curso granada 2004: how to write a medical article

How to write & publish a scientific paperF. Javier Rodriguez-Vera

Department of Internal Medicine.

Hospital do Barlavento Algarvio.

Portimão. Portugal. EU

http://fotodigital.home.sapo.pt/pages_L/DSCN0644.html

How many articles are sent to a journal?

How many are rejected?

Why are they rejected?

How many are reoriented to another journal?

I. Before start writing

II. Writing the article

III. Making the article to be published

How to write & publish a scientific paper

Why an article is published?

It says something new: Original

It is well plotted: IMRAD

It was timely sent to the appropriate publication: “MARKETED”

Block I. Before start writing

What we need to write an article?

a) Knowledge

b) Norms of publication

c) Hardware and software

d) Matter


a)Knowledge b) Norms of publication


d) Matter


Select a group of journals of interest and read them periodically:

-Updated

-”Get the tempo”

For General Internal Medicine:

NEJM

BMJ

Arch Int Med

Med Clin


To know how to perform an up-to-date

Are you really discovering anything new?

State of the Art


• Give overview of a topic; print textbooks, electronic textbooks, narrative reviews in journals

1. Harrison’s Online 2. Scientific American Medicine Online 3. MD Consult 4. Medline articles

a. Ovid b. PubMed


Knowledge of medical writing:

“it is concise, usually uses the passive form. The asseverations are based on other articles published. The conclusions are based on the results of the study”

Inductive thinking


“The situation with respect the subject A is 1(references of bibliography)…We have done a study to clarify the point B which was not clear. To do it, we have measured the parameters C, D and F with the device G. The results were that C had a value of 2, D had a value of 3, and F had a value of 4. We conclude that the point B has been cleared…”


a) Knowledge

b)Norms of publication


d) Matter


Norms of publication

Make a folder with the norms of publication of your “target journals”

Make a list of “target journals”


a) Knowledge



d) Matter


Microsoft Word.lnk

PC.

Internet.

Word processor


a) Knowledge



d)Matter


Clinical case

Series of clinical cases

Observational study

Trial

Randomized

Non randomized

Review

Metanalysis

Opinion

Matter


We are ready to start writing

We have an interesting subject

We know this finding had not been published before

We have a state of the art vision of the matter

We have a word processor and a web link

LET START WRITING!


http://viajar.clix.pt/com/fotos.php?id=284&lg=pt



III. Making the article to be published

The title

Once of the most important items to publish an article. It has to have “catch up”

First impressions are strong impressions; a title ought therefore to be well studied, and to give, so far as its limits permit, a definite and concise indications of what is to come

T Clifford Allbutt

Block II. Writing the article

Do:

Write the results of the article: “Absence of an Effect of Liposuction on Insulin Action and Risk Factors for Coronary Heart Disease”

Write the aim of the study:“Cardiovascular Effects of Continuous Positive Airway Pressure in Patients with Heart Failure and Obstructive Sleep Apnea”

“Influenza Vaccination and Reduction in Hospitalizations for Cardiac Disease and Stroke among the Elderly”

Ask a question:“Exposure to Lead in Children — How Low Is Low Enough?”


Don´t

Use very long titles:

“On the addition to the method of microscopic research by a new way of producin colour-contrast between an object and its background or between parts of the object itself”

Use metaphoric sentences


Structure IMRAD

oIntroduction

oMaterial and Method

oResults

oAnd

oDiscussion


Introduction

It has the aim of giving a brief vision of the state-of-art of the matter and justifying the study.

“The situation about the matter is A.....There is a blank of the knowledge with respect to B......so...we did C”

All the asseverations will have to be supported by bibliographical references


Rheumatoid arthritis is a systemic autoimmune disease that affects approximately 1 percent of the adult population.1 It is characterized by chronic inflammation in the synovial membrane of affected

joints that ultimately leads to loss of daily function due to chronic pain and fatigue. The majority of patients also have deterioration of cartilage and bone in the affected joints, which may eventually lead to permanent disability. Rheumatoid arthritis is associated with increased morbidity and mortality.2

Although the precise pathogenesis of rheumatoid arthritis remains unclear, it has been postulated that multiple exogenous or endogenous antigenic triggers, or both, act in the presence of a background

genetic predisposition to initiate a self-perpetuating series of autoimmune responses in the synovial compartment.3,4 Many cell populations, including monocytes, macrophages, B cells, T cells, endothelial cells, and fibroblasts, participate in the ongoing inflammatory process.3 The precise contribution of B cells to the immunopathogenesis of rheumatoid arthritis is not fully understood, although a number of mechanisms have been proposed.4,5,6 However, strong evidence for a critical role of B cells in rheumatoid arthritis came from a small open-label study of rituximab in combination with cyclophosphamide and corticosteroids.7

Rituximab is a genetically engineered chimeric anti-CD20 monoclonal antibody that is approved for the treatment of relapsed or refractory, low-grade or follicular, CD20+ B-cell non-Hodgkin's lymphoma.

