How to Write a Patient-Oriented Research Manuscript

How to Write a Patient-Oriented Research Manuscript
A guide for preparing a patient-oriented research manuscript. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:307-15 陳玉昆副教授: 高雄醫學大學口腔病理科 ~2755

Introduction Writing a patient-oriented research paper is a straightforward exercise that translates data into a clear, practical lesson for the clinician. Patients’ data Manuscript 1 Manuscript 2

Introduction Aphorisms guiding manuscript preparation:
● There is no such thing as a paper that is too short ● Write short declarative sentences; they contain more meaning than long convoluted ones ● All studies, no matter how complicated, can be simplified into a 2  2 table

Using your computer monitor as an X-ray viewing box. BJOMFS 2008;46:512-4

Examples of tortured English Tortured English Meaning Excessive interposed adipose tissue Fat Mobility of the leg was present The leg moved In the author’s opinion I think On account of the fact that Because One out of every two Half Surgical procedure Operation Exogenous nutrient elements Food

Superfluous words (in red) Positive action Distinct possibility Active consideration Absolute end In actual fact Personal opinion Real danger Agonising reappraisal Diametrically opposed

● You have, at most, 60 s to get a doctor’s attention, but only 30 s for a surgeon’s ● The purpose of writing a research manuscript is to communicate what you have learned to the reader ● Don’t make the reader guess your study purpose

● It is easier to write when you have something to say ● Avoid passive voice; the use of first person is okay ● You treat patients and do research with subjects ● A good paper is one that you would like to read For example: “The skin was incised” is shorter and clearer than “An incision was made through the skin”. Use simple words: ”do“ is better than ”perform“ or ”carry out

Introduction A manuscript submitted for journal publication is not a thesis. A thesis is an often excessively long-winded document reviewed by a committee, bound, filed in the library, and usually never again seen. A scientific paper should be topically focused with clearly delineated observations and recommendations.

Introduction A patient-oriented research paper has 7 elements:
title, introduction, materials and methods, results, discussion, conclusion, and abstract. The title has to grab the reader. The introduction should be short and focus the reader quickly and efficiently on the goals of the study. The materials and methods section needs to be only as long as necessary to cover the elements of the study.

Introduction A patient-oriented research paper has 7 elements:
title, introduction, materials and methods, results, discussion, conclusion, and abstract. Writing the results section is straightforward, and more so if you do the tables first. The discussion is variable in length, but the structure is formulaic. The conclusion is short. Write the abstract last. ● It may be the only element of your paper the reader reads. ● Given the space constraints, it may be the most challenging aspect of the manuscript to write. ● Word count limitations preclude wasted words.

Elements of a patient-oriented manuscript
Element 1: The title The title should be short and entice the reader to continue to read. A title composed of a declarative sentence or a question, rather than a technically correct but verbose title. e.g., instead of “Mortality in Pharmacologically Treated Older Adults With Diabetes: The Cardiovascular Health Study ” consider “Diabetes Is an Important Risk Factor for Cardiovascular and Other Diseases in Older Adults.” Salivary gland malignancy with divergent differentiation. Is it a teratocarcinosarcoma? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 104: 82-8. Avian Influenza: Should China be alarmed? Yonsei Med J 2007; 48:

Element 1: The title Another example, “Can Gene Expression Predict the Severity of Normal Tissue Damage After Radiation?” instead of “Analysis of Gene Expression Using Gene Sets Discriminates Cancer Patients With and Without Late Radiation Toxicity”. After writing the manuscript and internalizing the study, you will think of multiple, better titles and you can choose the best one.

Element 2: The introduction Purpose: provide enough information to hook the reader. Focused, short, & should be 500 words or less (about half an A4 page). Address the following questions: Why is this clinical problem of interest? What are the deficiencies in the current literature? What is the purpose of this paper? Composed of as few as 2 to 3 paragraphs is able to answer these 3 questions well.

