Reviewer ’s report  
 
Title: Validation of a New Risk Score System for Non -variceal Upper Gastrointestinal Bleeding  
 
Version: 0 Date: 21 Jan 2020  
 
Reviewer's report:  
 
PEER REVIEWER ASSESSMENTS:  
 
OBJECTIVE - Full research articles: is there a clear objective that addresses a testable research 
question(s) (brief or other article types: is  there a clear objective)?  
 
Yes - there is a clear objective  
 
 
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for the 
objective?  
 
No - there are minor issues  
 
 
EXECUTION - Are the experiments and analyses performed with technical rigor to allow 
confidence in the results?  
 
No - there are minor issues  
 
 
STATISTICS - Is the use of statistics in the manuscript appropriate?  
 
Not sure - I am not able to assess the statist ics in this study  
 
 
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not 
overstated?  
 
No - there are minor issues  
 
 
OVERALL MANUSCRIPT POTENTIAL - Is the current version of this work technically 
sound? If not, can revisi ons be made to make the work technically sound?  
 
Probably - with minor revisions  
 
 
PEER REVIEWER COMMENTS:  
GENERAL COMMENTS:  
 
* What is your overall impression of the study?  
 
Well conducted, thorough, but a retrospective analysis.  
 
 
* What have the authors d one well?  
 
They have tried to address the disparities with existing scoring systems by developing a new 
scoring system for international usage to predict 30 day mortality from UGIB.  
 
* In what ways does it not meet best practice?  
 
Minor: I get the impressio n that the study was developed for use in one country (Korea?) and a 
more international focus could be provided throughout the paper.  
 
Major: Complete and reproducible validation of a new scoring system would have to be done 
using a prospective design (that  is, test it on cohorts of patients in countries outside Korea, at 
presentation with UGIB, and then review whether the new scoring system performed better than 
existing scoring tools, using a retrospective review of outcomes).  This study is entirely 
retro spective in design.  
 
 
REQUESTED REVISIONS:  
 
Yes - there is a clear objective.  I have no major comments.  The intention of creating an 
internationally verified scoring scale for 30 -day post UGIB mortality is laudable, although the 
manuscript could be clearer about why this is needed as various other scoring systems have been 
developed and are in use. In fact t he introduction and perhaps the discussion could reference 
some of the recent work done by Y Tang and others on comparison of such scoring systems 
(please see some suggested references below).  There are numerous other examples of such work 
in the literatu re and this makes me hesitate to commend the paper under review as being entirely 
novel which meets a clinical need.  
 
 Tang Y Am J Emerg Med. 2018 Jan;36(1):27 -32. doi: 10.1016/j.ajem.2017.06.053. Epub 2017 
Jun 27. Scoring systems used to predict mortality in patients with acute upper gastrointestinal 
bleeding in the ED. )  
 
H Tuncer (Pak J Med Sci. 2018 May -Jun; 34(3): 649 -654. doi: 10.12669/pjms.343.14956 
PMCID: PMC6041537 PMID: 30034432 Comparison of four scoring systems for risk 
stratification of upper ga strointestinal bleeding  
 
Design acceptable?  
 
No - there are minor issues  
My major comment relates to the retrospective nature of the study and for validation, the scoring 
system would need to be tested prospectively in several international populations to en sure 
consistency of results.  
 
 
Execution acceptable?  
 
No - there are minor issues  
 
Please see above - I have some concerns about validation due to the retrospective mature of the 
study  
 
 
Statistics acceptable?  
 
Not sure - I am not able to assess the statistics in  this study  
 
I have not commented the statistics in detail as this is specialised branch of statistics. The 
methods used (multivariable logistic regression modelling appears to be appropriate).  
 
 
Interpretation acceptable?  
 
No - there are minor issues. The sam e issue - without prospective studies on validation in more 
populations, this scoring system is not ready for international clinical use.  
 
 
ADDITIONAL REQUESTS/SUGGESTIONS:  
 
Generally the interpretation appears to be valid, and if the new scoring system can predict 30 -day 
mortality better than existing tools then it will have clinical utility.  However I feel it is 
premature to promote the scoring system as 'validated' until further work has been done.  It is an 
interesting study and with some edits may be su itable for publication as a preliminary report of 
development of the scoring tool.  
  
