General Surgical Journals Research Articles

Evaluation of the proportional hazards assumption and covariate adjustment methods in comparative surgical observational studies with time-to-event endpoints

IntroductionComparative studies on surgical treatments with time-to-event endpoints have provided substantial evidence for clinical practice, but the accurate use of survival data analysis and the control of confounding bias remain big challenges. MethodsThis was a survey of surgical studies with survival outcomes published in four general medical journals and five general surgical journals in 2021. The two most concerned statistical issues were evaluated, including confounding control by propensity score analysis (PSA) or multivariable analysis and testing of proportional hazards (PH) assumption in Cox model. ResultsA total of 74 studies were included, comprising 63 observational studies and 11 randomized controlled trials. Among the observational studies, the proportion of studies utilizing PSA in surgical oncology and non-oncology studies was similar (40.9 % versus 36.8 %, P = 0.762). However, the former reported a significantly lower proportion of PH assumption assessments compared to the latter (13.6 % versus 42.1 %, P = 0.020). Twenty-five observational studies (25/63) used PSA methods, but two-thirds of them (17/25) showed unclear balance of baseline data after PSA. And the proportion of PH assumption testing after PSA was slightly lower than that before PSA, but the difference was not statistically significant (24.0 % versus 28.0 %, P = 0.317). Comprehensive suggestions were given on confounding control in survival analysis and alternative resolutions for non-compliance with PH assumption. ConclusionThis study highlights suboptimal reporting of PH assumption evaluation in observational surgical studies both before and after PSA. Efforts and consensus are needed with respect to the underlying assumptions of statistical methods.

Accuracy of Conflicts in Interest in General Surgical Journals.

To evaluate the accuracy of self-reported conflicts of interest (COIs) for articles published in prominent minimally invasive and general surgical journals. Accurate reporting of industry relationships and COIs is crucial for unbiased assessment of a particular study. Despite the enactment of COI laws, such as the Physician Payments Sunshine Act in 2010, prior work suggests that 40-70% of self-reported COIs have discrepancies. We utilized three public databases -- Open Payments (USA), Disclosure UK, and Disclosure Australia -- to assess the accuracy of COI disclosures among authors of 918 published articles from these respective countries. Seven journals were utilized to review the COIs for authors of manuscripts published in 2022 - JAMA Surgery, Annals of Surgery, British Journal of Surgery (BJS), Journal of American College of Surgeons (JACS), Surgical Endoscopy, Obesity Surgery, and Surgery for Obesity and Related Diseases (SOARD). Among the analyzed 6206 authors, 5675 belonged to countries of interest: USA (4282), UK (718), and Australia (213). Of these, 774 authors (12.5%) self-reported a conflict of interest in their papers. Overall, only 4055 researchers (69.1%) reported COIs accurately. Authors from the US had the lowest accuracy of reporting COI at 69% as opposed to UK (93%) and Australia (96%). Inaccurate COI reporting was most common in corresponding/senior authors (39%) and least common amongst first authors (18%). Most payments in excess of $50,000 made to authors by an industry sponsor were not disclosed appropriately. Our study shows that inaccuracy of self-reported COIs in general surgery journals remains high at 31%. While our findings should encourage authors to overreport any possible COI, journals should consider verifying the authors' COI to facilitate more accurate reporting.

Who is Committed to Education? An Analysis of Surgical Education Research Publications

