Written by admin on Monday, October 31st, 2011 in Swine Flu.
You may know Leryn Franco because she’s the hottest Paraguayan javelin thrower in the world. So you also may be interested to know that she made the trip to compete in the Pan Am Games in Guadalajara despite her battles with liver disease, swine flu and pharyngitis. Yikes. Rough translation from the story at Terra…
Written by admin on Monday, October 31st, 2011 in Swine Flu.
Several newspapers have reported that all pregnant women will “get the right to a caesarean”, regardless of whether there is a medical reason for having one. Currently, around one in four UK babies is delivered by caesarean.
The reports are based on new draft guidelines from the National Institute for Health and Clinical Excellence (NICE), the national body that evaluates which treatments should be available for specific conditions. The proposed guidelines are the first major update from NICE on caesarean sections since 2004, and take into account the latest research on the procedure.
Although newspapers focused on caesareans potentially being available to a wider range of women, the draft guidelines cover all aspects of caesarean sections, including planning, timing, the procedure itself and care after a caesarean. The guidelines include a number of new and updated recommendations about all these areas, but the ones relating to who should be offered a caesarean state that:
Requested caesareans
In addition, the draft guidelines set out specific processes to follow if a woman asks for a caesarean:
Cases when a caesarean is recommended
The guidelines also recommend offering a planned caesarean to pregnant women under specific medical circumstances. Caesareans should be offered when a woman has:
No. The draft guidelines do not recommend that every woman should be routinely offered a caesarean. Rather, they state the medical circumstances where one is recommended and where one is not, and discuss the options that are available when a woman has a preference for a caesarean over a vaginal birth.
There are also a number of scenarios where the guidelines specifically say that women should NOT be routinely offered caesarean sections; these include women with:
NICE’s existing caesarean guidance was issued in 2004. These new draft guidelines have take into account the evidence from newer research published since then. NICE’s system for updating its guidance is based on an in-depth, step-by-step process, involving:
Draft guidelines will then published on the NICE website to allow interested parties to review the recommendations and suggest changes.
No. These guidelines are still undergoing pre-publication checks and may be subject to further changes before they are made official. However, any further changes are likely to be small as the guidelines have already been adapted to incorporate changes suggested in the commenting phase, which occurred in May and June 2011. It is expected that the final, official guidelines will be published in November.
All ‘will get right to caesarean’. The Sun, October 31 2011
NHS give women right to caesarean section birth even if they don’t need it. Daily Mail, October 31 2011
Women ‘to be given right to Caesareans’. The Independent, October 31 2011
Written by admin on Monday, October 31st, 2011 in Swine Flu.
“A daily dose of drugs designed to lower cholesterol could also slash the risk of breast cancer recurring,” the Daily Mail reported today.
The news is based on the findings of a large Danish study that looked for an association between the use of statins and the recurrence of breast cancer. Researchers followed 18,769 women, for an average of 6.8 years, who had previously been diagnosed with invasive breast cancer. Of these, 17% had ever been prescribed statins. Compared to non-users, women who took simvastatin and other “lipophilic” (fat-soluble) statins were less likely to have breast cancer that reoccurred. Those who took “hydrophilic” (water-soluble) statins did not have a reduced risk. However, this type of statin was used by only 6% of the statin users, which limits the strength of this finding.
This type of study can only find associations, and further studies would need to confirm that the lower risk of recurrent breast cancer is caused by lipophilic statins. The findings do not mean that taking a statin provides any protection against developing breast cancer in the first place. Without further study, women who have had breast cancer but who have no medical reason to use statins should not be encouraged to take the medication to try to prevent their cancer from coming back.
The study was carried out by researchers from Brigham and Women’s Hospital, Harvard Medical School and Boston University School of Medicine in the US, and Aarhus University Hospital and Aalborg Hospital, Denmark. It was funded by Klinisk Institute of Aarhus University Hospital, the United States National Cancer Institute at the National Institutes of Health, the Danish Cancer Society, the Karen Elise Jensen Foundation, and the Congressionally Directed Medical Research Programs. The study was published in the peer-reviewed Journal of the National Cancer Institute.
The Daily Mail’s report was mainly accurate.
This cohort study examined the association between statin use and breast cancer recurrence in a cohort of Danish women diagnosed with invasive breast cancer. Statins are a class of drug that lower cholesterol levels, and are usually prescribed to prevent cardiovascular disease.
The study’s design is appropriate for finding associations between factors. However, it cannot show that one things causes another. The potential use of statins as an additional treatment to help prevent recurrent breast cancer would need to be assessed in a randomised controlled trial.
The researchers enrolled all female residents of Denmark diagnosed with stage I-III invasive breast cancer between 1996 and 2003 (18,769 women). Data on tumour, treatment and patient characteristics were collected. Women were followed for an average (median) of 6.8 years (maximum 10 years) after initial diagnosis, and follow-up examinations were performed every 3-6 months for the first five years after diagnosis and then annually.
Statin use was determined from the national electronic pharmacy database, which recorded filled statin prescriptions. The researchers analysed statin usage on a yearly basis. Women were defined as statin users if they had been prescribed statins at least once that year, and non-users if they had not.
The use of a lipophilic (fat-soluble) statin was defined as exclusive use of simvastatin, lovastatin, fluvastatin or cerivastatin. Lipophilic statins were used by 2,524 women, 92% of whom were prescribed simvastatin. The use of a hydrophilic (water-soluble) statin was defined as exclusive use of atorvastatin, pravastatin or rosuvastatin. Hydrophilic statins were used by 206 women.
The researchers then looked at the association between statin use and recurrent breast cancer, after they had adjusted the data to account for the women’s age and menopausal status at diagnosis, the type of tumour, treatment, hormonal therapy before diagnosis and other medications that the women were taking.
Over the median 6.8 years of follow-up, there were 3,419 breast cancer recurrences in this cohort of 18,769 women.
Of the cohort, 3,282 women were prescribed a statin at some point during the follow-up. The median length of time that the statin was prescribed for was four years.
Over the follow-up period:
To confirm that the association observed was due to simvastatin and was not affected by the medical condition that led to the women taking statins, the researchers compared the risk of recurrence in exclusive simvastatin users and people who received a different class of statins (hydrophilic statins). Again, they found that simvastatin was associated with a reduced risk of breast cancer recurrence (10-year adjusted HR 0.55, 95% CI 0.35 to 0.85).
