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J.R. Jett

Moderator of

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    MS17 - Imaging Developments (ID 34)

    • Event: WCLC 2013
    • Type: Mini Symposia
    • Track: Imaging, Staging & Screening
    • Presentations: 5
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      MS17.0 - N/A - Chair Intro (ID 535)

      • Abstract

      Abstract not provided

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      MS17.1 - Molecular Imaging - Where Are We and Where Is It Going (ID 536)

      T. Akhurst

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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      MS17.2 - Standardized Reporting; Guidelines for Imaging Protocols / Interpretation (ID 537)

      A. Devaraj

      • Abstract
      • Presentation
      • Slides

      Abstract
      The radiology report forms an essential component of any radiological examination, and an accurate radiology report requires two key components: the detection of abnormalities (if any), and subsequently their interpretation. However, for radiology reports to be useful to the clinician and patient, a third crucial factor is successful communication. In the setting of lung cancer reporting, radiologists rely on their perceptive ability to detect nodules or masses, while interpretation requires knowledge and experience of the appearances, staging and behaviour of lung carcinomas. Improvements in both of the factors have been achieved by developments such as the use of computer aided detection software or maximum intensity projections (MIPs), for example, to detect lung cancer; and the use of internationally recognized documents such as the IASLC lung cancer staging classification which aids radiological interpretation. By comparison, the communication of the radiology report has changed little over the years, and it could be argued that efforts to improve lung cancer detection and staging are diminished without satisfactory communication. Standardized reporting (SR) has been advocated as a tool that can improve the communication of radiology reports, and which may also have benefits in the detection and interpretation of radiological abnormalities. This presentation will review the definitions of SR, and examine its purported benefits and disadvantages. Studies investigating the impact of SR will be reviewed. In particular, its relevance to lung cancer imaging will be highlighted. There is no single definition of what a standardized report should look like, but a key principle is that standardized reports (SRs) follow a pre-defined format. At the most basic level this includes the use of brief headings within a report, such as “clinical information” or “impression”, each of which contains free-text. At the other extreme is the mandatory use of a check-list of itemised headings, and the selection from a list of only pre-defined terms (using standardized language) within these headings, rather than free-text. Itemised headings in a CT structured report of a patient with lung cancer might include tumour morphology, tumour location, tri-dimensional measurements, presence or absence of invasion of structures such as pleura or chest wall, the presence or absence of enlarged lymph nodes recorded for all of the nodal stations, and the presence or absence of metastatic disease in each of the body organs. The hypothesized advantages of SR is that it produces: i) reports that are more accurate, ii) reports that are easier to read and understand, and iii) reports from which it is straightforward to retrieve data for research purposes. It has also been suggested that SRs allow radiologists to better convey uncertainties and likelihoods to clinicians. This is standard practice in mammographic reporting, where abnormalities are given a score between 1(negative) and 5 (highly suggestive of malignancy) and could in theory be extrapolated to the description of lung nodules in a clinical or lung cancer screening setting. The main disadvantages of SR that are put forward include its negative impact on workflow and the interpretation process. Additionally, it is suggested that, in fact, free text can better capture the uncertainties within a radiological examination, as often findings cannot be simply categorized into negative or positive. Unlike standardized reporting, the subject of standardized protocols in lung cancer imaging is perhaps less controversial, but no less important. The protocols used for the imaging of lung cancer can have a significant impact on the accurate staging and treatment planning of lung cancer. Furthermore, the successful implementation of future lung cancer screening programmes will require consistent adherence to low-dose CT acquisition protocols. In the staging of patients with lung cancer, protocols such as the routine reconstruction of multi-planar reformats to better identify tumour invasion are becoming widely adopted. Less agreement exists on imaging pathways. For example, the role of routine brain MRI in lung cancer staging or the possible use of contrast-enhanced PET/CT as a “one-stop shop”.

