Is Open Access the Future of Medical Publishing?
An Interview with Dr. Sanford Shattil
Dr. Shattil is currently the Editor-in-Chief of Blood.
A movement to transform the way medical and scientific articles are made available to the public is generating heated debate in the publishing and research communities. "Open access" publishing is the issue. It has as its goal the immediate, complete, and free public availability of the full text of all medical and scientific literature via the World Wide Web. While few dispute the merits of the concept, the current controversy centers on the economic feasibility of open access publishing. The issue has now been escalated by the launching of the "Public Library of Science" (PLoS) initiative (www.publiclibraryofscience.org), an Internet-based publication which will be competing head-on for the best research papers with leading scientific journals, such as The New England Journal of Medicine, Science, Nature, Cell, and our own Blood journal. PLoS, which has initiated a wide publicity campaign, intends to support itself by shifting the costs of publication from the readers to the authors. PLoS and its proponents contend that "author pays" open access publishing was necessitated by the prohibitive increase in journal subscription prices in recent years, particularly by for-profit publishers like Elsevier which have enjoyed handsome profit margins. They also claim that authors should have little difficulty covering the costs of publication because these will be mostly subsidized by sponsoring research agencies and the authors' own institutions. Opponents of the PLoS are concerned that the new paradigm is unfair to authors and will allow publication by only those who can afford it. Furthermore, they contend that current charges to authors grossly underestimate actual costs and therefore the enterprise is not economically sustainable in the long run, and that PLoS publication will be subject to undue political and commercial influence. ASH has released its own statement on the issue, which is available on the ASH Web site. In view of the importance of this controversy to the membership of ASH, The Hematologist has interviewed Dr. Sanford Shattil, Editor-in-Chief of Blood.
EDITOR: The Public Library of Science (PLoS) currently charges authors $1,500 per article. It has been argued that this a reasonable publication cost because it represents a very small fraction of the total expense of completing a research project. Do you think PLoS has underestimated the costs of publication of a peer-reviewed paper, and is the cost likely to increase substantially in the future?
DR. SHATTIL: This amount does not begin cover the cost of publishing an article. PLoS is currently underwritten by a $9 million, five-year grant from the Gordon and Betty Moore Foundation which is used to subsidize the cost of journal operations. For Blood, the cost of publishing an article online and in print has been estimated at $5,100. Were Blood to publish the article only online, the cost would still be $2,700. Authors of Blood articles now pay page charges and a portion of the cost for color figures, resulting in a total amount that is generally considerably less than these numbers. The remainder of the bill is paid by income generated from subscriptions and advertising. This pay or mix may fluctuate in the future, but it is unlikely that many authors will be able or willing to support the entire cost of publication. The extent to which these costs will change in the future is dependent on many variables. Some have predicted that most journals will publish only online in the future, and this would reduce the costs of printing. On the other hand, a recent survey indicated that the majority of Blood readers still find the print version very useful. Consequently, at least for the foreseeable future, it seems likely that both online and print versions of Blood will be offered, and that authors will continue to represent one of several sources of financial support to maintain journal operations at the highest quality.
EDITOR: Research funding agencies like the National Institutes of Health and the Howard Hughes Medical Institute have already agreed to cover authors' costs of open access publishing. So why is there so much concern about the fairness of shifting the costs of publication from the reader to the author?
DR. SHATTIL: One concern is that authors who cannot pay the full costs of publication may feel inclined or even pressure to publish elsewhere. Currently, if authors cannot afford the modest page charges for Blood, these fees can be waived on a case-by-case basis. In an author-pay-all system, a substantial number of these "non-payers" would shift the burden even more to authors that can pay, creating a multi-tiered system that could be unfair and ultimately affect the mix of papers submitted or published. Thus, access to publishing in Blood might be "open" to some but not to others, certainly an unintended and unwelcome consequence of the open access movement.
