Tough EU smoking rules approved

By James Gallagher
Health and science reporter, BBC News

Man smoking

Anti-smoking legislation is to be introduced across the European Union in an attempt to cut the number of smokers by 2.4 million.

The rules, voted in by the European Parliament, mean picture health warnings will have to dominate the front and back of all packaging.

There will also be a ban on flavoured, such as menthol, cigarettes.

Pro-smoking groups have criticised a “nanny state mentality”, but cancer charities have backed the measures.

An estimated 700,000 premature deaths are caused by smoking across the EU each year.

The EU Tobacco Products Directive rules include:

  • picture warnings must cover 65% of the front and back of every packet of cigarettes, with additional warnings on the top of the pack
  • a ban on “lipstick-style” packs aimed at women – all packs must have at least 20 cigarettes to leave room for health warnings
  • roll-your-own tobacco packs to have similar picture warnings
  • a ban on promotional elements, such saying “this product is free of additives” or is less harmful than other brands
  • a ban on flavoured cigarettes, such as menthol, fruit and vanilla
  • a maximum nicotine-concentration level for e-cigarettes.
  • EU-wide tracking of cigarettes to combat illegal trade

Ministers are expected to endorse the rules in March, to come into force in May 2014. Member states will have two years to introduce the legislation.

‘Great day’

The European Commission says the new rules will “deter young people from experimenting with, and becoming addicted to, tobacco” and should lead to a 2% drop in the amount smoked over the next five years.

EU Health Commissioner Tonio Borg said: “Today is a great day for EU health policy.

“The new rules will help to reduce the number of people who start smoking in the EU.

“These measures put an end to products which entice children and teenagers into starting to smoke in the European Union.”

Simon Clark, the director of the pro-smoking campaign group Forest, said banning menthol cigarettes was a ban on consumer choice that “will do little” to deter children from smoking.

He also questioned the need for plain packaging legislation to remove any branding from packs, which is being considered in some EU countries, including the UK.

Uniform packaging in AustraliaUniform or plain packs have been introduced in Australia

“If health warnings are going to be even more prominent, dominating both sides of the pack, why on Earth do we need plain packaging?” he asked.

“At the very least the government should wait and see what impact the larger warnings have before introducing standardised packs which are opposed by so many people.”

The commission said plain packaging could go ahead when “justified on grounds of public health”.

Cancer Research UK’s head of tobacco policy, Alison Cox, said: “Today is a great day for health. The Tobacco Products Directive sets standards on tobacco which will bring real benefits for people’s health in the UK and across Europe.”

Archie Turnbull, the president the Smoke Free Partnership, said: “Today marks a genuine turning point for European tobacco control – and a huge stride towards a tobacco-free Europe.”

England’s Public Health Minister, Jane Ellison, said: “Today’s vote in the European Parliament to support new Europe-wide controls on tobacco is good news for people’s health.

“The Government is serious about reducing smoking rates and in particular stopping children from taking up smoking. I am very pleased that we have made a significant step towards further tough action on tobacco in the UK and across Europe.”

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Prenatal acetaminophen exposure linked to ADHD risk

(Reuters Health) – Children born to women who take acetaminophen during pregnancy may be at increased risk of attention deficit hyperactivity disorder (ADHD) and similar behavioral problems, new findings suggest.

The study does not show that prenatal exposure to the medication causes ADHD, and the increase in risk is small, Dr. Jorn Olsen, one of the study’s authors, told Reuters Health.

Nevertheless, “it’s reasonable to say that there’s no reason to use these drugs during pregnancy unless there is a clear medical indication,” said Olsen, a professor of epidemiology at UCLA and at Aarhus University in Denmark.

Acetaminophen, or paracetamol, has been available over the counter since the 1950s, Olsen and his colleagues note in their report in JAMA Pediatrics.

While the medication is widely considered to be safe to use during pregnancy, they add, recent studies have shown it can disrupt hormone function in pregnant rats and mice.

Given that hormones play a key role in guiding fetal development, the researchers decided to investigate whether acetaminophen exposure might be related to ADHD risk. They looked at 64,322 children and mothers enrolled in the Danish National Birth Cohort between 1996 and 2002.

