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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.

E-cigarette use, abortion legislation and mortality in marginally housed adults: Most read articles in September

9 Oct, 15 | by Emma Gray

Entering the Top 10 Most Read this month is Shiplo et al‘s paper on the prevalence and patterns of use of e-cigarettes in a sample of both smokers and non-smokers in Canada, measured via a cross-sectional survey. Also new are Hysing et al‘s paper on the relationship between adolescent use of electronic devices and sleep deficiency and Jones et al‘s paper, which evaluates the impact of treatable illnesses on mortality in adults living in marginal conditions. Returning to the list this month are a few popular papers, including Koch et al‘s paper published earlier this year on the association between abortion legislation and maternal mortality.

Rank Author(s) Title
1 Dall’Ora et al. Association of 12 h shifts and nurses’ job satisfaction, burnout and intention to leave: findings from a cross-sectional study of 12 European countries
2 Thienpont et al. Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive stud
3 Shiplo et al. E-cigarette use in Canada: prevalence and patterns of use in a regulated market
4 Deane et al. Priority setting partnership to identify the top 10 research priorities for the management of Parkinson’s disease
5 Hubble et al. Trunk muscle exercises as a means of improving postural stability in people with Parkinson’s disease: a protocol for a randomised controlled trial
6 Hysing et al. Sleep and use of electronic devices in adolescence: results from a large population-based study
7 Mills et al. Quantitative systematic review of the associations between short-term exposure to nitrogen dioxide and mortality and hospital admissions
8 Koch et al. Abortion legislation, maternal healthcare, fertility, female literacy, sanitation, violence against women and maternal deaths: a natural experiment in 32 Mexican states
9 Lee et al. Is clopidogrel better than aspirin following breakthrough strokes while on aspirin? A retrospective cohort study
10 Jones et al. Mortality from treatable illnesses in marginally housed adults: a prospective cohort study

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

Peer Review Week: An analysis of peer review style and quality

30 Sep, 15 | by Fay Pearson

This week celebrates the first ever Peer Review Week; a collaborative concept from ORCID, Wiley, Sense About Science and ScienceOpen, to highlight and celebrate the invaluable role peer review plays in scientific and medical publishing.

Here at BMJ Open we are, of course, advocates of open peer review and as such are pleased to be publishing a timely research article by our friends at Biomed Central.

The paper, from Maria Kowalczuk et al., is a retrospective analysis of the quality of referee reports from author-suggested and non-author-suggested reviewers in open or single blind peer review journals.

Their objective was to elucidate whether reviews from peers suggested by authors would show bias in quality and decision recommendation compared to reviewers selected by other means. They also aimed to assess whether open review vs. single blind review had an impact on quality and recommendation. To achieve this, the study looked at 200 reviewer reports submitted in 2010-2011 to BMC Microbiology, 200 submitted to BMC Infectious Diseases, and 400 that were submitted to the Journal of Inflammation, these journals use single blind peer review, open peer review and a combination of the two, due to policy change, respectively. Comparisons were made by assessing the quality of report (using the Review Quality Instrument), by analysing the editorial recommendation made, and with author surveys. After statistical analysis of the data, they could conclude that the reports from reviewers suggested by the authors were of comparable quality but were more likely to suggest publication.

They also conclude that the open peer review reports were of a slightly higher quality than those using single blind review. These findings are in line with those from the randomised trial conducted by The BMJ, after they became one of the first journals to use open peer review in 1999, and similar to another study by the British Journal of Psychiatry.

As BMJ Open is open access with fully open peer review, we are always happy to see further research demonstrating the success of this model.  As we use a combination of both author suggested and non-author suggested reviewers (with an in-house filtering process), we couldn’t help but agree when we spoke to the paper’s authors and they said the following,  ‘It is reassuring that reviewers suggested by the authors provided reports of as good quality as reviewers found by editors using other means. Author-suggested reviewers tended to recommend acceptance of the manuscript more often than other reviewers, which highlights the important role of the editor in making the final decision on the manuscript’ .

