Attitudes of Polish Medical Students toward Organ Donation in Cases of Brain Death

Round 1

Reviewer 1 Report

General Impression

The authors present the results of a survey on Polish Medical Students’ attitudes on organ donation and transplantation (ODT). The response rate to the survey was very good (88%) and the results are likely a true representation of the students attitudes at this point in time. The data are broken down by respondents’ beliefs in the possibility of recovery from brain death and analyzed for correlations with demographic and social factors. Data analysis and interpretation are solid, and the work provides insights into the roots of the problem of not having enough organ donor to meet the population needs. In this, the study should be of interest to readers and warrants publication.

Detailed critique

Results, lines 121 to 127: The paragraph refers to elements of the student survey that are neither described in the methods section nor shown in table1: Neuroticism, WART, BDI I-II. If this section is to remain in the manuscript, the authors need to provide more information on  the survey instrument, show the data and provide an interpretation (e.g., what does a BDI I-II score of 6.8 mean, and how does it support the conclusions of the study?)

Discussion: It is mentioned in passing that students from Poznan University held significantly different beliefs on the possibility of recovery after brain death. This raises the broader issue of curricular consistency among the surveyed institutions. The manuscript would benefit from a discussion of the medical curricula at Polish Universities as this reviewer is not familiar with the intricacies of Polish Medical education. Are there nationally normed competency standards? When and how is the topic of ODT taught at the participating schools?

Discussion: Could data on organ donations in Poland be added to the discussion? It is not clear how ODT in Poland compares to other parts of the world. Such a comparison would help the reader understand the magnitude of the problem and the urgency of finding a solution.

/

Author Response

Department of  Nursing, Faculty of Health Sciences

Head: Prof. Elżbieta Grochans

Adress: 71-210 Szczecin, 48 Żołnierska St.

Poland

tel. + 48 91 48 00 910

Szczecin, 15.04.2024

We take the liberty to thank you and the reviewers for insightful and careful evaluation of our article entitled “Attitudes of Polish medical students toward organ donation in cases of brain death” by Marzena Mikla, Kamila Rachubińska, Antonio Ríos, Daria Schneider-Matyka, Mariusz Panczyk, Artur Kotwas, Beata Karakiewicz, Elżbieta Grochans, Anna Maria Cybulska for allowing us to resubmit a revised manuscript.

The comments helped us to improve the quality of the manuscript. We considered all comments and recommendations and responded to Reviewers’ questions. The corrections throughout the manuscript were marked in yellow.

Our responses to the reviews are attached below.

Thank you for your consideration. We look forward to hearing from you.

Sincerely,

Kamila Rachubińska

Reviewer 1

Quality of English Language

( ) I am not qualified to assess the quality of English in this paper

( ) English very difficult to understand/incomprehensible

( ) Extensive editing of English language required

( ) Moderate editing of English language required

(x) Minor editing of English language required

() English language fine. No issues detected

Comments and Suggestions for Authors

General Impression

The authors present the results of a survey on Polish Medical Students’ attitudes on organ donation and transplantation (ODT). The response rate to the survey was very good (88%) and the results are likely a true representation of the students attitudes at this point in time. The data are broken down by respondents’ beliefs in the possibility of recovery from brain death and analyzed for correlations with demographic and social factors. Data analysis and interpretation are solid, and the work provides insights into the roots of the problem of not having enough organ donor to meet the population needs. In this, the study should be of interest to readers and warrants publication.

RESPONSE: Thank you for your comments. We used them as an important guide to improving the quality of our paper. The implemented corrections were done strictly according to their comments.

Detailed critique

Results, lines 121 to 127: The paragraph refers to elements of the student survey that are neither described in the methods section nor shown in table1: Neuroticism, WART, BDI I-II. If this section is to remain in the manuscript, the authors need to provide more information on  the survey instrument, show the data and provide an interpretation (e.g., what does a BDI I-II score of 6.8 mean, and how does it support the conclusions of the study?)

RESPONSE: Thank you for this suggestion. It was a text upload error. We have corrected this error.

Discussion: It is mentioned in passing that students from Poznan University held significantly different beliefs on the possibility of recovery after brain death. This raises the broader issue of curricular consistency among the surveyed institutions. The manuscript would benefit from a discussion of the medical curricula at Polish Universities as this reviewer is not familiar with the intricacies of Polish Medical education. Are there nationally normed competency standards? When and how is the topic of ODT taught at the participating schools?

