From the editor's desk: A systematic guide to revising a manuscript.

Once a manuscript is submitted, the journal editor decides whether the manuscript merits further peer review, and the section editor or editor-in-chief reviews those comments and makes a decision that is conveyed to the corresponding author. Almost all accepted manuscripts require revisions of some kind. One of the good things about writing a case report is that it does not usually require major revisions; for the most part, comments can be addressed rather quickly with a few changes. The most common revisions requested are providing followup imaging information or additional laboratory/pathology information, shortening the length, and modifying sentences that boast of a major conclusion based on a single case. This article focuses on how to deal with the revision process so that it is smooth for both the author and the editor; and that it leads to a quick acceptance.

Puneet Bhargava, MD, Editor-in-chief of Radiology Case Reports

Case reports continue to enrich and enhance the knowledge and understanding of the radiology community. They provide a platform for publication of an important, previously unreported observation; a unique presentation of a disease; or an unexpected association or new treatment based on a single or small series of cases. They remain the cornerstones for the search of new medical information and stimulate further scientific, hypothesis-driven research projects (1). Case reports also provide an excellent opportunity to encourage medical students and residents to test their interest in pursuing an academic career. In general, case reports require less effort and time to publish than large data-driven research manuscripts; thus, even busy clinicians can generate a short but valuable communication that has the potential to publicize a new discovery, interesting observation, or further investigate a proposed pathogenesis.

Selecting a journal that best fits the scope and goals of the manuscript is a crucial step. If you do a thorough review of journal guidelines, including reviewing recent similar articles published and strictly adhering to the journal style, it increases your chances of acceptance and expedites the publication process (2). For example, many submissions have incorrect formatting of references, legends, and so forth. Such errors show lack of attention to detail and are annoying for the editorial staff and the editorial team. The authors usually are promptly requested to make these changes and resubmit, causing undue delay in the already arduous review process.

Once a manuscript is submitted, the journal editor decides whether the manuscript merits further peer review; it may be rejected right away, especially if there is insufficient evidence to prove the diagnosis or if the submission is not suitable for the journal. The section editor or editor-in-chief reviews the comments of the reviewer and makes a decision that is conveyed to the corresponding author within a few weeks. Almost all accepted manuscripts require revisions of some kind (3). One of the good things about writing a case report is that it does not usually require major revisions; for the most part, comments can be addressed rather quickly with a few changes. The most common revisions requested are providing followup imaging information or additional laboratory/pathology information, shortening the length, and modifying sentences that boast of a major conclusion based on a single case. Often, authors are eager to label a case as very rare by stating this is the first or fifth or tenth ever-reported case, or the tenth ever-reported case in English literature. Statements like these are often marked for revision. Review the following suggestions for how to deal with the revision process so that it is smooth for both both the author and the editor; this fosters a quick acceptance.

Understand and accept the decision: An editor typically chooses one among the four types of decisions listed below with the help of comments provided by the reviewers and his or her own impression after reviewing the manuscript. These decisions are:

Accept

Accept with revisions requested

Resubmit for review

Reject

It is very rare for a manuscript to be accepted without any required revisions. Category 2 means that the manuscript will be considered for publication after incorporation of suggested revisions. Most well-written manuscripts with high-quality illustrations fall into this category. Category 3 requires that the manuscript undergo the whole process of peer review once again after it is modified. Typically, these manuscripts are about a rare case or interesting entity that would arouse the readers' interest but are poorly written, with significant areas that require improvement. As for category 4, the most common reason for rejection of a manuscript is a lack of new/useful knowledge or doubt about whether the diagnosis cannot be established with certainty (4).

It is encouraging to know that 70% of all manuscripts that are rejected are eventually published in another journal -so authorial perseverance is usually rewarded at the end (5). While the decision and the comments may seem frustrating at first, understand that the final goal of the reviewers and the editor is to improve the overall quality, credibility, and readability of the manuscript. Research shows that peer-review process enhances the quality of medical research reporting (6).

Scrutinize the reviewer's comments. When you read the comments for the first time, they may sound overwhelmingly negative, and the revision requested may look like a very long and tiring process. After a short delay (this allows the “normal” emotional response to subside), read the comments again with an open mind and positive attitude, and the issues will become clearer. The comments are usually constructive and geared toward the improvement of the manuscript as a whole. The reviewers are volunteers who work without any compensation or prejudice; they sincerely hope to improve the quality of the manuscript.

Start working promptly. Usually, you have 2-3 weeks to submit the revision. But do not wait until the last minute to finish the revision. Your promptness in submitting the revision expresses your eagerness and sincerity about your work.

Proper strategy. Organize yourself so that you can produce a clear and comprehensive revision of the manuscript (7). A strategy that often works well is to copy and paste all of the comments with numbered bullet points into a Word (or other document) file that you send along with the cover letter for your revised submission to the editor. If you isolate all the comments, you can be confident that you have addressed all of them. (The last thing you would want to do is forget to address a comment.) Take all comments seriously and answer them sincerely and respectfully. Begin by answering each comment in the Word file, using a different color or type style so that it is clear which are the comments and which are your replies. Then, create an annotated version of the manuscript in which each change is clearly marked (turn change-tracking on in the review mode).

There may be instances where you disagree with the reviewer. In such a case, respectfully express this (8)-for example, “Although we understand the concern raised by the reviewer, we disagree because of …”. Use additional citations to prove your point. You may see conflicting statements from two reviewers. If this happens, clearly outline your position and mention the conflict when addressing the comment. If the conflict is extreme, do not hesitate to contact the editor, who will help you resolve the issue. In addition, there may be comments that are beyond your scope to address. For example, you may be asked to provide a pathologic proof or provide followup information that is not practical or even possible. In these cases, acknowledging and explaining the limitation usually satisfies the query. Once all comments are addressed and all changes made to the annotated copy, save and submit an additional clean version of the revised manuscript (without any annotation).

Cover letter to the editor: When you compose the cover letter to the editor, acknowledge the effort and time taken by the reviewers and and express willingness to address any more issues or questions that may arise in the future. Attach both the annotated and clean copy of the revised manuscript. Usually, the editor goes through the revised submission; in most cases, the manuscript is not sent back to the reviewers (9). Be sure that your revisions are clear, comprehensive, and detailed. Make it as easy as possible for the editor to quickly review and accept your manuscript. If you are unable to address a comment in detail, show that you tried your best (editors recognize the effort) and use the evidence in literature to support your statements.

Conclusion

Manuscript revision, though challenging, is a rewarding task. The goal of all persons involved (reviewers, editors, and authors) is to produce a much-improved manuscript. Your positive, organized, and disciplined approach towards revision, using the abovementioned strategies, will very likely increase the likelihood of acceptance and decrease the time to eventual publication.