Cardiovascular Research 53 (2002) 279–285

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Editorial

Language and publication in Cardiovascular Research articles

a, a b c
R. Coates *, B. Sturgeon , J. Bohannan , E. Pasini
a
Centro Linguistico dell’ Universita` di Brescia, Contrada Santa Chiara, 25100 Brescia, Italy
b
P.G.C.E. L’ Universita` degli Studi di Bergamo, Bergamo, Italy
c
Fondazione ‘ Salvatore Maugeri’, IRCCS Gussago, Italy

Received 15 October 2001; accepted 5 November 2001

Abstract

Background: The acceptance rate of non-mother English tongue authors is generally a lot lower than for native English tongue authors.
Obviously the scientific quality of an article is the principal reason for publication. However, is editorial rejection purely on scientific
grounds? English mother tongue writers publish more than non mother-tongue writers—so are editors discriminating linguistically? We
therefore decided to survey language errors in manuscripts submitted for publication to Cardiovascular Research (CVR). Method: We
surveyed language errors in 120 medical articles which had been submitted for publication in 1999 and 2000. The language ‘error’
categories were divided into three principal groups: grammatical, structural and lexical which were then further sub-divided into key
areas. The articles were corrected without any knowledge of the author’s nationality or the corrections made by other language
researchers. After an initial correction, a sample of the papers were cross-checked to verify reliability. Results: The control groups of US
and UK authors had an almost identical acceptance rate and overall ‘error’ rate indicating that the language categories were objective
categories also for the other nationalities. Although there was not a direct relationship between the acceptance rate and the amount of
language errors, there was a clear indication that badly written articles correlated with a high rejection rate. The US / UK acceptance rate
of 30.4% was higher than for all the other countries. The lowest acceptance rate of 9% (Italian) also had the highest error rate.
Discussion: Many factors could influence the rejection of an article. However, we found clear indications that carelessly written articles
could often have either a direct or subliminal influence on whether a paper was accepted or rejected. On equal scientific merit, a badly
written article will have less chance of being accepted. This is even if the editor involved in rejecting a paper does not necessarily identify
language problems as a motive for rejection. A more detailed look at the types and categories of language errors is needed. Furthermore
we suggest the introduction of standardised guidelines in scientific writing.  2002 Elsevier Science B.V. All rights reserved.

1. Introduction [6–9]. However, an analysis of the influence of language

Various editors of important medical journals [1–3] have
indicated the importance of well-written scientific research.
Today written English research is the principal means of
spreading scientific knowledge. The subject of publication
and the nationality of authors has been touched on in this
journal in the past [4] and physicians whose native
language is not English have additional problems when
presenting work for publication. Publications are available
which look at the problem from a strictly medical approach
to the IMRAD (Introduction, Materials, Results And
Discussion) structure [5] or which give English mother
tongue doctors an outline of how to write medical articles
*Corresponding author.
E-mail address: crobbie@libero.it (R. Coates).
on publication in medical research has, to our knowledge,
not been made.
How can we define an article which is ‘well written’?
Given the large number of non-native English language
physicians this question should be answered in two words:
‘simple’ and ‘clear’. Unfortunately this is exactly the
opposite to how many, even native English users, write
medical research. We therefore decided to analyse the
language problems which could effect the clarity of
medical writing.
In co-operation with Cardiovascular Research, we
analysed 120 IMRAD articles which had been presented
for publication from eight different nationalities. Given
that we were looking for problems which made an article
difficult to understand, we had to consider style as well as
grammatical errors.

