How to improve your prospects of having your paper published in one of the top respiratory journals
Authoring Medical Abstracts
At the 11th Congress of the Asian Pacific Society of Respirology in Kyoto, Japan, a special symposium was held entitled Creating An Academic Career in Respiratory Medicine. It was presented by the editors-in-chief of four major respiratory journals. Two of the presentations focused on good practice and writing style for authors of medical abstracts.
Presentation 1: Factors Negatively Affecting Papers Being Accepted for Publication
Klaus F. Rabe, MD, PhD.
Editor in Chief, European Respiratory Journal
Professor, Department of Pulmonology, Leiden University Medical Center, Leiden, Netherlands
The European Respiratory Journal, like all reputable journals in the field, publishes original research covering a broad range of topics. The categories include clinical trials, case presentations, basic research papers and state of the art reviews. The peer review process involves the two chief editors, the editorial board, the reviewers and the technical editing. At regular meetings the editors encourage their section editors to formulate their publication plans in their field and to propose series and review articles. Furthermore, the board critically assesses the volume of material published with respect to quality, citations, and the journal's performance. The overall policy for the board obviously is one of positive selection on quality of papers rather than adhering to a pre-specified technical target.
Papers are uploaded electronically and further processing depends on the completeness of the submitted material, including author's statements on interest(1). Upon arrival in the editorial office all papers are assessed by the chief editors before papers are forwarded to associates. At this stage, the scope of the journal, novelty, methodological concerns and presentation of the manuscript are assessed and results in a chief editor's priority rating and thereby rejection of a proportion of papers. Manuscripts which are forwarded to the associates will usually be seen by at least two outside reviewers. Their recommendations together with the assessment of the respective associate editor are the basis of the final decision as to acceptance or rejection of a research paper in the ERJ, and this process is similar to almost all journals in biomedical science.
The reviewing process obviously aims to be as objective as possible but the selection of reviewers may sometimes be governed by factors of availability and/or collegiate relations. Since this process may introduce some form of variability it is the editors who in the end have to decide. Clearly, for original research papers there are well defined factors that will result into rejection, including inaccurate or inadequate description of material and methods, concerns about the sample size and methodological concerns regarding the statistical analysis. It is probably under-recognised that authors play a major role in the decision whether or not to publish a trial in the first place. One of the known driving factors of authors for submission is the significance of their results(2,3).
Furthermore, it appears that negative study data from clinical trials are more frequently found on the website of the respective sponsors than being submitted for peer review. In summary, there are accepted criteria that will determine the acceptability of a paper for publication in a journal but there are also strategic considerations such as the scope of the journal, and the perceived standards that can result in negative editorial decisions and which are sometimes more difficult to quantify. Eventually, a scientific journal is not just meant to handle manuscripts but needs to develop an editorial priority and "flavour" and thereby actively contributing to developments in the field. Responsible editorial policy requires at least an acceptable explanation why an editor came to a negative decision and these criteria may also vary between different publication categories. It should be borne in mind however, that authors themselves are a major factor in preventing papers to be accepted for publication since a recent study concluded that only 6 of 124 not published studies were rejected for publication by a journal(3).
1. Sterk PJ, Rabe KF. Serving researchers, the impact factor and other conflicts of interest. Eur Respir J 2005;25:3-5.
2. Hartling L, Craig WR, Russel K, Stevens K, Klassen TP. Factors influencing the publication of randomized controlled trials in child health research. Arch Pediatr Adolesc Med 2004;158:983-987.
3. Dickersin K, Min Y-I, Meinert CL. Factors influencing publication of research results. Follow-up of applications submitted to two institutional review boards. JAMA 1992;267:374-378.
Presentation 2: Factors Positively Affecting Acceptance of an Original Research Paper
Edward Abraham, MD
Editor in Chief, American Journal of Respiratory and Critical Care Medicine
Professor and Chair, Department of Medicine, University of Alabama at Birmingham, Birmingham, USA
General factors that enhance the likelihood that a manuscript will be accepted include the novelty of the data presented, the clarity of presentation, mechanistic insights, and general interest of the subject studied. The importance of each of these factors will depend on the focus of the journal selected for publication. In terms of the American Journal of Respiratory and Critical Care Medicine (AJRCCM), information that is linked to pulmonary pathophysiology and that relates directly to human disease or results from a relevant animal model of disease will receive a higher priority and be more likely to be viewed positively by the reviewers and the editors.
