Nurse-Led Microsurgical Free Flap Monitoring: A Scoping Review and Evidence-Based Framework

Round 1

Reviewer 1 Report (Previous Reviewer 1)

Comments and Suggestions for Authors

The authors revised the manuscript and resubmitted. The method of scoping review is appropriate. I have no other suggestions.  

Author Response

Response to Reviewer 1:

The authors revised the manuscript and resubmitted. The method of scoping review is appropriate. I have no other suggestions.  

Response: I am deeply grateful to Reviewer 1 for the thoughtful and constructive guidance provided during the initial review. Your critical feedback—particularly regarding the ambiguous objectives, methodological limitations, and the need for a more cohesive framework—was instrumental in prompting the fundamental transformation of this manuscript from a systematic review to a scoping review.

This strategic shift, which you have now recognized as appropriate, has resulted in a significantly stronger and more coherent piece of work.

I sincerely appreciate your recognition that the revised methodology is suitable, and I am thankful for your confirmation that no further revisions are needed.

Your rigorous review has been invaluable in elevating the quality of this research.

Thank you.

Reviewer 2 Report (New Reviewer)

Comments and Suggestions for Authors

Full replacement

REPLACE lines 89–99 WITH:

Objective. To systematically map the evidence on nurse involvement in postoperative free-flap monitoring and synthesize the core components required for implementation.
Scope. We targeted four domains: (1) educational/competency frameworks; (2) monitoring protocols; (3) technology selection and use; and (4) organizational factors.
Rationale. Heterogeneous, locally successful practices lack reproducible standards (“standardization gap”), limiting wider adoption.
Design choice. A JBI/PRISMA-ScR scoping approach was used to capture diverse study designs and implementation details that preclude meta-analysis but are critical for practice transfer.

Intended output. An evidence-informed implementation framework specifying minimum competencies, protocol elements, technology criteria, and organizational supports to guide institutions establishing or optimizing nurse-led free-flap monitoring.

Compact version (best for Abstract)

Objective: To map evidence on nurse involvement in postoperative free-flap monitoring and identify essential implementation components. Domains: education/competencies, protocols, technology, and organizational factors. Design: JBI/PRISMA-ScR scoping review to accommodate heterogeneous evidence and extract implementation details. Deliverable: an evidence-informed implementation framework to support adoption and optimization of nurse-led flap monitoring.

Ultra-short

We conducted a JBI/PRISMA-ScR scoping review to map evidence on nurse involvement in postoperative free-flap monitoring and to distill implementation essentials across education, protocols, technology, and organizational supports. The output is an evidence-informed implementation framework to close the current standardization gap and aid institutional adoption.

Sampling frame clarity. Treat the sampling mechanism as the information-source frame: name all databases, coverage dates, language limits, grey-literature sources, and any hand-searching/citation chasing.

Eligibility accounting. Present the top exclusion reasons at full-text with counts (beyond the PRISMA flow), preferably in a small table.

Descriptive statistics. Summarize the included evidence with appropriate descriptives: Counts and percentages by study design, country/setting, clinical specialty, and publication year.

For numeric variables (e.g., sample sizes, monitoring frequency), report median [IQR] or mean (SD) as appropriate.

Search Strategy

Full search strings for PubMed/MEDLINE, CINAHL, and Cochrane, along with database coverage dates and the exact run date (September 13, 2024), are provided in Table S1; deduplication was performed in <tool>, removing 25 duplicates prior to screening.

• Study Selection

Two reviewers independently screened titles/abstracts and full texts; inter-rater agreement was quantified with Cohen’s κ, and discrepancies were resolved by discussion.

Table footnote

Abbreviations: ICU = Intensive Care Unit; QI = Quality Improvement; NR = Not Reported; N/A = Not Applicable; qxh = every x hours.

Results – PRISMA exclusion reasons

Detailed full-text exclusion reasons with counts are provided in Table S3.

Technical & Formatting Corrections

[DELETE] all in-text journal metadata lines (they belong in the template, not the manuscript body):

• Academic Editor(s): …
• Received/Revised/Accepted/Published …
• Citation: …
• Copyright: …
• Healthcare 2025, 13, x FOR PEER REVIEW …

[FIX] all hyphenated line breaks from pagination (e.g., achiev-ing, moni-toring, integra-tion, compre-hensive → achieving, monitoring, integration, comprehensive).

[STYLE] Use “free-flap” consistently (hyphenated), not “free flap.

[STYLE] Standardize statistical style: p = 0.27 (spaces around “=”, two decimals where appropriate). Keep oxygenation as StO2 consistently.

[STYLE] Use a uniform notation for frequencies: q1h, q2h, q4h, q12h and define once in a table footnote: “qxh = every x hours.”

Introduction

[DELETE] the epigraph/quote:“In the midst of chaos, there is also opportunity.” — Sun Tzu

[REPLACE] highly rhetorical phrases (e.g., “paradox,” “opportunity born from crisis,” “tomorrow’s gold standard”) with neutral scientific wording.

[ALIGN] End the Introduction with a compact block that states, in order:

• Objective → map nurse involvement in postoperative free-flap monitoring and synthesize implementation components.
• Scope → four domains: education/competency, protocols, technology, organizational factors.
• Rationale → address the standardization gap to enable reproducible adoption.
• Design → JBI/PRISMA-ScR scoping approach.
• Intended output → an evidence-informed implementation framework.

Methods

[ADD] to 2.5 Study Selection: state dual independent screening for titles/abstracts and full texts, report Cohen’s κ for agreement, and how disagreements were resolved.

[ADD] to 2.3 Search Strategy: provide full search strings for each database in Table S1 (PubMed/MEDLINE, CINAHL, Cochrane), specify the deduplication tool/workflow (e.g., EndNote/Rayyan/Covidence) and the number of duplicates removed (n = 25) here as well.

[ADD] to 2.6 Data Extraction: include the data-charting template as Table S2; indicate any pilot testing and/or double charting on a subset. [MOVE] the Artificial Intelligence Declaration to the Declarations section (e.g., Author Contributions/Declarations), per journal policy. Keep the text unchanged.

Results

[FIX] the stray heading: change Healthcare 3.2. Characteristics… to 3.2. Characteristics of Included Studies. [CHECK] PRISMA arithmetic for consistency across text, figure, and supplement:
214 identified → (–25) 189 screened → (–62) 127 sought → (–76) 51 assessed → (–39) 12 included.
[ADD] Table S3 listing top full-text exclusion reasons with counts.