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      MS17.3 - Correlation of PET, CT and MRI with Pathology and Response (ID 538)

      D. Aberle

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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      MS17.4 - Radiotracers in Imaging and Therapy of Thoracic Oncology (ID 539)

      T. Akhurst

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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    O23 - Imaging and Screening (ID 125)

    • Event: WCLC 2013
    • Type: Oral Abstract Session
    • Track: Imaging, Staging & Screening
    • Presentations: 8
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      O23.01 - Volume doubling time measurement of pulmonary nodules: comparison between 2D- and 3D-methods (ID 178)

      D. Morimoto, S. Takashima, B. Jiang, Y. Takahashi, H. Numasaki, Y. Tomita, M. Higashiyama

      • Abstract
      • Presentation
      • Slides

      Background
      Measurement of volume doubling time (VDT) of small pulmonary nodules is clinically useful for discrimination between benign and malignant etiology, because this discrimination capability based only on the initial CT is limited. Recent advancement of CT technology enabled direct 3D measurement of volume of pulmonary nodules using commercially available software and enabled VDT measurement with these data. However, there are only a few reports in which accuracy of the 3D method was assessed with comparing the 3D method with the traditional 2D method. Here, we compared intra- and inter-observer variability (OV) to assess the accuracy of these two methods and compared VDT of pulmonary nodules in 2D-method with those in 3D-method. We also discussed the clinical relevance of our results.

      Methods
      Forty-two pulmonary nodules of 3 cm or smaller (CT type, 11 of ground-glass opacity, 15 of mixed type, and 16 of solid type) of peripheral lung cancer (37 of adenocarcinoma, 4 squamous cell carcinoma, and one small cell carcinoma) in 41 patients (mean age±SD, 67±10 years; 25 men and 16 women) who underwent 16-slice MDCT with 1-mm collimation twice (mean interval, 369 days, range 60-1119 days) before surgical resection during June 2006 and December 2008 were included in this study. Five examiners independently calculated VDT by 2D (nodule diameter measurement) and 3D methods (nodule volume measurement using in-house programmed software) with the use of Schwaltz equation and repeated the measurements one month after. Thus, intra- and inter-OV in VDT for the two methods was compared using 95% confidence intervals (CI) in Blant-Altman plots, and VDT calculated with the two methods was compared in each examiner. In evaluating inter-OV, averaged values of the two measurements in each examiner were used for analysis. A p of less than .05 was considered to be significant.

      Results
      As for inter-OV (n=10), 95% CI (mean±SD in days, 398±123) for 3D method was significantly greater than that (231±87) for 2D method (p=0.005). Regarding intra-OV (n=5), 95% CI (291±199) for 3D method tended to be greater than that (195±36) for 2D method (p=0.388). VDT calculated with 3D method was significantly greater than that calculated with 2D method in all of the 5 examiners (all p of <0.05).

      Conclusion
      Inter-OV in VDT measurement was significantly greater in 3D method than in 2D method and VDT calculated with 3D method was greater than that calculated with 2D method. Therefore, in calculating VDT of pulmonary nodules, the same examiner should evaluate with the same method.

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      O23.02 - Positron emission tomography (PET) in lung cancer screening<br /> - Final results after a 5 year screening programe. (ID 1021)

      H. Ashraf, Z. Saghir, A. Dirksen, J.H. Pedersen, J. Mortensen

      • Abstract
      • Presentation
      • Slides

      Background
      PET is a useful tool in the diagnostic workup of lung cancer. However, its role in lung cancer screening with low dose Computed Tomography (CT), in which small sized nodules are detected, is still to be determined. We present final PET results from the 5 year (2005-2010) randomized Danish Lung Cancer Screening Trial (DLCST).

      Methods
      DLCST participants with indeterminate nodules mostly between 5 and 15 mm were referred for a 3-month rescan. Between the initial scan and the 3-month rescan, participants were also referred for a PET scan. Uptake on PET was categorized as most likely benign or malignant on a scale from I to IV). Receiver operating characteristic (ROC) analyses were used to determine the sensitivity and specificity of PET. Resected nodules and indolent nodules (i.e. stable for at least 2 years) were included, and the latter was categorized as benign. Nodules were only included once in the study, thus repeat PET scans were excluded.

