Reviewer's report
Title:Reduced lymphocyte count as an early marker for secondary pancreatic
infection in acute pancreatitis
Version:3Date:19 August 2015
Reviewer: Vikesh Singh
Reviewer's report:
Shen et al. present a nice study evaluating early serologic markers and scoring
systems for predicting secondary infection in acute pancreatitis.
The major flaw of this study is that the predictor is being assessed at a time when
it may not be clear to the clinician that the patient has pancreatic necrosis. Early
CT scanning (within 72 hours of presentation) does not often clearly show that a
patient has pancreatic necrosis and that is why guidelines advocate that CT
scans be obtained later in the course of hospitalization. Therefore, a
retrospective assessment of early absolute lymphocyte counts show high
diagnostic accuracy in patients with established pancreatic necrosis but will likely
be less robust when applied prospectively and to a larger cohort of mixed
patients with both acute interstitial and necrotizing pancreatitis who have varying
degrees of severity and presentation times.
Major Compulsory Revisions:
1. The title should be changed to: "Reduced lymphocyte count as an early
marker for predicting infected pancreatic necrosis"
2. How many patients with acute necrotizing pancreatitis were excluded because
they presented beyond the first 48 hours from symptom onset which includes 793
patients? I am afraid you have likely enriched your study cohort with the sickest
patients as they often present early.
3. How did you define severe acute pancreatitis? If your study only focused on
necrotizing pancreatitis, then you should have no mild acute pancreatitis patients
per revised Atlanta. In addition, the liver and GI dysfunction variables are not
used to define organ failure in the revised Atlanta criteria. Similarly why are there
patients with pseudocysts if everyone included in the study has necrotizing
pancreatitis? Pseudocysts do not occur in necrotizing pancreatitis per the revised
Atlanta classification - only acute necrotic collections, and after 4 weeks,
walled-off necrosis.
4. Was the organ failure primary or secondary to infected pancreatic necrosis?
5. Your rates of acute necrotizing hypertriglyceridemic pancreatitis are higher
than I have ever seen reported in the literature. Are you sure that the
hypertriglyceridemia is not secondary to alcohol abuse?
6. There needs to be data on CTSI scores across this cohort or at least a
discription of how many patients had < or >30% necrosis on contrast enhanced
CT scans.
Minor Essential Revisions
Please have the entire manuscript reviewed for English grammar and sentence
construction.
Level of interest: An article of importance in its field
Quality of written English: Not suitable for publication unless extensively edited
Statistical review: Yes, and I have assessed the statistics in my report.
Declaration of competing interests:
I declare that I have no competing interests
Reviewer's report
Title:Reduced lymphocyte count as an early marker for secondary pancreatic
infection in acute pancreatitis
Version:3Date:19 August 2015
Reviewer: Vikesh Singh
Reviewer's report:
Shen et al. present a nice study evaluating early serologic markers and scoring
systems for predicting secondary infection in acute pancreatitis.
The major flaw of this study is that the predictor is being assessed at a time when
it may not be clear to the clinician that the patient has pancreatic necrosis. Early
CT scanning (within 72 hours of presentation) does not often clearly show that a
patient has pancreatic necrosis and that is why guidelines advocate that CT
scans be obtained later in the course of hospitalization. Therefore, a
retrospective assessment of early absolute lymphocyte counts show high
diagnostic accuracy in patients with established pancreatic necrosis but will likely
be less robust when applied prospectively and to a larger cohort of mixed
patients with both acute interstitial and necrotizing pancreatitis who have varying
degrees of severity and presentation times.
Major Compulsory Revisions:
1. The title should be changed to: "Reduced lymphocyte count as an early
marker for predicting infected pancreatic necrosis"
2. How many patients with acute necrotizing pancreatitis were excluded because
they presented beyond the first 48 hours from symptom onset which includes 793
patients? I am afraid you have likely enriched your study cohort with the sickest
patients as they often present early.
