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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.

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 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 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 …


Salt, eating disorders and the impact of funding deadlines: most read articles in April

6 May, 14 | by flee

This month’s most read article was Krijthe et al.’s study on non-steroidal anti-inflammatory drugs and the risk of atrial fibrillation. Newly-published papers in the top ten most read include He et al.’s paper on salt reduction in England, and it’s relationship to blood pressure, stroke and ischaemic heart disease mortality and also Räisänen et al.’s paper on the role of gendered constructions of eating disorders in delayed help-seeking in men. Also proving popular for another month, is the cross sectional study on symptoms related to GSM radiation from mobile phone bases by Gómez-Perretta et el.


Rank Author(s) Title
1 Krijthe et al. Non-steroidal anti-inflammatory drugs and the risk of atrial fibrillation: a population-based follow-up study
2 He et al. Salt reduction in England from 2003 to 2011: its relationship to blood pressure, stroke and ischaemic heart disease mortality
3 Herbert et al. The impact of funding deadlines on personal workloads, stress and family relationships: a qualitative study of Australian researchers
4 Gómez-Perretta et al. Subjective symptoms related to GSM radiation from mobile phone base stations: a cross-sectional study
5 Räisänen et al. The role of gendered constructions of eating disorders in delayed help-seeking in men: a qualitative interview study
6 Rao et al. Do healthier foods and diet patterns cost more than less healthy options? A systematic review and meta-analysis
7 Wager et al. Awareness and enforcement of guidelines for publishing industry-sponsored medical research among publication professionals: the Global Publication Survey
8 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 
9 Larney et al. Opioid substitution therapy as a strategy to reduce deaths in prison: retrospective cohort study
10 Krusche et al. Mindfulness online: an evaluation of the feasibility of a web-based mindfulness course for stress, anxiety and depression


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


Very overweight teens face stigma, discrimination, and isolation

30 Apr, 14 | by fpearson

Very overweight teens face a social world of stigma, discrimination, and isolation because of their body size, reveals an analysis of their views, published in the online journal BMJ Open.

And they have to overcome many other additional barriers to lose weight, making it especially hard for them to shed the pounds, the findings suggest.

The latest figures suggest that roughly two out of ten 11 to 15 year olds in England are classified as obese. But evidence on what young people think about larger body size is hard to come by.

The researchers therefore scanned 18 research databases in the fields of health, public health, education, social science and social care; 54 relevant websites; and six key journals, looking for published data on young people’s views of body size.

They focused on UK teens between the ages of 12 and 18, all of whom had taken part in in-depth or semi-structured interviews and/or focus groups, between 1997 and 2010. They excluded any research dealing only with eating disorders.

They found 30 relevant studies, involving just over 1400 12-18 year olds. Young people had talked about three main areas: general and societal perceptions of differing body sizes; what it was like to be overweight; and what it was like to try and lose excess weight.

The analysis revealed that young people of all body sizes in the UK predominantly felt that the social implications of a large body size were more important than the health consequences.

In general, young people thought that individuals were responsible for their own body size. They associated excess weight with negative stereotypes of laziness, greed, and a lack of control. And they felt that being overweight made an individual less attractive and opened them up to bullying and teasing.

Young people who were already overweight tended to blame themselves for their size. And those who were classified as very overweight said they had been bullied and physically and verbally assaulted, particularly at school. They endured beatings, kickings, name-calling, deliberate and prolonged isolation by peers, and sniggering/whispering.

Some young people described coping strategies, such as seeking out support from others. But the experiences of being overweight included feeling excluded, ashamed, marked out as different, isolated, ridiculed and ritually humiliated. Everyday activities, such as shopping and socialising, were difficult.

Overweight young people described others’ responses to their appearance as a key factor in loss of confidence, anxiety, loneliness and depression, and a vicious circle of subsequent comfort eating and further weight gain.

The level of ridicule they faced made it hard for them to take part in exercise to lose weight, but so too did breathlessness on exertion and other complications of overweight, such as asthma.

And the ready availability of calorie dense foods, poor dietary advice, and constant pressure to lose weight were cited as other barriers to achieving a healthy weight.

Few studies asked young people what would help them cope better with these pressures, but less judgemental responses from health professionals, and the support and encouragement of family and friends were seen as important.

“The perspectives of young people in the UK, when synthesised across the spectrum of body sizes, paint a picture of a stigmatising and abusive social world,” write the authors.

And they add: “Approaches that merely educate and admonish individuals about lifestyles and being overweight are not only insufficient but also potentially counter-productive.”

Lower salt intake likely to have had key role in plummeting cardiovascular disease deaths in past decade

14 Apr, 14 | by flee

The 15% fall in dietary salt intake over the past decade in England is likely to have had a key role in the 40% drop in deaths from heart disease and stroke over the same period, concludes research published in BMJ Open.

But average intake across the nation is still far too high, warn the authors. And much greater effort is needed to curb the salt content of the foods we eat, they insist.

Dietary salt is known to increase blood pressure, which is itself a major risk factor for heart disease and stroke.

The authors base their findings on an analysis of data from more than 31,500 people taking part in the Health Survey for England for the years 2003—when initiatives to curb population salt intake began across the UK—2006, 2008, and 2011.

This survey involves a random representative sample of the adult population of England living in private households, and includes information on diet and blood pressure measurements.

The average population salt intake was calculated from urine collected over a 24 hour period in almost 3000 people who were part of the National Diet and Nutrition Survey between 2003 and 2011. This survey involves random samples of the population.

During this period, nationally collated figures show that stroke deaths fell by 42% while deaths from coronary heart disease dropped by 40% in England.
Similarly, the prevalence of several risk factors for cardiovascular disease also fell, including average cholesterol, blood pressure (3/1.4 mm Hg), and smoking, although average weight (Body Mass Index) rose. And fruit and vegetable consumption rose slightly.

With the exception of increasing weight gain, all these trends, along with better treatment of cardiovascular disease and its risk factors would have probably contributed to the dramatic falls in stroke and heart disease deaths, explain the authors.

But daily salt intake fell by an average of 1.4 g during this period, amounting to a drop of 15%. And among those not taking blood pressure lowering drugs, average blood pressure still fell by 2.7/1.1 mm Hg, even after taking into account other influential factors.

Salt intake was not measured in this particular group, but the substantial fall in salt consumption in the population samples suggests that the decrease in blood pressure would largely have been attributable to less dietary salt rather than to medication, say the authors.

And previously published research suggests that the contribution of blood pressure lowering drugs to population falls in blood pressure is relatively small, they say.

The authors caution that they used several sets of data, involving different people, so were not able to track changes at the individual level, nor were they able to account for physical activity levels.

Nevertheless, they conclude: “The reduction in salt intake is likely to be an important contributor to the falls in blood pressure in England from 2003 to 2011. As a result, the decrease in salt intake would have played an important role in the reduction in stroke and ischaemic heart disease mortality during this period.”

And they go on to say that despite considerable progress, 70% of the adult population is still eating more than the recommended 6g/day, with 80% of intake coming from processed foods.

“Therefore, continuing and much greater efforts are needed to achieve further reductions in salt intake to prevent the maximum number of stroke and heart disease deaths,” they urge.

The perception that eating disorders are a women’s problem delays men getting help

8 Apr, 14 | by fpearson

The widespread perception that only women have eating disorders is preventing men with these problems from getting the help and support they need, indicates a small study published in the online journal BMJ Open.

Estimates suggest that around 1 in 250 women and 1 in 2000 men in the UK have anorexia nervosa, one of the four recognised types of eating disorder – the others being bulimia nervosa; binge eating disorder; and eating disorder not otherwise specified (EDNOS).

The incidence of eating disorders is on the rise among men, with some estimates suggesting that men now account for one in four cases. But poor recognition of the signs and symptoms of eating disorders in men is likely to mean that the true prevalence may be higher, still, say the authors.

They interviewed 39 young people between the ages of 16 and 25, 10 of whom were men, about their experiences of eating disorders, in a bid to gauge the impact of gender on diagnosis, treatment, and support.

The interviews were carried out to inform an online patient resource (Healthtalkonline), and participants were recruited from patient organisations, social media, and healthcare professionals.

Four themes emerged from the interviews: recognition of early signs and symptoms; recognition of the problem; getting help; and initial contact with healthcare and support services.

All the men took some time to realise that their experiences and behaviours were potential signs and symptoms of an eating disorder during which time these became entrenched.

Their behaviours included going days without eating; purging; and obsessive calorie counting, exercise, and weighing. Some also self-harmed and increasingly isolated themselves from others.

The perception that eating disorders are a women’s problem, and particularly a problem for young women, was cited as one of the main reasons why it took them so long to understand what was happening.

One young man, who described himself as “one of the lads,” said he thought eating disorders only affected “fragile teenage girls,” while another said he thought these disorders were “something girls got.”

None of the men was aware of the symptoms of an eating disorder, and friends, family, and teachers were also very slow to recognise the symptoms, frequently putting the changed behaviours down to personal choices.

It was only reaching a crisis point or being admitted as an emergency that triggered the realisation of what was happening to them, the men said.

They also delayed seeking help because they feared they wouldn’t be taken seriously by healthcare professionals, or didn’t know where to go for support.

And their experiences of the healthcare system were mixed. They said they often had to wait a long time for specialist referral and had sometimes been misdiagnosed, or, as in one case, told by the doctor “to man up.” They complained of insufficient information about eating disorders targeted specifically at men.

“Men with eating disorders are underdiagnosed, undertreated and under researched,” write the authors.

“Our findings suggest that men may experience particular problems in recognising that they may have an eating disorder as a result of the continuing cultural construction of eating disorders as uniquely or predominantly a female problem,” they add.

This perception has “also been embedded in clinical practice,” they note, adding that in order to improve the outlook for men with eating disorders, “early detection is imperative.”

Eating disorders cost the NHS between £50 and £70 million, while anorexia has the highest death rate of all adolescent psychiatric conditions, they point out.