PONE-D-21-03769

Pre-hospital causes for delayed arrival in acute ischemic stroke before and during the COVID-19 pandemic: A study at two stroke centers in Egypt

PLOS ONE

Dear Dr. Shokri,

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.

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Miguel A. Barboza, MD, MSc

Academic Editor

PLOS ONE

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Reviewer #1: Yes

Reviewer #2: Partly

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Reviewer #1: No

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #2: Yes

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Reviewer #1: It was my pleasure to read and review the manuscript: “Pre-hospital causes for delayed arrival in acute ischemic stroke before and during the COVID-19 pandemic: A study at two stroke centers in Egypt” a paper where the different causes of delayed arrival of patients with acute ischemic stroke during a five-month period pre and during de COVID-10 pandemic were analyze and compared.

Before considering this manuscript for publication, I have some comments to add:

Abstract:

Nothing to add

Introduction:

I understand the current situation of pre-hospital care in terms of acute ischemic stroke in Egypt, with the current introduction, but all these paragraphs could be summarized in two, giving special attention to all variables related to patients’ outcome after acute care.

Also, seems relevant to include information regarding the situation of stroke (or medical emergencies) delays after the outbreak of COVID-19 Pandemic in your region or related publications in this topic, as you are comparing both periods, and I cannot see the justification of this behavior in the rationale of your study. This also should be clearly stated in the last paragraph, when adding the main objective of the study.

Methods:

- You have to check the dates in the manuscript because you write that the first COVID’19 case in Egypt was “February 2019”, I assume this was a mistake.

-I suggest to include inclusion and exclusion criteria of your study.

- No information regarding IRB approval protocols are included in your manuscript.

- The survey is a critical part of your study in terms of plausible explanations for delay causes for acute management. I suggest to include the variables and questions for the survey ( a table could be adequate, in this part, instead in the supplementary section).

- Statistical analysis: I suggest to clarify outcome variables for your study, and those included as covariates.

Results:

-I suggest to unify table 1 and 2; both can include the basic variables for the pre-pandemic and trans-pandemic periods

-The section Causes of early hospital arrival within window before and during COVID-19 pandemic is not clear; I can’t find a clear definition for the word “orientation” in terms of the explanation for causes related to early arrival. I suggest to rephrase this section, as I couldn’t understand it.

-I can’t find a clear association among level of education and NIHSS severity…. Is this a relevant finding?? Or seems like a spurious association from the statistical analysis; if you consider this relevant, I suggest to justify a lot in the discussion section, if not, these results seem irrelevant.

Discussion:

-No clear explanation according to previous literature was done in terms of awareness of stroke as an explanatory variable for delay to consultation, at least from what I can read in this section; this should be analyzed since the first approach from your survey, and who is the responsible for this “not adequate awareness” if present.

-Many sections of the discussion are isolated, and no clear association in terms of explanation for the finding on each section were done. I suggest to follow the same order from your paragraphs, when discussing your findings and respective literature support (references).

-You should add a paragraph stating the limitations of your study.

Reviewer #2: Previous question:

The sample size is quite small and have different analyses that could be ineffective for the study objective .

However is a big effort and a good article for describe the barriers, also is a short period to determinate real differences with the pandemic period.

1. Abstract: Methods: it is important to mention wich period of the year, because not all months have the same number of cases of covid-19

Conclusion:

About this subject

Oriented with therapeutic window from media (type: TV. Radio. Social media, newspaper)) pre covid 3.4% during covid 2.3% valor p 0.5

The conclusion said pronounced effect of media in the time of COVID-19. However in the table 4, during COVID was less than the period before -COVID

2.The result should be given in both modalities (Number and Percentages)

3. The analysis about the distance from the hospital should be given in two separates groups, as the methods said with differences between delayed arrival and early arrival and explore statistical significance.

4. In the results:

Comparison of patients’ characteristics before COVID-19 and during COVID-19 time:

- The median time onset door was less, but should said if this time difference was statistical significance

Causes of early hospital arrival within window before and during COVID-19 pandemic:

- Had orientation window therapeutic a statistical significances?

Discussion:

"The type of management showed no significant difference between both time periods. However, it is noticeable that reperfusion therapy (thrombolysis, thrombolysis with thrombectomy and thrombectomy) increased by 8.8% during COVID-19 time, probably due to earlier arrival."

This paragraph is unclear and they don´t mention before any analysis before about treatment. Also the early arrival was 73 patients wich is less than delayed.

References:

References are incomplete. an has different format

Example Reference number 5

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Reviewer #1: No

Reviewer #2: Yes: Diana Manrique-Otero

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Attachments

Attachment

Submitted filename: plos one.docx

PONE-D-21-03769R1

Pre-hospital causes for delayed arrival in acute ischemic stroke before and during the COVID-19 pandemic: A study at two stroke centers in Egypt

PLOS ONE

Dear Dr. Shokri,

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.

The authors addressed all the requested comments and suggestions from reviewers, but there are some minor issues that should be evaluated by the authors before considering this manuscript suitable for publication

1. There are several grammatical mistakes throughout the manuscript, therefore English editing services are highly required.

2. When reading the abstract, Background doesn't reflect the purpose of the study; if you are stating that the rationale of the study is to evaluate causes for pre-hospital delay in acute stroke cases seeking for acute revascularization, knowing that your group previously studied this condition seem interesting for the introduction section, but does not explain the reason why you are performing the study. I suggest to re-write te background, and also CLEARLY state that the objective of the present study is to investigate the above-mentioned delay BEFORE and AFTER the COVID-19 outbreak.

3. Please adhere to Plos One guidelines in terms of tables and figures. Delete colors from columns and rows, and explain abbreviations used. Please erase final markup inside table's text (see table 2)

4. P value in table 2 refers to...?? There several variables compared among themselves, and only a P value, and I cannot see the correspondance of it; also, if you are intending to show association among both periods, I think that you should add p values comparing each one of the variables

5. Table 4: I feel that the last column is irrelevant; you could add a superscript explaining the statistical analysis you used. Admission NIHSS result in this table seems odd; I can't understand what you are intending to prove if the comparison is Onset-to-door time and NIHSS... If you are proving that higher of lower NIHSS could increase the delay in terms of consultation, this analysis should be better in a scatter plot, outside this table; if you intend to analyze NIHSS as categories, you should explain since the Methods section, how you manage this variable; as the correlation was negative, I see irrelevant to add this information in a table or a figure.

6. I don't understand the reason why the questionnaire was generated as a figure; It's a table, and this could be sent as a normal Word format document. 

Please submit your revised manuscript by Jul 01 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're 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.

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• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
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• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Miguel A. Barboza, MD, MSc

Academic Editor

PLOS ONE

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Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Pre-hospital causes for delayed arrival in acute ischemic stroke before and during the COVID-19 pandemic: A study at two stroke centers in Egypt

PONE-D-21-03769R2

Dear Dr. Shokri,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Miguel A. Barboza, MD, MSc

Academic Editor

PLOS ONE

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