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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.

Complimentary therapies, well-being and consultants as victims of bullying :Most read articles in July.

11 Aug, 16 | by Fay Pearson

 Tired Doc

July’s top 10 most read papers sees two studies taking into account doctors’ points of view. The first, by Bourne et al., takes a closer look at look at which aspects of the complaints process they find the most stressful. The second, by Shabazz et al., uses a survey of Royal College of Obstetricians and Gynaecologists to explore how significant numbers of consultants in the UK are victims of bullying.

We also have a study by Linton et al., that systematically reviews self-report measures for assessing well-being, and a randomised controlled trial by Levett et al., that concludes that the use of complementary therapies during birth can significantly reduce usage of epidurals and cesarean sections.

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 Levett, et al. Complementary therapies for labour and birth study: a randomised controlled trial of antenatal integrative medicine for pain management in labour
3 Eleftheriou et al. Does attractiveness influence condom use intentions in heterosexual men? An experimental study
4 Bourne et al. Doctors’ experiences and their perception of the most stressful aspects of complaints processes in the UK: an analysis of qualitative survey data
5 Teschke et al. Bicycling injury hospitalisation rates in Canadian jurisdictions: analyses examining associations with helmet legislation and mode share
6 Kristensen et al. The effect of statins on average survival in randomised trials, an analysis of end point postponement
7 Shabazz,et al. Consultants as victims of bullying and undermining: a survey of Royal College of Obstetricians and Gynaecologists consultant experiences
8 Oudin et al. Association between neighbourhood air pollution concentrations and dispensed medication for psychiatric disorders in a large longitudinal cohort of Swedish children and adolescents
9 Tsubokura et al. Estimated association between dwelling soil contamination and internal radiation contamination levels after the 2011 Fukushima Daiichi nuclear accident in Japan
10 Linton et al. Review of 99 self-report measures for assessing well-being in adults: exploring dimensions of well-being and developments over time

Volunteering in middle age and senior years linked to enhanced mental health

8 Aug, 16 | by Emma Gray

No positive association seen before age of 40, suggesting link varies across life course

Volunteering in middle and older age is linked to good mental health/emotional wellbeing, finds a large study of British adults, published in the online journal BMJ Open.

But no such association was seen before the age of 40, suggesting that the link may be stronger at certain points of the life course, say the researchers.

Previous research has shown that volunteering in older age is associated with better mental and physical health, but it’s unclear whether this extends to other age groups.

The researchers therefore mined responses to the British Household Panel Survey (BHPS), involving a representative sample of adults living in 5000 households in Great Britain.

The BHPS ran every year from 1991 until 2008 before being incorporated into a much larger survey.  It included a wide range of questions on leisure time activities, which covered the frequency of formal volunteering—from at least once a week through to once a year or less, or never.

The BHPS also included a validated proxy for mental health/emotional wellbeing known as the GHQ-12.

The researchers gathered 66,343 responses for 1996, 1998, 2000, 2002, 2004, 2006 and 2008.

Around one in five respondents (21%) said they had volunteered. Women tended to volunteer more than men, and while almost a quarter of those aged 60 to 74 said they volunteered, this proportion dropped to 17% among the youngest age group.

GHQ-12 scores were better (lower) among those who volunteered than among those who had never done so—10.7 vs 11.4—across the entire sample, irrespective of age.

The average GHQ score was the best (lowest) among those who were frequent volunteers and worst (highest) among those who never volunteered.

When age was factored in, the positive association between volunteering and good mental health/emotional wellbeing became apparent at around the age of 40 and continued up into old age (80+).

Those who had never volunteered had lower levels of emotional wellbeing, starting at midlife and continuing into old age, compared with those who did volunteer.

The findings held true even after taking account of a range of potentially influential factors, including marital status, educational attainment, social class, and state of health.

By way of an explanation for the findings, the researchers speculate that volunteering at younger ages may just be viewed as another obligation, while social roles and family connections in early middle age may spur people to become involved in community activities, such as in their child’s school.

