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Pamela W. Fried, MBA Getting published depends heavily on starting with a well-designed, well-
Andrew S. Wechsler, MD executed research question that is accurately described, and submitting it to a jour-
nal with an appropriate audience. (J Thorac Cardiovasc Surg 2001;121:S3-7)

ublication of the results of an original scientific article with strong epidemiologic interest may be less
P study entails producing a manuscript with content
that reflects a well-designed, well-executed research
well received if it is sent to a journal in a country where
that particular problem is of little concern.
question. It is a well-written description of the process, There are many journals, and the review process
the results, and the wide implications. Publication also varies greatly from one to another. (The process for The
depends on ones ability to choose the most appropriate Journal of Thoracic and Cardiovascular Surgery is
journalthe one with the best match in emphasis described in greater detail later). You may want to have
between the other articles in the journal and the one colleagues objectively assess your work and provide
being submitted. advice and criticism of its relative importance in rela-
tion to articles generally published in the same field. If
Selecting the appropriate journal your priority is early publication, it is important to
Most investigators are eager to have their work pub- choose a journal with rapid review and publication
lished, and choosing the most appropriate journal for cycles. On the other hand, the work may be of great and
submission is a critical step in the process. Although possibly enduring importance and involve complex
there is no standard approach, the choice of journal in investigations that require rigorous review to ensure
many instances should precede writing the manuscript. universal acceptance of the conclusions made by the
Each journal has a set of instructions for authors con- authors.
cerning the topics suitable for that journal and the types Instructions to authors can pose limitations that influ-
of papers that may be submitted, such as original arti- ence the choice of journal. A complex study with abun-
cles, reviews, and brief communications. Although it dant data and figures simply may not be condensed
seems as if the choice of journal should be last, we enough to meet space limitations. Color photomicro-
believe it should be first. graphs may be critical to understanding the experimen-
The process begins with careful consideration of the tal data but may not be allowed by a particular journal.
subject matter. There must be a match between the The work may be such that it is enhanced by a journal
emphasis of other articles in the journal and the one that allows an electronic link to a website that allows
being submitted. How much does the article emphasize review of a video.
basic science or clinical science? Is the approach taken Prolific authors generate many articles of varying
usually organ specific, tissue specific, system oriented, quality, importance, style, and emphasis over the course
technique driven, observational, or experimental? of their careers. The strength of having many excellent
Who is likely to read the article? Are they whom your peer-reviewed journals is the opportunity for publica-
article is likely to interest? Choose the appropriate spe- tion of a broad range of articles, each ideally matched
cialty and approach to that specialty. Readers of a car- to the particular style and nuance of that journal. Many
diology journal are more likely to be interested in authors have favorite journals to which they direct
results from cohorts of patients than in surgical tech- their best work but use many journals to communi-
nique. Some journals are more focused on a local or cate their experimental methods and findings. Deciding
regional audience than on an international audience. An which journal to use is critical in the strategy for having
a manuscript published.
From MCP Hahnemann University, Philadelphia, Pa.
Read on April 29, 2000, at the Eightieth Annual Meeting of The Writing and assembling the manuscript
American Association for Thoracic Surgery, Toronto, Ontario, Once you have decided where to submit your work, you
need to consider the myriad details that go into writing,
Copyright 2001 by The American Association for Thoracic
Surgery assembling, and sending your manuscript. An extremely
0022-5223/2001 $35.00 + 0 12/0/114493 helpful resource for anyone writing a scientific paper is
doi:10.1067/mtc.2001.114493 the Uniform Requirements for Manuscripts Submitted to
The Journal of Thoracic and
S4 Fried and Wechsler
Cardiovascular Surgery
April 2001

Biomedical Journals (UR)(available online at http:// words should represent the most important aspect of the article, followed by other terms in descending order
or in reprint form (American College of Physicians of importance. The abstract may be structured (not
Customer Service Department, phone 800-523-1546, ext more than 250 words) or unstructured (not more than
2600; fax 215-351-2799). Written initially in 1979 by a 150 words), depending on the type of article and spe-
small group of medical journal editors, UR provides cific journal requirements. The abstract should explain
instructions to authors on how to prepare manuscripts for the objective of the study and what was done, found,
submission to participating medical journals, which now and concluded.
number in the thousands. Editors of participating journals 2. Text. Medical journal articles have the following
do not refuse because of style manuscripts prepared predictable pattern:
according to UR criteria.
