Commentary

A Google search of “sensory issues in children” reveals more than 20 million results and a wide range of terminology that can be confusing to parents, providers, and youth themselves. Phenomena such as sensory processing disorder, sensory integration disorder, sensory discrimination disorder, and sensory defensiveness are noted, and autism spectrum disorder (ASD) is a label not uncommonly attached to the former terms.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) does not include a discrete diagnosis to apply to children who have sensory differences, (meaning that they have difficulties regulating sensory input and such difficulties affect their ability to successfully relate to the world around them), but these differences are now part of the diagnostic criteria for ASD. The literature indicates that a majority of youth with ASD demonstrate features of sensory overresponsiveness (JAMA Psychiatry. 2015 Aug;72[8]:778-86), and providers should rightfully be concerned about the possibility of autism in a youngster who is presenting with severe negative responses to auditory, visual, and/or tactile stimuli.

Notably, however, even though sensory problems are considered a feature of autism, they are not pathognomonic for the disorder, and most children with these problems are, in fact, not autistic. Children with deficits in their ability to modulate sensory stimuli can present with a wide range of emotional-behavioral problems, including externalizing behaviors and internalizing symptoms manifesting with anxiety, attention challenges, mood dysregulation, and overall poor adaptive functioning. The relationship between sensory issues (both underresponsiveness and overresponsiveness) and psychopathology is rather complicated as sensory dysfunction can exist independent of a psychiatric disorder, be a significant risk factor for the development of the disorder (J Abnorm Child Psychol. 2009 Nov;37[8]:1077-87), and have symptom overlap with the disorder.

All in all, in spite of this complexity, since the 1960’s (Am J Occup Ther. 1964 Jan-Feb;18:6-11), it’s been clear that sensory dysfunction in children is associated with impairments in development, learning, and self-regulation. Parents of these children experience elevated levels of stress (J Child Fam Stud. 2013 Oct 1;22[7]:912-21), and early identification of sensory differences, psychoeducation, and referral for treatment are critical to minimize these impacts and foster positive outcomes.

Case Summary

In gathering a history and administering the Autism Diagnostic Observation Schedule (ADOS), it became clear that Sarah did not present with the social-communicative impairments that characterize ASD, but she did demonstrate repetitive hand flapping, troubles tolerating large social get-togethers, hypersensitivities, and a vulnerability to getting stuck when attempting to transition between activities. It is not uncommon for Sarah to use “fight-and-flight” reactions when faced with internal or external discomfort. Child Behavior Checklist data revealed multi-informant endorsement of clinical range symptoms across broad-band and narrow-band domains. Additionally, the Sensory Profile–2 yielded elevated scores in categories measuring sensory seeking and sensory sensitivity. The Sensory Profile is a standardized tool that uses caregiver and teacher-completed questionnaires to examine a child’s sensory processing abilities and provide data regarding the effect of such sensory processing on functional performance. Integrating all the available data, our team certainly appreciated Sarah’s profound sensory overresponsiveness, and a diagnosis of an unspecified anxiety disorder was provided along with consideration for attention-deficit/hyperactivity disorder (ADHD) (with teacher input needed to further investigate this possibility). The family history revealed anxiety disorders occurring both maternally and paternally. Additionally, Sarah’s mother’s acknowledged having her own similar sensory issues as a child.

Discussion

Associations among anxiety, sensory overresponsiveness, and ADHD are recognized in the literature (Am J Occup Ther. 2009 Jul-Aug;63[4]:433-40) and have implications for treatment. Furthermore, there is evidence that there is a heritable aspect to sensory processing abnormalities, and tactile defensiveness is associated with fearful temperament and anxiety (J Abnorm Child Psychol. 2006 Jun;34[3]:393-407). In Sarah’s case, her intense behavioral response to ordinary sensory stimuli was striking, and she had not yet been referred for an occupational therapy evaluation, which was the primary recommendation to further assess and understand her complicated sensory profile. As one component of a comprehensive treatment plan, an occupational therapist (www.aota.org), by using evidence-based practices in a sensory-integration framework, could be helpful in addressing Sarah’s range of challenges and promoting positive outcomes related to socialization, behavioral regulation, and attention. Occupational therapists, with assistance from other team members, also could work with Sarah and her family on developing relaxation skills and use exposure and response prevention–oriented intervention strategies to address anxieties. Families, however, should be counseled about the limited data on the use of sensory-based therapies (Pediatrics. 2012 Jun;129[6]:1186-9); the use of parent-management training/family coaching should also be a treatment consideration to help promote overall regulatory functioning in the household.

Clinical pearl

When encountering youth with sensory-related challenges, a clinician’s diagnostic considerations should be more than just thinking about the possibility of an autism spectrum disorder. Symptoms of sensory overresponsiveness are associated with other emotional-behavioral conditions, but also can be seen without co-occurring psychopathology. With the latter, however, providers should be mindful that family-related impairments still may be quite noteworthy (J Am Acad Child Adolesc Psychiatry. 2011 Dec;50[12]:1210-9) and associated behavior problems could be attributed incorrectly to other diagnoses (which may lead to the recommendation of ineffective and inappropriate treatments). Much more research is needed to help develop a robust framework for diagnosing and labeling sensory issues in children and studying the efficacy of available intervention strategies.

Dr. Dickerson, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, Burlington, where he is director of the autism diagnostic clinic.

A Google search of “sensory issues in children” reveals more than 20 million results and a wide range of terminology that can be confusing to parents, providers, and youth themselves. Phenomena such as sensory processing disorder, sensory integration disorder, sensory discrimination disorder, and sensory defensiveness are noted, and autism spectrum disorder (ASD) is a label not uncommonly attached to the former terms.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) does not include a discrete diagnosis to apply to children who have sensory differences, (meaning that they have difficulties regulating sensory input and such difficulties affect their ability to successfully relate to the world around them), but these differences are now part of the diagnostic criteria for ASD. The literature indicates that a majority of youth with ASD demonstrate features of sensory overresponsiveness (JAMA Psychiatry. 2015 Aug;72[8]:778-86), and providers should rightfully be concerned about the possibility of autism in a youngster who is presenting with severe negative responses to auditory, visual, and/or tactile stimuli.

Notably, however, even though sensory problems are considered a feature of autism, they are not pathognomonic for the disorder, and most children with these problems are, in fact, not autistic. Children with deficits in their ability to modulate sensory stimuli can present with a wide range of emotional-behavioral problems, including externalizing behaviors and internalizing symptoms manifesting with anxiety, attention challenges, mood dysregulation, and overall poor adaptive functioning. The relationship between sensory issues (both underresponsiveness and overresponsiveness) and psychopathology is rather complicated as sensory dysfunction can exist independent of a psychiatric disorder, be a significant risk factor for the development of the disorder (J Abnorm Child Psychol. 2009 Nov;37[8]:1077-87), and have symptom overlap with the disorder.

All in all, in spite of this complexity, since the 1960’s (Am J Occup Ther. 1964 Jan-Feb;18:6-11), it’s been clear that sensory dysfunction in children is associated with impairments in development, learning, and self-regulation. Parents of these children experience elevated levels of stress (J Child Fam Stud. 2013 Oct 1;22[7]:912-21), and early identification of sensory differences, psychoeducation, and referral for treatment are critical to minimize these impacts and foster positive outcomes.