In addition to these fundamental concerns about the importance of the results, the presentation of the data plays a central role in the likelihood of a paper being accepted. A well written abstract that clearly summarizes the findings of the study, an introduction that provides a rationale for the studies, useful figures and tables in the Results section, and a Discussion that puts the findings into perspective, particularly with reference to previously published information, all will enhance the chances of the paper being accepted. The writing style should be clear and declarative.
The group sizes should be adequate to achieve statistical significance, where relevant. At the present time the AJRCCM only accepts about 20% of submitted manuscripts, meaning that even papers that receive positive reviews are frequently not selected for publication, based on priority reasons. Enhanced priority for publication is dependent on the novelty and importance of the results and the appeal of the subject matter to the broad, multidisciplinary readership of the journal. Decisions made on similar priority concerns are made at other high impact journals.
Presentation 3: Recent Changes in the Form and Substance of CHEST
Richard S. Irwin, MD, FCCP
Editor in Chief, CHEST
Professor of Medicine and Chief, Pulmonary, Allergy, and Critical Care Medicine, U Mass Medical School / U Mass Memorial Health Care, Worcester, USA
The recent changes in the form and substance of CHEST evolved from a systematic process that began with the change in editorial stewardship on July 1, 2005 and a commitment on the part of the new steward to: improve the quality of research and scholarly works and educational offerings published in CHEST that will advance our field while preserving what the readers of CHEST expect and need. CHEST is above all else an interdisciplinary clinical journal with a very important educational mission.
The evolutional process included focused conversations with many, surveys of our readership, and a strategic planning meeting with a newly established interdisciplinary, multinational, advisory group of associate editors. From this, decisions were made to 1) more sharply focus the content of cardiovascular subject matter to cardiovascular relationships as they relate to pulmonary, critical care, and sleep; 2) have CHEST become more reflective of contemporary societal issues and the practice of medicine; 3) enhance the subject matter published in print and online to make CHEST easier and faster to read and access; 4) revise the blueprint of CHEST; 5) publish as quickly as possible the large backlog of accepted manuscripts; and 6) appoint an outstanding editorial board with superior credentials and reviewing skills, and well defined reviewing expectations and responsibilities.
Strategically, the January 2006 issue of CHEST had a new cover that heralded that changes have taken place in the editorial content and format of what will be published in the pages of the journal as the new era begins in its 71 year history. The cover was designed to reflect the changes that will occur. While the new design of the cover appears fresher and more modern, it has not lost the identity of its heritage. Nor has the new blueprint shown in the accompanying Table.
Table. The New Table of Contents for CHEST
- Original Research
- Recent Advances in Chest Medicine
- Translating Basic Research into Clinical Practice
- Special Features
- Global Medicine
- Medical Ethics
- Topics in Practice Management
- Selected Reports
- Postgraduate Education Corner
- Contemporary Reviews in Sleep Medicine
- Contemporary Reviews in Critical Care Medicine
- Chest Imaging and Pathology for Clinicians
- Pulmonary and Critical Care Pearls
- Case Records from the University of Colorado
- Medical Writing Tips of the Month
Presentation 4: How to Select the Most Appropriate Journal for Your Paper
Philip J. Thompson, MD
Editor in Chief, Respirology
Professor, The Lung Institute of Western Australia & Centre for Asthma, Allergy and Respiratory Research, University of Western Australia, Nedlands, Australia
Choosing the right journal will depend upon why you wish to publish in conjunction with the nature and quality of your work and will reflect your awareness of what journals are available and the topicality, quality and performance of those journals.
Why you want to publish may reflect a desire: to communicate worldwide your discoveries to help advance human knowledge; to obtain good peer review of your work; to stimulate networking with other like-minded investigators; to help obtain funding; to assist your career/promotion; or some combination of the above.
The target audience and prestige of the journal will influence its content and standards. Do you wish to publish in a general topic-based journal or alternatively one with a specialised readership? Is your work relevant to an international audience or is it more regionally orientated? The nature, standard and depth of your work, as well as your aspirations, will need to match the status and standing of the journal. The qualities of the journal will be reflected in a number of dimensions, including its: impact factor; prestige; ease of submission; review process efficiency; quality of the review (constructive criticism); costs to authors; timeliness of publication (written or electronic) and the quality of the technical and layout aspects of the publication.