0008-6363 / 02 / $ – see front matter  2002 Elsevier Science B.V. All rights reserved.
PII: S0008-6363( 01 )00530-2
280 R. Coates et al. / Cardiovascular Research 53 (2002) 279 – 285
Some authors have indicated general language areas
which could create problems for comprehension [10]. The
problem with style is, however, objectivity; what is
difficult to understand for one editor might be perfectly
acceptable for another. It should be also noted that we give
a strict definition of ‘error’ categories in the Methods
section, and that this definition is limited to this research.
2. Methods
2.1. Grammatical errors
2.1.1. Passives
Different sources [7–9] have indicated that high passive
use makes a text obscure to read and difficult to under-
stand. We agree generally with this statement although it
should be noted that in a medical text which follows an
IMRAD structure there are times when use of the passive
is necessary. Indeed a very clear ratio of passive to active
has been shown for each of the IMRAD sections [11].
Thus, ‘A separate group of animals underwent coronary
artery perfusion . . . ,’ would count as one active use.
‘Coronary artery perfusion was performed on a sepa-
rate group of animals . . . ’ would count as a passive use.
The total number of verbs was then counted and
expressed as a single figure, i.e. passive verbs divided by
active verbs.
Generally once a subject is introduced, it is quite normal
to use the passive. For this reason the Methods section
usually has a high passive to active ratio as one subject is
used throughout, e.g. ‘We studied our patient group over a
six-month period. The group was interviewed at the
beginning of the study and informed consent was obtained
according to guidelines from our ethics department. The
group was sub-divided . . . ’ etc.
Furthermore, we looked at the overall average active to
passive ratio to simplify these ratios. This method was a
little simplistic but gave a clear indication of whenever use
of the passive was more than for an English language
author.
2.1.2. Tense
We simplified our definition of verb tense use as much
as possible using certain US sources [6,7] as the basic
criteria. Day [7] underlined that in a scientific work any
reference to a work which had been previously published,
and therefore accepted by the scientific community, should
be written in the present tense. Any reference to current
research work (i.e. that carried out and described by the
author) should be in the simple past tense (i.e. what the
authors did). With the exception of introducing new
concepts (the present perfect tense) and tables (the simple
present tense) and ‘reporting verbs’ e.g. said, found,
discovered etc. (the simple past tense). This ‘neatly’
simplifies tense use in scientific work, and especially so in
the Discussion section where authors switch back and
forward from his / her current research to published sci-
entific literature.
However, it should be noted that this is a simplification
of possible verb tense use. Indeed, the ‘IMRAD’ structure
is itself a simplification of how medical work could be
presented. Many currently published texts (especially UK
English authors) use a considerably more complex scheme.
2.1.3. General grammar problems
These were all grammatical errors which should have
been eliminated either by mother tongue colleagues or
professional translators before submission to an editor. For
example these included, third person errors, plural errors,
preposition errors, etc.
2.2. Structural errors (syntax)
We again restricted our categories to countable and
objectively verifiable groups.
2.2.1. Long sentences
We came across sentences which were often a paragraph
long or where the original subject was lost by the time the
end of the sentence was reached. For practical reasons we
considered any sentence which had more than one subordi-
nate clause (except for a clearly defined reason, e.g. a list
of procedures in an experiment) in this category.
2.2.2. Word order
By mixing up a simple subject1verb1compliment
structure, very often a sentence became totally incom-
prehensible. We included in this category, split infinitives,
out of place subordinate clauses, etc.
It should be noted that often just one or two confused
sentences could make a complete IMRAD section very
difficult to understand so therefore these categories could
be relatively more important than others.
2.3. Lexical errors (word choice)
2.3.1. Jargon
These were words (or groups of words) which were
unnecessarily obscure or complicated for no apparent
reason. Thus a child would become a ‘paediatric patient’,
experimental mice were ‘sacrificed’ instead of killed etc.
Note that specific medical terminology was very seldom a
problem for any nationality and was not included in this
category. To be sure that the authors of this work
considered the same words as jargon, each word was
written down and agreed as such by consensus. Individual
prepositions, articles etc. were considered in the grammar
category.
2.3.2. Noun misuse
A common specific lexical problem was the use of a
 R. Coates et al. / Cardiovascular Research 53 (2002) 279 – 285 281