Case Summary

In gathering a history and administering the Autism Diagnostic Observation Schedule (ADOS), it became clear that Sarah did not present with the social-communicative impairments that characterize ASD, but she did demonstrate repetitive hand flapping, troubles tolerating large social get-togethers, hypersensitivities, and a vulnerability to getting stuck when attempting to transition between activities. It is not uncommon for Sarah to use “fight-and-flight” reactions when faced with internal or external discomfort. Child Behavior Checklist data revealed multi-informant endorsement of clinical range symptoms across broad-band and narrow-band domains. Additionally, the Sensory Profile–2 yielded elevated scores in categories measuring sensory seeking and sensory sensitivity. The Sensory Profile is a standardized tool that uses caregiver and teacher-completed questionnaires to examine a child’s sensory processing abilities and provide data regarding the effect of such sensory processing on functional performance. Integrating all the available data, our team certainly appreciated Sarah’s profound sensory overresponsiveness, and a diagnosis of an unspecified anxiety disorder was provided along with consideration for attention-deficit/hyperactivity disorder (ADHD) (with teacher input needed to further investigate this possibility). The family history revealed anxiety disorders occurring both maternally and paternally. Additionally, Sarah’s mother’s acknowledged having her own similar sensory issues as a child.

Discussion

Associations among anxiety, sensory overresponsiveness, and ADHD are recognized in the literature (Am J Occup Ther. 2009 Jul-Aug;63[4]:433-40) and have implications for treatment. Furthermore, there is evidence that there is a heritable aspect to sensory processing abnormalities, and tactile defensiveness is associated with fearful temperament and anxiety (J Abnorm Child Psychol. 2006 Jun;34[3]:393-407). In Sarah’s case, her intense behavioral response to ordinary sensory stimuli was striking, and she had not yet been referred for an occupational therapy evaluation, which was the primary recommendation to further assess and understand her complicated sensory profile. As one component of a comprehensive treatment plan, an occupational therapist (www.aota.org), by using evidence-based practices in a sensory-integration framework, could be helpful in addressing Sarah’s range of challenges and promoting positive outcomes related to socialization, behavioral regulation, and attention. Occupational therapists, with assistance from other team members, also could work with Sarah and her family on developing relaxation skills and use exposure and response prevention–oriented intervention strategies to address anxieties. Families, however, should be counseled about the limited data on the use of sensory-based therapies (Pediatrics. 2012 Jun;129[6]:1186-9); the use of parent-management training/family coaching should also be a treatment consideration to help promote overall regulatory functioning in the household.

Clinical pearl

When encountering youth with sensory-related challenges, a clinician’s diagnostic considerations should be more than just thinking about the possibility of an autism spectrum disorder. Symptoms of sensory overresponsiveness are associated with other emotional-behavioral conditions, but also can be seen without co-occurring psychopathology. With the latter, however, providers should be mindful that family-related impairments still may be quite noteworthy (J Am Acad Child Adolesc Psychiatry. 2011 Dec;50[12]:1210-9) and associated behavior problems could be attributed incorrectly to other diagnoses (which may lead to the recommendation of ineffective and inappropriate treatments). Much more research is needed to help develop a robust framework for diagnosing and labeling sensory issues in children and studying the efficacy of available intervention strategies.

Dr. Dickerson, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, Burlington, where he is director of the autism diagnostic clinic.

A Google search of “sensory issues in children” reveals more than 20 million results and a wide range of terminology that can be confusing to parents, providers, and youth themselves. Phenomena such as sensory processing disorder, sensory integration disorder, sensory discrimination disorder, and sensory defensiveness are noted, and autism spectrum disorder (ASD) is a label not uncommonly attached to the former terms.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) does not include a discrete diagnosis to apply to children who have sensory differences, (meaning that they have difficulties regulating sensory input and such difficulties affect their ability to successfully relate to the world around them), but these differences are now part of the diagnostic criteria for ASD. The literature indicates that a majority of youth with ASD demonstrate features of sensory overresponsiveness (JAMA Psychiatry. 2015 Aug;72[8]:778-86), and providers should rightfully be concerned about the possibility of autism in a youngster who is presenting with severe negative responses to auditory, visual, and/or tactile stimuli.

Notably, however, even though sensory problems are considered a feature of autism, they are not pathognomonic for the disorder, and most children with these problems are, in fact, not autistic. Children with deficits in their ability to modulate sensory stimuli can present with a wide range of emotional-behavioral problems, including externalizing behaviors and internalizing symptoms manifesting with anxiety, attention challenges, mood dysregulation, and overall poor adaptive functioning. The relationship between sensory issues (both underresponsiveness and overresponsiveness) and psychopathology is rather complicated as sensory dysfunction can exist independent of a psychiatric disorder, be a significant risk factor for the development of the disorder (J Abnorm Child Psychol. 2009 Nov;37[8]:1077-87), and have symptom overlap with the disorder.

All in all, in spite of this complexity, since the 1960’s (Am J Occup Ther. 1964 Jan-Feb;18:6-11), it’s been clear that sensory dysfunction in children is associated with impairments in development, learning, and self-regulation. Parents of these children experience elevated levels of stress (J Child Fam Stud. 2013 Oct 1;22[7]:912-21), and early identification of sensory differences, psychoeducation, and referral for treatment are critical to minimize these impacts and foster positive outcomes.

Case Summary

In gathering a history and administering the Autism Diagnostic Observation Schedule (ADOS), it became clear that Sarah did not present with the social-communicative impairments that characterize ASD, but she did demonstrate repetitive hand flapping, troubles tolerating large social get-togethers, hypersensitivities, and a vulnerability to getting stuck when attempting to transition between activities. It is not uncommon for Sarah to use “fight-and-flight” reactions when faced with internal or external discomfort. Child Behavior Checklist data revealed multi-informant endorsement of clinical range symptoms across broad-band and narrow-band domains. Additionally, the Sensory Profile–2 yielded elevated scores in categories measuring sensory seeking and sensory sensitivity. The Sensory Profile is a standardized tool that uses caregiver and teacher-completed questionnaires to examine a child’s sensory processing abilities and provide data regarding the effect of such sensory processing on functional performance. Integrating all the available data, our team certainly appreciated Sarah’s profound sensory overresponsiveness, and a diagnosis of an unspecified anxiety disorder was provided along with consideration for attention-deficit/hyperactivity disorder (ADHD) (with teacher input needed to further investigate this possibility). The family history revealed anxiety disorders occurring both maternally and paternally. Additionally, Sarah’s mother’s acknowledged having her own similar sensory issues as a child.

Discussion

Associations among anxiety, sensory overresponsiveness, and ADHD are recognized in the literature (Am J Occup Ther. 2009 Jul-Aug;63[4]:433-40) and have implications for treatment. Furthermore, there is evidence that there is a heritable aspect to sensory processing abnormalities, and tactile defensiveness is associated with fearful temperament and anxiety (J Abnorm Child Psychol. 2006 Jun;34[3]:393-407). In Sarah’s case, her intense behavioral response to ordinary sensory stimuli was striking, and she had not yet been referred for an occupational therapy evaluation, which was the primary recommendation to further assess and understand her complicated sensory profile. As one component of a comprehensive treatment plan, an occupational therapist (www.aota.org), by using evidence-based practices in a sensory-integration framework, could be helpful in addressing Sarah’s range of challenges and promoting positive outcomes related to socialization, behavioral regulation, and attention. Occupational therapists, with assistance from other team members, also could work with Sarah and her family on developing relaxation skills and use exposure and response prevention–oriented intervention strategies to address anxieties. Families, however, should be counseled about the limited data on the use of sensory-based therapies (Pediatrics. 2012 Jun;129[6]:1186-9); the use of parent-management training/family coaching should also be a treatment consideration to help promote overall regulatory functioning in the household.

