Longitudinal ultrasound assessment of jugular venous pressure reliably detects hypervolemia: An observational study in healthy volunteers

Karin Vogt; David Widmer; Mark Kirsch; Laura Potasso

doi:10.1371/journal.pone.0346162

Peer Review History

Original SubmissionAugust 15, 2025
15 Aug 2025 Author Response Transfer Alert This paper was transferred from another journal. As a result, its full editorial history (including decision letters, peer reviews and author responses) may not be present. https://doi.org/10.1371/journal.pone.0346162.r001
1 Oct 2025 Decision Letter - Vincenzo Francesco Tripodi, Editor Dear Dr. Potasso, 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. Please submit your revised manuscript by Nov 15 2025 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.. 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.. 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Read more information on sharing protocols at . 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, Vincenzo Francesco Tripodi Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf.... 2. Thank you for stating in your Funding Statement: “This study was funded by a research grant from the Margot and Erich Goldschmidt & Peter René Jacobson-Foundation 122023 to LP (https://www.goldschmidtjacobsonstiftung.com/). LP was the sponsor/PI playing a role in study design, data collection and analysis and manuscript writing and submission” Please provide an amended statement that declares all the funding or sources of support (whether external or internal to your organization) received during this study, as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now. Please also include the statement “There was no additional external funding received for this study.” in your updated Funding Statement. Please include your amended Funding Statement within your cover letter. We will change the online submission form on your behalf. 3. 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If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. Additional Editor Comments (if provided): Dear Authors, Thank you for submitting your manuscript to our journal. The objectives and the rationale are clearly reported. The manuscript structure and writing are well-organized and easily comprehensible. The study design and limitations of the study are well described in the text. This manuscript requires some adjustments. I kindly invite you to examine the suggestions and advice offered, especially concerning the statistical aspects. Best regards, VF Tripodi [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? Reviewer #1: Partly Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: No ****** 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.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??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: Hello This is a good article Of course, I think you can make the title of the article shorter and more concise. The text of the article is good, but it is better to collect and present the important points of the article in one place and in a few lines. Good luck. Reviewer #2: The manuscript addresses an interesting and clinically relevant methodological question by assessing the reproducibility and feasibility of different ultrasound jugular venous pressure (uJVP) measurement techniques. The study is thoughtfully designed, clearly presented, and strengthened using a balanced, healthy volunteer population with blinded assessments. The authors are to be appreciated for their valuable contribution. With some refinements, this work has the potential to make a meaningful impact and be suitable for publication. 1. Correct the sequence of in-text citation references in the introduction (line 62), i.e., [1,2,12,4–11]. 2. Statistical analysis (line 177 to 182) I. The authors need to refine their choice of statistical tests. While the Wilcoxon rank-sum test is appropriate for comparing independent groups (e.g., male vs. female). Comparisons of uJVP values against expected values (one-sample data) would be more appropriately analyzed using a Wilcoxon signed-rank test. Similarly, when comparing different methods within the same patients (paired data), the Wilcoxon signed-rank test would be preferable. Suggestion: For clarity, the authors could revise the statistical analysis section to indicate that both the Wilcoxon signed-rank test (for paired and one-sample comparisons) and the Wilcoxon rank-sum test (for independent groups) were applied as appropriate. This adjustment would improve the accuracy and transparency of the statistical analysis. II. The authors need to reconsider how reproducibility is presented. Reporting it as the “percentage of participants with the same measurement within 1 cm” provides some indication of agreement but does not represent a standard reliability metric. More conventional approaches, such as intraclass correlation coefficient (ICC) or Bland–Altman analysis, would provide a stronger and more robust evaluation of inter-observer agreement. If these analyses are not possible, it would be helpful to explain the rationale for selecting a 1 cm tolerance and to note the potential limitations of this approach. ****** what does this mean?). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files. 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Revision 1