The researchers concluded that “simvastatin, a highly lipophilic statin, was associated with a reduced risk of breast cancer recurrence among Danish women diagnosed with stage I-III breast carcinoma, whereas no association between hydrophilic statin use and breast cancer recurrence was observed.”
In this cohort study, use of a lipophilic statin (including simvastatin, the most commonly prescribed of the statins) was associated with a reduced risk of recurrent breast cancer in women with invasive breast cancer.
The researchers also investigated the association between the exclusive use of simvastatin and the risk of recurrent breast cancer, and found that that use of simvastatin reduced the risk of recurrent breast cancer compared to no statin treatment or treatment with a hydrophilic statin. Use of a hydrophilic (water-soluble) statin, including atorvastatin, pravastatin or rosuvastatin, was not found to be associated with reduced risk, though the strength of this association is limited by the small proportion of statin users (only 6%) who used this type of statin. There trial also has numerous limitations, including the fact that it is not known whether the women who were prescribed statins actually took the drugs. Also, the study was not able to adjust for certain potential confounders that may have affected the risk of breast cancer recurrence, such as the women’s body mass index.
This finding is worthy of further study to investigate whether it is the use of lipophilic statins that directly reduces the risk of recurrent breast cancer. Further investigation into why these types of statins have this effect is also warranted.
On its own, this study can only demonstrate an association and does not provide conclusive evidence that statins reduce the risk of breast cancer recurrence. A randomised controlled trial would be needed to more accurately determine whether taking a statin reduces the risk of recurrence in women previously diagnosed with breast cancer. However, the ethics of using statins in women with no cardiovascular reason for taking them would need to be considered in such a trial.
The current study does not provide any evidence that taking a statin protects against developing breast cancer in the first place. Without further study, women previously diagnosed with breast cancer and who have no cardiovascular risk factors should not be encouraged to start taking statins to try to prevent cancer recurrence.
Daily dose of statins could cut risk of breast cancer by 30%. Daily Mail, October 31 2011
Ahern TP, Pedersen L, Tarp M et al. Statin Prescriptions and Breast Cancer Recurrence Risk: A Danish Nationwide Prospective Cohort Study. Journal of the National Cancer Institute (2011) 103 (19): 1461-1468.
Written by admin on Friday, October 28th, 2011 in Swine Flu.
Aspirin cuts the risk of bowel cancer in people with inherited susceptibility to the disease, The Guardian has today reported. The newspaper said that a study of long-term aspirin use found it cut the risk of bowel cancer by more than 60% in these individuals.
The news is based on research that examined how effectively aspirin prevented bowel cancer in over 800 patients with Lynch syndrome, a rare genetic condition that raises the risk of several types of cancer.
The researchers gave half the participants aspirin and the other half a dummy placebo for two years, looking at how many people from each group had developed bowel cancer in the years that followed. When the researchers analysed data on those participants that had completed the full two years of treatment they found that the group taking aspirin had 63% lower rate of the disease in the 5-10 years that participants were followed.
This well-conducted trial was the first to look at aspirin preventing cancer in this way. It suggests yet another use for the humble aspirin pill, which already has proven benefits in fighting heart disease and preventing blood clots. However, it should be remembered that the results apply only to people with this specific genetic condition, which is behind around 2-7% of bowel cancers. Also, regular aspirin is not suitable for everyone as it can cause side effects such as ulcers and stomach bleeds.
The study was carried out by researchers from numerous universities and hospitals throughout the UK and around the world. The research was funded by a number of governmental bodies, medical institutions and research foundations. The research was partially funded by Bayer Pharma, a pharmaceutical company that manufactures aspirin.
The study was published in the peer-reviewed medical journal The Lancet.
The media has generally reported the story accurately and appropriately. However, several news outlets reported that the research involved people with a family history of the disease. This could be misleading as the participants had a specific genetic condition that predisposed them to the disease, and were not recruited solely based on people in their family having a history of bowel cancer. While those with the condition would have inherited the faulty genes involved from their parents, it does not necessarily mean their parents had the condition.
This was a randomised control trial that looked at aspirin’s ability to prevent bowel cancer in a group of patients with a condition called Lynch syndrome. The syndrome is a type of inherited cancer in which people carry a faulty DNA mismatch repair (MMR) gene, which would ordinarily aid the repair of DNA mutations that occur during DNA replication, which can lead to cancer. The condition is also called hereditary nonpolyposis colorectal cancer (HNPCC).
These faulty genes predispose those with the condition to polyps and colorectal cancer, but also cancers in other locations, including:
People with this genetic condition are at significantly higher risk of developing bowel cancer than the general population. It is estimated that approximately 2-7% of colorectal cancer cases are caused by the syndrome. Patients with a genetic predisposition that puts them at higher risk of developing a disease are often enrolled in trials such as this to ensure that a sufficient number of cases will appear during the relatively short timeline.
The particular study design used – a randomised control trial – ensures that patients are randomly assigned to take either the genuine treatment or an inactive placebo and then follows them over time. Since they have an equal chance of receiving either treatment this should lead to an equal distribution of people with factors that might otherwise bias the results.
Since randomised control trials remove the influence of these ‘confounding’ factors and assess people before they start their treatment, they are capable of establishing a cause-and-effect relationship. This means that, if conducted and analysed correctly, the study design itself ensures we can be fairly confident that any difference in bowel cancer rates between the two groups is due to treatment with aspirin.
The researchers recruited 937 people with Lynch Syndrome to participate in the research. They randomised the participants to receive either 300mg of aspirin twice a day or a placebo. Of these, 76 participants (8%) opted out of the study due to aspirin sensitivity or history of ulcers.
The researchers predicted that those who received aspirin would go on to have lower rates of bowel cancer than those who received placebo. Two years after treatment began they compared rates of bowel cancer in the two groups, as well as rates of other cancers common to Lynch syndrome. They followed-up participants for a number of years to see if they until they developed a cancer, which was up to 10 years after randomisation for some early recruits.
The data was analysed based on the 861 participants enrolled in the aspirin portion of the study. The researchers adjusted for variables that might account for the rates of cancer, such as sex and the cancer history of each participant since randomisation. They then calculated the Incident Rate Ratio (IRR) to estimate the effect of aspirin. IRR is a measure that expresses how the rates of new cancer cases between two groups relate to each other.
