rmedicine2019 – some quick thoughts and good packages

Kenny McLean and I recently attended rmedicine 2019 in Boston MA. The conference is aimed at clinicians and non-clinicians who use R for day-to-day research and monitoring of clinical processes.

Day 1 covered two parallel workshops: R Markdown for Medicine and Wrangling Survival Data 

I attended R Markdown for Medicine run by Alison Hill from RStudio. Using .rmd files has become the default for the Surgical Informatics Group and, so it seems, a great number of others who attended rmedicine. Around a third of the presentations at rmedicine covered workflows involving sharing of data via either .rmd files or through shiny, an R package for creating deploy-able dashboards for data visualisation and interactive exploration.

R Markdown for Medicine

An Overview of Useful Tips and Tricks

R markdown is an extension of R which allows you to combine narrative text and R code within one document. This means your notes, code, results and plots are all in one place. Code is contained in between three backticks with an {r} after the first set. Inline code can also be used between single backticks followed by r without the curly brackets and then the code. This means that results can be changed automatically so that for a trial when you describe the results of numbers included / excluded, this only needs changed in one place so that the rest of the text (and / or flowcharts) updates automatically. It is also possible to mix-and-match other chunks of code from other languages.

Use Params!

Parameters are set in the YAML header at the top of the .rmd document. If you set a parameter of data to a default .csv or .rda file then this can be changed for other similar files without creating a new document. A really useful example would be when you have multiple hospitals or multiple diseases each with a separate data file, a report can then be generated for each file. If you use rmarkdown::render() along with purrr::pwalk you can generate a separate output file for any number of hospitals / diseases / countries / individuals etc. in just a couple of lines of code.

Use Helper Packages

There are some greater .rmd helper packages to improve the workflow, improve the rendering of documents and generally make life easier.

bookdown allows several .rmd documents to be combined to a book but also has some general usefulness for single documents as well. Using bookdown::word_document2 or bookdown::html_document2 in the YAML header under the output field is designed to improve cross-referencing of tables and figures compared to the default versions.

wordcountaddin allows an accurate word count to be performed which will not count YAML or code etc. without knitting the document. This is much easier than knitting the document and then performing a word count!

citr allows automated insertion of markdown citations to assist with referencing. Check out my earlier blog on referencing to get an idea of how to set up .bib files. I may add another blog on this topic, watch this space!

xaringan is a useful package for creating HTML presentations with high levels of customisation. It is possible to use an additional .css file for even greater customisation and styling of your slides but xaringan offers a great deal of user-friendly options.

distill appears to be good at supporting mobile-friendly web publishing for scientific communication with flexible figure layouts, table pagination, LaTeX math support and incorporation of javascript.

There are countless other helper packages and more likely to be on their way. Many allow additional aesthetic modification of the output documents and may allow you to run R code rather than modifying a .css file.

List Numbering the Lazy Way

List numbering in .rmd works without needing to manually enter the correct numbers. Just make a list where every element begins with 1. and .rmd will transform it into an appropriately-numbered list. Great if you need to add in a new element to the middle of the list later!

Multiple lots in a Grid

I’ve previously come across patchwork as a way to plot several plots into a grid which could be 1×2, 2×2, 3 in one column and one in the other etc. There are also two other packages cowplot and egg. I haven’t explored the differences between them but if you find that one doesn’t give you the exact customisation or alignment you need then possibly try another one. cowplot looks as if it might perform better at overlaying plots on top of another and at exact axis line matching.

Use the here package to help with file paths

here is a great package for swapping between Windows and Mac file paths (no more swapping backslashes and forward slashes!). Using here::here() will default to looking for a file in the .Rproj directory rather than the .rmd directory which is the default otherwise – great if you want to have multiple .rmd documents each in their own sub-directory with a shared data file in the parent directory.

Customise Code Outputs

R markdown allows customisation of appearance of code. Some of this can be done through modifying a .css file but there are some simpler ways to make basic changes. Try adding comment = "#>" to knitr::opst_chunk$set()to customise how comments appear in your document.

