Approach to manuscript preparation and submission: How to get your paper accepted

In our opinion, reading a well-written scientific article is not only informative but also fun. Quite often, reading occurs when the individual is through with their respective vocation at the end of the day, when tired eyes view the words. If the reader understands the sentence completely on first pass, that sentence is well written. In addition, the reader will be more likely to continue reading if points are well phrased and presented. As authors are eager to have their findings known, it would behoove them to write their report succinctly, so their peers will read the entire article, not just the abstract. The completed work is not as easy to produce as it appears. In an effort to outline how to perform this feat, we offer these insights and suggestions based on our experience and in support of our youngest colleagues for their future scientific publications. All trainees in cardiology are requested to participate in research, write and submit a scientific abstract and eventually a completed manuscript. This process is daunting, even to the best-prepared medical residents coming from fine undergraduate universities and residency programs. Learning to write a medical paper is an apprenticeship. No one can be expected to be successful on the initial attempt. However, nearly all advanced trainees and young attending physicians possess the requisite intelligence and writing skills to assemble the components of a manuscript, especially when appropriate directions can be given by an experienced associate. The first step in writing a medical paper is finding a mentor. The mentor's job is to help formulate, organize, criticize, support, and assist in any and all ways to move the work forward, with the trainee doing the bulk of the manual labor. The trainee should find an enthusiastic mentor who has written several papers and had them published in peer-review journals. The mentor must be available and consulted frequently to provide clear guidance with concrete goals and timelines. It is in this spirit of mentorship that we have compiled a brief outline on how to have a paper accepted to a scientific medical journal. The kind of research study will determine what advanced steps are needed to collect data for the study. For example, basic science laboratory studies, unlike clinical protocols, do not need institutional review board (IRB) approvals unless experimental animals or specialized tissues are used. For all human and animal studies, IRB approval is needed. The early preparations and planning will not be discussed in this review. For the purposes of the following discussion, it will be assumed that the project is approved and data collection from either a clinical or a basic laboratory is being started or is already underway. The trainee and mentor should identify a project that is feasible to finish in the training period. After a trainee leaves a program, all academic work stops unless the trainee moves into a faculty position. Ideally, the study should be done in the trainee's working or practice environment. To prevent potential oversight of valuable information for the manuscript, it is helpful to envision the process of the manuscript production during the data collection period. This step should be discussed with the mentor since most novices cannot yet filter the important from the unimportant items. These data should be obtained at one time to avoid going back over all the studies to extract a forgotten variable. By doing so, valuable time can be saved. The trainee investigator should keep all study data in organized spreadsheets and folders and ensure that extra copies are maintained in separate files in case of accidental, catastrophic destruction. The author should also build a study file index to keep tabs on what aspects of the manuscript process are complete, what need to be completed, and what data are missing. Of course, different study types will require different flow sheets and data organization. Analyzing each study individually as it is produced is the best way to stay ahead of the data and to be aware of trends, skewed data points, and errors. Several team members usually participate in the manuscript creation process. Each project will require a team leader and responsible individual with whom all data are housed, recorded, logged, and made available to the investigators, mentor, and sponsors. Quite often, this person is a study coordinator. To facilitate the manuscript process, the author should establish a relationship with the study coordinator. In this way, close timelines and project deadlines can be more easily met. The author should formulate a clear hypothesis, keeping the objective and purpose of the project in mind. A hypothesis statement indicates what the study is testing. For example, "This study tested whether coronary blood flow increased in response to biventricular pacing." The purpose of the study was to prove the hypothesis by measuring coronary blood flow during pacing. The objective of the study was to quantitate the change in blood flow before and after pacing. After each study is completed, review raw data for missing points, errors, and suspect entries. Organize the data in the flow sheet. Leave room for additional variables. Note in the index which study needed more work to fill in missing points. Design tables and produce descriptive statistics, including means, standard deviation, maximum and minimum values. Perform statistical analysis, including correlation, regression, chi-square and t-tests. Sketch proposed figures to highlight points of major emphasis. Review tables with mentor and fill in new or missing data. Discuss best format for display of data and types of figures. In the first draft, it is important to identify and write the major sections and/or phases of the work. The author must develop a skeleton on which to build information in an organized fashion, to flesh out and enlarge the work with detail. With each subsequent draft, time should be spent to edit, refine, and further clarify the manuscript. The following sections describe helpful steps in putting together the first draft. Writing the abstract forces the author to focus on the basic ingredients of the study. The five parts of the abstract will answer the fundamental questions of the reader: What question was asked (background)? What was supposed to happen (tested hypothesis)? How and in whom was the study done (methods)? What was found (results)? What does it mean to others (conclusion)? Brevity and clarity are essential to a good abstract. The abstract is a condensed version of the manuscript and should be easily understood on the first read. Likewise, the abstract should peak the reader's interest to read the manuscript in its entirety. Detailed exposition of the study sections will follow