The data was first analysed on an intention-to-treat (ITT) basis, where all participants who were randomised are included in the analysis, regardless of whether or not they stopped or started aspirin during the study or otherwise complied with the treatment regimen. This has the advantage of being more like treatment under real-world conditions, where some patients may not take their medication as prescribed or stop taking it all together. It also prevents bias from influencing the results, as people who do not comply with treatment may be different from those who remain in the study in ways that impact their risk of developing bowel cancer.
They also performed a second analysis that included only those participants who completed the full treatment regimen of two years or more.
Data analysis revealed that out of the 861 people enrolled, 20 developed bowel cancer within two years after randomisation, 10 people from each treatment group. After 10 or more years, however, a further 28 people had developed the disease, eight from the aspirin group and 20 from the placebo group. This equates to an overall 18 cases in the aspirin group and 30 cases in the placebo group.
Intention-to-treat analysis revealed a protective effect of treatment, with the aspirin group having a 44% lower rate of bowel cancer than the placebo group (IRR 0.56, 95% CI 0.32 to 0.99, p=0.05).
The restricted analysis, based on only those who had complied with the treatment regimen, revealed that:
The researchers concluded that their study provided clear evidence of aspirin’s effectiveness at preventing bowel cancer among Lynch syndrome patients, and that ‘the case for prescription of aspirin to this high-risk group is clear.’ They said that the results are consistent with more than two decades of observational study findings that show a reduced risk of developing bowel cancer among those who regularly consume aspirin.
This was a well-designed long-term trial. It examined the effect of regular aspirin consumption on bowel cancer rates in a specific group of patients with a raised risk of developing bowel and other cancers. The results indicate that regular treatment with aspirin is an effective method of preventing bowel cancer in this group of high-risk patients.
The study has several strengths, particularly related to design of the trial. For example, even at the end of the study neither the participants nor investigators were made aware of which individuals had received aspirin and which had received placebo. This helps ensure an unbiased analysis of long-term follow-up data, increasing the confidence we can have in the results.
There are, however, several things to consider when interpreting the results:
The researchers have planned a follow-up trial with thousands of participants in order to address these points. The trial will also compare multiple doses of aspirin, in order to identify the lowest effective dose. Ensuring that the lowest possible dose is used should help to balance the risk of developing ulcers with the benefit of preventing cancer.
Aspirin cuts bowel cancer risk by up to two-thirds. The Daily Telegraph, October 28 2011
Two aspirins daily. The Sun, October 28 2011
Aspirin cuts cancer risk in people with an inherited susceptibility. The Guardian, October 28 2011
Aspirin every day can cut cancer risk by 60%: British scientists find first proof of preventative effect. Daily Mail, October 28 2011
Two aspirins a day can help prevent colon cancer, 10-year study shows. Daily Mirror, October 28 2011
Burn J, Gerdes AM, Macrae F et al. Long-term effect of aspirin on cancer risk in carriers of hereditary colorectal cancer: an analysis from the CAPP2 randomised controlled trial. The Lancet, Early Online Publication, 28 October 2011
Written by admin on Thursday, October 27th, 2011 in Swine Flu.
IVF doubles the risk of non-fatal ovarian cancer, The Daily Telegraph has today reported. The newspaper said that a study on almost 30,000 women who were struggling to get pregnant found that tumours were more common in those women that were given IVF.
This story is based on a long-term Dutch study that examined the risk of ovarian cancer associated with in vitro fertilisation (IVF) treatment where ovaries had been stimulated to produce eggs using drugs.
Researchers wanted to assess the risk of developing the cancer in the 15 years following treatment, comparing it to the risks of cancer in the general population and in women who had difficulty conceiving but did not undergo IVF treatment. The researchers found that the IVF group was over four-times as likely to have developed borderline ovarian tumours (not yet cancerous) compared to the non-IVF group. However, they were at no greater risk of developing cancerous tumours.
Although this was a large, well-conducted study, the small number of cancer cases seen make the results uncertain and further research is required to confirm the findings. Women who are concerned about the risks of past or present IVF use can discuss the issue with their specialist or GP, although it is worth remembering that even in women who had used IVF the rates of cancer seen were still low at around 0.71%.
The study was carried out by researchers from The Netherlands Cancer Institute and medical centres throughout the Netherlands. The research was funded by the Health Research and Development Council and the Dutch Ministry of Health.
The study was published in the peer-reviewed medical journal Human Reproduction.
Generally, the media reported the study accurately and appropriately. The Daily Express correctly reported that many of the cases were considered non-fatal, that some of the results were not statistically significant, and that the overall number of cases was small.
The Daily Mirror also made the important point that, even independent of using IVF, women with fertility problems that require IVF are generally likely to have a different risk of developing ovarian cancer than women among the general population.
Ovarian cancer itself is relatively rare and both newspapers stressed that, while the relative risk of developing cancer was greatly raised, the absolute risk of developing the disease was still low. The research seems to suggest that among the general population there is a 0.45% chance of women developing ovarian cancer by the age of 55, and a 0.71% chance among IVF users.
This was a cohort study that aimed to examine how the long-term risk of developing ovarian cancer was affected by ovarian stimulation during IVF. The study included 19,146 women who had undergone IVF treatment in the Netherlands between 1983 and 1995, and compared their risk of developing ovarian cancer to that of a group of 6,006 women who also had difficulty getting pregnant, but who had not undergone IVF treatment. The researchers also compared the risk of ovarian cancer in the IVF group to that seen among the general population.
Some media outlets also included details of another recent study that examined the link between taking the birth control pill and risk of ovarian cancer, reportedly finding the Pill increased the risk. It should be noted that this is a separate piece of research, and that this study did not look at potential risks of IVF.
The researchers identified 19,146 women who had received IVF treatment and 6,006 women who had difficulty conceiving, but did not receive IVF, between 1983 and 1995. They collected data on reproductive risk factors using a mailed questionnaire. Information on the cause of subfertility and fertility treatment was extracted from medical records. This information was used during analyses to adjust for the influence of characteristics that may have been behind any observed association between treatment and subsequent cancer cases.
The participants were then followed-up for a median of 14.7 years, with the researchers using disease registries to determine the incidence of ovarian cancer (how many women from each group had developed the disease) during that time.
The researchers first examined how the number of new cancer cases in the IVF group and the group of subfertile non-IVF users compared to that of the general population. They did this using a measure called a ‘standardised ratio’ (SIR). An SIR expresses the risk of a disease in a particular group as having a value of 1, and then expresses the risk in other groups as a number in relation to this value. For example, an SIR value of 2.5 would indicate that a risk was two-and-a-half times greater in a particular group.
