Reviewer ’s report  
 
Title: Aetiologies and outcomes of patients with a bdominal pain presenting to an emergency  
department of a tertiary hospital in Tanzania: a Prospective Cohort Study  
 
Version: 1 Date: 14 Oct 2019  
 
Reviewer: Christian Backer Mogensen  
 
Reviewer's report:  
 
Aetiologies and outcomes of patients with abdominal pain presenting to an emergency  
depar tment of a tertiary hospital in Tanzania: a Prospective Cohort Study  
 
thank you for the opportunity to re -review this paper.  
Although the authors have addressed some of the issues raised in the assessment of their paper, 
there are still some problems to consider before it is acceptable for publications.  
 
Abstract:  
The aim of the study should be very clear in the last line of bac kground,  to enable readers to 
immediately recognize if this is a paper of their interest.  
Results: many of the reports results are not discussed or even mentioned in the main paper (apart 
from in the tables). Only the main results should be reported, and aligned with the paper.  Risk 
factors (RR and p -values)  for death like low BS, and fluid therapy and need for surgery is not 
mentioned at all in the papers calculation!!  
 
Background:  
Too long. Is discussion a lot of non -relevant issues for this paper. And  start to  mention results 
from the current study and discuss these in the background section (mean age and gender in the 
study). Keep background short and simple, so it becomes evident for the reader that we need this 
paper, since there is sparse knowledg e about the epidemiology including presentations, 
morbidity and mortality from this part of the world.  
The aim is still too vague.  You are not describing the "burden" of abdominal pain, avoid loaded 
statements here. As I see the paper, it is fulfilling a gap in our knowledge about the incidence, 
presentation, causes and mortality from abdominal pain in an established emergency department 
in a tertiary level hospital in Tanzania.  This is your aim as I read the paper.  
 
Methods:  
Study design: including per iods not clear. Mention the exact dates. Are we talking about one or 
two months?  
 
Study setting: write the full abbreviation first time the reader meets them (what is MNH ?). this 
is helpful, so the reader should not consult the abbrevation table every ti me a new occur.  If the 
MNH ED sees more than 200 patients every day, it is expected that the paper reports from 
around 6000 -12000 patients (1 -2 months inclusions) but only includes 3300.  Most likely this 
could be explained by the actual length and time  and method of inclusions ( &gt; 18 yrs), but it 
is not quite clear from the paper yet.  
 
It is claimed that the hospital receives referrals from all over the country to the ED. Is it a normal 
procedure that patients already identified with abdominal proble m passes through the ED?  and 
how big a proportion of your ED population are normally referred from other hospitals/ 
selfreferred ?  this figures are needed to understand the population you are dealing with in this 
paper and to allow others to compare with  their hospitals.  
 
Results:  
All percentage are with 1 decimal. This gives an impression of a certainty which is not present, 
example hypertension in 30 (15.1%). A common rule is that all numbers less than 100 -200 are 
reported in rounded whole numbers only (15%).  
 
No-one lost to follow -up. The authors have stated that this was due to electronic hospital system 
and telephone capture. A least 39 patients were discharged directly from ED, no length of stay 
otherwise is reported, but most likely the majority wi ll have been discharged before day 7 where 
follow up reaches. I have never seen a 100% follow up in high -income countries by day 7 where 
electronic registration and mobile coverage is high, but in order to convince it would be nice in 
your method section t o describe in more details how you managed this.  
 
The most impression result is the high % of malignancies. How was these diagnoses established? 
Clinically, radiology, histology?  And  it is reported as an alternative to intestinal obstruction, 
does this means than none of the malignancies gave rise to intestinal obstructions?  PUD = ?  
 
What is the meaning of "discharge" ? discharged from the ED or hospital ? please be specific. 
Normally discharge assumes that the patient has been admitted to hospital. If  it is from ED, a 
term like "not -admitted" or "treated in ED only" would be more precise.  
 
Table 2 is not mentioned in the aims, in the result written section or in the discussion. What is 
the meaning of table 2. I suggest to either omit it or include it in your aims and result reporting.  
 
