Knowledge, attitudes, and practices of orthopedic operating room personnel regarding the use of pneumatic tourniquets

Gang Zu; Quan Zhang; Genjun Chen; Enfeng Yao; Jun Fei; Guihe Han; Guanmin Tian

doi:10.1371/journal.pone.0307545

Peer Review History

Original SubmissionFebruary 23, 2024
15 Mar 2024 Decision Letter - Raffaele Vitiello, Editor PONE-D-24-05036Knowledge, Attitudes, and Practices of Orthopedic Operating Room Personnel Regarding the Use of Pneumatic TourniquetsPLOS ONE Dear Dr. Zu, 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 Apr 29 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. 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Additional Editor Comments: According to reviewer a major review is needed. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: No ****** 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 ****** 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 ****** 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: Thank the editors for inviting me to peer-review this manuscript. The topic is meaningful and exciting. However, there are some issues that need to be corrected before publication. I have some comments and hope that they are helpful to the authors. Abstract 1. “A total of 336 participants included orthopedic physicians (37.8%), orthopedic nurses (31.5%), anesthesiologists (8.9%), OR nurses (19.9%) and medical students (1.8%).” What does OR mean? Methods 2. Please include the estimated minimum sample size and the response rate (if available). 3. Cronbach’s alpha should be reported for each K, A, P part, not the overall. 4. The authors wrote: “This study was approved by the Ethic Committee of Hangzhou Red Cross Hospital (2023 Review No. 092), and the study obtained written informed consent from all participants.” “The Questionnaire Star platform, an online questionnaire software, was used to create and design the questionnaire. To access and complete the questionnaire participants scanned the provided QR code, using WeChat messenger on their smartphone.” How could the authors obtain participants’ written informed consent if data is collected via online platforms? 5. The authors wrote: “To ensure data quality and completeness, each IP address was restricted to one submission, and all questionnaire items were mandatory.” “Incomplete questionnaires or questionnaires with unanswered items were excluded.” If all questions were mandatory, why were there incomplete or unanswered questionnaires? 6. The authors used the Questionnaire Star platform to collect data. Did the authors send a QR code to each participant? The data collection process should be described more clearly. 7. In the Data analysis, please add information involving regression analyses used. 8. (Authors’ choice) The authors used cut-off points to categorize K, A, and P scores into two groups. It is ok. However, I recommend the authors not divide a numeric variable into groups (a categorical variable). This can lower the quality of data. For example, participants’ knowledge scores ranged from 0 to 10. The cut-off point was 8. All participants having a knowledge score of 0 to 7.9 were “unsatisfied” or "poor". However, someone with 1 point cannot be similar to someone with 7.5 points. And of course, the linear regression should be employed instead. 9. (Authors’ choice) The authors used backward LR for multivariate logistic regression. However, this method has many weaknesses. Several new methods, such as Ridge, LASSO, and BMA, are better than them when selecting independent variables for multivariable models. Results 10. Please explain “OR nurse” in Table 1 11. Tables 2, 3, and 4 are long. Please remove unnecessary rows that were repeated. 12. When I read the questions in the questionnaire, several questions confused me. “2. Are you familiar with the correct usage of the pneumatic tourniquet? 3. Do you know the appropriate site for cuff application in limb surgery? 4. Can you determine the appropriate tourniquet pressure? 5. Can you set the appropriate tourniquet application time?” “How often do you use pneumatic tourniquets in clinical practice?” I think these questions should not be taken into account when the authors computed the knowledge and practice scores for each participant. For example, the knowledge questions above are unspecific. Participants can lie/answer insincerely. Regarding the practice question above, it is inappropriate when a person usually using PTs can receive a score higher than a person rarely using PTs. The critical point is that participants can practice and use it correctly. The frequency is not essential. Discussion 13. I am relatively surprised by the following finding involving no previous training. “no previous training (OR=0.312, 95%CI: 0.187 - 0.520; p<0.001) were associated with better knowledge scores... no previous training (OR=0.325, 95%CI: 0.203 - 0.521; p<0.001) were associated with better practice scores...” I hope that the authors can discuss this result in detail. 14. Please check the format of references. 15. Please check spelling and grammar mistakes. Best wishes to the authors. ****** 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 ******** [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.0307545.r001
Revision 1
