Implementation of vascular surgery teleconsultation during the COVID-19 pandemic: Insights from the outpatient vascular clinics in a tertiary care hospital in Qatar

Hassan Al-Thani; Ahammed Mekkodathil; Ahmed Hussain; Ahmed Sharaf; Ahmed Sadek; Anas Aldakhl-Allah; Ahmed Awad; Nassar Al-Abdullah; Ahmad Zitoun; Jini Paul; Pushpalatha Pillai; Sara John; Ayman El-Menyar

doi:10.1371/journal.pone.0257458

Peer Review History

Original SubmissionJune 14, 2021
30 Jun 2021 Decision Letter - Robert Jeenchen Chen, Editor PONE-D-21-19489 Implementation of Vascular Surgery Teleconsultation during the COVID-19 Pandemic: Insights for Practice from a Tertiary Care Hospital in Qatar PLOS ONE Dear Dr. El-Menyar, 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 address the issues and revise accordingly. Please submit your revised manuscript by Aug 14 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Robert Jeenchen Chen, MD, MPH 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 2. 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. [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: Partly Reviewer #2: No ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: I Don't Know ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: 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: While not unique, the authors have done an excellent job at quantifying the effects of the covid pandemic on their outpatient practice and have highlighted the use of telemedicine during the pandemic and emphasized its ongoing utility after the pandemic. 1. Results, page 7: What was the indication for sclerotherapy? Even though decreased this was still the most common procedure. In most cases this is cosmetic and purely elective. Most places discontinued purely elective procedures during the height of the pandemic. 2. Do the authors have information on telephone vs computer/video visits? In our experience, not all patients have adequate computer resources for video visits, so telephone visits are necessary. 3. The authors focus on outpatient encounters. Do they have concomitant information on pandemic effects of inpatient encounters and surgical procedures? Reviewer #2: Please see the attached file for detailed comments. I think the present study does have potential, but would benefit from altered statistical analyses of the data file. According to the manuscript all needed data should be available. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. 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: Plos one.docx https://doi.org/10.1371/journal.pone.0257458.r001
Revision 1
13 Jul 2021 Author Response Reviewer #1: While not unique, the authors have done an excellent job at quantifying the effects of the covid pandemic on their outpatient practice and have highlighted the use of telemedicine during the pandemic and emphasized its ongoing utility after the pandemic. 1. Results, page 7: What was the indication for sclerotherapy? Even though decreased this was still the most common procedure. In most cases this is cosmetic and purely elective. Most places discontinued purely elective procedures during the height of the pandemic. 2. Do the authors have information on telephone vs computer/video visits? In our experience, not all patients have adequate computer resources for video visits, so telephone visits are necessary. 3. The authors focus on outpatient encounters. Do they have concomitant information on pandemic effects of inpatient encounters and surgical procedures? Reply: - This is a unique study in our Middle East region that describes the outpatient vascular surgery clinic experience during the covid-19 pandemic which needs to be shared with others to set the best patient care during such pandemic crisis. Sclerotherapy procedure was stopped during the Covid pandemic as illustrated in the figure. (In the first three month 459 cases done and only one case of sclerotherapy in September for bleeding varicose vein). - All the information based on telephone conversation. - During the pick of the pandemic there was a shift in the Multi-disciplinary outpatient vascular clinic for hemodialysis vascular access to inpatient consultation or direct consultation in the hemodialysis centers. This resulted in a significant drop in the number of physical visit to the vascular clinic for the hemodialysis patients. - On the other hand, vascular access for chemotherapy rarely came to the vascular clinic even before the pandemic. The vascular coordinator for chemotherapy access at the national oncology center (NCCR) referral done for new chemotherapy access or on going issues with patients need chemotherapy and patients seen at NCCR physically by the vascular team. - All the emergency vascular consultations are seen by the vascular surgeon on-call physically whether inpatient or in the emergency department. The pandemic did not impact on the overall number of consultation. On the other hand the surgical procedures decreased from 2506 in 2019 to 1849 in 2020 due to the discontinuation of elective varicose vein surgery. Reviewer #2: Please see the attached file for detailed comments. I think the present study does have potential, but would benefit from altered statistical analyses of the data file. According to the manuscript all needed data should be available. Statistical analyses especially table 2 should be presented more clearly in methods section and in the legend. Reply: done thanks Results table 2 is hard to read (p value chi test between which values?) more accurate presentation and legend would be helpful and provide sufficient information on what is presented. Figure 3 why not present year 2020 together with figure 5 on same panel? This would be more informative? It is not clear if authors present number of out-patient clinic or vascular department. Maybe mixed? State accurately what numbers stand for. Reply: The current study present vascular surgery outpatient clinic cases only. Tables and figures revised as per reviewer request Discussion would be nice to begin with the major observations of the study. Second and third paragraph essential for the manuscript? If authors could demonstrate significant differences between urgent and elective vascular patient workload during pandemics and possibly these patient groups vary in requirements of out-patient contact (face-to-face or telecommunication)? Also, the multidisciplinary patient groups are interesting on this concept. Reply: - Discussion revised as per reviewer request. - Our study demonstrated that 61% of the outpatient encounters at the vascular clinic