PONE-D-21-11324

Computerized History-Taking Improves Data Quality for Clinical Decision-Making. Comparison of EHR and Computer-Acquired History Data in Patients with Chest Pain.

PLOS ONE

Dear Dr. Zakim,

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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Academic Editor

PLOS ONE

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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: Partly

Reviewer #2: No

Reviewer #3: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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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: No

Reviewer #3: Yes

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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

Reviewer #3: Yes

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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: The authors conducted a prospective observational study where they compared the data collected by physicians during an ED encounter for chest pain vs the data collected by a computerized history taking software. They enrolled 410 patients and concluded that computerized data was more complete and more representative of patient perceptions. They also suggest that computer generated histories will be more beneficial for aggregated data bases to be used in research. The authors continue to mention that physician histories are inaccurate and incomplete to an extent that clinical outcomes and patient care are effected by this. However, they present no data here to suggest that this is the case. Overall, the manuscript is well written. However, there are issues with broad overarching conclusions based off of likely clinically irrelevant differences between CHT and EMR data. This study is very relevant to EMR based population studies and shows how CHT can significantly increase the value of research using this methodology. If the language and conclusions are paired down to only include what was evaluated within this study, then this manuscript should be re-considered.

Points

1. In methods, need to describe the clinical setting and selection criteria rather than referencing previous work without any description.

2. Need to include the explicit question of pain that was shown in CHT. Looking at figure 1 this is quite different then what is described in the body of your paper.

3. Multiple mentions of improving patient outcomes. Authors seem to suggest that CHT, given more available data, will lead to better patient care. However, there is no room for these conclusions to be made from this paper. They have no data on accuracy of diagnosis, patient outcomes, or patient satisfaction. Therefore it seems premature to make any comment on CHT improving patient care.

4. Further analysis of the data from the 20 interrupted CHT sessions should be examined for level of agreement between EMR and CHT. It would be interesting to see if after talking to a physician there was more agreement between the 2 history taking methods. It is possible that the physician could clarify points that the CHT was unable too leading to differences in CHT answers after interview.

5. If you are going to excluded data from 2 patients who appeared to make deliberately false entries during CHT, this data should be made available to the reader so that they can understand your conclusion.

6. The description of how patient’s selected CP location that is currently in the results section and should be moved into methods. Additionally, the description currently seems overly complicated and verbose.

7. A major sticking point of the authors is specific location of chest pain. They note that EHR data was documented as left, right, or central but rarely specified upper or lower. The main issue I take here with calling this “incomplete” EHR data is that when given more options to specify upper or lower, the patient likely will, as we see with the CHT data. However, the clinical relevance to such specificity is likely little to none. Looking at figure 2 the CHT system of location classification is extremely over complicated from a clinical perspective. I would recommend re-evaluating your data based on more reasonable expectations from a clinical standpoint. Consider dividing the locations into L and R anterior chest, L and R arm, and back. 15 locations to describe chest/torso pain would never be something reasonable or clinically relevant to document from a physicians perspective. Another option would to be rather than comparing a clinically meaningless variable to a clinical one (EHR hx), just present how much more granular data given in CHT can be. In this way you could make the argument that this level of granularity may at some point show clinical relevance and therefore must be studied. Currently I do not know of any literature that would suggest this level of granularity is of any clinical value.

8. This theme is repeated in the discussion regarding pain radiation to the arm. Authors note that EHR indicated isolated radiation to the arm, while CHT indicated arm + shoulder. This information again seems clinically irrelevant and likely highlights the point that CHT was collecting unnecessary data that would have slowed down physician history taking. Additionally, even if mentioned by the patient, this likely something that would have been documented in a truncated fashion by the physician in order to save time during EMR note composition. If the goal was to demonstrate fallibility of the EMR physician history, they you would need to specifically analyze what was said by the patient and then what was documented by the physician. In clinical encounters it is not uncommon to exclude portions of the history that you feel are irrelevant or combine portions during authoring of your HPI in order to save time.

