Diaphragm thickness and mobility elicited by two different modalities of inspiratory muscle loading in heart failure participants: A randomized crossover study

Tatiana Zacarias Rondinel; Lilian Bocchi; Gerson Cipriano Júnior; Gaspar Rogério da Silva Chiappa; Gabriela de Sousa Martins; Sérgio Ricardo Menezes Mateus; Lawrence Patrick Cahalin; Graziella França Bernardelli Cipriano

doi:10.1371/journal.pone.0302735

Peer Review History

Original SubmissionAugust 3, 2023
3 Sep 2023 Decision Letter - Yoshihiro Fukumoto, Editor PONE-D-23-21191Diaphragm thickness and mobility elicited by two different modalities of inspiratory muscle loading in heart failure participants: a randomized crossover studyPLOS ONE Dear Dr. Zacarias Rondinel, 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 submit your revised manuscript by Oct 18 2023 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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Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: I Don't Know ****** 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: No 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: This study reports the relationships among diaphragmatic thickness, at end-inspiration and end-expiration, diaphragmatic thickening index and mobility via US under two different modalities of inspiratory muscle loading, in two different modalities of inspiratory muscle loading and different load intensities at full-vital capacity maneuvers and the relationship between diaphragmatic thickness with pulmonary function tests in participants with HF. Interesting study but I have several comments to the authors. 1. Could the authors provide a schema how they measure diaphragm thickness (Tdi, mm), fractional thickness (TFdi, %), and mobility by US that would be helpful to the readers who are not familiar with this topic. 2. Does the authors have data on the relationships among cardiac parameters (e.g. cardiac-echo parameters), physical activity (e.g. 6MWD and peak VO2) and Tdi, TFdi and mobility? 3. What is clinical implications? Could the authors provide clinical implications section in discussion? Reviewer #2: The authors reported an ultrasonographic evaluation of the effects of two types of inspiratory muscle training on the diaphragm in HFpEF patients with normal pulmonary function. Minor comments 1. Specify whether the patients had any prior history that would affect diaphragm function, e.g., after open heart surgery or cardiac ablation etc. 2. Page13, Line 286-288: Specify what functional impairment it is. This reviewer cannot determine from the context whether the functional impairment is heart failure or diaphragm. 3. This reviewer feel that the superiority of ultrasonographic assessment of the diaphragm in patients with heart failure compared to respiratory function tests and CPX should be added. ****** 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.] 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. 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Revision 1
23 Dec 2023 Author Response Reviewer #1: C1: This study reports the relationships among diaphragmatic thickness, at end-inspiration and end-expiration, diaphragmatic thickening index and mobility via US under two different modalities of inspiratory muscle loading, in two different modalities of inspiratory muscle loading and different load intensities at full-vital capacity maneuvers and the relationship between diaphragmatic thickness with pulmonary function tests in participants with HF. Interesting study but I have several comments to the authors. A1. We appreciate your effort in reviewing our manuscript, and we also thank you for making the below comments and suggestions. C2. Could the authors provide a schema how they measure diaphragm thickness (Tdi, mm), fractional thickness (TFdi, %), and mobility by US that would be helpful to the readers who are not familiar with this topic. A2: We appreciate your comment. We have incorporated additional information in "Fig. 2. Diaphragmatic Assessment through Ultrasonography," detailing the Ultrasonography assessment, including thickness (Tdi, mm), fractional thickness (TFdi, %), and mobility (Lines 159-166, page 07). Additionally, we have inserted a reference (Line 171, page 07). Number 31: Yamaguti WP, Paulin E, Shibao S, Kodaira S, Chammas MC, Carvalho CR. Ultrasound evaluation of diaphragmatic mobility in different postures in healthy subjects. J Bras Pneumol. 2007 Jul-Aug;33(4):407-13. English, Portuguese. doi: 10.1590/s1806-37132007000400009. C3. Does the authors have data on the relationships among cardiac parameters (e.g. cardiac-echo parameters), physical activity (e.g. 6MWD and peak VO2) and Tdi, TFdi and mobility? A3. We thank you for its valuable comment; in fact, we had already analyzed these correlations. We did not find any differences when correlating LVEF (%), VO2 peak and VO2 max with TFdi, Tdi and Mobility. These correlations are shown below. Table. Correlation between cardiac US parameters and physical activity and TFdi (%), Tdi and Mobility. TFdi (%) Tdi (mm) Mobility (mm) r p r p r p LVEF (%) -0.17 0.495 0.18 0.484 -0.23 0.361 VO2peak 0.24 0.349 -0.04 0.851 -0.41 0.097 VO2máx 0.04 0.859 0.34 0.173 -0.23 0.356 TFdi, Fractional thickness of the diaphragm; Tdi, diaphragm thickness; LVEF, left ventricular eject