Palliative Care in the Community and the Relevance of Percutaneous Endoscopic Gastrostomy Placement to Quality of Life and Survival
, Hugo Ribeiro 1,2,3,4,*, Inês Rodrigues 1, Elisabete Costa 1, João Rocha Neves 3,5, José Paulo Andrade 3,5, António Bernardes 2,4,6 and MarÃlia Dourado 2,4
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsThis is an interesting report
There are some areas where the English is not so clear:
line 40 permissible would be better as possible
line77 superior or inferior would be better as before or after
line 80 existence would be better as presence
line 113 externalization would be better as removal
line 124 peg should be PEG
line 141 dysphagia prevention would be better as the anticipation of possible dysphagia
line 191 water would be better as fluid
line 277 carrier would be better a "a patient has a PEG"
line 324 prevent oral loss would be better as place in anticipation of potential dysphagia for fluids
There are areas that also need clarification:
line 126 it would be helpful to provide the survival rate for PEG patients - this does not seem to be stated anywhere and more details would be helpful here and later in the paragraph starting on line 177
In the discussion - line 202 - a study is quoted with the mortality details, and the result from this study should have been given as a comparison
Line 210 it is unclear if this is from this study or more generally from the literature
Line 217 paragraph. - the lack of statistical significance may be due to small numbers and this needs to be discussed
Section 5 the small numbers needs to be given as a limitation, and would then lead onto to the need for larger trials / studies
Comments on the Quality of English Language
As above
Author Response
Reviewer 1
- line 40 permissible would be better as possible; line77 superior or inferior would be better as before or after; line 80 existence would be better as presence; line 113 externalization would be better as removal ; line 124 peg should be PEG; line 141 dysphagia prevention would be better as the anticipation of possible dysphagia; line 191 water would be better as fluid; line 277 carrier would be better a "a patient has a PEG"; line 324 prevent oral loss would be better as place in anticipation of potential dysphagia for fluids
Answer: Thanks for your suggestions. We highlighted in the manuscript all these corrections.
- line 126 it would be helpful to provide the survival rate for PEG patients - this does not seem to be stated anywhere and more details would be helpful here and later in the paragraph starting on line 177
Answer: Thanks for your attention and suggestions. We realized that we had included several survival rates, but they were always related to some characteristics of the patients, such as age, sex, and length of follow-up. We added the overall survival time for patients with PEG in lines 186-187 and we highlighted it.
- In the discussion - line 202 - a study is quoted with the mortality details, and the result from this study should have been given as a comparison
Answer: Thanks for your comment and suggestion. We discussed those results with the results of our study and we highlighted it (lines 212-213 and lines 218-219).
- Line 210 it is unclear if this is from this study or more generally from the literature
Answer: Thanks for your comment and suggestion. We corrected this sentence and paragraph and we highlighted it (lines 226-228). In fact, in our study, the age at which PEG is placed has no impact on survival or the incidence of complications.
- Line 217 paragraph. - the lack of statistical significance may be due to small numbers and this needs to be discussed
Answer: Thanks for your comment and suggestion. We highlighted this discussion in lines 239-244.
- Section 5 the small numbers needs to be given as a limitation, and would then lead onto to the need for larger trials / studies
Answer: Thanks for your comment. We had already identified this limitation. We reinforced in line 317 stating that: “we need more and multicentric studies, with higher samples”.
Author Response File: 
Author Response.pdf
Reviewer 2 Report
Comments and Suggestions for AuthorsThis is a good study aimed at the impact of PEG placement on survival and quality of life in patients followed by a community palliative care team. I have the following:
1. The control group only has 20 nasogastric tube patients. I would recommend to try to increase the control group to improve comparative findings.
2. Perhaps take into consideration other factors such as BMI, immune status, other comorbidities in survival outcomes
3. Can you please confirm if all patients with PEG tube continued having it despite the presence of minor complications? Did any patients discontinue?
4. You mention that minor complications were resolved within 1 to 2 weeks in PEG patients. Please describe measures taken to resolve them.
Author Response
Reviewer 2
- The control group only has 20 nasogastric tube patients. I would recommend to try to increase the control group to improve comparative findings.
Answer: Thanks for your attention and suggestions. This may be a limitation, although it allows us to have statistical significance in the comparisons made. We cannot increase the number of patients in the control group in this study, as the methodology would not allow us to do so at this time. But we will take into account what you mentioned in a future study, which we want to be prospective.
- Perhaps take into consideration other factors such as BMI, immune status, other comorbidities in survival outcomes
Answer: Thanks for your suggestions. These are great suggestions to take into consideration in the future. However, as we only included patients who were at home, potentially at the end of their lives (last 12 months of life), the vast majority of whom were bedridden, with very poor venous access, in this study we did not consider the factors you mentioned. In relation to other comorbidities, we considered personal history and usual medication, but there was no possibility of an adequate statistical study given the very low numbers for each of these factors. The most relevant variables we found were high blood pressure and diabetes, but even so they did not present any statistical interest for this study. We highlighted this in lines 159-163.
- Can you please confirm if all patients with PEG tube continued having it despite the presence of minor complications? Did any patients discontinue?
Answer: Thanks for your attention and suggestion. None of the patients who had PEG discontinued its use until the end of this study or at the end of their lives. We highlighted this statement in lines 122-123.
- You mention that minor complications were resolved within 1 to 2 weeks in PEG patients. Please describe measures taken to resolve them.
Answer: Thanks for your suggestions. We highlighted in the manuscript all these corrections. In patients with mild bleeding, only local containment measures were necessary, without additional pharmacological therapy. In patients with soft tissue infection, antibiotic therapy was introduced. We highlighted this statement in lines 126-128.
Author Response File: Author Response.pdf