9. Authors note that CLEOS was programmed to ask about radiation only when patient had anterior chest pain therefore 6 patient’s did not have radiation data in this group. This concept perfectly illustrates the issue with concluding that CHT is more complete and beneficial to patient care than physician history taking. Many experienced clinicians have the same “programming” when it comes to history taking and only include or exclude questions based on overall gestalt and patient complaint. When presented with a limited amount of time for history taking the physician must rely on their ability to expand or contract their history taking in order to ask the most relevant and pertinent questions.

10. Sup Figure 1 and Figure 3 are very complicated and difficult to understand easily. Since this is a key component of your argument would recommend rethinking this figure.

11. Figures from CHT are poor resolution making them difficult to read.

12. Overall, the strongest point of this paper is that EHR data is likely inadequate for any population-based studies and that CHT could improve this process. It is overreaching and likely inaccurate that CHT improves any sort of patient outcomes or that physician history taking is deficient. There is certainly no data within this manuscript to suggest that CHT may have lead to any improvement in quality of patient care.

Typos: Page 5 “The problem was corrected during the course of this stud.”

Reviewer #2: The authors have developed a tool for patients to use to enter their clinical history electronically, when they attend an emergency department with chest pain. They have tested this by enrolling patients at a single site, university hospital in Sweden, who attended their ED with chest pain, who didn't have a diagnostic first ECG on arrival. Patients were asked to enter clinical data into the tool, which was compared to the medical notes made by their attending physician after they had seen the patient. They enrolled a convenience sample of 410 patients. They then compared the patient authored data to the physician medical notes in the Electronic Health Record. They conclude that there is a lot of variation between the patient and physician notes, then state that their tool is better than the physician evaluation of the patient.

Major issues:

The manuscript has multiple major issues. Some are domain issues, others relate to the write-up.

1. The structure of the manuscript - I strongly suggest that the authors review the appropriate equator guideline and rewrite their manuscript accordingly. This is a comparative observational study, so STROBE would be appropriate. If this is done, the authors will realise that multiple mandatory areas of information are absent from each section. They should end with re-writing the abstract into a structured format. Given that there is machine learning involved in the development of the tool, the authors should also consider reporting elements of the TRIPOD guidelines.

2. There seems to be a major misunderstanding by the author group about the role of medical notes. This has made their work fundamentally flawed, despite the valid work that has gone into their research. Medical notes are not a verbatim record of what the patient said, nor are they usually intended to be a complete record - physicians don't have time and would record medical interviews if this was required. Medical notes are a synthesis or interpretation of information provided from various sources, aiming at being concise and useful in explaining ongoing medical decision making. Physicians deliberately exclude some history features from their notes, when the patient thinks they have a symptom, but when clarified, the symptom is different to the one sought by the physician - for example pleuritic chest pain. Comparing patient reported symptoms to a medical note is not a reasonable comparison. Whilst it is very possible that physicians have missed important aspects of the history during their consultations, this hasn't been proven by this research.

The authors might be better off asking a different research question: If the physician is presented with the patient reported information to read prior to/during/after the consultation, does this change the medical management or decision making or differential diagnosis at all? It is possible that it does change management and that physicians don't always ask enough detail about patient symptoms, but this hasn't been investigated so far and would be much more important to physicians.

3. The length of the manuscript and the discussion is overwhelming. A more concise version may be better received by readers. In contrast, the limitations section is too short, seemingly failing to understand the limitations of the study.

4. If readers are to understand the research, some illustrative examples should be provided of the typical outputs obtained by the tool, compared to the medical notes.

Suggested write up improvements:

Abstract: Many important details are missing from the abstract. This includes a description of the aims, population, setting, intervention (and that you developed it and own the patent), demographics of participants, methods of comparison, and so on. You seem to have simply written up your conclusions. You have no evidence that your tool outperformed clinicians, simply that the data you compared were different.

