Review for 10.1186/s12876-024-03586-0 (2025)

Title: A validation Study of Three Early Warning Scores in Early Identification of Gastric
Cancer Patients with Deteriorating Condition after Gastrectomy
Version: 3 Date: 03 Dec 2024
Reviewer:  Anwar Ashraf Abouelnasr
Reviewer's report:
Dear Authors, please address the following points below
-The case group is defined as patients who developed complications within 24 hours post-
surgery. However, it would be beneficial to explicitly state whether these complications were
identified according to a specific clinical definition or protocol. Similarly, for the control group,
clarification is warranted regarding whether the "24-hour period" was selected based on patient
records or designated as a specific observation period following surgery.
-While the handling of missing data through mean imputation is mentioned, this approach may
not always be the most suitable for clinical data, particularly when data points are not missing at
random. It would be advantageous to provide an explanation for the selection of mean imputation
or to acknowledge the limitations associated with this method.
-The reference to the Japanese Clinical Oncology Group (JCOG) criteria for grading
postoperative complications is significant; however, a brief explanation or citation of these
criteria would enhance clarity and comprehension.
-Although the study effectively discusses the utility of the National Early Warning Score
(NEWS) within the context of gastric cancer surgery, the generalizability of the findings could
be strengthened by referencing other surgical populations or diseases. For instance, it would be
insightful to compare the effectiveness of NEWS in gastric cancer patients with its application in
other high-risk surgical groups, such as those undergoing major abdominal surgery or trauma. A
broader discussion regarding the applicability of NEWS across various surgical settings would
enrich the relevance of the study.
-Furthermore, the discussion would benefit from addressing the potential drawbacks of using
NEWS, the Standardized Early Warning Score (SEWS), and the Modified Early Warning Score
(MEWS). Specifically, it is crucial to consider issues related to false positives (patients identified
as at risk who do not deteriorate) and false negatives (patients who deteriorate despite low early
warning scores). This consideration is essential for ensuring that the findings are interpreted in
a realistic context, emphasizing that these tools should complement clinical judgment.
-In addition, the implications of the single-center design on the generalizability of findings to
other hospitals or regions warrant consideration, particularly given that practice patterns, such
as surgical techniques and ICU admission thresholds, may vary significantly across different
settings.
-Lastly, while the Hosmer-Lemeshow test indicates good calibration for all models, it would be
beneficial to elaborate on the real-world implications of this calibration. For example, one should
investigate whether good calibration corresponds to a reduction in unnecessary ICU admissions
or more accurate predictions of patient deterioration in routine clinical practice.