PONE-D-23-10059Sexual and reproductive health in Mexican patients with rheumatoid arthritis during the COVID-19 pandemic: A comprehensive approach from the biopsychosocial path.PLOS ONE

Dear Dr. Pascual-Ramos,

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.

Please submit your revised manuscript by Mar 28 2024 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,

Milad Khorasani, PhD

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at 

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and 

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Note from Emily Chenette, Editor in Chief of PLOS ONE, and Iain Hrynaszkiewicz, Director of Open Research Solutions at PLOS: Did you know that depositing data in a repository is associated with up to a 25% citation advantage (https://doi.org/10.1371/journal.pone.0230416)? If you’ve not already done so, consider depositing your raw data in a repository to ensure your work is read, appreciated and cited by the largest possible audience. You’ll also earn an Accessible Data icon on your published paper if you deposit your data in any participating repository (https://plos.org/open-science/open-data/#accessible-data).

3. When completing the data availability statement of the submission form, you indicated that you will make your data available on acceptance. We strongly recommend all authors decide on a data sharing plan before acceptance, as the process can be lengthy and hold up publication timelines. Please note that, though access restrictions are acceptable now, your entire data will need to be made freely accessible if your manuscript is accepted for publication. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If you are unable to adhere to our open data policy, please kindly revise your statement to explain your reasoning and we will seek the editor's input on an exemption. Please be assured that, once you have provided your new statement, the assessment of your exemption will not hold up the peer review process.

[Note: HTML markup is below. Please do not edit.]

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: Partly

**********

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

Reviewer #1: Yes

Reviewer #2: No

**********

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

**********

4. 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: No

Reviewer #2: Yes

**********

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: I have had the opportunity to review the manuscript entitled “Sexual and reproductive health in Mexican patients with rheumatoid arthritis during the COVID-19 pandemic: A comprehensive approach from the biopsychosocial path. “ which seems to me to address a relevant, relatively unexplored topic that would be very useful in the comprehensive clinical approach to patients with rheumatoid arthritis, and which seems appropriate to be published in Plos One.

However, although the authors approach the study phenomenon with a pertinent methodological approach, I consider that the manuscript must be improved in a series of aspects of form and substance in order to be accepted.

Below, I expose this series of aspects that I consider should be corrected or refuted with solid scientific arguments by the authors:

First of all, I recommend that the manuscript be reviewed and corrected by a native English speaker, since there are some paragraphs that are difficult to understand due to the writing style used.

Title and Abstract:

A first observation is the absence of correlation or inconsistency between the title and the actual content of the study. The title emphasizes the relevance of linking the central phenomena studied with the concurrence of the SARS-Covid 2 pandemic, however, while reading the manuscript I did not find any solid connection to justify these relationships, except the temporal concurrence of the conducting the study with the pandemic, this leads me to the following question:

Did the authors justify that the presence of the pandemic would have an effect on the sexual and reproductive health of patients with RA? In my opinion, I consider that in order to justify the inclusion of this factor in the title, a comparison of the behavior of the dependent variables of sexual function or health should have been carried out before or after the end of the pandemic.

The title also gives weight to the phenomenon of “reproductive health”, however this variable is barely explored or is explored with unstructured measurement instruments, since the instruments used for the core part of the study (sexual function) are specifically focused. to the domain of function (not health, which is broader from the point of view of semantic content) sexual, not reproductive.

Additionally, from the title and throughout the manuscript the authors use “sexual health” and “sexual function” interchangeably as synonyms, which are not exactly synonymous terms. I consider that for scientific accuracy the authors should standardize the concepts used throughout. of the manuscript.

Material and methods:

A fundamental problem is the risk of selection bias that the study has in relation to the population included, since the patients studied were defined as having RA “based on the criteria of the treating rheumatologist.” Since its verification does not impose much additional effort to carry out the study, it is currently very difficult to justify a research project in RA based on patients who have not met the EULAR/ACR classification criteria. If it is not possible to modify it, this aspect (potential selection bias) should be included and discussed in the limitations of the study.

An important question to evaluate the appearance of measurement biases: Were the various instruments used, in addition to having been translated into Spanish, transculturated for the Mexican population?

In the paragraph dedicated to the operational definition of the sexual function variable in men: Were the cut-off points defined to categorize the presence of impaired sexual function arbitrary definitions made by the authors for the purposes of the study?; Or have they been previously validated?

