Closing the door on pharma? A national survey of family medicine residencies regarding industry interactions.

PURPOSE: To assess the extent and type of interactions U.S. family medicine residencies permit industry to have with medical students and residents. METHOD: In 2008, the authors e-mailed a four-question survey to residency directors or coordinators at all 460 accredited U.S. family medicine residencies concerning the types of industry support and interaction permitted. The authors conducted quantitative and qualitative analyses of survey responses and written comments. Residencies that did not permit any industry food, gifts, samples, or support of residency activities were designated "pharma-free." RESULTS: The survey response rate was 62.2% (286/460). Among responding family medicine residencies, 52.1% refused drug samples, 48.6% disallowed industry gifts or food, 68.5% forbade industry-sponsored residency activities, and 44.1% denied industry access to students and residents at the family medicine center. Seventy-five residencies (26.2%) were designated as "pharma-free." Medical-school-based and medical-school-administered residencies were no more likely than community-based residencies to be pharma-free. Among the 211 programs that permitted interaction, 68.7% allowed gifts or food, 61.1% accepted drug samples, 71.1% allowed industry representatives access to trainees in the family medicine center, and 37.9% allowed industry-sponsored residency activities. Respondents commented on challenges inherent to limiting industry interactions. Many programs noted recent changes in plans or practices. CONCLUSIONS: Most family medicine residencies limit industry interaction with trainees. Because industry interactions can have adverse effects on rational prescribing, residency programs should assess the benefits and harms of these relationships.

Promotional tone in reviews of menopausal hormone therapy after the Women's Health Initiative: an analysis of published articles.

BACKGROUND: Even after the Women's Health Initiative (WHI) found that the risks of menopausal hormone therapy (hormone therapy) outweighed benefit for asymptomatic women, about half of gynecologists in the United States continued to believe that hormones benefited women's health. The pharmaceutical industry has supported publication of articles in medical journals for marketing purposes. It is unknown whether author relationships with industry affect promotional tone in articles on hormone therapy. The goal of this study was to determine whether promotional tone could be identified in narrative review articles regarding menopausal hormone therapy and whether articles identified as promotional were more likely to have been authored by those with conflicts of interest with manufacturers of menopausal hormone therapy. METHODS AND FINDINGS: We analyzed tone in opinion pieces on hormone therapy published in the four years after the estrogen-progestin arm of the WHI was stopped. First, we identified the ten authors with four or more MEDLINE-indexed reviews, editorials, comments, or letters on hormone replacement therapy or menopausal hormone therapy published between July 2002 and June 2006. Next, we conducted an additional search using the names of these authors to identify other relevant articles. Finally, after author names and affiliations were removed, 50 articles were evaluated by three readers for scientific accuracy and for tone. Scientific accuracy was assessed based on whether or not the findings of the WHI were accurately reported using two criteria: (1) Acknowledgment or lack of denial of the risk of breast cancer diagnosis associated with hormone therapy, and (2) acknowledgment that hormone therapy did not benefit cardiovascular disease endpoints. Determination of promotional tone was based on the assessment by each reader of whether the article appeared to promote hormone therapy. Analysis of inter-rater consistency found moderate agreement for scientific accuracy (κ=0.57) and substantial agreement for promotional tone (κ=0.65). After discussion, readers found 86% of the articles to be scientifically accurate and 64% to be promotional in tone. Themes that were common in articles considered promotional included attacks on the methodology of the WHI, arguments that clinical trial results should not guide treatment for individuals, and arguments that observational studies are as good as or better than randomized clinical trials for guiding clinical decisions. The promotional articles we identified also implied that the risks associated with hormone therapy have been exaggerated and that the benefits of hormone therapy have been or will be proven. Of the ten authors studied, eight were found to have declared payment for speaking or consulting on behalf of menopausal hormone manufacturers or for research support (seven of these eight were speakers or consultants). Thirty of 32 articles (90%) evaluated as promoting hormone therapy were authored by those with potential financial conflicts of interest, compared to 11 of 18 articles (61%) by those without such conflicts (p=0.0025). Articles promoting the use of menopausal hormone therapy were 2.41 times (95% confidence interval 1.49-4.93) as likely to have been authored by authors with conflicts of interest as by authors without conflicts of interest. In articles from three authors with conflicts of interest some of the same text was repeated word-for-word in different articles. CONCLUSION: There may be a connection between receiving industry funding for speaking, consulting, or research and the publication of promotional opinion pieces on menopausal hormone therapy.

