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A gunman stole his twin from him. This is what he's learned about grieving a sibling

Rhitu Chatterjee

At left, Zion Kelly holds a photo of his late twin brother Zaire Kelly. At right, Zion keeps this framed photo of he and his brother on the desk in his bedroom. Dee Dwyer for NPR hide caption

At left, Zion Kelly holds a photo of his late twin brother Zaire Kelly. At right, Zion keeps this framed photo of he and his brother on the desk in his bedroom.

The Science of Siblings is a new series exploring the ways our siblings can influence us, from our money and our mental health all the way down to our very molecules. We'll be sharing these stories over the next several weeks.

Zion Kelly still thinks of himself as a twin. By the time he and his fraternal twin, Zaire, were in their mid-teens, people often mistook Zaire as the older of the two brothers.

"He was taller than me, and his presence was just louder than mine," says the quiet, contemplative Zion, who is 23 now. "He was very social. He was extroverted. He had a lot of friends."

Despite their different personalities, Zion and Zaire were inseparable. They shared the same room, went to the same school, had the same group of friends and excelled at the same sports. "We played football," says Zion. "We ran track and we played basketball."

Special Series

The science of siblings.

And when not doing an activity together, they were always talking. "We talked a lot during the weekdays, the weekends. We were really close."

But September 20, 2017, was one of the rare days when the brothers had gone their separate ways after school.

Zion went straight home, and Zaire went to the competitive, academic mentoring program both teens attended. Later that night, when Zaire was walking home, a stranger approached him. "He attempted to rob Zaire," says Zion, "and, in his attempt, shot him."

When Zion reached the hospital where Zaire was taken, he could already see on the faces of his family that something was terribly wrong. Zaire had been pronounced dead. Zion was heartbroken. "I immediately broke down," Zion says. The Kelly brothers were 16.

Zion has spent the past seven years trying to find his way through grief and cope with the huge void left behind by Zaire's death.

A dearth of research

Most people who grieve the death of a sibling, do so well into adulthood. But every year, an estimated 60,000 children in the United States are bereaved by the death of a sibling. (And in the past few years, firearms have become the top cause for children's death.)

And yet, researchers know very little about the short and long-term impacts of such a loss. "The vast majority of studies that have focused on bereaved youth have tended to focus on the death of a parent," says psychologist Julie Kaplow , at the Trauma and Grief Center at the Meadows Mental Health Policy Institute, in Houston, Texas.

• In the womb, a brother's hormones can shape a sister's future

Kaplow and her colleagues, who work regularly with kids who have lost a sibling, say the death of a sibling is traumatic for the siblings left behind.

And while most such bereaved kids "will go on to lead healthy, happy, functional lives," says Kaplow, a significant minority are at risk of becoming stuck in their grief.

"They may have trouble functioning in their daily life," she says. "Their grief can also be accompanied by significant depression, or if the death is under traumatic circumstances, it can be accompanied by post-traumatic stress."

Finding purpose through grief

In the weeks and months after Zaire's death, Zion struggled to accept reality. "I was in denial," he says. "I couldn't really believe it."

What helped him cope, he says, was the love and support of his parents, his other siblings, extended family and friends. "I think because I'm a twin, a lot of people reached out to me."

Eventually, Zion came to accept his brother's death, and his loved ones helped him see that together they could keep his memory alive. "We just try to keep his name alive, keep his legacy alive by always having his pictures up, always talking about him."

Zion Kelly keeps a screensaver on his phone of he and his brother as young kids. Dee Dwyer for NPR hide caption

Zion Kelly keeps a screensaver on his phone of he and his brother as young kids.

Even now, the screensaver on his phone is a photo of him and Zaire when they were nearly 6 years old, both wearing yellow team jerseys and grinning at the camera.

Within a few months after Zaire's death, Zion also started speaking publicly about his loss to raise awareness about gun violence.

"I started to become more vocal," says Zion, "just telling my story and drawing attention to gun violence in Washington D.C."

Then, on Feb 14, 2018, 14 high school students and three adults died in a school shooting in Parkland, Florida. As teenagers across the country organized to protest gun violence in the wake of the Marjorie Stoneman Douglas High School shootings, Zion teamed up with them.

The introverted, soft-spoken teenager addressed the hundreds of thousands of people who gathered in the nation's capital that spring for the March for Our Lives rally to call for action against gun violence. Later, he traveled around the country and even to Italy to share his personal story of losing his twin brother to gun violence.

Zion Kelly's high school yearbook documented his efforts to bring attention to gun violence during the March for Our Lives rally. Dee Dwyer for NPR hide caption

"That's when I felt like he was really living through me, because the whole world, eventually, got to know his name, got to know my story," says Zion. He also felt that he was making his brother proud through his public speaking and activism. It gave him a passion and a purpose to focus on.

That can be a healthy way of coping, says Kaplow, and it's something she and her colleagues have seen in many grieving siblings.

"Living the legacy of the sibling who died, or wanting to do things that would make them proud," says Kaplow. "Or doing something to transform the circumstances [of their sibling's death] to something meaningful that can help other people not have to suffer in the same way."

National Siblings Day is a celebration born of love — and grief

Zion was doing all three of those things with his activism. Kaplow notes it can also be stressful, especially when the surviving sibling feels an unspoken pressure to fill in the void left behind by their sibling. "That can create a lot of distress – a lot of identity distress."

That identity struggle has been part of Zion's grief. "I was really struggling to find my identity of being a twin, but not really being a twin anymore," he says.

All his efforts to be more extroverted like Zaire had left him feeling exhausted. "I just felt drained trying to find myself," he says, "trying to find who I am, instead of thinking of the two of us."