Table 1 lexical items which had been considered errors and give a
Publication and average ‘error’ rates third opinion on any of the categories.
Country % Acceptance Overall error rate / article We divided the language categories first into the three
United States 31.8 21.9 principal linguistic areas, i.e. grammatical, structural and
United Kingdom 29 23.1 lexical. We then divided each of these groups into more
France 26.2 43.1 specific areas following indications both of leading editors
Germany 23.6 41.1 Day [7], Zeiger [6], and O’Connor [8], on clarity in
Spain 19.6 37.9
Japan 16.7 36.9 medical texts and our own previous findings (Coates
Sweden 11.6 35 [12,13]). Given that nearly all articles should have already
Italy 9 48.6 been checked for spelling errors, printing errors etc., we
had to define exactly what we considered ‘errors’ to be.
The number of errors per nation can be seen in Table 2.
group of words with a noun when either a verb, adjective The overall error count was deemed to be reliable with a
or adverb would have been clearer and simpler [12]. Thus; standard deviation of 64.2 errors in articles with an
‘a recovery was achieved in a quick way . . . ’ instead of average of 39 errors.
‘being a quick recovery . . . ’ However, the tense category was more difficult to agree
‘we studied the data in a statistical manner . . . ’ instead upon. As stated before, the original criteria for tense errors
of ‘statistically,’ was a simplification to make writing easier. In written
‘we made an analysis of the data . . . ’ instead of English there are numerous different ways of expressing
‘analysing the data . . . ,’ etc. scientific knowledge and especially discussing them. While
Most lexical corrections were not necessarily ‘true some authors were confident with this usage, others
errors’ as such. However, they were often pompous and (notably non-English speakers) were not. Therefore we
unclear thus obscuring the scientific data presented. Many were unable to find a clear definition of when tense use
of these items have been noted by various authors on this constituted an error or not.
subject [6–9]. Used sparingly, many of these words would This was interesting in our control groups (US and UK)
not even be noticed, however in abundance together with as the only relevant difference between the two groups was
other structural and grammatical errors the result could in the tense group (apart from active–passive use). This
confuse the scientific message of an article. One hundred would suggest that US writers prefer the simpler definition
and eighteen articles were surveyed (two were discounted we have already given while British writers were more
for procedural reasons) and the general error counts willing to use more complex forms. We were unable to
together with acceptance percentages were noted (see judge however, whether one form was clearer or ‘better’
Table 1). than the other. However, we did include the data in the
Each article was read twice and the errors in each of the tables as a point of reference.
categories were counted. In the first reading, the passive– The fact that both the error rate and the acceptance rate
active rate was counted and in the second all other errors for the two control groups was very similar would suggest
were counted. The research was ‘blind’ as we had no idea that they did offer a good comparison. Furthermore,
which country the articles came from as all references to although some of these studies were far from perfect, they
country / hospital etc. as well as the title and authors had did represent a standard. Thus the average of the two
been taken out by the editor of CVR. A sample of 10% of control groups (22.5 errors per article) was considered the
the articles were double checked by a second researcher zero point, i.e. what a normal native English speaker would
who had no idea of the error counts of the first. Finally a produce. The average of the other nationalities’ errors
third researcher (a medical doctor) was consulted to check (40.3) was considered the ‘upper error limit’. i.e. more

Table 2
General error frequencies (average no. errors / article)
Nationality Grammar Structure Lexical
Tense General grammar errors Long sentences Word order Noun misuse Jargon
UK 8.3 2.4 1.7 2 4 4.6
US 4.4 2.1 2.3 0.6 6.4 6.1
Sweden 5 8.1 1.1 2.7 9.7 8.4
Japan 3.9 6 2.7 2.6 11.7 7.9
Germany 7.3 6.7 5.5 3.8 10.7 7.1
France 7.9 6 5.6 5.4 14.6 9.4
Spain 7.9 8.8 2.7 2.6 10.1 6.4
Italy 7.9 13.9 2.2 4.3 12.8 7.5
282 R. Coates et al. / Cardiovascular Research 53 (2002) 279 – 285

Table 3
Percentage of articles with low and high ‘error’ rates per nationality
Countries % of articles with fewer than % of articles with more than
control average errors (22.5) total average errors (40.3)
United States 66% 26%
United Kingdom 66% 13%
France 26% 53%
Germany 26% 33%
Spain 0% 27%
Japan 26% 53%
Sweden 40% 40%
Italy 14% 64%