16 Apr 2024 Author Response Title: Knowledge, Attitudes, and Practices of Orthopedic Operating Room Personnel Regarding the Use of Pneumatic Tourniquets Journal: PLOS ONE Dear Editor, We thank you for your careful consideration of our manuscript. We appreciate your response and overall positive initial feedback and made modifications to improve the manuscript. After carefully reviewing the comments made by the Reviewers, we have modified the manuscript to improve the presentation of our results and their discussion, therefore providing a complete context for the research that may be of interest to your readers. We hope that you will find the revised paper suitable for publication, and we look forward to contributing to your journal. Please do not hesitate to contact us with other questions or concerns regarding the manuscript. Best regards, Gang Zu Department of Orthopedics, Hangzhou RedCross Hospital. Address: No. 208, East Huancheng Road, Hangzhou, 310003, Zhejiang，China. Email: hzhhzuganga@zcmu.edu.cn Tel: +86 18058787299 ORCID：0000-0002-8350-7995 Editor’s comments Comment 1: Please note that funding information should not appear in any section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. Please remove any funding-related text from the manuscript. Response: We thank the Editor. The Funding data was checked and removed from the manuscript. Comment 2: We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match. When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section. Response: We thank the Editor. This study was supported by Hangzhou Biomedicine and Health Industry Development Support Project (2021-067). This information was removed from the manuscript and submitted in the separate section. Comment 3: Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please ensure that your ethics statement is included in your manuscript, as the ethics statement entered into the online submission form will not be published alongside your manuscript. Response: We thank the Editor. Ethics statement was removed from the Declarations section. Reviewer’s comments Comment 1: A total of 336 participants included orthopedic physicians (37.8%), orthopedic nurses (31.5%), anesthesiologists (8.9%), OR nurses (19.9%) and medical students (1.8%).” What does OR mean? Response: We thank the Reviewer for the question. OR stands for “Operating room”. Manuscript was checked once more to make sure that all abbreviations are clear. Comment 2: Please include the estimated minimum sample size and the response rate (if available). Response: We thank the Reviewer for the comment. The sample size was calculated using the following formula: [n=(z^2 p(1-p))/d^2] where z=1.96 at 5% level of significance and 6%acceptable margin of error (d=0.06). The proportion of the expected population based on previous studies or pilot studies was set at 50%. Based on the above, the sample size was calculated as 267, and 355 questionnaires were collected in this study, of which 336 were valid. The sample size calculation is added to the Methods section (page 8, lines 128-131). Comment 3: Cronbach’s alpha should be reported for each K, A, P part, not the overall. Response: We thank the Reviewer for the comment. Cronbach’s alpha for Knowledge dimension was 0.908, for Attitudinal dimension – 0.866, for Practice dimension – 0.909 (page 7, lines 108). Comment 4: “This study was approved by the Ethic Committee of Hangzhou Red Cross Hospital (2023 Review No. 092), and the study obtained written informed consent from all participants.” “The Questionnaire Star platform, an online questionnaire software, was used to create and design the questionnaire. To access and complete the questionnaire participants scanned the provided QR code, using WeChat messenger on their smartphone.” How could the authors obtain participants’ written informed consent if data is collected via online platforms? Response: We thank the Reviewer for the comment. Before starting the questionnaire, participants were presented with a brief introduction to the contents of this study and needed to answer the question of whether they are willing to participate in this scientific research. Comment 5: The authors wrote: “To ensure data quality and completeness, each IP address was restricted to one submission, and all questionnaire items were mandatory.” “Incomplete questionnaires or questionnaires with unanswered items were excluded.” If all questions were mandatory, why were there incomplete or unanswered questionnaires? Response: We thank the Reviewer for the question. In this study questionnaires with the >90% of answers being the same option were regarded as incomplete and excluded. Among a total of 355 collected questionnaires (all of them seemingly completed) 19 questionnaires were eliminated: 1) did not agree to the use of the collected data for scientific research, 2 copies; 2) 15 copies of the questionnaire that took less than 114 seconds or more than 1800 seconds to fill in; 3) except for the basic information, all other answers were the same option, 2 copies. The corresponding part of Methods section (page 7, line 102) was revised to avoid misunderstanding. Comment 6: The authors used the Questionnaire Star platform to collect data. Did the authors send a QR code to each participant? The data collection process should be described more clearly Response: We thank the Reviewer for the comment. Hospitals with an annual orthopedic surgery volume of