PONE-D-22-25709A multicenter prospective study on the utility of a new scoring system to determine the adaptation of emergency endoscopy for colonic diverticular bleedingPLOS ONE

Dear Dr. UEHARA,

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:

The paper was found interesting in its original idea, but still has too many major concerns. Following the reviewers' suggestions, first it is necessary to better revise and structure the article with regard to scientific methodology. The M&M session requires more structural and scientifically presentation; the statistical part also needs to be better presented, scientifically, schematically and according to international standards. Consequently, the results must also follow the same logical presentation as in the M&M session. On discussion and conclusions, it is necessary to remain more factual. Last but not least, the introductory part needs to be better argued and make sure that each sentence has a background of scientific evidence without any speculation. Finally, reviewer #1's reflection on the background seems interesting to me; I think it needs to be explored further; if necessary, you can discuss it in the Discussion session.

As far as my critical thinking on the text is concerned, I prefer to expose my possible doubts to the Authors once the paper has been adjusted and revised according to this first absolutely necessary structural and content revision. As a leading journal, it is necessary not only to present an excellent paper, but to add clinical reflections and speculations that 'make a difference'. In order to do this, however, the structural and presentation basis must be as flawless as possible. At the moment, I ask the Authors to remain factual and resolve the doubts raised by the Reviewers; afterwards, we will consider whether a high-level speculative discussion is possible.

Please submit your revised manuscript by Jan 18 2023 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. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Samuele Ceruti

Academic Editor

PLOS ONE

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At this time, please address the following queries:

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Please complete your Competing Interests on the online submission form to state any Competing Interests. If you have no competing interests, please state "The authors have declared that no competing interests exist.", as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now 

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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: Partly

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

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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

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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

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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: Thank you to to the authors to submit this article. The authors evaluated the usefulness of a previously established score (the JD score) to detect the endoscopic source of bleeding in colonic diverticular bleeding. Unfortunately it is not very clear what was the aim of this research and accordingly, the design they used to state their hypothesis. E.g. in the abstract the authors stated that the aim of this study was "to establish an efficient and safe emergency endoscopy system", what it is neither clear, nor a scientific question. In the introduction they stated that the aim of this study was "to validate our scoring system" (i.e. JD score). The sentence before, the authors stated that "no study to date has examined whether emergency endoscopy should be performed for colonic diverticular bleeding using a scoring system". So, the hypothesis should be something challenging the indication of an emergency endoscopy, but the primary outcome was the identification of the bleeding source, which alone would have no impact. Why not using e.g. endoscopic hemostasis instead? This would be much more interesting. I read in the discussion first, that every patient in the emergency endoscopy group received endoscopic treatment, but exactly numbers and proportions in the elective endoscopy group are not given (which of course should be listed in the results). E.g. the article could be something like "Need for endoscopic treatment in acute colonic diverticular bleeding: a multicenter validation of the JD score". It would be however questionable to change the design of an intervention trial. Further, the JD score is based on CT scan findings, which is however not recommended for every patient with suspected diverticular bleeding (e.g. https://gut.bmj.com/content/gutjnl/68/5/776.full.pdf). Finally, 91% of the patients in the "emergency group" had an extravasation in the CT scan, what would of course increase the probability to see something in the endoscopy (what is the importance of the others parameters in the JD score?). The question of which patients need a CT scan remain open, unfortunately limiting the significance of this study.

Other comments

- methods: "to evaluate the benefit of hemostatic treatment, the patients were divided into those in whom the bleeding source could be identified (identified group) and those in whom it could not (non-identified group)" -> this is not clear, because identification of the bleeding source does not necessarily implicate hemostatic treatment. Additionally, there is no information about hemostatic treatment.

- an important number of patients received blood transfusions; however in the demographics (i.e. at least at presentation) none of the patient was unstable or with low hemoglobin. The authors should give more information about hemodynamic stability or low hemoglobin values in the course. It would be also interesting to know which patients needed ICU care.

- the power analysis is not clear. The authors should give more information. Additionally, the authors calculated 60 patients, but recruited 91 (?)

