Such costs are generally justified in terms of collateral benefits for the population of the host city, both during the event and for years after – the so called “legacy” of the event.

However, Researchers in Glasgow – host of the 2014 Commonwealth Games – have searched through the sparse published and unpublished research on the topic and found little overall evidence that major multi-sport events provide health or socioeconomic benefits for the population of the host city.

They looked for studies on the long term effects of major sports events held between between 1978 and 2008 and came across very few papers – only 54 poor quality studies.

Five studies looked at the benefits on the host population in terms of health; more specifically, rates of suicide, paediatric health service demand, presentations for asthma in children (two studies), and problems related to illicit drug use. Overall, the data did not show a clear cut negative or positive health impact of major multi-sport events.

Of the studies that looked at whether sports participation in the population was affected, one found a decrease in the Manchester after the 2002 Commonwealth Games, whereas another reported upward trend in sports participation from the early 1980s to 1994 in association with the 1992 Olympic Games in Barcelona, Spain.

More studies – 18 in total – looked at whether big sports events improved economic factors, which in turn might have a positive effect on the health of the population; for example, by giving people the cash flow to pay their dentist’s fees or make healthy eating choices. But again the overall effect was unclear. Most studies did associate big sports events with an increase in economic growth and employment, but the studies often used lots of estimated data and didn’t collect the data very long after the event, so are hardly water tight. The more robust studies weren’t any more conclusive when looked at collectively – inflation increased in Barcelona and Atlanta in the run up to hosting the Olympic Games, but not in Sydney.

“The available evidence does not refute expectations of a legacy, positive or negative, but it does establish that very little is known about the impacts of previous large multi-sport events and, therefore, the possible impacts of future events,” conclude the authors. “This contrasts with official documentation used recently to promote such events,” they add curtly.

However, we Brits may not be throwing money down the drain by financing the next Olympic Games. As the authors of this study acknowledge, the research on the legacy benefits of major multi-sports events is patchy to say the least, hence why they were unable to draw any clear positive or negative conclusion. The London 2012 Olympics will be the first for which long term health and socioeconomic impacts will be explicitly measured, so should hopefully clear up whether or not hosting these big events really does benefit the local population.

Editorialist Mike Weed isn’t so sure that this effort will give us the evidence we need though, as he feels the measures being used for the 2012 event are not detailed enough. “The risk for the UK population is not that we will not get the benefits we want for our £150 a head investment in London 2012, but that there will be no robust evidence of what we have paid for,” he says.

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McCartney G et al. (2010). The health and socioeconomic impacts of major multi-sport events: systematic review (1978-2008). BMJ 340. DOI: 10.1136/bmj.c2369

The meta-analysis looked at fourteen randomised controlled trials that assessed the effects of oral sucrose, glucose, or another sweet solution compared with placebo (water) or no treatment during 1674 injections in infants aged 1-12 months.

Thirteen (92.9%) of the trials found that the sweet solutions reduced various behavioural indicators of pain, such as crying, during and after immunisation compared with placebo. In the fourteenth study, the effects of a sucrose solution were only evident during a single immunisation and not for the second and third injections. The pain reduction was largely seen after the procedure had been completed rather than during the procedure.

Although the sweet solutions reduced behavioural signs of pain, they had less of an effect on physiological signs: none of the studies found that glucose or sucrose solutions reduced heart rate in infants during immunisation. On the other hand, one study found that infants who received a glucose solution (and were allowed to suck on a dummy) had lower levels of cortisol, the stress hormone,in their saliva after immunisation than infants who received water (with or without a dummy).

When data from the studies were pooled, sweet solutions were found to reduce the incidence of crying by 20%, the proportion of crying time by 10%, and the duration of crying time by 12 seconds compared with placebo.

The 14 studies all used different volumes and concentrations of sucrose and glucose, so the authors were not able to determine an optimal dose of sweet solution to be used in infants during immunisation. However, the findings did imply that more concentrated sugar solutions – for example, 50% sucrose in water – are more effective.

The authors recommend that “sucrose or glucose along with other recommended physical or psychological pain reduction strategies, such as non-nutritive sucking [e.g. using a dummy], breast feeding or effective means of distraction, should be consistently utilised for immunisation.”