The discussion section is overly long and could benefit from some editing for brevity.  
 
Please refer to the study patients as participants and not 'subjects'. The section about patient 
consent had been redacted from my review copy, but I hope this is present in the original 
version.  
 
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, please explain in your comments to the authors.  
 
No 
 
Are you able to ass ess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
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:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please complete a declaration of competing interests, consid ering the following questions:  
 
1.  Have you in the past five years received reimbursements, f ees, funding, or salary 
from an organisation that may in any way gain or lose financial ly from the 
publication of this manuscript, either now or in the future?  
 
2.  Do you hold any stocks or shares in an organisation t hat 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.  
 
This reviewer has been recruited by a partner organization, Research Square. Reviewers with 
declared or apparent competing interests are not utilized for t hese revie ws. This reviewer has 
agreed to publication of their comments online under a Creat ive Commons Attribution License 
attributed to  Research Square and was paid a small honorarium for  completing the review within 
a specified timeframe. Honoraria for reviews such as this are paid regardless of the reviewer 
recommendation.  
 
I agree to the open peer review policy of the journal. I underst and that my name will be included 
on my report to the authors and, if the manuscript is accepted f or 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 b e made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I unders tand that any comments 
which I do not wish to be included in my named report can be in cluded 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: Validation of a New Risk Score System for Non -variceal Upper Gastrointestinal Bleeding  
 
Version: 0 Date: 21 Jan 2020  
 
Reviewer's report:  
 
PEER REVIEWER ASSESSMENTS:  
 
OBJECTIVE - Full research articles: is there a clear objective that addresses a testable research 
question(s) (brief or other article types: is  there a clear objective)?  
 
Yes - there is a clear objective  
 
 
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for the 
objective?  
 
No - there are minor issues  
 
 
EXECUTION - Are the experiments and analyses performed with technical rigor to allow 
confidence in the results?  
 
No - there are minor issues  
 
 
STATISTICS - Is the use of statistics in the manuscript appropriate?  
 
Not sure - I am not able to assess the statist ics in this study  
 
 
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not 
overstated?  
 
No - there are minor issues  
 
 
OVERALL MANUSCRIPT POTENTIAL - Is the current version of this work technically 
sound? If not, can revisi ons be made to make the work technically sound?  
 
Probably - with minor revisions  
 
 
PEER REVIEWER COMMENTS:  
GENERAL COMMENTS:  
 
* What is your overall impression of the study?  
 
Well conducted, thorough, but a retrospective analysis.  
 
 
* What have the authors d one well?  
 
They have tried to address the disparities with existing scoring systems by developing a new 
scoring system for international usage to predict 30 day mortality from UGIB.  
 
* In what ways does it not meet best practice?  
 
Minor: I get the impressio n that the study was developed for use in one country (Korea?) and a 
more international focus could be provided throughout the paper.  
 
Major: Complete and reproducible validation of a new scoring system would have to be done 
using a prospective design (that  is, test it on cohorts of patients in countries outside Korea, at 
presentation with UGIB, and then review whether the new scoring system performed better than 
existing scoring tools, using a retrospective review of outcomes).  This study is entirely 
retro spective in design.  
 
 
REQUESTED REVISIONS:  
 
Yes - there is a clear objective.  I have no major comments.  The intention of creating an 
internationally verified scoring scale for 30 -day post UGIB mortality is laudable, although the 
manuscript could be clearer about why this is needed as various other scoring systems have been 
developed and are in use. In fact t he introduction and perhaps the discussion could reference 
some of the recent work done by Y Tang and others on comparison of such scoring systems 
(please see some suggested references below).  There are numerous other examples of such work 
in the literatu re and this makes me hesitate to commend the paper under review as being entirely 
novel which meets a clinical need.  
 
