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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.

Prediabetes, PoTS and Portuguese physicians: most read articles in June

9 Jul, 14 | by fpearson

Several new papers made our top ten this month including Mainous et al.’s study on the prevalence of prediabetes in England, and McDonald et al.’s paper on postural tachycardia syndrome predominantly affecting young women. Other popular papers were the recently published paper from Krüsi et al., which explores the effects of criminalisation and policing of sex buyers and a systematic review and network analysis from Cameron et al., comparing antithrombotic agents for the prevention of stroke and major bleeding in patients with atrial fibrillation.

Rank Author(s) Title
1 Mainous et al. Prevalence of prediabetes in England from 2003 to 2011: population-based, cross-sectional study
2 Zhang et al. Spatial analysis on human brucellosis incidence in mainland China: 2004–2010
3 McDonald et al. Postural tachycardia syndrome is associated with significant symptoms and functional impairment predominantly affecting young women: a UK perspective
4 Cameron et al. Systematic review and network meta-analysis comparing antithrombotic agents for the prevention of stroke and major bleeding in patients with atrial fibrillation
5 Krüsi et al. Criminalisation of clients: reproducing vulnerabilities for violence and poor health among street-based sex workers in Canada—a qualitative study
6 Jenkins et al. Effect of a 6-month vegan low-carbohydrate (‘Eco-Atkins’) diet on cardiovascular risk factors and body weight in hyperlipidaemic adults: a randomised controlled trial
7 Dahlen et al. Rates of obstetric intervention and associated perinatal mortality and morbidity among low-risk women giving birth in private and public hospitals in NSW (2000–2008): a linked data population-based cohort study
8 Rao et al. Do healthier foods and diet patterns cost more than less healthy options? A systematic review and meta-analysis
9 Granja et al. What keeps family physicians busy in Portugal? A multicentre observational study of work other than direct patient contacts
10 Abu Dabrh et al. Health assessment of commercial drivers: a meta-narrative systematic review

 

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

Premature newborn survival 30% higher in high volume neonatal centres

7 Jul, 14 | by flee

The survival of premature newborns in England is 30% higher in specialist units treating large numbers of neonates, reveals an analysis of national data published in BMJ Open.

The advantage is particularly evident for very premature babies born after less than 27 weeks of pregnancy, where the figure rises to 50%, prompting the authors to conclude that new services for newborns should promote delivery of very preterm babies in high volume units.

How best to organise critical care for newborns has been the focus of intense debate, with the results of various studies indicating that centralised care is linked to better outcomes.

But after a review in 2003, the government in England decided to reconfigure services into managed clinical networks (MCNs). These offer some of the benefits of centralisation, while still permitting smaller units to remain open, in a bid to maintain ease and equity of access to services.

To gauge the impact of treatment volume within an MCN, the researchers looked at the survival and health of 20,554 premature babies admitted to 165 NHS hospital neonatal units in England between 2009 and 2011.

These units regularly contribute outcomes data to the National Neonatal Research Database, and were all part of the Neonatal Economic, Staffing, and Clinical Outcomes Project (NESCOP).

Some 17,955 of the babies were born between 27 and 32 weeks of pregnancy; 2559 were born after less than 27 weeks.

In all, 44 of the 165 hospitals (27%) had a level 3 or tertiary level neonatal unit – a designated specialist centre which receives referrals from other hospitals; 81 (49%) had a level 2 unit, which offer high dependency and some short term intensive care; and 39 (24%) had level 1 units, which don’t provide high dependency or intensive care.

Almost one in 10 (1892) of the 20,554 babies were born in hospitals with neonatal units that were classified as high volume, but not tertiary level. And a slightly smaller proportion (1817) were born in neonatal units classified as tertiary level, but not high volume.

High volume was categorised as 3480 days of care each year given to babies born after less than 32 weeks of pregnancy.

There was no difference in survival rates between very premature babies admitted to either level 3 or other level neonatal units at the hospital of their birth. But there was a difference when it came to volume.