in the body of the text. To describe the study sections, recall what was done and describe it as if you were telling someone not familiar with the work what had occurred. Often, the protocol submitted to the IRB will serve as an excellent starting point as the study methodology is already written in great detail. What were the most important differences or findings? What were other data that must be examined to support the major changes or findings of data during the observation periods? Indicate the most important results of the study and refer to the tables and graphs for more detailed but secondary findings and supportive information. The second draft will reorganize the results in a more logical format. The first draft of the discussion should be brief with emphasis on the major points. Again, the IRB protocol can often serve as a valuable resource as it offers a background and discussion for the study submitted. Refer to the IRB protocol for background materials (and potential references). Use the initial paragraphs from the IRB protocol. Briefly restate what the abstract background and hypothesis state and add reasons as to why this is an important question. Do not include references at this time. When the first draft is done, review it with the mentor and discuss issues of authorship. Dr. William Parmley, immediate past Editor-in-Chief of the Journal of the American College of Cardiology, addressed the question of who should be an author [1]. The criteria suggested by the International Committee of Medical Journal Editors [2] are as follows. Each author should have participated sufficiently in the work to take public responsibility for the content. Authorship credit should be based on substantial contributions to the following: conception and design or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content; and final approval of the version to be published. All these conditions must be met. Dr. Parmley also reminds us that participation in data collection, being a laboratory or division head providing some funding, assaying some test results, providing technical help, and similar levels of lesser involvement do not qualify one for authorship if the preceding criteria are not met. Before proceeding, review the six phases of a project listed in Table I. Then ignore them and proceed to the second draft. After completing a first draft and discussing it with the mentor, writing the second draft will be easier but more involved than the first draft. Once the initial framework is complete, the author now fills in the details, polishes the language, and clarifies any obfuscating verbiage. The process is repeated with the mentor and coauthors several times until the final draft is finished and submitted to a journal. The following sections suggest a method to advance the second draft toward its conclusion. Include headings of the background and hypothesis (one to two sentences), methods (one to two sentences), results, (one paragraph), and conclusion (one to two sentences). The reader can delete/modify per journal, but the general formation of abstract stays. An example is provided in the appendix. Most journals request a paragraph for the table of contents. The condensed abstract should contain one sentence on the objective of the study and one to two sentences on what was found and its significance. Clearly and succinctly state problems and issues in favor of and opposing the hypothesis. Indicate why this study may be helpful or important. Examine the formulated hypothesis and identify for the reader the purpose of the study. The introduction should be no more than two to three pages. For this discussion, a page is defined as a double-spaced typewritten page with 12-point font and approximately 250 words per page. Include section headings such as patient populations, study inclusion and exclusion criteria, and whether there was an IRB-approved protocol. Clearly state what was done and answer the commonly asked questions of how and why. For example, how long between steps? What were the controls? What was the drug dosage regimen? The why of the methods will be explained later with the discussion, often in the limitations section. Continue writing the manuscript to include standard methodologies for echocardiography, angiography, nuclear protocols, hemodynamics, or any technique that is commonly used in a laboratory. For machines or products, give commercial names and the manufacturer's name, city, and state. Similar, previously published studies may provide identical descriptions of the methods used in your study. Refer to how those methods were written. Consider that many of the reading audience (including some of the reviewers) may not be familiar with your experimental protocol and use appropriately simple descriptions. Some methods may need to be described in fine detail and may be put in an appendix. It is better to have more rather than less detail for the second draft. State how a sample size was obtained. State what P values are used and that mean and standard deviation will be used unless otherwise indicated. The mentor may refer you to a statistician for additional help. For clinical studies, begin with the subjects. Clearly identify the patient groups and clinical differences and similarities and present data for combined and individual subgroups. It may be unnecessary in some presentations to provide whole-group data as well as subgroup data, but this will be individualized. Present data at the baseline phase of the study and then the same data after an intervention or challenge to the subjects. The change in results should be presented in both absolute and relative values (i.e., percent change). Present the comparisons within and between the subgroups. Organize results for patient data followed by measurements such as hemodynamics, echo findings, nuclear images, PET data, and the like. Comparative descriptions of important changes should follow the baseline data. Correlative data may then follow absolute and relative changes. Describe the figures referring to the major data sections. For clinical studies, emphasize clinical outcome data whenever possible. When planning graphs, avoid duplication of data from text. If a graph will replace text, use it. Complex tables are hard to read and should be minimal. There are generally five major sections to a discussion that review for the reader the salient features of the study. The recommended order is as follows: present major findings first (e.g., "These data show that …"); present the significance of the data ("These data imply that …"); compare data in a scholarly fashion ("These data are similar to or different from …"); present weaknesses of the current study ("There are limitations to this work …"); conclude with clinical or scientific significance ("These data mean that … and future studies may include …"). Add acknowledgment