The full text of the paper, Retrospective analysis of the quality of reports by author-suggested and non-author-suggested reviewers in journals operating on open or single-blind peer review models– Kowalczuk et al., can be found here:

Introducing ‘How to write and publish a Study Protocol’ using BMJ’s new eLearning programme: Research to Publication

22 Sep, 15 | by esucksmith

Study protocols are an integral part of medical research. They provide a documented record of a researcher’s plan of action, detailing in advance a study’s rationale, methodology and analyses. Publication of study protocols ensures greater transparency in the research process and protects the wider community against a number of damaging research practices. These include the selective publication of positive results, the selective presentation of data or analyses, the failure to adequately calculate statistical power and the failure to distinguish between hypothesis-generating (exploratory) and hypothesis-testing analyses. Publication of protocols also informs the research community about what research activity is currently being carried out in different fields, preventing unnecessary duplication of work and encouraging collaboration between research groups. The many benefits of publishing study protocols helps to ensure that medical research studies are conducted to the highest standards, leading to a stronger evidence base in medicine and ultimately better healthcare for patients.

BMJ Open is committed to improving standards in medical research by supporting the publication of study protocols. Furthermore, BMJ Open’s Editor-in-Chief, Trish Groves, leads an online eLearning programme, Research to Publication, which includes a free module on how to write and publish a study protocol. The aim of the Research to Publication programme is to equip researchers with the basic skills and knowledge needed to understand research designs, write manuscripts and become published authors.

Successful completion of the study protocol module is formally recognized with a certificate from The BMJ’s Editor-in-Chief. If a researcher completes the module and provides the certificate when they submit their study protocol to BMJ Open, then they will receive a 75% reduction on the Article Publishing Charge upon acceptance of their manuscript for publication (usual protocol APC: £1000). The protocol would need to be submitted to BMJ Open within six months of completion of the module and would need to go through the usual editorial and peer review processes, so we cannot promise acceptance.

We hope this combination of training, certification, and publication support will encourage more researchers to publish their study protocols. Further information about the Research to Publication eLearning programme can be found here.

12+ hour hospital nursing shifts linked to heightened risk of burnout and job dissatisfaction

10 Sep, 15 | by Emma Gray

Findings similar across 12 European countries, and run counter to perceived value of longer shifts

Working 12+ hour shifts is linked to a heightened risk of burnout, job dissatisfaction, and intention to leave among hospital nurses in 12 European countries, finds research published in the online journal BMJ Open.

The findings run counter to the perceived value among both nurses and employers of working longer shifts, which are increasingly common practice in England, Ireland, and Poland, say the researchers.

Job satisfaction and burnout are global concerns in the nursing workforce, because of the potential impact they have not only on the quality and safety of patient care, but also on retention.

And nursing shifts have been lengthening, driven by the perception that they boost efficiency and productivity and offer increased flexibility and more full days off work. But these extended working patterns have not been comprehensively evaluated, say the researchers.

They therefore surveyed 31 627 registered hospital nurses (response rate 62%), excluding those in intensive or long term care units, in 488 hospitals in Belgium, England, Finland, Germany, Greece, Ireland, The Netherlands, Norway, Poland, Spain, Switzerland and Sweden, between 2009 and 2010.

The survey included a total of 118 questions, relating to the demands and experience of the job itself; the most recent shift worked; and personal details. Burnout was assessed, using an internationally validated three-dimensional measure (MBI), and participants were asked directly about their levels of job satisfaction and intentions to leave.

The average age of the respondents was 38, and most were women. Almost two thirds worked in hi-tech and/or teaching hospitals. Over half (57%) worked in medical units; the remainder worked in surgical units.

