Reviewer’s report
Title:  The influence of various distractions prior to upper gastrointestinal endoscopy: A Prospective
Randomized Controlled Study
Version: 3 Date: 15 Jul 2018
Reviewer: Thorsten Brechmann
Reviewer's report:
General impression:
The manuscript has improved, but the main limitation remains. The study does not investigate the
effect of the particular distractions on the EGD itself or on the assessment of the procedure after
endoscopy. The explanation is comprehensive, but does not improve the study or its implications. From
the psychological view it is more important what the subjects think about the distraction and the
endoscopy after the procedure, particularly several days later. For instance, this recall could have been
solved by a telephone call one week later.
Results:
The „impression of distraction" of the control group (resting and waiting) is not reported.
Discussion:
This section has improved, but still the whole section is narrative and lists several studies with similar
aims or study protocols. Instead, it would be more interesting to discuss the results of the present study
closely on the basis of other author's results. Furthermore, the author should hypothesise and explain
the  way of action.  Why does  music  or the  sequence  of naturalistic  images, and particularly the
combination of both, reduce anxiety and autonomous nerve function? Why does the combination work
better? What about other forms of distraction, i.e. reading a book? And finally, what is the positive
effect for the subject regarding EGD?
Language:
The editing of the English was limited to the points I have focussed during last review. Unfortunately,
the authors did not take the chance to review the whole manuscript and transfer it to British English, so
that in my point of view there are still a lot of offences against the English language, for instance:
Abstract: 
„… distractions for person who …" - I think it should read „… distractions for a person who …"
„… and the rate of decrease in P and diastolic blood pressure in group 4 was highest …"- I think it
should read „… and the rate of decrease in P and diastolic blood pressure was highest in group 4 …"
„… Several scores of POMS and the impression for upper GI endoscopy in post-distraction improved
significantly than that in predistraction in all distraction groups and the satisfaction for distraction in
group 4 was significantly better than any other group (p < 0.01)." This sentence needs profound editing.
„Regarding with autonomic nerve function, the low- frequency power/ high- frequency power ratio
post-distraction was significantly lower than that pre-distraction in all distraction groups (p < 0.001)." -
I think it should read „Regarding autonomic nerve function, the low-frequency power/ high-frequency
power ratio post-distraction was significantly lower than that pre-distraction in all distraction groups (p
< 0.001)."
Should it not read „auditive" instead of „audio"?
„Although audio distraction alone and visual distraction alone were effective, a combination distraction
was more effective than any other distraction as measured by subjective and objective assessments."
This sentence needs profound editing.
Introduction:
„Additionally, there have been few reports on the influence of distractions for person who is going to
undergo upper GI endoscopy soon using subjective and objective assessments …" - I think it should
read „Additionally, there have been few reports on the influence of distractions for a subject who is
going to undergo upper GI endoscopy soon using subjective and objective assessments …"
There are many more examples among the whole text body, but it is beyond the scope of the reviewer
to improve the language.
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
No
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 manuscript or would you recommend an
additional statistical review?
If an additional statistical review is recommended, please specify what aspects require further
assessment in your comments to the editors.
I am able to assess the statistics
Quality of written English
Please indicate the quality of language in the manuscript:
Not suitable for publication unless extensively edited
Declaration of competing interests
Please complete a declaration of competing interests, considering the following questions:
1. Have you in the past five years received reimbursements, fees, funding, or salary from an
organisation that may in any way gain or lose financially from the publication of this
manuscript, either now or in the future?
2. Do you hold any stocks or shares in an organisation that 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 you 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 interests 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.
I declare that I have no competing interests.
I agree to the open peer review policy of the journal. I understand that my name will be included
on my report to the authors and, if the manuscript is accepted for publication, my named report
including any attachments I upload will be posted on the website along with the authors'
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 included as confidential comments
to the editors, which will not be published.
