Reviewer’s report
Title:  The influence of various distractions prior to upper gastrointestinal endoscopy: A Prospective
Randomized Controlled Study
Version: 2 Date: 17 Jun 2018
Reviewer: Thorsten Brechmann
Reviewer's report:
Topic and design:
This  randomised cohort study investigates the emotional and autonomic effects of three different
distraction protocols before elective upper GI endoscopy without sedation. Patients were assigned to
either one of four different groups (control group, listening to music, watching TV, listening to music
and watching TV). Heart rate, blood pressure and oxygen saturation, autonomic nerve function and
mood were evaluated before and after the program. Emotional were evaluated by questionnaires.
In summary, all three interventions influenced the autonomous nerval function and soothed the patient
during the waiting period; the most beneficial effects occurred among the combination group (visual
and auditive program).
General impression:
The main limitation is the missing information about the effects of the particular distractions on the
endoscopy procedure itself (i.e. satisfaction of the patient and the endoscopist, rating of the endoscopy
results etc.) and the patient's perception (i.e. POMS after endoscopy). Therefore, the present study
shows that audiovisual distraction methods are capable to improve the mood and the autonomous body
function while waiting for the upcoming endoscopy.
For the endoscopist and the patient it is crucial to report and improve the perception of the procedure.
Therefore, the most interesting effect would have been that on the perception of the endoscopy. Were
there any differences of blood pressure or heart rate, of pain, anxiety or other emotional parameters
during endoscopy? How did the patients rate the endoscopic procedure?
Additionally, it would have been interesting whether the beneficial effects persist after endoscopy; a
recall, for instance one week later would have been interesting to investigate. Furthermore, the authors
should report the willingness to undergo endoscopy again and associates the rating with the distraction
programs.
Results:
Subjects who do not meet in- and exclusion criteria should not be included; probably they were
screened and/or regarded as eligible.
„The remaining 206 subjects were randomly assigned to 4 groups. Two questionnaires, the POMS and
the  impression  for  upper  GI  endoscopy,  were  conducted  out  pre-  and  post-distraction.  Last
questionnaire about impression of distraction was conducted after upper GI endoscopy." explains the
study design and should be deleted or located into Methods section.
What was the rating of the distraction in group 1 (see Table 5)?
Discussion:
The discussion section is too long, not focused enough and exhausting to read.
Language:
Since I am not a native speaker either I comment the language cautiously. Nevertheless, I have the
impression that the English is somewhat flawed.
Do people really „hope to receive a GI endoscopy"?
„The mean experience number of upper GI endoscopy was 4.0 ± 3.4." - why not a stronger phrasing
using a full verb?
„Upper gastrointestinal (GI) endoscopy has become an indispensable examination to discovery upper
GI lesion." shall probably read „Upper gastrointestinal (GI) endoscopy has become an indispensable
examination to discover upper GI lesion."
Repetition of wording should be avoided, for instance 
„Strong anxiety before upper GI endoscopy may be a reason why some patients avoid undergoing
upper GI endoscopy."
„There was no significant difference in gender, age, the frequency of upper GI endoscopy, and the
duration of upper GI endoscopy among the 4 groups. There was no significant difference in the
baseline score of POMS and the impression for upper GI endoscopy among the 4 groups."
Some terms are unusual
why not „heart rate" (HR) instead of „pulse rate" (P)?
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.
No
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:
Needs some language corrections before being published
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 have no competing interests to declare.
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: 2 Date: 17 Jun 2018
Reviewer: Thorsten Brechmann
Reviewer's report:
Topic and design:
This  randomised cohort study investigates the emotional and autonomic effects of three different
distraction protocols before elective upper GI endoscopy without sedation. Patients were assigned to
either one of four different groups (control group, listening to music, watching TV, listening to music
and watching TV). Heart rate, blood pressure and oxygen saturation, autonomic nerve function and
mood were evaluated before and after the program. Emotional were evaluated by questionnaires.
In summary, all three interventions influenced the autonomous nerval function and soothed the patient
during the waiting period; the most beneficial effects occurred among the combination group (visual
and auditive program).
General impression:
The main limitation is the missing information about the effects of the particular distractions on the
endoscopy procedure itself (i.e. satisfaction of the patient and the endoscopist, rating of the endoscopy
results etc.) and the patient's perception (i.e. POMS after endoscopy). Therefore, the present study
shows that audiovisual distraction methods are capable to improve the mood and the autonomous body
function while waiting for the upcoming endoscopy.
For the endoscopist and the patient it is crucial to report and improve the perception of the procedure.
Therefore, the most interesting effect would have been that on the perception of the endoscopy. Were
there any differences of blood pressure or heart rate, of pain, anxiety or other emotional parameters
during endoscopy? How did the patients rate the endoscopic procedure?
Additionally, it would have been interesting whether the beneficial effects persist after endoscopy; a
recall, for instance one week later would have been interesting to investigate. Furthermore, the authors
should report the willingness to undergo endoscopy again and associates the rating with the distraction
programs.