CD20 is a B-cell surface antigen that is expressed only on pre-B and mature B cells. It is not present on stem cells and is lost before differentiation of B cells into plasma cells. Therefore, rituximab causes a selective transient depletion of the CD20+ B-cell subpopulation.7 To confirm the role of B cells in rheumatoid arthritis, we evaluated the effect of rituximab in patients with active rheumatoid arthritis in a multicenter, randomized, double-blind, controlled study.


Rheumatoid arthritis is a systemic autoimmune disease that affects

approximately 1 percent of the adult population.1 It is characterized by chronic inflammation in the synovial membrane of affected joints that ultimately leads to loss of daily function due to chronic pain and fatigue.

The majority of patients also have deterioration of cartilage and bone in the affected joints, which may eventually lead to permanent disability. Rheumatoid arthritis is associated with increased morbidity and mortality.2

Says what is known about the disease

Highlights the importance of a fact


Always backed by bibliographical references


Although the precise pathogenesis of rheumatoid arthritis remains unclear, it has been postulated that multiple exogenous or endogenous antigenic triggers, or both, act in the presence of a background genetic predisposition to initiate a self-perpetuating series of autoimmune responses in the synovial compartment.3,4 Many cell populations, including monocytes, macrophages, B cells, T cells, endothelial cells, and fibroblasts, participate in the ongoing inflammatory process.3 The precise contribution of B cells to the immunopathogenesis of rheumatoid arthritis is not fully understood, although a number of mechanisms have been proposed.4,5,6 However, strong evidence for a critical role of B cells in rheumatoid arthritis came from a small open-label study of rituximab in combination with cyclophosphamide and corticosteroids.7

Blank in the knowledge

Transition to the “so...”


Rituximab is a genetically engineered chimeric anti-CD20 monoclonal antibody that is approved for the treatment of relapsed or refractory, low-grade or follicular, CD20+ B-cell non-Hodgkin's lymphoma. CD20 is a B-cell surface antigen that is expressed only on pre-B and mature B cells. It is not present on stem cells and is lost

before differentiation of B cells into plasma cells. Therefore,

rituximab causes a selective transient depletion of the CD20+ B-cell subpopulation.7 To confirm the role of B cells in rheumatoid arthritis, we evaluated the effect of rituximab in patients with active rheumatoid arthritis in a multicenter, randomized, double-blind, controlled study

So...What we did?


Material and MethodHow we did it?

A short paragraph

Must include:

-What subjects we included,

-Definitions

-What parameters were assessed,

-What instrumentation was used to assess

-Was there a statistical study? What kind?


“We studied the patients with the characteristics A and excluded those with the item B. We measured C, D and F. We defined F as C+D. To make the measurements we used the device ABC. To study if there were statistical difference between the patients, we did the test X...”


Patients Patients were recruited from 26 rheumatology centers in 11 countries (Australia, Canada, Israel, and 8 European countries). Eligible patients were at least 21 years of age, fulfilled the revised 1987 American Rheumatism Association criteria,1 and had active disease despite treatment with at least 10 mg of methotrexate per week. Active disease was defined by the presence of at least eight swollen and eight tender joints and at least two of the following: a serum C-reactive protein level of at least 15 mg per liter, an erythrocyte sedimentation rate of at least 28 mm per hour, or morning stiffness lasting longer than 45 minutes. In addition, eligible patients were seropositive for rheumatoid factor, as defined by a plasma rheumatoid factor level of at least 20 IU per milliliter.

Patients were excluded if they had an autoimmune disease other than rheumatoid arthritis (except concurrent Sjögren's syndrome), American Rheumatism Association functional class IV disease,).

