Review for 10.1186/s12876-023-02813-4 (2023)

Title: Scoring System for Predicting 90-Day Mortality of In-hospital Liver Cirrhosis Patients
at Cipto Mangunkusumo Hospital
Version: 1 Date: 27 Jan 2023
Reviewer's report:
Authors have conducted a nice single center study, with an attempt to come up with a scoring
system for predicting 90-days mortality in those cirrhosis patients who got admitted to the
hospital non electively.
Overall, the authors have made a good effort and  succeed to some extent. However,  I have
some suggestions to improve the paper as noted below.
1. First and foremost there is need to improve the overall grammar, wording and  mistyping
which is present all over the paper. This will help with easily following the paper and improve
its readability. For this I would suggest, to get help from a professional editing agency and/or
use help from those with English as first language.
2. Abstract: Please improve the language, for example, in the background, 4th line----line ending
in "is a rise for concern." Please correct.
3. Background (1): In the first para, please take the redundant language out, example Gani et al,
study you may not mention the name of the hospital and just mention our hospital instead. In the
same para---you are mentioning that 90 day mortality was 54.8% which is around 13% higher
than in your cohort. Please explain the reason for this in the discussion as you are mentioning
that overall mortality of cirrhosis patients has increased in your country.
In 2nd Para, line 2, "external organs of liver" what does this mean, please write clearly. Consider
putting the ref 6 from here in the discussion section and discuss more.
In 3rd Para, Study by Kartoun et al is missing the reference number. Please put this reference
in. For reference, 3 in the same Para, in the beginning, "after the first treatment" ---can you tell
us what this treatment was?
4. Methods (2.2): Under Inclusion criterion please mention what was the inclusion age. Under
exclusion criterion, please mention if any special populations were excluded, like prisoners, etc
and how were patients admitted with  Ongoing Hepatic Encephalopathy recruited?
5. Results (3): In the first Para, I see multiple grammar mistakes and typos, please correct all.
Examples, A total of 195 pts. ----"with" is missing,  Then again, just write 47 patients were
excluded, so on and os forth. In the last line of this para, no need to talk about selection bias
here as you are talking about this in the "limitations section."
In the 2nd Para, Define what is NBNC----etiology wise separately, rather than lumping a bunch
of etiologies here together as NASH cirrhosis is emerging as an important cause of cirrhosis all
over the world. Please just summarize this para and refer the readers to Table. 1 as  there is no
need to repeat the information. However, would also want to see what was the Length of stay
in the hospital between the two groups in Table 1.
In the 3rd Para,  At 90- days, how were the patients followed up? Please mention this explicitly.
How did you know that the patient had died? You are mentioning that the most complications
were----are these the reasons for admission or causes of in patient mortality.
Again, I am not able to get any idea from the results, as to how many patient died during the index
hospitalization and or/were sent to Hospice services? Is it possible to clarify this information.
6. Discussion (4.1): In Ist Para, Non B Non C----Please tell us in detail what is in there, and
what about alcohol related cirrhosis? Please tell us why it is not common in your country if that
is the case.
In 2nd Para, add ref no. for Gani et al.
In 3rd Para, no need to write with a percentage of 42.2%? correct everywhere and just mention
42.2%.
Para 4, ----consider adding this info to Table 1.  and removing his para.
Para 5, Last line, does presence of HE also contribute to death? please mention.
Discussion: 5.3 ---Not sure if this should be 5.3 or 4.3----clarify please.
In Ist Para, Please rewrite information from ref 24 and tell us how it supports/or not your results.
In 2nd Para, you mention that at moderate risk----ICU level of care is required. However, I do
not think we can really make a generalization like this, as ICU beds are hard to come by and we
are able to manage some sicker cirrhosis patients on regular floors as well, albeit with additional
monitoring. However, we are able to get some of the sicker patient to the ICU on case to case
basis. Like if HE patients are obtunded and not able to protect their airways, then only the ICU
teams will accept them other wise these can be mentioned on a regular floor if not other issues
exist.
In Para 3, Ditto discussion fas above for generalization as made by ref 25. Please clarify.
In Para 4, the general scoring systems mentioned are not specific to liver cirrhosis and are used
for a variety of diseases. Please mention this explicitly.
7. Conclusion (5):
Please add a Separate Limitations section before the conclusion and not as you have done right
now in the bottom. Please mention in the limitations, that this is a single center  study with
a small sample size and hence, the conclusions may not be generalizable to other countries/
populations. Mention strengths of your study as well.
In the end, if  your scoring system tells you that the patient has moderate/higher risk for mortality
I think not only should we try to spent more resources on such patients while they are in the
hospital but these should receive intensive support in the outpatient settings including, early
speciality follow ups, case management support and early referral to transplant centers.