Prevalence and Characteristics of Patients with Pressure Ulcers at a Tertiary Hospital in the Eastern Cape, South Africa
, Nongiwe Linette Mhlanga 1,*, Wezile Wilson Chitha 1, Sibusiso Cyprian Nomatshila 1 and Sikhumbuzo Advisor Mabunda 1,2,3,4Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsThe manuscript addresses a clinically relevant topic and provides valuable data from a rural tertiary hospital in South Africa, a setting that is underrepresented in the literature. The study is generally well structured and clearly presented.
However, several points require clarification to strengthen the manuscript. The reported prevalence of pressure ulcers is notably low compared with most African and global studies. In addition to adequate care, alternative explanations such as underreporting or limitations of register-based data should be more critically discussed. The study design terminology should be clarified and used consistently, and the Methods section would benefit from additional detail regarding case identification, definitions of hospital-acquired pressure ulcers, and justification of the age cut-off.
The association between hospital-acquired pressure ulcers and mortality is an important finding, but care should be taken to avoid implying causality, as pressure ulcers may reflect disease severity rather than being a direct cause of death. Minor improvements in table presentation and language editing are also recommended.
With these revisions, the manuscript could make a useful contribution to the literature on pressure ulcers in low-resource hospital settings.
Comments on the Quality of English Language Minor improvements in language editing are also recommended.Author Response
The manuscript addresses a clinically relevant topic and provides valuable data from a rural tertiary hospital in South Africa, a setting that is underrepresented in the literature. The study is generally well structured and clearly presented. However, several points require clarification to strengthen the manuscript.
Comment: The reported prevalence of pressure ulcers is notably low compared with most African and global studies. In addition to adequate care, alternative explanations such as underreporting or limitations of register-based data should be more critically discussed.
Response: Thank you for pointing this out. We agree with the comment and have discussed how the low prevalence may be due to underreporting or limitations of register-based data. Page 10, lines 296-301, then page 11 line, 327.
Comment: The study design terminology should be clarified and used consistently.
Response: Thank you for pointing this out. We agree with the comment. The study design has been clarified and used consistently in the abstract and the methodology. Page 2, lines 91 to 95
Comment: The Methods section would benefit from additional detail regarding case identification, definitions of hospital-acquired pressure ulcers, and justification of the age cut-off.
Response: Thank you for pointing this out. We agree with the comment and added details on how cases were identified. Page 3, line 110. We have also defined hospital-acquired pressure ulcers, page 1, lines 38-39. We have justified the age cutoff, noting that only adult units, which admit patients aged more than 12 years, were included in the study. Page 3, lines 107 to 109.
Comment: The association between hospital-acquired pressure ulcers and mortality is an important finding, but care should be taken to avoid implying causality, as pressure ulcers may reflect disease severity rather than being a direct cause of death.
Response: Thank you for pointing this out. We agree with the comment. We have revised the sentence by removing the word “explain” and replacing it with “provides insight”. Page 11, line 316.
Comment: Minor improvements in table presentation and language editing are also recommended.
Response: Thank you for pointing this out. We agree with the comment and have aligned the table presentation to conform to the journal's requirements. We have also revised the minor English corrections throughout the manuscript with the assistance of a professional English editor.
Reviewer 2 Report
Comments and Suggestions for AuthorsPage 2: line 75, define NCD, I know it appears later, but it helps to define the term and then provide the acronym
Page 3: line 129, newly developed pressure injury or HAPI is an incident ulcer, not a prevalence issue
Page 3: line 137, please advance the document so that the table is on page 4
Page 4: were you not able to measure deep tissue pressure injury? Same table, gluteal, coccygeal and trochanteric are adjectives, use gluteus, coccyx and trochanter
Page 6: lots of comorbid conditions are listed, are you implying that these problems increase risk of pressure ulcers? On page 6, line 155, the incidence of hypertension is not written correctly. You make a point of the high rate of HIV but you do not develop the idea.
Page 8, the cross tabulations paragraph is very hard to read, there are too many numbers and too little discussion
Page 10, there is nothing in this paper about end of life patients, you cannot draw a conclusion when you had no supporting evidence
Author Response
Comment: Page 2: line 75, define NCD, I know it appears later, but it helps to define the term and then provide the acronym
Response: Thank you for pointing this out. We agree with the comment and have defined NCDs. Page 2, lines 66 to 68
Comment: Page 3: line 129, newly developed pressure injury or HAPI is an incident ulcer, not a prevalence issue
Response: Thank you for pointing this out. We agree with the comment and have noted that incidence rate of HAPI is 0.4%. Page 3, lines 140 to 141.
Comment: Page 3: line 137, please advance the document so that the table is on page 4
Response: Thank you for pointing this out. We agree with the comment. Table 1 is now on page 4.
Comment: Page 4: were you not able to measure deep tissue pressure injury? Same table, gluteal, coccygeal and trochanteric are adjectives, use gluteus, coccyx and trochanter
Response: Thank you for pointing this out. We did not find any records that described deep tissue pressure injury. We have also used the terms gluteus, coccyx and trochanter. Page 4, table 1.
Comment: Page 6: lots of comorbid conditions are listed, are you implying that these problems increase risk of pressure ulcers?
Response: Thank you for pointing this out. The implication of listing the co-morbid conditions is to highlight the likelihood of developing pressure ulcers. We have discussed this. Page 10, lines 266 to 268.
Comment: On page 6, line 155, the incidence of hypertension is not written correctly.
Response: Thank you for pointing this out. We agree with the comment and have correctly written the percentage of patients who had hypertension. Page 7. Line 201.
Comment: You make a point of the high rate of HIV, but you do not develop the idea.
Response: Thank you for pointing this out. We agree with the comment and have discussed the high HIV burden and increased likelihood of developing pressure ulcers. Page 10, lines 268 to 271.
Comment: Page 8, the cross tabulations paragraph is very hard to read, there are too many numbers and too little discussion
Response: Thank you for pointing this out. We agree with the comment and have revised the paragraph and removed some numbers. We have also used consistent terminology throughout the paragraph for easier reading. Page 8 lines 224-248
Comment: Page 10, there is nothing in this paper about end of life patients, you cannot draw a conclusion when you had no supporting evidence
Response: Thank you for pointing this out. We agree with the comment and have rephrased the last sentence. Page 1 lines 27 to 29 and Page 10, lines 331 to 333.
