Review for 10.1186/s12876-025-03677-6 (2025)

Title: Development and evaluation of a predictive model of upper gastrointestinal bleeding in
liver cirrhosis
Version: 1 Date: 26 Nov 2024
Reviewer's report:
The authors collected baseline information and clinical data for 291 patients with cirrhosis,
aimed to identify risk factors for upper gastrointestinal bleeding (UGIB), and developed a
predictive model. However, the study's description is unclear, making it difficult to understand
the entire research process. One key question is whether the patients had UGIB at baseline. If
UGIB was present, the study appears to compare baseline differences between UGIB and non-
UGIB patients to develop a nomogram (as inferred from the authors’ results). However, the
mention of follow-up is confusing. Were all patients free of UGIB at baseline, and did the authors
follow them for six months to observe UGIB occurrence before developing the nomogram? If
so, why was Cox regression not used?
The following suggestions may improve the completeness of the manuscript:
1.The variable selection method based on simple logistic regression, which could lead to
significant multicollinearity among included variables. The authors should conduct collinearity
analysis or generate a correlation heatmap.
2.“Studies have shown that certain laboratory markers, such as total bilirubin (TBIL), serum
creatinine (Scr), and total cholesterol (TC), along with clinical assessments like liver stiffness
(LS), spleen stiffness (SS), and the presence of abdominal fluid, are associated with the
occurrence of UGIB in cirrhotic patients. Although some clinical studies support these findings,
their sample sizes are small, and the critical values vary.” This section lacks references.
3.Please confirm whether this is a prospective or retrospective study. If prospective,why data
collection performed using electronic health records? But, the abstract describes the study as
“retrospectively enrolled.”
4..A detailed description of the patient enrollment process is needed. For retrospective studies,
the diagnostic codes(ICD-codes#used to identify patients should be included.
5.The sentence “Patients in the cirrhosis group must meet the diagnostic criteria for upper
gastrointestinal bleeding” appears to contain an error. Were all cirrhotic patients required to
meet UGIB diagnostic criteria? Please clarify.
6.The phrase “patients can cooperate with long-term follow-up” is unclear. Was a follow-up
period defined? Does whether patients completed follow-up affect the results?
7.How were patients with a history of UGIB managed? Such patients have a significantly higher
risk of UGIB recurrence, which may impact results.
8.The term “cirrhotic UGIB group” is uncommon. Did this refer to esophagogastric variceal
hemorrhage (EGVH)? If a cirrhotic patient has UGIB caused by peptic ulcer bleeding, does this
also qualify as “cirrhotic UGIB”? Please clarify.
9.Were patients receiving antiviral therapy or nonselective beta-blockers (NSBBs) included?
These treatments significantly influence UGIB risk.
10.How was missing data handled? Were patients with missing data excluded?
11.The variable selection process (univariate followed by multivariate analysis) is overly
simplistic. At least stepwise regression should be used.
12.Figure 1 duplicates the information already presented in Table 1. It would be more appropriate
to replace Figure 1 with a flowchart illustrating the patient inclusion process.
13.The reported UGIB rate of 48.1% (140/291) is unusually high and inconsistent with
epidemiological data. Please confirm whether all eligible cases from the study period were
included.
14.Age and sex were not included in univariate or multivariate analyses, but previous studies
suggest that age is a risk factor for UGIB and should be analyzed.
15.The discussion mentions several models (e.g., Child-Pugh score, MELD, ALBI, Yang LB
et al.). Why were ROC and DCA comparisons not performed between the proposed model and
these established models?
16.The predictive model was not validated. Cross-validation or bootstrap validation is essential,
especially given the limited sample size.
17.The manuscript states that the follow-up period was six months. Were only patients without
UGIB at baseline followed to observe UGIB occurrence? Clarification is required.
18.Reporting guidelines (e.g., TRIPOD) should be included.
19.The authors are advised to avoid using the term “early” in the title, as clinical guidelines
provide a specific definition for “early”EGVH in cirrhotic patients. This study is a case-control
design comparing UGIB and non-UGIB groups and does not define “early.”
20.Professional English editing is recommended, as the manuscript contains multiple
grammatical and stylistic errors.