Reviewer ’s report  
 
Title: Predictors of fifty days in -hospital mortality in patients with culture negative neutrocytic  
ascites  
 
Version: 0 Date: 30 Nov 2016  
 
Reviewer: Valentina Medici  
 
Reviewe r's report:  
 
This manuscript presents a study on a series of 170 cases of culture negative neutrocytic ascites 
admitted to intensive care unit. The study tried to identify predictors of 50 -day mortality among 
the 67 subjects who died  with the diagnosis of culture negative neutrocytic ascites. The major 
finding of the study was that aspartate aminotransferase (AST) levels >71 was a predictor of 
mortality with sensitivity and specific of 60% and 70% respectively. Other predictors of 
mortality, but with less predictive ability, included the MELD score, acute kidney injury, ALT 
levels and the presence of septic shock.  
 
 
 
The clinical issue about culture negative neutrocytic ascites is relevant and under studied and the 
proposed study is based  on a relatively large number of cases. However, the study is affected by 
several limitations:  
 
 
1) There was a high number of septic shock cases among non -survivors. What type of 
infections did they develop? How were infections studied? The non -survivors sh ould be 
further divided in subgroups according to the presence of other infections as those can 
cause worsening MELD score and kidney function.  
 
 
 
2) Were medications considered as factors affecting the development of ascites and 
worsening kidney function? fo r example, were NSDAIDs or diuretics stopped or taken 
into consideration?  
 
 
 
3) AST levels were statistically significant as predictors of mortality. However, it is difficult 
to believe that AST levels also have a clinical significance (more than MELD score or 
presence of septic shock). In addition, sensitivity and specificity of 60 -70% is very low 
and unlikely to benefit the clinical management of this condition  
 
 
 
4) The study did not include a control group, for example culture positive neutrocytic 
ascites. H owever, it is true that previous studies compared the two entities.  
 
 
 
5) The fact that ascites were culture negative does not completely rule out infections. This is 
also discussed by the authors in the limitations.  
 
 
Other considerations:  
 
1) The English langu age will need a major revision  
 
 
2) AST is aspartate aminotransferase (not aspartate transaminase) and ALT is alanine 
aminotransferase  
 
 
3) abbreviations should be listed just once, the first time they are cited   
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is  required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, p lease explain in your comments to the authors.  
 
Yes 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require furt her 
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Not suitable for publication unless extensively edited  
 
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares  in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you recei ved reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
I declare I have no competing interests  
 
I agree to the open peer r eview policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors'  
responses. I agree for my report to be made available under an Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments  
which I do not wish to be included in my named report can be included a s confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Reviewer ’s report  
 
Title: Predictors of fifty days in -hospital mortality in patients with culture negative neutrocytic  
ascites  
 
Version: 0 Date: 30 Nov 2016  
 
Reviewer: Valentina Medici  
 
Reviewe r's report:  
 
This manuscript presents a study on a series of 170 cases of culture negative neutrocytic ascites 
admitted to intensive care unit. The study tried to identify predictors of 50 -day mortality among 
the 67 subjects who died  with the diagnosis of culture negative neutrocytic ascites. The major 
finding of the study was that aspartate aminotransferase (AST) levels >71 was a predictor of 
mortality with sensitivity and specific of 60% and 70% respectively. Other predictors of 
mortality, but with less predictive ability, included the MELD score, acute kidney injury, ALT 
levels and the presence of septic shock.  
 
 
 
The clinical issue about culture negative neutrocytic ascites is relevant and under studied and the 
proposed study is based  on a relatively large number of cases. However, the study is affected by 
several limitations:  
 
 
1) There was a high number of septic shock cases among non -survivors. What type of 
infections did they develop? How were infections studied? The non -survivors sh ould be 
further divided in subgroups according to the presence of other infections as those can 
cause worsening MELD score and kidney function.  
 
