Personal and psychosocial factors of burnout: A survey within the French neurosurgical community

Clément Baumgarten; Estelle Michinov; Géraldine Rouxel; Vincent Bonneterre; Emmanuel Gay; Pierre-Hugues Roche

doi:10.1371/journal.pone.0233137

Peer Review History

Original SubmissionJanuary 9, 2020
27 Feb 2020 Decision Letter - Sergio A. Useche, Editor PONE-D-20-00752 Personal and Psychosocial factors of Burnout: A Survey within the French Neurosurgical Community. PLOS ONE Dear MR Baumgarten, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Our reviewers have identified a certain potential in your submitted manuscript, highlighting its possible contribution to the development of applied measures and strategies for the improvement of the job quality and physical/mental health of specialized healthcare providers. Even though, you will find a relatively short (but substantial) set of comments and suggestions that you should consider responding to, in order to improve the manuscript and its scientific value. Also, and as a personal suggestion, please consider updating the theoretical framework of the paper, taking into account recent studies on (e.g.) burnout and health issues among vulnerable occupational groups apart from physicians and healthcare providers, that share key factors such as a highly stressful work environment, time pressure and limited degrees of skill discretion. For instance, the relationship between EE (Emotional Exhaustion) and different health complaints affecting working populations (same as among medical personnel) is a factor that recent sources strongly highlight, and may enrich the comparability of your findings. This might contribute to strengthen the explanatory potential of the findings and empirical support given to your discussion. We would appreciate receiving your revised manuscript by Apr 12 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'. Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out. We look forward to receiving your revised manuscript. Kind regards, Sergio A. Useche, Ph.D. Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements: 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at http://www.plosone.org/attachments/PLOSOne_formatting_sample_main_body.pdf and http://www.plosone.org/attachments/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Considerations: The object of the study is very significant. Burnout is a syndrome that appears in several professional categories and affects the care of the population, due to causing mental exhaustion in the affected professionals. 1- The search objective is not clearly defined in the Abstract. 2- Methods should not contain the objectives (line 59). The objectives should be described in the previous session. Reviewer #2: This ms reports results of a well-designed study that used validated assessment instruments to evaluate the role of personality, effort/reward ratio, and other factors like pleasure at work-flow to identify personal and psychosocial factors associated with burnout in the French neurosurgical community. There are some concerns the authors need to address to maximize the impact of this study. 1. While the associations documented by the rigorous statistical analyses are strong, it will help the reader understand the nature of those associations if the authors provided figures (or tables) that illustrate the directions of those associations – e.g., graphs showing levels of Emotional Exhaustion as Neuroticism increases, Depersonalization as Agreeable decreases, Personal Accomplishment as Effort/Reward ratio changes. 2. While they are probably correct in noting that “personality modification does not seem either ethical or desirable,” it could help appreciate the implications of the associations they have found if they consider the potential paths whereby the personality dimensions lead to burnout – e.g., high neuroticism � high depression �high emotional exhaustion. Interventions that reduce levels of such mediators could reduce the impact of personality factors on burnout. In a study of Chinese medical students, for example, Chun et al. (Efficacy of Williams LifeSkills training for improving psychological health: a pilot comparison study of Chinese medical students. Asia Pac Psychiatry. 2014;6(2):161-9. PMID: 23857943) found that training in cognitive behavioral stress management and interpersonal interaction skills produced improvements in anxiety, depression, negative coping, social support, and self-esteem. 3. Some minor concerns need to be addressed: a. line 82 – “Maslach Burnout Inventory scale6” – what does the 6 refer to? b. line 133 – The only significant difference between residents and neurosurgeons was for DP in Table 2, not PA as stated in the text. c. line 151 – They say Pleasure at work is positively associated with each burnout dimension, but inspection of Table 3 show that Pleasure at Work-Flow is negatively associated with EE and DP, but positively associated with PA – suggesting that high Pleasure at Work is associated with lower EE and DP but higher PA, all of which makes sense. As per comment 1 above, it would help the reader understand these associations if figures were provided to illustrate them. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0233137.r001
