Drug reps and the academic medical center: a case for management rather than prohibition

Abstract:Academic physicians and bioethicists are increasingly voicing objections to "drug rep" detailing. Leaders in academic medical centers are considering proposals to ban the small gifts of detailing within their walls. Such bans would be a mistake, as the small gifts are unlikely to act as bribes and do not create unacceptable conflicts of interest for physicians. Drug rep detailing does influence physician behavior, but this influence has not been shown to be harmful. Calls for a ban are premised on empirical evidence for harm that is inconclusive at best, and emerging literature in economics suggests that detailing may well be socially beneficial. A preponderance of harm over benefit is not, however, the primary source of the animus against detailing, which stems from moral considerations that are independent of its social consequences. However, pharmaceutical advertising, including detailing, is a morally legitimate aspect of the world of medical practice that we in academic medicine ought to be preparing our trainees to encounter and properly sift.     

Parasitism may enhance rather than reduce the predatory impact of an invader

Invasive species can have profound impacts on communities and it is increasingly recognized that such effects may be mediated by parasitism. The ‘enemy release’ hypothesis posits that invaders may be successful and have high impacts owing to escape from parasitism. Alternatively, we hypothesize that parasites may increase host feeding rates and hence parasitized invaders may have increased community impacts. Here, we investigate the influence of parasitism on the predatory impact of the invasive freshwater amphipod Gammarus pulex. Up to 70 per cent of individuals are infected with the acanthocephalan parasite Echinorhynchus truttae, but parasitized individuals were no different in body condition to those unparasitized. Parasitized individuals consumed significantly more prey (Asellus aquaticus; Isopoda) than did unparasitized individuals. Both parasitized and unparasitized individuals displayed Type-II functional responses (FRs), with the FR for parasitized individuals rising more steeply, with a higher asymptote, compared with unparasitized individuals. While the parasite reduced the fitness of individual females, we predict a minor effect on population recruitment because of low parasite prevalence in the peak reproductive period. The parasite thus has a large per capita effect on predatory rate but a low population fitness effect, and thus may enhance rather than reduce the impact of this invader.     

Developmental origins of childhood overweight: potential public health impact

Several modifiable pre- and postnatal determinants of childhood overweight are known, but no one has examined how they influence risk of overweight in combination. We estimated the risk of overweight at age 3 years according to levels of maternal smoking during pregnancy, gestational weight gain, breastfeeding duration, and infant sleep duration. We studied 1,110 mother-child pairs in Project Viva, a prospective prebirth cohort study. The main outcome measure was child overweight (BMI for age and sex >or=95th percentile) at age 3. We ran logistic regression models with all four modifiable risk factors as well as the covariates maternal BMI and education, child race/ethnicity, and household income. From the model, we obtained the estimated probability of overweight for each of the 16 combinations of the four risk factors. During pregnancy, 9.8% of mothers smoked and 50% gained excessive weight. In infancy, 73% mother-child pairs breastfed for <12 m, and 31% of infants slept <12 h/day. Among the 3-year-old children in the cohort, 9.5% were overweight. In the prediction model, the estimated probability of overweight ranged from 0.06 among children exposed to favorable levels of all four risk factors, to 0.29 with adverse levels of all four. Healthful levels of four behaviors during early development predicted much lower probability of overweight at age 3 than adverse levels. Interventions to modify several factors during pregnancy and infancy could have substantial impact on prevention of childhood overweight.     

Gulping rather than sipping: macropinocytosis as a way of virus entry

Macropinocytosis has emerged as a major endocytic mechanism in the cell entry of animal viruses. The process differs fundamentally from other endocytic mechanisms involved in virus internalization. By activating growth factor receptors or other signaling molecules, plasma membrane-bound viruses trigger the activation of a signaling pathway. When amplified, this causes a transient, global change in cell behavior. The consequences of this change include the actin-dependent formation of membrane protrusions, the elevation of non-specific uptake of fluid, and the internalization of membrane together with surface-bound ligands and particles including viruses. Recent studies show that this strategy is used by a variety of enveloped and non-enveloped viruses.     

Medical and public health impact of sleep problems

Sleep and Biological Rhythms -     

Quantitative impact of mental health preparedness training for public health professionals

Coordinating and integrating mental health topics into emergency preparedness planning is a critical step for ensuring effective response to the psychological issues connected with trauma. In order to remedy the current lack of integration, potential response providers must receive effective mental health preparedness training. The current study provided mental health preparedness training to public health and allied health professionals in Kansas and assessed the impact of the training on perceived mental health preparedness knowledge. Participants included 157 potential first and secondary responders from public health and allied fields who attended one of 10 training presentations on mental health emergency preparedness. Pre- and post-presentation, participants responded to six Likert-scale questions about their perceived knowledge of topics and level of mental health preparedness. Questions addressed common psychological responses to disaster or terrorist events, stress reactions of specific populations, psychological resiliency, mental health preparedness integration, and level of agency preparedness. Post-training, participants reported statistically significant (p<0.001) increases in perceived level of knowledge on all topics. Participants were also significantly more likely (p<0.001) to report that their agency could respond to the mental health issues related to a disaster or emergency. The current study provides data about gaps in practitioner knowledge regarding mental health preparedness in Kansas. While the self-report nature of responses is a limitation, these findings serve as the first step toward producing and implementing effective mental health preparedness information and training on a wide scale.     

