Dear Editor and Reviewers, Thank you for your constructive feedback and the opportunity to improve our manuscript. We have carefully addressed all comments and revised the paper accordingly. Below is our point-by-point response to the reviewers' concerns. Changes in the revised manuscript are highlighted in red and blue for ease of review

Meng-meng Zhang¹Rui Xu¹Juan Wang¹Chuanyan Wu¹Huicong Ren¹Zhao-Hui Zhang²Juan Li^1*

• ¹Second Affiliated Hospital of Xinxiang Medical University, Xinxiang, China
• ²The First Affiliated Hospital of Xinxiang Medical University, Xinxiang, Henan Province, China

Background: Electroconvulsive therapy (ECT), a common method used to treat mental disorders, has several side effects, including fever. The purpose of this study was to elucidate the incidence, clinical characteristics, and risk factors related to fever after ECT.Methods: A retrospective study was conducted the medical records of patients who underwent modern ECT at our hospital from April 2019 to January 2020. According to whether the body temperature exceeds 38℃(including 38℃), we divided the patients into the fever group and the non-fever group.Results: A total of 895 patients underwent 7801 units of ECT treatment, of whom 11.6%(n = 104) experienced fever within 24 h after ECT. Overall, fever occurred in 129 units, who had a median maximum temperature (range) of 38.5 (38.0-40.3)℃. Following ECT, 55.8% (72/129) of fever units' temperatures returned to normal body temperature as assessed by clinical observation or by cooling measures, whereas 44.2% (57/129) required cooling combined with antibiotics. Compared to baseline, fever units have higher white blood cell counts, neutrophil counts ( P < 0.001), and lower lymphocyte countsa ( P < 0.001).In 79.8% (103/129) of units, the fever was evident observed during 5-8 h of the ECT treatment was completed, whereas 94.6% (122/129) returned to normal body temperature within 24 h of treatment. Only 5.4% (7/129) of the units opted to stop ECT treatment due to fever. The fever group showed statistically significant differences in age, gender, types of psychiatric ward(closed or open), and anesthetic type (all P < 0.05) but not in the total number of ECT units or diagnoses. Logistic regression analysis 4 identified the risk variables for fever as younger age(≦29), closed psychiatric ward, etomidate injection, and male sex.Fever after ECT is relatively common within the Chinese population.Closed psychiatric wards, the use of etomidate as an anesthetic, male sex, and younger age(≦29)were found to be risk factors for fever after ECT.