22 Oct 2025 Author Response Longitudinal ultrasound jugular venous pressure assessment shows high reproducibility and feasibility to detect hypervolemia – an observational study in healthy volunteers � New title: Longitudinal ultrasound assessment of jugular venous pressure reliably detects hypervolemia: an observational study in healthy volunteers PONE-D-25-44241 Point-by-point answer Dear Authors, Thank you for submitting your manuscript to our journal. The objectives and the rationale are clearly reported. The manuscript structure and writing are well-organized and easily comprehensible. The study design and limitations of the study are well described in the text. This manuscript requires some adjustments. I kindly invite you to examine the suggestions and advice offered, especially concerning the statistical aspects. Best regards, VF Tripodi Dear Professor Tripodi, We sincerely thank you for your thoughtful feedback and positive evaluation of our manuscript. We appreciate your acknowledgment of our study’s clarity, structure, and design. We have carefully considered the reviewers’ and your suggestions, particularly regarding the statistical aspects, and have made the necessary revisions to improve the manuscript accordingly. Detailed responses to each comment are provided in the attached revision report. Here you find the point-by-point answers addressing all comments and suggestions. Best regards Laura Potasso on behalf of all authors Review Comments to the Author Reviewer #1: Hello This is a good article Of course, I think you can make the title of the article shorter and more concise. The text of the article is good, but it is better to collect and present the important points of the article in one place and in a few lines. Good luck. We sincerely thank the reviewer for this helpful suggestion. Following your advice, we have shortened the title to make it more concise and focused. In addition, we have summarized the most important findings of the study in a few lines at the end of the results section to provide a clear overview of the main results. New Title: Longitudinal ultrasound assessment of jugular venous pressure reliably detects hypervolemia: an observational study in healthy volunteers New paragraph (lines 244-258): 3.6 Summary of the results In our observational, methodological study of 30 healthy volunteers (50% female) comparing four uJVP methods, we found: • uJVP measurements: All values were <8 cmH₂O, correctly below the hypervolemia threshold, whereas the hypovolemia threshold was exceeded in 56.7%, 21.4%, 51.7%, and 83.3% for methods 1–3b, respectively. • Best-performing method: Longitudinal assessment at the base of the IJV tapering portion (method 3b) showed the highest interrater agreement (25/30, 83.3%) and could be visualized in 30/30 participants. Bland-Altmann analysis supported the use of Method 3b for consistent uJVP assessment between investigators (bias -0.25, limits of agreement -2.26 to 1.76). Acquisition time was 38.5 seconds, and tolerability (VAS 9.5) was comparable to other methods. • Practical recommendation: Individualized head-of-bed elevation, visualizing uJVP in the mid-third of the neck, can help minimize confounding factors such as proximity to the subclavian vein or venous valves. Reviewer #2: The manuscript addresses an interesting and clinically relevant methodological question by assessing the reproducibility and feasibility of different ultrasound jugular venous pressure (uJVP) measurement techniques. The study is thoughtfully designed, clearly presented, and strengthened using a balanced, healthy volunteer population with blinded assessments. The authors are to be appreciated for their valuable contribution. With some refinements, this work has the potential to make a meaningful impact and be suitable for publication. 1. Correct the sequence of in-text citation references in the introduction (line 62), i.e., [1,2,12,4–11]. We thank the reviewer for pointing at this. We updated the references accordingly. 2. Statistical analysis (line 177 to 182) I. The authors need to refine their choice of statistical tests. While the Wilcoxon rank-sum test is appropriate for comparing independent groups (e.g., male vs. female). Comparisons of uJVP values against expected values (one-sample data) would be more appropriately analyzed using a Wilcoxon signed-rank test. Similarly, when comparing different methods within the same patients (paired data), the Wilcoxon signed-rank test would be preferable. Suggestion: For clarity, the authors could revise the statistical analysis section to indicate that both the Wilcoxon signed-rank test (for paired and one-sample comparisons) and the Wilcoxon rank-sum test (for independent groups) were applied as appropriate. This adjustment would improve the accuracy and transparency of the statistical analysis. Thanks for this important suggestion. We revised the method section accordingly (lines 176-180): We compared uJVP values to the predefined threshold using a one-sample Wilcoxon signed-rank test. Differences between methods within the same participants were assessed using a paired Wilcoxon signed-rank test. Sex differences in uJVP values were evaluated using the Wilcoxon rank-sum test (Mann–Whitney U test). II. The authors need to reconsider how reproducibility is presented. Reporting it as the “percentage of participants with the same measurement within 1 cm” provides some indication of agreement but does not represent a standard reliability metric. More conventional approaches, such as intraclass correlation coefficient (ICC) or Bland–Altman analysis, would provide a stronger and more robust evaluation of inter-observer agreement. If these analyses are not possible, it would be helpful to explain the rationale for selecting a 1 cm tolerance and to note the potential limitations of this approach. Thank you for raising this important point. We have added the Bland-Altman analysis to better visualize and compare the results. The rationale for using the percentage-based method was that, although the Bland-Altman analysis showed that Method 3b had the narrowest limits of agreement, these limits were within ca. 2 cm, which we considered insufficiently precise for clinical use. Therefore, we retained the analysis using a 1 cm difference to quantify the proportion of participants whose measurements fell within this stricter range. We added the Bland-Altmann analysis in the section methods (lines 183-185), results (lines 227-236) and discussion (lines 294-295) as well as Figure 4. Figure 4 – Bland-Altmann analysis Bland-Altman plots for methods 1 to 3b. uJVP= ultrasound jugular venous pressure, LoA= limits of agreement. Attachments Attachment Submitted filename: Point-by-point answer.docx https://doi.org/10.1371/journal.pone.0346162.r003