Advances in surgical training have led to the recent emergence of surgical education research. While the importance of surgical education research is well recognized, not all surgical journals are publishing these works. The objective of this study was to analyze the volume and types of surgical education publications in general surgery and surgical subspecialty journals. A PubMed search string was developed to identify surgical education publications in general surgery (GS, n = 10) and surgical subspecialty (SS, n = 16) journals from 2015 to 2019. Publications were catalogued into 7 categories: curriculum and/or teaching, trainee assessment, program evaluation, wellness and/or burnout, resident research, case outcomes with resident involvement, and other. Journals were also categorized by impact factor into 3 groups. Statistical analysis was performed using linear regression and Wilcoxon rank-sum to analyze differences in education publication number and percent between GS and SS journals, as well as between different impact factor groups. The median proportion of surgical education publications was 1.2% (IQR 0.3-2.8%) of total publications for journals queried. The highest proportion of surgical education publications by a journal was 13.9%. All other journals had median ≤ 5.5%. GS journals had a significantly higher median percent of surgical education publications than SS journals (2.9% [IQR 1.7-4.8%] vs 0.5% [IQR 0.0-1.4%] p < 0.01). Additionally, no significant differences were found for number of surgical education publications when journals were categorized by IF (p > 0.05). Education research is an important component of the surgical literature, with similar publication rates among journals of different impact factors. Publication volume is higher among general surgery than surgical subspecialty journals. With the ever-changing paradigm of surgical training, a rigorous scientific approach is needed to ensure effective training of future surgeons. Subspecialty journals should promote surgical education research to further understand and develop training in their field.

O54: GENDER REPRESENTATION IN EDITORIAL BOARDS OF INTERNATIONAL GENERAL SURGERY JOURNALS

Abstract Introduction Despite women constituting over half of new UK doctors, and a similar proportion worldwide, gender disparity remains an issue throughout academic medicine. Surgery has shown particularly slow progress towards gender parity. This study aims to quantify gender representation within editorial boards of the top 25 general surgical journals. Method All surgical journals were collated using the SCImago Journal Rank (SJR) and Journal Impact Factor (JIF). Non general surgery journals were excluded. Journals were contacted requesting gender editorial team demographics. Editorial board data was collected via journal websites on 20th November 2019. Result The top 25 surgical journals were determined through SJR and JIF ranking methods. Editorial board data was publicly available for 31 of these 32 different surgical journals. This data was then examined. Women accounted for 18.4% (576/3135) of total editorial board positions. Women constituted 12.5% (5/40) of Editors-in-Chief positions, 31.6% (31/98) of Deputy Editors and 17.2% (416/2415) of general editorial board positions. Conclusion For the first time, gender disparity has been demonstrated within editorial boards of the most prominent general surgery journals. The implications of such significant gender disparity are wide reaching. Action should be taken to champion fair female representation, eliminate risk of bias and provide more visible female role models in academic surgery. Take-home message For the first time, this study demonstrates gender disparity in Editorial boards of major general surgery journals. Action should be taken to champion fair female representation, eliminate risk of bias and provide more visible female role models in academic surgery.

O41: JOURNAL RANKING METHODS AND THEIR APPLICATION IN GENERAL SURGERY - A SYSTEMATIC REVIEW

Abstract Introduction Bibliometrics enable the objective assessment of a journals quality and prestige, making them vital to academic surgical integrity. This paper systematically reviews the evidence for current journal-ranking platforms. Method An initial systematic search identified published journal bibliometrics on 5th November 2019. Studies assessing journal bibliometrics were identified through a second systematic search through OVID Medline database (PROSPERO:159689) on 18th November 2019. Non-English papers and those solely referring to author and institutional ranking methods were excluded. A coding framework was developed to assess strengths and limitations of journal bibliometrics. Result The systematic search returned 2480 articles. All abstracts were reviewed leaving 474 for full assessment. 306 papers were included in the final synthesis. 12 journal bibliometrics were identified. SCImago Journal Rank (SJR) was deemed the most robust journal ranking method. Impact Factor (IF) is the most commonly used but has clear limitations. Altmetrics are likely to become more important. Ranking the Top 25 general surgical journals using SJR and IF results in clear discordance. Conclusion Impact Factor is susceptible to manipulation by journals putting its reliability into question. This has huge implications for academic surgery, the appraisal of evidence and its downstream assessment for inclusion into clinical guidelines and practice. SJR is more robust and it is recommended that this ranking method is adopted by the academic surgical community going forward. Take-home message The widely used Impact Factor can be manipulated by journals, which has implications for academic surgery and evidence-based medicine. SCImago Journal Rank is more robust and should be adopted by the academic surgical community.