3. How did you define severe acute pancreatitis? If your study only focused on
necrotizing pancreatitis, then you should have no mild acute pancreatitis patients
per revised Atlanta. In addition, the liver and GI dysfunction variables are not
used to define organ failure in the revised Atlanta criteria. Similarly why are there
patients with pseudocysts if everyone included in the study has necrotizing
pancreatitis? Pseudocysts do not occur in necrotizing pancreatitis per the revised
Atlanta classification - only acute necrotic collections, and after 4 weeks,
walled-off necrosis.
4. Was the organ failure primary or secondary to infected pancreatic necrosis?
5. Your rates of acute necrotizing hypertriglyceridemic pancreatitis are higher
than I have ever seen reported in the literature. Are you sure that the
hypertriglyceridemia is not secondary to alcohol abuse?
6. There needs to be data on CTSI scores across this cohort or at least a
discription of how many patients had < or >30% necrosis on contrast enhanced
CT scans.
Minor Essential Revisions
Please have the entire manuscript reviewed for English grammar and sentence
construction.
Level of interest: An article of importance in its field
Quality of written English: Not suitable for publication unless extensively edited
Statistical review: Yes, and I have assessed the statistics in my report.
Declaration of competing interests:
I declare that I have no competing interests
Please review this paper.
user
Reviewer's report
Title:Reduced lymphocyte count as an early marker for secondary pancreatic
infection in acute pancreatitis
Version:3Date:19 August 2015
Reviewer: Vikesh Singh
Reviewer's report:
Shen et al. present a nice study evaluating early serologic markers and scoring
systems for predicting secondary infection in acute pancreatitis.
The major flaw of this study is that the predictor is being assessed at a time when
it may not be clear to the clinician that the patient has pancreatic necrosis. Early
CT scanning (within 72 hours of presentation) does not often clearly show that a
patient has pancreatic necrosis and that is why guidelines advocate that CT
scans be obtained later in the course of hospitalization. Therefore, a
retrospective assessment of early absolute lymphocyte counts show high
diagnostic accuracy in patients with established pancreatic necrosis but will likely
be less robust when applied prospectively and to a larger cohort of mixed
patients with both acute interstitial and necrotizing pancreatitis who have varying
degrees of severity and presentation times.
Major Compulsory Revisions:
1. The title should be changed to: "Reduced lymphocyte count as an early
marker for predicting infected pancreatic necrosis"
2. How many patients with acute necrotizing pancreatitis were excluded because
they presented beyond the first 48 hours from symptom onset which includes 793
patients? I am afraid you have likely enriched your study cohort with the sickest
patients as they often present early.
3. How did you define severe acute pancreatitis? If your study only focused on
necrotizing pancreatitis, then you should have no mild acute pancreatitis patients
per revised Atlanta. In addition, the liver and GI dysfunction variables are not
used to define organ failure in the revised Atlanta criteria. Similarly why are there
patients with pseudocysts if everyone included in the study has necrotizing
pancreatitis? Pseudocysts do not occur in necrotizing pancreatitis per the revised
Atlanta classification - only acute necrotic collections, and after 4 weeks,
walled-off necrosis.
4. Was the organ failure primary or secondary to infected pancreatic necrosis?
5. Your rates of acute necrotizing hypertriglyceridemic pancreatitis are higher
than I have ever seen reported in the literature. Are you sure that the
hypertriglyceridemia is not secondary to alcohol abuse?
6. There needs to be data on CTSI scores across this cohort or at least a
discription of how many patients had < or >30% necrosis on contrast enhanced
CT scans.
Minor Essential Revisions
Please have the entire manuscript reviewed for English grammar and sentence
construction.
Level of interest: An article of importance in its field
Quality of written English: Not suitable for publication unless extensively edited
Statistical review: Yes, and I have assessed the statistics in my report.
Declaration of competing interests:
I declare that I have no competing interests
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