Reviewer’s report
Title: The role of a multidisciplinary team in the management of portal hypertension
Version: 1 Date: 19 Nov 2019
Reviewer: Mario Masarone
Reviewer's report:
Dear Editor,
Tseng et al wrote a paper on the role of a multidisciplinary team in the management of upper intestinal
hemorrhage caused by portal hypertension in liver disease patients. With this aim, they analyzed the
clinical outcomes (in terms of overall survival and rebleeding occurrence) of 86 patients underwent to a
multidisciplinary team evaluation (MDT patients) in a follow-up study and confronted them with an
historical  cohort  of  462  patients  treated  for  "portal  hypertension"  that  weren't  managed  by  the
multidisciplinary  team  (non-MDT).  They  found  that  MDT patients  had  a  statistically  significant
advantage (in terms of less events of rebleed) in a follow-up of 12 months, without differences in
overall survival. Due to the differences found in terms of previous treatments and type of treatment,
etiology of portal hypertension, presence of portal vein thrombosis and type of gastroesophageal
varices, they performed a propensity score matching (PSM) that led to the selection of 58 MDT vs 111
non-MDT patients. The results of the analysis on the PSM selected patients confirmed the advantage of
MDT managed patients in respect to non-MDT in terms of rebleeding at 12 months. The paper has
some elements of interest, nevertheless there are some points of discussion.
Major points: 
1) Patients selection and characteristics: it is not clear how many patients underwent to the selected
therapies for an acute active hemorrage and how many were treated for high risk varices without active
hemorrage.
2) There was a difference between MDT and Non-MDT patients in terms of presentation with acute
hemorrage?  This may be considered as a variable to insert in the propensity score matching, because it
can change drastically the outcome measures.  
3)  What  was  the  timing  for  the  referral  to  the  MDT?  Did  the  MDT met  on  every single  case
presentation or there were scheduled meetings? And if it so, how often took place? 
4) What was the mean time to the treatment in MDT and non-MDT patients? It may be interesting to
report that MDT management positively influenced the outcome even if its application deferred the
treatment.
5) As the authors stated themselves in the limitations section, the major limitations of the paper are the
small sample size, the differences in the treatment methods between the two groups and the short time
of follow-up. The sample size, as well as the follow-up time should be increased (recruit other MDT
patients and increase the follow-up period). Unfortunately, the differences in treatment methods are
difficult to overcome.
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.
No
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:
Acceptable
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.
I declare that I have no competing interests
I agree to the open peer review 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 as 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: The role of a multidisciplinary team in the management of portal hypertension
Version: 1 Date: 19 Nov 2019
Reviewer: Mario Masarone
Reviewer's report:
Dear Editor,
Tseng et al wrote a paper on the role of a multidisciplinary team in the management of upper intestinal
hemorrhage caused by portal hypertension in liver disease patients. With this aim, they analyzed the
clinical outcomes (in terms of overall survival and rebleeding occurrence) of 86 patients underwent to a
multidisciplinary team evaluation (MDT patients) in a follow-up study and confronted them with an
historical  cohort  of  462  patients  treated  for  "portal  hypertension"  that  weren't  managed  by  the
multidisciplinary  team  (non-MDT).  They  found  that  MDT patients  had  a  statistically  significant
advantage (in terms of less events of rebleed) in a follow-up of 12 months, without differences in
overall survival. Due to the differences found in terms of previous treatments and type of treatment,
etiology of portal hypertension, presence of portal vein thrombosis and type of gastroesophageal
varices, they performed a propensity score matching (PSM) that led to the selection of 58 MDT vs 111
non-MDT patients. The results of the analysis on the PSM selected patients confirmed the advantage of
MDT managed patients in respect to non-MDT in terms of rebleeding at 12 months. The paper has
some elements of interest, nevertheless there are some points of discussion.
Major points: 
1) Patients selection and characteristics: it is not clear how many patients underwent to the selected
therapies for an acute active hemorrage and how many were treated for high risk varices without active
hemorrage.
2) There was a difference between MDT and Non-MDT patients in terms of presentation with acute
hemorrage?  This may be considered as a variable to insert in the propensity score matching, because it
can change drastically the outcome measures.  
3)  What  was  the  timing  for  the  referral  to  the  MDT?  Did  the  MDT met  on  every single  case
presentation or there were scheduled meetings? And if it so, how often took place? 
4) What was the mean time to the treatment in MDT and non-MDT patients? It may be interesting to
report that MDT management positively influenced the outcome even if its application deferred the
treatment.
5) As the authors stated themselves in the limitations section, the major limitations of the paper are the
small sample size, the differences in the treatment methods between the two groups and the short time
of follow-up. The sample size, as well as the follow-up time should be increased (recruit other MDT
patients and increase the follow-up period). Unfortunately, the differences in treatment methods are
difficult to overcome.
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.
No
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:
Acceptable
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.
I declare that I have no competing interests
I agree to the open peer review 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 as 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: The role of a multidisciplinary team in the management of portal hypertension
Version: 1 Date: 19 Nov 2019
Reviewer: Mario Masarone
Reviewer's report:
Dear Editor,
Tseng et al wrote a paper on the role of a multidisciplinary team in the management of upper intestinal
hemorrhage caused by portal hypertension in liver disease patients. With this aim, they analyzed the
clinical outcomes (in terms of overall survival and rebleeding occurrence) of 86 patients underwent to a
multidisciplinary team evaluation (MDT patients) in a follow-up study and confronted them with an
historical  cohort  of  462  patients  treated  for  "portal  hypertension"  that  weren't  managed  by  the
multidisciplinary  team  (non-MDT).  They  found  that  MDT patients  had  a  statistically  significant
advantage (in terms of less events of rebleed) in a follow-up of 12 months, without differences in
overall survival. Due to the differences found in terms of previous treatments and type of treatment,
etiology of portal hypertension, presence of portal vein thrombosis and type of gastroesophageal
varices, they performed a propensity score matching (PSM) that led to the selection of 58 MDT vs 111
non-MDT patients. The results of the analysis on the PSM selected patients confirmed the advantage of
MDT managed patients in respect to non-MDT in terms of rebleeding at 12 months. The paper has
some elements of interest, nevertheless there are some points of discussion.
Major points: 
1) Patients selection and characteristics: it is not clear how many patients underwent to the selected
therapies for an acute active hemorrage and how many were treated for high risk varices without active
hemorrage.
2) There was a difference between MDT and Non-MDT patients in terms of presentation with acute
hemorrage?  This may be considered as a variable to insert in the propensity score matching, because it
can change drastically the outcome measures.  
3)  What  was  the  timing  for  the  referral  to  the  MDT?  Did  the  MDT met  on  every single  case
presentation or there were scheduled meetings? And if it so, how often took place? 
4) What was the mean time to the treatment in MDT and non-MDT patients? It may be interesting to
report that MDT management positively influenced the outcome even if its application deferred the
treatment.
5) As the authors stated themselves in the limitations section, the major limitations of the paper are the
small sample size, the differences in the treatment methods between the two groups and the short time
of follow-up. The sample size, as well as the follow-up time should be increased (recruit other MDT
patients and increase the follow-up period). Unfortunately, the differences in treatment methods are
difficult to overcome.
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.
No
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:
Acceptable
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.
I declare that I have no competing interests
I agree to the open peer review 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 as confidential comments
to the editors, which will not be published.
I agree to the open peer review policy of the journal
assistant