In this same paragraph,: given that the acronym ISF ¿meaning impaired sexual function? is the first time it is used in the manuscript, it should be expressed non-acronymized, followed by its acronym in parentheses. The same observation applies to the SF acronym in the subtitle of this paragraph.

Another important point that the authors should reflect on is that the instrument used to evaluate sexual function in men has the specific objective of evaluating the phenomenon of erectile dysfunction, which, although similar, is not exactly the same as sexual function. Depending on sexual preference, a person could have decreased erectile function, but be sexually satisfied with this degree of erectile function. This aspect is also susceptible to being included in the limitations of the study.

An important aspect is that in the Methods section the variable “(past or present) sexual discomfort” is not operationally defined, althaugh is used repeatedly in the results section.

Discussion:

It seems too extensive to me, covering aspects of descriptive information of data that are not relevant to the fundamental aspect of the study: the factors associated with altered sexual health in patients with RA, which only occupies 1.5 of the 5.5 pages dedicated to this section of the manuscript.

Since it was carried out on a population from the same country, the authors should include in the introduction and discussion the paper: Alvarez-Nemegyei J, Cervantes-Díaz MT, Avila-Zapata F, Marín-Ordóñez J. Pregnancy outcomes before and after the onset of rheumatoid arthritis. Rev Med Inst Mex Seguro Soc. 2011 Nov-Dec;49(6):599-604, which addresses reproductive health topics in Mexican women with RA.

In relation to the results of the logistic regression analysis carried out, I consider that, instead of being presented as a Forrest-type graph presenting only the variables that reached statistical significance, it should be presented in tabular form with all the variables included in the model, each one with its OR, 95% CI and corresponding p value.

Reviewer #2: This is a very interesting manuscript that includes a subsection of the population that deserves more attention in research. I congratulate them on their efforts.

there are some topics though that I think could improve the manuscript:

In general, The authors indicate that the variables that are affected by RA include non SRH factors. However there are measures that are reported that are more psychosocial factors: The HADS (anxiety and depression), the RAPID-3 (disease activity/severity), the EQ-5D (health related-quality of-Life), the FACIT-F (fatigue) (which I do understand is part of the listed ´biopsychosocial path´, however this can be simplified.

Please use ´participants´ not ´patients´ throughout.

Title: should better reflect what is being studied/found in a more simplified way: one example could be Psychosocial factors associated with sexual function of male and female Rheumatoid Arthritis patients of a. xxxx hospital in Mexico City (or something to that effect)

Abstract:

The writing of the abstract can be improved, especially in the results section to correctly describe results.

What is impaired SF? The defintion is not adequate to understand what you present in results.

The dates seem to be missing when the study was undertaken.

What is ´multiple logistic regression´? Do you mean Multivariable? You do not present multivariable results, nor do you indicate what is being controlled for. You present bivariable results (at least in the abstract…). Were there no significant results with multivariable? If so this is important to state.

In the results section, the results need to be presented more clearly. Example: I do not understand this sentence: ´ Overall, 49.6% of the patients referred to the current family planning method, and 89.7% had children, with a median of 2´.

The measures that are undertaken with males and females (FSFI, satisfaction) should be presented by sex.

It wouldn´t be that ´erectile dysfunction was present in 29.4% of males, but instead 29.4% of males reported erectile dysfunction. You´re are not actually measuring the erectile dysfunction but instead the report.

´Male` is not a gender, it is sex.

The OR and p values can be truncated at two numbers after the decimal.

% results should be presented with OR values.

Could there be confounding variables that need to be controlled for (age)?

Conclusions:

You cannot conclude that RA compromises SRH, you have no control group (non RA). All you can say that some psychosocial factors were found in individuals with RA, and there were differences of participant sex

Introduction:

You state that WHO recommends using SH (which includes RH), yet you continue to use SRH. Why is this?

Authors write: ´RH in RA patients has focused on reduced fertility (30-35) which has been related to the disease process itself [30], therapy [29], gonadal dysfunction [36], physicians’ advice [30, 31], and individual decisions [30, 31]. ´ what do you mean by physicians´advice and individual decisions?

This last sentence and the following starting line 86 need to be put together into one. You´ve already said reduced fertility (subfertility should be called ´infertility´ . This one item (infertility) can be included in the previous sentence as ´infertility´ and put the citations together.

*Methods*

The study was undertaken between 2020 and 2022. Were there still covid instruments being included in 2022?

No need to cite STROBE and include it in as supplementary material. I believe it is just the journal that needs this when submitting.