Overall, 394 (4.1%) newborns born prematurely after less than 33 weeks of pregnancy died in high volume units compared with 395 (3.6%) premature newborns in other units.

Babies born after less than 33 weeks of pregnancy and admitted to a high volume neonatal unit at the hospital of their birth were around 30% less likely to die within 28 days than those not admitted to this type of unit.

And very premature babies born after less than 27 weeks of pregnancy were almost 50% less likely to die if admitted to a high volume neonatal unit.

“The effect of volume on neonatal outcomes is an important consideration for policy makers deciding the optimal organisation of neonatal specialist services,” conclude the authors.

Future research should also assess the impact of transfers, particularly in light of the reorganisation of MCNs into Operational Delivery Networks following the 2012 Health and Social Care Act, they add.

Poorly understood postural syndrome blights lives of young well educated women

16 Jun, 14 | by fpearson

A debilitating syndrome that causes an excessively rapid heartbeat on standing up, predominantly affects young well educated women, and blights their lives, because it is so poorly understood and inconsistently treated, reveals a small study published in the online journal BMJ Open.

Postural tachycardia syndrome, or PoTS for short, is a by-product of orthostatic intolerance – a disorder of the autonomic nervous system in which the circulatory and nervous system responses needed to compensate for the stress put on the body on standing upright, don’t work properly.

PoTS is associated with an excessively rapid heartbeat, or tachycardia. Symptoms include dizziness, fainting, nausea, poor concentration, excessive fatigue and trembling, and can be so severe as to make routine activities, such as eating and bathing, very difficult to do.

The impact of the syndrome has been likened to the level of disability associated with serious and debilitating long term conditions, such as chronic obstructive pulmonary disease (COPD) and congestive heart failure.

In the US, PoTS is thought to affect around 170 per 100,000 of the population, one in four of whom is disabled and unable to work.

But the symptoms, and their impact, are frequently not recognised in the UK, or attributed to anxiety, panic disorder, or chronic fatigue syndrome (CFS), say the researchers, who wanted to find out if PoTS affects particular groups, and how.

They therefore assessed 84 members of the national charity and support group, PoTS UK, and 52 patients diagnosed with the syndrome at the NHS falls and syncope clinic in Newcastle, north east England, between 2009 and 2012.

All participants completed a validated set of questionnaires specifically aimed at gauging levels of fatigue; sleepiness; orthostatic intolerance; anxiety and depression; ability to carry out routine tasks; and brain power.

The profile of the two groups was broadly similar, and indicated that people with PoTS are predominantly young – average age of diagnosis 30-33 – well educated to degree or postgraduate degree level, and female.

Poor health had prompted a significant number to change their jobs or give up working altogether, and both groups experienced high levels of fatigue, daytime sleepiness, orthostatic symptoms, anxiety and depression, memory and concentration problems, and considerable difficulty carrying out routine tasks.

Around one in five people had been diagnosed with CFS and a similar proportion had Ehlers-Danlos syndrome (inherited connective tissue disorders), suggesting that there may be an underlying overlapping cause, say the researchers.

Beta blocker drugs, which regulate heart rate, were the most common treatment for PoTS. But altogether, patients reported taking 21 different combinations of drugs. And a significant number were taking nothing at all or just salt.

“Patients with PoTS … have significant and debilitating symptoms that impact significantly on their quality of life,” write the researchers. “Despite this, there is no consistent treatment, high levels of disability, and associated comorbidity.”

They go on to emphasise that their findings indicate that patients with PoTS experience a similar level of disability to people with CFS, but yet don’t receive the same protection in law. “Our experience suggests that some patients never recover, and that a subset will worsen over time,” they conclude.

HIV, prostate cancer and food insecurity: most read articles in May

16 Jun, 14 | by flee

This month’s most read article was Dahlen et al.’s study on the rates of obstetric intervention and associated perinatal mortality among women who give birth in private and public hospitals. Newly-published papers in the top ten most read include O’Brien et al.’s paper on evidence-informed recommendations for rehabilitation with older adults living with HIV. Also proving popular for another month, was He et el’s  paper about salt reduction and it’s relationship to blood pressure, stroke and ischaemic heart disease.

