Comparative Analysis of Coagulation and Liver Parameters in Individuals with Alcohol and Substance Use Disorders and Healthy Controls

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This study is important, timely and well done. You conclude that future studies are needed in particular to prospectively confirm (you note that your study is retrospective and non-randomiized) your results. Thus collaboration with other interested centers should be considered.

The main question explored in this study is whether PSMD6  in HCC cases is helpful in assessing survival.

This topic is important, particularly in liver centers. Early recognition hopefully, will lead to improvement in prognosis that may be lifesaving.
 There is a wide spectrum of caregivers, basic scientists, and pharmaceutical companies who would be interested.

The authors conclude that the expression level of  PSMD6  in HCC patients can be useful.  Only prospective studies in collaboration with other interested centers can validate this conclusion.
The references are appropriate, but none after 2024.
The figures and tables are helpful and well done.

 

Author Response

Comments 1: This study is important, timely and well done. You conclude that future studies are needed in particular to prospectively confirm (you note that your study is retrospective and non-randomiized) your results. Thus collaboration with other interested centers should be considered.

Response 1: We thank you for reviewing our article and for your valuable comments and contributions. In line with your suggestion., The following sentences have been added to the Discussion/Limitations section: “Finally, because this was a single-center, retrospective study, the generalizability of our findings may be limited. In collaboration with other relevant centers in the future, prospective multicenter studies are needed to increase the generalizability and to confirm our results.”

Comments 2: The references are appropriate, but none after 2024.

Response 2: Thank you. In line with your suggestion, some references for 2024 and beyond have been added.

 

Comments 3: The figures and tables are helpful and well done.

Response 3: Thank you for your supportive comment.

Reviewer 2 Report

Comments and Suggestions for Authors

Overall a well conducted study, however little-moderate interest in the filed. 

1. please reconsider the statement : 

When integrating these findings from the literature with our results, it can be concluded that alcohol, methamphetamine, and opiate addiction can contribute to liver damage, particularly in individuals who consume alcohol. 

Methamphetamine, and opiate addiction did not increase AST or ALT, please reconsider the statement.

2. Please consider providing a graphical overview of the methods and results

3. Main limitation of the study is that it is a retrospective study, and the dosage of the substances were not taken into consideration for the analysis. However this has been discussed in the manuscript.

Author Response

Comments 1: Overall a well conducted study, however little-moderate interest in the filed. 

1. please reconsider the statement : 

When integrating these findings from the literature with our results, it can be concluded that alcohol, methamphetamine, and opiate addiction can contribute to liver damage, particularly in individuals who consume alcohol. 

Methamphetamine, and opiate addiction did not increase AST or ALT, please reconsider the statement.

Response 1: We appreciate your supportive comments and suggestions. In line with your recommendation, the statement has been revised as follows:

“When integrating these findings from the literature with our results, it can be concluded that alcohol consumption, in particular, contributes to liver damage. The presence of conflicting data in the literature regarding the effects of methamphetamine and opiate use on the liver, together with our findings, can be explained by the fact that liver enzyme levels are influenced by factors such as the duration of substance use, nutritional status, and muscle mass [42]. Careful monitoring of liver function in these patients would also be beneficial.”

Comments 2: Please consider providing a graphical overview of the methods and results.

Response 2: Thank you. Graphs have been added to the results section as per your suggestion.

Comments 3: Main limitation of the study is that it is a retrospective study, and the dosage of the substances were not taken into consideration for the analysis. However this has been discussed in the manuscript.

Response 3: Thank you for your valuable comment. We agree that the retrospective design of the study and the lack of detailed information on substance dosage are important limitations. As you noted, these issues have already been discussed in the Limitations section of the manuscript.No further changes were made to the manuscript in response to this comment.

Reviewer 3 Report

Comments and Suggestions for Authors

The article entitled “Comparative Analysis of Coagulation and Liver Parameters in Individuals with Alcohol and Substance Use Disorders and 3 Healthy Controls” is self-explanatory. The authors have claimed that they enrolled a cohort of 451 inpatients undergoing addiction detoxification and 150 healthy controls. They checked liver enzyme and coagulation factor parameters using traditional methodology. The outcome was diverse as predicted. This led them to conclude regarding “the importance of

considering substance-specific physiological impacts when assessing liver and coagulation health in addicted populations”.

The article has been submitted to the journal “Diagnostics” as an “Article”.

