Applicability of Anatomic and Physiologic Scoring Systems for the Prediction of Outcome in Polytraumatized Patients with Blunt Aortic Injuries

Round 1

Reviewer 1 Report

Interesting retrospective paper. I would like to know which visual exams (US/CT/MRI) were done for the patients to evaluate aortic wall hematoma, aortic wall rupture, dissection, combined rupture and dissection. 

Author Response

We thank the reviewer for the question. The routine diagnostic modality for diagnosing aortic injuries was a contrast enhanced CT scan of the head, chest and abdomen. Additionally, during the endovascular intervention an aortography was performed. In case of an unclear finding in the CT scan follow-up examinations were done. A transesophageal ultrasound was not performed as part of the standard diagnostic for thoracic aortic injuries.

Reviewer 2 Report

In the paper entitled “Applicability of anatomic and physiologic scoring systems for prediction of the outcome in polytraumatized patients with blunt aortic injuries” the authors describe a study specifically direct to evaluate the applicability of several scoring systems for prediction of the outcome in polytraumatized patients with blunt aortic injuries. In my personal opinion, considering the relevance of the topic for evidence-based clinical decisions this manuscript represents a study that should be published and disseminated across the scientific community. In such context, I would like to suggest that minor revisions could be undertaken to improve the scientific value of the manuscript before its acceptance.

INTRODUCTION

- Some statistics about trauma patients would be beneficial to evaluate the magnitude of the problem under study;

(lines 60-62) Aim(s) of this study deserve to be reconsidered because it misses details and secondary/specific aims that were addressed in this manuscript;

MATERIALS AND METHODS

(line 102) More background on the score calculation could be provided;

(lines 115-123) Details about how many different professionals evaluate imaging results (or if the diagnosis was made based only on Radiologists reports) should be provided.

RESULTS

(line 136) Demographic data provived only on the text could be included in a Table just to help readers in finding relevant information;

DISCUSSION

- A summary of discussion could be the proposed clinical application of some scoring systems, that could be illustrated in a flowchart;

- Future perspectives on this topic should be provided: do the authors intend to evaluate clinical application of this scoring systems according to the findings of this study in a larger sample of patients? Are there any other scoring systems that could be evaluated? Do the authors feel that a new combined scoring system is need for this clinical context?

Author Response

We thank the reviewer for the helpful comments. We took the suggestions to improve the manuscript.

Please find a point-by-point response below. Alternations to the text are indicated in the correction mode in the manuscript itself.

Introduction:

Point 1: Some statistics about trauma patients would be beneficial to evaluate the magnitude of the problem under study.

Response 1:

Thank you for your comment. To highlight the relevance of this topic we added an additional citation at the beginning of the introduction. Rhee at al. have demonstrated in their study that the number of trauma death is rising faster (22.8%) than the US population (9.7%).

Point 2: Aim(s) of this study deserve to be reconsidered because it misses details and secondary/specific aims that were addressed in this manuscript (lines 60-62).

Response 2:

Thank you for this remark. We extended the aim of the study from mortality prediction to correlation analysis for clinical outcome parameters.

Material and Methods: 

Point 3:  More background on the score calculation could be provided (line 102).

Response 3:

Thank you for this comment. We highlighted the fact that prehospital data was used to calculate RTSc. This is a relevant addition, because it prevents a bias from prehospital emergency treatment, but also results in a lower number of data sets.

Point 4: Details about how many different professionals evaluate imaging results (or if the diagnosis was made based only on Radiologists reports) should be provided (lines 115-123).

Response 4:

The evaluation of the imaging data was done by the Institute for Diagnostic and Interventional Radiology. Every data set was evaluated by at least one consultant radiologist. We added this in method part 2.7

Results:

Point 5: Demographic data provived only on the text could be included in a Table just to help readers in finding relevant information (line 136).

Response 5:

We thank you for this suggestion and changed the presentation to a table. (Table 1)

Discussion:

Point 6: A summary of discussion could be the proposed clinical application of some scoring systems, that could be illustrated in a flowchart;

Response 6:

Due to the retrospective character of the study and the special patient collective, a non-validated flow chart for practical application without prior testing in a prospective approach seems to be of limited use. However, we take this valuable note into account in future practical applications.

Point 7: Future perspectives on this topic should be provided: do the authors intend to evaluate clinical application of this scoring systems according to the findings of this study in a larger sample of patients? Are there any other scoring systems that could be evaluated? Do the authors feel that a new combined scoring system is need for this clinical context?

Response 7:

We thank you for this suggestion and added it to the discussion. The only way to increase the number of patients would be a prospective multicenter study. The prospective design could improve the evaluation of RTS and TRISS, which suffered in this study from an impairment caused by missing data.

The current focus has been on “traditional” scoring systems. “Novel” scoring systems like Kampala Trauma Score (KTS); Mechanism, GCS, Age and Pressure (MGAP) and GCS, Age and Pressure (GAP)could be an alternative. These scores are till now not commonly used. We wouldn’t suggest the development of a new scoring system for this patient population, because of the rare occurrence of blunt aortic injuries.

Further revisions were executed according to the reviewer´s suggestions. Alternations to the text are indicated in the correction mode in the manuscript itself.

Author Response File: Author Response.docx

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.