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Article types and preparation
At The BMJ , we offer authors the opportunity to submit a range of article types. You can find out more about preparing and submitting a particular style of article by clicking on the links below. Please take the time to explore these instructions before proceeding with a submission. Further details about each of these individual sections and article types are discussed further down this page.
Article Types at The BMJ
Requirements for all manuscripts.
Please ensure that anything you submit to The BMJ conforms to the International Committee of Medical Journal Editors’ Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly work in Medical Journals uniform recommendations for manuscripts submitted to biomedical journals.
Before submitting an article, please ensure that you have followed all guidelines below. We recommend learning about our house style and ways to incorporate images into your submission .
Title page and authorship
The title should be informative and, for research papers, a subtitle with the study design (for example, "a phase III clinical trial" or "a systematic review and meta-analysis").
In this page, please provide for each author his or her name, affiliation (job title) at the time the paper was written, email and, for the corresponding author, the best contact address. All authors must fulfill the ICMJE criteria for authorship . If the number of authors is very large we may ask for confirmation that everyone listed met the ICMJE criteria for authorship . We also offer the option of joint first authorship when two authors meet criteria for such a designation. We reserve the right to require that authors form a group whose name will appear in the article byline. MEDLINE guidance explains that group authorship is acceptable, stating "When a group name for a specific consortium, committee, study group, or the like appears in an article byline, the personal names of the members of that group may be published in the article text. Such names are entered as collaborator names for the MEDLINE citation."
Further details about The BMJ 's stance on authorship, contributorship, and group authorship can be found on our Authorship and contributorship page.
Please note that from 30 November 2018 The BMJ is mandating ORCiD iDs for corresponding authors for all research articles if accepted, and this information will be required alongside submitted manuscripts. Co-authors and reviewers are strongly encouraged to also connect their ScholarOne accounts to ORCiD. We firmly believe that the increased use and integration of ORCiD iDs will be beneficial for the whole research community. For those who do not currently have an iD they will be required to register but this is free and takes a matter of seconds - we strongly encourage all authors to register for an ORCiD profile .
To learn more about ORCiD, please visit http://orcid.org/content/initiative
Contributor and guarantor information
Each contributorship statement should make clear who has contributed what to the planning, conduct, and reporting of the work described in the article, and should identify one, or occasionally more, contributor(s) as being responsible for the overall content as guarantor(s). The guarantor accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish. The following line should also be included - "The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted."
For articles in The BMJ that do not report original research - such as editorials, clinical reviews, and education and debate - please state who had the idea for the article, who performed the literature search, who wrote the article, and who is the guarantor (the contributor who accepts full responsibility for the finished article, had access to any data, and controlled the decision to publish). For non-research articles that include case reports such as lessons of the week, drug points, and interactive case reports, please also state who identified and/or managed the case(s). We encourage authors to fully acknowledge the contribution of patients and the public to their research where appropriate.
Copyright/license for publication
Since January 2000, The BMJ has not asked authors of journal articles to assign us their copyright and authors (or their employers) retain their copyright in the article. All we require from authors is an exclusive licence (or, from government employees who cannot grant this, a non-exclusive licence) that allows us to publish the article in The BMJ (including any derivative products) and any other BMJ products (such as the Student BMJ or overseas editions), and allows us to sublicense such rights and exploit all subsidiary rights.
We ask the corresponding author to grant this exclusive licence (or non-exclusive for government employees) on behalf of all authors by reading our licence and inserting in the manuscript on submission the following statement:
“The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all authors, a worldwide licence to the Publishers and its licensees in perpetuity, in all forms, formats and media (whether known now or created in the future), to i) publish, reproduce, distribute, display and store the Contribution, ii) translate the Contribution into other languages, create adaptations, reprints, include within collections and create summaries, extracts and/or, abstracts of the Contribution, iii) create any other derivative work(s) based on the Contribution, iv) to exploit all subsidiary rights in the Contribution, v) the inclusion of electronic links from the Contribution to third party material where-ever it may be located; and, vi) licence any third party to do any or all of the above."
This licence allows authors to use their own articles for their own non-commercial purposes without seeking permission from us. Only if the use is commercial do we need to know about it. In addition, we will pay authors a royalty on certain commercial uses that we negotiate.
Information on permissions for authors and third parties for reuse can be found here .
Manuscripts authored or co-authored by one or more NIH employees must be submitted with a completed and signed NIH Publishing Agreement and Manuscript Cover Sheet according to NIH’s Employee Procedures .
Patient consent (if applicable)
Publication of any personal information about a patient in The BMJ - for example, in a case report or clinical photograph - will normally require the signed consent of the patient. If this is the case, please include a statement that any identifiable patients have provided their signed consent to publication and submit, as a supplemental file, The BMJ 's patient consent form that is available in several languages .
Competing interests declaration
A competing interest - often called a conflict of interest - exists when professional judgment concerning a primary interest (such as patients' welfare or the validity of research) may be influenced by a secondary interest (such as financial gain, academic promotion, or personal rivalry). It may arise for the authors of an article in The BMJ when they have a financial interest that may influence, probably without their knowing, their interpretation of their results or those of others.
We believe that, to make the best decision on how to deal with an article, we should know about any competing interests that authors may have, and that if we publish the article readers should know about them too. We are not aiming to eradicate such interests across all article types in The BMJ . However, certain articles (see below) fall under a stricter policy announced in 2014 . This means that authors whose financial conflicts of interest are judged to be relevant by the BMJ team are not permitted to write these articles. We also ask our staff and reviewers to declare any competing interests.
A declaration of interests for all authors must be received before an article can be reviewed and accepted for publication. It should take one of two forms, depending on what type of article you are submitting. The links to the relevant forms are provided at the end of this section.
For editorials and education articles (excluding State Of The Art reviews and Therapeutics articles)
Since 2014, The BMJ requires that such articles must be written by authors without relevant financial ties to industry . By "industry" we mean companies producing drugs, medical foods, nutraceuticals, devices, apps or tests; medical education companies; or other companies with a financial or reputational interest in the topic of the article. We consider the following relationships with industry to be relevant, making it unlikely that we would be able to publish your work: employment; ownership of stocks and shares (this excludes mutual funds or other situations in which the person is not in a position to control investment decisions) ; travel and accommodation expenses; paid consultancy or directorship; patent ownership; aid membership of speakers' panels or bureaus and advisory board; acting as an expert witness ; being in receipt of a fellowship, equipment, writing, or administrative support; writing or consulting for a medical education promotional or communications company. If you are in doubt about the relevance of any potential conflict of interest please discuss with the editor of the appropriate section before submission.
All authors must review the updated COI policy and complete The BMJ 's Education Declaration of Interests form . If the article is accepted for publication these completed forms will be stored and made available on request. The corresponding author should insert within their manuscript a summary statement derived from the information provided in the COI forms (link below): " I/We have read and understood BMJ policy on declaration of interests and declare the following interests: [list them or state that you have none]."
Examples of different sorts of summary statements:
No competing interests : "We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests."
Competing interests disclosed: " We have read and understood BMJ policy on declaration of interests and declare the following interests: AA is an unpaid member of XX group developing guidelines for ZZ."
For Research and RMR papers
We ask authors of research papers to use a revised version of the ICMJE’s unified disclosure form . The unified form can be used for several journals. Each journal, will, however, integrate the form into its processes in different ways.
Authors must disclose three types of information:
Associations with commercial entities that provided support for the work reported in the submitted manuscript (the timeframe for disclosure in this section of the form is the lifespan of the work being reported).
Associations with commercial entities that could be viewed as having an interest in the general area of the submitted manuscript (in the three years before submission of the manuscript).
Non-financial associations that may be relevant or seen as relevant to the submitted manuscript.
All authors must complete the disclosure form and send it to the corresponding author who will use the information in the forms to craft the COI statement for the paper (examples provided below). The statement but not the forms must be included with the submission. and that must be included with the initial submission. If the paper is accepted, these forms will be required and will be published alongside the article.
The statement in the manuscript should take the following format:
"Competing interests: All authors have completed the ICMJE uniform disclosure form at http://www.icmje.org/disclosure-of-interest/ and declare: no support from any organisation for the submitted work [or describe if any]; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years [or describe if any]; no other relationships or activities that could appear to have influenced the submitted work [or describe if any].”
Examples of statements:
No competing interests: "All authors have completed the ICMJE uniform disclosure form at http://www.icmje.org/disclosure-of-interest/ and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work."
Grant funding for research but no other competing interest: "All authors have completed the ICMJE uniform disclosure form at http://www.icmje.org/disclosure-of-interest/ and declare: all authors had financial support from ABC Company for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work."
Mixed competing interests: "All authors have completed the ICMJE uniform disclosure form at http://www.icmje.org/disclosure-of-interest/ and declare: no support from any organisation for the submitted work; AB has received research grants and honorariums from XYZ company, BF has been paid for developing and delivering educational presentations for BBB foundation, DF does consultancy for HHH and VVV companies; no other relationships or activities that could appear to have influenced the submitted work."
For all other papers
Complete The BMJ 's Disclosure form . We do not need to receive signed copies of the statements regarding competing interests or the licence to publication: these are for information only. When submitting your article (or a revised version of it) you will be prompted at our online editorial office to tick two boxes , confirming that you have read and complied with our policies on competing interests and licence to publication. Please also ensure that your manuscript, whether in original or revised form, also includes your written statements of competing interests and licence to publication.
Additional requirements by Article Type
In addition to the above, all of our articles have additional requirements which should be fulfilled before submitting. For more information on any of the requirements below, please contact [email protected] .
We have produced a checklist to help authors decide whether The BMJ is the right journal for their research. If the work does not seem to fit in The BMJ , it may be better sent straight to another journal with a more specialist or local readership or a higher acceptance rate.
To learn more about the kind of research articles we give priority to, and what services we offer to authors of research, please read the editorial "Publishing your research study in the BMJ ?" . Please note that we welcome studies - even with "negative" results - as long as their research questions are important, new, and relevant to general readers and their designs are appropriate and robust.
Word count and style
To encourage full and transparent reporting of research we do not set fixed word count limits for research articles. Nonetheless, we ask you to make your article concise and make every word count. You will be prompted to provide the word count for the main text (excluding the abstract, references, tables, boxes, or figures) when you submit your manuscript.
Original research articles should follow the IMRaD style (introduction, methods, results, and discussion) and should include a structured abstract (see below), a structured discussion, and a succinct introduction that focuses - in no more than three paragraphs - on the background to the research question.
For an intervention study, the manuscript should include enough information about the intervention(s) and comparator(s) (even if this was usual care) for reviewers and readers to understand fully what happened in the study. To enable readers to replicate your work or implement the interventions in their own practice, please also provide any relevant detailed descriptions and materials (uploaded as one or more supplemental files, including video and audio files where appropriate). Alternatively, please provide in the manuscript URLs to openly accessible websites where these materials can be found.
Please ensure that the discussion section of your article comprises no more than a page and a half and follows this overall structure, although you do not need to signpost these elements with subheadings:
• Statement of principal findings • Strengths and weaknesses of the study • Strengths and weaknesses in relation to other studies, discussing important differences in results • Meaning of the study: possible explanations and implications for clinicians and policymakers • Unanswered questions and future research
This video gives more detailed advice on writing each section of a research paper for The BMJ .
Structured abstract
Please ensure that the structured abstract is as complete, accurate, and clear as possible and has been approved by all authors. We may screen original research articles by reading only the abstract.
Abstracts should be 250- 300 words long: you may need up to 400 words, however, for a CONSORT or PRISMA style abstract. MEDLINE can now handle up to 600 words. Abstracts should include the following headings, but they may be modified for abstracts of clinical trials or systematic reviews and meta-analyses according to the requirements on the the CONSORT extension for abstracts and the PRISMA extension for abstracts , respectively.
• Objectives - a clear statement of the main aim of the study and the major hypothesis tested or research question posed • Design - including factors such as prospective, randomisation, blinding, placebo control, case control, crossover, criterion standards for diagnostic tests, etc. • Setting - include the level of care, eg primary, secondary; number of participating centres. Be general rather than give the name of the specific centre, but give the geographical location if this is important • Participants (instead of patients or subjects) - numbers entering and completing the study, sex, and ethnic group if appropriate. Give clear definitions of how selected, entry and exclusion criteria. • Interventions - what, how, when and for how long. This heading can be deleted if there were no interventions but should normally be included for randomised controlled trials, crossover trials, and before and after studies. • Main outcome measures - those planned in the protocol, those finally measured (if different, explain why). • Results - main results with (for quantitative studies) 95% confidence intervals and, where appropriate, the exact level of statistical significance and the number need to treat/harm. Whenever possible, state absolute rather than relative risks. • Conclusions - primary conclusions and their implications, suggesting areas for further research if appropriate. Do not go beyond the data in the article. Conclusions are important because this is often the only part that readers look at. • Trial registration - registry and number (for clinical trials and, if available, for observational studies and systematic reviews).
When writing your abstract, use the active voice but avoid "we did" or "we found". Numbers over 10 do not need spelling out at the start of sentences. p-values should always be accompanied by supporting data, and denominators should be given for percentages. Confidence intervals should be written in the format (15 to 27) within parentheses, using the word "to" rather than a hyphen. Abstracts do not need references.
Statistical issues
We want your piece to be easy to read but also as scientifically accurate as possible. We encourage authors to review the "Statistical Analyses and Methods in the Published Literature or The SAMPL Guidelines" while preparing their manuscript.
Whenever possible, state absolute rather than relative risks. Please include in the results section of your structured abstract (and in the article's results section) the following terms, as appropriate:
For a clinical trial:
• Absolute event rates among experimental and control groups. • RRR (relative risk reduction). • NNT or NNH (number needed to treat or harm) and its 95% confidence interval (or, if the trial is of a public health intervention, number helped per 1000 or 100,000).
For a cohort study:
• Absolute event rates over time (eg 10 years) among exposed and non-exposed groups • RRR (relative risk reduction)
For a case control study:
• OR (odds ratio) for strength of association between exposure and outcome
For a study of a diagnostic test:
• Sensitivity and specificity • PPV and NPV (positive and negative predictive values)
The box stating 'what is known' and 'what this study adds' should also reflect accurately the above information. Under what this study adds, please give the one most useful summary statistic eg NNT.
Please do not use the term 'negative' to describe studies that have not found statistically significant differences, perhaps because they were too small. There will always be some uncertainty, and we hope you will be as explicit as possible in reporting what you have found in your study. Using wording such as "our results are compatible with a decrease of this much or an increase of this much" or 'this study found no effect' is more accurate and helpful to readers than "there was no effect/no difference." Please use such wording throughout the article, including the structured abstract and the box stating what the paper adds.
Provide one or more references for the statistical package(s) used to analyse the data - for example, RevMan for a systematic review. There is no need to provide a formal reference for a very widely used package that will be familiar to general readers - for example, Stata - but please say in the text which version you used.