30 Nov 2025 Decision Letter - Vincenzo Francesco Tripodi, Editor Dear Dr. Potasso, 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. DATE_REVISION_DUE%. 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.. 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.. 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.. 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. 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 applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. 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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, Vincenzo Francesco Tripodi Academic Editor PLOS ONE Journal Requirements: If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. 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. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #3: All comments have been addressed Reviewer #4: (No Response) ******** 2. Is the manuscript technically sound, and do the data support the conclusions??> Reviewer #3: Yes Reviewer #4: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #3: Yes Reviewer #4: Yes ****** 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.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 #3: Yes Reviewer #4: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #3: Yes Reviewer #4: Yes ****** Reviewer #3: Dear authors, I appreciate the opportunity to review the manuscript titled "Longitudinal ultrasound assessment of jugular venous pressure reliably detects hypervolemia: an observational study in healthy volunteers". The manuscript structure and writing are well-organized and easily comprehensible. The topic is truly interesting, and the manuscript has been revised in accordance with the reviewers’ requests. Reviewer #4: • Primary endpoint choice and interpretation—be explicit and justify it What you used: “proportion of participants whose measurements differed >1 SD from the expected uJVP value (6.5 ± 1.5 cm H₂O).” • Reproducibility: add standard reliability metrics (ICC ± CI) and present complete Bland-Altman numbers What you did: percent agreement within ±1 cm and Bland-Altman plots; you state method 3b bias -0.25 and LoA -2.26 to 1.76 and percentages within 1 cm for each method. Why this is insufficient: percent within ±1 cm is informative but not a standard reliability metric; ICC (two-way random, absolute agreement) with 95% CI and a table of Bland-Altman bias and 95% limits of agreement (numerical values for all methods) are expected • Missing/ambiguous denominators — make “n/total” consistent and transparent Issue: method 2 has only 14 successful visualizations; Table 3 reports results for method 2 with denominators that look inconsistent (e.g., 3/14 appears in snippet). The abstract and different parts of the manuscript show slightly different percentages for method 2 (e.g., 21.4% vs 28.6% appears in different places of the document snippets). These inconsistencies must be fixed. • Sample size calculation wording and assumptions need clarification The sample size section says “alpha and beta error of 0.05 and a power of 95%” that wording is confusing (alpha = 0.05 is fine; beta = 0.05 corresponds to power = 95%, but writing “alpha and beta error of 0.05 and a power of 95%” is redundant/unclear). Also, the formula printed is not standardly presented (formatting/notation broken). • Methodological suggestions Report full Bland-Altman statistics for all methods (bias, SD, and lower/upper 95% LoA numeric values) in a table (not just plots). You already show 3b numbers; add the others. Add ICC (with 95% CI) for each method (two-way random, absolute agreement) Explain the rationale for 1-cm tolerance: • Line/figure comments • Table 3: add a footnote explaining denominators for method 2 (only 14/30 visualized) and show for duration/VAS. • Figures 3 & 4: Label the axes with units (cmH₂O), add sample sizes to boxplots and Bland-Altman plots, and include a dashed line at the +5 cm constant if you show raw IJV height. • Abstract: ensure the percentage reported for method 2 is the same as in the Results/Table (fix the 21.4% vs 28.6% inconsistency). ****** what does this mean?). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files. 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Revision 2
12 Dec 2025 Author Response We have uploaded the response to the reviewer (file docx named Point-by-point_2_Vogt) Attachments Attachment Submitted filename: Point-by-point_2_Vogt.docx https://doi.org/10.1371/journal.pone.0346162.r005
16 Mar 2026 Decision Letter - Vincenzo Lionetti, Editor Longitudinal ultrasound assessment of jugular venous pressure reliably detects hypervolemia: an observational study in healthy volunteers PONE-D-25-44241R2 Dear Dr. Potasso, 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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support.... 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, Vincenzo Lionetti, M.D., PhD Academic Editor PLOS One Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0346162.r006
Formally Accepted
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