PONE-D-22-26894Poisoning Cases and Their Management in Amhara Region, Ethiopia: Hospital Based Prospective StudyPLOS ONE

Dear Dr. Asrie,

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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We look forward to receiving your revised manuscript.

Kind regards,

Senthil Kumaran, MBBS, MD, DNB

Academic Editor

PLOS ONE

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Additional Editor Comments:

The paper can be accepted if only following queries by the reviewers is done accordingly.

Reviewer 1:

1. This manuscript requires spelling corrections and grammatical corrections.

2. The spelling mistakes and the few of the required grammatical corrections are commented and highlighted in the attached manuscript itself.

Reviewer 2:

1. Percentage would be rounded off to the first decimal place.

2. What is “DDT”? “DDT” should be spelled fully on the first mention.

3. How many patients were intubated or ventilated mechanically? The description about intubation and mechanical intubation would be helpful.

4. What was the indication of gastric lavage in this study?

5. What was the indication of frusemide and vitamin B complex?

6. Were there admission cases to the hospital without IV fluid in this study?

7. What kind of laboratory tests in poisoning test do you have in this study? CBC, ECG, or blood toxicant concentration? What was the indication of laboratory test in poisoning cases?

8. Authors stated that the distance from the place of poisoning to hospital (10-20 and >40km) was associated with treatment outcome. Why was not associated with 20-30 or 30-40km? The discussion about that differences would be helpful.

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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: Yes

Reviewer #2: Yes

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

Reviewer #1: N/A

Reviewer #2: Yes

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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: 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: No

Reviewer #2: No

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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: This manuscript requires spelling corrections and grammatical corrections. The spelling mistakes and the few of the required grammatical corrections are commented and highlighted in the attached manuscript itself. Authors may relook at entire manuscript for spelling mistakes and grammatical corrections.

Reviewer #2: Thank you for giving the opportunities to review this manuscript.

Authors reviewed the 442 poisoning cases for two years in Ethiopia. The majority of causes were organophosphate and metal phosphides. Older ages, impaired consciousness on arrival, distance from the institution, and no laboratory test were found to be associated with the mortality or poor outcome. This study had important observations, but please addresses all my concerns below for a potentially better paper:

1. Percentage would be rounded off to the first decimal place.

2. Causes of poisoning (P9)

What is “DDT”? “DDT” should be spelled fully on the first mention.

3. How many patients were intubated or ventilated mechanically? The description about intubation and mechanical intubation would be helpful.

4. What was the indication of gastric lavage in this study?

5. What was the indication of frusemide and vitamin B complex?

6. Were there admission cases to the hospital without IV fluid in this study?

7. What kind of laboratory tests in poisoning test do you have in this study? CBC, ECG, or blood toxicant concentration? What was the indication of laboratory test in poisoning cases?

8. Authors stated that the distance from the place of poisoning to hospital (10-20 and >40km) was associated with treatment outcome. Why was not associated with 20-30 or 30-40km? The discussion about that differences would be helpful.

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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

**********

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Attachments

Attachment

Submitted filename: PONE-D-22-26894.pdf

PONE-D-22-26894R1Poisoning Cases and Their Management in Amhara Region, Ethiopia: Hospital Based Prospective StudyPLOS ONE

Dear Dr. Asrie,

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.

Unfortunately the two reviewers from the first round were not available to reassess your manuscript, so we have sought input from an additional reviewer whose report can be found below. As you will see from the comments, there remain significant concerns relating to the framing of the study within the body of existing literature and the reporting of the methodology which must be addressed before your manuscript is suitable for publication.

Please submit your revised manuscript by Apr 15 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.

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: https://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,

Dr Joseph Donlan

Senior Editor

PLOS ONE

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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: (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 #3: Partly

**********

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

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 #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 #3: No

**********

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: The article still has residual errors in grammar, I would suggest the authors use Grammarly or tools within their word processor.

Poisoning in emerging countries is a significant problem. It seems to me that his article needs to be clear upon its focus. It is long and information is repeated especially in the results section

It is important to describe the nature poisons being seen which this article does well. What is lacking is clearer description of the clinical setting such as rates of inter hospital transfer, antidote supply, health staff training and resources for advanced supportive care. This provides a context for the treatment and the results being provided. Given the breadth of significant toxicity I found the discussion of treatment rationale to be a bit superficial and in places outside established guidelines for treatment in these settings. Your article may describe the treatment your patients received but it is not an article about how to treat poisoned patients

Specific comments

Abstract

Poisoning is a significant public health problem globally and cases are being increased from time to time. As the advances in technological and social developments have led to ease accessibility of most drugs and chemical substances in the society, the number of incidences of poisoning can be higher. Ethiopia is one of the low-income countries that share its considerable burden of poisoning incidences and deaths.

