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Welcome to the BMJ Open blog. BMJ Open is an open access journal, dedicated to publishing medical research from all disciplines and therapeutic areas.

Find out more about the journal here.

We will be updating the blog with news about the journal, highly accessed papers, press coverage, events and matters of interest in the open access and publishing world, and anything else that catches our eye.

Evidence for potential harms of light drinking in pregnancy ‘surprisingly’ limited

11 Sep, 17 | by Emma Gray

But review confirms alcohol best avoided ‘just in case’, say researchers

The evidence for the potentially harmful effects of light or occasional drinking in pregnancy is ‘surprisingly limited,’ but women are still better off avoiding all alcohol while pregnant, just in case, concludes a pooled analysis of the available data, published in the online journal BMJ Open.

The UK Chief Medical Officer recently commissioned a review of current alcohol guidelines for the general public and also specifically for mums-to-be, which resulted in a proposal to recommend that women should not drink any alcohol at all while trying to conceive or while pregnant, on the grounds that it is ‘better to be safe than sorry.’

Women often ask about ‘safe’ levels of drinking during pregnancy, but there are no clinical trial data on this issue. In response, the researchers systematically reviewed all the data from a wide range of high quality observational studies on the impact of light drinking (two units up to twice a week, or four units a week, equivalent to a total of around 32 g) compared with no alcohol at all.

They looked particularly at complications of pregnancy and birth characteristics, such as miscarriage, premature birth, and undersized babies, and longer term issues, such as the developmental delays, impaired intellect, and behavioural difficulties typical of fetal alcohol syndrome–a consequence of heavy drinking in pregnancy.

From among nearly 5000 articles, they selected 26 relevant studies with data suitable to be pooled.

The analysis showed that drinking up to four units a week while pregnant, on average, was associated with an 8 per cent higher risk of having a small baby, compared with drinking no alcohol at all . There was also some evidence of a heightened risk of premature birth, but this was less clear.

For most of the outcomes the researchers analysed, there were only a few studies  that compared light to non-drinkers.

The issue remains of great public health importance, say the researchers, because up to 80 per cent of mums-to-be in the UK, Ireland, New Zealand and Australia drink some alcohol during their pregnancy.

But the evidence on how much, if any, is safe to drink, or at what stages of pregnancy, is notable by its absence, they add.

The lack of high quality data illustrates the difficulties of designing research that can truly evaluate the causal impact of light drinking while minimising the risks of bias and confounding, say the researchers.

And it also illustrates the failure of researchers so far to focus on ‘light’ drinking versus no drinking, rather than just on moderate and heavy drinking – a question many expectant mums care very much about (‘But one glass is OK, isn’t it?’), they add.

“Despite the distinction between light drinking and abstinence being the point of most tension and confusion for health professionals and pregnant women, and contributing to inconsistent guidance and advice now and in the past, our extensive review shows that this specific question is not being researched thoroughly enough, if at all,” they write.

In the absence of any strong evidence, advice to women to steer clear of alcohol while pregnant should be made on the basis that it is a precautionary measure, they say.

“Women who have had a drink while pregnant should be reassured that they are unlikely to have caused their baby considerable harm, but if worried, they should discuss this with their GP or midwife,” say the researchers.

They conclude: “Evidence of the effects of drinking up to 32 g/week in pregnancy is sparse. As there was some evidence that even light prenatal alcohol consumption is associated with being SGA [underweight] and preterm delivery, guidance could advise abstention as a precautionary principle.”

People with disabilities face major hurdles accessing healthcare in UK

11 Sep, 17 | by Emma Gray

Disabled women are particularly disadvantaged

People with disabilities in the UK face major hurdles accessing healthcare, reveals research published in the online journal BMJ OpenDisabled women are particularly disadvantaged, the findings show

Around one in five (19%) people in the UK is thought to live with a disability, but little is known about their access to healthcare services and what barriers they might face.

In a bid to rectify this, the researchers analysed nearly 13,000 anonymised responses from the European Health Interview Survey (2013 and 2014) to assess use of services and any unmet healthcare need.

From among this sample, more than 5,200 adults (aged 16+) had disabilities, defined as a health problem which limited routine activities and had lasted for more than six months.

Depending on the severity of their disability, they were classified as ‘mild’ or ‘severe.’ The remaining 7,500 people in the sample were classified as having no disability.

