PONE-D-21-02993

Altered mental status is a predictor of poor outcomes in COVID-19 patients: A cohort study

PLOS ONE

Dear Dr. Aboueisha,

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 24 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.

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We look forward to receiving your revised manuscript.

Kind regards,

Tai-Heng Chen, M.D.

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

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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 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: No

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: In this study, authors investigated the association between altered mental status and outcomes in COVID- 19 patients. They found that patients with altered mental status had poor outcomes compared to those patients without altered mental status. Despite the results, I think that there are some concerns.

1. The altered mental status is a vague term and definition. Please clarify the definition of altered mental status.

2. Depth of sedation could be related to altered mental status. Please provide the information of sedative agents.

3. Please provide the causes of altered mental status such as seizure, sepsis associated encephalopathy, metabolic encephalopathy and stroke.

4. When did evaluate the altered mental status during hospitalization? Please provide this information.

Reviewer #2: My comments are below:

Comment 1: In the line 81 and 82, 'Patients were divided into two groups: with and without altered mental status (AMS).' The definition of AMS was not clear. In order to get a more objective results, an operational definition for AMS is essential.

Comment 2:In the line 109 and 110, '...(BMI) was 33.32...with 57.2% being obese and 24.7 being overweight.' It's better to more clearly define 'obese' and 'overweight' . In addition, obesity is a critical issue for COVID-19 patients, it's also suitable to provide the BMI of normal population in New Orleans for comparison if possible.

Comment 3: The data of table 2 needs to be carefully corrected. For example, the meaning of the data in every parentheses made me confusing (e.g. in the first row of ED disposition : 134 (77) , 31 (72.1); however in the first row of Hospital admission: 310 (72.3), 41(57.7) ; the calculation method of each parentheses was inconsistent ! the inconsistency also noted in the sub-table of Procedures . Besides, the case numbers of hospital admission in Non-AMS group was 310+119=429 , but in the first row : Non-AMS (n=431), the authors should explain the discrepancy).

Comment 4:　In line 211-212 '... patients with AMS were less likely to be African American or have obesity...', but the authors didn't provide possible reasons for the differences. Besides, I wonder the body surface area might also differed between non-AMS and AMS groups.

Comment 5: According to fig 2, the AMS group was more likely to be intubated and needs mechanical ventilation, but in table 1, the respiratory symptoms of AMS group seemed to be less, especially ' Shortness of breath', this contradiction needs to be discussed.

**********

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: Yes: Chi-Hsiang Chou

[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: COVID-19-AMS.docx

PONE-D-21-02993R1

Altered mental status is a predictor of poor outcomes in COVID-19 patients: A cohort study

PLOS ONE

Dear Dr. Aboueisha,

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 Jun 20 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,

Tai-Heng Chen, M.D.

Academic Editor

PLOS ONE

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)

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: (No Response)

Reviewer #2: Partly

**********

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

Reviewer #1: (No Response)

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: (No Response)

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 Response)

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: I did not find "Author's response to reviewer recommendation".

My comments were as follows

In this study, authors investigated the association between altered mental status and outcomes in COVID- 19 patients. They found that patients with altered mental status had poor outcomes compared to those patients without altered mental status. Despite the results, I think that there are some concerns.

1. The altered mental status is a vague term and definition. Please clarify the definition of altered mental status.

2. Depth of sedation could be related to altered mental status. Please provide the information of sedative agents.

3. Please provide the causes of altered mental status such as seizure, sepsis associated encephalopathy, metabolic encephalopathy and stroke.

4. When did evaluate the altered mental status during hospitalization? Please provide this information.

Reviewer #2: Comment 1:In the line 81 and 82, 'Patients were divided into two groups: with and

without altered mental status (AMS).' The definition of AMS was not clear. In order to

get a more objective results, an operational definition for AMS is essential.

Author Response Thank you for the comment. The Definition has been clarified in the

manuscript and it is as following: altered mental status (AMS) which encompasses

confusion, amnesia, loss of alertness, disorientation, defects in judgment or thought,

unusual or strange behavior, poor regulation of emotions, and disruptions in

perception, psychomotor skills, and behavior. Line (82-85)

Responses 1: Although the authors described ‘altered mental status (AMS)’ in detail, it’s still difficult to practice in real world. The contents in Line (82-85) were only ‘descriptions’ of AMS, not ‘definitions’. In my opinion, it might be better to use the scores of Glasgow Coma Scale (GCS). In this way, we will be able to quantify AMS. It would also be easier for the audience to realize.