- the authors should give a reference for the comorbidity index

- results without importance (e.g. minimally statistically differences in platelets count or diastolic pressure) should not be reported in the text (is instead OK in the table)

- it would be interesting to know if anticoagulant reversal was performed in these patients

- how did the authors assess re-bleeding? There was a follow-up? How was performed?

- the limitations section should be expanded

- statements in the discussion e.g. by platelets and blood pressure are overreaching; additionally the authors should not repeat the results but stick to a global interpretation before assessing for external validity

- in the discussion the authors should compare endoscopic treatment vs endovascular treatment (especially when an extravasation is seen on the CT scan)

Reviewer #2: I would like to thank the editor for allowing me to review this paper by the Japanese group who thought to create an effective and safe emergency endoscopy system in diverticular bleeding.

1. I advise authors, when submitting a manuscript to a journal to always include the continuous line number so that reviewers can make a timely and accurate review.

2. For manuscript review, I entered the count on the submitted manuscript without making any other changes.

References

3. I advise authors to set the style of references as required by the journal. Perhaps using a computer system reference management tool so that it is done properly. https://journals.plos.org/plosone/s/submission-guidelines#loc-references

Title

4. I advise authors to edit the title.

Since, after reading the manuscript completely I understood that you wanted to do a validation study regarding the previously developed JD score so it would be important that the title also highlight that this is a validation study.

Keywords

5. I advise the authors to double-check through the MESH batabase the keywords:

a. colonic diverticular bleeding does not exist, however, Diverticulum Colon; Bleeding; Diverticular Diseases is present

b. scoring system does not exist, there is score; scoring;

c. emergency endoscopy does not exist, there is however: endoscopy; Endoscopy, Digestive System; Endoscopy, Gastrointestinal;

Introduction

6. Line 37: I suggest to the authors, as they included reference to the Japanese Gastroenterological Associatio guideline they should also include that of the American Gastroenterological Association (Strate LL, Gralnek IM. ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding. Am J Gastroenterol. 2016 Apr;111(4):459-74. doi: 10.1038/ajg.2016.41. Epub 2016 Mar 1. Erratum in: Am J Gastroenterol. 2016 May;111(5):755. PMID: 26925883; PMCID: PMC5099081.) I'm not absolutely sure if this is the very latest version but it seems to be.

7. Line 38-39 Is this statement an inference by the authors or is it supported by the low evidence in the guidelines? I suggest the authors specify this better, perhaps putting the guideline passage with what it states and the level of evidence.

8. Line 64. I suggest the authors move the written references or add more in correlation to the statement made about "and size of the exposed blood vessel, whether the source of bleeding is an artery or vein, and the location of the diverticulum (visibility)." If these conditions are always integrated into the previously cited references I recommend citing them again, otherwise it seems like a statement by the authors themselves, without a rationale.

9. Line 64-67 I advise the authors to include references about it here as well or modify the sentence so that it is understood to be a statement by the authors.

10. Line 75. The score states that 1 point is taken for the use of oral anticoagulants. It would be important to perhaps specify which types, whether any type of anticoagulant or a particular type.

Materials and methods

11. Line 96-97 Why do the authors in point 2 of the exclusion criteria include "one or more episodes of bloody stools in the previous 30 days" They should justify why this is so.

12. Also at line 98 item 4 of the exclusion criteria what do the authors mean by "could not undergo endoscopy at the time indicated in the score." In what way, why could patients not undergo endoscopy? It would be better to justify

13. I would advise the authors to restructure the materials and methods with subchapters so as to make the work easier and more readable, for example with subchapters such as: inclusion and exclusion criteria, a subchapter with the JD score, perhaps tightening the part in the introduction and expanding the part in the methods, not forgetting that there is already a manuscript about it, so it should not be repetitive but quickly explanatory. I hope I have explained myself. One last subchapter with the two groups of patients, elective and emergency endoscopy.

14. With related subgroup developments. This would make the work more linear and logical and easily understood perhaps even by those not fully in the profession.

15. Another piece of advice I would give to the authors is to explain whether the election group was being "prepped" with a purgative in order to better assess the bowel or was it conservative without using laxatives for bowel cleansing. Because in Table 2 it is understood that 85% of the elective patients were bowel-prepared but it is not stated in the methods.