Clinical pearl

When encountering youth with sensory-related challenges, a clinician’s diagnostic considerations should be more than just thinking about the possibility of an autism spectrum disorder. Symptoms of sensory overresponsiveness are associated with other emotional-behavioral conditions, but also can be seen without co-occurring psychopathology. With the latter, however, providers should be mindful that family-related impairments still may be quite noteworthy (J Am Acad Child Adolesc Psychiatry. 2011 Dec;50[12]:1210-9) and associated behavior problems could be attributed incorrectly to other diagnoses (which may lead to the recommendation of ineffective and inappropriate treatments). Much more research is needed to help develop a robust framework for diagnosing and labeling sensory issues in children and studying the efficacy of available intervention strategies.

Dr. Dickerson, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, Burlington, where he is director of the autism diagnostic clinic.

To the Editor:

A recent Cutis article, “Merkel Cell Carcinoma in a Vein Graft Donor Site” (Cutis. 2016;97:364-367), highlighted the localization of a Merkel cell carcinoma (MCC) within a well-healed scar resulting from a vein harvesting procedure performed 18 years prior to presentation. Their discussion focused on factors that may have contributed to the development of the MCC at that specific location. As noted by the authors, this case does not classically fit under the umbrella of a Marjolin ulcer given the stable, well-healed clinical appearance of the scar. We agree and believe it is not secondary to chance either but consistent with Wolf isotopic response.

This concept was originally described by Wyburn-Mason in 1955¹ and later revived by Wolf et al.² Wolf isotopic response describes the development of dermatologic disorders that localize to a site of another distinct and clinically healed skin disorder. Originally, it was reserved for infections, malignancies, and immune conditions restricted to a site of a prior herpetic infection but recently has been expanded to encompass other primary nonherpesvirus-related skin disorders. The pathophysiology behind this phenomenon is unknown but thought to be the interplay of several key elements including immune dysregulation, neural, vascular, and locus minoris resistentiae (ie, a site of lessened resistance).³ Immunosuppression is a known risk factor in the development of MCCs,⁴ thus the proposed local immune dysregulation within a scar may alter the virus-host balance and foster the oncogenic nature of the MCC polyomavirus. A recent article describes another case of an MCC arising within a sternotomy scar,⁵ lending further credibility to a skin vulnerability philosophy. These cases provide further insight into the pathomechanisms involved in the development of this rare and aggressive neoplasm and sheds light on an intriguing dermatologic phenomenon.

To the Editor:

A recent Cutis article, “Merkel Cell Carcinoma in a Vein Graft Donor Site” (Cutis. 2016;97:364-367), highlighted the localization of a Merkel cell carcinoma (MCC) within a well-healed scar resulting from a vein harvesting procedure performed 18 years prior to presentation. Their discussion focused on factors that may have contributed to the development of the MCC at that specific location. As noted by the authors, this case does not classically fit under the umbrella of a Marjolin ulcer given the stable, well-healed clinical appearance of the scar. We agree and believe it is not secondary to chance either but consistent with Wolf isotopic response.

This concept was originally described by Wyburn-Mason in 1955¹ and later revived by Wolf et al.² Wolf isotopic response describes the development of dermatologic disorders that localize to a site of another distinct and clinically healed skin disorder. Originally, it was reserved for infections, malignancies, and immune conditions restricted to a site of a prior herpetic infection but recently has been expanded to encompass other primary nonherpesvirus-related skin disorders. The pathophysiology behind this phenomenon is unknown but thought to be the interplay of several key elements including immune dysregulation, neural, vascular, and locus minoris resistentiae (ie, a site of lessened resistance).³ Immunosuppression is a known risk factor in the development of MCCs,⁴ thus the proposed local immune dysregulation within a scar may alter the virus-host balance and foster the oncogenic nature of the MCC polyomavirus. A recent article describes another case of an MCC arising within a sternotomy scar,⁵ lending further credibility to a skin vulnerability philosophy. These cases provide further insight into the pathomechanisms involved in the development of this rare and aggressive neoplasm and sheds light on an intriguing dermatologic phenomenon.

To the Editor:

A recent Cutis article, “Merkel Cell Carcinoma in a Vein Graft Donor Site” (Cutis. 2016;97:364-367), highlighted the localization of a Merkel cell carcinoma (MCC) within a well-healed scar resulting from a vein harvesting procedure performed 18 years prior to presentation. Their discussion focused on factors that may have contributed to the development of the MCC at that specific location. As noted by the authors, this case does not classically fit under the umbrella of a Marjolin ulcer given the stable, well-healed clinical appearance of the scar. We agree and believe it is not secondary to chance either but consistent with Wolf isotopic response.

This concept was originally described by Wyburn-Mason in 1955¹ and later revived by Wolf et al.² Wolf isotopic response describes the development of dermatologic disorders that localize to a site of another distinct and clinically healed skin disorder. Originally, it was reserved for infections, malignancies, and immune conditions restricted to a site of a prior herpetic infection but recently has been expanded to encompass other primary nonherpesvirus-related skin disorders. The pathophysiology behind this phenomenon is unknown but thought to be the interplay of several key elements including immune dysregulation, neural, vascular, and locus minoris resistentiae (ie, a site of lessened resistance).³ Immunosuppression is a known risk factor in the development of MCCs,⁴ thus the proposed local immune dysregulation within a scar may alter the virus-host balance and foster the oncogenic nature of the MCC polyomavirus. A recent article describes another case of an MCC arising within a sternotomy scar,⁵ lending further credibility to a skin vulnerability philosophy. These cases provide further insight into the pathomechanisms involved in the development of this rare and aggressive neoplasm and sheds light on an intriguing dermatologic phenomenon.

For years, we advocated to repeal the sustainable growth rate (SGR) payment formula. Congress, by passing the MACRA legislation, eliminated SGR but created a new process that links provider reimbursement to value (quality and cost). Value-based reimbursement is here to stay. We now must help CMS devise reasonable linkages that will truly improve patient care, yet keep us in business. MACRA’s final rule is an improvement over the preliminary rule published earlier this spring. Gastroenterologists that plan to practice (and accept Medicare reimbursement) must educate themselves about both the incentive portion (MIPS) and alternative payment models.

http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_156.pdf

https://blog.cms.gov/2016/10/14/a-letter-from-cms-to-medicare-clinicians-in-the-quality-payment-program/

https://innovation.cms.gov/initiatives/Transforming-Clinical-Practices/

I hope you will take it to heart that we are moving into a new world of care delivery and payment. We need physician leaders and innovators to make sure this works well for our patients and our profession.

John I. Allen MD, MBA, AGAF
Editor in Chief

For years, we advocated to repeal the sustainable growth rate (SGR) payment formula. Congress, by passing the MACRA legislation, eliminated SGR but created a new process that links provider reimbursement to value (quality and cost). Value-based reimbursement is here to stay. We now must help CMS devise reasonable linkages that will truly improve patient care, yet keep us in business. MACRA’s final rule is an improvement over the preliminary rule published earlier this spring. Gastroenterologists that plan to practice (and accept Medicare reimbursement) must educate themselves about both the incentive portion (MIPS) and alternative payment models.

http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_156.pdf

https://blog.cms.gov/2016/10/14/a-letter-from-cms-to-medicare-clinicians-in-the-quality-payment-program/

https://innovation.cms.gov/initiatives/Transforming-Clinical-Practices/

I hope you will take it to heart that we are moving into a new world of care delivery and payment. We need physician leaders and innovators to make sure this works well for our patients and our profession.

