How to write a medical article

How to write & publish a scientific paper
F. Javier Rodriguez-Vera
Department of Internal Medicine.
Hospital do Barlavento Algarvio.
Portimão. Portugal. EU

How many articles are sent to a journal?
How many are rejected?
Why are they rejected?
How many are reoriented to another journal?

How to write & publish a scientific paper

I. Before start writing
II. Writing the article
III.Making the article to be published

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
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

d) Matter


Norms of publication

Make a list of “target journals”

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


a) Knowledge

d) Matter


PC.
Internet.
Word processor

Microsoft Word.lnk


a) Knowledge

d) Matter


Matter

Clinical case
Series of clinical cases
Observational study
Trial
Randomized
Non randomized
Review
Metanalysis
Opinion

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!


II.Writing the article

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.


Says what is known about the disease

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

Highlights the importance of a fact


Always backed by bibliographical references


Blank in the knowledge

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

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 Method
How 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...”


Inclusion criteria
Definitions
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,).

Exclusion criteria

What was done?

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 instrument was used?

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. ...

Definitions


What do we study-measure?

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 tools we use to detect differences?

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.

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


Enumerates results

...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).


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.

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

Conclusion/Hypotesis Comparison with respect to other studies
Although not all associations were statistically significant in subgroup analyses, the
different measurements produced similar results.

Limitations of the study

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

AND IF IT IS A CLINICAL CASE?

Introduction
Clinical case
Conclusions


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...


II. Writing the article

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

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 No
1. 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?

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

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

Yes

No

REVIEWER GUARANTEE: - IMPORTANT: PLEASE COMPLETE THIS
SECTION
I, 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

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…”

Modified acceptation:
The article is accepted but to be published in another
s
e
c
t
i
o
n
.

“We have read your article and we considered it
a
Block III. Making the article to be published c

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

How to write a medical article

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