Death Due to Anaphylactic Reaction: The Role of the Forensic Pathologist in an Accurate Postmortem Diagnosis

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Congratulations for for this literature review. The article begins with an introduction to anaphylaxis as an acute, life-threatening reaction and explains the challenges of postmortem diagnosis. It emphasizes the significance of laboratory investigations such as serum tryptase concentration as an indicator of mast cell mediator release. Furthermore, it discusses the role of immunohistochemistry and the importance of markers like tryptase, CD117, and chymase in examining deaths due to anaphylaxis.

The article also covers the materials and methods for systematic literature review. The authors conduct a critical review of the collected studies and an evaluation of bias. They present the results of a selection of scientific articles describing the research pattern and characteristics of the included studies, along with the findings of immunohistochemical investigations using various antibodies to identify mast cells and their degranulation.

Overall, the article extensively explores the significance of immunohistochemical methods in the postmortem diagnosis of anaphylaxis-related deaths and provides a comprehensive overview of the current literature on this topic.

Author Response

Dear Reviewer 1,

Our research group has read your analysis with great interest. We believe that we have identified the need to clarify the issue of post-mortem diagnosis related to anaphylaxis. The immunohistochemistry method, widely used in anatomopathological studies, has the characteristic of providing clear data on the positivity of a sample. This feature is very useful in forensic science as it is connected to justice purposes. Thank you for your attention and congratulations.

Best regards.

Reviewer 2 Report

Comments and Suggestions for Authors

1.      Methodology section in the “main text” (lns 69. à) should be thoroughly rewritten ; logical order should be introduced

2.      Please, define how was the Google Scholar database scoped? Was the third-party software used (e.g. Zotero)?

3.      ., Why is not the individual number of records retrieved from each database given (e,g, Science Direct = 15; Google Scholar = 45; ENBASE = 33…) – please, do so

4.      In the PRISMA flow diagram, when listing “excluded records”, please specify, how many records were excluded by the human/ automated software.

5.      Bottom of that figure (figure 1), prior to the ln. 99 should be erased (insert only figure – without the original caption

6.      Figure in the lns. 238/239 dos does not have any caption whatsoever

7.      supposing, in that “figure 2”, different shapes mean different stages in the flow process?

 

8.      Please, check your references  

Author Response

Dear reviewer2, 

Thank you for your support for improving our manuscript. Our research group has read you advises with attention, here you can find a point-by-point response.

Revi2: 1.      Methodology section in the “main text” (lns 69. à) should be thoroughly rewritten ; logical order should be introduced

We have reorganized the materials and methods section, providing the exact composition of the string used. In fact, we have introduced the concept of a systematic review, cited the PRISMA protocol, and detailed the investigated databases. We have rewritten the search terms and subsequently outlined the entire remaining selection process, adhering to suitable inclusion and exclusion criteria.

We comunicate to you that Prisma protocol is cited in the main text. 

Revi2:  2.      Please, define how was the Google Scholar database scoped? Was the third-party software used (e.g. Zotero)?

Thanks to your advice, the paper has been improved. In fact, we checked all databases to refine our dataset. Here, we found some typos and errors, corrected based on your tips. We used Zotero 6-030 as a citation manager and duplicates removal tool, but not as third-party software for systematic review [but thanks to you, we learned how to use it].

Revi2:  3.      Why is not the individual number of records retrieved from each database given (e,g, Science Direct = 15; Google Scholar = 45; ENBASE = 33…) – please, do so

The number of retrieved records has been included. To standardize the research, we utilized the same terms.

Revi2: 4.      In the PRISMA flow diagram, when listing “excluded records”, please specify, how many records were excluded by the human/ automated software.

It has been better specified that no records are excluded by automated tool, by it has been highlighted that 344 records are excluded before selection. 

Revi2: 5.      Bottom of that figure (figure 1), prior to the ln. 99 should be erased (insert only figure – without the original caption

Thank for your support. original caption is deleted.

Revi2: 6.      Figure in the lns. 238/239 dos does not have any caption whatsoever

Caption is inserted on figure 2. Our research group has identified a typographical error in the flowchart (measurement). It has been corrected. 

Revi2: 7.      supposing, in that “figure 2”, different shapes mean different stages in the flow process? 

Actually, flowcharts serve the purpose of designing and documenting straightforward processes. Each process step, commonly referred to as an activity, is represented by a rectangular box. Additionally, a decision is typically indicated by a diamond shape. Here we identified one only decision step. 

Revi2 8.      Please, check your references

All reference were checked by using the MDPI Style preference present on Zotero 6-030.

Thanks to your advice, we were able to significantly improve our article, enhancing both its quality and reproducibility.

Reviewer 3 Report

Comments and Suggestions for Authors

The article deals with the forensic evaluation of anaphylactic reaction-related fatalities by reviewing the literature about the application if immunhystochemical methods. The topic is impportant since establishing the diagnosis of anaphylaxis with autopsy can be a challenging diagnosis, especially because the post-mortem tryptase and IgE examination are not always available. Immunohistochemistry can give a solution to the problem in these cases.
The article is well-structured and well-written.

There is only one thing that should be cleared:
In lines 132-134, the article says that ati-chymase positivity and anti cd117 positivity is low (14,8 and 2,5 %). This percentage seems to be too low to say that these ABs are indicators of anaphylaxia. Either this statement is not good(falsleading), or it has to be discussed in the conclusion that ant-tryptase AB should be the choice.

 

Author Response

Dear reviewer 3, 

Thank you for your support and your kind words of appreciation, your guidance has allowed us to make substantial improvements to our article. 

Rev3: In lines 132-134, the article says that anti-chimase positivity and anti cd117 positivity is low (14,8 and 2,5 %). This percentage seems to be too low to say that these ABs are indicators of anaphylaxia. Either this statement is not good (fasleading), or it has to be discussed in the conclusion that anti-tryptase AB should be the choice.

We emphasized the significance of assessing the positivity of Anti-tryptase through immunohistochemistry as second line. Conversely, tryptase is also present in other pathological samples, such as in the case of myocardial ischemia. To enhance sensitivity, it could be useful to confirm Tryptase positivity with Anti-CD117 and Anti-Chymase . Here is the additional information we included:

Lines 243- 249: 

"[...]In fact, as shown in the results, while anti-tryptase on lung tissues appears to be the most reliable marker, on the other hand, it is too promiscuous. So, as found in the literature review, an association with other markers such as Anti-chymase and Anti-CD117 is required to confirm the diagnosis. These two IHC markers of anaphylaxis seem to be not specific but have a good rate of sensitivity. Further studies are needed to confirm this hypothesis.". 

Thank you again for your support.