Comparison of Automated Point-of-Care Gram Stainer (PoCGS^®) and Manual Staining

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The conclusion is too long and contains repetitive ideas, including a lot of references, which are inappropriate for this section. Phrases such as “as I mentioned above” should not be used. The conclusion should be structured in a much clearer and more concise manner. Many of the details presented are already included in the introduction and should be removed. Lines 312–313 state the obvious, and this information does not belong in the conclusion.

The plan for future studies using PoCGSR should be significantly more synthesized and clearly articulated. Additionally, the study’s limitations should be specified. The study involves clinical urine samples—why were only samples with a "cloudy appearance" selected? Could the results be influenced differently if the samples were hematuric or pyuric? These aspects should be explicitly mentioned.

Comments on the Quality of English Language

The academic language and overall quality of the English throughout the manuscript should be improved.

Author Response

Comments1

[The conclusion is too long and contains repetitive ideas, including a lot of references, which are inappropriate for this section. Phrases such as “as I mentioned above” should not be used. The conclusion should be structured in a much clearer and more concise manner. Many of the details presented are already included in the introduction and should be removed. Lines 312–313 state the obvious, and this information does not belong in the conclusion.

The plan for future studies using PoCGSR should be significantly more synthesized and clearly articulated. Additionally, the study’s limitations should be specified. The study involves clinical urine samples—why were only samples with a "cloudy appearance" selected? Could the results be influenced differently if the samples were hematuric or pyuric? These aspects should be explicitly mentioned.]

 

Response 1:

[Thank you for this valuable comment. We agree that the conclusion is too long and contains repetitive ideas. We have revised the conclusion to more clearly articulate a final, concise overview of the key findings of the study and their significance. We also mentioned the reason why we only used cloudy urine samples with cloudy appearance and limitations of the test. We plan to expand the scope of automated staining to other clinical samples such as sputum and pus, so we have described more more clearly in the conclusion.]

 

Comments 2

[The study involves clinical urine samples—why were only samples with a "cloudy appearance" selected? Could the results be influenced differently if the samples were hematuric or pyuric? These aspects should be explicitly mentioned.]

Response 2:

[We appreciate your valuable comment. As mentioned above, we have included it in the conclusion.]

 

Comments 3

[Comments on the Quality of English Language

The academic language and overall quality of the English throughout the manuscript should be improved.]

Response 3:

[We appreciate this pertinent comment. We have rewritten the manuscript with the help of a native English speaker.]

Reviewer 2 Report

Comments and Suggestions for Authors

Review of

Comparison of Automated Point-of-Care Gram Stainer 2 (PoCGS®) and Manual Staining.

Goh Ohji, Kenichiro Ohnuma, Kei Furui Ebisawa, Mari Kusuki, Shunkichi Ikegaki, Hiroaki Ozaki, Reiichi Ariizumi, Masakazu Nakajima, Makoto Taketani

The authors describe the evaluation of a novel, point-of-care device for performing single-slide Gram staining. They performed a preliminary evaluation of the device’s performance against both skilled and unskilled individuals. Although many issues are raised in the manuscript such as processing time, adaptation to various specimens, staining uniformity, and background clarity, the authors performed a thorough assessment of their development process by highlighting future steps. Overall, the language/grammar of the manuscript could be improved but the scientific conclusions are sound and supported by the data. This preliminary assessment of a novel device is the first step towards an improved product.

MAJOR COMMENTS

Line 117: The authors indicate that AI is integrated in PoCGS to facilitate clinical decision-making. However, the authors do not mention it further in the manuscript. Can the authors clarify whether PoCGS currently        analyzes slides on its own, or were all PoCGS-stained slide also observed by regular light microscopy under oil immersion?

Line 147: Could the authors provide more details/rephrase the rationale behind the placement of nozzles and why they are mostly duplicated? The rationale seems clear for methanol, i.e., placed in the center to avoid sample removal, but it’s not clear in this section why the other nozzles are where they are. Is it still to mimic a human performing the procedure, where one hand holds the slide and the other applies the reagent?

Line 174: The sentence refers to Figure 3, containing 4 panels (a, b, c, d). However, panels c) and d) seems to be missing. Then on line 176, the authors refer to Figure 3 again, so it appears a whole figure might be missing? If so, figure numbering needs to also be adjusted.

Line 223: This reviewer believes that the manuscript would benefit from the addition of typical staining images from each described category (GPC, GNR, yeasts, no organisms, etc.), compared to expert manual staining, complementing the missing figure that is described in the methods on Line 174.

Table 5: Could the authors clarify within the table itself which samples were clinical and which were artificial? It seems that 1-20 are clinical and 21-40 are artificial, but confirmation by the authors through an update of the table would be beneficial.

MINOR COMMENTS

Line 82: Could the authors clarify what is considered “large size” for readers that are not familiar with this type of equipment? Maybe provide a range for the most What does this mean in terms of footprint? This will give an idea of the size reduction achieved by the PoCGS, given the fact that the authors did provide dimensions for their system.

Line 182: Maybe this isn’t a journal requirement, but usually the IRB study number is disclosed in the methods’ section.