The researchers then applied five different variables to assess unmet healthcare need over the previous 12 months. These were: long waiting list(s); distance or transport issues; cost of medical examination or treatment; cost of prescribed medicines; cost of mental healthcare.

The analysis showed that those who were severely disabled made up the largest proportion of those with an unmet healthcare need. By far the biggest obstacle they faced was a long wait for treatment, which affected more than one in four living with a severe disability.

A comparison of unmet healthcare needs in people with and without a disability, showed that those who were severely disabled were most likely to be affected, followed by those who were mildly disabled.

The largest difference in unmet healthcare needs between the two groups was generated by the cost of mental healthcare: those with a mild or severe disability were between 4.5 and more than 7 times as likely to face hurdles in accessing this as were those without a disability.

Similarly, those with a mild disability were 3.6 times, and those with a severe disability nearly 5.5 times, more likely to experience difficulties accessing healthcare because of the cost of prescribed drugs.

Transport was another barrier: people with a mild or severe disability were between 2 and more than 4 times as likely to say this hindered their access as people without a disability.

The smallest difference in unmet healthcare needs between those with and without a disability was generated by long waiting lists, although people with a mild or severe disability were still up to 2.4 times as likely to face access problems because of this.

Disabled women were the most badly affected across all five domains.

They were more than 7 times as likely to have an unmet healthcare need because of the cost of treatment, and more than 5 times as likely to face a problem because of the cost of prescribed medicines as were men with no disability.

Men without a disability were the least likely to experience access problems.

Women’s lower income and caring responsibilities – factors that health services tend to ignore – may help explain this gender divide, explain the researchers.

This is an observational study, so no firm conclusions can be drawn about cause and effect.

There was also no information available on the type of disability people had, while disability was self-assessed, a fact which might have introduced response bias, say the researchers.

But the study’s strengths lie in the nationally representative sample and the focus on several factors that might affect healthcare access, say the researchers, who describe the findings as “alarming” on several counts.

“People with disabilities often have greater healthcare needs and therefore may need to access healthcare services more than the general population,” they write. “The existence of barriers in their access may further compromise their health, leading to a vicious cycle: poorer access to healthcare can lead to even poorer health.”

And they conclude: “The fact that these results come from the UK, a country with a national, public and free at the point of access healthcare system (apart from prescriptions), is particularly worrying.”

Top 10 most read in August: Caesarean sections and private medical insurance, seeking ambulance treatment for primary care problems, and social network interventions in type 2 diabetes

5 Sep, 17 | by Hemali Bedi

August sees eight new entries in the top 10 most read articles. Maintaining the top position for the second consecutive month is longitudinal cohort study by Xie et al, which examines the association between Proton Pump Inhibitors and the risk of all-cause mortality.

At number two is a new entry from Vreman et al, who use a microsimulation model to assess the health and economic benefits of reducing sugar intake in the USA. This is followed by an ecological analysis by Diniz et al, looking at the factors associated with breast cancer mortality in São Paulo, Brazil between 2006 and 2012.

Booker at al reach number four this month with a qualitative systematic review that investigates the motivation for and experience of seeking emergency ambulance treatment for primary care conditions. The findings suggest that complex socioemotional factors and physical symptoms are involved in the decision making process, which can be influenced by caregivers.

At number six is a systematic review and meta-analysis exploring the association between private medical insurance and the odds of caesarean section. The authors found that caesarean sections were more likely to be performed in women who were privately insured, compared to those who were not. The authors call for a review of payment and reimbursement schemes to determine influencing factors.

Finally, at number 10 this month is a systematic review and meta-analysis from Spencer-Bonilla et al. The authors sought to establish the effect of social network interventions on health outcomes in patients with type 2 diabetes. The authors conclude that while the existing body of evidence is limited, the findings are encouraging.

