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PONE-D-22-01818Development of diagnostic criteria for differential diagnosis of alcohol-related brain injury (ARBI) among heavy drinkers: a systematic scoping reviewPLOS ONE

Dear Dr. Jones,

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.

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Academic Editor

PLOS ONE

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(We are grateful to Dr Amanda Atkinson, Public Health Institute, Liverpool John Moores University who contributed to study screening in the initial phase of the project, and Professor Harry Sumnall, also of Public Health Institute, Liverpool John Moores University who provided advice on the development of the systematic scoping review methods. This study was funding by charitable funds from the Gastroenterology Fund, (formerly) Royal Liverpool and Broadgreen University Hospitals NHS Trust. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.)

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Additional Editor Comments:

Thank you for submitting your paper. I am very grateful to the two expert reviewers for their thorough read of your manuscript and for their insightful suggestions. Like the reviewers, I feel the paper has its strengths and addresses an important issue, but feel it would benefit from a much stronger rationale –by explaining some of issues, limitations with the existing criteria. At the moment it lacks a clearly defined purpose and reads more of a summary of what others have done and where they overlap. By providing some context in terms of the complexity, difficulties we face in defining/diagnosing alcohol-related cognitive impairment its contribution to the literature will become a lot clearer.

When revising your manuscript, I would encourage you to refer the recent systematic review by Ko et al (2021) and to look carefully at the conditions under which cognitive impairment screening tools can be used.

Other minor issues

Make it clear that the statement below refers to people with Korsakoff’s, particularly since this is a criticism of the recent, similar Heirene et al. (17) review

With treatment, Smith and Hillman (13) estimated that full recovery can be achieved in approximately 25% of patients, and among the remainder, 50% can achieve a partial or minor recovery

The paper would benefit from starting clearer objectives. Currently aim 2 (on page 4) seems rather weak, “the identification of further work in identifying the best tools”, surely this would be a by-product of addressing aim 1 “summarising the evidence of existing tools/criteria and any validations of those”.

As noted by one of the reviewers, the fact that a protocol was developed in advance (but not registered) is a major limitation and should be acknowledged.

Finally with regards to the title - perhaps it needs a word like "Towards developing" or "Informing the development" as it appears rather overstated in its current form, relative to what the paper describes.

I am confident you will find the reviewers comments helpful in the revision of the manuscript

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Reviewers' comments:

Reviewer's Responses to Questions

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: Yes

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

Reviewer #1: N/A

Reviewer #2: N/A

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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: Yes

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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: Thank you for the opportunity to review this manuscript entitled Development of diagnostic criteria for differential diagnosis of alcohol-related brain injury among heavy drinkers: a systematic scoping review. This manuscript is a timely and useful review highlighting an important issue in the addiction field regarding the lack of criteria for diagnosing alcohol related brain injury.

Overall the manuscript is of an appropriate quality and followed a systematic scoping review methodology to extract key themes from the included literature. Prior to recommendation for publication, however, I would like to see the following comments addressed.

General comments

Overall I missed a more in-depth critique of the currently available criteria. For instance, specifically what are the current issues or practical concerns with applying the available criteria? I think inclusion of this within the introduction and discussion would be helpful for readers in highlighting the specific issues experienced by clinicians along with some potential avenues for improvement that future studies could incorporate or explore. This would help strengthen the discussion which has only a very small section devoted to this issue before moving onto screening tools.

Introduction

In the introduction/methods, it might be helpful for Table 1 to be expanded to include all available formal diagnostic classification systems for ARBI/ARD. This would help summarise the lay of the land for readers and provide a better context for the review.

Further to this, I think the manuscript could benefit from some additional commentary about the DSM and ICD diagnostic classification systems including any strengths and identified limitations.

Methods

The systematic scoping review procedure was well executed and described.

Please provide a stronger justification for excluding studies that solely used DSM/ICD classifications and a statement regarding the number of studies that were excluded on this basis.