Results:
Subjects who do not meet in- and exclusion criteria should not be included; probably they were
screened and/or regarded as eligible.
„The remaining 206 subjects were randomly assigned to 4 groups. Two questionnaires, the POMS and
the  impression  for  upper  GI  endoscopy,  were  conducted  out  pre-  and  post-distraction.  Last
questionnaire about impression of distraction was conducted after upper GI endoscopy." explains the
study design and should be deleted or located into Methods section.
What was the rating of the distraction in group 1 (see Table 5)?
Discussion:
The discussion section is too long, not focused enough and exhausting to read.
Language:
Since I am not a native speaker either I comment the language cautiously. Nevertheless, I have the
impression that the English is somewhat flawed.
Do people really „hope to receive a GI endoscopy"?
„The mean experience number of upper GI endoscopy was 4.0 ± 3.4." - why not a stronger phrasing
using a full verb?
„Upper gastrointestinal (GI) endoscopy has become an indispensable examination to discovery upper
GI lesion." shall probably read „Upper gastrointestinal (GI) endoscopy has become an indispensable
examination to discover upper GI lesion."
Repetition of wording should be avoided, for instance 
„Strong anxiety before upper GI endoscopy may be a reason why some patients avoid undergoing
upper GI endoscopy."
„There was no significant difference in gender, age, the frequency of upper GI endoscopy, and the
duration of upper GI endoscopy among the 4 groups. There was no significant difference in the
baseline score of POMS and the impression for upper GI endoscopy among the 4 groups."
Some terms are unusual
why not „heart rate" (HR) instead of „pulse rate" (P)?
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.
No
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:
Needs some language corrections before being published
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 have no competing interests to declare.
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: 2 Date: 17 Jun 2018
Reviewer: Thorsten Brechmann
Reviewer's report:
Topic and design:
This  randomised cohort study investigates the emotional and autonomic effects of three different
distraction protocols before elective upper GI endoscopy without sedation. Patients were assigned to
either one of four different groups (control group, listening to music, watching TV, listening to music
and watching TV). Heart rate, blood pressure and oxygen saturation, autonomic nerve function and
mood were evaluated before and after the program. Emotional were evaluated by questionnaires.
In summary, all three interventions influenced the autonomous nerval function and soothed the patient
during the waiting period; the most beneficial effects occurred among the combination group (visual
and auditive program).
General impression:
The main limitation is the missing information about the effects of the particular distractions on the
endoscopy procedure itself (i.e. satisfaction of the patient and the endoscopist, rating of the endoscopy
results etc.) and the patient's perception (i.e. POMS after endoscopy). Therefore, the present study
shows that audiovisual distraction methods are capable to improve the mood and the autonomous body
function while waiting for the upcoming endoscopy.
For the endoscopist and the patient it is crucial to report and improve the perception of the procedure.
Therefore, the most interesting effect would have been that on the perception of the endoscopy. Were
there any differences of blood pressure or heart rate, of pain, anxiety or other emotional parameters
during endoscopy? How did the patients rate the endoscopic procedure?
Additionally, it would have been interesting whether the beneficial effects persist after endoscopy; a
recall, for instance one week later would have been interesting to investigate. Furthermore, the authors
should report the willingness to undergo endoscopy again and associates the rating with the distraction
programs.
Results:
Subjects who do not meet in- and exclusion criteria should not be included; probably they were
screened and/or regarded as eligible.
„The remaining 206 subjects were randomly assigned to 4 groups. Two questionnaires, the POMS and
the  impression  for  upper  GI  endoscopy,  were  conducted  out  pre-  and  post-distraction.  Last
questionnaire about impression of distraction was conducted after upper GI endoscopy." explains the
study design and should be deleted or located into Methods section.
What was the rating of the distraction in group 1 (see Table 5)?
Discussion:
The discussion section is too long, not focused enough and exhausting to read.
Language:
Since I am not a native speaker either I comment the language cautiously. Nevertheless, I have the
impression that the English is somewhat flawed.
Do people really „hope to receive a GI endoscopy"?
„The mean experience number of upper GI endoscopy was 4.0 ± 3.4." - why not a stronger phrasing
using a full verb?
„Upper gastrointestinal (GI) endoscopy has become an indispensable examination to discovery upper
GI lesion." shall probably read „Upper gastrointestinal (GI) endoscopy has become an indispensable
examination to discover upper GI lesion."
Repetition of wording should be avoided, for instance 
„Strong anxiety before upper GI endoscopy may be a reason why some patients avoid undergoing
upper GI endoscopy."
„There was no significant difference in gender, age, the frequency of upper GI endoscopy, and the
duration of upper GI endoscopy among the 4 groups. There was no significant difference in the
baseline score of POMS and the impression for upper GI endoscopy among the 4 groups."
Some terms are unusual
why not „heart rate" (HR) instead of „pulse rate" (P)?
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.
No
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:
Needs some language corrections before being published
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 have no competing interests to declare.
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