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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.

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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.

Top 10 Most Read: The Male-Female Gap in Alcohol Use, requests for genital cosmetic surgery and opposition to standardised tobacco packaging in the UK.

8 Nov, 16 | by Ed Sucksmith

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October sees six new entries make it into our top ten most read articles. In at number 2 is a systematic review investigating birth cohort changes in male-to-female ratios in indicators of alcohol use and related harms. The authors concluded that the male–female gap in alcohol use was closing over time, with women now drinking almost as much as men. At number 3 is a survey of GPs’ knowledge, attitudes and practice regarding female genital cosmetic surgery in Australia. The study found high rates of women contacting their GP about genital normality concerns, with those requesting female genital cosmetic surgery frequently having a suspected or diagnosed psychological problem.

Other new entries include a documentary analysis of opponents to standardised packaging in the UK by Dr Jenny Hatchard and colleagues from the University of Bath and Aston University. The authors found that opposition to standardised packaging was primarily undertaken by third parties with financial relationships to major tobacco manufacturers, whilst a lack of transparency regarding these links created a misleading impression of diverse and widespread opposition.

Ravnskov et al.’s systematic review on the associations between low-density-lipoprotein cholesterol and mortality remains in first place for a fifth month in a row.

 

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 Slade et al. Birth cohort trends in the global epidemiology of alcohol use and alcohol-related harms in men and women: systematic review and metaregression
3 Simonis et al. Female genital cosmetic surgery: a cross-sectional survey exploring knowledge, attitude and practice of general practitioners
4 Fenton et al. Systematic review of the association between dietary acid load, alkaline water and cancer
5 Power et al. Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach
6 Nazar et al. New transfer of care initiative of electronic referral from hospital to community pharmacy in England: a formative service evaluation
7 Hatchard et al. Standardised tobacco packaging: a health policy case study of corporate conflict expansion and adaptation
8 Pound et al. What do young people think about their school-based sex and relationship education? A qualitative synthesis of young people’s views and experiences
9 Dean et al. Community-based Rehabilitation Training after stroke: protocol of a pilot randomised controlled trial (ReTrain)
10 Johnson et al. Early real-world evidence of persistence on oral anticoagulants for stroke prevention in non-valvular atrial fibrillation: a cohort study in UK primary care

‘Worried well’ may be boosting their risk of heart disease

3 Nov, 16 | by Emma Gray

Potential consequences of health anxiety underlines need to treat it, say researchers

People who needlessly worry that they have, or will develop, serious illness—popularly referred to as ‘the worried well’—may be boosting their risk of developing heart disease, suggests research published in the online journal BMJ Open.

Anxiety is a known risk factor for heart disease. And health anxiety, which describes persistent preoccupation with having or acquiring a serious illness, and seeking prompt medical advice, on the basis of misattributed bodily symptoms in the absence of any physical disease, seems to be no exception, say the researchers.

And as such, it needs to be taken seriously and treated properly, they suggest.

They base their findings on 7052 participants of the Norwegian Hordaland Health Study (HUSK), a long term collaborative research project between the National Health Screening Service, the University of Bergen, and local health services.

The participants, all of whom were born between 1953 and 1957, filled in two questionnaires about their health, lifestyle, and educational attainment. And they had a physical check-up, consisting of blood tests, weight, height, and blood pressure measurements, taken between 1997 and 1999.

Levels of health anxiety were assessed using a validated scale (Whiteley Index), comprising 14 items scored from 1-5. Those (710) whose total score amounted to 31 or more were in the top 10% of the sample and considered to have health anxiety.

The heart health of all the participants was subsequently tracked using national data on hospital treatment episodes and death certification up to the end of 2009.

Anyone who received treatment for, or whose death was linked to, coronary artery disease occurring within a year of entering the study, was excluded, on the grounds that they might already have been ill.

In all, 234 (3.3%) of the entire sample had an ischaemic event—a heart attack or bout of acute angina—during the monitoring period, with the average time to the first incident just over 7 years.

But the proportion of those succumbing to heart disease was twice as high (just over 6%) among those who displayed health anxiety as it was among those who didn’t (3%).

While established risk factors for heart disease explained part of the association found, health anxiety was still linked to a heightened risk, after taking account of other potentially influential factors.

Those with health anxiety at the start of the study were 73% more likely to develop heart disease than those who weren’t in this state of mind, the analysis showed. And the higher the Whiteley Index score, the greater was the risk of developing heart disease.

This is an observational study, so no firm conclusions can be drawn about cause and effect, added to which the researchers admit that health anxiety often exists alongside other mental health issues, such as general anxiety and depression, making it hard to differentiate.