The exclusion criteria regarding mixed samples of drug and alcohol users is a reasonable one, however, this should be acknowledged as a general limitation given the clinical reality that polysubstance use is often the norm in AOD settings rather than the exception and research studies often struggle to reflect this.

Page 6 paragraph 3: Typo. Diagnosis should be diagnose.

Results

Table 3 – Note that the MoCA now requires training certification to administer. Note also that some assessment measures have user restrictions that prevent unqualified individuals being able to purchase or administer the measure. For instance, the RBANS and NIS have a User Level B (Psychologist, Speech Pathologist, Occupational Therapist, Special Education Teacher, Human Resources Professional, Psychiatrist, Paediatrician). Check with each test publisher to determine the User level.

In highlighting these screening tools I would recommend a note of caution that they ought to be administered and interpreted by an appropriately qualified health professional with experience in the field of cognition. For instance, I note that the TEDCA personnel use is “unclear” given the lack of formal guidance by a test publisher or equivalent, however, it is clear that the measure contains several neuropsychological assessment tools that are generally recommended for use by clinical neuropsychologists and I would not consider them to fall into the category of “easy brief administration by non-specialised healthcare personal in the clinical and research field”, as was concluded by the TEDCA study authors!

A good description of the concerns associated with the use of screening tools in the AOD sector is in the second paragraph of the clinical recommendations section of the following paper: doi:10.1017/S135561772100103X.

This paper also includes an extensive review of screening tools utilised in the AOD sector and would be worth cross checking and discussing where appropriate. For instance, their conclusions are quite similar in that very few studies have validated the use of screening tools in AOD populations with the MoCA being the most commonly used.

Table 3 includes abbreviations that were not described in the table notes: ROCFT, TMT.

In the section describing the findings of studies using screening measures (page 16-17), was abstinence discussed in any of these studies? If this data is available in the included studies it may be worth including as a column in Tables 4 & 5 to aid interpretation of the findings.

Did any of the included studies present information regarding comorbid diagnoses that could impact on the provision of a diagnosis of ARBI?

Discussion

The discussion may benefit from commentary on the ICD-11 now being in effect given there has been a change in the diagnostic criteria for alcohol related dementia compared with the ICD-10. Highlighting this and discussing any avenues for further development could be valuable for readers.

Within paragraph three could the authors provide some commentary on any observations regarding the presence of psychiatric comorbidity or other factors observed in the included studies that may impact the differential diagnosis of ARBI in this cohort?

Reviewer #2: You Plos One

Feb 2022

OVERALL COMMENTS

Thank you for the opportunity to review this interesting manuscript. This is a very important systematic review that highlights a real gap in the literature regarding this condition. It notes a paradox: we (myself included) consistently call for valid diagnostic criteria for ARBD/ARBI/ARNI but have failed to invest resources into developing them through rigorous empirical work. There are a few areas where I think the introduction/ discussion could be expanded to better account for the complexity involved in defining and diagnosing this condition, but these can be easily addressed in a revision of the paper.

Below I provide specific comments on each of the individual sections within the manuscripts.

INTRODUCTION

The authors choose to use the term “alcohol related brain injury”. This term is not widely used outside of very small circles in the UK and is semantically confusing/ambiguous — “injury” suggests the person has sustained a physical injury, and the term overall insinuates that somebody has experienced a brain injury that occurred whilst intoxicated, which is certainly not what the authors are referring to. I strongly suggest the authors consider alternative terms if they wish to attract international attention with this work, some of which I discuss below:

• Alcohol related brain damage - this phrase has been used in several studies published by myself and others in the UK over the last few years and is widely recognised by many clinicians in the UK, although it is admittedly not widely used outside of the UK. Further, some clinicians dislike the use of terms like “damage” and “injury” as they imply permanent physical damage. See the following paper (please note, I am referring you to this paper that I authored as I think it is relevant to this point and several others in your paper, but I do not expect you to cite the paper or discuss it in any way if you do not feel it is suitable/relevant to your work):