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Harrison D et al. (2010) Efficacy of sweet solutions for analgesia in infants between 1 and 12 months of age: a systematic review. Archives of Disease in Childhood DOI: 10.1136/adc.2009.174227

A hookah or shisha comprises an upright device with a small platform where tobacco, often flavoured, is burned, a metal body, a base half-filled with water, and a tube with a mouthpiece for inhaling.

Smoking tobacco using water pipes is an old Arabic tradition that is becoming more popular in the Western world, with an estimated 40% of US college students and 38% of British university students having ever used a hookah.

The rise in popularity is thought to be linked to the perception that smoking tobacco through a water pipe is harmless. However, water pipe smoke may contain greater amounts of tar and heavy metals, such as lead, than cigarette smoke and has been linked to lung cancer, heart disease, and infectious diseases.

In this study, the authors posted questionnaires to 1,208 18-24 year olds who lived in the Montreal area of Canada, 878 (73%) of whom responded and 871 (72%) of whom were included in the analyses.

A total of 204 participants (23%) reported having smoked tobacco using a water pipe in the past year. Among these water-pipe users, 78% smoked water-pipes less than once per month, 19% smoked 1-3 times per month, and 3% smoked 1-6 times per week. None used a water pipe every day.

Individuals who had used a hookah were younger, more likely to be male and not living with their parents, and had a higher household income than those who hadn’t, leading the authors to suggest that “Water-pipe users may represent an advantaged group of young people with the leisure time, resources, and opportunity to use water-pipes.” So hookah smokers are nice middle class kids with too much time on their hands then?

Compared with people who hadn’t used a water pipe in the previous year, those who had were more likely to have also used cigarettes and other tobacco products like chewing tobacco or snus and to have used alcohol, including having up to five or more drinks on one occasion (i.e. to a binge drinking level). Interestingly, a third of water-pipe users had not smoked cigarettes in the past year, perhaps using a hookah as a perceived “healthier” alternative.

Water-pipe users were more likely to have used marijuana (74% vs 35%) or other illicit drugs like speed or cocaine (33% vs 11%) in the past year, suggesting perhaps that smoking tobacco through a water pipe may act as a “gateway” to using more harmful substances. Nevertheless, the authors point out that the design of their study means no cause and effect inferences can be drawn between using a hookah and illicit drug use.
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Dugas E et al. (2010) Water-Pipe Smoking Among North American Youths. Pediatrics DOI: 10.1542/peds.2009-2335

Life isn’t all rosy on the pill though. The various different formulations have been associated with all sorts of side effects, the most issue being venous thromboembolism.

Now new research from female medical students in Germany has found that hormonal contraception such as the pill could also reduce sex drive.

Several previous studies have suggested that oral contraception might affect female sexual function, but overall the evidence as to whether they have a positive or negative effect is pretty mixed.

The researchers behind this study emailed female students at six medical schools in Germany and asked them to fill in an online questionnaire about their sexual function in the past four weeks and their usual means of contraception over the past six months.  A total of 1,086 women (15-20%) aged mostly under 25 years responded.

A total of 87.4% of women had used contraception in the previous 6 months, most of whom had used oral hormonal contraception (69.5%).

About a third (32.4%) of participants were considered at high risk of sexual dysfunction.  However, this figure actually isn’t too bad compared with a previous study of 78 female medical students in the US, which found that 63% were at high risk of sexual dysfunction.  Other larger studies put the rate at a more conservative 38% in Germany and 43% in the States.

When the sexual dysfunction data were analysed on the basis of single usual form of contraception (1,046 participants), women who used oral hormonal contraception or non-oral hormonal contraception were most at risk of having sexual dysfunction. Oral hormonal contraception was associated in particular with low desire and arousal compared with other forms of contraception and no contraception.

The authors suggest that the link between oral hormonal contraceptives and sexual dysfunction may be because oral contraceptives decrease the circulating levels of testosterone, “which is needed to (i) stimulate sexual desire and (ii) regulate genital blood flow and the structural and functional integrity of the genitals.”

Interestingly, smoking was associated with a lower risk of sexual dysfunction than not smoking, an effect the authors hilariously suggest might be down to the fact that “smokers might have greater ability to enjoy themselves.”

