Reviewer ’s report  
 
Title: Indications and complications of intestinal stomas at a tertiary care hospital in a resource -
limited setting: A Tanzan ian experience  
 
Version: 3 Date: 31 Jan 2019  
 
Reviewer: Reviewer 2  
 
Reviewer's report:  
 
REVISION ASSESSMENT FROM THE ACADEMIC PEER REVIEWER:  
 
Has the author addressed your concerns s ufficiently for you to now recommend the work as a 
technically sound contribution? No  
 
Reviewer comments: Additional suggestions  
1. I would change the title a bit at the start to "Indications for and complications of —— " 
2. Background. Change to " An intes tinal aroma, though a lifesaving procedure on the care of 
many gastrointestinal conditions, carries —-" 
3. Page 2 line 22 change "and their management" to "and management of aromas"  
4 page 2 line 51 change to "the most frequent complication of a stoma" and  line 54 to " "the most 
frequent complication after stoma closure" and alter delete the word "about" and wrote out the 
word 35. Line 36 and page 3 line 4 the word "rank" is not ideal use the phrase "level of training" 
would be better  
5.page 3 line11 delet e the phrase "this study shows that"  
6. Page 3 line 19 change to "in the formation and complications of intestinal stomas are the 
following:"  
7 page 3 line 24 "specialists using change to "and specialists using proper meticulous techniques, 
and the need t o determine —-" 
 
8 page 4 line 7 put "has long been one of the more commonly performed" after the word "stoma"  
 
9. Page 4 line 55 change "colonies" to "colonic"  
 
10 page 5 line 11 add the word "patient" before the word "education"  
 
11. Page 7 lines 4 -6 change "cut circumferentially " to "completely transected"  
 
12. Page 7 line 9 Change "Vircyl" to " polyglactin" use the non -generic name  
 
13. Page 7 line 9 the sentence starting with "in this study" delete it this sentence makes no sen se 
 
14. Page 7 line 14 change to " under either direct or indirect ( by phone) supervision"  
 
15 page 7 line 38. Were the antibiotics given IV or orally?  
16. Page 7 line 38 the sentence starting with " Whereas in the majority" makes no sense, a loop 
colost omy is not divided.  
 
17. Page 8 line 47 add the phrase  ( + \-standard deviation) after the word "mean"  
 
18. Page 9 line 11 too many significant figures change 3.72 to 3.7 and 1.38 to 1.4 also line 14 
add the word "children" after the word "those"  
 
19. Page  9 Line 50 delete the phrase "had double barreled colostomy" because it was in the start  
of that same  sentence and on line 50 add the phrase "performing these colostomies" after the 
word "surgeons". With this the last 2 sentences in this paragraph are un necessary.  
 
20. Page 10 line 7 reword to complications related to stoma formation  
 
21. Page 10 line 11 drop the word "About" because you give an exact number  
 
22. Page 10 lines 15 -23 wouldn't it be better to report the %complications in each type of stoma 
for instance  33 complications developed in the Xnumber of patients who had a sigmoid 
colostomy rather than the % of complications that occurred in the sigmoid colostomy of all the 
complications. More important is the %  that occurs in each type of colosto my 
 
23. Page 10 line 23 -30 add the actual percentages here because this OS THE PRIMARY 
FINDING OF YOUR PAPER!!!  
 
Page 10 lines 42 -49 which type of stoma (% ) has the greatest rate of need for revision?  
 
24. Page 11 line 19 is 33% correct with only 2 patients that suggests that there were only 6 total 
patients  
 
25. Page 11 line 40 I would add the phrase ( through the stoma site" after the word 
"extraperitoneally) and the phrase " via a formal laparotomy" a t the end of the sentence.  
 
26. After reading the results section, nowhere do you describe the policy that at night, the 
majority of operations were done by junior colors without direct supervision by specialists - I 
know that you are going to high light th is in the discussion but somewhere you should mention 
this in more depth.  
 
27. First paragraph of discussion the references 4 and 10 come from the developed world I would 
add that into the sentence where appropriate and when you review those papers again, be certain 
that they were not ONLY adults!!!! If so then say so and quite your mean age in adults as a 
comparison. The same holds true for references 3,11,and 12 in the next paragraph of these papers 
o let address adults the change your paragraph to only c ompare your adults and not I Claude the 
children of your study because the indications differ so radically between adults and children.  
 
28. Page 13 I really think that the discussion on page 13 lines 4 -19 is not helpful -these studies 
are most likely from  practices that are radically different from yours and thus comparison is not 
appropriate. Sorry but here is where your study will. be criticized!  
 