John I. Allen MD, MBA, AGAF
Editor in Chief

For years, we advocated to repeal the sustainable growth rate (SGR) payment formula. Congress, by passing the MACRA legislation, eliminated SGR but created a new process that links provider reimbursement to value (quality and cost). Value-based reimbursement is here to stay. We now must help CMS devise reasonable linkages that will truly improve patient care, yet keep us in business. MACRA’s final rule is an improvement over the preliminary rule published earlier this spring. Gastroenterologists that plan to practice (and accept Medicare reimbursement) must educate themselves about both the incentive portion (MIPS) and alternative payment models.

http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_156.pdf

https://blog.cms.gov/2016/10/14/a-letter-from-cms-to-medicare-clinicians-in-the-quality-payment-program/

https://innovation.cms.gov/initiatives/Transforming-Clinical-Practices/

I hope you will take it to heart that we are moving into a new world of care delivery and payment. We need physician leaders and innovators to make sure this works well for our patients and our profession.

John I. Allen MD, MBA, AGAF
Editor in Chief

It is an exciting time for dermatologists. In the 16 years that I have been in practice our knowledge of disease pathogenesis has increased and has shaped treatments that can now offer life-changing improvement for patients with extensive dermatologic disease. The everyday practice of cosmetic dermatology also has advanced. Sixteen years ago the only cosmetic options we had for our patients were bovine or human collagen injections, traditional CO₂ laser resurfacing, and the older generations of pulsed dye lasers. Neuromodulators were just being introduced. We quickly learned the limitations and complications associated with these modalities. Collagen injections were directed at fine perioral lines and lasted 3 to 4 months. The worst complication would be a bruise or an allergic reaction to the bovine collagen. If we really needed to restore volume beyond the perioral regions, our only option was autologous fat transfer. CO₂ laser resurfacing was used to firm skin, erase deep wrinkles, and improve sun damage, but its use was limited to older, fair-skinned individuals due to the inherent risk for hypopigmentation and depigmentation. Pulsed dye lasers similarly had no means of cooling the skin, thus they were limited to lighter-skinned individuals and had notable risk for blisters, burns, and hypopigmentation. Since then, our understanding of skin healing, laser-tissue interaction, and facial aging has driven the field to new heights of technological advances and safety. Just as I tell my patients and residents, there is no better time to be in this field than at this moment. Dermatologists have driven the advances behind many of the technologies that are now in widespread use among physicians in a variety of specialties.

Our understanding of facial aging has evolved to include the complex interplay of skeletal change, fat atrophy, and skin aging, which must all be considered when improving a patient’s appearance. Fillers have evolved in physical characteristics to give us the ability to choose between lift, spread, neocollagenesis, or water absorption. Thus, we can select the proper filler for the specific anatomic area we are rejuvenating.

Our understanding of photoaging and laser-tissue physics has allowed for the development of a newer generation of lasers ranging from fractionated lasers to noninvasive modalities that can safely be used in a variety of ethnic skin types to address acne scars, wrinkles, and inflammatory processes such as acne and rosacea. Similarly, the desire to tighten redundant skin has continued to drive ultrasound and radiofrequency technology and sparked growth in a newer field of cryolipolysis and chemical lipolysis agents.

Our dialogue with patients also has evolved to include the 4 R’s of antiaging: resurfacing the skin (eg, lasers, peels), refilling the lost volume (eg, fillers, fat), redraping the excess skin (eg, radiofrequency, ultrasound, laser, surgery), and relaxing dynamic lines (eg, neuromodulators). I propose an additional R: renewal! We must focus on the need for constant renewal so that patients maintain the results we have achieved. I apply the analogy of exercising to get into shape. One must go to the gym regularly to get to the desired level of fitness, but you do not stop exercising, otherwise you will quickly relapse to your former lack of fitness. Similarly, patients should receive the appropriate treatments to bring them to the desired level of rejuvenation, but then some form of constant renewal process is needed to maintain them at that level. Without the stimulation of the skin, the aging process continues and the cycle begins all over again.

In my practice, renewal is achieved by driving the skin to maintain the glow and smoothness that enhances the results of the fillers, neuromodulators, lasers, and peels that we have used. The skin is the first thing people notice. Without the glow, the patient will look good but not great. I tell patients that this part of the process is their responsibility. They must adhere to the skin care regimen specifically designed to address their needs. By incorporating the patient in the rejuvenation process, he/she is empowered to take control over the aging process and has grown more confident in you as a physician.

These are exciting times and there is still so much in the pipeline. By continually learning, reading, and attending workshops and meetings, you can make sure our specialty continue to be the leader in the antiaging field.

It is an exciting time for dermatologists. In the 16 years that I have been in practice our knowledge of disease pathogenesis has increased and has shaped treatments that can now offer life-changing improvement for patients with extensive dermatologic disease. The everyday practice of cosmetic dermatology also has advanced. Sixteen years ago the only cosmetic options we had for our patients were bovine or human collagen injections, traditional CO₂ laser resurfacing, and the older generations of pulsed dye lasers. Neuromodulators were just being introduced. We quickly learned the limitations and complications associated with these modalities. Collagen injections were directed at fine perioral lines and lasted 3 to 4 months. The worst complication would be a bruise or an allergic reaction to the bovine collagen. If we really needed to restore volume beyond the perioral regions, our only option was autologous fat transfer. CO₂ laser resurfacing was used to firm skin, erase deep wrinkles, and improve sun damage, but its use was limited to older, fair-skinned individuals due to the inherent risk for hypopigmentation and depigmentation. Pulsed dye lasers similarly had no means of cooling the skin, thus they were limited to lighter-skinned individuals and had notable risk for blisters, burns, and hypopigmentation. Since then, our understanding of skin healing, laser-tissue interaction, and facial aging has driven the field to new heights of technological advances and safety. Just as I tell my patients and residents, there is no better time to be in this field than at this moment. Dermatologists have driven the advances behind many of the technologies that are now in widespread use among physicians in a variety of specialties.

Our understanding of facial aging has evolved to include the complex interplay of skeletal change, fat atrophy, and skin aging, which must all be considered when improving a patient’s appearance. Fillers have evolved in physical characteristics to give us the ability to choose between lift, spread, neocollagenesis, or water absorption. Thus, we can select the proper filler for the specific anatomic area we are rejuvenating.

Our understanding of photoaging and laser-tissue physics has allowed for the development of a newer generation of lasers ranging from fractionated lasers to noninvasive modalities that can safely be used in a variety of ethnic skin types to address acne scars, wrinkles, and inflammatory processes such as acne and rosacea. Similarly, the desire to tighten redundant skin has continued to drive ultrasound and radiofrequency technology and sparked growth in a newer field of cryolipolysis and chemical lipolysis agents.