Rank Author(s) Title
1 Dahlen et al. Rates of obstetric intervention and associated perinatal mortality and morbidity among low-risk women giving birth in private and public hospitals in NSW (2000–2008): a linked data population-based cohort study
2 O’Brien et al. Evidence-informed recommendations for rehabilitation with older adults living with HIV: a knowledge synthesis
3 Jenkins et al. Effect of a 6-month vegan low-carbohydrate (‘Eco-Atkins’) diet on cardiovascular risk factors and body weight in hyperlipidaemic adults: a randomised controlled trial
4 Xiong et al. Comparative efficacy and safety of treatments for localised prostate cancer: an application of network meta-analysis
5 Hsia et al. Analysis of variation in charges and prices paid for vaginal and caesarean section births: a cross-sectional study
6 He et al. Salt reduction in England from 2003 to 2011: its relationship to blood pressure, stroke and ischaemic heart disease mortality
7 Rao et al. Do healthier foods and diet patterns cost more than less healthy options? A systematic review and meta-analysis
8 Krijthe et al. Non-steroidal anti-inflammatory drugs and the risk of atrial fibrillation: a population-based follow-up study
9 Neter et al. Food insecurity among Dutch food bank recipients: a cross-sectional study
10 Rees et al. ‘It’s on your conscience all the time’: a systematic review of qualitative studies examining views on obesity among young people aged 12–18 years in the UK

 

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

Use of cement in partial hip replacement linked to risk of death

12 Jun, 14 | by fpearson

The use of cement in partial hip replacement surgery may be linked to a risk of death – often occurring within minutes - finds research published in the online journal BMJ Open.

The risk is relatively rare. But the alarm was first sounded in 2009, and most of the cases that have come to light have occurred since that date, say the authors, who include the former chief medical officer for England.

This suggests that measures to reduce the risks are not being acted on widely enough, they say.

They base their findings on an analysis of cases submitted between 2005 and 2012 to the National Reporting and Learning System (NRLS) – a database of patient safety incidents associated with the delivery of healthcare across the NHS in England and Wales.

All the cases involved sudden and severe deterioration among patients undergoing partial hip replacement, known as hemiarthroplasty, for fractured neck of femur (broken hip), and associated with the use of cement to help hold the artificial hip joint in place.

This sudden deterioration is referred to as bone cement implantation syndrome or BCIS for short. In each of the cases in this study, it caused either death; cardiac arrest, where the heart stops beating; or periarrest – severe deterioration in the patient’s condition.

Between 2005 and 2012, the NRLS received 62 reports of BCIS, equivalent to one incident for every 2900 hemiarthroplasties performed for fractured neck of femur, indicating that it is a rare occurrence.

In 2012, 22,000 people in the UK underwent partial hip replacement for a fractured neck of femur, although not all these would have involved the use of cement.

But in 41 of the cases reported to the NRLS the patient died, and in most (80%), this was on the operating table. A further 14 patients had a heart attack but were resuscitated; and seven sustained a periarrest from which they recovered.

In most cases (55 out of 62; 89%), these events occurred within minutes of the cement being inserted.

A further 39 cases of hip surgery associated with BCIS were also reported to the NRLS during this period, but were not included because it was not clear whether the procedures specifically related to partial hip replacement for fractured neck of femur.

In 2009, the now defunct National Patient Safety Agency raised the alarm about the use of cement and associated patient harm during hemiarthroplasty and issued guidance to the NHS on how to minimise the risks.

Fifty one of the 62 cases were reported to the NLRS after this date, possibly because of heightened awareness in the wake of the guidance, say the researchers.

But the fact that deaths are continuing to occur “clearly shows that the implementation of mitigation measures set out in the alert was suboptimal, or that their effectiveness is suboptimal, or both,” they write.

In an accompanying video abstract, lead researcher Dr Paul Rutter emphasises that the risk of BCIS remains rare, but not so rare that orthopaedic surgeons don’t need to know about it, or what steps they need to take to reduce it.