Comment 2:In the line 109 and 110, '...(BMI) was 33.32...with 57.2% being obese and

24.7 being overweight.' It's better to more clearly define 'obese' and 'overweight' . In

addition, obesity is a critical issue for COVID-19 patients, it's also suitable to provide

the BMI of normal population in New Orleans for comparison if possible.

Author Response Thank you for pointing this out. We agree with this comment.

Therefore, we have added the definition of the Obesity and overweight in the results.

(line114,115)

The % of Obese population in Louisiana has been added to the discussion where our

cohort had higher percentage of obese patient than the average of Louisiana

population. Changes has been marked in the manuscript. (215-217)

Responses 2: Agree.

Comment 3(A):The dat of table 2 needs to be carefully corrected. For example, the

meaning of the data in every parentheses made me confusing (e.g. in the first row of

ED disposition: 134 (77) , 31 (72.1); however in the first row of Hospital admission:

310 (72.3), 41(57.7) ; the calculation method of each parentheses was inconsistent !

the inconsistency also noted in the sub-table of Procedures .

Author Response Thank you for pointing this out. The ED depositions data account for patients how came through the Emergency Room a total of 166 in non AMS and 43 for AMS and between the parentheses represent the (%) of the ER cases but these datadon’t show any significance, so it was removed to avoid any confusion. (table 2)

Response 3(A): Agree.

Comment 3(B)the calculation method of each parentheses was inconsistent! the

inconsistency also noted in the sub-table of Procedures

Author Response Thank you for pointing this out. The data has been clarified in the

table caption. The data for the Extubation were calculated based on intubated patients and the no. of patients requiring reintubation were based on the no. of extubated patients. (Table 2)

Response 3(B): Agree.

Comment 3(C)Besides, the case numbers of hospital admission in Non-AMS group

was 310+119=429, but in the first row: Non-AMS (n=431), the authors should explain

the discrepancy).

Author response:Thank you for pointing this out. Revising our data showed it was a

Clerical error. The correct no. is 431 in the Non-AMS group divided into Floor admission (312) and ICU (119) (table 2)

Response 3(C): Floor admission was still 310 in table 2. This should be corrected.

Comment 4: In line 211-212 '... patients with AMS were less likely to be African

American or have obesity...', but the authors didn't provide possible reasons for the

differences.

B-Besides, I wonder the body surface area might also differed between non-AMS and

AMS groups.

Author response:

A-Thank You for raising such an important point, however. Our Data could not explain

why the AMS patients were less likely to be African or have obesity, but this

strengthens the argument that AMS may be an independent risk factor for poor health outcomes in COVID-19 patients. This point was added as one of the limitations in the study to be addressed by future research. Line (235)

Response 4(A): Agree.

B-We did not have access to the data for body surface area of the patients. So, we

cannot address this point.

Responses 4(B): Agree.

Comment 5:According to fig 2, the AMS group was more likely to be intubated and

needs mechanical ventilation, but in table 1, the respiratory symptoms of AMS group

seemed to be less, especially ' Shortness of breath', this contradiction needs to be

discussed.

Author Response:

We agree with this suggestion the contraindication could be explained due to the

decreased reporting of presenting complain with AMS Patients according to

Han JH, Bryce SN, Ely EW, et al. The effect of cognitive impairment on the accuracy of

the presenting complaint and discharge instruction comprehension in older emergency department patients. Annals of emergency medicine 2011;57(6):662-71.e2. doi:10.1016/j.annemergmed.2010.12.002 [published Online First: 2011/01/29].Amended in the discussion (199-201)

Responses 5: Agree.

**********

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: Yes: Chi-Hsiang Chou

[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-COV-19-Revised.docx

PONE-D-21-02993R2

Altered mental status is a predictor of poor outcomes in COVID-19 patients: A cohort study

PLOS ONE

Dear Dr. Aboueisha,

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 Sep 05 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,

Tai-Heng Chen, M.D.

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.

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: Partly

**********

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: Yes

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: Thank you for your revised manuscript.

Authors modified and updated the manuscript based on the reviewer's comments.

Reviewer #2: I suggested the authors to provide the Glasgow Coma Scale (GCS) score of the AMS patients previously. However, I still cannot get any GCS data by this revised article. I think this point needs to be well explained.

**********

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.

Altered mental status is a predictor of poor outcomes in COVID-19 patients: A cohort study

PONE-D-21-02993R3

Dear Dr. Aboueisha,

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,

Tai-Heng Chen, M.D.

Academic Editor

PLOS ONE

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

**********

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

**********

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

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 #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 #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 #2: The description "(9.41 ± 4.0815.00 ± 0.00, p<0.001)" on line 129-130 should be corrected. (I think the correct description might be "(9.41 ± 4.08 versus 15.00 ± 0.00, p<0.001)".

**********

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