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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.

Guest blog: Improving peer review using peer-reviewed studies #PeerRevWk16

19 Sep, 16 | by aaldcroft

This week is the second ever “peer review week”. The theme for this year is “Recognition for Review”. Peer review week aims to highlight the importance of peer review, which is a crucial part of the research process. We asked Dr Adrian Barnett, from the Queensland University of Technology, and a member of our editorial board, to survey articles published in BMJ Open that present research on medical publishing and peer review

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It’s challenging to do peer review well and current models of peer review in health and medical research are regularly criticised by researchers who all have personal stories of when peer reviewers got things badly wrong. My own favourite recent example is a reviewer asking us to consider snow in our study of how rainfall impacts on salmonellosis in sub-tropical Queensland.

If we believe in peer review then we should believe in using peer review to improve peer review, and there are interesting studies that have highlighted problems with peer review. This introspective research is part of the growing field of meta-research or research on research, which uses research to examine and improve the entire research process. Such research is sorely needed considering that 85% of current health and medical research is wasted.

BMJ Open welcomes research on peer review and there are 54 papers in the category of “Medical publishing and peer review” including research on peer review as well other important meta-research issues, such as unpublished studies and how research is reported. The first paper in the category from 2011 examined reporting guidelines, and the most recent in 2016 looks at the reporting of conflicts of interest.

Can meta-research help when it comes to the difficult problem of recognition for review? To recognise good peer review we need to judge the quality of peer review, which means reviewing the reviewers.

An observational study compared the quality of reviews for reviewers suggested by authors with reviewers found by editors. The concern is that author-suggested reviewers may be too friendly, and in extreme cases be fake reviewers. The benefit of author-suggested reviewers is that it saves editors time in finding suitable experts. The study found no difference between the quality of reviews, but author-suggested reviewers were far more likely to recommend publication, with 64% of author-recommend reviewers recommending acceptance compared with just 35% of reviewers found by editors. It is possible that many authors suggest reviewers whose views agree with their own and whose work they have cited. Does this count as rigorous peer review, or would it be better if papers were critically analysed by researchers with a variety of views?

Another observational study examined peer reviewers comments for drug trials sponsored by industry compared with non-industry studies. The industry-sponsored studies had fewer comments on poor experimental design and inappropriate statistical analyses, and my guess is (based on personal experience) the industry trials employed more specialist staff because they have bigger budgets.

Both these studies had to spend time and effort reviewing the peer reviewers’ comments, and this extra effort is a key barrier to improving peer review.

Instead of reviewing every review a solution is to randomly check a sample of reviews. This would allow a reasonable number of reviews to be examined and graded in detail. If peer reviewers realise there’s a chance their work will be checked, then they should provide better reviews. The same idea is used by the tax office, who can’t afford to audit everyone but can increase compliance by random auditing.

Another benefit of regular random audits is that it would provide great data for tracking the quality of peer review over time, and allow a journal to ask whether things are getting better, or whether a policy change improved average review quality.

Of course the random tax audit works because there are severe penalties for those who are caught. A peer review audit would likely have to provide positive incentives, which could include a letter of commendation for the best reviews, promotion to the editorial board, or even the well-used incentive of money.

Dr Adrian Barnett is a statistician at the Queensland University of Technology, Brisbane. He works in meta-research which uses research to analyse how research works with the aim of making evidence-based recommendations to increase the value of research. @aidybarnett

School sex education often negative, heterosexist, and out of touch

12 Sep, 16 | by Emma Gray

And taught by poorly trained, embarrassed teachers, say young people

School sex education is often negative, heterosexist, and out of touch, and taught by poorly trained, embarrassed teachers, finds a synthesis of the views and experiences of young people in different countries, published in the online journal BMJ Open.

Schools’ failure to acknowledge that sex education is a special subject with unique challenges is doing a huge disservice to young people, and missing a key opportunity to safeguard and improve their sexual health, conclude the researchers.

They base their findings on 55 qualitative studies which explored the views and experiences of young people who had been taught sex and relationship education (SRE) in school based programmes in the UK, Ireland, USA, Australia, New Zealand, Canada, Japan, Iran, Brazil and Sweden between 1990 and 2015.

Most of the participants were aged between 12 and 18.

The researchers synthesised the feedback and found that despite the wide geographical reach of the studies, young people’s views were remarkably consistent.

Two overarching themes emerged to explain most of the data. The first of these was that schools have failed to recognise the distinctive and challenging nature of SRE, for the most part preferring to approach it in exactly the same way as other subjects, say the researchers.

Yet the feedback indicated there are distinct challenges when teaching SRE: in mixed sex classes young men feared humiliation if they weren’t sexually experienced and said they were often disruptive to mask their anxieties; their female class mates felt harassed and judged by them.