“This is a very important research investigation,” stated Dr Irwin Goldstein, Editor-in-Chief of Journal of Sexual Medicine, which published this study. “There are hundreds of millions of women, in particular young women at the beginning of their sexual lives, who regularly use hormonal contraception for many years. The irony is that these women are provided a medication that enables freedom from reproductive worries but these same women are not provided information that there are significant adverse sexual effects that may ensue.  Agents that interfere with the hormonal milieu of women may adversely affect their sexual lives.”

Don’t panic yet though, this study isn’t the final word and has various shortcomings, not least the possibly of participation bias – where women with perceived sexual problems might have felt more inclined to participate than women with no sexual problems – and reporting bias – where participants might have overestimated or underestimated the scale of their sexual difficulties.

Furthermore, the low response rate to the questionnaire (15-20%) means the study population probably isn’t a great reflection of all the female medical students at the eight schools studied, much less students worldwide, and, as the authors say, their stats suggest that “the factors considered can only explain a small fraction of the variability of total [female sexual function] scores.”

As it is, hormonal forms of contraception – both oral and non-oral – are the most successful forms around.  So I wouldn’t throw away your pills just yet.

• Put off oral hormonal contraceptives? Nature Medicine has an article on the 50th anniversary of the pill that highlights some possible alternatives under development.

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Wallwiener C et al. (2010) Prevalence of Sexual Dysfunction and Impact of Contraception in Female German Medical Students. Journal of Sexual Medicine DOI: 10.1111/j.1743-6109.2010.01742.x

Researchers in California have shown that sildenafil (Viagra) and a similar drug called vardenafil can improve the delivery of the chemotherapeutic drug Herceptin (trastuzumab) in women with breast cancer that has spread to the brain. Their studies in mice have found that PDE5 inhibitors help Herceptin cross the blood vessels of brain tumours into the heart of the cancer, thus improving the therapeutic efficacy of Herceptin for brain metastases from primary tumors.

Although only about 22,000 patients in the US are diagnosed with a primary brain tumor each year, nearly 10 times that many people develop brain tumors from cancers that began elsewhere in the body. For example, one study found that 36% of women receiving Herceptin for breast cancer developed brain metastases.

These secondary brain tumours are very hard to treat thanks to the fact that chemotherapy drugs can’t cross the walls of the tumour’s blood vessels – the blood-brain tumor barrier – and into the cancer. “Mother Nature created this barrier to protect our brains from dangerous substances, but here we need to get through the barrier to deliver the drugs, and that’s a problem,” said study author Julia Y Ljubimova, a research scientist at the Cedars-Sinai Maxine Dunitz Neurosurgical Institute in Los Angeles.  This means that drugs that can kill the primary tumour in the breast or lung aren’t effective on secondary tumours in the brain.

Ljubimova and her colleagues looked at the effects of PDE5 inhibitors on drug delivery in mice whose brains had been implanted with human lung and breast tumors. Oral administration of vardenafil to such mice doubled the uptake of Herceptin by brain tumours. Importantly, vardenafil had no effect on the uptake of Herceptin in neighbouring healthy tissue, an unfortunate effect of many chemotherapy drugs that is responsible for making cancer patients feel so awful and lose their hair.

Furthermore, combination treatment of mice with vardenafil and Herceptin increased the survival time of these mice by 20% compared with those that received Herceptin only.  This effect was only seen in mice whose brain tumours were positive for HER2, the growth factor targeted by Herceptin, and not those that were HER negative, indicating that the survival benefit was indeed due to an increase in the amount of Herceptin reaching the tumors.

“Now that we’ve demonstrated that big molecules can cross the blood-brain tumor barrier, we’re going to continue this strategy with other big molecule drugs, such as nanomedicine drugs” said Ljubimova. “This opens a new world for brain tumor treatments.”

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Hu J et al. (2010) Phosphodiesterase Type 5 Inhibitors Increase Herceptin Transport and Treatment Efficacy in Mouse Metastatic Brain Tumor Models. PLoS ONE 5 (4). DOI: 10.1371/journal.pone.0010108

Donations from living people only made up 37% of the total UK kidney transplant programme in the same period, and as such this approach represents a key method by which to increase the number of organs available.

