Title: Magnitude, Patterns, and Factors Associated with Liver Disease among Clinically
Suspected Clients in Eastern Ethiopia: Hidden Public Health Tragedy
Version: 5 Date: 18 Dec 2024
Reviewer's report:
"PEER REVIEWER ASSESSMENTS:
OBJECTIVE - Full research articles: is there a clear objective that addresses one or several
testable research questions? (Brief or other article types: is there a clear objective?)
Yes - there is a clear objective
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for
the objective?
No - there are minor issues
EXECUTION - Are the experiments and analyses performed with sufficient technical rigor to
allow confidence in the results?
No - there are minor issues
STATISTICS - Is the use of statistics in the manuscript appropriate?
No - there are issues with the statistics in the study
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not
overstated?
No - there are minor issues
OVERALL MANUSCRIPT POTENTIAL - Has the author addressed your concerns sufficiently
for you to now recommend the work as a technically sound contribution? If not, can further
revisions be made to make the work technically sound?
Maybe - with major revisions
PEER REVIEWER COMMENTS:
GENERAL COMMENTS: The study addresses a critical public health issue in Ethiopia by
investigating the magnitude, patterns, and factors associated with liver disease among clinically
suspected patients, and the authors have partly addressed the previous reviewer’s comments.
The study highlights significant findings  such as high liver disease prevalence (76%) and key
associated risk factors such as alcohol consumption or khat chewing. Thus, this study provides
valuable regional data. However, the manuscript lacks clarity regarding case selection criteria
and does not provide a detailed flowchart for case exclusions.
REQUESTED REVISIONS:
The authors have addressed several concerns of the previous reviewer’s comments. However,
some points are still missing. While the response to the reviewers clarifies that only clinically
suspected cases were included, the manuscript remains ambiguous regarding how patients
were screened initially (symptoms or laboratory-based). The exclusion of patients with pre-
existing liver disease (n=16) is mentioned in the response document but should be more clearly
explained in the manuscript. Some tests requested by reviewers are not available, and this is
a limitation of the manuscript. Multivariable analysis needs elaboration, particularly regarding
adjustments for confounders.  • Hosmer and Lemeshow test results for model fitness are
mentioned, but variance inflation factor (VIF) details should be provided to confirm the absence
of multicollinearity issues. There is no mention of HIV status, which is relevant for liver disease
contexts. Additionally, the study’s reliance on a single center may limit generalizability.
In addition to this, these previous comments does not seem to have been addressed or answered:
-As khat is not a substance that is not commonly known all over the world, authors are
encouraged to provide further explanation about it in the Methods section.
-OPD needs to be spelled out before being used.
-Instead of liver function tests, authors are encouraged to use liver enzymes as they do not
actually measure the liver function.
-In the first sentence of Variables in the study of Methods, do they mean the dependent variable
was presence of liver disease?
-388 participants were interviewed or were approached for interview and 92% accepted?
Minor comments
The reliance on self-reported substance use and history of intestinal worm infections introduces
recall bias. Please consider discussing this more explicitly as a limitation."
Title: Magnitude, Patterns, and Factors Associated with Liver Disease among Clinically
Suspected Clients in Eastern Ethiopia: Hidden Public Health Tragedy
Version: 5 Date: 18 Dec 2024
Reviewer's report:
"PEER REVIEWER ASSESSMENTS:
OBJECTIVE - Full research articles: is there a clear objective that addresses one or several
testable research questions? (Brief or other article types: is there a clear objective?)
Yes - there is a clear objective
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for
the objective?
No - there are minor issues
EXECUTION - Are the experiments and analyses performed with sufficient technical rigor to
allow confidence in the results?
No - there are minor issues
STATISTICS - Is the use of statistics in the manuscript appropriate?
No - there are issues with the statistics in the study
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not
overstated?
No - there are minor issues
OVERALL MANUSCRIPT POTENTIAL - Has the author addressed your concerns sufficiently
for you to now recommend the work as a technically sound contribution? If not, can further
revisions be made to make the work technically sound?
Maybe - with major revisions
PEER REVIEWER COMMENTS:
GENERAL COMMENTS: The study addresses a critical public health issue in Ethiopia by
investigating the magnitude, patterns, and factors associated with liver disease among clinically
suspected patients, and the authors have partly addressed the previous reviewer’s comments.
The study highlights significant findings  such as high liver disease prevalence (76%) and key
associated risk factors such as alcohol consumption or khat chewing. Thus, this study provides
valuable regional data. However, the manuscript lacks clarity regarding case selection criteria
and does not provide a detailed flowchart for case exclusions.
