Healthcare Interventions in the Management of Rheumatic Diseases: A Narrative Analysis of Effectiveness and Emerging Strategies

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Nursing care is integral to the comprehensive management of rheumatic diseases. Through education, symptom management, coordination of care, psychosocial support, and advocacy, nurses significantly enhance patient outcomes and quality of life for individuals living with these chronic conditions. Their holistic approach addresses not only the physical aspects of the disease but also the emotional and social challenges faced by patients. Therefore, the review article of Dr. Verga et al. is very important.

Comments

1. Line 335: The authors state that pain is the fundamental aspect of medical care but nothing else was added to this statement. This issue should be described in more detail.
2. The aspect of advocacy was also not described in the paper. However, nurses advocate for patients’ needs within the healthcare system, ensuring they receive appropriate resources, referrals, and support services. They also educate patients about their rights and available community resources. This should be corrected.

Author Response

Dear reviewer,

Thank you for your constructive comments.

Following the comments received, we have completed the paragraph in row 335 with information on the importance of pain management in the care of patients with rheumatic diseases.  Line change: 344-350

We have also added a paragraph on the essential role of nurses in advocacy, emphasizing how they support patients in accessing needed resources and services. Lines : 444-452

 

 

 

Reviewer 2 Report

Comments and Suggestions for Authors

Comments and Suggestions for Authors

The manuscript addresses a topic of great health relevance: the comparison of two pharmacological treatments—cytisine and varenicline—for smoking cessation, with special attention to psychological and psychiatric variables. The topic is relevant and timely, especially given the resurgence of interest in cytisine in Western clinical practice and the persistent challenge posed by smoking in populations with mental comorbidities. However, despite the potential usefulness of this work for mental health professionals and clinicians in general, the article presents significant deficiencies in its conceptual development, methodological rigor, and technical writing, which compromise its quality as a publishable article in a high-impact journal.

From a theoretical perspective, the article presents a narrative review that attempts to integrate findings on the efficacy, tolerability, and emotional effects of both drugs, but without constructing a solid conceptual framework. Although relevant sources are cited, there is a notable lack of articulation between the theoretical frameworks of emotional regulation and the neuropsychological role of nicotinic agonists. The text tends to list studies cumulatively, without critically analyzing their methodological differences, limitations, or applicability to specific clinical populations. The introduction, while capturing the importance of the public health problem, does not clearly establish a central hypothesis or adequately delimit the scope of the review. Furthermore, general statements are frequently used without immediate empirical support or a critical discussion of the levels of evidence involved. This weakens the integrative function of the review and diminishes its value as an evidence-based clinical guidance tool.

The organization of the text is functional, but not entirely consistent with the requirements of a rigorous systematic or integrative review. Although the drugs are comparatively described from a pharmacodynamic and pharmacokinetic perspective, this is done in a style more appropriate for a summary of product characteristics than a critical review. The technical language is generally adequate, although it presents some terminological inconsistencies (e.g., the alternating and imprecise use of "cytisinicline" and "cytisine," or errors such as "varenicicline") and redundancies that could be eliminated without affecting the content. The writing style fluctuates between an informative tone and unsubstantiated opinion, with passages lacking updated references or presenting clinical inferences without adequate empirical support.

From a methodological perspective, it is presented as an evidence-based review, but no systematic review protocol (such as PRISMA) is specified, nor is a reproducible literature search strategy mentioned. No information is provided on the databases consulted, the inclusion and exclusion criteria for studies, the assessment of methodological quality, or the bias analysis. This significantly weakens the validity of the work as a scientific review. Instead, the article adopts a narrative structure with selective treatment of sources, which could lead to confirmation bias. Furthermore, studies with general and psychiatric populations are mixed without clear categorization or differentiated analysis, making it difficult to accurately identify the populations to which the conclusions drawn are applicable.