Inclusion criteriaDefinitions

Exclusion criteria


Study Protocol

Therapy with Patients were randomly assigned to receive one of four treatments: oral methotrexate at a dose of 10 mg or more per week plus placebos for rituximab and cyclophosphamide (control group), rituximab plus placebos

for methotrexate and cyclophosphamide, rituximab plus cyclophosphamide in an intravenous infusion of 750 mg on days 3 and 17 plus placebo for methotrexate, and rituximab plus methotrexate at a dose of 10 mg or more a week plus placebo for cyclophosphamide. In all three groups that received rituximab (MabThera, Roche; Rituxan, Genentech and IDEC Pharmaceuticals), rituximab was administered as a 1000-mg intravenous infusion on days 1 and 15. Investigators

and patients remained blinded to the assigned study medications.

Clinical assessments were performed at baseline (day 1) and

at weeks 12, 16, 20, and 24 according to the American College of

What was done?


Rheumatology (ACR) core set of disease-activity measures.

These consisted of a count of swollen joints (66 joints evaluated),... and laboratory evaluation of acute-phase reactants (serum C-reactive protein level and erythrocyte sedimentation rate).

Laboratory assessments (including complete blood counts and serum biochemical analyses) were performed at screening (three weeks before baseline), on days 1, 3, 15, and 17, and at weeks 4, 8, 12, 16, 20, and 24. ...

What instrument was used?

Definitions


Clinical Outcome Measures

The primary end point of the study was the proportion of patients with an ACR 50 response at week 24. ...and the value for one acute-phase reactant (either serum C-reactive protein level or erythrocyte sedimentation

rate).9

Secondary outcomes included ACR 20 and ACR 70 responses (20 percent and 70 percent improvement, respectively, according to the ACR criteria), ... 10 and the response according to the criteria of the European League against Rheumatism (EULAR response).11

What do we study-measure?


Statistical Analysis

Sample-size calculations were based on the assumption..... On the basis of these assumptions and with the use of Fisher's exact test with a two-sided significance level of 0.05, we calculated that a sample of 40 patients per treatment group would provide the study with 82

percent power to detect a difference between the two proportions.

What tools we use to detect differences?

How the assessed parameters were statistically treated


Results

Short and concise paragraph

Answers the questions on the section Material and Method

We might write it in the same order than it was in the section Material and Method.

Never try to explain the results or take any conclusion


“N patients were studed. A were included. B were excluded for having 1, demographical features being D, E and F. With respect to the parameter A the result was 1, with respect to B, the result was 2. With respect to C, the result was D....”


Of the 4164 hospital admissions sampled from the participating hospitals, 3745 patient charts (89.9%) were eligible for a full screening by the stage 1 reviewers (Fig. 1). Of these, 1527 (40.8%) were assessed as positive for 1 or more screening criteria (Table 1)...

Included & excluded


http://www.cmaj.ca/cgi/content/full/170/11/1678#F128

http://www.cmaj.ca/cgi/content/full/170/11/1678#T128


...the physician reviewers identified a total of 1133

injuries or complications in 858 charts. In 401 (46.7%) of these charts the injuries resulted in death, disability at the time of discharge or prolonged hospital stay. In 255 of the charts one or more of the AEs were rated 4 or higher on the 6-point causation scale (Box 1).

Enumerates results


http://www.cmaj.ca/cgi/content/full/170/11/1678#FB128

Statistical analysis (if necessary)

There was a trend for AEs to occur more frequently in the teaching hospitals than in the large community or small hospitals (Table 2). The trend was significant for AEs across the 3 hospital types (p < 0.001) but not for preventable AEs (p = 0.8)...




Discusion

Highlights the importance of the subject. It may start with a short review.

Gives an explanation of the results

Compares the results with those of other studies

Result-comparation-explanation

Signs limitations of the study

A review of the state of the art can be done


“Is an extended version of the introduction, followed by a summary of the results, comparison with those of other studies, and what our results mean.”

“Starts where the introduction ended”

“It is the place for new hypotesis”


“ A is a very important parameter to determine B, as other studies have shown. Ours showed that A

had the characteristics 1, 2 and 3, which is similar to other studies carried out to this

respect. Nevertheless, It had the characteristic 4, which was different. We think that it may be due

to...”


Incident rates of endometrial cancer vary more than 10-fold

worldwide.18 In addition to host susceptibility, dietary factors may play an important role...