More than half – 56 percent – of mothers reported using acetaminophen during pregnancy.

Children born to these women were 37 percent more likely to be diagnosed with hyperkinetic disorder (HKD), a severe form of ADHD. They were 29 percent more likely to be prescribed ADHD medications, and 13 percent more likely to exhibit ADHD-like behaviors at age 7.

The acetaminophen-ADHD link was stronger for women who used the medication during more than one trimester of pregnancy, and increased with the frequency of exposure.

Five to six percent of babies born today will develop ADHD symptoms during their lifetimes, Dr. Olsen noted; based on the current findings, that risk would increase to about 7 percent for children exposed to acetaminophen prenatally.

“It’s still a modest increase,” he said. “For the women that are taking these drugs there are no special reasons for concern….for women who are pregnant and who have not taken these drugs, I think that the take-home message would be a lot of the use of these particular drugs during pregnancy is not really necessary.”

An editorial accompanying the study pointed out that Olsen’s team adjusted for things that might have also influenced fetal development, such as the mothers’ inflammation or fever, while possibly explaining why the women took acetaminophen. But the researchers could not account for every reason the women took acetaminophen, so more study is needed.

Pregnant women should consult their physician about whether or not they should be taking acetaminophen during pregnancy, one of the editorial’s coauthors, Dr. Kate Langley, told Reuters Health.

Even if acetaminophen exposure does turn out to have a causal relationship with ADHD, she added, it is only one of many environmental and genetic risk factors involved in the disease, said Langley, a professor of psychology at Cardiff University and the MRC Center for Neuropsychiatric Genetics and Genomics.

“In terms of research, it’s definitely something that should be followed up, but it’s the first step on a long road to try to determine how we should interpret these findings,” she said.

SOURCE: and JAMA Pediatrics, online February 24, 2014.

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Receipts may be source of endocrine disruptor: study

(Reuters Health) – Handling receipts may increase the body’s level of a chemical that has been linked to reproductive and neurological problems, suggests a new small study.

The researchers write in JAMA that bisphenol A – commonly known as BPA – typically enters the body when people eat food from a can. But it can also be absorbed through the skin from receipts, according to the study’s lead author.

“It’s not the main source of exposure, but it’s an additional source that wasn’t previously recognized,” Dr. Shelley Ehrlich of the Cincinnati Children’s Hospital Medical Center in Ohio told Reuters Health.

BPA is used in the process of making hard plastics, and has been banned from use in manufacturing baby bottles. The chemical is also used in the interior lining of many food cans.

The chemical can leach into foods that are stored in such containers and eventually end up in the body when people eat the food. More recent research has found that people can also end up with increased BPA levels after touching materials containing the chemical.

BPA is in thermal paper, which used to be a mainstay in fax machines and is still commonly used for receipts.

Thermal paper is coated with a material that turns black when heat is applied. At the cash register, the printer applies small amounts of heat to create numbers and letters.

BPA is chemically similar to the hormone estrogen, and is thought to mimick that hormone’s effects in the body, making it a member of a class of chemicals known as “endocrine disruptors.”

In the past, BPA has been linked to a number of health problems, including reproductive disorders and brain development anomalies among children exposed in the womb.

Higher levels of BPA in urine have also been tied to an increased risk of obesity among children (see Reuters Health story of Sep. 18 here:

For the new study, Ehrlich and her colleagues recruited 24 Harvard School of Public Health students and staff between 2010 and 2011. The participants were at least 18 years old and not pregnant.

First, the participants were asked to handle receipts for two hours with their bare hands. After at least one week, they were asked to handle receipts again while wearing gloves.

Before they handled the receipts, the researchers found that 20 of the 24 participants’ urine samples had small but measurable amounts of BPA. After the first experiment, BPA was present in all urine samples, though at levels that remained within national averages.

The concentration of BPA in the urine samples had increased, though by an amount equivalent to about a quarter of what would be expected from eating canned soup, for example.

After waiting a week and having the participants handle receipts for two hours while wearing gloves, the researchers found no significant increase in the BPA levels in the participants’ urine samples afterwards.