An Audit of General Surgery Publications by Indian Authors

Indian surgeons have a substantial workload. But how much of it do we document and publish thus facilitating evidence-based practice? We undertook to document the contribution of Indian authors to the world literature in general surgery and to elicit the view of Indian surgeons regarding scientific publications. We carried out a search of articles in general surgical journals, published by Indian authors working in India. The journals chosen were those with an impact factor of more than 2. In addition, the Indian Journal of Surgery, with an impact factor of 0.55, was included as it is our flagship journal. The period of study was between January 2014 and April 2020. Additionally, a survey was carried out among the members of the Karnataka State Chapter of the Association of Surgeons of India. The survey was designed to elicit responses from surgeons regarding their attitude towards surgical publications. In American Journal of Surgery, British Journal of Surgery and Annals of Surgery only one original publication each was found. In Canadian Journal of Surgery and Journal of American Medical Association Surgery there were no publications in the study period. Surgeons put forth several reasons for this lack of publication culture—the main ones being lack of motivation, lack of data and lack of training to write. It is clear that Indian authors contributed to a minuscule number of papers in scientific surgical journals. The culture of publication must be inculcated from an early stage of surgical training.

Adequate reporting of the sample size calculation in surgical randomized controlled trials

BackgroundThe sample size calculation for a randomized controlled trial should assure that a statistically significant and clinically relevant difference can be detected with a high probability. To be certain that readers of a randomized controlled trial can critically judge whether the assumptions for the sample size calculation were realistic, a number of specific subitems should be reported. MethodsIn this minireview, the frequency of adequate reporting of specific sub-items of the sample size was assessed from surgical randomized controlled trials that were published in the 5 leading general surgical journals in 2017. Subitems from the Consolidated Standards for Reporting Trials and from the Standard Protocol Items: Recommendations for Interventional Trials Statement were considered. ResultsA total of 85 relevant randomized controlled trials were identified over PubMed. The overall adequate reporting of the sample size according to the Consolidated Standards for Reporting Trials was 53% (45 of 85). When considering additional subitems from the Standard Protocol Items: Recommendations for Interventional Trials Statement which are not explicitly requested by the Consolidated Standards for Reporting Trials Statement, the adherence decreased to 12% (10 of 85). ConclusionThe adherence in reporting potentially important subitems of the sample size from the Consolidated Standards for Reporting Trials Statement was moderate among surgical randomized controlled trials. It is crucial that surgeons who plan and conduct randomized controlled trials be aware of these subitems.

Compliance of Randomized Controlled Trials Published in General Surgical Journals With the CONSORT 2010 Statement.

Compliance of Randomized Controlled Trials Published in General Surgical Journals With the CONSORT 2010 Statement.

Commentary on "Compliance of Randomized Controlled Trials Published in General Surgical Journals With the CONSORT 2010 Statement".

Commentary on "Compliance of Randomized Controlled Trials Published in General Surgical Journals With the CONSORT 2010 Statement".

Commentary on “Compliance of Randomized Controlled Trials Published in General Surgical Journals With the CONSORT 2010 Statement”

Commentary on “Compliance of Randomized Controlled Trials Published in General Surgical Journals With the CONSORT 2010 Statement”

Compliance of randomised controlled trials in general surgical journals with the CONSORT 2010 statement: A retrospective cohort study and review of the literature

Compliance of randomised controlled trials in general surgical journals with the CONSORT 2010 statement: A retrospective cohort study and review of the literature

Compliance of Randomized Controlled Trials Published in General Surgical Journals With the CONSORT 2010 Statement

Compliance of Randomized Controlled Trials Published in General Surgical Journals With the CONSORT 2010 Statement

Underreporting of Secondary Endpoints in Randomized Trials: Cross-sectional, Observational Study.