29. Page 13 line 32. Your % really is no different than that of Husain say they are similar.  
 
30. Page 13 li ne 39 I disagree. How many of these stomas created by junior doctors were at night 
when there was little of any direct supervision!!! This MUST be changed!  
 
31. Page 13 line 55 here you need to add a sentence like " in our study, another likely 
explanation  for the morbidity and mortality of emergency operations was that at night, the 
overwhelming majority of these operations were done by junior surgeons without any direct 
supervision by specialists. ISN'T THIS ONE OF YOUR PRIMARY FINDINGS????  
 
32. Page 14 l ine 26 add also extraperitoneal pathway of the existing stoma  
 
33.page 15 line 4 Add the word "item" after the word "Laparotomy"  
 
34. Page 15 line 31 maybe adding the phrase" who have not shown true objective proficiency in 
stoma construction " after the word "doctors"  
 
35. Page 15 line 49 was the rate much higher when done by junior doctors? If so then say so  
 
36. Page 16 line 45. If you really want to be strong and try to make a difference you can add this 
sentence after the word "operations".   " our s tudy provides direct  evidence that junior doctors 
who have not demonstrated objectively documented competence in creation and closure of 
stomas should never be allowed to do these operations without direct supervision by specialists, 
even in operations af ter hours and at night."  A strong statement but  that is what your study 
shows!  
 
37. Table 1 what was the etiology of. Peel perforation? Diverticulitis,  bowel obstruction? Add as 
a footnote  
 
   Tables  2 - 6  Round off all the percentages  
 
    Table 4 you need to add the total number of each type of stoma created in the 4th line of the 
table  
 
Finally as the authors you will need more help with the grammar and writing thisis well done but 
there are multiple places that the grammar and word u sage needs to be polished  the content I 
have addressed above but it still needs help with the writing that many/perhaps most journals 
may not offer  
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following ques tions:  
 
1. Have you in the past five years received reimbursements, f ees, funding, or salary from an 
organisation that may in any way gain or lose financial ly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or  shares in an organisation t hat may in any way gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
 
4. Have yo u received reimbursements, fees, funding, or salary from an organization that 
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing int erests in relation to this paper?  
If you can answer no to all of the above, write 'I declare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
This reviewer has been recruited by a partner organization, Research Square. Reviewers with 
declar ed or apparent competing interests are not utilized for these reviews. This reviewer has 
agreed to publication of their comments online under a Creative Commons Attribution License 
attributed to Research Square and was paid a small honorarium for completin g the review within 
a specified timeframe. Honoraria for reviews such as this are paid regardless of the reviewer 
recommendation.  
 
I agree to the open  peer review policy of the journal. I understan d that my name will be included 
on my report to the authors and, if the manuscript is accepted f or publication, my named report 
including any attachments I upload will be posted on the website along with the a uthors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be in cluded as confidential comments 
to the editor s, which wi ll not be published.   
 
I agree to the open peer review policy of the journal  
Reviewer ’s report  
 
Title: Indications and complications of intestinal stomas at a tertiary care hospital in a resource -
limited setting: A Tanzan ian experience  
 
Version: 3 Date: 31 Jan 2019  
 
Reviewer: Reviewer 2  
 
Reviewer's report:  
 
REVISION ASSESSMENT FROM THE ACADEMIC PEER REVIEWER:  
 
Has the author addressed your concerns s ufficiently for you to now recommend the work as a 
technically sound contribution? No  
 
Reviewer comments: Additional suggestions  
1. I would change the title a bit at the start to "Indications for and complications of —— " 
2. Background. Change to " An intes tinal aroma, though a lifesaving procedure on the care of 
many gastrointestinal conditions, carries —-" 
3. Page 2 line 22 change "and their management" to "and management of aromas"  
4 page 2 line 51 change to "the most frequent complication of a stoma" and  line 54 to " "the most 
frequent complication after stoma closure" and alter delete the word "about" and wrote out the 
word 35. Line 36 and page 3 line 4 the word "rank" is not ideal use the phrase "level of training" 
would be better  
5.page 3 line11 delet e the phrase "this study shows that"  
6. Page 3 line 19 change to "in the formation and complications of intestinal stomas are the 
following:"  
7 page 3 line 24 "specialists using change to "and specialists using proper meticulous techniques, 
and the need t o determine —-" 
 
8 page 4 line 7 put "has long been one of the more commonly performed" after the word "stoma"  
 
9. Page 4 line 55 change "colonies" to "colonic"  
 
10 page 5 line 11 add the word "patient" before the word "education"  
 
11. Page 7 lines 4 -6 change "cut circumferentially " to "completely transected"  
 
12. Page 7 line 9 Change "Vircyl" to " polyglactin" use the non -generic name  
 
13. Page 7 line 9 the sentence starting with "in this study" delete it this sentence makes no sen se 
 
14. Page 7 line 14 change to " under either direct or indirect ( by phone) supervision"  
 
15 page 7 line 38. Were the antibiotics given IV or orally?  
16. Page 7 line 38 the sentence starting with " Whereas in the majority" makes no sense, a loop 
colost omy is not divided.  
 