Other factors that may play a role relate to a journal's visibility, the development of some rapport with a particular journal or editor and a desire to support a particular organisation that is associated with the journal. For new authors it is important to discuss with peers and mentors, to read the instructions to authors and to read articles in the journal you are selecting before committing to a particular journal. Periodically it is sensible for all authors to consider widening the journals they associate with but counterbalancing this is the risk of highly specialised journals becoming unsustainable. However in the end you should choose the highest quality journal in the context of your work and try to tailor you future work to the standards they are setting.
I would like to open the panel for discussion. As I said earlier this is a very unique event. Please do not hesitate to make use of it to ask any question you have about publishing.
Question 1: Thank you for a wonderful lecture for us. Could you tell us what some of the factors are that would make you decide not to send the paper for peer review?
For us there are really, I suppose, three reasons and maybe more. One is, as I mentioned the issue with case reports, so articles that fall outside the focus of the journal if there is very little chance that the article will be accepted, then I think the fairest thing for the authors, is if we send it back very, very quickly. I try and provide a reason for that, too, such as that it is not appropriate for the journal. Sometimes we get an article, for example, that really is on cardiology. Well that is not an appropriate article for a respiratory journal, at least for the Blue Journal. So I will send it back and say that. Sometimes there are quality issues as well. So if the paper really has major problems, I know the reviewers will note that, and the paper will not get a sufficient priority to allow revisions. So again I would try to do the authors a service, and send it back fast enough so they do not waste a month or longer. I always try and provide a reason. I think it is very important for us to have a dialogue with the authors, and not to just sort of imperiously send it back. There are certain journals, for example, where you pay a submission fee; you send in the article, three days later you get a rejection, your money is gone, you do not know why the paper was rejected, and you just have to move on. I think that is not fair. So the main reasons for us are quality and focus more than anything else.
May I just quickly add something to that? If we make a priori rejections at the editor's level, the luxury that we have two people, so what we try to do is to get this not based on one single opinion, because sometimes you are uncertain. There is always a grey area. Something that is quite clear is a trial that has an uncontrolled nature, uncontrolled trials for example. This is something that we think that is unacceptable. I mean that is something that is a quality that we do not want. The second one is clinical material. I guess, at all of the journals we get a lot of case presentations and case reports and we have different ideas on that. For the ERJ I personally review all case reports. I do them all myself. What I do is I have a list of cases that we have had over the last 15 years as case presentations or cases for diagnoses, and I just looked on that I accept or I reject and I have not got a complaint letter so far, I tell people: give me a new disease, give me a new gene, give me a new side effect, then you are in. But I have about 300 cases submitted but only 12 slots per year. Usually people accept the decision if they get the reason and I think that is something we are all saying. If you write a letter and take the time to tell an author, why it just did not make it, people understand this if the response comes in as quickly as possible. I think that is the second part. I think a rather clean, quick rejection is less of a worry than three months wiggling about with bad reviews and finally you do not make it. I mean that is something that people do not like, and I accept that.
I would add two other things to what has already been said about us being able to make a rapid decision without sending the manuscript out. That would be when IRB approval is clearly required but was not obtained, and a phase three trial that was not registered in an independent registry. Those would just automatically be rejected. We would get back in touch with the authors, usually our staff would first un-submit them and say did you forget to mention that you had IRB approval, or did you forget to enter the registry number. If we do not hear back, and they just submit again then we will reject without sending it out.
I would like to endorse all of those comments. Our editorial office screens every manuscript to make sure they have complied with instructions to authors. It might sound a very basic comment, but you would be surprised how many authors submit articles missing their ethics approval and so on. They are just automatically screened for all of those criteria and will be sent back automatically to be rectified. If our editorial staff cannot follow the English, so just a basic English screening test at that level, it will go back as well. So we are not talking about sophisticated English, we are just talking basic English that our staff can follow. Then as Klaus said, for all the clinical studies that come to me first, particularly the case reports, we reject about half of the case reports up front. In our instructions to authors it clearly says that case reports will be assessed on their originality for new mechanisms, new treatments, or if it is a timely review of an unusual but important condition. I guess that is a bit vague, the other two are very clear. So all of those are reasons why we might reject right at the beginning. Initially not complying with instructions to authors does not mean that they cannot be resubmitted of course.
Thank you. Any other questions?