Revision 1
20 Mar 2020 Author Response Editors Plos ONE Ref : PONE-D-20-00752R1 Personal and Psychosocial factors of Burnout: A Survey within the French Neurosurgical Community To Sergio A. Useche, Academic Editor Dear Sir, Please find enclosed a revised manuscript entitled “Personal and Psychosocial factors of Burnout: A Survey within the French Neurosurgical Community” by Clément Baumgarten, Estelle Michinov, Géraldine Rouxel, Vincent Bonneterre, Emmanuel Gay and Pierre-Hugues Roche. This manuscript is submitted for consideration after revisions for publication in the PLOS ONE journal. We have addressed and clarified all the concerns that were raised by the academic editor and the reviewers. We believe that this revised version results in a much stronger paper for your journal. All the authors have reviewed and approved this revised version of the manuscript. In addition to the revised version of our manuscript (in Word format), please find enclosed the following documents: - A point-by-point list of all changes made in response to suggestions of the reviewers. - A version of the manuscript in “track changes” format, with changes highlighted (in Word format). In the hope that you find that this paper falls within the scope of PLOS ONE, and that it will be of interest to your readers, I look forward to hearing from you soon. Please do not hesitate to contact me if you have any questions. Yours faithfully, Clément Baumgarten Response to reviewers Ref: PONE-D-20-00752R1 Personal and Psychosocial factors of Burnout: A Survey within the French Neurosurgical Community I. INTRODUCTION The authors would like to thank the reviewers for their relevant remarks and suggestions for improving the paper. In this document, we provide a point-by-point response to each of the issues raised. Each issue is written in bold text, the corresponding response is in normal text, and we provide in italics the text added/modified in the paper to address the issue. In the main paper, all changes are clearly marked in yellow. Each modification in the text of the manuscript was highlighted in red to be more easily visible for the reviewers. Here is a point-by-point list of all changes made in response to the suggestions of the reviewers: II. ACADEMIC EDITOR Also, and as a personal suggestion, please consider updating the theoretical framework of the paper, taking into account recent studies on (e.g.) burnout and health issues among vulnerable occupational groups apart from physicians and healthcare providers, that share key factors such as a highly stressful work environment, time pressure and limited degrees of skill discretion. For instance, the relationship between EE (Emotional Exhaustion) and different health complaints affecting working populations (same as among medical personnel) is a factor that recent sources strongly highlight and may enrich the comparability of your findings. This might contribute to strengthen the explanatory potential of the findings and empirical support given to your discussion. We thank you for your suggestion to enhance the theoretical discussion of the paper. We revised the introduction accordingly. We added several references to discuss and strengthen our findings. Added text: Line 45: “Workers in many occupational sectors are susceptible to creating a situational context that leads to burnout symptoms[1] . Burnout is a syndrome defined by emotional exhaustion (EE), feelings of depersonalization (DP) and a lack of personal accomplishment (PA) in relation to professional activity[2]. Studies have demonstrated that chronic stressors could increase burnout arise from an imbalance between job demands and job resources[3]. Burnout is associated with several comorbid factors such as chronic fatigue, addictive behaviors, substance use and suicidal ideation, and different health complains[4]. Studies suggest that burnout has a negative impact on psychological and physical health of workers, but also on their interpersonal relationships and job environment. For healthcare professionals and physicians, burnout affects the quality of patients’ care through increased medical errors, decreased empathy and decreased productivity at work[5]. Thus, efforts to identify and prevent burnout should lead to better health at work and better quality of care. The prevalence of burnout within different surgical specialties is about 40%[6], and for certain subspecialties such as neurosurgery, the prevalence of burnout is estimated to be 27% to 56.7%[7–9]. Neurosurgery is a demanding specialty in medicine. Work hours are among the longest[10] as the number of night shifts, and has a heavy medicolegal burden due to high malpractice risk[11].” Line 223 : “Zoer et al[18] drew similar conclusions when they studied