The most common shift length was 8 or fewer hours (50%); almost a third (31%) worked 8-10 hours; 4% worked 10 to less than 12 hours; and 14% worked 12-13 hours. Just 1% worked more than 13 hours.

But 12 hour+ shifts were more common in certain countries, with 39% of respondents in England, 79% in Ireland, and 99% in Poland, working this shift length. And more than one in four of the entire sample (27%) had worked overtime on their last shift.

Around one in four (27%) reported high emotional exhaustion, while 10%  said they experienced high depersonalisation and 17% low personal accomplishment—the three dimensions of burnout.

Around one in four expressed dissatisfaction with their job; a similar proportion were equally dissatisfied with their work schedule flexibility, and a third said they planned to leave their current job.

The analysis of the responses showed that shift length of 12+ hours was associated with greater levels of burnout in all three dimensions; job dissatisfaction; working schedule dissatisfaction; and intention to leave.

For example, job dissatisfaction rose to 40% among those clocking up shifts of 12+ hours compared with those working shifts of 8 hours or less, while the intention to leave rose to 31%.

Furthermore, working 8 hour shifts was associated with poorer job satisfaction, while working overtime was linked to unfavourable outcomes in all domains, irrespective of the actual additional hours worked.

This is an observational study, so no definitive conclusions can be drawn about cause and effect. But the findings run counter to perceived wisdom and practice, say the researchers.

“Current literature tends to report that 12 h shifts represent a way to retain nurses in hospital clinical practice because it is believed to be the preferred shift length and that nurses are more satisfied with their jobs: our results suggest the opposite,”  they write.

“Therefore, our findings pose substantial questions for managers, most notably because job satisfaction is a consistent and robust predictor of remaining in a job,” they say.

They add that employers need to be aware of the potential effects of burnout, which include a heightened risk of making a mistake, poorer quality of care, compromised wellbeing, and increased absenteeism and high staff turnover.

Euthanasia requests, the risks of heavy smoking and alcohol use in older people: Most read articles in August

8 Sep, 15 | by Emma Gray

A few new entries are included in August’s Top 10 Most Read as well as some popular articles from previous months. New entries include Thienpont et al‘s paper on euthanasia requests among psychiatric patients and Elwyn et al‘s paper on the motivations of patients to record their clinical encounters, measured by a mixed-methods analysis of survey data. A Mendelian randomisation meta-analysis from Morris et al aimed to investigate whether heavier smoking is associated with abdominal adiposity phenotypes, concluding that smoking in an effort to control weight may lead to accumulation of central adiposity. Rao et al‘s paper on exploring the relationship between alcohol consumption, health, ethnicity and socioeconomic deprivation was also popular this month.

Rank Author(s) Title
1 Thienpont et al. Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study
2 Rao et al. Alcohol use, socioeconomic deprivation and ethnicity in older people
3 Elwyn et al. Patients recording clinical encounters: a path to empowerment? Assessment by mixed methods
4 Parand et al. The role of hospital managers in quality and patient safety: a systematic review
5 Rachiotis et al. What has happened to suicides during the Greek economic crisis? Findings from an ecological study of suicides and their determinants (2003-2012)
6 Deane et al. Priority setting partnership to identify the top 10 research priorities for the management of Parkinson’s disease
7 Whiting et al. How well do health professionals interpret diagnostic information? A systematic review
8 Hubble et al. Trunk muscle exercises as a means of improving postural stability in people with Parkinson’s disease: a protocol for a randomised controlled trial
9 Branas et al. The impact of economic austerity and prosperity events on suicide in Greece: a 30-year interrupted time-series analysis
10 Morris et al. Heavier smoking may lead to a relative increase in waist circumference: evidence for a causal relationship from a Mendelian randomisation meta-analysis. The CARTA consortium

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

Forum 2015: Global Forum on Research and Innovation for Health

8 Sep, 15 | by Emma Gray

With the aim of identifying solutions to the world’s unmet health needs through research and innovation, Forum 2015 provided delegates with a unique global platform on which to present ideas for innovation in health and create partnerships for action.

