Publishing your manuscript

Joost PH Drenth

Department of Gastroenterology and Hepatology Radboud University Nijmegen Medical CenterThe Netherlands

Buzz word: the 3 C’s

• Clear, Correct and Concise, but also• Structure

Research & Reporting

• Proposal

• Research

• Submission• Decision

The basics of writing a paper Before you begin

• What do I have to say?

• Is it worth saying?• What is the right format for the message?

• What is the audience for the message?

• Where should I publish the message?

Basic principle

Make sure that readers know where they are, where they are

going, and whySo

The best is that you, as author know where you want to go and

why

Why publish?

• Expand medical knowledge• Hey, you want some brownies!

– Career prospects

• It is nice to be the expert– 4 articles on Proflox in peptic ulcer disease

make you the world expert

• Research not published = not done– If it is not listed in Pubmed, consider it not

done

Why publish?

• Because you have something important to say• To change practice• To promote thought or debate• To allow examination of your work• “Fame and the love of beautiful women”• Money• To entertain/divert/amuse• To educate• Career advancement

Smith R. www.bmj.com

Why publish?

• Papers are important in Academia– 236 applicants for GI fellowships– 53 applicants had ‘published’ a paper

– But….

Why publish?

• Papers are important in Academia– 236 applicants for GI fellowships– 53 applicants had ‘published’ a paper

– But….– 30% published in non existing journals or

published non existing articles…

Sekas, Ann Int Med 1995 123 38-41

Writing an article

• Try to align the content presentation of your paper with the Journal’s interest: aim well– Know your stuff, check the journal

– A clinical study is unlikely to end up in J Biol Chemistry

– The case report “healing of reflux esophagitis with pantoprazol” is unlikely to be published now in NEJM

Writing and submitting is marketing

– How does my baby sell?

– Editors buy Authors sell

– It’s E-bay, buddy!!

What do editors want?

• Excitement/ “wow”

• Importance

• Originality• Relevance to the audience

• True

• Clearly / Engagingly written

Smith R. www.bmj.com

Publish your paper

• Crap in Crap out principle

• A clear Hypothesis is key

• A solid research question• Biological plausibility

• KISS

KISS

• Keep it simple, stupid

Ideal paper

• Correct

• Consistent

• Concise• Well organised

• Clearly written

• Accessible

Title page

• Careful in selection of the title– Factual, caption of the results

• Infliximab for Induction and Maintenance Therapy for Ulcerative Colitis

• Chromosome 1p and 11q deletions and outcome in neuroblastoma.

– Avoid acronyms• Ambient BTEX and MTBE in the neighborhoods of different

industrial parks in Southern Taiwan

– Don’t try to be funny• Not: Big’n Fat: junk in the trunk • But: Behavorial intervention in moderate obesity: absence of

a clinical effect

Abstract

• This is what editor’s or referee are likely to read first– first hit is worth a dollar!

• Keep the Journal’s format– Word count– Structured or not– No abbreviations

Abstract

• Provide the real meat

• Do not overinterprete– Conclusion is supported by the data

Article consist of 4 key sentences

• First sentence of he introduction– miniseminar

• Last sentence of the introduction– What you actually did

• First sentence of the discussion– What you found

• Last sentence of the discussion– What it means

How to do it: an example

Famotidine for the Prevention of Gastric and Duodenal Ulcers

• First sentence of he introduction– Gastroduodenal damage can be seen on endoscopy

in 20 to 40 percent of people who take NSAIDs. • Last sentence of the introduction

– We compared two doses of famotidine (20 mg twice daily and 40 mg twice daily) with placebo to test the hypothesis that famotidine provides protection against NSAID-associated gastric and duodenal ulcers.

Famotidine for the Prevention of Gastric and Duodenal Ulcers

• First sentence of the discussion– The results of this study show that treatment with a

high dose of famotidine significantly reduces the cumulative incidence of both gastric and duodenal ulcers in patients with arthritis receiving long-term NSAID therapy.

• Last sentence of the discussion– High doses of famotidine were well tolerated and

effective in preventing both gastric and duodenal ulcers in patients with arthritis receiving long-term NSAID therapy.