more than 1,000 and more than 50 orthopedic beds were chosen for questionnaire distribution. After contacting each hospital to ensure cooperation, QR code link to the questionnaire was distributed through the Orthopedic Medical Care WeChat Group and the Surgical Anesthesia Medical Care WeChat Group for voluntary filling. Comment 7: In the Data analysis, please add information involving regression analyses used. Response: We thank the Reviewer for the comment. In this study univariate and multivariate logistic regression was used. The corresponding part of the manuscript was amended to add the description (page 9, lines 144-145) Comment 8: (Authors’ choice) The authors used cut-off points to categorize K, A, and P scores into two groups.It is ok. However, I recommend the authors not divide a numeric variable into groups (a categorical variable). This can lower the quality of data. For example, participants’ knowledge scores ranged from 0 to 10. The cut-off point was 8. All participants having a knowledge score of 0 to 7.9 were “unsatisfied” or "poor". However, someone with 1 point cannot be similar to someone with 7.5 points. And of course, the linear regression should be employed instead. Response: We thank the Reviewer for the comment. We used multivariate logistic regression, mainly based on the following considerations: the data were not normally distributed, and the sample size was not large, so the conditions for linear regression were not fully met. The classification was mainly based on the median and took into the account the non-normal distribution of the data, in the same manner as in some previous studies, such as: Feleke BT, Wale MZ, Yirsaw MT. Knowledge, attitude and preventive practice towards COVID-19 and associated factors among outpatient service visitors at Debre Markos compressive specialized hospital, north-west Ethiopia, 2020. PloS one. 2021;16(7):e0251708 Comment 9: (Authors’ choice) The authors used backward LR for multivariate logistic regression. However, this method has many weaknesses. Several new methods, such as Ridge, LASSO, and BMA, are better than them when selecting independent variables for multivariable models. Response: We thank the Reviewer for the comment and we fully agree that some new methods gave a better perspective on the topic. In our particular case, since there were only few demographic variables (about 10), and the current sample size and positivity rate (discussed in the previous answer) would not lead to the notable sparse effect, and the meaning between the variables was clear, we might assume that the difference between the results of lasso and the variable screening results of multivariate logistic regression should not be large; in addition, current (more common) method were also chosen to increase interpretability and comparability of results. Comment 10: Please explain “OR nurse” in Table 1 Response: We thank the Reviewer for the comment. OR stands for “Operating room”. Manuscript was checked once more to make sure that all abbreviations are clear. Comment 11: Tables 2, 3, and 4 are long. Please remove unnecessary rows that were repeated. Response: We thank the Reviewer for the comment and a very sound suggestion. Entries with the same option in Tables 2, 3, 4 were removed. Comment 12: When I read the questions in the questionnaire, several questions confused me. “2. Are you familiar with the correct usage of the pneumatic tourniquet? 3. Do you know the appropriate site for cuff application in limb surgery? 4. Can you determine the appropriate tourniquet pressure? 5. Can you set the appropriate tourniquet application time?” “How often do you use pneumatic tourniquets in clinical practice?” I think these questions should not be taken into account when the authors computed the knowledge and practice scores for each participant. For example, the knowledge questions above are unspecific. Participants can lie/answer insincerely. Regarding the practice question above, it is inappropriate when a person usually using PTs can receive a score higher than a person rarely using PTs. The critical point is that participants can practice and use it correctly. The frequency is not essential. Response: We thank the Reviewer for the comment. Unfortunately, the possibility of lie under the social pressure to appear more knowledgeable or to demonstrate more socially acceptable attitude is one of the important limitations of the KAP design, as discussed in the references below. In this type of setting, negative results, such as insufficient knowledge, are less biased than positive, and should be discussed as such (eg knowledge gaps). By assuring anonymity and setting different options, like Likert scales, we hoped to lessen social bias – although, individual cases is still a possibility, the overall picture might suggest some common features. Andrade C, Menon V, Ameen S, Kumar Praharaj S. Designing and Conducting Knowledge, Attitude, and Practice Surveys in Psychiatry: Practical Guidance. Indian J Psychol Med. 2020 Aug 27;42(5):478-481. doi: 10.1177/0253717620946111. PMID: 33414597; PMCID: PMC7750837. Santesso N, Akl E, Bhandari M, Busse JW, Cook DJ, Greenhalgh T, Muti P, Schünemann H, Guyatt G. A practical guide for using a survey about attitudes and behaviors to inform health care decisions. J Clin Epidemiol. 