The Council on Health Research for Development (COHRED) partnered with the Philippines for this event, which took place in August 2015, to allow stakeholders in development from around the world (including public, private and non-profit stakeholders) to set an agenda with the ultimate outcome of improving health, equity and socio-economic development in a sustainable way.

Understanding the importance of ongoing research and innovation in health is of growing importance, particularly with the impending 2015 Sustainable Development Goals. With over 4,000 registered delegates representing over 72 countries, this understanding was key to the programme, which featured not only the conference activities onsite in the Philippines but also an online discussion platform to encourage participation from those who were not able to attend in person.

A message from Benigno Simeon S. Aquino III, President of the Philippines, was delivered by Mario G. Montejo, Secretary of the Department of Science and Technology, commenting that this type of constant and pro-active vigilance from the global research community is what is needed to improve and secure the wellbeing of people all over the world, especially those in low- and middle-income countries.

BMJ Open is pleased to support this meeting by publishing Forum 2015 abstracts – all of which can be found online at: With topics ranging from e-health to music therapy and disaster response, there is likely to be something of interest to all professionals working in global health.

Readers may also be interested in the newly launched journal BMJ Global Health – an online, open access journal from the BMJ dedicated to publishing high-quality peer-reviewed content relevant to those involved in global health. Further information on this journal can be found here:

“Substantial” number of NHS hospital staff treat victims of human trafficking

18 Aug, 15 | by Emma Gray

Maternity services most likely to do so; but staff across NHS don’t know how best to respond

A “substantial” proportion of NHS hospital staff—around one in eight, in some places—treat the victims of people trafficking, with maternity services most likely to do so, finds research published in the online journal BMJ Open.

Although understanding of the sorts of health problems trafficked patients are likely to have, is generally high, few NHS staff feel adequately prepared to respond appropriately, the findings suggest.

International law requires that the UK provides victims of human trafficking with whatever medical treatment they require, which includes psychological help, counselling, and further information on support services.

It is thought that around 2.5 million people are trafficked every year, with every country in the world either a source, transit point, or destination.

The researchers wanted to know just how likely it is that NHS hospital staff will encounter patients who have been trafficked, and how well prepared they feel to respond to them.

They therefore quizzed almost 800 NHS staff from a wide range of specialties to gauge their experience and knowledge of people trafficking, as well as their confidence in responding appropriately to it, using a validated questionnaire (PROTECT) between August 2013 and April 2014.

All the healthcare professionals were attending either mandatory training in child protection and vulnerable adult issues at 10 secondary care trusts across England, where at least five victims of human trafficking had been reported to the police the previous year, or were at meetings of the Royal College of Emergency Medicine.

In all, around one in eight (13%) staff said they had treated a patient whom they either knew, or suspected, had been trafficked. In eight trusts, this proportion rose to more than one in 10 of the staff.

Maternity services staff were the most likely to encounter victims of human trafficking, with one in five (20.4%) saying they had treated such patients.

But most staff in every specialty represented said they didn’t know what questions to ask to spot potential victims (just under 89%), while more than three quarters (78%) said they didn’t feel sufficiently trained to enable them to help victims adequately.

Over half said they lacked the confidence to make appropriate referrals, with referrals for men vexing the most staff (71%).

Most participants (over 95%) had no idea of the scale of human trafficking in the UK, and three out of four (76.5%) didn’t realise that without appropriate safeguards, a call to the police could put patients in even more danger.

“In particular [staff] lack knowledge about how to ask about experiences of human trafficking, how and when to contact law enforcement agencies, and how to make referrals to local and national support agencies,” write the researchers.

Three out of four of those surveyed said they would be interested in targeted training around people trafficking, particularly those working in mental health and emergency medicine services.

The researchers caution that their findings may not be applicable to the entire NHS, but suggest that additional training for NHS staff could improve the wellbeing and safety of such a vulnerable group of people.

A video abstract for this manuscript is available to view here:

Research priorities for Parkinson’s, aphasia rehabilitation and urban planning: Most read articles in July

10 Aug, 15 | by Emma Gray

A number of new papers are included in July’s Top 10 Most Read, including a realist policy analysis research programme by Harris et al which aims to observe the land-use planning system in New South Wales, Australia, and how it incorporates health and health equity at multiple levels. Power et al‘s article takes a look at best practice statements for use in post-stroke aphasia rehabilitation. Deane et al‘s paper on identifying and prioritising evidential uncertainties that impact on everyday management of Parkinson’s disease and O’Keeffe et al‘s paper on predictors of alcohol use during pregnancy were also popular papers this month.

Rank Author(s) Title
1 Branas et al. The impact of economic austerity and prosperity events on suicide in Greece: a 30-year interrupted time-series analysis
2 Iparraguirre Socioeconomic determinants of risk of harmful alcohol drinking among people aged 50 or over in England
3 Power et al. Development and validation of Australian aphasia rehabilitation best practice statements using the RAND/UCLA appropriateness method
4 O’Keeffe et al. Prevalence and predictors of alcohol use during pregnancy: findings from international multicentre cohort studies
5 Parand et al. The role of hospital managers in quality and patient safety: a systematic review
6 Rachiotis et al. What has happened to suicides during the Greek economic crisis? Findings from an ecological study of suicides and their determinants (2003-2012)
7 Whiting et al. How well do health professionals interpret diagnostic information? A systematic review
8 Marston et al. Anal heterosex among young people and implications for health promotion: a qualitative study in the UK
9 Deane et al. Priority setting partnership to identify the top 10 research priorities for the management of Parkinson’s disease
10 Harris et al. ‘Including health in systems responsible for urban planning’: a realist policy analysis research programme

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

Depression and personality disorders most common diagnoses in psychiatric patients requesting euthanasia

28 Jul, 15 | by Richard Sands, Managing Editor


Most common diagnoses among those requesting help to die, due to unbearable suffering

Depression and personality disorders are the most common diagnoses among Belgian psychiatric patients requesting help to die, on the grounds of unbearable suffering, finds research published in BMJ Open today.

Drugs, given either by mouth or administered intravenously, are used to perform euthanasia in Belgium, where the practice has been legal since 2002.

The researchers wanted to find out if there were any discernible patterns in requests for euthanasia among mentally ill patients in Belgium in a bid to inform recommendations for future research.

So they tracked requests for help to die, made by patients receiving treatment for psychiatric problems in outpatient clinics in the Dutch speaking part of Belgium between 2007 and 2011, and followed up to the end of 2012.

During this period, 77 women and 23 men asked for euthanasia on the grounds of unbearable suffering associated with mental illness. Their average age was 47, but this ranged from 21 to 80.

Most (91) of the patients had been referred for counselling. Seventy three had been deemed medically unfit to work, and 59 were living alone.

Ninety had more than one mental health issue, with depression (58 patients) the most frequent diagnosis, followed by personality disorder (50).

Thirty eight patients required further tests and/or treatment, 13 of whom were specifically tested for autistic spectrum disorders. Twelve were subsequently diagnosed with Asperger’s syndrome, a form of high functioning autism.

In all, 48 of the requests were accepted, and 35 carried out. Among the remaining 13, eight cancelled or delayed the procedure on the grounds that simply having the option gave them enough peace of mind to continue living.

By December 2012, 43 of the patients had died, including six who had taken their own lives. Among this group, one patient committed suicide because she found the approvals process too long, while another did so because her family had objected to euthanasia. A third woman killed herself after a spell in a psychiatric ward.

Another had died as a result of palliative sedation by the end of 2012, and one had died of the eating disorder, anorexia nervosa.

Thirty patients died surrounded by family/friends, and in a serene and positive atmosphere, “which would have been impossible to attain in the case of unassisted traumatic suicide,” note the authors.

In 2010 and 2011, 2086 patients died by euthanasia in Belgium, accounting for 1% of all deaths during that period, with those who were not terminally ill making up less than 10% of the total.

But as yet, there is no consensus on what constitutes ‘unbearable suffering,’ nor are there any guidelines in Belgium on how best to deal with requests for help to die from those who are mentally ill, say the researchers.

“Taking into account the ongoing fierce ethical debates, it is essential to develop such guidelines, and translate them into clear and detailed protocols that can be applied in practice,” they conclude.

A video abstract for this manuscript is available to view here:

‘Successful ageing’ linked to harmful drinking among over 50s

23 Jul, 15 | by Fay Pearson

The over 50s who are ‘successful agers’—healthy, active, sociable, and well off—are more at risk of harmful drinking than their less successful peers, concludes research published in the online journal BMJ Open.

Harmful drinking is a “middle class phenomenon” which may be a hidden health and social problem in otherwise successful older people, warn the researchers, who call for explicit guidelines on alcohol consumption for this group.

They base their findings on more than 9000 responses to the two most recent waves (2008-9 and 2010-11) of the English Longitudinal Survey of Ageing (ELSA)—a long term study of a representative sample of those aged 50 and above living independently at home in England.

Given that alcohol consumption is on the rise among older people in England, the researchers wanted to tease out the social and economic factors associated with harmful drinking, and changing patterns of consumption over time.

They used national guidance to define increasing risk of harmful drinking at 22-50 weekly units for men and 15 to 35 weekly units for women; and higher risk, at more than 50 and more than 35 weekly units, respectively, for men and women.

Survey participants were asked about a range of potentially influential factors: income; educational attainment; self reported health; whether they smoked; diet; physical activity levels; whether they felt lonely or depressed; ethnic background; marital status; caring responsibilities; religious beliefs; employment status; and social engagement (civic participation, networks of friends, cultural activities).

Analysis of the responses showed that the risk of harmful drinking peaked for men in their early 60s and then gradually tailed off, whereas for women risky drinking fell in tandem with age.

These patterns suggest that the current group of over 50s may be carrying on levels of higher consumption developed in their younger years, in later life, say the researchers.

Certain factors were linked to a heightened or lowered risk of harmful drinking.

Income was associated with a higher risk, but only among women, while smoking, higher educational attainment, and good health were all linked to heightened risk in both sexes.

Higher risk of harmful drinking was not linked to feelings of loneliness or depression, but it was more likely among men living on their own, including those who were separated/divorced. And it was more common among men of white ethnicity.

Caring responsibilities lowered the probability of being at higher risk among women, but religious belief did not—for either sex.

Employment status did not seem to be a significant factor, but women who had retired were more likely to be at higher risk.

When the researchers looked at changes in alcohol consumption between the two waves of the survey, they found that among women, loneliness, younger age, and higher income were all associated with the likelihood of becoming a higher risk drinker by 2010-11. A healthy diet seemed to lessen the risk.

Among men, these transition patterns were similar, except that caring responsibilities, loneliness, older age and lower income increased the likelihood of no longer drinking at risky levels by wave 2 of the survey.

“We can sketch—at the risk of much simplification—the problem of harmful drinking among people aged 50 or over in England as a middle class phenomenon: people in better health, higher income, with higher educational attainment and socially more active are more likely to drink at harmful levels,” write the researchers.

“Our findings suggest that harmful drinking in later life is more prevalent among people who exhibit a lifestyle associated with affluence and with a ‘successful’ ageing process,” they add.

“Harmful drinking may then be a hidden health and social problem in otherwise successful older people,” they warn, concluding: “Consequently, and based on our results, we recommend the explicit incorporation of alcohol drinking levels and patterns into the successful ageing paradigm.”