Reviewer’s report
Title: 
Risk factors of poor prognosis and impairment of activities of daily living
in patients with hemorrhagic gastroduodenal ulcers
Version: 
0 
Date: 
08 Jun 2020
Reviewer's report:
1. In method section you state that you only included index ulcer case in patient
with multiple ulcer related admission. Than you state that you collected patients
with history of gastroduodenal ulcers. Both are paradoxical statements. Modify
this. I include both statements below for your reference.
If patients experienced two or more episodes of HGU during the study period,
the first episode alone was included in the analysis.
The following comorbidities were recorded: heart disease, pulmonary disease,
brain stroke, diabetes mellitus, liver disease, renal disease, and history of
gastroduodenal ulcers. 
My point is if you include only the first episode, than how can that patient have a
'history of ulcer'!
2. "brain stroke' - make it 'stroke'.
3. Why did you define 75 as elderly and not above 70? I know it is a bit of hassle
to redo the stats again etc but I suggest consider 70 yrs as elderly. Or else cite a
reference for 75 years as elderly to support. Your own citation 7 also reports 70
years. So overall it makes more sense for 70 years and not 75 years. 
4. Delete the following statement - 
All procedures performed in studies
involving human participants were in accordance with the ethical standards of
the institution and/or national research committee and with 1964 Helsinki
declaration and its amendments or comparable ethical standards -- This is not
relevant.
5. The statement in second paragraph of results, authors need to tell significant
difference for what variable is for which group of patients. Authors have to
clarify rather than just report difference. The following statement - "Significant
differences were found between patients < 75 years old and those > 75 years old
in terms of the location of HGU (gastric body [33% vs. 47%, p = 0.001], anterior
wall of duodenal bulb 
[25% vs. 14%, p = 0.0024]), Forrest classification IIa (37% vs. 27%, p = 0.02),
HGU size (> 20 mm) (23% vs. 33%, p = 0.02), comorbidities (heart disease
[21% vs. 34%, p < 0.001], pulmonary disease [7% vs. 12%, p = 0.044], brain
stroke [5% vs. 14%, p < 0.001], and history of gastroduodenal ulcers [27% vs.
16%, p = 0.0023]), symptoms of hematemesis (24% vs. 36%, p = 0.0038), and
antiplatelet use (19% vs. 38%, p < 0.001). " - needs to be revised accordingly.
6. Same issue with paragraph 3 statement based on table 2 - authors have to tell
what is for <75 and what is for above 75. 
7. Your focus is on 'elderly'. Elderly have limited physiologic reserves,
sarcopenia and frailty. This all has to be added to enhance the discussion.
Consider citation of a recent paper on prehabilitation and parts on ageing and
sarcopenia are relevant to enhance discussion - Mohan R, et al. Prehabilitation in
elderly patients scheduled for liver resection and protocol for Recovery Of
Surgery in Elderly. Hepatoma Res 2020;6:13. http://dx.doi.org/10.20517/2394-
5079.2019.53. This discussion should be in second paragraph as such. 
8. Third paragraph which includes 'interventional procedure - early endoscopy'.
This paragraph you need to cite a recent paper on WSES guidelines. It is
essential to enhance discussion. As you have rightly pointed, timing of
endoscopy determines outcomes. Consider adding the citation - Tarasconi A,
Coccolini F, Biffl WL, et al. Perforated and bleeding peptic ulcer: WSES
guidelines. World J Emerg Surg. 2020;15:3. Published 2020 Jan 7.
doi:10.1186/s13017-019-0283-9.
9. Agree that renal dysfunction is associated with poor outcomes in patients with
perforated and bleeding ulcer. Please include that this in general is poor
prognosticator for many diseases and pathologies. In particular bleeding leads to
acute on chronic kidney injury and hence drives poor outcomes. Consider
citation of - Chung KT, Shelat VG. Perforated peptic ulcer - an update. World J
Gastrointest Surg. 2017;9(1):1
‐
12. doi:10.4240/wjgs.v9.i1.1.
10. You are right. Low dose of omeprazole doesn't help with ulcer prevention.
Further, if patient develops ulcer despite PPI, they tend to be recalcitrant. Good
point. 