I could probably add a little comment that I think we have different ways of how we deal with papers where the research and/or the author was supported by the tobacco industry. Respiratory journals have failed in the past to uniformly, I guess, formulate a policy on that. We have always been thinking that should not happen, but we will within a certain period of time strongly discourage research that has been funded by the tobacco industry. The Blue Journal has done this years ago. Not all of the journals have a policy on authors being funded by the tobacco industry to submit papers to the journal. As of next year we will not publish papers that are coming in from that sort of funding. I think it is worth discussing amongst our colleagues.
Question 2: So you would not send it to the reviewer in that case?
Yes, and for us it is the American Thoracic Society's position to absolutely not publish an article that has been supported by the tobacco industry. So we will not consider it all. It will be turned down by the office.
Same for Chest. The only way it conceivably might happen is if the authors never disclose that information, and that has happened. But in the spirit of full disclosure that kind of information, as described in our instructions to authors, is supposed to be disclosed.
Can we go to the next question, please?
Question 3: Thank you very much. If we have a letter from the editor-in-chief saying that the paper has been rejected, could it be there are any "code words" in the letter that indicate that the paper is completely rejected?
You mean any words that indicate that a resubmission would not be welcome.
I think I understand the question. We will sometimes send a letter and say that there are multiple problems with the paper, and though we find the idea interesting there are too many problems to ask for a revision. However, if you do additional crucial experiments or provide additional crucial data, we will reconsider the manuscript. It is not often, but once in a while we will open the door to that. Then another thing that sometimes happens, although it is very rare, is we do have a dialogue, and if there are really major problems that were shown by the reviews we considered it a reject. But a lot of times letters come in about a paper that has been rejected, and they say they disagree with the reviewers, but that is really not enough. I mean there are differences of opinion, but you have to really show that the reviewer made a major mistake for us to reconsider. But we are open to that.
If you are trying to indicate that the problems are such you would not welcome a resubmission, would you put in something like, the paper does not have sufficient priority? Would that convey a meaning that a resubmission is not welcome?
We are even more blunt. We actually say that we will not consider a resubmission of the manuscript. It is very, very clear. Sometimes the authors do not understand, even though we say that, they will write back in a few months and say they fixed everything the reviewers asked for, all their criticisms, and now we are resubmitting. The answer is, you cannot resubmit in that case. I will not even send it out for review. That is another example of a manuscript that does not go out for review again.
This young person has been waiting a long time.
Question 4: Do you believe in the saying "publish or perish"? And if so, how can a young researcher advance one's academic career, say for applying for grants, through means other than purely the number of papers you have published?
It would depend upon your situation. So you would have to define what it would take in your mind to be successful. That depends on whether you are a clinician scientist, whether you are a clinician researcher, whether you are a clinician who enjoys teaching. In order to really specifically answer your question, it would be very important for me to know what you would define as being successful. If you wanted to educate the rest of the community you could do a scholarly review of something. You could write textbook chapters. I think it is very important for us to understand the context in which you would define success.
I am trying to identify where you are coming from. First of all I think presenting at major meetings is number one. That way you can get feedback on your work. People can become familiar with your work. That then will help facilitate you to have a successful publication and if we believe the analysis that Klaus presented in his presentation this today, then this is almost guaranteed. So that is one point. I think the other is to network with other people, and if you are at a stage where publishing is difficult, one way forward is to join forces with other people who have had success in publishing, and start to interact with other groups, other people. Generally most people are enthusiastic if someone wants to interact and work with them. So those are two ways that I would suggest. If you are asking whether "publish or perish" is just a numbers game or is it a quality game, then my answer is that I think it a bit of both. I think you need numbers to show that you are active. If you do not publish for three years and then get your Nature paper, you may have perished in the three years beforehand because no one really knows what you are doing. Equally though, if you do not publish quality papers people ultimately will not respect what you are trying achieve.
May I add something? I guess there is no uniform answer to that, because it depends on the system in the university that you work. I think all of us who work in a university setting recognize the problem in evaluating the value of a CV, for example. Now I can tell you that in the Netherlands, people have been recognizing this as an increasing problem. What we have been doing is we are trying to start up career tracks for people who do not publish, but teach. So you can have a very good career in an academic institution, which is probably different than ten years ago, recognizing that your teaching skills and your skills with students and how many courses you have done could weigh a lot against impact factor of publications. So I would hope that your faculty and your university would allow this diversity, because in clinical science and in basic science in the academic career track, teaching is something that is undervalued and there is not even a real career track for that and I hope this is going to change in other countries as well.