Rates of pre-diabetes have tripled over past decade in England

9 Jun, 14 | by fpearson

The prevalence of pre-diabetes – higher than normal blood glucose levels – has tripled within the space of 8 years in England, reveals research published in the online journal BMJ Open.

More than a third of adults in England now have pre-diabetes, the findings suggest, with those who are disadvantaged and of black and minority ethnicity disproportionately affected. If nothing is done to halt this trend, the country faces a steep rise in the prevalence of diabetes, as up to one in 10 of those with pre-diabetes will progress to diabetes every year, warn the authors.

They base their findings on an analysis of data collected for the representative Health Survey for England for the years 2003, 2006, 2009 and 2011 and those participants who had provided a blood sample. In all, the data covered more than 20, 000 people.

Pre-diabetes was classified as a glycated haemoglobin – a measure of blood glucose control – of between 5.7% and 6.4%. Diabetes is usually classified as a glycated haemoglobin of 6.5%.

Analysis of the data showed that the prevalence of diagnosed diabetes rose from 3.55% in 2003 to 5.59% in 2011. But the rise in the prevalence of pre-diabetes was much greater. This rose from 11.6% to 35.3% between 2003 and 2011. Older age, overweight, obesity, high blood pressure and high cholesterol were all associated with pre-diabetes risk.

By 2011, half the survey participants (50.6%) who were overweight with a BMI of more than 25, and aged at least 40, had pre-diabetes. There was no gender difference in rates.

Those living in some of the most deprived areas of the country were more likely to have pre-diabetes in 2003 and 2006, but this association was no longer significant by 2009 and 2011.

But after taking account of age, sex, ethnicity, BMI and high blood pressure, people who lived in the second most economically deprived areas of the country were 45% more likely to have diabetes by 2011.

Although diabetes is associated with more complications than its precursor condition, people with pre-diabetes are still at risk of vascular, kidney, and eye problems, the authors point out.

They admit that the data don’t reveal whether any of the survey participants had been screened or treated for their condition, and while this does not alter the prevalence figures, it could affect the policy implications, they say.

Nevertheless, they describe the rise in the proportion of adults who meet the criteria for pre-diabetes as “extremely rapid,” and conclude: “In the absence of concerted and effective efforts to reduce risk, the number of people with diabetes is likely to rise steeply in coming years.”

Divorce may be linked to higher risk of overweight/obesity among kids involved

4 Jun, 14 | by fpearson

Divorce may be linked to a higher risk of overweight and obesity among children affected by the marital split, suggests research published in the on-line journal BMJ Open.

Boys may be especially prone to excess weight gain, the findings indicate.

The researchers base their findings on a nationally representative sample of more than 3000 pupils attending 127 schools across Norway. All the children were part of the national 2010 Norwegian Child Growth Study.

School nurses measured the height, weight, and waist circumference of the children whose average age was 8, to gauge general overweight, as defined by the International Obesity Task Force (IOTF), and (abdominal) obesity, as defined by a waist to height ratio of 0.5 or more.

The results were stratified by gender and parents’ marital status – married, never married, to include co-habiting, single and separated, and divorced – taking account of influential factors, such as the mother’s educational attainment, ethnic origin and area of residence.

Around one in five (19%) of the children was overweight or obese according to the IOTF definition, while just under one in 10 (8.9%) was (abdominally) obese.

Overall, significantly more of the 1537 girls were overweight or obese than the 1629 boys, but there were no differences in the prevalence of (abdominal) obesity.

More of the children whose parents were categorised as divorced were overweight or obese than those whose parents remained married.

They were 54% more likely to be overweight/obese and 89% more likely to be (abdominally) obese. Children whose parents had never married had a similar prevalence of overweight and obesity to those with married parents.

The findings held true even after taking account of other possible explanatory factors.

But these differences were generally larger for boys whose parents were divorced. They were 63% more likely to be generally overweight/obese than boys whose parents were married. And they were 104% more likely to be abdominally obese.

The absolute differences were 9.9 and 7.4 percentage points, respectively.