Rank Author(s) Title
1 Xie et al. Risk of death among users of Proton Pump Inhibitors: a longitudinal observational cohort study of United States veterans
2 Vreman et al. Health and economic benefits of reducing sugar intake in the USA, including effects via non-alcoholic fatty liver disease: a microsimulation model
3 Diniz et al.
4 Booker et al. Seeking ambulance treatment for ‘primary care problems: a qualitative systematic review of patient, carer and professional perspectives
5 Manduca et al. A cross sectional study of the relationship between the exposure of pregnant women to military attacks in 2014 in Gaza and the load of heavy metal contaminants in the hair of mothers and newborns
6 Hoxha et al. Caesarean sections and private insurance: systematic review and meta-analysis
7 Nickel et al. Words do matter: a systematic review on how different terminology for the same condition influences management preferences
8 Gadie et al. How are age-related differences in sleep quality associated with health outcomes? An epidemiological investigation in a UK cohort of 2406 adults
9 Ferrando et al. Rationale and study design for an individualised perioperative open-lung ventilatory strategy with a high versus conventional inspiratory oxygen fraction (iPROVE-O2) and its effects on surgical site infection: study protocol for a randomised controlled triCarlos
10 Spencer-Bonilla et al. A systematic review and meta-analysis of trials of social network interventions in type 2 diabetes

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Improvised explosive devices inflict much more serious injuries than land mines

23 Aug, 17 | by Emma Gray

Multiple amputations much more likely

The types of close contact injuries inflicted by improvised explosive devices (IEDs) are much more serious than those associated with land mines, finds research published in the online journal BMJ Open.

Landmines came into widespread use in the Second World War, where they were designed to injure/maim rather than to kill, with a view to stressing the medical resource of the enemy.

Many were left buried in the ground in regions of conflict long after the fighting had ended, causing them to be inadvertently detonated by civilians stepping on them. But after a high profile campaign, 162 countries signed the 1997 Ottawa Treaty pledging to stop their production and use.

However, they have increasingly been replaced in modern warfare with improvised explosive devices, usually known as IEDs.

The mechanism of injury is the same for landmines and IEDs, while the seriousness of injuries for either device depends on how close the victim is to the centre of the explosion, say the researchers.

But they suspected that pattern 1 injuries—those where the victim suffers the full effects of the explosion at close quarters—would be more serious when they involved IEDs.

They therefore assessed pattern 1 injuries sustained by 100 people during IED attacks in Afghanistan over 18 months in 2010-11 and compared them with pattern 1 injuries previously described for landmines.

All the casualties, who comprised both local civilians and military personnel, were male, and aged between 6 and 44 years of age. Their average age was 25; nine were under the age of 18.

They were all treated at the NATO Role 3 Multinational Medical Unit in Kandahar Air Field, Afghanistan, a facility equivalent to a level II civilian trauma centre.

Eleven victims were dead on arrival; a further eight subsequently died of their wounds in hospital, giving a fatality rate of one in five (19%).

IED victims were more likely than those similarly injured by landmines to have more than one amputation (70% vs 10.5%). Five out of the 70 multiple amputees had four amputations; 27 had three amputations, and 38 had a double amputation.

Among the nine children and teens, three had a triple amputation; five had a double amputation.

IED victims were also twice as likely to sustain genital/gluteal (buttocks) injuries (26% vs 13.4%).

Pelvic fracture was more common among IED victims who had multiple amputations and/or genital/gluteal injuries than it was among landmine victims with similar injuries (28.6% vs 3.3%).

And IED victims with this pattern of injuries were also nearly four times as likely to die than were similarly injured landmine victims (24.3% vs 6.7%).

In all, the typical injury profile of IED victims included amputations of both legs (often above the knee); mangling or amputation of an arm/hand; extensive soft tissue injuries with deep penetration of soil, extending into the gluteal and perineal areas; pelvic fracture; and genital mutilation.

Soil forced into a soft tissue injury may worsen the level of amputation required and condemns the victim to serial surgery to remove it. And even then, it may leave that person at the mercy of antibiotic resistant soil organisms, the researchers point out.

IEDs are sometimes portrayed as a primitive or crude weapon crafted from locally available resources because of a lack of access to conventional weapons, but they have evolved and are now more sophisticated, directed, and destructive, say the researchers.

Just like landmines, they indiscriminately maim and kill. And that includes children, who tend to suffer the most severe injuries as a result of the powerful explosive force of an IED.

“The injury pattern suffered by the survivors of the IED is markedly worse than that of conventional [landmines],” they write. “It is a weapon, which, of its nature, causes superfluous injury and unnecessary suffering.”

The evidence gathered on the horrors inflicted by the use of landmines prompted international condemnation resulting in a ban. And the researchers conclude: “It is hoped that reports regarding the pattern of injury caused by the modern IED will result in an abhorrence of this weapon and those that use it.”

Editors picks

22 Aug, 17 | by aaldcroft

BMJ Open: August Editor’s Picks

File:The harrowing tales of Female Genital Mutilation-Cutting (12344890033).jpg

Each month the editorial team at BMJ Open will be selecting highlights from our recently published articles. We hope you enjoy our August highlights. You can access all the material published in August here

When are interventions justified? Attitudes towards female genital cutting

Sometimes baseline data can reveal that implementing an intervention is unnecessary and, perhaps, unethical. In a study from Wahlburg and colleagues looking at attitudes to female genital cutting (FGC) in Somali migrants in Sweden, baseline data revealed that the majority–including those newly arrived–were opposed to all forms of FGC with increased opposition over time after migration. The researchers determined that it would be unethical to carry out their planned intervention, designed to change attitudes to FGC, given that the change was already occurring.

Clinical decision support systems: Are they trustworthy?

Using the best evidence to inform clinical decisions remains a challenge. Rapid response clinical decision support systems represent an attractive option, but their trustworthiness is unknown. Izcovich and colleagues use PubMed clinical queries and Epistemonikos based on the GRADE approach to answer 100 clinical questions and compared it to a gold standard. The approach proved feasible and provided appropriate guidance for most questions.

What contributes to psychological distress in doctors?

Doctors can experience high levels of psychological distress–a concept that includes stress, burnout, depression, and anxiety. Using a qualitative study design, Tallentire and colleagues explore the specific workplace stressors that contribute to psychological distress. Key themes include work overload, long hours, uncertainty about the role, and relationships with colleagues.

Telehealth and patient satisfaction

Telehealth incorporates technology into diverse modes of delivery such as videoconferencing, mobile applications, and secure messaging. However, when using technology, it is important to listen to patients “to help guard against the implementation of technology merely for its convenience or shiny appeal”. By conducting a systematic review, Kruse and colleagues investigate what patients believe to be the most satisfying modes of telehealth.

NHS Health Check programme: What works, and what can be improved?

NHS Health Checks are a public health service in the UK designed to identify early signs of stroke, kidney disease, heart disease, type 2 diabetes, or dementia in individuals aged 40-74. In a systematic review and qualitative synthesis of the literature, Usher-Smith and colleagues investigate patients’ experiences of the service, finding that, while patients are broadly supportive, there are key areas with room for improvement; for example, providing more proactive support for lifestyle change.

Top 10 Most Read in July: Link Worker social prescribing, best practice in sex and relationship education, and menstrual hygiene management among Bangladeshi adolescent schoolgirls

14 Aug, 17 | by Emma Gray

Image result for colourful condoms

An assortment of study designs made it into the Top 10 Most Read articles in July: among the popular studies were a systematic review, a protocol for a prospective observational study, and a qualitative study of service user perceptions.

At number one this month is a longitudinal cohort study by Xie et al examining the association between Proton Pump Inhibitors and the risk of all-cause mortality. Moffatt et al enter the chart at number two with their study on Link Worker social prescribing to improve health and well-being for people with long-term conditions. Undertaking a qualitative study using semistructured interviews with thematic analysis, they seek to describe the experiences of patients with long-term conditions who are referred to and engage with a Link Worker social prescribing programme and identify the impact of this programme.

Reaching number three this month is a study from Pound et al looking at what makes sex and education programmes effective, acceptable and sustainable. At number four is a systematic review investigating how different terminology used for the same condition can influence management preferences and psychological outcomes, concluding that changing the terminology used may be one strategy to reduce patient preferences for aggressive management responses to low-risk conditions. A cross-sectional study on the use of snus and its association with respiratory and sleep-related symptoms remains in the top ten this month at number six, while at number ten we have a new entry from Bangladesh examining the association of menstrual hygiene management knowledge, facilities and practice with absence from school during menstruation among Bangladeshi schoolgirls.

Rank Author(s) Title
1 Xie et al. Risk of death among users of Proton Pump Inhibitors: a longitudinal observational cohort study of United States veterans
2 Moffatt et al. Link Worker social prescribing to improve health and well-being for people with long-term conditions: qualitative study of service user perceptions
3 Pound et al.
4 Nickel et al. Words do matter: a systematic review on how different terminology for the same condition influences management preferences
5 Rambaud et al. Criteria for Return to Sport after Anterior Cruciate Ligament reconstruction with lower reinjury risk (CRSTAL study): protocol for a prospective observational study in France
6 Gudnadóttir et al. An investigation on the use of snus and its association with respiratory and sleep-related symptoms: a cross-sectional population study
7 Ooba et al. Lipid-lowering drugs and risk of new-onset diabetes: a cohort study using Japanese healthcare data linked to clinical data for health screening
8 Kennedy et al. Coffee, including caffeinated and decaffeinated coffee, and the risk of hepatocellular carcinoma: a systematic review and dose-response meta-analysis
9 Fabbri et al. A cross-sectional analysis of pharmaceutical industry-funded events for health professionals in Australia
10 Alam et al. Menstrual hygiene management among Bangladeshi adolescent schoolgirls and risk factors affecting school absence: results from a cross-sectional survey

Most read figures are based on pdf downloads and full text views. Abstract views are excluded.

Top 10 Most Read in June: snus and snoring, long-term antibiotic treatment in times of resistance, the success of the NIHR Academic Clinical Fellowship, and serious video gaming for coping with pain

7 Jul, 17 | by Yaiza del Pozo Martin

Six new articles made their way up to the Top 10 Most Read list of BMJ Open in June. Maintaining the top position for the second consecutive month is the systematic review and meta-analysis by Oliver Kennedy and colleagues establishing an association between coffee consumption and reduced risk of hepatocellular carcinoma, the most common type of liver cancer. The study suggests that drinking two cups of caffeinated coffee or more per day can reduce the risk of developing liver cancer. The authors also include for the first time in this type of analysis decaffeinated coffee, finding a similar but weaker positive association.

At number two, making its way to the top, is a new entry associating snus, a moist powder tobacco product shown in the image below, with a higher occurrence of common respiratory conditions such as asthma and snoring. Previous studies examining the health impact of this type of moist oral tobacco were contradictory; therefore Gudnadóttir and colleagues conducted a survey in a large population living in Sweden to shed some light on this issue. The study found that snus use by never-smokers was associated with a higher risk of developing asthma and respiratory conditions. Snoring and difficulty to fall asleep was equally related to both, former and current users of snus.

At number six, a systematic review and meta-analysis by Ahmed and colleagues compiling evidence from three clinical trials shows that long-term antibiotic therapy can prevent recurrent urinary tract infection in old adults. This study is timely given that nowadays, with antibiotic resistance on the rise, antibiotic use must be justified by robust evidence.

Among the other new entries last month is a retrospective analysis assessing the impact of the NIHR Academic Clinical Fellowship (ACF) scheme on clinical academic careers in England over the last 10 years. The Integrated Academic Training Programme was launched in October 2005 by the National Institute for Health Research (NIHR) to provide predoctoral academic training during the specialty training period for doctors and dentists. The researchers found that trainee doctors undertaking this fellowship were more likely to secure an externally funded doctoral training award and the vast majority of awardees move into academic roles, with many completing PhDs. The study concludes that the NIHR ACF scheme is successful as part of an integrated training pathway in developing careers in academic medicine and dentistry.

Finally, at the bottom of the list, is a protocol describing a mixed-methods study to evaluate whether serious video games, as part of a multidisciplinary rehabilitation intervention, can improve the health outcomes of patients with complex chronic pain and fatigue complaints. ‘Serious games’ are video games developed to promote health benefits. Previous studies have shown that different serious games can improve motivation for physical activity and cognitive stimulation.  In this study protocol, Vugts and colleagues propose a new serious game called LAKA that aims to facilitate patient learning about living with complex chronic pain. The study is still ongoing, but the upcoming results may determine whether improvements in pain intensity, pain coping and fatigue in people with chronic pain can be attributed to serious gaming.

 

Rank Author(s) Title
1 Kennedy et al. Coffee, including caffeinated and decaffeinated coffee, and the risk of hepatocellular carcinoma: a systematic review and dose-response meta-analysis
2 Gudnadóttir et al. An investigation on the use of snus and its association with respiratory and sleep-related symptoms: a cross-sectional population study
3 Ferrando et al. The accuracy of postoperative, non-invasive Air-Test to diagnose atelectasis in healthy patients after surgery: a prospective, diagnostic pilot study
4 Brignardello-Petersen et al. Knee arthroscopy versus conservative management in patients with degenerative knee disease: a systematic review
5 Bjellmo et al. Is vaginal breech delivery associated with higher risk for perinatal death and cerebral palsy compared with vaginal cephalic birth? Registry-based cohort study in Norway
6 Ahmed et al. Long-term antibiotics for prevention of recurrent urinary tract infection in older adults: systematic review and meta-analysis of randomised trials
7 Albarqouni et al. The quality of reports of medical and public health research from Palestinian institutions: a systematic review
8 Clough et al.  What impact has the NIHR Academic Clinical Fellowship (ACF) scheme had on clinical academic careers in England over the last 10 years? A retrospective study
9 Gartlehner et al. Pharmacological and non-pharmacological treatments for major depressive disorder: review of systematic reviews
10 Vugts et al. Serious gaming during multidisciplinary rehabilitation for patients with complex chronic pain or fatigue complaints: study protocol for a controlled trial and process evaluation

*Most read figures are based on pdf downloads and full text views. Abstract views are excluded.

Drugs to curb excess stomach acid may be linked to heightened risk of death

3 Jul, 17 | by Emma Gray

May be time to restrict use of widely available proton pump inhibitors, say researchers

Proton pump inhibitors (PPIs)—a widely available class of drug designed to curb excess stomach acid production—may be linked to a heightened risk of death, indicates research published in the online journal BMJ Open.

Given how widely available these drugs are, and the accumulating evidence pointing to links with a range of potentially serious side effects, it may be time to restrict the indications for use and duration of treatment with PPIs, suggest the researchers.

Recent research has indicated a link between PPI use and a heightened risk of chronic kidney disease/kidney disease progression, dementia, C difficile infections, and bone fractures in people with brittle bone disease (osteoporosis).

Although far from conclusive, emerging evidence suggests that PPIs may boost the risk of tissue damage arising from normal cellular processes, known as oxidative stress, as well as the shortening of telomeres, which sit on the end of chromosomes and perform a role similar to the plastic tips on the end of shoelaces.

The researchers base their findings on national US data obtained from a network of integrated healthcare systems involving more than 6 million people whose health was tracked for an average of almost six years—until 2013 or death, whichever came first.

They carried out three comparative analyses: those taking PPIs with those taking another type of drug used to dampen down acid production called histamine H2 receptor antagonists or H2 blockers for short  (349, 312 people); users and non-users of PPIs (3,288,092 people);  and users of PPIs with people taking neither PPIs nor H2 blockers.

Compared with H2 blocker use, PPI use was associated with a 25% heightened risk of death from all causes, a risk that increased the longer PPIs were taken.

The other analyses revealed a similar level of risk between users and non-users of PPIs and between those taking PPIs and those taking no acid suppressant drugs.

The risk of death was also heightened among those who were taking PPIs despite having no appropriate medical indication for their use, such as ulcers, H pylori infection, Barrett’s oesophagus (pre-cancerous changes to the food pipe) and gullet (oesophageal) cancer.

This is an observational study, so no firm conclusions can be drawn about cause and effect, added to which participants were mostly older white US veterans, possibly limiting the wider applicability of the findings. Nor were the researchers able to obtain information on the causes of death.

Although there is no obvious biological explanation for their findings, the researchers nevertheless suggest that the consistency of their results and the growing body of evidence linking PPI use with a range of side effects is “compelling.”

They write: “Although our results should not deter prescription and use of PPIs where medically indicated, they may be used to encourage and promote pharmacovigilance [monitoring the side-effects of licensed drugs] and [they] emphasise the need to exercise judicious use of PPIs and limit use and duration of therapy to instances where there is a clear medical indication and where benefit outweighs potential risk.”

Top 10 Most Read in May: Coffee and liver cancer risk, vaginal breech delivery and perinatal death, and the association between area deprivation and generalised anxiety disorder in women versus men.

14 Jun, 17 | by Ed Sucksmith

7 new entries make it into May’s top 10 most read articles. Knocking Ravnskov et al.’s study off the top spot is a systematic review and meta-analysis of coffee and hepatocellular carcinoma (HCC) by Oliver Kennedy and colleagues. Their study suggests that increasing coffee consumption by two cups per day is associated with a 35% reduction in the risk of HCC. At number 3 is a national cohort study of over 520,000 term-born singletons by researchers from Norway who have found that vaginal breech delivery is associated with an excess risk for neonatal mortality compared with vaginal cephalic delivery, but not with an excess risk for cerebral palsy. Other new entries include a large population study of generalised anxiety disorder (GAD) in the UK by researchers from the University of Cambridge, who have found that area deprivation is significantly associated with an increased risk for GAD in women, but not in men.