EDITOR: Do you think there are potentially ethical or conflict-of-interest concerns if commercial sponsors of research, such as pharmaceutical companies, pick up the authors' costs for publication?
DR. SHATTIL: Not necessarily. If the author has received a grant-in-aid from a commercial sponsor, then I see no reason why that grant cannot be used to pay publication costs. However, it is crucial that the author declare the financial relationship up-front prior to the review process. Complete disclosure of financial interests and other real or potential conflicts is the key.
EDITOR: Another potential source of covering authors' costs is their own institutions. Won't universities and medical schools save enough money from cancellation of journal subscriptions and institutional licenses to enable them to underwrite open access publication by their faculty members who have no other source to cover the costs?
DR. SHATTIL: I presume that most institutional libraries have a long list of useful items or services that they would like to provide their faculty and are unable to do so now. Although I do not buy the premise that institutional journal subscriptions are going to disappear anytime soon, even if funds were freed up by cancellation of some subscriptions or licenses, I suspect that underwriting publications by faculty members might not be high on the priority list for most libraries or institutions.
EDITOR: The Proceedings of the National Academy of Sciences (PNAS) has recently published the results of its investigator survey, which found that 50 percent of authors of accepted PNAS papers are in favor of the open access option. Doesn't this indicate to you that migration to this publishing model is inevitable?
DR. SHATTIL: It is inevitable that open access has and will continue to change the ways that journals do business. But unless publication costs per article become more reasonable, I do not think the current open access model of PLoS is viable long term. In the PNAS survey, of those corresponding authors who responded and favored open access, the overwhelming majority (about 80 percent) declared they would be willing to pay a surcharge of only $500, far less than the cost of publishing an article in that journal (Cozzarelli, N.R., Fulton, K.R. and Sullenberger, D.M.: Results of a PNAS author survey on an open access option for publication. PNAS 101:1111, 2004). Many journals, including Blood, are experimenting with ways to open access to varying degrees (Shattil, S.J.: Open access, yes! Open excess, no! Blood {in press, May 1 issue}). Time will tell which models work best for journals operated by not-for-profit scientific societies like ASH.
EDITOR: How would you respond to comments of the respected Wellcome Trust that "the publishing of scientific research does not operate in the interest of scientists and the public, but is instead dominated by a commercial market intent on improving its market position?"
DR. SHATTIL: Such statements are over-simplistic. While this comment may be true for some commercial publishers, it is not true for Blood or ASH, and, I suspect, for most scientific societies that operate journals. One has only to peruse materials on the ASH Web site (www.hematology.org) to see that its many programs are squarely in the interests of scientists, clinicians, and the public.
EDITOR: ASH and Blood are committed to the principles of free access to scientific publications. In this regard, is there any consideration at Blood to transition it to an author- and/or advertising-funded publication or some form of hybrid model?
DR. SHATTIL: We are committed to making Blood as accessible as possible and have a number of ongoing initiatives to make a portion of our online content freely available to all (Shattil, S.J.: Open access, yes! Open excess, no! Blood {in press, May 1 issue}). This includes the popular "Inside Blood" synopses of key articles and the "How I Treat" series. In addition, authors will retain non-exclusive rights to reproduce and distribute their published work for specific educational, non-commercial purposes. Finally, readers working in low-income countries are granted immediate free access to the entire online journal through the WHO-sponsored HINARI program. We at Blood view open access as a laudable goal, but a moving target, and one that must be joined in a careful, step-wise manner, without jeopardizing the quality of the journal and its financial stability. Comments and suggestions from our readership are most welcome with regard to this important and evolving process.
EDITOR: Thank you, Sandy.
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Anemia in the Elderly: Agenda for Research
By Lodovico Balducci, M.D.
Dr. Balducci is currently the Program Leader of the Senior Adult Oncology Program and Professor of Medicine & Oncology at the H. Lee Moffitt Cancer Center.