17. Page 8 line 47 add the phrase  ( + \-standard deviation) after the word "mean"  
 
18. Page 9 line 11 too many significant figures change 3.72 to 3.7 and 1.38 to 1.4 also line 14 
add the word "children" after the word "those"  
 
19. Page  9 Line 50 delete the phrase "had double barreled colostomy" because it was in the start  
of that same  sentence and on line 50 add the phrase "performing these colostomies" after the 
word "surgeons". With this the last 2 sentences in this paragraph are un necessary.  
 
20. Page 10 line 7 reword to complications related to stoma formation  
 
21. Page 10 line 11 drop the word "About" because you give an exact number  
 
22. Page 10 lines 15 -23 wouldn't it be better to report the %complications in each type of stoma 
for instance  33 complications developed in the Xnumber of patients who had a sigmoid 
colostomy rather than the % of complications that occurred in the sigmoid colostomy of all the 
complications. More important is the %  that occurs in each type of colosto my 
 
23. Page 10 line 23 -30 add the actual percentages here because this OS THE PRIMARY 
FINDING OF YOUR PAPER!!!  
 
Page 10 lines 42 -49 which type of stoma (% ) has the greatest rate of need for revision?  
 
24. Page 11 line 19 is 33% correct with only 2 patients that suggests that there were only 6 total 
patients  
 
25. Page 11 line 40 I would add the phrase ( through the stoma site" after the word 
"extraperitoneally) and the phrase " via a formal laparotomy" a t the end of the sentence.  
 
26. After reading the results section, nowhere do you describe the policy that at night, the 
majority of operations were done by junior colors without direct supervision by specialists - I 
know that you are going to high light th is in the discussion but somewhere you should mention 
this in more depth.  
 
27. First paragraph of discussion the references 4 and 10 come from the developed world I would 
add that into the sentence where appropriate and when you review those papers again, be certain 
that they were not ONLY adults!!!! If so then say so and quite your mean age in adults as a 
comparison. The same holds true for references 3,11,and 12 in the next paragraph of these papers 
o let address adults the change your paragraph to only c ompare your adults and not I Claude the 
children of your study because the indications differ so radically between adults and children.  
 
28. Page 13 I really think that the discussion on page 13 lines 4 -19 is not helpful -these studies 
are most likely from  practices that are radically different from yours and thus comparison is not 
appropriate. Sorry but here is where your study will. be criticized!  
 
29. Page 13 line 32. Your % really is no different than that of Husain say they are similar.  
 
30. Page 13 li ne 39 I disagree. How many of these stomas created by junior doctors were at night 
when there was little of any direct supervision!!! This MUST be changed!  
 
31. Page 13 line 55 here you need to add a sentence like " in our study, another likely 
explanation  for the morbidity and mortality of emergency operations was that at night, the 
overwhelming majority of these operations were done by junior surgeons without any direct 
supervision by specialists. ISN'T THIS ONE OF YOUR PRIMARY FINDINGS????  
 
32. Page 14 l ine 26 add also extraperitoneal pathway of the existing stoma  
 
33.page 15 line 4 Add the word "item" after the word "Laparotomy"  
 
34. Page 15 line 31 maybe adding the phrase" who have not shown true objective proficiency in 
stoma construction " after the word "doctors"  
 
35. Page 15 line 49 was the rate much higher when done by junior doctors? If so then say so  
 
36. Page 16 line 45. If you really want to be strong and try to make a difference you can add this 
sentence after the word "operations".   " our s tudy provides direct  evidence that junior doctors 
who have not demonstrated objectively documented competence in creation and closure of 
stomas should never be allowed to do these operations without direct supervision by specialists, 
even in operations af ter hours and at night."  A strong statement but  that is what your study 
shows!  
 