 
 
2) Were medications considered as factors affecting the development of ascites and 
worsening kidney function? fo r example, were NSDAIDs or diuretics stopped or taken 
into consideration?  
 
 
 
3) AST levels were statistically significant as predictors of mortality. However, it is difficult 
to believe that AST levels also have a clinical significance (more than MELD score or 
presence of septic shock). In addition, sensitivity and specificity of 60 -70% is very low 
and unlikely to benefit the clinical management of this condition  
 
 
 
4) The study did not include a control group, for example culture positive neutrocytic 
ascites. H owever, it is true that previous studies compared the two entities.  
 
 
 
5) The fact that ascites were culture negative does not completely rule out infections. This is 
also discussed by the authors in the limitations.  
 
 
Other considerations:  
 
1) The English langu age will need a major revision  
 
 
2) AST is aspartate aminotransferase (not aspartate transaminase) and ALT is alanine 
aminotransferase  
 
 
3) abbreviations should be listed just once, the first time they are cited   
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is  required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, p lease explain in your comments to the authors.  
 
Yes 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require furt her 
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Not suitable for publication unless extensively edited  
 
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares  in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you recei ved reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
I declare I have no competing interests  
 
I agree to the open peer r eview policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors'  
responses. I agree for my report to be made available under an Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments  
which I do not wish to be included in my named report can be included a s confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Please review this paper.
user
Reviewer ’s report  
 
Title: Predictors of fifty days in -hospital mortality in patients with culture negative neutrocytic  
ascites  
 
Version: 0 Date: 30 Nov 2016  
 
Reviewer: Valentina Medici  
 
Reviewe r's report:  
 
This manuscript presents a study on a series of 170 cases of culture negative neutrocytic ascites 
admitted to intensive care unit. The study tried to identify predictors of 50 -day mortality among 
the 67 subjects who died  with the diagnosis of culture negative neutrocytic ascites. The major 
finding of the study was that aspartate aminotransferase (AST) levels >71 was a predictor of 
mortality with sensitivity and specific of 60% and 70% respectively. Other predictors of 
mortality, but with less predictive ability, included the MELD score, acute kidney injury, ALT 
levels and the presence of septic shock.  
 
 
 
The clinical issue about culture negative neutrocytic ascites is relevant and under studied and the 
proposed study is based  on a relatively large number of cases. However, the study is affected by 
several limitations:  
 
 
1) There was a high number of septic shock cases among non -survivors. What type of 
infections did they develop? How were infections studied? The non -survivors sh ould be 
further divided in subgroups according to the presence of other infections as those can 
cause worsening MELD score and kidney function.  
 
 
 
2) Were medications considered as factors affecting the development of ascites and 
worsening kidney function? fo r example, were NSDAIDs or diuretics stopped or taken 
into consideration?  
 
 
 
3) AST levels were statistically significant as predictors of mortality. However, it is difficult 
to believe that AST levels also have a clinical significance (more than MELD score or 
presence of septic shock). In addition, sensitivity and specificity of 60 -70% is very low 
and unlikely to benefit the clinical management of this condition  
 
 
 
4) The study did not include a control group, for example culture positive neutrocytic 
ascites. H owever, it is true that previous studies compared the two entities.  
 
 
 
5) The fact that ascites were culture negative does not completely rule out infections. This is 
also discussed by the authors in the limitations.  
 
 
Other considerations:  
 
1) The English langu age will need a major revision  
 
 
2) AST is aspartate aminotransferase (not aspartate transaminase) and ALT is alanine 
aminotransferase  
 
 
3) abbreviations should be listed just once, the first time they are cited   
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is  required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, p lease explain in your comments to the authors.  
 
Yes 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require furt her 
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Not suitable for publication unless extensively edited  
 
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares  in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you recei ved reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
I declare I have no competing interests  
 
I agree to the open peer r eview policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors'  
responses. I agree for my report to be made available under an Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments  
which I do not wish to be included in my named report can be included a s confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
assistant