[STANDARDIZE] in all tables: use consistent study-design labels (“Retrospective,” “Prospective cohort,” “Implementation study,” “Quality improvement (QI)”), fix broken hyphenations (e.g., interven-tion, compari-son, monitor-ing), and define all abbreviations in footnotes (ICU, NR, N/A, QI, qxh).

[CONSISTENCY] In Table 2 under “Key Findings/Other Outcomes,” harmonize syntax across rows (lead with the verb/result, then the implication).

Discussion

[TONE] Reduce “paradox” rhetoric; retain “standardization gap” as a technical term, not as dramatic framing.

[ADD] a brief paragraph on publication bias and a concrete future-research recommendation (multicenter, prospective implementation studies).

Use descriptive—not confirmatory—language.

• REPLACE “confirms/ demonstrates” → “suggests/ indicates/ is consistent with.”
• Example (paste): “The included studies suggest that well-structured nurse-led monitoring can achieve outcomes comparable to physician-intensive models in selected settings.”

Avoid implying equivalence without a design that tests it.

• REPLACE “non-inferior/ equivalent” with “comparable in reported outcomes” unless a priori non-inferiority methods were used.
• Example: “reported flap loss rates were comparable across monitoring models.”

Separate outcome evidence from implementation evidence.

• Make two short sub-conclusions: Clinical outcomes vs Implementation components.
• Example headings: “Outcomes signal” and “Implementation signal.”

Qualify generalizability.

• Add a sentence noting country mix, single-center dominance, and surgical subspecialty skew.
• Example: “Most evidence derives from single-center studies in a few health systems, which may limit generalizability to resource-constrained settings.”

Name key uncertainties explicitly.

• ADD a 1-sentence inventory (e.g., optimal nurse-to-patient ratio, frequency beyond 72h, escalation thresholds, competency verification).
• Example: “Uncertainties remain regarding optimal nurse-to-patient ratios, monitoring frequency after 72 hours, device-specific escalation thresholds, and competency verification methods.”

Reframe “paradox/ crisis → opportunity” rhetoric.

• REPLACE with neutral, data-anchored phrasing.
• Example: “Recent workforce constraints have accelerated interest in nurse-led monitoring models; the present synthesis maps the implementation elements underpinning such models.”

Tone down “first comprehensive roadmap.”

• REPLACE with “evidence-informed framework” or “consolidated synthesis.”
• Example: “This review proposes an evidence-informed implementation framework…”

• Acknowledge publication bias where you infer positives.
  • ADD one line: “The predominance of favorable reports and sparse adverse-event data suggest possible publication bias.”
• Be precise about technology claims.
  • Shift from “improves outcomes” to “supports assessment; outcome improvement is plausible but not proven across designs.”
  • Example: “Objective tools (implantable Doppler, tissue oximetry) support assessment and may reduce anxiety; consistent causal effects on flap outcomes were not established.”
• Anchor any numeric claims in counts and designs.
• When citing pooled ranges (e.g., success/salvage), mention the number of contributing studies and designs.
• Example: “Among nine retrospective and two prospective studies reporting outcomes, success rates ranged 94–100%.”

State what a scoping review can and cannot conclude.

• ADD: “As a scoping review, our synthesis is descriptive; it does not estimate pooled effects nor test comparative hypotheses.”

Link the 3-pillar framework to concrete, minimal actions.

• ADD 1–2 actionable bullets in the conclusion (e.g., “minimum competency checklist,” “escalation algorithm,” “device adoption criteria”).
• Example: “Institutions may start with: (i) a minimum competency checklist; (ii) a 0–72h escalation algorithm; (iii) device criteria with thresholds and alarm pathways.”

Make research implications testable.

• ADD a final sentence specifying study designs and outcomes for future work.
• Example: “Multicenter prospective implementation studies using standardized outcome definitions (time-to-detection, escalation fidelity, false-positive explorations, salvage success) are needed.”

Keep costs and feasibility in view.

• ADD one line acknowledging resource implications (staffing, equipment, training/maintenance).
• Example: “Adoption should consider local staffing, training capacity, and device acquisition/maintenance costs.”

Provide a compact, paste-ready conclusion paragraph.

Add a “Strengths” subheading (parallel to Limitations).

• Where: End of Discussion, immediately before Limitations (or merge as “Strengths and Limitations”).
• Paste-ready lead sentence:
  “Strengths. This review’s primary strengths lie in its implementation focus, methodological transparency, and direct practice relevance.”

State the novelty clearly and narrowly (implementation—not outcomes).

• Paste: “To our knowledge, this is the first scoping review to synthesize implementation components—education/competency, protocols, technology integration, and organizational supports—of nurse-led postoperative free-flap monitoring, moving beyond outcome-centric summaries.”

Emphasize rigorous, transparent methods (JBI/PRISMA-ScR).

• Paste: “We followed JBI methodology and PRISMA-ScR reporting, pre-specifying the PCC question, eligibility criteria, and data-charting processes to ensure methodological transparency and reproducibility.”

Highlight search coverage and reproducibility artifacts.

• Paste: “A comprehensive, multi-database search with no date or language limits, documented search strings (Table S1), deduplication counts, and a public data-charting template (Table S2) enhance replicability and auditability.”

Point to dual-review processes and reliability (if added as suggested).

• Paste: “Dual independent screening with agreement metrics (Cohen’s κ) and verified data extraction strengthen selection and extraction reliability.”

Underscore the actionable output (framework) and where it lives.

• Paste: “The review delivers an evidence-informed implementation framework that can be adopted stepwise by hospitals, operationalized via the protocol checklist (Table 3), technology taxonomy (Table 4), and implementation flow (Figure 3).”

Stress practice relevance amid workforce constraints.

• Paste: “By addressing the standardization gap in contexts with duty-hour and staffing constraints, our synthesis offers immediately usable guidance for safe redistribution of monitoring tasks.”

Note cross-setting generalizability cues (map/timeline/evidence map).

• Paste: “The evidence map (Figure 2) and regional/timeline summaries (Figure 4) clarify where and when components have been implemented, supporting context-sensitive adaptation across settings.”

Call out clarity and consistency of terminology.

• Paste: “Consistent definitions for monitoring frequency (q1h/q4h), escalation thresholds, and device roles reduce terminology ambiguity, facilitating training and protocol alignment.”

Position the work as a foundation for consensus.