To determine if underreporting of secondary endpoints in randomized controlled trials occurs, using surgical site infection (SSI) as an example. SSI is a commonly measured endpoint in surgical trials and can act as a proxy marker for primary and secondary endpoint assessments across trials in a range of medical specialties. Cross-sectional observational study of randomized trials including patients undergoing gastrointestinal surgery published in a representative selection of general medical and general surgical journals. Studies were included if SSI assessment was a prespecified endpoint. Adjusted binary logistic regression was used to identify factors associated with a high rate of SSI detection (≥10%). From 216 trials including 45,633 patients, the pooled SSI rate was 7.7% (3519/45,633), which was significantly higher when assessed as a primary endpoint (12.6%, 1993/15,861, 49 studies) vs as a secondary endpoint (5.1%, 1526/29,772, 167 studies, P < 0.001). When assessed as a secondary outcome, standardized definitions and formal clinical reviews were used significantly less often. When adjusted for surgical contamination and methodological confounders, secondary assessment was associated with reduced SSI detection compared with primary assessment (adjusted odds ratio 0.24, 95% confidence interval 0.08-0.69, P = 0.008). Secondary endpoint assessment of SSI in randomized trials was associated with significantly reduced rigor and subsequent detection rates compared with assessment as a primary endpoint. Trial investigators should ensure that primary and secondary endpoint assessments are equally robust. PRISMA guidelines should be updated to promote the conduct of meta-analysis based only on primary outcomes from randomized controlled trials.

Science, Medicine, and the Anesthesiologist

MAJOR clinical trials and breakthroughs in fundamental knowledge of relevance to anesthesiologists are often published in general medical or scientific journals, like New England Journal of Medicine or Nature. Yet, few of us have time to browse the medical literature within our own specialty, to say nothing of the dozen or more major medical and science journals which only occasionally contain information relevant to us. American Society of Anesthesiologists member surveys indicate a strong interest in receiving brief news reports of articles published in journals outside of the specialty, and many are unaware that there is just such a two-page section following the Table of Contents in Anesthesiology, which we have aptly named Science, Medicine, and the Anesthesiologist. The new feature is easily located from the home page of the journal Web site (fig. 1); clicking on the link to this feature will take you to an easy-to-read Web and mobile-platform-friendly version, and an additional link to a PDF version of this feature is always available for free download (fig. 2). This editorial is part of a series meant to alert our readers to sections of the journal and its Web site, such as this one, of relevance to your practice.Science, Medicine, and the Anesthesiologist evolved from Literature Reviews, begun by Editor Dr. Timothy Brennan several years ago. The current version provides each month brief (less than 100 words) reviews of eight high-profile articles chosen from a broad array of general medical, surgical, and scientific journals. Articles are chosen and summarized by a small group of Editors and Associate Editors with a focus on articles with direct clinical relevance to anesthesiologists practicing in the intensive care unit, the operating room, the pain clinic, or other perioperative realms. Typically, we summarize four articles in the area of perioperative medicine, two in critical care, one in pain, and one in education. These may include the occasional basic science articles of particular importance to guiding or understanding clinical practice decisions. The goal is to make it easy for the reader to skim these two pages and easily identify the articles in their areas of interest. Each summary provides the gist of the article’s findings and its importance and can be read in a few seconds. The full reference is provided should the reader want more. Images are placed adjacent to the summaries to help visually alert the reader to the topic while they are quickly skimming.Below are but a few examples of recent articles highlighted in Science, Medicine, and the Anesthesiologist, which address the following key questions in daily practice in critical care, pain, and perioperative medicine:Should we routinely give sedative premedication to surgical patients?How should perioperative antiplatelet therapy be managed?Should we change our practices for mechanical ventilation in the operating room?Is there a “best blood pressure” to be targeted during the early phase of septic shock?What novel biomarkers predict outcome after surgery?What is the role of high-fidelity simulation in education in the specialty?We hope the new look of Science, Medicine, and the Anesthesiologist will better meet your needs. Review of Web usage, which demonstrates several hundred views per month, suggested that it does so. Finally, we would like to warmly thank all the individuals who have contributed to and developed this section from its inception: Timothy J. Brennan, Ph.D., M.D. (Departments of Anesthesia and Biostatistics, University of Iowa, Iowa City, Iowa), Lance Lichtor, M.D. (Departments of Anesthesiology and Pediatrics, Yale University School of Medicine, New Haven, Connecticut), Jean-François Pittet, M.D. (Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama), Alan Jay Schwartz, M.D., M.S.Ed. (Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania), and J. David Clark, M.D., Ph.D. (Stanford University School of Medicine, Stanford, California), and Franklin P. Cladys, M.D., F.A.A.P. (The Children Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania), and Cathleen Peterson-Layne, Ph.D., M.D. (Division of Women's Anesthesia, OB Anesthesia, Duke University, Durham, North Carolina).Drs. Mantz and Rathmell receive honoraria from the American Society of Anesthesiologists for their service on the Editorial Board of Anesthesiology and are chiefly responsible for the Science, Medicine, and the Anesthesiologist section. Dr. Eisenach receives salary support from the American Society of Anesthesiologists as Editor-in-Chief of Anesthesiology.