 

Rank Author(s) Title
1 Kennedy et al. Coffee, including caffeinated and decaffeinated coffee, and the risk of hepatocellular carcinoma: a systematic review and dose-response meta-analysis
2 Ravnskov et al. Lack of an association or an inverse association between low-density-lipoprotein cholesterol and mortality in the elderly: a systematic review
3 Bjellmo et al. Is vaginal breech delivery associated with higher risk for perinatal death and cerebral palsy compared with vaginal cephalic birth? Registry-based cohort study in Norway
4 Ferrando et al. The accuracy of postoperative, non-invasive Air-Test to diagnose atelectasis in healthy patients after surgery: a prospective, diagnostic pilot study
5 Brignardello-Petersen  et al. Knee arthroscopy versus conservative management in patients with degenerative knee disease: a systematic review
6 Fenton et al. Systematic review of the association between dietary acid load, alkaline water and cancer
7 Remes et al. Sex differences in the association between area deprivation and generalised anxiety disorder: British population study
8 May et al. Autism spectrum disorder: updated prevalence and comparison of two birth cohorts in a nationally representative Australian sample
9 Bickerdike et al. Social prescribing: less rhetoric and more reality. A systematic review of the evidence
10 Li et al. Randomised controlled trial of online continuing education for health professionals to improve the management of chronic fatigue syndrome: a study protocol

*Most read figures are based on pdf downloads and full text views. Abstract views are excluded.

Top 10 most read in April: low-density-lipoprotein cholesterol and mortality in the elderly, social prescribing and non-pharmacological interventions for behavioural disturbances in older patients with dementia

8 May, 17 | by Hemali Bedi

April sees five new entries in the top 10 most read articles. Reaching number one this month is a systematic review of cohort studies by Ravnskov et al, which investigates the association between low-density-lipoprotein cholesterol (LDL-C) and mortality in the elderly. Results indicate that high LDL-C is inversely associated with mortality in most people aged over 60, questioning the validity of the cholesterol hypothesis. In light of their results, Ravnskov et al suggest that a re-evaluation of the guidelines recommending pharmacological reduction of LDL-C in the elderly is needed.

Palser et al are in at number three with a qualitative study exploring the views of people with cystic fibrosis, and those close to them, of their first experience of respiratory infection from Pseudomonas aeruginosa. Reaching number five is a systematic review assessing the evidence for the effectiveness of social prescribing. Bickerdike at al were not able to measure success or cost effectiveness due to limited detail in the data collected, but found that social prescribing is widely implemented and encouraged.

Also making its way into the top ten is a systematic review and meta-analysis by Whiting et al evaluating the risks and benefits of temporarily discontinuing medications to prevent acute kidney injury. Finally, at number 10 this month is a systematic review of systematic reviews by Abraha et el, which provides an overview of non-pharmacological interventions for behavioural and psychological symptoms in dementia (BPSD). Abraha et el found great variation in how the same treatments are applied and assessed and that conclude that music therapy and behavioural management treatments were effective for reducing BPSD.

Rank Author(s) Title
1 Ravnskov et al. Lack of an association or an inverse association between low-density-lipoprotein cholesterol and mortality in the elderly: a systematic review
2 Fenton et al. Systematic review of the association between dietary acid load, alkaline water and cancer
3 Palser et al. Perception of first respiratory infection with Pseudomonas aeruginosa by people with cystic fibrosis and those close to them: an online qualitative study
4  Loo et al. Association between neighbourhood walkability and metabolic risk factors influenced by physical activity: a cross-sectional study of adults in Toronto, Canada
5 Bickerdike et al. Social prescribing: less rhetoric and more reality. A systematic review of the evidence
6 Williams et al. Childhood academic ability in relation to cigarette, alcohol and cannabis use from adolescence into early adulthood: Longitudinal Study of Young People in England (LSYPE)
7 Nguyen et al. Fruit and vegetable consumption and psychological distress: cross-sectional and longitudinal analyses based on a large Australian sample
8 Whiting et al.  What are the risks and benefits of temporarily discontinuing medications to prevent acute kidney injury? A systematic review and meta-analysis
9 Hoxha et al. Caesarean sections and for-profit status of hospitals: systematic review and meta-analysis
10 Abraha et al. Systematic review of systematic reviews of non-pharmacological interventions to treat behavioural disturbances in older patients with dementia. The SENATOR-OnTop series

*Most read figures are based on pdf downloads and full text views. Abstract views are excluded.