Discussion

16. Line 209-279 The authors make a long digression of the results obtained but unfortunately list the results of the study again in a descriptive manner without going into the results and data obtained but especially not making a comparison with the present literature.

17. The discussion should be a deepening of the results by comparing them with the present, or even past, literature, comparing their own results with those present, perhaps criticizing or pointing out the differences. The fact that no score is present does not mean that one cannot compare the results obtained, perhaps just with primary endpoint and then the secondary ones.

18. How is endoscopy time in the literature? bleeding after urgent or elective endoscopy? Or the days of hospitalization? Do they change from the literature? Transfusions?

19. I recommend that the authors remerge in the discussion and elaborate on the various points, not re-describing the results but elaborating on them.

Tables

20. I suggest the authors create legends for the tables, each table a title and an explanatory legend, not meaning to describe the results but to specify acronyms or data presentation and whatnot.

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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

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[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.

PONE-D-22-25709R1Need for emergency endoscopy in acute colonic diverticular bleeding: a multicenter validation of the JD score.PLOS ONE

Dear Dr. UEHARA,

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. I thank the Authors for this interesting and potentially useful pilot study for the entire scientific community. The study is, however, burdened by an approximation in the methodological presentation that in my opinion needs to be clarified and resolved; the most important advice is to involve an additional expert colleague who can give a methodological revision in the presentation of the paper. Specifically: a) in M&M it is necessary to immediately clarify the Multicenter study; the two hospitals mentioned must be framed as dimensions (Primary Care, Tertiary Care, etc...) and it is necessary to know approximately how many endoscopists were involved (one per centre? more endoscopists per centre? etc...). b) the allocation is never clearly explained, which is only apparent from Figure 1. It must be clearly explained that based on the JD score, it is determined how to treat patients (elective vs urgent). This point is fundamental. c) There are patients who are excluded because they are then managed differently from what was initially planned. They must be reported in absolute value (as has been done), but also in percentage. This shows the limitations of the JD score, which will perhaps require further study in the future with additional parameters to avoid having these exclusions which are significant in percentage terms. d) What reviewer #2 pointed out is fundamental and should be placed as a clear limitation in the methodology.

e) The Authors should reflect on whether it would not be better to present this paper as a Pilot Study, even in the title. The numbers are objectively low and it would be better to call it that.

I find the paper interesting, but there is a lack of methodological clarity in the exposition. I would therefore ask the authors to tidy up the M&M session, put this part in order as if it were the first time we were re-reading this paper - explaining well each step in the: 1. selection of patients (inclusion/exclusion), 2. allocation of patients according to JD, 3. taking care of patients medically (crystalloids, transfusions, antibiotics, etc.) and 4. when you are further excluded. Because it is unclear to understand the pathway.

Consequently, the presentation of the results must also be ordered as in M&Ms, and the limits must be adjusted.

I mark the paper as a Major Revision because the work to be done is still structural, but I strongly encourage the Authors to adapt this revision and then proceed with the next steps.

Please submit your revised manuscript by May 11 2023 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. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Samuele Ceruti

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. 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: Partly

Reviewer #2: (No Response)

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: (No Response)

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4. 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

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5. 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

**********

6. 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: Thank you to the authors to resubmit a revised version of the manuscript. Unfortunately there is a major design concern, which appears not possible to address.

The JD score was developed to predict the endoscopic identification of the bleeding source in patients with suspected colonic diverticular bleeding. A validation study should accordingly prospectively confirm that patients with a JD score ≥ 3 have an higher endoscopic identification rate of the bleeding source in patients with suspected colonic diverticular bleeding (compared with JD score < 3). This means that each patient should undergo endoscopy and categorized as JD score ≥ 3 (or JD score < 3), and identification of the bleeding source (yes/no). However, at least two patients (with JD score ≥ 3) did not undergo emergency endoscopy and were treated conservatively at the physician's discretion. A physician-based decision in a validation study is however not acceptable. Further, the authors divided patients in an emergency endoscopy vs elective endoscopy group. This seems to refer to another outcome than the identification of the bleeding source (e.g. identification of patients who need emergency endoscopy). If so (which again is not validation of the score), the authors should state another hypothesis and especially another power calculation. Additionally, each patient with a JD score ≥ 3 should undergo emergency endoscopy, and each patient with a JD score < 3 should not. Both of these conditions were not applied to this study.

