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

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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.

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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.

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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

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And while we’re talking about patient privacy…

Today Pulse reports that pharmaceutical companies are directly approaching NHS staff to try to get their grubby paws on patient-identifiable data. The story reports that “two staff members had been approached by a pharmaceutical company while at a conference in London, given access to a website and asked to upload patient-identifiable data”.

A spokesperson for Poole Hospital NHS Foundation Trust went on to say: “For some time the trust has been concerned about the lengths to which pharmaceutical companies, or companies working on their behalf, will go to seemingly bypass the research governance route and encourage staff to release person-identifiable data onto third-party databases. A number of attempts have been thwarted by the trust.” So it seems that for some time pharmaceutical companies have been trying to weasel patient information out of NHS employees.

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Hospital employees fired for posting photos of patients on MySpace

I recently wrote a post about how patient privacy can be threatened in blogs written by doctors. Now a new case illustrates another way that healthcare professionals can violate patient privacy online.

Yesterday the Associated Press reported that two hospital workers in New Mexico had been fired for taking pictures with their mobile phone cameras of patients being treated. Even worse, these pictures – “mainly close-ups of injuries being treated in the Albuquerque hospital’s emergency room over the past few months” – were posted online on MySpace. This all happened despite the fact that hospital employees were banned from taking mobile phones int patient areas.

Unbelievably, this incident doesn’t represent the first time this sort of thing has happened. In May last year the Tri-City Hospital in San Diego confirmed that medical workers in the hospital had been taking photos of patients with their mobile phones, and the Associated Press reports that there have also been similar violations in Arizona and South Dakota. Also, UCLA banned mobile phones and laptops earlier this year after a patient posted group photos of other patients on a social networking website, although I feel this instance is a slightly different issue.

This issue was picked up in the blogosphere (WSJ Health Blog, Kevin, M.D. and Scalpel or Sword to name a few) as bloggers were horrified that hospital employees could do something so stupid. Posting photos of patients online, particularly patients in an emergency room who are may well be unconscious and totally unaware that they are being photographed, is an unbelievable violation of patient privacy. Let’s hope this is the last time this sort of thing happens.

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Digging for the best healthcare information on the internet

You may have noticed that ‘Vote’ buttons have appeared at the bottom of my blog posts. Clicking on one of these buttons will submit the particular blog entry to Healthcare Today, a new website where users proffer and vote for the best healthcare news and blogs on the internet.

The majority of information for doctors and other healthcare professionals comes from traditional outlets like journals, but this route is a slow and very formal way of getting stuff out there. In comparison, the internet is far more immediate, but information online is liable to be poorly written, filled with inaccuracies, penned by crackpots, or hopelessly biased, and that’s just for starters.

Healthcare Today aims to unearth good medical news and blogs online and highlight the most interesting stories. But as Shane, a creator of the site, says, “instead of being a reflection of some editor’s (possibly biased) perception, it’s the professionals in healthcare who decide what’s interesting and how interesting it is by submitting links and adding their votes.”

Healthcare Today works in a similar way to the website Digg, in that users are invited to submit news articles, journal papers or blog posts that they discover on the net and then vote on links they find interesting. The front page of the site contains the most popular links, representing an essentially peer reviewed overview of the best medical information online.

The site is aimed at healthcare professionals – i.e. doctors, nurses and the like – so a lot of the links on Healthcare Today are to blog posts that discuss the day to day trials and tribulations of these groups. There are also plenty of links to medical or medicine-related news stories; for example, the most popular link at this exact moment is time is from ABC News: ‘Grey’s Anatomy’ lesson? TV ups awareness, a story about a new study that has quantitatively shown that audiences of TV shows such as Grey’s Anatomy absorb health messages in the programmes.