But how do you convince someone to just give away a kidney?  One very controversial way is to pay donors. Given that kidneys from living donors work so much better than those from deceased donors, even giving donors pretty large payments (for example, $90,000/£58,600) is thought to be a cost-effective way to increase the supply of kidneys available for transplantation.

Unsurprisingly, this approach hasn’t really got off the ground because people are worried about donors blithely selling a kidney without adequately weighing up the risks just to get their hands on some “easy money” or payment disproportionally luring poorer donors. Also, there’s a chance that payments may dissuade altruistic donation or cause potential altruistic donors to request financial compensation.

A study of a hypothetical regulated US market for kidneys has addressed all three of these questions and concluded that “theoretical concerns about paying persons for living kidney donation are not corroborated by empirical evidence.”

The authors surveyed 342 commuters on regional rail and urban trolley lines in Philadelphia County using 12 fictional scenarios in which the risk of subsequent kidney failure in the donor (0.1%, 1%, or 10%), the payment ($0, $10 000, or $100 000), and the recipient of the kidney (either a close family member or the next eligible patient on the waiting list) were varied. Participants responded to each scenario by stating their willingness to donate a kidney on a five-point scale ranging from “definitely would not donate” to “definitely would donate.”

As would be expected, people were more willing to donate to a family member than to a stranger. Lower risk and higher payment also encouraged donation, in particular when the scenario covered donating to a stranger.

More interestingly, incremental household income affected willingness to donate independent of payment – people with a household income of $20,000 a year or less were much more likely to donate than those who earned $100,000 or more. As such, “poorer persons may contribute disproportionately to the supply of organs with or without payment.”

The promise of hard cash didn’t affect people’s perception of the risk involved in living kidney donation: “the magnitude of reductions in willingness to donate associated with increased risk for renal failure was virtually identical across payment levels.” And the effect of a bigger paycheck on willingness to donate was the same across all income strata.

Finally, the introduction of payment for organs did not reduce the level of altruistic donation. “We found no evidence that any of the three main concerns with a regulated system of payments for living kidney donation would manifest if such a market were established,” the authors conclude.

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Halpern SD et al. (2010) Regulated payments for living kidney donation: an empirical assessment of the ethical concerns. Annals of Internal Medicine 152 (6): 358-65. PMID: 20231566

As well as pushing plans on the economy, immigration, the environment and such like, the parties are also making promises regarding health and the NHS. But do you know one party’s policy from the other?

Independent health think-tank the King’s Fund has launched a fun interactive “election check-up” game to test your knowledge of where the three main parties stand on health policy.

Rebecca Gray, director of communications at The King’s Fund, said: “We wanted to inject some fun into our election activities while at the same time promote the more heavy-weight work we do in shaping health and social care policy.

“When we came up with the concept we knew the game would need to be fun and witty, but not too frivolous and definitely hold some informative value. The aim is to hook people into the issues and prompt them to visit The King’s Fund’s site to access our more in-depth resources.”

With dancing, yabbering “bobble head” figures of the leaders of the three main parties, the quiz is certainly entertaining. The quiz also includes plenty of facts I didn’t know.  For example, according to a MORI political poll, health is the second most important issue to voters, coming after managing the economy but topping education, unemployment, and immigration.

Shockingly I did quite badly – only four out of seven.  Even more outrageously, I didn’t recognize Andy Burnham‘s sultry gaze, but did spot Andrew Lansley‘s steely glare.

How did you get on with the quiz?  Are you already fully informed on the Labour, Tory, and Lib Dem health policies?  Or, like me, do you need to do some serious swotting before 6 May?

First, Sally spoke about the passing of the health reform bill in the US and all the BMJ‘s coverage of the legislation itself and the bill’s rocky passage. Then I covered a remarkable news story about a British boy who received fledgling trachea transplant built with his own stem cells that then grew into a fully functioning organ within his body.

I’ve always had trouble with public speaking and being articulate during presentations, so I was very nervous about doing my first podcast.  Despite our countless rehearsals, Sally and I both found it quite hard to simultaneously speak fluently and get all the facts into our segments.  The experience was a lot of fun though and I think the finished product turned out OK.  Have a listen and let me know what you think.