errors than this and language would begin to make an An interesting point was that the British authors used the
article difficult to read as can be seen in Table 3. passive considerably more than the US. This would fit the
general description that the US authors tended to prefer a
simpler style. However, there was no indication that this
3. Results effected the acceptance rate at all. The high passive use by
German authors reflected the high natural passive use in
As might be expected, there was no direct relationship the German language.
between the average number of language errors and the In reality, active–passive use is a much more complex
acceptance rate (see Table 1). However, there was a subject than mere frequency. When a subject is unequivoc-
naturally high difference between the number of articles al, (for example when the subject of an experiment in the
with low error rates (below the control average number of Materials section has been well introduced) passive use is
errors) presented by mother tongue writers and other perfectly acceptable. It is only when an author had
countries. These would represent those articles where different subjects that this created problems for com-
language (hopefully) would have no effect either good or prehension.
bad on the scientific value of a work. Furthermore, there
were considerably more articles with a high error rate 3.1.2. Tense
(above the total average of errors) in countries whose Given the procedural problems in agreeing with the
publication rates were considerably less than the control definition of ‘tense’ errors in scientific work we had to
(see Table 3). The exception to this were the Spanish come to the conclusion that this category was not an
papers who had a small number of both high and low error accurate indicator of problems. We suggest that more
rates. research should be carried out for a clear definition of what
editors expect in this category. Indeed there was no clear
3.1. Grammatical errors difference between the nationalities. Interestingly, the
Japanese and the Swedes had fewer corrections in this
3.1.1. Passive–active ratio group than the control. This probably reflected the use of
This ratio varied greatly both between individual authors simpler constructions used by these authors.
and between national averages. We found that normal
ratios for our controls were as follows (i.e. passive verbs 3.1.3. General grammatical errors
divided by active verbs): Abstract, 0.6; Introduction, 0.7; Given that these errors should have been eliminated
Materials and methods, 2.0; Results, 0.67; Discussion 0.6. before presentation for publication, this category could be
Average passive:active use per nationality can be seen in considered a ‘general sloppiness’ category. Furthermore
Table 4. this category would be almost instantly picked up on by
most referees and editors. It is not therefore surprising that
Table 4
Average passive / active use rate the group with the highest average of this group also had
the highest general error count and the lowest acceptance
Country Average passive / active ratio
rate (Italian authors) (Table 2).
United States 0.58
United Kingdom 0.78
France 0.84
3.2. Structural errors
Germany 0.97
Spain 0.65 Although the smallest group in terms of numbers, the
Japan 0.69 structural category was probably more important in terms
Sweden 0.58 of overall comprehension. Thus only a few long rambling
Italy 0.79
sentences (often as long as a paragraph) would make a
 R. Coates et al. / Cardiovascular Research 53 (2002) 279 – 285
whole article sometimes incomprehensible whereas a
relatively large number of lexical ‘errors’ would often have
no effect on an otherwise well-written article.
3.2.1. Long sentences
These were possibly the single most obvious problem
especially as the controls wrote relatively short sentences.
Indeed, several sentences seemed to try to hide rather than
clarify medical data! The following was a typical example.
‘The soluble form of B2 micro-globulin (B2 m) HLA class
I heavy chain (FHC) consists of three size variants,
namely the intact lipid-soluble 43 kDa heavy chain (A
variant), released through a shedding process; the trun-
cated water soluble 39 kDa heavy chain (B variant),
which lacks the trans-membrane segment and is produced
by an alternative RNA splicing and the 34–36 kDa (C
variant), which lacks the trans-membrane and intratoplas-
matic portion of the molecules.’
Simply breaking such sentences into a number of
smaller ones or using suitable connectors would have made
such sentences considerably easier to understand. German
and French authors had twice the amount of long sentences
than the other nationalities.
3.2.2. Word order
Given the importance of word order in English (with no
agreeing nouns / adjectives, declining verbs etc.), this cate-
gory was very important for simple comprehension. Given
that the word order of the controls was very simple, this
problem was even more evident. The French and Italians
had the highest ‘error’ rate in this category.
Some examples: ‘In all patients, bioptic material was
taken and was studied in the period from December 1999
to May 2000.’
corrected to
‘Bioptic material was taken from all patients in the
period between December 1999 and May 2000. It was then
studied.’
or
‘Brown detected, after LSD-treatment, by in-situ hybrid-
isation, striking regional and cellular differences in the
rabbit spinal cord.’ (Was it Dr. Brown or the rabbits who
had had the LSD treatment?)
corrected to
‘Brown detected striking regional and cellular differ-
ences, by in-situ hybridisation, after LSD treatment in the
rabbit spinal cord.’
3.3. Lexical
3.3.1. Jargon
Numerically this group was the biggest source of
‘errors’ although taken independently many of the words
considered here as being unnecessarily complex could be
perfectly acceptable. However, we took as our criteria the
following points: (1) did the word / s appear in one of the
283
numerous lists of ‘words to avoid’ [6–9] already pub-
lished? (2) Did a simpler word / s exist? (3) Did the word / s
unnecessarily complicate the text? We then sub-divided
these word categories into three groups, (a) confusing
words, (b) unnecessary words, (c) inaccurate words.
For the sake of uniformity, each lexical ‘error’ was
written down independently by the two language special-
ists and further checked by the medical specialist. There-
fore in some of the ‘well-written’ articles (i.e. with fewer
errors than the control mean), we noted these lexical items
in any case to maintain uniformity. In context, many of
these articles could be considered to be without any real
mistakes at all. Many lexical ‘errors’, only really could
become a potential problem for editors when they were
summed with other errors, thus creating a ‘fog of words’.
3.3.2. Noun misuse
We divided this category from the jargon category
because noun misuse was generally very widespread.
This involved using nouns when either a verb, adjective
or adverb would have been simpler, easier to understand
and less pretentious. Furthermore this ‘error’ also mirrored
correct language use in the other languages.
Thus:
‘are in agreement with . . . ’ rather than ‘agree with’ (a noun used instead of a
verb)
‘The care of the patient . . . ’ rather than ‘patient care’ (a noun used instead of
an adjective)
‘in recent years . . . ’ rather than ‘recently’ (a noun used instead of an adverb)
For an indicative list of some examples see Table 5.
4. Discussion
The purpose of this study was not to try to find a direct
correlation between language errors and acceptance rates.
Obviously all papers are accepted or rejected on scientific
merit rather than literary skill. However, we wanted to
pin-point certain language area problems which could
either directly or subliminally effect the possibility of an
otherwise sound medical work being rejected. Summa-
rising the language areas we looked at, we can say the
following.
1. Passive use. Apart from the Materials (patients) section,
the norm in medical articles was to have as high an
active–passive ratio as possible. However, if the subject
is clearly defined then the passive is acceptable.
2. Tense. We were unable to outline an objective tense use
in this study principally due to the different use of tense
by US and UK authors. However, we would prefer the
simplest possible use of tense as outlined by Day [7],
i.e. the past tense to refer to the current work being
described and the present tense to describe other
284 R. Coates et al. / Cardiovascular Research 53 (2002) 279 – 285

