Obesity as a Risk Factor in the Appearance of Haematomas Caused by Low-Molecular-Weight Heparin: A Cross-Sectional Study
Round 1
Reviewer 1 Report
The writing and format quite different from the scientific manuscript:
The introduction section just summarized the knowledge of Thromboembolic disease and obesity. This section should focus on the importance of such issue, the latest advances in current research, and what scientific hypotheses the study will address.
The presentation of the results is messy, and fragmented. The most important core results should be the association of Thromboembolic and BMI or obesity, but unfortunately, there is not even a table to display the ORs. And I am unsure if the proper statistical methods were used to analyze the data.
Minor comments:
1. In lines 95 and 162, the author has not yet defined the abbreviations "SF" and "SC" that first appear.
2. As we know, HMT is affected by many factors, such as coagulation disorders, diabetes, hypertension, etc. However, patients with coagulation disorders, which may have a great impact on the results of this study, were not excluded from the part of the methodology. Moreover, these variables were not included in the analysis.
3. Each patient received 4 injections on consecutive days. What was the interval between each injection, and whether there was a range between injection sites.
4. HMT may affect the measurement of SF. Is SF measured before or after the patient receives the injection?
5. It is suggested to provide a line chart to analyze the relationship between obesity and HMT in different age groups and different genders, as well as a line chart to analyze the relationship between obesity and HMT in different age groups of the same sex.
6. The imitations and advantages of this study should be highlighted in the discussion.
Author Response
Dear review. Grateful for the evaluation of this article. You will find the document with the changes attached. Because the article is being revised by 5 reviewers, I have assigned a color to each one of them, so that they can see the inclusion of their suggestions. Reviewer 1: orange color.
Regarding your suggestions, I will respond to each of them:
- The introduction section just summarized the knowledge of Thromboembolic disease and obesity. This section should focus on the importance of such issue, the latest advances in current research, and what scientific hypotheses the study will address. I have redone part of the introduction, however, I have left aspects that I consider important: a) LMWH as a prevention of PE; b) the information issued in the technical sheet (in my opinion and that of many other authors) is far removed from reality in terms of the number of HMTs; c) the evolution of the administration technique since 1981; d) variables that have been modified by other authors in their studies and the results; e) the skin as a barrier to cross to access the subcutaneous tissue, where the folds are measured and the small blood vessels that produce HMTs are injured, which is important for understanding the effects of estrogens in women; f) show the increase in obesity worldwide, how to measure it and classify it. I hope you can appreciate that all this journey helps to understand this problem with a more complete vision, and not with fragmentation of knowledge. The objective of the study is clear.
- The presentation of the results is messy, and fragmented. The most important core results should be the association of Thromboembolic and BMI or obesity, but unfortunately, there is not even a table to display the ORs. And I am unsure if the proper statistical methods were used to analyze the data.The objective of the study is not to find an association between thromboembolic disease and LMWH, it is only one of the treatments to prevent it. The association sought is between obesity (based on the WHO or by measuring skinfolds), in addition to including other variables from other studies (age, gender...). The epigraphs of the results try to give a clear answer to each of them. In statistics I have had the help of a professional.
Minor comments:
- In lines 95 and 162, the author has not yet defined the abbreviations "SF" and "SC" that first appear.Rectified, skinfold (SF) & subcutaneous (SC)
- As we know, HMT is affected by many factors, such as coagulation disorders, diabetes, hypertension, etc. However, patients with coagulation disorders, which may have a great impact on the results of this study, were not excluded from the part of the methodology. Moreover, these variables were not included in the analysis. It was verified that the patients prescribed by their traumatologist did not present coagulation disorders. Other factors that they mention (pathologies) may be influenced in the appearance of HTMs, but it is not the objective of this study, but it has been included as limitations of the study.
- Each patient received 4 injections on consecutive days. What was the interval between each injection, and whether there was a range between injection sites. . Clarified in the document, each participant received 4 LMWH injections, one every day, at the same time, all prescribed.