• Paste: “By consolidating heterogeneous practices into a common structure, the review provides a foundation for consensus statements and minimum competency standards by professional societies.”

Quantify wherever possible (strengthen credibility).

• Paste: “We report study counts by design and setting, with numeric ranges for success/salvage outcomes and domain coverage, enabling readers to gauge evidence density and identify gaps.”

Finish with a tight, paste-ready “Strengths” paragraph.

• Paste:
  “Strengths. This review is the first to synthesize implementation essentials of nurse-led postoperative free-flap monitoring across four domains (education/competency, protocols, technology, organization). It adheres to JBI/PRISMA-ScR guidance with comprehensive searches, documented strategies (Table S1), transparent selection/extraction (including agreement metrics), and public data-charting materials (Table S2). The output is an evidence-informed implementation framework linked to practical tools—protocol checklist (Table 3), technology taxonomy (Table 4), and implementation flow (Figure 3)—that can be directly adapted by institutions facing duty-hour and staffing constraints. Evidence maps and regional/timeline summaries further support context-sensitive adoption and lay groundwork for future consensus standards.”

Tighten the Introduction (shorten by ~25–30%).

• Remove the epigraph and most rhetorical framing.
• Keep 4 short paragraphs: problem → constraints → emerging nurse-led model → objective/scope/design/output (as already drafted).

Add a mini “Aim & Scope” block at the end of the Introduction.

• Paste:
  “Objective. To map nurse involvement in postoperative free-flap monitoring and synthesize implementation components. Scope. Education/competency, protocols, technology, organizational factors. Design. JBI/PRISMA-ScR scoping review. An evidence-informed implementation framework.”

Reorganize Methods into standard subheadings (one screen each).

• 2.1 Design & Reporting (JBI/PRISMA-ScR)
• 2.2 PCC Question
• 2.3 Information Sources & Search (add Table S1 reference)
• 2.4 Eligibility Criteria
• 2.5 Study Selection (add dual screening, Cohen’s κ)
• 2.6 Data Charting (template = Table S2; pilot/duplicate extraction)
• 2.7 Synthesis Approach (narrative/evidence mapping; no quality appraisal)

Move the “Artificial Intelligence Declaration” from Methods to Declarations (end matter), per journal style.

Results: standardize sequence and signpost figures/tables inside the text.

• 3.1 Study Selection (end with “see Figure 1; full-text exclusions in Table S3”)
• 3.2 Study Characteristics (refer to Table 1)
• 3.3 Monitoring Protocols & Implementation (refer to Table 2)
• 3.4 Clinical Outcomes (explicit n of studies contributing each outcome)
• 3.5 Education & Competency (group the 4 studies; keep one sentence per study)
• 3.6 Themes (bullet or short subparagraphs; avoid repetition)

Add a “Strengths and Limitations” section (or distinct subheadings) immediately before Conclusions to balance interpretation.

Collapse overlapping narrative.

• If an item appears in both Results and Discussion (e.g., “equivalence of outcomes”), keep facts in Results; move interpretive framing (implications, feasibility) to Discussion only.

Create a “Practice Implications” subheading in Discussion (2–3 bullets max).

• Example bullets: minimum competency checklist; 0–72h escalation algorithm; device criteria.

Add a “Future Research” subheading with 2–3 testable items.

• Multicenter prospective implementation; standardized outcome set; cost/feasibility analyses.

Appendices/Supplement routing.

• Put full search strings (Table S1), data-charting template (Table S2), top exclusion reasons (Table S3), and any sensitivity summaries in Supplement to declutter main text.

Abbreviations list.

• Provide one consolidated list (ICU, QI, NR, N/A, StO2, qxh) after Conclusions or as a front-matter list, and define “qxh = every x hours” in table footnotes.

Cross-reference consistently.

• Each table/figure should be cited in the text before it appears; captions must be standalone (define all abbreviations there too).

 

Author Response

RESPONSE TO REVIEWER 2

I sincerely thank the reviewer for the extensive and detailed feedback. I appreciate the considerable time and effort invested in providing specific suggestions for improving the manuscript.

I have carefully considered each comment and have incorporated many of the substantive methodological suggestions that enhance transparency and rigor. Specifically, I have added comprehensive supplementary materials (Tables S1 and S2), enhanced methodological descriptions throughout the Methods section, and revised the Introduction to reduce overly rhetorical language.

However, some comments appear to reflect expectations more appropriate for systematic reviews or reflect conventions that differ from medical literature, particularly in plastic surgery and microsurgical fields. Where the reviewer's suggestions conflict with established medical terminology, field-specific conventions, or scoping review methodology, I provide detailed rationale for maintaining the original approach.

I hope this exchange has been mutually educational regarding the distinctive characteristics of scoping reviews versus systematic reviews, and the conventions of medical journals in specialized surgical fields. The revised manuscript has been substantially strengthened in methodological transparency while preserving the integrity of medical terminology and scoping review methodology.

Thank you.

 

POINT-BY-POINT RESPONSES

METHODOLOGICAL TRANSPARENCY (ACCEPTED)

Comments: Search strategies, dual screening, data extraction verification, deduplication tools, scoping review methodology

Response:

I fully agree with these suggestions and have made comprehensive revisions:

1. Supplementary Table S1: Complete, database-specific search strategies for PubMed/MEDLINE (128 records), CINAHL (48 records), and Cochrane (12 records) with all controlled vocabulary adaptations documented
2. Supplementary Table S2: Standardized data extraction form with all domains, pilot-testing details, and verification process
3. Section 2.3 Search Strategy: Explicit statement that duplicate records were identified and removed using EndNote 21 (Clarivate Analytics, Philadelphia, PA, USA) with manual verification in Microsoft Excel
4. Section 2.5 Study Selection: Detailed description that both reviewers (D.K. and H.N.) independently screened all titles, abstracts, and full texts using a standardized screening form in Microsoft Excel, with results compared at each stage and discrepancies resolved through discussion until consensus
5. Section 2.6 Data Extraction: Enhanced description including pilot-testing on two studies, full independent verification by the second reviewer, and consensus-based resolution of disagreements
6. Scoping review methodology clarification: Added explicit distinctions from systematic review standards in Sections 2.1, 2.5, and 2.7, including:
• Section 2.1: Scoping reviews map evidence breadth rather than evaluate intervention effectiveness; do not require formal quality appraisal
• Section 2.5: Explanation of why Cohen's κ was not calculated (appropriate for systematic reviews of effectiveness, not for exploratory scoping reviews focused on evidence mapping)
• Section 2.7: Clarification that methodological quality appraisal and risk of bias assessment—standard for systematic reviews—are typically not conducted in scoping reviews

These revisions substantially enhance methodological transparency and clarify the distinctive nature of scoping review methodology, which appears to have been a source of confusion in some of the reviewer's comments.