associations between psychosocial workload and mental health complaints in different age groups in a railway company. Understanding those subtle differences is crucial to provide accurate interventions.” Line 238: “Work to family conflict is a well-documented association with burnout. Jensen et al[30,31] rigorously demonstrated in a longitudinal study the reciprocal relationships between work to family conflict, emotional exhaustion and psychological health complaints in a population with a lot of business travels.” Line 255:” According to the conclusion of Jensen et al, it is likely that today’s organization in neurosurgery produces a vicious circle leading to burnout and its consequences.” Line 299: “Neurosurgeons shares many well documented associated factors of burnout with other occupational groups. While we did not measure occupational stress in this study it is certainly a shared features, notably with lawyers[43] and non-medical occupational health staff[44].” III. REVIEWER 1 The object of the study is very significant. Burnout is a syndrome that appears in several professional categories and affects the care of the population, due to causing mental exhaustion in the affected professionals. 1- The search objective is not clearly defined in the Abstract. Methods should not contain the objectives (line 59). The objectives should be described in the previous session. We thank the reviewer 1 for helping us clarify the structure and the objectives of our manuscript. We clarify the objective section accordingly. Added text line 25: The objectives of this study were to report the prevalence and associated factors of burnout within the French neurosurgical community using validated academic and psychologic scales. Added text: line 70: “The objectives of this work were to report the prevalence and associated factors of burnout within the French neurosurgical community using validated academic and psychologic scales.” IV. REVIEWER 2 This ms reports results of a well-designed study that used validated assessment instruments to evaluate the role of personality, effort/reward ratio, and other factors like pleasure at work-flow to identify personal and psychosocial factors associated with burnout in the French neurosurgical community. There are some concerns the authors need to address to maximize the impact of this study. 1. While the associations documented by the rigorous statistical analyses are strong, it will help the reader understand the nature of those associations if the authors provided figures (or tables) that illustrate the directions of those associations – e.g., graphs showing levels of Emotional Exhaustion as Neuroticism increases, Depersonalization as Agreeable decreases, Personal Accomplishment as Effort/Reward ratio changes. We totally agree and thank the reviewer for this relevant suggestion. We provided a supplemental figure with each univariate analysis that were significant during the stepwise multiple regression. The figure provides the reader the direction of the association. Added material: S4 Figure. Univariate analysis of each associated factors with the main dimensions of burnout. Added text: line 172: “The univariates analysis and direction of each associated factors obtained during the stepwise multiple regression are represented in the S4 Appendix.” 2. While they are probably correct in noting that “personality modification does not seem either ethical or desirable,” it could help appreciate the implications of the associations they have found if they consider the potential paths whereby the personality dimensions lead to burnout – e.g., high neuroticism � high depression �high emotional exhaustion. Interventions that reduce levels of such mediators could reduce the impact of personality factors on burnout. In a study of Chinese medical students, for example, Chun et al. (Efficacy of Williams LifeSkills training for improving psychological health: a pilot comparison study of Chinese medical students. Asia Pac Psychiatry. 2014;6(2):161-9. PMID: 23857943) found that training in cognitive behavioral stress management and interpersonal interaction skills produced improvements in anxiety, depression, negative coping, social support, and self-esteem. Burnout is a complex phenomenon intricated with a multitude of human factors. We agree that those kinds of interventions might affect the factors associated with personality and burnout. Added text: line 241 : “Still, cognitive and psychosocial interventions[24,25] that reduce stress, and anxiety while increasing social support and self-esteem might reduce the complex impact of personality factors on burnout.” 