Element 2: The introduction The most important part is the paragraph summarizing the study purpose. The purpose paragraph has 3 elements: (1) A statement of purpose (2) A hypothesis statement (3) Specific-aims statements.

Element 2: The introduction Two different techniques to state the study purpose. Conventional technique: state the purpose literally: The purpose of this study is to measure the efficacy of prophylactic antibiotics in preventing postoperative complications in patients undergoing third molar removal.

Element 2: The introduction Two different techniques to state the study purpose. Alternative approach: in form of a clinical question by using PICO - patient (P), intervention (I), control or comparison (C), & outcome (O). Reformulated as a clinical question: Among patients with impacted third molars (patient sample), does the use of prophylactic antibiotics (intervention of interest), when compared with a placebo control (control group or treatment), reduce the frequency of postoperative infections (outcome of interest)? Case series have the purpose stated in the form of a clinical question, without the C component.

Element 2: The introduction Hypotheses statements can be formal or informal. Formal hypothesis statements: The frequency of postoperative infections in the treatment group equals (or does not equal) the frequency of infections in the control group. This statement implies a 2-tailed test of hypothesis. (2) The frequency of postoperative infections in the treatment group is lower than the frequency of infections in the control group. This statement implies a 1-tailed test of hypothesis.

Element 2: The introduction Hypotheses statements can be formal or informal. Less formal hypothesis statements : There exists a set of 1 or more factors that can be manipulated by the clinician to improve implant survival. (2) Giant cell lesions are vascular tumors and treatment with antiangiogenic products can decrease the risk of recurrence.

Element 2: The introduction Specific aim(s) statement: tell, unambiguously, the reader what you did in the study. Commonly used terms: measure, design, identify, implement, estimate, compare, or identify. Examples of specific aims: ● To measure the length of hospitalization in a sample undergoing orthognathic surgery and identify factors associated with decreased length of stay ● To estimate the 1-year survival rates of implants loaded immediately and of implants loaded in a delayed manner

Element 3: The material and methods section Four major components : (1) study design, (2) sample identification & selection, (3) variables, (4) data analyses. The first sentence unambiguously states the study design, e.g.: the investigators designed and implemented a double-blind, placebo-controlled, randomized clinical trial.

Element 3: The material and methods section Four major components : (1) study design, (2) sample identification & selection, (3) variables, (4) data analyses. Choices of study design (in descending levels of validity)—Randomized clinical trial (multi-institutional or single institutional, double-blind or single-blind, placebo-controlled), cohort (prospective or retrospective), case-control, cross-sectional, case series (prospective or retrospective), & case series or report.

Element 3: The material and methods section Four major components : (1) study design, (2) sample identification & selection, (3) variables, (4) data analyses. The second sentence summarizes the parameters used to select the study sample. Include the population from which the sample is derived and inclusion and exclusion criteria. The study sample was derived from the population of patients who presented to the Department of Oral & Maxillofacial Surgery at the Massachusetts General Hospital for evaluation and management of mandibular fractures between January 1, 1998 & December 31, 2000.

Element 3: The material and methods section Four major components : (1) study design, (2) sample identification & selection, (3) variables, (4) data analyses. Variables can be categorized as predictor, outcome, & other. In most patient-oriented research, the goal is to establish an association/relationship between the predictor (independent) and outcome (dependent) variables. These include exposures, risk or prognostic factors, or treatments of interest, e.g., treatment (active vs. placebo), age (25 years vs. 25 years), implant loading (immediate vs. delayed), or radiation dose (cGy).

Element 3: The material and methods section Four major components : (1) study design, (2) sample identification & selection, (3) variables, (4) data analyses. May be numerous outcomes of interest, but the study should be designed to measure 1 primary outcome of interest, e.g., postoperative inflammatory complication (yes/no), duration of implant survival (months), or development of osteoradionecrosis (yes/no). Clear to the reader which variables are primary and which are secondary outcomes of interest

Element 3: The material and methods section Four major components : (1) study design, (2) sample identification & selection, (3) variables, (4) data analyses. Data collection: information regarding the details of randomization, how the standard and experimental treatments rendered, how subjects are managed, or details of how data are abstracted from charts. Data collection: information regarding methods used to assess intraexaminer and interexaminer variability and standardization of examiners, or processes for data collection or abstraction.

