This study examines the effectives of a recent set of guidelines published by the Baveno VI conference, which states that patients with chronic liver disease and a low liver stiffness (<20kPa) and high platelet count (>150) are at low risk of having varices and do not need a screening endoscopy. Varices are a complication of cirrhosis, confer a risk of serious bleeding, and can be diagnosed and treated by endoscopy. Our study reviewed the clinical records of patients who have had liver stiffness scans and endoscopy over a 9-year period at two hospitals. The results show that only about 2% of patients who meet the Baveno VI criteria will be miss-classified as not having varices.

We read with great interest the article 1 describing the impact of COVID-19 on medical education in Hong Kong, where a pilot study implemented distant surgical teaching for final year medical students using web-based surgical skills learning (WSSL) via Zoom. As UK based medical students at King's College London, who have recently

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Response to Editor and ReviewersReferee 1 Comments to the Author: This report comes from the Imperial College where the surgeons have led in models used for simulation. They have developed a model for axillary lymph node dissection and then studied it amongst "experts, senior residents and junior residents" and claim their findings provide construct validity. Referee 2Comments to the Author: Timely article and fascinating results. Authors' response: We thank the reviewer and agree the results are extremely timely given the attenuation in the number of axillary lymph node procedures and recently documented worldwide attenuation in training opportunities in axillary procedures. The results are indeed fascinating with relevance for both residents in training and board-certified cancer surgeons.Referee 1, comment 1. How were the raters trained? Did they assess videos until their scores were congruent? Authors' response: The attendings received no additional training in axillary lymphadenectomy assessment. However, both raters were involved in the development of this simulation and in designing the assessment methods therein. Moreover, they regularly teach and assess axillary lymph node dissection in both clinical practice and across the region on behalf of the London Deanery Skills Training Programme using breast simulation. The authors performed post-hoc analyses to evaluate both the consistency and reliability between raters (see R1 supplementary digital content -SDC5); these results demonstrated good internal consistency (Cronbach's =0.89-0.97) and modest inter-rater reliability (Cohen's Kappa=0.1-0.2).