Introduction

• Three types of introduction• Discussion

– The optimal therapy for peptic ulcer disease is under debate

• Alarmist– Peptic ulcer is a devastating disease and a major

killer in the western world

• Seminar– Peptic ulcer disease is a major public health burden

Introduction

• Be accurate– No misrepresentation of literature– Avoid selective referencing– Avoid tailoring introduction to the results

• Concise and to the point• Put the potential results of the study in

perspective with the literature– Do not give an elaborate review of the

literature here

Methods

• Concise but complete• Do not repeat complex methods

– If your lab discovered alpha pipelemic acid measurement in 1985, do not list the complete method here

• Describe controls• Provide statistical methods• Provide Medical Ethical Committee

approval

Results

• Clear and Concise– Do not repeat data from figures in the text – Stick to the relevant issues

• Be sure to include basic descriptive data• Do not overdo with tables and figures

– Figures tell the story– Tables give the evidence

• Do not discuss strengths / weaknesses of your study (here)

Discussion of scientific papers

• Statement of principal findings • Strengths and weaknesses of the study • Strengths and weaknesses in relation to other

studies, discussing particularly any differences in results

• Meaning of the study: possible mechanisms and implications for clinicians or policymakers

• Unanswered questions and future research

Smith R BMJ 1999;318:1224-1225 ( 8 May )

Discussion

• Again be concise• Do not restate results or introduction• Explain differences from other studies

• How does your data further the field (what this study adds)

• Place your results in perspective with other results

• Sell but be aware of overstating• Mention limitations

Discussion

• Last sentence• Another puzzle solved

– It is clear that proflox 40 mg o.d enables healing of Forest II peptic ulcer even in geriatric patients

• More research is needed– Further studies are needed to determine the optimum

dosage and duration of therapy• Perhaps possibly

– Proflox may well heal peptic ulcers, but other treatments may be as effective and it is unsure whether peptic ulcers in geriatric patients need treatment at all

References

• Avoid abstracts• Avoid selective referencing

– Mention the co-discoverer• Self citations

– Dr. X is a big proponent of self citation. Out of the 24 references he elects to cite 9 (38%) of his own studies. These 9 represent all Dr. X’s 9 first author papers on Pubmed

• Check for duplicates (happens!)• Political referencing

– Reviewers (references to likely reviewer)– Editors (references to Journal)

Submission

• Check, check, double check– Watch MS Office spell check!

• Favors non-medical above medical terms– sprue -> spree or spruced– We look forward to you reply

• Keep the journal’s format– Title page OK?– Abstract OK?

• Background & Aims vs. Introduction– References OK?– SI units

• mg/dl vs. mmol/l

Writing style

• Active• Short• Plain

Write active

• Not:– Histological analysis by Dr. X of nicely cut

liver samples by the very able technician Y revealed moderate steatosis and hepatitis in the liver of rat A and B but rat C had only minor steatosis and rat D displayed severe hepatitis

• But– At eight weeks livers showed a variable

degree of steatosis and hepatitis

Words editors prefer

• About > approximately

• Has > possesses

• More > additional• Raised > elevated

• Start > initiated

• Study > investigation

Plain is better

• If you can cut out a word do so• Never use long words when short one will do• Never use a foreign phrase if there is an

everyday English equivalent

• Never use passive when active will do– The finger of the physician was inserted into the

rectum– The physician inserted her finger in the rectum

Journal

• Take care in selecting a journal: right platform– Try to aim accurately: Donald Duck or NEJM– A letter of inquiry to the Editor might help

• Follow the specific requirements• References

– Use an automatic reference programme

• Check the cover letter– Is the Editor in Chief still in place– In case of resubmitting: reference to the ‘other’ journal

deleted?

Submission

• Dry run at a (local) scientific meeting – Jot down the questions– See what might be improved

Cover Letter 1

Your cover letter sells your article• Introductionary sentence

– Please find enclosed our manuscript "Proflox improves peptic ulcer healing " intended for publication in Gastroenterology.

• Caption of your study– As already outlined, peptic ulcer disease is a

devastating disease with a high mortality in the elderly. Current therapy includes proton pump inhibition.Although this is an effective therapy, some patients fail. Proflox is a new alpha-pipelimic acid inhibitor that specifically inhibits gastric acid production.

Cover letter 2

• What you actually did– We performed a 24-week randomised clinical trial in

1256 subjects and show that Proflox is a very effective peptic ulcer healing drug, especially in the elderly.