"Disenfranchised grief" for a sibling

Many children and teens grieving the death of a sibling don't have the kind of emotional support Zion did after his brother's death. Even his older sister, who was in college at the time in Philadelphia felt lonely and struggled to cope with her grief once she returned to campus after Zaire's funeral, he says.

A family portrait honors the life of the late Zaire Kelly. Dee Dwyer for NPR hide caption

That is a common experience among grieving siblings, says Kaplow. Usually when a child dies, everyone around the family focuses on supporting the parents.

"There is less of a focus on the siblings who are left behind, and we know that their grief can be just as powerful and potent as the caregivers' grief."

And so these children end up experiencing what she describes as "disenfranchised grief."

"Somehow their grief doesn't feel as important or relevant as the grief of their parents," says Kaplow. "And [that] is a big problem."

That was Meghan Britton's experience after she lost her only brother, Andrew, when he was seven years old. She was 12 at the time.

Meghan Britton holds her childhood journal and her brother's teddy bear at her home in Fort Wayne, Ind. The journal was given to her by her mother's friend after the death of her brother. Kaiti Sullivan for NPR hide caption

In the weeks and months after Andrew's death, her parents struggled to cope. "They were just trying to survive the experience," says Meghan. And "everyone that came to visit, they focused on my parents."

No one knew what to say to her. If they did, it was with advice to be "strong" for her parents, or to ask her how they were doing.

"It was really lonely," she says. "And now that I didn't have any siblings anymore, there wasn't anyone that I could really talk to about it."

She struggled to process her loss and struggled to resume her normal life, especially school.

"I had a hard time going back to school because it just felt so jarring," she says. "Last week my brother passed away, and then this week, I'm supposed to go back to school. That was weird. That was hard."

Meghan and her brother Andrew in Michigan. The Britton family hide caption

Meghan and her brother Andrew in Michigan.

What made things harder, she says, is that neither her parents, nor anyone at school talked about Andrew after his death. She remembers thinking, "Did they not think about him anymore?"

What did help her in those early months and years, she says, is a present from her mother's best friend on the day of Andrew's funeral.

"She was a really frugal person, and so she wouldn't spend money unless it was critical," says Meghan. "And she pulled me out of the funeral home and took me to a Hallmark store."

At the store, she bought Meghan a journal and a pen. "She said, 'I want you to write down how you're feeling, because you need to get this out. You need to capture these things,'" Meghan recalls. "That's something that still, to this day, has served me well."

Eventually, Meghan also sought therapy, which helped her understand and accept her own emotions around her brother's death. And she began other healthy ways to cope with her grief – mainly by bringing up memories of Andrew – the sweet, funny and even annoying moments she shared with him.

For example, his habit of running into her, his head pointed at her belly, aiming to knock her over, and his love of science and Albert Einstein. "He dressed up as [Einstein] one year for Halloween," Meghan says.

Kids who are grieving need the help and support of their caregivers and other adults to cope, says Kaplow. "What we want to do is provide kids with enough of the coping skills needed to deal with that grief over time," she says.

Living with grief

Today, Zion lives in Washington, D.C., and works at College Bound, the same competitive academic mentoring program that he and Zaire attended when they were in high school. He shares a two-bedroom apartment with a friend.

But Zaire's absence still looms large in his life. And so he has filled his room with Zaire's photos – his way of keeping memories of his brother alive. Their high school yearbook – with photos of himself and Zaire in it – sits on top of a dresser along with the family photos.

In his bedroom, Zion Kelly keeps his brother's memory alive by displaying photos of them in happier times. Dee Dwyer for NPR hide caption

In his bedroom, Zion Kelly keeps his brother's memory alive by displaying photos of them in happier times.

He also tries to "be intentional" about how he lives his daily life. "[I] wake up every day and just try to live every day like it's your last day because you never really know when it's going to be your last day."

And when things feel really hard, he can still rely on his family for unconditional love and support. "If I have a lot going on, I can always go back home," he says. "I feel rejuvenated around my family, spending time with them."

Meghan, now in her mid-40s, is a mother of two girls – 9 and 12 years old. She's had three decades of learning to cope with her brother's absence and has come to accept the loss. Still, she says, she's been surprised by all the times waves of grief took her by surprise over the years. When her daughters were born, for instance, she was overcome with grief, realizing they would never know their uncle.

Meghan, with her brother Andrew, says that she is still surprised by all the times waves of grief took her by surprise over the years. The Britton family hide caption

More recently, when her grandparents were terminally ill and her mother and her four siblings came together to care for their parents and support each other in their grief after they died.

"I was just like, 'Son of a gun, I'm going to have to do this alone someday, and that is going to suck,'" she says. "Because, that's not how it was supposed to work."

The long tail of grief with such losses is normal, says Kaplow.

"As a society, we need to move away from this idea that we want the grief to go away, because it does not go away," she says. "This is a natural response of the love we have for the person who died, and we don't want it to go away."

Kids who are grieving the death of a sibling need help in learning that, she adds. They need help knowing that they may be dealing with reminders of their loss for the rest of their lives.

More from the Science of Siblings series:

• The order your siblings were born in may play a role in identity and sexuality
• Blended families are common. Here are tips to help stepsiblings get along
• Science of Siblings
• children grief
• child psychology

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• 10 April 2024

How to supercharge cancer-fighting cells: give them stem-cell skills

• Sara Reardon 0

Sara Reardon is a freelance journalist based in Bozeman, Montana.