Reporting guidelines
Reporting guidelines promote clear reporting of methods and results to allow critical appraisal of the manuscript. We ask that all manuscripts be written in accordance with the appropriate reporting guideline. Please submit as supplemental material the appropriate reporting guideline checklist showing on which page of your manuscript each checklist item appears. A complete list of guidelines can be found in the website of the Equator Network . Below is the list of most often used checklists but others may apply.
For a clinical trials , use the CONSORT checklist and also include a structured abstract that follows the CONSORT extension for abstract checklist, the CONSORT flowchart and, where applicable, the appropriate CONSORT extension statements (for example, for cluster RCTs, pragmatic trials, etc.). A completed TIDieR checklist is also helpful as this helps to ensure that trial interventions are fully described in ways that are reproducible, usable by other clinicians, and clear enough for systematic reviewers and guideline writers.
For systematic reviews or meta-analysis of randomised trials and other evaluation studies, use the PRISMA checklist and flowchart and use the PRISMA structured abstract checklist when writing the structured abstract.
For studies of diagnostic accuracy , use the STARD checklist and flowchart.
For observational studies , use the STROBE checklist and any appropriate extension STROBE extensions.
For genetic risk prediction studies, use GRIPS .
For economic evaluation studies , use CHEERS .
For studies developing, validating or updating a prediction model , use TRIPOD .
For articles that include explicit statements of the quality of evidence and strength of recommendations, we prefer reporting using the GRADE system.
For studies using data from electronic health records, please use CODE-EHR .
Cover letter
A cover letter is your opportunity to introduce your study to the editor, highlighting the most important findings and novelty. Please also include in the letter the following information:
Mandatory patient and public involvement reporting
The BMJ is encouraging active patient and public involvement in clinical research as part of its patient partnership strategy . This is research which is "co produced" with patients, carers, or members of the public. Patient involvement in this context is not about being a research participant, answering surveys, or being an interviewee. It encompasses setting research priorities, defining research questions and outcome measures, providing input into study design and conduct, dissemination of results, and evaluation.
To support co production of research we request that authors provide a short paragraph as a subsection within the methods section of their papers entitled Patient and Public Involvement detailing how they involved the patients and the public in their research. We request this to both encourage the movement and ensure that BMJ readers can easily see whether, and if so how, patients and the public were involved in the research. If they were not involved in any way this information should be formally documented in the Patient and Public Involvement section.
As co production of research with patients and the public is relatively new we appreciate that not all authors will have involved them in their studies. We also appreciate that patient / public involvement may not be feasible or appropriate for all papers. We therefore continue to consider papers where they were not involved.
The Patient and Public Involvement section should provide a brief response to the following questions, tailored as appropriate for the study design reported:
• At what stage in the research process were patients/public first involved in the research and how? • How were the research question(s) and outcome measures developed and informed by their priorities, experience, and preferences? • How were patients/public involved in the design of this study? • How were they involved in the recruitment to and conduct of the study? • Were they asked to assess the burden of the intervention and time required to participate in the research? • How were (or will) patients and the public be involved in choosing the methods and agreeing plans for dissemination of the study results to participants and wider relevant communities? You may find this link helpful.
In addition to considering the points above we advise authors to look at guidance for best reporting of patient and public involvement as set out in the GRIPP2 reporting checklist.
If information detailing whether there was patient and public involvement, or not, is missing in the submitted manuscript we will request authors to provide it.
Where they have been involved we consider it good practice for authors to name and thank them in the contributorship statement after seeking their permission to do so; and to clearly identify them as patient/public contributors. When they have contributed substantially and meet authorship criteria they should be invited to coauthor the manuscript.
Links to selected examples of Patient and Public Involvement statements in published BMJ research papers showing patient and carer involvement at various stages of the research process.
Comparison of the two most commonly used treatments for pyoderma gangrenosum: results of the STOP GAP randomised controlled trial
Evidence based community mobilization for dengue prevention in Nicaragua and Mexico
Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial .
Real world effectiveness of warfarin among ischemic stroke patients with atrial fibrillation: observational analysis from Patient-Centered Research into Outcomes Stroke Patients Prefer and Effectiveness Research (PROSPER) study.
Example PPI statements to adapt for use in a paper
Examples to guide the wording for PPI statements
Data sharing
We require a data sharing statement for all research papers. For papers that do not report a trial, we do not require that the authors agree to share the data, just that they say whether they will.
For reports of clinical trials, we ask that the authors commit to making the relevant anonymised patient level data available on reasonable request (see editorial ). This policy applies to any research article that reports the main endpoints of a randomised controlled trial of one or more drugs or medical devices in current use, whether or not the trial was funded by industry.
"Relevant data" encompasses all anonymised data on individual patients on which the analysis, results, and conclusions reported in the paper are based. As for "reasonable request," The BMJ is not in a position to adjudicate, but we will expect requesters to submit a protocol for their re-analysis to the authors and to commit to making their results public. We will encourage those requesting data to send a rapid response to thebmj.com, describing what they are looking for. If the request is refused we will ask the authors of the paper to explain why.
In addition, we will follow the new ICMJE data sharing policy that goes into place on July 1, 2018 (see editorial ): manuscripts submitted to ICMJE journals that report the results of clinical trials must contain a data sharing statement that indicates whether individual de-identified participant data (including data dictionaries) will be shared; what data in particular will be shared; whether additional, related documents will be available (study protocol, statistical analysis plan, etc); when the data will become available and for how long; by what access criteria data will be shared (including with whom, for what types of analyses, and by what mechanism). Clinical trials that begin enrolling participants on or after January 1, 2019 must also include a data sharing plan in the trial’s registration. If the data sharing plan changes after registration this should be reflected in the statement submitted and published with the manuscript, and updated in the registry record.
We encourage authors of all research articles in The BMJ to link their articles to the raw data from their studies. For clinical trials, we require data sharing on request as a minimum and- if authors of such trials are willing to go further and share the data openly, so much the better. The BMJ has partnered with the Dryad digital repository datadryad.org to make open deposition easy and to allow direct linkage by doi from the dataset to The BMJ 's article and back (for The BMJ 's articles' datasets see here ).
Data requesters should do the following: • Submit a rapid response to the paper and email the corresponding author for the paper to request the relevant data. • Be prepared to provide the authors of the paper a detailed protocol for your proposed study, and to supply information about the funding and resources you have to carry out the study. • If appropriate, invite the original author[s] to participate in the re-analysis. • If a month elapses without a response from the authors, please email the head of research for The BMJ (presently [email protected] ) and cc [email protected] . • The BMJ will assess the request and if appropriate we will encourage the authors or their institution to share the data, although we are not in a position to compel data release or broker agreements. Our role is limited to making the request process public, and all correspondence related to the request may be made public through rapid responses to the paper.
Statements that must be included in Research submissions (Ethics approval, funding, and transparency)
Ethics approval
All research studies published in The BMJ should be morally acceptable, and must follow the World Medical Association's Declaration of Helsinki . To ensure this, we aim to appraise the ethical aspects of any submitted work that involves human participants, whatever descriptive label is given to that work including research, audit, and sometimes debate. This policy also applies on the very rare occasions that we publish work done with animal participants. The manuscript must include a statement that the study obtained ethics approval (or a statement that it was not required), including the name of the ethics committee(s) or institutional review board(s), the number/ID of the approval(s), and a statement that participants gave informed consent before taking part.
Transparency statement
Please include in your manuscript a transparency declaration : a statement that the lead author (the manuscript's guarantor) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as originally planned (and, if relevant, registered) have been explained.
The BMJ is committed to making the editorial process transparent and ethical. The BMJ ’s transparency policies are accessible from this link .
Role of the funding source
Please include in the manuscript a statement giving the details of all sources of funding for the study. As appropriate, the statement must include a description of the role of the study sponsor(s) or funder(s), if any, in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. In addition, the statement must confirm the independence of researchers from funders and that all authors, external and internal, had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis is also required.
If you are submitting an original article reporting an industry sponsored clinical trial, postmarketing study, or other observational study please follow the guidelines on good publication practice (GPP2) and on properly reporting the role of professional medical writers. Another resource, the Authors' Submission Toolkit: A practical guide to getting your research published summarises general tips and best practices to increase awareness of journals' editorial requirements, how to choose the right journal, submission processes, publication ethics, peer review, and effective communication with editors - much of which has traditionally been seen as mysterious to authors.
The BMJ will not consider for publication any study that is partly or wholly funded by the tobacco industry, as explained in this editorial .
Patient and Public Involvement statement
Within the Methods section of your paper, please state if and how patients and the public were involved in the research you are describing. For more information, please see the specific guidance on mandatory reporting of patient and public involvement above. If patients and the public were not involved this information should be formally documented in the Patient and Public Involvement statement.
Dissemination to participants and related patient and public communities
For accepted papers we will ask you to confirm when and how the results of your study were (or will be) sent to research participants and whether they are also being sent to relevant patient and public communities, as applicable. If you have not disseminated and have no plans to do so, please state why.
Summary boxes
Please produce a box offering a thumbnail sketch of what your article adds to the literature. The box should be divided into two short sections, each with 1-3 short sentences.
Section 1: What is already known on this topic
In two or three single sentence bullet points, please summarise the state of scientific knowledge on this topicbefore you did your study, and why this study needed to be done. Be clear and specific, not vague.
Section 2: What this study adds
In one or two single sentence bullet points, give a simple answer to the question “What do we now know as a result of this study that we did not know before?” Be brief, succinct, specific, and accurate. For example: "Our study suggests that tea drinking has no overall benefit in depression." You might use the last sentence to summarise any implications for practice, research, policy, or public health. For example, your study might have asked and answered a new question (one whose relevance has only recently become clear); contradicted a belief, dogma, or previous evidence provided a new perspective on something that is already known in general; or provided evidence of higher methodological quality for a message that is already known. DO not make statements that are not directly supported by your data.
Additional information that must be included with reports of Clinical Trials
Trial registration
In accordance with the International Committee of Medical Journal Editors' Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals , The BMJ will not consider reports of clinical trials unless they were registered prospectively before recruitment of any participants. This policy on prospective registration applies to trials that started after 1 July 2005; for older trials retrospective registration will be acceptable, but only if completed before submission of the manuscript to the journal. The trial registration number and name of register should be included as the last line of the structured abstract. The BMJ accepts registration in any registry that is a primary register of the WHO International Clinical Trials Registry Platform (ICTRP) or in ClinicalTrials.gov , which is a data provider to the WHO ICTRP.
In your submission, please include details about registration: registry, date registered, affirmation that registration was prospective before enrolling the first patient (if applicable) and registry number. The BMJ relies on information contained in trial registries. If authors believe that information in the registry is incorrect they should make their case to registry officials.
Eligible trials have been defined by ICMJE since 1 July 2008 as trials "where human participants are prospectively assigned to one or more health-related interventions (including health services and behavioural interventions) to evaluate the effects on health outcomes," and before that were defined more narrowly as trials "where human participants are prospectively assigned to investigate the cause and effect relationship between a medical intervention and health outcome." The ICMJE further states that, "Some trials assign healthcare providers, rather than patients, to intervention and comparison/control groups. If the purpose of the trial is to examine the effect of the provider intervention on the health outcomes of the providers' patients, then investigators should register the trial. If the purpose is to examine the effect only on the providers (for example, provider knowledge or attitudes), then registration is not necessary." We will take these definitions into account when evaluating if trials were adequately registered.
The BMJ does not consider posting of protocols and results in clinical trial registries to be prior publication. We also will consider research articles that have been posted on preprint servers, provided this is clearly disclosed on submission of the paper.
The BMJ encourages but does not require registration of protocols and posting of results in publicly accessible registries for studies that are not clinical trials if they involve human participants, particularly observational studies . If the study was registered, please provide the registration details, explaining whether the study was registered before data acquisition or analysis began.
The BMJ expects authors of clinical trials to report their findings in accordance with the outcomes listed in the trial registry. Outcomes that were not pre-specified in the registration should be identified as such in the text of the paper and in any tables. All registered outcomes should be described in the BMJ paper. If results for any outcomes will be or have been reported in another publication this should be made clear to readers. The timing and reasons for any changes in registered outcomes should also be disclosed.
The BMJ requires authors of clinical trials to upload a protocol for their study. This protocol will be published alongside other materials if the article is accepted. Any discrepancies between the protocol-specified outcomes and those listed in the trial registry or reported in the paper should be explained in the paper. In cases where pre-specified outcomes differ between the trial registration and the protocol, our policy is to consider the outcomes listed in the registry as pre-specified. Outcomes listed in the protocol but not the trial registry can be reported in the paper, but should be identified as post-hoc outcomes. Protocols vary in completeness and content. There are often multiple versions of a protocol and the timing of decisions about outcomes in relation to the onset of a trial cannot easily be determined. This is in contrast to trial registries, where date stamps are reliable and can be easily verified by readers.Trial registry entries should be updated if new outcomes are added or existing ones deleted, promoted, or demoted.
The BMJ requires authors of clinical trials to upload a statistical analysis plan (SAP) for their study. The SAP will be published alongside other materials if the article is accepted. A SAP provides more detailed information about statistical analysis than a protocol, including detailed descriptions of procedures used to execute the analyses. Please follow the guidance on producing a SAP contained in the table of this document: https://jamanetwork.com/journals/jama/fullarticle/2666509
Open access
Research papers in The BMJ are published with open access. Moreover, The BMJ immediately fulfils the requirements of the US National Institutes of Health, the UK Medical Research Council, the Wellcome Trust, and other funding bodies by making the full text of publicly funded research freely available to all on bmj.com and sending it directly to PubMed Central, the National Library of Medicine's full text archive. The BMJ occasionally publishes as open access other types of (non-research) articles arising from work funded by a funder who mandates open access publication.
Open access articles may be reused according to the relevant Creative Commons licence. The BMJ 's default licence for open access publication of research is the Creative Commons Attribution Non Commercial licence (CC BY-NC 4.0) . But where the funder requires it the author can select the Creative Commons Attribution (CC BY 4.0) licence during the submission process (funders who mandate CC BY include the Wellcome Trust, RCUK, and MRC).
To support this, we ask authors to pay an open access article processing charge - you can find our author charges for open access here . We can offer discounts and waivers for authors who cannot pay. Consideration of the paper is not related to whether authors can or cannot pay the fee. We will ask for the fee only once we have accepted a paper, and we will send an invoice only once authors tell us (via [email protected] ) they can claim the fee. Seeking and processing fees will not delay editing or publication. Please do not contact editors about open access fees: neither editors nor reviewers will know whether a fee is payable, and administrative staff will handle payments and all associated correspondence. For non-research articles published with open access we will ask authors to pay the open access fee. We do not offer refunds for Open Access once articles have been published. For further information, contact [email protected] .