Introduction: A well structured, medical manuscript introduction should be about 4 paragraphs, broken up into the initial description of the problem and its magnitude; what is currently known; what is the gap in the literature and why does it matter and then a short goals of the investigation section.

Methods:

Each section needs improvement (or creation). It is not enough to state that you have published a study protocol, and not to describe your setting and population. Readers shouldn't have to look up another study for such basic information. You need a statistical plan - sample size calculation, statistical methods etc. Please refer to the equator guidelines +/- TRIPOD for more information

Results:

This should start with a flow diagram or statement, beginning with how many patients attended your ED with chest problem (either at triage or as a discharge diagnosis), how many patients were screened, how many were excluded and why, how many were enrolled, how many complete datasets (per participant) you obtained, how many were analysed, how many weren't and why etc. (see CONSORT guidelines for examples)

Next you require a section on your participant demographics, compared to those you didn't enrol.

Finally the main results should be presented. I would move much of your description to an appendix, the length is overwhelming to read. I would suggest that the narrative text that remains is more concise and less judgemental - present that something was present or absent from one set of notes or another. You have some odd groupings to your section sub-headings. Why for example is there a heading about both sweating and pleuritic pain, this should be broken up as the symptoms are completely unrelated clinically.

Discussion

Much of the discussion reads as though there is a perception that the patient notes are better (more accurate) and more useful. At best the authors can state that the data was different. Heuristics are extremely important in clinical medicine, to effectively write this off is deeply flawed. The medical evaluation and the medical notes are intended to be a synthesis and the way the manuscript is written seems to have completely misunderstood this point.

Much of the discussion is giving unproven opinions. I would suggest that as this manuscript is intended for a medical audience (I assume) that the structure is 1. a short summary of important results 2. A comparison to previous literature (does it confirm or refute previous work) 3. external generalisability (or lack of same) 4. limitations and future work

It would be important to discuss multiple limitations to this work in the discussion. One very important point is that patients rarely present to the ED with differentiated, well defined symptoms - such as chest pain. Many patients, even those with chest pain, wouldn't have only chest pain. To only obtain a history regarding their chest symptoms, would be a mistake that will lead to medical errors.

Reviewer #3: The manuscipt addresses an important question in this era of computerized medicine - does the traditional EHR record compare favorably to a patient-entered computerized history taking program. However the manuscript in the current form has several critical issues that must be addressed in order to be publishable.

Abstract:

The abstract has no background or context for the study. It dives right into methods. What do we know about computerized history taking? Why is it important to compare computerized history taking to the standard EHR history? What were the primary and secondary aims of the study?

Introduction:

This needs some major editing. There are many unclear statements such as: "Moreover, objective data cannot yet supplant medical history data". The introduction includes results and interpretation which are inappropriate for this part of the manuscript. This needs to be restructured: what is the background, what is unknown about the problem, what knowledge holes are you hoping to fill in, what are your primary and secondary aims?

Materials and Methods:

Also needs major edits. Clinical setting, selection criteria, and recruitment need to be spelled out here, not listed in a separte document. There needs to be an explanation of how the EHR history was taken by the physician and entered into the computer as well. There needs to be a discussion of the statistical analysis. Finally, the last sentence (Four patients did not...) should be in the results section.

Results:

This is far too long. Please summarize the major findings and point to the specifics in your tables. Also, the tables need improvement. What are the Ns for each grouping? Are the congruences reported statistically significant? Also there is occasionally author interpretation in these results which should be in the discussion

Discussion:

This discussion veers way off topic and needs improvement. This isn't a review article about the challenges of history taking. This is a study comparing EHR vs computerized history taking and the discussion should reflect that. How do these findings fit in with what is known? What remains to be discovered? Is this clinically relevent? Maybe physicians obtain what they need to in order to make the correct diagnosis and the rest is not needed. Maybe the physicians do ask the questions but don't waste their time on entering it into the EHR. The statement "It is fair to argue that history-taking by physicians has become an inefficient use of the physician's time with the patient" is not supported - what about building rapport? What about the nuance that comes from non-verbal or non-written conversation?