The methods include qualitative research. These results are not reflected in the abstract.

How were the quantitative questionnaires administered? Paper format? Electronic?

In the definitions and groups (what is ´groups´?) you only mention impaired sexual function for males and females. This is not a ´reproductive health´ measure per se, but instead by definition, a sexual health measure. Perhaps think about this (as these are you outcome variables) when reworking your title and focus in your abstract.

Sample size: if you only needed 151 patients, why did you include more than 100 more?

what is the overall population estimated with RA in CDMX?

Results seem to be expressed (at least in the abstract as OR not AOR or aOR which would be adjusted).

Furthermore, you do not indicate what you are adjusting for (other than RAPID-3), but surely age must be a confounder when dealing with sexual function (although it is shocking to me- the literature says that starting late 20´s early 30s, women´s sexual function may start to decline!)

Results:

NO need to duplicate in written results what is in the table. This section could be rearranged, considering the recommendations below of the tables.

What is ´middle aged female? This is a vague definition that can mean a lot of things to different people. Median and IQR should be used for age.

The table 1 needs some better structure. For example, many variables are presented with mean or medians? This needs to be defined better. But there are variables like Religious beliefs (what does this mean? Is it ANY religious beliefs? Is it being spiritual? Being in a relationship is the same. So it should be set up as categories for some of these variables: Employment (formal is one category and informal is another category), etc.

Table 2 is perhaps important, but these variables need to described in light of your outcome variables (and included in the abstract and better woven into the paper). Otherwise it´s just information that is hanging in the air. Are the anxiety and depression scales ONLY covid related? Why are they not part of other tables? Where these

Now I see RH results (these seem to be missing sadly from a lot of the paper)

For the results section- I would organize like this:

Table 1: demographic characteristics with medians(IQR), means(SD) and categories correctly presented

Table two: Outcome variables presented of impaired SF and non-impaired SF(columns) against demographic variables (rows). The covid variables should just be other non-outcome variables but labeled correctly.

Table three: OR with significant variables found in table two.

Discussion:

This should be in sync with the more developed results. As it is, it is quite long and wordy, but does not need to be. You need to decide if COVID is going to be main non-outcome variables or not (depending on results), this is not even mentioned in the first paragraph of the discussion.

**********

6. 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.

PONE-D-23-10059R1Biopsychosocial factors are associated with impaired sexual function in Mexican patients with rheumatoid arthritis.PLOS ONE

Dear Dr. Pascual-Ramos,

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.

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

Please submit your revised manuscript by May 16 2024 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,

Milad Khorasani, PhD

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

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

**********

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: Partly

**********

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

**********

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: I consider that the authors have carried out all the suggested corrections, or have refuted in a solid argumentative manner those with which they did not agree, so I consider that the manuscript could be accepted.

However, before being accepted there are some specific aspects that require correction or clarification:

The aOR values of the predictor variables that were significant in the logistic regression model that are mentioned in the abstract, in the text of the results and in Figure 3 do not coincide with those shown in Table 3. In fact, none of the aOR and p values in the corresponding column are significant.

There appears to be an error in placing the value of the decimal point in the confidence interval of the FACIT variable in Figure 3, it is mentioned as (0.92-0.10), when in reality its correct value appears to be (0.92-1.00).

I consider that once these specific situations have been corrected or clarified, the article can be accepted.

Reviewer #2: Thank you for the opportunity to review this manuscript. Although it is much improved from the last version, I still feel there are things that can be improved upon.

Abstract

- In the intro (line 83) you say there are characteristics for the LA region (greater female: male ratio and younger age at presentation, although you show this in the intro (with a citation), this sentence alone in the abstract is a bit distracting. Perhaps an opening statement should be that RA affects sexual function or something more general as you are not focused on comparing LA patients to others in the world but instead the affects on

- The abstract still indicates ´patients´ (the term participants was recommended to use). No need to mention more than the term ´Methods´ in the subsection.

- Idncate in the methods section if questionnaires were provider-administered? Study-team administered? self-administered?

- No need to say 1st and 31st (you can just say September 1 yyyy -January 31 yyyy (same with Methods section in body of document)

- Descriptive statistics and multivariable logistic regression analysis were used. (were used to…? (to study x factors related to y)

- What is FACIT-F.? Please don´t use acronyms without defining.

- The conclusion needs to be more explicit. X, y and z were found to be associated with ISF…. We recommend….or a conclusion of the findings.