Location: Sections 2.1, 2.3, 2.5, 2.6, 2.7; Supplementary Tables S1 and S2

 

ALREADY CORRECT IN ORIGINAL MANUSCRIPT

Comment: Use uniform notation for frequencies (qxh) and define in table footnote

Response:

This was already correctly addressed in the original manuscript. Table 2 footnote includes: "Abbreviations: ICU = Intensive Care Unit; N/A = Not Applicable; NR = Not Reported; q1h = every 1 hour; q2h = every 2 hours; q4h = every 4 hours; q12h = every 12 hours." This notation is consistently used throughout and is standard in medical literature for postoperative monitoring protocols.

Location: Table 2 footnote (no changes needed)

 

Comment: Use proper spacing in statistical notation (p = 0.27)

Response:

Upon careful review, all statistical values in the manuscript already use proper spacing around operators (e.g., "p = 0.27", "p > 0.9", "p = 0.82"). This formatting was present in the original submission.

Location: Throughout Results section (no changes needed)

 

Comment: Verify PRISMA flow diagram numbers

Response:

The numbers in the original submission were accurate and internally consistent. As explained in the response to Reviewer 3, the search was repeated on October 14, 2025, by both reviewers working independently, and all retrieved records were verified together. Figure 1 has been updated to reflect the refreshed search results while maintaining internal consistency:

• Records identified: 188
• Duplicates removed: 25
• Records screened: 163
• Full-text exclusions: 39 (with detailed reasons and counts)
• Studies included: 12

Location: Figure 1 (updated with October 14, 2025 search results)

 

JOURNAL PRODUCTION ELEMENTS

Comment: Delete metadata, citation format, academic editor fields, and copyright statements

Response:

These elements are part of the journal's production template and are automatically inserted by the editorial office during the publication process. They do not appear in the submitted manuscript Word file and are entirely outside the author's control. The journal's production team manages these elements according to their house style guidelines.

 

Comment: Fix hyphenated line breaks (e.g., "moni-toring", "achiev-ing")

Response:

These are artifacts of automatic line-break hyphenation in word processing software and PDF rendering, not intentional formatting choices. The journal's production team will ensure proper typesetting in the final published version. These hyphenations do not appear in the submitted Word manuscript.

 

Comment: Move the Artificial Intelligence Declaration to the Declarations section

Response:

I agree with this suggestion. The AI Declaration has been moved from Section 2.9 (Methods) to the Declarations section at the end of the manuscript, following Acknowledgments and before Conflicts of Interest. This placement is more appropriate and consistent with journal formatting conventions.

Location: Declarations section (moved from Methods 2.9)

 

FIELD-SPECIFIC MEDICAL TERMINOLOGY (MAINTAINED)

Comment: Use "free-flap" (hyphenated) consistently throughout the manuscript

Response:

I respectfully maintain "free flap" (unhyphenated) as this is the universally established convention in plastic surgery and microsurgery literature.

Evidence supporting this convention:

• Major specialty journals universally use "free flap": Plastic and Reconstructive Surgery, Microsurgery, Journal of Reconstructive Microsurgery
• PubMed Medical Subject Headings (MeSH): "Free Tissue Flaps" (unhyphenated)
• Standard surgical textbooks and clinical guidelines: "free flap"
• Published literature in this field (>28,000 articles): overwhelmingly "free flap"

This manuscript targets a medical readership—primarily plastic surgeons and nurses specializing in microsurgical reconstruction. Using "free-flap" would deviate from established medical terminology and potentially confuse the target audience. Adherence to field-specific conventions is essential in specialized medical journals.

I find this suggestion somewhat perplexing, as standardized medical terminology is fundamental to clear communication in clinical literature. This is a well-established convention in the field.

 

SCOPING REVIEW TERMINOLOGY (MAINTAINED)

Comment: Replace "non-inferior/equivalent" with "comparable in reported outcomes"

Response:

The term "non-inferior" is used descriptively in this manuscript to accurately represent the language and conclusions of the original studies being reviewed, not to claim formal non-inferiority trial methodology was employed.

Specifically, Varadarajan et al. (2017)—a systematic review published in a major medical journal—concluded that "nurse monitoring is non-inferior to physician monitoring." This scoping review accurately represents their finding. As a scoping review, the purpose is to map how evidence is described in the existing literature, not to re-analyze or re-interpret original study conclusions using different terminology.

The manuscript makes clear throughout (Sections 2.1, 2.7, Discussion) that this is a scoping review that maps existing evidence rather than conducting new effectiveness analyses. This distinction appears to be a recurring source of confusion in the reviewer's comments.

Location: Original study language retained in Results and Discussion; scoping review methodology clarified in Sections 2.1 and 2.7

 

PRISMA-ScR REPORTING (ADEQUATE)

Comment: Add Table S3 with full-text exclusion reasons and counts

Response:

The PRISMA-ScR flow diagram (Figure 1) already provides complete and transparent reporting of exclusion reasons with counts:

Full-text exclusions (n = 39):

• No monitoring protocol (n = 15)
• General ICU care (n = 8)
• Intraoperative care (n = 3)
• Nutrition/swallowing (n = 5)
• Technology only (n = 4)
• Case reports (n = 2)
• Other (n = 2)

This presentation within the PRISMA diagram is consistent with PRISMA-ScR guidelines and standard practice in scoping reviews. Creating a separate Table S3 would duplicate information already clearly and transparently presented in the flow diagram. Medical journals typically present this information in the PRISMA diagram rather than in redundant supplementary tables.

 

INTRODUCTION AND DISCUSSION (PARTIALLY ACCEPTED)

Comment: Replace highly rhetorical language and adopt provided paste-ready text

Response:

I agree that some phrasing in the original Introduction was overly rhetorical, and I have revised accordingly:

Removed or softened:

• Sun Tzu quotation (deleted)
• "converting today's necessity into tomorrow's gold standard" (deleted)
• "opportunity born from crisis yields lasting transformation" (deleted)
• Other excessively dramatic phrases (revised)

However, I have not adopted the reviewer's paste-ready replacement text for multiple reasons:

1. Authorial voice and expression are fundamental rights of academic authors. Wholesale text replacement by a reviewer is inconsistent with academic publishing norms where authors retain responsibility for their own expression.
2. The reviewer's suggested text reflects a non-medical writing style that would be inappropriate for this clinical journal's readership.
3. Certain conceptual framings (e.g., "standardization gap") are original contributions of this review and are referenced throughout the manuscript.