So let me give a not subtle and more brutal answer to your question. When we look at promotions at the universities in the United States and when we look at grant applications, promotions more than anything, particularly for physician scientists are looked at in terms of having been able to achieve external funding, more than anything else. Publications are a bit of a surrogate, because you are not going to achieve external funding without publications. If you come up for promotion and in particular for us the major promotion point for a 10-year track is between assistant and associate professor, it is really based on your continuity of funding. So publication becomes very important for that in high impact journals that will impress the review groups at the National Institutes of Health. The same kind of thing goes on in Europe, and many places as well, in many countries. I guess the answer here is not so subtle. You have to publish in high impact factor journals that are looked at appropriately by review panels, and ultimately that will leverage yourself into getting a grant, and then getting the grant renewed. So I think it is all tied to together in the process.
Again getting back to what I said. If you had said to me that you wanted to be a clinician teacher, again in our institution and many others in the United States, you actually are valued and there is a separate track for doing that. If you said to me you wanted to become a world famous clinician and consultant in certain areas, I think you could get there with writing books, giving talks, doing fewer publications as Dr. Abraham had talked about, and actually having a mentor that helps you along in presenting at national meetings. So understanding what your ultimate goal is, is very important.
Could we go on to the next questioner because he has been waiting a long time.
Question 5: I have one quick question about selecting the reviewers. Sometimes reviewers are so nice and very educational, and then following that instruction I got published in one paper in the Blue Journal. At that time the reviewer, one of the reviewers was Dr. Rabe and then I was very impressed about his instruction. But sometimes the reviewer's comment is very, very short and very low quality. My question is do you have any criteria for selecting the reviewers in general?
There are several criteria. We do look at suggested reviewers by the authors and also the reviewers that you say should not look at the paper. We look at those lists and take that into consideration. It does not mean that we will use any of the reviewers you suggest, but we will look at that. We also look reviewers' performance. So reviewers who are always late or say they will review a paper and then do not review it, we do not go back to. We also look at the quality of the reviews in a consistent way. We have 14 or 15 associate editors now and so each of them knows their field and knows who provides good reviews. The other issue that I wanted mention too, is there is a section on our review form for confidential comments. Sometimes the review to the authors can come back and be relatively nice and yet in the confidential comments the reviewer will tell us there is low priority for the article and we will end up rejecting it and then the author will say why did you reject it, the comments were nice? In fact it was because we saw those other comments that were not shared with the author. So those kind of issues also come into play. But in general it is consistency of approach for the reviewer's expertise in the area, timeliness, and the quality of the reviews.
Question 6: Who decides if that reviewer is an expert at this?
The associate editors will decide. If you are the chief or the associate editor in every journal you make the selection because that is what you are trusted to be a master in your area. So the selection of the reviewer is something that has been given as a task to the associate editors or those editors handling the manuscript. They are termed differently at different journals. But I think the point you are making is crucial. That is why we just try to get back to that. I mean if you look at journals and I think we have all worked for some one of them, the fact is that every associate editor asks the people around him to review his papers. That is the way it works. You get a lot papers that you need reviewers for, two, three, four reviewers. I mean there is a finite amount of individuals that you can ask regularly, these need to be people that you know. In selecting those you have to make a very balanced choice. We all know that there are better and worse reviewers. So what you can expect and what you should be expecting and that is the argument of Phil Thompson, I think if you have a very bad review in terms of short, no explanation, if it is very positive or very negative for an editor it has less value. Someone gives no comment and says that is the best thing since sliced bread, something that you cannot do anything with. That is the same thing for the negative decision. So you can expect an editor, - and that is where we have discussions on reviews are very different in quality and we know that. The final letter and decision to you should be based on evaluating the quality, not only the length of it.
I just wanted to say one other thing about how manuscripts are handled, at least at the Blue Journal, which I think is somewhat different from the ERJ, for example. In the past the associate editor would make a decision on the manuscripts for acceptance. Those manuscripts that would go out for review. We have now added a second tier to this. So what happens now at the Blue Journal is those manuscripts that each associate editor or deputy editor or myself think should be considered for revisions to be sent back to authors, we actually discuss at a weekly meeting that the deputy editors and myself have, and so we will look at the reviews but also a lot of the articles fall within the areas of expertise of our deputy editors, such as asthma, COPD, critical care. So that provides another level of review and another issue where we are able to consider the issues of priority. So the decision to accept or reject an article, to ask for a revision or not, is not based only on what the reviewers say, but also about the priority, the distribution of articles for the journal, and how we consider it given all the articles that we are looking at over a period of time.