BMJ Podcast 26 March 2010: Variolae Vaccina

It seems that backpackers in Oz aren’t just looking for fun and sun though – according to a new study they’re also looking for flings, and are bringing sexually transmitted diseases with them.

Research published in the journal Sexually Transmitted Infections has found that international backpackers in Sydney had a higher number of sexual partners and drunk more alcohol than native Australians. Backpackers also had higher rates of chlamydia and more previous sexually transmitted infections than locals.

The authors of this study retrospectively looked through the medical records at the Sydney Sexual Health Centre and identified 5,702 backpackers – people who had been born outside of Australia and been in the country for less than two years – and 7256 comparison patients – natives or people who had lived in the country for longer than 2 years. The average age of the backpacker group was 25 and almost half had come from the UK.

Backpackers were twice as likely to report drinking alcohol at hazardous levels than were comparison patients. More than a quarter (27%) of female backpackers reported drinking more than 17.5 units of alcohol a week, equivalent to about eight glasses of wine, whereas only 14% of comparison women drank at this level. A total of 17% of male backpackers drank more than 35 units of alcohol a week, roughly 15 pints of beer, compared with 5% of comparison men.

About 40% of backpackers reported having had two or more sexual partners in the previous 3 months, compared with 30% of comparison patients.  Interestingly, condom use was low in both the backpacker group and the comparison group: two thirds of each group reported having had unprotected sex.

When it came to rates of sexually transmitted infections, backpackers were more likely to be diagnosed with chlamydia (7% vs 5%) and have a history of sexually transmitted infections (15% vs 10%).  However, locals were more likely to have genital warts.

The authors point out the public health implications of their findings – international backpackers are a potential risk population for either acquiring sexually transmitted diseases or transmitting them to other travellers or local residents.  “Although we could not determine the extent of the risk of transmission to local residents from our study,” they say, “it has been demonstrated that being born overseas or having a partner from overseas was a risk factor for chlamydia infection in Sydney women.”

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McNulty A et al. (2010) The behaviour and sexual health of young international travellers (backpackers) in Australia. Sexually Transmitted Infections DOI: 10.1136/sti.2009.038737

But it’s not just a case of “all publicity is good publicity.” Research published recently in Archives of Internal Medicine has shown that newspaper and magazine stories on cancer tend to focus on survival and aggressive treatments but steer clear of covering treatment failure, side effects of treatment, end of life care, and death.

The authors of this study looked at 436 500-word articles from top American newspapers and magazines, such as Chicago Tribune, New York Times, Newsweek, and Time. The 312 newspaper articles and 124 magazine pieces largely covered breast cancer (35.1%) and prostate cancer (14.9%), two of the most common types of cancer in the US.

Articles were more likely to focus on people who had survived or been cured of cancer than on people who had died of the disease (32.1% vs 7.6%).  In fact, those articles that covered individual patients (173 articles; 216 individuals), more than three quarters covered success stories and only a fifth told the story of someone who had died of cancer.

Few articles (13.1%) pointed out that aggressive treatments such as chemotherapy can fail or that late stage cancer can be incurable. Moreover, less than a third highlighted the side effects associated with such treatments, like pain, hair loss, and nausea.

Only two articles (0.5%) exclusively covered palliative or hospice care for when treatment options had run out, whereas more than half (57.1%) instead focused solely on aggressive treatment.

Given that one in every two men and one in every three women in the US will be diagnosed with cancer in their lifetime, half of whom will die from their cancer or related complications, this optimistic skew in media reporting of cancer is somewhat misleading.

Cancer news coverage is known to affect the beliefs and behaviours of patients; for example, media coverage of mammography screening is known to increase the use of mammography in women. As such, “The tendency of the news to report on aggressive cancer treatments and survival but not on alternatives is also noteworthy given that unrealistic information may mislead the public about the trade-offs between attempts at heroic cures and hospice care,” say the authors.

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Fishman, J., Ten Have, T., & Casarett, D. (2010). Cancer and the Media: How Does the News Report on Treatment and Outcomes? Archives of Internal Medicine, 170 (6), 515-518 DOI: 10.1001/archinternmed.2010.11