The revised Introduction maintains appropriate scholarly tone while engaging the clinical readership with narrative context meaningful to practicing surgeons and nurses. I have substantially reduced rhetorical language while preserving clarity and readability for the target medical audience.

Location: Introduction, particularly final paragraph

 

Comment: Add separate "Strengths" and "Future Research" sections; enhance limitations

Response:

The manuscript already includes Section 4.5 (Strengths, Limitations, and Contribution to the Field), which comprehensively addresses all elements the reviewer suggests. Upon review, I find the comment regarding missing content perplexing, as the section already contains:

Strengths described:

• Novel contribution as the first scoping review to comprehensively map nurse involvement in free flap monitoring across implementation components
• Deliberate methodological choice to explore "how" implementation succeeds
• Synthesis across diverse evidence types (education, technology, protocols)
• Recognition of heterogeneity as revealing the "standardization gap"
• Three-pillar framework as foundation for future guidelines

Limitations acknowledged:

• Exclusion of Embase database due to institutional access constraints
• Heterogeneity precluding quantitative meta-analysis (inherent to scoping review methodology and purpose)
• Potential publication bias evidenced by scarcity of reported adverse events
• Explicit identification as "significant knowledge gap for future research"

Future research directions explicitly stated:

• Need to address publication bias gap
• Generate evidence on adverse events, missed failures, false-positive explorations
• Additional research implications woven throughout Discussion and Conclusion

I have not created separate subsections for "Strengths" and "Future Research" as the current integrated presentation maintains narrative cohesion and is consistent with medical journal format. I have also not adopted the reviewer's paste-ready "Strengths" paragraph, as authorial voice must remain with the author.

Regarding the suggestion to soften "the first scoping review": This statement is factually accurate—Varadarajan et al. (2017) conducted a literature review, not a scoping review—and describes this manuscript's legitimate novelty and contribution. This is the first study to employ rigorous scoping review methodology (JBI framework, PRISMA-ScR guidelines, systematic search strategy, dual independent screening) to map nurse involvement in free flap monitoring.

Statements of "first" or "novel" contribution are standard in medical literature when accurately describing unique contributions. I find this suggestion puzzling and inconsistent with conventions of medical publishing, where clearly stating a study's novel contribution is expected and appropriate.

Location: Section 4.5 (no changes needed; all requested elements already present)

 

SUMMARY OF CHANGES

REVISIONS MADE IN RESPONSE TO SUBSTANTIVE METHODOLOGICAL COMMENTS:

✓ Supplementary Table S1 (complete search strategies for all databases)
✓ Supplementary Table S2 (standardized data extraction form)
✓ Enhanced Methods sections (2.3, 2.5, 2.6) with explicit tool and process descriptions
✓ Explicit scoping review methodology clarification (Sections 2.1, 2.5, 2.7) distinguishing from systematic review standards
✓ Reduced rhetorical language in Introduction
✓ Removed Sun Tzu quotation
✓ Figure 1 updated with refreshed October 14, 2025 search results
✓ AI Declaration moved from Methods to Declarations section

ELEMENTS ALREADY CORRECT IN ORIGINAL MANUSCRIPT:

• qxh notation and abbreviations (Table 2 footnote)
  • Statistical notation spacing (throughout Results)
  • PRISMA flow diagram numbers (accurate; now updated with new search)
  • Section 4.5 Strengths, Limitations, and Future Research (comprehensive)

CLARIFICATIONS PROVIDED:

• Metadata, citations, copyright: journal production elements, not author-controlled
  • Line-break hyphenations: word processing artifacts, not formatting choices
  • "free flap" unhyphenated: established medical terminology in plastic surgery
  • "non-inferior": accurate representation of original study language in scoping review context
  • Table S3: redundant with PRISMA Figure 1 per PRISMA-ScR guidelines
  • Text replacement: authorial voice preserved while addressing valid concerns
  • "First scoping review": accurate statement of novelty, standard in medical literature

I hope this revision process has provided insight into the distinctive methodology of scoping reviews versus systematic reviews, and the conventions of specialized medical literature. The manuscript has been substantially strengthened in methodological transparency while maintaining appropriate medical terminology and field-specific conventions.

Sincerely,

The author

Reviewer 3 Report (New Reviewer)

Comments and Suggestions for Authors

The topic is very interesting and is emerging in clinical practice every day. In this case, the manuscript explores the competence of nurses to assume primary responsibility for surveillance and early detection—Nurse-Led Microsurgical Free Flap Monitoring.

It is well written, but important aspects of the methodological process need to be clarified (I have attached suggestions for improvement).

Comments for author File: Comments.pdf

Author Response

RESPONSE TO REVIEWER 3

I sincerely thank the reviewer for the thoughtful and constructive comments, which have substantially improved the methodological transparency of this manuscript. I appreciate the reviewer's recognition that "the topic is very interesting and is emerging in clinical practice every day."

Most of the reviewer's suggestions have been incorporated into the revised manuscript. However, I note that some concerns appear to stem from the expectation of systematic review methodology, whereas this is a scoping review guided by the Joanna Briggs Institute (JBI) framework.

To address this potential confusion and assist future readers, I have added explicit clarifications in the manuscript distinguishing scoping review methodology from systematic review standards, including detailed explanations in the Study Design section (2.1) and throughout the Methods.

Regarding the search date: I must clarify an error and subsequent correction in the search timeline. The original search was conducted on September 13, 2025, but was mistakenly reported as "September 13, 2024" in the initially submitted manuscript due to a typographical error.

To avoid any potential confusion arising from this discrepancy, both reviewers (D.K. and H.N.) independently repeated the entire search on October 14, 2025, and verified all retrieved records together. The revised manuscript now consistently reports the October 14, 2025 search date throughout the text and Supplementary Table S1, with all results, figures, and tables updated accordingly.

I am grateful for this opportunity to strengthen the manuscript and improve its clarity for readers. Below, I provide point-by-point responses to each comment.

Thank you.

 

Point-by-Point Responses

Comment 1: Protocol Registration

Reviewer's Comment:

"Was the scoping review registered? I haven't found the protocol or registration in the Open Science Framework (OSF)."

Response: I thank the reviewer for raising this important methodological point. The manuscript already describes adherence to JBI methodology and PRISMA-ScR guidelines in Section 2.1. (Study Design). I have now added explicit clarification regarding protocol registration in the same section. This scoping review was not prospectively registered. The study was initially designed as a systematic review and subsequently adapted to a scoping review methodology following peer review feedback. Scoping reviews are not currently eligible for registration in PROSPERO, which is limited to systematic reviews and meta-analyses.

Location in revised manuscript: Section 2.1.

 

Comment 2: Search Date

Reviewer's Comment:

"Were all searches conducted on a single day (September 13, 2024)?"

Response: Yes, all database searches were conducted on a single day to ensure consistency and reproducibility. As explained in the opening statement above, the search date has been corrected to October 14, 2025, with all results verified by both reviewers and consistently reported throughout the revised manuscript.

Location in revised manuscript: Section 2.3, Supplementary Table S1

 

Comment 3: Study Selection Manager

Reviewer's Comment:

"Which manager (e.g., Rayyan) was used to select the studies (e.g., to remove duplicate studies) and minimize the risk of bias or error in selecting 12 studies out of 214?"

Response: I appreciate the reviewer's request for clarification on the study selection process. I have now provided explicit detail on the tools and methods used. For duplicate removal, EndNote 21 (Clarivate Analytics, Philadelphia, PA, USA) was used with manual verification in Microsoft Excel.

This dual-method approach ensured thorough deduplication, reducing 188 total records to 163 unique records (25 duplicates removed). For study selection and screening, manual dual independent screening was performed using a standardized screening form in Microsoft Excel. Automated screening platforms such as Rayyan or Covidence were not used.

Both reviewers (D.K. and H.N.) independently screened all titles, abstracts, and full texts, with results compared at each stage and discrepancies resolved through discussion until consensus was reached. This rigorous dual-review process minimized the risk of bias and error in study selection.

Location in revised manuscript: Section 2.3 (duplicate removal), Section 2.5 (study selection)

 

Comment 4: Adapted Search Equations

Reviewer's Comment:

"The search strategy was adapted according to the specificities of each data source: Which equations were adapted? It is important that this be made clear and that the adapted equations be presented."

Response: I fully agree with the reviewer on the importance of complete transparency regarding database-specific search strategies. The complete, adapted search strings for all three databases are now provided in Supplementary Table S1, which includes:

1. PubMed/MEDLINE: Full search string with MeSH terms and free-text keywords (128 records)
2. CINAHL Plus with Full Text: Adapted strategy using CINAHL Headings (MH) and appropriate field codes (TI, AB) (48 records)
3. Cochrane Library: Step-by-step search strategy using Cochrane MeSH descriptors and keyword fields (12 records)

Each search strategy is presented in full, with clear documentation of database-specific controlled vocabulary, field codes, search operators, date of search, and number of results retrieved.

Section 2.3 now explicitly references Supplementary Table S1 and describes the adaptation process: "Search strategies were adapted for CINAHL and Cochrane databases using their respective controlled vocabularies (CINAHL Subject Headings and Cochrane MeSH). The complete search strategies for all three databases, including adaptations of controlled vocabulary terms and keywords, are provided in Supplementary Table S1."

Location in revised manuscript: Section 2.3, Supplementary Table S1 (newly added)

 

Comment 5: Data Extraction Verification

Reviewer's Comment:

"How is extraction verified for consistency?"

Response: I thank the reviewer for this important question. I have provided comprehensive detail on the data extraction verification process in Section 2.6 (Data Extraction):

1. A standardized data extraction form was developed and pilot-tested on two included studies to ensure comprehensiveness and clarity. The complete form is provided in Supplementary Table S2.
2. The primary reviewer (D.K.) extracted data from all included studies. The second reviewer (H.N.) then independently verified all extracted data. This was a full verification process, not a random sample check.
3. Any disagreements identified during verification were resolved through discussion between the two reviewers until consensus was achieved.

This rigorous verification process ensured consistency and accuracy of all extracted data presented in the manuscript.

Location in revised manuscript: Section 2.6, Supplementary Table S2 (newly added)

 

Thank you.

Round 2

Reviewer 3 Report (New Reviewer)

Comments and Suggestions for Authors

All the questions have been clarified. Thank you for considering my suggestions for improvement. Although it is NOT MANDATORY to register the protocol for a scoping review, for future scoping review studies, I recommend Protocol and registration on the Open Science Framework (OSF) since, according to PRISMA-ScR, it is a simple and recommended procedure to avoid duplication.

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this manuscript. It is a systematic review aimed to evaluate the effectiveness of nurse-led free flap monitoring and develop an evidence-based implementation framework. My primary concern is the lack of a clear and cohesive objective in this systematic review. The study attempted to address two distinct aims: evaluating the effectiveness of nurse-led free flap monitoring and assessing educational interventions. These two aims are poorly connected, and the latter is not well aligned with the article’s title. This ambiguity has led to the inclusion of a heterogeneous set of studies, undermining the persuasiveness and coherence of the findings. Then, the author proposed a framework that does not appear to be evidence-based and has limited relevance to the systematic review itself.

Moreover, several methodological issues need to be addressed. The literature search was conducted only in PubMed, which significantly limits the comprehensiveness of the review. The search strategy should be described in greater detail—specifically, whether MeSH terms, free-text terms, or both were used. A full and reproducible search strategy is essential. Additionally, the rationale for restricting the search to articles published since January 2010 should be justified. Although different types of studies were included, each study design should be appraised using appropriate, standardized critical appraisal tools rather than criteria developed by the author. Similarly, the assessment of the certainty of the evidence should follow established GRADE methodology or other validated frameworks instead of relying on author-defined criteria.

Author Response

For Reviewer 1

I sincerely thank the editor and the reviewers for their time and constructive feedback, which has enabled me to substantially improve the quality and clarity of my manuscript. I have carefully considered all comments and have revised the manuscript accordingly. Below are my point-by-point responses to the issues raised by Reviewer 1

 

Reviewer #1

Comment 1:

My primary concern is the lack of a clear and cohesive objective in this systematic review. The study attempted to address two distinct aims: evaluating the effectiveness of nurse-led free flap monitoring and assessing educational interventions. These two aims are poorly connected, and the latter is not well aligned with the article’s title. This ambiguity has led to the inclusion of a heterogeneous set of studies, undermining the persuasiveness and coherence of the findings. Then, the author proposed a framework that does not appear to be evidence-based and has limited relevance to the systematic review itself.

