The Influence of the COVID-19 Pandemic on Patients Admitted with Pericardial Effusion
, Iftach Sagy 2,3,4,5,†, Elizaveta Rabaev 2, Hezzy Shmueli 1 and Leonid Barski 2,5
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsThe manuscript “ The influence of the COVID-19 pandemic on patients admitted with pericardial effusion ”, submitted to Diagnostics, Manuscript ID
diagnostics-4132872, sought to “ investigate the influence of the COVID-19 outbreak on trends in pericardiocentesis. “ The authors “ performed a retrospective population study including all > 18 years patients undergoing pericardiocentesis in a single tertiary hospital between January 2018 and April 2022.” The autors compared “ 92 patients underwent pericardiocentesis cases during the COVID-19 period compared to 65 patients during the pre-COVID-19 period studies) “.
The authors concluded that : “A numerical, yet statistically insignificant increase in pericardiocentesis was observed following the COVID-19 outbreak. We assume this observation cannot be attributed solely to the virus and vaccines per se. Neglect of other chronic diseases, social distancing, and widespread availability of point-of-care ultrasound may have contributed to this observation.”
The investigation seems to be very useful for a clinical overview of the cases that were treated in that hospital due to pericardial effusion that needed pericardiocentesis. Introduction seems to be concise and informative. Limitations of the investigations are well stated in the limitations sections (very limited to a specific population of a very specific region of the world, concerning a small cohort). COVID-19 and changes in pericardial effusion thatt went to pericardiocentesis during the COVID-19 outbreak. Perhaps this information could come to the Title of the manuscript, as no or lack of influence of COVID-19 in the need of pericardiocentesis in such patients. That should be stated. Also that would be informative to have the in-hospital information of the COVID patients that went to pericardiocentesis (how many died, type of complications, survival).
It seems to be valuable to have a picture of a point-of-care ultrasound case Illustrated in the text.
It would be interesting to have information concerning pre COVID period and the characteristics of the patients that needed pericardiocentesis in the hospital.
Grammar revision seems to be necessary as well as the revision of the abstract.
Best wishes.
Comments on the Quality of English Language
Grammar revision seems to be necessary.
Author Response
Comment 1: The investigation seems to be very useful for a clinical overview of the cases that were treated in that hospital due to pericardial effusion that needed pericardiocentesis. Introduction seems to be concise and informative. Limitations of the investigations are well stated in the limitations sections (very limited to a specific population of a very specific region of the world, concerning a small cohort). COVID-19 and changes in pericardial effusion thatt went to pericardiocentesis during the COVID-19 outbreak. Perhaps this information could come to the Title of the manuscript, as no or lack of influence of COVID-19 in the need of pericardiocentesis in such patients. That should be stated.
Response 1: Thank you for pointing this out. We believe that despite a (statistically) insignificant rise in pericardiocentesis cases during the COVID-19 epidemic, the etiologies leading to pericardiocentesis changed. Moreover, patients' behavior and in-hospital medical treatment itself changed, and therefore we prefer to keep the title of the manuscript as it is.
Comment 2: Also that would be informative to have the in-hospital information of the COVID patients that went to pericardiocentesis (how many died, type of complications, survival).
Response 2: Agreed. Among 15 COVID-19 related pericardiocentesis cases, 2 died in-hospital, a proportion comparable to the in-hospital mortality rate of the general study population. This information has been added to the manuscript now (lines. 134-136).
Comment 3: It seems to be valuable to have a picture of a point-of-care ultrasound case Illustrated in the text.
Response 3: Thank you for this comment. We added an image (figure 4) of point-of-care ultrasound of a patient with large pericardial effusion that eventually went to pericardiocentesis. The picture is a screenshot from a mobile phone, as portable ultrasound devices in our institution do not produce DICOM images, but rather allow real-time imaging only.
Comment 4: It would be interesting to have information concerning pre COVID period and the characteristics of the patients that needed pericardiocentesis in the hospital.
Response 4: Please refer to table 2 which describes patient characteristics in the pre-COVID-19 period and the COVID-19 epidemic period.
Comment 5: Grammar revision seems to be necessary as well as the revision of the abstract.
Response 5: Revisions were made and highlighted as necessary.
Author Response File: 
Author Response.pdf
Reviewer 2 Report
Comments and Suggestions for AuthorsThe influence of the COVID-19 pandemic on patients admitted with pericardial effusion
Retrospective population study including all > 18 years patients undergoing pericardiocentesis in a single tertiary hospital between January 2018 and April 2022.
Group1) Patients admitted between January 2018 and February 2020 (Pre COVID-19 group), Group2) Patients admitted between March 2020 and April 2022 (Post COVID-19 Outbreak group).
Groups were selected 24 months before and after Covid epidemic
49.2% rise in pericardiocentesis cases was observed in the post-COVID-19 group (n=92 vs. 65 in the preCOVID-19 group) However, this difference did not reach statistical significance (𝜒2=3.07, P=0.0796)
In-hospital mortality was numerically higher during the post post-COVID-19 group (7.7% vs. 14.4%), but this difference did not reach statistical significance (p=0.22)
The choice of 0.05 as the cutoff for statistical significance was not based on a deep scientific principle but rather was historically assigned. It was popularized by the statistician Ronald Fisher in the early 20th century as a convenient benchmark for significance. P= .22 means your results of dying are not due to chance 78% of the time which is a good and meaningful result. Covid -19 did increase the number of pericardiocentesis procedures not due to chance 92% of time.
House staff recognized the significance before your study completion resulting in more bedside echocardiograms POCUS done (n,%) 25 (39.7) 48 (49.5) 0.25. Your House staff are smarter than your statisticians! Large language models, which will be doing your thinking, do not rely on statistical significance but slopes peaks and valleys. Do not shortchange your study based on a P value.
Covid 19 due to inflammation reduces lymphatics amplitude and frequency resulting in accumulation of pericardial effusions and in some cases tamponade. Lymphatic dysfunction is the reason for more pericardial effusions and requirement for pericardiocentesis.
Example of statistical significance altering medical care.
Apixaban 2.5 versus 5 Recommendations
5 mg BID is the standard dose for most adults with nonvalvular atrial fibrillation to reduce the risk of stroke and systemic embolism.
2.5 mg BID is recommended only if the patient meets at least two of the following criteria:
- Age ≥ 80 years
- Body weight ≤ 60 kg (132 lbs)
- Serum creatinine ≥ 1.5 mg/dL (impaired kidney function)
The efficacy is the same with lower bleeding risk at 2.5 dosages. If 2.5 is as good as 5 with lower bleeding risk, shouldn’t the dose be 2.5? The difference is the statistical significance which depends on the number of individuals treated. The study allowed a lower dose in high-risk patients and there were not enough of these patients to reach significance in 2.5. For this reason, I personally break the rules and use 2.5 in anyone who I deem has increased bleeding risk. I use more 2.5 than 5.
This long discussion can be summarized Clinical significance is not necessarily Statistical significance and I would appreciate your article more if you emphasized clinical over statistical
Author Response
Comment 1: Clinical significance is not necessarily Statistical significance and I would appreciate your article more if you emphasized clinical over statistical
Response 1: Thank you for this comment, we agree. Unfortunately our study was single center, but an almost 50% rise in pericardiocentesis cases is indeed hypothesis generating and warrants further, larger scale investigations. We emphasized this notion in lines 271-275.
Author Response File: Author Response.pdf