This is an observational study so no firm conclusions can be drawn about cause and effect, added to which the researchers were not able to gauge the extent of ‘informal’ volunteering, such as helping out neighbours, so couldn’t capture the full spectrum of voluntary activities.

But they nevertheless suggest that the findings show that volunteering may be more meaningful at certain points of the life course, and they call for greater efforts to involve middle aged to older people in some sort of volunteering.

“Volunteering might provide those groups with greater opportunities for beneficial activities and social contacts, which in turn may have protective effects on health status…With the ageing of the population, it is imperative to develop effective health promotion for this last third of life, so that those living longer are healthier,” they write.

Previous research indicates that people who volunteer are likely to have more resources, a larger social network, and more power and prestige, all of which have knock-on effects on physical and mental health, they point out.

“Volunteering may also provide a sense of purpose, particularly for those people who have lost their earnings, because regular volunteering helps maintain social networks, which are especially important for older people who are often socially isolated,” they add.

BMJ Open works with Publons to give credit for peer review

1 Aug, 16 | by aaldcroft


We’re pleased to announce that BMJ Open has partnered with Publons to help reviewers gain credit for their work.

Publons is a free service for reviewers, which enables them to gain public recognition for the reviews they complete. To take advantage of this service, you will first need to create a profile on Publons. When you submit your review via ScholarOne you will then be asked whether you would like to be credited for your review on Publons. Selecting ‘yes’ means that your review details will automatically be exported.

ORCID integration

In addition, Publons has partnered with ORCID so that reviewers can opt to have their verified review history automatically added to their ORCID profile.

Follow the steps below to make use of this service:

  1. Register for an ORCID profile (if you haven’t already).
  2. Sign in to Publons.
  3. Click on your profile picture in the top right-hand corner and select ‘Settings’.
  4. Under the ‘Reviews’ tab, click on the box ‘Authorise Publons to add reviews to ORCID’. Complete the relevant fields and click ‘Authorise’.
  5. Under the ‘Emails’ tab on the Publons site, add and verify any email addresses you have used for past peer review work.

Top 10 Most Read: Cholesterol and mortality in the elderly, chronic pain in the UK and smokers’ quitting attempts

8 Jul, 16 | by Ed Sucksmith


Several new entries make it into our top 10 Most Read list this month. In first place is a systematic review on the associations between low-density-lipoprotein cholesterol and mortality in the elderly. Further down the list is an analysis of Italian medical societies’ websites to examine conflicts of interest between professional medical societies and industry. Other new entries this month include an investigation into the relationship between air pollution and child and adolescent mental health by researchers from Umeå University in Sweden. Using a cohort of over half a million individuals under 18 years of age, the authors found that neighbourhood air pollution concentration is associated with dispensed medications for certain psychiatric disorders. At number 6 is a systematic review and meta-analysis of the prevalence of chronic pain in the UK. The authors conclude that chronic pain affects between one-third and one-half of the population of the UK, corresponding to just under 28 million adults. Lastly, making it in at number 9 is a study by Chaiton and colleagues on smokers’ quitting behaviour. The authors found that it may take as much as 30 or more attempts before a smoker quits successfully.


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 Eleftheriou et al. Does attractiveness influence condom use intentions in heterosexual men? An experimental study
3 Oudin et al. Association between neighbourhood air pollution concentrations and dispensed medication for psychiatric disorders in a large longitudinal cohort of Swedish children and adolescents
4 Fabbri et al. Conflict of interest between professional medical societies and industry: a cross-sectional study of Italian medical societies’ websites
5 Kristensen et al. The effect of statins on average survival in randomised trials, an analysis of end point postponement
6 Fayaz et al. Prevalence of chronic pain in the UK: a systematic review and meta-analysis of population studies
7 Teschke et al. Bicycling injury hospitalisation rates in Canadian jurisdictions: analyses examining associations with helmet legislation and mode share
8 Thomas et al. When procedures meet practice in community pharmacies: qualitative insights from pharmacists and pharmacy support staff
9 Chaiton et al. Estimating the number of quit attempts it takes to quit smoking successfully in a longitudinal cohort of smokers
10 Fenton et al. Systematic review of the association between dietary acid load, alkaline water and cancer

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

Third to half of UK population lives with chronic pain

20 Jun, 16 | by Emma Gray

Proportion likely to rise as population ages; major cause of disability and distress

Between a third and half (43%) of the UK population—roughly 28 million adults—lives with chronic pain, finds an analysis of the available evidence, published in the online journal BMJ Open.