Element 3: The material and methods section Four major components : (1) study design, (2) sample identification & selection, (3) variables, (4) data analyses. Data management: include information regarding who and how data were input and stored, what software was used for data storage and analyses, methods used to assure accurate input (e.g., double-entry techniques or checks for erroneous inputs) and how missing data were managed.

Element 3: The material and methods section Four major components : (1) study design, (2) sample identification & selection, (3) variables, (4) data analyses. Data analyses: a brief description of analytic methods used & specification of level of  error (i.e., P value) Descriptive statistics (mean, frequency, range, standard deviations) were computed for each study variable. Bivariate analyses (e.g., chi-square, t test) were computed to measure the association between any 2 variables of interest (e.g., treatment type and age or treatment type and sex).

Element 4: The results section The easiest way to write the results section is to complete all of the tables first. The text flows naturally from the tables. All studies should include at least 2 tables (Tables I & II): Using descriptive statistics, Tables I & II summarize for the reader the characteristics of the study sample. Unless the sample size too small and the sample’s characteristics are summarized in the text, e.g.: the sample was composed of 3 cases with ages ranging from 10 to 14 and 2 subjects were female.

Element 4: The results section

Element 5: The discussion The most challenging aspect of the preparation of the paper: 4 sections The goal of the first section: limited to a single paragraph - draw the reader’s attention back to the goal of the study. 3 sentences: The first sentence restates the study purpose, the second summarizes the hypothesis, and the third recapitulates the specific aims.

Element 5: The discussion The most challenging aspect of the preparation of the paper: 4 sections The second section summarizes the key results relate to the study purpose or hypothesis. e.g.: The results of this study confirm the hypothesis that antibiotics administered after the surgical procedure are as effective as no antibiotics in preventing postoperative inflammatory complications. The frequency of complications in the antibiotic and no-antibiotic groups were 6.2% & 5.8%, respectively . Based on the results of this study, the post-operative use of oral antibiotics is unwarranted & is associated with an increased risk of undesirable side effects such as nausea, allergic reactions, & unnecessary patient expense.

Element 5: The discussion The most challenging aspect of the preparation of the paper: 4 sections The third section (in lieu of having a literature review in the introduction) summarizes how the results of this study compare to other studies published on the topic. The fourth section summarizes the weaknesses and strengths of the study. Addressing a study weakness and how it was offset or neutralized by a strength, e.g., a study design or analytic method. If the weakness persists, outline how it may affect the reader’s interpretation of the results.

Element 6: The conclusion Summarize the key findings of the study. Similar to an abbreviated second paragraph of the discussion. A brief outline of future research questions that have been raised by the current study.

Conclusions 多閱讀：勤於閱讀自己領域有關之雜誌，累積靈感，了解各雜誌之特色、屬性與狀況 (是否屬SCIE、IF?; 是否缺稿、某類文章是否已數度刊登、不接受病例報告、……) (是區域性或國際性雜誌、審稿時間是否很長、…….) 。多了解：徹底了解自己文章的特色，加以發揮。多嘗試：勇於執筆與投稿，累積經驗 (需熟讀instruction to authors, reference formats, ....)。不畏懼：不害怕失敗(退稿)，鍥而不捨，一而再，再而三。

Conclusions An Aiming Device for an Extraoral Radiographic Technique
J Endod 2007;33:758–60 Case Report/Clinical Techniques An Aiming Device for an Extraoral Radiographic Technique Chia-Hue Chen, Shui-Hui Lin, Hui-Lin Chiu, Yu-Ju Lin, Yuk-Kwan Chen, Li-Min Lin Newman ME, Friedman S. Extraoral radiographic technique: an alternative approach. J Endod 2003;29:419 –21