Our dialogue with patients also has evolved to include the 4 R’s of antiaging: resurfacing the skin (eg, lasers, peels), refilling the lost volume (eg, fillers, fat), redraping the excess skin (eg, radiofrequency, ultrasound, laser, surgery), and relaxing dynamic lines (eg, neuromodulators). I propose an additional R: renewal! We must focus on the need for constant renewal so that patients maintain the results we have achieved. I apply the analogy of exercising to get into shape. One must go to the gym regularly to get to the desired level of fitness, but you do not stop exercising, otherwise you will quickly relapse to your former lack of fitness. Similarly, patients should receive the appropriate treatments to bring them to the desired level of rejuvenation, but then some form of constant renewal process is needed to maintain them at that level. Without the stimulation of the skin, the aging process continues and the cycle begins all over again.

In my practice, renewal is achieved by driving the skin to maintain the glow and smoothness that enhances the results of the fillers, neuromodulators, lasers, and peels that we have used. The skin is the first thing people notice. Without the glow, the patient will look good but not great. I tell patients that this part of the process is their responsibility. They must adhere to the skin care regimen specifically designed to address their needs. By incorporating the patient in the rejuvenation process, he/she is empowered to take control over the aging process and has grown more confident in you as a physician.

These are exciting times and there is still so much in the pipeline. By continually learning, reading, and attending workshops and meetings, you can make sure our specialty continue to be the leader in the antiaging field.

It is an exciting time for dermatologists. In the 16 years that I have been in practice our knowledge of disease pathogenesis has increased and has shaped treatments that can now offer life-changing improvement for patients with extensive dermatologic disease. The everyday practice of cosmetic dermatology also has advanced. Sixteen years ago the only cosmetic options we had for our patients were bovine or human collagen injections, traditional CO₂ laser resurfacing, and the older generations of pulsed dye lasers. Neuromodulators were just being introduced. We quickly learned the limitations and complications associated with these modalities. Collagen injections were directed at fine perioral lines and lasted 3 to 4 months. The worst complication would be a bruise or an allergic reaction to the bovine collagen. If we really needed to restore volume beyond the perioral regions, our only option was autologous fat transfer. CO₂ laser resurfacing was used to firm skin, erase deep wrinkles, and improve sun damage, but its use was limited to older, fair-skinned individuals due to the inherent risk for hypopigmentation and depigmentation. Pulsed dye lasers similarly had no means of cooling the skin, thus they were limited to lighter-skinned individuals and had notable risk for blisters, burns, and hypopigmentation. Since then, our understanding of skin healing, laser-tissue interaction, and facial aging has driven the field to new heights of technological advances and safety. Just as I tell my patients and residents, there is no better time to be in this field than at this moment. Dermatologists have driven the advances behind many of the technologies that are now in widespread use among physicians in a variety of specialties.

Our understanding of facial aging has evolved to include the complex interplay of skeletal change, fat atrophy, and skin aging, which must all be considered when improving a patient’s appearance. Fillers have evolved in physical characteristics to give us the ability to choose between lift, spread, neocollagenesis, or water absorption. Thus, we can select the proper filler for the specific anatomic area we are rejuvenating.

Our understanding of photoaging and laser-tissue physics has allowed for the development of a newer generation of lasers ranging from fractionated lasers to noninvasive modalities that can safely be used in a variety of ethnic skin types to address acne scars, wrinkles, and inflammatory processes such as acne and rosacea. Similarly, the desire to tighten redundant skin has continued to drive ultrasound and radiofrequency technology and sparked growth in a newer field of cryolipolysis and chemical lipolysis agents.

Our dialogue with patients also has evolved to include the 4 R’s of antiaging: resurfacing the skin (eg, lasers, peels), refilling the lost volume (eg, fillers, fat), redraping the excess skin (eg, radiofrequency, ultrasound, laser, surgery), and relaxing dynamic lines (eg, neuromodulators). I propose an additional R: renewal! We must focus on the need for constant renewal so that patients maintain the results we have achieved. I apply the analogy of exercising to get into shape. One must go to the gym regularly to get to the desired level of fitness, but you do not stop exercising, otherwise you will quickly relapse to your former lack of fitness. Similarly, patients should receive the appropriate treatments to bring them to the desired level of rejuvenation, but then some form of constant renewal process is needed to maintain them at that level. Without the stimulation of the skin, the aging process continues and the cycle begins all over again.

In my practice, renewal is achieved by driving the skin to maintain the glow and smoothness that enhances the results of the fillers, neuromodulators, lasers, and peels that we have used. The skin is the first thing people notice. Without the glow, the patient will look good but not great. I tell patients that this part of the process is their responsibility. They must adhere to the skin care regimen specifically designed to address their needs. By incorporating the patient in the rejuvenation process, he/she is empowered to take control over the aging process and has grown more confident in you as a physician.

These are exciting times and there is still so much in the pipeline. By continually learning, reading, and attending workshops and meetings, you can make sure our specialty continue to be the leader in the antiaging field.

The following opinions are my own and not those of the U.S. Department of Defense.

We often lament the shortage of psychiatrists in the United States, but the problem is dire across the globe. According to the World Health Organization, in low- and middle-income countries, 45% of the population lives with less than one psychiatrist per 100,000 citizens.

For many countries, this translates into increased costs for medical care, loss of employee productivity, higher percentages of the population living in poverty, impacts to national security, and an inability to respond to disasters or war. Therefore, significant expansions of mental health approaches need to take place to extend the scope of care beyond traditional therapeutic modalities.

Ms. Garrick is a special assistant, manpower and reserve affairs for the U.S. Department of Defense. Previously, she served as the director of the Defense Suicide Prevention Office. She has been a leader in veterans’ disability policy and suicide prevention and peer support programs; worked with Gulf War veterans; and provided individual, group, and family therapy to Vietnam veterans and their families dealing with posttraumatic stress disorder.

The following opinions are my own and not those of the U.S. Department of Defense.

We often lament the shortage of psychiatrists in the United States, but the problem is dire across the globe. According to the World Health Organization, in low- and middle-income countries, 45% of the population lives with less than one psychiatrist per 100,000 citizens.

For many countries, this translates into increased costs for medical care, loss of employee productivity, higher percentages of the population living in poverty, impacts to national security, and an inability to respond to disasters or war. Therefore, significant expansions of mental health approaches need to take place to extend the scope of care beyond traditional therapeutic modalities.

Ms. Garrick is a special assistant, manpower and reserve affairs for the U.S. Department of Defense. Previously, she served as the director of the Defense Suicide Prevention Office. She has been a leader in veterans’ disability policy and suicide prevention and peer support programs; worked with Gulf War veterans; and provided individual, group, and family therapy to Vietnam veterans and their families dealing with posttraumatic stress disorder.

The following opinions are my own and not those of the U.S. Department of Defense.

We often lament the shortage of psychiatrists in the United States, but the problem is dire across the globe. According to the World Health Organization, in low- and middle-income countries, 45% of the population lives with less than one psychiatrist per 100,000 citizens.

For many countries, this translates into increased costs for medical care, loss of employee productivity, higher percentages of the population living in poverty, impacts to national security, and an inability to respond to disasters or war. Therefore, significant expansions of mental health approaches need to take place to extend the scope of care beyond traditional therapeutic modalities.

Ms. Garrick is a special assistant, manpower and reserve affairs for the U.S. Department of Defense. Previously, she served as the director of the Defense Suicide Prevention Office. She has been a leader in veterans’ disability policy and suicide prevention and peer support programs; worked with Gulf War veterans; and provided individual, group, and family therapy to Vietnam veterans and their families dealing with posttraumatic stress disorder.