Reviewer #2: Certainly an adequate level of review has been carried out by the authors.

The work certainly appears to be much more supported by scientific evidence and evidence also present in the literature, although weak, but stated by the authors with a less speculative development of the work and the results obtained by relying solely on the present results.

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7. 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

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[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.

PONE-D-22-25709R2Evaluation of the Jichi Medical University diverticular hemorrhage score in the clinical management of acute diverticular bleeding using endoscopy: a pilot studyPLOS ONE

Dear Dr. UEHARA,

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:I kindly ask the Authors to be extremely precise and clear in their answers to all reviewers, especially to Reviewer #1 in order to process the request. The delay in journal replying was mainly due to a strong disagreement between Reviewers. I think the paper should go ahead, but with the need to process the reviewer's requests and smooth out some of the edges of the text, according to Reviewer #1 suggestion.

Please submit your revised manuscript by Jul 13 2023 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. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Samuele Ceruti

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. 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.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

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2. 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: Partly

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

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4. 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

Reviewer #3: Yes

**********

5. 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

Reviewer #3: Yes

**********

6. 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: Thank you to the authors for this resubmission. This study still not show a clear hypothesis, which has been tested. Starting from the title, the «clinical management … using endoscopy» has for me no meaning. What I previously suggested, was the validity of the score to determine emergent endoscopy. However the score has not been developed for this. The authors showed in the course of this review a "data driven" approach, instead of an "hypothesis driven" approach, what would have been preferable. Accordingly, conclusion are not based on the data, but are derived indirectly. E.g. stating that "...patients with a JD score <3, emergency endoscopy can be avoided without any clinical disadvantage" as a conclusion is fault. In fact, 3 patients with a JD score < 3 needed emergency endoscopy. Further, the hospitalization was shorter for patients with identified bleeding source, BUT was not shorter based on the JD score (Table 2). Finally, what would have happened if patients with a JD score > 3 would have received elective endoscopy? In fact, 2 patients underwent elective endoscopy and in the group with a JD score < 3, 11 patients had an identified bleeding source necessitating clipping. This study accordingly does not determine the need for emergency lower GI endoscopy. There is still some data that are difficult to imagine, e.g. no patient had ICU care, but at least one patient received 36 (!) unit of blood (Table 2). Last but not least, the authors should be more precise on the studied population. E.g. the JD score was develop for diverticular bleeding, but the authors use "lower GI" interchangeable along the paper.

Reviewer #2: This further review of the work perhaps places it in its own specific domain. A pilot study for an initial investigation toward identifying a possible categorization of this type of patient. To accept the work as a multicenter study would have been too much. As a pilot study is the right placement of the work done.

Reviewer #3: The utility of the JD score devised for patients with diverticular bleeding was evaluated. The primary and secondary endpoints were the bleeding source identification rate and clinical outcomes. The rate of bleeding source identification was significantly higher in the JD ≥3 group than in the JD <3 group. The groups did not differ significantly with respect to clinical outcomes.

Minor revisions:

1- Line 191: State the statistical testing method which achieves 80% power.

2- Line 204: Use a lower case p for “p-values”.

3- For some comparisons of proportions, chi-square tests may be more powerful than Fisher’s exact tests, considering the expected sample sizes.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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Evaluation of the Jichi Medical University diverticular hemorrhage score in the clinical management of acute diverticular bleeding with emergency or elective endoscopy: a pilot study

PONE-D-22-25709R3

Dear Dr. UEHARA,

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Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

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Reviewer #2: Yes

Reviewer #3: (No Response)

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Reviewer #2: Yes

Reviewer #3: (No Response)

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Reviewer #2: Yes

Reviewer #3: (No Response)

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Reviewer #2: Yes

Reviewer #3: (No Response)

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6. 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 #2: (No Response)

Reviewer #3: (No Response)

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Reviewer #2: No

Reviewer #3: No

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