Introduction: a description of the general problem
The most recent version of UR covers issues to con-
followed by a statement of the specific problem
sider before submitting a manuscript, such as redun-
and the motivation for the study
dant or duplicate publication, acceptable secondary
Methods: what was done
publication, and protection of patients rights to priva-
Results: what was learned
cy. It provides detailed guidelines for preparation and
Discussion: how the results fit into the larger pic-
submission of manuscripts and statements on the fol-
ture, the limitations of the study, and comments on
lowing issues of relevance to authors and publishers:
what next?
Definition of a peer-reviewed journal
3. Figures. Clear, succinct graphs, charts, pho-
Editorial freedom and integrity
tographs, and drawings can quickly convey the prima-
Conflict of interest
ry findings of research. This is greatly appreciated by
Project-specific industry support for research
busy physicians and scientists. Check with the journal
Corrections, retractions, and expressions of con-
to which you are submitting your article to determine
cern about research findings
the specific technical requirements, especially for on-
line submission. The following are guidelines:
Medical journals and the popular media
Advertising Submit photographic prints, laser-quality prints, or
The role of the correspondence column electronic files. When submitting electronic files,
Competing manuscripts based on the same study use graphics software (eg, Photoshop, Illustrator,
Freehand). Do not use presentation software (eg,
Authors writing an article are responsible for being
PowerPoint, CorelDraw, Harvard Graphics) or
clear, consistent, and correct. Busy readers balk at hav-
word-processing software (Microsoft Word;
ing to wind their way through a maze of complicated
WordPerfect) for illustrations.
prose, inconsistent thoughts, and incorrect analysis.
Avoid direct juxtaposition of patterned bars in bar
Although many pairs of eyes see each manuscript, from
graphs; this can cause a moir, or shimmering,
the journal editor to the copy editor, no one knows the
effect, which is jarring to the reader.
subject matter more intimately than does the author.
Avoid the use of gray filler in bar graphs because
The correctness of the information is the authors
gray does not reproduce well.
Minimize the use of black.
An author preparing a comprehensive manuscript is
Identify figures on the back with a soft pencil (ball-
responsible for the elements in the following summary.
point pens cause indentations on the surface of the
The topics are discussed in depth in the resources list-
photograph that are difficult to hide during repro-
ed in Selected Readings.
duction. Include authors name, the figure number,
1. Title and abstract. Considerable thought should
and the word top.
go into the title and abstract because they provide
Avoid the use of paperclips with photographs.
reviewers and readers with their first impression of a
Paperclips cause surface indentations.
paper. They are the first elements read by reviewers;
they are often the only parts of a manuscript accessible 4. Tables. Tables should be self-explanatory and self-
electronically (via MEDLINE), and they are the first, contained. Textual description should summarize and
and possibly only, elements read by readers. The title highlight table content. Tables can be used to display
should be concise but informative; it can be either a precise numeric values (figures are better for conveying
declarative or an interrogative statement. The initial trends or proportions), to present a large number of
The Journal of Thoracic and Fried and Wechsler S5
Cardiovascular Surgery
Volume 121, Number 4

numeric values in compact form, to summarize infor- Reasonableness of the conclusions

mation, to explain variables, and to present the wording Clarity of the abstract
of survey questions, to name a few options. Length of the article
5. Permission. To avoid breaking copyright laws, the Relevance of the work in general
author needs to obtain permission to reproduce materi- Priority the work should receive for publication
al from a copyrighted source. For example, to repro-
duce a figure, table, or a large amount of text, the writer In some instances the reviewer may recommend pro-
must obtain permission from the original copyright fessional statistical review, raise ethical concerns, or
holder, cite the original source, and include the question duplicate publication by the authors. The
required credit line. An author citing another authors reviewers are particularly sensitive to failure of authors
data or original idea should name the original source. If to disclose relationships with industry or the use of
a copyright holder charges a fee to reproduce the mate- industrial support for investigative work. The author
rial, the author usually is responsible for paying the fee. must make industrial relationships clear in the disclo-
6. References. The author is responsible for the cor- sure form provided.
rectness and completeness of all citations. According to The reviewer recommends acceptance without
UR, references are numbered in order of first mention. change, need for revision with subsequent review, need
The textual reference should be Arabic numbers in for revision without additional review, or rejection. The
parentheses. It is always best to limit references to the reviewer writes comments for transmission to the
most pertinent. An excessive number of references fre- authors and comments for transmission to the editor.