The researchers then compared cancer risk between the IVF and non-IVF group. They analysed the data separately for two grades of cancer, borderline and invasive. Borderline ovarian cancer is an early form of the disease that has not yet developed into full cancer. Borderline cases are marked by abnormal growths that are less aggressive than invasive cancers, although they may develop into cancer if left untreated. Invasive cancers, on the other hand, have fully developed into tumours.
During data analysis, the researchers controlled for known risk factors for ovarian cancer, such as age, total number of pregnancies and the underlying cause of infertility.
After a median follow-up of 14.7 years, 77 cases of ovarian cancer had occurred in the total cohort of 25,152 women; 61 cases in the IVF group and 16 in the non-IVF group. When compared to the general population:
When the researchers analysed the data based on type of ovarian cancer (borderline or invasive), they found that:
The researchers then further stratified the cohort by length of follow-up. They found that, compared to the general population, the only group with a significantly increased risk of developing ovarian cancer was the IVF group that had been followed-up for 15 years or more (SIR 3.54, 95% CI 1.62 to 6.72). However, only nine cases of ovarian cancer were observed in this group.
The researchers compared women who had received IVF with those who had difficultly conceiving but did not receive IVF. They found that:
When examining the impact of fertility treatment, the researchers found that the number of IVF cycles, responsiveness to ovarian stimulation and damage to the ovary were not significantly associated with the risk of subsequently developing ovarian cancer.
The researchers say their results ‘give reason for some concern’, but that further prospective cohort studies with long-term follow-up are needed, especially as the results are based on small numbers of cases. The need for further research is also supported by the fact that the increased risk of invasive ovarian cancer was not statistically significant in the most robust data analysis, they add.
This was a large, long-term cohort study that examined the association between ovarian stimulation during fertility treatment and the subsequent risk of developing ovarian cancer. The study was well designed, especially in terms of its selection of an appropriate comparator group and its attempts to account for potential confounders.
In their attempt to control potential confounders the researchers collected information on baseline ovarian cancer risk through a mailed questionnaire, and on treatment factors through medical record examination. However, data on factors such as family history of cancer, number of pregnancies, use of birth control and lifestyle characteristics were available in only 65.2% of the total cohort. This may bias the results, as there is no way of telling whether those who returned the survey were significantly different from non-respondents. This bias is further enhanced as the two groups did not respond proportionately: 48.7% of the subfertile/non-IVF group responded, compared to 71.1% of the IVF group.
Similarly, medical record data extraction was only conducted for 76% of the women who had received IVF. Given this large body of missing data there is no way of knowing whether or not these 24% of women were significantly different from those whose records were extracted.
Another strength of this study was that it also examined ovarian cancer risk in subfertile women who did not undergo IVF treatment. Studies that compare women receiving IVF to women in the general population are useful, but their results are open to debate as any increased risk seen in women having IVF could arguably be due to whatever was causing their fertility problem, rather than IVF itself. By comparing the ovarian cancer risk profiles of different subfertile groups, the study could potentially allow us to tease out the effects of IVF, and allow us to ignore the influence of infertility itself.
The researchers also consider the possibility that some of the increased risk for borderline ovarian cancer may be due to increased contact with medical professionals during the IVF process. Ovarian cancer is generally detected at a late stage, in part due to its vague or asymptomatic nature during its early stages. The researchers attempted to determine whether medical surveillance accounted for the difference by interviewing the patients’ doctors. They say that, based on the interviews they were able to conduct, increased surveillance is an unlikely explanation for the trend.
The researchers say that they are concerned by their finding which suggests an elevated risk of developing invasive ovarian cancer in the IVF group after more than 15 years of follow-up. However, there are statistical difficulties in conducting such extensive subgroup analyses: the likelihood of finding a statistically significant result purely by chance increases the more the data is broken down into subgroups. In this instance the small number of observed cases in this subgroup (nine cases in the IVF group, 13 in the general population) suggest the result is unlikely to be robust.
It is important to remember that all the increased risks detected in this study were relative to the risk seen in other groups, and not absolute risks. While IVF-treated women may be at double the risk of developing ovarian cancer relative to women not given IVF, this absolute risk is still small. In the Netherlands, for example, the researchers say that only about 45 among every 10,000 women (0.45%) may develop an ovarian malignancy (including borderline malignancy) by age 55 years. The rate for women who had used IVF was estimated to be 0.71%.
Another key point is that at the time the women received IVF (1983-1995), the technique was not as widespread or advanced as it was today. This means that both the specific treatment used and the women involved may not be representative of IVF used in more-recent times.
Overall, this was a well-conducted study but further research is needed in order to confirm the results. Women contemplating using or currently using IVF can discuss the matter with their specialist, while women who are concerned about their past use of IVF can consult their doctor. However, the level of risk identified in this study is low, and the matter should not be seen as a cause for alarm.
IVF doubles risk of non-fatal ovarian cancer. The Daily Telegraph, October 27 2011
IVF treatment doubles the risk of ovary cancer, scientists warn. Daily Mirror, October 27 2011
IVF pill cancer threat. The Sun, October 27 2011
IVF increases women’s risk of ovarian cancer. Daily Express, October 27 2011
van Leeuwen FE, Klip H, Mooij TM et al. Risk of borderline and invasive ovarian tumours after ovarian stimulation for in vitro fertilization in a large Dutch cohort. Human Reproduction, 2011
Written by admin on Thursday, October 27th, 2011 in Swine Flu.
NEW YORK ( MainStreet) — Researchers at the University of Minnesota are calling for stronger seasonal flu shots after discovering the yearly vaccination prevents only about 59% of seasonal flu infections in adults. Some shots were more effective than others. H1N1 (swine flu) shots were found to be 69% effective for adults under 65, as were flu vaccines delivered as nasal spray to children …
Written by admin on Wednesday, October 26th, 2011 in Swine Flu.
Government drug advisers have today called for tighter regulation of ‘legal highs’ – recreational drugs sold legally due to loopholes in the law. In a new report the Advisory Council on the Misuse of Drugs (ACMD) has published details of how drugs such as ‘meow meow’ (mephedrone), which was banned last year, have been openly sold over the internet under the guise of being ‘plant food’ or ‘research chemicals’.
The report also highlighted the false perception that just because a drug is technically legal it must be safe, pointing out that there have been at least 42 deaths associated with the use of mephedrone, and dozens more where its use has been suspected.