37. Table 1 what was the etiology of. Peel perforation? Diverticulitis,  bowel obstruction? Add as 
a footnote  
 
   Tables  2 - 6  Round off all the percentages  
 
    Table 4 you need to add the total number of each type of stoma created in the 4th line of the 
table  
 
Finally as the authors you will need more help with the grammar and writing thisis well done but 
there are multiple places that the grammar and word u sage needs to be polished  the content I 
have addressed above but it still needs help with the writing that many/perhaps most journals 
may not offer  
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following ques tions:  
 
1. Have you in the past five years received reimbursements, f ees, funding, or salary from an 
organisation that may in any way gain or lose financial ly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or  shares in an organisation t hat may in any way gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
 
4. Have yo u received reimbursements, fees, funding, or salary from an organization that 
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing int erests in relation to this paper?  
If you can answer no to all of the above, write 'I declare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
This reviewer has been recruited by a partner organization, Research Square. Reviewers with 
declar ed or apparent competing interests are not utilized for these reviews. This reviewer has 
agreed to publication of their comments online under a Creative Commons Attribution License 
attributed to Research Square and was paid a small honorarium for completin g the review within 
a specified timeframe. Honoraria for reviews such as this are paid regardless of the reviewer 
recommendation.  
 
I agree to the open  peer review policy of the journal. I understan d that my name will be included 
on my report to the authors and, if the manuscript is accepted f or publication, my named report 
including any attachments I upload will be posted on the website along with the a uthors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be in cluded as confidential comments 
to the editor s, which wi ll not be published.   
 
I agree to the open peer review policy of the journal  
Please review this paper.
user
Reviewer ’s report  
 
Title: Indications and complications of intestinal stomas at a tertiary care hospital in a resource -
limited setting: A Tanzan ian experience  
 
Version: 3 Date: 31 Jan 2019  
 
Reviewer: Reviewer 2  
 
Reviewer's report:  
 
REVISION ASSESSMENT FROM THE ACADEMIC PEER REVIEWER:  
 
Has the author addressed your concerns s ufficiently for you to now recommend the work as a 
technically sound contribution? No  
 
Reviewer comments: Additional suggestions  
1. I would change the title a bit at the start to "Indications for and complications of —— " 
2. Background. Change to " An intes tinal aroma, though a lifesaving procedure on the care of 
many gastrointestinal conditions, carries —-" 
3. Page 2 line 22 change "and their management" to "and management of aromas"  
4 page 2 line 51 change to "the most frequent complication of a stoma" and  line 54 to " "the most 
frequent complication after stoma closure" and alter delete the word "about" and wrote out the 
word 35. Line 36 and page 3 line 4 the word "rank" is not ideal use the phrase "level of training" 
would be better  
5.page 3 line11 delet e the phrase "this study shows that"  
6. Page 3 line 19 change to "in the formation and complications of intestinal stomas are the 
following:"  
7 page 3 line 24 "specialists using change to "and specialists using proper meticulous techniques, 
and the need t o determine —-" 
 
8 page 4 line 7 put "has long been one of the more commonly performed" after the word "stoma"  
 
9. Page 4 line 55 change "colonies" to "colonic"  
 
10 page 5 line 11 add the word "patient" before the word "education"  
 
11. Page 7 lines 4 -6 change "cut circumferentially " to "completely transected"  
 
12. Page 7 line 9 Change "Vircyl" to " polyglactin" use the non -generic name  
 
13. Page 7 line 9 the sentence starting with "in this study" delete it this sentence makes no sen se 
 
14. Page 7 line 14 change to " under either direct or indirect ( by phone) supervision"  
 
15 page 7 line 38. Were the antibiotics given IV or orally?  
16. Page 7 line 38 the sentence starting with " Whereas in the majority" makes no sense, a loop 
colost omy is not divided.  
 
17. Page 8 line 47 add the phrase  ( + \-standard deviation) after the word "mean"  
 
18. Page 9 line 11 too many significant figures change 3.72 to 3.7 and 1.38 to 1.4 also line 14 
add the word "children" after the word "those"  
 
19. Page  9 Line 50 delete the phrase "had double barreled colostomy" because it was in the start  
of that same  sentence and on line 50 add the phrase "performing these colostomies" after the 
word "surgeons". With this the last 2 sentences in this paragraph are un necessary.  
 