The public health and safety consequences of sleep disorders

Sleep deprivation and medical disorders of sleep are common in today's society and have significant public health implications. In this article, we address 3 specific issues related to the public health and safety consequences of sleep disorders. First, we review data that has linked sleep restriction to a variety of adverse physiologic and long-term health outcomes including all-cause mortality, diabetes, and cardiovascular disease. Second, we will review recent data that has demonstrated that therapy for obstructive sleep apnea (the most common respiratory disorder of sleep) is an extremely efficient use of healthcare resources (in terms of dollars spent per quality adjusted life year gained), and compares favorably with other commonly funded medical therapies. Finally, we will review data that illustrate the potential adverse patient and occupational safety impacts of the extreme work schedules of housestaff (physicians in training).     

The use of operational modeling of HIV/AIDS in a systems approach to public health decision making.

Compartmental models of infectious diseases readily represent known biological and epidemiological processes, are easily understood in flow-chart form by administrators, are simple to adjust to new information, and lend themselves to routine statistical analysis such as parameter estimation and model fitting. Technical results are immediately interpretable in epidemiological and public health terms. Deterministic models are easily stochasticized where this is important for practical purposes. With HIV/AIDS, serial data on both HIV prevalence and AIDS morbidity have been available from San Francisco. Assuming the distribution of the incubation period to be biologically stable, statistical analysis is quite feasible in other regions, even those with no reliable HIV data. Transmission rates must be estimated locally. It is also often possible to estimate the effective size of a population subgroup at risk, from population data on AIDS morbidity only. Computer simulation provides estimates of the evolving pattern of both HIV prevalence and AIDS morbidity. Some public health questions can be answered only by appropriately formulated stochastic models.     

N-acyl-homoserine lactone-mediated quorum-sensing in Azospirillum: an exception rather than a rule

Forty Azospirillum strains were tested for their ability to synthesize N-acyl-homoserine lactones (AHLs). AHL production was detected for four strains belonging to the lipoferum species and isolated from a rice rhizosphere. AHL molecules were structurally identified for two strains: Azospirillum lipoferum TVV3 produces 3O,C(8)-HSL (N-3-oxo-octanoyl-homoserine-lactone), C(8)-HSL (N-3-octanoyl-homoserine-lactone), 3O,C(10)-HSL (N-3-oxo-decanoyl-homoserine-lactone), 3OH,C(10)-HSL (N-3-hydroxy-decanoyl-homoserine-lactone) and C(10)-HSL (N-3-decanoyl-homoserine-lactone), whereas A. lipoferum B518 produced 3O,C(6)-HSL (N-3-oxo-hexanoyl-homoserine-lactone), C(6)-HSL (N-3-hexanoyl-homoserine-lactone), 3O,C(8)-HSL, 3OH,C(8)-HSL and C(8)-HSL. Genes involved in AHL production were characterized for A. lipoferum TVV3 by generating a genomic library and complementing an AHL-deficient strain with sensor capabilities. Those genes, designated alpI and alpR, were found to belong to the luxI and luxR families, respectively. When cloned in a suitable heterologous host, alpI and alpR could direct the synthesis of the five cognate AHLs present in A. lipoferum TVV3. These two adjacent genes were found to be located on a 85 kb plasmid. Southern hybridization experiments with probes alpI/R indicated that genes involved in AHL production in the three other AHL-producing strains were not closely related to alpI and alpR. This study demonstrates that AHL-based quorum-sensing is not widespread among the genus Azospirillum and could be found only in some A. lipoferum strains.     

Molecular detection of Histoplasma capsulatum indoors: A public health approach

BackgroundHistoplasmosis, caused by the dimorphic fungus Histoplasma capsulatum, represents an important public health problem, especially in urban environments where bats and humans cohabit indoors.AimsTo detect the presence of H. capsulatum indoors, using samples of bat droppings collected in roost sites inside houses.MethodsA Real-Time TaqMan PCR assay targeting the ITS1 region of the ribosomal DNA of H. capsulatum was carried out.ResultsFifty-nine sampling points in the municipality of São Paulo were inspected, all of them located at inhabited places. H. capsulatum was isolated from nine samples.ConclusionsThe rapid identification and monitoring of sites where the fungus is present may contribute to make a more reliable database of H. capsulatum distribution.