This proportion is likely to rise as the population ages, warn the researchers, who add that chronic pain is a major cause of disability and distress among those affected by it.

There is no consensus on the proportion of people living with long term pain in the UK, and in a bid to try and gain an accurate picture, the researchers trawled relevant databases to find research on different types of pain, published after 1990.

Their search included studies on population based estimates of chronic pain—defined as lasting more than 3 months—chronic widespread pain, fibromyalgia (a rheumatic condition characterised by muscular or musculoskeletal pain), and chronic neuropathic pain (pain caused by nerve signalling problems).

From among 1737 relevant articles, 19 studies, involving just under 140,000 adults, were deemed suitable for inclusion in the final analysis.

They pooled the study data to arrive at an estimate of the prevalence of chronic pain, overall, and chronic widespread pain. Summary estimates were also drawn up for moderate to severely disabling chronic pain, fibromyalgia, and chronic neuropathic pain among UK adults.

Based on seven studies, the researchers worked out that the prevalence of chronic pain ranged from 35% to 51% of the adult population, with the prevalence of moderate to severely disabling chronic pain (based on four studies), ranging from 10% to 14%—equivalent to around 8 million people.

Pooling of the data showed that 43% of the population experience chronic pain, and 14% of UK adults live with chronic widespread pain. The summarised data also showed that 8% of UK adults experience chronic neuropathic pain, and 5.5% live with fibromyalgia.

Twelve of the studies categorised the prevalence of pain by age group, and unsurprisingly, these showed that older people were more likely to live with pain over the long term.

Among 18-25 year olds, the prevalence was 14%, although it may be as high as 30% among 18-39 year olds, the analysis indicates—a sizeable chunk of the working population, say the researchers.

Among those aged 75 and above, the prevalence was almost two thirds (62%), suggesting that if current trends continue, the burden of chronic pain may increase further still as the population ages, say the researchers.

Women were more likely than men to be affected by chronic pain, irrespective of age or pain type.

The researchers point out that the included studies varied considerably, and that not all of them were of high quality, so making it difficult to draw firm conclusions.

The studies showed gradually increasing prevalence of chronic pain over time, from 1990. And the researchersestimate that the prevalence of chronic pain in the UK is now around 43%, equating to around 28 million people, based on population stats for 2013.

“Such prevalence data does not itself define need for care or targets for prevention, but reliable information on prevalence will help to drive public health and healthcare policymakers’ prioritisation of this important cause of distress and disability in the general population,” they conclude.

Drug treatment of hyperactivity in kids may have levelled off in UK

20 Jun, 16 | by Emma Gray

But it lasts much longer than it does in rest of Europe or US

The tendency to treat childhood hyperactivity (ADHD) with drugs may have reached a plateau in the UK, following a steep rise in the number of prescriptions for these medicines over the past 20 years, reveals research published in the online journal BMJ Open.

But when kids with attention deficit and hyperactivity disorder (ADHD) do go down the pharmacological route, their treatment lasts for much longer than that of their European or US peers, the findings show.

Drugs are one of several treatment options for ADHD, which includes parental training and behavioural therapies. ADHD drugs have been in use since the 1960s and are on the World Health Organization’s list of essential medicines for common psychiatric disorders.

The researchers base their findings on an analysis of Clinical Practice Research Datalink (CPRD) records, relating to children up to the age of 16 who had been prescribed at least one drug to treat ADHD between 1992 and 2013.

The CPRD is one of the world’s largest collections of long term anonymised primary care medical records. It is broadly representative of the UK population, covering around 8% of the total.

The researchers analysed the data to estimate trends in ADHD prescribing patterns among children between 1995 and 2013, and the length of treatment for those diagnosed with the condition.