Young people also criticised the overly ‘scientific’ approach to sex, which ignored pleasure and desire, and they felt that sex was often presented as a ‘problem’ to be managed. Stereotyping was also common, with women depicted as passive, men as predatory, and little or no discussion of gay, bisexual, or transgender sex.

The second principal theme was that schools seem to find it difficult to accept that some of their students are sexually active, leading to content that is out of touch with the reality of many young people’s lives and a consequent failure to discuss issues that are relevant to them, say the researchers.

This was evident in what young people perceived as an emphasis on abstinence; moralising; and a failure to acknowledge the full range of sexual activities they engaged in.  Sex education was delivered too late, some students felt.

But it also manifest in a failure to deliver helpful and practical information, such as the availability of community health services, what to do if they got pregnant, the pros and cons of different methods of contraception, or the emotions that might accompany sexual relationships.

Young people also disliked having their teachers deliver SRE, not only because they felt teachers were poorly trained and too embarrassed, but also because of the potential for this arrangement to disrupt teacher-pupil relationships and breach boundaries.

The researchers point out that despite its low status and variable content and quality, school based SRE is seen as vital by policy makers for protecting young people from ill health, unwanted pregnancies, sexual abuse and exploitation.

And the evidence suggests that young people themselves want SRE to be taught in schools, using an approach that is ‘sex positive’—one that aims for young people to enjoy their sexuality in a way that is safe, consensual, and healthy.

They conclude: “Schools should acknowledge that sex is a special subject with unique challenges, as well as the fact and range of young people’s sexual activity, otherwise [they] will continue to disengage from SRE, and opportunities for safeguarding and improving their sexual health will be reduced.”

BMJ Open to publish abstracts for the UCL Qualitative Health Research Network symposium

9 Sep, 16 | by aaldcroft

On the Tuesday 7th February 2017, the UCL Qualitative Health Research Network will be hosting their third symposium entitled ‘Engagement, Co-production, and Collaborative Meaning-Making: Collaboration in Qualitative Health Research’, supported by The Wellcome Trust.

Held within the Institute of Child Health, 30 Guildford Street, London, the Network invite all those with an interest in qualitative health research, from policy makers to the general public, to come along and engage in presentations, workshops and discussions on the theme of collaboration.

Abstracts can be submitted up until the closing date of 26th September 2016, with successful submissions published in BMJ Open shortly after the symposium. The call for abstracts and details on of the submission process are available here.

Registration will open in November 2016 but please check the website or follow the QHRN on Twitter to keep up to date on key dates and plans.

Volunteering and mental health, breast feeding outcomes and condom use intentions: Most read articles in August

7 Sep, 16 | by Emma Gray

Association of volunteering and mental well-being, breast feeding outcomes and place of birth, and condom use intentions of heterosexual men

File:FEMA - 15337 - Photograph by Andrea Booher taken on 09-10-2005 in Texas.jpg

The August most read list contains papers with a number of different study designs, on a number of different topics. Returning to the top spot this month is a systematic review on the lack of an association or an inverse association between low-density-lipoprotein cholesterol and mortality in the elderly, by Ravnskov et al. At numbers three and six respectively, we have Quigley et al with a cross-sectional study examining the association between breast feeding outcomes and place of birth, and Tabassum et al with a study on the association of volunteering with mental well-being which also received a press release. Levett et al come in at number eight with randomised controlled trial which concludes that an antenatal integrative medicine education programme in addition to usual care significantly reduced epidural use and caesarean section in nulliparous women. Finally, at number ten is an experimental study by Eleftheriou et al looking at the influence of attractiveness on the condom use intentions of heterosexual men.

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 Kristensen et al. The effect of statins on average survival in randomised trials, an analysis of end point postponement
3 Quigley et al. Association between home birth and breast feeding outcomes: a cross-sectional study in 28 125 mother-infant pairs from Ireland and the UK
4 Teschke et al. Bicycling injury hospitalisation rates in Canadian jurisdictions: analyses examining associations with helmet legislation and mode share
5 Hill et al. Development and initial cohort validation of the Arthritis Research UK Musculoskeletal Health Questionnaire (MSK-HQ) for use across musculoskeletal care pathways
6 Tabassum et al. Association of volunteering with mental well-being: a lifecourse analysis of a national population-based longitudinal study in the UK
7 Smyth et al. Identification of adults with sepsis in the prehospital environment: a systematic review
8 Levett et al. Complementary therapies for labour and birth study: a randomised controlled trial of antenatal integrative medicine for pain management in labour
9 Jaber et al. New method of preoxygenation for orotracheal intubation in patients with hypoxaemic acute respiratory failure in the intensive care unit, non-invasive ventilation combined with apnoeic oxygenation by high flow nasal oxygen: the randomised OPTINIV study protocol
10 Eleftheriou et al. Does attractiveness influence condom use intentions in heterosexual men? An experimental study

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

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.”