Editor's Choice US editor's choice

It's all about being first

BMJ 2007; 334 doi: http://dx.doi.org/10.1136/bmj.39155.711400.43 (Published 15 March 2007) Cite this as: BMJ 2007;334:0-a
  1. Elizabeth Loder, research editor, Boston
  1. eloder{at}bmj.com

    In the age-old competition among siblings, it's always been advantageous to be the first child. Firstborn sons, for example, may have special claims to family money, titles, or other assets. First children may get extra parental attention and time, and may be more successful at school or work than their later born siblings. As it turns out, though, for twins it is not just life's rewards but life itself that may hinge on being born first. Gordon Smith and colleagues (doi: 10.1136/bmj.39118.483819.55) performed a retrospective cohort study of over 1300 twin pregnancies in which one twin died and the other survived. For preterm infants, perinatal deaths were largely related to complications of prematurity and not birth order. For vaginal deliveries of twins at term, however, the second twin was at increased risk of death. The authors cautiously suggest that planned caesarean section for twin deliveries might reduce this risk. This proposal is strongly endorsed by editorialist Philip Steer (doi: 10.1136/bmj.39146.541100.80), who despite his obvious enthusiasm for planned caesarean deliveries sensibly comments that “it is important that we obtain evidence from randomised controlled trials before caesarean section for twin pregnancies at term becomes universal and a trial becomes impossible.”

    And in the age-old competition among medical journals, it's also advantageous to be first—or failing that at least in the first tier—in the annual impact factor rankings of medical and scientific journals compiled by the Institute of Scientific Information. The subject of impact factors is perennially fascinating to journal editors and academics alike. The former are often under pressure to raise their journal's impact factor, and the dubious practices that can be employed to do so are detailed in Christopher Martyn's witty, tongue-in-cheek advice to an imaginary, newly appointed journal editor (doi: 10.1136/bmj.39142.475799.AD). The latter are often under pressure to “publish or perish” and in institutions with lazy promotions committees their academic advancement may depend upon the impact factors of the journals in which they publish. For those less familiar with impact factors, Hannah Brown explains the ins and outs of this measure doi: 10.1136/bmj.39142.454086.AD), and Gareth Williams and Richard Hobbs debate whether impact factors should be “ditched” or just “refined” (doi: 10.1136/bmj.39146.545752.BE, doi: 10.1136/bmj.39146.549225.BE). The BMJ's impact factor of 9.052 does not, of course, put it first among general medical journals, but it's far from last. The top spot falls to the New England Journal of Medicine, whose 2005 impact factor of 44.016 gives it a sizeable lead, with nearest rivals Lancet and JAMA both trailing by a good 20 points. Deputy editor Trish Groves (doi: 10.1136/bmj.39154.666528.43) lays out the BMJ's philosophical view on the matter of impact factors.

    It's not the first, nor will it be the last, scandal involving the military, but American readers will be especially interested in Princeton economist Uwe Reinhardt's take on revelations of substandard conditions at Walter Reed Army Hospital (doi: 10.1136/bmj.39153.611111.59). Reinhart invokes the idea of “moral hazard”—in which “a decision maker does not bear the full negative consequences of his or her actions”—to explain how, in a country that routinely expresses gratitude to soldiers, the populace can fail to notice or redress the bad medical care some soldiers receive.

    A final “first” in this week's issue is the debut of an occasional series about how to manage pre-existing medical conditions in pregnancy. The first article in this series reviews the management of asthma. Authors Evelyne Rey and Louis-Philippe Boulet (doi: 10.1136/bmj.39112.717674.BE) provide practical advice about the management of pregnant migraineurs, recommending, for example, that potential bronchoconstrictor agents such as prostaglandin F2alpha or carboprost be avoided for management of labour or postpartum hemorrhage.

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