fraction; VO2, oxygen uptake. Spearman’s correlation. C4. What is clinical implications? Could the authors provide clinical implications section in discussion? A4. Thank you for the suggestion for the clinical implications. As suggested, we addition of the information in discussion. Lines 348-355, pages 15 and 16. Reviewer #2: C5: The authors reported an ultrasonographic evaluation of the effects of two types of inspiratory muscle training on the diaphragm in HFpEF patients with normal pulmonary function. A5. We appreciate your effort in reviewing our manuscript, and we also thank you for making the below comments and suggestions. Minor comments C6. Specify whether the patients had any prior history that would affect diaphragm function, e.g., after open heart surgery or cardiac ablation etc. A6. Thank you for your question . The patients enrolled in the study did not undergo open-heart surgery or cardiac ablation procedures, which could potentially affect diaphragmatic function. Fifteen participants were excluded based on the exclusion criteria: smoking (n=4), infections disease (n=3) and angina (n=3) and being uninterested in participating in the study (n=5) (Fig.1). C7. Page13, Line 286-288: Specify what functional impairment it is. This reviewer cannot determine from the context whether the functional impairment is heart failure or diaphragm. A7. We appreciate your suggestion. We have revised the phrase to specify the functional impairment (at Line 300, page 14). C8. This reviewer feel that the superiority of ultrasonographic assessment of the diaphragm in patients with heart failure compared to respiratory function tests and CPX should be added. A8. We thank you for comment. We believe that diaphragmatic ultrasound emerges as a complementary technique for assessing the mass, contraction, and function of the diaphragm in individuals with heart failure. We have included additional information about US assessment in the text. (Lines 339- 345, page 15). Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0302735.r002
22 Jan 2024 Decision Letter - Yoshihiro Fukumoto, Editor PONE-D-23-21191R1Diaphragm thickness and mobility elicited by two different modalities of inspiratory muscle loading in heart failure participants: a randomized crossover studyPLOS ONE Dear Dr. Zacarias Rondinel, 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 submit your revised manuscript by Mar 07 2024 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. 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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. [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 Reviewer #3: (No Response) ******** 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 Reviewer #3: Partly ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: I Don't Know Reviewer #3: No ****** 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 Reviewer #3: 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 Reviewer #3: 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: (No Response) Reviewer #2: The authors' response is appropriate but not described in the manuscript. The authors should add the following text to the Results. The patients enrolled in the study did not undergo open-heart surgery or cardiac ablation procedures, which could potentially affect diaphragmatic function. Reviewer #3: I have some comments on the statistical methods employed. Bearing in mind that correlation does not imply causation (and I feel that this should be clearly stated in the manuscript), please provide evidence that all the assumptions underlying the employed parametric tests are met. The authors state that they checked for the Gaussianity of the data distributions, but no evidence was provided. From the figures showing the correlations across variables, the risk of interpreting it as causation is clear. Please, remove the straight lines from the graphs. Moreover, at first look, heteroscedasticity may arise. Accordingly, as supplementary material, please show that: - the data follow a Gaussian distribution; - there is homoscedasticity; – outliers are not present, they can significantly skew the correlation coefficient and make it inaccurate. All these are fundamental to avoid misleading inference, as the sample size is rather tiny. The ANOVA might not be the most suited method for the data at hand. Due to the clear difference between the baseline values and the others, it is not surprising that the p-value is less than .05 (given that the underlying assumptions are met). I strongly suggest to consider regression modelling, with univariable analyses first and with interactions then, to better appreciate between groups differences. Of course, the Gauss-Markov assumptions should be checked as well. ****** 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. https://doi.org/10.1371/journal.pone.0302735.r003
Revision 2