While the mephedrone family of drugs has now been banned, the ACMD said those manufacturing legal highs are increasingly tweaking the chemical formulas of banned legal highs to bypass bans on specific substances. In response, it suggested that legislation should be used to make it illegal to produce substances with similar effects to banned drugs, rather than just banning specific chemicals as they emerge.
In its report, the ACMD made further recommendations aimed at trying to reduce sales, demand and harms.
Legal highs are drugs that are intended to mimic the effects of illegal drugs but can technically be sold or possessed legally. However, the lack of legal control does not imply that they are safe, and a number of substances sold as legal highs in the past have since been associated with health problems and even death. For example, until it was banned in 2010, the substance mephedrone (also known as meow meow) was legally allowed to be sold when labelled as a research chemical or as a plant food. However, recent data has shown that despite perceptions that it was safe, the drug has contributed to at least 42 recorded deaths. Its use has also been suspected in dozens of further deaths.
While many substances that were once sold as legal highs have since been banned, the ACMD says that chemists are constantly using their knowledge to develop new ‘legal highs’ that fall outside existing drug legislation. These are often chemically similar to banned substances and produce similar effects, but due to them having different chemical compositions they may not technically be governed by existing laws. Given the new, or novel, nature of legal highs, the ACMD refers to them as Novel Psychoactive Substances (NPS).
The ACMD says legal highs generally fall into four broad categories:
NPS products cannot be marketed, sold or labelled as being intended for human consumption, which would make them subject to strict pharmaceutical legislation. To circumvent these laws they are often labelled as something else; for example, plant food, bath salts, research chemical or boat cleaner, with disclaimers saying they are ‘not for human consumption’.
The report considered a number of different factors relating to NPS, their use and measures to tackle them. Among the specific issues examined were:
The ACMD was keen to point out that the report does not provide a solution to the current problem or guidance on specific NPS products, but rather options that may help reduce the harmful impact of legal highs. However, in considering the issue in general, the report described cases studies for mephedrone, which was banned in 2010, and Ivory Wave (also known as Desoxypipradrol or 2-DPMP), an NPS that has not yet been classified as a controlled substance.
In the case of mephedrone the report highlighted how quickly the novel drug rose in popularity, but also that there has been a growing number of adverse incidents reported, and at least 42 deaths where the drug played a significant role. The report also stated that a few months after mephedrone was banned, those manufacturing legal highs started producing a similar (and technically legal) substance called naphyrone, highlighting how quickly existing laws can be circumvented.
Desoxypipradrol, the main active ingredient in Ivory Wave, is not yet a ‘controlled substance’ (illegal to supply or possess), although its import into this country has been banned. However, testing of Ivory Wave products has shown its chemical contents can vary, and at times it may contain controlled substances. This means that a person who had bought an Ivory Wave product thinking it was legal could still subject to prosecution if they were stopped by the police and found to carrying a controlled substance.
Generally, there is a lack of safety data on the legal highs, which mostly appear to be untested and unregulated compounds. Aside from these obvious risks, the contents of products are often variable and not specified on packaging, meaning people can never be sure exactly what they are taking, even if they have used a product before.
Even though there is limited data available on these substances, there appears to have been an increase in hospital admissions and medical appointments due to the toxicity of legal highs. In addition, health services are starting to see health problems caused by regular use of legal highs, including, dependence that requires detoxification treatment.
Testing has also shown that many NPS are synthetic amphetamine-like stimulants, meaning they are likely to share many of the well-documented adverse effects of amphetamines, such as dependence. It also means that it is possible that the more potent NPS are likely to carry an overdose risk at just a few milligrams, which is likely to be associated with acute toxic effects.
The ACMD says that NPS use is such a new phenomenon that it is hard to gauge how popular and readily available these substances are. However, while the council says that robust data on the issue is often unavailable, sources such as the British Crime Survey have recently started collecting data on their use. The council highlights some of the survey’s data on mephedrone for 2010/11, which suggested that:
The report also cited a 2011 survey run by the dance music magazine Mixmag, which asked clubbers several question on their use of drugs. Although the survey was aimed specifically at clubbers, 75% of them said it was easy or very easy to obtain prior to the ban. Post-ban 38% of respondents said it was easy or very easy to obtain. The same survey, however, said that 42% of respondents had tried the drug pre-ban, but that 61% had tried it post-ban.
The ACMD report noted that British Crime Survey figures suggested that overall drug use is coming down in the UK.
The report made extensive recommendations relating to policy, the law, public health messages and how to close loopholes that mean that drugs are legal until the are specifically deemed controlled substances. Some suggested measures recommend that:
Mephedrone users told they are playing Russian roulette. The Independent, October 26 2011
Legal high linked to up to 100 deaths. The Daily Telegraph, October 26 2011
98 deaths fuel calls for legal highs ban. The Sun, October 26 2011
Government advisers call on ministers to launch a war on “legal highs”. Daily Mirror, October 26 2011
Party drug meow meow kills one young Briton a week. Daily Mail, October 26 2011
‘Legal highs’ should be automatically banned, says government drugs adviser. The Guardian, October 26 2011
Legal highs need more controls, say drug council. BBC News, October 26 2011
Advisory Council on the Misuse of Drugs: Consideration of the Novel Psychoactive Substances (‘Legal Highs’). October 2011
Written by admin on Wednesday, October 26th, 2011 in Swine Flu.
“The annual flu jab given to hundreds of thousands of people this winter provides only limited protection against the illness,” reported The Independent.
This news story is based on a systematic review of studies looking at the effectiveness of two common flu vaccines in the prevention of seasonal flu infection. The vaccines assessed were: trivalent inactivated vaccine (TIV) – the most widely used vaccine in the UK, and live attenuated influenza vaccine (LAIV), which is less commonly used. Over 5,550 studies were screened resulting in 31 studies being included in the review.
Pooling the results of these studies showed that TIV was effective at preventing seasonal flu in 59% of adults aged 18-65 years while LAIV was effective in 83% of children aged six months to seven years. Information on other age groups was not available.
It is a well-known fact that current flu vaccines are not 100% effective. They do however, remain the best available protection for groups who are more vulnerable to the effects of seasonal flu such as people aged over 65 years, people with a serious medical condition and pregnant women.