You can also search for this author in PubMed   Google Scholar

A CAR T cell (orange; artificially coloured) attacks a cancer cell (green). Credit: Eye Of Science/Science Photo Library

Bioengineered immune cells have been shown to attack and even cure cancer , but they tend to get exhausted if the fight goes on for a long time. Now, two separate research teams have found a way to rejuvenate these cells: make them more like stem cells .

Both teams found that the bespoke immune cells called CAR T cells gain new vigour if engineered to have high levels of a particular protein. These boosted CAR T cells have gene activity similar to that of stem cells and a renewed ability to fend off cancer . Both papers were published today in Nature 1 , 2 .

The papers “open a new avenue for engineering therapeutic T cells for cancer patients”, says Tuoqi Wu, an immunologist at the University of Texas Southwestern in Dallas who was not involved in the research.

Reviving exhausted cells

CAR T cells are made from the immune cells called T cells, which are isolated from the blood of person who is going to receive treatment for cancer or another disease. The cells are genetically modified to recognize and attack specific proteins — called chimeric antigen receptors (CARs) — on the surface of disease-causing cells and reinfused into the person being treated.

But keeping the cells active for long enough to eliminate cancer has proved challenging, especially in solid tumours such as those of the breast and lung. (CAR T cells have been more effective in treating leukaemia and other blood cancers.) So scientists are searching for better ways to help CAR T cells to multiply more quickly and last longer in the body.

Cutting-edge CAR-T cancer therapy is now made in India — at one-tenth the cost

With this goal in mind, a team led by immunologist Crystal Mackall at Stanford University in California and cell and gene therapy researcher Evan Weber at the University of Pennsylvania in Philadelphia compared samples of CAR T cells used to treat people with leukaemia 1 . In some of the recipients, the cancer had responded well to treatment; in others, it had not.

The researchers analysed the role of cellular proteins that regulate gene activity and serve as master switches in the T cells. They found a set of 41 genes that were more active in the CAR T cells associated with a good response to treatment than in cells associated with a poor response. All 41 genes seemed to be regulated by a master-switch protein called FOXO1.

The researchers then altered CAR T cells to make them produce more FOXO1 than usual. Gene activity in these cells began to look like that of T memory stem cells, which recognize cancer and respond to it quickly.

The researchers then injected the engineered cells into mice with various types of cancer. Extra FOXO1 made the CAR T cells better at reducing both solid tumours and blood cancers. The stem-cell-like cells shrank a mouse’s tumour more completely and lasted longer in the body than did standard CAR T cells.

Master-switch molecule

A separate team led by immunologists Phillip Darcy, Junyun Lai and Paul Beavis at Peter MacCallum Cancer Centre in Melbourne, Australia, reached the same conclusion with different methods 2 . Their team was examining the effect of IL-15, an immune-signalling molecule that is administered alongside CAR T cells in some clinical trials. IL-15 helps to switch T cells to a stem-like state, but the cells can get stuck there instead of maturing to fight cancer.

The team analysed gene activity in CAR T cells and found that IL-15 turned on genes associated with FOXO1. The researchers engineered CAR T cells to produce extra-high levels of FOXO1 and showed that they became more stem-like, but also reached maturity and fought cancer without becoming exhausted. “It’s the ideal situation,” Darcy says.

Stem-cell and genetic therapies make a healthy marriage

The team also found that extra-high levels of FOXO1 improved the CAR T cells’ metabolism, allowing them to last much longer when infused into mice. “We were surprised by the magnitude of the effect,” says Beavis.

Mackall says she was excited to see that FOXO1 worked the same way in mice and humans. “It means this is pretty fundamental,” she says.

Engineering CAR T cells that overexpress FOXO1 might be fairly simple to test in people with cancer, although Mackall says researchers will need to determine which people and types of cancer are most likely to respond well to rejuvenated cells. Darcy says that his team is already speaking to clinical researchers about testing FOXO1 in CAR T cells — trials that could start within two years.

And Weber points to an ongoing clinical trial in which people with leukaemia are receiving CAR T cells genetically engineered to produce unusually high levels of another master-switch protein called c-Jun, which also helps T cells avoid exhaustion. The trial’s results have not been released yet, but Mackall says she suspects the same system could be applied to FOXO1 and that overexpressing both proteins might make the cells even more powerful.

doi: https://doi.org/10.1038/d41586-024-01043-2

Doan, A. et al. Nature https://doi.org/10.1038/s41586-024-07300-8 (2024).

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Chan, J. D. et al. Nature https://doi.org/10.1038/s41586-024-07242-1 (2024).

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Writing and Publishing Your Research Findings

Charles t. quinn.

* Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, TX

† Department of Clinical Sciences, University of Texas Southwestern Medical Center at Dallas, TX

A. John Rush

‡ Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas, TX

§ Clinical Sciences, Duke-National University of Singapore, Singapore

Writing clearly is critical to the success of your scientific career. Unfortunately, this skill is not taught in medical school or postgraduate training. This article summarizes our approach to the writing and publication of your research. Here we focus on empirical or experimental reports of translational and clinically oriented research. We review the process of choosing what to write, how to write it clearly, and how to navigate the process of submission and publication.

INTRODUCTION

Articulate writing is critical to scientific success.

This article summarizes material presented in a course that we have taught at the University of Texas Southwestern Medical Center at Dallas. The material is a synthesis of material from a variety of sources (see References), to which we have added our own, sometimes idiosyncratic, suggestions for developing peer-reviewed journal reports of clinical and translational research. We particularly want to acknowledge Essentials of Writing Biomedical Research Papers by Mimi Zeiger 1 at the University of California at San Francisco, whose book we highly recommend.