22 Mar 2024 Author Response 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 #2: The authors' response is appropriate but not described in the manuscript. The authors should add the following text to the Results. The patients enrolled in the study did not undergo open-heart surgery or cardiac ablation procedures, which could potentially affect diaphragmatic function. A: Thank you for the comment. As suggested, we added the sentence “The patients enrolled in the study did not undergo open-heart surgery or cardiac ablation procedures, which could potentially affect diaphragmatic function” at section Results, page 9, line 221-223. Reviewer #3: I have some comments on the statistical methods employed. Bearing in mind that correlation does not imply causation (and I feel that this should be clearly stated in the manuscript), please provide evidence that all the assumptions underlying the employed parametric tests are met. The authors state that they checked for the Gaussianity of the data distributions, but no evidence was provided. A: Thank you for the observation. We added, as suggested, the sentence “and assuming that correlation does not imply causation,” at section Results, page 13, line 276-277. Regarding data distributions of this data, we provided below a table with normality test (Shapiro-Wilk). Also, we elaborated a Supplementary Material with normality test represented as Figure and Table. Shapiro-Wilk test Tdi Rest MIP FVC S-Index MEP W 0,9789 0,9141 0,9174 0,9614 0,9434 P value 0,9464 0,1176 0,1336 0,6571 0,3608 Passed normality test (alpha=0.05)? Yes Yes Yes Yes Yes P value summary ns ns ns ns ns From the figures showing the correlations across variables, the risk of interpreting it as causation is clear. Please, remove the straight lines from the graphs. Moreover, at first look, heteroscedasticity may arise. A: As suggested, we removed straight lines from correlations graphs in Figure 3. Accordingly, as supplementary material, please show that: - the data follow a Gaussian distribution; - there is homoscedasticity; – outliers are not present, they can significantly skew the correlation coefficient and make it inaccurate. A: As suggested, we build a Supplementary Material, that shows the normal distribution of data and the absence of outliers, demonstrated at Tabel 1 e Figure 1. Since the analysis was revised considering the Paired Student t test for pairwise comparisons (see the question below), it is no longer necessary to check for equality of variances. All these are fundamental to avoid misleading inference, as the sample size is rather tiny. The ANOVA might not be the most suited method for the data at hand. Due to the clear difference between the baseline values and the others, it is not surprising that the p-value is less than .05 (given that the underlying assumptions are met). I strongly suggest to consider regression modelling, with univariable analyses first and with interactions then, to better appreciate between groups differences. Of course, the Gauss-Markov assumptions should be checked as well. A: Thank you for your comment and, in fact, ANOVA is not the best test for this analysis, as the data are paired. In this context, the analysis was revised considering the Paired Student t test with Bonferroni correction for multiple tests (added at Statistical Analysis section, page 9, line 204-205). A total of 8 pairwise comparisons were performed: 1. Baseline vs MTL-low; 2. Baseline vs MTL-high; 3. Baseline vs TFRL-low; 4. Baseline vs TRFL-high; 5. MTL-low vs MTL-high; 6. TFRL-low vs TFRL-high; 7. MTL-low vs TFRL-low; 8. MTL-high- vs TFRL-high. As a new statistical test was applied, we rewrite the pharagrafh at Diaphragm thickness, diaphragm thickening fraction and mobility section at Results, page 11, lines 243-248. Changes at Table 2 were added at Results section, line 257, page 12. Also, this information of statistical tests was added at Table’s legend, at line 260, page 12. Also, according to the analysis, we adjust the text at Discussion and Conclusion section. Furthermore, due to the paired observations, a regression analysis is also not suitable, since the same individual participates in both groups and to different intensities. Regarding the question of normality, the Shapiro-Wilk test did not reject the normality of the data. https://doi.org/10.1371/journal.pone.0302735.r004
11 Apr 2024 Decision Letter - Yoshihiro Fukumoto, Editor Diaphragm thickness and mobility elicited by two different modalities of inspiratory muscle loading in heart failure participants: a randomized crossover study PONE-D-23-21191R2 Dear Dr. Zacarias Rondinel, 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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, 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, Yoshihiro Fukumoto 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 #3: 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 #3: (No Response) ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #3: (No Response) ****** 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 #3: (No Response) ****** 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 #3: (No Response) ****** 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 #3: (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 #3: No ******** https://doi.org/10.1371/journal.pone.0302735.r005
Formally Accepted
7 May 2024 Acceptance Letter - Yoshihiro Fukumoto, Editor PONE-D-23-21191R2 PLOS ONE Dear Dr. Zacarias Rondinel, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, 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. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Yoshihiro Fukumoto Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0302735.r006

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