Conclusions Tuberculosis of the head and neck: a review of 20 cases
Table I. Summary of data relating to the 13 patients with oral tuberculosis in the present study Patient no.a Year of presentation Age at diagnosis Sex Duration of symptoms Location Clinical Impression prior to diagnosis Chest radiograph findings Classification 1 1991 78 M 1.5 months Vestibule, lower, Left Squamous cell carcinoma NA 3 1992 57 1 year Tongue, lateral, right Free Primary 5 1995 44 1 week Buccal & vestibule, Right Active Secondary 6 7 2 months Palate, middle Benign salivary gland tumor 2001 36 2 weeks Buccal, left 8b 2002 54 1 month Vestibule, lower lip, left Chronic ulcer 10b 2005 68 F Retromolar, soft palate, right Ulcerative lesion 11 55 5 days Edentulous ridge, left, lower Ulcer 13 2006 62 3 years Tuberosity, unhealed extraction wound, right 14 15 3 months Lower lip, left ulcer 16 2007 70 3 weeks Edentulous ridge, unhealed extraction wound, left, lower 18 27 Mucocele aPatients have been ordered according to the chronological sequence of presentation during the series; bMultiple involvement; M: Male; F: female; NA: not available

Table II. Summary of data on the seven patients identified with tuberculosis in the neck Patient no. a Presentation time Age at diagnosis Sex Duration of symptoms Location Clinical Impression before diagnosis Chest radiograph findings Classification 2 1992 6 F 4 months Lymph node, submandibular, left Lymphadenopathy NA 4 17 Lymph node, submandibular, right Cellulitis, lymphadenopathy N/A 9 2002 56 M Neck lymph node, unspecified, right Squamous cell carcinoma with neck metastasis Free Primary 12 2006 85 Lymph node, supra-omohyoid, right Squamous cell carcinoma with neck metastasis Old TB, no active lesion Secondary 2007 8 3 months Benign salivary gland tumor 19 7 Lymph node, submental, left Granuloma 20 41 1 month Lymph node, submental, right Mesenchymal tumor aPatients have been ordered according to the chronological sequence of presentation during the series; M: Male; F: female; NA: not available

Table III. Presenting symptoms of patients found to have oral TB in the present study Symptom Number of patients Ulceration 9 Swelling or mass (not lymph node) 5 Cervical lymphadenitis 3 Fever 2 Focal pain Non-healing extraction wound

Introduction (1) Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis, an acid-fast bacillus that is transmitted primarily through the respiratory tract. Tuberculosis is a global health problem with 8 million people infected annually and 3 million people dying from diseases related to TB complications.1,2 The incidence of TB in underdeveloped countries is increasing, and this is thought to be due to associated poor hygiene conditions and the greater prevalence of AIDS.3 In Taiwan in the last five years, there have been approximately 8-10 thousand people identified with pulmonary TB and 6000 people identified with extra- Pulmonary TB each year.4 In addition, people died from TB each year during this five year time period and the disease was ranked as the 13th cause of death in our country.4

Introduction (2) Tuberculosis chiefly affects the pulmonary system but it can also involve extra-pulmonary sites including the head and neck region. Upon reviewing the English-language literature, oral TB has been generally regarded as a rare entity (effecting approximately % of patients with TB).1,5 In this way, this disease rarely features in the differential diagnoses of head and neck lesions. The aim of this study was to retrospectively evaluate the clinical characteristics of head and neck TB lesions in the Oral Pathology Department of a tertiary medical center from 1991 to 2007.

In conclusion, TB of the head and neck may not be as uncommon as previously thought. The correct identification and treatment of head and neck lesions (and particularly wounds that are slow to heal and undiagnosed cervical swellings) cannot be over emphasized.

