Distance Education for Basic Surgical Skills Using Homemade Tools—DIY Methods for Emergency Situations

Round 1

Reviewer 1 Report

The work presents an interesting material; however, the authors have to improve the presentation of it. It is recommended to review the following recommendations and comments.

·       The introduction should be improved. The Introduction is to provide the reader with sufficient background to allow him to place the topic and the article in the context of past and present literature. The literature in this section should be chosen carefully and it should be made clear why, given all that information, the article being presented is necessary. The definition of the problem, its nature and scope must be exposed in a clear and direct way, starting from a broad vision of the problem to reach the specifics that the manuscript deals with. The objective is not clear, nor how it will be addressed. There is an explanation in the methodology part, you will need to reorganize this section.

·       An introduction is presented with 18 citations in 21 lines of writing, the writing must be sequenced.

·       In line 80 the author mentions “the alternative solution is acceptable to the students.” It seems affirmation or result instead of criterion.

·       It is indicated that the activity started on a date when the universities were starting the pandemic period, is that correct? Since this would imply that it is an activity that was previously planned.

·       The methodology is well explained, in great detail, this is good, a table or diagram would help to understand better. The objective tables help to understand the work and its scope.

·       A statistical analysis under a certain methodology is mentioned, however, it is not reflected in the results, they seem to be averages with a standard deviation. Explain this! (indicate in table presented).

·       The discussion begins as a conclusion, be careful in the wording. The discussion of what is exposed in the work, which is usually done together with the results, constitutes an essential part in which the results shown in the article must be analyzed, discuss their meaning, analyze their scope, and compare them with other results. of literature. It is not enough to mention the results and say they were compared against values ​​of past courses, which we do not know.

·       The conclusions do not give much information about what has been achieved in the work, improve this section, it is recommended to review the discussions and results, since the information feels mixed. Also being very similar in journals.lww.com

·       Financing appears to be from 2016 and this project is from 2020. Can you explain this situation?

·       Special importance should be given to the mainstream literature of recent years, 8 of the 22 materials cited are more than 5 years old, these sources should be updated as far as possible to give strength to the topic that is presented as current.

 

Author Response

„The work presents an interesting material; however, the authors have to improve the presentation of it. It is recommended to review the following recommendations and comments.”

Dear Reviewer, first of all, we would like to thank you for your detailed review and valuable recommendations. We made a great effort to improve the manuscript following your recommendation. We hope the presentation of our results in this form will reach the high standards of the journal.

 

„1.  The introduction should be improved. The Introduction is to provide the reader with sufficient background to allow him to place the topic and the article in the context of past and present literature. The literature in this section should be chosen carefully and it should be made clear why, given all that information, the article being presented is necessary. The definition of the problem, its nature and scope must be exposed in a clear and direct way, starting from a broad vision of the problem to reach the specifics that the manuscript deals with. The objective is not clear, nor how it will be addressed. There is an explanation in the methodology part, you will need to reorganize this section.”

Respected Reviewer, thank you very much for your valuable comment and suggestions. You are absolutely right, the “Introduction” part was not detailed enough, missed recent and important publications, therefore, it was unprecise. We have extended this part and involved the most recent findings from the field. Furthermore, we have re-positioned and rephrased the mentioned paragraph from the methodology (2.2), and summarized the aim of the study. We hope that in the current form, it is more comprehensible and professional. (The introduction was expanded with 30 lines and 11 citations.)

 

„2. An introduction is presented with 18 citations in 21 lines of writing, the writing must be sequenced.”

Thank you for your valuable suggestion! We expanded and resequenced the introduction section. We hope it will be more readable and understandable this way.

 

„3. In line 80 the author mentions “the alternative solution is acceptable to the students.” It seems affirmation or result instead of criterion.”

Thank you for your comment! We agree with you, although it was one of the most important factor, when we designed the curriculum. However, with this wording it might seems like a result than a criterion. We have changed the formulation: “the alternative solutions should be acceptable and available to the students.”

 

„4. It is indicated that the activity started on a date when the universities were starting the pandemic period, is that correct? Since this would imply that it is an activity that was previously planned.”

Thank you for your question! Indeed, the project was started after the outbreak of the COVID 19 Pandemic, when the Hungarian universities had to switch to non-contact education. Because of this, we can not say, this activity was previously planned. Although, there were more ongoing projects on distance education development (including surgical skills training), so we can not say that either, that we were totally unprepared. We could use a lot of elements from these previous researches (e.g. some part of the methodology or the instruments). Please find one of our previous publications from these projects below.

Pinter, Z.B.; Maroti, P.; Kopjar, E.; Gasz, B.; Duga, Z.; Rendeki, S.; Nagy, B.; Fuzesi, Z.; Schlegl, A.T. Effectivity of Distance Learning in the Training of Basic Surgical Skills—A Randomized Controlled Trial. Sustainability 2022, 14, 4727. https://doi.org/10.3390/su14084727

 

„5. The methodology is well explained, in great detail, this is good, a table or diagram would help to understand better. The objective tables help to understand the work and its scope.”

Thank you for your suggestion. A modified CONSORT diagram was added to the manuscript for a better understanding.