quently leads to a request from the journal editor to cut When all reviews are completed, the editor studies the
entries from and renumber the list, which can be manuscript and the reviews. Consultation with the sub-
tedious. Personal communications should be cited in specialty-specific associate editor frequently is needed.
the text only, not in the list of references, and should A joint decision is reached, and the information is trans-
include the name of the person and the date of the com- mitted to the authors. This process ideally takes about 1
munication. The author should obtain written permis- month. Reality occasionally falls short of the ideal, how-
sion and confirmation of accuracy from the source of ever, given the many conflicting demands on the review-
the personal communication. The sources cited in ers time. If revision is requested, the authors are asked
Selected Readings contain extensive sections on how to to respond within 2 weeks. The process goes on from
cite references. there, resulting in acceptance or rejection. We use mail
and fax for this process. Conversion to a Web-based
The review process electronic method should be complete within the next
Once a manuscript arrives in the editorial office, it year. This eventually will shorten the review period.
begins its journey through peer review. The following Revision is critical and is the greatest source of delay
are the procedures of the Journal of Thoracic and in publication. Providing revised manuscripts to
Cardiovascular Surgery. We believe our process is rig- reviewers and editors while the work is fresh in the
orous, ensures quality, and provides authors with infor- authors mind is of great benefit. Authors should re-
mation that enhances current and future manuscripts. spond in a clearly identifiable manner. The revised
When an article is received, an associate editor manuscript should be marked to show every addition
assigns at least three reviewers known to be experts in and deletion so there is never a need for the reviewer to
the subject of the study. Each reviewer receives the revert to the original manuscript. A cover letter should
entire article, including the text, legends, figures, and address every suggestion the reviewers have made and
tables. The editorial office checks adherence to the identify each change made or defend why a change was
requirements of the journals instructions to authors. not made. Above all, authors should recognize that the
Each reviewer is asked to read the manuscript in detail goal of the reviewer is to enhance the quality of the
and to comment on it paying particular attention to the manuscript and the journal. They should not take
following: reviewers comments personally.
Authors have rights and responsibilities that can aug-
Importance of the hypothesis ment the likelihood of publication of their work.
Reliability of the results Sometimes there is keen competition between inves-
Appropriateness of the methods tigative groups, and reviews may reflect that competi-
Validity of the statistics used tion as much as they do critical assessment of the man-
Relevance of the discussion uscript. An author can influence this process by
The Journal of Thoracic and
S6 Fried and Wechsler
Cardiovascular Surgery
April 2001

suggesting to the editor, at the time of manuscript sub- 2. Nuremberg Code (available online at http://ecco.bsee.swin.
mission, that certain persons not be used as reviewers.
Most editors respect such requests. Authors of work 3. World Medical Association Declaration of Helsinki. Re-
commendations guiding physicians in biomedical research
with a narrow focus may help review by suggesting the
involving human subjects. JAMA 1997;277:925-6 (available
names of several possible reviewers. Editors usually online at
honor such a request for at least one of the reviewers, if
the person is not related to the author. Peer Review
1. Evans AT, McNutt RA, Fletcher SW, Fletcher RH. The charac-
Publication teristics of peer reviewers who produce good-quality reviews. J
Gen Intern Med 1993;8:422-8.
Once a manuscript is written, reviewed, and accepted
2. International Congress on Peer Review in Biomedical Publication
for publication, it is sent to the publisher. The publishers (available online at
responsibility is to copy edit, lay out, print, bind, and home.htm).
mail the journal. The copy editor reads the manuscript 3. Lock S, Smith J. What do peer reviewers do? JAMA 1990;
line for line, editing for grammar, journal-specific style, 263:1341-3.
clarity of language, and completeness. The copy editor 4. Yankauer A. Who are the peer reviewers and how much do they
ensures that the manuscript adheres to the journals review? JAMA 1990;263:1338-40.
instructions and that the author has not forgotten to
Manuscript Preparation
include materials such as tables and figures. The pub- 1. Gopen GD, Swan JA. The science of scientific writing. Am Sci
lisher sends proofs, and usually an order blank for 78;1990:550-8.
reprints, to the author and asks that the materials be 2. Haynes RB, Mulrow CD, Huth EJ, Altman DG, Gardner MJ.
returned in 24 to 48 hours. Some journals send manu- More informative abstracts revisited. Ann Intern Med 1990;
scripts to the publisher as soon as the article is accepted. 113:69-76.