Ehrlich said the average person should not be alarmed by the findings, but cashiers and bank tellers who handle receipts throughout the day may want to take precautions – especially if they’re pregnant or of child-bearing age.

“Handle receipts with care,” she said. “They are a source of exposure to BPA and if people are handling them a lot on a daily basis . . . they should perhaps consider using gloves for now.”

In the current study, the researchers used nitrile gloves. Ehrlich said additional research would be needed to determine whether latex or other types of gloves also work.

She also said people may want to wash their hands after handling receipts.

“I don’t think people should be super alarmed, but they should be aware,” she said.

SOURCE: JAMA, online February 25, 2014.

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NHS staff say care 'good enough'

By Michelle Roberts
Health editor, BBC News online

nurse and patient

More than two-thirds of NHS staff would recommend the care on offer at their local trust to their own friends and family, an annual poll shows.

Of 203,000 staff questioned for the 2013 NHS survey, 65% said care was fit for relatives, 24% were unsure, while 11% would not recommend the service.

The survey included GPs, ambulance staff, nurses, midwives and dentists as well as other health professionals.

There were improvements on the previous year in 21 of the 28 poll categories.

Some 90% of staff believed their job makes a difference to patients, 78% are satisfied with the quality of work and patient care they are able to deliver, and 68% say in their role they are able to contribute improvements to the organisation.

Compared with 2012, more said there was good communication between staff and management, and more were being appraised and getting appropriate health and safety training.

‘Could do better’

But work-related stress was up slightly, with more than a third saying they had experienced it in the last 12 months.

And a third said they had witnessed or reported potentially harmful errors or near-misses at work in the last month.

Only 56% of staff said hand-washing materials – such as soap – are always available, with the figure being 59% in acute hospital trusts.

Some 15% said they had been the victim of violence in the last year from visitors, patients or relatives, 28% had been bullied or abused by the same group, and 11% suffered workplace discrimination.

Sue Covill of NHS Employers said abuse and harassment of workers from patients and the public was a concern and more needed to be done to protect staff.

But she said many of the survey’s other findings were encouraging.

“Staff feeling valued and being valued is absolutely vital to the effective delivery of patient care and we believe it is an important factor behind many of the positive results.”

Peter Carter of the Royal College of Nursing was more critical, saying: “Only 30% of staff feel that there are enough staff to enable them to do their jobs properly and high numbers of nurses in particular continue to work extra hours. (82% compared with 81% the previous year.)

“Some 68% of staff have attended work while not being well enough to perform their duties in the last three months alone. It is hardly surprising that there has been an increase in work-related stress.

“Clearly, nurses and other staff are working hard to ensure that patient care is delivered. However, it is simply not sustainable to have staff stretched too thinly and working beyond breaking point.”

Health Secretary Jeremy Hunt said: “NHS staff have some of the hardest and most respected jobs in our country. It is good to see that more staff would recommend the NHS as a place to work and would want friends and relatives to be treated where they work.

“But we know we need to do even more and our response to the Francis report set out how the NHS can promote openness and support staff to raise concerns in order to protect patients and give high quality care.”

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Teen pregnancy rate 'lower still'


The number of teenage pregnancies in England and Wales has continued to drop, latest figures show.

Office for National Statistics data show the under-18 conception rate is the lowest since 1969 at 27.9 conceptions per 1,000 women aged 15-17.

This is a drop of 10% on the previous year, but experts say it is not enough to bring the UK in line with other western European countries.

At the same time, the conception rate among women over 35 has been rising.

Since 1990, the conception rate for women aged over 40 has more than doubled from 6.6 to 14 conceptions per 1,000 women.

The data also revealed a continuing rise in the number of pregnancies and births outside marriage.

Ann Furedi, chief executive of the British Pregnancy Advisory Service, said: “These statistics demonstrate the trend towards older motherhood is continuing.

“We see many younger women who are choosing to postpone starting their family for a number of reasons – some have not met the right partner, whereas others want to wait until they have greater financial security, a home of their own, or progressed further in their chosen career.

“It is important that reproductive healthcare services, whether providing contraception, abortion or maternity care, reflect this shift.