 

„6. A statistical analysis under a certain methodology is mentioned, however, it is not reflected in the results, they seem to be averages with a standard deviation. Explain this! (indicate in table presented).”

Thank you for your question! Mann-Whitney U-test was used to compare the post-course exam results to the outcome of the previous years. You can find the results of the statistical tests in the second paragraph of results section (line 287-290). Regarding your valuable suggestion the title of Table 4. and 5. were extended to explain the presented results.

 

„7. The discussion begins as a conclusion, be careful in the wording. The discussion of what is exposed in the work, which is usually done together with the results, constitutes an essential part in which the results shown in the article must be analyzed, discuss their meaning, analyze their scope, and compare them with other results. of literature. It is not enough to mention the results and say they were compared against values ​​of past courses, which we do not know.”

Thank you for your recommendation! We performed a great effort to improve the discussion section. A wide scope of international literature was involved and compared to our results. The students’ results from the previous two years are mentioned in the second paragraph of the results section (line 288-290).

 

„8. The conclusions do not give much information about what has been achieved in the work, improve this section, it is recommended to review the discussions and results, since the information feels mixed. Also being very similar in journals.lww.com”

Thank you for calling our attention to this deficiency. The conclusion session was expanded and redrafted.

 

„9. Financing appears to be from 2016 and this project is from 2020. Can you explain this situation?”

Thank you for your question! EFOP-3.6.1-16-2016-00004 and GINOP-2.3.2.-15-2016-00022 grants were comprehensive 5-year-long education development projects. Both of them contained a sub-project about distance education development. Although the topic of the recent paper was not planned in these grants’ program originally, some elements of it (IT instruments, methodology) were used in this research.

 

„10. Special importance should be given to the mainstream literature of recent years, 8 of the 22 materials cited are more than 5 years old, these sources should be updated as far as possible to give strength to the topic that is presented as current.

Respected Reviewer, thank you very much for highlighting this weakness of the proposed study. Undoubtedly, the references were not up-to-date in all cases. We have included several new scientific works in the “Introduction” and “Discussion” parts and summarized their most important findings. (20 citations were added to the manuscript, 14 of them were published in the past 2 years.)

Author Response File: Author Response.docx

Reviewer 2 Report

"2.2. Population of the study
Thirty students were included in the study."

I'm sorry but the population is too small for statistical calculations. 30 students are too few. Enlarge the lot of students and you resubmit the article.

 

Author Response

Thirty students were included in the study."

I'm sorry but the population is too small for statistical calculations. 30 students are too few. Enlarge the lot of students and you resubmit the article.”

Respected Reviewer, thank you for your comment!

We agree with you, the study population of 29 samples is not a large number. Unfortunately, we do not have the opportunity to involve more students, since the restrictions regarding the pandemic have been resolved.

Although, we believe our statistical calculations are still reliable. We made a Post-hoc Power Calculation (Continuous Endpoint, Two Independent Sample Study, Alpha= 0,05) what gave us 100% Post-hoc Statistical Power.

In addition, the comparison of the previous two years’ and this course’s results is just a smaller part of the study. We believe our paper contains other interesting outcomes beside of this.

We hope these reasons convince you about the value of our paper.

Author Response File: Author Response.docx

Reviewer 3 Report

I really like the originality of the study and the implications of the findings particularly since the COVID-19 pandemic will take years to subside. My only critique is the structure of the course could be summarized in the Methods section and details of the structure could be provided as an appendix to the paper instead of explicitly stated within the text of the manuscript. 

Author Response

„I really like the originality of the study and the implications of the findings particularly since the COVID-19 pandemic will take years to subside. My only critique is the structure of the course could be summarized in the Methods section and details of the structure could be provided as an appendix to the paper instead of explicitly stated within the text of the manuscript.”

Respected Reviewer, thank you for your appraising opinion!

Following your valuable suggestion, the detailed description of the course plan was moved to the Supplementary material section.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

 

Good corrections were made which were sent in the first revision. I think it's a good job. The presentation improved a lot, however, the authors must solve the new comments and recommendations.

·       The reviewer recommends giving the introduction a good read: a) Review the concept: Knot tying, knotting, and knot-tying. What is correct? Or explain why it is different? b) Take care of the wording, in line 55 “As is it demonstrated before, …” In this job or in other jobs?; take care of the sequence sometimes you feel topic changes that make you lose the rhythm of the reading and it is understood until after reading 3 or 4 times; c) line 93, there is an extra hyphen in the quote; c) lines 67 and 68 are repeated in lines 83 and 84; d) there are nine authors, I recommend that each one should read it and when it is clear for each, the new version is delivered.

·       Write impersonal sentences (line 105)

·       Correct colors in Figure 1, consider publication guidelines, also colors make some texts difficult to read.

·       The information on page 5 is repeated on page 18

·       Explain for Tables 2-3 What does partially mean within your results? sounds ambiguous

·       In section 4. Discussion. The wording needs to be improved. In addition, this section constitutes an essential part in which the results shown in the article must be analyzed, discuss in their meaning, analyze their scope, and compare with other results in the literature (if the author wants to mention that there are other proposals and its costs, the correct section is the introduction, in this section, you should compare what advantages and disadvantages your proposal presents to others, you have to argue).

·       On what is it based to affirm that the percentages indicated in lines 371 and 372 could be achieved.

·       At line 393 “A training and an evaluating session were organized to assess the experiences [35].” Is the prayer worth the reference?

·       Conclusions need to be improved. In the view of the reviewer, the concluding comments are combined in the discussion section.

·       In line 442 “We believe…”? Do you mean you're not convinced?

Author Response

Answer to Reviewer 1.

 

„Good corrections were made which were sent in the first revision. I think it's a good job. The presentation improved a lot, however, the authors must solve the new comments and recommendations.”

Respected Reviewer, thank you for your appraising opinion and the further recommendations. We made a significant effort to follow your instructions and believe it improved the quality of the paper.

 

“The reviewer recommends giving the introduction a good read: a) Review the concept: Knot tying, knotting, and knot-tying. What is correct? Or explain why it is different? b) Take care of the wording, in line 55 “As is it demonstrated before, …” In this job or in other jobs?; take care of the sequence sometimes you feel topic changes that make you lose the rhythm of the reading and it is understood until after reading 3 or 4 times; c) line 93, there is an extra hyphen in the quote; c) lines 67 and 68 are repeated in lines 83 and 84; d) there are nine authors, I recommend that each one should read it and when it is clear for each, the new version is delivered.”

Thank you for your recommendations and advices.

1. After discussion with native English speaker, the right form is knot tying, but knotting can be used as a synonym. Knot-tying is grammatically incorrect, we amended these versions.
2. Thank you for calling our attention to this unfortunate wording, we rephrased it.
3. We deleted the extra hyphen, thank you for highlighting this mistake.
   We believe the repetition is just a technical issue. Line 83 and 84 were deleted, the “Track changes” function of MS Word could make it see.
4. Thank you for your advice. All authors have reviewed each versions of the paper. We have asked them again, to check this version in detail. We hope we could improve the rhythm of the reading.

 

“Write impersonal sentences (line 105)”

Thank you for your recommendation, we rephrased that section.

 

“Correct colors in Figure 1, consider publication guidelines, also colors make some texts difficult to read.”

Thank you for your suggestion. We retoned the figure.

 

“The information on page 5 is repeated on page 18”

Thank you for calling our attention to this technical issue. Following the recommendation of Reviewer 3, we have moved the detailed course plan to an appendix. We think, the “Track changes” function of MS Word made this duplication. We corrected it.

 

“Explain for Tables 2-3 What does partially mean within your results? sounds ambiguous”

Thank you for your recommendation, we have added some explanation to the title of the tables.

 

“In section 4. Discussion. The wording needs to be improved. In addition, this section constitutes an essential part in which the results shown in the article must be analyzed, discuss in their meaning, analyze their scope, and compare with other results in the literature (if the author wants to mention that there are other proposals and its costs, the correct section is the introduction, in this section, you should compare what advantages and disadvantages your proposal presents to others, you have to argue).”

Thank you for your recommendation. The discussion section was reedited, and the comparison with the literature was expanded.

 

“On what is it based to affirm that the percentages indicated in lines 371 and 372 could be achieved.”

Thank you for your question! Using household tools 79% of the learning objectives could performed completely, and 15% partially. Equipping the students with basic surgical and laparoscopic tools would make also possible to fulfil the following objectives:

Suturing:

• Knowledge of the tools needed for wound closure, mastering their utilization / application
• Proper use of forceps

Laparoscopy

• To adapt to the elongated laparoscopic instruments
• Familiarize with the equipment and instruments
• To be able to suture and tie knots with laparoscopic instruments

We have expanded the paragraph to help the understanding.

 

“At line 393 “A training and an evaluating session were organized to assess the experiences [35].” Is the prayer worth the reference?”

Thank you for calling our attention to this unfortunate placement of the reference. We meant to refer the whole paragraph. We replaced the citation to make it clearer.

 

“Conclusions need to be improved. In the view of the reviewer, the concluding comments are combined in the discussion section.”

Thank you for your suggestion. We expanded the conclusions section with the new findings of the study.

 

“In line 442 “We believe…”? Do you mean you're not convinced?”

Thank you for calling our attention to this unfortunate phrasing. We are convinced, of course. We deleted the unnecessary clause.

Author Response File: Author Response.docx

Reviewer 2 Report

1. The fact that they are few is not a justification! Write about it at the limits of the study! 2. What is new in your study? Write this in the title, abstract and conclusions.

Author Response

Answer to Reviewer 2. 

 

“1. The fact that they are few is not a justification! Write about it at the limits of the study! “

Respected Reviewer, thank you for your suggestion. The limitation section was expanded to highlight this weakness of the study.

 

“2. What is new in your study? Write this in the title, abstract and conclusions.”

Thank you for your question!  To our knowledge this is the first study, where not only the simulators but the surgical instruments were replaced with household tools. Also this was the first occasion, where to learning objectives of a regular course were compared with an emergency situation solution. We have expanded the manuscript to highlight these.

Author Response File: Author Response.docx