Review for 10.1186/s12876-025-03684-7 (2025)

Title: The Efficacy and Comparison of Upper Gastrointestinal Bleeding Risk Scoring Systems
on Predicting Clinical Outcomes Among Emergency Unit Patients
Version: 1 Date: 07 Jan 2025
Reviewer:  Chikamasa Ichita
Reviewer's report:
This study evaluates the efficacy of four widely used scoring systems (GBS, AIMS65, RS,
and INBS (ABC)) for predicting clinical outcomes in adult emergency unit patients with
upper gastrointestinal bleeding. The authors demonstrated that these scoring systems were
statistically significant predictors of hospitalization, need for blood transfusion, high- and low-
risk classification, and mortality. Additionally, the study highlights that the Rockall score (RS)
was the only scoring system with predictive value for determining the need for endoscopic
intervention, which is an interesting finding.
However, several concerns need to be addressed:
1. Lack of novelty and generalizability:
This study validates previously well-established scoring systems using single-center data. While
the validation of less-studied models can hold significance even in single-center settings, the
scoring systems examined in this study have already been extensively validated in various
populations. The rationale for conducting this study is unclear, given the limited novelty and
generalizability of the findings. If there are compelling reasons for undertaking this study, they
should be more clearly articulated in the introduction to justify its significance.
2. Limited predictive performance for endoscopic intervention:
Although the finding that RS was the only score with predictive value for endoscopic
intervention is noteworthy, the ROC curve analysis indicates that its performance was
suboptimal. Furthermore, as mentioned earlier, the single-center nature of the study limits the
generalizability of this finding, which could lead to misinterpretation.
3. Adherence to TRIPOD guidelines:
Reporting of validation studies should align with the Transparent Reporting of a Multivariable
Prediction Model for Individual Prognosis or Diagnosis (TRIPOD) statement (validation
version). The manuscript would benefit from being revised to comply with these guidelines.
4. Timing of variable measurements:
Prediction models are context-dependent; the timing of variable measurement is critical. It is
unclear whether the variables used in each scoring system were obtained at admission, during
hospitalization, or at another time point. This distinction is important and should be clarified
in the manuscript.
5. Sample size considerations:
The study reports 34 mortality events, yet the event-per-variable (EPV) criterion recommends at
least 10 events per variable. Given that each score comprises three or more variables, the sample
size may not be sufficient to ensure robust validation. This limitation should be explicitly stated
in the discussion.
6. Missing data handling:
The manuscript does not address whether there were missing data and, if so, how they were
managed. Missing data handling strategies, if applicable, should be described in the methods
section to ensure transparency.
Conclusion:
While this study provides useful insights into the performance of these scoring systems in a
single-center setting, addressing the above points would improve the manuscript's clarity, rigor,
and clinical relevance.