Title: Comparative Diagnostic Accuracy of the IOTA SRR and LR2 Scoring Systems for
Discriminating Between Malignant and Benign Adnexal Masses by junior physicians in Chinese
Patients: A Retrospective Observational Study
Version: 3 Date: 12 Sep 2023
Reviewer's report:
Dear Authors,
I hope this message finds you well. Thank you for your efforts in revising the manuscript
titled "Comparative Diagnostic Accuracy of the IOTA SRR and LR2 Scoring Systems for
Discriminating Between Malignant and Benign Adnexal Masses in Chinese Patients: A
Retrospective Observational Study." I appreciate the changes made in response to the previous
review. Below, I provide detailed feedback and recommendations for each section of the revised
manuscript:
Abstract notes:
1.Clarity and Conciseness: The abstract has improved in terms of clarity. However, it should be
made more concise by reducing some of the detailed statistics. Focus on highlighting the main
findings and implications.
2. Missing Key Findings: While you mention the good agreement and high sensitivity
and specificity of the scoring systems, numerical values and confidence intervals for these
performance metrics should be included to enhance clarity.
3. Keywords: Ensure that the keywords section includes broader terms related to ovarian cancer
and ultrasound imaging for improved discoverability.
Introduction notes:
1. Lack of Citations: The introduction would benefit from citations to support the statements
made. Include references to relevant studies and statistics to strengthen the background.
2. Research Gap: Emphasize the research gap and the significance of addressing it. Explain why
it is important to compare these scoring systems in a Chinese patient population.
3. Study Objectives: Explicitly state the primary objectives or research questions that the study
aims to answer to provide clarity to the readers.
4. Language Clarity: Simplify sentences for better readability. For example, rephrase
"Concurrently, due to the scarcity of US experts in China..." to improve comprehension.
5. Motivation: Strengthen the motivation behind the study. Explain the importance of comparing
these scoring systems in the context of clinical practice.
Methods notes:
1. Sample Size and Generalizability: Acknowledge that the sample size might affect the
generalizability of the findings. Discuss how a larger sample size might improve validity and
generalizability explicitly.
2. Patient Selection: Provide more information on how patients were selected or recruited for
the study. Clarify if a consecutive sampling method was used and address potential sources of
selection bias.
3. Training of Junior Physicians: Elaborate on the nature and duration of training for junior
physicians and describe measures taken to ensure the quality of their assessments.
4. Data Collection: Explain how data collection was standardized to minimize bias in
retrospectively collected information. Address the handling of missing data and mention if
sensitivity analyses were conducted.
Results notes:
1. Discussion of Clinical Significance: Discuss the clinical significance of diagnostic accuracy
findings. Explain how the high sensitivity and specificity of the scoring systems might influence
clinical decision-making.
2.Limitations and Generalizability: Expand on the limitations of the study and discuss their
potential impact on results. Address the study's generalizability to other populations or settings.
3. Graphical Representation: Include the actual ROC curve figure and discuss it explicitly in the
results section for better visualization and interpretation.
4. Table Presentation: Clarify the meanings of abbreviations like PPV and NPV (positive
predictive value and negative predictive value) for readers unfamiliar with these terms.
5. Consistency Analysis: Provide more statistical details on the assessment of consistency
between the two scoring systems, including the methods used (e.g., kappa statistics) and the
interpretation of results.
Statistical Analysis notes:
1.Sample Size and Power Analysis: Consider performing a power analysis to justify the sample
size and determine its adequacy for detecting statistically significant differences between the
scoring systems, especially for subgroups.
2. Missing Data Handling: Explicitly address how missing data, if any existed, were handled
in the statistical analysis.
3. Sensitivity Analysis: Conduct sensitivity analyses to assess the robustness of the results,
especially in terms of varying the thresholds used to classify adnexal masses as high or low risk.
Discussion notes:
1. Clinical Implications: Expand on the clinical implications of diagnostic accuracy. Explain
how the findings could be practically applied, particularly for junior physicians.
2. Comparative Analysis: Provide a more detailed comparative analysis of the scoring systems.
Discuss scenarios or patient groups where one system might be preferred over the other and the
advantages or limitations of each.
3. Limitations and Generalizability: Thoroughly discuss the limitations of the study, including
the retrospective data collection and the single-center design. Explain how these limitations
might affect the study's validity and generalizability.
4. Future Directions: Include a section on future research directions. Suggest next steps in
investigating the utility of these scoring systems in clinical practice or potential modifications
to improve their performance.
5. Concluding Remarks: Conclude the discussion section with a concise summary of the main
findings and their clinical relevance to provide readers with a clear takeaway message.
Conclusion notes:
1.Future Directions: Dedicate a section to future research directions, outlining potential avenues
for further investigation in the field.
2. Limitations: Reiterate and emphasize the study's limitations in the conclusion to remind
readers of important considerations when interpreting the findings.
References notes:
1. Reference Updating: Update the reference list with more recent sources to ensure the inclusion
of the most up-to-date information.
2. Consistent Formatting: Ensure consistent formatting and citation style for all references,
including author names, titles, journal names, and publication dates.
3. DOI Links: Provide DOI links for all references when available to facilitate readers' access
to cited articles online and ensure citation accuracy.
4. Journal Title Formatting: Review the formatting of journal titles to maintain consistency
throughout the reference list.
5. Accuracy Check: Double-check the accuracy of all references, including authors' names,
journal titles, publication dates, and page numbers.
6. Diversity of Sources: Consider adding references from different geographical regions or
institutions to provide a broader perspective on ovarian cancer diagnosis and improve source
diversity.
7. Reference Descriptions: In a review paper or research report, include brief descriptions of
each reference's relevance to the study to help readers understand why each source was chosen
and how it contributes to the research.
Incorporating these recommendations will further enhance the clarity, depth, and
comprehensiveness of your manuscript. I appreciate your attention to these details and look
forward to reviewing the revised version of your work.
Sincerely