RESPONSE: Thank you for this suggestion. We will use this advice in the future. In Poland, we are nationally normed competency standards. The syllabus of subjects is prepared in accordance with the expected learning outcomes, depending on the fields of study. Each medical school prepares its own syllabi and conducts classes. The topic of ODT is most often discussed in subjects such as surgery and ethics.

Discussion: Could data on organ donations in Poland be added to the discussion? It is not clear how ODT in Poland compares to other parts of the world. Such a comparison would help the reader understand the magnitude of the problem and the urgency of finding a solution.

RESPONSE: Thank you for your comments. We improved our discussion. According to the Organizational and Coordination Center for Transplantation Poltransplant, in 2022, 1,402 organs from deceased donors were transplanted in Poland, over 120 more than a year earlier. Last year, there was a dramatic increase in these procedures - 1,805 internal organs were transplanted, such as kidneys, heart, liver, pancreas and lungs. We were not able to perform such a large number of transplants even in the best years in this respect, i.e. over 10 years ago. In 2012, 1,546 organs were transplanted, 133 more than in 2011. In the following two years, the number of internal organ transplants exceeded 1,500. In 2013, 1,536 such transplants were performed, and in 2014 - 1,531. Then stagnation occurred. In 2015, there were 1,432 transplants, in 2016 - 1,469, and in 2017 their number only temporarily increased to 1,531. In 2018, another decline was recorded - only 1,390 internal organs were transplanted. The situation improved in 2019, when 1,475 such procedures were performed. However, the pandemic brought another breakdown: in 2020, only 1,180 transplants were performed, and in 2021 - 1,274.

The sharp increase in transplants in 2023 indicates that Polish transplantology is starting to rebuild and develop when it comes to transplants from deceased donors. Last year, 573 so-called deceased real donors, i.e. those from whom the collected organs were suitable for transplantation. The total number of donors was 764. In 2022, there were 445 actual donors and 640 total donors. Obtaining deceased donors is crucial for the development of transplants, which Polish transplantology has been struggling with for decades. In 2023, as in previous years, the most transplants included kidneys (977), livers (523), hearts (178) and lungs (98). Last year, four pancreases were transplanted (very rare and difficult operations) and 24 kidneys and pancreas.

Apart from kidney transplants, liver transplants have been developed in our country for many years. In 2007, 178 of them were performed, while in 2015 there were 314, and this number is constantly growing. Lung transplants have also been under development for several years. In 2007, only 7 were performed, and in 2015 - 16. In 2021, despite the pandemic, 91 lung transplants were performed, in 2021 - 68, and in 2022 - 93.

In 2020, 31 kidneys from living donors were transplanted in Poland. For comparison, in the same year, 284 transplants from living donors were performed in Italy, 558 in Great Britain, and 116 in Sweden. These data show that, compared to other countries, Poland has a relatively low rate of living donation.

In conclusion, it seems that despite the awareness and favorable attitudes toward ODT among medical students, the number of registered donors among them was low. It is important to implement effective methods, such as workshops to change students’ beliefs about organ donation.

Thank you very much for your kind consideration of our paper. 

Yours faithfully,

Kamila Rachubińska

Kamila Rachubińska, corresponding author

Department of Nursing, Faculty of Health Sciences, 

Pomeranian Medical University in Szczecin,
Head: Prof. Elżbieta Grochans

48 Żołnierska St., 71 – 210 Szczecin, Poland

Tel. (091) 48-00-910

E-mail: [email protected] 

Author Response File: Author Response.pdf

Reviewer 2 Report

Thank you for submitting your paper which addresses an important and perennial ethical issue. I agree with you that it is important to understand the beliefs of future doctors regarding brain dead donation (BDD). In my opinion your paper would benefit from some minor and some moderate editing.

You are right to say that the development of transplant technology introduced new ethical challenges but wasn't it also the development of life sustaining technologies (ventilators etc.) which resulted in the reconsideration of the definition of death and thus the permissibility of BDD? In both cases these are no longer new (recent) - perhaps you could acknowledge this by given a more accurate historical account with references.  It would also be useful if you could briefly summarise the Polish position both in law and /or through professional guidance/ regulation. Is BDD legal and if so what kinds of consent are required? If it is legal is there a problem in practice? You discuss the fact that the majority of your participants are not registered donors, how does this compare to the general Polish population?