was through teleconsultation in the year 2020 (COVID-19 era). Females were the majority of patients who accessed care in this period, and many of cases were follow-ups. Consultations for new vascular cases reduced significantly. The duration from February 2020 to April 2020 witnessed 95% drop in the physical visits of patients and more than 25 times increase in the telemedicine encounters. Similarly, there was 97% decrease in procedures performed in the vascular clinics during the COVID-19 period. During the pick of the pandemic, there was a shift in the multi-disciplinary outpatient vascular clinic for hemodialysis vascular access to inpatient consultation or direct consultation in the hemodialysis centers. This resulted in a significant drop in the number of physical visit to the vascular clinic for the hemodialysis patients. - On the other hand, patients for vascular access for chemotherapy rarely come to the vascular clinic even before the pandemic. The vascular coordinators for chemotherapy access at the national oncology center (NCCR) arrange referral for new chemotherapy access or ongoing issues with patients need chemotherapy and patients will be seen at the NCCR physically by the vascular team. - All the emergency vascular consultations are seen by the vascular surgeon on-call physically whether inpatient or in the emergency department. The pandemic did not impact on the overall number of consultation. On the other hand, the surgical procedures decreased from 2506 in 2019 to 1849 in 2020 due to the discontinuation of elective varicose vein surgery. Oncology-Vascular surgery Multidisciplinary Video Conferencing Meetings Calling using Microsoft Teams to support other surgical specialties for cancer cases take place twice-weekly ; one the uro-oncology Multidisciplinary and the other one in the sarcoma Multidisciplinary team. - Diagnosis Category for the patients seen in the outpatient clinic is illustrated in figure 3&4. Figure 6 added In the present manuscript authors have analyzed the frailty and benefit of telecommunication as tool for organizing vascular surgery outpatient clinic during Covid-19 era. This is a timely topic for the research and authors have a large cohort. Authors have a valid scope for the study “The goal of this study is to describe the utilization of telemedicine services in the vascular surgery clinic in a tertiary hospital in Qatar and explore some considerations for practice from the Qatar context that may be relevant in other settings globally” The major criticism is the grouping of this nice amount of valuable data, which can provide potentially interesting valuable new data on which patient sub-groups can be managed with telecommunication and who really require face-to-face contact to out-patient clinic. Comparing groups like nationals versus non-nationals does not provide globally relevant new data. The over 10 000 visits would provide more general importance if divided based on clinical presentation of vascular disease or requirement of vascular services (access patients etc). Comparing numbers of venous patients C1-3 versus C4-6 telecommunication versus face-to-face, similarly numbers treated and referred before and after Covid-19 pandemic, claudication versus CLI patients, AAA, internal consultations (nephrology, neurology) etc would provide more general new insight to utility of telemedicine in special patient groups and workload of vascular services during pandemic. This data should be available on authors data base? Reply: thanks for these invaluable comments. As you said we mainly aimed at describing our experience from a developing country and to share it with others to improve our learning curve in such unprecedented crisis. We are working on the follow up of such subgroups as per your suggestion which will take long time and will be the scope of further publication. We added this point to the current study limitations Abstract: Background. Last sentence not fluent and could be pasted to another paragraph? Reply: Sentence moved to the introduction of the main manuscript Objectives and methods should be more accurate. Reply: thanks, done Results is hard to follow, and it is impossible to know where authors present data and numbers from outpatient clinic and when numbers present the workload of vascular clinic. This is also major criticism for all sections of the manuscript. Reply: we addressed clearly that these data are from outpatient clinics only Conclusions first sentence is on focus and as stated in the major criticism the present study has potential answering many important aspects of vascular out-patients clinic. Reply: thanks Introduction is nice Reply: thanks Methods: please see above. The grouping of the data could be more relevant. Table 1 figures 1-2 could be more readable? Statistical analyses especially table 2 should be presented more clearly in methods section and in the legend. Reply: tables and figures improved accordingly Attachments Attachment Submitted filename: Plos one (1)reply.doc https://doi.org/10.1371/journal.pone.0257458.r002
21 Jul 2021 Decision Letter - Robert Jeenchen Chen, Editor PONE-D-21-19489R1 Implementation of Vascular Surgery Teleconsultation during the COVID-19 Pandemic: Insights from the Outpatient vascular Clinics in a Tertiary Care Hospital in Qatar PLOS ONE Dear Dr. El-Menyar, 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 revise accordingly. Please submit your revised manuscript by Sep 04 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Robert Jeenchen Chen, MD, MPH 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: 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? 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 ****** 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 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 ****** 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 Reviewer #2: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: (No Response) Reviewer #2: I think the manuscript has improved after revision. My only comment concerns paragraph above conclusions ...covid-19 pandemic which needs to be shared with others... in the final manuscript the "needs to be shared with others" could be deleted? This applies to editor and reviewers? ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No [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.0257458.r003
Revision 2