 Tang Y Am J Emerg Med. 2018 Jan;36(1):27 -32. doi: 10.1016/j.ajem.2017.06.053. Epub 2017 
Jun 27. Scoring systems used to predict mortality in patients with acute upper gastrointestinal 
bleeding in the ED. )  
 
H Tuncer (Pak J Med Sci. 2018 May -Jun; 34(3): 649 -654. doi: 10.12669/pjms.343.14956 
PMCID: PMC6041537 PMID: 30034432 Comparison of four scoring systems for risk 
stratification of upper ga strointestinal bleeding  
 
Design acceptable?  
 
No - there are minor issues  
My major comment relates to the retrospective nature of the study and for validation, the scoring 
system would need to be tested prospectively in several international populations to en sure 
consistency of results.  
 
 
Execution acceptable?  
 
No - there are minor issues  
 
Please see above - I have some concerns about validation due to the retrospective mature of the 
study  
 
 
Statistics acceptable?  
 
Not sure - I am not able to assess the statistics in  this study  
 
I have not commented the statistics in detail as this is specialised branch of statistics. The 
methods used (multivariable logistic regression modelling appears to be appropriate).  
 
 
Interpretation acceptable?  
 
No - there are minor issues. The sam e issue - without prospective studies on validation in more 
populations, this scoring system is not ready for international clinical use.  
 
 
ADDITIONAL REQUESTS/SUGGESTIONS:  
 
Generally the interpretation appears to be valid, and if the new scoring system can predict 30 -day 
mortality better than existing tools then it will have clinical utility.  However I feel it is 
premature to promote the scoring system as 'validated' until further work has been done.  It is an 
interesting study and with some edits may be su itable for publication as a preliminary report of 
development of the scoring tool.  
  
The discussion section is overly long and could benefit from some editing for brevity.  
 
Please refer to the study patients as participants and not 'subjects'. The section about patient 
consent had been redacted from my review copy, but I hope this is present in the original 
version.  
 
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, please explain in your comments to the authors.  
 
No 
 
Are you able to ass ess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
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:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please complete a declaration of competing interests, consid ering the following questions:  
 
1.  Have you in the past five years received reimbursements, f ees, funding, or salary 
from an organisation that may in any way gain or lose financial ly from the 
publication of this manuscript, either now or in the future?  
 
2.  Do you hold any stocks or shares in an organisation t hat 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.  
 
This reviewer has been recruited by a partner organization, Research Square. Reviewers with 
declared or apparent competing interests are not utilized for t hese revie ws. This reviewer has 
agreed to publication of their comments online under a Creat ive Commons Attribution License 
attributed to  Research Square and was paid a small honorarium for  completing the review within 
a specified timeframe. Honoraria for reviews such as this are paid regardless of the reviewer 
recommendation.  
 
I agree to the open peer review policy of the journal. I underst and that my name will be included 
on my report to the authors and, if the manuscript is accepted f or 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 b e made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I unders tand that any comments 
which I do not wish to be included in my named report can be in cluded 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: Validation of a New Risk Score System for Non -variceal Upper Gastrointestinal Bleeding  
 
Version: 0 Date: 21 Jan 2020  
 
Reviewer's report:  
 
PEER REVIEWER ASSESSMENTS:  
 
OBJECTIVE - Full research articles: is there a clear objective that addresses a testable research 
question(s) (brief or other article types: is  there a clear objective)?  
 
Yes - there is a clear objective  
 
 
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for the 
objective?  
 
No - there are minor issues  
 
 
EXECUTION - Are the experiments and analyses performed with technical rigor to allow 
confidence in the results?  
 
No - there are minor issues  
 
 
STATISTICS - Is the use of statistics in the manuscript appropriate?  
 
Not sure - I am not able to assess the statist ics in this study  
 
 
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not 
overstated?  
 
No - there are minor issues  
 
 
OVERALL MANUSCRIPT POTENTIAL - Is the current version of this work technically 
sound? If not, can revisi ons be made to make the work technically sound?  
 
Probably - with minor revisions  
 
 
PEER REVIEWER COMMENTS:  
GENERAL COMMENTS:  
 
* What is your overall impression of the study?  
 
Well conducted, thorough, but a retrospective analysis.  
 
 
* What have the authors d one well?  
 
They have tried to address the disparities with existing scoring systems by developing a new 
scoring system for international usage to predict 30 day mortality from UGIB.  
 
* In what ways does it not meet best practice?  
 