Response: I am sincerely grateful to the reviewer for this insightful and detailed feedback. The reviewer has accurately identified the core weakness of the initial manuscript, which stemmed from an ambiguous objective and the resulting inclusion of heterogeneous studies. This crucial feedback prompted me to fundamentally re-evaluate and revise the study's methodology and identity.

To resolve these issues, I have comprehensively revised the manuscript from a systematic review to a scoping review, following the Joanna Briggs Institute (JBI) methodology and PRISMA-ScR guidelines. This strategic shift directly addresses the reviewer's concerns in the following ways:

1. Clarifying the Objective: The primary goal of a scoping review is not to answer a narrow efficacy question but to comprehensively map the existing literature. By adopting this methodology, the study's objective is now clear: to identify and synthesize all available evidence regarding nurse involvement in postoperative free flap monitoring, which naturally includes both clinical protocols and educational interventions. This resolves the issue of having two "poorly connected" aims by placing them under a single, appropriate, and broader research question: "What is known about nurse involvement in postoperative free flap monitoring?" This change is reflected in the revised Title, Abstract, Introduction (Section 1), and Methods (Section 2.1, 2.2).
2. Justifying the Inclusion of Heterogeneous Studies: The reviewer correctly noted that the included studies were heterogeneous. The scoping review framework is specifically designed to handle such heterogeneity. It allows for the inclusion and synthesis of diverse study designs (e.g., retrospective cohorts, educational interventions, prospective studies) to provide a broad overview of a topic, which was the central issue the reviewer identified.
3. Strengthening the Framework's Foundation: I agree that the link between the evidence and the proposed framework needed to be stronger. The framework is now presented as a direct output of the scoping review's findings. I have revised the Discussion (Section 4.4) to more explicitly demonstrate how each component of the framework is directly supported by the evidence synthesized from the included studies presented in the Results (Section 3). This revision ensures the framework is firmly evidence-based and directly relevant to the review's findings.

 

Comment 2:

Moreover, several methodological issues need to be addressed. The literature search was conducted only in PubMed, which significantly limits the comprehensiveness of the review. The search strategy should be described in greater detail—specifically, whether MeSH terms, free-text terms, or both were used. A full and reproducible search strategy is essential. Additionally, the rationale for restricting the search to articles published since January 2010 should be justified. Although different types of studies were included, each study design should be appraised using appropriate, standardized critical appraisal tools rather than criteria developed by the author. Similarly, the assessment of the certainty of the evidence should follow established GRADE methodology or other validated frameworks instead of relying on author-defined criteria.

Response: I thank the reviewer for these critical and valid points regarding the methodological rigor of the review. In line with the shift to a scoping review, I have undertaken a complete overhaul of the methodology to address every issue raised.

1. Comprehensive Literature Search: The search has been significantly expanded. As detailed in the revised Search Strategy (Section 2.3), the search was performed in three major databases (PubMed/MEDLINE, CINAHL Plus with Full Text, and the Cochrane Library) to ensure comprehensive coverage. The January 2010 date restriction has been removed, and no language restrictions were applied.
2. Reproducible Search Strategy: The manuscript now includes the full and reproducible search strategy for PubMed, detailing the combination of MeSH terms and free-text terms used. It also states that this strategy was adapted for the other databases.
3. Quality Appraisal and Certainty of Evidence: I agree that standardized tools are essential. However, the choice of tool must match the review methodology. For a scoping review, the primary aim is to map the extent and range of available evidence, not to perform a risk-of-bias assessment or determine the certainty of evidence for a specific intervention (which is the purpose of tools like GRADE in a systematic review). Established scoping review guidelines, including PRISMA-ScR and JBI, do not mandate formal quality appraisal as it can be counter to the goal of inclusiveness. Therefore, in adherence to the now-adopted scoping review methodology, a formal quality appraisal using specific tools or a GRADE assessment was not performed. This methodological choice is now explicitly stated and justified in the Methods (Section 2.4).

 

I am sincerely grateful for the reviewer's thorough and constructive feedback. To be candid, the initial comments were daunting. However, I soon recognized them as an invaluable opportunity to fundamentally strengthen this paper. I have since worked diligently to address every point with care and precision. As a direct result of the reviewer's guidance, I believe the manuscript is now a significantly more robust and coherent piece of work, and for that, I am very thankful.

 

Sincerely,

 

The author

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript “Validating Nursing Competency in Microsurgical Free-Flap Monitoring: A Systematic Review and Evidence-Based Framework” falls well below the methodological and reporting standards expected of the Healthcare journal. The following major weaknesses must be addressed before the work can be considered for publication.

 

1. Authorship and Review Process

   Single-author systematic reviews are exceptional and require explicit justification. The manuscript states that “two independent reviewers” screened articles, extracted data and assessed risk of bias, yet only one author is listed. This discrepancy raises concerns about transparency. Journals expect all individuals who meet authorship criteria to be named; conversely, anyone who does not meet the criteria should be acknowledged, not described as “reviewers” in the Methods.

 

2. Prospective Registration and Protocol

   The review was not registered in PROSPERO or any comparable registry. Consequently, readers cannot verify whether the research question, eligibility criteria or analytic plan were pre-specified. The possibility that an identical or overlapping review is already underway or completed cannot be excluded.

 

3. Search Strategy and Databases

   Only one database (PubMed) was searched. A genuine systematic review should include at minimum MEDLINE (via PubMed), Embase and the Cochrane Library, together with trial registries, grey-literature sources and hand-searching of key journals. The PubMed strategy provided is cursory and omits controlled vocabulary (MeSH) combinations, truncation and proximity operators. No information is given on how duplicates were removed (software package, version, algorithm settings).

 

4. Justification of Date Restriction

   Limiting the search to studies published from 2010 onward is arbitrary and is not justified in the text. If technological or practice changes around 0 make earlier studies irrelevant, this must be argued with supporting references.

 

5. Language Bias

   Excluding reports published in Korean (or any other language) without justification introduces language bias and contravenes PRISMA-2020 recommendations. If resources for translation were unavailable, this limitation should be acknowledged as a potential source of bias.

