Technical Editing part 2

1. Technical Editing part 2 Laura Mellor (John Wiley) Margaret Cooter (BMJ)

2. Workshop aims • To help authors produce reviews in which the conclusions are presented as such and are expressed clearly and succinctly • To help readers to pick out the key points of the review • To help readers pick out the key points of the review quickly and easily

3. Communicating the key message Organise Summarise

4. Plan: workshop 2 • Introduction • Format: thinking about organisation of the information • Exercise: organising the information • Summarising: shortening the text and retaining the key points • Exercise: applying organisational and summarising skills to your review

5. Aims of technical editing • Clarity • Conciseness • Consistency • Accuracy • Balance between needs of the paper and needs of the reader

6. Haynes RB. “Of studies, syntheses, synopses, and systems: the “4S” evolution of services for finding current best evidence.” ACP Journal Club (2001 March-April; 134(2):A11-3.)

7. Haynes RB. “Of studies, syntheses, synopses, and systems: the “4S” evolution of services for finding current best evidence.” ACP Journal Club (2001 March-April; 134(2):A11-3.)

8. Format: organising the information • Introduction • Methods • Results • And Discussion • IMRAD is standard in scientific papers

9. IMRAD • “…not simply an arbitrary publication format, but rather a direct reflection of the process of scientific discovery.” (International Committee of Medical Journal Editors) • IMRAD-practiced readers can easily find the information they need in a scientific paper if the information is in the correct place

10. ELPS electronic long – paper short

11. Do people read papers? • About 80% of BMJ’s readers read the title of a paper • 50% read the abstract • 2-5% (at most) read the whole paper

12. Full version, abridged version • The long paper (full version) goes on the web as soon as it is ready • Canonical version • Indexed in Medline • The short paper (abridged version) goes in the print BMJ – and is posted on bmj.com when the issue is published

13. Long version • Accepted, preprocessed • Usually 2500 words (or so) • But 4000 and 5000 words have been known • Tables and figures – 4-5 is average, but 13 appear sometimes • Web extras • Edited • Proofs to author

14. Position of letters and numbers in filename is interchanged to differentiate long and short versions Keeping track of the versions

15. Who are the elpsers? • Medical editors • Ex-staff • Experience of review process • Technical editors • Know papers inside out • Exercise critical judgment

16. What’s lost in elpsing? • Parts of scholarly introduction • Detailed information on methods • Complicated results that aren’t of help to the non-specialist • Learned and/or speculative discussions (For details see Müllner M. Publishing short articles in the print journal and full articles on the web? The BMJ is doing it with most research papers. European Science Editing 2003;29:6-9.)

17. How short? • Aim for 1500 words, or reduce by at least a third • Reduce the number of tables and figures • But keep scientific integrity

18. Principles of shortening • Take out redundancy (eg context explained in introduction AND discussion) • In Methods, most of the concepts essential for CONSORT and QUOROM can be omitted (eg search terms will appear only in the long version) • Sample size calculations can usually be omitted • Statistical methods are reported in detail only in the long version (which may also have a statistical appendix) • Take out redundancy in discussion (the conclusion section usually repeats the first paragraph) • Unduly large tables go on the web only • Results given in tables can be deleted from text

19. Shortening systematic reviews • References to included studies go in long version, unless certain studies are discussed in the text of the short version • Detailed search terms don’t appear in the short version • Sensitivity analysis and funnel plot information is shortened to a mention that they were done, with details in the long version

20. What stays the same? • Title • Authors’ footnote • Abstract • “Key messages” • What is already known about this topic • What this study adds

21. QUOROM statement: format of systematic reviews

22. Format: Cochrane Reviews

23. Too much information, not enough time • 5000 biomedical articles published every day • How can we get our message to readers who do not have time to read the entire article? • How can we retain IMRAD but increase our impact?

24. The answer? • Be disciplined with IMRAD (ensure the right information is in the right section) • Think about how the information is organised • Consider incorporating elements of news reporting style (most important message first)

25. Some common formats • Chronological order (eg case history) • Inverted pyramid (news triangle) • Statement followed by evidence in support of statement • Evidence first followed by a statement that is supported by the evidence (building a case) • Question and answer

26. Chronological order • Ciprofloxacin was given as primary prophylaxis for spontaneous bacterial peritonitis in a 55 year old woman who had been admitted with alcoholic liver disease. Ten days after admission she went out sunbathing for several hours. Within 48 hours she developed well demarcated erythema over the front of her legs, and large blisters over each knee and the dorsum of her feet. Ciprofloxacin was discontinued, and fluid from the blisters was aspirated under aseptic technique. The erythema gradually dissipated. Phototoxicity has been described for all quinolones, but few cases of ciprofloxacin induced photosensitivity have been reported.

27. News triangle Existing data could be used to better assess NHS performance Until better data are available, a more rigorous analysis of currently collected routine data should be used to assess NHS performance in England. On page 1426, Lakhani and colleagues say that current measures don't adequately reflect improvements in services and outcomes achieved. They propose new indicators that should include improved measure of hospital case fatality, measures reflecting primary care, cancer survival, and comprehensive measurement of managing high blood pressure and stroke.

28. Statement followed by evidence Discussion The addition of a help question to the two screening questions from the Prime-MD questionnaire has a good sensitivity and an excellent specificity for a screening questionnaire for depression. The sensitivity of 79% for the general practitioner diagnosis of depression is an improvement over the 29-35% often reported.15 We previously found about five false positive responses for every true positive response when the two screening questions were asked verbally.19 In our present study this ratio changed from 4.3 to 1.5 when patients responded to either screening question plus the help question. This is much improved and provides a way around the traditional issue of large numbers of false positives in screening studies. Another way of looking at these results is that the likelihood ratio for asking for help today is 17.5, which is high and as such will significantly raise the post-test probabilities above the pretest value.21 In our study this means going from a 5.2% pretest probability of major depression to 48% if patients request help today in response to the help question. Asking a few more questions would confirm or refute the diagnosis of major depression.