page to the manuscript. Identify manuscript preparers, the laboratory team, and significant nonauthor contributors. Circulate draft to coauthors for comment. Indicate the return of their comments to you by a specific date. If no comments are returned by the deadline, assume the draft is satisfactory for them. The first author and mentor may wish to review criteria of authorship again for those to be included, especially when their review comments are not returned and their contribution to the intellectual content of the study is minimal. Finally, reflect on the six phases of any project (Table I). Then proceed to the next draft. It is worth noting here that the second draft may require 5 to 10 drafts as the mentor and coauthors suggest new revisions. As the author approaches this phase, he or she should view the manuscript as if never having seen it before. Reading it (aloud) offers the author an opportunity to hear how the paper flows, its level of organization, repetition, and whether areas need some cleanup. The following steps help outline this most important phase. Reread tables. Spell out abbreviations for clarity. Eliminate redundancies. Add units of measure and check all statistical markers on the tables. A well-designed table should be able to stand on its own without further explanation. Write figure legends, with emphasis on clarity and brevity. Spell out abbreviations. Cite sources for any figures borrowed from published work(s). List references in correct format for journal. Polish the paper. Read the instructions for authors. Read the instructions for authors again. Examine the language for simplicity, clarity, and directness. Eliminate ambiguity and hyperbole. Keep consistent tense and voice. Do not become attached to your own words. Edit yourself with impunity. Remember, if you need to reread a sentence to understand it, it needs to be rewritten. Eliminate unnecessary words and redundant phrasing, figures, and data. The majority of readers are not experts in your area. Be clear about why the project was done and what the results mean to the reader. Put the manuscript away for 2 days. Review a photocopy of it for a last look. Make final changes. Identify a submission date. This phase is what the author has been dreaming of since having started the project. Once the manuscript is submitted to the journal, the pending journal response moves the author to the next phase, the waiting game. To submit a manuscript to a journal properly, follow these basic steps. Follow the instructions to authors and be sure to include word count, key words, and short title. Adhere to page format, figures, and reference style of the journal in question. Write a cover letter to the editor. Tell the editor what he or she will find with this paper and briefly anything especially new or unusual in the work. Be honest and modest. Make extra copies of the paper in both hard copy and electronic format. Keep a file of the manuscript and place for future correspondences. Send a copy with the cover letter to each coauthor and, of course, to the mentor. Cross fingers and continue working on other projects. No paper is accepted to a journal without revision to some degree. All excellent papers have minor points to address. Others may need a major rewrite or even a major change in direction of work. Still others will be rejected. The reasons for rejection (without de novo consideration of revision and resubmission) are generally because of one or more "fatal" flaws. Such flaws include invalid statistics, using a method that cannot answer the question asked, an error in methods, too small a sample size, the wrong conclusion from the data, or poor scholarship (wrong references, errors in citation, errors in grammar, spelling and sentence structure). However, the first submission to a publication will always be followed by another, either to the same or to a different journal, until the article is accepted. Remember, every article has a home. It may be a small house, but it is a home (in other words, another journal other than your first choice). Ask your mentor for further insights as to what the reviewers or editors are suggesting. Address the comments that can be answered immediately. Consider why other comments cannot be addressed and state the reasons clearly. Ignore any mean-spirited language. Use page, paragraph, and line keyed to the reviewer's responses and the changes in the revised manuscript. Discuss with the mentor about resubmission to the same journal or to a different one. Read the acceptance letter fully. Read it again to feel good. Send copies to coworkers. Call mentor. Start next paper. It is hoped that this article will serve as a guide on the road to publication and make it a straighter path. An enthusiastic mentor and author make a productive team. Exciting scientific work from a busy laboratory should be reported soon after the results are completed so that it can be read and appreciated by all in the field to continue the tradition of high-quality research in cardiovascular medicine. The following, taken from Pijls et al. [3], is an example of a structured abstract. Background: Guidewire–based simultaneous measurement of fractional flow reserve (FFR) and coronary flow reserve (CFR) is important to understand microvascular disease of the heart. The aim of this study was to investigate the feasibility of simultaneous measurement of FFR and CFR by one pressure-temperature sensor-tipped guidewire with the use of coronary thermodilution and to compare CFR by thermodilution (CFRthermo) with simultaneously measured Doppler CFR (CFRDoppl). Methods and Results: In 103 coronary arteries in 50 patients, a pressure-temperature sensor-tipped 0.014-inch floppy guidewire and a 0.014-inch Doppler guidewire were introduced. Both normal vessels and a wide range of stenotic vessels were included. With 3 mL of saline at room temperature used as an indicator, by hand-injection, thermodilution curves in the coronary artery were obtained in triplicate, both at baseline and at intravenous adenosine-induced maximum hyperemia. After adequate curve fitting, CFRthermo was calculated from the ratio of inverse mean transit times and compared with CFRDoppl calculated by velocities at hyperemia and baseline. Adequate sets of thermodilution curves and corresponding CFRthermo could be obtained in 87% of the arteries versus 91% for Doppler CFR and 100% for FFR. CFRthermo correlated fairly well to CFRDoppl (CFRthermo = 0.84 CFRDoppl + 0.17; r = 0.80; P < 0.001), although individual differences of > 20% between both indexes were seen in a quarter of all arteries. Conclusions: This study shows the feasibility of simultaneous measurement of FFR (by coronary pressure) and CFR (by coronary thermodilution) in humans by one single guidewire in a practical and straightforward way and will facilitate assessment of microvascular disease.