The same pattern was seen among girls, but the associations were less marked and, unlike the boys, not statistically significant.

The authors caution that the design of their study does not provide a basis for establishing cause and effect. Furthermore, they were unable to glean how long parents had been divorced, nor were they able to include lifestyle factors such as the children’s normal diet and exercise regime.

But the associations they found are consistent with findings from other studies they say.

Possible explanations for the link could include less time spent on domestic tasks such as cooking; an over-reliance on unhealthier convenience foods and ready meals; and lower household income.

The emotional fall-out of a divorce and resulting stress generated by disruptions in the parent-child relationship, ongoing conflict between the exes, moving home and the need to create new social networks, might also explain the findings, the authors suggest. And boys might just be more vulnerable, they say

Bringing old trials to light in BMJ Open

14 May, 14 | by Richard Sands, Managing Editor

 

Today we have published the first trial prompted by the Restoring Invisible and Abandoned Trials (RIAT) initiative.

Dr Tom Treasure from UCL, with colleagues from University of Sussex and Imperial College, have brought back from obscurity the results of the ‘CEA Second-Look’ trial.

The study asked the question: in patients who have undergone a potentially curative resection of colorectal cancer, does a ‘second-look’ operation to resect recurrence, prompted by monthly monitoring of carcinoembryonic antigen, confer a survival benefit?

As well as the inherent clinical significance of the study to colorectal surgery the paper is important in the context of the AllTrials and RIAT initiatives to bring greater transparency to the conduct and reporting of clinical trials.

We are delighted that this paper has been published in BMJ Open and you can read more about the background to the paper’s preparation in an accompanying Analysis piece in The BMJ.

We are enthusiastic supporters of the AllTrials campaign (BMJ was a founder). We encourage submission of so-called negative results, such as this trial of weekly chloroquine therapy for malaria-associated anaemia. These papers may show genuine evidence of absence of an effect, but they may also report trials that were inconclusive (reporting an absence of evidence).  Results of trials that had to shut down early, perhaps due to recruitment problems or unexpected side-effects will also be considered. As well as RIAT trials, trials that just happen to be old are also important to publish. We also publish trial protocols and research into trial methods.

For many years The BMJ has campaigned for all trial results to be published and the creation of BMJ Open in 2010 was intended, in part, to provide a venue for trials that may struggle to be published by journals looking only for definitive, new or positive results.

Unfortunately, we also have to turn away some trials that are submitted to BMJ Open.

Before sending any trial or trial protocol for review we check the registration details. We follow rigorously the International Committee of Medical Journal Editors’ recommendations that trials should be registered prospectively, i.e. before any participants are recruited. Unfortunately we receive several studies every month that fail this check and are rejected. Doubtless they’ll end up published somewhere, but that is where we set the bar for ethical and methodological soundness of trial conduct.

If you have any questions about whether your study is suitable for BMJ Open, or about trial registration, please contact the editorial office at editorial.bmjopen@bmj.com. We would be delighted to hear from you.

The CEA Second-Look Trial: a randomised controlled trial of carcinoembryonic antigen prompted reoperation for recurrent colorectal cancer

13 May, 14 | by flee

A trial that remained unpublished for 20 years casts doubt on the survival benefit of repeat (“second look”) surgery for bowel cancer.

The trial is published in BMJ Open today. It is the first to be restored under the restoring invisible and abandoned trials (RIAT) initiative that allows third parties to publish previously abandoned studies when the original researchers or sponsors fail to do so.The initiative was announced last year by editors of The BMJ and PLOS Medicine as a way to complete and correct the scientific record, so that doctors and patients have access to accurate information to make decisions about treatments.

On bmj.com today, Professor Tom Treasure and colleagues tell the story behind the trial and discuss what it means today.

The trial started in 1982 and examined the use of a tumour marker (carcinoembryonic antigen or CEA) to detect cancer recurrence early and prompt second look surgery. The researchers wanted to see whether this would result in better survival.

