Comparison of RIPASA and ALVARADO scores for risk assessment of acute appendicitis: A systematic review and meta-analysis

Giuliana Favara; Andrea Maugeri; Martina Barchitta; Andrea Ventura; Guido Basile; Antonella Agodi

doi:10.1371/journal.pone.0275427

Peer Review History

Original SubmissionAugust 1, 2022
4 Sep 2022 Decision Letter - Ibrahim Umar Garzali, Editor PONE-D-22-21559COMPARISON OF RIPASA AND ALVARADO SCORES FOR RISK ASSESSMENT OF ACUTE APPENDICITIS: A SYSTEMATIC REVIEW AND META-ANALYSISPLOS ONE Dear Dr. Agodi, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. ACADEMIC EDITOR:Is the protocol for the meta-analysis registered in any database like Prospero?Is there a particular reason for the authors not to assess for publication bias? Please submit your revised manuscript by Oct 19 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. 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If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. Additional Editor Comments: A very good meta-analysis. But there is need to mention if the protocol for the meta-analysis was registered in any database like prospero and if it was registered, provide the number. Also there may be need to asses publication bias in some meta-analysis, why wasn't that done? [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The study topic is relevant to clinical practice, moderately well-written, clear and as a systematic review contributes to the body of literature on the topic of clinical diagnosis of acute appendicitis. It may go a long way in informing clinicians on what tool may or may not be superior in decision-making. However, the following questions need to be clarified: 1. The authors mention 33 articles from 35 studies. While it may be normal to expect 35 articles from 33 studies as some studies can generate more than one articles, how were 35 studies reduced to 33 articles? Further, in the “Results” section while mentioning study design, the authors clarify 30 observational and 3 cross-sectional studies, making 33! 2. In discussing the individual studies included in the systematic review, the authors discuss NPV and PPV of RIPASA vis-à-vis Alvarado but only give the sensitivity and specificity values in the results of the meta analysis. Can the combined NPV and PPV be generated by the methods used to carry out the analysis because this may guide the clinicians further when comparing the two tools? 3. In the manuscript the authors admit that all the studies were done in a specific sub-set of global population. Furthermore, most of the studies that as argued by the authors used a higher cut-off for RIPASA/Alvarado to improve diagnostic parameters of the score are from a specific sub-set of the study groups. In authors opinion, what is the universal applicability of the results of this analysis and the studies reviewed, especially to the sub-set of global population not covered by the studies? Reviewer #2: The study has highlighted the significance of RIPASA and Alvarado scoring systems and most importantly it has provided an insight into the diagnostic value of these test in terms of both their sensitivity and specificity. The authors however, the to address the following issues: 1.State the mean age ± SD 2. Discuss the implication of high sensitivity and low specificity of RIPASA as its relates to clinical practice; especially in diagnosis of fatal/severe conditions like AA and its role in reducing morbidity, mortality and healhtcare cost. 3. Kindly explain the statement that "In general the risk of bias was unclear or high in all domains. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. Attachments Attachment Submitted filename: PONE-D-22-21559.docx https://doi.org/10.1371/journal.pone.0275427.r001
Revision 1
15 Sep 2022 Author Response Dear Editor, this document is intended for the convenience of the editor and reviewers and contains the list of the requested changes. We hereby submit to your attention a revised version of the manuscript in which we have considered all comments and suggestions. The following list of changes and answers to comments of Academic Editor and Reviewers addresses all changes made in the manuscript (in red font). ACADEMIC EDITOR AE: Is the protocol for the meta-analysis registered in any database like Prospero? Authors: We would like to take this opportunity to thank the Academic Editor for his/her comments and suggestions which helped us in improving our manuscript. We apologize for not giving information on the registration in the PROSPERO database. Please consider details described in the revised version of our manuscript (lines 83-84). AE: Is there a particular reason for the authors not to assess for