- HMT may affect the measurement of SF. Is SF measured before or after the patient receives the injection?. It was included in the document, indicating that the skin fold was measured at the participant's intake (3 abdominal measurements and the average was taken), one day before starting the follow-up of the first injection. A clarification has been added to the document, the reason for doing so being to avoid stimulating the blood vessels in the skin of the abdominal area before injecting, and also not applying pressure with a caliper after administering it, in both cases it is being avoided. A bias that increases the incidence of HMTs.
- It is suggested to provide a line chart to analyze the relationship between obesity and HMT in different age groups and different genders, as well as a line chart to analyze the relationship between obesity and HMT in different age groups of the same sex. Sounds like an interesting proposal, thanks. I have not been able to make the recommendations in the time indicated by the journal, trying to respond to 5 reviewers. On the other hand, due to the high number of tables, it would significantly increase the length of the document.
- The imitations and advantages of this study should be highlighted in the discussion. It was included in the document (discussion).
Due to not being my 1st language, after finishing the review it will be sent to MDPI's English editing service.
Greetings
Author Response File: 
Author Response.pdf
Reviewer 2 Report
Thank you for giving the opportunity to review this paper.
I highly recommend to rewrite the introduction. It is very long and have some unnecessary information.
- The manuscript needs a proofreading by a professional. There are many long sentences that require breakdown in addition to typos and some words that are in Spanish.
- It is very unusual to see that many tables for an article of this type. Some of these tables can be described in text.
- in the inclusion criteria, the author mentions that they only included patients taking Clexane, did you exclude patients taking the generic form ? if yes, please explain why. if not, please change Clexane to enoxaparin.
- In tables, please rewrite nXX to n=XX
- Please add a limitations section
- The author uses the pronoun "we" (e.g., We aimed to determine) while there is only one author on this manuscript.
Author Response
Dear review ,
Grateful for the evaluation of this article.
You will find the document with the changes attached. Because the article is being revised by 5 reviewers, I have assigned a color to each one of them, so that they can see the inclusion of their suggestions. Reviewer 1: green color.
Regarding your suggestions, I will respond to each of them:
- I highly recommend to rewrite the introduction. It is very long and have some unnecessary information. I have redone part of the introduction, however, I have left aspects that I consider important: a) LMWH as a prevention of PE; b) the information issued in the technical sheet (in my opinion and that of many other authors) is far removed from reality in terms of the number of HMTs; c) the evolution of the administration technique since 1981; d) variables that have been modified by other authors in their studies and the results; e) the skin as a barrier to cross to access the subcutaneous tissue, where the folds are measured and the small blood vessels that produce HMTs are injured, which is important for understanding the effects of estrogens in women; f) show the increase in obesity worldwide, how to measure it and classify it. I hope you can appreciate that all this journey helps to understand this problem with a more complete vision, and not with fragmentation of knowledge.
- The manuscript needs a proofreading by a professional. There are many long sentences that require breakdown in addition to typos and some words that are in Spanish. It right, due to not being my 1st language, after finishing the review it will be sent to MDPI's English editing service.
- It is very unusual to see that many tables for an article of this type. Some of these tables can be described in text. It right, tables 4, 5, 10 have been removed, and described in text.
- In the inclusion criteria, the author mentions that they only included patients taking Clexane, did you exclude patients taking the generic form ? if yes, please explain why. if not, please change Clexane to enoxaparin. It right, tables 4, 5, 10 have been removed, and described in text.
- In tables, please rewrite nXX to n=XX. Modified.
- Please add a limitations section. Added.
- The author uses the pronoun "we" (e.g., We aimed to determine) while there is only one author on this manuscript. Sorry, modified.
Receive a cordial greeting
Author Response File: Author Response.pdf
Reviewer 3 Report
The study presents high quality and deals with important clinical issue, such type of study is needed. I have only few small remarks that authors should address properly.