2020 Dec;128:93-100. doi: 10.1016/j.jclinepi.2019.11.020. Epub 2020 Sep 25. PMID: 32987165. We based the “frequency of use” question only on the fact that it is one of the applicable skills in the setting. During the pre-test, reliability and validity testing showed that the score of this item was consistent with the overall score, which might suggest that the frequency of use affects the actual experience of the study population to a certain extent. Comment 13: I am relatively surprised by the following finding involving no previous training. “no previous training (OR=0.312, 95%CI: 0.187 - 0.520; p<0.001) were associated with better knowledge scores... no previous training (OR=0.325, 95%CI: 0.203 - 0.521; p<0.001) were associated with better practice scores...” I hope that the authors can discuss this result in detail. Response: We thank the Reviewer for the comment. In this study no previous training was indeed associated with lower knowledge (OR=0.312, 95%CI: 0.187 - 0.520; p<0.001) and practice (OR=0.325, 95%CI: 0.203 - 0.521; p<0.001) scores. Abstract and results section were revised to avoid misunderstanding. Comment 14: Please check the format of references. Response: We thank the Reviewer for the suggestion. References were carefully checked one more time. Comment 15: Please check spelling and grammar mistakes. Response: We thank the Reviewer for the comment. The manuscript was carefully proofread and checked once more to eliminate grammatical and spelling errors. Attachments Attachment Submitted filename: Response letter.docx https://doi.org/10.1371/journal.pone.0307545.r002
2 May 2024 Decision Letter - Raffaele Vitiello, Editor PONE-D-24-05036R1Knowledge, Attitudes, and Practices of Orthopedic Operating Room Personnel Regarding the Use of Pneumatic TourniquetsPLOS ONE Dear Dr. Zu, 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. According to reviewer Please submit your revised manuscript by Jun 16 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. 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, Raffaele Vitiello Academic Editor PLOS ONE Journal Requirements: 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. [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: (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 ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: No ****** 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: 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 #1: Thank the authors respond my comments in detail. I also have several comments and hope that they are helpful to the authors. 1. Regarding data availability, the authors declared, “All data generated or analyzed during this study are included in this article.” However, the raw data of 336 participants cannot be found. Please check PLOS ONE’s policy for the data. 2. As far as I know, a written consent form is signed by the subject or the subject's legally authorized representative. I think the authors had participants’ online informed consent in this study, not written one. 3. Please check spelling and grammar mistakes. For example, “This study was approved by the Ethic Committee...” “Among factors, associated with the KAP scores (Table 6),” ****** 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 ******** [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.0307545.r003
Revision 2
22 May 2024 Author Response Title: Knowledge, Attitudes, and Practices of Orthopedic Operating Room Personnel Regarding the Use of Pneumatic Tourniquets Journal: PLOS ONE Response to Reviewers' comments Dear Editor, Thank you for your detailed review and the opportunity to revise our manuscript. In response to your request, we have thoroughly checked our reference list and confirmed that we have not cited any retracted papers. However, we have updated Reference 15 due to incorrect publication date and page numbers. The specific changes are as follows: Original reference information: [Alameri M, Sulaiman SA, Ashour A, Ad M. Knowledge and Attitudes of Venous Thromboembolism for Surgeons in Two Saudi Arabian Medical Centers. 2020.] Updated reference information: [Mariam A, Syed Azhar S, Abdullah A, Ma’ad A-S. Knowledge and Attitudes of Venous Thromboembolism for Surgeons in Two Saudi Arabian Medical Centers. Archives of Pharmacy Practice. 2019;10(3):107-11.] We wholeheartedly thank the Reviewer for all comments and suggestions. Manuscript has been revised one more time according to it. Below are point-by-point answers to all comments made by the highly respected Reviewer. Thank you again for your guidance. We look forward to your feedback. Best regards, Gang Zu Department of Orthopedics, Hangzhou RedCross Hospital. Address: No. 208, East Huancheng Road, Hangzhou, 310003, Zhejiang, China. Email: hzhhzuganga@zcmu.edu.cn Tel: +86 18058787299 ORCID：0000-0002-8350-7995 Comment 1. Regarding data availability, the authors declared, “All data generated or analyzed during this study are included in this article.” However, the raw data of 336 participants cannot be found. Please check PLOS ONE’s policy for the data. Response: Thank you for the comment. The data statement was changed to the following: “The raw anonymized data on each participant of this study are available on request from the corresponding author.” (Page 48, line 299) Comment 2. As far as I know, a written consent form is signed by the subject or the subject's legally authorized representative. I think the authors had participants’ online informed consent in this study, not written one. Response: Thank you for the comment. Yes, indeed, the online inform consent was used in this study. Corresponding part of the methods section was revised accordingly. Comment 3. Please check spelling and grammar mistakes. For example, “This study was approved by the Ethic Committee...” “Among factors, associated with the KAP scores (Table 6),” Response: We thank the Reviewer for suggestions. Manuscript has been carefully proofread one more time. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0307545.r004