A number of institutions have open access institutional memberships with BMJ (the publishing group), which either cover the whole cost of open access publishing for authors at participating institutions or allow authors to receive a discount on the article processing charge. For a list of member institutions and their policies on how to receive a discount or to publish free of charge, please visit http://journals.bmj.com/site/authors/openaccess.xhtml
For articles not published with open access, The BMJ 's publication licence allows each author to post their article's URL (provided above) on either their own or their employer's website, thereby giving users free access to the full text of the article on bmj.com. Authors will need to use the toll free link to ensure visitors have free access to the article. Alternatively, authors can post the full text of their published article on their own website or their employer's website.
For additional information, please see the section of instructions to authors on copyright, open access, and permission to reuse .
Living systematic reviews
The BMJ will pilot a small number of living systematic reviews
Duration : We will typically host a living systematic review which is live for up to 2 years after initial publication. The triggers for updates, and their frequency, will be decided with authors on a case by case basis. Communication : The title will reflect the living nature of the review and the most recent update will become the default publication on bmj.com. Reviews will have a single digital object identifier (DOI) to keep the information in one place. However, previous versions will remain available as data supplements. An updates table will be included in the review to make tracking the history of the review easier and to signal planned changes. Updates will be flagged on bmj.com, including in rapid responses. They will also be communicated to third parties including PubMed and PubMedCentral. Updates : Updates should be submitted as a “track changes” version of the final MIcrosoft Word version of the previous iteration of the review. A clean version should also be submitted via the ScholarOne manuscript system. Subsequent internal or external peer review reports will be added to the pre-publication history tab on bmj.com with each version of the paper. The approach to any authorship changes should be negotiated before the first version of the paper is published. Resources : The usual BMJ article open access processing fee will be charged for the initial version of the review and an additional fee will be added to cover the cost of up to three updates per year (£2000 per update). After the first year the price may be revised based on the scope of the revisions and the work done on each one.
Preliminary reporting guidance for living reviews
COVER LETTER: This should explain and defend the need for the review to be “living.” Briefly describe other extant reviews, in particular any other living systematic reviews that have recently been published. The cover letter should acknowledge the authors’ acceptance of the following special conditions that apply to living reviews: 1) the need to provide current conflict of interest declarations or updates for all authors at each revision; 2) the single DOI for the paper and updates; agreement that open access fees cannot be waived for living reviews and that additional fees apply to cover the extra work of producing and maintaining living reviews.
TITLE: The phrase “living systematic review” should appear in the title. If additional terms apply, those may be included as appropriate (e.g. “network meta-analysis,” “meta-analysis,” “critical appraisal,” etc.).
ABSTRACT: The abstract should include: 1) A statement of the research question or objective, including a statement that one objective is to provide regular updates and keep the review live. 2) The rationale for a living systematic review should be described, e.g. rapidly evolving evidence base, anticipated impact on policy or practice, etc. 3) A “Readers’ note” at the end of the abstract that provides information about the version of the paper, the date it went live, and gives notice of planned updates. For example: “Readers’ note: This article is a living systematic review that will be updated periodically over the next 2 years to reflect emerging evidence. This version is update XXX of the original article published XXXXXX (give BMJ DOI), and previous updates can be found as data supplements (give link). When citing this paper please consider adding the version number and date of access for clarity.”
MAIN PAPER: Please address the following matters in the appropriate section of the paper: Introduction: -- Include the information required in the abstract (see above paragraph) at the end of the introduction section. -- In updates, consider including a short paragraph that describes how the living review has evolved. For example, what are the key developments since the previous version of the review, and what developments might be expected? Methods -- Mention and include a reference to any published or publicly available protocol for this review. If not registered, consider registering the review. -- Describe the methods that will be used to keep the review living, including the processes that will be used to search for new evidence, anticipated triggers for updates, and the circumstances under which the review might end before the 2 year time limit for BMJ Living Reviews. -- In updated versions of the review, make clear when and why any methods have evolved over time. If these descriptions are lengthy or complex, consider doing this in a table that can be included in an appendix or supplemental file. Such a table will ideally describe important changes to the review protocol, statistical analyses, or other aspects of the review, along with the dates of these changes. -- A table at the end of the discussion section might be used to highlight new evidence that was not included in the review. Results -- Clearly state the updated dates of the search. Discussion -- Consider additional subheadings to separate, e.g. What remain the important findings so far? Versus what are the main new findings to highlight? -- Consider additional table updates to this article. This will make clear historical and anticipated change. Columns trigger, date and action. Declaration of competing interests -- All authors must complete the ICMJE Competing Interests form with the initial submission. At each revision, we will ask the corresponding author to state whether there have been any changes to competing interests among any of the existing authors. If there are changes or if new authors have been added, the corresponding author is responsible for ensuring the this information is up to date. Otherwise there will be no change to the declaration of interests. Supplementary files -- Previous versions of the paper
Please contact Dr. Elizabeth Loder ( [email protected] ) with any questions.
Supplemental material, video
You may submit the following materials as supplemental files if you think they will help the authors and reviewers make a decision or readers better understand your study:
Original raw data if you think they will help our reviewers (and maybe readers), or if we specifically request them. Please note our policy on data sharing, explained above.
Video and audio files that will add educational value to your article, for example by explaining the intervention in a trial.
A video abstract that summarizes your findings and that will be posted on bmj.com with your paper. You can find additional information about video abstracts here and here .
Public and patient involvement materials used in your research.
Copies of any non-standard questionnaires and assessment schedules used in the research.
Copies of patient information sheets used to obtain informed consent for the study or to comprise or deliver the intervention in a clinical trial.
Copies of closely related articles you have published (this is particularly important when details of the study methods are published elsewhere).
Copies of any previous reviewers' reports on this article . We appreciate that authors may have tried other journals before sending their work to The BMJ , and find it helpful if you let us know how you have responded to previous reviewers' comments.
Research Methods and Reporting (RMR)
We are willing to consider papers that present new or updated research reporting guidelines, but only if the guideline pertains to a study type that we publish in The BMJ. The checklist itself must be included as part of the paper. We prefer to be the only journal publishing the guideline, but under some circumstances we will consider co-publication with up to two other journals. For an example of how to format a reporting guideline to appear in our research methods and reporting section, see http://www.bmj.com/content/346/bmj.f1049.full.pdf+html .
Preparing a RMR article
Word count We do not set fixed word count limits for RMR articles. Nonetheless, we ask you to make your article concise and make every word count. For some submissions this might be published in full on bmj.com with a shorter version in the print BMJ
Overall structure Research Methods and Reporting should have the following elements:
Title and standfirst A short title is followed by an 100-150 word italicised single sentence (the standfirst) which encapsulates the article’s central message.
Introduction Articles should begin with a brief paragraph that captures readers’ attention and explains the aim of the piece.
Text The body of the text should be broken up under subheadings that provide a logical narrative structure. Avoid acronyms and abbreviations unless they are universally recognised e.g. DNA. The evidence on which key statements are based should be explicit and referenced, and the strength of the evidence (published trials, systematic reviews, observational studies, expert opinion etc.) addressed.
Boxes, tables and figures Include tables, boxes, or illustrations (clinical photographs, imaging, line drawings, and figures) to enhance the text and add to or substantiate key points made in the body of the article. Figures may be in color. Worked out examples that use specific methods under discussion can be included as additional boxes. If appropriate, include a box of linked information such as website urls for those who want to pursue the subject in more depth.
Web extras We may be able to publish on bmj.com some additional boxes, figures, and references (in a separate reference list numbered w1, w2,w3, etc. and marked as such in the main text of the article). Also may include suggestions for linked podcasts or video clips, as appropriate.
Contributors and sources We ask for a 100-150 word supplementary paragraph (excluded from word count) to explain the article’s provenance. It should include the relevant experience and expertise of each author, his or her contribution to the paper, and the sources of information used to prepare it. One author must be nominated as the guarantor of the article. Include a statement of sources and selection criteria.
Key messages box Include up to four sentences, in the form of bullet points, highlighting the article's main points.
References Must be in Vancouver style and should be kept to a minimum; ideally no more than 20.
“Analysis” is a distinct article type at The BMJ , and differs from other sections such as Research, Education, Editorials, and Personal Views. A great Analysis article makes an argument and supports it with reference to a robust (not cherry picked) evidence base. It has academic heft yet is a journalistic read. 'Academic heft' means the argument is evidence-based and supported by data. 'Journalistic read' means the article is really engaging (not dry nor dull; written in clear language and avoiding technical jargon; and pitched to our international audience of doctors of all specialties, academics, and policy makers). Keep in mind that Analysis articles are “long reads” at around 1800-2000 words, so they need to be absolutely great reading to keep readers’ attention, particularly readers that may not be familiar with the topic.
We receive many manuscripts that are not a good fit for the Analysis section. We generally do not consider:
• Case studies (e.g. where the article mostly concerns the author’s writing about their own work) • Manuscripts containing primary research data (such papers should be submitted as Research) • Narrative review articles (as a general practice, The BMJ does not accept unsolicited submissions of review articles) • Articles presenting a new hypothesis
If you are unsure if your work is suitable for The BMJ 's Analysis section we are willing to consider succinct pre-submission inquiries, please complete the form in this link and await a response from one of the analysis editors.
Preparing an Analysis article
We recommend looking at this Analysis article template and using it as a basis for your work before considering submission.
Word count and style The BMJ has an international readership that includes policy makers, health professionals, and doctors of all disciplines. Authors are advised to keep this readership in mind and to write their article for the non-expert. It’s important to avoid jargon. Specialised terminology and references to organisations or practices that are specific to one country need to be explained. Clear writing and an attractive presentation are essential. Analysis papers should be 1,800-2,000 words long.
Overall structure The manuscript should have the following elements:
Title and standfirst A short title is followed by an italicised single sentence (the standfirst) which encapsulates the article’s central message.
Text The body of the text should be broken up under sub-headings that provide a logical narrative structure. Avoid acronyms and abbreviations unless they are universally recognised e.g. DNA. The evidence on which key statements are based should be explicit and referenced, and the strength of the evidence (published trials, systematic reviews, observational studies, expert opinion, etc.) made clear. Articles should present a balanced, even-handed look at the evidence rather than selectively citing evidence that supports a particular view.
Boxes, tables and figures These should extend and substantiate points made in the body of the paper. Words in boxes and tables are excluded from the word count of the body of the text, but the additional material should be concise.
Key messages box This should be at the end of the article and include 2 to 4 points summing up the main conclusions. When submitting your article at submit.bmj.com, please enter your key messages when prompted to enter the abstract.
Contributors and sources We ask for a 100-150 word supplementary paragraph (excluded from word count) to explain the article’s provenance. It should include the relevant experience and expertise of each author, his or her contribution to the paper, and the sources of information used to prepare it. One author must be nominated as the guarantor of the article.You are welcome to invite co-authors to work with you on the article. We suggest including 2-3 co-authors with different locations and perspectives to help ensure articles are international in scope and accessible to our broad readership online and in print.
Report of patient involvement As The BMJ is seeking to advance partnership with patients, we also ask authors to seek their input into articles wherever relevant, and document their involvement as patient contributors or coauthors.
Conflicts of Interest All authors should read our competing interests policy and include the appropriate declaration in their manuscript. Where a competing interest exists that might disqualify an author from contributing, it is wise to discuss it with a BMJ editor before writing the article.
Peer review The BMJ has fully open peer review for analysis articles. This means that every accepted analysis article submitted from February 2016 onwards will have its prepublication history posted alongside it on thebmj.com. This prepublication history comprises all previous versions of the manuscript, the report from the manuscript committee meeting, the reviewers’ signed comments, and the authors’ responses to all the comments from reviewers and editors. Authors are welcome to suggest names of suitable reviewers, including patient reviewers.
What happens after submission
What happens after publication.
In most cases we will publish the prepublication history alongside an accepted analysis article. This prepublication history comprises all previous versions of the manuscript, the report from the manuscript committee meeting, the reviewers’ comments, and the authors’ responses to all the comments from reviewers and editors. In rare instances we may determine after careful consideration that we should not make certain portions of the prepublication record publicly available. For example, in cases of stigmatised illnesses we seek to protect the confidentiality of reviewers who have these illnesses. In other instances there may be legal or regulatory considerations that make it inadvisable or impermissible to make available certain parts of the prepublication record. In all instances in which we have determined that elements of the prepublication record should not be made publicly available, we expect that authors will respect these decisions and also will not share this information.
Education (inc. Minerva Pictures and Endgames)
The BMJ publishes different types of educational articles to engage and challenge a range of postgraduate doctors and clinical researchers internationally. We strive to publish articles that are original in their content and/or presentation, and cannot be found elsewhere or in textbooks. We prioritise topics and situations that are common or have serious consequences, have international appeal, and that interest a variety of doctors, including GPs and specialists.
We encourage authors to write in teams, including those from other specialties, professions, and countries. We ask that one author is routed in the clinical environment of the intended reader. We encourage authors to write in plain English, to be clear about where there is uncertainty, and to include numbers and phrases where possible that will help doctors in conversation with their patients.
Our educational articles are shaped by two initiatives:
• We believe that financial interests can distort education articles and we minimise or exclude authors who we judge have such a conflict.
• We believe that patient involvement strengthens content. We encourage authors to seek input from patients either to inform the scope, develop the content, contribute to, or co-author articles. For help with this, please read our guidance on what we mean by patient involvement and co-production .
Submission process and presubmission enquiries
We receive more articles and suggestions than we can publish. We require all authors to contact us before submitting a manuscript to us. Send us your proposal using our Education Article Proposal Form , together with your completed Declaration of Financial Interests .
The proposal form will guide you through the following questions:
• What is your idea? • Can you sum up the aim of your article in a sentence? • Why is the topic important to The BMJ 's readers? • What is the prevalence of the symptom/condition/situation you wish to write about? • Why cover it now? Has something new happened? • What has The BMJ 's Education section covered on this topic in the last five years? What will your contribution add? • Can you provide the key evidence/references you might use? • Why are your writing team well placed to cover the topic? • Have you thought about what a patient would say about your idea?
Policies for Education articles
Authorship Education articles can have can have up to four authors. One author should be from the relevant specialty or setting, unless agreed otherwise. For example, if the article discusses presentation to the emergency department one author should be an emergency care doctor. All authors should meet authorship criteria . We welcome authors or contributions from allied health professions and patient authors, and actively encourage authors from a primary care background.
Competing interests The BMJ will not consider authors with financial interests when writing Education articles. It is important that we understand the financial interests of every author, and can judge to what extent we believe that they may be relevant to the article that you propose. We do not publish content from authors who we judge have relevant financial ties to the industry (excluding State of the Art reviews, Therapeutics articles, and Summaries of NICE Guidelines). The relevance of declared interests are judged by the BMJ team. This applies to every author. Any additional authors and their financial interests must be discussed and agreed with the commissioning editor before the article is submitted.