20. Page 10 line 7 reword to complications related to stoma formation  
 
21. Page 10 line 11 drop the word "About" because you give an exact number  
 
22. Page 10 lines 15 -23 wouldn't it be better to report the %complications in each type of stoma 
for instance  33 complications developed in the Xnumber of patients who had a sigmoid 
colostomy rather than the % of complications that occurred in the sigmoid colostomy of all the 
complications. More important is the %  that occurs in each type of colosto my 
 
23. Page 10 line 23 -30 add the actual percentages here because this OS THE PRIMARY 
FINDING OF YOUR PAPER!!!  
 
Page 10 lines 42 -49 which type of stoma (% ) has the greatest rate of need for revision?  
 
24. Page 11 line 19 is 33% correct with only 2 patients that suggests that there were only 6 total 
patients  
 
25. Page 11 line 40 I would add the phrase ( through the stoma site" after the word 
"extraperitoneally) and the phrase " via a formal laparotomy" a t the end of the sentence.  
 
26. After reading the results section, nowhere do you describe the policy that at night, the 
majority of operations were done by junior colors without direct supervision by specialists - I 
know that you are going to high light th is in the discussion but somewhere you should mention 
this in more depth.  
 
27. First paragraph of discussion the references 4 and 10 come from the developed world I would 
add that into the sentence where appropriate and when you review those papers again, be certain 
that they were not ONLY adults!!!! If so then say so and quite your mean age in adults as a 
comparison. The same holds true for references 3,11,and 12 in the next paragraph of these papers 
o let address adults the change your paragraph to only c ompare your adults and not I Claude the 
children of your study because the indications differ so radically between adults and children.  
 
28. Page 13 I really think that the discussion on page 13 lines 4 -19 is not helpful -these studies 
are most likely from  practices that are radically different from yours and thus comparison is not 
appropriate. Sorry but here is where your study will. be criticized!  
 
29. Page 13 line 32. Your % really is no different than that of Husain say they are similar.  
 
30. Page 13 li ne 39 I disagree. How many of these stomas created by junior doctors were at night 
when there was little of any direct supervision!!! This MUST be changed!  
 
31. Page 13 line 55 here you need to add a sentence like " in our study, another likely 
explanation  for the morbidity and mortality of emergency operations was that at night, the 
overwhelming majority of these operations were done by junior surgeons without any direct 
supervision by specialists. ISN'T THIS ONE OF YOUR PRIMARY FINDINGS????  
 
32. Page 14 l ine 26 add also extraperitoneal pathway of the existing stoma  
 
33.page 15 line 4 Add the word "item" after the word "Laparotomy"  
 
34. Page 15 line 31 maybe adding the phrase" who have not shown true objective proficiency in 
stoma construction " after the word "doctors"  
 
35. Page 15 line 49 was the rate much higher when done by junior doctors? If so then say so  
 
36. Page 16 line 45. If you really want to be strong and try to make a difference you can add this 
sentence after the word "operations".   " our s tudy provides direct  evidence that junior doctors 
who have not demonstrated objectively documented competence in creation and closure of 
stomas should never be allowed to do these operations without direct supervision by specialists, 
even in operations af ter hours and at night."  A strong statement but  that is what your study 
shows!  
 
37. Table 1 what was the etiology of. Peel perforation? Diverticulitis,  bowel obstruction? Add as 
a footnote  
 
   Tables  2 - 6  Round off all the percentages  
 
    Table 4 you need to add the total number of each type of stoma created in the 4th line of the 
table  
 
Finally as the authors you will need more help with the grammar and writing thisis well done but 
there are multiple places that the grammar and word u sage needs to be polished  the content I 
have addressed above but it still needs help with the writing that many/perhaps most journals 
may not offer  
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following ques tions:  
 
1. Have you in the past five years received reimbursements, f ees, funding, or salary from an 
organisation that may in any way gain or lose financial ly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or  shares in an organisation t hat may in any way gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
 
4. Have yo u received reimbursements, fees, funding, or salary from an organization that 
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing int erests in relation to this paper?  
If you can answer no to all of the above, write 'I declare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
This reviewer has been recruited by a partner organization, Research Square. Reviewers with 
declar ed or apparent competing interests are not utilized for these reviews. This reviewer has 
agreed to publication of their comments online under a Creative Commons Attribution License 
attributed to Research Square and was paid a small honorarium for completin g the review within 
a specified timeframe. Honoraria for reviews such as this are paid regardless of the reviewer 
recommendation.  
 
I agree to the open  peer review policy of the journal. I understan d that my name will be included 
on my report to the authors and, if the manuscript is accepted f or publication, my named report 
including any attachments I upload will be posted on the website along with the a uthors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be in cluded as confidential comments 
to the editor s, which wi ll not be published.   
 
I agree to the open peer review policy of the journal  
assistant