The data analysis, although indirect, is based on the results of meta-analyses and high-quality clinical studies, but is summarized superficially. Outcomes such as dropout rates and adverse events are cited, but their heterogeneity, effect size, statistical power, and the quality of the original studies are not discussed. Moderating variables are not considered, nor is there any serious reflection on the replicability of the findings or their external validity. The focus on the emotional dimension, the central focus proposed by the title, is particularly limited: most arguments are based on secondary or limited references, and the instruments used to measure emotional regulation, anxiety, or depression in the comparative studies are not systematically evaluated.

This undermines the original purpose of the article. The conclusions drawn are moderate and plausible, but also ambiguous and poorly differentiated. The authors suggest that both molecules are effective, with different tolerability profiles, and that the choice should be based on individual and contextual criteria. However, these statements, while reasonable, lack the analytical depth necessary to guide clinical decisions in complex populations, such as those with psychiatric comorbidities. The analysis does not critically assess the gaps in the literature, the scarcity of head-to-head trials in vulnerable populations, or the need for longitudinal studies that address neuropsychiatric effects in greater depth.

Regarding the bibliographic references, high-impact and current sources were selected, although some citations do not fit correctly into the text, and inconsistencies were detected in the transcription of article titles and journal names. Regarding formal quality, it would be essential to review all references and strictly adapt them to the Vancouver style.

In summary, the article proposes a relevant review, but it is still immature in its conceptual development and deficient in its integration methodology. It offers a useful synthesis for the clinical public interested in therapeutic alternatives for smoking cessation, but lacks the rigor and critical depth required by a high-level scientific publication. Suggestions for authors to consider:

• Reformulate the theoretical framework to more fully articulate the relationship between emotional regulation, nicotine dependence, and the differential mechanisms of action of the drugs.
• Define the central hypothesis of the article, specify objectives, and clearly justify the relevance of comparing these drugs specifically in a population with psychiatric comorbidity.
• Restructure the introduction by eliminating statements without empirical support and better contextualizing the available evidence.
• Apply a systematic or integrative review methodology (e.g., PRISMA) or, at least, accurately describe the search strategies, inclusion criteria, and study quality assessment.
• Organize the presentation of comparative results according to population subgroups, quality of evidence, and key clinical dimensions (efficacy, tolerance, adherence, emotional impact, etc.).
• Expand the critical discussion of the limitations of the source studies, potential biases, gaps in the evidence, and future research needs.
• Reformulate the conclusions to reflect the findings in a more nuanced way and propose specific clinical implications.
• Correct the citation style, adapting all references to the Vancouver format, and thoroughly review any transcription errors, author omissions, or bibliographic inaccuracies.
• Reduce linguistic redundancies and strengthen terminological precision throughout the text, especially when referring to technical concepts and pharmacological entities.

Consider incorporating a clinical evidence table with methodological quality and main results of the comparative studies, if the journal format allows it.

   

Comments on the Quality of English Language

In addition to the technical and scientific aspects already mentioned, I believe it is important to note that the English version requires careful editing. While the overall message is understandable, there are instances where the writing is clumsy, with grammatical errors or constructions that make the text difficult to read fluently. In some passages, this affects the clarity of ideas and can cause confusion for readers unfamiliar with the subject matter.

Therefore, I recommend that the manuscript be reviewed by a native speaker or a professional with experience in proofreading scientific texts in English. It is not just about correcting errors, but also about ensuring that the language accurately reflects the solidity of the content, facilitating understanding and increasing the chances of acceptance in high-level international journals. Good writing not only improves the presentation of the work but also reflects the quality of the effort behind it.

Comments on the Quality of English Language

Corrections related to form and style are appropriate, but the text already reads fluently and is well understood by non-native English speakers.

Author Response

Dear reviewer,

 

Thank you for sending your comments on my article. However, I would like to inform you that the comments received do not correspond to the content of my paper.