“While pregnancy and childbirth for older women may present particular challenges, with some mothers requiring additional support, the answer is to provide the services that they need, rather than attempt to cajole women into having children earlier than they feel is right for them.”

Alison Hadley, an adviser to Public Health England on teen pregnancy, said: “Continued investment and dedication over the last 10 years has paid real dividends but the England under-18 conception rate remains higher than other western European countries.

“We need to find ways to both sustain the significant reductions we’ve made and accelerate progress.

“Evidence and lessons from local areas shows us young people need comprehensive sex and relationship education in and out of school, easy access to young people-centred contraceptive and sexual health services, and targeted support for those most at risk.”

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Baby's ventilator 'removed too soon'

Rohan Rhodes

Rohan Rhodes was born 14 weeks early

A premature baby’s ventilator was removed too soon by hospital staff, his parents told an inquest into his death.

Rohan Rhodes from Narberth, Pembrokeshire, was born 14 weeks early at Singleton Hospital, Swansea, in 2012 and was transferred to St Michael’s Hospital, Bristol, for surgery.

Alex and Bronwyn Rhodes told the coroner’s court near Bristol that Rohan’s feeding tubes were inserted “aggressively” and caused him pain.

Their son died aged five weeks.

Mrs Rhodes told the inquest at Flax Bourton she was initially delighted Rohan had been taken off the ventilator, but Mr Rhodes believed “something wasn’t right” with the boy’s care.

Rohan RhodesThe inquest was told Rohan’s feeding tubes were inserted ‘aggressively’ and caused him pain

The couple said they were concerned a nurse did not wear gloves when handling Rohan’s feeding tube and became worried a day later when he looked exhausted and his oxygen dependency had increased.

Mrs Rhodes said her son was a healthy and active baby, despite being premature, and had consistently put on weight after he was born.

Watching in ‘horror’

A team of leading doctors had told the couple they had no plans to stop Rohan’s ventilation during a handover meeting the day after he was admitted.

But he was later removed from the machine and placed on a breathing mask.

His conditioned worsened and his heart rate began to fall, the inquest heard.

Mrs Rhodes said: “We were terrified and were watching all this in horror. He was so pale and lifeless during this time, we were terrified we were losing him.”

Bronwyn Rhodes

Bronwyn Rhodes spoke to reporters after the first day of the inquest

Doctors apologised and he was put back on the machine, but he never recovered and was unable to have surgery he needed to repair an open heart duct.

Recalling her son’s final moments, Mrs Rhodes wept: “I asked them to stop compressions, but they were not able to remove all the lines so I couldn’t hold him.

“He died in his incubator, swollen beyond belief.”

A pathologist told the inquest he found multiple perforations to Rohan’s bowel and said the likely cause of death was acute peritonitis and pneumonia.

The hospital is part of the same trust as Bristol Children’s Hospital, which is the subject of a new investigation into the deaths of several children over the past three years.

Robert Woolley, chief executive of University Hospitals Bristol NHS Foundation Trust, said: “We would like to offer our sincere condolences to the Rhodes family for the loss of their son, Rohan.

“The coroner will conduct a thorough and independent inquiry into the death of this child and we are committed to working with her to provide all the information she needs to do this.

“It would not be appropriate for us to comment further until the inquest has concluded.”

The hearing continues.

Rohan's coffin was made by his father using wood intended to make his first cotRohan’s coffin was made by his father using wood intended to make his first cot

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U.S. insurers say proposed Medicare cuts less than feared

A trader points up at a display on the floor of the New York Stock Exchange August 20, 2012. REUTERS/Brendan McDermid

A trader points up at a display on the floor of the New York Stock Exchange August 20, 2012.

Credit: Reuters/Brendan McDermid

(Reuters) – U.S. health insurers including Humana Inc said on Monday that the government’s proposed cuts to privately run Medicare programs appear to represent a funding decline of around 4 percent, less than the possible cuts of 7 percent or deeper that analysts had been expecting.

Shares of most insurers rose on Monday, with Humana leading the pack, up 9.2 percent at $112.29 on the New York Stock Exchange in early afternoon. Shares of UnitedHealth Group Inc were up 2.8 percent at $75.91 and Aetna Inc was up 2.6 percent at $72.24.