At the moment links only need about 4-5 votes in order to make it onto the front page, but hopefully as the number of users and of submitted links continues to grow Healthcare Today will come to truly represent the most up to minute source of healthcare information on the net.
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And here comes the shameless self promotion – if you think a post of mine is good and other people interested in medicine might want to read it, give the old vote button a click and submit the entry to Healthcare Today!

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Do common pain medications mask signs of prostate cancer?

A study recently published in the journal Cancer has suggested that common painkillers such as paracetamol and aspirin might affect blood levels of a marker commonly used to diagnose prostate cancer.

In this study, Singer et al. examined levels of prostate specific antigen (PSA) in the bloodstream of 1,319 men aged over 40 years. PSA is a protein produced in the prostate gland. Blood levels of PSA will be minuscule in healthy men, but raised levels often indicate the presence of prostate cancer. If a simple blood test detects serum levels of PSA higher than a specific threshold (4 ng/ml to be exact), your doctor will be booking you in for a digital rectal examination with a prostate cancer specialist faster than you can say “He wants to stick his finger where?!”

In addition, study participants were asked how often they took analgesic drugs classed as non-steroidal anti-inflammatory drugs (NSAIDs) – common types being aspirin and ibuprofen – or the drug acetaminophen, which you’ll probably be familiar with as paracetamol. NSAIDs and acetaminophen act as painkillers by reducing inflammation. Given that inflammation in the prostate has been implicated in the development of prostate cancer, the authors of this study wanted to find out whether NSAIDs or acetaminophen affected the risk of prostate cancer in men who took these drugs.

The results of this study showed that serum levels of PSA in men who took NSAIDs or acetaminophen “nearly every day” were considerably lower than levels in men who did not take either drug. Seeing as this study didn’t then follow these men for several years to find out whether there were fewer instances of prostate cancer in the men who took these analgesics than in those who didn’t, it is not clear whether this decrease in PSA levels means that the drugs reduce the risk of cancer. In fact, it it possible that NSAIDs and acetaminophen may reduce serum levels of PSA despite suspicious goings on in the prostate and thus cause doctors to miss cases of prostate cancer, which would otherwise be flagged by raised PSA levels.

So what are the implications of the study? Should men chew down aspirin every day to prevent prostate cancer, or would they make detection of the malignancy more difficult for their doctor by doing so? Dr Eric Singer, one of the authors of this study, told Reuters news, “If you’re a guy who’s close to the upper limit of normal [in PSA levels] or would have been over the upper limit and now you’re under it because of [these drugs], that could certainly change whether or not you would be referred for a biopsy [to check for a tumor]”. He also emphasizes that these findings are preliminary and shouldn’t prompt men to change their behaviour.

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Eric A. Singer, Ganesh S. Palapattu, Edwin van Wijngaarden (2008). Prostate-specific antigen levels in relation to consumption of nonsteroidal anti-inflammatory drugs and acetaminophen Cancer DOI: 10.1002/cncr.23806

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Music, memories and the mind

Yesterday I went down (no, make that up – up a very steep hill, on my bike) to Jackson’s Lane in Highgate for some neurology theatre – not of the surgical kind but a performance of the play Reminiscence.

Inspired by a case study published by the neurologist Oliver Sacks, the play tells the story of elderly Mrs O’Connor, who, following a stroke, experiences temporal lobe seizures accompanied vivid auditory hallucinations. Although she recognises the songs she hears, Mrs O’Connor can’t put her finger on where she knows the melodies from. Through these seemingly familiar “experiential hallucinations”, she re-lives events that she believes are buried memories from her distant past.

As far as I was concerned, a key aspect of the play was how Theatre DaCapo approached a dry medical case study and transformed it into an engaging piece of theatre. Instead of depicting the story of Mrs O’Connor through the objective view of the neurologist, the whole case study is portrayed from the perspective of the patient, bringing an altogether more human angle to the case study.

Thus, the onus was on the theatre group to represent effectively the subjective, difficult-to-quantify experiences of a neurology patient. In order to do this, the five-man group of actors used clever staging and a myriad of props and visuals.

