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Education And Debate

Alteplase for stroke: money and optimistic claims buttress the “brain attack” campaignCommentary: Who pays the guideline writers?Commentary: Thrombolysis in stroke: it works!

BMJ 2002; 324 doi: (Published 23 March 2002) Cite this as: BMJ 2002;324:723

Alteplase for stroke: money and optimistic claims buttress the “brain attack” campaign

  1. Jeanne Lenzer, medical investigative journalist. (
  1. Oak Ridge Journalism, Ellenville, NY 12428, USA
  2. University Department of Clinical Neurosciences, Western General Hospital, Edinburgh EH4 2XU
  3. UCLA Stroke Center, Department of Neurology, and Department of Emergency Medicine, University of California, Los Angeles, USA

    Both doctors and the public are becoming more alert to potential conflicts of interest, and an increasing number of journals now require competing interest statements from their authors and reviewers. In this article Jeanne Lenzer uses the example of guidelines produced by the American Heart Association to discuss some of the questions that can arise when interests conflict

    As doctors and the public become more aware of conflicts of interest involving study bias,1 publication bias,2 and industry gift giving3 they turn to credible non-profit organisations for sound medical recommendations. Unfortunately, many groups (and their individual panellists) that serve as arbiters of inconclusive data may also suffer from conflicts of interest. 4 5

    One such conflict is self referencing bias. An example of this is in specialty guidelines for colon cancer screening, where radiologists recommend barium enemas while gastroenterologists recommend colonoscopy. A more important conflict arises when corporations with a financial stake in the recommendations issued by a non-profit making organisation provide financial support for that organisation.

    In this paper I examine an example of such a conflict, in which a treatment recommendation that could cost more lives than the disease itself was supported by statistics from only one randomised controlled study. Additionally, poor outcomes and dissenting opinion appear to have been obscured. This recommendation may have been made in a true spirit of unbiased scientific inquiry, but the appearance of dispassionate analysis was eroded by large donations from a drug company to the organisation making the recommendation and payments for research and lecture fees to its individual expert panellists.

    Summary points

    The American Heart Association rated the thrombolytic agent alteplase (tPA) as a class I (definitely recommended) intervention for stroke despite controversy about its safety and efficacy

    Most of the association's stroke experts have ties to the manufacturers of …

    Correspondence to: Dr Starkman

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