Comments from the Editors and Reviewers: This is a fairly well-written case series report of patients diagnosed with TB of the head and neck region from 1991 to 2007 in the pathology department of a medical center in Taiwan. The article is timely. The possible association with HIV infection is noted but not explored in the dataset that shows increases in case numbers in the most recent years. The extent to which Taiwan is affected by infections involving MDR TB strains is not discussed; however oral lesions subsided following 4-11 months of TB treatment. Received for publication Feb 21, 2008; returned for revision Oct 14, 2008; accepted for publication Nov 5, 2008.

Conclusions Our recent clinical research papers
1. Hsue SS, Wang WC, Chen CH, Lin CC, Chen YK*, Lin LM. Malignant transformation in patients with potentially malignant oral mucosal disorders: a follow-up study based in a Taiwanese hospital. J Oral Pathol Med 2007;36:25-9. (SCI) 2. Chen CH, Lin SH, Chiu HL, Lin YJ, Chen YK*, Lin LM*. An aiming device for an extraoral radiographic technique. J Endod 2007;33: (SCI) 3. Chen YK, Hsue SS, Lin DC, Wang WC, Chen JY, Lin CC, Lin LM*. An application of virtual microscopy in the teaching of an oral and maxillofacial pathology laboratory course. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105: (SCI) 4. Wang WC, Chen YK*, Lin LM*. Oral care experiences with 181 nasopharyngeal carcinoma patients receiving radiotherapy in a Taiwanese hospital. Auris Nasus Larynx 2008;35: (SCI) 5. Chiu HL, Lin SH, Chen CH, Wang WC, Chen JY, Chen YK*, Lin LM*. Analysis of photostimulable phosphor plate image artifacts in an oral and maxillofacial radiology department. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106: (SCI) 6. Lin CT, Chuang FH, Chen JH, Chen CM, Chen YK. Peripheral odontogenic fibroma in a Taiwan Chinese population: a retrospective analysis. Kaohsiung J Med Sci 2008; 24: (SCI) 7. Wang WC, Chen JY, Chen YK*, Lin LM*. Tuberculosis of the head and neck: a review of 20 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:381-6. 8. Chen JY, Wang WC, Chen YK*, Lin LM. A retrospective study of trauma-associated oral and maxillofacial lesions in a population from southern Taiwan. J Appl Oral Sci 2010; 18: 5-9. (SCI)

Conclusions A few words on ISSN, JCR, SCI (SCIE), ......
（1）ISSN：國際標準期刊號碼即期刊的身份證字號（International Standard Serial Number）（2）Total Cites：該年度被當年資料庫內其他期刊引用的總次數。（3）Impact Factor：出版當年之前兩年該期刊在當年被引用次數總和 ÷ 前兩年該期刊出版文獻之總篇數（例：某刊2006 及2007 年共出版181 篇文章，而在2008年共被引用210 次，則Impact Factor 為210÷181＝1.16，一般而言Impact Factor＞1表引用率頗高）。（4）Immediacy Index：出版當年該期刊在當年被引用次數總和 ÷ 當年該期刊出版文獻之總篇數（例：某刊2008 年共出版89 篇文章，而在2008 年共被引用72 次，則Immediacy Index 為72÷89＝0.809，Immediacy Index＞1 表立即引用率頗高，但需考量期刊之出版頻率可能影響當年之立即引用率）。（5）Cited Half-life 被引用之半生期：以年為單位，顯示由最新出版年回溯十年該期刊被引用之累進次數已達該期刊出版文獻累進總數之50%（在最新出版年之被引用次數低於100 者不被列入，若10年以上其數字仍未達50%，以＞10.0 表示）。 JCR 最常被參考的數據是各學科的期刊點數及排名；是針對期刊本身作整體評估，查詢自己或他人發表的文章被引用的情形，需利用Science Citation Index（SCI）或 Social Sciences Citation Index（SSCI）引用文獻資料庫，而非JCR。

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