Reviewing grammar and punctuation

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2], Usama Talib, BSc, MD [3], Ahmed Younes M.B.B.CH [4]


Writing is quite different from speaking. During speaking you can add expressions to what you say. Expressions mean what you do with your voice, or with your hands and face, while you are talking. You can make your voice go up or down; you can make it loud or soft, you can pause, hesitate or repeat things. But in writing, there are no voices or faces or hands to give expressions. Written words are just flat on the page. To bring them to life, you need punctuation marks:

  • Full stop .
  • Question mark ?
  • Exclamation mark  !
  • Comma ,
  • Colon  :
  • Semicolon  ;
  • Dash –
  • Brackets ( )

Period .

Whether a sentence is short or long, it needs a period (full stop) at the end. Full stops come at the end of complete sentences. You can put as much information into one long sentence as you can put into several short ones. Good writing is a mixture of short, medium, and long sentences.

  • Example:
    • The management of the patient with acute decompensated heart failure depends upon whether the patient has acute decompensated systolic heart failure or acute decompensated diastolic heart failure.

Question mark  ?

There are sentences which ask you something. Questions, as you would expect, end with a question mark, and like all sentences they begin with a capital letter.

  • Example:
    • Is the patient symptomatic?

Exclamation mark  !

Exclamation marks are used for sentences which have expressions, such as anger, surprise, urgency, amusement, or annoyance in them. An urgent or angry command can have an exclamation mark. Commands can be very short, sometimes as short as one word.

  • Example:
    • Thank you!

Comma ,

The job of the comma is to make sentences, particularly longer sentences, easier to read. When you are reading aloud, commas usually mark a slight pause or change of voice. Often, when you name someone or something, you need a description as well. Do not forget to put space after comma.

  • Example:
    • Oxygen improves the patient's status if hypoxemia is present, and the goal is to keep the oxygen saturation above 90%.

Commas are also useful to show the joints in a sentence: for example, where a phrase or clause has been added, or two sentences made into one.

  • Example:
    • Following transmission, the agent inoculates the tracheobronchial epithelium.

Commas are particularly important when the sentence has an extra part stuck in the middle. When this happens there should be a comma before and after the extra part.

  • Example:
    • During a streptococcal infection, activated antigen-presenting cells such as macrophages, present the bacterial antigen to helper T cells.

Semicolon  ;

A semicolon marks a bigger break than a comma but does not replace a full stop. Unlike a comma, a semicolon can go between two sentences. Use a semicolon if the sentences are alike, or belong together. Unlike full stops, semicolons can come in the middle of sentences. Use them only when you want a strong break between two parts of your sentence.

  • Example:
    • The most recent classification according to the left ventricular ejection fraction; heart failure with reduced ejection fraction vs heart failure with preserved ejection fraction, is widely used.

Colon  :

Use a colon when you have a list of things coming after a heading. A colon is used before giving an example – or examples – of something. You also use a colon between two sentences, when the first one says something, and the second one says what you mean by it. Colons are often found before instructions even if they are pictures.

  • Example:
    • There are numerous systemic risk factors associated with thrombus formation following plaque rupture:
      1. Smoking: Smoking increases platelet aggregation and plasma epinephrine levels.
      2. Fibrinogen: Elevated levels of fibrinogen have been associated with thrombosis including abnormal levels of fibrinogen.

Brackets ( )

Brackets come in pairs, with words, phrases, or sentences inside them. Inside brackets, you put things that may be helpful, but not really necessary. Sometimes just a part of a sentence is in brackets.

  • Example:
    • Atherosclerosis is the gradual buildup of cholesterol and fibrous tissue (collagen and smooth muscle cells) throughout the vascular tree.

Dash -

Dashes are sometimes used to mark a big break, or interruption, in a sentence. A dash can be used like a colon. Sometimes dashes are used instead of brackets. Dashes are very useful in writing speech and they are also very useful for showing where someone is interrupted, and doesn’t finish what they’re saying.

  • Example:
    • Pathology studies indicate that it is often mild-to-moderate, lipid-laden, inflamed plaques that are the ones most likely to rupture and cause an ST elevation MI.


When you start a new sentence, you should use a capital letter. Proper nouns—the words which name people, places, or things—also begin with a capital letter, wherever they come in a sentence.

  • Always capitalize:
    • The first word of every new sentence or bullet
      • Example 1: "Heart failure" is defined as the inability of the heart to pump enough blood to meet the demands of the body.
      • Example 2: (Bullet)
        • "Headache"
    • The name of a disease, named after someone, but not the general disease names
      • Example 1: The patient is suffering from "Münchausen syndrome" but has no symptoms of "major depressive disorder."
    • Trade names of medications but not the generic names
      • Example 1: The preferred drug for the symptoms of this disease is "Tylenol," which contains "acetaminophen."
    • Abbreviations
      • Example 1: Pathogens: Chickenpox is caused by "varicella zoster virus (VZV)."
      • Example 2: Organizations: The "United States Preventive Task Force (USPSTF)" has established guidelines for screening various diseases.
    • Names of individuals, cities, countries, race or study design
      • Example 1: Individuals: In 1836, "Joseph Parrish" described three cases of severe lower urinary tract symptoms without the presence of a bladder stone.
      • Example 2: Race: Pyelonephritis is more prevalent among "Asian" population as compared to "Caucasians."
      • Example 3: Race: New information suggests that elements of heart failure in "African Americans" and "Caucasians" may be different.
      • Example 4: Countries: It is estimated that about 5.7 million adults in the "United States" have heart failure (about 2,650,000 males, and 2,650,000 females).
      • Example 5: Cities/States: A study conducted in "Olmsted County," 'Minnesota" showed that the incidence of heart failure (ICD9/428) has not declined during two decades, but survival after onset has increased overall, with less improvement among women and elderly persons.
      • Example 6: Study Design: Data from the NHLBI’s "Framingham Heart Study" indicate that heart failure (HF) incidence approaches 10 per 1,000 population after age 65.
    • Headings
      • Example 7: Headings: "Country-Specific Causes"
      • Example 8: Headings: "Natural History, Complications and Prognosis"
  • In case of any confusion, google the word and look for its utilization within a sentence.