Table 4: very problematic. As mentioned no figures for RR reported in the abstract. Furthermore 
only univariate analysis. Finally, what is a risk factor ?  is ICU, IV fluid, surgical therapy risk 
factors for death? They are off course associated with death, but that is something else.  
Reconsider your risk factor definition.  
 
Mortality: is currently the main outcome, but not mentioned at all in the result text. And only 
mentioned in the abstract, reported as 24 -hours (4) , 7 days (7) - and total in -hospital mortality 
(16).  The only place anything is mentioned concerning mortal ity is in figure 1, and here the 
calculations are not correct. Example ward mortality = 3/145 = 2%,  or maybe 3/199 = 1.5%.  
which is correct?  Use the same calculation method for taken to the theatre: 4/15 = 27% or 
maybe 4/199 = 2%.  (but not 3.5% as you have calculated.  
 
Discussion:  
Some sections needs to be changed when the above mentioned questions have been addressed.  
In the limitation section the authors writes   "hence efforts were made to ensure appropriate 
sampling was done to maximize the inclusi on of patients referred from different parts of the 
country".  This is not mentioned in the method section. Does this mean that the population 
examined is NOT a straight forward inclusion of all patients coming to the ED and fulfilling the 
inclusion criter ias ?  the sentence raises some concerns about the sampling method and must be 
clarified.  
 
 
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.  
 
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 t he 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 o f 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 i n 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: Aetiologies and outcomes of patients with a bdominal pain presenting to an emergency  
department of a tertiary hospital in Tanzania: a Prospective Cohort Study  
 
Version: 1 Date: 14 Oct 2019  
 
Reviewer: Christian Backer Mogensen  
 
Reviewer's report:  
 
Aetiologies and outcomes of patients with abdominal pain presenting to an emergency  
depar tment of a tertiary hospital in Tanzania: a Prospective Cohort Study  
 
thank you for the opportunity to re -review this paper.  
Although the authors have addressed some of the issues raised in the assessment of their paper, 
there are still some problems to consider before it is acceptable for publications.  
 
Abstract:  
The aim of the study should be very clear in the last line of bac kground,  to enable readers to 
immediately recognize if this is a paper of their interest.  
Results: many of the reports results are not discussed or even mentioned in the main paper (apart 
from in the tables). Only the main results should be reported, and aligned with the paper.  Risk 
factors (RR and p -values)  for death like low BS, and fluid therapy and need for surgery is not 
mentioned at all in the papers calculation!!  
 
Background:  
Too long. Is discussion a lot of non -relevant issues for this paper. And  start to  mention results 
from the current study and discuss these in the background section (mean age and gender in the 
study). Keep background short and simple, so it becomes evident for the reader that we need this 
paper, since there is sparse knowledg e about the epidemiology including presentations, 
morbidity and mortality from this part of the world.  
The aim is still too vague.  You are not describing the "burden" of abdominal pain, avoid loaded 
statements here. As I see the paper, it is fulfilling a gap in our knowledge about the incidence, 
presentation, causes and mortality from abdominal pain in an established emergency department 
in a tertiary level hospital in Tanzania.  This is your aim as I read the paper.  
 
Methods:  
Study design: including per iods not clear. Mention the exact dates. Are we talking about one or 
two months?  
 
Study setting: write the full abbreviation first time the reader meets them (what is MNH ?). this 
is helpful, so the reader should not consult the abbrevation table every ti me a new occur.  If the 
MNH ED sees more than 200 patients every day, it is expected that the paper reports from 
around 6000 -12000 patients (1 -2 months inclusions) but only includes 3300.  Most likely this 
could be explained by the actual length and time  and method of inclusions ( &gt; 18 yrs), but it 
is not quite clear from the paper yet.  
 
It is claimed that the hospital receives referrals from all over the country to the ED. Is it a normal 
procedure that patients already identified with abdominal proble m passes through the ED?  and 
how big a proportion of your ED population are normally referred from other hospitals/ 
selfreferred ?  this figures are needed to understand the population you are dealing with in this 
paper and to allow others to compare with  their hospitals.  
 