Patient involvement As part of our drive to co-produce our content with patients we ask that you seek patient input into articles at the planning stage. We believe that their experience and perspectives will make articles more useful for doctors in their quest to help improve patients well being and outcomes.
We ask all authors to what extent patients have been involved in their article and how their involvement changed the article. We ask that all writing encourages honesty and partnership with patients. Where uncertainty exists, share it. Where data exists present the numbers in a way that can be shared with the patient (use absolute numbers, natural frequencies, and graphics where you can). Use language that empowers patients to make the right choices for them in their situation (write that a doctor should/could offer a test, rather than should do a test).
When patients are involved in the manuscript, we ask for their consent. We have two types of consent forms for BMJ education articles:
• A patient consent form is required if any anonymised patient information is included in the review. Consent is needed for images even if the patients are not identifiable for example, in X-rays and histology slides, and for patients’ stories/vignettes even if details are anonymised.
• A patient contributor form is required for any patients who are named within the review, for example, patient co-authors, patient contributors or named authors of patient stories.
Preparing your manuscript
We want our readers to have the ability to share decisions with their patients and make clear for them the degree of certainty ( or lack of it) about a potential course of action. We therefore ask that, in addition to the format and instructions detailed below for the specific Education article that you are writing, you follow these recommendations:
• Consider including in your manuscript a box explaining your strategy to search for evidence. It should include a search date, the sources searched, and brief inclusion criteria. • Clearly distinguish suggestions made based on your experience, standard practice, guidelines, and evidence. • Provide specifics about the evidence you discuss. For example, for key statements, please say: "A large, well conducted, randomised controlled trial showed INSERT number [CI] and or p value". "The findings of a small case series suggest...". “A subgroup analysis found…”. etc. • Use absolute numbers or explain why you have not used them. • Consider how these numbers can be communicated by the clinician read to their patient in a clear way. • Where evidence is lacking or of poor quality make this clear. • Write about known and unknown benefits and harms.
"What you need to know" box . No more than three bullet points for practice articles and five for clinical updates encapsulating the specific take home messages from this article.
"How patients were involved in the creation of this article" box. Please include: Which patients were asked (e.g. patient advocates, networked patient communities and organisations, patients in your clinic etc). What they said (e.g. include more practical advice on how to inject insulin.) How you changed your article as a result (e.g. we included a box to address this.)
"Education into practice" box . Include two to three bullet points about how a reader might at an individual or organisational level improve their practice (e.g. do you offer lifestyle advice to all patients with newly diagnosed hypertension?)
At least one other box or table and at least one figure or image that complement the text of the article.
Article types
We accept pitches for the following article types. Once our editors have made a decision to encourage a pitch, we will provde authors will a full, detailed set of instructions on how best to format your content.
Additional requirements for all other article types
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How to Write a Medical Research Paper
Last Updated: May 29, 2020 References Approved
This article was co-authored by Chris M. Matsko, MD . Dr. Chris M. Matsko is a retired physician based in Pittsburgh, Pennsylvania. With over 25 years of medical research experience, Dr. Matsko was awarded the Pittsburgh Cornell University Leadership Award for Excellence. He holds a BS in Nutritional Science from Cornell University and an MD from the Temple University School of Medicine in 2007. Dr. Matsko earned a Research Writing Certification from the American Medical Writers Association (AMWA) in 2016 and a Medical Writing & Editing Certification from the University of Chicago in 2017. wikiHow marks an article as reader-approved once it receives enough positive feedback. In this case, 90% of readers who voted found the article helpful, earning it our reader-approved status. This article has been viewed 191,632 times.
Writing a medical research paper is similar to writing other research papers in that you want to use reliable sources, write in a clear and organized style, and offer a strong argument for all conclusions you present. In some cases the research you discuss will be data you have actually collected to answer your research questions. Understanding proper formatting, citations, and style will help you write and informative and respected paper.
Researching Your Paper
- Pick something that really interests you to make the research more fun.
- Choose a topic that has unanswered questions and propose solutions.
- Quantitative studies consist of original research performed by the writer. These research papers will need to include sections like Hypothesis (or Research Question), Previous Findings, Method, Limitations, Results, Discussion, and Application.
- Synthesis papers review the research already published and analyze it. They find weaknesses and strengths in the research, apply it to a specific situation, and then indicate a direction for future research.
- Keep track of your sources. Write down all publication information necessary for citation: author, title of article, title of book or journal, publisher, edition, date published, volume number, issue number, page number, and anything else pertaining to your source. A program like Endnote can help you keep track of your sources.
- Take detailed notes as you read. Paraphrase information in your own words or if you copy directly from the article or book, indicate that these are direct quotes by using quotation marks to prevent plagiarism.
- Be sure to keep all of your notes with the correct source.
- Your professor and librarians can also help you find good resources.
- Keep all of your notes in a physical folder or in a digitized form on the computer.
- Start to form the basic outline of your paper using the notes you have collected.
Writing Your Paper
- Start with bullet points and then add in notes you've taken from references that support your ideas. [1] X Trustworthy Source PubMed Central Journal archive from the U.S. National Institutes of Health Go to source
- A common way to format research papers is to follow the IMRAD format. This dictates the structure of your paper in the following order: I ntroduction, M ethods, R esults, a nd D iscussion. [2] X Research source
- The outline is just the basic structure of your paper. Don't worry if you have to rearrange a few times to get it right.
- Ask others to look over your outline and get feedback on the organization.
- Know the audience you are writing for and adjust your style accordingly. [3] X Research source
- Use a standard font type and size, such as Times New Roman 12 point font.
- Double-space your paper.
- If necessary, create a cover page. Most schools require a cover page of some sort. Include your main title, running title (often a shortened version of your main title), author's name, course name, and semester.
- Break up information into sections and subsections and address one main point per section.
- Include any figures or data tables that support your main ideas.
- For a quantitative study, state the methods used to obtain results.
- Clearly state and summarize the main points of your research paper.
- Discuss how this research contributes to the field and why it is important. [4] X Research source
- Highlight potential applications of the theory if appropriate.
- Propose future directions that build upon the research you have presented. [5] X Research source
- Keep the introduction and discussion short, and spend more time explaining the methods and results. [6] X Research source
- State why the problem is important to address.
- Discuss what is currently known and what is lacking in the field.
- State the objective of your paper.
- Keep the introduction short.
- Highlight the purpose of the paper and the main conclusions.
- State why your conclusions are important.
- Be concise in your summary of the paper.
- Show that you have a solid study design and a high-quality data set.
- Abstracts are usually one paragraph and between 250 – 500 words.
- Unless otherwise directed, use the American Medical Association (AMA) style guide to properly format citations.
- Add citations at end of a sentence to indicate that you are using someone else's idea. Use these throughout your research paper as needed. They include the author's last name, year of publication, and page number.
- Compile your reference list and add it to the end of your paper.
- Use a citation program if you have access to one to simplify the process.
- Continually revise your paper to make sure it is structured in a logical way.
- Proofread your paper for spelling and grammatical errors.
- Make sure you are following the proper formatting guidelines provided for the paper.
- Have others read your paper to proofread and check for clarity. Revise as needed.
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- Ask your professor for help if you are stuck or confused about any part of your research paper. They are familiar with the style and structure of papers and can provide you with more resources. ⧼thumbs_response⧽ Helpful 1 Not Helpful 0
- Refer to your professor's specific guidelines. Some instructors modify parts of a research paper to better fit their assignment. Others may request supplementary details, such as a synopsis for your research project . ⧼thumbs_response⧽ Helpful 0 Not Helpful 0
- Set aside blocks of time specifically for writing each day. ⧼thumbs_response⧽ Helpful 0 Not Helpful 0
- Do not plagiarize. Plagiarism is using someone else's work, words, or ideas and presenting them as your own. It is important to cite all sources in your research paper, both through internal citations and on your reference page. ⧼thumbs_response⧽ Helpful 4 Not Helpful 2
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- ↑ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3178846/
- ↑ http://owl.excelsior.edu/research-and-citations/outlining/outlining-imrad/
- ↑ http://china.elsevier.com/ElsevierDNN/Portals/7/How%20to%20write%20a%20world-class%20paper.pdf
- ↑ http://intqhc.oxfordjournals.org/content/16/3/191
- ↑ https://www.councilscienceeditors.org/wp-content/uploads/v23n2p039-044.pdf
- ↑ http://www.ruf.rice.edu/~bioslabs/tools/report/reportform.html#form
About This Article
To write a medical research paper, research your topic thoroughly and compile your data. Next, organize your notes and create a strong outline that breaks up the information into sections and subsections, addressing one main point per section. Write the results and discussion sections first to go over your findings, then write the introduction to state your objective and provide background information. Finally, write the abstract, which concisely summarizes the article by highlighting the main points. For tips on formatting and using citations, read on! Did this summary help you? Yes No
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Publishing your Medical Research Paper: Find the right journal
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Table of Contents
Finding the ideal journal to publish a paper – any paper – is challenging enough, let alone such a specific kind like medical research. Its specialized nature may make the choice of an ideal journal for your paper difficult.
Nowadays, just in the medical and health care field, there are hundreds of journals available for publishing. But because this study field is so segregated by specialization, research methodologies, and even audience groups, the search range narrows itself almost instantly. Having this in mind, it is of extreme importance that you keep focused on your own personal goals and make a strategic choice in terms of where your paper fits.
You also need to consider what you want to achieve in terms of visibility and impact – maybe you prefer a more generalized journal to get to more people or a more specific one, impacting a smaller – but more desirable – niche of an audience.
Medical Editing Services
At Elsevier, we know how important it is to get your medical paper published in the journal of your choice. Therefore, we offer medical editing services to ensure your manuscript fits the targeted journal, not only in terms of grammar but also in responding to its specific guidelines. Our team of proficient medical writers can help you tailor your text according to your highest standards and expectations in terms of text quality.
We are also aware that for practicing physicians it is quite challenging to find time to write and prepare an acceptable manuscript for the high demands of peer review. But it is these practicing professionals who often deliver the most original and exciting research. So, for those who don’t believe that time should be a constraint for publishing great research, Elsevier offers a wide range of medical text editing options. These can include just minor amendments in order to fit a scientific journal’s guidelines, or a more profound review, including reformatting or rewriting as you find suitable.
Medical Paper Editing
Medical text editing comprises a number of highly specialized tasks that may or may not intersect other fields of knowledge. Also, the audience matters. Note these three examples:
- Education Medical Writing – For the general public or other researchers who are indirectly involved in the topic; medical terms need to be adapted to simpler and more explicative expressions;
- Regulatory Medical Writing – For experts in medicine and/or in a field of medicine; high-level specialized writing;
- Medico-marketing – A combination of medical writing and advertising and/or marketing writing.
At Elsevier, thanks to a multidisciplinary team, we guarantee ready-to-publish medical manuscripts, fulfilling the expectations of the targeted audience or topic, as heterogeneous as it might be. Also, if you have already written a document about your research, but you are unsure about the right formatting for publication, we’re happy to help reviewing it according to your objectives.
Publishing your Medical Research Paper
Publishing is a necessary step for every researcher. It brings visibility, a sense of recognition and appreciation for one’s work and, in a more realistic and practical point of view, also funding and financial support for the future. The higher a journal is ranked, and the bigger impact it has among the scientific community, the better are your chances of being noticed. Therefore, flawless text and submission are the key to a successful publishing process. In Elsevier, you can find the right partner to increase the visibility of your medical research, leaving you time for the bigger decisions, such as… let’s say…finding the right journal:
- Take into consideration the global characteristics of the article you want to publish (full length, letter, review and research output)
- References in your article might give a clue of journals of interest
- Check the journal’s aim and scope (for Elsevier’s journals you can find them on our homepage Elsevier.com)
- Check the journal’s Guide for Authors
- Find out if your targeted journal is invitation only – some journals only accept articles after inviting the author to submit
- Remember to consult the journal’s performance for review and publication timelines
- In case you would like to publish Open Access, know that most Elsevier journals explain their open access options and policy on their homepage
- Submit your work only to one journal at a time
Even if the choice of the perfect medical journal runs smoothly for you, or it’s not the first time you are submitting to a journal, remember to give – or maintain – a professional image by delivering a high-quality manuscript for peer review. Elsevier ensures maximum dedication to your project with guarantees a successful submission.
Language Editing Plus Service by Elsevier Author Services:
The most advanced language editing package available:
- Unlimited rounds of language review up to 1 year to support you at every stage of the submission process
- Special focus on the logic and flow of the manuscript’s content
- Manuscript formatting to meet the requirements of the journal of your choice
- Reference check for consistency, completeness, and structure
- Customized Cover Letter and an Assessment Report on your document
- Manuscript Preparation
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Nutritional requirements for the elderly in India: A status paper : Indian Journal of Medical Research
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Nutritional requirements for the elderly in India: A status paper
Tattari, Shalini 1 ; Gavaravarapu, SubbaRao M. 2 ; Pullakhandam, Raghu 3 ; Bhatia, Neena 4 ; Kaur, Supreet 4 ; Sarwal, Rakesh 4 ; Rajkumar, Hemalatha † ; Reddy, G. Bhanuprakash 1,
1 Division of Biochemistry, Communication & Health Education, Hyderabad, Telangana, India
2 Division of Nutrition Information, Communication & Health Education, Hyderabad, Telangana, India
3 Division of Drug Safety, Indian Council of Medical Research, Hyderabad, Telangana, India
† Division of National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, Telangana, India
4 Division of NITI Aayog, New Delhi, India
For correspondence : Dr G. Bhanuprakash Reddy, Department of Biochemistry, National Institute of Nutrition, Hyderabad 500 007, Telangana, India e-mail: [email protected]
This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 4.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Advances in the medical field and healthcare sector during the last few decades have resulted in increased longevity. Increased lifespans have in turn led to a rapid global rise of the elderly population. However, ensuring the health and quality of life, especially in the context of chronic age-related ailments, among the growing geriatric population is a challenge. Ageing is associated with several changes in body composition including a decline in the lean body mass usually accompanied by an increase in body fat content which have a bearing on the nutrient requirements for the elderly. The nutrient requirements currently recommended for Indian adults are primarily computed using a factorial approach, that considers the cumulative loss of nutrients and is adjusted for optimal body weights and bioavailability. It is logical that physiological and metabolic changes associated with ageing influence several of these factors: body weight, lean mass, energy expenditure, nutrient retention and bioavailability and thus alter nutrient requirements compared to the adult population. Acknowledging these age-related changes, some international organizations have suggested nutrient requirements specific to the elderly. Given the contextual differences in physiology , caution needs to be exercised in adopting these guidelines for the Indian elderly. In addition, in the Indian context, there is sparse information on the diet and nutrient intakes vis-à-vis nutritional status and physiology of the elderly. This status paper highlights some of the pertinent issues related to nutritional requirements for the elderly that advocate a need for deriving nutritional requirements for the elderly in India.