21 Jul 2021 Author Response Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed Reviewer #2: All comments have been addressed Reply: thanks ________________________________________ 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes Reply: thanks ________________________________________ 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes Reply: thanks ________________________________________ 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes Reply: thanks ________________________________________ 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 Reviewer #2: Yes Reply: thanks, Done ________________________________________ 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: (No Response) Reviewer #2: I think the manuscript has improved after revision. My only comment concerns paragraph above conclusions ...covid-19 pandemic which needs to be shared with others... in the final manuscript the "needs to be shared with others" could be deleted? This applies to editor and reviewers? Reply: thanks, Done ________________________________________ 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No 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. Reply: no retracted ref found Attachments Attachment Submitted filename: reply2.docx https://doi.org/10.1371/journal.pone.0257458.r004
18 Aug 2021 Decision Letter - Robert Jeenchen Chen, Editor PONE-D-21-19489R2 Implementation of Vascular Surgery Teleconsultation during the COVID-19 Pandemic: Insights from the Outpatient vascular Clinics in a Tertiary Care Hospital in Qatar PLOS ONE Dear Dr. El-Menyar, 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 address the issues and revise accordingly. Please submit your revised manuscript by Oct 02 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Robert Jeenchen Chen, MD, MPH Academic Editor PLOS ONE [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #2: All comments have been addressed 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? 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 #2: Yes Reviewer #3: Yes Reviewer #4: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: Yes Reviewer #3: N/A Reviewer #4: 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 #2: Yes Reviewer #3: Yes 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 #2: Yes Reviewer #3: Yes Reviewer #4: 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 #2: All presented comments are addressed. Reviewer #3: It is clear that a lot of hard work has gone in to preparing this manuscript, however it is my feeling that rather than generating new knowledge this is more of an audit/local service evaluation and perhaps could be usefully relayed in a short letter to the editor rather than a full manuscript. Reviewer #4: Dear author, Your submission is very well-written and was able to adress all suggested comments raised from the previous revision. There is still a minor mistake at page 22: "Vascular surgery for arthrosclerosis" instead of atherosclerosis, which should be corrected. ****** 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 #2: No 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. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0257458.r005
Revision 3
19 Aug 2021 Author Response Thanks for the reviewers and editor. There was only one comment that already has been addressed. 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 #2: All comments have been addressed 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? 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 #2: Yes Reviewer #3: Yes Reviewer #4: Yes ________________________________________ 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: Yes Reviewer #3: N/A Reviewer #4: 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 #2: Yes Reviewer #3: Yes 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 #2: Yes Reviewer #3: Yes Reviewer #4: 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 #2: All presented comments are addressed. Reviewer #3: It is clear that a lot of hard work has gone in to preparing this manuscript, however it is my feeling that rather than generating new knowledge this is more of an audit/local service evaluation and perhaps could be usefully relayed in a short letter to the editor rather than a full manuscript. Reply: Thanks, This is the first paper of this kind in the Middle East (and few worldwide) that addresses the importance and feasibility of teleconsultation in the field of vascular surgery during the unprecedented pandemic, therefore full manuscript is needed Reviewer #4: Dear author, Your submission is very well-written and was able to adress all suggested comments raised from the previous revision. There is still a minor mistake at page 22: "Vascular surgery for arthrosclerosis" instead of atherosclerosis, which should be corrected. Reply: thanks, corrected ________________________________________ 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 #2: No Reviewer #3: No Reviewer #4: No Attachments Attachment Submitted filename: reply3.doc https://doi.org/10.1371/journal.pone.0257458.r006
2 Sep 2021 Decision Letter - Robert Jeenchen Chen, Editor Implementation of Vascular Surgery Teleconsultation during the COVID-19 Pandemic: Insights from the Outpatient vascular Clinics in a Tertiary Care Hospital in Qatar PONE-D-21-19489R3 Dear Dr. El-Menyar, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Robert Jeenchen Chen, MD, MPH 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 #2: 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? 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 #2: Yes Reviewer #4: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: Yes Reviewer #4: 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 #2: Yes 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 #2: Yes Reviewer #4: 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 #2: All presented comments are addressed Reviewer #4: Dear authors, thank you for submitting your review. There are not any other comments regarding your manuscript. ****** 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 #2: No Reviewer #4: No https://doi.org/10.1371/journal.pone.0257458.r007
Formally Accepted
17 Sep 2021 Acceptance Letter - Robert Jeenchen Chen, Editor PONE-D-21-19489R3 Implementation of Vascular Surgery Teleconsultation during the COVID-19 Pandemic: Insights from the Outpatient vascular Clinics in a Tertiary Care Hospital in Qatar Dear Dr. El-Menyar: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. 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 plosone@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. Robert Jeenchen Chen Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0257458.r008

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