Psychiatrists are trained to view involuntary treatment as an unpleasant means to a desirable end, a necessary evil. And we make the assumption that patients who are helped by the care they receive involuntarily will ultimately be grateful for that care.

Dinah Miller, MD, and Annette Hanson, MD, were inspired to write “Committed: The Battle Over Involuntary Psychiatric Care,” when they discovered that this assumption is false, that there are no clear data about the long-term effects of involuntary care, and that many patients whose mental illnesses improved as the result of involuntary care were terribly traumatized by their experiences of being forced into treatment. In writing “Committed,” Dr. Miller and Dr. Hanson set out to understand those experiences, and the contexts, both psychiatric and legal, in which they occurred.

Psychiatrists are trained to view involuntary treatment as an unpleasant means to a desirable end, a necessary evil. And we make the assumption that patients who are helped by the care they receive involuntarily will ultimately be grateful for that care.

Dinah Miller, MD, and Annette Hanson, MD, were inspired to write “Committed: The Battle Over Involuntary Psychiatric Care,” when they discovered that this assumption is false, that there are no clear data about the long-term effects of involuntary care, and that many patients whose mental illnesses improved as the result of involuntary care were terribly traumatized by their experiences of being forced into treatment. In writing “Committed,” Dr. Miller and Dr. Hanson set out to understand those experiences, and the contexts, both psychiatric and legal, in which they occurred.

Psychiatrists are trained to view involuntary treatment as an unpleasant means to a desirable end, a necessary evil. And we make the assumption that patients who are helped by the care they receive involuntarily will ultimately be grateful for that care.

Dinah Miller, MD, and Annette Hanson, MD, were inspired to write “Committed: The Battle Over Involuntary Psychiatric Care,” when they discovered that this assumption is false, that there are no clear data about the long-term effects of involuntary care, and that many patients whose mental illnesses improved as the result of involuntary care were terribly traumatized by their experiences of being forced into treatment. In writing “Committed,” Dr. Miller and Dr. Hanson set out to understand those experiences, and the contexts, both psychiatric and legal, in which they occurred.

In mid-September, the American Congress of Obstetricians and Gynecologists’ state legislative chairs and lobbyists from 41 states met to discuss top state legislative issues. This group meets annually in the early fall in order to share legislative issues from the previous legislative session and discuss goals for the upcoming session. The attendees sit state by state around a large, rectangular table, where they can share challenges experienced and challenges expected with current legislation and emerging issues.

The discussion included recent legal decisions and new issues. One hot topic was the June 2016 Supreme Court ruling related to TRAP (Targeted Regulation of Abortion Providers) laws. Some states are still encumbered by TRAP laws, despite the recent ruling against the Texas abortion regulations. There are actions underway in some states to get these regulations reversed to be in compliance with the Supreme Court decision.

Dr. Bohon is an ob.gyn. in private practice in Washington, D.C. She is an ACOG state legislative chair from the District of Columbia and a member of the Ob.Gyn. News Editorial Advisory Board. She reported having no relevant financial disclosures.

In mid-September, the American Congress of Obstetricians and Gynecologists’ state legislative chairs and lobbyists from 41 states met to discuss top state legislative issues. This group meets annually in the early fall in order to share legislative issues from the previous legislative session and discuss goals for the upcoming session. The attendees sit state by state around a large, rectangular table, where they can share challenges experienced and challenges expected with current legislation and emerging issues.

The discussion included recent legal decisions and new issues. One hot topic was the June 2016 Supreme Court ruling related to TRAP (Targeted Regulation of Abortion Providers) laws. Some states are still encumbered by TRAP laws, despite the recent ruling against the Texas abortion regulations. There are actions underway in some states to get these regulations reversed to be in compliance with the Supreme Court decision.

Dr. Bohon is an ob.gyn. in private practice in Washington, D.C. She is an ACOG state legislative chair from the District of Columbia and a member of the Ob.Gyn. News Editorial Advisory Board. She reported having no relevant financial disclosures.

In mid-September, the American Congress of Obstetricians and Gynecologists’ state legislative chairs and lobbyists from 41 states met to discuss top state legislative issues. This group meets annually in the early fall in order to share legislative issues from the previous legislative session and discuss goals for the upcoming session. The attendees sit state by state around a large, rectangular table, where they can share challenges experienced and challenges expected with current legislation and emerging issues.

The discussion included recent legal decisions and new issues. One hot topic was the June 2016 Supreme Court ruling related to TRAP (Targeted Regulation of Abortion Providers) laws. Some states are still encumbered by TRAP laws, despite the recent ruling against the Texas abortion regulations. There are actions underway in some states to get these regulations reversed to be in compliance with the Supreme Court decision.

Dr. Bohon is an ob.gyn. in private practice in Washington, D.C. She is an ACOG state legislative chair from the District of Columbia and a member of the Ob.Gyn. News Editorial Advisory Board. She reported having no relevant financial disclosures.

The following opinions are my own and not those of the Veterans Health Administration.

A recurring question at many of the talks I give on posttraumatic stress and related topics is: “How can civilian providers relate to military service members and veterans?”

There are now online and in-person courses on this topic. The Center for Deployment Psychology in Bethesda, Md., and Massachusetts General Hospital in Boston are two of the better sources for these. Here, I would like to offer my condensed version.

Dr. Ritchie is a forensic psychiatrist with expertise in military and veterans’ issues. She retired from the U.S. Army in 2010 after serving for 24 years and holding many leadership positions, including chief of psychiatry. Currently, Dr. Ritchie is chief of mental health for the community-based outpatient clinics at the Washington, D.C., VA Medical Center. She also serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University and Howard University, both in Washington. Her recent books include “Forensic and Ethical Issues in Military Behavioral Health” (Department of the Army, 2015) and “Posttramatic Stress Disorder and Related Diseases in Combat Veterans (Springer, 2015). Dr. Ritchie’s forthcoming books include “Intimacy Post-Injury: Combat Trauma and Sexual Health (Oxford University Press, 2016) and “Psychiatrists in Combat: Mental Health Clinicians’ Experiences in the War Zone” (Springer, 2017 ed.)

The following opinions are my own and not those of the Veterans Health Administration.

A recurring question at many of the talks I give on posttraumatic stress and related topics is: “How can civilian providers relate to military service members and veterans?”

There are now online and in-person courses on this topic. The Center for Deployment Psychology in Bethesda, Md., and Massachusetts General Hospital in Boston are two of the better sources for these. Here, I would like to offer my condensed version.

Dr. Ritchie is a forensic psychiatrist with expertise in military and veterans’ issues. She retired from the U.S. Army in 2010 after serving for 24 years and holding many leadership positions, including chief of psychiatry. Currently, Dr. Ritchie is chief of mental health for the community-based outpatient clinics at the Washington, D.C., VA Medical Center. She also serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University and Howard University, both in Washington. Her recent books include “Forensic and Ethical Issues in Military Behavioral Health” (Department of the Army, 2015) and “Posttramatic Stress Disorder and Related Diseases in Combat Veterans (Springer, 2015). Dr. Ritchie’s forthcoming books include “Intimacy Post-Injury: Combat Trauma and Sexual Health (Oxford University Press, 2016) and “Psychiatrists in Combat: Mental Health Clinicians’ Experiences in the War Zone” (Springer, 2017 ed.)

The following opinions are my own and not those of the Veterans Health Administration.

A recurring question at many of the talks I give on posttraumatic stress and related topics is: “How can civilian providers relate to military service members and veterans?”