Nearly 1,500 bowel cancer patients who had already had surgery took part in the trial. Those with high CEA levels, suggesting their cancer had returned, were randomised to further surgery (active arm) or to continued review (control arm).

But the trial was stopped early in 1993 when it was found that there were more deaths in the active arm than the control arm.

Although there was a clear intention to publish the results, various factors led to the trial team breaking up and the data were thought to be irretrievably lost.

When the RIAT initiative was announced, Professor Tom Treasure at University College London and colleagues at the University of Sussex and Imperial College London had already retrieved the archived files and were in the process of analysing the data.

Spurred on by the initiative, their updated analysis confirms that there is no hint of a survival advantage associated with knowledge of the CEA.

They acknowledge that methods of detection, imaging, and surgical resection have changed over the intervening 20 years, but they do not believe that the findings can be readily discounted.

They say the new evidence “should fuel uncertainty about present day second look surgery for colorectal cancer in its various forms and hope that it will give some encouragement to undertake the randomised trials that are needed.”

Comparing the results from two surveys of BMJ Open authors

9 May, 14 | by Richard Sands, Managing Editor

 

BMJ Open authors were among those surveyed by Professor David J Solomon of Michigan State University for a study recently published in the journal PeerJ.

Needless to say we read this with great interest (we were unaware of the survey until the results were published). The survey reported a generally positive response to BMJ Open specifically and open access megajournals in general. The low response rates mean that many of the specific results should be interpreted with caution, though.

The response rate from BMJ Open authors was the lowest in the Solomon study (187/728 respondents; 26%). A possible explanation for this is that we were surveying the same people (authors published in 2013) at what seems to have been around the same time, asking some similar questions. BMJ journals regularly survey authors, readers and reviewers to help us stay in touch with the research community. There were some notable similarities in results and some major differences.

We achieved a 47% response rate (401/849) and thought it might be of interest to summarise our results which were roughly comparable with Professor Solomon’s.

Like Professor Solomon we surveyed our authors about the most important factors behind their decision to submit to BMJ Open. We offered 12 options from which authors could choose three. There was no ranking of these three choices.

The three most important reasons for submitting to BMJ Open in Solomon’s survey were

  • the quality of the journal (28%)
  • reputation of the publisher (18%)
  • the impact factor (IF) (13.5).

In our survey, impact factor was much less important. The three most selected options were

  • open access (59%)
  • BMJ Group branded journal (50%)
  • speed of review (37%).

Reputation of the journal (34%) was the fourth most selected in our survey (the most comparable option we had to Solomon’s ‘quality of the journal’). Impact factor was only the ninth most important reason given (13%). The most popular option in our survey without a rough equivalent in Solomon’s was ‘ease of transfer from another BMJ journal’, selected by 29% of respondents as one of their three most important reasons for submitting.

Although open access was the most-selected reason for submitting to BMJ Open in our survey, 84% of respondents believed publishing in an open access journal was not a requirement of their funder or their institution.

66% of our respondents said BMJ Open was not their first choice for submission, similar to the 68% in Solomon’s paper. The broad scope of the journal was a 35% said they used institutional funds to pay the publishing charge followed by 29% who said they used a direct grant. The number who received a waiver (9%) in our survey was roughly similar to those in Prof. Solomon’s survey (11.4%); the actual figure for 2013 was around 10%.

Further comments
BMJ Open’s IF was announced in July 2013. Many of the authors surveyed may have submitted to and/or published in the journal before it was announced. This may make the answers that relate to its importance when submitting less reliable (in both surveys). Alternatively there may be a balance between authors who didn’t care that no IF had been announced and those that would not have submitted if the journal didn’t have one.

Though omitted as an option from the Solomon survey BMJ also has institutional membership schemes that cover APCs and you can read more about them here.

With regard to publishing preliminary findings, BMJ Open publishes research protocols as well as results papers. So some of the authors surveyed would not have been publishing any research findings in BMJ Open.

It was nice to see that Professor Solomon opted to make the peer review comments open. We use open review and are glad to see more journals bringing transparency into the review process.

We’ll gloss over BMJ Open being referred to as BMC Open. Twice …