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PONE-D-24-30053‘Patera syndrome’ during the COVID-19 pandemic in the Canary Islands (Spain)PLOS ONE

Dear Dr. Carranza-Rodriguez,

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Academic Editor

PLOS ONE

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Additional Editor Comments (if provided):

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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: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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

Reviewer #1: No

Reviewer #2: N/A

Reviewer #3: Yes

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Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: 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: The paper describes the called “Patera syndrome” during the COVID-19 pandemic in the Canary Islands (Spain). First, I am agreeing with the title, especially with the “patera patients and syndrome” terms. It is very illustrative and true. The bibliography is actual and appropriate.

It is generally well written and not too long (However, the data should be provided as supplementary material, especially those used for the data analysis). The purpose of the study is well explained in the introduction and appears to be adequately referenced. The conclusions are brief but summarize the obtained results well.

However, the statistical analysis is poor or incomplete. The authors provided a section called “statistical analysis” (see line 198), where the different statistic tests are described and its application. However, the obtained results from the different contrast or situations were not provided or simply commented and discussed in the paper. For instance, in the Table 2 and Table 5, the authors used different test but any information about the results was provided. In the Table 2, only the criteria for APS was significative (p<0.05), whereas it was not significance for the rest of contrast. A similar situation was observed for the Table 5 results. This needs an explanation.

In the Discussion section (see lines 434-448) the authors speak on the analytical data but any information was provided. In this context, the authors comments data in terms of percentages on different clinical situations but no statistical analysis data.

In addition, there is a section called “Analytical data” (see lines 280-285). The authors says “However, there was no significant correlation between determinations obtained at the two time points”. What does this sentence mean? It is very confused. Does this apply only to laboratory data or to all variables used to define PSA? This needs some explanation.

In opinion of this reviewer, the manuscript is suitable for publication in the PLOS ONE Journal after minor revision.

Reviewer #2: This work is a retrospective study of patients who are admitted to a University Hospital after a crossing in patera, arriving to the island of Gran Canaria. The work is well developed and presented, and provides relevant information on this type of patients. We set out below some issues that in our opinion should be clarified.

Major issues:

1- The title should be improved, as it does not only relate to Patera Syndrome, but also to Skin and soft tissue or musculoskeletal patera syndrome (SSTMSPS). Perhaps including “COVID-19” in the title is misleading in terms of the objective of the article, since the data on this disease are very few and of a marginal nature with respect to other pathologies detected.

2- The bibliographic reference of the definition of APS and SSTMSPS is not clear. Is it being defined by the authors for the first time? If so, other conditions should in our opinion be included in APS, such as cardiorespiratory arrest (even if they had no cases in their series). The division of SSTMSPS, from the APS, of which we believe it is a part, should also be justified.

3- Given that probably not all patients who come to the hospital emergency department are admitted, the admission criteria should be included. Is it understood that all patients with PHC criteria were admitted to the ward or did some remain in the Emergency Department and were later discharged?

4- As these were severe cases, was there any out-of-hospital treatment on arrival and prior to admission to the Hospital (serum therapy, etc)?

Minor questions:

1- Line 90. Indicate how many of the migrants from the province of Las Palmas correspond to the island of Gran Canaria, where the study was carried out (therefore not including the islands of Lanzarote and Fuerteventura).

2- Line 134. Is this hospital the reference center for all the migrants on patera or is there another university hospital on the island that could attend them?

3- M&M: did all the patients come to the Hospital directly from the port or did some of them come later, from the interbording center?

4- Discussion:

- Line 344. I think there is an error, as the series only includes data from one of the hospitals in the Canary Islands. If the 56,000 are only from the island of Gran Canaria, this should be made clear in the text. This is important when calculating the % requiring hospitalization, which in any case would be very low.

-Should pneumomedicine be included as a criterion for PHC?

- Did they receive admissions from other islands (Lanzarote and Fuerteventura)?

- It should be noted that, after the study, the pressure of arrivals has moved to the island of El Hierro, where there have been some deaths in hospital care and transfers in critical condition to the referral hospital. (Mora Peces I, Galvez Rodríguez M. Seven nights, Sept nuits. Emergencias. 2024;36:148-148. Mora Peces I, Gálvez Rodríguez M. Health response of El Hierro to maritime migration in 2023. Rev Esp Urg Emerg. 2024;3:1-2)

5- Limitations:

-Possible attendances in other centers on the island of Gran Canaria?

-Missed cases of final diagnosis (line 245), should be included in the limitations and indicate possible reasons for these losses.

6- Tables and figures:

- Figure 3: Distribution of arrivals by month. Does this refer to arrivals on the island of Gran Canaria, the province or the entire Canary archipelago?

- Figure 5. The pneumomediastinum images do not seem to provide new information. We suggest deleting it.

Reviewer #3: The ‘patera syndrome’ during the COVID-19 pandemic in the Canary Islands (Spain)’ is a well-written review of patients treated for “patera syndrome” in a specific significant setting.

Concept, data and presentation of the work will be interesting for the future management of this type of patients.

Minor comments

- If possible, it would be very interesting to complete the text with data on antibiotic treatment, especially initial empirical treatment. A new table in “RESULTS” and a clear conclusion in the last part of the DISCUSSION are recommended.

- The reviewer assumes that there are few specimens for pathological review. But still, if possible, consider adding histological data from the amputation specimens: inflammation only? vasculitic findings?

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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‘Patera syndrome’ during the COVID-19 pandemic in the Canary Islands (Spain)

PONE-D-24-30053R1

Dear Dr. Carranza-Rodriguez,

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.

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Kind regards,

Felix Bongomin, MB ChB, MSc, MMed, FECMM

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: