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CME- 3 AMA PRA Category 1 Credits per review
Essentials of the Manuscript
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EditorsJames H. Lubowitz, M.D. Editor-in-Chief
Michael J. Rossi, M.D. Assistant Editor-in-Chief
Jefferson C. Brand, M.D. Assistant Editor-in-Chief
Editorial StaffDeborah VanNoy Managing Editor
Journal Staff
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• Nam-Hong Choi
• Aman Dhawan
• Michael Feldman
• Joshua Harris
• Erik Hohmann
• Tim Jackson
• Jüri Kartus
• Darius Moezzi
• Nikoloas Paschos
• Mark Siegel
• Dan Solomon
• Brian Waterman
• Mark P. Cote, Statistics
• Marty Leland, Technology
Associate Editors
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How to Organize a Manuscript
•Title
•Abstract
• Introduction
•Methods
•Results
•Discussion
•Conclusions
•References
•Tables
•Figures and Legends
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Introduction
1. Be brief
2. Identify the Controversy
3. State your Purpose
4. State your Hypothesis
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Introduction
•1. Be brief
•2. Identify the Controversy
•3. State your Purpose
•4. State your Hypothesis
•Nothing else!
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Introduction
Example
•Controversy: Does double-row rotator cuff improve outcome?
•Purpose: To compare double-row repair with single-row.
•Hypothesis: What you think answer will be before you start the study.
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Methods
Should include:
1. Step-by-step description• Reproducible• Like a cookbook
2. Rationale for experimental design
for basic science
3. Statistical methods
4. All methods reflected in results and vice versa
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Methods Are Most Important
•Fatal Flaws in Methods •Can not be fixed
•Get advice on Methods BEFORE you start•Prospective
• Before starting study
•Retrospective• Before extracting data
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Levels of Evidence
•Clinical: “Therapeutic” Studies Most Common
•Randomized controlled trial = Level I• Rare
•Comparative study = Level II or III• Prospective versus retrospective• Same time/same institution
•Case series (no control group) = Level IV
•Expert opinion = Level V
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Bias in Clinical Trials
Prevent “Reporting Bias”Appropriate outcome measures are
- Validated
- Universal (allows comparison to similar studies)
- Condition specific and- General health, and both
- Surgeon reported and- Patient reported
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Bias in Clinical Trials
Selection (Allocation) Bias
•Treatment groups have different prognoses.•Apples versus oranges•Meniscus repair plus ACL in younger patients
versus meniscectomy without ACL in older
•Prevent Selection Bias•Randomize•Strict inclusion and exclusion criteria
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Bias in Clinical Trials
Prevent Recording Bias
•Don’t influence the patient• Complete forms in private
•Don’t influence the physical exam• Operating surgeon should not perform assessment
•The patient may want to please the surgeon• So take steps to minimize recording bias
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Bias in Clinical Trials
Transfer bias•Patients are lost to follow-up.•80% follow-up at 2 years is “gold standard”
Performance bias•Who performs the procedure
• No “right answer”
•Important to consider
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Statistics
•Statistics for Authors and Reviewers
What are the common mistakes?
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Which Statistical Test Should Be Used?
• Too many possibilities to show
• Writers should consult a statistician
• Reviewers should consult the 2017 Research Pearls Series
• http://www.arthroscopyjournal.org/pearls
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Statistical Significance
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Statistical Significance
•Statistical significance is only a guide
•Statistical significance cannot address clinical relevance
•Statistical significance is frequently “fragile”
• Different outcomes in a few patients
• Could change results
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Clinical Significance
Clinical Significance is more important
•Statistical significance is only a guide
•Consider
• Minimal clinically important differences (MCID)
• Significant clinical benefits (SCB)
• Patient Acceptable Symptomatic States (PASS)
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Clinical Significance
Overlapping Confidence Intervals may indicate lack of
Clinical Significance
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Confidence Interval
• 95% confidence interval give degree of certainty
• Clinically significant differences
• Confidence Intervals tend not to overlap
More Informative Than a P Value
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Reviewing the Statistics
Multiple Statistical Testing•Lots of outcome measures•Researcher will eventually get lucky
• 1/20 chance = 0.05• Results may not be reproducible
•Solution•Choose Primary Outcome Measure
• for hypothesis• and power analysis
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Reviewing the Statistics
Results show “No difference”
•RED FLAG!!
•Check the
power analysis
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Null Hypothesis
β (beta error)
BE ALERT FOR RED FLAG
•“No difference between groups”
BECAUSE IF
• too few patients
• too small a sample size
• not enough statistical power
RESULTS COULD BE WRONG
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Results
•Organize parallel to Methods
• Everything in Methods must be reported… and vice versa
• Put the data in Tables or Figures
• Cite Table and Figures in text – Summarize the highlights in the text
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Tables
Concise Results Summary
•Group data logically
•Label columns clearly
•Provide stand alone message• Include N, Mean, and Confidence Interval•Define all abbreviations in each Table
• May use Headers and/or Footers
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Discussion
Compare and Contrast Similar Publications
• Try to explain contrasts
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Limitations wrap up the Discussion
•Point out weaknesses before the conclusion
•Point out weaknesses before the Reviewer
•Consider bias:•Reporting•Recording•Performance•Transfer•Selection (allocation)
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Conclusions
• Is hypothesis supported?• Yes or no?
•Based only on the specific reported results
•Conclusion should be word-for-word identical in the text and abstract
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Title
Make the Title extremely interesting
• “Revise the Title and make it sexy”• Einar Eriksson, Founding Editor, KSSTA
• Delete “New” or “Novel”• Let the readers decide
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Abstract
Introduction/Methods/Results/Conclusion
•Clinical• Add Level of Evidence
•Basic Science• Add Clinical Relevance
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References
Past 2-5 years plus a few classics
•Weak• the most references
•Strong• the most recent references
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Figures
“A Picture is Worth a Thousand Words.”
-Labels and arrows essential
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Figure Legends
Provide stand-alone message
Include:
•Side
•patient position
•viewing portal or imaging view
• Labels and/or arrows
•Detailed description
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What’s New?
•SYSTEMATIC REVIEWS• Strict search inclusion and exclusion criteria minimize bias
in article selection• Caveat: “Research waste”? (Lancet, 2015)
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What’s New?
•SYSTEMATIC REVIEWS• Strict search inclusion and exclusion criteria minimize bias
in article selection• AVOID improper pooling • Perform “qualitative” synthesis of
• Low LOE• High ROB• Heterogeneous studies
• AND explore the heterogeneity
•META-ANALYSES• Generally “quantitative” synthesis should be limited to
Randomized Controlled Trials
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Arthroscopy on Social Media
@ArthroscopyJ
ArthroscopyJournal
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Publish in Arthroscopy Techniques!
• Video-oriented
• Peer-reviewed
• Open access
• PubMed cited
The Open Access article processing charges for published
manuscripts in Arthroscopy Techniques are:
• $600 for AANA members • $900 for non-members
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What’s Out?
•CASE REPORTS• Rare exceptions
• New complications
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Become a Top Reviewer
•Confidential comments
• Line-by-line review
•Reviewers are not copy editors
•But Copy editors are not surgeons/scientists• Copy editors correct spelling and grammar• Reviewers correct confusing science
•Merit-based promotion• Best reviewers start young• Best reviewers join Editorial Board• Best Editorial Board reviewers become AEs
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Essentials of the Manuscript
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Essentials of the Manuscript
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Panel Discussion and Questions
•Common Errors• Writing repetitious • Introduction or Discussion too long• Statistical (but not clinical) significance• Too few patients (no power analysis)• Too short minimum follow-up (< 2 years)• Excessive transfer bias (>20% at 2 years)• Weak inclusion/exclusion criteria (selection bias)• Poor randomization (selection bias)• No control group (Level 4 evidence)• Out of date references
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Essentials of the Manuscript