Word document creations tips

R markdown is generally great for HTML and PDF formats. The options for knitting to Word are not as well developed but there are some good options. The bookdown package is useful as discussed. The redoc package has been used to facilitate conversion to and from word – not tried it personally but if it can print out to word and then handle tracked changes back into markdown then it could be very useful.

For converting more complex tables and figures to word an option is to knit to rtf (rich text format) and then open the rtf file in word. This tends to be very good at keeping the desired formatting.

Future updates – hopefully!

R markdown is a great resource although there are a handful of minor issues which are currently difficult to resolve. One of the main problems I find it with tables and cross-referencing. I really like the syntax and customisation of the gt package but at present it appears cross-referencing in a way which works across HTML, PDF and Word outputs is not supported – a great opportunity to submit a pull request if you think you can get this to work.

Other Useful rmedicine Packages and Ideas

survival Package Update

The latest version (version 3.0) of the survival package was presented by Terry Therneau and is now available on github. This package is used by over 650 additional downstream dependencies. The latest version allows for multiple observations per subject, multiple endpoints per subject and multiple types of end-point. This will be particularly useful for competing risks analyses e.g. outcomes for liver transplant patients (transplanted, still on list, removed from list as no longer eligible or died).

Keep an eye-out for Kenny McLean’s blog where he plans to cover the survival package and many other useful packages presented at rmedicine 2019.

hreport Automated Trial Reporting

hreport by Frank Harrel (currently available on github) is for automated reporting of trials and studies with generation of interactive html graphs based in plotly. Several aspects of a study can be rendered easily into plots demonstrating accrual, exclusions, descriptive statistics, adverse events and time-to-event data. Another key theme of rmedicine 2019 appears to have been the use of plotly or similar packages to enable interaction with data.

timevis – interactive timelines

timevis allows generation of highly interactive timeline plots which allow zooming, adding or removal of events, resizing, etc.

Holepunch package

For working with projects that require a number of packages that then need shared with a colleague, holepunch provides a quick method for generating a list of dependencies and a Dockerfile. The package creates a link for another user to open a free RStudio server with all of the required packages installed. This may be useful for trouble-shooting in a department and showing code examples.


rmedicine 2019 has shown that clinical researchers are moving increasingly towards literate programming, interactive visualisations and automated workflows using R and Rmarkdown.

The conference was a great mix of methods presentations and data presentations from R users. You definitely don’t need any in-depth knowledge of R to benefit from it and I’d highly recommend booking for rmedicine 2020.

Reference Management – An Efficient Setup for writing a Thesis

This blog is intended for researchers, PhD students, MD students and any other students who wish to have a robust and effective reference management setup. The blog has a particular focus on those using R markdown, Bookdown or LaTeX. Parts of the blog can also help setup Zotero for use with Microsoft Word. The blog has been designed to help achieve the following goals:

  • Effective citation storage
    • Fast and easy citation storage (one-click from Chrome)
    • Fast and easy PDF storage using cloud storage
    • Immediate, automatic and standardised PDF renaming
    • Immediate, automatic and standardised citation key generation
  • Effective citation integration with markdown etc.
    • Generation of citation keys which work with LaTeX and md (no non-standard characters)
    • Ability to lock citation keys so that they don’t update with Zotero updates
    • Storage of immediately updated .bib files for use with Rmd, Bookdown and LaTeX
    • Automated update of the .bib file in RStudio server

Downloads and Setup

For my current reference management setup I need the following software:

  • Zotero
    • Zotero comes with 300MB of free storage which allows well over 1000 references to be stored as long as PDFs are stored separately
    • From the same download page download the Chrome connector to enable the “save to zotero” function in Google Chrome
  • ZotFile
    • Zotfile is a Zotero plugin which helps with PDF management, download the .xpi file and then open Zotero, go to “Tools → Add-Ons” and click the little cog in the top right corner and navigate to file to install (Figure 1)
  • Better BibTeX
    • Better BibTeX is a plugin to help generate citation keys which will be essential for writing articles in LaTeX, R Markdown or Bookdown
    • If the link doesn’t work go to github and scroll down to the ReadMe to find a link to download the .xpi file
    • The same approach is then used to install the Better BibTeX plugin for zotero (“Tools → Add-Ons”)

After downloading Zotero, ZotFile and Better BibTeX create an account on Zotero online.