Okay Richard you have been waiting patiently.
I would agree with what everybody else has said. I would just add one other thing. I am sure everybody else does it, I know we do, we actually grade the reviewers. We grade them on timeliness as well as quality of their reviews, and over time scores actually appear next to the names of the reviewers, so that we know whether they have done a good job in the past. That is important, because I am sure the other journals have similarly sized data bases of reviewers, we have a database of 8,000 reviewers. Over the years and certainly since I have been doing this, I have been grading them and the associate editors have been grading them in a very consistent way. You can tell who is a good reviewer or not, based upon the criteria that have already been described.
One quick comment. Many journals, including our own, appoint the associate editors, or whatever designation they have in their journal, based on their specialty interests as well. Certainly with our journal when the manuscript comes in we will try to send it to an associate editor who already has a specialty interest in that area, and then we are relying, as Klaus has said, on that person knowing people who specialize in the area for refereeing. So by channeling your manuscript right from the start towards an associate editor who has some background in that area, we are hopeful that we get high quality referees in that particular area, and then all the other things that have been said we would try to practice as well. The electronic systems, like Manuscript Central, have systems for storing referees and grading them, which is then available to your editorial staff as well.
Question 7: Thank you for giving me the opportunity to listen to your editorial policy. We all are pulmonologists. We have different professional fields such as the scientific assembly. My question is, do you have any idea or a good way to keep balance of the citation ratio between the different professional fields?
We actually look at that for various areas. We look at pediatrics, we look at asthma, we look at COPD papers in the various areas, how often are they cited. Now we do not make a decision, I think what Dr. Rabe said was very important. We still make all decisions based on the scientific quality of papers for publication. Although we take into account these other issues. So for example, if it is a wonderful paper on ciliary dysfunction for example, we are going to accept it even though there are very few people working in that area. But if it really moves the field forward we still take the paper. So it is always a question of the best science. In terms of priorities, what field it comes from is a small factor, but that really is reflected by the number of papers that come in in the area. The major criterion for us always is the quality of the paper.
I would say that we do not pay any attention at all beyond making certain that the manuscript is in the areas that we are focusing on; we just look at the quality of the paper. We are less interested in enhancing our impact factor than we are serving the people who are sending good papers through us and the readership. I think that is what Ed has also said.
This may be the last question.
Question 8: I have a question concerning publication of a case report with research results because you are talking today about positive and negative factors affecting the paper. I know that case reports with original research data appear very rarely, but can you mention a little bit about the positive and negative factors about publishing those. Thank you.
I think that is a very interesting question. Thank you for asking this. There is a very, very good case to be made for observational papers. An observational paper couldn't be an n of one. So a paper that in fact is not so much a case report but actually highlights a new mechanism, even if it is very rare, should be published and we should be smart enough to realize that, because there is only one way to detect rare mechanisms. Those sorts of things that do not happen very frequently. If several people put together very rare events and if they never get published, we will never recognize it. A case that would highlight a mechanism would advance, as Ed Abraham was saying, the field in that, a case can do that. We have had examples where someone by a single case detected a gene defect. I mean, you know, they did a lot of stuff in a single case and identified the locus where things got wrong. This is the ideal case for a case report that we would all like to see. I think none of us that realized it would reject this up front. Unfortunately, this is an extreme minority of cases that you get. What you usually get is something which is relatively rare, reasonably well presented, and is yet another one of a story that has been told before. In our case we only have 12 slots per year, so even though everything is very nicely presented, if it is known to the field, it does not advance it, that would have a negative decision. And we have society journals that can put these in an educational publication like, Breathe is an example of that. Other societies have these as well. But for original publications that would be the limiting factor.
I think the other kind of case report is a very interesting negative case report, particularly genetic, where you present a patient who has a classic disease, that is always supposed to be associated with a particular genetic abnormality, and this case does not have it, that is very useful too. That is an n of one that can be quite useful. But most of the case reports are just as we heard, that they are the third, or the twelfth presentation of an unusual disease, that is not going to go forward.
Time is up so I would like to thank all of the panelists and the societies who very generously supported this event. I have to apologize to Dr. Paul Reynolds who is here to give a presentation about next year's APSR meeting in the Gold Coast, but we will make another slot later on in the Congress. Thank you all very much for a very interesting event. Thank you.