Reporting quality of statistical methods in surgical observational studies: protocol for systematic review.

BackgroundObservational studies dominate the surgical literature. Statistical adjustment is an important strategy to account for confounders in observational studies. Research has shown that published articles are often poor in statistical quality, which may jeopardize their conclusions. The Statistical Analyses and Methods in the Published Literature (SAMPL) guidelines have been published to help establish standards for statistical reporting.This study will seek to determine whether the quality of statistical adjustment and the reporting of these methods are adequate in surgical observational studies. We hypothesize that incomplete reporting will be found in all surgical observational studies, and that the quality and reporting of these methods will be of lower quality in surgical journals when compared with medical journals. Finally, this work will seek to identify predictors of high-quality reporting.Methods/DesignThis work will examine the top five general surgical and medical journals, based on a 5-year impact factor (2007–2012). All observational studies investigating an intervention related to an essential component area of general surgery (defined by the American Board of Surgery), with an exposure, outcome, and comparator, will be included in this systematic review. Essential elements related to statistical reporting and quality were extracted from the SAMPL guidelines and include domains such as intent of analysis, primary analysis, multiple comparisons, numbers and descriptive statistics, association and correlation analyses, linear regression, logistic regression, Cox proportional hazard analysis, analysis of variance, survival analysis, propensity analysis, and independent and correlated analyses. Each article will be scored as a proportion based on fulfilling criteria in relevant analyses used in the study. A logistic regression model will be built to identify variables associated with high-quality reporting. A comparison will be made between the scores of surgical observational studies published in medical versus surgical journals. Secondary outcomes will pertain to individual domains of analysis. Sensitivity analyses will be conducted.DiscussionThis study will explore the reporting and quality of statistical analyses in surgical observational studies published in the most referenced surgical and medical journals in 2013 and examine whether variables (including the type of journal) can predict high-quality reporting.

Registration Rates, Adequacy of Registration, and a Comparison of Registered and Published Primary Outcomes in Randomized Controlled Trials Published in Surgery Journals