Population ageing reflects an inevitable and irreversible demographic transition. Ageing is characterized by progressive deterioration in several biological functions along with the natural age-related changes in viability and increased vulnerability 1 . In general, the term ‘elderly’ or ‘old age’ or ‘senior citizens’ apply to people with ages nearing or surpassing the average lifespan of human beings, which may vary with geography and population groups. Thus, there is no universal cut-off for old age, and it may not convey the same meaning across societies. The measures and indicators commonly used to relate the sizes of different age groups are based on people’s chronological age, stereotypically defining older persons as those aged 60 or 65 yr or over 2 . According to the World Health Organization (WHO), the number of persons aged 60 yr and above globally was over 1.0 billion in 2019 and this is expected to rise to 1.4 billion by 2030 and 2.1 billion by 2050 3 . According to the United Nations (UN), globally, the number of persons aged 65 yr and above was 703 million in 2019, and by 2050, it is expected to reach 1.5 billion 2 . The life expectancy at birth during 2015-2020 was 72.3 yr and it is projected to increase by an additional 4.5 yr by 2045-2050 2 .
According to the ‘National Policy on Older Persons’ adopted by the Government of India in January 1999, ‘senior citizens’ or ‘elderly’ are those aged 60 yr and above 4 . The population in India has nearly tripled in the last 50 yr, and the number of the elderly has increased over four-fold during the same time frame 5 . In 2019, of the estimated 1.366 billion population of India, the number of aged population (>65 yr) was 87 million, and by 2050, it is expected to reach 225 million 2 . However, increased longevity is associated with non-communicable diseases (NCDs) and the average annual per capita out-of-pocket health spending in India is almost four times as high for older adults as that of younger adults 6 .
Ensuring the quality of life, especially in relation to age-related changes and age-associated ailments, among the growing geriatric population is a challenge. Some of these could be minimized, mitigated and/or prevented through appropriate dietary guidelines and nutrient recommendations. For such recommendations to be developed and disseminated, context-specific nutritional requirements must be derived. The existing nutritional requirements, mainly for Indian children and adults, are computed using factorial approach and may not be fully relevant to the elderly. This problem is compounded by the dearth of information on the dietary intakes, nutritional status and physiology of the elderly in India. Against this background, this paper elucidates the nutritional linkages to ageing and argues that there is an imminent need to derive context-specific nutritional requirements for the elderly in India.
Ageing and Nutrition
Ageing is an unavoidable biological process controlled by environmental and genetic factors. Biological ageing is multifactorial and accompanied by a variety of physiological, psychological, economic and social changes, which have a direct bearing on nutritional status and thus the health of the elderly 7 , 8 .
Physiological changes associated with ageing include changes in body composition where the proportions of lean body mass (LBM, predominantly the muscle mass and bone mass) as well as bone mineral density decrease, while the proportion of fat mass, particularly visceral fat, increases. The loss of muscle mass and strength (sarcopenia) and bone mass (osteopenia) is a normal age-associated phenomenon. Longitudinal studies demonstrated that resting energy expenditure declines by about 2-4 per cent per decade from 30 to 80 yr with an accelerated decline between 40 and 50 yr 9 . As a result, the basal metabolic rate (BMR) declines by 10-20 per cent in the elderly as compared to younger adults 10 , which has a direct bearing on the nutritional requirements. In addition, older people often develop disorders of the gastrointestinal tract, which ultimately limit the digestion, absorption and/or bioavailability of multiple nutrients including vitamins and minerals 11 . Delayed gastric emptying and decline of olfactory, gustatory and visual food perception in the elderly result in decreased appetite (anorexia of ageing), leading to reduced energy intake, decreased food choices and low diversity in meal composition 7 . There are several molecular and cellular hallmarks associated with ageing, linked to decline in physical activity and inflammation both of which can be interceded by nutrition. Ageing is also associated with increased risk of NCDs 12 ; this could be a ramification of unavoidable physiological changes and could be accelerated by unhealthy diet, physical inactivity and sedentary life ( Figure ). Suboptimal nutritional status, particularly deficiency of micronutrients, is a contributing factor to the prevalence and severity of NCDs such as cardiovascular diseases (CVD), cognitive, musculoskeletal, metabolic and ophthalmic diseases 13 ( Table I ) 14 - 28 .
Determining nutritional requirements for the elderly: Factors to consider
Nutrition is an important determinant of health among the elderly. The total calorie needs tend to decrease with age because of reduced physical activity and a lower resting metabolic rate (RMR), while the needs for some micronutrients increase with age. Prominent determinants that influence lifespan include environmental factors, and among these, the most important are dietary diversity and physical activity 29 . Therefore, some of the following factors need careful consideration while determining the nutritional requirements for the elderly.
With ageing, energy requirement gradually decreases because of the changes in LBM, BMR and a reduction in physical activity. In 2010, the Longitudinal Ageing Study in India (pilot) reported that 69 per cent of 1500 older adult respondents in four States had no physical exercise and it further decreased with age and significantly more so among females 30 . Reduction in physical activity of an individual leads to a reduction in the total energy expenditure and this is one of the important factors contributing to reduced energy requirements among the elderly. Several lines of evidence demonstrate that even in apparently healthy older adults, there is dysregulation of energy intake, thus increasing the risk of energy imbalance 31 . In the elderly population, especially those with very low energy requirements, the likelihood of their diets not meeting the micronutrient requirements is very high.
During ageing, the body becomes resistant to the normal growth signals shifting the balance towards catabolism and muscle loss, leading to sarcopenia. Inadequate protein intake in the long run can not only accelerate the loss of muscle mass and functional inability but also impair the immune function and wound healing 32 , while resulting in significant clinical consequences such as frailty, increased risk of falls with associated injuries and fractures leading to death. Therefore, the main anabolic stimulus for skeletal muscle other than exercise is protein intake; hence, protein requirement increases with age 33 . The European Society for Clinical Nutrition and Metabolism recommends 1.0-1.2 g/kg body weight/day for healthy older people and 1.2-1.5 g/kg/day for older people who are malnourished or with chronic illness 34 . As energy requirements generally decline with ageing, the dietary protein-to-energy (PE) ratio would become higher among the elderly. Thus, it is the PE ratio that is more important than the protein intake per se . In addition, due to reduced appetite or inability to masticate protein-containing foods such as meat, greater quantity of essential amino acids, particularly branched-chain amino acids such as leucine, isoleucine and valine, is required 33 .
Adequate carbohydrates, especially complex carbohydrates, need to be provided to protect the protein from being used as an energy source. As per the recommendations, 55-65 per cent of energy should be provided by carbohydrates 35 . Dietary fat is the source of essential fatty acids and is also required for absorption of fat-soluble vitamins. Monounsaturated and polyunsaturated fats, particularly omega-3-rich fats, should be substituted for saturated fats (SFAs) as these fats help protect the heart and the brain. Therefore, except in cases of overweight or obesity, it is not required to restrict fat intake to <30 per cent of energy for those who are sedentary and 35 per cent of energy for those who are active 35 . An upper limit of 10 per cent from the energy of SFAs, desirable intakes of n6 PUFA is 4-10 per cent of energy and a ratio of n6/n3 PUFA between 5:1 to 10:1 are recommended 35 .
Several studies have alluded to the beneficial effects of fibre on physiologic activities (gut transit time, crypt formation and intestinal thickness, bioavailability of minerals and vitamins, protein digestion, cholesterol and other lipid metabolism, glycaemic and insulinaemic responses and immune response) in the elderly 36 . Since older people have a greater proportion of fat mass to lean muscle mass and the water content of fat mass is lesser than the muscle mass, the elderly are more likely to become dehydrated. Impaired thirst and physical limitations tend to reduce water intake. Therefore, the elderly should be encouraged to consume water frequently. Daily fluid needs for the healthy older adults are approximately 30 ml/kg body weight, with a minimum of 1.5 l/day or 1 to 1.5 ml/kilocalorie consumed 37 . Adequate fibre, along with adequate fluid, not only helps maintain normal bowel function but also reduces the risk of intestinal inflammation.
With the reduction in energy requirements and the lower intake of food along with the impaired absorption, metabolism and utilization, deficiency of certain micronutrients is more likely to occur in the elderly. Epidemiological evidence suggests that there is a clear association between subclinical micronutrient deficiencies and acceleration of the natural ageing process as well as several chronic age-related diseases ( Table I ). Conversely, adequate micronutrients can play an important role in healthy ageing and each of them needs a different approach and consideration for defining the requirements. For instance, vitamin A (VA) improves vision; contributes to proper functioning of the digestive system, urinary tract and immune function and protects skin in the elderly. Its requirements are factorially computed considering the catabolic loss, liver stores, liver-to-body weight ratio, total body store versus liver stores, efficiency of storage and the dietary beta-carotene conversion to VA 35 , 38 . Since many of these factors are expected to alter during normal ageing process, there is a need to systematically review these for determining VA requirements in the elderly.
Vitamin D (VD) deficiency is today considered as a worldwide epidemic, more so in the elderly, as a result of decreased sunlight exposure (particularly in institutionalized older adults), decreased intrinsic synthesis of VD metabolites, increased parathyroid hormone as well as age-related changes in body composition, lower dietary intake and decreased VD receptor activity 39 . Furthermore, the kidney’s ability to convert 25-hydroxy VD into 1, 25-dihydroxy VD is reduced, and the absorption of VD from the gut is also decreased. Low VD levels are related to the risks of fractures, falls, reduced muscle strength, low physical performance, impaired cognitive function and depression in older adults 40 , 41 .
The association between poor thiamine (B1) status and neurodegenerative diseases, cognitive impairment and depression 25 is well established. In the elderly, riboflavin (B2) supplementation is effective in lowering high amounts of homocysteine (Hcys) in the blood 42 . Vitamin B6 occurs as pyridoxine, pyridoxal-5’-phosphate (PLP) and pyridoxamine. Pyridoxamine is a potent inhibitor of advanced glycation end products (AGEs) by sequestering the glucose and reactive products of glucose and lipid degradation. The AGEs are the main culprits in many age-related disorders 43 . Low PLP levels may decrease the production of glutathione and impair the antioxidant defence system. Pyridoxine is required for the metabolism of several neurotransmitters, including dopamine, serotonin and histamine, essential in brain health. Vitamin B9 (folate), along with vitamins B12 and B2, plays an important role in the metabolism of Hcys. In older adults, hyperhomocysteinaemia is an independent risk factor for CVD 44 . Supplementation of folate can bring down the elevated Hcys levels. In the elderly, the consumption of foods rich in B12 (animal foods) can decrease with age due to poor dentition and dysphagia. Malabsorption of food-bound cobalamin is the prime cause of low B12 status in the elderly. This could stem from a variety of reasons including decrease in gastric acid secretion, lack of intrinsic factor, bacterial overgrowth or defects in the cobalamin uptake system 45 .
In the elderly, zinc (Zn) also plays a pivotal role in immune response as well as in neurological functions. A reduced capacity to absorb Zn, increased likelihood of disease states that alter Zn utilization and increased use of drugs that lead to higher Zn excretion may contribute to an increased risk of mild Zn deficiency in older adults. Deficiency of Zn may cause dermatitis, diarrhoea, impaired wound healing, decreased appetite and impaired taste and is also associated with Alzheimer’s disease 15 and age-related macular degeneration 14 . Malnourished elderly are at an increased risk of iron (Fe) deficiency due to inadequate dietary intake, chronic gastrointestinal blood loss, low absorption (due to atrophic gastritis) and bioavailability 46 , 47 . However, only about 15-50 per cent anaemia among the elderly is associated with iron deficiency, while the other causes of anaemia remain unknown 46 , 48 . This could be due to age-dependent decline in blood haemoglobin levels among healthy adults as results of reduced lean mass and tissue functions 49 . Excess intake of Fe increases the risk of type 2 diabetes as it induces insulin resistance and modifies the glucose transport in adipocytes 50 . These observations together suggest that iron metabolism during ageing is distinct compared to adulthood.
Calcium (Ca) is central in many physiological processes, and requirements for Ca increase with age as there is decreased intestinal absorption of Ca and VD, decreased circulation of gonadal hormones, increased excretion of urinary Ca and decreased physical activity. However, Ca absorption is dependent on VD intake as it facilitates the intestinal absorption of Ca. Calcium deficiency is linked to the development of osteopenia, osteoporosis and fractures 51 . Reduced glomerular filtration rate is yet another important factor associated with ageing that can eventually affect the renal conservation of Ca and result in secondary hyperparathyroidism, which is a potential cause for significant bone loss. Absorption of Ca decreases with age and the fractional Ca absorption declines by about 0.21 per cent per year after 40 yr of age 52 .
The sensitivity of BP to sodium chloride intake increases with age and also accounts for reduced renal and cardiovascular functions in older adults 53 . Potassium (K) not only aids in the acid-base balance, but also contributes to generation of transmembrane electrochemical potentials required for the nerve fibres and muscle cells. While the relationship between K intake and BP is known 54 , high intake of K from foods, especially when it is associated with bicarbonate precursors, is linked to decreased bone loss 55 .
Current recommendations and the need for deriving India-specific nutritional requirements for the elderly
The ICMR Expert Group on Nutrient Requirements 35 has revised the nutrient requirements and recommended dietary allowances (RDA) for Indians by employing the latest state-of-the-art methodological framework in harmony with the dietary reference intake recommendations of international organizations like FAO/WHO/UNU (Food and Agriculture Organization/World Health Organization/United Nations University). The latest ICMR-2020 recommendations include three important dietary reference values (specific to age, gender and physiological groups): estimated average requirements (EAR), RDA and tolerable upper intake level (TUL). While the EAR is an average requirement of population, RDA is sufficient to meet the requirements of nearly all (97.5%) healthy individuals in a particular life stage and gender group. The TUL is derived from toxicological framework; the intake beyond this level increases the risk of toxicity. In addition, ICMR-EAR-RDA (2020) also suggested assessing the population dietary inadequacy against the requirement distribution 38 , 56 . A factorial approach, where the losses and additional requirements for growth and their associated variance are summed to generate the physiological requirement distribution per kilogram body weight, was adopted during formulation of the aforementioned recommendations with a few exemptions. For example, in the case of energy, the actual energy expenditure was considered, whereas functional attributes were considered for some vitamins (B-vitamins). These requirements were then adjusted for bioavailability, age, gender and physiological group-specific reference body weight to derive the dietary requirements.
However, as outlined in the preceding section, age-related physiological and sensory changes could potentially compound the requirements in the elderly, and thus, more evidence-based nutrient requirement recommendations need to be derived and adopted. For example, the ICMR (2020) recommendations for energy and VD for the elderly are lower and higher, respectively 35 ( Table II ). These are based on the postulates that the energy requirement will decrease by 100 and 70 Kcal per decade for men and women, respectively, while increased VD was recommended considering the higher need of VD to prevent age-associated osteopenia and high prevalence of VD deficiency among the elderly population in India. Similarly, such an exercise is required for deriving the dietary requirements of other nutrients for the elderly in India.