Abstract - I find the following sentence difficult to understand: '(3) The majority of the respondents aware that it is impossible to recover and function normally after brain death were women, practicing Catholics (p = 0.000), and those convinced that their church was against organ donation after death.' 

Are you able to express this differently to make it clearer - otherwise it seems an odd conjunction of things the significance of which is hard to decipher even in the light of your discussion.

Point 4 in the abstract has a typo.

References 2,3, are Polish papers but aren't you referring to principlism here and thus should reference e.g. Beauchamp and Childress?

Line 52 'negative religious beliefs' - do you mean that some respondents have negative attitudes to BDD on the grounds of their religious beliefs? I think that you do because of what you later say about religious opposition. Perhaps you can express this more accurately.

What you say in lines 50 -73 is in my opinion problematic, you should either use this section to describe factually the Polish situation with regard to organ donation and BDD in particular. Or you should be much more upfront about your own ethical position with regard to donation/BDD - implicitly you are arguing for a particular 'position' yet your declared intention with regard to the research is simply to discover attitudes and beliefs. Currently you are mixing up agendas here.

This also becomes problematic in your discussion. Your opening sentence:

Medical students’ knowledge and attitudes toward brain death and transplantation

199

are important, because after graduation they should be able to opt for organ donation and

200

improve public awareness of these issues

This reveals something of your own ethical agenda and it is confusing - what is the significance of becoming a registered donor after graduation? presumably all adults can/ should have a donor status?

Line 176 'vast majority' is not a good phrase because 'vastness' is too vague a concept - stating the actual majority works better.

Line 263 - as far as I am aware 'Roma' is an ethnic group and not a religion.

Line 281 'main strength' - there is a typo/ sentence construction problem.

I have mentioned my language concerns above.

Author Response

Department of  Nursing, Faculty of Health Sciences

Head: Prof. Elżbieta Grochans

Adress: 71-210 Szczecin, 48 Żołnierska St.

Poland

tel. + 48 91 48 00 910

Szczecin, 15.04.2024

We take the liberty to thank you and the reviewers for insightful and careful evaluation of our article entitled “Attitudes of Polish medical students toward organ donation in cases of brain death” by Marzena Mikla, Kamila Rachubińska, Antonio Ríos, Daria Schneider-Matyka, Mariusz Panczyk, Artur Kotwas, Beata Karakiewicz, Elżbieta Grochans, Anna Maria Cybulska for allowing us to resubmit a revised manuscript.

The comments helped us to improve the quality of the manuscript. We considered all comments and recommendations and responded to Reviewers’ questions. The corrections throughout the manuscript were marked in yellow.

Our responses to the reviews are attached below.

Thank you for your consideration. We look forward to hearing from you.

Sincerely,

Kamila Rachubińska

Reviewer 2

Quality of English Language

( ) I am not qualified to assess the quality of English in this paper

( ) English very difficult to understand/incomprehensible

( ) Extensive editing of English language required

(x) Moderate editing of English language required

( ) Minor editing of English language required

() English language fine. No issues detected

Comments and Suggestions for Authors

Thank you for submitting your paper which addresses an important and perennial ethical issue. I agree with you that it is important to understand the beliefs of future doctors regarding brain dead donation (BDD). In my opinion your paper would benefit from some minor and some moderate editing.

You are right to say that the development of transplant technology introduced new ethical challenges but wasn't it also the development of life sustaining technologies (ventilators etc.) which resulted in the reconsideration of the definition of death and thus the permissibility of BDD? In both cases these are no longer new (recent) - perhaps you could acknowledge this by given a more accurate historical account with references.  It would also be useful if you could briefly summarise the Polish position both in law and /or through professional guidance/ regulation. Is BDD legal and if so what kinds of consent are required? If it is legal is there a problem in practice? You discuss the fact that the majority of your participants are not registered donors, how does this compare to the general Polish population?

