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• Microsoft Internet Explorer 6.0 and higher (Windows platform only)
• Mozilla Firefox 1.5.07 and higher (Windows and Macintosh platforms)
• Safari current production version (Macintosh platform only)

Here are several ways that you can reduce image size:

1. Check the dimensions and resolution of the image.

   The image should fit within the U.S. letter dimensions of 8.5 X 11 inches. If the image is oversized, it will create a larger file than is needed. For best results, the width of the image should be close to 8 inches or the height should be close to 10 inches, whichever is the longer dimension.

   Resolution generally applies only to raster (bitmap) images and not to vector images as they are resolution-independent; however, if you export a vector image as a different file type such as JPEG or TIFF you are able to set the resolution. The recommended DPI for the conversion process is 300. If the DPI is set above 300, it will create a much larger file which may not be needed for the peer review process.

   To check dimensions and resolution of raster images using Photoshop:

   1. Choose Image > Image Size
   2. To maintain the current proportions of image width to image height, select Constrain Proportions. This option automatically updates the width as you change the height and vice versa.
   3. Under Document Size, enter new values for the height and width. If desired, choose a new unit of measurement. Note that for Width, the Columns option uses the width and gutter sizes specified in the Units & Rulers preferences.
   4. Choose resolution and enter a new value of 300.

   To check dimensions of a vector image using Illustrator and then export to a raster format:

   1. To change the size of a vector image, choose Select > All and use the Scale Tool.
   2. Hold down the shift key to maintain proportion. You can also use the Transform Palette to set the width and height of your image explicitly (Window > Transform).
   3. Select the type and save.
   4. Select File>Export.
   5. Select image format (JPEG or TIFF) then click the Export button.
   6. Input custom resolution at 300 DPI.
   NOTE: Changing the size of a vector image using Illustrator will only reduce the file size if the image is exported to a raster format (JPEG, TIFF, etc.)

2. Flatten the image.

   In a flattened image, all visible layers are merged into the background, which greatly reduces the file size. Flattening an image discards all hidden layers and fills the remaining transparent areas with white. In most cases, you won't want to flatten a file until you have finished editing the individual layers.

   To flatten an image using Photoshop:

   1. Make sure that all the layers you want to keep are visible.
   2. Choose Layer > Flatten Image or choose Flatten Image from the layers palette menu.

   You may also flatten an image by converting the image format to Indexed Color Mode because this mode does not support layers. Be sure to save a copy of your file that includes all layers if you want to edit the original image after the conversion.

   To convert an image format to Indexed Color mode using Photoshop:

   1. Choose Image > Mode
   2. Select Indexed Color Mode

   To flatten an image using Illustrator:

   1. Click the name of the layer into which you want to consolidate the artwork.
   2. Select Flatten Artwork from the Layers palette menu.

3. Choose the most appropriate file type and method of compression.

   The biggest impact upon image size is the file type. Images saved as TIFF and EPS are generally much larger files than images saved as JPEG, GIF, or PDF. TIFF and EPS files are most often required for printing purposes while JPEG and GIF are optimal for online viewing. If your journal does not need print-ready images for the peer review cycle and you need to reduce image size, you might consider saving the image as a JPEG or GIF for the peer review cycle and submitting higher resolution images at the point of revision or acceptance. You first decide upon the file type you need and then select the most appropriate compression.

   There are basically two types of compression methods: lossy and lossless. Lossy compression creates smaller files by discarding some information about the original image. It removes details and color changes it deems too small for the human eye to differentiate. Lossless compression never discards any information about the original file. Compression is done by the software program you use to create the image. You generally have a choice of what type of compression to use.

   Lossless Compression

   • LZW

     Supported by TIFF, PDF, GIF, and PostScript language file formats. Most useful for images with large areas of single color.

   • ZIP

     Supported by PDF and TIFF file formats. Like LZW, ZIP compression is most effective for images that contain large areas of single color.

   Lossy Compression

   • JPEG

     Supported by JPEG, TIFF, PDF and PostScript language file formats. To specify image quality, choose an option from the quality menu, drag the quality pop-up slider or enter a value between 0 and 13 in the quality text box.

     NOTE: Avoid great amounts of JPEG compression. As you apply greater amounts of JPEG compression, the image gets smaller in size and the image quality deteriorates. Since this approach removes image data, once an image has been compressed (or over compressed), the damage done is permanent.

     To select a file type and method of compression in PhotoShop:

     1. Choose File > Save as... and select the desired file type.
     2. Specify a filename and location, and click Save.
     3. Select a compression method and click OK.

     To select a file type and method of compression in Illustrator:

     1. Select File > Export.
     2. Select image format (JPEG or TIFF) then click the Export button.
     3. Input custom resolution at 300 DPI.
     4. If you selected JPEG file format compression is set automatically. If you select TIFF, select LZW.

Please do not include figures in your manuscript file if you will be uploading them separately.

Please note: if you are using the system for the first time, you must create an account before you can submit a paper. To do so, please click on the Home button on the navigation bar, and then click on Create a new account.

To submit a manuscript, enter the author area and click on Submit a new manuscript. You will be presented with a series of fields for entering your manuscript metadata and will then be asked to upload your manuscript file and any image files not embedded within your manuscript file. Supplemental data and images can also be uploaded. The system will convert your files to a single PDF file for reviewing purposes. You will receive an email message when conversion of your manuscript is completed, and you can then visit the Ready to Proof queue in the author area to approve your submission. Your approval is required for the paper to enter the review process.
Note: To view the PDF of your manuscript you will need to have Adobe Acrobat installed. Acrobat is available for free download at http://www.adobe.com/products/acrobat/readstep2.html. Follow the instructions on that page to download and install the necessary software.

These are the steps involved in creating an electronic submission:

To include a special character or HTML tag, copy (Ctrl-C or Cmd-C) the desired code from the special character window and paste (Ctrl-V or Cmd-V) it into the appropriate field. Please note that you must indicate both a starting and ending point for the HTML tags. For example, to italicize the word "is" you must paste the Italic Start code before the "i", then place your cursor after the "s", and paste the Italic End code. The tags will appear in your text like this:

What <I>is</I> Quality Health Care?

In the cover letter, include any relevant information not specified elsewhere. Please do not include this cover letter in your manuscript file.

Suggested Reviewers: You can suggest reviewers for your paper here, but keep in mind that the final selection of reviewers is at the editor's discretion. Please enter as much contact information as possible.