11. You discuss mortality and ulcer hemostasis: I have 3 comments and querries:
A. What is your local strategy for hemostasis based on Forrest classification. Do
you do hemostasis for Forrest 2b and 2c lesions? Do you dislodge the clot?
Please state this in protocol / methods. 
B. Once hemostasis is done, do you perform routine endoscopy to check? Do
you perform routine endoscopy or reserve endoscopy 'on demand'? i.e. only do
when there is rebleeding. Please clarify this aspect in method section and
consider citation of - Ho, M.L., Ahmed, S. & Shelat, V.G. Outcomes of Salvage
Emergency Surgery for Bleeding Peptic Ulcer. Indian J Surg (2020).
https://doi.org/10.1007/s12262-020-02358-w.
C. What are your indications for surgery or angioembolization? Include a brief
1-2 statement in method section.
12. In the method section also add the rationale for considering gastric and
duodenal ulcers togather. I agree. We treat them both the same way i.e. ppi,
endoscopy etc and do H Pylori eradication for both. Hence for clinical reasons,
they both can be grouped togather. This is clarified in citation - Anbalakan K,
Chua D, Pandya GJ, Shelat VG. Five year experience in management of
perforated peptic ulcer and validation of common mortality risk prediction
models - are existing models sufficient? A retrospective cohort study. Int J Surg.
2015;14:38
‐
44. doi:10.1016/j.ijsu.2014.12.022. Add this.
13. Also, this is acute presentation, but there could be some role of in hospital
rebabilitation or prehabilitation for selected elderly patients. COnsider adding
this in discussion - Mohan R, et al. Prehabilitation in elderly patients scheduled
for liver resection and protocol for Recovery Of Surgery in Elderly. Hepatoma
Res 2020;6:13. http://dx.doi.org/10.20517/2394-5079.2019.53 
14. You also need to add socio-cultural diversity and health infrastructure in
hospital - These determines the discharge destination. 
15. lastly you need to explain why Forrest 2b predicts mortality but not Forrest 1
and Forrest 2a lesions which are theoretically more severe? Please formulate
some logical reasoning and explain in discussion. 
Thanks
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
Yes
Does the work include the necessary controls?
If not, please specify which controls are required in your comments to the
authors.
Yes
Are the conclusions drawn adequately supported by the data shown?
If not, please 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 further assessment in your comments to the editors.
I am able to assess the statistics
Quality of written English
Please indicate the quality of language in the manuscript:
Needs some language corrections before being published
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 received 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.
none
Reviewer Publication Consent.
 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
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the editorial
office before completing the review.
If you wish, you can include your name in your published report. Please note
you must decide whether to include your name at the start of the process and
confirm this decision whenever prompted. If you change your decision later, we
will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name
with my report. (default)
Reviewer’s report
Title: 
Risk factors of poor prognosis and impairment of activities of daily living
in patients with hemorrhagic gastroduodenal ulcers
Version: 
0 
Date: 
08 Jun 2020
Reviewer's report:
1. In method section you state that you only included index ulcer case in patient
with multiple ulcer related admission. Than you state that you collected patients
with history of gastroduodenal ulcers. Both are paradoxical statements. Modify
this. I include both statements below for your reference.
If patients experienced two or more episodes of HGU during the study period,
the first episode alone was included in the analysis.
The following comorbidities were recorded: heart disease, pulmonary disease,
brain stroke, diabetes mellitus, liver disease, renal disease, and history of
gastroduodenal ulcers. 
My point is if you include only the first episode, than how can that patient have a
'history of ulcer'!
2. "brain stroke' - make it 'stroke'.
3. Why did you define 75 as elderly and not above 70? I know it is a bit of hassle
to redo the stats again etc but I suggest consider 70 yrs as elderly. Or else cite a
reference for 75 years as elderly to support. Your own citation 7 also reports 70
years. So overall it makes more sense for 70 years and not 75 years. 
4. Delete the following statement - 
All procedures performed in studies
involving human participants were in accordance with the ethical standards of
the institution and/or national research committee and with 1964 Helsinki
declaration and its amendments or comparable ethical standards -- This is not
relevant.