RESPONSE: Thank you for this suggestion. We improved our Introduction. Act on the collection, storage and transplantation of cells, tissues and organs of July 1, 2005, the so-called The transplantation act is the most important legal act in Poland in the field of transplantation medicine. The Act regulates and organizes the transplant system in Poland, where the legislation is consistent with European Union law, the regulations of the World Health Organization and the Council of Europe. Poland has been a member of the European Union since 2004, so the legal acts issued by it are binding on Poland. The European Union has so far adopted five directives on transplantation, three of them concern the collection, banking and transplantation of cells and tissues, and the remaining ones concern organs intended for transplantation. In Poland, the state budget unit established by the Minister of Health in 1996 is the Organization and Coordination Center for Transplantation "Poltransplant", which is responsible for supervising the organ procurement and transplantation program in Poland. In Poland, according to law, brain death is confirmed by a commission consisting of three specialists - including a specialist in anesthesiology and intensive care, neurology or neurosurgery. In case of any doubt, the commission is obliged to refrain from declaring brain death. The condition for collecting organs from deceased persons is to confirm death in accordance with the regulations in force in a given country. In Poland, organs can be harvested from people with irreversible damage to the central nervous system and after brain death has been confirmed. Before disconnecting the patient from the equipment, the possibility of harvesting some organs for transplantation should be considered. One of the strategic areas of hospital activity, apart from treatment, disease prevention and education, is organ donation. The hospital's legal obligation is to report the possibility of harvesting organs from deceased persons. There are only a few hours left between the moment brain death is confirmed and the organs are harvested to ascertain the deceased's will regarding the donation of tissues and organs after death. Public health problems Scientific monograph 68 Pursuant to the Act of July 1, 2005 on the collection, storage and transplantation of cells, tissues and organs, a doctor or a person authorized by him is obliged to determine whether the deceased person did not express any objection to the donation of organs, cells, tissues during his lifetime. . This Act also specifies the form of expressing opposition to the donation of organs, cells and tissues for transplantation during the lifetime of a person who is over 16 years of age. Pursuant to this Act, an objection may be expressed by: − entry in the Central Register of Objections to the collection of cells, tissues and organs from human cadavers, − a written declaration with a handwritten signature, − an oral declaration made in the presence of at least two witnesses, confirmed by them in writing. It should be emphasized that the expressed objection is revocable and may be withdrawn in any of the three forms appropriate for its submission. The Transplantation Act also applies to a situation in which the deceased person did not express any objection during his or her lifetime. According to it, a transplant of cells, tissues and organs can be performed from a deceased person who did not express any opposition during life and this is the so-called presumed consent. In Poland, despite the applicable presumed consent, doctors always ask relatives for their opinion on the removal of organs from the deceased. People who wish to express their willingness to donate cells, tissues and organs for transplantation after death have the opportunity to complete a declaration of will, which is for information purposes only and is not obliged to report it anywhere. It has no legal value, but it is a huge expression of support for organ transplantation. Statistical data provided by Poltransplant show that in 2016, 677 potential deceased organ donors were reported. Organs were harvested from 80% of those reported, while 20% of the deceased were not harvested due to lack of authorization for collection (10.8%) and for medical reasons (9%). On December 31, 2016, 29,545 declarations were registered in the Central Register of Oppositions, including 29,249 oppositions and 296 withdrawals of oppositions.

The development of transplantology has allowed the treatment of people with end-stage organ failure without harm to the donor. However, the process of consenting to a transplant still encounters many difficulties. The basic one is, despite the presumed consent to organ donation provided for in the law, asking the family for such consent. It is hardly surprising that the family of the deceased, in shock and mourning after the loss of their loved one, does not  consent to organ donation. It seems that providing the public more widely about the possibilities and effects of transplantation may increase their number. Also, the number of transplants from living donors, which in Poland is very low, is probably the result of low public awareness in this area.

Abstract - I find the following sentence difficult to understand: '(3) The majority of the respondents aware that it is impossible to recover and function normally after brain death were women, practicing Catholics (p = 0.000), and those convinced that their church was against organ donation after death.' 

Are you able to express this differently to make it clearer - otherwise it seems an odd conjunction of things the significance of which is hard to decipher even in the light of your discussion.

RESPONSE: Thank you for this suggestion. We changed this sentence.

Point 4 in the abstract has a typo.

RESPONSE: Thank you for this comment. We corrected this typo.

References 2,3, are Polish papers but aren't you referring to principlism here and thus should reference e.g. Beauchamp and Childress?

RESPONSE: Thank you for this suggestion. We corrected references.

Line 52 'negative religious beliefs' - do you mean that some respondents have negative attitudes to BDD on the grounds of their religious beliefs? I think that you do because of what you later say about religious opposition. Perhaps you can express this more accurately.