The U.S. Department of Health and Human Services late on Friday released its proposal for 2015 Medicare Advantage funding. The 148-page document includes details that the companies use to calculate the government funding for the program and to set next year’s premiums.

Analysts and some companies said on Friday their first look indicated that the cuts would be worse than the 7 percent expected by the industry, and would require deeper reductions in benefits for the program’s elderly beneficiaries. Shares of insurers fell in after-hours trading on Friday.

Republican lawmakers said the proposed funding was too low and would hurt the elderly and disabled, adding to the party’s criticism of President Barack Obama’s healthcare reform law. The Patient Protection and Affordable Care Act requires some cuts in Medicare funding and also introduces new taxes and fees.

More than 15 million of nearly 50 million Americans eligible for Medicare are enrolled in Medicare Advantage plans, which are managed by private insurers.

Insurer shares were higher on Monday as the view changed to a “less-worse” outcome, according to CRT Capital’s Sheryl Skolnick. Insurers will likely lobby for less of a cut, but even if they fail to get it, she said, “it’s not the disaster people thought it could be.”

Humana said in a regulatory filing on Monday that its analysis showed the proposed funding included cuts of about 3.5 percent to 4 percent. It had told investors earlier this month that it was anticipating a cut of 6 percent to 7 percent.

The company said the funding calculation includes a positive effect of 3.25 percent from an increasing number of younger, healthier baby boomers in the mix of Medicare recipients.

Humana also said that its analysis excluded risk assessments that it planned to protest and which could potentially result in additional significant funding declines. The government is expected to release final Medicare payment rates on April 7.

An executive at another Medicare Advantage provider said on Monday that his company was also interpreting the proposal as a cut of about 4 percent. When the document was released on Friday, the company initially viewed the cut as 8 to 10 percent, but after further analysis over the weekend it found that the proposal actually included an unexpected increase in payments related to the baby boom population. The executive requested anonymity because he was not authorized to discuss the matter.

A spokeswoman for Aetna said her company was still evaluating the rate notice, but that it believed any cuts on top of last year’s 6 percent would disrupt the Medicare Advantage program and be harmful to seniors.

One analyst, Ana Gupte of Leerink Research, said she believes the proposal represents a proposed cut of up to 7 percent but that industry lobbying will reduce the cut to 3.5 to 4 percent in the final rule.

(Reporting by Caroline Humer in New York; editing by Bernadette Baum and Matthew Lewis)

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Anti-gay communities linked to shorter lives: study

(Reuters Health) – People who are gay, lesbian or bisexual tend to die earlier in communities where citizens are less accepting of same-sex relationships, according to a new study.

“The size of the relationship between anti-gay prejudice and mortality was large,” Mark Hatzenbuehler told Reuters Health.

“This research indicates that reducing prejudice may improve the life expectancy of sexual minorities in the United States,” he added in an email.

Hatzenbuehler is the study’s lead author from the Mailman School of Public Health of Columbia University in New York.

He and his colleagues write in the journal Social Science and Medicine that although it has been thought that the amount of prejudice or stigma in a community is tied to the health of its residents, it has been hard to measure stigma.

To give that a try, the researchers used data from the General Social Survey, which was conducted annually beginning in 1972 and then every other year after 1994.

The survey asked a group of U.S. adults about their social attitudes, including anti-gay prejudice, through questions such as, “Do you think that sexual relations between two adults of the same sex is always wrong, almost always wrong, wrong only sometimes, or not wrong at all?”

Participants were also asked whether their sexual partners were exclusively male, female or both.

Hatzenbuehler’s team linked responses from participants surveyed in 1988 through 2002 to national death records to see how many had died by 2008 and whether there were differences tied to the amount of anti-gay stigma in their communities.

Overall, there were data from 21,045 people. Of those, about 4 percent said they had been involved in same-sex relationships.

By the end of the study, about 92 percent of people from low-stigma areas who said they were lesbian, gay or bisexual were alive, compared to about 78 percent of those from high-stigma areas.

The difference translates into a shortened life expectancy of about 12 years in high-stigma communities, according to the researchers.

