PONE-D-24-45843Association of abbreviated burn severity index with mortality in severely burned patients: a meta-analysisPLOS ONE

Dear Dr. Li,

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.

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Thank you for your patience with the reviews of this manuscript.  In short, you will see a number of suggestions that are really needed to improve this story for acceptance. Particular attention to the comments of Reviewer 1 and Reviewer 2 are needed. Overall, more in depth analysis of the ASBI needs to be done, and what stands this work apart from previous studies on the ASBI is needed. Additionally, your conclusions need to be updated. Presumably, this score includes age, TBSA, and inhalation injury, as was developed over 4 decades ago. Your conclusion that "ABSI could serve as a novel and reliable prognostic indicator in severely burned patients" is not true because the ASBI is not novel. Was there any comparison to other scoring systems (e.g., Baux)? Moreover, your conclusion that "patients with an elevated ABSI are exposed to increased risk of death." is also not new- age and TBSA have been known predictors of mortality for nearly 70 years. As such, I encourage your new conclusions to better highlight the uniqueness of this work, and what it brings to the field.

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Additional Editor Comments (if provided):

Dr. Li,

Thank you for your patience with the reviews of this manuscript.

In short, you will see a number of suggestions that are really needed to improve this story for acceptance. Particular attention to the comments of Reviewer 1 and Reviewer 2 are needed. Overall, more in depth analysis of the ASBI needs to be done, and what stands this work apart from previous studies on the ASBI is needed.

Presumably, this score includes age, TBSA, and inhalation injury, as was developed over 4 decades ago. Your conclusion that "ABSI could serve as a novel and reliable prognostic indicator in severely burned patients" is not true because the ASBI is not novel. Was there any comparison to other scoring systems (e.g., Baux)? Moreover, your conclusion that "patients with an elevated ABSI are exposed to increased risk of death." is also not new- age and TBSA have been known predictors of mortality for nearly 70 years.

As such, I encourage you to better highlight the uniqueness of this work, and what it brings to the field.

[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: Partly

Reviewer #3: Yes

Reviewer #4: Yes

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

Reviewer #1: Yes

Reviewer #2: I Don't Know

Reviewer #3: Yes

Reviewer #4: 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

Reviewer #3: Yes

Reviewer #4: No

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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: No

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: 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: This manuscript analyzes the prognostic relevance of the ABSI score based on 16 studies published between 2015 and 2024. The statistical analysis is thorough and the results are presented in a clear and understandable form. However, the overall quality of the text lacks in multiple areas. Overall, many of the chosen formulations are inadequate and articles are often missing, which makes the text not very pleasant to read.

The authors claim, that the ABSI score could possibly be used as a novel prognostic score, which doesn't make any sense as the score was introduced in 1982 and has been in use ever since. It is true, that the relevance of the score has been questioned in the past, however, there are multiple (very recent) studies which test the score for its validity. However, the authors repeatedly claim in this manuscript that the ABSI score is novel, which could be very misleading for readers.

Furthermore, the authors don't provide enough references for the claims in the introduction as well as the discussion. Following claims need to be undermined with references:

Introduction:

- Young children and the elderly, due to thinner skin and weaker immune function, tend to have poorer

outcomes when faced with burns of the same severity. (??)

- Additionally, underlying conditions such as diabetes, heart disease, and renal failure can impair the

body's ability to recover from burns, leading to a poorer prognosis. (e.g. Resch A, Neumueller A, Christ A, Staud C, Hacker S. Chronic kidney disease and cardiovascular disease reduce survival rates after burn injury: A retrospective study over 20 years.)

- Severe burn patients are prone to infections, especially with extensive burns, and infection is one of the

leading causes of death in these cases.

- However, due to weaker immunity and lower treatment compliance, children may have a worse prognosis compared to adult patients in the same situation. (The ABSI score is especially relevant for severely burned patients, who require intensive care treatment. There is no such thing as "lower treatment compliance" in children in ICU's.)

In the materials and methods section the authors write "Studies met following criteria were included: 1) severely burned patients with the degree II burns ≥30% or degree II burns ≥10% of the total body surface area,...." which doesn't make any sense and needs to be rewritten and clarified.

Overall the discussion is weak and lacks in relevant information about the ABSI score and why it's validity has been questioned over the past decades.

I would highly suggest extensive major revision, as the findings of this meta-analysis are clinically relevant and statistic analysis seems thorough, however the manuscript lacks in multiple areas. The text must be revised by a native english speaker and above mentioned points have to be revisited by the authors.

Reviewer #2: ABSTRACT:

* The conclusion should be a statement in the affirmative rather than subjuctive, i.e. 'ABSI serves as a reliable prognostic indicator for mortality in burned patients'. By the way, it is not novel,... This phrase should be deleted.

INTRODUCTION:

* Age is included as a major factor in all useful predictors, which are burn size and age and should be introduced together.

* ABSI has been around for a long time, and the major inclusion over age and burn size alone (a.k.a. Baux score) is inhalation injury, which goes back and forth. The paper should really include an analysis of Baux score too. Is ABSI better than the Baux score in a meta-analysis?

METHODS:

* How exactly were the studies selected? Was inclusion confirmed by more than one independent assessor? Were PRISMA guidelines used?

RESULTS:

* What exactly does 'elevated ABSI' mean? The statistical methodology should be much clearer. This should probably be done with categorical variables. For instance, an OR of 68 is massive and not all that instructive. Further, most evidence would suggest that this is non-linear which is not really reflected in the analysis.

DISCUSSION:

* What is the range of ABSI? The amount of data available suggest a much more detailed analysis.

Reviewer #3: Dear author

Congratulations about this work

I suggest that you correct line 15 degree II to Degree III > 10%

And in discussion if you found another characteristics related to mortality beyond ABSI ( as face, inhalation) i suggest that you commented

thanks

Reviewer #4: The article entitled "Association of abbreviated burn severity index with mortality in severely burned patients: a meta-analysis" aimed to validate a commonly used tool in burn research to predict mortality, performed as a meta-analysis of data from around the world.

The aims of this study are important to both research and clinical practice. From a technical standpoint the meta-analysis is performed well.

Suggestions:

•Consider discussing the ABSI more – even showing the formula – so that the general readership understands how it works and how it is applied

•At minimum, the original paper that introduced the ABSI (Tobiasen J, Hiebert JM, Edlich RF. The abbreviated burn severity index. Ann Emerg Med. 1982;11:260–2.) should be referenced.

•You report odds ratios for the ABSI. As a clinician who would use this tool in practice, this is not a particularly useful statistic. I would consider elements such as sensitivity, specificity, PPV, NPV, and probably most helpful, ROC curves, to help communicate the accuracy of the ABSI. There are at least 10 tools to predict mortality in burns, all with pros and cons. The paper should ideally make this as clinically relevant as possible.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

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Association of the abbreviated burn severity index with mortality in severely burned patients: a meta-analysis

PONE-D-24-45843R1

Dear Dr. Li,

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,

David M. Burmeister, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

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 #4: 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 #4: Yes

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

Reviewer #4: 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 #4: 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 #4: Yes

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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 #4: (No Response)

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If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #4: No

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