Aging is associated with the loss of functional reserve of multiple organ systems and increased comorbidity. Functional restrictions predispose to diseases, and diseases accelerate functional loss. The interruption of this vicious cycle may delay or even reverse senescence. This article explores the anemia of aging, an often reversible condition that may cause functional loss.
Epidemiology, Etiology, and Pathogenesis:
The incidence and prevalence of anemia increase with age, due to a combination of comorbidity and reduced erythropoiesis. Among outpatients aged 65 and older, iron deficiency and anemia of chronic inflammation account for more than 50 percent of the diagnoses. The prevalence of B12 deficiency may be as high as 15 percent, but this condition rarely causes anemia. In approximately 20 to 30 percent of cases, the cause of anemia cannot be identified, suggesting age-related abnormalities of erythropoiesis. At least some of these cases may represent early myelodysplasia or occult renal insufficiency.
While exhaustion of stem cell self-replication appears unlikely to be the mechanism, qualitative stem cell abnormalities are suggested by the increasing incidence of myelodysplasia in the elderly. Abnormalities in erythropoietin production may result from the decreased glomerular filtration rate that becomes more prevalent after age 65. The responsiveness of erythropoietic progenitors to erythropoietin may be reduced by increased concentration of circulating cytokines, in particular interleukin-6 (IL-6). IL-6 has been correlated with a number of geriatric syndromes, such as dementia, osteoporosis, and wasting, and is increased in the circulation of anemic older individuals.
Clinical Consequences of Anemia:
Anemia in the elderly has been associated with decreased survival, increased prevalence of functional dependence and comorbidity, increased incidence of therapeutic complications, congestive heart failure, coronary death, and possibly dementia. Of special interest, the Women's Health and Aging Studies (WHAS), a longitudinal study of home-dwelling women aged 65 and over, has shown that hemoglobin levels <13.5 gm/dl were an independent risk factor for mortality. If this study is confirmed, the definition of anemia may be redefined. The WHAS and two additional longitudinal studies of older individuals have shown that the risk of functional dependence and disability was inversely related to hemoglobin levels. It is reasonable to stipulate that the development of functional dependence, which predisposes to disease as well as deconditioning and sarcopenia, is associated with acceleration of the aging process. The risk of both surgical and medical interventions increases with anemia. In patients with renal failure, anemia is associated with an increased risk of congestive heart failure and dementia. A review of Medicare data has shown that anemia is associated with increased risk of coronary death. Since there has been as yet no definitive demonstration of a causal relationship between the anemia of aging and these clinical complications, it is possible that both the anemia and the associated clinical events are the result of an unrecognized additional factor in many patients.
ASH-Sponsored Research Agenda-Setting Workshop for Anemia and the Aging:
Clearly, anemia is a major problem for older individuals, and it is reasonable to hypothesize that reversal of anemia may improve function and survival, and minimize other manifestations of aging. In a conference sponsored by the American Society of Hematology (ASH) on March 1-2, 2004, these issues were reviewed and a research agenda outlined.
Definition of Anemia:
The World Health Organization definition represents average hemoglobin values of unselected men and women and has not been validated by clinical outcomes. In addition, low hemoglobin levels may be appropriate for frail elderly with reduced oxidative metabolism due to reduced lean body mass and mitochondrial function. Longitudinal studies of older individuals should try to correlate hemoglobin levels with function and comorbidity, and explore the interaction of hemoglobin concentration and lean body weight.
Causes of Anemia:
It appears prudent that any case of anemia, including mild anemia and borderline anemia (hemoglobin concentrations between 12 and 13 gm/dl for women and 13 and 14 gm/dl for men), be investigated with a standard battery of tests including red blood cell indices, reticulocyte count, iron studies, serum creatinine, B12 and folate, and erythropoietin levels, to establish the real prevalence of different causes of anemia in the older population. Those conditions in which a cause of anemia cannot be identified may need bone marrow studies to rule out myelodysplasia.