Introduction:

- You cite Caucasians and which sex is most affected (please correct to females and males as gender is not as much a factor as sex is)- can you find a citation that looks at the F:M ratio among Latin Americans?

Methods

- Normally the ethics section goes at the end of the Methods section

- It is not clear (line 136) who applied the paper survey. They say administered, how was that administration (this should be discussed in the limitations section as well as any way you apply a survey there are bias’s to how people respond)

- Definitions subtitle could be better titled as ´Measures´

- ´Statistical analysis´ subtitle could be better called ´Statistical Analyses´ as there are more than one.

- I think the terms univariable/multivariable or univariate/multivariate should be homogenized. Right now, there is univariate/multivariable.

- What was the adjustment in the aOR for? (i.e. what did you adjust for)

- Missing data : (line 222) is this only per question? Or if someone said I don´t want to answer to one question then none of their questions were included?

- Line 226´A value of p<0.05 was considered statistically significant.´ seems wrongly placed

Results

- Line 230 missing data needs to be better explained as above (and no need to repeat if this has already been explained in methods)

- Table 1: what are ´self-referring Catholics and self-referring non-religious?´ is this self-reported? If so, could probably drop it as would think all religion is self-reported?

- This table could be better presented as

Variable N=xxx

Category n % or median(IQR)

Category n

category n

And some variables could be kept as one (e.g. age)

Please indicate what the * stands for

Table 1 should be presented with male and females as well:

All participants Male participants Female participants

Variable N=xxx % or median(IQR) (should be denoted as median if you present median) N=xxx % or median(IQR) (should be denoted as median if you present median) N=xxx % or median(IQR) (should be denoted as median if you present median)

Category n

Category n

category n

Please don´t repeat written results if they are in the table, unless they are some of the main results. The written results can be cut down a lot I think.

Table three could be presented as two extra columns of table 2 (in the same format as my suggestion for Table 1 above), as its best to be able to see OR and aOR against %. Please define what the current table 2 p-values are describing.

Figures 1 and 2: make sure data is not repeated in tables. If it is, please eliminate figures.

Figures 3 (it´s not titled but I think it is figure 3) doesn´tadd much to the data as this is already presented in the table.

Was age added in the model as an adjusting factor? This should be explained in the methods perhaps.

Discussion.

The first paragraph should highlight a few findings from your analyses and the following paragraphs explain these findings further and compare to other research in the same paragraph.

Please check grammar throughout but (line 340, 341 especially)

Your discussion on male participants (lines aprox. 350) is biased because of your low sample size, this should be highlighted.

Fully discuss limitations (some ideas above)

**********

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: Yes: José Alvarez-Nemegyei

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.

Attachments

Attachment

Submitted filename: RA_r1notes.docx

PONE-D-23-10059R2Biopsychosocial factors are associated with impaired sexual function in Mexican patients with rheumatoid arthritis.PLOS ONE

Dear Dr. Pascual-Ramos,

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.

Please submit your revised manuscript by Jul 12 2024 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,

Milad Khorasani, PhD

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.

[Note: HTML markup is below. Please do not edit.]

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 #3: (No Response)

**********

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 #3: Partly

**********

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

Reviewer #1: Yes

Reviewer #3: 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 #3: Yes

**********

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 #3: 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: (No Response)

Reviewer #3: Could authors explain the differences regarding a previous paper that explored the prevalence of sexual dysfunction in Mexican women with rheumatoid arthritis (Rojo-Contreras et al. Healthcare (Basel) 2022 Sep 21;10(10):1825. doi: 10.3390/healthcare10101825) focusing on the associated factors of sexual dysfunction to establish the main differences regarding this. In addition to see for the main contributions of the study carried out, author´s should incorporate into the Discussion section the advantages, disadvantages and areas of opportunity for the internal and external validity of the study carried out.

**********

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: Yes: Jose Alvarez-Nemegyei

Reviewer #3: 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.

Biopsychosocial factors are associated with impaired sexual function in Mexican patients with rheumatoid arthritis.

PONE-D-23-10059R3

Dear Dr.  Pascual-Ramos,

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.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Milad Khorasani, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

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 #3: All comments have been addressed

**********

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 #3: Yes

**********

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

Reviewer #3: 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 #3: Yes

**********

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 #3: 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 #3: Authors have attended the comments and suggestion, and accordingly them the manuscript in the Discussion section was improved.

**********

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 #3: No

**********