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Dear authors,
As all issues or questions have been resolved/answered, I am now accepting your manuscript for publication. Congratulations!
**PeerJ Staff Note:** Although the Academic Editor is happy to accept your article as being scientifically sound, a final check of the manuscript shows that it would benefit from further English editing. Therefore, please identify necessary edits and address these while in proof stage.
Dear authors,
Thank you for your thoughtful and detailed responses to the reviewers' comments. Your manuscript significantly improved, and the strengths of your study are acknowledgment, particularly improved statistical analyses and proposed future directions. However, several areas that have been previously flagged require further clarification and refinement before the manuscript can be considered for publication.
While you have addressed key concerns, particularly those related to baseline differences in nodule size, additional emphasis on bias mitigation is important to assure the study's scientific rigor. A more robust discussion of how selection bias could be minimized through techniques such as propensity score matching or inverse probability weighting would provide greater confidence in the validity of the findings. Additionally, the absence of long-term follow-up data remains a limitation, and while your recommendation for future prospective studies is noted, an indication of whether follow-up data is being collected at your institution would be valuable.
The generalizability of your findings also requires further elaboration. While Wuhan Union Hospital admits patients from diverse regions within China, addressing potential genetic or ethnic variations in pulmonary nodule characteristics and treatment responses would enhance the external validity of the study (thus, i think this was what one of the reviewers was referring to and not necessarily foreigners in the study population). Furthermore, while your comparison with Tian et al. is useful, a broader discussion of how your complication and success rates align with findings from multiple studies would provide better contextualization. Strengthening this literature critique would allow readers to better understand how your results fit within the existing body of research.
The manuscript is well-structured and the improvements you have made to statistical reporting and table formatting enhanced its readability and quality.
Given the remaining concerns, particularly those related to study design, generalization, and literature contextualization, your manuscript still requires some revisions before acceptance. We encourage you to carefully refine these aspects to ensure the study meets the highest scientific standards.
Side-notes (apologies if I misinterpreted the information):
- The ENB group had significantly larger nodules compared to the CT-guided group (p<0.001). This could inherently influence the success rates and complications associated with each method. You answered with table 2. but since you did not control for this variable, how can validity of comparing outcomes between the 2groups be assured?
- The absence of randomization in assigning patients to the ENB or CT-guided groups introduces a risk of selection bias. But i see your point about be more close to real-life clinical settings. However, means that the allocation of participants may not truly reflect the efficacy of each technique, as other unaccounted factors could affect the outcomes. So, these aspects need to be well discussed and explained in the manuscript to not induce the reader in error.
- Also worrisome: without blinding, observers involved in assessing results may inadvertently introduce bias into the evaluation process. Observers knowing which technique was used could influence their interpretation of success or complications, affecting the reliability of the outcomes. Not sure the re-submitted manuscript fully addresses this the best way.
- for the inadequate exploration of anatomical location you had table 2, correct? but i think that it mentioned a lack of significant lobar preference for CT-guided localization, it did not delve deeper into the implications of anatomical site on the success rates or complications, limiting the understanding of these results in clinical practice.
- The manuscript fails to include long-term follow-up data, such as complete nodule resection rates and subsequent patient outcomes (e.g., recurrence, survival rates). This absence means the clinical relevance and long-lasting effects of the localization methods remain unclear, thereby diminishing the practical applicability of the findings.
- The lack of diversity in patient demographics and clinical settings limits the external validity and generalizability of the results. Findings may not accurately represent other populations or healthcare environments, and without information on variables such as race and gender, the results may be less applicable to various demographic groups.
The title needs rewording to reflect also some of these limitations, and not induce a more robust and comprehensive study, but rather a somewhat "pilot" or "proof of concept" type of study... because with these aspects still as it is evidence-based conclusions from its findings are limited. But may be a case of language and proper data-based conclusions...
Dear Authors,
Thank you for your detailed and constructive responses to my criticisms of your work. When I reviewed your responses, I was pleased to see that you took into consideration most of my suggestions and made the necessary corrections.
Overall, I found your responses to my criticisms satisfactory and believe that your work has been significantly improved.
Dear Authors,
Thank you for your detailed and constructive responses to my criticisms of your work. When I reviewed your responses, I was pleased to see that you took into consideration most of my suggestions and made the necessary corrections.
Overall, I found your responses to my criticisms satisfactory and believe that your work has been significantly improved.
Best regards
Dear Authors,
Thank you for your detailed and constructive responses to my criticisms of your work. When I reviewed your responses, I was pleased to see that you considered most of my suggestions and made the necessary corrections.
Overall, I found your responses to my criticisms satisfactory and believe that your work has been significantly improved.
Best regards
Dear Authors,
Thank you for your detailed and constructive responses to my criticisms of your work. When I reviewed your responses, I was pleased to see that you considered most of my suggestions and made the necessary corrections.
Overall, I found your responses to my criticisms satisfactory and believe your work has significantly improved.
Best regards
Dear authors, thank you for your submission.
The reviewers raised some questions of which I highlight the potential for bias. Please, address this and other questions raised.
no comments
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The study suffers from several significant flaws that undermine its reliability and generalizability.
1. there is a risk of bias in the study design, as the nodules in the ENB group were significantly larger (p<0.001), and this baseline difference, which may directly influence success rates and complications, was not adequately controlled.
2. the lack of randomization and blinding raises concerns about selection and observer bias, affecting the objectivity of the results.
3. the study provides insufficient analysis of how anatomical location impacts the outcomes of both methods, with findings such as the lack of significant lobar preference for CT-guided localization (p=0.073) not thoroughly explored.
4. the absence of long-term follow-up data, such as the completeness of nodule resection or patient outcomes, limits the clinical significance and practical applicability of the findings.
Finally, the study’s reliance on single-center data from Wuhan Union Hospital, without demographic details such as race or gender, restricts the external validity and generalizability of the results to other populations or institutions. Given these critical issues, the study’s conclusions are not robust, and it is not recommended for acceptance.
1. Results
Some results, such as the success rate differences for lower lobes between ENB and CT-guided techniques, are presented with limited explanations of clinical implications.
-Please provide a clearer explanation of the practical impact of lower lobe localization differences. For instance, why might ENB have reduced efficacy for lower lobes? Could this be addressed through procedural modifications or improved technology?
2. Statistical Presentation
While statistical methods are mentioned, key p-values and confidence intervals could be better highlighted in the results tables for ease of interpretation.
-Please add confidence intervals (CIs) to complement p-values and provide a more robust statistical context. This would enhance the reader's confidence in the reliability of comparisons.
The retrospective nature and single-center scope of the study limit generalizability.
-Please emphasize plans for future multicenter, prospective studies to validate these findings in diverse patient populations and clinical settings.
4. Discussion
The discussion briefly touches on some limitations of both techniques (e.g., radiation exposure for CT-guided and labor-intensiveness of ENB) but lacks depth in comparing these drawbacks.
-Please expand on these points to discuss how these limitations might be mitigated in clinical practice. For instance, consider addressing cost-effectiveness, accessibility, or training implications for ENB.
5. Figures and Tables
Tables presenting results, especially complications and success rates, could be formatted more effectively for readability.
Recommendation: Simplify tables and use bold or color-coded highlights for significant values. For example, visually differentiate between statistically significant and non-significant findings.
6-Literature
Some referenced studies (e.g., Tian's findings) are cited but not adequately critiqued.
-Please contextualize the findings by making a more critical comparison with other literature. For instance, how does this study’s reported complication rate compare with similar cohorts?
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