Table 5
Lexical categories
Lexical category Sub-type Example Correction
Jargon (a) Confusing word use Paediatric patient Child
Sacrificed Killed
Utilised Used
Advocate Suggest
(b) Inaccurate word use Evidenced Showed
Actually Now
Employed Used
Represents Is
(c) Unnecessary word use Studies in the scientific literature Studies
It could be hypothesised Might
The above mentioned . . . These
Experience a meaningful response Benefit
Until healing occurs Until healed
At variance with Contrasting
Noun misuse (a) instead of adjectives (participles) The termination of Finished
The number was fewer Were fewer
(b) Instead of adverbs In recent years Recently
In a first step Initially
Not in a specific way Not specifically
By optical observation Optically
(c) Instead of a verb Are in agreement with Agree
The necessity of Needed
Is the possibility to Can
For the treatment of To treat
In detecting the presence of On detecting

published work (see exceptions). This does not cover all
potential English use but it does considerably simplify
the task of writing, especially if the author is not
mother-tongue English.
3. General grammar errors. When a research paper is
presented for publication, there should be no general
grammar errors. If there are it means that the work has
not been checked by either mother-tongue colleagues or
professional scientific writers. A computer spell checker
alone is not enough!
4. Long sentences. Avoid sentences with more than one
subordinate clause. Shorter sentences in English denote
a simple style and clearer science.
5. Word order. In English the word order is fundamental
for understanding due to the lack of declensions or
agreeing adjective, nouns etc. Thus a simple word
structure (in simple sentences), i.e. subject1verb1
object would be easier to understand.
6. Jargon. Given that only a relatively small circle of
doctors will be comfortable with the precise vocabulary
of any given specialisation, there is already a lot of
effort required to understand a text without complicat-
ing general language. If a simpler alternative exists, use
it.
7. Noun misuse. Given the formation of many European
languages, the ‘misuse’ of nouns in English was very
common. However, in English these structures tend to
be overly complex if not necessarily an error. The verb
is the strongest means of conveying meaning in En-
glish.
Generally we did not find a direct correlation between
the number of ‘errors’ written and the final acceptance rate
of articles presented for publication to Cardiovascular
Research. There was however a closer relationship be-
tween the number of well-written articles and acceptance
rates. That is, a well-written article would be judged solely
on its scientific merit without any language interference.
The partial exception to this were the Spanish articles
which had no very well written articles although a high
proportion were reasonably written. Thus it would seem
that a well-written medical article was one which had as
little ‘language interference’ as possible, i.e. as simple as
possible.
A large scale, cross reference survey including such data
as study design and data management are needed to
indicate exactly how important language interference is in
medical writing. We suggest that further work is done on
this subject to make these clear to publishing doctors.
Furthermore we would suggest that standardised if not
universal guidelines be made to make both the work of
medical writers and editors easier.
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