5. The statement in second paragraph of results, authors need to tell significant
difference for what variable is for which group of patients. Authors have to
clarify rather than just report difference. The following statement - "Significant
differences were found between patients < 75 years old and those > 75 years old
in terms of the location of HGU (gastric body [33% vs. 47%, p = 0.001], anterior
wall of duodenal bulb 
[25% vs. 14%, p = 0.0024]), Forrest classification IIa (37% vs. 27%, p = 0.02),
HGU size (> 20 mm) (23% vs. 33%, p = 0.02), comorbidities (heart disease
[21% vs. 34%, p < 0.001], pulmonary disease [7% vs. 12%, p = 0.044], brain
stroke [5% vs. 14%, p < 0.001], and history of gastroduodenal ulcers [27% vs.
16%, p = 0.0023]), symptoms of hematemesis (24% vs. 36%, p = 0.0038), and
antiplatelet use (19% vs. 38%, p < 0.001). " - needs to be revised accordingly.
6. Same issue with paragraph 3 statement based on table 2 - authors have to tell
what is for <75 and what is for above 75. 
7. Your focus is on 'elderly'. Elderly have limited physiologic reserves,
sarcopenia and frailty. This all has to be added to enhance the discussion.
Consider citation of a recent paper on prehabilitation and parts on ageing and
sarcopenia are relevant to enhance discussion - Mohan R, et al. Prehabilitation in
elderly patients scheduled for liver resection and protocol for Recovery Of
Surgery in Elderly. Hepatoma Res 2020;6:13. http://dx.doi.org/10.20517/2394-
5079.2019.53. This discussion should be in second paragraph as such. 
8. Third paragraph which includes 'interventional procedure - early endoscopy'.
This paragraph you need to cite a recent paper on WSES guidelines. It is
essential to enhance discussion. As you have rightly pointed, timing of
endoscopy determines outcomes. Consider adding the citation - Tarasconi A,
Coccolini F, Biffl WL, et al. Perforated and bleeding peptic ulcer: WSES
guidelines. World J Emerg Surg. 2020;15:3. Published 2020 Jan 7.
doi:10.1186/s13017-019-0283-9.
9. Agree that renal dysfunction is associated with poor outcomes in patients with
perforated and bleeding ulcer. Please include that this in general is poor
prognosticator for many diseases and pathologies. In particular bleeding leads to
acute on chronic kidney injury and hence drives poor outcomes. Consider
citation of - Chung KT, Shelat VG. Perforated peptic ulcer - an update. World J
Gastrointest Surg. 2017;9(1):1
‐
12. doi:10.4240/wjgs.v9.i1.1.
10. You are right. Low dose of omeprazole doesn't help with ulcer prevention.
Further, if patient develops ulcer despite PPI, they tend to be recalcitrant. Good
point. 
11. You discuss mortality and ulcer hemostasis: I have 3 comments and querries:
A. What is your local strategy for hemostasis based on Forrest classification. Do
you do hemostasis for Forrest 2b and 2c lesions? Do you dislodge the clot?
Please state this in protocol / methods. 
B. Once hemostasis is done, do you perform routine endoscopy to check? Do
you perform routine endoscopy or reserve endoscopy 'on demand'? i.e. only do
when there is rebleeding. Please clarify this aspect in method section and
consider citation of - Ho, M.L., Ahmed, S. & Shelat, V.G. Outcomes of Salvage
Emergency Surgery for Bleeding Peptic Ulcer. Indian J Surg (2020).
https://doi.org/10.1007/s12262-020-02358-w.
C. What are your indications for surgery or angioembolization? Include a brief
1-2 statement in method section.
12. In the method section also add the rationale for considering gastric and
duodenal ulcers togather. I agree. We treat them both the same way i.e. ppi,
endoscopy etc and do H Pylori eradication for both. Hence for clinical reasons,
they both can be grouped togather. This is clarified in citation - Anbalakan K,
Chua D, Pandya GJ, Shelat VG. Five year experience in management of
perforated peptic ulcer and validation of common mortality risk prediction
models - are existing models sufficient? A retrospective cohort study. Int J Surg.
2015;14:38
‐
44. doi:10.1016/j.ijsu.2014.12.022. Add this.