To determine the proportion of registered trials published in the surgical literature, to compare, in registered trials, the primary outcomes registered with those published and to determine whether outcome-reporting bias favored significant primary outcomes. Trial protocol registration before patient enrolment for randomized controlled trials (RCTs) is a perquisite for many journals in attempt to decrease publication and selective reporting bias. Analysis of the medical literature demonstrates poor registration rates with discrepancies between reported and registered primary outcomes. This has not been evaluated in contemporary surgical journals. RCTs were identified for 2009 and 2010 from 10 high-impact factor surgical journals. One investigator identified all RCTs and extracted primary and secondary outcomes, dates of commencement and completion of study, funding source, and trial registration number. Trial registers were searched using the trial registration number for primary and secondary outcomes, dates of commencement and completion of study, and date of registration. Trial registration rates and registration adequacy were recorded. Register and published primary outcomes were then compared. A total of 246 papers were analyzed, among which 86 (34.9%) were not registered and 52 (21%) were inadequately registered. Of the 108 adequately registered trials, 32 (29%) had a discrepancy between the published primary outcome and that registered in trial register. In the 24 published studies where it was possible to assess, the discrepancy favored a statistically significant primary outcome in 22 (91.7%) whereas in 2 (8.3%) the discrepancy produced a statistically insignificant result. Less than half of all RCTs published in general surgical journals were adequately registered, and approximately 30% had discrepancies in the registered and published primary outcome with 90% of those assessable favoring a statistically positive result.

Comparison of Randomized Controlled Trial Registry Entries and Content of Reports in Surgery Journals

To evaluate discrepancies between trial registry entries and final reports of randomized controlled trials (RCTs) published in major general surgical journals. Health care decisions are based on published results in peer-reviewed journals. Mandatory trial registration was introduced to increase transparency and reduce publication and outcome reporting bias. The discrepancy rate between trial registry entries and final reports of all RCTs published during 2010 in the Annals of Surgery, Archives of Surgery, and British Journal of Surgery was evaluated. Of 596 identified studies, 545 were excluded because they were not RCTs or interim reports/secondary analysis of RCTs or because of missing trial registry information.In the remaining 51 RCTs, prospective registration was found in 9.8% (n = 5), registration during trial conduct in 33.3% (n = 17), and retrospective registration in 56.9% (n = 29), respectively.For the primary and secondary outcomes, there was no discrepancy in 54.9% and 33.3%, complete omission in 7.8% and 31.3%, new introduction in 7.8% and 39.2%, a change in definition in 9.8% and 5.8%, downgrading from primary to secondary in 21.6%, and upgrading from secondary to primary in 13.7%. There were few discrepancies in randomization, blinding, and intervention and some in targeted sample size and inclusion/exclusion criteria. When interpreting the results of surgical RCTs, the possibility of selective reporting, and thus outcome reporting bias, has to be kept in mind. For future trials, prospective registration should be strictly respected with the ultimate goal to increase transparency and contribute to high-level evidence reports for optimal patient care in surgery.

GMS Hygiene and Infection Control.

Since 2006, the German Society for Hospital Hygiene patronages the Journal “GMS (GermanMedical Science) Krankenhaushygiene Interdisziplinar”, an open access peer-reviewed PubMed listed e-journal. German Medical Science is a portal for online journals, meeting and research reports and offers all researchers in the field of medicine an open access to scientific articles and the possibility to publish their research results online. The journal “GMS Krankenhaushygiene Interdisziplinar” was founded to foster both, understanding and practice in the field of infection control. The Journal provides a forum for continuing exchange of information and opinions through contributions from scholars, professionals, policymakers, and others involved in infection control. Although the field of Infection Control is a dedicated medical speciality on its own rights, as other medical and surgical specialities as well, Infection Control is maybe unique in one aspect: Very few other medical disciplines have to be so much involved into the complete spectrum of medical treatment, diagnostics, and preventive aspects. There is not one single medical field, where an infection may not be present or may not be a known complication. Furthermore, healthcare associated infections are not restricted to one single hospital, one single region, country, or continent, but are a global challenge. The Journal specifically emphasises on amultidisciplinary approach aiming at collaboration with other medical societies at a higher level. Since 2008, the journal is PubMed-listed. It can be accessed at the web address http://www.egms.de/en/journals/dgkh/. In light of this discipline’s enormous scope, it is not surprising that Infection Control related research is published in almost all categories of medical literature. Papers with Infection Control related content are found as lead articles in general medical, internal medicine, general surgical, urological, vascular surgical, and many more journals. Aside of this a number of high-impact dedicated Infection Control journals do exist. This realises the question, why a journal such as “GMS Krankenhaushygiene Interdisziplinar” is needed. There are at least two reasons: Firstly, a number of authors from German speaking countries have frequently made the experience how difficult it is to publish epidemiologic data relevant for Infection Control aspects in Germany, Austria, or Switzerland in international journals, mostly dominated by US or British publishers. Indeed, some Infection Control aspects related to German or Austrian federal laws are of importance there, but US readers may correctly ask what the relevance of such articles is to them. Therefore, a “local” Infection Control Journal is needed to serve as platform to share important “local” information. An example of this is an article published in this issue of the journal which reports important data on infrastructure of German hospitals and institutions caring for elderly inand outpatients [1]. Secondly, as highlighted, the scope of Infection Control is so broad, that some important articles on very rare, rather unusual, or extremely selective aspects may not be publishable, simply because they do not fall into any category of existing journals. One example for this is an article which explores the practice of none-replacement of i.v. administration sets after each change of intermittently administrated antibiotic infusions [2]. The Journal was given the name “GMS Krankenhaushygiene Interdisziplinar”, which means translated interdis-