Alternatively, the other available nutritional requirements for the elderly which are internationally adopted are the Institute of Medicine (IOM; now The National Academy of Medicine) guidelines. The IOM came out with the report on dietary reference intakes in 2006 57 and another one in 2011 58 for people >50 yr of age. These reference intakes were formulated keeping in view the growing public concerns over diet quality of the elderly, and a careful assessment of data on how dietary needs change with ageing, and which nutrients, in particular, are important for the ageing populations, and the challenges faced in consumption of high-quality diets. However, adequate caution should be exercised in adopting these recommendations as these are not context-specific and the age >50 yr does not actually represent the elderly category. Similarly, the European Food Safety Authority (EFSA) has also made recommendations for different age and physiological groups 59 . Although EFSA’s recommendations are more recent, they do not provide any specific recommendations for the elderly.
Way forward
The elderly population in India has increased over four-fold in the last 50 years 5 . Ensuing health span ( i.e . maintaining health and functional capacity) rather than mere lifespan of the elderly needs attention from the point of optimal nutrition. An important step in achieving this is through practicable dietary guidelines based on scientifically developed context-specific nutritional requirements. As we set out the way forward, the following factors need consideration ( Box & Table III ).
Financial support & sponsorship : Author (GBR) was supported by grants from the Indian Council of Medical Research (F.N.5/9/1447/2021-Nutr) and the Department of Biotechnology ((BT/PR36689/PFN/20/1524/2020), New Delhi.
Conflicts of Interest : None.
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How to write a medical research paper for publishing in a high impact journal?
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Why Perform A Meta – Analysis Evidence Based Research?
Publishing a medical research paper in a high impact journal comes with its perks. Firstly, there’s the fame, the recognition by your peers and also among other scientific communities. Then, there are the material benefits; like grants, funds, and sponsorships for your future projects, and job promotions. Then there is also the increase in responsibility owing to the recognition.
But publishing in a high impact journal is not an easy feat. Only less than 10% of all the works submitted get published. It is understood that to get posted the communication is as important as the science part. High impact journals are the ones that get cited the most and vigorously strive to maintain a high standard for their publishing. Various factors go into consideration for work to be published.
The essential considerations for a researcher writing a manuscript for publishing must be the cover letter, conclusion part of their paper, keywords, literature references, abstract, and visual information. An editor will look at this first, sometimes only this before publishing. And the readers view the title and the abstract before deciding to read. Although written after the rest of the paper, the title and the abstract give the readers the first impression of the article.
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Keep the cover letter precise and concise, as this will help the editor note the key points.
Almost all research papers follow a similar general format. The final draft of the document opens with the abstract of the whole paper, followed by the introduction, the literature review, the methodology, research results, discussions, conclusion, reference, and the appendices.
The general rules for medical writing include all the regulatory, academic writing guidelines like sticking to the same tense, providing proper citations depending on the chosen or given style, limiting the use of jargons depending on the target audience. The critical components to get the paper published are the style and the structure.
It is better to start writing the main body of the research at first. This includes the literature review , methodology, results, and discussions. The literature review provides an overview of the existing knowledge and related investigations. The methodology chapter contains all the processes followed in the study and the justifications for choosing the specific method. It provides the reader with knowledge of the research design and approach. The chapter must provide thorough information on the means for another investigator to apply elsewhere.
The research results and discussions chapters go into details of the achievement or the lack thereof, of the research. It explains the thesis proved or disproved. These chapters form the crux of the study. The conclusion reiterates the salient features of the investigation while explaining the significance of it to the field of study.
The benefit of writing introduction and conclusion after the completion of the main body of the paper is that it will be easier to cite from the research. The introduction is written with the reader in mind, for it introduces the study. The chapter provides the context and the background of the research and also hints at the style and structure of the paper. The introduction contains the thesis statement in the middle or at the end.
The abstract is the summary of the paper that doesn’t exceed a page. The references, bibliography, and appendices are provided appropriate to the chosen style.
If you follow high impact journals regularly, you may note that certain authors get published more often than others. This isn’t because the editors favour them, instead the quality of their writing. The paper must explain why what you have done matters than what you have done. After everything is said and done, publishing is still up to the editor and referees and if you think you were rejected unfairly, do write them about it.
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This paper is in the following e-collection/theme issue:
Published on 6.5.2011 in Vol 13 , No 2 (2011) :Apr-Jun
A Smartphone Client-Server Teleradiology System for Primary Diagnosis of Acute Stroke
Authors of this article:
Original Paper
- J Ross Mitchell 1, 2, 3 , PhD ;
- Pranshu Sharma 1 , MD ;
- Jayesh Modi 1 , MD ;
- Mark Simpson 1 , MSc ;
- Monroe Thomas 3 , BSC ;
- Michael D Hill 2 , MD FRCPC ;
- Mayank Goyal 2 , MD FRCPC
1 Imaging Informatics Lab, Department of Radiology, University of Calgary, Calgary, AB, Canada
2 Department of Clinical Neurosciences, Calgary, AB, Canada
3 Calgary Scientific Incorporated, Calgary, AB, Canada
Corresponding Author:
J Ross Mitchell, PhD
Imaging Informatics Laboratory
Department of Radiology
Heritage Medical Research Building, Room 372
3330 Hospital Drive NW
Calgary, AB, T2N 4N1
Phone: 1 403 210 6667
Fax:1 403 210 6667
Email: [email protected]
Background: Recent advances in the treatment of acute ischemic stroke have made rapid acquisition, visualization, and interpretation of images a key factor for positive patient outcomes. We have developed a new teleradiology system based on a client-server architecture that enables rapid access to interactive advanced 2-D and 3-D visualization on a current generation smartphone device (Apple iPhone or iPod Touch, or an Android phone) without requiring patient image data to be stored on the device. Instead, a server loads and renders the patient images, then transmits a rendered frame to the remote device.
Objective: Our objective was to determine if a new smartphone client-server teleradiology system is capable of providing accuracies and interpretation times sufficient for diagnosis of acute stroke.
Methods: This was a retrospective study. We obtained 120 recent consecutive noncontrast computed tomography (NCCT) brain scans and 70 computed tomography angiogram (CTA) head scans from the Calgary Stroke Program database. Scans were read by two neuroradiologists, one on a medical diagnostic workstation and an iPod or iPhone (hereafter referred to as an iOS device) and the other only on an iOS device. NCCT brain scans were evaluated for early signs of infarction, which includes early parenchymal ischemic changes and dense vessel sign, and to exclude acute intraparenchymal hemorrhage and stroke mimics. CTA brain scans were evaluated for any intracranial vessel occlusion. The interpretations made on an iOS device were compared with those made at a workstation. The total interpretation times were recorded for both platforms. Interrater agreement was assessed. True positives, true negatives, false positives, and false negatives were obtained, and sensitivity, specificity, and accuracy of detecting the abnormalities on the iOS device were computed.
Results: The sensitivity, specificity, and accuracy of detecting intraparenchymal hemorrhage were 100% using the iOS device with a perfect interrater agreement (kappa = 1). The sensitivity, specificity, and accuracy of detecting acute parenchymal ischemic change were 94.1%, 100%, and 98.09% respectively for reader 1 and 97.05%, 100%, and 99.04% for reader 2 with nearly perfect interrater agreement (kappa = .8). The sensitivity, specificity, and accuracy of detecting dense vessel sign were 100%, 95.4%, and 96.19% respectively for reader 1 and 72.2%, 100%, and 95.23% for reader 2 using the iOS device with a good interrater agreement (kappa = .69). The sensitivity, specificity, and accuracy of detecting vessel occlusion on CT angiography scans were 94.4%, 100%, and 98.46% respectively for both readers using the iOS device, with perfect interrater agreement (kappa = 1). No significant difference ( P < .05) was noted in the interpretation time between the workstation and iOS device.
Conclusion: The smartphone client-server teleradiology system appears promising and may have the potential to allow urgent management decisions in acute stroke. However, this study was retrospective, involved relatively few patient studies, and only two readers. Generalizing conclusions about its clinical utility, especially in other diagnostic use cases, should not be made until additional studies are performed.
Introduction
Recent advances in the treatment of acute ischemic stroke have made rapid acquisition, visualization, and interpretation of images a key factor for positive patient outcomes. Some teleradiology systems can accelerate image interpretation and reduce treatment delays [ 1 - 3 ]. However, teleradiology systems have three important features that limit their utility for acute stroke diagnosis. First, the systems may require that patient digital imaging and communications in medicine (DICOM) images be transferred to a remote device for viewing before interpretation can begin. Acute stroke imaging exams often contain several hundred megabytes (MB) of data. The delay caused by transmission of the image data may significantly reduce treatment effectiveness. In addition, if there is confidential information in the headers of the DICOM files, then meeting security requirements may cause additional delays and/or restrict the locations where the remote device may be located. Second, the devices used for remote visualization may limit or inconvenience physician mobility. This may result in additional delays while a physician on call travels to the nearest remote visualization device. Third, mobile devices may lack the computational capabilities to perform advanced visualizations that can aid the diagnostic process. In turn, this may prevent mobile devices from achieving functional equivalence to workstation systems and, therefore, make regulatory approval of mobile devices for this purpose more difficult.
Client-server based teleradiology systems have been described in the literature previously [ 4 , 5 ]. However, these are designed primarily to communicate with workstation class devices. There are no reports in the literature of interactive, streaming, client-server systems that can provide sufficient functionality, image quality, and frame rates to a current generation smartphone device to allow for primary diagnosis.
We have developed a new teleradiology system based on a client-server architecture to try to address these limitations. As a remote visualization device, our system can use an Apple (Apple Inc, Cupertino, CA) iPhone, iPod Touch, iPad (hereafter, referred to as iOS device), or a device running Android (Google Inc, Mountain View, CA) version 2.1 or newer equipped with a touch screen. When using our system, DICOM images are not transferred to the remote device. Instead, the server loads and renders the patient DICOM images, then transmits a rendered frame to the remote device. This process can occur within a few seconds and allows a remote physician to view the first frame and begin interpretation quickly. The server can be placed in a secure location, and all transmissions can occur using standard protocols over secure connections. In addition, since a server is performing the rendering, advanced visualization methods not possible on the remote device, such as three-dimensional volume rendering, may be used to generate frames for remote viewing.
Here, we report results from an initial feasibility study to determine if the new system is capable of providing accuracies and interpretation times sufficient for diagnosis of acute stroke from computerized tomography (CT) brain scans viewed using an iOS device.
One hundred and twenty recent consecutive noncontrast computed tomography (NCCT) brain scans and 70 computed tomography angiogram (CTA) head scans were obtained from the Calgary Stroke Program database. The Calgary Stroke Program is recognized as one of the leading programs in North America for stroke treatment and research.
NCCT Brain Scans
NCCT brain scans were obtained using sequential acquisition of data on a 64-row multidetector CT (Somatom Sensation 64, Siemens Healthcare, Germany) from the foramen magnum to the skull vertex using a 5-mm slice thickness. NCCT brain scans were evaluated for early signs of infarction, which includes early parenchymal ischemic changes and dense vessel sign, and to exclude acute intraparenchymal hemorrhage and any stroke mimics, such as tumor, infective/inflammatory disease, or any vascular malformation. Acute parenchymal ischemic changes were graded according to the Alberta Stroke Program Early CT Score (ASPECTS) scoring system [ 6 ]. ASPECTS is a 10-point scale that grades the extent of ischemic change within the territory of the middle cerebral artery.
CTA Head Scans
CTA scans of the head and neck were performed on 64-row multidetector CT (Somatom Sensation 64, Siemens Healthcare, Germany). Data were acquired from the ascending aorta to the skull vertex using a standard spiral acquisition after infusion of 100 ml of nonionic iodinated contrast. Axial slices of 1-mm thickness were obtained from the aortic arch to the skull base, while 0.6-mm axial slices were obtained from the skull base to the skull vertex. All images had a 220-mm field of view and contained 512 x 512 pixels. Reformations with 3-mm slices were performed in the axial, sagittal, and coronal planes for the head region and reviewed on a workstation. For the purpose of this study, only axial CTA head scans were used for interpretation on the iOS device. CTA head scans were evaluated for any intracranial vessel occlusion.
The scans were read by two neuroradiologists. One reader (author PS) interpreted scans first on a workstation located in a radiology reading room equipped with a medical-grade display (hereafter, referred to as the workstation) and then on the iOS device. The second reader (author JM) interpreted scans only on the iOS device. To avoid bias, a delay of 2 weeks was allowed between interpretation on the workstation and interpretation on the iOS device. The readers were blinded to the patients’ clinical data. Furthermore, the patient exams were presented in different orders on the workstation and on the client-server teleradiology system.
The workstation (IMPAX 6.3.1.3815, Agfa Healthcare, Belgium) was connected to a medical-grade 21-inch liquid crystal display (MD21GS-3MP, NEC). This display has a resolution of 2048 x 1536 pixels (pixel pitch = 0.21 mm) and a luminance of 400 (candela) cd/m 2 . All interpretations on the medical workstation were performed in a lighting-controlled (darkened) radiology reading room. All patient imaging exams were then anonymized and loaded on the server to be analyzed on the iOS device. The iOS device used in this study had a 3.5-inch diagonal screen having a resolution of 320 x 480 pixels (pixel pitch = 0.15 mm) and a luminance = 500 cd/m 2 . All interpretations on the iOS device were performed under normal office lighting conditions in a room with overhead florescent light panels.
The time to interpret each exam was recorded by the readers themselves using a digital stopwatch. When using the iOS device, the interpretation time included the time required to launch the application, establish a connection to the server, select the study for interpretation, and perform the interpretation. When using the workstation, the recorded time included the time to select the study and perform the interpretation.
The Server Configuration
The visualization server had a 2.4 gigahertz (GHz) Intel Core 2 Quad Core central processing unit, 8 GB RAM and two NVIDIA GeForce 8800 (512 MB) graphics cards. It ran Red Hat Enterprise Linux 5 (Red Hat Inc, Raleigh, NC) and included the application ResolutionMD Enterprise (Calgary Scientific Inc, Calgary, Canada). ResolutionMD Enterprise (hereafter referred to as the server software) allows interactive 2-D and 3-D visualization of DICOM images on remote displays via secure hypertext transfer protocol (http). Visualization is initiated by a remote user, who connects to a particular uniform resource locator (URL) address on the server using a Web browser. The server will perform different actions depending upon the URL specified. For example, the visualization server might send a small Flash (Adobe Systems Inc, San Jose, California) or Silverlight (Microsoft Inc, Redmond, Washington) client program to the Web browser. This client program is executed by the browser and used to implement the remote user interface and manage communication with the server.