Results:  
All percentage are with 1 decimal. This gives an impression of a certainty which is not present, 
example hypertension in 30 (15.1%). A common rule is that all numbers less than 100 -200 are 
reported in rounded whole numbers only (15%).  
 
No-one lost to follow -up. The authors have stated that this was due to electronic hospital system 
and telephone capture. A least 39 patients were discharged directly from ED, no length of stay 
otherwise is reported, but most likely the majority wi ll have been discharged before day 7 where 
follow up reaches. I have never seen a 100% follow up in high -income countries by day 7 where 
electronic registration and mobile coverage is high, but in order to convince it would be nice in 
your method section t o describe in more details how you managed this.  
 
The most impression result is the high % of malignancies. How was these diagnoses established? 
Clinically, radiology, histology?  And  it is reported as an alternative to intestinal obstruction, 
does this means than none of the malignancies gave rise to intestinal obstructions?  PUD = ?  
 
What is the meaning of "discharge" ? discharged from the ED or hospital ? please be specific. 
Normally discharge assumes that the patient has been admitted to hospital. If  it is from ED, a 
term like "not -admitted" or "treated in ED only" would be more precise.  
 
Table 2 is not mentioned in the aims, in the result written section or in the discussion. What is 
the meaning of table 2. I suggest to either omit it or include it in your aims and result reporting.  
 
Table 4: very problematic. As mentioned no figures for RR reported in the abstract. Furthermore 
only univariate analysis. Finally, what is a risk factor ?  is ICU, IV fluid, surgical therapy risk 
factors for death? They are off course associated with death, but that is something else.  
Reconsider your risk factor definition.  
 
Mortality: is currently the main outcome, but not mentioned at all in the result text. And only 
mentioned in the abstract, reported as 24 -hours (4) , 7 days (7) - and total in -hospital mortality 
(16).  The only place anything is mentioned concerning mortal ity is in figure 1, and here the 
calculations are not correct. Example ward mortality = 3/145 = 2%,  or maybe 3/199 = 1.5%.  
which is correct?  Use the same calculation method for taken to the theatre: 4/15 = 27% or 
maybe 4/199 = 2%.  (but not 3.5% as you have calculated.  
 
Discussion:  
Some sections needs to be changed when the above mentioned questions have been addressed.  
In the limitation section the authors writes   "hence efforts were made to ensure appropriate 
sampling was done to maximize the inclusi on of patients referred from different parts of the 
country".  This is not mentioned in the method section. Does this mean that the population 
examined is NOT a straight forward inclusion of all patients coming to the ED and fulfilling the 
inclusion criter ias ?  the sentence raises some concerns about the sampling method and must be 
clarified.  
 
 
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.  
 
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 t he 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 o f 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 i n 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: Aetiologies and outcomes of patients with a bdominal pain presenting to an emergency  
department of a tertiary hospital in Tanzania: a Prospective Cohort Study  
 
Version: 1 Date: 14 Oct 2019  
 
Reviewer: Christian Backer Mogensen  
 
Reviewer's report:  
 
Aetiologies and outcomes of patients with abdominal pain presenting to an emergency  
depar tment of a tertiary hospital in Tanzania: a Prospective Cohort Study  
 
thank you for the opportunity to re -review this paper.  
Although the authors have addressed some of the issues raised in the assessment of their paper, 
there are still some problems to consider before it is acceptable for publications.  
 
Abstract:  
The aim of the study should be very clear in the last line of bac kground,  to enable readers to 
immediately recognize if this is a paper of their interest.  
Results: many of the reports results are not discussed or even mentioned in the main paper (apart 
from in the tables). Only the main results should be reported, and aligned with the paper.  Risk 
factors (RR and p -values)  for death like low BS, and fluid therapy and need for surgery is not 
mentioned at all in the papers calculation!!  
 
