Use of Peak Glucose Level and Peak Glycemic Gap in Mortality Risk Stratification in Critically Ill Patients with Sepsis and Prior Diabetes Mellitus of Different Body Mass Indexes

Round 1

Reviewer 1 Report

The manuscript investigates the relationships between glycaemic variability, glycemic gap, and mortality outcomes in sepsis patients with diabetes. The authors employ a large and diverse dataset from various ICUs and hospitals, which enhances the study's external validity. They introduce the novel concept of the glycemic gap, a valuable addition to the field, and develop modified SOFA scores (mSOFA-pg and mSOFA-pgg) to predict mortality in specific patient subgroups.

Suggestions for improvement:

1.      The authors should provide more detailed information about the sources of data, including electronic health records and databases. They should describe the quality assurance procedures undertaken to ensure data accuracy and completeness. Address any potential limitations in the data, such as missing values or errors.

2.      The authors should acknowledge the potential limitations of generalizability due to the study's reliance on data from specific ICUs and hospitals. They should discuss how the findings might be applicable to broader patient populations and diverse healthcare settings.

3.      The authors should offer additional information about the glycemic control protocols used in the different ICUs. Understanding the variations in these protocols can help interpret the impact on peak glucose levels and glycemic variability.

4.      The authors should discuss the potential benefits of continuous glucose monitoring (CGM) compared to intermittent glucose measurements. They should consider the implications of using CGM data in future studies to capture more granular information on glycemic variability.

5.      The authors should acknowledge the possibility of unmeasured confounders and discuss potential strategies for addressing or minimizing their impact on the study's outcomes.

6.      The authors should elaborate on the clinical implications of the findings. They should discuss how the results could inform clinical practice, particularly in terms of setting glycemic control targets for sepsis patients with diabetes. Consider practical recommendations for healthcare providers.

7.      If possible, the authors should distinguish between type 1 and type 2 diabetes in the analysis and discussion. They should highlight any differences in responses to glycemic control and their potential impact on outcomes.

8.      If data are available, the authors should explore the influence of the duration of diabetes on outcomes. They should discuss whether patients with long-standing diabetes exhibit different responses compared to those with recent diagnoses.

9.      The authors should conclude the study with a section on future research directions. They should suggest areas where further investigation is needed to build upon the current findings and address any remaining questions or limitations.

 

Comments for author File: Comments.pdf

Author Response

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Reviewer 2 Report

Comments to the Author

In this study, Tsai et al. examined the peak glucose levels and peak glycemic gap in patients with sepsis. With data from more than 5000 patients analyzed, the authors concluded a significant association between peak glycemic gaps or peak glucose levels and the mortality of patients with sepsis and diabetes. The authors developed a mSOFA-pg score and mSOFA-pgg score systems which were showed to have a better have a better predic-28 tion of the mortality risk of such patients than SOFA scores. The manuscript is characterized by its clarity and coherence. The conclusions drawn from their well-designed studies hold immense significance.

Author Response

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Reviewer 3 Report

The authors aimed to prove the utility of modified SOFA score in the prediction of mortality risk in critically ill patients with sepsis and diabetes using peak glycemic gap and peak glucose score.

 

This is a very nicely performed study with a large number of patients included utilizing new variables into prediction model of mortality risk assessment in ICU patients with diabetes and sepsis. Although retrospective in design, possible flaws are overcome with large sample and statistical analysis.

In a discussion section the authors should speculate on the reasons behind the difference in relationship between nutritional status and dynamic glucose change since this is one of the most important study findings.

English language needs moderate editing, there are spelling and grammar errors throughout the text that need to be corrected.

Author Response

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Reviewer 4 Report

Manuscript is interesting and covers important aspects of intensive care of patients with diabetes and sepsis. Al large sample size is analyzed.

Although Manuscript is well written there are serious issues probably with copy-pasting. For example in abstract the first sentence:

Abstract: Background: To examine peak glucose level and peak glycemic gap in the first 3 days after admission to the intensive care unit (ICU) were associated with mortality in patients with sepsis and prior diabetes of different BMI.

Sentence is incompete or wrong, as "to examine..." something must have been done. But second part of the sentence does not fit to the first.

I would also add a sentence or a short paragraph on why glucose may be elevated and why it can be also so damaging in case of infection and diabetes.

 

English can be improved by checking by native speaker.

Author Response

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Round 2

Reviewer 1 Report

All my comments have been addressed. No further comments.

Minor grammatical errors that need checking/correction before publication.