Corso di clinical writing
What to expect today?
Core modules
•
Introduction
•
Correction of abstracts submitted by participants
•
Practical session 2 – Abstract drafting
•
Results drafting
•
Discussion drafting
•
Tables and Figures drafting
•
Peer review and publication
•
Synthetic example – database creation, analysis and
Results drafting
Discussion
What do these findings mean?
Discussion
What do these findings mean?
The answer is in the Discussion.
Discussion vs Results
Remember:
Results and Discussion sections
should appear as written by
two different people!
Discussion
Discussion
Discussion
Nepal's Maoists come out of the jungle, into the mainstream
The New York Times
FRIDAY, JUNE 2, 2006
The rebels are coming out of the bush.
Ten years after waging war from their jungle redoubts in the hills, Nepal's Maoists are tiptoeing out
onto mainstream political turf, raising hopes for an end to the deadly conflict but also clouds of
uncertainty about the country's future.
Maoist cadres are openly organizing meetings in town squares and trolling for "donations" for their
party coffers. Senior leaders, who have spent most of the 10 years underground, are holding news
conferences. A series of rallies across the country is scheduled to culminate with a giant gathering
this Friday in the capital, Katmandu.
For Nepal, the challenge of reintegrating the rebels could not be more important. The country stands
on the brink of historic change and the rebels, in large measure, hold the key to whether it treads the
path of war or peace.
The rebels have already scored important victories. In late April, after three weeks of nationwide
protests, King Gyanendra ceded
Discussion
Dura replica del vicepresidente rossonero ad un articolo de «La
Stampa»
Galliani: «C'era solo il sistema Juve» «Cercano di far passare il concetto secondo cui
il sistema Juve e il sistema Milan fossero la stessa cosa. Non è così»
Corriere della Sera – 2 giugno 2006
VILLASIMIUS (CAGLIARI) - «Cercano di far passare il concetto secondo cui il sistema Juve e il sistema
Milan fossero la stessa cosa. Non è così: c'era solo il sistema Juve, e tutti gli altri erano i danneggiati»: lo
ha detto il vicepresidente rossonero, Adriano Galliani, parlando al workshop del Milan a Villasimius.
TENTATIVO PROVENIENTE DA TORINO - È in atto un «tentativo proveniente da Torino» di coinvolgere il
Milan nel calcioscandalo con l'intento di rendere meno pesante la situazione bianconera: ha spiegato
Galliani, in risposta a un articolo della Stampa di Torino in cui si dà conto della intercettazione di una
telefonata tra il collaboratore del Milan addetto agli arbitri, Leonardo Meani, e il direttore sportivo
dell'Udinese, prima della partita Udinese-Milan, ultima del campionato 2004-2005, che terminò in parità
sull'1-1. L'intercettazione lascerebbe intendere che tra le due società ci sarebbe stato un accordo per
concludere la partita su un risultato di parità.
«Non so di che telefonata si tratti - ha detto Galliani -. È evidente e ovvio, e appare chiaro anche a un
bambino, che è in atto uno scorretto tentativo proveniente da Torino, attraverso anche i suoi quotidiani…
Expanded IMRAD algorithm
Introduction
Background
Limitations of current evidence
Study hypothesis
Methods
Design
Patients
Procedures
Follow-up
End-points
Additional analyses
Statistical analysis
Results
Baseline and procedural data
Early outcomes
Mid-to-long term outcomes
Additional analyses
Discussion
Summary of study findings
Current research context
Implications of the present study
Avenues for further research
Limitations of the present study
Conclusions
Discussion
• Present the principles, relationships, and
generalizations shown by the Results
• Briefly summarize the Results in the first
sentences
• But discuss — not thoroughly recapitulate — the
Results
• Include a beginning, middle, and end
• Write in present tense, active voice─ except for the
findings, which are described in past tense
• Discuss this study only, in light of the others
Discussion
 State the main finding, then discuss how technicalities
might have impacted it
 Interpret the magnitude of the main and any other
findings qualitatively
 Reconcile the finding with those in other articles: a
qualitative mini meta-analysis if you will
 Explain possible mechanisms and confounders
 Devote space to discussion of a finding in proportion to
the certainty of its magnitude
 Introduce no new results!
 Explain any major limitations
Discussion
• Beginning:
• Answer the research question
• Begin with a signal
– We found that
– Blood pressure increased in
patients who …
• Give your conclusions,
based on your results
• Give your strongest result first!
• May use the a), b), c) approach…
Discussion
• Answer the question from the Introduction!
