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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.

Salty cheese, unprepared graduates and coercive anal sex: most read articles in August

29 Sep, 14 | by fpearson

August’s top ten includes the highly accessed, survey based study by Marston et al. on anal sex amongst young people,  a study on Ecuadorian medical graduates being prepared enough for a year of  compulsory rural service in obstetrics and a popular cross-sectional survey by Hashem et al. of salt content in cheese which concludes that it is a major contributor to salt intake in the UK.

 

Rank Author(s) Title
1 Marston et al. Anal heterosex among young people and implications for health promotion: a qualitative study in the UK
2 Abu Dabrh et al. Health assessment of commercial drivers: a meta-narrative systematic review
3 Hsia et al. Variation in charges for 10 common blood tests in California hospitals: a cross-sectional analysis
4 Todd et al. The positive pharmacy care law: an area-level analysis of the relationship between community pharmacy distribution, urbanity and social deprivation in England
5 Rao et al. Do healthier foods and diet patterns cost more than less healthy options? A systematic review and meta-analysis
6 Sánchez del Hierro et al. Are recent graduates enough prepared to perform obstetric skills in their rural and compulsory year? A study from Ecuador
7 Hashem et al. Cross-sectional survey of salt content in cheese: a major contributor to salt intake in the UK
8 Zhang et al. Spatial analysis on human brucellosis incidence in mainland China: 2004–2010
9 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
10 Howick et al. Current and future use of point-of-care tests in primary care: an international survey in Australia, Belgium, The Netherlands, the UK and the USA

 

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

Skirt size increase linked to 33% greater postmenopausal breast cancer risk

24 Sep, 14 | by flee

Going up a skirt size over a period of 10 years between your mid 20s and mid 50s is linked to a 33% greater risk of developing breast cancer after the menopause, finds a large observational study published in BMJ Open.

Overall weight gain during adulthood is known to be a risk factor for breast cancer, but a thickening waist seems to be particularly harmful, indicating the importance of staving off a midriff bulge, the research shows.

The researchers base their findings on almost 93,000 women taking part in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) in England.

The women were all aged over 50, had gone through the menopause, and had no known breast cancer when they entered the study between 2005 and 2010.

At enrolment they provided detailed information on height and weight (BMI); reproductive health; fertility; family history of breast and ovarian cancer; and use of hormonal contraceptives and HRT, all of which influence breast cancer risk.

They were also asked about their current skirt size, and what this had been in their 20s.

After a monitoring period of three to four years they were asked about continuing use of HRT; their general health; a subsequent diagnosis of cancer; and lifestyle, including how much they smoked and drank.

Most of the women were white, educated to university degree level, and overweight at the point of study entry, with a BMI of 25-26.

During the monitoring period, 1090 women developed breast cancer, giving an absolute risk of just over 1%. As expected, infertility treatment, family history of breast/ovarian cancer, and use of HRT were all significantly associated with a heightened risk of being diagnosed with the disease, while pregnancies were protective.

But after taking account of other influential factors, increases in skirt size emerged as the strongest predictor of breast cancer risk.

At the age of 25, the women’s average skirt size had been a UK 12 (US 8; Europe 40-44), and when they entered the study at the average age of 64, it was a 14 (US: 10; Europe 42-46). Skirt size increased over the course of their adult lives in three out of four of the women.

The analysis revealed that going up one skirt size every 10 years was associated with a 33% greater risk of developing breast cancer after the menopause; going up two skirt sizes in the same period was associated with a 77% greater risk.

The researchers estimate that the five year absolute risk of postmenopausal breast cancer rises from 1 in 61 to 1 in 51 with each increase in skirt size every 10 years. Adding BMI to the calculations did not significantly improve the prediction of risk.

As this is an observational study, no definitive conclusions can be drawn about cause and effect, and there is likely to have been some variation in skirt sizing over the years, say the researchers.

But an expanding waistline has been linked to other cancers, including those of the pancreas, lining of the womb, and ovaries, they point out, possibly because midriff fat is more harmful.

“Although the exact mechanism of these relationships need to be better understood, there is a suggestion that body fat around the waist is more metabolically active than adipose tissue elsewhere,” they write, adding that extra fat is known to boost levels of the female hormone oestrogen, on which many breast cancer cells rely for fuel.

 

Update: Tuesday 30th September

Clarification: skirt size increase linked to 33% greater postmenopausal breast cancer risk

[Association of skirt size and postmenopausal breast cancer risk in older women: a cohort study within the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) Doi 10.1136/nmjopen-2014-005400]The release issued last week didn’t make it clear that the heightened breast cancer risk was associated with a skirt size increase every 10 years between the mid 20s and mid 60s, rather than one skirt size increase over 10 years during that timeframe.

We do our very best to ensure that the releases we issue are accurate and clear, and have in place a comprehensive review process. But on this occasion it didn’t work as well as it should have done, for which we can only apologise.

Gun deaths twice as high among African Americans as white citizens in US

18 Sep, 14 | by fpearson

Gun deaths are twice as high among African Americans as they are among white citizens in the US, finds a study of national data, published in the online journal BMJ Open.

But the national figures, which have remained relatively steady over the past decade, mask wide variation in firearms deaths by ethnicity and state, the findings show.

The researchers looked at all recorded gun deaths across the USA between 2000 and 2010, to include murders, suicides, and unintentional shooting, using data from the Injury Statistics Query and Reporting System.

Hawaii recorded the lowest rate of gun deaths at 3.02 per 100 000 citizens, while the District of Columbia topped the league table at 21.71 per 100 000. Rates rose in Florida and Massachusetts, largely owing to more gun deaths among people of white and non-Hispanic ethnicities, and an increase in the gun related murder rate.

Firearm deaths fell in Arizona, California, Illinois, Maryland, Nevada, New York, North Carolina, and the District of Columbia, mostly among people of Hispanic and African-American ethnicities.

Nationally, unintentional firearm deaths fell significantly, but the number of gun related murders and suicides remained unchanged. In California, the fall in gun deaths was largely attributable to a reduction in suicides.

The national rate of gun deaths was twice as high among African-Americans as it was among people of white ethnicity. But these deaths fell in seven states and DC, compared with comparable falls in only four states among people of white ethnicity. Similarly, rates of gun deaths among Hispanics fell in four states, and rose among non-Hispanics in nine states.

The authors point out that the patterns of gun deaths they found didn’t seem to reflect firearm control efforts and legislation in individual states. Some of the states with the most stringent gun laws showed an expected fall in firearm deaths, while some with strong gun control laws reported an increase.

For example, The Brady Center to Prevent Gun Violence ranked Massachusetts the third most restrictive state for firearm legislation, while Florida was ranked 40th in 2011.

After Massachusetts passed its tough law restricting gun use in 1998, gun ownership rates plummeted, yet violent crimes and murders increased, possibly because of an influx of firearms from neighbouring states with weaker firearm laws, suggest the authors. And in Florida gun deaths rose, despite an overall fall in violent crime over the same period.

Clamping down on gun violence may require a broader approach, including curbing firearm availability and ramping up interstate border controls on the transport of firearms, the authors conclude.

Plain cigarette packs don’t hurt small retailers or boost trade in illicit tobacco

28 Aug, 14 | by flee

Plain packs for tobacco products don’t hurt small retailers, flood the market with very cheap cigarettes, or boost the trade in illicit tobacco, finds research on the early experience of the policy in Australia, and published in journal BMJ Open.

The findings suggest there is no evidence for these particular arguments against the policy, put forward by the tobacco industry, say the researchers.

Australia was the first country in the world to introduce standardised packaging for tobacco products in December 2012. New Zealand, Ireland, and the UK are currently considering similar legislation.

The researchers wanted to find out if the policy would deter people from buying their tobacco from small independent retailers, prompt a rise in the availability of cheap products sourced from Asia, and increase the use of illicitly traded tobacco, as predicted by the tobacco industry.

They therefore quizzed adult smokers on the phone about their tobacco purchasing habits a year before the plain packaging policy was introduced in 2011; during roll-out in 2012; and one year after implementation.

All participants were already taking part in an annual representative population survey about smoking and health in the Australian state of Victoria, which yielded around 4000 interviews in total for each of the years.

The researchers wanted to know if there had been any changes in the proportions of people buying from supermarkets rather than small independent retailers, and whether smokers had switched to very cheap cigarettes sourced from Asia or illicit unbranded tobacco.

In all, responses were received from just under 2000 smokers. They showed no change in the places smokers usually bought their tobacco from between 2011 and 2013.

Almost two thirds of respondents said they bought their tobacco from supermarkets in 2011 (65.4%) and in 2013 (65.7%). Similarly, there was no fall in the proportion who bought from small independent retailers: just over 9% said they bought their tobacco in these outlets in 2012 and just over 11% said they did so in 2013.

Use of low cost Asian brands was low, and scarcely changed between 2011, when it was 1.1%, and 2013, when it was 0.9%. And use of illicit unbranded tobacco didn’t increase either: this was 2.3% in 2011, and 1.9% in 2013.

In 2013, just 2.6% of cigarette smokers said they had bought one or more packs that did not comply with the new regulations—and so may have been contraband— within the preceding three months.

And 1.7% said they had bought from informal sources, such as a market stall or the back of a van, on one or more occasions over the past 12 months.

The researchers admit that the surveys were restricted to the State of Victoria where only a quarter of the population of Australia lives, so may not be applicable elsewhere.  And any potential unintended consequences of the standardised packaging legislation should continue to be monitored, they say.

But they conclude: “In the meantime, this study provides no evidence of the unintended consequences of standardised packaging predicted by opponents [having] happened one year after implementation.”

BMJ Open now publishes cohort profiles

22 Aug, 14 | by Richard Sands, Managing Editor

 

BMJ Open currently publishes articles reporting research results or study protocols. We have now expanded our scope to include cohort profiles, articles that describe major, ongoing research cohorts.

What’s the difference between a protocol, a cohort profile and a research paper?
Detailed information about cohort profiles is in our instructions for authors. In brief, cohort profiles will describe large, collaborative prospective studies that identify a group of participants and follow them for long periods. They will usually be population based, with sufficient funding to ensure their intended lifespan, and the original investigators must welcome wide use of the datasets beyond their own research group.

We will publish cohort profiles to provide information on a cohort’s establishment that goes beyond what can reasonably be described in the methods section of a research paper and to advise other researchers of existing datasets and opportunities for collaboration.

If a study has yet to begin recruiting participants, is still recruiting or is still collecting baseline data, please submit the study protocol. If you have completed baseline recruitment and have at least baseline data to publish, we would consider this a cohort profile as long as the cohort meets our other requirements.

We publish protocols to alert researchers to forthcoming research and to explain how specific research questions will be answered. Research papers are traditional results papers and should address a specific research question. Many cohort studies are conducted at a single institution by a single research group with no plans to answer further questions. Here “cohort study” is a research method. We welcome protocol and results papers for these studies but would not consider cohort profiles.

Why publish cohort profiles?
When presented with cohort studies to review, editors, peer reviewers and readers often think “exactly how were patients recruited? how representative were they of the wider population? were the questionnaires used to gather information on diet reliable?” and so on; things that too often are not well enough reported in research papers.

There is a clear advantage to publishing detailed profiles of ongoing cohort studies in an open access journal like BMJ Open, so anyone interested can easily access them when planning or appraising studies that arise from them. We hope to generate an ongoing database for answering many different research questions.

Will cohort profiles be peer-reviewed?
Cohort profiles will be externally peer-reviewed as normal, regardless of the cohort’s age or funding status and article publishing charges will apply as for research papers.

Anal sex between young men and women often seems coercive and painful

13 Aug, 14 | by flee

Anal sex between young men and women often seems coercive and painful, suggests research published in BMJ Open.

Feedback from young people reveals an oppressive culture around anal sex, with some young men apparently neglecting or not caring about young women’s consent or pleasure – both when they have anal sex and when they talk about it with their friends.

More open discussion is needed to challenge the culture and attitudes surrounding anal sex between young men and women—a subject that people often find  difficult to talk about in many social contexts, say the researchers.

They interviewed 130 16-18 year olds from diverse social and economic backgrounds living in different parts of the country: London; an industrial city in the north; and a rural area in the south west.

The interviews explored the range and meaning of different sexual practices, and included nine group and 71 individual in-depth discussions in 2010, and further interviews of 43 of the in-depth interviewees in 2011.

The group discussions focused on what sexual practices participants had heard of, what they felt about them, and whether they thought their peers would engage in them—and if so, under what circumstances.

During the in-depth discussions, interviewees were also asked what sexual practices they had engaged in, under what circumstances, and how they felt about them. Young people described‚ a culture where men compete to have anal sex with women, even if they expect women to find it painful.

Women also said their male partners repeatedly asked them for anal sex. And their accounts suggest that they had sometimes ended up having anal sex without giving their explicit consent. “Currently, this apparently oppressive context, and indeed the practice of anal heterosex itself, appears to be largely ignored in policy and in sex education for this young age group,” write the researchers.

The interviewees sometimes said that young men wanting to copy what they saw in porn, explained why they had anal sex, but the feedback suggests that other factors are more important, say the researchers.

These include a lack of concern about getting consent, or the levels of pain female partners might experience, and competitiveness among young men to have anal sex with women. ‘People must like it if they do it’ was also given as an explanation by those who hadn’t experienced anal sex, which, the researchers point out, was made alongside the seemingly contradictory expectation that women would find it painful.

Not all men coerce their partners, the researchers emphasise. Some young women may wish to have anal sex, and both partners may find it pleasurable, they add.

But the findings suggest that teachers, parents, and wider society need to talk more openly about anal sex with young people, particularly the importance of “mutuality” – where both partners listen and respond to each others’ desires and concerns, they write.

Attitudes, such as the inevitability of pain for women, or the failure to recognise or reflect on potentially coercive behaviour, seem to go unchallenged, which risks coercion emerging as a dominant element of anal sex, they add.

Cheese still laden with salt, despite many products meeting reduction targets

6 Aug, 14 | by fpearson

The salt content of cheese sold in UK supermarkets remains high, despite many products meeting the recommended government targets on salt reduction, finds research published in the online journal BMJ Open.

And salt content varies widely, even within the same type of cheese, the findings show, prompting the researchers to call for much tougher targets on salt lowering.

A high dietary salt intake is linked to high blood pressure, which is a risk factor for stroke, heart attacks, heart failure and kidney disease. It also increases the risk of stomach cancer and osteoporosis, and is indirectly linked to obesity.

Salt reduction is widely recognised to be one of the most cost effective ways of improving public health, and at the 66th World Assembly, all countries unanimously agreed to cut their salt intake by 30% towards a target of 5 g/day by 2025.

The current recommended dietary salt intake in the UK is 6 g/day, but is widely exceeded, according to dietary surveys. Cheese is a major contributor to dietary salt intake, with the average person consuming 9 kg of cheese every year.

The researchers analysed the salt content (g/100 g) of 612 different cheeses produced in the UK or imported from overseas and sold in the seven major UK supermarket chains in 2012. This information was collected from the product packaging and nutritional information panels.

In general, salt content was high, averaging 1.7 g/100 g of cheese. But salt levels varied widely – and not only among different types of cheese, but also within the same type.

Halloumi and imported blue cheese contained the most salt (2.71 g/100 g), while cottage cheese contained the least (0.55 g/ 100 g).

Among the 394 cheeses with salt reduction targets, most (84.5%) had already met them for 2012.

Cheddar and cheddar-style cheeses are the most popular/best-selling lines and 250 of these products were included in the analysis.

On average, salt content tended to be higher in branded (1.78 g/100 g) than in supermarket own label (1.72 g/ 100 g) cheddar and cheddar-style cheeses.

And more of the supermarket own-label cheeses in this category met the 2012 target for salt reduction than did the branded products: 90% compared with 73%.

“Our finding of a high salt content in cheeses sold in the UK is similar to those observed in the USA, Australia, France, Belgium, Canada, New Zealand, South Africa, and Brazil, showing that high levels of salt in cheese is a global challenge,” write the authors.

But they suggest that UK salt reduction targets could be more ambitious.

“The results indicate that much larger reductions in the amount of salt added to cheese could be made, and more challenging targets need to be set,” they conclude.

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

9 Jul, 14 | by fpearson

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

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

 

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

Premature newborn survival 30% higher in high volume neonatal centres

7 Jul, 14 | by flee

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Poorly understood postural syndrome blights lives of young well educated women

16 Jun, 14 | by fpearson

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

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

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

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

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

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

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

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

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

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

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

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

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

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