During this period, 14,748 children under the age of 16 (85% of them boys) were given at least one prescription for an ADHD drug, with methylphenidate accounting for 94% of all prescriptions.

Over half (58%) of the children received their first prescription between the ages of 6 and 11; around 4% were 5 years old when they were first prescribed an ADHD drug.

The use of these drugs in this age group soared by a factor of 35, from 1.5 per 10,000 children in 1995 to 50.7/10,000 in 2008, after which it seemed to level off at 51.1/10,000 children by 2013.

The rate of new prescriptions rose 8-fold over the same timeframe, reaching 10.2 per 10,000 children in 2007, but subsequently falling to 9.1/10,000 in 2013.

These patterns may reflect the impact of National Institute for Health and Care Excellence guidelines issued in 2008, and/or concerns about the potential impact on the heart of long term use, suggest the researchers.

UK prescribing rates for ADHD drugs are considerably lower than they are in many other countries, the researchers point out. They are 10 times lower than in the US, up to 5 times lower than in Germany, and 4 times lower than in the Netherlands, although UK rates are twice as high as in France.

Nevertheless, the course of treatment tends to be longer than in these countries, the published evidence indicates. More than three out of four UK children (around 77%) were still being prescribed ADHD drugs 1 year after diagnosis and 60% were still on treatment 2 years later, the figures show.

The probability of stopping ADHD drugs within six years seemed to be higher in 11-15 year olds than it was in 6-10 year olds, the data showed, which may indicate that treatment is being stopped too early among young adults, say the researchers.

This is an observational study, and the researchers point out that their analysis cannot determine the causes behind the prescribing patterns they found. Furthermore, the data relate only to  the issuing of prescriptions, and not to their being dispensed or drugs actually taken.

But they conclude: “Although the prevalence and incidence of ADHD drug use in children have substantially increased during the past two decades, it seems that it may have reached a plateau recently…Our study indicates a turning point in the patterns of ADHD drug prescribing in children in the UK.”

Prolonged sitting, non-fatal self-harm, and institutional mental healthcare: Most read articles in May

6 Jun, 16 | by Emma Gray

Prolonged sitting and fatigue, non-fatal self-harm, and trends in institutional mental healthcare in Western Europe

File:Une femme lisant à la biblothèque des Champs Libres de Rennes.jpg

This month sees a mixture of some old favourites and some new entries in the Top 10 Most Read list. First up is a pilot study by Wennberg et al which uses a randomised two-condition crossover trial to compare the acute effects of uninterrupted sitting with sitting interrupted by brief bouts of light-intensity walking on self-reported fatigue, cognition, neuroendocrine biomarkers and cardiometabolic risk markers in overweight and obese adults. Kristensen et al‘s paper on the effect of statins remains popular at number two this month and at number four we have an observational study by Geulayov et al which received a press release – it examines trends in non-fatal self-harm and its management in England. In at number five this month is a study by Chow et al investigating how institutional mental healthcare has changed in Western Europe since 1990, finding that there are ongoing overall trends of a decrease in the number of psychiatric hospital beds and an increase in the number of places in other institutions, including prisons. Last month’s most read paper by Gunn et al remains in the top ten, and at number ten we have a new entry by Laver et al with a systematic review of systematic reviews, assessing the effects of interventions to delay functional decline in people with dementia.

Rank Author(s) Title
1 Wennberg et al. Acute effects of breaking up prolonged sitting on fatigue and cognition: a pilot study
2 Kristensen et al. The effect of statins on average survival in randomised trials, an analysis of end point postponement
3 Teschke et al. Bicycling injury hospitalisation rates in Canadian jurisdictions: analyses examining associations with helmet legislation and mode share
4 Geulayov et al. Epidemiology and trends in non-fatal self-harm in three centres in England, 2000–2012: findings from the Multicentre Study of Self-harm in England
5 Chow et al. How has the extent of institutional mental healthcare changed in Western Europe? Analysis of data since 1990
6 Dickstein et al. Multicentre open-label randomised controlled trial to compare colistin alone with colistin plus meropenem for the treatment of severe infections caused by carbapenem-resistant Gram-negative infections (AIDA): a study protocol
7 Martinez Steele et al. Ultra-processed foods and added sugars in the US diet: evidence from a nationally representative cross-sectional study
8 Gunn et al. Prenatal exposure to cannabis and maternal and child health outcomes: a systematic review and meta-analysis
9 Hirono et al. Is health impact assessment useful in the context of trade negotiations? A case study of the Trans Pacific Partnership Agreement
10 Laver et al. Interventions to delay functional decline in people with dementia: a systematic review of systematic reviews