Suggest

Poisoning is a significant public health problem globally. Ethiopia is a low-income country undergoing technological and social change that may increase access to drugs and chemicals potentially increasing the incidence of poisoning. This study describes the epidemiology of hospital admissions due to poisoning in a region of Ethiopia

Methods: Include a time period eg 2 years

Results

Some reorganisation of the order of the text would be useful and shortening as much of this is repeating the main results section

Eg

There were ZZZ cases with XX deaths. Almost all poisoning cases were intentional self- poisonings The most frequent poisonings were Organophosphate compounds, 145 (32.8%), and metal phosphides (majorly aluminum phosphide), 115 (26.0%). The ingested poison was most frequently accessed from the patients home,243 (55.0%), followed by purchase from local shops, 159 (36%)

The median duration of admission was XX. YY% required ventilation, the most poisoned case requiring ventilation was (insert compound) 43/78 deaths were due to aluminium phosphide

From the multivariate logistic regression analysis, age, altered level of consciousness on hospital arrival, distance from the area where the poisoning incidence happened to the hospital they attended, and no laboratory result as a part of the diagnosis process or investigation of the extent of toxicity were found to be significantly associated with the likelihood of poor treatment outcome or death.

Main Article

Background

I think this could be shortened, the first two paragraphs don’t add much to the background

The paragraph

“Poisoning is a common cause for emergency visit and hospital admission worldwide and a major reason for illness and death in many countries (3). The incidence of poisoning could be intentional or unintentional, and in children, because of the desire for imitating adults, the unintentional or accidental poisoning is frequent among them (4).”

Comment: most hospital admissions for poisoning are intentional and in the context of deliberate self harm. The second sentence regarding children is not supported by the reference nor is it correct that the motivation is a “desire for imitating adults”. In very young children accidental poisoning is common but in ages greater than 12 years it is commonly deliberate self harm with a wide range of precipitating factors including domestic violence, sexual assault, relationship difficulties etc I think this sentace is probably not required

Consider

“Intentional self-poisoning is a common cause for emergency visit and hospital admission worldwide and a major reason for illness and death in many countries (3).” And join this with the subsequent paragraph starting poisoning from pesticides

Methods

Please clarify are these 4 referral hospitals the only referral hospitals in the region? What population size do they serve? Are there specific transfer criteria from smaller hospitals for example are all poisoning cases transferred or only severe ones…..if it is the later then that referal bias needs to be discussed later

Results

Most of the result data sits in the tables, you should not repeat those results in the text rather you can provide a shorter overview of the table. In the discussion section you have an opportunity to bring the various themes together

Socio-demographic

This is well described in the table, your text is really just repeating the information in the table. So try rephrasing the text into a succinct overview of the table. Eg the majority of the patients were under 40 years of age, female, Christian of Amhara ethnicity see table 1

Distance and time of arrival to hospital

Please clarify is the primary hospital that they have presented to (ie not the referal hospital)

What percentage were direct admissions to the referral hospital versus transfer…this may have impact on outcomes as well as data interpretation

(see: Senarathna L, Buckley NA, Jayamanna SF, Kelly PJ, Dibley MJ, Dawson AH. Validity of referral hospitals for the toxicovigilance of acute poisoning in Sri Lanka. Bulletin of the World Health Organization. 2012;90:436-43a.)

Signs and symptoms

I am not sure what this section adds. The signs and symptoms will often depend upon the poisoning….the frequency of signs and symptoms with various poisons is well described in the literature. It may be more useful to characterise the patients using a poison severity score , or perhaps need for ventilation

Persson HE, Sjöberg GK, Haines JA, de Garbino JP. Poisoning severity score. Grading of acute poisoning. Journal of Toxicology: Clinical Toxicology. 1998 Jan 1;36(3):205-13.

Davies JO, Eddleston M, Buckley NA. Predicting outcome in acute organophosphorus poisoning with a poison severity score or the Glasgow coma scale. QJM: An International Journal of Medicine. 2008 May 1;101(5):371-9.

Types of poisoning

The text here is also just duplicating the table. I would suggest a summary statement.

In the table you could potentially add the deaths attributed to each poisoning ie the data that is in table 8

Dosage form of the poisons encountered and the routes of exposure

Reasons for poisoning incidents

Again the text is just duplicating the tables in these sections

Treatment

Probably the most important area of treatment is the need for advanced supportive care such as ventilation. Such treatment has important resource implications. Move the section from the discussion to the results

You mention gastric lavage but there is no mention of activated charcoal as part of the decontamination.

The subsequent list of treatment would be more informative if it focused upon recognised antidotal treatment eg atropine and perhaps calcium and magnesium. The rest of the drugs mentioned to not seem to specifically relate to poisoning

Duration of hospital stay

Time is a continuous variable, it is not clear to me why you have moved into a categorical variable, if you have the original data it may worth while in analysing it as continuous data especially for death

In the predictor of death analysis I think you should include the major poison groups, clinically it is likely that coma is driven by with organophophate or aluminium phosphide toxicity. Type of poisoning may be significant for the distance from primary hospital which would be a surrogate for delay to treatment. An adjusted analysis may help explain this

Discussion

In the discussion you need to discuss the potential referal bias as a potential limitation.