      Results
      A total of 90 nodules were included, 50% men, mean age 67 years (58-79), prevalence of lung cancer was 38% (35/90). Mean follow-up time for benign non-resected nodules was approx. 2.8 years in screening. Clinical follow-up in central digital medical logs was done for all participants in 2013. The sensitivity and specificity of PET was 66% and 91%, respectively, with cut-off points for malignancy at PET>II (i.e. categorized as possibly or probably malignant at PET). The positive predictive value was 82% (23/28) and negative predictive value was 81% (50/62). 12 PET results were false negative, and of these 75% (9/12) were either ground glass nodules or partly solid nodules. Figure 1

      Conclusion
      PET is a valuable tool in lung cancer screening; our results show fair sensitivity and high specificity in a trial with long time follow-up of benign nodules. False negative PET results were found in non-solid nodules. We recommend PET as an integrated part of future lung cancer screening programs.

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      O23.03 - Metabolic Imaging Based Prognostic Model for Predicting Survival of Patients with Stage I Non-Small Cell Lung Cancer (ID 1841)

      S.H. Hyun, J.Y. Choi, J. Kim, Y.M. Shim, K. Lee, B. Kim

      • Abstract
      • Presentation
      • Slides

      Background
      The objective of this study was to develop a pretreatment prognostic model based on metabolic imaging biomarkers that could be used to predict overall survival (OS) in patients with stage I non–small cell lung cancer (NSCLC).

      Methods
      We evaluated 198 patients with pathologic stage I NSCLC who underwent pretreatment FDG PET/CT. Metabolic imaging biomarkers included maximum standardized uptake value (SUVmax), total lesion glycolysis (TLG), and coefficient of variation (COV) for primary tumors. SUV is a semiquantitative index of metabolic activity. TLG is a volumetric measurement of tumor glycolytic activity. COV is an index of tumor uptake heterogeneity. The prognostic significance of clinical variables and imaging biomarkers (age, sex, histologic cell type, tumor size, SUVmax, TLG, COV) was assessed by Cox proportional hazards regression model. Statistically significant clinical variables and imaging biomarkers in the multivariable analysis were used to construct a prognostic model for predicting survival. The predictive accuracy of the prognostic model was evaluated by Harrell's concordance index (C-index).

      Results
      Median follow-up for surviving patients was 7.5 years with a range of 5.2 to 9.9. At the time of analysis, 52 (26.3%) patients had died. Age (HR = 1.05 for 1-year increase, P = 0.007), histologic cell type (HR = 0.54 for adenocarcinoma, P = 0.027), SUVmax (HR = 1.08 for 1-unit increase, P = 0.002), and TLG (HR = 1.23 for a doubling of TLG, P = 0.021) were significantly associated with OS by univariable analysis, whereas only age (HR = 1.07 for 1-year increase, P = 0.005) and SUVmax (HR = 1.04 for 1-unit increase, P = 0.012) were significantly associated with OS by multivariable analysis. The final prognostic model included age as a clinical variable and SUVmax as a metabolic imaging biomarker to predict OS. The predictive performance of the prognostic model for OS was not improved by addition of TLG or COV. The C-index was 0.694 for the final model with age and SUVmax. Kaplan-Meier survival curves stratified by risk score showed high-risk group of patients (n = 58, SUVmax > 12 and age > 60) and low-risk group of patients (n = 48, SUVmax ≤ 12 and age ≤ 60). Figure 1

      Conclusion
      A new prognostic model based on pretreatment metabolic imaging may have potential clinical utility for risk stratification of stage I NSCLC patients.

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      O23.04 - Improved interobserver agreement with PERCIST 1.0, compared to a qualitative method for early response evaluation using FDG-PET/CT in NSCLC (ID 1195)

      J. Fledelius, A.A. Khalil, J. Frokiaer

      • Abstract
      • Presentation
      • Slides

      Background
      During the past decade many studies have used FDG-PET/CT for response evaluation to therapy, both in NSCLC and several other cancer forms. A preferential method for evaluation has not been established as of yet. Two main approaches tend to single out: A visually based model as described by Mc Manus et al in 2003 and semi-quantitative approaches, like the recently proposed PERCIST 1.0 2009, by R. Wahl et al. Few studies have evaluated the interobserver variability when using sequential PET/CT scans for response evaluation, and comparison of qualitative- and semi quantitative approaches are also scarce. The aim of this study is to determine which method will provide the more robust evaluation of response when using FDG-PET/CT, the qualitative approach or the SUV based semi quantitative approach prior to the introduction of routine early response evaluation in NSCLC.