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

International Clinical Trials Day

19 May, 16 | by aaldcroft

By Sir George Chalmers, c 1720-1791 - [1], Public Domain,

Today is Clinical Trials Day. Celebrated around the world on or near May 20, Clinical Trials Day commemorates the date when, in 1747, James Lind started the first clinical trial to test citrus fruits as a treatment for scurvy.

This year’s campaign from the NIHR is OK To Ask, which encourages patients and carers to inquire about research opportunities that could be available. We here at BMJ Open support initiatives for patient involvement in research and decision-making and hope that, in making our content freely available online, we help make research more familiar and accessible to the public, including patients, for whom the research is ultimately intended.

While James Lind’s basic principle for the trial remains, the scale, sophistication, and problems surrounding modern trials are evolving rapidly. The importance of registering drugs and publishing all trial results is recognised, but adherence remains unsatisfactory. The notion of what constitutes an intervention is also changing, with text messaging and educational methods now being studied using the same framework as drugs.

BMJ Open will continue efforts to improve the quality of reporting trials, emphasizing the importance of publishing null and negative results and study protocols. The clinical trial is certainly worthy of celebration, along with improvement.

Celebrating International Nurses Day #IND2016

12 May, 16 | by Emma Gray


International Nurses Day, celebrated on 12th May each year and coinciding with Florence Nightingale’s birthday, marks the important contributions nurses make to society. As the single largest group of health professionals, nurses care from the first moments of life right through to the final days. To show our appreciation of the work that nurses do, BMJ Open are joining in the celebrations today with a round-up of some of our most popular papers on nursing.

Published in 2015, Dall’Ora et al surveyed registered nurses across 12 European countries to find associations between working 12 hour shifts and job satisfaction, burnout and intention to leave. Receiving over 10,000 downloads since publication, this paper has some important conclusions, finding that longer work hours were indeed associated with adverse outcomes – not only for nurses but potentially for patients as well.

Also published last year was a cross-sectional study into the prevalence of workplace violence that nurses have encountered in Chinese hospitals. The authors, Jiao et al, found that a total of 7.8% of the nurses interviewed for the study had experienced physical violence at work in the previous year, and 71.9% reported experiencing non-physical violence. They aimed to identify risk factors and provide a basis for future interventions, concluding that preplacement education for high-risk groups should take place to reduce workplace violence, and increased awareness from the public as well as policymakers is necessary to develop effective control strategies at individual, hospital and national levels.

One of our most popular papers this year, receiving a press release and over 7,000 downloads since its publication in February, is the paper ‘Registered nurse, healthcare support worker, medical staffing levels and mortality in English hospital trusts: a cross-sectional study’ by Griffiths et al.  Aiming to examine associations between mortality and registered nurse staffing in English hospital trusts, the authors found that ward-based registered nurse staffing is significantly associated with reduced patient mortality, as are higher doctor staffing levels. They conclude by saying that current policies and practices on the staffing in hospital wards should be reviewed in line with the evidence, to reduce risks to patients.

A paper by Schlicht et al published back in 2013 sought to determine the safety and acceptability of the Australian TrueBlue model of nurse-managed care of depression in patients with diabetes or heart disease in the primary healthcare setting. Using a mixed methods study involving a clinical record audit as well as focus groups and interviews with nurses, the study found that nurses were able to identify, assess and manage mental health risks in patients with diabetes or heart disease.  The nurse consultations also meant that there was an opportunity for patients to set goals, as they received scheduled follow-up visits and were monitored regularly, leading to stepped care when appropriate.