13. Also, this is acute presentation, but there could be some role of in hospital
rebabilitation or prehabilitation for selected elderly patients. COnsider adding
this in discussion - Mohan R, et al. Prehabilitation in elderly patients scheduled
for liver resection and protocol for Recovery Of Surgery in Elderly. Hepatoma
Res 2020;6:13. http://dx.doi.org/10.20517/2394-5079.2019.53 
14. You also need to add socio-cultural diversity and health infrastructure in
hospital - These determines the discharge destination. 
15. lastly you need to explain why Forrest 2b predicts mortality but not Forrest 1
and Forrest 2a lesions which are theoretically more severe? Please formulate
some logical reasoning and explain in discussion. 
Thanks
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
Yes
Does the work include the necessary controls?
If not, please specify which controls are required in your comments to the
authors.
Yes
Are the conclusions drawn adequately supported by the data shown?
If not, please 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 further assessment in your comments to the editors.
I am able to assess the statistics
Quality of written English
Please indicate the quality of language in the manuscript:
Needs some language corrections before being published
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 received 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.
none
Reviewer Publication Consent.
 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
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the editorial
office before completing the review.
If you wish, you can include your name in your published report. Please note
you must decide whether to include your name at the start of the process and
confirm this decision whenever prompted. If you change your decision later, we
will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name
with my report. (default)
Please review this paper.
user
Reviewer’s report
Title: 
Risk factors of poor prognosis and impairment of activities of daily living
in patients with hemorrhagic gastroduodenal ulcers
Version: 
0 
Date: 
08 Jun 2020
Reviewer's report:
1. In method section you state that you only included index ulcer case in patient
with multiple ulcer related admission. Than you state that you collected patients
with history of gastroduodenal ulcers. Both are paradoxical statements. Modify
this. I include both statements below for your reference.
If patients experienced two or more episodes of HGU during the study period,
the first episode alone was included in the analysis.
The following comorbidities were recorded: heart disease, pulmonary disease,
brain stroke, diabetes mellitus, liver disease, renal disease, and history of
gastroduodenal ulcers. 
My point is if you include only the first episode, than how can that patient have a
'history of ulcer'!
2. "brain stroke' - make it 'stroke'.
3. Why did you define 75 as elderly and not above 70? I know it is a bit of hassle
to redo the stats again etc but I suggest consider 70 yrs as elderly. Or else cite a
reference for 75 years as elderly to support. Your own citation 7 also reports 70
years. So overall it makes more sense for 70 years and not 75 years. 
4. Delete the following statement - 
All procedures performed in studies
involving human participants were in accordance with the ethical standards of
the institution and/or national research committee and with 1964 Helsinki
declaration and its amendments or comparable ethical standards -- This is not
relevant.
5. The statement in second paragraph of results, authors need to tell significant
difference for what variable is for which group of patients. Authors have to
clarify rather than just report difference. The following statement - "Significant
differences were found between patients < 75 years old and those > 75 years old
in terms of the location of HGU (gastric body [33% vs. 47%, p = 0.001], anterior
wall of duodenal bulb 
[25% vs. 14%, p = 0.0024]), Forrest classification IIa (37% vs. 27%, p = 0.02),
HGU size (> 20 mm) (23% vs. 33%, p = 0.02), comorbidities (heart disease
[21% vs. 34%, p < 0.001], pulmonary disease [7% vs. 12%, p = 0.044], brain
stroke [5% vs. 14%, p < 0.001], and history of gastroduodenal ulcers [27% vs.
16%, p = 0.0023]), symptoms of hematemesis (24% vs. 36%, p = 0.0038), and
antiplatelet use (19% vs. 38%, p < 0.001). " - needs to be revised accordingly.
6. Same issue with paragraph 3 statement based on table 2 - authors have to tell
what is for <75 and what is for above 75. 
7. Your focus is on 'elderly'. Elderly have limited physiologic reserves,
sarcopenia and frailty. This all has to be added to enhance the discussion.