      Methods
      FDG-PET/CT scans at baseline and after 2 cycles of chemotherapy from 35 patients with locally advanced NSCLC were analysed by 8 different readers using two different methods: PERCIST 1.0 and the qualitative McManus approach. Both methods result in allocating patients into one of four response categories. Observers were given short written presentations outlying the criteria for evaluation by the two methods. The observers represent a wide range in experience with PET evaluation, only half had experience in response evaluation in NSCLC, but most were experienced in similar evaluation in lymphoma patients.

      Results
      When using PERCIST 1.0, the agreement between observers in determining the percentage change in SULpeak was “almost perfect” with ICC=0.959 similar ICC values were found looking at SUL peak at baseline and follow up scans. There was strong agreement amongst readers allocating patients to the different response categories with Fleiss kappa of 0.761 (0.714-0.808). In 22 of the 35 patients there was complete agreement. When using the qualitative method (A.M. McManus), agreement was lower, down to moderate agreement, with Fleiss kappa of 0.596 (0.554-0.639). And complete agreement was observed in only 10 of the 25 patients. Using chi squared the difference is statistically significant (p < 0.005). No difference was found between experienced and non-experienced observers.

      Conclusion
      In spite of a wide range of experience among 8 readers receiving minimal introduction to the two methods they were to use, we found rather high kappa values, for both methods compared to its nearest competitor: Size change in CT images, known to be very observer dependent. The more objective, semi-quantitative method showed substantially higher agreement than the more subjective method. We suspect that a more detailed introduction into the methods would have improved the kappa values even further, but believe that our method is more likely to provide an introduction similar to the one you receive when introduced as a new physician at the department. Perhaps then the agreement reflects the long-term agreement.

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      O23.05 - DISCUSSANT (ID 3980)

      S. Leong

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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      O23.06 - Diffusion-weighted magnetic resonance imaging at 3.0-T versus fluorine 18 fluorodeoxyglucose positron emission tomography/computed tomography for detection of pulmonary malignant tumors (ID 88)

      J. Zhang, L. Cui, X. Tang, Y. Zhang, H. Yang, L. Chen, X. Ren, J. Shi, H. Yin

      • Abstract
      • Presentation
      • Slides

      Background
      Emerging evidences suggests that diffusion-weighted magnetic resonance imaging (DW MRI) at 1.5-T could be useful for tumor detection, together with N and M staging in patients with lung cancer, especially non-small cell lung cancer (NSCLC), with accuracy as good as, or even better than, that of FDG PET/CT most recently. This investigation prospectively examined whether DW MRI at 3.0-T might be as useful as FDG PET/CT for detection of pulmonary malignant tumors.

      Methods
      This study was approved by the institutional review board, and written informed consent was obtained from all patients. DW MRI and FDG PET/CT were performed before therapy in 113 patients with pulmonary nodules, including lung cancer, lung metastases, and benign lesions, diagnosed by pathological examination. Apparent diffusion coefficient (ADC), maximal standardized uptake value (SUV~max~), and five-point visual scoring were assessed. Immunohistochemical staining for Ki-67 was performed in 36 patients with lung cancer, and Ki-67 score was evaluated. Receiver operating characteristic (ROC) curve analysis was used to determine feasible threshold values. Diagnostic capabilities for detection of pulmonary malignant tumors were compared with the McNemar test on a per-patient basis, and correlation between malignant degree of lung cancer and ADC or SUV~max~ was analyzed by Spearman rank test.

