starting the rTMS? As rTMS is a new method uncommonly used for urinary incontinence in clinical practice, it is essential for obtaining the ethical consent. Minor concerns : 1) Abstract: "Many efforts had been made to combat the symptoms of incontinence over the past decades, yet difficulties still remain", the incontinence should be clarified as urinary incontinence; 2) Abstract: there are a lack of treatments before rTMS; 3) Abstract: the conclusion was too absolute since a case was obviously not for a clear result and further studies are still needed. 4) Introduction: the paragraph 1 of the section was almost Duplicated with Abstract. The therapeutic effect was not discussed in the INTRODUCTION. The authors should introduce the conventional method for treating urinary incontinence and emphasized the necessity of rTMS; 5) ethical consent should be added in the section of case report. Is the background of the case’s history and progression described in sufficient detail? No Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise perioperative neurocognitive disorders; surgery; tDCS; elderly patients; postoperative delirium I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 26 Jun 2024 yuangao liao, Huanggang Central Hospital of Yangtze University, China Dear Penghui Wei, We would sincerely thank you for your time and effort that you have put into reviewing the previous version of this manuscript. Your suggestions have enabled us to improve our work. According to your nice suggestions, we have made extensive corrections to our previous draft and the detailed corrections are labeled on the new version of the manuscript which we hope to meet with approval. For details about the corrections according to your suggestions, here we list them as follows. 1) Firstly, as a matter of fact, we did not obtain ethical consent before starting the rTMS. However, we did all of the treatment on patient according to our clinical team decision and oral consent from the patient’s family. Since rTMS were used in patients of almost all kinds of disease and were proven to be a safe therapeutic way in the past decades, we were not asked to obtain ethical consent before starting rTMS from Ethic Committee of our hospital. Hope you accept our irretrievable deficiency. 2) Secondly, the ABSTRACT and INTRODUCTION have been rewritten that would be matched to the criterion of medical thesis in our perspective. 3) Thirdly, we have rephrased some sentences adopting your sensible suggestion. Thank you a lot for your sincerely instructions which would help us to improve our abilities in clinical practice and research work. Hope you kindly accept our new version. Yours sincerely, Yuangao Liao. Department of neurology, Huanggang Center Hospital, Huanggang, Hubei, China. [email protected] . View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Wei P. Peer Review Report For: Case Report: Effect of rTMS on urinary incontinence in major vascular neurocognitive disorder [version 2; peer review: 1 approved, 1 not approved] . F1000Research 2024, 12 :1505 ( https://doi.org/10.5256/f1000research.147220.r233454) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-1505/v1#referee-response-233454 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Mukaetova Ladinska E. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 26 Feb 2024 | for Version 1 Elizabeta B Mukaetova Ladinska , University of Leicester, Leicester,, UK 0 Views copyright © 2024 Mukaetova Ladinska E. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Abstract is not connected to the case report. Especially the introduction requires rephrasing of some statements required. i.e. ‘To stimulate the cortical urination centre might theoretically be useful for regulating urination process.’ The background last sentence. In this case of urinary incontinence with major vascular neurocognitive disorder, repetitive transcranial magnetic stimulation (rTMS) on the bilateral paracentral lobule was applied and therapeutic effect was obvious.’ is best suited to conclusion. Case report: Introduction needs rewriting, raising the importance of addressing incontinence in both ageing and people with dementia. This needs to be better documented, and concentrating on introducing the importance of the topic, and therapeutic issues around it. I would suggest the authors to avoid sentences that do not add much to the text, i.e. ‘Efforts to combat the symptoms of incontinence have been made over the past decades, yet difficulties still remain.’ If using such statements, please rephrase it and document it. The second part of the introduction is part of the discussion/conclusion, and not introduction. The case report needs to be better structured I wonder why authors did not exclude hypoactive delirium as one of he differential diagnosis? Vitamin B12 deficiency can lead to delirium and authors’ discussion points towards its regulation contributing to improvement in both physical and mental state. There is not documentation of CRP, or the reasons why patients required inpatient admission (the latter points towards seriousness of patient’s physical state), or when the Vitamin B12 blood levels were normalised, i.e. whether this coincided with regulation of urine incontinence. Also, why implementing rTMS before physical state is normalised? Was the patient assessed for delirium with CAM or AT4? The case presentation and discussion indicate that the use of rTMS in this case are highly speculative, with other studies conducted in this areas requiring further confirmation. Is the background of the case’s history and progression described in sufficient detail? No Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? No Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? No Is the case presented with sufficient detail to be useful for other practitioners? No Competing Interests No competing interests were disclosed. Reviewer Expertise dementia, Alzheiemr's disease, treatment, diagnosis I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. reply Respond to this report Responses (1) Author Response 26 Jun 2024 yuangao liao, Huanggang Central Hospital of Yangtze University, China Dear Elizabeta B Mukaetova Ladinska, We would sincerely thank you for your time and effort that you have put into reviewing the previous version of this manuscript. Your suggestions have enabled us to improve our work. According to your nice suggestions, we have made extensive corrections to our previous draft and the detailed corrections are labeled on the new version of the manuscript which we hope to meet with approval. For details about the corrections according to your suggestions, here we list them as follows. 1) Firstly, the ABSTRACT have been rewritten in which some statements was rephrased and the last sentence of BACKGROUND was been substituted into CONCLUSION. 2) Secondly, almost all of the INTRODUCTION have been rewritten that would be matched to the criterion of introduction in our perspective. 3) Thirdly, that we did not make differential diagnosis about hypoactive delirium in part of CASE REPORT was an irreparable deficiency. The reason that we did not assess the patient with CAM or AT4 was that we had experientially excluded the diagnosis of delirium at our first glance. In fact, we might do more to improve our scientific strictness when preparing an academic report. 4) Fourthly, it was about the effect of vitamin B12 supplement on patient’s psychiatric status. We had mentioned in the last paragraph of DISCUSSION that all other symptoms except for urinary incontinence did not alleviate at all. Based on this, we speculated that vitamin B12 supplement did not effect on urinary incontinence improvement in our observational period. 5) Lastly, there were others questions in part of CASE REPORT such as documentation of CRP, reasons of inpatient admission and implementing rTMS before physical state normalized. We hardly make comprehensive explanations to them, but we declare that we did those clinical practices according to our team decision and oral consent from the patient’s family. Thank you a lot for your sincerely instructions which would help us to improve our abilities in clinical practice and research work. Hope you kindly accept our new version. Yours sincerely, Yuangao Liao. Department of neurology, Huanggang Center Hospital, Huanggang, Hubei, China. [email protected] . View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Mukaetova Ladinska EB. Peer Review Report For: Case Report: Effect of rTMS on urinary incontinence in major vascular neurocognitive disorder [version 2; peer review: 1 approved, 1 not approved] . F1000Research 2024, 12 :1505 ( https://doi.org/10.5256/f1000research.147220.r239435) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-1505/v1#referee-response-239435 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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