Finally:

There are multiple spelling and typographical errors that need to be addressed.

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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

Reviewer #3: 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.]

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PONE-D-21-11324R1

Computerized History-Taking Improves Data Quality for Clinical Decision-Making. Comparison of EHR and Computer-Acquired History Data in Patients with Chest Pain.

PLOS ONE

Dear Dr. Zakim,

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.

Thank you for reviewing and responding to the reviewer concerns. However, additional modifications are needed. Please note reviewer comments. Id advise you to pay special attention to common themes among reviewers as this usually signifies an area of opportunity. Particularly, the results section needs to be pared down to be more organized and sensible. Some data may be better displayed in tables - I strongly recommend moving some data to supplementary or supporting tables/figures. I hope you will consider the comments and make adjustments accordingly. 

Please submit your revised manuscript by Aug 08 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.

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). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• 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,

Amit Bahl

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: (No Response)

Reviewer #3: (No Response)

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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: No

Reviewer #3: Partly

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: I Don't Know

Reviewer #3: No

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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: (No Response)

Reviewer #3: Yes

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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: (No Response)

Reviewer #3: No

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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: In my first review of this paper the main issue I took was with a broad over-reaching conclusion based off of likely clinically irrelevant differences between CHT and EMR data. The authors have pared down their claims to a level that fits within the scope of their paper. However there are still several mentions such as in the abstract, “CHT out-performed history taking by physicians” yet there is still no clinically relevant indication of this. While I understand the authors opinion that CHT was created by experts and is likely a better representation of an accurate chest pain history, there is no indication that clinical outcomes are at all effected by this. The authors should carefully re-read their manuscript to eliminate any indication that CHT outperforms EMR history in any manor that would improve clinical outcomes.

Overall, this version of the manuscript is much stronger. I think that while adding some relevant findings, the results section remains too long and verbose. Much of the “results” section should be moved to discussion instead.

Reviewer #2: (No Response)

Reviewer #3: The study authors have made several edits relating to the concerns from the first submission, however the manuscript as it requires further editing or rewriting to be at an acceptable level for publication.

Abstract – lacks objective (statistical) data to support its conclusions

Introduction – authors should remove their conclusions from the introduction – specifically “Our data shows that CHT records contain more complete and more accurate representations of patients' perceptions of their symptoms than patients' corresponding EHRs.” Please refer to the STROBE checklist if there is confusion on this point.

Methods – Gender and age data should be reported in the results section. Authors need to include a description of their statistical methods.

Results – The data on location of primary pain, location of radiated pain, setting of pain onset, and frequency/duration of pain, and data for associated symptoms, use of nitroglycerin, and dimensionality is very difficult to interpret. The descriptions are very long and would be best presented in table format, with limited narrative. Also, many values are reported as integers, where percentages would be better used. Finally, only raw data is presented; testing for statistical significance in the different outcomes between the EHR and CHT data sets would greatly strengthen the results.

Discussion - The authors should situate their findings in the context of prior research comparing EHRs and CHTs (ie. this is the first study, or consistent with prior studies, or contrary to prior studies) .

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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

Reviewer #3: 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.]

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 PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Computerized History-Taking Improves Data Quality for Clinical Decision-Making. Comparison of EHR and Computer-Acquired History Data in Patients with Chest Pain.

PONE-D-21-11324R2

Dear Dr. Zakim,

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.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. 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 help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- 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.

Kind regards,

Amit Bahl

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

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 #3: All comments have been addressed

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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 #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: Yes

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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 #3: Yes

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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 #3: Yes

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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: (No Response)

Reviewer #3: The authors have satisfactorily addressed the issues I highlighted in the last review of the manuscript. I thank them for this interesting and important study.

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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.

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Reviewer #1: No

Reviewer #3: No