Is less clinical research being published by surgeons in the United Kingdom?

Introduction Concerns about the decline of surgical research have been expressed in parallel to the debate on the future of academic surgery in the United Kingdom. The aim of this study was to survey the output of UK surgeons in ten high impact general surgical journals between 1987 and 2009 to estimate whether less clinical academic activity is occurring. Methods Ten general surgical journals with consistently the highest impact factors (1.2–7.9) were selected for review. All articles excepting letters and news articles were included in the study. The region of origin was identified for each paper and classified as USA, Japan, Europe, UK and Rest of the World (RoW). In articles from multiple centres, the region of the corresponding author was used. Results Over the study period, the annual number of surgical papers published from the UK dropped both in absolute values (from 286 to 214) and as a percentage of global output (17.7–8.8%). The USA also saw a drop (from 867 to 763/yr), while the output has increased steadily for Europe (from 266 to 822/yr) and RoW (from 151 to 476/yr). In 2009, the percentage of total yearly output was roughly equal for Europe and USA (31–33%), UK and Japan (7–8%). Conclusions These data suggests that clinical surgical research in the UK has suffered over the last 20 years. The declining emphasis on research as part of surgical training, the strategic decisions about fund allocation, and the increasing role of centres from Europe and RoW may all play a role. This limited “snapshot” fails to provide information on the output in journals focused on basic science. As more of the current research involves collaborations between clinicians and non-clinicians it is likely that many more papers were published in such journals during the period analysed. It remains to be monitored whether recent initiatives will strengthen academic surgery in the UK in future years.

Fate of manuscripts declined by theBritish Journal of Surgery

The fate of papers submitted and subsequently rejected by the British Journal of Surgery (BJS) is currently unknown. The present study was designed to investigate whether, when and where these papers are published following rejection. All rejected manuscripts in the year 2006 were identified from the Manuscript Central electronic database. Between December 2008 and February 2009, a PubMed search was conducted spanning the period 2006-2009 using the corresponding author's last name and initials to identify whether and when manuscripts had been published elsewhere. From the 926 manuscripts rejected by BJS, 609 (65.8 per cent) were published in 198 different journals with a mean(s.d.) time lapse of 13.8(6.5) months. Some 165 manuscripts (27.1 per cent) were published in general surgical journals, 250 (41.1 per cent) in subspecialty surgical journals and 194 (31.9 per cent) in non-surgical journals. The mean(s.d.) impact factor of the journals was 2.0(1.1). Only 14 manuscripts (2.3 per cent) were published in journals with a higher impact factor than that of BJS. Rejection of a manuscript by BJS does not preclude publication, but rejected manuscripts are published more often in surgical subspecialty journals and journals with a lower impact factor, although the occasional exception exists.