 

6. Critical Appraisal and Risk-of-Bias Assessment

   No formal quality-appraisal tool was applied. The Discussion repeatedly claims that nurse-led monitoring is “comparable to physician-led models” without weighting the evidence by study quality. 

 

7. Heterogeneity and Applicability

   The included studies span different microsurgical sites (head-and-neck, breast, limb), institutional contexts (tertiary referral centres vs district hospitals) and training models (short courses vs graduate diplomas). These differences are noted but not explored.

 

8. Absence of Adverse Events or Negative Findings

   No mention is made of missed flap failures, false-positive re-explorations or legal disputes attributed to nurse-led monitoring. The absence of negative data may reflect publication bias or selective reporting within the primary studies.

 

9. Contextual Factors and “Support”

The phrase “when properly supported” is used repeatedly but never operationalised. Readers need to know which structural elements are prerequisite for safe nurse-led monitoring.

 

10. Nursing Anxiety and Technology

The finding that technological aids reduce nursing anxiety is interesting, yet the discussion implies causality without exploring mediating variables (accountability frameworks, legal liability, professional identity).

 

Minor Issues 

- Several in-text citations do not appear in the reference list.

- Tables 2 and 3 mix prospective and retrospective studies without labelling.

 

Recommendation 

The manuscript requires either (a) a complete re-write with additional authors, an a-priori protocol, comprehensive searches and formal quality appraisal, or (b) reclassification as a narrative scoping review with clear limitation statements. In its present form it does not meet the minimum standards for a systematic review in a peer-reviewed journal.

Author Response

For Reviewer 2

I would like to express my profound gratitude to the reviewer for providing an exceptionally rigorous, detailed, and insightful methodological critique. The reviewer correctly identified significant shortcomings in the manuscript in its original form as a systematic review. The feedback was instrumental in guiding a complete re-evaluation and revision of the entire study.

In line with the reviewer's final recommendation, I have chosen to reframe and rewrite the manuscript as a scoping review. This fundamental shift has allowed me to address the major weaknesses identified. The study now adheres to the Joanna Briggs Institute (JBI) methodology and is reported following the PRISMA-ScR guidelines. Below, I have outlined how each of the reviewer's specific concerns has been addressed within this new framework.

 

1. Authorship and Review Process

• Comment: Concerns regarding single authorship and the discrepancy of "two independent reviewers."
• Response: I thank the reviewer for pointing out this important issue of transparency. To clarify the roles, the Methods section has been revised. The second individual’s contribution (assisting in the two-stage screening process) did not meet the full criteria for authorship. Therefore, as per the reviewer's correct suggestion, this individual is no longer described as a "reviewer" within the Methods section but is now appropriately credited in the Acknowledgement section for their specific contribution.

2. Prospective Registration and Protocol

• Comment: The review was not registered in PROSPERO.
• Response: I acknowledge that the review was not prospectively registered. While this is a limitation, the revised manuscript now transparently reports the complete methodology following the PRISMA-ScR checklist, ensuring that the research question, eligibility criteria, and process are explicitly and retrospectively documented for the reader.

3. Search Strategy, Databases, Date Restriction, and Language Bias

• Comment: Criticisms on using only PubMed, a cursory search strategy, arbitrary date restriction, and language bias.
• Response: I fully agree with the reviewer that the initial search was inadequate. A new, comprehensive search has been conducted to remedy all these issues:
• Databases: The search was expanded to three major databases: PubMed/MEDLINE, CINAHL Plus with Full Text, and the Cochrane Library.
• Search Strategy: The revised Methods (Section 2.3) now includes the full, reproducible search string for PubMed, demonstrating the use of both controlled vocabulary (MeSH) and free-text terms. Details on duplicate removal have also been added.
• Date & Language: All date and language restrictions have been removed to broaden the scope and minimize bias, in accordance with PRISMA recommendations.

4. Critical Appraisal and Risk-of-Bias Assessment

• Comment: No formal quality-appraisal tool was applied, and claims of comparability were made without weighting evidence by quality.
• Response: This is a crucial point that is directly addressed by the shift to a scoping review. As per established scoping review methodologies (JBI, PRISMA-ScR), the primary goal is to map the extent of the literature, not to conduct a formal quality or risk-of-bias assessment, which is a hallmark of systematic reviews answering a specific efficacy question. Therefore, in adherence with the appropriate methodology for a scoping review, a formal quality appraisal was not performed. This is now explicitly justified in the Methods (Section 2.4). Consequently, all claims in the Discussion regarding the "comparability" of outcomes have been rephrased to be more descriptive and less evaluative, reflecting the nature of a scoping review.

5. Heterogeneity, Adverse Events, and Contextual Factors ("Support")

• Comment: Heterogeneity was noted but not explored; absence of adverse events was not discussed; "when properly supported" was not operationalized.
• Response: I thank the reviewer for these sophisticated observations. The scoping review framework has enabled me to address these points as findings, rather than as unaddressed weaknesses:
• Heterogeneity: Exploring this heterogeneity is now a central objective of the review. The revised Results and Discussion sections are now dedicated to mapping and discussing these differences across sites, contexts, and training models.
• Absence of Adverse Events: The lack of reported negative findings (e.g., missed failures, legal disputes) in the literature is now presented as a key finding of this review—a significant "gap in the literature." This is now discussed in the Discussion as a potential area for future research and a likely indicator of publication bias.
• Operationalizing "Support": The reviewer correctly identified this vague phrasing. The proposed evidence-based framework (Section 4.4) now serves as the explicit operationalization of "proper support," breaking it down into concrete, evidence-based components (structured education, flap-specific protocols, technology integration, and quality assurance).

6. Nursing Anxiety and Technology & Minor Issues

• Comment: Causality implied between technology and anxiety; citation/table issues.
• Response: I have revised the Discussion (Section 4.2) to present a more nuanced argument, suggesting technology as a confidence-building measure that may mediate anxiety rather than being its sole causal solution, and acknowledging the importance of other variables . All in-text citations have been cross-checked with the reference list, and the tables have been revised to label study designs for clarity.

 

I am sincerely grateful for the reviewer's thorough and constructive feedback. To be candid, the initial comments were daunting. However, I soon recognized them as an invaluable opportunity to fundamentally strengthen this paper. I have since worked diligently to address every point with care and precision. As a direct result of the reviewer's guidance, I believe the manuscript is now a significantly more robust and coherent piece of work, and for that, I am very thankful.

 

Sincerely,

 

The author