3. Some minor concerns need to be addressed: a. line 82 – “Maslach Burnout Inventory scale6” – what does the 6 refer to? This typography error was corrected. b. line 133 – The only significant difference between residents and neurosurgeons was for DP in Table 2, not PA as stated in the text. We thank the reviewer 2 for correcting this mistype error. Corrected text line 149: “There was only a significant difference between residents and neurosurgeons for DP” c. line 151 – They say Pleasure at work is positively associated with each burnout dimension, but inspection of Table 3 show that Pleasure at Work-Flow is negatively associated with EE and DP, but positively associated with PA – suggesting that high Pleasure at Work is associated with lower EE and DP but higher PA, all of which makes sense. As per comment 1 above, it would help the reader understand these associations if figures were provided to illustrate them. We apologize for this misinterpretation error. We addressed this issue in the first comment answer. Added text line 167: Pleasure at work was negatively associated with EE and DP while it was positively associated with PA. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0233137.r002
17 Apr 2020 Decision Letter - Sergio A. Useche, Editor PONE-D-20-00752R1 Personal and Psychosocial factors of Burnout: A Survey within the French Neurosurgical Community PLOS ONE Dear MR Baumgarten, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please refer to the comments appended below, where one of the reviewers requires you to perform a relatively small (but important) amendment in regard to (i) the reported burnout levels in this group of professionals, and (ii) the scale indicating whether burnout levels are high or low. Once you send you revisions, and if the quality of the amendments is good enough, I will proceed to accept the paper without a new round of reviews. We would appreciate receiving your revised manuscript by Jun 01 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'. Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out. We look forward to receiving your revised manuscript. Kind regards, Sergio A. Useche, Ph.D. Academic Editor PLOS ONE [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed Reviewer #2: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The research is relevant. The burnout syndrome is a disease that affects various professional categories and grow the number of research on this subject. In the Abstract the authors reported a high prevalence of burnout in French Neurosurgeons. However, in the final conclusion the authors did not make any reference to the burnout levels in this category of professionals. Also i did not realise the scale wich indicates the burnout levels are high or low. Please, check it. Reviewer #2: (No Response) ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0233137.r003
Revision 2
18 Apr 2020 Author Response This is indeed a relevant point in the move of our paper that was missing. We compared our results with a meta-analysis of French physicians and American surgeons. Our conclusion of high prevalence of burnout was drawn on this comparison because such scale does not exist. Burnout definition and high, medium, or low level of each subscales (i.e. emotional exhaustion, depersonalization and personal accomplishment) were based on [1]. 1. Maslach C, Jackson SE. The measurement of experienced burnout. J Organ Behav. 1981;2: 99–113. doi:10.1002/job.4030020205 Added text line 196: which is higher than the 29 % rate in comparison with the most comprehensive and complete meta-analysis of French physicians[17] following the same burnout definition. As for surgeons, Campbell et al[18] reported a 32% rate in a population of American surgeons. Added text line 300: Burnout prevalence is high in comparison with physicians and even among surgeons. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0233137.r004
29 Apr 2020 Decision Letter - Sergio A. Useche, Editor Personal and Psychosocial factors of Burnout: A Survey within the French Neurosurgical Community PONE-D-20-00752R2 Dear Dr. Baumgarten, We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements. Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication. Shortly after the formal acceptance letter is sent, an invoice for payment will follow. To ensure an efficient production and billing process, please log into Editorial Manager at https://www.editorialmanager.com/pone/, click the "Update My Information" link at the top of the page, and update your user information. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, you must inform our press team as soon as possible and no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. With kind regards, Sergio A. Useche, Ph.D. Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0233137.r005
Formally Accepted
13 May 2020 Acceptance Letter - Sergio A. Useche, Editor PONE-D-20-00752R2 Personal and Psychosocial factors of Burnout: A Survey within the French Neurosurgical Community Dear Dr. Baumgarten: I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. For any other questions or concerns, please email plosone@plos.org. Thank you for submitting your work to PLOS ONE. With kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Sergio A. Useche Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0233137.r006

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