There are now online and in-person courses on this topic. The Center for Deployment Psychology in Bethesda, Md., and Massachusetts General Hospital in Boston are two of the better sources for these. Here, I would like to offer my condensed version.

Dr. Ritchie is a forensic psychiatrist with expertise in military and veterans’ issues. She retired from the U.S. Army in 2010 after serving for 24 years and holding many leadership positions, including chief of psychiatry. Currently, Dr. Ritchie is chief of mental health for the community-based outpatient clinics at the Washington, D.C., VA Medical Center. She also serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University and Howard University, both in Washington. Her recent books include “Forensic and Ethical Issues in Military Behavioral Health” (Department of the Army, 2015) and “Posttramatic Stress Disorder and Related Diseases in Combat Veterans (Springer, 2015). Dr. Ritchie’s forthcoming books include “Intimacy Post-Injury: Combat Trauma and Sexual Health (Oxford University Press, 2016) and “Psychiatrists in Combat: Mental Health Clinicians’ Experiences in the War Zone” (Springer, 2017 ed.)

Writing should be fun! While some may view writing as painful (i.e., something you rather put off until all your household work, taxes, and even changing the litter boxes are done), writing can and will become more enjoyable the more you do it. Over the years that I have been writing with students, residents, and faculty, I have found that writing the discussion section of a manuscript remains the most daunting aspect of writing a paper and the No. 1 reason people put off writing. Thus, I have developed a strategy that distills this process into a very simple task. When followed, manuscript writing won’t seem so intimidating.

I like to consider the writing process in three phases: preparing to write, writing, and then revising. Let’s address each one of these.

Preparing to write

In preparing to write, it is important to know what audience you want to reach when selecting a journal. I recommend that you peruse the table of contents of the journals you have in mind to determine if that journal is publishing papers similar to yours. You also may want to consider the impact factor of the journal, as the journals you publish in can have an effect on your promotion and tenure process. Once you have decided upon a journal, retrieve the Instructions for Authors (IFA). This section will contain very important information about how the journal would like for you to format the manuscript. Follow these instructions!

If you do not follow these instructions, the journal may reject your manuscript without ever sending it out for review (that is, the managing editor will reject it). Think of it this way, if an editor takes the time to develop the IFA, you’d better believe that the requirements are important to that editor.

Once you have decided upon the journal and read the IFA, it is time to make an OUTLINE. Yes – I said it – an outline. So often we skip this simple task that we were taught in grade school. For a manuscript, the outline I start with includes the figures and/or tables. Your figures and/or tables should tell the story. If they don’t tell a cohesive story, something is wrong. I like to draw out story board on 8.5” x 11” plain paper. Each sheet of paper represents one figure (or table), and I literally draw out each panel. Then I spread the pieces of paper out on a desk to see if they tell the story I want. Once the story is determined, the writing begins.
 

Writing

The main structure of a manuscript is simple: introduction, methods, results, and discussion. The introduction section should tell the reader why you did the study. The methods section should tell the reader how you did the study. The results section should tell the reader what you found when you did the study. The discussion section should tell the reader what it all means. The introduction should spark the readers interest and provide them with enough information to understand why you conducted the study. It should consist of two to three paragraphs. The first paragraph should state the problem. The second paragraph should state what is known and unknown about the problem. The third paragraph should logically follow with your aim and hypothesis. All manuscripts can and should have a hypothesis.

The methods section should be presented in a straightforward and logical manner and include enough information for others to reproduce the experiments. The information should be presented with subheadings for each different section. For example, a clinical manuscript may have the follow subheadings: study design, study population, primary outcome, secondary outcomes, and statistical analysis.

The results section should also be presented in a logical manner, with subheadings that make sense. Be sure to refer to the IFA on the type of subheadings to use (descriptive versus simple, etc.) and remember to tell a story. The story can be told with data of most to least important, in chronological order, in vitro to in vivo, etc. The main point is to tell a good story that the reader will want to read! Be sure to cite your figures and table, but don’t duplicate the information in the figures and tables.

A nice trick is to present the data in each paragraph, and end with a sentence summarizing the results. Remember, data are the facts obtained from the experiments while results are statements that interpret the data.

The discussion section should be seen as a straightforward section to write instead of an intimidating discourse. The discussion section is where you tell the reader what the data might mean, how else the data could be interpreted, if other studies had similar or dissimilar results, the limitations of the study, and what should be done next. I propose that all discussion sections can be written in five paragraphs.

Paragraph 1 should summarize the findings with respect to the hypothesis. Paragraphs 2 and 3 should compare and contrast your data with published literature. Paragraph 4 should address limitations of the study. Paragraph 5 should conclude what it all means and what should happen next. If you start by outlining these five paragraphs, the discussion section becomes simple to write.
 

Revising

The most important aspect of writing a manuscript is revising. The importance of this is often overlooked. We all make mistakes in writing. The more you reread and revise your own work, the better it gets. Aim for writing simple sentences that are easy for your reader to read. Choose words carefully and precisely. Write well-designed sentences and structured paragraphs. The Internet has many short online tutorials to remind one how to do this. Use abbreviations sparingly and avoid wordiness. Avoid writing flaws, especially with the subject and verb. For example, “Controls were performed” should read “Control experiments were performed.”

In summary, writing should be an enjoyable process in which one can communicate exciting ideas to others. In this short article, I have presented a few tips and tricks on how to write and revise a manuscript. For a more in-depth resource, I refer the reader to “How to write a paper,” published in 2013 (ANZ J Surg. Jan;83[1-2]:90-2).

Dr. Kibbe is the Zack D. Owens Professor and Chair, department of surgery, the University of North Carolina at Chapel Hill.
 

Writing should be fun! While some may view writing as painful (i.e., something you rather put off until all your household work, taxes, and even changing the litter boxes are done), writing can and will become more enjoyable the more you do it. Over the years that I have been writing with students, residents, and faculty, I have found that writing the discussion section of a manuscript remains the most daunting aspect of writing a paper and the No. 1 reason people put off writing. Thus, I have developed a strategy that distills this process into a very simple task. When followed, manuscript writing won’t seem so intimidating.

I like to consider the writing process in three phases: preparing to write, writing, and then revising. Let’s address each one of these.

Preparing to write

In preparing to write, it is important to know what audience you want to reach when selecting a journal. I recommend that you peruse the table of contents of the journals you have in mind to determine if that journal is publishing papers similar to yours. You also may want to consider the impact factor of the journal, as the journals you publish in can have an effect on your promotion and tenure process. Once you have decided upon a journal, retrieve the Instructions for Authors (IFA). This section will contain very important information about how the journal would like for you to format the manuscript. Follow these instructions!

If you do not follow these instructions, the journal may reject your manuscript without ever sending it out for review (that is, the managing editor will reject it). Think of it this way, if an editor takes the time to develop the IFA, you’d better believe that the requirements are important to that editor.

Once you have decided upon the journal and read the IFA, it is time to make an OUTLINE. Yes – I said it – an outline. So often we skip this simple task that we were taught in grade school. For a manuscript, the outline I start with includes the figures and/or tables. Your figures and/or tables should tell the story. If they don’t tell a cohesive story, something is wrong. I like to draw out story board on 8.5” x 11” plain paper. Each sheet of paper represents one figure (or table), and I literally draw out each panel. Then I spread the pieces of paper out on a desk to see if they tell the story I want. Once the story is determined, the writing begins.
 

