Following the lead of several journals, Cardiology in the Young introduced, in 1997, a section for publication of images relevant to congenital cardiac disease. It was hoped that these would be “definitive, unique, or extraordinary”,¹ with both educational value and visually pleasing appearance. As we now approach our tenth year, and one hundredth submission for “Images in Congenital Heart Disease”, it is, perhaps, appropriate to review and reflect upon this small segment of the activity of the journal, as well as its place in the grander scheme of contemporary biomedical communication.

The section devoted to “Images”, like most other new publications, has followed a well-trodden path of development and evolution. As described for the journal produced by the medical society of Saint Andrews University, and called Chiasma,² the first contributors were, of necessity, also the original readers and, in this case, editors, of the papers. Subsequent imposition upon friends and associates widened the field of authorship somewhat, but, nonetheless, seven of the first fourteen images, published between 1998 and 2000, can be traced directly or indirectly to the University of Saskatchewan in Canada. Since then, there has been a progressive diversification of contributors, such that the 97 manuscripts submitted to date have come from 83 different first authors, and from virtually every part of the world. Moreover, recent years have seen a steady increase in the number of manuscripts submitted for publication (Fig. 1). I believe that this is a healthy and sustainable trend, which bodes well for both the content and quality of future publications. The rejection rate for the manuscripts submitted has been only about 6%, although withdrawal of submissions, sometimes for an alternative section of the journal, or failure to follow through with requested revisions, has resulted in an overall publication rate closer to 85% (Fig. 2). More recently, seven of these printed images have been linked, in addition, to on-line movies.

Figure 1. Manuscripts submitted to Cardiology in the Young for “Images in Congenital Heart Disease”. The year 2006 represents three months.

Figure 2. Acceptance rate of manuscripts submitted for “Images in Congenital Heart Disease”.

To what should this popularity of publication be attributed? In part, the sub-sub-specialty of congenital cardiac disease lends itself to brief communications. Our patients arrive as small packages, bringing with them unique information and experiences, which may be relevant to the care of other patients. Prospective, randomized, double-blind controlled trials of many thousands of cases simply do not exist for the vast majority of patients with congenital cardiac malformations, or their management, and they probably never will. But even with the valuable contributions from large, multicentric, databases on both sides of the Atlantic Ocean, the complexity and diversity of this topic itself ensures the continued value of an accurate, well-documented, individual observation. In addition, many of the newer imaging modalities are now being used in younger patients with cardiac disease. This has produced elegant pictures of things that we may have seen before, but not with such clarity or spatial resolution.

Another factor impacting upon biomedical publications in recent years is the proliferation of digital communication, such that people in many segments of society now routinely interact with each other by means of brief messages. Entrepreneurs work “B-to-B”, and fast packers walk “C-to-C”. One rarely sits down and writes out a letter with five or six lines of address and salutations. Instead, one frequently receives e-mails, or a text message, with fewer than five or six words: “Hi. That's fine. Thanks.” It is not too surprising, then, that authors of clinical papers may now find particular satisfaction in writing brief and focused manuscripts of 250 words, for example, as well as the more traditional longer case reports, reviews and full-length scientific papers. Paradoxically, the creation of meaningful text to accompany an image is often more challenging than other types of scientific writing, because, like a text message, each of the small number of words must be chosen carefully, and connected so as accurately to convey a maximal amount of information to the reader.

At a time when impact factors, and citations, weigh heavily upon editors and authors, and constrained journal space adds to the financial concerns of publishers, it might be questioned if the inclusion of anecdotal experience can any longer be justified in biomedical publications. Along with the other Editors and our Editorial board, I think that it can, and should be, for a number of reasons. In the first place, it provides at least one level playing field where researchers and clinicians at any level of experience, and from all parts of the world, have an opportunity to make a contribution to the literature. While the possibility of reviewing large clinical series may not exist in small units, and those centres in developing countries rarely have the resources or infrastructure to carry out either basic science or clinical research, any observant and thoughtful physician or scientist can reflect upon his or her unique experiences. Moreover, the discipline and rigour of carefully reviewing the relevant literature, and crafting these observations into a succinct and meaningful communication, provides a good introduction to scientific writing for trainees, or a useful exercise for established professionals. The excitement and pride of seeing one's first manuscript, however small, pass through the processes of submission and review, and finally appear in print, is rarely forgotten.³ At a time when many trainees in our profession complete their education heavily in debt, and find the satisfaction they earn from clinical activity constrained by limited hours of work, it may be just such rewarding experiences that help to keep them connected with productive, academic, careers.

With regard to those who read “Images in Congenital Heart Disease”, our goal has been to offer clinically relevant information in a form that is readily appreciated and assimilated. To that end, many authors have been asked to include additional material in the revision of their manuscripts, and we appreciate their efforts to place observations in perspective for the reader. As speed continues to accelerate in the fast lane for professionals in many cultures, it becomes increasingly important that what time remains available for reading journals should be as productive as possible. Many of the published images have thus distilled into ultra-mini case reports that can be read in a few spare minutes. Can such information be worth the space it occupies in a medical journal if clinicians generally need to read between 15 and 16 full length articles to find the answer to a specific clinical question?⁴ Suffice it to say that, a few days after reviewing the manuscript by Kaltman et al.,⁵ I was called into the intensive care unit to see a patient whose monitor showed apparent atrial flutter … and, yes, when the haemofiltration was turned down, he did “convert” to sinus rhythm without further investigations or amiadarone …

But, perhaps, most of all, in the “Images” there seems to be, for both the author and reader, a kind of spontaneity and refreshing directness which often becomes less apparent in longer publications. It is more like sharing the excitement of a new discovery with a colleague in the hallway. It's just plain fun! I thank all of those who have submitted manuscripts for “Images in Congenital Heart Disease” during the past ten years, and look forward to opening the next hundred packages, where we hope to find more small gems, which have been carefully polished to perfection.