Interventional Studies:
Patients in whom the cause of anemia cannot be identified, including those without a well-defined anemia of chronic disease, should be offered participation in a randomized placebo-controlled study of epoetin, having as its goal the maintenance of hemoglobin levels of =12 gm/dl and having as end points functional independence, incidence of comorbidity, and, possibly, survival. This study is aimed to establish whether reversal of anemia may interrupt the vicious cycle of senescence.
Other Studies of Interest:
Other studies of interest may explore the association of aging with increased red cell oxidative damage, changes in O2 delivery to the tissues, and elevated levels of erythropoietin transcription factor.
Suggested Reading:
- Balducci L. Epidemiology of anemia in the elderly: information on a diagnostic evaluation. J Am Ger Soc 2003; 51 (3 suppl): S2-9.
- Cohen HJ, Harris T, Pieper CF. Coagulation and activation of inflammatory pathways in the development of functional decline and mortality in the elderly. Am J Med 2003; 114: 180-187.
- Rothstein G. Disordered hematopoiesis and myelodysplasia in the elderly. J Am Ger Soc 2003; 52 (3 suppl) 2:22-26.
- Penninx BW, Guralnik JM, Onder G, et al. Anemia and decline in physical performance among older persons. Am J Med 2003;
115:104-110
- Balducci L. Anemia, cancer and aging. Cancer Control 2003; 10: 478-486.
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Open That Cellophane Wrapper and Read Blood
By Samuel Silver, M.D., Ph.D
If you look in the office of many of our ASH colleagues in clinical practice, you will see a stack of unopened, hermetically sealed issues of Blood. I don't think that there is much disagreement that excellent basic science papers are published in the Journal of our Society, but these articles are thought of as arcane and quite dense. Well, I have a secret that unfortunately too few of our members know: Blood has changed over the last few years and it has become much more clinician-friendly. Under the leadership of previous editor Ken Kaushansky and present editor Sandy Shattil, excellent, readable, clinically relevant articles appear in every issue. This is a definite change from five, maybe even three, years ago. Recent articles include such titles as: "Allogeneic hematopoietic stem cell transplantation for myelofibrosis," "Safety and effectiveness of long-term therapy with the oral iron chelator deferipone," and "Rituximab in lymphocyte-predominant Hodgkin disease: results of a phase 2 trial." Many of these articles of clinical interest are found in a single section: "Clinical Observations, Interventions, and Therapeutic Trials."
Many new sections have been added to Blood. The most notable is "Inside Blood." Ten short discussions review the top 20% of papers in each issue. They allow the reader to get the most important points of these articles, and more significantly, the expert reviewers place into context the significance of papers that might easily be overlooked; these are trends of the future of our field. "Controversies in Hematology" such as "Transplantation of multiple myeloma: who, when, how often?" asks the questions that we ask when we care for patients. "Reviews in Translational Hematology" emphasizes translational aspects of molecular hematology to the practicing hematologist.
For the more adventuresome, Internet-savvy reader, Blood is available online and is fully searchable. For the impatient, Blood's First Edition Papers allows readers to access papers in their manuscript form shortly after acceptance, giving the reader a four-month head start. The full table of contents can be delivered to your e-mail inbox every two weeks; this allows you to access papers of interest immediately.
So open up those cellophane wrappers or click onto Blood's Web site (www.bloodjournal.org) and see what you have been missing. You will be surprised and informed.
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2004 Legislative Advocacy Campaign Kicks Off with Lobby Day on Capitol Hill
The Society's Committee on Government Affairs kicked off ASH's 2004 Legislative Advocacy Campaign with its Spring Meeting and Capitol Hill Lobby Day on February 23-24, 2004. Committee Chair Kenneth Zuckerman, M.D., welcomed 11 members of the Committee to Washington to educate as well as advocate before Members of Congress and their staffs. These Committee members visited 20 House and Senate offices, bringing hematology research and practice issues to the forefront.