Why lunch matters: assessing physicians' perceptions about industry relationships.

Many studies have shown that pharmaceutical marketing affects prescribing choices. Studies that have assessed the effects of educational interventions on perceptions of pharmaceutical promotion have found mixed results. This study assesses the short-term effects of an educational intervention about marketing tactics on the attitudes and fund of knowledge of residents, medical students, and attending physicians. A 1-hour slide show that covered detailing, prescription tracking, drug samples, medical meetings, and journals was developed by PharmedOut and presented at a total of 14 grand rounds and seminars at departments of family medicine, internal medicine, pediatrics, psychiatry, cardiology, and neurology. Pre- and posttests included attitudinal and fact questions addressing the influence of drug reps, gifts, pharmaceutical advertising and drug samples on prescribing behavior. The posttest asked whether attendees intended to change their prescribing behavior. The Mann-Whitney U test was used for Likert-scale questions and the Fisher exact test was used to compare the number of pre- and posttest correct answers for the multiple choice and true/false questions. Three hundred seventy-three participants completed pre- and posttests. Significant attitudinal shifts were seen overall, particularly in questions addressing influence of salespeople on physicians in general and on the respondent individually. Some participants commented that they intended to stop seeing drug reps or stop attending industry-funded meals. A new educational presentation can substantially shift attitudes toward perceived susceptibility to pharmaceutical marketing activities. Further research is needed to see if attitude change persists.

Effects of Photosystem II inhibiting herbicides on mangroves--preliminary toxicology trials.

Mangroves are sensitive to the root application of Photosystem II inhibiting herbicides and Avicennia marina is more sensitive than other mangroves tested. Seedlings of four mangrove species, including two salt-excreting species (A. marina and Aegiceras corniculatum) and two salt-excluding species (Rhizophora stylosa and Ceriops australis) were treated with a range of concentrations of the herbicides diuron, ametryn and atrazine. Assessment of responses required the separation of seedlings into two groups: those that had only their roots exposed to the herbicides through the water (A. marina and R. stylosa) and those that had both roots and leaves exposed to herbicides through the water (A. corniculatum and C. australis). Salt-excreting species in each group were more susceptible to all herbicide treatments than salt-excluding species, indicating that root physiology was a major factor in the uptake of toxic pollutants in mangroves. Submergence of leaves appeared to facilitate herbicide uptake, having serious implications for seedling recruitment in the field. Each herbicide was ranked by its toxicity to mangrove seedlings from most damaging to least effective, with diuron>ametryn>atrazine. The relative sensitivity of A. marina found in these pot trials was consistent with the observed sensitivity of this species in the field, notably where severe dieback had specifically affected A. marina in the Mackay region, north eastern Australia.

Herbicides implicated as the cause of severe mangrove dieback in the Mackay region, NE Australia: consequences for marine plant habitats of the GBR World Heritage Area.

Herbicides, particularly diuron, were correlated with severe and widespread dieback of the dominant mangrove, Avicennia marina (Forsk.) Vierh. var. eucalyptifolia (Val.) N.C. Duke (Avicenniaceae), its reduced canopy condition, and declines in seedling health within three neighbouring estuaries in the Mackay region of NE Australia. This unusual species-specific dieback, first observed in the early 1990s, had gotten notably worse by 2002 to affect >30 km(2) of mangroves in at least five adjacent estuaries in the region. Over the past century, agricultural production has responded well to the demands of increasing population with improvements in farm efficiency assisted by significant increases in the use of agricultural chemicals. However, with regular and episodic river flow events, these chemicals have sometimes found their way into estuarine and nearshore water and sediments where their effects on marine habitats have been largely unquantified. Investigations over the last three years in the Mackay region provide compelling evidence of diuron, and possibly other agricultural herbicides, as the most likely cause of the severe and widespread mangrove dieback. The likely consequences of such dieback included declines in coastal water quality with increased turbidity, nutrients and sediment deposition, as well as further dispersal of the toxic chemicals. The implications of such findings are immense since they describe not only the serious deterioration of protected and beneficial mangrove habitat but also the potential for significant direct and indirect effects on other highly-valued estuarine and marine habitats in the region, including seagrass beds and coral reefs of the Great Barrier Reef lagoon. This article reviews all key findings and observations to date and describes the essential correlative and causative evidence.