The final paper in this short overview of our content on nursing is a review of the cost-effectiveness of nurse practitioners in primary and specialised ambulatory care. A systematic review of randomised controlled trials, conducted by Martin-Misener et al, found that nurse practitioners in alternative provider ambulatory primary care roles have equivalent or better patient outcomes than comparators and are potentially cost-saving. This evidence is promising, but there are few studies contributing to this evidence base at the moment: the authors conclude that while some evidence indicates nurse practitioners in complementary specialised ambulatory care roles improve patient outcomes, their cost-effectiveness requires further study.

More on International Nurses Day:

BMJ is offering free content and discounts on resources for nursing professionals until 12th June: 

To join in with the celebrations, tweet today to show appreciation of nurses using the hashtags #thankanurse #IND2016 and #InternationalNursesDay

Radiotherapy during surgery could save millions of travel miles and tonnes of CO2

9 May, 16 | by Emma Gray

…plus free up thousands of hours for women with early stage breast cancer, every year

One targeted dose of radiotherapy given during surgery to remove early stage breast cancer could save millions of travel miles, enough CO2 emissions for a 100 hectare forest, and free up thousands of hours of women’s time, concludes research published in the online journal BMJ Open.

Standard treatment for early stage breast cancer is surgical removal of the cancerous tissue (lumpectomy), followed by a course of (external) radiotherapy beamed onto the affected breast every day for between three and six weeks.

But single dose targeted intraoperative radiotherapy, or TARGIT for short, is delivered by an applicator directly into the breast tissue during surgery. This adds around 20 to 40 minutes to the operating time, but in most cases avoids the subsequent need for daily hospital visits to complete a standard course of radiotherapy.

Previous international research (TARGIT-A trial) indicates that TARGIT is as good as standard external beam radiotherapy (EBRT) in suitable patients with early stage disease, and it is routinely offered as a treatment option in many countries, say the researchers. But TARGIT is not yet widely available in the UK’s 62 hospitals with radiotherapy units.

To assess the travel implications, journey times, and environmental impact of TARGIT and EBRT, the researchers compared these factors in 485 patients who had taken part in the TARGIT-A trial, 249 of whom had been randomly assigned to TARGIT and 236 to EBRT.

They also included a further 22 patients treated with TARGIT in two other semi-rural centres after the trial had finished.

They calculated the shortest driving distance from home to the radiotherapy unit and average travel time, excluding traffic delays, using Google Maps. They then calculated the total distance travelled and time spent to complete the entire course of radiotherapy.

On average, TARGIT-A trial participants in the UK live 13 miles (21 km) from a radiotherapy unit, and accounting for population density, the researchers estimated that two thirds of the UK population lives further away than this.

CO2 emissions were estimated for a standard family car with an average fuel consumption of 40 miles/gallon (7 litres/100 km). This would produce 299 g/mile (186 g/km) of CO2 emissions for a diesel car and 272 g/mile (169 g/km) for a petrol vehicle.

The TARGIT patients travelled significantly fewer miles (21,681) than EBRT patients (92,591) for their treatment, and spent significantly less time in transit: 3 hours compared with 14 hours.

Their journeys also emitted significantly less CO2: 24.7 kg compared with 111 kg for the EBRT patients.

The researchers worked out that the patients treated in the two semi-rural radiotherapy units each saved themselves journeys adding up to 753 miles, 30 hours of travel time, and they spared the planet 215 kg of CO2.

There are around 50,000 cases of breast cancer diagnosed in the UK every year, of which around three quarters are treated with lumpectomy and EBRT.

Based on these figures, the researchers calculate that if TARGIT became widely available across the UK,  it could save 5 million miles (800,000 km) in journeys, 170,000 hours of travel time, and 1200 tonnes of CO2—equivalent to a forest of 100 hectares—every single year.

This is a lot ‘greener’ than the estimated environmental benefits of introducing mobile breast cancer screening, they say.

“The management of breast cancer has changed over the decades. However, the requirement of patients to travel to receive these specialist services is often forgotten by policy-makers,” they write.

And they conclude that “introducing TARGIT as an option for appropriate patients in the UK will contribute significantly to saving patients time, cost, fuel and CO2 emissions.”