• End of Introduction:
". . . to test whether laparoscopic surgery for colon cancer,
performed by experienced operators, provides equivalent
early and long-term results to those of open surgical
resection"
• Beginning of the Discussion:
"This study, to the best of our knowledge for the first time,
originally demonstrates that laparoscopic surgical resection
of colon cancer, when performed by expert operators, was
associated with non-inferior event-free and overall survival
in comparison to open surgery “
Discussion
• Middle:
• Interpret your results
• Discuss key studies — but only those relevant to
your work
• Compare your work with others’ work
• Present ambiguous results and discrepancies with
others objectively
• Explain unexpected findings
• Describe limitations
• Use subheadings (most of the times helpful)
Discussion
Introduce Points With Your Findings
Example:
“In this study, multivariate analysis revealed that
laparoscopic surgery was an independent
predictor of early hospital discharge…. Levy et al17
reported less striking differences …However, the
retrospective nature of their study and the uneven
distribution of baseline clinical characteristics in
their patient population … could account for the
relatively narrow difference in their results.”
Discussion
• Compare With Earlier Work
Own work first:
“The fact that our study was prospective lends support to the
evidence (1-3) of a causal role of ultrasonic microdissection on
limiting local complications of thyroidectomy…”
• Other’s work first:
“Previous studies on the clinical impact of ultrasonic
microdissection on local complications during and after
thyroidectomy … have reported conflicting and inconclusive
results … Findings of this study further expand previous
knowledge, showing that current state of the art ultrasonic
dissection devices provides indeed major clinical benefits, …
Discussion
Why using a structured format for the
Discussion:
1. Helps organizing your writing
2. Enhances readability
3. Shows off that you follow a
structured approach in everything
you do
Structuring the Discussion
The usual structure of the Discussion is:
1. Brief summary of the study findings (no need for
heading)
2. Current research context (use as heading)
3. Implications of the present study (use as heading)
4. Avenues for further research (use as heading)
5. Limitations of the present study (use as heading)
6. Conclusions (may use as heading)
Discussion – Brief summary of findings
• In the first phrase(s) of the Discussion you
may stress the main findings
• Use plain language
• Target the busy or non-expert reader
• Emphasize the novelty of your data!
(if this applies)
Discussion – Brief summary of findings
Cosgrave et al,
JACC 2006
Discussion – Historical perspective
Nelson et al,
NEJM 2004
Boldness, if you can!
Biondi-Zoccai et al, Eur Heart J 2006
Discussion – Current research context
• Continue (from the Introduction) your
brief review of current research
evidence
• This time, take into account your study
• But keep emphasis on other studies
Discussion – Current research context
Biondi-Zoccai et al, Eur Heart J 2006
Discussion – What this study adds
• Introduce the clinical and research
implications of your study
• Do you want to suggest a change in clinical
practice?
• You can be moderately bold, here
Discussion – What this study adds
Biondi-Zoccai et al, Ital Heart J 2003
Discussion – Avenues for further research
• In this section you may spell out what should
be the target of new research
• This is an important part of the manuscript, if
you feel only a collaborative effort can
achieve your goal
• Remember not to disclose too much
Discussion – Avenues for further research
Biondi-Zoccai et al, Ital Heart J 2003
Discussion - Limitations
• Limitations:
– Show yourself as a critical thinker
– Do not overdo it; otherwise why did you do the
stupid study
– Complete the argument (think it through): many
limitations may be true but they would not explain
the results
– Better to acknowledge a limitation in advance,
than having to address it later because the
referee raised this issue!
Discussion - Limitations
Biondi-Zoccai et al, Ital Heart J 2003
Discussion - Limitations
O’Brien et al,
Ann Intern Med 2006
Discussion - Conclusions
• End:
• Write a strong conclusion
• Begin with a signal
– In summary; In conclusion
• May briefly mention applications,
implications, speculations
• Use present tense except when making
comparisons to previous studies or results
Conclusions
 If the journal has such a section…
 State the main findings and/or applications in plain
language, without being too repetitious
 It must stand alone; therefore…
• cite no references
• refer to no tables or figures.
 Make no substantial new points of discussion
 Avoid generalizations and "should"s that go beyond
your findings
Conclusions
Miccoli et al, AOHNS 2006
Questions?
Take home messages
1. The Discussion is important but
should include a few traps and
distractors for reviewers
2. In most cases, the busy reader will
focus on Abstract, Methods and
Results, and will just have a brief
glance at the Introduction and
Discussion
And now let’s move to Tables & Figures…