RESPONSE: Thank you for this suggestion. Uncertainty about the concept of brain death. Some people have negative attitudes to brain death donation on the grounds of their religious beliefs. These beliefs probably play an important role in the decision to donate organs of the deceased for transplantation. We improved these sentences. 

What you say in lines 50 -73 is in my opinion problematic, you should either use this section to describe factually the Polish situation with regard to organ donation and BDD in particular. Or you should be much more upfront about your own ethical position with regard to donation/BDD - implicitly you are arguing for a particular 'position' yet your declared intention with regard to the research is simply to discover attitudes and beliefs. Currently you are mixing up agendas here.

RESPONSE: Thank you for this comment. We improved our introduction and discussion. We described the Polish situation with regard to organ donation and BDD in particular.   

This also becomes problematic in your discussion. Your opening sentence:

Medical students’ knowledge and attitudes toward brain death and transplantation

199

are important, because after graduation they should be able to opt for organ donation and

200

improve public awareness of these issues

This reveals something of your own ethical agenda and it is confusing - what is the significance of becoming a registered donor after graduation? presumably all adults can/ should have a donor status?

RESPONSE: Thank you for your comments. We changed these sentences. It seems that despite the awareness and favorable attitudes toward ODT among medical students, the number of registered donors among them was low. It is important to implement effective methods, such as workshops to improve public awareness of issues about organ donation, so that they can make their own conscious decision to be a donor.

Line 176 'vast majority' is not a good phrase because 'vastness' is too vague a concept - stating the actual majority works better.

Line 263 - as far as I am aware 'Roma' is an ethnic group and not a religion.

Line 281 'main strength' - there is a typo/ sentence construction problem.

RESPONSE: Thank you for your comments. We used them as an important guide to improving the quality of our paper. The implemented corrections were done strictly according to their comments.

Thank you very much for your kind consideration of our paper. 

Yours faithfully,

Kamila Rachubińska

Kamila Rachubińska, corresponding author

Department of Nursing, Faculty of Health Sciences, 

Pomeranian Medical University in Szczecin,
Head: Prof. Elżbieta Grochans

48 Żołnierska St., 71 – 210 Szczecin, Poland

Tel. (091) 48-00-910

E-mail: [email protected] 

Author Response File: Author Response.pdf

Reviewer 3 Report

Thank you for the opportunity to review this interesting paper. Overall, the manuscript is nicely written and adds to the current state of knowledge on the topic. The sample of collected student responses is impressive and a standardized tool was used, positively influencing the reliability of the study. I have only several minor comments for the authors:

-            a thorough proof-reading is required as there are some minor spelling/grammar mistakes ( for example “he medical 30 students in our study” instead of ‘the’)

-            the need for the study could be more emphasized in the introduction – the authors say that “there are few studies assessing knowledge and awareness of brain death among medical students” so how is this study different for them? I am aware that some of the authors’ rationale may seem obvious (e.g. different sample, country) but this alone seems to be insufficient. I think it would be a good idea to strengthen the second part of the introduction (just before the aims) to provide a description of what is currently known on the topic of the study versus what are the literature gaps and how this study attempts to fill them.

-            a brief justification of why these 3 universities were chosen is needed – just logistic reasons?

-            this sentence seems strange (Out of 1,530 medical students invited to the study, 1,348 were qualified who met all the 84 inclusion criteria and correctly completed the questionnaire (completion rate: 88.10%).) – did you mean that the rest of the students simply did not agree to participate?

-            in methods section please add what statistical tests were used

-            when discussing your results (especially the demographic factors) please add brief descriptions of how you interpret these data and what do you think is their practical significance (e.g. just saying that “the year of study had a significant impact on the students’ opinions about brain death” seems too little to call this a discussion – it is just repeating the results)

-            please keep the limitations section just for that (without the ‘second’ conclusion)

-            in line 277 you mention ‘implications for professional practice’ originating from your study – please describe them either in the discussion or conclusion sections

some minor errors are present as indicated above

Author Response

Department of  Nursing, Faculty of Health Sciences

Head: Prof. Elżbieta Grochans

Adress: 71-210 Szczecin, 48 Żołnierska St.

Poland

tel. + 48 91 48 00 910

Szczecin, 15.04.2024

We take the liberty to thank you and the reviewers for insightful and careful evaluation of our article entitled “Attitudes of Polish medical students toward organ donation in cases of brain death” by Marzena Mikla, Kamila Rachubińska, Antonio Ríos, Daria Schneider-Matyka, Mariusz Panczyk, Artur Kotwas, Beata Karakiewicz, Elżbieta Grochans, Anna Maria Cybulska for allowing us to resubmit a revised manuscript.