In addition to the Zotero downloads this guide will focus on an efficient setup for writing with R markdown or Bookdown and assumes that you have access to the following software / accounts:

  • Dropbox / Google Drive / other cloud storage service which allows APIs
    • It will also be necessary for these to be accessible using Windows Explorer or Mac Finder (there are many guides online for syncing Google Drive and Dropbox so that they appear in file explorers)
  • RStudio (this is not 100% essential but it is far harder to use Rmd without it)
    • Packages which will be required for this setup include rdrop2 (if using dropbox, other packages are available to convert this setup to Google Drive etc.), encryptr, bookdown or Rmarkdown, tinytex and a LaTeX installation (the Bookdown author recommends using tinytex which can be installed by the similarly named R package: tinytex::install_tinytex())

Folder Setup

When using Zotero it is a good ideal to create a folder in which you will store PDFs retrieved from articles. Ultimately it is optional whether or not PDFs are stored but if you have access to cloud storage with a good quota then it can make writing in Rmd etc. much faster as there is no requirement to search online for the original PDF. This folder should be set up in Google Drive, Dropbox or another cloud storage service which can be accessed from your own computer through the file explorer.

A second folder may be useful to store bibliographies which will be generated for specific projects or submissions. Again this folder should be made available in cloud storage.

ZotFile Preferences

To setup Zotero so that retrieved PDFs are automatically stored and renamed in the cloud storage without consuming the Zotero storage quota go to “Tools → ZotFile Preferences” and on the first tab: General Settings and set the folder and subfolder naming strategy for PDFs. I have set the location of the files to a Custom location and in this case used the path to a Google Drive folder (~\Google Drive\Zotero PDF Library). ZotFile will also store retrieved PDFs in subfolders to help with finding PDFs at a later date. The current setup I use is to create a subfolder with the first author surname so that all papers authored by one (or more) author with the same name are stored together using the \%a in the subfolder field (Figure 2). Other alternatives are to store PDFs in subfolders using year (\%y); journal or publisher (\%w); or item type (\%T).

Next the Renaming Rules tab can be configured to provide sensible names to each of the files (this is essential if PDFs are not to be stored as random strings of characters which provide no meaning). In this tab I have set the format to: {%a_}{%y_}{%t} which provides names for the PDFs in the format of: Fairfield_2019_Gallstone_Disease_and_the_Risk_of_Cardiovascular_Disease.pdf. I find that this shows author, year and first word of title without needing to expand the file name (Figure 3).

I have not changed any of the default settings in either the Tablet Settings or Advanved Settings tabs apart from removing special characters in the Advanced Settings (this stops things from breaking later).

General Zotero Settings

Zotero has several configurable settings (accessed through: “Edit → Preferences”) and I have either adopted the defaults or made changes as follows:


  • I have ticked the following:
    • Automatically attach associated PDFs
    • Automatically retrieve metadata for PDFs
    • Automatically rename attachments using parent metadata
    • Automatically tag items with keywords and subject headings
    • All options in Group section
  • I have left the following unticked:
    • Automatically take snapshots
    • Rename linked files


  • Enter the account details
  • Tick sync automatically
  • Untick sync full text (if you choose to save PDFs then syncing full text will quickly consume the 300MB quota)


  • Left unchanged


  • Left unchanged


  • There are several sensible defaults but if there is a new citation style you wish to be able to use in Microsoft Word for example then click “Get additional styles” as there is probably a version that you need already created. You can click the “+” button to add a style from a .csl file if you have one already. Finally, if you are desperate for a style that doesn’t already exist then you can select a citation style and click Style Editor and edit the raw .csl file.
  • In the Word Processors subtab (on the main Cite tab), you can install the Microsoft Word add-in to allow Zotero to work in Microsoft Word.