Minor: I get the impressio n that the study was developed for use in one country (Korea?) and a 
more international focus could be provided throughout the paper.  
 
Major: Complete and reproducible validation of a new scoring system would have to be done 
using a prospective design (that  is, test it on cohorts of patients in countries outside Korea, at 
presentation with UGIB, and then review whether the new scoring system performed better than 
existing scoring tools, using a retrospective review of outcomes).  This study is entirely 
retro spective in design.  
 
 
REQUESTED REVISIONS:  
 
Yes - there is a clear objective.  I have no major comments.  The intention of creating an 
internationally verified scoring scale for 30 -day post UGIB mortality is laudable, although the 
manuscript could be clearer about why this is needed as various other scoring systems have been 
developed and are in use. In fact t he introduction and perhaps the discussion could reference 
some of the recent work done by Y Tang and others on comparison of such scoring systems 
(please see some suggested references below).  There are numerous other examples of such work 
in the literatu re and this makes me hesitate to commend the paper under review as being entirely 
novel which meets a clinical need.  
 
 Tang Y Am J Emerg Med. 2018 Jan;36(1):27 -32. doi: 10.1016/j.ajem.2017.06.053. Epub 2017 
Jun 27. Scoring systems used to predict mortality in patients with acute upper gastrointestinal 
bleeding in the ED. )  
 
H Tuncer (Pak J Med Sci. 2018 May -Jun; 34(3): 649 -654. doi: 10.12669/pjms.343.14956 
PMCID: PMC6041537 PMID: 30034432 Comparison of four scoring systems for risk 
stratification of upper ga strointestinal bleeding  
 
Design acceptable?  
 
No - there are minor issues  
My major comment relates to the retrospective nature of the study and for validation, the scoring 
system would need to be tested prospectively in several international populations to en sure 
consistency of results.  
 
 
Execution acceptable?  
 
No - there are minor issues  
 
Please see above - I have some concerns about validation due to the retrospective mature of the 
study  
 
 
Statistics acceptable?  
 
Not sure - I am not able to assess the statistics in  this study  
 
I have not commented the statistics in detail as this is specialised branch of statistics. The 
methods used (multivariable logistic regression modelling appears to be appropriate).  
 
 
Interpretation acceptable?  
 
No - there are minor issues. The sam e issue - without prospective studies on validation in more 
populations, this scoring system is not ready for international clinical use.  
 
 
ADDITIONAL REQUESTS/SUGGESTIONS:  
 
Generally the interpretation appears to be valid, and if the new scoring system can predict 30 -day 
mortality better than existing tools then it will have clinical utility.  However I feel it is 
premature to promote the scoring system as 'validated' until further work has been done.  It is an 
interesting study and with some edits may be su itable for publication as a preliminary report of 
development of the scoring tool.  
  
The discussion section is overly long and could benefit from some editing for brevity.  
 
Please refer to the study patients as participants and not 'subjects'. The section about patient 
consent had been redacted from my review copy, but I hope this is present in the original 
version.  
 
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, please explain in your comments to the authors.  
 
No 
 
Are you able to ass ess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
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:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please complete a declaration of competing interests, consid ering the following questions:  
 
1.  Have you in the past five years received reimbursements, f ees, funding, or salary 
from an organisation that may in any way gain or lose financial ly from the 
publication of this manuscript, either now or in the future?  
 
2.  Do you hold any stocks or shares in an organisation t hat 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.  
 
This reviewer has been recruited by a partner organization, Research Square. Reviewers with 
declared or apparent competing interests are not utilized for t hese revie ws. This reviewer has 
agreed to publication of their comments online under a Creat ive Commons Attribution License 
attributed to  Research Square and was paid a small honorarium for  completing the review within 
a specified timeframe. Honoraria for reviews such as this are paid regardless of the reviewer 
recommendation.  
 
I agree to the open peer review policy of the journal. I underst and that my name will be included 
on my report to the authors and, if the manuscript is accepted f or 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 b e made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I unders tand that any comments 
which I do not wish to be included in my named report can be in cluded as confidential comments 
to the editors , which will not be published.  
 
I agree to the open peer review policy of the journal  
assistant