What this study highlighted is the need for further research into the effectiveness of the vaccines in some groups, especially the over 65s. It also highlighted the need for the development of more effective vaccines in the future. While the LAIV vaccine is reported as being more effective, there is currently no high quality data on its effectiveness in age groups other than children aged six months to seven years.
Those recommended to have a flu jab by their GP should have no reservation in doing so based on this study.
The study was carried out by a collaboration of researchers led by the Centre for Infectious Disease Research and Policy at the University of Minnesota. Funding was provided by the Alfred Sloan Foundation.
The study was published in the peer-reviewed medical journal The Lancet Infectious Diseases.
The coverage of this story in the media was generally balanced, although many media outlets presented the finding that the flu vaccine used in this country is not 100% effective as new. It is a well-documented fact that the vaccine is not completely effective, and many studies have looked into this before now, finding different levels of effectiveness. The difference with this study is that it reviewed the body of research to date and carried out an overarching analysis of the findings from these studies.
This was a systematic review and meta-analysis that pooled the results of 31 studies assessing the effectiveness of the two most common types of flu vaccine used in the US and the UK. The researchers included studies that looked at vaccine effectiveness in any age group, which had confirmed the presence or absence of flu using reliable laboratory testing methods.
Systematic reviews aim to identify all relevant studies on a specific topic with the aim of reaching an overall conclusion based on all the evidence available.
The authors of this systematic review suggest that previous systematic reviews on flu vaccines have included many studies that did not adequately diagnose or confirm flu infection in participants. They aimed to address this weakness in this current systematic review by including studies with a more reliable assessment of flu infection.
The researchers searched databases of published scientific studies to identify randomised controlled trials (RCTs) and observation studies that looked at the effectiveness of flu vaccines i.e. how well the vaccine works in the real world. To be eligible, studies had to be published between 1967 and 2011, and looked at how successful the vaccines were at preventing flu infection against all circulating influenza viruses (of which there are many) during individual flu seasons. The researchers also included studies assessing the effectiveness of flu vaccine against pandemic flu.
Two common flu vaccines were assessed:
TIV is the most commonly used flu vaccine in the UK and accounts for about 90% of the vaccine given in the US.
Studies were only included if they used either a method of measuring cases of flu called real-time PCR (RT-PCR) or viral culture (a culture grown in a lab typically from a nasal swab) or both. These methods of flu detection were reported by the authors to be more accurate than other tests commonly used, such as a blood serum test.
The researchers screened 5,707 potentially eligible studies and identified 31 that were eligible for inclusion in the systematic review. This included 17 RCTs and 14 observational studies. The 17 RCTs contained data for 24 influenza seasons and 53,983 participants from 23 countries.
Where sufficient data were available, the researchers performed a meta-analysis, a method of statistically pooling the results of many studies. This was an appropriate method to summarise the overall effect of flu vaccine based on multiple studies.
The pooled results showed that TIV prevented seasonal flu in 59% (95% confidence interval [CI] 51 to 67%) of adults aged 18-65 years. Individual studies showed that this protection varied considerably between seasons. No eligible studies were available for TIV effectiveness for children aged 2-17 years or adults aged 65 years or over.
LAIV showed better results and was effective in 83% (95% CI 69 to 91%) of children aged six months to seven years. No pooled data was available for other age groups, and individual studies included in the analysis again showed significant variation in effectiveness between seasons.
Five studies assessed the effectiveness of flu vaccine for the prevention of pandemic flu strain H1N1 (swine flu). The pooled results showed that the vaccine prevented influenza in an average (median) of 69% of cases (range 60-93%). Comparatively few cases of influenza occurred in individuals aged 65 years or older.
The authors concluded that ‘in?uenza vaccines can provide moderate protection against virologically con?rmed in?uenza, but such protection is greatly reduced or absent in some seasons’.
The authors acknowledge that because they used quite strict inclusion criteria for their systematic review (to minimise the effect of bias and any effect of other influencing factors) there were ‘substantial gaps in the evidence base for some age groups.’ Most notably there was a lack of information on the 65-year and older age group, the main group recommended to have the flu jab in the UK.
This systematic review screened over 40 years’ worth of published studies. It serves to highlight a relative lack of high quality evidence on the effectiveness of flu vaccine in certain age groups, one of which is the over 65s. The review provides good evidence that the flu vaccine provides moderate protection against infection and illness for the majority of adults, but that it is not 100% effective.
One strength of the study is that it only included studies that used accurate methods of assessing flu infection. By doing this, the authors believe they have produced the ‘most accurate estimates of the efficacy and effectiveness of influenza vaccines’. While it is not possible to verify this claim, these results do provide valuable information to inform the current debate on how effective flu vaccines are, which is not a clear-cut issue.
The study has many strengths but also some limitations. These include:
Current flu vaccines are already known to not be 100% effective, but they remain the best intervention available for seasonal influenza at present, and people in at-risk groups should still be vaccinated. What this study highlighted is the need for vaccine developers to continue trying to produce more effective vaccines in the future and a lack of good quality evidence for the effectiveness of flu jab in people aged 65 years and over.
‘Limited’ flu jabs need to be improved, says study. The Independent, October 26 2011
Only six out of 10 protected by flu vaccine. The Daily Telegraph, October 26 2011
Flu vaccine ‘fails in 41% of adult patients’. Daily Mirror, October 26 2011
Current flu vaccines not good enough to beat global pandemic, says report. Metro, October 26 2011
Osterholm MT, Kelley NS, Sommer A, Belongia EA. Efficacy and effectiveness of influenza vaccines: a systematic review and meta-analysis. The Lancet Infectious Diseases 2011, Early Online Publication, October 26
Written by admin on Tuesday, October 25th, 2011 in Swine Flu.
According to the Daily Mail, a method of inducing labour that dates back to the 1930s “has been found to work as well as modern treatments but with fewer side effects”.
The news is based on a large Dutch trial that examined inducing labour using of a simple mechanical device, called a Foley catheter. Researchers tested the device against the use of hormone gels designed to trigger contractions. The study, which featured 824 women, found that both techniques led to similar rates of spontaneous vaginal deliveries, instrumental deliveries (such as using forceps) and women requiring a caesarean section.
The Foley catheter also seemed to lead to fewer side effects in the women and their babies, although using the method of induction in the first 24 hours led to longer labours. It is unclear which method women would prefer to be offered, as patient satisfaction was not assessed in this study.
Current guidelines from the National Institute for Health and Clinical Excellence (NICE) recommend the use of hormone gels for induction of labour, but not the routine use of mechanical devices for induction. This is because there was limited evidence for their use when the guidelines were written. This new, relatively large trial has shown no important differences between the two methods used in these women. It is possible that the mechanical technique might find a place for women where there may be risks from using hormone gel. The safety and effectiveness of the technique could be reassessed in the light of this new evidence to see whether the guidelines should be amended.
The study was carried out by researchers from various hospitals in the Netherlands and received no external funding. The study was published in the peer-reviewed medical journal The Lancet.
The Daily Mail covered this research well.
The researchers say that a high proportion of induced labours are performed because a woman’s cervix is not ready for the birth and does not open appropriately.
This randomised controlled trial compared two methods for inducing birth in women who had single babies and a reason to be induced. The women were either induced using mechanical means (a Foley catheter) or with application of a hormone gel into the vagina. A Foley catheter is a mechanical device that helps open the cervix. A fluid-filled balloon is inflated in the cervix, which stretches it until it is at an appropriate size to allow birth. The prostaglandin hormone gel mimics the natural mechanism by which a woman’s hormones cause the cervix to open.
The researchers say that hormonal induction has become the method of choice in several countries, but that use of the Foley catheter may result in similar numbers of successful inductions without the need for a caesarean section. They also say that that Foley catheter induction may have several advantages over hormone methods, such as not causing “over-stimulation” of the birthing processes (when hormones cause contractions to be too frequent or too long).
The researchers compared the two methods. They were particularly interested in the rates of caesarean section, but also looked at foetal distress during induction and bleeding after birth.
The trial was carried out in twelve hospitals in the Netherlands. The study included 824 women who were over 37 weeks pregnant without twins, who had an “unfavourable cervix”, whose baby was positioned head down and whose waters had not broken. The study did not include women who had already had a caesarean section or who had a condition called placenta praevia, where the placenta is positioned so that it grows over the cervix. Women whose baby had a developmental abnormality or a known hypersensitivity to either method were also excluded.
The women were randomly allocated to either the Foley catheter or the hormone gel groups. They were induced using these methods and, when the cervix was open sufficiently, their waters were broken. In both groups, if the cervix was still unfavourable after 48 hours, the women were assigned a day of rest followed by another 48 hours of induction. If after these five days the cervix was still unfavourable, induction was defined as having failed. Further management was decided on by the obstetrician looking after the women.
The main outcome that the researchers looked at was the rate of caesarean sections. Other outcomes included resorting to instrumental vaginal delivery (for example using forceps), reasons for operative delivery, and time from induction to delivery. The researchers also assessed whether the uterus had been overstimulated, defined as when the women experienced more than 6 contractions within 10 minutes for more than two 10-minute periods, or when they had a contraction lasting more than 3 minutes where the baby’s heart rate changed. Researchers also looked at rates of damage to the uterus, the use of painkillers and antibiotics, infection and whether the women had a haemorrhage in the 24 hours after delivery. Finally, they assessed the health of the baby and recorded any cases where the baby had picked up an infection.
The researchers found that the caesarean section rates were much the same between the two groups: 23% of women who had been induced using a Foley catheter required a caesarean section compared to 20% of the women induced using the hormone gel (relative risk [RR] 1.13, 95% confidence interval [CI] 0.87 to 1.47). Likewise, a similar number of women in each group needed extra mechanical help with the birth, such as the use of forceps (11% in the Foley catheter group and 13% in the hormone gel group).
A greater number of women induced with the Foley catheter required a caesarean because they failed to progress in the first stage of birth (12%) than the hormone gel group (8%) (RR 1.63, 95% CI 1.07 to 2.50). The first stage of labour is when contractions cause the neck of the uterus to open. Similar proportions of each group had a caesarean section because their baby was becoming distressed (7% in the Foley catheter group compared to 9% in the hormone gel group).
A similar number of women in each group had assisted deliveries because their babies were distressed. Fewer women in the prostaglandin hormone group (59%) needed an additional hormone called oxytocin to stimulate uterus contractions than in the Foley catheter group (86%). The time from the start of induction to birth was on average 29 hours (range 15-35 hours) in the Foley catheter group and 18 hours (range 12-33 hours) in the hormone gel group.
The groups did not differ in terms of painkillers taken, haemorrhage, overstimulation or health status of the baby. Fewer babies delivered with the Foley catheter (12%) needed to be admitted to the general ward (not an intensive care ward) than those induced using hormones (20%). More women treated with the hormone gel (3%) had suspected infections during birth compared to those induced with Foley catheter (1%).
Overall, there was no difference in the number of adverse events in each group.
The researchers said similar rates of vaginal delivery and caesarean section occurred when using the Foley catheter and the hormone gel for induction of labour in women who needed it. However, use of the Foley catheter led to fewer maternal and newborn side effects. They say that health professionals should consider a Foley catheter for induction of labour in women with an unfavourable cervix at full term of pregnancy.
This large randomised controlled trial showed no difference in caesarean or vaginal delivery rates after women were induced with either a Foley catheter or hormone gel. The Foley catheter seemed to be associated with fewer maternal and newborn side effects, although not all these associations were statistically significant. The researchers point out that one benefit of the method is that it reduces the need to monitor contractions as closely as with hormonal induction, which carries the risk of overstimulation. They also say that because of the low cost and easy storage of the Foley catheter, its use could be suitable in developing countries.
However, labour lasted longer following induction with the Foley catheter and it is unclear whether this would affect women’s preference for either of the induction methods. The researchers said that a limitation of the study was that they did not assess their patients’ satisfaction with the treatments. Another limitation is that the study did not assess whether this longer birth period would be more costly or use up more staff time. These unexplored factors could be important in deciding which method is more appropriate for a particular birth. Since the treatments appear equally effective, these are both important areas where further research might help clinicians choose between the two methods.
In the UK, NICE recommends that women with uncomplicated pregnancies should usually be offered induction of labour between 41 and 42 weeks of pregnancy to avoid the risks of prolonged pregnancy. There are other reasons to induce labour and the exact timing should take into account the woman’s preferences and local circumstances. NICE recommends the use of vaginal hormone gels and a pessary, but not the routine use of mechanical procedures. When the NICE guidelines were written (2008), they suggested that there should be further research into the use of mechanical methods in situations where hormone methods carried risks. The guidelines state that there had been a large number of studies, but that these were small and had used different methods, so they did not provide suitable evidence to support the recommendation of mechanical procedures.