In treatment it would be useful to have some discussion about supply of medications, do you have shortages, how does your antidote stock compare with say WHO essential antidote list. What training do your medical staff have specifically for treatment of poisoning. I think it would be more useful to focus upon these bigger general questions than the discussion of individual drugs. Especially as many of the drugs you are suggesting to have a role in poisoning treatment are not mainstream and don’t feature in evidence based guidelines.

Within the discussion you mention activated charcoal but this doesn’t appear to have been used in your patients

The need for intubation and ventilation should move into the results

Referencing

Many of your references are old and have been superceded by bigger studies or systematic reviews….this is particularly the case with treatment

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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 #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.

PONE-D-22-26894R2Poisoning Cases and Their Management in Amhara Region, Ethiopia: Hospital Based Prospective StudyPLOS ONE

Dear Dr. Asrie,

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 Dec 29 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.

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: https://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,

Jianhong Zhou

Staff Editor

PLOS ONE

Additional Editor Comments:

This revision is evaluated by two reviewers. Please see their comments below.

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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: (No Response)

Reviewer #4: (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 #3: Partly

Reviewer #4: No

**********

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

Reviewer #3: I Don't Know

Reviewer #4: 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 #3: No

Reviewer #4: 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 #3: No

Reviewer #4: No

**********

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: You need be more specific about design, although it is not explicitly stated it appears that you targeted a total of 440 patients recruiting 110 in each site. If that is the case you should say that explicitly including whether all consecutive patients were approached, how many refused (and include some basic information about the refusal such as the poison they were exposed to , gender and age) Further how Lon did it take you in each site to recruit the patients eg how many weeks

Reviewer #4: Manuscript ID: PONE-D-22-26894R2

Thank you for the opportunity to review this manuscript entitled: “Poisoning Cases and Their Management in Amhara Region, Ethiopia: Hospital Based Prospective Study”

There are still numerous errors relating to grammar, syntax and academic one. I suggest that the authors employ the services of a professional English language editor with a background in medical journal articles

In the Methods section of the Abstract it is stated that data collection was from Jan to Dec 2028, which implies that a convenience sampling was used. However, in the main text under Methods, the authors indicate that sample size determination was used. This is conflicting and needs to be clarified.

Overall, there are too many tables and figures. Most of the data can be included in 2-3 tables. Also, there is a lot of repetition between the text and figures/tables. Table 3: Seems like “Died” and “Cured” under “Treatment outcome” have been incorrectly labelled. The authors are encouraged to read through other similar publications which will assist them with improving the layout and design of this article. The discussion section is too long.

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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 #3: No

Reviewer #4: No

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PONE-D-22-26894R3Poisoning Cases and Their Management in Amhara Region, Ethiopia: Hospital-Based Prospective StudyPLOS ONE

Dear Dr. Asrie,

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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Suzit Bhusal

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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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: (No Response)

Reviewer #5: 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 #3: Yes

Reviewer #5: Yes

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

Reviewer #3: Yes

Reviewer #5: 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 #3: Yes

Reviewer #5: 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 #3: No

Reviewer #5: (No Response)

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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 #3: There are still some errors in English or confusing expressions, in some places repetition. I have marked up your tracked document in yellow and also suggested strike thru to address this.

In the results you need to detail how many patients were approached and how many refused consent and were subsequently excluded.

Your paper and discussion is really about the epridemioogy of poisoning and some service utilisation. In this context I would avoid to much discussion around the rationale for treatments inevitably it will be a bit superficial.

In the discussion the use of exisiting medicines for antidotes is rarely approved it is more commonly recommended in guidelines based on the level of evidence. As this is an epidimology paper you probably do not need to discuss the evidence for the role of magnesium.

For magnesium I have suggested shortening that section. Alos a more approbate reference if needed is

Brvar M, Chan MY, Dawson AH, Ribchester RR, Eddleston M. Magnesium sulfate and calcium channel blocking drugs as antidotes for acute organophosphorus insecticide poisoning–a systematic review and meta-analysis. Clinical Toxicology. 2018 Aug 3;56(8):725-36.

Reviewer #5: All the comments have been addressed. The manuscript can be accepted for publication. No further changes required

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Reviewer #3: No

Reviewer #5: No

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[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.

Attachments

Attachment

Submitted filename: PONE-D-22-26894_R3_Edit.pdf

Poisoning cases and their management in Amhara National Regional State, Ethiopia: hospital-based prospective study

PONE-D-22-26894R4

Dear Dr. Asrie,

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.

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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,

Senthil Kumaran, MBBS, MD, DNB

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

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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 #3: Yes

**********

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

Reviewer #3: 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 #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 #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 #3: (No Response)

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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 #3: No

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