Writing clearly and accurately is critical to the success of your scientific career. If you do not write clearly, your article will not be cited. If you are not cited, you will not get promoted. If you do not get promoted, you will not have a job. Writing clearly to maximize your likelihood of being cited by others is key to your scientific survival. Published research is your only final product. A poorly written report could mean that you have wasted years conducting your study, because what you have done will not be cited or known. As such, it will not impact the field. The threat of career failure should be a powerful motivator for writing clearly, as is doing the very best science that one can.

Each article tells a story, but there is no “one true path” to writing. We each learn how to use our talents, overcome our deficiencies, and develop our skills differently. Each article we write is less difficult, but none is ever easy. To avoid feeling overwhelmed by the effort, we suggest that you approach writing as a series of questions to be clearly answered. What was the research question? Why does the answer matter? What was done? What was found? Has anyone else found that (or not)? What might it mean? What limitations or qualifications apply to the findings?

Define What to Report

What are you going to write? Obviously, the primary paper focuses on the main hypotheses that you tested. But there may be several secondary hypotheses and maybe a couple of tertiary papers that are hypothesis generating. But be careful. Do not write trivial papers (third-rate papers with too small samples). They take too much time, are not cited, and have minimal to no payoff.

So, consider at the outset what aspects of the project are to be submitted, where, and in what order. What is the primary paper? Are there secondary papers? Clinical investigation often requires many people, so consider which colleagues might like to take the lead on a secondary paper. That is, depending on the size of the study and the contributions, needs, and expertise of your multidisciplinary research team, think about additional papers for others than yourself.

Getting Started

How often have you heard, “I have writer’s block”? What does that mean? Everybody who has attended medical, dental, or nursing school can write. Thus, “writer’s block” is a fiction— an excuse. The underlying fear may be that either one cannot think clearly enough to be able to say what was done (in which case, a career change is indicated!) or one is afraid that the product will not be “good enough” and therefore procrastinates.

To overcome “writer’s block,” simply realize at the outset that most of the words in the first draft will not make it to the final draft. Once you have something on paper, however, you can edit it—repeatedly. To get it on paper, dictate, type, or handwrite it (whatever is fastest for you). We recommend that you start with an outline. The outline is straightforward: title, abstract, introduction, methods, results (with tables and figures), discussion, conclusions, references, acknowledgements, and disclosures. Then write a topic sentence for each paragraph in each section. The outline and the topic sentences should take you about an hour-and-a-half to write. Then start to write each paragraph in the 4 key sections (introduction, methods, results, and discussion).

One place to begin is with the protocol that you followed to conduct the study. The protocol contains the aims, hypotheses/questions, rationale, and methods. Thus, the protocol is the basis for the first drafts of the introduction and methods. You may need to update the significance (to beef up the introduction) and to cite the newest relevant literature. Borrow from what you have done to begin.

Recall that journals limit articles to 3000 to 4000 words. If each paragraph has 200 words, you have to write 18 to 20 paragraphs ( Table 1 ). The introduction has 3 to 4 paragraphs (never longer than 2 manuscript pages); discussion has 5; results typically has 4 to 6, depending on the number of questions; leaving 5 to 6 for methods. Once you break it down this way, it does not seem so bad.

The Main Elements of a Manuscript

Prepare to Spend Time

Realize that writing takes a lot of time. You must set aside uninterrupted time, which in our view is best inserted between other activities that do not involve writing. Write for a while, then stop and leave it alone. When you go back later, you will be more objective and be better able to edit your prior work. Too many people frustrate themselves by expecting to write up 4 years of work in 4 weeks. That is not realistic, especially if you have not written many prior papers, if you have other duties, or both. So think about what you want to produce and divide the work into “doable” pieces (eg, the major sections noted above). Allocate a fixed amount of uninterrupted time each day to work on 1 section at a time to assemble these pieces without regard to how well it is written and without thinking about references. Simply tell the story.

Tell the Story

Look at the big picture first. Recall that you know more about what you have done than anybody else, so do not get nervous. You know the story—what you did and why you did it. Writing the first draft should not be a big thing. Polishing your drafts is where the time is.

The most important thing is to tell the story. Most people get stuck in the details and lose track of the story. Readers want to know what the issues were, why they matter, and what questions were asked (introduction). Then how were the issues addressed, questions answered, and hypotheses tested (methods)? Next, what were the answers (results)? The results section is divided into subheadings, often based on the questions or hypotheses at the end of the introduction. A table or figure should accompany each question. Finally, what do you make of the results (discussion)? These are the major sections of each empirical report for scientific journals ( Tables 1 and ​ and2 2 ).

Elements of the Story Line

Recall for Whom You Are Writing

Do not write your paper for scientists, colleagues, the promotion and tenure committee, or your department chair. Tell the story as if you were talking to somebody who is not an expert in your area. If you make the article that simple and straightforward, readers will be able to understand what you did and be able to cite the paper. If you use a lot of jargon, compound sentences, or obscure wording, only you and your coauthors will actually know what you are saying.

Table 3 highlights the most common reasons for rejection/revision. Most of these issues can be addressed by being pithy (succinct but full of substance and meaning) and consistent. Sentences should be simple: subject, verb, object, period. Whenever possible, avoid compound sentences. Do not change terminology throughout the paper (eg, do not interchangeably use subjects, participants, patients, or volunteers). Readers will wonder why you changed the names. Whatever word or phrase you use to describe something, keep using the same term. This is not an English essay or creative-writing class. A scientific article uses an expository writing style—it simply tells the facts. The reader needs specificity, clarity, and brevity—not engaging phraseology. Be very specific. Avoid general statements such as, “The patients improved.” What does that mean? Better to say something like “Patients in group A had a greater reduction in X than did patients in group B; test, P value (Table X).” Finally, physicians tend to be pompous in their style of writing. Avoid this; it prevents clear communication. Invest in a guide to clear medical writing to help. 2

Common Reasons for Rejection or Revision

Let us now consider each element in a manuscript.

THE MANUSCRIPT

The title should have 12 words or fewer (pithy). Notice that movies do not have long titles. The Fugitive . Not Escaping Jail Following an Unfair Conviction in Chicago . Just The Fugitive .

Do not say: “A study of X.” Of course it is a study. That wastes words. Begin the title with a key word. Be to the point. Grab the reader’s attention. Table 4 lists characteristics of a good title.

Characteristics of a Good Title

There are 2 kinds of abstracts: structured and unstructured. Structured abstracts have distinct subsections: objectives, methods, results, and conclusions (these may vary by journal). Unstructured abstracts contain the same information, but are just 1 long paragraph.

Most people do not read an entire article. Everyone reads the abstract. So whatever is in the abstract is what everyone thinks is in the article. Therefore, it is critical to edit, polish, and perfect the abstract, because it is almost the only information that readers will take home.

What is the state of knowledge? What was the question (background)? What did you do and how did you do it (methods)? What did you find (results)? What is the bottom line (conclusion)? That’s it!

We like to write the abstract first because it forces us to give the 10-second version of the paper. Then we polish it repeatedly after we write the article. The abstract will change a lot—often not substantively, but especially in terms of clarifying and simplifying the presentation. If you write your abstract first, you must ensure that it matches the final manuscript.

Introduction

At the beginning, tell the readers the problem ( Table 5 ). What do we know and what do we not know? Why does this matter? Then, what are the questions or hypotheses to be addressed or tested? What, in brief, was the approach?

The Introduction: Start Broadly, Then Narrow

The introduction should hook the reader. Paragraph no. 1: What is known? For example, “Diabetes is bad news, especially when it is associated with fatty liver.” Paragraph no. 2: What is unknown? For example, “We do not know how to treat patients with this complication.”

Paragraph no. 3: What is the question or hypothesis? “This study was conducted to determine whether A is better than B in improving fatty liver in patients with diabetes.” What was done? “We addressed this question by conducting a randomized controlled trial of A versus B in diabetic patients with fatty liver.” Be sure the introduction states your questions or hypotheses. End the introduction with a statement of your hypothesis: “We hypothesized that A was significantly better than B at decreasing fatty liver because….” Bingo, the introduction is done.

The introduction is NOT a literature review. Do not over-reference. Seven to 10 references are plenty. Less experienced writers seem to feel the need to cite the entire literature before getting to the methods. Do not. Everybody will trust that you can read. What they want to know is what was the issue. Why is it important? How did you approach the problem?

A poorly written methods section is a major reason for rejection. Be specific. Give details. Readers must know what you did. Remember, someone may try to replicate what you did! If the replication fails, your credibility is questioned. Give enough detail to ensure that another scientist can replicate exactly what you did. Give no more detail than is necessary, but give all the details that are required for replication.

The methods section is typically in chronological order. What did you do first? Then what did you do? Methods can be dense. Use subheadings in the text to guide the reader. Table 6 lists common elements (subheadings) of methods.

Common Elements of the Methods

First, provide the study overview. What was the design? When was the study done? Where was it done? For example, “We conducted a multicenter randomized clinical trial of drug A versus placebo for 6 months in participants with type 2 diabetes and fatty liver.” This brief, 30,000-ft overview primes the reader for the dense (but clear) text that follows.

Then provide the details ( Table 6 ). How did you recruit the sample? Consecutive? When you felt like it? How did you define who is eligible? When did the study start and stop? And so on. Do not include results in the methods section. The rules for obtaining the sample are in methods. The sample that you obtained by using these rules is described in the first paragraph of results. 3 , 4 It is very important to say how the current sample relates to other reports of the same or related samples. Be very clear about whether patients in your study were or were not included in any prior reports. People doing meta-analyses or literature reviews, for example, must know whether the present sample is distinct or not from other samples. Surprisingly, you often cannot tell whether 2 reported samples are partially overlapping, the same, or distinct.

Describe where the study was conducted. Define all the variables used in the report, but none of the variables not in the report. Sometimes you might collect variables not included in this report. If they are in another report, you do not have to put them in this report.

What was the rationale for the randomization? Was it stratified? Was it computer based or did you use a table? Did you randomize in blocks? What was the informed consent process? Was there institutional review board or data safety monitoring board oversight? Were measurements blinded? Who was blinded and how?

How did you deliver the treatment of interest? How often were they treated? Who provided the treatment? How else were they managed? Could there be home visits? Could there be extra visits? Be very specific.

Did you assess whether patients adhered to treatment? If so, how? Did you ask them, count pills, or use MEMS caps?

How did you ensure that the people who delivered the study treatment did what they were supposed to do? Was there a manual? Was there quality control?

How were concomitant medicines managed? What rescue treatments or other efforts were used when patients worsened?

What were your outcomes or end points? Which was your primary outcome? Which were secondary? Who measured or obtained the end points? How? When? Was there quality control for these measures? Who did it? How? How often?

What sample size did you use? What kind of difference did you expect? What difference was expected? Did you power the study to detect this difference? What is the power? Why did you choose the statistical tests you did? Who did the analyses? Finally, it is very important that your coauthors see the data and have some discussion with the statistician so they really understand how the study was analyzed. You have to assume that your coauthors are going to make slides from this study and present it somewhere. If they do not understand the analysis, the audience will not. And they will be misinformed, unfairly judge your study, or both.

When writing the results, we first build the tables and figures. Then we write the text to tell the story, answering the study questions, around the tables and figures. The text of results is often brief because the tables and figures provide the findings. Be pithy. The less you elaborate, the clearer you will be. You want the bottom line to be very, very clear. Remember, results is for the results. The introduction tells readers why you did the study. How you arrived at the results is in methods. What the results mean is in discussion.

Start with the results of the most important question, then the second most important, and so on. Or organize the section chronologically. Use subheadings to denote each question or section. There should be no interpretation of findings in results. Make the results exciting, but do not hype. Table 7 lists important points to consider when writing this section.

The Results

If your patient sample is not extremely simple in composition, use a CONSORT chart. 3 , 4 This chart explicitly and clearly shows how you obtained the evaluable sample. It will save you many words. Journals may require this chart, especially for clinical trials. If 2 (or more) groups were compared, describe and compare these groups at baseline. Serious adverse events, tolerability, attrition, and dosing may be in subsequent tables. Describe patients sensitively. People are not schizophrenics or diabetics. They are patients with schizophrenia or diabetes. They are participants, not subjects. Why participants? Because they chose to participate by giving consent. Subjects, such as rats, do not give consent. 5

It is critical that the tables and figures carry the message. Do not repeat in the text what is in the tables and figures. Why? People can read the tables and figures. Use the text to direct the reader to the tables and figures. A sentence or 2 in the text to draw attention to a few key findings might be useful in the results section, but do not comment on every item in each table.

Tables and Figures

Figures and tables should stand alone. That is, each should be understood without reference to the text. The text simply alerts the reader when to look for them. So, if you use abbreviations or acronyms here, spell them out in the footnotes and legends. A figure has a title and legend that explains it; a table has a title and footnotes, if necessary, but no legend. Each figure or table should be on a separate sheet of paper. Remember, readers may use your tables and figures as slides. Make them clear and self-contained so that the slide has meaning.

Provide clear names for each column of your table. The study variables (eg, age, sex, severe adverse events, remission rates) are typically in the leftmost column, and each defines a row. The data are in the columns to the right. Avoid vertical lines in tables. The rows should have few to no horizontal lines.

Whenever you use a percentage in tables (and elsewhere), give the numerator and denominator so the reader can see how you derived it. We like to put significant P values in bold, but always follow journal style. Give the actual P value, not “NS” or “<0.05.” Only use decimal places that are informative. For example, nobody knows what 48.134 years of age means. Report 48.1 years. Keep it simple.

Good figures are worth a thousand words and probably several tables. Figures should show your primary comparisons. The reader should be able to look at the figures and tables and know what the questions and answers are without reading the text. Avoid 3-dimensional figures and gratuitous color and shading. Most of the ink used to print your table should represent your data, not explanatory or decorative material. Creating clear and meaningful figures is a skill one learns. Practice it. Texts by Tufte 6 and Goodman and Edwards 2 can aid you in good design.

Next to the abstract, we find the discussion to be the most difficult part to write. We may be excited about what we have found and have lots to say about it. This may make the discussion wander. Here is a way to organize the discussion ( Table 8 ).

Elements of the Discussion

The first paragraph summarizes what you found. “This study was designed to determine whether A is better than B with regard to X. We found A was better than B in terms of tolerability, side effects, and remission rates, but not in terms of Y.” If there was a second question, then the findings follow in the same first paragraph. You told them the questions (hypotheses) at the end of the introduction. Now, you summarize the answers. Avoid repeating the results; you just stated them.

The second paragraph of discussion addresses the question: “Has anybody else found anything like or different from what you found?” That is, how does it compare to the literature? If your findings are different, why? Is it the method, the sample, or measurement differences?

The third paragraph addresses the theoretical or clinical implications of the findings. What do these results mean about the utility or mechanisms of the study treatment or the pathophysiology of the disease being studied?

The fourth paragraph highlights limitations (and strengths). Limitations commonly include design, methods, generalizability, and internal validity. How certain are you about the results? A small study cannot be generalized. Measurements may have been too infrequent or too insensitive to detect an effect. Attrition may have been high. How does that affect certainty? Do not overstate the certainty of your findings. If you do not acknowledge the limitations of your report, the reviewers will make you. This is low-hanging fruit. Do not give reviewers the opportunity. Be honest, but this is your chance to frame the limitations in the best light. Remember, all studies have weaknesses. Do not feel embarrassed to list and discuss them. If your study has particular strengths, you may also highlight them here. This may soften the blow of the limitations.

Conclusions are pithy. Three sentences are enough—only 1 paragraph. A conclusion is: “A is better than B for these kinds of patients. This conclusion is limited by X and Y.” Some journals like you to suggest policy, economic, or practice implications—this is your final sentence: “Since X is better than Y and we have no other treatment for these patients, we recommend despite the limitations of this first trial that X might be a better treatment, but confirmatory studies are needed.” A common phrase that ends the conclusion is “more studies are needed.” Do not use it. More studies are always needed. Instead, state what studies you think are needed.

Leave the insertion of citations for the end. Where do references come up in the article? Largely in the introduction (7–10), methods (6–9), and discussion (15–20) (maximum, 30–40). The few references in the introduction should help lay out the problem and say why it is important. An introduction is NOT a literature review. The references in methods refer to measurements or techniques described in detail elsewhere. You do not have to describe them again; reference them.

If you use someone else’s idea, give appropriate credit. Remember, that person could be a reviewer. You do not have to cite everything, just that which is immediately relevant to support your point. Rely on peer-reviewed literature, reports, and reviews.

Acknowledgements

Acknowledgements are undervalued by authors but highly valued by colleagues. Be generous. Cite those people who substantially assisted in the project (eg, research assistants, key staff). Remember all the people who truly contributed to the success of the study, but who are not authors, and recognize them here.

Disclosures

Journals have different but increasingly strict rules about disclosure. Follow them closely. If you are in doubt about a relationship, disclose it. Only underdisclosing, not overdisclosing, will embarrass you.

GETTING IT PUBLISHED

This is a thorny issue. If you are the principal investigator, we strongly advise that you meet with your study team when you launch a study to talk about authorship. Consider who will write up the primary question and key secondary questions. Talk it through early, so everybody knows the expectations from the beginning. This is especially important for junior faculty who need to know, after spending a couple of years on the study, what are they going to get out of it.

Who is supposed to be an author? Most journals have specific requirements. Those who have contributed to the design and execution of the project and helped in developing the manuscript are logical possible coauthors. Just raising funds or being the chairman of the department does not qualify (use the acknowledgements for these individuals).

Typically, hired or support staff are not authors, but there may be exceptions, depending on their contributions. Students or fellows can certainly qualify if they make a substantive contribution either at the beginning, during the data analysis, or with the writing.

For large or multisite studies, it is extremely important to have a publication committee. Try to get on the publication committee. Some studies base authorship on enrollment, scientific expertise, execution of the study, and leadership. Have these discussions early and be up-front about authorship. Most people do not like to talk about authorship (as they do not like to talk about their salary). But you cannot be shy. Younger faculty need to be first, second, or third author. Beyond third author, you are “et al.” Last is for senior authors.

Rewrites are critical. There are many reasons to rewrite ( Table 9 ). We suggest that you go after specific targets with each rewrite. If you have coauthors, use them. The first author should not have to write everything if coauthors are to merit the recognition. Once you get a draft, share it with coauthors and direct each one to a task. “X, please revise the introduction.” “Y, please revise the methods.” You distribute the work and have it come back to you. You have final editorial say as the first author. It also helps you to see how your coauthors interpret what you have written, what questions they have, and what changes they suggest.

Reasons to Rewrite

When you ask coauthors to rewrite, set the time frame and tell them exactly what you want them to do. “Please give me feedback on the results section. Please review and revise within 7 days.” Everybody has a large pile of things to do. Without a scheduled time limit, the article goes to the bottom of the pile. Rewrite 1 section at a time. Sequence the writers, so somebody does one section and someone else does another. But remember, the manuscript should not read as if there was a different author for each section. So, you have to ensure that the entire text “flows” and is stylistically consistent.

Table 9 shows areas of attention for rewrites. Shorten the introduction. Polish the abstract. Shorten the discussion. Double-check the methods to be sure the words are totally explicit, specific, and detailed. Delete jargon. Delete words. Make sure your tables and figures, if read alone, tell the results all by themselves.

Outside Readers

Once you and coauthors have written the article to its “final version,” send it to 2 people who have no idea what you do, but who are intelligent and can communicate. They do not have to be experts in your area. Ask them to proofread the paper. Then ask them to tell you in their own words what you found. That way you will know whether they got the message.

Choosing a Journal

In choosing a journal, select one that is highly regarded with a high citation index. The journal content should match what you are reporting, so the readership will be interested in what you have to say. Some journals restrict length a lot—some less so, which might be a consideration in choosing a journal. Pick a journal as your first target that is bit of a long shot (sort of a stretch), but have in mind a second choice if the first rejects the paper. It is helpful if your second choice has similar requirements as the first. For example, you do not want to be limited to 4000 words for the first journal but to 2500 words for the second.

Rejections and Resubmissions

Rejections and negative reviews can be very frustrating. You may even feel angry or defeated. This is normal. Read the reviews through once, then put them aside for a while. If you are given the opportunity to resubmit, do not formulate your responses yet. Return several days later and read the reviews again. You will have a clearer mind then, and you will be less likely to respond angrily or with condescension. Some rejections are valid. Some are due to misunderstanding, which means that you were not clear. The reviewers took the time to read your article. If they did not “get it,” it is your writing.

Sometimes the editorial response highlights the problem and seems to say either “Please fix this and resubmit” or “It’s a long shot, but we’ll re-review it if you want to try—no guarantee though.” Always respond item-by-item to each of the reviewers’ comments in a detailed letter. Be careful with your tone. A negative tone in your responses will work against you. We like to write the response letter before revising the paper. Think through everything you want to do, then revise the paper and show your changes. Always include your coauthors in this process, because they are signing off on what you are resubmitting.

We hope this synopsis is helpful. It took 15 drafts. It could still be better. So, writing is never easy. But what you want to get back from the reviewers is “This is a clearly written, succinct report of X. I have some remaining questions….” No report is perfect. Recall that the reviewers are your helpers, but they cannot help improve your manuscript (or science) if you have not been clear in telling the story, specific in describing what you’ve done, and to the point throughout the paper. Good luck!

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What Worries Me Most About a Trump Presidency

By Caroline Fredrickson

Ms. Fredrickson is an adviser at the Open Markets Institute, a senior fellow at the Brennan Center for Justice and a visiting professor of law at Georgetown University.

There are almost daily headlines now describing what Donald Trump would do if elected: the mass deportations, the pardons handed out to his friends and golf buddies, the Justice Department settling scores and waging personal vendettas. The former president has even promised violence if the election goes against him, warning that it could be a “ blood bath .”

But as worrying as these prospects are, they are far from the biggest threats he poses. What we should fear most is Mr. Trump transforming our government into a modern-day Tammany Hall, installing a kleptocratic leadership that will be difficult if not impossible to dislodge.

I do not discount the possibility of state-sponsored violence, and I worry deeply about the politicization of the civil service . But those are, for the most part, threats and theories, and while they need to be taken seriously, people should be paying more attention to a far more likely reality: that Mr. Trump would spend much of his time in office enriching himself. He failed spectacularly as an insurrectionist and as a disrupter of the civil service, and his clownish and chaotic style may well lead to failure again — but he has succeeded time and time again in the art of the steal. If his grift continues into a second term, it will not only contribute to the fraying trust Americans have in their institutions, but also impair our ability to lead the world through a series of escalating crises.

Recall how Mr. Trump operated in his first term. Not only did he keep his stake in more than a hundred businesses, he made it a practice to visit his properties around the country, forcing taxpayers to pay for rooms and amenities at Trump hotels for the Secret Service and other staff members who accompanied him — money that went straight into his bank accounts and those of his business partners. Those interested in currying favor with the president, from foreign governments to would-be government contractors, knew to spend money at his hotels and golf clubs. According to internal Trump hotel documents, T-Mobile executives spent over $195,000 at the Trump Washington Hotel after announcing a planned merger with Sprint in April 2018. Two years later, the merger was approved.

Government, like fish, rots from the head down. Mr. Trump’s example freed up cabinet members to award huge contracts to their friends, business associates and political allies, while others ran their departments like personal fiefs. After the State Department’s inspector general was fired , Secretary of State Mike Pompeo’s use of official trips for clandestine meetings with conservative donors and allegations that his family misused staff members for tasks like walking his dog, picking up his wife from the airport and fetching his takeout came to light. And, in addition to being accused of improperly accepting gifts from those seeking influence, several other cabinet members were alleged to have used government funds for private travel . These may seem like banal infractions, but taken together, they are a reflection of who Mr. Trump is and how he governs.

Throughout his life, through Trump-branded wine, chocolate bars, sneakers, NFTs, ties, MAGA paraphernalia, a $59.99 Bible (of all things ) and, most recently, his Truth Social meme stock ploy, he has shown an unstoppable drive to enrich himself at all costs. He sees politics, like business, as a zero-sum game in which he wins only if someone else loses. These are the instincts that drive corruption, kleptocracy and grift. And, if past is prologue, we’re looking at a much more damaging sequel.

In a second term, Mr. Trump will have more freedom and power to undertake grift. He has already vowed to use pardons to protect supporters and possibly even himself from efforts to curb corruption (which may explain the nonchalance with which his son-in-law Jared Kushner has greeted criticism about the conflicts of interest raised by his recent real estate investments in Serbia and Albania, as well as the Saudi, Qatari and Emirati investments in his wealth fund). And he and his political advisers are building a deep bench of committed and loyal employees who could corrode and potentially destroy mechanisms of accountability in government, paving the way for kleptocratic leaders to entrench themselves in the bureaucracy where many would be able to remain past Mr. Trump’s term. And the mere presence of a phalanx of unquestioning lieutenants in the civil service will ensure that other civil servants fear retribution for objecting to the self-enrichment.

Naturally, I worry about other things, too, particularly the possibility of political violence. Mr. Trump could well claim he has won the election no matter the vote count and call on his supporters to rise up to ensure his takeover. Even before the votes are cast, his supporters are threatening election officials, judicial officials and state legislators, trying to intimidate them into either helping Mr. Trump or stepping aside to be replaced by Trumpists.

But legal, law enforcement and security obstacles are still in place to slow down or stop these efforts. We must remember that this time around, President Biden will still be president, able to control the military and federal law enforcement, and Congress has amended the outdated and vague Electoral Count Act to make it much harder for Mr. Trump’s congressional allies to contest a Trump loss in the electoral college or on Capitol Hill.

No such guardrails exist to curb Trumpian corruption. The Supreme Court, itself corrupt , has made it virtually impossible to prosecute even the most blatant corruption by government officials.

In a kleptocracy, corruption is a feature, not a bug, where politicians apply the law inconsistently , favoring friends and punishing enemies. By controlling government assets and handing them out to friends and family — and dangling possibilities in front of would-be supporters — as well as using politically motivated prosecutions, kleptocrats cement their control of government and disempower opponents. We need only recall Russia’s erstwhile effort to create a democracy: It quickly drained away into the pockets of Vladimir Putin and his oligarchs, leading to the hopelessness and acquiescence of Russian citizens once they realized they could no longer change their situation through democratic means.

Now we face that danger at home. If Mr. Trump wins, America will have a leader invested in his own personal power, both financial and punitive, and supported by a much more capable team. When lucrative contracts are handed out to Trumpist loyalists regardless of merit and dissident voices are targeted and silenced, America’s leadership on the global stage will dissolve when it’s needed most.

The consequences will echo for generations if we lack the ability and the will to attack problems like climate change, mass migration, a new space race and multiple wars. Nothing of substance will be done, Mr. Trump’s cronies will continue to act with impunity, and millions of Americans — already worried that elites are held to a different standard than regular people are — will lose even more confidence in their government, convinced that everyone in Washington is out for himself.

This combination of passivity on the one hand and impunity on the other could be fatal for our democracy. This is the true danger Mr. Trump poses.

Caroline Fredrickson is an adviser at the Open Markets Institute, a senior fellow at the Brennan Center for Justice and a visiting professor of law at Georgetown University.

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