• USP– This is a solid result and we would like to emphasize

that randomised drug trials are rare, if ever done, in peptic ulcer disease. In clinical practice peptic ulcer patients are randomly exposed to various drug regimens, all of them completely uncontrolled. We believe that it is in the interest of these patients and physicians alike that these results are disseminated. For these reasons we therefore sincerely hope that our manuscript merits publication in Gastroenterology

Cover letter 3

• Potential reviewers– Reviewers you pick give a better score than random

ones

• Obligatory stuff– The contents of this manuscript have not been

published elsewhere, and likewise the manuscript is not being submitted elsewhere. There is no potential conflict of interest for the individual authors. We would prefer to be contacted by e-mail. Thank you for your consideration.

Decision

• Revision requested– Accept with grace and humility– Respond with grace and humility

– Do provide a point to point review• Yeah…

– Mark your changes in the manuscript• Use the track mechanism in Word

– Do not be confrontational• It is a game and these are the rules

Rejection

• That is a bummer

• S… happens

• Sit down, sigh and move on• Do not write an angry response

• Did I aim at the wrong target?

• Can you do something with the criticism raised by referee?

Case report

• And now something completely different…

Case reports are ‘bad’

• New ideas from case reports are not sustained on further research

• Contain "misleading elements" in clinical presentation

• More harm than good by emphasizing the bizarre

• Editors do not like it– Sloppy reviewing (nice observation)– Get few citations

• Few Journals publish case reports• Lowly status in the medical literature

Hierarchy of evidence

Case reports

Case series

Case control

Cohort studies

Randomised trial

Systematic review

Case reports in Journals

• Lancet (1)• Netherlands Journal of Medicine (3)• Digestive & Liver Disease (2)• Gut (0-1)• Am J Gastroenterol (0-3)• Eur J Gastroenterol & Hepatol (4-7)• Dig Dis & Sci (10)• J Clin Gastroenterol (3-4)

Case Report Journals

• Case Reports and Clinical Practice Review (CRCPR) – www.crcpr-online.com

• Grand Rounds– http://www.grandrounds-e-med.com/

Merits of a Case report

– Description of new disease• mitochondrial diabetes

– Study of mechanism • Clotting abnormality in a family

– Recognition of a rare manifestation of a common disease

• Extraintestinal manifestation of Crohn– Therapy

• New indication for drugs• Side effects of drugs

– Education • If you see this, think of that• Do not make the stupid mistake we made

Vandebroucke 1999 J Roy Soc Med 159-163

How to case report?

• Why is this observation important? • What does it teach us? • Is it contrary to common thinking

– If so, explain Does it run counter to some particular cherished truth? (spell it out) this truth and explain the reader how and why it is contradicted.

• Does it strike the "prepared mind"? – Yeah, that we did not think of this

• Is it an unexpected association? – What was expected?

• Is it a rarity that could be missed?

Vandebroucke 1999 J Roy Soc Med 159-163

Case report

“Case reports often introduce readers to new clinical techniques and allow them so see how

treatment can be made more efficient and effective”

“The writer (or narrator) should lay bare his or her thought process, as crisply and pointedly as

possible, because that it the only way to impress and strike a chord with the reader”

The anatomy of a case report• Introduction

– Explaining what is the paper is about: “• We are presenting a case of. . . , which is instructive because. . . . ” • Basic description of syndrome

• Case summary – Focus of the manuscript

• Provides detail to make the case• Include an illustrative figure!! • Exclude crap • Seek advice / consult with expert

• Discussion – Emphasises unique or important aspects

• Starts with a brief statement why we reported the case • Followed by concise description of the disease• What sets it apart , differential diagnosis• Finish with a concise statement of the lesson to be learned

• References – Provide additional general information – Back up specific points

Practice Run

• Introduction– Explaining what is the paper is about: “

• Drug-related acute pancreatitis remains an uncommon clinical entity….. We report a case that is unique in that acute pancreatitis occurred after many years of treatment with TMP/SMX.

• Case summary – Focus of the manuscript

• A 53-year-old woman presented with epigastric pain, radiating to the back. Elevated amylase. Prolonged (20 yrs) prophylactic TMP/SMX.

Versleijen et al. Neth J Med 2005 63 275 www.njmonline.nl

Practice Run

Practice Run

• Discussion – Emphasises unique or important aspects

• Here, we report a patient who developed acute pancreatitis after having taken TMP/SMX for many years as prophylaxis. Known causes of acute pancreatitis were ruled out. Discontinuation of TMP/SMX improved symptoms and we observed a relapse of acute pancreatitis within four days of restarting.

• Absence of a rash did not support hypersensitivity as a cause.

• Prolonged TMP/SMX use (20 yrs) can result in pancreatitis.