The comments helped us to improve the quality of the manuscript. We considered all comments and recommendations and responded to Reviewers’ questions. The corrections throughout the manuscript were marked in yellow.

Our responses to the reviews are attached below.

Thank you for your consideration. We look forward to hearing from you.

Sincerely,

Kamila Rachubińska

Reviewer 3

Quality of English Language

( ) I am not qualified to assess the quality of English in this paper

( ) English very difficult to understand/incomprehensible

( ) Extensive editing of English language required

( ) Moderate editing of English language required

(x) Minor editing of English language required

() English language fine. No issues detected

Comments and Suggestions for Authors

Thank you for the opportunity to review this interesting paper. Overall, the manuscript is nicely written and adds to the current state of knowledge on the topic. The sample of collected student responses is impressive and a standardized tool was used, positively influencing the reliability of the study. I have only several minor comments for the authors:

-            a thorough proof-reading is required as there are some minor spelling/grammar mistakes ( for example “he medical 30 students in our study” instead of ‘the’)

RESPONSE: Thank you for your comments. We used them as an important guide to improving the quality of our paper. The implemented corrections were done strictly according to their comments.

-            the need for the study could be more emphasized in the introduction – the authors say that “there are few studies assessing knowledge and awareness of brain death among medical students” so how is this study different for them? I am aware that some of the authors’ rationale may seem obvious (e.g. different sample, country) but this alone seems to be insufficient. I think it would be a good idea to strengthen the second part of the introduction (just before the aims) to provide a description of what is currently known on the topic of the study versus what are the literature gaps and how this study attempts to fill them.

RESPONSE: Thank you for this suggestion. We improved the introduction. Due to the fact that available studies show different results and there is a lot of literature gap about the attitudes toward organ donation in Polish samples. We decided to do some research among Polish students. Therefore, the aim of our study was to determine the attitudes of medical students toward organ donation in the event of brain death.

-            a brief justification of why these 3 universities were chosen is needed – just logistic reasons?

RESPONSE: Thank you for this suggestion. These 3 universities represent 3 different regions of Poland: west, north and central. These universities were selected to make the research as reliable as possible.

-            this sentence seems strange (Out of 1,530 medical students invited to the study, 1,348 were qualified who met all the 84 inclusion criteria and correctly completed the questionnaire (completion rate: 88.10%).) – did you mean that the rest of the students simply did not agree to participate?

RESPONSE: Thank you for this suggestion. Out of 1,530 medical students, 1,348 were qualified who met all the inclusion criteria and correctly completed the questionnaire (completion rate: 88.10%). The rest of the students simply did not agree to participate or did not complete the questionnaire.

-            in methods section please add what statistical tests were used

RESPONSE: Thank you for your comment. We improved the methods section. The socio-demographic data were presented as the number of cases and %, and the group equipotency was verified with the chi-square test (χ2).

 -            when discussing your results (especially the demographic factors) please add brief descriptions of how you interpret these data and what do you think is their practical significance (e.g. just saying that “the year of study had a significant impact on the students’ opinions about brain death” seems too little to call this a discussion – it is just repeating the results)

RESPONSE: Thank you for this suggestion. We improved the discussion.

-            please keep the limitations section just for that (without the ‘second’ conclusion)

RESPONSE: Thank you for this suggestion. We changed the limitations section.

-            in line 277 you mention ‘implications for professional practice’ originating from your study – please describe them either in the discussion or conclusion sections

RESPONSE: Thank you for this suggestion. We added and described implications for the practice section.

Thank you very much for your kind consideration of our paper. 

Yours faithfully,

Kamila Rachubińska

Kamila Rachubińska, corresponding author

Department of Nursing, Faculty of Health Sciences, 

Pomeranian Medical University in Szczecin,
Head: Prof. Elżbieta Grochans

48 Żołnierska St., 71 – 210 Szczecin, Poland

Tel. (091) 48-00-910

E-mail: [email protected] 

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Thank you for addressing my comments, I have no further suggestions.

Language is fine, just needs a little copy editing.

Reviewer 2 Report

Thank you for your revised manuscript.

Reviewer 3 Report

the authors have now satisfactorily addressed my previous comments - thank you!