28 May 2024 Decision Letter - Raffaele Vitiello, Editor PONE-D-24-05036R2Knowledge, Attitudes, and Practices of Orthopedic Operating Room Personnel Regarding the Use of Pneumatic TourniquetsPLOS ONE Dear Dr. Zu, 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. ============================== ACADEMIC EDITOR: According to reviewer============================== Please submit your revised manuscript by Jul 12 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. 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Reviewer #1: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: 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). 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For examples, Univariate and multivarieate logistic Out of all participants 10.7% were unfamiliar with the correct usage of PTs However, notable number of participants In this study median knowledge score was 75.0% out of maximum ... ****** 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 ******** [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". 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Revision 3
17 Jun 2024 Author Response Manuscript ID: PONE-D-24-05036R2 Title: Knowledge, Attitudes, and Practices of Orthopedic Operating Room Personnel Regarding the Use of Pneumatic Tourniquets Dear Dr. Raffaele Vitiello and Reviewers, We appreciate the time and effort that you and the reviewers have dedicated to providing your insightful comments on our manuscript. We have carefully considered all the feedback and have made the necessary revisions to address each point. Below are our detailed responses to the comments raised: Reviewer #1: Comment 1: As per PLOS ONE's policy, PLOS journals require authors to make all data necessary to replicate their study’s findings publicly available without restriction at the time of publication. All data and related metadata underlying reported findings should be deposited in appropriate public data repositories, unless already provided as part of a submitted article (Supporting Information files). Therefore, the authors cannot announce that "The raw anonymized data on each participant of this study are available on request from the corresponding author". Response 1: We apologize for the oversight. In this revised submission, we will include the raw anonymized data as supplementary files to ensure compliance with PLOS ONE's policy. This will make all data necessary to replicate our study’s findings publicly available without restriction. Comment 2: Please check spelling and grammar mistakes. For example: Univariate and multivarieate logistic Out of all participants 10.7% were unfamiliar with the correct usage of PTs However, notable number of participants In this study median knowledge score was 75.0% out of maximum Response 2: We have thoroughly reviewed the manuscript and made corrections to the spelling and grammar throughout the text to ensure clarity and accuracy. Specific examples mentioned have been addressed, and we have meticulously checked the entire document to rectify any additional errors. We believe that these revisions have improved the clarity and robustness of our manuscript, and we hope that it now meets PLOS ONE’s publication criteria. We appreciate your consideration and look forward to your positive response. Kind regards, Gang Zu Department of Orthopedics, Hangzhou RedCross Hospital. Address: No. 208, East Huancheng Road, Hangzhou, 310003, Zhejiang，China. Email: hzhhzuganga@zcmu.edu.cn Tel: +86 18058787299 Attachments Attachment Submitted filename: renamed_75835.docx https://doi.org/10.1371/journal.pone.0307545.r006
9 Jul 2024 Decision Letter - Raffaele Vitiello, Editor Knowledge, Attitudes, and Practices of Orthopedic Operating Room Personnel Regarding the Use of Pneumatic Tourniquets PONE-D-24-05036R3 Dear Dr. Zu, 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, Raffaele Vitiello 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 ******** 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 ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes ****** 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 ****** 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: From my perspective, this revised manuscript is of high quality for publication. Best wishes to the authors. ****** 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 ******** https://doi.org/10.1371/journal.pone.0307545.r007
Formally Accepted
15 Jul 2024 Acceptance Letter - Raffaele Vitiello, Editor PONE-D-24-05036R3 PLOS ONE Dear Dr. Zu, 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. Raffaele Vitiello Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0307545.r008

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