The article I sent for review is on rheumatic diseases, (Manuscript ID: healthcare-3687543, Title: Healthcare Interventions in the Management of Rheumatic Diseases: A Narrative Analysis of Effectiveness and Emerging Strategies), while the comments received concern a manuscript comparing pharmacologic treatments for smoking cessation, namely cytisine and varenicline - a completely different topic.

There may have been a mix-up in the assignment of review comments, which is why I respectfully request that you reanalyze my manuscript against the actual content and send me the comments for the correct article.

 

Thank you in advance for correcting this and for your support.

 

Yours sincerely,

Verga Gabriela Isabela

 

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for the opportunity to review your work. It is clear that the topic you address—the management of rheumatic diseases through diverse healthcare interventions—is highly relevant, both for clinicians and researchers. Rheumatic conditions continue to pose a major global burden, and synthesizing effective strategies remains a key priority in health sciences. Your manuscript touches upon important aspects, and the inclusion of both conventional and emerging interventions is appreciated.

That said, I believe the current version would benefit from a number of improvements in order to fully meet the standards expected in a narrative literature review.

Clarity and purpose
One of the first aspects that could be strengthened is the clarity of the article’s aims. Although the topic is relevant, the manuscript lacks a clearly defined objective or guiding question. As a result, the narrative sometimes feels more descriptive than analytical. I would recommend explicitly stating what your review sets out to explore—whether it is to compare interventions, identify promising alternatives, or outline areas of clinical uncertainty.

Transparency of sources and search process
A key issue in the current version is the absence of a clear description of how the literature was selected. While narrative reviews are more flexible than systematic reviews, it is still essential to briefly indicate where you searched for the literature (e.g., PubMed, Scopus), what time frame was covered, and what criteria guided the inclusion of sources. This will improve the transparency and credibility of your analysis.

Depth and synthesis of the content
At present, some sections remain relatively general, summarizing existing practices without offering a critical or comparative view. For example, claims about the effectiveness of certain treatments would be more convincing if supported by specific data, study examples, or comparative outcomes. Including contrasting perspectives, limitations, or gaps in current practice would help build a more analytical tone and engage the reader in a deeper reflection on the evidence.

Use of references
Some of the references included are dated, and there is room to integrate more recent literature, particularly when discussing advances in multidisciplinary care or the integration of novel technologies. Wherever possible, I recommend updating references from the past five years and ensuring that each major claim is grounded in a robust source.

Structure and visual aids
The organization of the manuscript is generally clear, though the use of visual summaries—such as a table of interventions or a figure showing the scope of strategies addressed—could significantly enhance clarity. This would allow readers to grasp the breadth of interventions reviewed, along with their proposed benefits or evidence level, at a glance.

Final remarks
The topic you address is meaningful and relevant, and the manuscript provides a solid starting point. With a clearer research aim, a more transparent explanation of your literature selection process, and a more analytical tone throughout, this paper could become a valuable contribution. I encourage you to revise the manuscript accordingly, as it has good potential for publication once these aspects are addressed.

Thank you again for your contribution, and I hope these comments are helpful as you continue refining your work.

Warm regards,

Recommended Bibliography

The following studies are suggested to enhance the scientific and clinical relevance of the manuscript. Each reference is highly pertinent to the themes of innovation, sensory prediction, and biopsychosocial integration in rheumatologic care.

1. Cuenca-Zaldívar JN et al. (2025). Fourteen‐Year Retrospective Cohort Study on the Impact of Climatic Factors on Chronic Musculoskeletal Pain: A Spanish Primary Care Analysis.

   • DOI:10.1111/1756-185x.70125

   This study offers long-term insights into how weather patterns affect chronic pain in rheumatology patients, reinforcing the importance of environmental variables in clinical management.

Author Response

Dear reviewer,

            Thank you sincerely for your thoughtful and constructive feedback. I have revised the manuscript and responded in a timely manner to the five issues raised, improving the clarity of the objectives, the transparency of the literature selection process, the updating of references, the analytical tone of the text and the integration of visual elements for better readability.