Writing

The main structure of a manuscript is simple: introduction, methods, results, and discussion. The introduction section should tell the reader why you did the study. The methods section should tell the reader how you did the study. The results section should tell the reader what you found when you did the study. The discussion section should tell the reader what it all means. The introduction should spark the readers interest and provide them with enough information to understand why you conducted the study. It should consist of two to three paragraphs. The first paragraph should state the problem. The second paragraph should state what is known and unknown about the problem. The third paragraph should logically follow with your aim and hypothesis. All manuscripts can and should have a hypothesis.

The methods section should be presented in a straightforward and logical manner and include enough information for others to reproduce the experiments. The information should be presented with subheadings for each different section. For example, a clinical manuscript may have the follow subheadings: study design, study population, primary outcome, secondary outcomes, and statistical analysis.

The results section should also be presented in a logical manner, with subheadings that make sense. Be sure to refer to the IFA on the type of subheadings to use (descriptive versus simple, etc.) and remember to tell a story. The story can be told with data of most to least important, in chronological order, in vitro to in vivo, etc. The main point is to tell a good story that the reader will want to read! Be sure to cite your figures and table, but don’t duplicate the information in the figures and tables.

A nice trick is to present the data in each paragraph, and end with a sentence summarizing the results. Remember, data are the facts obtained from the experiments while results are statements that interpret the data.

The discussion section should be seen as a straightforward section to write instead of an intimidating discourse. The discussion section is where you tell the reader what the data might mean, how else the data could be interpreted, if other studies had similar or dissimilar results, the limitations of the study, and what should be done next. I propose that all discussion sections can be written in five paragraphs.

Paragraph 1 should summarize the findings with respect to the hypothesis. Paragraphs 2 and 3 should compare and contrast your data with published literature. Paragraph 4 should address limitations of the study. Paragraph 5 should conclude what it all means and what should happen next. If you start by outlining these five paragraphs, the discussion section becomes simple to write.
 

Revising

The most important aspect of writing a manuscript is revising. The importance of this is often overlooked. We all make mistakes in writing. The more you reread and revise your own work, the better it gets. Aim for writing simple sentences that are easy for your reader to read. Choose words carefully and precisely. Write well-designed sentences and structured paragraphs. The Internet has many short online tutorials to remind one how to do this. Use abbreviations sparingly and avoid wordiness. Avoid writing flaws, especially with the subject and verb. For example, “Controls were performed” should read “Control experiments were performed.”

In summary, writing should be an enjoyable process in which one can communicate exciting ideas to others. In this short article, I have presented a few tips and tricks on how to write and revise a manuscript. For a more in-depth resource, I refer the reader to “How to write a paper,” published in 2013 (ANZ J Surg. Jan;83[1-2]:90-2).

Dr. Kibbe is the Zack D. Owens Professor and Chair, department of surgery, the University of North Carolina at Chapel Hill.
 

Writing should be fun! While some may view writing as painful (i.e., something you rather put off until all your household work, taxes, and even changing the litter boxes are done), writing can and will become more enjoyable the more you do it. Over the years that I have been writing with students, residents, and faculty, I have found that writing the discussion section of a manuscript remains the most daunting aspect of writing a paper and the No. 1 reason people put off writing. Thus, I have developed a strategy that distills this process into a very simple task. When followed, manuscript writing won’t seem so intimidating.

I like to consider the writing process in three phases: preparing to write, writing, and then revising. Let’s address each one of these.

Preparing to write

In preparing to write, it is important to know what audience you want to reach when selecting a journal. I recommend that you peruse the table of contents of the journals you have in mind to determine if that journal is publishing papers similar to yours. You also may want to consider the impact factor of the journal, as the journals you publish in can have an effect on your promotion and tenure process. Once you have decided upon a journal, retrieve the Instructions for Authors (IFA). This section will contain very important information about how the journal would like for you to format the manuscript. Follow these instructions!

If you do not follow these instructions, the journal may reject your manuscript without ever sending it out for review (that is, the managing editor will reject it). Think of it this way, if an editor takes the time to develop the IFA, you’d better believe that the requirements are important to that editor.

Once you have decided upon the journal and read the IFA, it is time to make an OUTLINE. Yes – I said it – an outline. So often we skip this simple task that we were taught in grade school. For a manuscript, the outline I start with includes the figures and/or tables. Your figures and/or tables should tell the story. If they don’t tell a cohesive story, something is wrong. I like to draw out story board on 8.5” x 11” plain paper. Each sheet of paper represents one figure (or table), and I literally draw out each panel. Then I spread the pieces of paper out on a desk to see if they tell the story I want. Once the story is determined, the writing begins.
 

Writing

The main structure of a manuscript is simple: introduction, methods, results, and discussion. The introduction section should tell the reader why you did the study. The methods section should tell the reader how you did the study. The results section should tell the reader what you found when you did the study. The discussion section should tell the reader what it all means. The introduction should spark the readers interest and provide them with enough information to understand why you conducted the study. It should consist of two to three paragraphs. The first paragraph should state the problem. The second paragraph should state what is known and unknown about the problem. The third paragraph should logically follow with your aim and hypothesis. All manuscripts can and should have a hypothesis.

The methods section should be presented in a straightforward and logical manner and include enough information for others to reproduce the experiments. The information should be presented with subheadings for each different section. For example, a clinical manuscript may have the follow subheadings: study design, study population, primary outcome, secondary outcomes, and statistical analysis.

The results section should also be presented in a logical manner, with subheadings that make sense. Be sure to refer to the IFA on the type of subheadings to use (descriptive versus simple, etc.) and remember to tell a story. The story can be told with data of most to least important, in chronological order, in vitro to in vivo, etc. The main point is to tell a good story that the reader will want to read! Be sure to cite your figures and table, but don’t duplicate the information in the figures and tables.

A nice trick is to present the data in each paragraph, and end with a sentence summarizing the results. Remember, data are the facts obtained from the experiments while results are statements that interpret the data.

The discussion section should be seen as a straightforward section to write instead of an intimidating discourse. The discussion section is where you tell the reader what the data might mean, how else the data could be interpreted, if other studies had similar or dissimilar results, the limitations of the study, and what should be done next. I propose that all discussion sections can be written in five paragraphs.

Paragraph 1 should summarize the findings with respect to the hypothesis. Paragraphs 2 and 3 should compare and contrast your data with published literature. Paragraph 4 should address limitations of the study. Paragraph 5 should conclude what it all means and what should happen next. If you start by outlining these five paragraphs, the discussion section becomes simple to write.
 

Revising

The most important aspect of writing a manuscript is revising. The importance of this is often overlooked. We all make mistakes in writing. The more you reread and revise your own work, the better it gets. Aim for writing simple sentences that are easy for your reader to read. Choose words carefully and precisely. Write well-designed sentences and structured paragraphs. The Internet has many short online tutorials to remind one how to do this. Use abbreviations sparingly and avoid wordiness. Avoid writing flaws, especially with the subject and verb. For example, “Controls were performed” should read “Control experiments were performed.”

In summary, writing should be an enjoyable process in which one can communicate exciting ideas to others. In this short article, I have presented a few tips and tricks on how to write and revise a manuscript. For a more in-depth resource, I refer the reader to “How to write a paper,” published in 2013 (ANZ J Surg. Jan;83[1-2]:90-2).

Dr. Kibbe is the Zack D. Owens Professor and Chair, department of surgery, the University of North Carolina at Chapel Hill.