Initially, the user interacts with the client program to choose a DICOM series to visualize. Typically, the DICOM images are resident on a picture archiving and communication system (PACS). The server then loads the series of 2-D DICOM images from the PACS into memory and reformats them into a 3-D volume. It then performs a rendering operation on the 3-D volume to produce a 2-D frame, which is compressed using a lossy joint photographic experts group (JPEG) algorithm and encoded for transmission to the remote client for display. The JPEG standard includes a user definable “quality factor” that varies between 1 and 100, where 100 is the highest possible lossy JPEG encoding quality. In our study, the quality factor was set to 25 during interactive image presentation. During static image presentation, the quality factor was automatically set to 100. The quality factor has a variable effect on the achievable compression ratio for neurological CT images [ 7 ]. Compression ratios were not measured in our studies. However, previous research indicates that for neurological CT scans, a quality factor of 85 produces a compression ratio of 10:1, while a quality factor of 92 produces a compression ratio of 8:1 [ 7 ]. These compression ratios are well within published guidelines that suggest a maximum compression ratio of 12:1 for (static) neurological CT scans [ 8 ].
All quantitative operations (for example, adjusting the image intensity window and level) are performed by the server on the original DICOM data. The results are then transmitted interactively to the remote client, either as a new encoded frame, or as updated textual information. DICOM files are not transmitted to, or stored on, the client. Nevertheless, the server-side rendered image is stored temporarily in client-side volatile random-access memory (RAM) in both JPEG and decompressed image formats. Any confidential patient information (eg, patient name) that has been rendered into the image pixels is thus temporarily present on the client. Some textual attributes from the originating image’s DICOM file may also be temporarily stored in volatile RAM on the client. These attributes may be used as navigational and informational displays within the client user interface. When the user exits the Web browser or moves to a new webpage, the connection to the server is closed, the rendering operation ends, a blank image is displayed on the client, and the volatile RAM on the client is cleared.
The server software provides a number of visualization protocols, including 2-D, 2-D side-by-side, linear and curvilinear multiplanar reformatting, and several 3-D volume rendering modes. At this level, the system has similarities with others that have been described in the literature [ 9 ]. However, unlike previous systems, our server software includes two important novel and proprietary enhancements. The first of these allows more efficient use of available bandwidth. The server software decomposes the sequence of 2-D frames into static and dynamic components. To do this, the server keeps track of the last image sent to the client before compression. When the next image is to be sent, the server compares 8 x 8 blocks within the new image with corresponding blocks of the previous image. Only blocks that contain changes in pixel data between the two images are compressed and transmitted to the client. The second enhancement allows Web-client applications with sophisticated and complex user interfaces. The system provides server- and client-side application program interfaces (APIs) and libraries for maintaining and synchronizing a hierarchical state model between the server and one or more clients, without requiring tight coupling of compatible data types, data structures, and programming languages. Efficiency is achieved by ensuring that the internal state model can be mapped onto the extended markup language (XML), which can be easily manipulated such that only the differences in the state between a client and server are ever transmitted. This allows the application state to be managed efficiently and shared and synchronized simultaneously with multiple clients. In turn, this permits simultaneous collaboration between multiple users across large distances and diverse networks.
This framework also allows a single client application to connect to multiple servers, then observe and manipulate the images and states of those servers. In turn, this allows one to “mix and match” components of multiple server-side applications into a single client-side application.
The Client Configuration
The iOS device (iPod or iPhone) used in our experiments included 8 gigabytes (GB) of flash memory and an operating system version 3.1.2. The Safari Web browser application available on iOS devices is not capable of running Flash or Silverlight programs. Therefore, we developed a custom application for iOS devices to implement a remote user interface and manage communication with the server. This software was written in Objective-C 2.0 using the Xcode 3.0 integrated development environment. Our application was installed on the iOS device used in this experiment using Apple Inc’s ad-hoc distribution method. This process allows one to install and test applications without having them released on Apple Inc’s online iOS device application store. The version of our iOS device application used in these experiments only exposed some of the advanced visualization modes available in the server software. It allowed 2-D and 3-D visualizations, interactive window/level, translation, rotation, and zoom. In 3-D mode, the user could also select from a range of tissue rendering settings.
Once launched, the custom iOS device application initiates communication with a remote server running the server software ( Figure 1 ). Users can use default server addresses provided with the iOS device application, or they can enter and save custom server addresses. The iOS device application then captures user interaction events, communicates these to the server, and manages the sequence of encoded frames for visualization. We set the default server address to point to the server used in our experiments. This eliminated the need for the user to specify an address, thereby reducing the delay before image interpretation. Communication between the visualization server and the iOS device occurred over a secure wireless network (Wi-Fi 802.11g). Communication via https to the server over third generation (3G) cellular networks is also possible on the iOS device 3GS. However, preliminary experimentation suggested that frame rates over 3G cellular networks are insufficient for practical use at this time. Consequently, cellular networks were not tested during this study. An overview of the iOS device system is provided in Figure 1 .
The interpretations on an iOS device were compared to those of a workstation. Readings of reader 1 (author PS) on the workstation were considered ground truth for comparison. Any differences between the iOS device and workstation platforms in detecting stroke mimics or acute intraparenchymal hemorrhage, acute parenchymal ischemic changes, hyperdense vessel sign on NCCT brain scans and intracranial vessel occlusion on CTA brain scans were considered errors. If the difference in APSECTS scoring was more than one, it was considered a discrepancy in reading. Interrater agreement between the readers was assessed by calculating kappa using Stata 10.0 (StataCorp, College Station, Texas, USA). True positives, true negatives, false positives, and false negatives were obtained, and sensitivity, specificity, and accuracy of detecting the abnormalities on the iOS device were computed. The mean interpretation times on the workstation and iOS device were compared.
NCCT Brain Evaluation
Of the 120 NCCT brain scans, poor image quality (from patient motion during scanning) resulted in 8 patient scans being excluded leaving 112 scans for review. There were no stroke mimics identified on the workstation or the iOS device. Thus, none were falsely diagnosed as stroke on the iOS device.
Acute intracranial hemorrhage (ICH) was detected using the workstation in 7 of the 112 patients. The remaining 105 patients were then assessed for early ischemic changes. Both readers correctly diagnosed intracranial hemorrhage in all 7 patients. The sensitivity, specificity, and accuracy of detecting hemorrhage on NCCT brain scans were 100% using the iOS device with perfect interrater agreement (kappa = 1).
Acute parenchymal ischemic changes were seen when using the workstation in 34 of 105 patients. The sensitivity, specificity, and accuracy of detecting acute parenchymal ischemic change ( Figure 2 ) were 94.1%, 100%, and 98.09% respectively for reader 1 and 97.05%, 100%, and 99.04% for reader 2 using the iOS device. There was nearly perfect interrater agreement (kappa = .8) between the readers.
Dense vessel sign was detected in 18 of 105 patients with acute ischemic changes seen on the workstation. There were 4 false positives by reader 1, and 5 false negatives by reader 2 in diagnosing dense vessel sign on the iOS device. The sensitivity, specificity, and accuracy of detecting dense vessel sign ( Figures 2 and 3 ) on NCCT brain scan were 100%, 95.4%, and 96.19% respectively for reader 1 and 72.2%, 100%, and 95.23% for reader 2 using the iOS device. There was good interrater agreement (kappa = .69) between the readers.
The mean time to interpret NCCT exams on the workstation was 2.1 minutes (SD 0.77), while the mean time using the iOS device was 2.7 minutes (SD 0.9) for reader 1 and 2.3 minutes (SD 1.4) for reader 2. These mean times were not statistically significantly different from each other at P > .05. The interpretation time ranged between 1 and 6 minutes on both platforms.
CT Angiogram Evaluation
Of the 70 CTA head scans, patient motion and/or poor contrast opacification of vessels resulted in the exclusion of 5 poor quality CTA exams, leaving 65 exams for our review. Vessel occlusion was detected in 18 of the 65 patients on the workstation.
Both readers correctly diagnosed vessel occlusion ( Figure 4 ) in 17 of 18 patients on the iOS device. However, both readers missed an occlusion of the V4 segment of the vertebral artery using our system. All patients with patent intracranial vessels were correctly diagnosed using our system without any false-positive errors.
The sensitivity, specificity, and accuracy of detecting vessel occlusion on CT angiography scans were 94.4%, 100%, and 98.46% respectively for both readers using the iOS device. There was perfect interrater agreement (kappa = 1) between the readers.
The mean time to interpret CTA exams on the workstation was 3.5 minutes (SD 1.2), while using the iOS device the mean time was 3.63 minutes (SD 1.48) for reader 1 and 3.83 minutes (SD 0.83) for reader 2. These mean times were not statistically significantly different from each other at P > .05. The interpretation time ranged between 1 and 7 minutes on both platforms.
True positives, true negatives, false positives, and false negatives and sensitivity, specificity, and accuracy of detecting the abnormalities on the iOS device by both readers are shown in Tables 1 and 2 .
a True positive on the iOS device
b False positive on the iOS device
c True negative on the iOS device
d False negative on the iOS device
Acute ischemic stroke is the most common form of stroke, and it is also the most treatable. For each minute of acute brain ischemia, 1.9 million neurons are destroyed [ 10 ]. Treatment with thrombolysis is highly time dependent and entirely dependent upon quick imaging to make an inclusive diagnosis. Equally, expertise remains limited. Any method that can reduce the time from image acquisition to expert review and decision is beneficial. It is clear that every 15-minute delay results in a measureable reduction in the probability of good outcome after thrombolysis [ 11 ]. Hence, rapid image visualization by an expert wherever that expert is is a key factor in improving patient outcomes.
We developed a teleradiology system based on a client-server architecture that enables rapid access to radiological images on a current generation smartphone device. Through this system, a physician can securely assess remote imaging wherever a cellular or wireless network is available, which allows urgent management decisions to be made.
It is important to exclude any intracranial hemorrhage, as this is a contraindication to thrombolytic agents. A previous study has shown that acute intracranial hemorrhage is detected with high accuracy and interrater reliability (kappa = .87 - .94) on NCCT brain scans [ 12 ]. In our study, the presence of intraparenchymal hemorrhage was accurately diagnosed with perfect interrater reliability on NCCT brain scans reviewed on an iOS device. Our experience reflects that of Toomey et al [ 13 ], who found a personal digital assistant to be accurate in diagnosing acute intraparenchymal hemorrhage when compared with a workstation.
The extent of early ischemic changes in the parenchyma has been correlated with poorer clinical outcomes and increased risk of hemorrhage [ 14 ]. Previous meta-analysis has shown mean sensitivity of 66% (range 20% - 87%) and mean specificity of 87% (range 56% - 100%) with varying interrater agreement (kappa = .14 - .78) to detect an early infarction sign on NCCT brain scans [ 15 ]. Studies have been published demonstrating good sensitivity and specificity in detecting early ischemic signs using the ASPECTS scoring system [ 16 , 17 ]. ASPECTS is a well-validated scoring system that has good interrater reliability (kappa .71 - .89) [ 6 , 16 ]. In our study, there was high accuracy with nearly perfect interrater agreement (kappa = .8) in detection of early ischemic parenchymal changes on an iOS device. There were no false-positive diagnoses of early ischemic parenchymal changes by either of the readers using our system. Importantly, no large infarcts were missed by either of the readers using our system.
Hyperdense vessel sign on NCCT brain scan is a marker of intraluminal thrombus [ 18 , 19 ]. Studies have shown that hyperdense vessel sign is a highly specific but only moderately sensitive indicator of thromboembolic occlusion [ 18 ] with a wide range of interrater reliability (kappa = .36 - 1.00) [ 15 ]. False-positive hyperdense sign can be seen in calcified atherosclerotic vessel or a high hematocrit [ 20 ]. In this study, there were discrepancies in the detection of dense vessel signs on the iOS and the workstation with average interrater agreement (kappa = .69). There were 4 false positives by reader 1, and 5 false negatives by reader 2 in detecting hyperdense vessel sign on the iOS device. We feel that measuring the density in Hounsfield units and comparing with the opposite side vessel helps reduce false-positive and false-negative diagnoses rather than relying solely on the observed local CT image contrast. The workstation software allowed the reader to analyze and display the CT scan Hounsfield units ( Figure 3 ). The server software does provide functions to analyze Hounsfield units. However, the iOS client software used in this study did not expose this functionality to the user. It was subsequently added to the version licensed by Health Canada.
Diseases that can mimic stroke such as tumors, infection/inflammatory diseases, and functional conditions may be sometimes difficult to distinguish from acute stroke based solely on neurological examinations. In addition, NCCT brain scans may be normal in the presence of acute ischemia if the patient is imaged very early. Thus, an objective method for confirming intracranial vessel occlusions prior to treatment is preferable. CT angiography is rapid and widely available. The location and extent of intracranial thrombus has been shown to predict functional outcome and risk of parenchymal hematoma [ 21 ]. CTA and perfusion studies provides an effective add-on to NCCT brain scans in acute stroke imaging by significantly increasing the sensitivity and reliability of acute infarct and vessel occlusion detection [ 22 ]. In our study, there was high sensitivity, specificity, and accuracy and good interrater agreement to diagnose intracranial occlusion on CTA scans reviewed on an iOS device. One patient with an occlusion of the distal segment of the vertebral artery was identified as normal on an iOS device. This false-negative error may have been avoided if our system allowed the user to view orthogonal and multiplanar reformats of the source data. Once again, the server software does provide functions for orthogonal and multiplanar reformatting. However, the iOS client software used in this study did not expose this functionality to the user. These functions were added to the new version licensed by Health Canada.
Prior to developing our iOS client software, we had a number of concerns about both the iOS device and the client-server architecture that we thought might limit clinical utility. In particular, the iOS device display is (1) much smaller than that of a workstation; (2) has only 320 x 480 pixels—insufficient to display a full 512 x 512 CT scan image; and (3) is not a medical-grade display being used in a lighting-controlled radiology reading room. In addition, we were concerned that our client-server architecture might provide insufficient interactivity for practical use. In practice, we discovered several factors that helped alleviate our concerns. First, in most NCCT brain scans, the patient’s brain does not fill the entire 512 x 512 image array. In addition, readers were able to easily observe all image regions at native resolution through interactive translation, while interactive zoom allowed them to focus in on image areas of interest. Next, when interpreting images, users tend to position the iOS device display much closer to their eyes, which helps compensate, to some degree, for the smaller size of the iOS device display. In addition, the iOS device display has 25% higher pixel density and luminance than those on the medical-grade liquid crystal display (LCD) monitor of the workstation used in these experiments.