I agree to the open peer review policy of the journal
Reviewer’s report
Title:  The influence of various distractions prior to upper gastrointestinal endoscopy: A Prospective
Randomized Controlled Study
Version: 3 Date: 15 Jul 2018
Reviewer: Thorsten Brechmann
Reviewer's report:
General impression:
The manuscript has improved, but the main limitation remains. The study does not investigate the
effect of the particular distractions on the EGD itself or on the assessment of the procedure after
endoscopy. The explanation is comprehensive, but does not improve the study or its implications. From
the psychological view it is more important what the subjects think about the distraction and the
endoscopy after the procedure, particularly several days later. For instance, this recall could have been
solved by a telephone call one week later.
Results:
The „impression of distraction" of the control group (resting and waiting) is not reported.
Discussion:
This section has improved, but still the whole section is narrative and lists several studies with similar
aims or study protocols. Instead, it would be more interesting to discuss the results of the present study
closely on the basis of other author's results. Furthermore, the author should hypothesise and explain
the  way of action.  Why does  music  or the  sequence  of naturalistic  images, and particularly the
combination of both, reduce anxiety and autonomous nerve function? Why does the combination work
better? What about other forms of distraction, i.e. reading a book? And finally, what is the positive
effect for the subject regarding EGD?
Language:
The editing of the English was limited to the points I have focussed during last review. Unfortunately,
the authors did not take the chance to review the whole manuscript and transfer it to British English, so
that in my point of view there are still a lot of offences against the English language, for instance:
Abstract: 
„… distractions for person who …" - I think it should read „… distractions for a person who …"
„… and the rate of decrease in P and diastolic blood pressure in group 4 was highest …"- I think it
should read „… and the rate of decrease in P and diastolic blood pressure was highest in group 4 …"
„… Several scores of POMS and the impression for upper GI endoscopy in post-distraction improved
significantly than that in predistraction in all distraction groups and the satisfaction for distraction in
group 4 was significantly better than any other group (p < 0.01)." This sentence needs profound editing.
„Regarding with autonomic nerve function, the low- frequency power/ high- frequency power ratio
post-distraction was significantly lower than that pre-distraction in all distraction groups (p < 0.001)." -
I think it should read „Regarding autonomic nerve function, the low-frequency power/ high-frequency
power ratio post-distraction was significantly lower than that pre-distraction in all distraction groups (p
< 0.001)."
Should it not read „auditive" instead of „audio"?
„Although audio distraction alone and visual distraction alone were effective, a combination distraction
was more effective than any other distraction as measured by subjective and objective assessments."
This sentence needs profound editing.
Introduction:
„Additionally, there have been few reports on the influence of distractions for person who is going to
undergo upper GI endoscopy soon using subjective and objective assessments …" - I think it should
read „Additionally, there have been few reports on the influence of distractions for a subject who is
going to undergo upper GI endoscopy soon using subjective and objective assessments …"
There are many more examples among the whole text body, but it is beyond the scope of the reviewer
to improve the language.
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
No
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 manuscript or would you recommend an
additional statistical review?
If an additional statistical review is recommended, please specify what aspects require further
assessment in your comments to the editors.
I am able to assess the statistics
Quality of written English
Please indicate the quality of language in the manuscript:
Not suitable for publication unless extensively edited
Declaration of competing interests
Please complete a declaration of competing interests, considering the following questions:
1. Have you in the past five years received reimbursements, fees, funding, or salary from an
organisation that may in any way gain or lose financially from the publication of this
manuscript, either now or in the future?
2. Do you hold any stocks or shares in an organisation that 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 you 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 interests 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.
I declare that I have no competing interests.
I agree to the open peer review policy of the journal. I understand that my name will be included
on my report to the authors and, if the manuscript is accepted for publication, my named report
including any attachments I upload will be posted on the website along with the authors'
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 included as confidential comments
to the editors, which will not be published.
