PONE-D-21-06570

Adrenal suppression in patients with chronic obstructive pulmonary disease treated with glucocorticoids: role of specific glucocorticoid receptor polymorphisms

PLOS ONE

Dear Dr. Pradeesh Sivapalan,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

The manscript is interesting but it needs appropriate revision following reviewers' suggestions in order to reach the standard of the journal.

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PLOS ONE

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The manucript is interesting but the authors should improve it following the reviewers' suggestions.

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Reviewers' comments:

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: No

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Manuscript number: PONE-D- 21-06570

Adrenal suppression in patients with chronic obstructive pulmonary disease treated with glucocorticoids: role of specific glucocorticoid receptor polymorphisms

Sivapalan and co-workers investigated the possible association between single-nucleotide polymorphisms (SNPs) of glucocorticoid receptor (GR) and metabolic disorders in patients with chronic obstructive pulmonary disease (COPD). In particular, the authors focused on the connection between GR haplotypes and adrenal suppression in patients with COPD following administration of systemic glucocorticoid (therapy for COPD exacerbation treatment). The authors conclude that COPD patients treated with systemic GC for their exacerbation and characterized by BclI and N363S gene polymorphisms did not have a major risk of acute adrenal suppression or metabolic disorders.

It is an interesting study, but the following should be addressed:

Major comments:

1) The author in the Material and Methods section not reported the primer sequence used for genotyping the four GR polymorphisms. Please provide this information; it is useful for the readers that want to perform a similar analysis.

2) Please provide a new table with the clinical, functional and biologic characteristics of all 77 patients included in the study: i.e. the prevalence of male and female, COPD step based on GOLD guidelines, age, BMI, etc.

3) on Results section authors affirm that: “the ischaemic heart disease, which seemed more prevalent in the low plus wild type (25%) than 139 in the high (3%) GC-sensitivity group.” In my opinion, it is necessary to report this statistical significance in Table 1. This could be misleading for the readers.

4) Page 4 lines 131-134 authors underline that: “We found a negative association between male gender and stimulated cortisol response ( Rho = -0.24, p = 0.042), but no correlation to other possible confounders: BMI (Rho = -0.15, p =133 0.22), age (Rho = 0.06, p = 0.63), accumulated GC use 6 months before test (Rho = -0.14, p = 0.23) and days since completed GCs (Rho = 0.09, p = 0.47)”. Please provide a table or figure that show these findings.

Minor comments

1) Page 2, line 65: provide reference.

2) The authors did not indicate the inhaled corticosteroid considered for the analyses (beclomethasone or fluticasone). Please provide this information.

3) Page 3, line 97: replace the square with the symbol β.

4) Page 8, lines 225-227: consider moving the sentence in the “Corticotropin test” (Materials and Methods section).

Reviewer #2: In the present study, Sivapalan et al evaluate the role of glucocorticoid receptor polymorphisms in the development of adrenal suppression following ICS treatment for COPD exacerbations. As rightly pointed out in the discussion, uniting subjects with low-sensitive haplotypes with mixed ones (wild-type) does not make particular sense, if not to increase the numerosity. In this way, however, the real comparison between low-sensitive and high-sensitive is lost. In fact, I would expect wild-types to have an intermediate behavior between low- and high-sensitive haplotypes. How many subjects are actually with low-sensitive haplotypes and how many are wild-type? Furthermore:

- The authors enroll 77 patients, but the description in table 1 is only about 50. What characteristics do these additional 27 have and why were they excluded?

- What is the real distribution of haplotype sets in the population? The individual SNPs are instead reported.

- In estimating the sample size, how do the authors define the reported corticotropin values ​​and why do they choose a 3:1 ratio?

- In the materials and methods it is not clear how the continuous data are expressed.

- In Table 3 and Figure 2, the authors found an inverse association between ICS and P-cortisol only in high-sensitive subjects (which are 2.5 times more numerous than low + wild-types).

- Figure 1 shows a value probably to be considered an outlier.

- Tables are not numbered consecutively

- There are typos

The work is interesting, however, it should be re-evaluated with a better subdivision of the groups.

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Reviewer #1: No

Reviewer #2: No

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PONE-D-21-06570R1Adrenal suppression in patients with chronic obstructive pulmonary disease treated with glucocorticoids: Role of specific glucocorticoid receptor polymorphismsPLOS ONE

Dear Dr. Pradeesh Sivapalan,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

ACADEMIC EDITOR: the manuscript needs an additional revision following the comments by the reviewer 2.

==============================

Please submit your revised manuscript by Jan 06 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Fabio Luigi Massimo Ricciardolo

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments (if provided):

The manuscript has been significantly improved but it needs an additional revision following suggestions by one reviewer.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors accurately reviewed the manuscript and is now considered to be suitable for publication in Plos One.

Reviewer #2: Sivapalan and collaborators have significantly improved their manuscript over the previous version. However, this version still had pitfalls and unclear passages, albeit of minor importance.

Why did the number of enrolled patients go from 77 to 78? In the description of the numerosity calculation, the authors wrote: "16 and 48 patients were included in each of the two groups (i.e., 64 patients in total). Assume that 20% of the recruited patients would not be placed in either of the two groups, additional 13 patients were needed, resulting in recruitment of 78 patients to the study". However, adding 13 to 64, the result is 77, as in the previous version of the manuscript, and not 78. Furthermore, a posteriori, it would have been helpful to predict the non-usability of data from "mixed genotype" subjects to recruit more individuals.

Had the authors designed the used primers? If so, how were primers designed? Otherwise, what is their source?

In the text, the descriptions of tables 3 and 5 are missing. Furthermore, given the small population, it would have been interesting to evaluate the characteristics of the "mixed genotype" population. Would intermediate features be conceivable, like wild-type, or would one component prevail?

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Adrenal suppression in patients with chronic obstructive pulmonary disease treated with glucocorticoids: Role of specific glucocorticoid receptor polymorphisms

PONE-D-21-06570R2

Dear Dr. Pradeesh Sivapalan,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Fabio Luigi Massimo Ricciardolo

Academic Editor

PLOS ONE

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