      Results
      As for diagnostic capability, area under ROC curve (A~z~) for ADC (0.91) were significantly higher than that for SUV~max~ (0.78, P < 0.05), and A~z~ value for DW MRI (0.94) were not significantly different from that for FDG PET/CT (0.92, P > 0.05). For quantitative assessment, specificity and accuracy of ADC (91.7%, 92.9%) proved to be significantly higher than those of SUV~max~ (66.7%, 77.9%, P < 0.05), although sensitivity of ADC (93.5%) was not significantly different from that of SUV~max~ (83.1%, P > 0.05). When feasible threshold values were used to assess qualitatively, sensitivity, specificity, and accuracy of DW MRI (96.1%, 83.3%, 92.0%) were also not significantly different from that of FDG PET/CT (88.3%, 83.3%, 86.7%, P > 0.05). Significant correlation was found between Ki-67 score and ADC (Spearman coefficient r = -0.66, P < 0.05), as well as ADC and SUV~max~ (r = -0.37, P < 0.05). On the contrary, Spearman coefficient was -0.11 between Ki-67 score and SUV~max~ (P > 0.05).

      Conclusion
      In conclusion, quantitative and qualitative assessments for detection of pulmonary malignant tumors obtained with DW MRI at 3.0-T are as useful as, even superior to, those obtained with FDG PET/CT. Furthermore, another significant outcome of this study was that ADC in DW MRI at 3.0-T can also play a role in prediction for malignant degree of lung cancer in particular, but SUV~max~ did not in FDG PET/CT.

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      O23.07 - Comparison of diffusion-weighted magnetic resonance imaging versus<br /> F-18 fluorodeoxyglucose positron emission tomography in the assessment of N2 lymph node metastasis due to non-small cell lung cancer (ID 350)

      E. Yilmaz, A. Akkoclu, A. Gulsen, F. Sever, B. Genc, S. Kalaycioglu, I. Karapolat, A. Onen

      • Abstract
      • Presentation
      • Slides

      Background
      To compare the diagnostic efficacies of diffusion-weighted magnetic resonance imaging (DWI) and F-18 fluorodeoxyglucose positron emission tomography (PET) findings for the preoperative prediction of mediastinal nodal metastasis in stage N2 disease of non–small cell lung cancer (NSCLC).

      Methods
      The study included 68 patients (42 men and 26 women; mean age, 62 years) with a supicious stage N2 due to NSCLC. In all patients, DWI (using a sigle-shot echo-planar sequence with diffusion factor of 0-600 s/mm² at 1.5 Tesla) and PET were performed before surgery. In DWI, a patient was regarded to have stage N2 disease when an ipsilateral mediastinal lymph node showed apparent diffusion coefficent (ADC) value of ≤0.98 s/mm², regardless of nodal size. A node was considered as positive for malignancy, if it showed standardized uptake value (SUV) of 3 or higher by PET. Both DWI and PET images were prospectively evaluated for malignancy on a per-node basis by two observers. Histopathologic results served as the reference standard. N2 disease was decided by using the American Joint Committee on Cancer staging system. The results were compared between the two modalities and statistically significant differences in nodal metastasis between DWI and PET were determined with p<.05 obtained by using the McNemar test or with a generalized estimating equation.

      Results
      Nodes were positive for malignancy in 36 (32%) of 114 nodal stations and 22 (32%) of 68 patients. The N2 staging was correctly diagnosed in 56 (82%) and 52 (76%) patients by DWI and PET (p=.09), respectively. For the depiction of malignant nodes, DWI and PET showed sensitivities of 78% (31 of 40 nodal groups) and 78% (28 of 36), specificities of 93% (69 of 74) and 90% (70 of 78), positive predictive values of 86% (31 of 36) and 78% (28 of 36), negative predictive values of 88% (69 of 78) and 90% (70 of 78) and accuracies of 88% (100 of 104) and 86% (91 of 104), respectively (p=.23, p<.05, p<.01, p=.08, and p=.12). There were nine false-positive interpretations by DWI, compared with eight by PET. Eight false-negative assessments were present on PET images, but only five false-negative results were found in DWI. .Figure 1

      Conclusion
      DWI has a higher specificity for N2 staging of NSCLC compared with PET and has the potential to be a reliable alternative imaging method with an advantage of radiation-free imaging for the preoperative staging of mediastinal lymph nodes in patients with NSCLC.

