Comparing the Accuracy of Micro-Focus X-ray Technology to Standard Clinical Ultrasound for Locating Small Glass Foreign Bodies in Soft Tissue

Round 1

Reviewer 1 Report

The instrument presented in the article brings an important innovation to the detection of small glass pieces in wounds, and the description of advantages and potential limitations are well described. I do not see any reasons to modify the structure of the paper or to add any correction, so I suggest to publish it in its present form.

Author Response

Thank you for reviwing our paper.

Reviewer 2 Report

The methodologies and statistical results are sound, well presented and unambiguously identify that MFXI is superior to POCUS in finding Foreign Bodies, even for EM physicians who did not receive additional training in the former modality. 
It is also reassuring to read that the authors are already training an AI to further increase the hit rate of the recommended method. 

Author Response

Thank you for reviewing our paper.

Reviewer 3 Report

I have a fundamental comment to this research. Even though Butterfly has been fairly popular recently, the image quality is way worse than the standard ultrasound machine.

Also I would not consider the standard clinical ultrasound (as mentioned in the abstract) to be a handheld device.

 

MFXI and FB abbreviations should also be defined in abstract.

 

I would suggest that the authors also compare the cost of using MFXI vs POCUS.

 

In abstract, the centre frequency of ultrasound probe should be reported.

 

While testing the techniques on chicken wings, the operator has the freedom to rotate the object and find the best possible angle to detect the FBs. This is not the case in practice and real life. How would the authors discuss this fact and relate it to the real patient cases?

 

Line 137- More information should be included about the ultrasound. What was the imaging setup and optimization?

 

Fig.1

Imaging from the two modalities of X-ray and ultrasound should be presented side by side so that the reader can compare quality of the images and how the FBs of the same sample would look on different modalities.

 

Author Response

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Author Response File: Author Response.pdf

Reviewer 4 Report

Comments:

Please highlight the novelties at Introduction section comparing to the similar strategies used clinically and reported at published articles.

 

 

Please add last paragraph at introduction section including qualitative discuss on the achievements.

 

Please re-write the text clearly avoiding long complicated sentences (like last sentences at Introduction section)

 

Although X-ray imaging method proposed in this work is helpful but it will cause unwanted dose to the patient. Please indicate to this issue at Discussion Section according to ALARA principle.   

 

Is there any possibility to text the proposed method on real patient, who already injured?

 

The reference Section is weak. Please add more updating references

Author Response

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Author Response File: Author Response.pdf

Reviewer 5 Report

The authors compared two imaging modalities i.e., portable ultrasonic and micro focused x-ray imaging for emergent diagnosis of patients although both are improved "traditional" methodologies.  I quoted from the document below about Butterfly iQ+ and believe the results are predictable due to the simplicity of the whole device which can not be comparable to full scale machines. However, it provides conveniency during field applications and has some merit of research.

 

https://www.nice.org.uk/advice/mib254/resources/butterfly-iq-for-diagnostic-ultrasound-imaging-pdf-2285965693413061

 Studies suggest that Butterfly iQ+ is an effective, but imperfect, point-of-care ultrasound device in a low resource emergency setting. Key uncertainties around the technology are that experts expressed concerns about image quality and size on a smartphone screen. Key uncertainties around the evidence are that there were only 2 comparative studies, and these did not report patient outcomes. Also, only 1 study was done in the UK. 

The evidence for the technology is of low to moderate methodological quality, and most of the studies have small patient numbers. All studies evaluated the prognostic value of the Butterfly iQ+. Two studies had comparators, but they did not report patient outcomes. One study was done in the UK. The studies show that the Butterfly iQ+ can be effective as a diagnostic ultrasound tool across a variety of indications. Further evidence is needed comparing the Butterfly iQ+ with standard care, using a large sample size and reporting patient outcomes. 

As for the micro-focused X-ray, It is another story. For imaging of tissues at small distance under the skin it definitely can provide much better quality images since not much energy is required and is just right for a portable device, of course at higher costs.

 

The design of trials is fine but I have one caveat or suggestion. Commercial phantom with micro or mini level objects can be found in the market and it can serve a standard before in vitro or clinical trials are proceeded. If the experiments can include the imaging results from suitable phantom the uncertainty can be further reduced.

 

Final words, the bibliography is too short. Only 11 references are listed, which is not qualified for a sound full scientific paper. Please do a better survey of the literature and make up the number of listing.

Author Response

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Author Response File: Author Response.pdf

Round 2

Reviewer 3 Report

The manuscript has been improved and I have received answers to all my questions.

Good luck with your research

Author Response

No response needed.

Reviewer 4 Report

The revised version of MS can be considered for publishing in the Journal.

 

 

Author Response

No response needed.

Reviewer 5 Report

 must say that the response from the authors is not satisfactory to me. The Ultrasonic transducer in the experiment was designed to make direct contact with tissue or skin while the trial was couple with water. They can not be directly correlated. 

Secondly, the phantom is necessary and really cheap compared to the total the expense per medical case. Even there are quite a few tutorial over the internet for DIY phantom e.g., https://www.youtube.com/watch?v=TVPlZhOcBJk   .

The authors declares "accuracy" in the title of the manuscript and I think the accuracy of the modality has to be evaluated first. I do not agree that this procedure should come after the in vitro tissue trials.

Author Response

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