Line 186: Do the authors mean that the size of the slide is 7.6 x 2.6 cm, i.e., that the urine sample was spread across this whole surface? Also, shouldn’t the unit be “cm”? If the authors prefer using “cm2”, then they should write it as “19.76 cm2”.

Line 231: Typo in “nott”.

Table 5: This reviewer believes that Table 5 could benefit from the addition of two additional lines, where in one, the individual average score for each expert/non-expert/PoCGS is displayed, with a final line displaying the average score for grouped experts and non-experts. This way, the table would stand alone better and the reader would be able to rapidly assess the overall efficacy of each group.

Comments on the Quality of English Language

Language could be improved. While the introduction is near perfect, the discussion requires a major re-write as some points made by the authors were more difficult to follow.

Author Response

MAJOR COMMENTS

Comments 1: [Line 117: The authors indicate that AI is integrated in PoCGS to facilitate clinical decision-making. However, the authors do not mention it further in the manuscript. Can the authors clarify whether PoCGS currently        analyzes slides on its own, or were all PoCGS-stained slide also observed by regular light microscopy under oil immersion?]

Response 1: [We appreciate your suggestion on this point. AI integrated PoCGS is still under planning. Then we have deleted Line117 to Line119.]

Comments 2: [Line 147: Could the authors provide more details/rephrase the rationale behind the placement of nozzles and why they are mostly duplicated? The rationale seems clear for methanol, i.e., placed in the center to avoid sample removal, but it’s not clear in this section why the other nozzles are where they are. Is it still to mimic a human performing the procedure, where one hand holds the slide and the other applies the reagent?]

Response 2: [We appreciate your valuable comment on this point. We have rewritten from Line130 to Line151.]

Comments 3: [Line 174: The sentence refers to Figure 3, containing 4 panels (a, b, c, d). However, panels c) and d) seems to be missing. Then on line 176, the authors refer to Figure 3 again, so it appears a whole figure might be missing? If so, figure numbering needs to also be adjusted.]

Response 3: [We appreciate your comment. Yes, the entire Figure 3 is missing, and "Figure 3" on Line 176 should be "Figure 4".  We have added Figure 3 (a, b, c, d) and corrected the sentence on Line 176 (now 181).]

Comments 4: [Line 223: This reviewer believes that the manuscript would benefit from the addition of typical staining images from each described category (GPC, GNR, yeasts, no organisms, etc.), compared to expert manual staining, complementing the missing figure that is described in the methods on Line 174.]

Response 4: [We appreciate your valuable suggestion.The new Figure 3 shows the images of GNR and GPC stained by PoCGS and the experts.]

Comments 5: [Table 5: Could the authors clarify within the table itself which samples were clinical and which were artificial? It seems that 1-20 are clinical and 21-40 are artificial, but confirmation by the authors through an update of the table would be beneficial.]

Response 5: [We appreciate this valuable comment. Yes, you are right and we have added a sentence to the table legend to describe this.]

 

MINOR COMMENTS

Comments 6: [Line 82: Could the authors clarify what is considered “large size” for readers that are not familiar with this type of equipment? Maybe provide a range for the most What does this mean in terms of footprint? This will give an idea of the size reduction achieved by the PoCGS, given the fact that the authors did provide dimensions for their system.]

Response 6: [Thank you for your suggestion. We have added the size of one of the two systems we mentioned.]

Comments 7: [Line 182: Maybe this isn’t a journal requirement, but usually the IRB study number is disclosed in the methods’ section.]

Response 7: [We appreciate your comment. We have added the IRB number.]

Comments 8: [Line 186: Do the authors mean that the size of the slide is 7.6 x 2.6 cm, i.e., that the urine sample was spread across this whole surface? Also, shouldn’t the unit be “cm”? If the authors prefer using “cm2”, then they should write it as “19.76 cm2”]

Response 8: [We appreciate your comment.We have corrected “cm2” to “cm”.]

 

Comments 9: [Line 231: Typo in “nott”]

Response 9: [We appreciate for your comment. We have fixed the typo.]

Comments 10: [Table 5: This reviewer believes that Table 5 could benefit from the addition of two additional lines, where in one, the individual average score for each expert/non-expert/PoCGS is displayed, with a final line displaying the average score for grouped experts and non-experts. This way, the table would stand alone better and the reader would be able to rapidly assess the overall efficacy of each group.]

Response 10: [Thanks for your valuable suggestion. We have added two lines to Table 5.]

Comments 11: [Comments on the Quality of English Language. Language could be improved. While the introduction is near perfect, the discussion requires a major re-write as some points made by the authors were more difficult to follow.]

Response 11: [We appreciate your suggestion. We have rewritten the manuscript with the help of a native English speaker.]

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Some English expressions could be refined, such as 'we believe that there are no problems with these two bacterial forms.' Additionally, there are a few editorial and punctuation errors that should be corrected.

Author Response

[Comment 1: Some English expressions could be refined, such as 'we believe that there are no problems with these two bacterial forms.' ]

Response1: Thank you for your suggestion. We have rewritten from Line 297 to Line 302.

[Comment 2: Additionally, there are a few editorial and punctuation errors that should be corrected.]

Response2: We appreciate your suggestion. We have rewritten the manuscript again with the help of a native English speaker.