Comments

1. The article lacks novelty. Several articles on the same or similar subjects have been published, and the total will reach several hundred or more. I did not mention that the authors are aware of that. The article could have had a greater impact if the authors had described prior publications and highlighted the novel aspects of the assigned article.
2. The inclusion criteria of the patient seem to be improper. The authors mentioned that “Admission criteria for the detoxification unit required the absence of acute intoxication, operationally defined as a breath alcohol level of ≤ 0.5‰ for alcohol users and the lack of clinically observable psychoactive effects for individuals using other substances”. At the same time, other patients were enrolled; the mechanisms underlying the disorders may differ in this population.
3. The study is a retrospective one, and any analysis of this nature can be validated by taking data from the register only. This should be a prospective study.
4. Another major limitation is also associated with the retrospective nature of the article. The amounts of the toxic substances could not be elucidated.
5. Alcohol and other toxic materials exert considerable influence on different factors of interest, depending on the duration of usage, time of withdrawal, and other factors.
6. The data retrieved in this article are known to the relevant scientific community, and it is tough to find out what the authors intend to contribute to this article.

Author Response

We thank you for reviewing our article and for your important contributions that will improve it.

Comments 1: The article lacks novelty. Several articles on the same or similar subjects have been published, and the total will reach several hundred or more. I did not mention that the authors are aware of that. The article could have had a greater impact if the authors had described prior publications and highlighted the novel aspects of the assigned article.

Response 1: Thank you for your valuable comment regarding the novelty and positioning of our study. We agree that several studies have examined similar topics, and that it is important to clearly describe prior publications and highlight the specific contribution of the present work. In line with your suggestion, we have substantially revised the Introduction. We now provide a more detailed overview of previous studies on the effects of alcohol, amphetamines, opioids, nicotine and cannabis on coagulation and liver function, and we explicitly state that most existing studies have evaluated these substances in isolation. In addition, we highlight the novelty of our study design, namely the simultaneous comparison of five substance-use groups and two age-matched healthy control groups within a single clinical framework, while considering key confounders (sociodemographic characteristics, smoking, HIV/HBV/HCV infection, calcium level, etc.). These changes are reflected in the revised Introduction section (pages 2–3), particularly in the paragraphs beginning with “As seen in the literature…” and “Considering the rising prevalence of AUD and SUD… taking into account possible confounding factors (sociodemographic characteristics, smoking, HIV-HBV-HCV infection, calcium level, etc.), compared with healthy control groups.”.

Comments 2: The inclusion criteria of the patient seem to be improper. The authors mentioned that “Admission criteria for the detoxification unit required the absence of acute intoxication, operationally defined as a breath alcohol level of ≤ 0.5‰ for alcohol users and the lack of clinically observable psychoactive effects for individuals using other substances”. At the same time, other patients were enrolled; the mechanisms underlying the disorders may differ in this population.

Response 2: Thank you for this helpful comment. In the revised Methods (Sample selection) section, we clarified that the criteria regarding the absence of acute intoxication (breath alcohol level ≤ 0.5‰ for alcohol users and lack of clinically observable psychoactive effects for other substances) are routine clinical admission criteria of the inpatient detoxification unit, rather than study-specific inclusion criteria. This clarification emphasizes that the laboratory measurements obtained on the first day of hospitalization predominantly reflect chronic or subacute effects of substance use, not transient changes due to acute intoxication. We also now explicitly describe the study-specific inclusion and exclusion criteria (age 18–65 years; no history of schizophrenia, other psychotic disorders, bipolar disorder, intellectual disability, severe neurological or metabolic disease, recent anticoagulant or analgesic/anti-inflammatory use, and—for controls—no Alcohol or Substance Use Disorders or regular alcohol/illicit substance use), as well as the composition of the five SUD groups and two age-matched healthy control groups, to make the sample selection process clearer.

Comments 3: The study is a retrospective one, and any analysis of this nature can be validated by taking data from the register only. This should be a prospective study.

Response 3: Thank you for your valuable comment. We agree that prospective studies will present variables in a more controllable manner. However, retrospective studies, such as ours, also provide valuable information for generating hypotheses and identifying trends based on large samples. We emphasized in the Discussion section that this is a limitation of our study and that we hope this study will provide preliminary data for prospective, randomized controlled trials to be conducted in the future.

Comments 4: Another major limitation is also associated with the retrospective nature of the article. The amounts of the toxic substances could not be elucidated.

Response 4: Thank you for this important comment. We agree that the inability to precisely determine the amount of toxic substances used is a major limitation of our study. In our clinical setting, approximate dose and duration can be documented for alcohol use (e.g. standard drinks per day and years of use); however, for illicit substances such as methamphetamine, cannabinoids and opiates, reliable quantitative dose information is not available in routine medical records because these drugs are obtained from illegal and highly variable markets. This is a well-recognized methodological challenge in substance use research, where detailed consumption-level data for illicit drugs are rarely available and both biochemical markers and self-report have important limitations for quantifying cumulative exposure over time, as noted in previous work (e.g. Normand et al., Moss et al., Napper et al.). In the revised manuscript, we have made this point explicit in the Limitations section and have added to the Conclusion that future prospective studies should systematically collect standardized, dose-related measures of illicit substance use to better clarify potential dose–response relationships.