publication bias? A: We recognize that publication bias is one of the main source of misinterpretation of findings from meta-analyses. However, to our knowledge, there are no currently adequate methods to investigate publication bias in meta-analyses of diagnostic tests. For this reason, we have added this point as a main limitation of our work (lines 237-241). REVIEWER 1 R: The authors mention 33 articles from 35 studies. While it may be normal to expect 35 articles from 33 studies as some studies can generate more than one articles, how were 35 studies reduced to 33 articles? Further, in the “Results” section while mentioning study design, the authors clarify 30 observational and 3 cross-sectional studies, making 33! A: We would like to take this opportunity to thank the Reviewer for his/her comments and suggestions which helped us in improving our manuscript. We apologize if this point was not so clear. The meta-analysis included 33 studies. However, Abdelrhman et al. (2018) reported findings from two different populations, while Erdem et al. (2013) used two different couples of cut-offs for the RIPASA and ALVARADO scores. Accordingly, the meta-analysis was conducted on 35 different estimates of sensitivity and specificity. We have better described this point in lines 149-152. R: In discussing the individual studies included in the systematic review, the authors discuss NPV and PPV of RIPASA vis-à-vis Alvarado but only give the sensitivity and specificity values in the results of the meta analysis. Can the combined NPV and PPV be generated by the methods used to carry out the analysis because this may guide the clinicians further when comparing the two tools? A: We agree with this comment on the importance of NPV and PPV in interpreting the performance of a diagnostic test. Accordingly, we have reported the individual parameters for each study included in the meta-analysis. However, to our knowledge there are currently no methods to pool this kind of data through a meta-analysis. R: In the manuscript the authors admit that all the studies were done in a specific sub-set of global population. Furthermore, most of the studies that as argued by the authors used a higher cut-off for RIPASA/Alvarado to improve diagnostic parameters of the score are from a specific sub-set of the study groups. In authors opinion, what is the universal applicability of the results of this analysis and the studies reviewed, especially to the sub-set of global population not covered by the studies? A: We are grateful for this comment that allowed us to discuss an important point of our study. Please consider changes in lines 251-255. REVIEWER 2 R: The study has highlighted the significance of RIPASA and Alvarado scoring systems and most importantly it has provided an insight into the diagnostic value of these test in terms of both their sensitivity and specificity. The authors however, the to address the following issues: State the mean age ± SD A: We would like to take this opportunity to thank again the Reviewer for his/her comments and suggestions which helped us in improving our manuscript. Since data on the mean age of individual studies are not reported uniformly, it is not possible to calculate the mean age and standard deviation of all included studies. R: Discuss the implication of high sensitivity and low specificity of RIPASA as its relates to clinical practice; especially in diagnosis of fatal/severe conditions like AA and its role in reducing morbidity, mortality and healhtcare cost. A: We agree with this suggestion and thus we have discussed the implications in the discussion section. Please consider changes in lines 222-228. R: Kindly explain the statement that "In general the risk of bias was unclear or high in all domains. A: As requested, we have better explained this point in the limitation section (lines 234-237). https://doi.org/10.1371/journal.pone.0275427.r002
19 Sep 2022 Decision Letter - Ibrahim Umar Garzali, Editor COMPARISON OF RIPASA AND ALVARADO SCORES FOR RISK ASSESSMENT OF ACUTE APPENDICITIS: A SYSTEMATIC REVIEW AND META-ANALYSIS PONE-D-22-21559R1 Dear Dr. Agodi, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Ibrahim Umar Garzali, MBBS, FWACS Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0275427.r003
Formally Accepted
21 Sep 2022 Acceptance Letter - Ibrahim Umar Garzali, Editor PONE-D-22-21559R1 COMPARISON OF RIPASA AND ALVARADO SCORES FOR RISK ASSESSMENT OF ACUTE APPENDICITIS: A SYSTEMATIC REVIEW AND META-ANALYSIS Dear Dr. Agodi: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Ibrahim Umar Garzali Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0275427.r004

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