Dear Dr. Desai,

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 Jan 11 2025 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.

• 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,

Amirmohammad Khalaji

Academic Editor

PLOS ONE

Journal Requirements:-->--> -->-->When submitting your revision, we need you to address these additional requirements.-->--> -->-->1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at -->-->https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and -->-->https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf?>

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: No

Reviewer #2: Yes

**********

Reviewer #1: As a reviewer, I commend the authors for conducting a well-designed study to investigate the impact of different warming strategies on intraoperative hypothermia. The use of a randomized controlled trial and the objective measure of AUC below 36°C are the strengths of the study.

However, a few areas could be further explored:

Sample Size: Consider whether the sample size was adequate to detect clinically significant differences, especially for secondary outcomes, as it was mentioned in the study limitations.

Heterogeneity in Surgical Procedures: The inclusion of various surgical procedures might have influenced the results. A more homogeneous patient population could provide clearer insights.

Non-Standardized Blanket Use: The lack of standardization in blanket use in the NAPW arms is a limitation that could affect the results

The abstract is well-structured and concise. However, consider further condensing the methods section by focusing on the key aspects of the study design, such as the randomization process, intervention details, and primary outcome measure.

Revise the whole manuscript for any grammatical and language mistakes

Line 31: Consider rephrasing "We conducted a prospective observational study" to "We conducted a prospective randomized controlled trial."

Line 36: The equation for calculating AUC could be simplified or presented in a more concise format.

Line 48: Consider rephrasing "CW is associated with significantly less intraoperative hypothermia than FAW when FAW was used without prewarming" to "CW is more effective than FAW at reducing intraoperative hypothermia, especially when FAW is used without prewarming."

Line 54: Consider rephrasing "PH is associated with increased blood loss, increased time to emerge from anesthesia, prolonged hospitalization, surgical site infections, and general thermal discomfort" to "PH is associated with various adverse outcomes, including increased blood loss, prolonged emergence time, extended hospital stay, surgical site infections, and patient discomfort."

Line 61: The phrase "is there is no superiority" should be corrected to "there is no superiority."

Line 69: Consider rephrasing "Recently, conductive warming (CW) devices, which conduct heat from a thermal blanket directly to the patient, have become popular" to "Recently, conductive warming (CW) devices have gained popularity due to their ability to directly transfer heat to the patient."

Line 71: The phrase "CW devices have variable efficiency, but may be more efficient than FAW" could be rephrased to "While CW devices can vary in efficiency, they may offer superior heat transfer compared to FAW."

Line 73: Consider rephrasing "Studies comparing CW and FAW efficacy have been inconclusive" to "Studies comparing CW and FAW have yielded mixed results."

Line 272: Consider rephrasing "we assessed the association of four warming strategies" to "we compared the effectiveness of four warming strategies."

Line 276: Consider rephrasing "CW/CW was associated with 51% less hypothermia than NAPW/FAW" to "CW/CW resulted in 51% less hypothermia compared to NAPW/FAW."

Line 281: The phrase "No significant difference was observed in the pairwise comparisons between CW/CW and FAW/FAW, and NAPW/CW and FAW/FAW" is a bit convoluted. You could rephrase it as "No significant differences were observed between CW/CW and FAW/FAW, or between NAPW/CW and FAW/FAW."

Lines 289-291: Consider combining the two sentences to improve readability. For example, "One possible reason for CW's superiority over NAPW/FAW is the use of an underbody CW mattress, which was not used with FAW, despite being standard practice."

Line 293: The phrase "variable device implementation, low-powered studies, and heterogeneity between studies making conclusions difficult" could be rephrased for better clarity. For instance, "variable device implementation, underpowered studies, and heterogeneity between studies, making it difficult to draw definitive conclusions."

Lines 294-316: Consider breaking up the long paragraph into smaller paragraphs to improve readability. You could separate the discussion of the Cochrane review, the Joanna Briggs Institute review, and the specific studies by Harper et al. and others.

To improve the clarity and impact of your manuscript, please adhere to the following:

1. Prioritize clarity and conciseness in writing.

2. Ensure strong evidence base and clear methodology.

3. Address limitations and propose future directions.

4. Proofread carefully for grammar and style consistency.

Reviewer #2: This is a very interesting paper. This reviewer is participating in the re-submission. I have a few minor comments. Normally, when referring to the AUC of core body temperature, it suggests accumulated heat (i.e., heat storage), so it is somewhat difficult to interpret the AUC in the context of this experiment. Please add a figure with data from a representative subject to illustrate the AUC.

In the abstract, there is no explanation of T1 and T2. If possible, please state in the abstract that core body temperature during surgery was assessed using esophageal temperature. In the methods section, please provide the gender ratio of the subjects in each group. The impact of body size differences has been considered, but as a precaution, please present basic physical characteristics in a table. This should include age and gender ratio. I have no particular comments regarding the results and discussion, so please address the above points.

**********

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: Yes:  Hassan El-Masry

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. 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-24-44335R1

The optimal warming strategy to reduce perioperative hypothermia: A prospective randomized non-blinded clinical trial

PLOS ONE

Dear Dr. Desai,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we have decided that your manuscript does not meet our criteria for publication and must therefore be rejected.

I am sorry that we cannot be more positive on this occasion, but hope that you appreciate the reasons for this decision.

Kind regards,

Amirmohammad Khalaji

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: No

Reviewer #2: (No Response)

**********

Reviewer #1:  The discussion is so short with many passages without citations that strengthen their evidence

The methodology is deficient in many essential areas

Reviewer #2:  The authors responded to this reviewer's comments. However, the Y-axis label in Figure 1 should be the name of the temperature measured site, which is esophageal temperature.

**********

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.]

- - - - -

For journal use only: PONEDEC3

Dear Professor Desai,

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 May 5th. 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.

• 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 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,

Stefano Turi

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.

Additional Editor Comments (if provided):

The authors should report in the description of Table 1 of the main manuscript how the data are presented in the table (values and values in brackets). 

Considering table 1, surgical approach is not similar in all groups; could the authors comment on this point?

Could the authors report the mean duration of surgery in each group? 

The planned sample size was not reached and this is an important limitation that could reduce the strength of conclusions. The authors should emphasize this point in the conclusion. 

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #3: All comments have been addressed

Reviewer #4: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #3: Yes

Reviewer #4: Yes

**********

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

Reviewer #3: Yes

Reviewer #4: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #3: Yes

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #3: Yes

Reviewer #4: Yes

**********

Reviewer #3: This study evaluated the effectiveness of four different combinations of preoperative and intraoperative warming by comparing them to reduce perioperative hypothermia. The study design was rigorous, but some areas for improvement remain.

1.In the inclusion criteria, it is stated that the expected duration of the operation is more than 90 minutes and less than 240 minutes. This criterion is not supported by the literature, and it is hoped that the authors will add relevant evidence to enhance the rationality and scientific validity of the inclusion criteria.

2.The frequency of intraoperative temperature measurement using the esophageal probe placed after induction of anesthesia every 15 minutes was not supported in the literature. Since the frequency of temperature monitoring has a significant impact on the accuracy of the study results, it is recommended that the authors review and supplement the literature.

3.Considering that different types of surgeries may have different impacts on patients' temperature changes, has this study considered subgroup analyses of different types of surgeries to explore in more depth the effects of warming strategies under various types of surgeries?

Reviewer #4: (No Response)

**********

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

**********

[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

The optimal warming strategy to reduce perioperative hypothermia: A prospective randomized non-blinded clinical trial

PONE-D-24-44335R3

Dear Dr. Desai,

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,

Stefano Turi

Academic Editor

PLOS ONE