29. Building a case Introduction While patients with stable angina have low mortality,1-3 the risk of myocardial infarction and stroke remains substantial and quality of life is often reduced by symptoms. In managing these patients, physicians face complex choices concerning secondary prevention, drugs to treat angina, and indications for coronary angiography and revascularisation.4 Because the absolute benefit of any treatment to improve prognosis depends on the risk of disease events, such risks require consideration, especially if treatment has possible complications. Scoring cardiovascular risk was first developed in Framingham.5 Many studies have followed, mainly for scoring risk in the primary prevention of cardiovascular diseases.6 No similar risk score is available for patients with angina. Development of a risk score requires a large comprehensive database on patients followed for several years. A potential source is data from large randomised clinical trials.7 We used data from the ACTION trial (a coronary disease trial investigating outcome with nifedipine GITS), which followed 7665 patients with stable symptomatic angina for a mean of 4.9 years,3 to develop a score for predicting the combined risk of death from any cause, myocardial infarction, and stroke.

30. Exercise 1: organising the information • Describe the format (eg IMRAD, inverted pyramid) • Where is the message? • Who is the text aimed at (what sort of reader)?

31. Summarising • Shortening the text and retaining the key points • In addition to the review: plain language summary • Within the review: summary of main results in the discussion section of a review

32. Summarising the discussion: guidance Cochrane Handbook: discussion section • “Summarisethe main findings and outstanding uncertainties, balancing important benefits against important harms” QUORUM checklist: discussion section • “Summarise key findings; discuss clinical inferences based on internal and external validity”

33. How? • Cut extraneous text (sifting) • Choose key sentences to retain (cherry picking) • Communicate same information with fewer words (condense)

34. Summarising the discussion: guidance • Find the key sentence and lead with it • “Key sentence” is subjective • What information will be useful to the reader? • Key sentence likely to contain general finding about the effectiveness of the intervention under investigation Example: “Anticoagulants reduced mortality and cardiovascular events compared with control.”

35. Make every word count • Can the information be expressed more succinctly?

36. Before “Whilst there is evidence of benefit from long-term oral anticoagulation in certain groups of patients, oral anticoagulation has been proven to be extremely effective in reducing stroke and other embolic events in patients with atrial fibrillation.” [36 words]

37. After “Oral anticoagulation is effective in reducing stroke and other embolic events in atrial fibrillation patients.” [15 words]

38. Where’s the message? Summaries in the BMJ

39. An example BMJ  2004;329:705 (25 September) Interventions for basal cell carcinoma of the skin: systematic review Fiona Bath-Hextall, Jan Bong, William Perkins, Hywel Williams CD003412

40. Final paragraph of abstract Conclusions Little good quality research has been done on the treatments used for the most common cancer in humans. Most trials have included only people with basal cell carcinoma occurring at low risk sites. Only one trial measured recurrence at four years; recurrence rates at one year should be interpreted with caution. Surgery and radiotherapy seem to be the most effective treatments; surgery showed the lowest failure rates. Other treatments might have some use but need to be compared with surgery.

41. First paragraph of Discussion Discussion Despite the enormous workload associated with the treatment of BCC, very little good quality research has been done on the efficacy of the treatment modalities used. Most studies have been done on low risk BCCs, the results of which are probably not applicable to tumours of the morphoeic type and those occurring in difficult areas such as the nasolabial fold or around the ears and eyes. Specific trials or subgroup analyses are needed for morphoeic tumours. Two trials randomised patients with multiple BCCs, whereas all other trials randomised patients with one BCC. Pooling of data was not possible in many cases, as the trials did not have similar designs, methods, or outcome measures. Operator differences should also be taken into consideration, especially for cryotherapy and photodynamic therapy

42. “Key messages” box What is already known on this topic Basal cell carcinoma of the skin is the most common form of human cancer; many tumours recur years after apparent initial clearance, and most are locally destructive Excisional surgery, curettage and cautery, radiotherapy, cryotherapy, and more recently photodynamic therapy and imiquimod are the main treatments used What this study adds Only one trial included adequate long term data on recurrences of basal cell carcinoma, showing that excisional surgery with frozen section control was more effective than radiotherapy Radiotherapy is associated with significant long term cosmetic defects, and the evidence for curettage and cautery, cryotherapy, photodynamic therapy, and imiquimod is inconclusive Simple long term studies that document site, size, and type of basal cell carcinoma are needed to compare these treatments against excisional surgery

43. Summary at front of journal Basal cell carcinoma should be excised Surgical excision provides the best long term results in people with basal cell carcinoma of the skin. Reviewing 25 randomised trials, Bath-Hextall and colleagues (p 705) found that little good quality research is available on the treatment of this most common cancer. Surgery, which showed the lowest failure rates, and radiotherapy seem to be the most effective treatments, but radiotherapy may cause scarring. Only one trial included adequate long term data on recurrence; most had a follow up period of six months or less.

44. Another way of looking at the skeleton of an article ....

45. Four key sentences • 1st sentence of introduction • Why we did the study • Final sentence of introduction • What we did • First sentence of discussion • What we found • Final sentence of discussion • What it means Based on Tim Albert’s concept of “storyboarding”

46. Exercise 2 • Choose one of the summary formats discussed and practice applying it to your own review • Think about: • the order of the information • the key message(s) to convey to the reader

47. Thank you for your attention lmellor@wiley.co.uk mcooter@bmj.com