REQUESTED REVISIONS:
The authors have addressed several concerns of the previous reviewer’s comments. However,
some points are still missing. While the response to the reviewers clarifies that only clinically
suspected cases were included, the manuscript remains ambiguous regarding how patients
were screened initially (symptoms or laboratory-based). The exclusion of patients with pre-
existing liver disease (n=16) is mentioned in the response document but should be more clearly
explained in the manuscript. Some tests requested by reviewers are not available, and this is
a limitation of the manuscript. Multivariable analysis needs elaboration, particularly regarding
adjustments for confounders.  • Hosmer and Lemeshow test results for model fitness are
mentioned, but variance inflation factor (VIF) details should be provided to confirm the absence
of multicollinearity issues. There is no mention of HIV status, which is relevant for liver disease
contexts. Additionally, the study’s reliance on a single center may limit generalizability.
In addition to this, these previous comments does not seem to have been addressed or answered:
-As khat is not a substance that is not commonly known all over the world, authors are
encouraged to provide further explanation about it in the Methods section.
-OPD needs to be spelled out before being used.
-Instead of liver function tests, authors are encouraged to use liver enzymes as they do not
actually measure the liver function.
-In the first sentence of Variables in the study of Methods, do they mean the dependent variable
was presence of liver disease?
-388 participants were interviewed or were approached for interview and 92% accepted?
Minor comments
The reliance on self-reported substance use and history of intestinal worm infections introduces
recall bias. Please consider discussing this more explicitly as a limitation."
Please review this paper.
user
Title: Magnitude, Patterns, and Factors Associated with Liver Disease among Clinically
Suspected Clients in Eastern Ethiopia: Hidden Public Health Tragedy
Version: 5 Date: 18 Dec 2024
Reviewer's report:
"PEER REVIEWER ASSESSMENTS:
OBJECTIVE - Full research articles: is there a clear objective that addresses one or several
testable research questions? (Brief or other article types: is there a clear objective?)
Yes - there is a clear objective
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for
the objective?
No - there are minor issues
EXECUTION - Are the experiments and analyses performed with sufficient technical rigor to
allow confidence in the results?
No - there are minor issues
STATISTICS - Is the use of statistics in the manuscript appropriate?
No - there are issues with the statistics in the study
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not
overstated?
No - there are minor issues
OVERALL MANUSCRIPT POTENTIAL - Has the author addressed your concerns sufficiently
for you to now recommend the work as a technically sound contribution? If not, can further
revisions be made to make the work technically sound?
Maybe - with major revisions
PEER REVIEWER COMMENTS:
GENERAL COMMENTS: The study addresses a critical public health issue in Ethiopia by
investigating the magnitude, patterns, and factors associated with liver disease among clinically
suspected patients, and the authors have partly addressed the previous reviewer’s comments.
The study highlights significant findings  such as high liver disease prevalence (76%) and key
associated risk factors such as alcohol consumption or khat chewing. Thus, this study provides
valuable regional data. However, the manuscript lacks clarity regarding case selection criteria
and does not provide a detailed flowchart for case exclusions.
REQUESTED REVISIONS:
The authors have addressed several concerns of the previous reviewer’s comments. However,
some points are still missing. While the response to the reviewers clarifies that only clinically
suspected cases were included, the manuscript remains ambiguous regarding how patients
were screened initially (symptoms or laboratory-based). The exclusion of patients with pre-
existing liver disease (n=16) is mentioned in the response document but should be more clearly
explained in the manuscript. Some tests requested by reviewers are not available, and this is
a limitation of the manuscript. Multivariable analysis needs elaboration, particularly regarding
adjustments for confounders.  • Hosmer and Lemeshow test results for model fitness are
mentioned, but variance inflation factor (VIF) details should be provided to confirm the absence
of multicollinearity issues. There is no mention of HIV status, which is relevant for liver disease
contexts. Additionally, the study’s reliance on a single center may limit generalizability.
In addition to this, these previous comments does not seem to have been addressed or answered:
-As khat is not a substance that is not commonly known all over the world, authors are
encouraged to provide further explanation about it in the Methods section.
-OPD needs to be spelled out before being used.
-Instead of liver function tests, authors are encouraged to use liver enzymes as they do not
actually measure the liver function.
-In the first sentence of Variables in the study of Methods, do they mean the dependent variable
was presence of liver disease?
-388 participants were interviewed or were approached for interview and 92% accepted?
Minor comments
The reliance on self-reported substance use and history of intestinal worm infections introduces
recall bias. Please consider discussing this more explicitly as a limitation."
assistant