Heart disease, suicides, murders and violence appeared to be responsible for the shortened life expectancy.

“These are the specific causes of death that are elevated among sexual minorities living in high-prejudice communities, and they provide information on potential mechanisms or explanations for why sexual minorities living in these communities had increased risk of mortality,” Hatzenbuehler said.

For example, he and his colleagues write that one possibility is that experiencing discrimination, prejudice and being marginalized creates stress. That may be an indirect way that stigma contributes to early deaths.

HIV, AIDS and behaviors such as smoking and drinking did not appear to be behind the shorter life expectancies.

What’s more, the researchers found that people who reported only opposite-sex relationships also tended to have shorter lives if they lived in high-stigma communities rather than low-stigma ones.

It’s too early to say why there would also be a link between stigma and life expectancy among the sexual majority, according to Hatzenbuehler.

In a separate study published in the American Journal of Public Health, Hatzenbuehler and his colleagues found that people who were straight and had high levels of anti-gay prejudice died about three years earlier than straight people without such strong anti-gay feelings.

“This adds to a very large literature that Dr. Hatzenbuehler cites in his paper that prejudice is bad for your health when you experience it,” Ron Stall told Reuters Health.

Stall, who was not involved with the new study, is the director of the Center for LGBT Health Research at the University of Pittsburgh Graduate School of Public Health.

“If you buy the idea – and the evidence is getting stronger and stronger – that this kind of stigma is worsening the health of the sexual minority population, then you can think of things we can address to make it stop,” Stall said.

Those include enforcing anti-bullying laws, supporting the creation of gay-straight alliance groups in schools and advocating for civil rights protections, he said.

Stall said the fight against anti-gay stigma is in the pursuit of life, liberty and happiness.

“Dr. Hatzenbuehler’s paper shows it’s literally in the pursuit of life,” he said.

SOURCES: Social Science and Medicine, online June 18, 2013 and American Journal of Public Health, online December 12, 2013.

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REACT clinical trial provides valuable new insights for community gastroenterologists that benefit patients

The final results from an international clinical trial involving nearly 2,000 patients with Crohn’s disease support the use of a new management strategy referred to as accelerated step-care as a best practice for the care of active Crohn’s disease. The REACT (Randomized Evaluation of an Algorithm for Crohn’s Treatment) study, led by Robarts Clinical Trials at Western University (London, Canada) provides valuable new insights for community gastroenterologists which should benefit patients. The results of the study will be presented at the European Crohn’s and Colitis Organisation (ECCO) annual congress taking place in Copenhagen, Denmark on February 20-22, 2014.

Crohn’s disease is a chronic, potentially debilitating, condition of the gastrointestinal tract which can cause abdominal pain, diarrhea, vomiting, and weight loss among other symptoms. Well over five million people globally are affected by Crohn’s disease and ulcerative colitis.

Dr. Brian Feagan, CEO and Senior Scientific Director of Robarts Clinical Trials and a professor in the Division of Gastroenterology at Western’s Schulich School of Medicine & Dentistry, says the medical management of Crohn’s disease has undergone important changes over the past two decades with the introduction of TNF antagonists such as adalimumab and infliximab. The current treatment approach features sequential and incremental treatment intensification based on symptoms. In contrast, an accelerated step-care approach involves the early introduction of combined immunosuppression in high risk patients, which has been shown to induce and maintain remission, reduce the use of corticosteroids, and heal intestinal ulceration in those who fail conventional treatment.

Subsequent research, performed in both Crohn’s disease and rheumatoid arthritis, indicated that TNF antagonists work best when: 1) used in combination with antimetabolites (e.g., azathioprine, methotrexate) and 2) introduced early in the course of the disease. Controlled studies such as CHARM (Crohn’s Trial of the Fully Human Antibody Adalimumab for Remission Maintenance) have also demonstrated that TNF antagonist-based regimens can reduce the rate of surgery and hospitalization in comparison to conventional therapy.

“However, adoption of these key concepts by community gastroenterologists has been relatively slow,” says Dr. Feagan. “This is primarily because many believe that the safety and efficacy of these agents may not be generalizable to their individual practice, since they were tested in academic centers. The REACT study was designed to address these concerns.”

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