Special Case of Capitalization in Titles

  • Capitalize all words except the following:
  • Articles such as a, an, and the.
  • Short conjunctions such as and, as, but, if, or, and nor.
  • Short prepositions such as at, by, for, in, of, off, on, out, to, and up.
  • Exceptions:
Articles, short conjunctions, and short prepositions should be capitalized as follows:
  • Capitalize the first and last words of titles, no matter the length of the words.
  • Capitalize the word the at the beginning of a title only if it is actually part of the title.
  • Capitalize the first word following a dash or colon in a title.
  • Capitalize words such as in, out, off, up, and by in titles when they serve as adverbs rather than as prepositions.
  • Capitalize short prepositions such as up, in, on, and for when used together with prepositions having four or more letters.
  • Examples:
  • Retinal Hemangioblastoma in von Hippel–Lindau Disease
  • Von Recklinghausen's Disease and Breast Cancer
  • Autism in Children Born After In Vitro Fertilization
  • A Fine-Scale Chimpanzee Genetic Map from Population Sequencing
  • Stepwise Screening of Atrial Fibrillation in a 75-Year-Old Population: Implications for Stroke Prevention

Apostrophe S ‘S and S’

For singular words you always show belonging by ‘s. Even if a singular word already ends in –s, you still add ‘s. If the word ends in –s because it’s plural, the apostrophe goes after it. If the word is plural but it doesn’t end in –s, then stick to ‘s. Don’t make the common mistake of putting an apostrophe wherever you see an "s." Most words that end in –s are just plain plurals. The –s on the in is not for belonging, so there is NO apostrophe! There is an odd-one-out you have to remember: its. When its means there’s something belonging to it, there’s no apostrophe. When it’s a contraction of "it is," there is an apostrophe.

  • Example:
    • The patient's heart
    • Ankles' bones
    • Appendix's entries


Bullet points help to make what you’re saying more clear. They break up blocks of text into tidy chunks so the reader can take in what you’re saying. They present lists in a clear format so people can see, it’s a list.
When using bullets, be consistent throughout the document with the formatting (e.g. capital letters and punctuation at the start and end of each bullet). Most often, bullets should be indented by at least an inch from the left margin. Also, most lists included in academic papers must be double spaced and properly referenced. The text introducing the list of bullet points should end with a colon. The first word in each entry is normally capitalized. When the entries look like titles, they may use title capitalization.

  • Example:
  • The following are other risk factors:
    • Low socioeconomic status
    • Prior or current STD
    • New or multiple sex partners

i.e and e.g

i.e. is Latin for id est and means that is or in other words. Use i.e. before clarifying or adding to the previous statement.

  • Example:
    • Cortex of the long bones of the body (i.e. bones of the leg, potentially resulting in bowing of the legs)

e.g. is Latin for exempli gratia and means for example. Use e.g. before listing examples of the previous statement.

  • Example:
    • Certain types of medications (e.g. long-term steroid use)

Users of American English frequently put a comma after i.e. and e.g. Note that it is not necessary to set these abbreviations in italics in normal use

Such as and as well as

It is more professional to use such as instead of like. Also, use as well as instead of and.

  • Example:
    • Activated antigen-presenting cells, such as macrophages.


Code for reference should be inserted at the end of sentence, after period.

  • Example:
    • Acute or decompensated heart failure refers to an episode in which a patient sustains a change in heart failure signs and symptoms that necessitate urgent therapy or hospitalization.[1]

Test passage

Passage 1

Coagulation necrosis, characterized by Hypereosinophilia and nuclear pyknosis followed by karyorrhexis, karyolysis, total loss of nuclei and loss of cytoplasmic cross-striations is generally first visible in the period from 4,12 hours following infarction. necrotic myocytes may retain their striations for a long time
Neutrophilic infiltration (Acute inflammation) edema and hemorrhage are also first visible at 4-12 hours but generally closer to 12 hours. the interstitium at the margin of the Infarcted area is initially infiltrated with Neutrophils, then with Lymphocytes and Macrophages, who phagocytose or eat the myocyte debris; The necrotic area is surrounded and progressively invaded by granulation tissue: which will replace the infarct with a fibrous or collagenous scar (which are typical steps in wound healing). the interstitial space or the space between cells outside of blood vessels may be infiltrated with red blood cells.
Infiltration by macrophages, lymphocytes, eosinophils, fibroblasts and capillaries begins around the periphery at 3-10 days. contraction band necrosis, characterized by hypereosinophilic transverse bands of precipitated Myofibrils in dead myocytes is usually seen at the edge of an Infarct or with reperfusion for example with Thrombolytic therapy.



Passage 2

Acute Bronchitis may be caused by either Viral bacterial or environmental factor.
Influenza virus is the most common overall cause
other causes's of Acute bronchitis are mostly viruses including;

  1. Respiratory Syncytial Virus (rsv)
  2. coronavirus
  3. Enterovirus



Additional Editing Help

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  1. Jessup. M, et al. 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults. Circulation. 2009 Apr 14;119(14):1977-2016. PMID 19324967