The Capitol Hill visits focused on four issues:
The need to provide the National Institutes of Health (NIH) with a 10 percent funding increase in FY 2005. In fiscal year (FY) 2005, ASH is supporting the Ad Hoc Group for Medical Research Funding's recommendation of $30.6 billion for NIH, a $2.8 billion or 10 percent increase over FY 2004. Committee members stressed to Capitol Hill offices that the Bush Administration's proposed NIH funding level of $28.8 billion - a $764 million or 2.6 percent increase over last year - may erase any of the gains in biomedical research funding attained during the five-year effort to double NIH's budget. ASH also highlighted the fact that annual NIH increases of 8-10 percent are necessary to ensure that the momentum over the past several years is not threatened; a 2.6 percent increase for NIH in FY 2005 is effectively a cut, as it doesn't keep up with the cost of inflation. Although ASH members found that very strong support for NIH still remains on Capitol Hill, House and Senate appropriators emphasized that significant annual funding increases for NIH are becoming increasingly difficult in the current budget environment and it is likely that the NIH will see an increase close to the President's request.
Inclusion of hematology research report language in the Appropriations Committee Reports. The visits to Capitol Hill also focused on inserting ASH's suggested report language for NIH into both the House and Senate Appropriations Committee Reports. Placing language in the annual appropriations report is a common advocacy tool for organizations such as ASH. Although report language does not require the NIH Institutes to perform specific actions, it is generally viewed as the House and Senate's "advice" on each Institute's research agenda. By and large, NIH Institute Directors use the report language to help shape their research priorities for the coming year. The Society's recommended report language focuses on the importance of hematologic research at the National Heart, Lung, and Blood Institute, the National Cancer Institute, the National Institute on Aging, and across Institutes.
ASH's concerns about the impact of changes to the Average Wholesale Price (AWP) reimbursement formula on hematology/oncology practices {as discussed in the cover story, "Wither Chemotherapy Margins"}
Request for co-sponsoring the Sickle Cell Treatment Act (S 874/HR 1736) {as discussed in "Take Action on Sickle Cell Disease" on page 6}
Overall, the Committee on Government Affairs had a very successful Capitol Hill Day. The Capitol Hill visits are just one step in advocating for the Society's annual legislative agenda. ASH needs the help of its entire membership to implement its advocacy agenda. Please support the Society by joining the ASH Grassroots Network.
If you would like more information about ASH's advocacy efforts, please contact ASH Director of Government Relations & Practice Mila Becker or Government Affairs Manager Jeff Coughlin at 202-776-0544.
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A Change in the Abstract Deadline
The electronic abstract submission deadline for the 46th ASH Annual Meeting has been set for August 10th, 2004.
Please note that this deadline is earlier than in previous years.
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SAP Second Edition Set to Launch in San Diego
The 46th ASH Annual Meeting in San Diego will feature the launch of the second edition of ASH's Self-Assessment Program - the ASH-SAP. The ASH-SAP is the premier review resource in hematology, providing preparation materials for the hematology boards as well as recertification exams, and is the only hematology self-assessment product available that addresses both adult and pediatric medicine. Users can earn up to 50 category 1 CME credits.
The second edition of the SAP will again include both a printed syllabus and a self-assessment test composed of case-based, multiple-choice questions and critiques. In addition, the following enhancements are available in the second edition:
- A new chapter covering myelodysplastic syndromes
- The addition of pediatric co-authors to provide even more pediatric content
- Four-color text containing the latest advancements in hematology
- More than 200 all-new case-based, multiple-choice questions and critiques
A companion Web site adds an interactive element to the self-assessment, allowing users to move back and forth between questions and critiques, chapter text, and illustrative slides with just a few mouse clicks. In addition, the ASH-SAP will integrate cutting-edge information with resources from other ASH educational products, such as the Image Bank, Education Program Book, and Blood. Full access to the interactive Web site is included in the SAP package price.
For more details about the SAP second edition launch, visit the ASH Web site.