Consider citation of a recent paper on prehabilitation and parts on ageing and
sarcopenia are relevant to enhance discussion - Mohan R, et al. Prehabilitation in
elderly patients scheduled for liver resection and protocol for Recovery Of
Surgery in Elderly. Hepatoma Res 2020;6:13. http://dx.doi.org/10.20517/2394-
5079.2019.53. This discussion should be in second paragraph as such. 
8. Third paragraph which includes 'interventional procedure - early endoscopy'.
This paragraph you need to cite a recent paper on WSES guidelines. It is
essential to enhance discussion. As you have rightly pointed, timing of
endoscopy determines outcomes. Consider adding the citation - Tarasconi A,
Coccolini F, Biffl WL, et al. Perforated and bleeding peptic ulcer: WSES
guidelines. World J Emerg Surg. 2020;15:3. Published 2020 Jan 7.
doi:10.1186/s13017-019-0283-9.
9. Agree that renal dysfunction is associated with poor outcomes in patients with
perforated and bleeding ulcer. Please include that this in general is poor
prognosticator for many diseases and pathologies. In particular bleeding leads to
acute on chronic kidney injury and hence drives poor outcomes. Consider
citation of - Chung KT, Shelat VG. Perforated peptic ulcer - an update. World J
Gastrointest Surg. 2017;9(1):1
‐
12. doi:10.4240/wjgs.v9.i1.1.
10. You are right. Low dose of omeprazole doesn't help with ulcer prevention.
Further, if patient develops ulcer despite PPI, they tend to be recalcitrant. Good
point. 
11. You discuss mortality and ulcer hemostasis: I have 3 comments and querries:
A. What is your local strategy for hemostasis based on Forrest classification. Do
you do hemostasis for Forrest 2b and 2c lesions? Do you dislodge the clot?
Please state this in protocol / methods. 
B. Once hemostasis is done, do you perform routine endoscopy to check? Do
you perform routine endoscopy or reserve endoscopy 'on demand'? i.e. only do
when there is rebleeding. Please clarify this aspect in method section and
consider citation of - Ho, M.L., Ahmed, S. & Shelat, V.G. Outcomes of Salvage
Emergency Surgery for Bleeding Peptic Ulcer. Indian J Surg (2020).
https://doi.org/10.1007/s12262-020-02358-w.
C. What are your indications for surgery or angioembolization? Include a brief
1-2 statement in method section.
12. In the method section also add the rationale for considering gastric and
duodenal ulcers togather. I agree. We treat them both the same way i.e. ppi,
endoscopy etc and do H Pylori eradication for both. Hence for clinical reasons,
they both can be grouped togather. This is clarified in citation - Anbalakan K,
Chua D, Pandya GJ, Shelat VG. Five year experience in management of
perforated peptic ulcer and validation of common mortality risk prediction
models - are existing models sufficient? A retrospective cohort study. Int J Surg.
2015;14:38
‐
44. doi:10.1016/j.ijsu.2014.12.022. Add this.
13. Also, this is acute presentation, but there could be some role of in hospital
rebabilitation or prehabilitation for selected elderly patients. COnsider adding
this in discussion - Mohan R, et al. Prehabilitation in elderly patients scheduled
for liver resection and protocol for Recovery Of Surgery in Elderly. Hepatoma
Res 2020;6:13. http://dx.doi.org/10.20517/2394-5079.2019.53 
14. You also need to add socio-cultural diversity and health infrastructure in
hospital - These determines the discharge destination. 
15. lastly you need to explain why Forrest 2b predicts mortality but not Forrest 1
and Forrest 2a lesions which are theoretically more severe? Please formulate
some logical reasoning and explain in discussion. 
Thanks
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
Yes
Does the work include the necessary controls?
If not, please specify which controls are required in your comments to the
authors.
Yes
Are the conclusions drawn adequately supported by the data shown?
If not, please 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 further assessment in your comments to the editors.
I am able to assess the statistics
Quality of written English
Please indicate the quality of language in the manuscript:
Needs some language corrections before being published
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 received 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.
none
Reviewer Publication Consent.
 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
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the editorial
office before completing the review.
If you wish, you can include your name in your published report. Please note
you must decide whether to include your name at the start of the process and
confirm this decision whenever prompted. If you change your decision later, we
will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name
with my report. (default)
assistant