I agree to the open peer review policy of the journal
Please review this paper.
user
Reviewer’s report
Title:  The influence of various distractions prior to upper gastrointestinal endoscopy: A Prospective
Randomized Controlled Study
Version: 3 Date: 15 Jul 2018
Reviewer: Thorsten Brechmann
Reviewer's report:
General impression:
The manuscript has improved, but the main limitation remains. The study does not investigate the
effect of the particular distractions on the EGD itself or on the assessment of the procedure after
endoscopy. The explanation is comprehensive, but does not improve the study or its implications. From
the psychological view it is more important what the subjects think about the distraction and the
endoscopy after the procedure, particularly several days later. For instance, this recall could have been
solved by a telephone call one week later.
Results:
The „impression of distraction" of the control group (resting and waiting) is not reported.
Discussion:
This section has improved, but still the whole section is narrative and lists several studies with similar
aims or study protocols. Instead, it would be more interesting to discuss the results of the present study
closely on the basis of other author's results. Furthermore, the author should hypothesise and explain
the  way of action.  Why does  music  or the  sequence  of naturalistic  images, and particularly the
combination of both, reduce anxiety and autonomous nerve function? Why does the combination work
better? What about other forms of distraction, i.e. reading a book? And finally, what is the positive
effect for the subject regarding EGD?
Language:
The editing of the English was limited to the points I have focussed during last review. Unfortunately,
the authors did not take the chance to review the whole manuscript and transfer it to British English, so
that in my point of view there are still a lot of offences against the English language, for instance:
Abstract: 
„… distractions for person who …" - I think it should read „… distractions for a person who …"
„… and the rate of decrease in P and diastolic blood pressure in group 4 was highest …"- I think it
should read „… and the rate of decrease in P and diastolic blood pressure was highest in group 4 …"
„… Several scores of POMS and the impression for upper GI endoscopy in post-distraction improved
significantly than that in predistraction in all distraction groups and the satisfaction for distraction in
group 4 was significantly better than any other group (p < 0.01)." This sentence needs profound editing.
„Regarding with autonomic nerve function, the low- frequency power/ high- frequency power ratio
post-distraction was significantly lower than that pre-distraction in all distraction groups (p < 0.001)." -
I think it should read „Regarding autonomic nerve function, the low-frequency power/ high-frequency
power ratio post-distraction was significantly lower than that pre-distraction in all distraction groups (p
< 0.001)."
Should it not read „auditive" instead of „audio"?
„Although audio distraction alone and visual distraction alone were effective, a combination distraction
was more effective than any other distraction as measured by subjective and objective assessments."
This sentence needs profound editing.
Introduction:
„Additionally, there have been few reports on the influence of distractions for person who is going to
undergo upper GI endoscopy soon using subjective and objective assessments …" - I think it should
read „Additionally, there have been few reports on the influence of distractions for a subject who is
going to undergo upper GI endoscopy soon using subjective and objective assessments …"
There are many more examples among the whole text body, but it is beyond the scope of the reviewer
to improve the language.
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
No
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 manuscript or would you recommend an
additional statistical review?
If an additional statistical review is recommended, please specify what aspects require further
assessment in your comments to the editors.
I am able to assess the statistics
Quality of written English
Please indicate the quality of language in the manuscript:
Not suitable for publication unless extensively edited
Declaration of competing interests
Please complete a declaration of competing interests, considering the following questions:
1. Have you in the past five years received reimbursements, fees, funding, or salary from an
organisation that may in any way gain or lose financially from the publication of this
manuscript, either now or in the future?
2. Do you hold any stocks or shares in an organisation that 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 you 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 interests 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.
I declare that I have no competing interests.
I agree to the open peer review policy of the journal. I understand that my name will be included
on my report to the authors and, if the manuscript is accepted for publication, my named report
including any attachments I upload will be posted on the website along with the authors'
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 included as confidential comments
to the editors, which will not be published.
I agree to the open peer review policy of the journal
assistant