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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.

Open access: the research funders’ perspective

24 Oct, 13 | by Richard Sands, Managing Editor


Anyone following progress on open access since the Finch Review report last year might think that the UK’s direction of travel is pretty much set. Since the Government and then Research Councils UK (RCUK) backed Gold open access, the same policy endorsed by the Wellcome Trust, it seemed likely that this would become much more prevalent for UK academics wishing to publish their work. Once a funder throws both its weight and its money behind a particular course of action, researchers have little reason not to comply.

But for medical research, the Medical Research Council (MRC) and the Wellcome Trust are not the whole story. Certainly, they are major funders and are widely recognised for leading the development of open access policy. But they are part of a wider community of charities, government bodies and commercial organisations who fund medical research. Many UK researchers receive funding from these organisations and, when those researchers come to publish their findings, they must comply with their funders’ rules.

That’s why BMJ commissioned a small qualitative study of ten medical research funders, designed to explore their approach to open access and communicating research findings. The study included the MRC and the Wellcome Trust, but also sought the views of the National Institute for Health Research (NIHR), charities of all sizes, and some pharmaceutical companies who invest in research. The aim was to understand the different policies and priorities of all these funders, in order to ensure that when a researcher submits to one of BMJ’s 50+ journals, they are offered a publication route that allows them to be compliant with their funder’s requirements.

The full findings of the study are available in an article that’s just been published in BMJ Open, or you can see a brief digest on the BMJ blog. If you read either, you’ll see that open access is welcomed by all of the funders in the study, but the route to implementation is causing them some concerns. There’s also a podcast with the report’s author, available here.

Meeting the costs, monitoring the move, supporting researchers as they transition from one model to another, and ensuring compliance, were issues for most of the funders we spoke to.

This is interesting because it really echoes some work BMJ undertook earlier this year with university staff. Back in January 2013, we ran a series of workshops for librarians, looking at some of the issues that they were facing when trying to implement RCUK’s open access mandate. We heard many of the same messages about money, monitoring, compliance and researcher support. These conversations informed the development of our open access membership model, which is designed to support institutions in meeting some of the challenges they described.

The key message that we heard from both funders and institutions is that researchers must remain in control of how and where they publish their work. Although they might want to see price become more of a factor in that decision, they are very uncomfortable with any suggestion that they should exert direct control over a researcher’s choice of journal. So, the onus is on publishers to help by ensuring that, whichever journal the researcher chooses, they can comply with any conditions imposed on their grant or employment contract. And that’s what we’re trying to do at BMJ.

New cases of autism in UK have levelled off after five-fold surge during 1990s

16 Oct, 13 | by flee

The number of newly diagnosed cases of autism has levelled off in the UK after a five-fold surge during the 1990s, finds research published in BMJ Open.

The findings differ from widely publicised results issued by the US Centers for Disease Control and Prevention (CDC) last year, which reported a 78% increase in the prevalence of the condition in eight year old children between 2004 and 2008 in the US.

Prompted by these data, which found that one in every 88 eight year old children in the US had been diagnosed with an autistic spectrum disorder in or before 2008, the authors wanted to find out if there were comparable rates in the UK.

They used entries into the General Practice Research Database (GPRD), which contains around three million anonymised active patient records from over 300 representative general practices in the UK – equivalent to 5% of the UK population.

Data from practices enrolled from 1990, when the GPRD was set up, were used to calculate the annual prevalence (number of people living with the condition) and the annual incidence (number of newly diagnosed cases) of autistic spectrum disorders among eight year olds, all of whom were born after 1996.

Annual prevalence rates for 2004-2010 were calculated by dividing the number of eight year olds diagnosed as autistic in that or any previous year, by the number of eight year olds enrolled in the database for each year.

Annual incidence rates were calculated by dividing the number of eight year olds who had been newly diagnosed with autism between 2004 and 2010 by the number of eight year olds enrolled into the database for each of those years.

The results showed that the annual prevalence and incidence of autism did not materially change over the entire study period, for either boys or girls.

The annual prevalence of autistic spectrum disorders was estimated at 3.8 per 1000 boys and 0.8 per 1000 girls, while the annual incidence was estimated at 1.2 per 1000 boys  (1190 in total) and 0.2 per 1000 girls (217 in total).

Girls were about 75% less likely to be diagnosed with an autism spectrum disorder as boys.

The UK prevalence of about 4/1000 children is substantially lower than the equivalent US figure of about 11/1000 children in 2008, which was reported in 2012.

“The large difference between countries is closely similar to differences in rates reported for children diagnosed and treated for attention deficit hyperactivity disorder in the two countries,” the authors point out.

Their previously published research, based on the same database, showed that the cumulative incidence of autism among children born in UK between 1988 and 1995 increased continuously by a factor of five during that period.

And they say that both studies provide “compelling evidence that a major rise in incidence rates of autism, recorded in general practice, occurred in the decade of the 1990s but reached a plateau shortly after 2000 and has remained steady through 2010.”

Similar widespread sharp rises in the number of children diagnosed as autistic were also seen in the 1990s in other parts of Europe and North America, they add, making it unlikely that better understanding of the condition or a broadening of the diagnostic criteria alone could have been responsible for these simultaneous large increases.

Given the apparent sudden halt in the rise in rates from early 2000 onwards – at least in the UK – the “actual cause of the dramatic rise in the 1990s remains a mystery,” they write, emphasising that the suggestion that it might be linked to the MMR vaccine has  been conclusively ruled out.

Journal policy on research funded by the tobacco industry

15 Oct, 13 | by Richard Sands, Managing Editor


This article is being copublished as an editorial in the BMJ, Heart, and Thorax and as a blog in BMJ Open. Full references, competing interests, provenance and citation details can be read here.

Fiona Godlee editor in chief [1], Ruth Malone editor, Tobacco Control [2], Adam Timmis current/outgoing editor, Heart [2], Catherine Otto incoming editor, Heart [2], Andy Bush coeditor, Thorax [2], Ian Pavord coeditor, Thorax [2], Trish Groves editor in chief, BMJ Open [2]
[1]BMJ, London WC1H 9JR, UK; [2]BMJ Journals, London WC1H 9JR, UK

As editors of the BMJ, Heart, Thorax, and BMJ Open we have decided that the journals will no longer consider for publication any study that is partly or wholly funded by the tobacco industry. Our new policy is consistent with those of other journals including PLoS Medicine, PLoS One, PLoS Biology[1]; Journal of Health Psychology[2]; journals published by the American Thoracic Society[3]; and BMJ’s own Tobacco Control.[4]

Critics may argue—as many did when journals stopped publishing cigarette adverts—that publishing such research does not constitute endorsing its findings and that, as long as funding sources are fully disclosed, readers can consider that information and make up their own minds about the quality of the work. Peer review should prevail, goes this line of thinking: it’s not the editor’s job to make these kinds of judgments. However, this view ignores the growing body of evidence that biases and research misconduct are often impossible to detect,[5] and that the source of funding can influence the outcomes of studies in invisible ways.[6, 7]

Underlying all the activity of peer review, editing, and publishing is the assumption that medical journals exist for the purpose of advancing knowledge that can be used to promote health and reduce disease. But the deputy editor of JAMA, Drummond Rennie, who has perhaps studied the process of scientific publishing longer than anyone, has written about what he calls “little murders.” These are deceptive publication practices that are “destructive of the delicate web of trust between colleagues that keeps the whole enterprise functioning and afloat.”[8] The editor’s job, observes Rennie, is to “try to separate the insufferable behaviors of mere jerks from the illegal actions of bona fide crooks.”

The tobacco industry, far from advancing knowledge, has used research to deliberately produce ignorance and to advance its ultimate goal of selling its deadly products while shoring up its damaged legitimacy.[9] We now know, from extensive research drawing on the tobacco industry’s own internal documents, that for decades the industry sought to create both scientific and popular ignorance or “doubt.” At first this doubt related to the fact that smoking caused lung cancer; later, it related to the harmful effects of secondhand smoke on non-smokers and the true effects of using so called light or reduced tar cigarettes on smokers’ health.[9-12] Journals unwittingly played a role in producing and sustaining this ignorance.9

Some who work within public health and who buy the notion of “harm reduction” argue that the companies that now produce modified cigarette products and non-cigarette tobacco products, including electronic nicotine delivery devices (e-cigarettes), are different from the tobacco industry of old, or that the tobacco industry has changed. For “hardened” cigarette smokers who can’t or won’t quit cigarettes,[13] the argument goes, new tobacco products could represent potential public health gains, and company sponsored research may be the first to identify those gains.

But one fact remains unassailably true: the same few multinational tobacco companies continue to dominate the market globally and, as smaller companies develop promising products, they are quickly acquired by the larger ones. However promising any other products might be, tobacco companies are still in the business of marketing cigarettes. As US federal court judge Gladys Kessler pointed out in her judgment in the case of US Department of Justice versus Philip Morris et al, the egregious behaviour of these companies is continuing and is likely to continue into the future.[14] And just this summer documents leaked from one company showed a concerted campaign to “ensure that PP [plain packaging of tobacco products, bearing health warnings but only minimal branding] is not adopted in the UK.”[15] The tobacco industry has not changed in any fundamental way, and the cigarette—the single most deadly consumer product ever made—remains widely available and aggressively marketed.

Editors of BMJ journals are committed to integrity in scientific publishing and to ensuring that—as far as possible—their journals publish honest work that advances knowledge about health and disease. Back in 2003, the editor of the BMJ defended publication of a study with tobacco industry funding saying “The BMJ is passionately antitobacco, but we are also passionately prodebate and proscience. A ban would be antiscience.”[16] But it is time to cease supporting the now discredited notion that tobacco industry funded research is just like any other research. Refusing to publish research funded by the tobacco industry affirms our fundamental commitment not to allow our journals to be used in the service of an industry that continues to perpetuate the most deadly disease epidemic of our times.



War Veterans, OTC Medications and Dementia: Most read articles in September

4 Oct, 13 | by flee

The most-read article in September was once again, Carpenter et al‘s article on Bed sharing and the risk of SIDS. Wakefield et al‘s study of Australian packaging policy stayed in the top ten for another month.  Other newly-published papers in the top ten include Brabers et al‘s survey investigating consumers’ attitudes towards over the counter medication.

Rank Author(s) Title
1 Carpenter et al Bed sharing when parents do not smoke: is there a risk of SIDS? An individual level analysis of five major case–control studies
2 Billings et al Choosing a model to predict hospital admission: an observational study of new variants of predictive models for case finding
3 McBride et al The mortality and cancer experience of New Zealand Vietnam war veterans: a cohort study
4 Shaw et al The work of commissioning: a multisite case study of healthcare commissioning in England’s NHS
5 Hope et al Prevalence of, and risk factors for, HIV, hepatitis B and C infections among men who inject image and performance enhancing drugs: a cross-sectional study
6 Ford et al Current treatments in diabetic macular oedema: systematic review and meta-analysis
7 Brabers et al Where to buy OTC medications? A cross-sectional survey investigating consumers’ confidence in over-the-counter (OTC) skills and their attitudes towards the availability of OTC painkillers
8 Griffiths et al How active are our children? Findings from the Millennium Cohort Study
9 Wakefield et al Introduction effects of the Australian plain packaging policy on adult smokers: a cross-sectional study
10 Gao et al Effects of centrally acting ACE inhibitors on the rate of cognitive decline in dementia


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

Plentiful mid-life stress linked to heightened risk of dementia in late life

30 Sep, 13 | by flee

Coping with a lot of stress in middle age may boost the risk of developing dementia in late life – at least among women – suggests research published in BMJ Open.

The response to common life events may trigger long lasting physiological changes in the brain, say the authors.

They base their findings on 800 Swedish women whose mental health and wellbeing was formally tracked over a period of almost 40 years as part of the larger Prospective Population Study of Women in Gothenburg, Sweden, which started in 1968.

The women, who were all born in 1914, 1918, 1922 and 1930, underwent a battery of neuropsychiatric tests and examinations in 1968, when they were in their late 30s, mid 40s, and 50s, and then again in 1974, 1980, 1992, 2000 and 2005.

At their initial assessment, the women were quizzed about the psychological impact on them of 18 common stressors, such as divorce, widowhood, serious illness or death of a child, mental illness or alcoholism in a close family member, personal or partner’s unemployment, and poor social support.

How many symptoms of distress, such as irritability, fear, and sleep disturbances, and how often they had experienced these in the preceding five years, were noted at every assessment.

In 1968 one in four of the women had experienced at least one stressful event;  a similar proportion (23%) had experienced at least two, while one in five had experienced at least three, and 16% four or more. The most commonly reported stressor was mental illness in a close family member.

During the monitoring period, 425 of the women died (at the average age of 79). Between 1968 and 2006, around one in five (19%, 153) developed dementia, 104 of whom developed Alzheimer’s disease.

On average, it took 29 years for dementia to develop, with 78 the average age at which the condition was diagnosed.

The number of stressors reported by the women was associated with longstanding symptoms of distress at all of the time points assessed, irrespective of the year of birth.

And the number of stressors reported in 1968 was associated with a 21% heightened risk of developing Alzheimer’s disease and a 15% heightened risk of developing any type of dementia, the analysis showed.

The findings held true even after taking account of factors likely to influence the results, including a family history of mental health problems.

The authors emphasise that further research is needed to confirm the results of their study, and to look at whether stress management and behavioural therapy might help.

But they suggest that “stress may cause a number of physiological reactions in the central nervous, endocrine, immune and cardiovascular systems,” and point to other studies showing that stress can cause structural and functional damage to the brain and promote inflammation.

Furthermore, research has also shown that stress hormones can remain at high levels many years after experiencing a traumatic event.

International “war” on illegal drugs is failing to curb supply

30 Sep, 13 | by flee

The international war on illegal drugs is failing to curb supply, despite the increasing amounts of resource being ploughed into law enforcement activities, finds research published in BMJ Open.

Since 1990, the street price of illegal drugs has fallen in real terms while the purity/potency of what’s on offer has generally increased, both of which are indicators of availability.

The United Nations recently estimated that the illicit drug trade is worth at least US $350 billion every year. And needle sharing is one of the key drivers of blood borne infections, including HIV. The drug trade is also linked to high rates of violence.

Over the past several decades most national drug control strategies have focused on law enforcement to curb supply, despite calls to explore approaches, such as decriminalisation and strict legal regulation.

The researchers analysed data from seven international government-funded drug surveillance systems, which had at least 10 years of information on the price and purity of cannabis, cocaine and opiates, including heroin.

They also reviewed the number of seizures of illegal drugs in drug production regions and rates of consumption in markets where demand for illegal drugs is high.

Three of the seven surveillance systems reported on international data; three reported on US data; and one reported on data from Australia. In some cases the data went back as far as 1975, with the most recent data going back to 2001.

Three major trends emerged from the data analysis: the purity/potency of illegal drugs either generally remained stable or increased between 1990 and 2010; with few exceptions, the street price generally fell; and seizures of drugs increased in both the countries of major supply and demand.

In the US, after adjusting for inflation and purity, the average street price of heroin, cocaine and cannabis fell by 81%, 80%, and 86%, respectively, whereas the purity and/or potency of these drugs increased by 60%, 11%, and 161%, respectively.

Similar trends were observed in Europe where, during the same period, the average price of opiates and cocaine, adjusted for inflation and purity, decreased by 74% and 51%, respectively, and in Australia, where the price of cocaine fell by 14% and the price of heroin and cannabis dropped by 49%.

In the US seizures of cocaine roughly halved between 1990 and 2010, but those of cannabis and heroin rose by 465% and 29%, respectively; in Europe seizures of cocaine and cannabis fluctuated, but seizures of heroin had risen 380% by 2009.

On the basis of the data, the authors conclude, as previous studies have, “that the global supply of illicit drugs has likely not been reduced in the previous two decades.”

They add: “In particular, the data presented in this study suggest that the supply of opiates and cannabis have increased, given the increasing potency and decreasing prices of these illegal commodities.”

And they conclude: “These findings suggest that expanding efforts at controlling the global illegal drug market through law enforcement are failing.”

“It is hoped that this study highlights the need to re-examine the effectiveness of national and international drug strategies that place a disproportionate emphasis on supply reduction at the expense of evidence based prevention and treatment of problematic illegal drug use,” they add.

In an accompanying podcast, co-author Dan Werb says that other indicators of the effectiveness of illegal drug policies are needed, such as rates of HIV related transmission.

Hospital admissions, podcasts and rural vaccinations: Most read articles in August

24 Sep, 13 | by bdevaney

The most-read article in August was Hornshøj et al‘s article on vaccination coverage in rural Guinea-Bissau. Carter et al‘s interview study of workplace bullying in the NHS stayed in the top ten for another month. Another title was the subject of the first BMJ Open podcast: Griffiths et al on how active our children are.  Other newly-published papers in the top ten include Aveling et al‘s quality study comparing surgical safety checklists in high-income and low-income countries and Billings et al‘s observational study on hospital admissions.

Rank Author(s) Title
1 Hornshøj et al Vaccination coverage and out-of-sequence vaccinations in rural Guinea-Bissau: an observational cohort study
2 Carpenter et al Bed sharing when parents do not smoke: is there a risk of SIDS? An individual level analysis of five major case–control studies
3 Griffiths et al How active are our children? Findings from the Millennium Cohort Study
4 Gao et al Effects of centrally acting ACE inhibitors on the rate of cognitive decline in dementia
5 Kerns et al How patients want to engage with their personal health record: a qualitative study
6 Aveling et al A qualitative study comparing experiences of the surgical safety checklist in hospitals in high-income and low-income countries
7 Wallace et al The epidemiology of malpractice claims in primary care: a systematic review
8 Wakefield et al Introduction effects of the Australian plain packaging policy on adult smokers: a cross-sectional study
9 Ford et al Current treatments in diabetic macular oedema: systematic review and meta-analysis
10 Billings et al Choosing a model to predict hospital admission: an observational study of new variants of predictive models for case finding


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

Half of all UK 7 year olds sedentary for 6 to 7 hours every day and not exercising for recommended minimum

21 Aug, 13 | by bdevaney

Half of all UK seven year olds are sedentary for six to seven hours every day, and only half clock up the recommended daily minimum of moderate to vigorous physical activity, indicates research published in BMJ Open.

Click here to listen to the podcast

Girls, children of Indian ethnic origin, and those living in Northern Ireland are the least physically active of all seven year olds, the findings show.

The authors base their findings on a representative population sample of almost 7000 UK primary school children who were all part of the Millennium Cohort Study. This is tracking the long term health of around 19,000 children born in the UK between 2000 and 2002.

The duration and intensity of children’s daily physical activity levels were captured for a full week between May 2008 and August 2009, using a gadget called an accelerometer, worn on an elasticated belt. The children only took this off when they bathed or went to bed.

UK guidelines on daily physical activity levels across the life course were revised in 2011. These recommend that children engage in moderate to vigorous physical activity for at least an hour every day, and that they spend less time sitting down, although no maximum has been specified for this.

The analysis showed that on average, across the entire sample, children managed 60 minutes of moderate to vigorous physical activity every day, and that they took an average of 10,299 steps.

But the accelerometer readings also showed that half the children were sedentary for six or more hours every day, and that half of them didn’t reach the daily recommended exercise target.

Girls fared worse than boys, in terms of total physical activity, moderate to vigorous physical activity, and in the number of steps they took every day.

They were also more sedentary and less likely to meet their recommended daily exercise target than the boys. Just 38% of girls achieved this compared with almost two thirds of the boys (63%).

And children of Indian ethnic origin spent the least time in moderate to vigorous exercise, and took the fewest stepseach day, while only one in three (33%) children of Bangladeshi origin met the recommended daily exercise minimum.

Among the four UK countries, children in Northern Ireland were the least active, with just 43% managing 60 minutes of moderate to vigorous physical activity every day, while children in Scotland were most likely (52.5%) to achieve the minimum daily target.

And while around 52% of children in England managed 60 minutes of moderate to vigorous exercise each day, there were regional differences, with children living in the North West (58%) the most likely, and those in the Midlands (46%), the least likely, to do so.

In an accompanying podcast, senior author Professor Carol Dezateux describes the gender differences in exercise levels as “striking” and calls for policies to promote more exercise among girls, including dancing, playground activities, and ball games.

The authors refer back to the legacy of the London 2012 Olympic Games, which promised to inspire a generation to take part in sport.

“The results of our study provide a useful baseline and strongly suggest that contemporary UK children are insufficiently active, implying that effort is needed to boost [physical activity] among young people to the level appropriate for good health,” they write.

This is likely to require population wide interventions, they say, including policies to make it easier for kids to walk to school, in a bid to increase physical activity and curb the amount of time they are sedentary.

“Investing in this area is a vital component to deliver the Olympic legacy and improve the short and long term health of our children,” they conclude.

Cigarette packaging, twitter and workplace bullying: Most read articles in July

5 Aug, 13 | by flee

The most-read article in July was Wakefield et al‘s article on effects of the Australian plain cigarette packaging policy on adult smokers, which received widespread press coverage. Another popular title was Brynolf et al‘s paper on physician’s use of Twitter.  Other newly-published papers in the top ten include Wallace et al‘s systematic review on the epidemiology of malpractice claims in primary care as well as Carter et al‘s interview study of workplace bullying in the NHS.

Rank Author(s) Title
1 Wakefield et al Introduction effects of the Australian plain packaging policy on adult smokers: a cross-sectional stud
2 Carpenter et al Bed sharing when parents do not smoke: is there a risk of SIDS? An individual level analysis of five major case–control studies
3 Brynolf et al Virtual colleagues, virtually colleagues—physicians’ use of Twitter: a population-based observational study
4 Wallace et al The epidemiology of malpractice claims in primary care: a systematic review
5 Gao et al Effects of centrally acting ACE inhibitors on the rate of cognitive decline in dementia
6 Doyle et al A systematic review of evidence on the links between patient experience and clinical safety and effectiveness
7 Ford et al Current treatments in diabetic macular oedema: systematic review and meta-analysis
8 Pearce et al Obesity in young men, and individual and combined risks of type 2 diabetes, cardiovascular morbidity and death before 55 years of age: a Danish 33-year follow-up study
9 Heneghan et al Evidence for non-communicable diseases: analysis of Cochrane reviews and randomised trials by World Bank classification
10 Carter et al Workplace bullying in the UK NHS: a questionnaire and interview study on prevalence, impact and barriers to reporting


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

Certain blood pressure drugs slow dementia deterioration

25 Jul, 13 | by flee

A class of drug, called ACE inhibitors, which are used to lower blood pressure, slow the rate of cognitive decline typical of dementia, suggests research published in BMJ Open.

Furthermore, these drugs may even boost brain power, the research indicates.

The researchers compared the rates of cognitive decline in 361 patients who had either been diagnosed with Alzheimer’s disease, vascular dementia, or a mix of both.

Eighty five of the patients were already taking ACE inhibitors; the rest were not.

The researchers also assessed the impact of ACE inhibitors on the brain power of 30 patients newly prescribed these drugs, during their first six months of treatment. The average age of all the participants was 77.

Between 1999 and 2010, the cognitive decline of each patient was assessed using either the Standardised Mini Mental State Examination (SMMSE) or the Quick Mild Cognitive Impairment (Qmci) screen on two separate occasions, six months apart.

Compared with those not taking ACE inhibitors, those on these drugs experienced marginally slower rates of cognitive decline.

In those whose brain power had been assessed by Qmci, which is a more sensitive screen than the SMMSE, the difference was small, but significant.

And the brain power of those patients newly prescribed ACE inhibitors actually improved over the six month period, compared with those already taking them, and those not taking them at all.

This might be because these patients stuck to their medication regimen better, or it might be a by-product of better blood pressure control, or improved blood flow to the brain, suggest the authors.

But it is the first time that there has been any evidence to suggest that blood pressure lowering drugs may not only halt cognitive decline, but may actually improve brain power.

“This [study] supports the growing body of evidence for the use of ACE inhibitors and other [blood pressure lowering] agents in the management of dementia,” write the authors.

“Although the differences were small and of uncertain clinical significance, if sustained over years, the compounding effects may well have significant clinical benefits,” they add.

They caution, however, that recent evidence indicates that ACE inhibitors may be harmful in some cases, so if larger studies confirm that they work well in dementia, it may be only certain groups of patients with the condition who stand to benefit.