I recommend to accept the manuscript after minor revision.
There are only some points to correct:
- please provide the list of abbreviations
- please provide the number of ethical approval
- - introduction and discussion section need improvement; please provide information on how your results will translate into clinical practice;
- in discussion section please provide study strong points and study limitation section
- please correct typos
All abovementioned issues are crucial for the credibility of the results. The paper can be accepted only after addressing all the issues and another subsequent review.
I recommend to accept the manuscript after minor revision.
Author Response
Dear review,
Grateful for the evaluation of this article.
I have attached the responses to your suggestions (changed in text to blue color):
-Please provide the list of abbreviations
Added to the end of the document, waiting for the editor to tell me where to put it.
-Please provide the number of ethical approval
Approved by Ethics Committee, Continuing Education Committee, Education and Research of the management of the Hospital Insular de Gran Canaria (nº 4/13) for studies involving humans. With this authorization, the doctoral thesis and the published studies were carried out.
-Introduction and discussion section need improvement
It will be modified, unifying the suggestions of the 5 reviewers.
-Please provide information on how your results will translate into clinical practice
The study shows that obesity is a risk in the development of HMTs (both based on BMI and skinfold assessment), and that this risk remains when adjusted for by removing confounding variables, finding that for every mm of ASF increases the risk of HMT by 4%. Among the limitations of the study is giving an answer: from what ASF value is it necessary to look for a LMWH administration technique? However, more studies are needed with modified techniques for obese patients.
-In discussion section please provide study strong points and study limitation section
The study shows that obesity is a risk in the development of HMTs (both based on BMI and skinfold assessment), and that this risk remains when adjusted for by removing confounding variables, finding that for every mm of ASF increases the risk of HMT by 4%. Among the limitations of the study is giving an answer: from what ASF value is it necessary to look for a LMWH administration technique? However, more studies are needed with modified techniques for obese patients.
- please correct typos
Once the content review requested by the 5 reviewers is complete, the document will be sent to English Editing (MDPI) (English is not my first language) and
Receive a cordial greeting
Author Response File: Author Response.pdf
Reviewer 4 Report
I have some suggestions:
Page 3, line 96: What is SF stand for?
Table 9: odds ratio adjusted for what?
Page 11, line 383: please replace bellow by above.
Author Response
Dear fourth Reviewer,
Grateful for the evaluation of this article.
I have attached the responses to your suggestions (changed in text to red color):
-page 3, line 96: Revised, skinfold (SF).
-Table 9: AOR has been adjusted for age, sex, height and abdominal circumference variables associated with the presence or absence of HMTs.
Receive a cordial greeting.
Author Response File: Author Response.pdf
Reviewer 5 Report
First of all, I would like to congratulate the authors on undertaking very important problem.
The objectives of this study were to identify the prevalence of abdominal HMTs secondary to administration to LMWH and to analyse the relationship between obesity (as determined by ASF and BMI) and the incidence of the appearance of abdominal cutaneous HMTs, as well as their location, in patients receiving LMWH.
The subject matter of the manuscript corresponds to the scope of research proposed by the Journal. The research methodology was presented in a reliable and understandable way. The results are presented clearly and legibly in the form of tables. All conclusions are justified and supported by the results.
For me, as a practicing nurse and also a nursing teacher, such research helps to expand knowledge and improve the technique of nursing procedures.
Author Response
Dear fifth reviewer,
Grateful for the evaluation of this article.
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Round 2
Reviewer 1 Report
Thanks for the author's response. Most replied and explained comments were acceptable. But I insist that the presentation of results should follow the STROBE guideline and meet the requirements of the journal.
Author Response
Dear reviewer,
I have made the recommendations indicated in the results section (STROBE).
Grateful for your suggestions.
Greetings
Author Response File: Author Response.pdf
Reviewer 2 Report
I have no further comments.
Author Response
Dear reviewer,
Grateful for the time and interest shown in reviewing this article.
Greetings