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      O23.08 - DISCUSSANT (ID 3981)

      M.J. Fulham

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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Author of

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    Y - Young Investigator & First Time Attendee Session (ID 77)

    • Event: WCLC 2013
    • Type: Other Sessions
    • Track: Other Topics
    • Presentations: 1
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      Y.4 - How to Get your Papers Published (ID 645)

      J.R. Jett

      • Abstract
      • Presentation
      • Slides

      Abstract
      HOW TO GET YOUR PAPERS PUBLISHED? James R. Jett, M.D. Professor of Medicine National Jewish Health Denver, Colorado, USA 80206 Scientific writing is not something that comes easily to most of us. I personally struggled with my own publications for the first five years of my academic career. However, I advise young colleagues that they should aim for three to five publications per year. If this is accomplished, then at the end of ten years, you would have 30-50 publications on your curriculum vitae. This would be enough to result in promotion from Assistant Professor to Associate Professor in most institutions. How does one get started with publishing articles? Before starting, I would suggest that you read about publishing scientific articles. An excellent book that covers all aspects of scientific writing is “How to Write and Publish a Scientific Paper” by Robert Day and Barbara Gastel. This book has individual chapters on preparing Abstract, Introduction, Methods, Results, Discussion, and References. This text is an excellent source on “how to do it”. There are also chapters on writing review papers, editorials, book chapters, and writing for the public. Additional chapters address ethics in publication, use and misuse of English, use of abbreviations. Especially useful to authors whose first language is not English is the chapter, “How to Write Science in English as a Foreign Language”. Another good source, available on the internet, is the International Committee of Medical Journal Editors (ICMJE) web site. Just type those initials into your web browser and review the “Uniform Requirements for Manuscript Submitted to Biomedical Journals: Preparing a Manuscript for Submission to a Biomedical Journal.” Major ethical issues include simultaneous submission to two journals, duplicate publication of the same data, plagiarism, and ghost writing. Violation of any of these issues will likely result in significant damage to your reputation and potential punishment by your institution. Violations often result in authors being banned from publishing in journals for several years. It can destroy your academic career. Needless to say, it will make your boss very unhappy! Before you submit a manuscript to any journal, it is mandatory that you review the “Instructions to Authors” for the specific journal. When I was Editor of Journal of Thoracic Oncology, one of the most common reasons for rejection was that authors did not follow the instructions. It is also advisable that you should read several articles, in the journal where you wish to publish, to be sure that you follow a similar style to articles that the journal has published. I also recommend searching for articles on the same topic in the journal for which you are planning the submission. If they have published several articles in the past year or two on this same topic, then you may want to consider a different journal, unless your article contains new and original information. The following are some of the most common reasons for articles to be rejected: Failure to read and follow instructions to authors Poor quality of English Non-structured Abstract Lack of novelty (me too articles) Dataset too small; flawed statistics The title and the abstract are extremely important. Often they are the only part of the article that is read. Readers decide, after reviewing these, if they wish to read the entire article. The words in the title should be carefully chosen. Pay careful attention to syntax. Avoid the temptation to be “too clever” in the title. Titles are used by indexing and abstracting services and help readers find your article in the morass of the medical literature. Write the abstract last. It should be a condensed version of the manuscript. Readers look at the abstract to see if they wish to read more. Sometimes an editor will read only the abstract and make a decision on rejection. I have done this many times. A poor abstract frequently means a poor manuscript. Most journals have a word limit for the abstract, frequently 250 words or fewer, and require a four-part structured abstract. Make sure that all of the numbers in the abstract match the numbers in the results section. This is a common error and reflects poorly on the author. Be concise! Remember that the abstract is your chance to get the attention of the reader (reviewer). Lastly, do not let a rejection discourage you. Pay careful attention to the critique that you have received and consider revising your article accordingly. Remember that the “peer review” process is not perfect. Reviewers can make mistakes and not recognize the merits of your manuscript. Revise your manuscript and send it to another journal. The majority of my own peer-reviewed publications were not accepted in the first journal where they were submitted. I have personally been rejected by many of the best medical journals. Do not take rejection personally. Try, try again!!!

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