In this case, the manuscript is typeset immediately and 3. Huth EJ. How to write and publish papers in the medical sci-
ences. 2nd ed. Baltimore: Williams & Wilkins; 1990.
placed in a queue for publication. Depending on the
4. Instructions to Authors in the Health Sciences (available online
backlog of articles, publication occurs months after at: Links to websites
the author sees the proofs. An alternative is to assign the that provide instructions to authors for more than 3000 journals
article to a specific issue and typeset the manuscript for in the health and life sciences. All links are to primary sources,
that issue. The article appears in print soon after the that is, to publishers or organizations with editorial responsibili-
ties for the titles.
author returns the proofs.
5. Iverson C, Flanagan A, Fontanarosa PB, Glass RM, Glitman P,
For society journals such as ours, the relationship with Lantz JC, et al, editors. American Medical Association manual of
the publisher can enhance the role and profitability of the style. 9th ed. Baltimore: Williams & Wilkins; 1998.
journal. Because of its extensive resources and distribu- 6. Style Manual Committee, Council of Biology Editors. Scientific
tion networks, the publisher works with the society to style and format: the CBE manual for authors, editors, and pub-
market the journal to new subscribers, to sell advertising, lishers. 6th ed. New York: Cambridge University Press; 1994.
and to develop new initiatives, such as publishing the 7. Tufte ER. The visual display of quantitative information.
Cheshire, CT: Graphics Press; 1983.
journal on line. The publisher also produces reprints,
8. Uniform requirements for manuscripts submitted to biomedical
back issues, bound volumes, and supplements. journals. Ann Intern Med 1997;126:36-47 (available online at
The peer review and publication processes are
designed to ensure the accuracy, reliability, and acces- 9. Welch HG. Preparing manuscripts for submission to medical
sibility of scientific information. Although publication journals: the paper trail. Eff Clin Pract 1999;2:131-7.
of a submitted article is never guaranteed, following the 10. World Association of Medical Editors (available online at Extensive list of references and other
guidelines outlined herein will improve your chances.
websites related to publication issues.

Address for reprints: Pamela W. Fried, Managing Editor, Statistics, Study Design
The Journal of Thoracic and Cardiovascular Surgery, MCP 1. Altman DG, Dore CJ. Randomisation and baseline comparisons
Hahnemann University, 245 North 15th St, Mail Stop 496, in clinical trials. Lancet 1990;335:149-53.
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SELECTED READINGS 3. Begg C, Cho M, Eastwood S, Horton R, Moher D, Olkin I, et al.
Ethical Issues Improving the quality of reporting of randomized controlled tri-
1. Guide for the care and use of laboratory animals. Washington, als: the CONSORT statement. JAMA 1996;276:637-9.
DC: National Academy Press; 1996 (available online at 4. Bland JM, Altman DG. Multiple significance tests: the Bonferroni method. BMJ 1995;310:170.
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5. Braitman LE. Confidence intervals extract clinically useful infor- research: principles and quantitative methods. New York: John
mation from data. Ann Intern Med 1988;108:296-8. Wiley & Sons; 1982.
6. Braitman LE. Confidence intervals assess both clinical signifi- 13. Meinert CL. Clinical trials dictionary: terminology and usage
cance and statistical significance. Ann Intern Med 1991;114: recommendations. Baltimore: Johns Hopkins University; 1996.
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patients. Ann Intern Med 1996;125:406-12. 15. Sackett DL, Haynes RB, Tugwell P. Clinical epidemiology: a
8. Concato J, Feinstein AR, Holford TR. The risk of determining risk basic science for clinical medicine. 2nd ed. Philadelphia:
with multivariable models. Ann Intern Med 1993;118:201-10. Lippincott-Raven: 1991.
9. Everitt BS. The Cambridge dictionary of statistics in the medical 16. Salsburg DS. The religion of statistics as practiced in medical
sciences. Cambridge, UK: Cambridge University Press; 1995. journals. Am Stat 1985;39:220-3.
10. Gardner MJ, Altman DG. Confidence intervals rather than P val- 17. Simon R. Confidence intervals for reporting results of clinical tri-
ues: estimation rather than hypothesis testing. BMJ 1986; als. Ann Intern Med 1986;105:429-35.
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1986;292:810-2. pretation of treatment effects in subgroups of patients in random-
12. Kleinbaum DG, Kupper LL, Morgenstern H. Epidemiologic ized clinical trials. JAMA 1991;266:93-98.