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Call for Award Nominations
ASH members are invited to submit nominations for the William Dameshek Prize, Henry M. Stratton Medal, and E. Donnall Thomas Lecture and Prize for the year 2004. Letters of nomination must include a brief paragraph summarizing the nominee's contributions to hematology as well as a current bio-sketch or curriculum vitae. Please send nominations to:
American Society of Hematology
Attn: LaFaundra Neville
1900 M Street, NW, Suite 200
Washington, DC 20036
Phone: 202-776-0544
Fax: 202-776-0545
E-mail: lneville@hematology.org.
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ASH Scholar Award Letter of Intent Deadline is April 30, 2004
The 2004 ASH Scholar Award competition is just around the corner. The ASH Scholar Awards program is a highly competitive grants program that provides partial salary or other support during the critical period required for completion of training and achievement of status as an independent investigator. The goal of the program is to encourage hematologists to pursue a research career. Awards are made for both basic and clinical/translational research.
To be eligible for the Junior Faculty Scholar Award (either basic or clinical/translational research), applicants must be within the first two years of their initial faculty appointment as Assistant Professor at the time of application.
To be eligible for the Fellow Scholar Award (either basic or clinical/translational research), applicants must have more than two years, but less than six years of postdoctoral research training at the time of application. In addition to fellows, instructors, lecturers, and research associates should now apply in the fellow award category. The same six-year maximum applies to those applying as instructors, lecturers, or research associates.
The junior faculty award provides recipients with $150,000 and the fellow award provides $100,000. The awards can be spread over a two- or three-year period with an annual maximum of $75,000 for junior faculty and $50,000 for fellows.
Your required letter of intent is due on Friday, April 30, 2004. The applicant's curriculum vitae, brief abstract, and project title must be included with this letter. For more details, please visit the ASH Web site. If you have any questions, please contact Karin Lombardi, ASH Development Manager, at klombardi@hematology.org.
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Save the Date
ASH State of the Art Symposium
Hematologic Malignancies
September 11 & 12, 2004
Washington, D.C.
The American Society of Hematology is pleased to announce the first of a series of State of the Art meetings. The first meeting will be a clinically focused two-day forum designed to identify recent advances and place them into the context of current clinical practice. It is designed for practicing hematologists and oncologists, as well as internists and family practitioners. Residents and trainees are also welcome to attend.
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Call for Nominations for ASH Officers and Committee Members
ASH is currently accepting nominations for leadership and committee member positions for the year 2005. Nominations for any of the positions available must include name, institution, and a brief paragraph to describe why the ASH member is being recommended for service. These nominations should be sent to LaFaundra Neville at lneville@hematology.org. Nominations must include all requested information. Please visit the ASH Web site for more information about ASH committees.
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Scott N. Swisher, Jr., M.D. (1918-2003)
The American Society of Hematology's first Treasurer, Scott N. Swisher, Jr., M.D., passed away on Sept. 14, 2003, in East Lansing, Michigan, at the age of 85. Dr. Swisher graduated from the University of Minnesota Medical School in 1945, served in the Army, and completed his internship, residency, and hematology training at the University of Rochester. After completing his training, Dr. Swisher joined the hematology unit at the Department of Medicine at Rochester, becoming its head in 1957. In 1967, he accepted appointment as the founding Chairman of the Department of Medicine at the Michigan State University College of Human Medicine, a position he held until 1978 when he became Associate Dean of Research and Graduate Education. Dr. Swisher was a contributor to the development of transfusion medicine as a discipline and coauthored a textbook on that subject. He also coauthored a textbook on interviewing and patient care and published over 150 papers and chapters on subjects ranging from hematological research to medical education. Dr. Swisher served on several national boards and received numerous national and international honors. Dr. Swisher is remembered by his students, friends, and colleagues as a skilled clinician and raconteur with wide-ranging enthusiasms, from old cars and music to flying his own plane. He is survived by his wife, two sons, and two grandchildren.
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