Comments 5: Alcohol and other toxic materials exert considerable influence on different factors of interest, depending on the duration of usage, time of withdrawal, and other factors.

Response 5: Thank you for this important comment. We fully agree that alcohol and other toxic substances can influence liver and coagulation parameters depending on the duration and intensity of use, the time elapsed since last consumption, and the stage of withdrawal. In our study, all laboratory measurements were obtained on the first day of admission to the detoxification unit, after excluding acute intoxication, in order to minimize variability related to the withdrawal process. However, we did not have precise information on the exact timing of last use and detailed cumulative dose for all substances, and we acknowledge that early withdrawal-related physiological and biochemical changes may still have acted as potential confounders. This point has been explicitly emphasized in the Discussion/Limitations section, and we note that future prospective studies should systematically record duration, dose, and time since last use to better account for these factors.

Comments 6: The data retrieved in this article are known to the relevant scientific community, and it is tough to find out what the authors intend to contribute to this article.

Response 6: Thank you for this valuable comment. We agree that it is essential to clearly state the specific contribution of our study beyond what is already known. In the revised manuscript, we have reorganized and expanded the Discussion and Conclusion sections to better highlight the novel aspects of our work. We now emphasize that our study (i) simultaneously compares five DSM-5 substance use disorder groups (alcohol, cannabinoid, methamphetamine, multiple-substance use, and opiate) with two age-matched healthy control groups within a single clinical setting; (ii) examines both liver enzymes (AST, ALT) and coagulation parameters (PT, aPTT, platelet count) together, allowing identification of substance-specific biological profiles; and (iii) shows that smoking status did not significantly affect these biochemical parameters, supporting the interpretation that the observed alterations are primarily substance-related. In the Conclusions, we explicitly underline that lower PT values in methamphetamine and multiple-substance users and prolonged aPTT in cannabinoid users indicate differential haemostatic risks, while elevated liver enzymes in alcohol users point to a higher need for liver monitoring. We believe these revisions make the specific contributions and clinical relevance of our findings clearer to the reader.

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

Response to the authors

The authors have submitted a revised version of the manuscript. We appreciate the authors' attempt to address the reviewer's questions. However, the quality of responses depends on their specific nature and scientific validity. This leads to the article's acceptance or rejection. The reviewer questions (1) the novelty of the study, (2) the inclusion criteria, (3) the nature of the study (retrospective), (4) the design of the study regarding the amount of toxic materials, and (5) the importance of the article in basic and clinical perspectives. Although the authors responded to these queries and revised some sections with additional information or data, the fundamental aspects of the article have not been altered. For instance, a retrospective study may not contribute to the novelty, and revising the inclusion criteria cannot alter the design. In fact, all articles provide some insights to readers, but the study's impact is determined during review based on the nature and implications of the JOURNAL.

 

 

Author Response

Comments 1: 

Response to the authors

The authors have submitted a revised version of the manuscript. We appreciate the authors' attempt to address the reviewer's questions. However, the quality of responses depends on their specific nature and scientific validity. This leads to the article's acceptance or rejection. The reviewer questions (1) the novelty of the study, (2) the inclusion criteria, (3) the nature of the study (retrospective), (4) the design of the study regarding the amount of toxic materials, and (5) the importance of the article in basic and clinical perspectives. Although the authors responded to these queries and revised some sections with additional information or data, the fundamental aspects of the article have not been altered. For instance, a retrospective study may not contribute to the novelty, and revising the inclusion criteria cannot alter the design. In fact, all articles provide some insights to readers, but the study's impact is determined during review based on the nature and implications of the JOURNAL.

Response 1: We sincerely thank the reviewer for clearly summarizing these major concerns. We fully agree that our retrospective design and the lack of detailed dose information are important limitations that cannot be altered at this stage. We have therefore made these limitations more explicit and further moderated our conclusions, framing the study as a descriptive, hypothesis-generating analysis. Recent methodological literature emphasizes that retrospective, real-world studies can provide clinically meaningful and sometimes novel insights when appropriately designed and analysed, and that real-world evidence is now regarded as an important complement to randomized trials in both clinical and regulatory decision-making (Sherman et al., 2016; Corrigan-Curay et al., 2018). In line with this perspective, our study provides a unique contribution by demonstrating substance-specific alterations in both liver and coagulation parameters within the same clinical population—specifically, lower PT values in methamphetamine and multiple-substance users, and prolonged aPTT in cannabinoid users—thereby highlighting differential haemostatic risks associated with specific substances, while clearly acknowledging all design-related constraints.

-Sherman RE, Anderson SA, Dal Pan GJ, et al. Real-world evidence – what is it and what can it tell us? N Engl J Med. 2016;375(23):2293–2297.

-Corrigan-Curay J, Sacks L, Woodcock J. Real-world evidence and real-world data for evaluating drug safety and effectiveness. JAMA. 2018;320(9):867–868.