In our study population, the average intake of isoflavones from soya food was about 25 times that reported in a Western population....11

Some of these previous studies were not specifically designed to investigate the role of soya food...The sample sizes of the previous studies were relatively small, which limited the statistical power ...This population based case-control study... indicates that usual consumption of soya foods by adults, ... is associated with a significantly reduced risk of endometrial cancer....

Although not all associations were statistically significant in subgroup analyses, the different measurements produced similar results.

...Studies with measured oestrogen concentrations are needed to better understand the joint effect of soya and endogenous oestrogen on endometrial cancer risk.Block II. Writing the

article

http://bmj.bmjjournals.com/cgi/content/full/328/7451/1285#REF18


Incident rates of endometrial cancer vary more than 10-fold worldwide.18 In addition to host susceptibility, dietary factors may play an important role...

In our study population, the average intake of isoflavones from soya food was about 25 times that reported in a Western population....11 Some of these previous studies were not specifically designed to investigate the role of soya food...The sample sizes of the previous studies were relatively small, which limited the statistical power ...This population based case-control study... indicates that usual consumption of soya foods by adults, ... is associated with a significantly reduced risk of endometrial cancer....

Although not all associations were statistically significant in subgroup analyses, the different measurements produced similar results.

...Studies with measured oestrogen concentrations are needed to better understand the joint effect of soya and endogenous oestrogen on endometrial cancer risk.

ReviewResults of our study

Comparison with respect to other studies

Limitations of the study

Conclusion/Hypotesis




Introduction

Clinical case

Conclusions

AND IF IT IS A CLINICAL CASE?


Introduction: Usually based on rarity.

Clinical case:

“A N yr-old (wo)man was admitted for a feature of....his/her clinical history was....in the physical

examination…the laboratory findings showed…the radiological techniques were…To exclude a…the A test was asked, with the result 1. With the suspect of a B,

test B, was asked….Thus, we diagnosed the pathology P”


A 28-year-old man was admitted to the hospital because of abdominal pain and fever.

The patient had been well until 10 days earlier, when mild epigastric pain developed. Two days before admission...

On physical examination, the patient did not appear to be in severe pain, and there was...

The urine was positive (+) for ketones; the sediment contained....

...Radiographs of the abdomen obtained both while the patient was supine and while he was upright showed ..... A cystic mass, 1.5 cm in diameter, was contiguous with the head and neck of the pancreas. The remainder of the pancreas was unremarkable

Oral intake was stopped. The patient was given fluid and electrolytes as well as ranitidine, metronidazole, ampicillin, minidose heparin, and morphine, which was administered...




III.Making the article to be published

Block III. Making the article to be published

The article has been written And now....?

Cover page

Be sure it has the conditions required by the journal (length, structure....)

Submit it to the editor

Undergo the review process


Writing the first page

It is a cover with the name of the article, the names of the authors and the institution, and in the lower left corner, coreespondence to...


TAMPONADE AS THE CLINICAL ONSET OF A CARDIAC ANGIOSARCOMA

Rodriguez-Vera FJ, Sobrino JM, Garcia JM.

Departments of Internal Medicine and Cardiology.Hospital Juan Ramón Jiménez de Huelva. Spain

Correspondence to:F. Javier Rodriguez-VeraDr Cantero Cuadrado Nbr 4, 4ºE21005-HuelvaSpainE-mail: [email protected]

Be sure it has the conditions required by the journal (length, structure....)

Submit it to the editor

Undergo the review process


Get the folder “target journals”

Be sure that this subject is at least occasionally treated in this publication

Select the section were it fits better (Original papers, clinical case, letters to editor…)

Verify that the article has the structure required for this format

Verify (once again) with the tool of “counting words” that the whole do not exceed the maximum number of characters

Verify that once again that the article “has to do” with his title


The document is ready

Let´s send it:

By conventional mail:

Use first class paper

First class mail

Presentation letter

Original and 3 copies

Diskette 3 ½.

Copy of photographs


By e-mail:

-Letter of presentation

-Attached file with text

-Attached file with photographs


Presentation letter:Dear Dr….:

“Enclosed are two complete copies of a manuscript by ….and…. Titled “…….” which is going to be submitted for possible publication in the “…” section of the “(name of the journal)”

This manuscript is new, is not being considered elsewhere and reports new findings that extends results we reported earlier in “(name of the Journal)”. An abstract of this manuscript was presented earlier ( write Congress)

Sincerely yours

Author A Author B Author C Author D


Delays:

a) To the notification of receiving the article:

a) 1-7 days

b) To the rejection letter:

a) 2-3 weeks

c) To the acceptation letter:

a) 3-8 weeks

d) To the publication

a) Up to 2 years


The reviewing process


The reviewer CHECK POINTS Yes No1. Does the paper fall within the scope of a general interest quality assurance

journal?

2. Is this a new and original contribution?3. Is the title suitable and well worded?

4. Is the abstract clearly written and free of abbreviations?5. Are the keywords concise and appropriate to the material?

6. Are the methods sound and adequately described?7. Are the concepts appropriately defined and used?

8. Is the statistical treatment adequate?

9. Are the points of interpretation clearly separated from the results?

10. Are the conclusions and interpretations sound and justified by the data?

11. Are the figures adequate?12. Are the tables adequate?

13. Is the article unnecessarily long?

14. Are all the references necessary?

15. Is the English acceptable?

16. Is the paper addressed to an international audience?

In the event the manuscript is revised, would you like to serve as reviewer?

Yes

No

OVERALL RECOMMENDATION

1 Accept

2 Minor Revision - reassessment not required

3 Major Revision - reassessment required

4 Reject - Fair, but contributing little

5 Reject - Not acceptable


REVIEWER GUARANTEE: - IMPORTANT: PLEASE COMPLETE THIS SECTIONI, guarantee that, to the best of my knowledge, I have no conflict of interest in reviewing this paper that might influence the comments I have provided on these pages.

Yes

No

PRIORITY OF PUBLICATION

Merits rapid publication

No urgency

Low priority


Are all acceptations equal?

Kinds of acceptation: The “negotiation”

a) Unconditional acceptation:

“Dear Dr....We have read the article titled...and we have considered it acceptable for publication....In 4 weeks you will be sent the printing proofs for correction”

b) Conditioned acceptation.

“We have read the article and have found the following points that have to be set…”

1…..

2…..

3….

Consider it published.

Make the corrections suggested

Conditioned acceptation (cont)

After the corrections, verify that the article has the allowed length and send a letter:

“Dear editor. Thank you for your kind suggestions with respect to the article…with reference number….Following your instructions, the next points were restructured:

1. Write the point 1 of the letter 1 and write what you did: “1. As it was suggested, the epidemiology of Salmonella was updated, the new result being…..”

2. Do the same with all the points.

Thank you again for these suggestions that have contributed to improve the quality of the article.Sincerely yours…”Block III. Making the article to be

published

Modified acceptation:

The article is accepted but to be published in another section.

“We have read your article and we considered it acceptable for publication. Nevertheless, we consider it has an excessive length. We advice you to restructure it to fit in the section…(usually is a shorter section Original papers---Clinical Cases----Letters to Editor)”


Rejection

a) Absolute rejection:

“We have read with interest your article…since we have to ponder many papers, yours has not been selected for publication…”

b) Relative rejection:

“We think your article is not appropriate to be published in our journal since it has the defects A, B and C…”


What to do with a “relative rejection?”

Option A. Make the corrections the editor pointed to reject the article and resend the article as if it were a “Conditioned acceptation”. 80% new rejections.

Option B. Don´t desperate. Get advantage of the commentaries and send to another publication (the reviewers are sometimes the same and they will like to see the corrections they suggested done)


Resending the article

Most articles are not published for a lack of persistance

Think that once the article has been written making it to be published is only a question of time.

Look for another publication, make changes (if neccesary) to fit the requirements and send it again

Before sending the article for the first time, it has to be set that it will have to travel through a “spiral of impact factor” before being published


After an average of 3-4 tries, your article will be accepted for a publication


The printing proofs

Once the article has been accepted, a preliminar version is sent to the author

Don´t modify or add contents

Don´t make modifications on grammar

It is only done to correct ortography

Sent them back as soon as possible, since they are ussually sent just before being published

Preferable to be sent by Fax


Epilogue.After the publication

Separatas

Letters about your article

After publication

Separatas

Number depending on the publications

Only in originals

You can buy separatas

After publication

Letters about the article

In the fisrt two months after the publication of the article.

Possitive or negative commentaries on the study

The author of the study has the right to answer the questions of the letter, but the authors are rarely allowed to reply.

A letter of the editorial together with the letter commenting the article is sent two months before the publication

A GOOD EXCUSE TO PUBLISH OTHER LETTER

[email protected]

[email protected]