  • I changed nothing on the General subtab
  • In the Files and Folders subtab I have selected the path to base directory for attachments
  • I have not changed the Shortcuts subtab
  • I have not changed the Feeds subtab

Better BibTex:

  • In this section I have set my Citation Key format to [auth:lower:alphanum]_[year:alphanum]_[veryshorttitle:lower:alphanum]_[journal:lower:clean:alphanum] (Figure 4). This generates a citation key for each reference in the format of fairfield_2019_gallstones_scientificreports or harrison_2012_hospital_bmj. It always takes the first author’s surname, the year, the first word of the title and the journal abbreviation if known. The clean and alphanum arguments to this field are used to remove unwanted punctuation which can cause citation to fail in LaTeX.
Figure 4: Better BibTeX Citation Key

Once the settings have been configured if you already had references stored in Zotero and wish to change the citation key for old references select your entire library root (above all folders), select all references, right click and use “Better BibTex → Refresh BibTeX Key” and all of the citation keys should be updated.

Creating a .bib file

For referencing in a new project, publication or submission it may be helpful to have a dynamic .bib file that updates with every new publication and can be accessed from any device through cloud storage.

To set up a .bib file, first find the folder that you wish to create the file from (this should be the folder which contains any citations you will use and ideally not the full library to cut down on unnecessary storage and syncing requirements). Note that the .bib file will generate a bibliography from any citations stored directly in the folder when using default settings. This prevents use of subfolders which I find particularly helpful for organising citations and I have therefore changed the setting so that folders also show any citations stored in subfolders. To make this change go to “Edit Preferences” and select the “Advanced” tab and at the bottom of the “General” subtab select “Config Editor”. This will bring up a searchable list of configurations (it may show a warning message before this) and search in the search box for “extensions.zotero.recursiveCollections”. Set “Value” to TRUE and then when you click a folder you should see all of the citations also stored in subfolders.

Right click the folder and select “Export Collection”. A pop-up window will appear at which point select “Keep Updated” and if using RStudio desktop save the file in the directory where you have your Rmd project files. If you are working with RStudio server then save the file in a cloud storage location which will then be accessed from the server. I have a .bib file stored in Dropbox which I access from RStudio server.

Linking Dropbox and RStudio Server to Access the .bib File

The following covers linking Dropbox to RStudio server but could be adapted to cover another cloud storage service.

Dropbox provides a token to allow communication between different apps. The rdrop2 package is what I used to create a token to allow this. I actually created the token on RStudio desktop as I couldn’t get the creation to work on the server but this is perfectly ok.

Caution: The token generated by this process could be used to access your Dropbox from anywhere using RStudio if you do not keep it secure. If somebody were to access an unencrypted token then it would be equivalent to handing out your email and password. I therefore used the encryptr package to allow safe storage of this token.

Token Creation

Open Rstudio desktop and enter the following code:

The code will create two files, a token and the .httr-oauth file from which a token can also be made. The encryptr package can then encrypt the files using a public / private key pair. It is essential that the password that is set when using genkeys() is remembered otherwise the token cannot then be used. In this case the original token can’t be retrieved but could be created again from scratch.

The following files will then be needed to upload to the RStudio server:

  • droptoken.rds.encryptr.bin – or the name provided for the encrypted Dropbox token
  • id_rsa – or the name provided for the private key from the private / public key pair

Dropbox Linkage for Referencing the .bib File

Now that the encrypted token and necessary (password-protected) private key are available in RStudio server, the following can be saved as a separate script. The script is designed to read in and decrypt the encrypted token (this will require a password and should be done if the .bib file needs updated). Only the drop_download() needs repeated if using the token again during the same session. The token should be cleared at the end of every session for additional security.

Now that the .bib file has been created and is stored as “my.bib” in the local directory, it should update whenever the token is loaded and drop_download() is run.

Final Result

On clicking “Save to Zotero” button in Chrome and running drop_download() the following should all happen almost instantaneously:

  • Zotero stores a new reference
  • A PDF is stored in the cloud storage having been named appropriately
  • A link to the PDF is stored in Zotero (without using up significant memory)
  • A citation key is established for the reference in a standardised format without conflicts
  • Pre-existing citation keys which have been referenced earlier in the writing of the paper are not altered
  • A .bib file is updated in the RStudio server directory
  • And much unwanted frustration of reference management is resolved

This is my current reference management system which I have so far found to be very effective. If there are ways you think it can be improved I would love to hear about them.