1.Clarity and purpose

      We have revised the manuscript to include a clearly defined objective. The objective of the revision is now explicitly stated as exploring how health care interventions influence disease progression and quality of life in patients with rheumatic diseases, with a particular emphasis on comparing the effectiveness of these interventions and identifying promising alternatives for improving clinical outcomes and quality of life.  We believe that this addition strengthens the analytical focus and depth of the paper. Lines 97-102.

       The research hypothesis( the staggering sting) is found in line 130.

2. Transparency of sources and the search process

    We have revised the manuscript by detailing the section on data collection methods as suggested. We specified the databases consulted (e.g. PubMed, Scopus, etc), the period covered by our search (2014-2025). These additions aim to increase the transparency and credibility of our analysis as recommended. Lines 121-128, 161.

3. Depth and synthesis of the content

            In the revised version, we have strengthened the analytic tone by including concrete examples of studies, comparative data, and references that illustrate the effectiveness of various nursing interventions. Lines 413-437.

4. Use of references

            In response, we have carefully reviewed the entire list of references and updated it to ensure alignment with the current state of research. We have replaced references older than 2014. All included sources now fall within the 2014-2025 range, which reflects the timeframe defined in our literature search strategy. This update particularly strengthens the sections addressing multidisciplinary approaches and digital health interventions, where emerging evidence has been incorporated to enhance the paper's relevance and scientific rigor. The changed references are : 62,64,66 ( lines 929,933,938).

5. Structure and visual aids

We have included a figure showing the relationship between health care interventions and quality of lifeicare and a table showing the main health care interventions, their scope and their reported benefits. This addition is intended to enhance the clarity of the manuscript and to provide readers with a concise overview of the strategies addressed, in line with your recommendation. Lines 386-389. 

6. Final remarks

            Thank you for your valuable comments and we hope that the changes made will be appreciated so that the manuscript can be considered for publication.

 

 

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

Dear authors,

Thank you very much for submitting the revised version of your manuscript. I truly appreciate the effort you have put into addressing the comments raised during the previous review round.

Upon carefully analyzing this new version, I can confirm that the overall quality of the manuscript has significantly improved. The narrative is now more coherent and better aligned with the stated objectives. Key sections such as the introduction and discussion have been clarified and enriched, and the structure is now more reader-friendly.

I particularly value the improvements made to the presentation of emerging strategies, as well as the better integration of the biopsychosocial framework throughout the manuscript. The inclusion of illustrative examples and the update of some references have helped strengthen the practical relevance of the paper.

One final reminder: please ensure you include the following reference, as previously suggested, given its relevance to the topics of sensory prediction, environmental influences, and chronic musculoskeletal pain in rheumatology:

Cuenca-Zaldívar JN et al. (2025). Fourteen‐Year Retrospective Cohort Study on the Impact of Climatic Factors on Chronic Musculoskeletal Pain: A Spanish Primary Care Analysis.
DOI: 10.1111/1756-185x.70125

This will further consolidate your manuscript’s impact, especially regarding environmental and predictive factors in rheumatologic care.

Congratulations again on your progress. I would now recommend acceptance with minor editorial adjustments, mostly regarding stylistic polishing and final proofreading.

Warm regards,

Author Response

Dear reviewer,

         Thank you very much for your kind feedback and for your appreciation for the improvements to our manuscript. We are grateful for the constructive guidance provided during the review process, which clearly helped us to increase the quality and relevance of the paper. As recommended by you, we have included some information on the integration of climatic factors in the assessment and management of chronic musculoskeletal pain in lines: 660-664, and the valuable reference is listed in the bibliography at number 176, lines: 1223-1225. All changes made are appropriately marked in the manuscript by shading in yellow and specifying the lines for ease of reading.

Please refer to the attachment. We have attached the manuscript with the changes made. We hope that the current form of the manuscript conforms to editorial requirements and is considered suitable for publication.

Yours sincerely,

Verga Gabriela Gabriela Isabela

on behalf of all authors