Heirene, R. M., John, B., O’Hanrahan, M., Angelakis, I. & Roderique-Davies, G. (2021). Professional Perspectives on Supporting Those with Alcohol-Related Neurocognitive Disorders: Challenges & Effective Treatment. Alcoholism Treatment Quarterly, 39(3), 1–27. https://doi.org/10.1080/07347324.2021.1898294

Full text access: https://robheirene.netlify.app/publication/heirene_et_al_2021_perspectives_on_arbd_treatment/Heirene_et_al_%282021%29_Perspectives_on_ARBD_treatment.pdf

Alcohol-related cognitive impairment - this phrase is unambiguous, uncontroversial, and widely accepted worldwide

• alcohol-related neurocognitive impairment - again, this phrase is unambiguous, uncontroversial, and widely accepted worldwide. This term is also more semantically accurate and simply cognitive impairment”.

It is good that the authors note the other diagnostic terms used in the confusion this brings.

Third paragraph: the Smith and Hillman study referred to here only discussed recovery rates in those with Korsakoff’s syndrome. The authors appear to exclude this manifestation from ”ARBI” in their introduction, no? If they include this syndrome under their definition of ARBI then this needs to be clarified in the first paragraph or two.

Final paragraph: further to my first comment, the authors state that criteria for ARD have been adapted for a probable diagnosis of “ARBI” but Wilson actually used the term “alcohol related brain damage” in the article cited.

Given the overall purpose of this review, the authors need to better clarify what they mean by “ARBI” at the start of the manuscript. What is and isn’t included under this definition? Can you detailed description of the symptomology be provided, whilst acknowledging heterogeneity in presentation and noting this as key? It needs to be absolutely clear what “condition” is been referred to before we move on to determining how best to screen for it. Later in the article, the authors refer to a variety of different study populations as having “ARBI” including those in Brown et al. and Wester et al., but these are described differently by their respective authors. Perhaps the authors could discuss some of these studies and the samples studied in the introduction as examples of populations with ARBI according to their definition?

METHODS

Why was the protocol not registered in advanced if it was developed prior to conducting the review? This seems very strange and needs clarifying.

INCLUSION CRITERIA

the objectives stated here differ slightly from those stated at the end of the introduction? There is some inconsistency here.

Were reviews included? Please clarify

Was there a language restriction? Please clarify

The authors state they excluded samples “where they included mixed samples of drug and alcohol users.” Did this include samples will use both alcohol and drugs simultaneously? Please clarify. Polysubstance misuse is common and among this group.

SEARCHING FOR AND SELECTING RELEVANT STUDIES

This process of searching for and selecting articles seems scientifically valid and thorough. It is great that the authors used three reviewers to independently screen for potential studies at the full text level. At the title and abstract screening level, did the authors record the level of consistency between the two reviewers when screening the initial 20% of articles? It would be good to have some indication of interrater reliability.

DATA CHARTING PROCESS AND QUALITY ASSESSMENT

DATA SYNTHESIS

I have no other concerns or comments regarding the other subsections of the methods section—everything is clearly explained.

RESULTS

in the first paragraph of this section, the authors state that “20 records were kept and comprised the final set of included studies in the review”, but figure 1 shows only 19 studies were kept. Please clarify which is correct.

The authors state that only one study (32) included patients with a diagnosis of ARBI. However, our study (19; see below) included participants with a diagnosis of alcohol related brain damage, which the authors appear to include in the definition of ARBI. Please clarify whether this is because you only included studies that diagnose participants according to the ARD criteria.

19: Brown P, Heirene RM, John B, Evans JJ. Applicability of the ACE-III and RBANS cognitive tests for the detection of Alcohol-Related Brain Damage. Frontiers in psychology. 2019;10:2636.

Page 14: can the authors please provide a brief narrative summary of the results from the quality assessment process? I think it’s fine to include the full table of outcomes in supplemental information, but the readers need to have some indication of what the outcomes were here for ease of interpretation. A simple sentence or two stating what percentage of studies met each of the criteria in the assessment would suffice.

DISCUSSION

First paragraph: the authors provide a clear and succinct summary of the findings here and make some important inferences regarding the lack of research in this area despite calls for validation of diagnostic criteria.