This relatively large trial contributes to the available evidence, and is likely to be considered when labour induction guidelines are reviewed in the future.
Bringing on birth the 30s way ‘is safer’: Trial finds fewer side effects than with modern practices. Daily Mail, October 25 2011
Jozwiak M, Oude Rengerink K, Benthem M et al. Foley catheter versus vaginal prostaglandin E2 gel for induction of labour at term (PROBAAT trial): an open-label, randomised controlled trial. The Lancet, Early Online Publication, 25 October 2011
Written by admin on Tuesday, October 25th, 2011 in Swine Flu.
“Teens who down more than five cans of soft fizzy drinks a week are more likely to be violent or carry a weapon,” reported the Daily Mirror. It said that researchers believe the “sugar or caffeine content in carbonated, non-diet drinks could be to blame – although they admit there may also be other factors involved”.
Many newspapers covered this study of 1,878 high school students in the US. Researchers surveyed the teenagers on how many non-diet soft drinks they drank and their violent behaviour. Those who drank five or more cans of non-diet soft drinks a week were about 9 to 15% more likely to say they had been violent towards others in the past 30 days, or to have carried a weapon in the past year.
Despite the level of news coverage this study received, the results do not show that fizzy drinks cause violent behaviour. This is because the findings are from a single survey that assessed soft drink consumption and violence at the same time. As such, we cannot be sure which came first and therefore whether one could have contributed to causing the other.
It is important that we put these results into context. The participants may not represent all teenagers, as the study was based in schools and so may have not included the manifestly most violent teenagers who may have been excluded from school or those who had been incarcerated, it also excluded children at private schools.
The violence in this study also ranged from pushing someone to threatening them with a weapon, and no indication is given of how severe the average level of violence was.
The causes of violence are complex and unlikely to be simply due to the consumption of fizzy drinks.
The study was carried out by researchers from the University of Vermont and Harvard School of Public Health in the US. It was funded by the US Centers for Disease Control and Prevention. The study was published in the peer-reviewed medical journal Injury Prevention.
This story is covered in several newspapers. Though the reports included quotes from experts highlighting some of the limitations to this study, it could have been made clearer that the findings cannot tell us whether soft drinks cause violent behaviour.
This was a cross-sectional study assessing whether there is a link between soft drink consumption and violence among adolescents in the US. The researchers say some people think that diet, including level of sugar consumption, may be linked to antisocial behaviour. They say one theory that might explain such an association is that people who consume a lot of sugary drinks may do so because they have low blood sugar levels, which have been linked to irritability and violent behaviour.
This type of study assesses two factors at the same time, and does not tell us which came first. This means that it cannot prove that one factor caused the other.
The researchers surveyed a sample of 1,878 public high school students from Boston in the US. They asked them how often they drank non-diet soft drinks in the past week, and whether they had carried a weapon or engaged in physical violence with a peer group member. They then analysed the results to see if those who drank more sugary drinks were more likely to have engaged in violence.
The survey included students in grades 9-12, who would be aged about 14 to 18 years. Religious and private schools were not included in the survey, nor were schools where students were transitioning back to school following incarceration, or schools for disabled children. Of the eligible schools, 71% participated and about four classrooms were selected at random from each school, with one class sampled for each grade. Of the 2,725 eligible students, 69% participated and filled in the study questionnaire.
Students were asked how many non-diet soft drink cans (12 ounces or 355ml) they had drunk in the past week (a 20-ounce bottle was counted as two cans). Based on their answers they were grouped into those who drank up to four cans in the past week and those who drank five or more. The students also answered questions about whether they had been violent towards other adolescents, another child in their family or someone they were dating in the past 30 days. Violence was defined as:
They were also asked if they had carried a gun or knife anywhere in the past year.
In their analyses, the researchers compared violent behaviours between those who drank soft drinks more often and those who drank them less often. These analyses took into account factors that were also assessed in the questionnaire and could influence their results, including age, sex, race, body mass index (BMI), typical sleep patterns, tobacco use, alcohol use and having family dinners.
The researchers found that 29.8% of the participating adolescents reported drinking more than five cans of non-diet soft drinks each week, and 70.2% drank less than this. Adolescents who drank more than five cans a week were more likely to have used tobacco or alcohol in the past 30 days.
Overall, 30.8% reported carrying a gun or knife in the past year. In the last 30 days, 44.4% reported being violent to a peer, 19.5% being violent in a dating relationship, and 31.6% being violent to a child in their family.
Adolescents who drank more than ?ve cans of soft drinks in a week were signi?cantly more likely to:
The link between soft drink consumption and these measures remained even after taking into account factors, such as age, sex and race, which could influence results. The researchers found consumption of high quantities of soft drinks was associated with a 9 to 15% higher likelihood of engaging in violent behaviour or carrying a weapon. The link between high soft drink consumption and violence was similar to the links between violence and tobacco or alcohol use, which were associated with a 6 to 20% higher likelihood of engaging in violent behaviour. The link between high soft drink consumption and carrying a weapon (9% increase) was weaker than the link between tobacco or alcohol use and carrying a weapon (15 to 26% increase).
The researchers conclude that there was a strong link between soft drinks and violence. They say that this “may be a direct cause-and-effect relationship, perhaps due to the sugar or caffeine content of soft drinks, or there may be other factors, unaccounted for in our analyses, that cause both high soft drink consumption and aggression”.
This study has found a link between soft drink consumption and violent behaviour. However, there are a number of limitations to this study that need to be considered when interpreting its findings:
Explanations for links found in research might not always be causal. The researchers mention that low blood sugar may plausibly be linked to both aggressive behaviour and consumption of sugary drinks. This study raises questions about such unmeasured variables rather than providing answers.
The causes of violence are complex, and unlikely to be simply due to the consumption of fizzy drinks.
Fizzy drinks make kids violent claims study. Daily Mirror, October 25 2011
Fizzy drinks may lead to teenage violence. The Independent, October 25 2011
Two fizzy drinks a week can turn teens into thugs. Daily Express, October 25 2011
Just one can of fizzy drink a day will make teenagers behave more aggressively. Daily Mail, October 25 2011
Fizzy drinks make teenagers violent. The Daily Telegraph, October 25 2011
Solnick SJ, Hemenway D. The ‘Twinkie Defense’: the relationship between carbonated non-diet soft drinks and violence perpetration among Boston high school students. Injury Prevention 2011, Published Online First October 24