Background:  
Too long. Is discussion a lot of non -relevant issues for this paper. And  start to  mention results 
from the current study and discuss these in the background section (mean age and gender in the 
study). Keep background short and simple, so it becomes evident for the reader that we need this 
paper, since there is sparse knowledg e about the epidemiology including presentations, 
morbidity and mortality from this part of the world.  
The aim is still too vague.  You are not describing the "burden" of abdominal pain, avoid loaded 
statements here. As I see the paper, it is fulfilling a gap in our knowledge about the incidence, 
presentation, causes and mortality from abdominal pain in an established emergency department 
in a tertiary level hospital in Tanzania.  This is your aim as I read the paper.  
 
Methods:  
Study design: including per iods not clear. Mention the exact dates. Are we talking about one or 
two months?  
 
Study setting: write the full abbreviation first time the reader meets them (what is MNH ?). this 
is helpful, so the reader should not consult the abbrevation table every ti me a new occur.  If the 
MNH ED sees more than 200 patients every day, it is expected that the paper reports from 
around 6000 -12000 patients (1 -2 months inclusions) but only includes 3300.  Most likely this 
could be explained by the actual length and time  and method of inclusions ( &gt; 18 yrs), but it 
is not quite clear from the paper yet.  
 
It is claimed that the hospital receives referrals from all over the country to the ED. Is it a normal 
procedure that patients already identified with abdominal proble m passes through the ED?  and 
how big a proportion of your ED population are normally referred from other hospitals/ 
selfreferred ?  this figures are needed to understand the population you are dealing with in this 
paper and to allow others to compare with  their hospitals.  
 
Results:  
All percentage are with 1 decimal. This gives an impression of a certainty which is not present, 
example hypertension in 30 (15.1%). A common rule is that all numbers less than 100 -200 are 
reported in rounded whole numbers only (15%).  
 
No-one lost to follow -up. The authors have stated that this was due to electronic hospital system 
and telephone capture. A least 39 patients were discharged directly from ED, no length of stay 
otherwise is reported, but most likely the majority wi ll have been discharged before day 7 where 
follow up reaches. I have never seen a 100% follow up in high -income countries by day 7 where 
electronic registration and mobile coverage is high, but in order to convince it would be nice in 
your method section t o describe in more details how you managed this.  
 
The most impression result is the high % of malignancies. How was these diagnoses established? 
Clinically, radiology, histology?  And  it is reported as an alternative to intestinal obstruction, 
does this means than none of the malignancies gave rise to intestinal obstructions?  PUD = ?  
 
What is the meaning of "discharge" ? discharged from the ED or hospital ? please be specific. 
Normally discharge assumes that the patient has been admitted to hospital. If  it is from ED, a 
term like "not -admitted" or "treated in ED only" would be more precise.  
 
Table 2 is not mentioned in the aims, in the result written section or in the discussion. What is 
the meaning of table 2. I suggest to either omit it or include it in your aims and result reporting.  
 
Table 4: very problematic. As mentioned no figures for RR reported in the abstract. Furthermore 
only univariate analysis. Finally, what is a risk factor ?  is ICU, IV fluid, surgical therapy risk 
factors for death? They are off course associated with death, but that is something else.  
Reconsider your risk factor definition.  
 
Mortality: is currently the main outcome, but not mentioned at all in the result text. And only 
mentioned in the abstract, reported as 24 -hours (4) , 7 days (7) - and total in -hospital mortality 
(16).  The only place anything is mentioned concerning mortal ity is in figure 1, and here the 
calculations are not correct. Example ward mortality = 3/145 = 2%,  or maybe 3/199 = 1.5%.  
which is correct?  Use the same calculation method for taken to the theatre: 4/15 = 27% or 
maybe 4/199 = 2%.  (but not 3.5% as you have calculated.  
 
Discussion:  
Some sections needs to be changed when the above mentioned questions have been addressed.  
In the limitation section the authors writes   "hence efforts were made to ensure appropriate 
sampling was done to maximize the inclusi on of patients referred from different parts of the 
country".  This is not mentioned in the method section. Does this mean that the population 
examined is NOT a straight forward inclusion of all patients coming to the ED and fulfilling the 
inclusion criter ias ?  the sentence raises some concerns about the sampling method and must be 
clarified.  
 
 
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.  
 
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 t he 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 o f 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 i n 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