There were limitations in our study. In particular, it was a retrospective analysis performed of 173 patients’ brain scans by two neuroradiologists in a research laboratory environment with high-speed network infrastructure. Only 7 of 112 (6%) hemorrhagic strokes occurred among these patients, which would cause the sensitivity of hemorrhagic diagnosis to be high regardless of how the images were interpreted. Consequently, care should be taken when drawing conclusions from our results. In the future, a larger prospective study performed by physicians on-call working under clinical constraints will be required to demonstrate the clinical utility of our system. We would also like to test the potential usefulness of our system for other acute conditions like renal colic, skeletal trauma, and acute coronary disease.
The system should provide practical frame rates over cellular or wireless networks. In our experience, a single visualization server can accommodate 10 or more simultaneous iOS device users and is capable of delivering and displaying up to 14 frames per second on an iOS device connected over a 802.11g Wi-Fi network. The frame rate was enough to provide sufficient interactivity for comfortable use. However, the frame rate on a 3G cellular network was 1 to 4 frames per second, which was insufficient for practical use. We know that fourth generation (4G) cellular networks are now installed in many metropolitan centers. We estimate that the higher bandwidth of these new cellular networks should allow 10 to 15 frames per second to be delivered to smartphones. However, currently only the iPhone 4 and a few Android-based smartphones are capable of utilizing greater network bandwidth.
Our system has been approved as a medical device under device class 2 with Health Canada. It is under review by the US Food and Drug Administration. We suspect that the regulatory agencies will have two major concerns regarding this system: that it has functional equivalence to previously licensed image interpretation platforms and that it does not unduly jeopardize patient confidentiality. Our client-server architecture may help address each of these concerns. First, protection of patient confidentiality is aided by the fact the no DICOM data is stored outside the hospital firewall on the iOS device. Second, since the server performs all rendering operations, it may be possible to expose sufficient workstation-class functionality on the iOS device to demonstrate functional equivalence. For example, the iOS device and other current generation smartphones do not have sufficient computational resources and rapid access memories to perform interactive multiplanar reformatting or advanced 3-D visualization. Yet, these functions may be required by the regulatory agencies to demonstrate functional equivalence to existing interpretation platforms. We are investigating new methods to usefully expose additional advanced visualization capabilities to the remote user on an iOS device and to optimize both server and client performance to enhance interactivity over both Wi-Fi and cellular networks.
In summary, the smartphone client-server teleradiology system appears promising and may have the potential to allow urgent management decisions in acute stroke. However, this study was retrospective, involved relatively few patient studies, and only two readers. Widespread conclusions about its clinical utility, especially in other diagnostic use cases, should not be made until additional studies are performed.
Acknowledgments
J Ross Mitchell is funded by the Alberta Informatics Circle of Research Excellence and by the Alberta Heritage Foundation for Medical Research. Michael D Hill is funded by the Heart and Stroke Foundation of Alberta and the Alberta Heritage Foundation for Medical Research.
Conflicts of Interest
J Ross Mitchell is the co-founder and chief scientist of Calgary Scientific Inc (CSI). Mayank Goyal, Michael Hill, and J Ross Mitchell are shareholders of CSI. Monroe Thomas is the Vice President of Architecture with CSI. The iOS device client software was originally developed by J Ross Mitchell and Mark Simpson as a research platform. The source code was subsequently transferred to CSI. No equity in CSI was involved in this exchange. CSI enhanced and improved the source code to create ResolutionMD Mobile. The value of CSI shares may increase if ResolutionMD Mobile becomes a successful product.
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Abbreviations
Edited by G Eysenbach; submitted 12.01.11; peer-reviewed by H Baloch, J Cafazzo; comments to author 11.02.11; revised version received 01.03.11; accepted 10.03.11; published 06.05.11
©J Ross Mitchell, Pranshu Sharma, Jayesh Modi, Mark Simpson, Monroe Thomas, Michael D. Hill, Mayank Goyal. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 06.05.2011.
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Leading American medical journal continues to omit Black research, reinforcing a legacy of racism in medical knowledge
PhD Candidate, Northeastern University
Assistant Professor of English, Emory University
Associate Professor of English, Northeastern University
Disclosure statement
The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.
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The leading U.S. medical journal, read regularly by doctors of all specialties, systematically ignores an equally reputable and rigorous body of medical research that focuses on Black Americans’ health.
The American Medical Association created a segregated “whites only” environment more than 100 years ago to prohibit Black physicians from joining their ranks. This exclusionary and racist policy prompted the creation in 1895 of the National Medical Association , a professional membership group that supported African American physicians and the patients they served. Today, the NMA represents more than 30,000 medical professionals.
In 2008, the AMA publicly apologized and pledged to right the wrongs that were done through decades of racism within its organization. Yet our research shows that despite that public reckoning 15 years ago, the opinion column of the AMA’s leading medical journal does not reflect the research and editorial contributions by NMA members.
Invisibility in the opinion column of one of the most prominent medical journals in the U.S. is another form of subtle racism that continues to lessen the importance of equitable medical care and health issues for Black and underserved communities.
As rhetoricians and researchers who study scientific communication, we look at the ways scientific writing perpetuates or addresses racial inequity. Our recent study traced how research is referenced by medical professionals and colleagues, known as citations, of flagship journals of the NMA and AMA: the Journal of the National American Association and the Journal of the American Medical Association .
Invisible research
Our research began with a question: Has the AMA’s 2008 apology had any effect on the frequency with which JAMA opinion writers draw on insights and research of JNMA scholars and authors?
We studied opinion columns, also referred to as editorials, precisely because they are useful indicators of current and future research as well as priorities and agendas . The purpose of editorials is to critically analyze and sift through various opinions and evidence. Effective editorials in scientific journals are especially rich forums for debate within the medical community.
Medical publications like JNMA and JAMA do not simply convey knowledge. They also establish professional community values through the topics that are studied and who is credited for ideas related to research. When writers choose to reference or cite another scholar, they are acknowledging and highlighting that expertise.
As such, citations play an important role in the visibility of research. Articles and authors with more citations are more likely to have a greater effect on the scientific community and patient care. Opinion pieces can shape the broader conversation among medical professionals, and citations can widen that circle of communication.
Invisible racism
We traced how frequently JAMA and JNMA opinion writers referenced one another from 2008 to 2021 by reviewing the 117 opinion pieces published in JNMA and 1,425 published in JAMA during this 13-year period. We found that JAMA opinion columns have continued to, in effect, uphold racial bias and segregation by ignoring JNMA findings.
Even when focusing on race, racism and health disparities, topics that JNMA has explored in great detail, JAMA opinion columns did not reference JNMA colleagues or research. Only two JNMA articles were credited and referenced in the 1,425 JAMA opinion pieces that we reviewed.
Editors at JAMA did not respond to our requests for their comments on our analysis.
Racial equity in medicine
The story of the AMA and NMA is not only a reminder of the racist history of medicine. It demonstrates how the expertise of Black professionals and researchers continues to be ignored today. The lack of JNMA citations in JAMA research undercuts the AMA’s own work on racial equity and potentially compromises the quality of medical knowledge published in its journals.
For example, a recent study in the Proceedings of the National Academy of Sciences found that scientists from underrepresented groups innovate, or contribute novel scientific findings, at a higher rate than those from majority groups.
An article published in the weekly medical journal of the Public Library of Science noted that diverse research teams are often more successful in developing new knowledge to help treat women and underrepresented patients with greater precision.
Dissolving systemic bias
One way to intentionally tackle racial bias and segregation in medical knowledge is by deliberately referencing Black researchers and their work. To change this dynamic of racial bias, medical journals must pay attention to how much and how often the Black medical establishment is referenced. Health issues in underserved communities would likely become more visible and achieve greater quality of care in keeping with the AMA’s commitment to social justice .
Journal editors could tell writers and editorial staff to prioritize citation practices. Individual authors might conduct research and evaluate their reading habits to intentionally include research from the Black medical community.
However, this work must go beyond individuals. Undoing decades of collective habits and embedded racism requires collaborations that work across systems, institutions and disciplines.
For example, libraries, databases, and search engines that help researchers find and evaluate medical publications might review today’s research tools. It is hard to contribute to a research conversation if your work is invisible or can’t be found.
Many tools, like impact factors , rank research according to how influential it is. If research begins in a category of less importance, it can be harder for the technology to rank it equitably. JNMA’s work was already marginalized when the tools that rank research were developed.
Thus, search results can hinder efforts of individual authors to work toward equitable citation practices. Black researchers and their research of Black health were excluded from the beginning, and existing systems of sharing knowledge and drawing attention to important studies incorporate that structural racism.
The AMA apology in 2008 and its recent progress on addressing racism in its publication process are promising steps. Influential medical journals serve to inform and shape health care. Who is referenced in these journals matters to the medical establishment, research funders and, ultimately, to the patients that are served by innovations in medicine.
Attention to citation can help reduce systemic bias in medical knowledge to achieve greater fairness in health care and, in the long run, help increase attention and resources that will help solve health issues in underserved communities.
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Leading American medical journal continues to omit Black research, reinforcing a legacy of racism in medical knowledge
The leading U.S. medical journal, read regularly by doctors of all specialties, systematically ignores an equally reputable and rigorous body of medical research that focuses on Black Americans’ health.
The American Medical Association created a segregated “whites only” environment more than 100 years ago to prohibit Black physicians from joining their ranks. This exclusionary and racist policy prompted the creation in 1895 of the National Medical Association , a professional membership group that supported African American physicians and the patients they served. Today, the NMA represents more than 30,000 medical professionals.
In 2008, the AMA publicly apologized and pledged to right the wrongs that were done through decades of racism within its organization. Yet our research shows that despite that public reckoning 15 years ago, the opinion column of the AMA’s leading medical journal does not reflect the research and editorial contributions by NMA members.
Invisibility in the opinion column of one of the most prominent medical journals in the U.S. is another form of subtle racism that continues to lessen the importance of equitable medical care and health issues for Black and underserved communities.
As rhetoricians and researchers who study scientific communication, we look at the ways scientific writing perpetuates or addresses racial inequity. Our recent study traced how research is referenced by medical professionals and colleagues, known as citations, of flagship journals of the NMA and AMA: the Journal of the National American Association and the Journal of the American Medical Association .
Invisible research
Our research began with a question: Has the AMA’s 2008 apology had any effect on the frequency with which JAMA opinion writers draw on insights and research of JNMA scholars and authors?
We studied opinion columns, also referred to as editorials, precisely because they are useful indicators of current and future research as well as priorities and agendas . The purpose of editorials is to critically analyze and sift through various opinions and evidence. Effective editorials in scientific journals are especially rich forums for debate within the medical community.
Medical publications like JNMA and JAMA do not simply convey knowledge. They also establish professional community values through the topics that are studied and who is credited for ideas related to research. When writers choose to reference or cite another scholar, they are acknowledging and highlighting that expertise.
As such, citations play an important role in the visibility of research. Articles and authors with more citations are more likely to have a greater effect on the scientific community and patient care. Opinion pieces can shape the broader conversation among medical professionals, and citations can widen that circle of communication.
Invisible racism
We traced how frequently JAMA and JNMA opinion writers referenced one another from 2008 to 2021 by reviewing the 117 opinion pieces published in JNMA and 1,425 published in JAMA during this 13-year period. We found that JAMA opinion columns have continued to, in effect, uphold racial bias and segregation by ignoring JNMA findings.
Even when focusing on race, racism and health disparities, topics that JNMA has explored in great detail, JAMA opinion columns did not reference JNMA colleagues or research. Only two JNMA articles were credited and referenced in the 1,425 JAMA opinion pieces that we reviewed.
Editors at JAMA did not respond to our requests for their comments on our analysis.
Racial equity in medicine
The story of the AMA and NMA is not only a reminder of the racist history of medicine. It demonstrates how the expertise of Black professionals and researchers continues to be ignored today. The lack of JNMA citations in JAMA research undercuts the AMA’s own work on racial equity and potentially compromises the quality of medical knowledge published in its journals.
For example, a recent study in the Proceedings of the National Academy of Sciences found that scientists from underrepresented groups innovate, or contribute novel scientific findings, at a higher rate than those from majority groups.
An article published in the weekly medical journal of the Public Library of Science noted that diverse research teams are often more successful in developing new knowledge to help treat women and underrepresented patients with greater precision.
Dissolving systemic bias
One way to intentionally tackle racial bias and segregation in medical knowledge is by deliberately referencing Black researchers and their work. To change this dynamic of racial bias, medical journals must pay attention to how much and how often the Black medical establishment is referenced. Health issues in underserved communities would likely become more visible and achieve greater quality of care in keeping with the AMA’s commitment to social justice .
Journal editors could tell writers and editorial staff to prioritize citation practices. Individual authors might conduct research and evaluate their reading habits to intentionally include research from the Black medical community.
However, this work must go beyond individuals. Undoing decades of collective habits and embedded racism requires collaborations that work across systems, institutions and disciplines.
For example, libraries, databases, and search engines that help researchers find and evaluate medical publications might review today’s research tools. It is hard to contribute to a research conversation if your work is invisible or can’t be found.
Many tools, like impact factors , rank research according to how influential it is. If research begins in a category of less importance, it can be harder for the technology to rank it equitably. JNMA’s work was already marginalized when the tools that rank research were developed.
Thus, search results can hinder efforts of individual authors to work toward equitable citation practices. Black researchers and their research of Black health were excluded from the beginning, and existing systems of sharing knowledge and drawing attention to important studies incorporate that structural racism.
The AMA apology in 2008 and its recent progress on addressing racism in its publication process are promising steps. Influential medical journals serve to inform and shape health care. Who is referenced in these journals matters to the medical establishment, research funders and, ultimately, to the patients that are served by innovations in medicine.
Attention to citation can help reduce systemic bias in medical knowledge to achieve greater fairness in health care and, in the long run, help increase attention and resources that will help solve health issues in underserved communities.
This article is republished from The Conversation , an independent nonprofit news site dedicated to sharing ideas from academic experts. The Conversation is trustworthy news from experts, from an independent nonprofit. Try our free newsletters .
It was written by: Cherice Escobar Jones , Northeastern University ; Gwendolynne Reid , Emory University , and Mya Poe , Northeastern University .
Republicans are trying to build a multiracial right – will it work?
Declaring racism a public health crisis brings more attention to solving long-ignored racial gaps in health
The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.
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Treatment of Genital Burns, about A Case
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Perineum and genital burns are infrequent, especially as isolated episodes. The primary objective of perineum burn care is to maintain urine and fecal continence. Cleaning, gentle debridement of loose burnt tissue with gauze, topical antibacterial treatments, and dressing changes are all part of the first therapy for burns on the perineum and genitals. Before attempting acute debridement, burns should be delineated.
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International Journal Of Medical Science And Clinical Research Studies ISSN(print): 2767-8326, ISSN(online): 2767-8342 Perineum and genital burns are infrequent, especially as isolated episodes. The primary objective of perineum burn care is to maintain urine and fecal continence.