But the findings back current thinking on the potentially harmful effects of anxiety on health, they say.

“[Our research] further indicates that characteristic behaviour among persons with health anxiety, such as monitoring and frequent check-ups of symptoms, does not reduce the risk of [coronary heart disease] events,” they write.

If anything, putting the body on a permanent state of high alert may have the opposite effect, they suggest.

“These findings illustrate the dilemma for clinicians between reassuring the patient that current physical symptoms of anxiety do not represent heart disease, contrasted against the emerging knowledge on how anxiety, over time, may be causally associated with increased risk of [coronary artery disease],” they conclude.

The findings “underline the importance of proper diagnosis and treatment of health anxiety,” they add.

Current system unlikely to pick up surgeons with above average patient death rates

31 Oct, 16 | by Emma Gray

Performance within ‘expected’ range not good enough to detect outliers, say researchers

Publishing the patient death rates of individual surgeons in England is unlikely to pick up those whose mortality rates are above average, because the caseload varies so much, concludes the first analysis of its kind published in the online journal BMJ Open.  

Performance within the ‘expected’ range is too crude a measure to detect doctors whose practice might be a cause for concern, and is therefore creating a false sense of security, say the researchers.

When the patient death rates for individual surgeons were first published in June 2013, the move was hailed as a major breakthrough in transparency that would drive up standards of care in England.

But the chances of detecting a surgeon whose death rates are worse than the national average is a question of statistical power, say the researchers: in other words, the greater the caseload, the greater the ability to detect worrying trends.

To assess how reliable the available data for individual surgeons are, the researchers reviewed the outcomes for three common high risk procedures—bowel surgery, gullet surgery, and planned aortic aneurysm repair—and three common low risk procedures—hip replacement, bariatric surgery, and thyroid removal.

And they analysed every surgeon’s caseload for each of the procedures, all of which were carried out between 2010 and 2014 across England.

They focused in particular on how well these data would be able to detect a surgeon whose patient death rate in hospital or within 30 or 90 days of the patient’s discharge was between two and five times higher than the national average.

Unsurprisingly, the higher risk procedures were associated with a higher death rate of between 2.2-4.5% while the lower risk ones were associated with a death rate of 0.07-0.4%.

But caseload was an issue. For example, the average number of bowel surgery operations carried out by individual surgeons was 55 over three years, but ranged from just 3 to 237.

With an average national 90 day death rate of 3%, the national average of 55 cases provides 20% statistical power to detect a mortality rate three times the national average. That means that around 20 out of 100 individual surgeons with an actual death rate of 9% would fall outside the expected range.

But the caseload would have to be more than 200 to provide 90% statistical power of detecting a surgeon whose 90 day mortality rate is three times the national average.

Similar findings emerged for gullet surgery, where the average number of procedures was 23 over a two year period, but ranged from 10 to 81.

Based on national 30 day death rates of 2.4%, the average number of cases would provide less than 20% statistical power to detect a surgeon with a patient death rate four times the national average.

And a caseload of 300 procedures would be needed to provide 80% statistical power to detect a 90 day mortality rate twice as high as the national average over two years.

For low risk procedures, the national average caseload ranged from 48 to 75 per surgeon, meaning that fewer than 20 out of 100 surgeons with an actual mortality rate five times the national average would be picked up.

For hip replacements, for example, an annual caseload of more than 500 cases would be needed to provide 80% statistical power to pick up just one individual with a mortality rate five times the national average.

At these kinds of rates it is unlikely that a surgeon would ever perform enough procedures in his/her entire career for a mortality rate five times the national average to be detected, say the researchers.

“On the basis of these rates and published case volumes, surgeons with mortality rates in excess of that expected are highly unlikely to be detected,” they write. “Performance within an expected mortality rate range cannot therefore be considered reliable evidence of acceptable performance.”

More meaningful outcome measures are required, they say. These could include patient satisfaction, the ease with which routine daily tasks can be performed (functional health status), and other health related quality of life indicators.

And an individual’s performance could be addressed by regular internal appraisal and feedback from multiple sources, they suggest.

Interpreting performance data for individual surgeons has major implications for patient care, the individual practitioner, and their employer, they emphasise

But they conclude: “This analysis demonstrates that, for these common procedures, mortality rates are not a robust method for detecting divergent practice. It is not surprising that the performance of all but one surgeon across all six procedures was found to be acceptable.”

Women catching up with men in alcohol consumption and its associated harms

24 Oct, 16 | by Emma Gray

Trend most evident among young adults, international analysis shows

Women are catching up with men in terms of their alcohol consumption and its impact on their health, finds an analysis of the available international evidence, spanning over a century and published in the online journal BMJ Open.

The trend, known as ‘sex convergence’, is most evident among young adults, the findings show.

Historically, men have been far more likely than women to drink alcohol and to drink it in quantities that damage their health, with some figures suggesting up to a 12-fold difference between the sexes. But now evidence is beginning to emerge that suggests this gap is narrowing.

In a bid to quantify this trend over time, the researchers pooled the data from 68 relevant international studies out of a total of 314, all of which had been published between 1980 and 2014. All the studies included explicit regional or national comparisons of men’s and women’s drinking patterns across at least two time periods.

The studies included data collected between 1948 and 2014, representing people born as far back as 1891, all the way up to 2000, and including a total sample size of more than 4 million. Sixteen of the studies spanned 20 or more years; five spanned 30 or more.

The researchers used the following criteria to inform their data search: lifetime and/or current alcohol misuse or dependence; alcohol related problems; treatment for alcohol issues; and the timeframe of use and the development of related problems.

And they used 11 key indicators of alcohol use and associated harms for their analysis. These were grouped into three broad categories of: any use, which included quantities and frequency; problematic use, which included binge/heavy drinking; and the prevalence of associated harms.

Births were grouped into cohorts—specific timeframes from 1891 to 2000—all of which spanned 5 years, with the exception of the first (1891-1910) and the last (1991-2000).

The pooled data showed that the gap between the sexes consistently narrowed across all three categories of any use, problematic use, and associated harms over time.

Men born between 1891 and 1910 were twice (2.2) as likely as their female peers to drink alcohol; but this had almost reached parity among those born between 1991 and 2000 (1.1).

The same patterns were evident for problematic use, where the gender gap fell from 3 to 1.2, and for associated harms, where the gender gap fell from 3.6 to 1.3.

After taking account of potential mathematical bias in the calculations, the gender gap fell by 3.2% with each successive five year period of births, but was steepest among those born from 1966 onwards.

The calculation used was not designed to address whether alcohol use is falling among men or rising among women, the researchers caution.

But among the 42 studies that reported some evidence for sex convergence, most indicated that this was driven by greater use of alcohol among women, and 5% of the sex ratios were less than 1, suggesting that women born after 1981 may actually be drinking more than their male peers, say the researchers.

While they did not set out to explain the reasons behind their observed findings, they emphasise that their results “have implications for the framing and targeting of alcohol use prevention and intervention programmes.”

And they conclude: “Alcohol use and alcohol use disorders have historically been viewed as a male phenomenon. The present study calls this assumption into question and suggests that young women in particular should be the target of concerted efforts to reduce the impact of substance use and related harms.”

Most read articles in September: young people’s views on school sex education, gender equity in academic medicine and improving patient safety

7 Oct, 16 | by Hemali Bedi

cellular-1352613_1920September’s most read list sees several new entries as well as some popular non-movers. This month’s top spot still belongs to Ravnskov et al and their systematic review on the associations between low-density-lipoprotein cholesterol and mortality in the elderly. Pound et al come in at number three with a qualitative synthesis of young people’s views and experiences of school sex and relationship education (SRE). They concluded that SRE should be delivered by experts who maintain clear boundaries with students and taught using a ‘sex-positive’ approach – one that aims for young people to enjoy their sexuality in a way that is safe, consensual and healthy.

Other new entries this month include Caffrey et al, who performed a multimethod, qualitative study investigating how a gender equity programme, Athena SWAN, could be enabled and whether  interactions between the programme and the context it is implemented into might produce unintended consequences.

At number ten is a multimethod study by Power et al, looking at whether a large-scale two-phase quality improvement programme achieved its aim to improve patient safety using a harm-free care approach.

See below for a full round up of September’s top 10 most read articles.

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 Ferrer et al. Comparative study analysing women’s childbirth satisfaction and obstetric outcomes across two different models of maternity care
3 Pound et al. What do young people think about their school-based sex and relationship education? A qualitative synthesis of young people’s views and experiences
4 Caffrey et al. Gender equity programmes in academic medicine: a realist evaluation approach to Athena SWAN processes
5 Teschke et al. Bicycling injury hospitalisation rates in Canadian jurisdictions: analyses examining associations with helmet legislation and mode share
6 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
7 Pradhan et al. Nutrition interventions for children aged less than 5 years following natural disasters: a systematic review
8 Ma’som et al Attitudes and factors affecting acceptability of self-administered cervicovaginal sampling for human papillomavirus (HPV) genotyping as an alternative to Pap testing among multiethnic Malaysian women
9 Assiri et al Investigating the epidemiology of medication errors and error-related adverse drug events (ADEs) in primary care, ambulatory care and home settings: a systematic review protocol
10 Power et al. Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach

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

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