Title: Uncovering unsuspected advanced liver fibrosis in patients referred to alcohol nurse
specialists using the ELF test
Version: 3 Date: 02 Mar 2021
Reviewer:  Ian Rowe
Reviewer's report:
Thank you for the thoughtful revisions to the manuscript.  The information regarding
downstream investigation and linkage to care is important.  I am inclined to agree with the
authors that there is a substantial advantage to using a blood-based fibrosis test to identify
patients in secondary care, to maximise the identification of liver disease in this at risk cohort.
However, the data from the elastography examinations suggest that advanced fibrosis (as
assessed by ELF) was not present in 10 of the 17 patients with usable data.  The comment in the
discussion that the elastography data cannot be considered a robust standard due to the impact
of inflammation and alcohol is in part correct but is also likely to lead to false positive rather
than false negative examinations.
This study is important in highlighting a role for direct fibrosis testing in secondary care for this
at risk population.  In my view, the elevated ELF places a patient at high risk of having advanced
fibrosis, requiring further evaluation.
The terminology regarding "1/4 of patients in hospital with AUD had advanced fibrosis (as
assessed by ELF" needs to be reconsidered.  The additional information provided strongly
suggests that the positive predictive value of ELF in this study, in line with the PPV reported by
Thiele et al, is not sufficient to make a diagnosis of advanced fibrosis.
Title: Uncovering unsuspected advanced liver fibrosis in patients referred to alcohol nurse
specialists using the ELF test
Version: 3 Date: 02 Mar 2021
Reviewer:  Ian Rowe
Reviewer's report:
Thank you for the thoughtful revisions to the manuscript.  The information regarding
downstream investigation and linkage to care is important.  I am inclined to agree with the
authors that there is a substantial advantage to using a blood-based fibrosis test to identify
patients in secondary care, to maximise the identification of liver disease in this at risk cohort.
However, the data from the elastography examinations suggest that advanced fibrosis (as
assessed by ELF) was not present in 10 of the 17 patients with usable data.  The comment in the
discussion that the elastography data cannot be considered a robust standard due to the impact
of inflammation and alcohol is in part correct but is also likely to lead to false positive rather
than false negative examinations.
This study is important in highlighting a role for direct fibrosis testing in secondary care for this
at risk population.  In my view, the elevated ELF places a patient at high risk of having advanced
fibrosis, requiring further evaluation.
The terminology regarding "1/4 of patients in hospital with AUD had advanced fibrosis (as
assessed by ELF" needs to be reconsidered.  The additional information provided strongly
suggests that the positive predictive value of ELF in this study, in line with the PPV reported by
Thiele et al, is not sufficient to make a diagnosis of advanced fibrosis.
Please review this paper.
user
Title: Uncovering unsuspected advanced liver fibrosis in patients referred to alcohol nurse
specialists using the ELF test
Version: 3 Date: 02 Mar 2021
Reviewer:  Ian Rowe
Reviewer's report:
Thank you for the thoughtful revisions to the manuscript.  The information regarding
downstream investigation and linkage to care is important.  I am inclined to agree with the
authors that there is a substantial advantage to using a blood-based fibrosis test to identify
patients in secondary care, to maximise the identification of liver disease in this at risk cohort.
However, the data from the elastography examinations suggest that advanced fibrosis (as
assessed by ELF) was not present in 10 of the 17 patients with usable data.  The comment in the
discussion that the elastography data cannot be considered a robust standard due to the impact
of inflammation and alcohol is in part correct but is also likely to lead to false positive rather
than false negative examinations.
This study is important in highlighting a role for direct fibrosis testing in secondary care for this
at risk population.  In my view, the elevated ELF places a patient at high risk of having advanced
fibrosis, requiring further evaluation.
The terminology regarding "1/4 of patients in hospital with AUD had advanced fibrosis (as
assessed by ELF" needs to be reconsidered.  The additional information provided strongly
suggests that the positive predictive value of ELF in this study, in line with the PPV reported by
Thiele et al, is not sufficient to make a diagnosis of advanced fibrosis.
assistant