In scenes such as the one shown here, actors popped out from between the folds of a giant white backdrop, portraying in this instance the characters Mrs O’Connor begins to see as her hallucinations gather more sensory components. In another scene, the actors, posing as doctors, appeared in the windows within the backdrop and bounced neurological terms off each other, depicting Mrs O’Connor’s disorientation at the mass of medical information she was being bombarded with.

Folk songs – reworked in a classical style and performed by the actors – and the pitching and swaying of the scenery indicated when Mrs O’Connor was experiencing a seizure.

I was also interested in how the play was going to depict the neurology that underlines the case study. In the scene shown here, a dish of jelly was used to represent the brain and the affected region scooped out with gusto to demonstrate how the seizures and hallucinations could be cured by surgical removal of the damaged part of the brain.

One of the issues raised by the play is whether the hallucinations Mrs O’Connor experiences actually reflect real memories, or are false and are in fact the result of Mrs O’Connor’s psychological motivation to come to terms with her past. This issue was one of many debated in a a panel discussion after the play in which the audience quizzed the director Michael Callahan, clinical psychologist and Mind Hacks blogger Dr Vaughan Bell, and actors Ian Harris and Katie Pattison. During the discussion, we touched on whether the verity or not of our memories is important – although they may be revised through telling at different points in our life, they still represent an important part of our identity.

It was a refreshing change to learn about a clinical case study through such an imaginative and well-realised play rather than from a journal paper.

  • Reminiscence will be performed at 8pm at Jackson’s Lane theatre until Saturday 20th September (matinee 2pm Wednesday 17th September). For tickets, contact the box office on 0208 341 4421 or buy online at jacksonslane.org.uk

(Thanks to Theatre-DaCapo.co.uk for the photos)

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Blogging and doctoring: a hazardous mix

Medical blogs, in particular those written by doctors, have come into the spotlight thanks to a study of 271 medical blogs published recently in the Journal of General Internal Medicine, titled ‘Content of Weblogs Written by Health Professional‘.

The study found that over half of the medical blogs examined contained enough information to identify the doctor writing the blog. In addition, 42% described individual patients, and 16% included enough information for users to figure out the identity of the doctor or patient. (The Pharmalot blog helpfully has a PDF of the full text version if you want to peruse the data yourself) Granted, this study was looking at blogs that published in 2006, so the conclusions may well not reflect the level of professionalism among doctors who blog today, but it raises some important issues about patient privacy.

Of course, the study got the media frothing about whether blogs written by doctors compromise patient confidentiality and prompted the American Medical Association ethics committee to discuss the issue.

Most doctors and medical bodies seem to agree that medical blogs have an important role in providing medical information and demystifying the medical profession. However, the issue of unguarded blogging and patient privacy is real, and there are many instances of doctors’ blog posts coming back to bite them.

Canadian Medicine describes the case of pediatrician Robert Lindeman, who blogged anonymously about the death of a patient and the subsequent malpractice trial under the pseudonym “Flea”. As the Boston Globe reported: “Unexpectedly, during cross-examination, the prosecutor asked Dr Lindeman if he was ‘Flea’. The case was lost, his lawyers realized immediately. They settled the next day.” Dr Lindeman used his blog – and his anonymity – to say on permanent record things that he would not otherwise have said in the open. He lost his case and his professional reputation was trampled on.

The main point of the Journal of General Internal Medicine study and the case of Flea seems to be that, anonymous or not, doctors who blog should always remember that the internet is a public space and write about patients with this fact in mind. Of course, this concept brings up questions of free speech, but inappropriate blogs could comprise the trust that forms the foundation of the patient-doctor relationship and undermine the authority of the medical profession.

However, as Canadian Medicine points out: “Whatever the subject, blogging is a positive development in medicine and something that doctors should not and must not abandon because of some medical association analysts’ largely unfounded fears”

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