Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors, I have had the opportunity to review your manuscript, which aims to analyze the use of biomarkers in trauma management, with a particular focus on comparing Damage Control Orthopaedics (DCO) and Early Appropriate Care (EAC) strategies. The article provides an interesting and well-documented analysis; however, there are several aspects that would benefit from further exploration to enhance the understanding and applicability of your findings. Specifically, while your work makes good use of biomarkers as predictive tools, it would be useful to expand the discussion on the variability and limitations of these tools in real clinical settings. While biomarkers such as lactate, monocyte and neutrophil L-selectin, and CD16bright/CD62Ldim neutrophils are identified as useful, their practical application may be influenced by factors such as availability, diagnostic tool precision, and patient-specific variability. It would be beneficial to further explore how these factors can affect the efficacy of biomarkers in critical situations. Additionally, a more detailed analysis of combining biomarkers in a multivariate approach could strengthen the argument that these tools can improve surgical decision-making. In the comparison between DCO and EAC, unfortunately, there is a lack of deeper discussion on clinical guidelines that could facilitate the decision-making process. While you acknowledge that the choice between DCO and EAC depends on patient physiology and injury severity, it would be helpful to include a discussion on how these choices can be standardized through institutional decision-making protocols. Variability in clinical practices across different hospital settings is a crucial aspect to consider, and emphasizing the standardization of biomarker-based decisions would be valuable. I would suggest exploring the existing literature on algorithmic decision-making for complex trauma, which could add value to your discussion. The issue of "surgical timing" is fundamental in trauma management and should be addressed with greater determination. While you have rightly pointed out that lactate is the only biomarker with defined thresholds, it would be interesting to see if other biomarkers with clinically relevant thresholds have been identified to help determine the most appropriate time for surgical intervention. In this regard, it would be appropriate to also consider whether other variables, such as organ function monitoring and acid-base balance, could influence the timing of surgical decisions. The choice between DCO and EAC involves distinct risks and benefits that merit careful evaluation by the patient and their family. Therefore, it would be very important to at least mention the importance of informed consent in relation to these strategies. Informed consent is a crucial element in complex surgical contexts and should be an integral part of the preoperative discussion, particularly when opting for approaches that may have long-term implications for the patient's quality of life. I would suggest considering the article (https://doi.org/10.1016/j.jflm.2024.102674), which I believe will be useful in this context, and including it in your references to enrich the discussion. In conclusion, your article provides a solid overview of the use of biomarkers and DCO and EAC strategies in trauma care. In my opinion, the requested enhancements would further strengthen the understanding of their clinical impact, with a particular focus on practical application, standardization of decisions, and the integration of ethical considerations such as informed consent.

Author Response

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Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors

First of all, I would like to express my sincere gratitude for giving me the opportunity to contribute my opinion to the evaluation of your manuscript. However, the research presents such evident limitations that I would advise against proceeding in its current form. Below, I outline the main points that justify my decision:

Editing: Attention should be paid to the correct use of acronyms and to making the tables more user-friendly; Table 2, in particular, is practically unreadable in its current form and lacks a header (line 158).

Title: I suggest shortening the title and specifying the type of study conducted, namely a systematic review.

Abstract: The abstract is lacking in several areas:

• The objectives are not clearly stated (not even the main ones) nor is there any real interpretation in the conclusions regarding the clinical implications of the studied phenomenon, with specific suggestions and recommendations for the scientific community.

• Line 29 contains the unclear phrase “Level of Evidence.”

Keywords: Although the editor allows for 8–10 keywords, I recommend focusing on 4–5 highly specific terms related to the type of study conducted.

Introduction: It would be helpful to include an international epidemiological overview and context of the reference setting, perhaps expanding the bibliography, which is currently very limited. The section as it stands does not support the rest of the manuscript and should be completely restructured. The objectives are unclear and expressed too generically. I suggest rephrasing them in the standard format: “The primary objective of the study was…” and “while the secondary objectives were….”

Methods: This is the most controversial aspect and certainly warrants more attention. It is lacking in several key areas:

• The chosen reporting method did not adequately support the authors in drafting the manuscript, as it is deficient in many aspects;

• For transparency and reproducibility, the DOI for the registration is missing;

• The supplementary checklist and the reference to the PRISMA Method are absent from the text;

• The flowchart does not align with the declared model. These gaps are significant, and I recommend that the authors follow the reporting tool to enhance the manuscript’s quality.

Results: This is the least controversial section of the study, which would certainly benefit from the suggestions mentioned above.

Discussion: This section also needs to be completely revised, as it is not sufficiently supported by the scientific literature.

Limitations: In my humble opinion, a dedicated section on limitations would be useful, with a more in-depth discussion on why the results are not generalizable to similar populations.

Bibliography: The bibliography needs to be greatly expanded as it currently does not adequately support either the introduction or the discussion. Moreover, it seems to be incomplete relative to the summary table.

In summary, the manuscript presents valuable scientific results that could be more fully developed. In its current form, it requires a near-complete revision.

 

Comments on the Quality of English Language

I suggest native english review

Author Response

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Author Response File: Author Response.docx

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,

the comments in the annex file.

Best

Comments for author File: Comments.pdf

Author Response

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Author Response File: Author Response.docx