The Lancet website relaunch

Today medical journal The Lancet relaunched a sleek and efficient new version of their website TheLancet.com.

The team at The Lancet consulted 100 authors, readers, doctors and clinicians - or 'development partners' - to find out what users wanted, and the result is a much cleaner and easier to use website. In the new design, The Lancet journals The Lancet, The Lancet Infectious Diseases, The Lancet Oncology, and The Lancet Neurology are now all accessible and searchable from a single website.

In a special podcast to accompany the launch, the Editor-in-Chief Richard Horton outlines his favourite features:

"The most exciting things about The Lancet's new site for me are first, we have the possibility for internet television ... in the YouTube would that we live in I think that's immensely important for communication, especially in health when you've got some pretty difficult concepts sometimes. And secondly, I think we're also able to convey the personality of The Lancet in ways that we've never been able to before: the idea that we're publishing research, educational material, and also opinion."

The new video functionality is showcast TheLancet.com Story, a very flashy and professional-looking production in which members of the journal staff and Dr Anne Szarewski, clinical consultant at Cancer Research UK and one of the development partners, discuss what the new website means to them. The Lancet hopes that in the future users will be able to submit their own medical videos to the site.

Richard Horton boasts that the website has "the best search engine in medicine", and certainly it's an awful lot faster than the search on the previous incarnation. Importantly, the search results include not only results from The Lancet family of journals, but also all relevant results in Medline, a life sciences and biomedical publication database run by the US National Library of Medicine.

Articles now include links to related material as well as social bookmarking tools, including parent company Elsevier's 2Collab social networking tool. In addition, online community features are planned, including social networking, debates, wikis and discussion boards.

On the editorial side of things, original research articles now include drop-down Editors' Notes within the table of contents - 2 or 3 sentences that summarize what is important about the research - while journal homepages feature three articles that represent the Editor's choice. The news aspect of the website has been expanded with the inclusion of 'This Week in Medicine', short paragraph-long summaries of what has been going on in medicine worldwide. Specialty-based online collections comprising content from across The Lancet family of journals will launch in the near future, one mooted project being a cardiology portal.

I think the new version of TheLancet.com is a vast improvement on the previous website, not least because it is so much easier to navigate and doesn't trip you up with sign-ins every 5 minutes. The site also looks far crisper, in stark contrast to it's cluttered forebear. I'm more into text than multimedia so I'm not fussed about using the new video content, but it's certainly very impressive and a new direction for The Lancet.

New Scientist cancer special

The latest issue of New Scientist is a cancer special titled 'Old killer, new hope'.

The main focus of the issue is a large article on genomics - 'Living with the enemy'. Instead of classifying tumors according to where in the body they appear, for example the prostate or the lung, scientists are now starting to groups cancers according to which molecular pathway the cancer uses in order to grow and spread.

New targeted therapies can act specifically on a particular molecular pathway, sparing the normal dividing cells that are often killed off in conventional forms of cancer therapy. For example, breast cancer patients with mutations that cause overproduction of the protein HER2 can be treated specifically with with an antibody called trastuzumab, better known as Herceptin, whereas those with receptors to the hormone estrogen can be treated with a drug called tamoxifen. An interactive graphic shows how these modern therapies work.

'Patients doing it for themselves' describes how powerful, well-funded patient groups are setting the agenda for cancer research. The article cites the example of the Multiple Myeloma Research Foundation, which amazingly donates as much money to research on multiple myeloma as the US National Cancer Institute.

The capacity of the immune system to hold tumors dormant is discussed in 'Tumors under lock and key'. Apparently about a third of breast cancer survivors still have tumor cells circulating in their blood after successful treatment, in cases up to 22 years after therapy. Finding out how the immune system keeps microtumors, which are thought to be responsible for these circulating tumor cells, from running amok could provide new strategies for fighting cancer.

The special issue also contains a list of expert tips for evading cancer and an editorial lamenting how patients and healthcare providers are ever going to be able to afford these fancy new treatments.

All these articles are currently available online for free, so go check them out.

Attitude has no effect on survival in women with breast cancer

Many patients with cancer feel that their attitude towards the 'fight' is an important part of beating the disease, but maintaining a positive perspective is pretty tough in the face of a life-threatening malignancy.

A large, population-based study published in the Journal of Clinical Oncology has now found that psychosocial factors such as fighting spirit and fatalism have no effect on survival in patients with breast cancer. The authors Phillips et al. emphasize that their results could allay the concerns of anxious women who believe that their mental attitude towards breast cancer will affect their likelihood of survival, and could in fact lift the burden of responsibility such women may feel.

Phillips et al. studied 708 Australian women diagnosed with nonmetastatic breast cancer before the age of 60 (average age 40 years old). At study entry approximately 11 months after diagnosis, all women completed an array of psychosocial tests that were designed to assess factors such as anxiety and depression, coping style, and social support. These women were then followed up for an average of 8.2 years.

In total, 33% of women experienced distant recurrence of their cancer and 24% died during follow-up. Once the patient data had been adjusted to take into account other factors that affect chances of recovery, such as tumour size, no associations could be found between psychosocial factors and either distant disease-free survival or overall survival.

The authors conclude that their study does not support the controversial theory that psychosocial factors influence survival after breast cancer. They state, "This should be reassuring for women, particularly those who experience substantial levels of psychosocial distress after their diagnosis."

It is important to note, however, that therapies that aim to reduce psychosocial stress in women with breast cancer should not be discounted, as such interventions do seem to improve quality of life.

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K.-A. Phillips, R. H. Osborne, G. G. Giles, G. S. Dite, C. Apicella, J. L. Hopper, R. L. Milne (2008). Psychosocial Factors and Survival of Young Women With Breast Cancer: A Population-Based Prospective Cohort Study. Journal of Clinical Oncology 26 (28): 4666-4671 DOI: 10.1200/JCO.2007.14.8718

Would you like a defibrillator with your coke sir?

Authorities in Japan have taken an interesting approach to improving the dire survival rates after out-of-hospital sudden cardiac arrest (SCA), i.e. heart attack in the home or in a public place rather than in a ward on a hospital.

Nature Clinical Practice Cardiovascular Medicine reports that automated external defibrillator devices (AEDs) are being placed in vending machines and advertising hoardings in public spaces in Japan. Members of the public can then use these devices to provide defibrillation at the scene of a SCA, saving precious minutes before emergency services arrive.

The American Heart Association estimates that 166,200 people die in the United States each year from out-of-hospital SCA and only 6.4% of patients who are admitted to hospital for SCA survive until discharge.

Early medical response is crucial for people who suffer an out-of-hospital SCA. For every minute that passes between collapse and defibrillation, survival from witnessed SCA falls by 7-10%. In most cases it is the emergency services who provide defibrillation, but time is lost waiting for paramedics to arrive at the scene.

An obvious way to shorten the time between SCA and defibrillation is for lay witnesses to perform the procedure. In fact, studies have found that defibrillation by members of the public considerably improves survival after SCA.

The Japanese government authorized the lay use of AEDs in July 2004. Subsequently, a study by the Japanese Fire and Disaster Management Agency in 2006 found that 32.1% of the 140 SCA victims who were defibrillated by a member of the public were still alive at 1 month, compared with 8.3% of the 18,180 people who did not receive defibrillation from a lay person.

In most countries public-access AEDs can only be used by trained individuals, be they members of the public, first aiders, paramedics and so on; however, what is interesting in Japan is that no training is necessary in order to use these devices. In addition, the Japanese government has formally declared that the liability of an individual who uses an AED is limited, irrespective of the outcome of resuscitative efforts.

Another interesting point about public-access AEDs in Japan is that rather than being directed by the government, the positioning of AEDs in public places is being spearheaded by commercial companies. As Nature Clinical Practice Cardiovascular Medicine reports:

"The cost of keeping an AED in a vending machine is primarily covered by the revenue from drink purchases and is shared by the manufacturer of the drink, the provider of the machine, the distributor of the AED, and the proprietor who provides the space and electricity. Allowing paid advertising on a display panel above a box housing an AED is another method of funding public access AEDs. Again, the proprietor has only to provide the space and electricity. These creative efforts are surely effective in keeping down AED dissemination costs."

Although Japan was a little behind other countries when it came to introducing public-access AEDs, the creative approaches to accessibility undertaken by the Japanese are in a class of their own.

Last night the Bee Gees saved my life

The Bee Gees' disco smash 'Stayin' Alive' is more appropriately titled than anyone could have realized - the 1977 hit is the ideal speed at which to perform chest compressions in heart attack victims. Having practiced cardiopulmonary resuscitation (CPR) with the song, participants in a recent study could maintain the ideal rhythm weeks later by simply thinking of the tune as they performed the procedure.

Dr David Matlock, an author of the study, said many people were put off performing CPR as they were not sure about keeping the correct rhythm. CPR can more than double the chance of survival after cardiac arrest, if performed properly.

The research from the University of Illinois, which will be presented during the American College of Emergency Physicians' scientific assembly in Chicago this month, found that at 103 beats per minute, Stayin' Alive is almost the same pace as the American Heart Association's recommendation of 100 compressions per minute for CPR.

In this study, 15 students and doctors first performed chest compressions on mannequins to the beat of Stayin' Alive. Five weeks later, they performed the same procedure without the music but were told to think of the song while doing compressions. The average number of compressions the first time was 109 per minute; the second time it was 113.

Dr Matlock acknowledged that the pace kept in the second round was a little fast, but stated that when it comes to trying to revive a stopped heart, a few extra compressions per minute is better than too few. "It drove them and motivated them to keep up the rate, which is the most important thing," he told the Associated Press.

According to the BBC, a spokesman for the American Heart Association said that the organization had been using Stayin' Alive as a training tip for CPR instructors for about two years.

Diabetes gonna get you

About 10 days ago Diabetes UK launched their biggest ever UK public awareness campaign - Beware the silent assassin. I first got wind of the campaign when I spotted this arresting poster at Old Street tube station in east London.

The campaign has been launched on the back of research by Mori showing that people tend to underestimate the severity of the complications associated with diabetes; for example, only 29% of adults are aware of the link between diabetes and heart disease, and only 46% appreciate that diabetes shortens life expectancy. Diabetes UK says, "This research tells us that the public see diabetes as rather mild and easily managed – something of an inconvenience rather than the serious condition it can be."

In addition, an estimated 500,000 people in the UK have the condition but are not aware of it, so are at risk of being diagnosed too late to prevent the complications of diabetes. “Dealing with the diabetes time-bomb is a matter of urgency if we want to prevent millions of people from facing a grim future of ill-health," said Douglas Smallwood, Chief Executive of Diabetes UK.

The 'hard-hitting campaign' launched by the charity aims to spook the public into realizing that diabetes is serious condition that can potentially cause heart disease, stroke, amputations, kidney failure and blindness.

The images, which will appear on outdoor posters as well as in newspapers and magazines, feature an ominous ghostly figure - the specter of undiagnosed diabetes presumably - pouncing on unsuspecting members of the public. The ads also include secondary warning messages such as:
- Diabetes causes more deaths than breast and prostate cancer combined.
- The death certificate will say heart attack. It was really diabetes.
- Diabetes causes heart disease, stroke, amputations, kidney failure and blindness.
So far so portentous.

The campaign also encourages people at risk of developing type 2 diabetes, i.e. the overweight, to make changes in their lifestyle to avoid a future of chronic disease. As the blurb states, "With early diagnosis and by leading a healthier lifestyle and improving diabetes control, the risk of developing these serious complications can be minimised. "

The adverts refer readers to a microsite developed especially for the campaign, which has quizzes to help users establish their risk of developing diabetes and gives information and support on managing the condition.

I personally feel that these adverts suggest that diabetes could to strike you dead on the spot - assassinate you - the way heart disease might, but is this really the case? On the other hand, a campaign educating our increasingly overweight population that diabetes is a serious and mostly preventable disease is certainly needed, and it is quite likely that striking adverts such as these will get people thinking more seriously about their health.

Herbal remedies and acute kidney disease

Nature Clinical Practice Nephrology has recently published a review by Luyckx and Naicker highlighting the link between traditional medicines and kidney injury.

Traditional and herbal remedies are widely used worldwide, with as many as 80% of people in some populations using such treatments. The use of herbal remedies becoming increasing common in Western countries, as shown by a 2002 survey that found that 36% of people in the US use alternative or complementary medicines.

Herbal therapies all pass through the kidney on their way out of the body; consequently, many have been associated with acute kidney disease. Luyckx and Naicker report that "folk remedies account for up to 35% of cases of acute kidney injury and mortality rates for acute kidney injury range from 24% to 75%."

The herbal remedies most commonly used in the US include echinacea, which is used as an immunostimulant, and St John’s wort, which is used to treat depression among other things. Echinacea, however, has been associated with acute kidney injury and St John's Wort with kidney transplant rejection.

Various factors besides direct toxicity of the agent can contribute to kidney injury, such as contamination of the preparation or incorrect administration. In addition, the type of nephrotoxicity experienced by an individual taking a herbal remedy is dependent on which part of the kidney is affected, and the authors discuss these factors in more detail in their review.

Luyckx and Naicker do point out that the effects of herbal remedies are something of an unknown quantity; for example, some studies have shown that cranberry decreases the risk of kidney stones, whereas other studies find that cranberry increases this risk.

The review concludes by saying "The incidence and prevalence of acute kidney injury associated with the use of traditional remedies is unknown and probably varies greatly from place to place. Since the use of traditional remedies is common worldwide, it is probably safe to assume that the incidence of acute kidney injury is not high. Individual morbidity, however, can be considerable."

Skin test to detect Parkinson's disease

A recent study published in the Journal of Neuropathology & Experimental Neurology has shown that neural signs of Parkinson's disease can be identified by taking a simple skin sample.

Parkinson’s disease is a progressive neurodegenerative disease that affects about 1 in every 500 people in the UK. There is no biochemical test to definitively diagnose Parkinson's disease; diagnoses are instead made on the basis of various clinical assessments. Parkinson's disease is, however, characterized by the presence of Lewy bodies (LBs) - tiny protein deposits in nervous tissue.

LBs can only be identified from a tissue sample, which is then stained and examined under a microscope (see right). These proteins tend to accumulate in the central nervous system and in the sympathetic ganglia, nervous tissue that runs like train tracks down either side of the spine - places that are nearly impossible to get biopsy samples.

In this study, the authors looked for LBs in various tissues in 279 patients undergoing autopsy. A total of 85 patients had evidence of LBs in their central nervous system, so were diagnosed as having had a LB disease (LBD) - Parkinson's with or without dementia, dementia with LBs or LB-related progressive autonomic failure.

The authors then examined skin biopsy samples taken the patients with proven LBD and found that 20 (23.5%) patients showed LB pathology in the cutaneous nerves of skin samples. None of the 194 individuals who did not have LBD showed evidence of LBs in skin samples; therefore, the skin test didn’t mistakenly identify any patients as having LBD.

More specifically, LBs were found in the skin of 70% of patients who had Parkinson’s disease with dementia and in 40.4% of those who had dementia with LBs. On the other hand, LB pathology was found in the skin of only 20% of patients who had subclinical LBD, i.e. patients who would have had few symptoms of LBD but not enough signs to meet all the criteria for a diagnosis. This skin biopsy test might not, therefore, be a useful test for early diagnosis in individuals suspected of having LBD.

When the authors looked at the clinical records of the patients that they had autopsied, they found that LBD patients who had evidence of LB pathology in their skin were more likely to have been bedridden and unable to walk independently before they died than were those patients with LBD who did not have cutaneous LB pathology (P<0.001 style="font-style: italic;">P=0.065, respectively). This finding suggests that skin biopsy testing could be used to predict which patients’ physical functioning might be affected most seriously by their disease, and physiotherapy could be prescribed accordingly.

Ikemura et al.’s study is the first to find evidence of LB pathology in the skin of patients with LBD; however, their results do not support the use of skin biopsy as an early diagnostic test. Testing for LBs in the skin could be used to confirm the diagnosis in a patient with clinical Parkinson’s disease or dementia with LBs and to predict the effect the disease might have on their physical functioning, both of which could help clinicians tailor treatment.

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Ikemura M, Saito Y, Sengoku R, Sakiyama Y, Hatsuta H, Kanemaru K, Sawabe M, Arai T, Ito G, Iwatsubo T, Fukayama M, Murayama S (2008). Lewy Body Pathology Involves Cutaneous Nerves. J Neuropathol Exp Neurol, 67 (10), 945-953 PMID: 18800013

From homeopaths to psychopaths

To celebrate the launch of the book Medical London: City of diseases, city of cures, the Wellcome Collection is hosting a selection of events in the city. Written by Richard Barnett and Mike Jay, Medical London offers "a unique ... view of the roles played by diseases, treatments and cures in London's sprawling story". Yesterday I took part one of the Wellcome events - a walk around west London titled From homeopaths to psychopaths.

We started out in Sloane Square, where leader Max Décharné, author of King's Road, gave us a bit of background on the area. Throughout the 16th and 17th century, the Chelsea region served as a rural outpost of London, the clean air and clean water of the village a welcome reprieve for the visitors looking to recuperate from the filthy mêlée of the east end.

First stop was the statue of Hans Sloane, which stands outside of the Duke of York's Headquarters (Photo: Matt from London on Flickr). Sloane, born in 1660, was physician to Queen Anne, George I and George II and was the first medical practitioner to receive a peerage, given the title Baron in 1716. In clinical practice, Sloane promoted innovations such as inoculation against smallpox and the use of quinine (a treatment for malaria). He was also a president of the Royal College of Physicians and succeeded Sir Isaac Newton as President of the Royal Society.

As well as being a proficient doctor, Sloane was an avid collector of pretty much anything and everything, and on his death his vast collection of natural history specimens and antiquities was sold to the nation at a knock-down price and housed in the newly created British Library, and later at the Natural History Museum.

We next passed through Chelsea Walk, which was originally built by William III and intended as a wide boulevard linking the newly-built Royal Chelsea Hospital with Kensington Palace, but actually only extends from the hospital to King's Road.

The Royal Chelsea Hospital itself was commissioned by Charles II for the "succour and relief of veterans broken by age and war" (Photo: stevecadman on Flickr). Until the 17th century injured or elderly soldiers were not provided for in any way by the state. Many were kept on regimental rolls and still took part in duties so that they could continue to receive payment as there were no pension provisions. Charles II recognized that the state owed a debt to these soldiers, marking a shift from the tactic of previous kings who often left the poor and infirm to fend from themselves. The hospital was built by Sir Christopher Wren and completed in 1692, with the first 479 in-pensioners in residence by the end of the year. The hospital is still a home to elderly or injured British soldiers, and is also the site of the annual Chelsea Flower Show.

On the way to the hospital we passed Bram Stoker's house on St Leonard's Terrace, who, despite writing rather morbid literature, has an interesting health connection. In 1882 Stoker was awarded a Royal Humane Society Bronze Medal for attempting to save the life of a man who had jumped into the River Thames.

At this point I sadly had to abandon the walk as I had been totally soaked through by the torrential rain. I was particularly disappointed to miss the trip to Chelsea Physic Garden, not least because for many years I thought it was called Chelsea Psychic Garden and was hoping for some horticultural glimpse into my future (incidentally, the word ‘physic’ refers to the science of healing, not the science of matter and forces. So much opportunity for confusion). The garden was founded in 1673 as a site to train apothecary apprentices in the art of identifying plants and still hosts the Garden of World Medicine, a special collection of plants used for medicinal purposes by different cultures around the world.

Not so Ignoble

On Thursday the Ig Nobel prizes were awarded at Harvard University. Sponsored by the Annals of Improbable Research, these prizes are an irreverent alternative to the Nobel Prizes, which will be awarded over the next ten days, and aim to "celebrate the unusual, honor the imaginative -- and spur people's interest in science, medicine, and technology".

This year the winners of the medicine prize were Dan Ariely of Duke University, Rebecca L Waber of MIT, Baba Shiv of Stanford University, and Ziv Carmon of INSEAD (Singapore), who demonstrated that high-priced placebos are more effective than low-priced placebos.

In their study, published in the Journal of the American Medical Association no less, 87 healthy, paid volunteers were told that they were receiving a new opioid analgesic; however, one group of patients was told that they were receiving a drug at its regular price of $2.50 per pill, whereas the other patients were told that they were receiving a discounted medication priced at $0.10 per pill. All patients then received a series of electric shocks before and after taking the placebo, supposedly to test the efficacy of this treatment. More patients in the regular price group than in the discounted price group said that the electric shocks were less painful after taking the drug.

Rather than being frivolous, this study sounds like it may be of some importance. Patients switching from expensive branded medications to generic drugs have a tendency to perceive that the generic equivalents are less effective, and some might actually experience reduced efficacy thanks to a negative placebo effect (or nocebo response). Healthcare providers could, therefore, incur unnecessary costs by keeping patients on brand drugs on the basis of perceived efficacy. Doctors could prevent this problem by playing down potentially deleterious commercial factors when discussing treatment options with their patients; for example, steering clear of terms like 'low-priced' and 'generic'.

To be fair, the overarching aim of the Ig Nobels Prizes is to "honor achievements that first make people laugh, and then make them think". The study by Ariely et al. certainly meets both criteria, as do several of the winning pieces of research.

Read more: Nature News has a blow-by-blow account of the raucous ceremony, while The Guardian celebrates Britain's double win.

Irresponsible reporting of clinical trials by the news media

It is important for journalists to highlight any potential bias in medical research so that patients and physicians alike can judge how valid clinical trial findings are. Today the Journal of the American Medical Association published a study showing that almost half of news stories on clinical trials fail to report the funding source of the trial. In addition, two-thirds of news articles refer to study medications by their brand names instead of by their generic names.

The authors Hochman et al. reviewed papers published between 1st April 2004 and 30th April 2008 in the top five medical journals (New England Journal of Medicine, JAMA, the Lancet, Annals of Internal Medicine and Archives of Internal Medicine) to find pharmaceutical-company-funded studies that evaluated the efficacy or safety of medications. They then searched 45 major US newspapers (for example New York Times and USA Today) and 7 US-based primary news websites (including ABC News, CNN and MSNBC) for news stories that reported these clinical trials.

A total of 358 company-funded clinical trials were identified, and 117 of these yielded 306 distinct news stories. Of the 306 news stories, 42% did not report the funding source of the clinical study. A total of 277 of these news articles were about medications that had both brand names and generic names, but 67% of stories used brand names in at least half of the references to the medication and 38% used only brand names.

By using a brand name in news articles instead of a generic name, journalists are inadvertently favouring one pharmaceutical company over another. For example, the cholesterol lowering drug atorvastatin (generic name) is manufactured by several different pharmaceutical companies who all give it a different brand name - Pfizer call it Lipitor, whereas Merck until recently marketed a version called Zocor. Drugs are often referred to by their brand name because these titles tend to be better known - you've probably heard of paracetamol but not of acetaminophen; fair enough, maybe, but this practice still represents biased reporting.

Hochman et al. also surveyed 94 newspaper editors to find out whether these individuals thought that their publication accurately reported clinical trials. Interestingly, 88% of editors stated that their newspaper often or always reported reported company funding in articles about medical research, and 77% said that their publication often or always referred to medications by their generic names.

It seems that news outlets think they are reporting funding sources in medical articles when actually they're not. Academic journals have strict policies for disclosing funding and potential conflicts of interest, so why don't newspapers follow suit?

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M. Hochman, S. Hochman, D. Bor, D. McCormick (2008). News Media Coverage of Medication Research: Reporting Pharmaceutical Company Funding and Use of Generic Medication Names JAMA: The Journal of the American Medical Association, 300 (13), 1544-1550 DOI: 10.1001/jama.300.13.1544