Third paragraph: the varied mechanisms underlying ARBI is an important point here. I think we have a good enough understanding of the mechanisms involved to know that they are multiple and varied. As a corollary, we shouldn’t expect there to be strict diagnostic/ screening criteria that apply to every case of ARBI/ARBD/ARNI. I think the authors need to make more of a point of this and, although we need to better test existing and new criteria and cut-off scores for these, we should recognise that there will always be some degree of clinical judgement involved in making this diagnosis. It seemed like the complexity diagnosis and heterogeneity in presentation is not fully appreciated here and could be expanded upon.

The conclusions derived are appropriate and important.

FINAL COMMENTS

I hope the authors find the above comments useful in revising their manuscripts for publication.

Sincerely,

Rob Heirene (I sign my reviews)

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Reviewer #1: Yes: Dr James R. Gooden

Reviewer #2: Yes: Robert Heirene

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Submitted filename: PLOS Feb 2022.docx

PONE-D-22-01818R1Informing the development of diagnostic criteria for differential diagnosis of alcohol-related brain injury (ARBI) among heavy drinkers: a systematic scoping reviewPLOS ONE

Dear Dr Jones,

Thank you for submitting your manuscript to PLOS ONE. Thank you for carefully addressing the reviewers comments -the paper is much improved. We invite you to submit a revised version of the manuscript that addresses the final remaining point raised during the second review.

Please submit your revised manuscript by Oct 13 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.

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We look forward to receiving your revised manuscript.

Kind regards,

A/Prof Victoria Manning

Academic Editor

PLOS ONE

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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:

I agree with reviewer 1 that the paper would be strengthened with the addition of just a few sentences explaining how and why there were adaptations to the criteria.

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: (No Response)

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: N/A

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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

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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: Thank you for the opportunity to review this revised manuscript and I thank the authors for addressing the comments with some excellent additions to the manuscript.

I have some minor comments that the authors and editor may wish to consider prior to publication.

Discussion

I recognise this is a challenging point to address so it may not feasible, however, I still think the discussion could benefit from some elaboration on the available criteria and any emerging themes or issues from the included studies to help advance our thinking and maybe guide some next steps. For instance, a few of the included studies made adaptions to existing criteria, so what were these adaptions? Where they similar or not? Why did these authors feel the need to made such adaptions?

Another example worth raising is highlighting how disparate the criteria are vs rates of abstinence reported in the screening studies. Your description of the abstinence rates in the results is very illuminating because it shows many studies don’t adhere to the criteria, if indeed they even report abstinence rates in the first place! This is a worthy theme regarding any future criteria for clinicians and researchers to think about given the limitations in existing research and the practicalities of having patients maintain abstinence long enough to this meet criterion.

Minor:

As a reader there are a lot of abbreviations to keep track of and this risks adding to the already slightly confusing nature of all the different terms for alcohol related cognitive impairment. I would suggest considering a quick review of which abbreviations are absolutely necessary and which ones would read better in full. I realise this might add to the word count but I think for ease of reading it would be worthwhile.

Results (page 15): I was a little lost with the revised sentence following mention of Table S4 referring to “The tool from the review by Heirene…”. I was trying to understand “what tool” so maybe this paragraph just needs a slight restructure or framing for the reader to link the previous sentence with the next.

Reviewer #2: The authors have appropriately revised their manuscript according to the comments provided. I have no further concerns.

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Reviewer #1: Yes: James R. Gooden

Reviewer #2: Yes: Robert Heirene

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Informing the development of diagnostic criteria for differential diagnosis of alcohol-related cognitive impairment (ARCI) among heavy drinkers: a systematic scoping review

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,

Victoria Manning

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Thank you for your considered response to the issues and comments raised in the peer-review process. I think the review now provides a much more contextualised and nuanced account of what has been established to date and remaining knowledge gaps in relation to screening tools for alcohol-related cognitive impairment, and as a result it makes a useful contribution to the literature.

Reviewers' comments: