Peer Review Standards for Clinical Manuscripts

Overview of Clinical Manuscript Peer Review

Purpose

Peer review ensures that clinical manuscripts meet standards for scientific rigor, ethical conduct, and clear communication before publication.

Objectives:

• Assess scientific validity and methodology
• Evaluate clinical significance
• Verify ethical compliance
• Ensure clarity and completeness
• Improve manuscript quality

Types of peer review:

• Single-blind (reviewer knows author, author doesn't know reviewer)
• Double-blind (both parties anonymous)
• Open peer review (both parties known)
• Post-publication peer review

Reviewer Responsibilities

Accept reviews only when:

• Qualified in the subject area
• No conflicts of interest
• Adequate time available (typically 2-3 weeks)
• Can provide constructive, unbiased evaluation

Maintain confidentiality:

• Do not share manuscript content
• Do not use information for personal advantage
• Do not involve others without editor permission

Provide timely review:

• Complete within requested timeframe
• Notify editor promptly if unable to complete

Case Report Review Criteria

CARE Guideline Compliance

Verify manuscript includes:

• Title identifies it as case report
• Keywords provided (2-5)
• Structured or unstructured abstract
• Introduction explaining why case is novel
• Patient information (de-identified)
• Clinical findings
• Timeline of events
• Diagnostic assessment
• Therapeutic interventions
• Follow-up and outcomes
• Discussion with literature review
• Patient perspective (if applicable)
• Informed consent statement

Novelty and Significance

Assess:

• Is this case truly novel or does it add to medical knowledge?
• What makes this case worth reporting?
• Is the condition rare or presentation unusual?
• Does it challenge existing knowledge?
• Are there clinical lessons that can be generalized?

Red flags:

• Common presentation of common condition
• Single case without unique features
• Overgeneralization from single case
• Lack of literature review showing novelty

Privacy and Ethical Considerations

Verify:

• Informed consent obtained and documented
• Patient adequately de-identified (18 HIPAA identifiers removed)
• No identifiable images without explicit consent
• Dates removed or approximated
• Geographic information limited to state/country
• Age appropriate (exact age or range)
• Institutional identifiers removed

Ethical concerns:

• Missing consent documentation
• Identifiable information present
• Lack of IRB approval for retrospective chart review (if applicable)
• Vulnerable populations without additional protections

Clinical Quality

Diagnostic process:

• Appropriate workup for presenting symptoms
• Differential diagnosis considered
• Logical progression to final diagnosis
• Adequate documentation of findings

Treatment:

• Evidence-based interventions
• Rationale for treatment choices
• Alternative treatments considered
• Appropriate monitoring and follow-up

Outcome:

• Clear description of clinical outcome
• Follow-up duration appropriate
• Complications documented
• Long-term outcome if available

Literature Review

Assess:

• Adequate search of existing literature
• Similar cases identified and discussed
• Current understanding of condition reviewed
• Case appropriately contextualized
• References current and relevant
• Comparison to prior cases

Writing Quality

Structure:

• Logical flow and organization
• CARE guideline structure followed
• Clear, concise writing
• Appropriate medical terminology

Clarity:

• Medical jargon explained
• Timeline clear and easy to follow
• Chronology of events logical
• Conclusions supported by case details

Clinical Trial Manuscript Review Criteria

Study Design and Methodology

Assess:

• Appropriate study design for research question
• Clear objectives and hypotheses
• Well-defined primary and secondary endpoints
• Adequate sample size with power calculation
• Randomization and blinding appropriate
• Control group appropriate

Red flags:

• Post-hoc changes to endpoints
• Underpowered study claiming equivalence
• Inappropriate statistical methods
• Lack of blinding when feasible
• Selection bias in enrollment

CONSORT Compliance

Verify:

• Title identifies as randomized trial
• Structured abstract
• Trial registration number provided
• Protocol accessible
• CONSORT flow diagram included
• Baseline characteristics table
• All outcomes reported (not just significant ones)
• Adverse events reported
• Funding source disclosed
• Conflicts of interest declared

Randomization and Allocation

Assess:

• Adequate sequence generation method
• Allocation concealment appropriate
• Baseline characteristics balanced
• Stratification factors specified
• Crossovers and protocol deviations documented

Participant Flow

Verify:

• Number screened reported
• Exclusion reasons provided
• Number randomized clear
• Dropouts and reasons documented
• Lost to follow-up minimized and explained
• ITT and per-protocol analyses specified
• CONSORT diagram complete and accurate

Outcome Measures

Primary outcome:

• Clearly defined a priori
• Clinically meaningful
• Appropriate for research question
• Measured reliably and validly
• Statistical analysis appropriate

Secondary outcomes:

• Pre-specified in protocol
• Analyzed appropriately
• Multiple comparison correction if needed
• Not over-interpreted if underpowered

Exploratory outcomes:

• Clearly labeled as exploratory or post-hoc
• Not given same weight as primary
• Hypothesis-generating, not confirmatory

Statistical Analysis

Assess:

• Analysis plan specified before unblinding
• Appropriate statistical tests
• Assumptions verified (normality, etc.)
• Missing data handled appropriately
• Multiplicity adjustments when needed
• Confidence intervals provided
• Effect sizes reported

Common issues:

• p-hacking (selective reporting)
• Multiple testing without correction
• Inappropriate subgroup analyses
• Switching between ITT and per-protocol analyses
• Missing data ignored or improperly handled

Safety Reporting

Verify:

• All adverse events reported
• Serious adverse events detailed
• Deaths fully described
• Causality assessed
• Laboratory abnormalities reported
• Discontinuations due to AEs documented

Clinical Significance

Assess:

• Statistical significance vs. clinical significance
• Magnitude of effect clinically meaningful
• Number needed to treat (NNT) if applicable
• Benefit-risk ratio favorable
• Generalizability to practice
• Cost-effectiveness considerations

Diagnostic Study Review Criteria

STARD Guidelines (Standards for Reporting Diagnostic Accuracy Studies)

Assess compliance:

• Study design described
• Participant selection criteria
• Sampling method
• Data collection procedure
• Reference standard defined
• Index test described in detail
• Blinding addressed
• Flow of participants clear
• 2×2 table provided
• Diagnostic accuracy estimates

Reference Standard

Verify:

• Appropriate gold standard used
• Same reference standard for all participants
• Reference standard performed regardless of index test result
• Time between index test and reference standard appropriate
• Independent interpretation of index test and reference standard

Test Performance

Required metrics:

• Sensitivity and specificity
• Positive and negative predictive values (with prevalence)
• Likelihood ratios
• ROC curve and AUC (if continuous outcome)
• 95% confidence intervals for all estimates

Consider:

• Pre-test and post-test probabilities
• Clinical utility beyond accuracy
• Comparison to existing tests
• Cost and availability

Spectrum and Verification Bias

Assess:

• Spectrum of disease severity included
• Avoiding spectrum bias (only severe cases)
• Verification bias avoided (all participants get reference standard)
• Differential verification avoided (different reference standards for different participants)

Observational Study Review Criteria

STROBE Guidelines (Strengthening the Reporting of Observational Studies in Epidemiology)

For cohort, case-control, or cross-sectional studies, verify:

• Title and abstract identify study design
• Background and rationale clear
• Objectives specified
• Study design present in methods
• Setting described
• Participants described
• Variables clearly defined
• Data sources and measurement detailed
• Bias addressed
• Study size justified
• Statistical methods described
• Results reported with effect sizes and CIs

Exposure and Outcome Assessment

Assess:

• Exposure clearly defined
• Outcome clearly defined
• Measurement methods valid and reliable
• Blinding of assessors when possible
• Consistent measurement across groups
• Time relationship between exposure and outcome appropriate

Confounding and Bias

Verify:

• Potential confounders identified
• Adjustment for confounders in analysis
• Residual confounding discussed
• Selection bias addressed
• Information bias considered
• Sensitivity analyses performed

Causality

Bradford Hill Criteria consideration:

• Strength of association
• Consistency across studies
• Specificity
• Temporality (exposure precedes outcome)
• Biological gradient (dose-response)
• Plausibility
• Coherence with existing knowledge
• Experimental evidence
• Analogy

Avoid:

• Causal language for observational studies without strong evidence
• Confusing association with causation

Systematic Review and Meta-Analysis Review Criteria

PRISMA Guidelines

Verify:

• Title identifies as systematic review/meta-analysis
• Structured abstract
• Research question (PICO format)
• Protocol and registration (PROSPERO)
• Search strategy comprehensive
• Study selection process described
• Data extraction process
• Quality assessment of included studies
• Synthesis methods appropriate
• Results with forest plots
• Assessment of heterogeneity
• Publication bias assessed
• Certainty of evidence (GRADE)

Search Strategy

Assess:

• Multiple databases searched
• Search terms comprehensive
• Limits and filters justified
• Gray literature considered
• Hand-searching of references
• Contact with authors for missing data
• Search reproducible

Study Selection

Verify:

• Inclusion/exclusion criteria pre-specified
• Independent screening by ≥2 reviewers
• Disagreements resolved appropriately
• PRISMA flow diagram complete
• Excluded studies with reasons

Quality Assessment

Assess:

• Appropriate quality assessment tool used
  • RCTs: Cochrane Risk of Bias tool
  • Observational: Newcastle-Ottawa Scale
  • Diagnostic: QUADAS-2
• Independent quality assessment
• Results of quality assessment reported
• Quality incorporated into synthesis

Statistical Methods

For meta-analysis:

• Fixed vs. random effects model justified
• Heterogeneity assessed (I², Q statistic)
• Forest plot provided
• Publication bias assessed (funnel plot, Egger's test)
• Sensitivity analyses performed
• Subgroup analyses pre-specified

GRADE Assessment

Certainty of evidence:

• High: Very confident in effect estimate
• Moderate: Moderately confident
• Low: Limited confidence
• Very low: Very little confidence

Factors decreasing certainty:

• Risk of bias
• Inconsistency
• Indirectness
• Imprecision
• Publication bias

Manuscript Quality Assessment

Structure and Organization

Assess:

• Logical flow from introduction through discussion
• Sections appropriately organized
• Figures and tables support text
• Supplementary materials appropriate

Writing Quality

Clarity:

• Clear, concise language
• Jargon minimized and defined
• Abbreviations defined at first use
• Consistent terminology

Grammar and style:

• Correct grammar and spelling
• Appropriate verb tense (past for study results, present for established facts)
• Active voice when appropriate
• Concise without sacrificing clarity

References

Verify:

• Adequate number of references
• Current literature included
• Key papers cited
• References formatted correctly
• All citations in reference list and vice versa
• No excessive self-citation

Tables and Figures

Assess:

• Appropriate for data type
• Clear labels and legends
• High quality images
• Can stand alone
• No redundancy with text
• Statistical notation correct

Ethical Considerations in Review

Conflicts of Interest

Disclose and recuse if:

• Personal relationship with authors
• Financial interest in outcome
• Competing research
• Strong bias for or against topic
• Institutional conflict

Fair and Constructive Review

Provide:

• Balanced assessment of strengths and weaknesses
• Specific, actionable suggestions
• Respectful tone
• Objective evaluation
• Recognition of limitations of study design

Avoid:

• Personal attacks
• Dismissive language
• Demanding unreasonable revisions
• Expecting perfect study
• Imposing personal preferences over standards

Confidentiality

Maintain:

• Do not share manuscript
• Do not discuss with colleagues without permission
• Do not use ideas or data
• Destroy copies after review

Recommendation Categories

Accept:

• Manuscript meets publication standards
• Minor editing only

Minor revisions:

• Small issues that can be addressed
• No additional data required
• Typically one round of revision

Major revisions:

• Significant concerns requiring substantial changes
• May require additional analyses
• May require additional data or experiments
• Typically re-reviewed

Reject:

• Fundamental flaws that cannot be corrected
• Insufficient novelty or significance
• Unethical conduct
• Fraudulent data

Reject and resubmit:

• Study has potential but needs substantial work
• Essentially new submission after major changes

Writing the Review Report

Structure

Summary:

• Brief overview (2-3 sentences)
• Overall assessment
• Key strengths (2-3 points)
• Key weaknesses (2-3 points)
• Recommendation

Major comments:

• Numbered
• Significant issues affecting validity, interpretation, or impact
• Specific and actionable
• Prioritized

Minor comments:

• Numbered
• Editorial, formatting, or clarification issues
• Line-specific comments
• Table/figure comments

Tone and Language

Use:

• Professional, collegial tone
• "The authors state..." not "You state..."
• "This study shows..." not "Your study shows..."
• Constructive criticism
• Suggestions for improvement

Avoid:

• Harsh or dismissive language
• Personal pronouns
• Sarcasm
• Vague criticism
• Unreasonable demands

Specific and Actionable Feedback

Good: "The sample size calculation (page 8) does not account for expected dropout rate. Please revise to include expected dropout and explain how this affects enrollment targets."

Poor: "Sample size is inadequate."

Good: "Figure 2 would be clearer if error bars represented 95% CI rather than SEM. Please revise and update figure legend accordingly."

Poor: "Figure 2 is confusing."

This reference provides comprehensive peer review standards for clinical manuscripts including case reports, clinical trials, diagnostic studies, observational studies, and systematic reviews. Use these criteria to conduct thorough, constructive peer reviews.