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INSIDE HEALTH

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Programme 4.

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TX:听 14.10.14听 2100-2130

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PRESENTER:听 MARK PORTER

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PRODUCER:听听GERALDINE FITZGERALD听

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Porter

Hello.听 We鈥檝e an eclectic mix for you today. Coming up in the next half hour:听 Ankle pain - we meet a surgeon taking part in the world鈥檚 first ever trial into the best way to treat advanced osteoarthritis of the ankle. Do you fuse the joint, or do you replace it?

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Hypochondriac - we answer a listener鈥檚 question as to the origins of the term.

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And the menopause - does this ring any bells?

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Music 鈥� Fascinating Aida

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Hot flushes.听 I will be talking to a leading authority on HRT to find out how it should be used to help women struggling with them.

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And we investigate Guillian-Barre Syndrome - a rare but fascinating cause of paralysis.

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Clip

When I came to in ICU my family told me that I had been totally paralysed, I had no impression in my face and I couldn鈥檛 move my mouth, so I couldn鈥檛 even mouth words at them.

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Porter

But first, how confident are you when it comes to deciding if your child should have a day off school when they are ill? Well a new booklet issued to parents in South Wales - A Parent鈥檚 Guide to Managing Sickness Absence from School - has caused some upset according to reports in the press. Inside Health鈥檚 Dr Margaret McCartney has been following the story. Margaret I have got the booklet here and it all looks to be something of a storm in a teacup - the guidance actually looks quite good to me.

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McCartney

I agree, I see this as something that should liberate parents.听 So, for example, when it says that the recommended time off school for conjunctivitis is none, that means that parents are able to send their children to school with conjunctivitis if they feel that the child is otherwise well.听 It鈥檚 not saying that all children with conjunctivitis should go to school, it鈥檚 just saying that you don鈥檛 need any time off school if you have conjunctivitis.

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Porter

So looking at the leaflet here, I鈥檝e got a few things like you mentioned conjunctivitis, glandular fever, no reason for the child to be off school, head lice, threadworm, tonsillitis and then there are few things where you do have to be off school 鈥� so impetigo, until the lesions are crusted or healed; German measles, six days from the onset of the rash etc. etc.听 So it鈥檚 quite a useful guide but what you鈥檙e saying is parents are seeing this as saying if your child鈥檚 got glandular fever he or she has to be at school, it鈥檚 not an excuse?

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McCartney

This kind of guidance has actually been around for almost a decade, the Health Protection Authority were always a place that I went out to print out the information to give to parents.听 So it was always a really useful sheet, you can now get it from the Public Health England website.听 But what鈥檚 really important is on this leaflet it says:听 鈥淎 number of illnesses can be classified as minor health conditions and whether you send your child to school will depend on how ill you deem your child to be鈥�.听 So this is guidance, it鈥檚 only guidance and the prime position here is the parents鈥� responsibility to decide whether or not they think their child is ill enough to be at home or well enough to go to school.

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Porter

So if your child has glandular fever and you don鈥檛 think they鈥檙e well enough to go to school then don鈥檛 send them to school, doesn鈥檛 matter that it says in the leaflet there鈥檚 no need for them to have time off school, you鈥檙e the final arbiter of that.

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McCartney

Absolutely, the parents are the best judge, they know the child, they鈥檝e got the child in front of them.

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Porter

What about parents who want some proof that their child鈥檚 been unwell because the school are demanding it, so if you like they鈥檙e wanting a sick note for their child?

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McCartney

Yeah and I think there鈥檚 a real dichotomy here.听 So a lot of schools are saying they need some kind of medical evidence to prove that the child鈥檚 been off and they鈥檙e saying that you don鈥檛 need a note from the doctor and indeed schools should not be asking for a note from the doctor, an appointment card or note of a telephone consultation will do. But this is really a bit daft because you could just as well speak to the pharmacist or actually parents may know just as well themselves actually this is a minor self-limiting illness, child will be well in 48 hours, I鈥檒l just ride the storm and take it as it comes and send the child back to school when they鈥檙e ready and that鈥檚 what parents should be able to do.听 And I think it鈥檚 a real shame that people are being told they need some kind of evidential proof and we鈥檙e not actually willing to trust the parents themselves.

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Porter

But what you鈥檙e saying is looking at this you think that it鈥檚 actually quite a useful document for parents if it鈥檚 taken the right way?

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McCartney

Yes, it鈥檚 really important that parents feel as though they鈥檙e the ones with responsibility to make decisions.听 And even minor illnesses, sometimes that will require the child to be seen by a doctor or a pharmacist, very often it won鈥檛 require anything other than the parents own skill and judgement in looking after their child.听 And people should feel empowered by this kind of advice, know that it鈥檚 only guidance rather than feeling that this is something that must be adhered to.

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Porter

Thank you very much Margaret.

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And there is a link to the Parent鈥檚 Guide to Managing Sickness Absence from School on the Inside Health page of the Radio 4 website. And although it originates in South Wales the guidance is the same for all parts of the UK.

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Now, mention the term osteoarthritis and most people automatically think of creaky hips and knees and clever surgical treatments like joint replacement and resurfacing. But other big joints are affected and surgery is an option for them too.

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At least 3,000 people in the UK have surgery for arthritis of the ankle every year. Two thirds of them will have their ankle fused, while the remainder will try a newer option - joint replacement. But which works best?

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Well to answer that question the National Institute for Health Research is funding the world鈥檚 first ever randomised clinical trial comparing fusion with replacement, and it will involve patients from centres right across the UK.

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But the results will come too late for Peter Timms, who opted for a joint replacement when he was told he needed surgery.

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Timms

I ended up with a problem with my ankle because I had an accident at work, I fell about eight foot and landed on both feet and I had multiple fractures in one ankle.听 The accident changed everything for me, even walking upstairs and I couldn鈥檛 do the garden, couldn鈥檛 do any DIY, I definitely couldn鈥檛 walk up a ladder, so it meant that I felt extremely limited and frustrated in what I could achieve and what I could do.

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Goldberg

My name is Andy Goldberg and I鈥檓 a consultant orthopaedic foot and ankle surgeon at the Royal National Orthopaedic Hospital in Stanmore and Central London.听 So ankle arthritis affects approximately 30,000 people in the United Kingdom each year.听 There鈥檚 some good evidence now that鈥檚 come out that shows that the effect on your quality of life is as much as end stage hip arthritis, end stage kidney failure and end stage heart disease.

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Timms

It became clear to the doctors that were treating me that arthritis set in soon after, that it was caused by the accident rather than 鈥� I had no feeling of arthritis before the accident.

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Goldberg

The commonest cause of ankle arthritis is actually following injury, such as an ankle fracture, an ankle break or severe often repeated sprains.听 Unlike hip or knee arthritis which typically are in your genes, ankle arthritis primary, which is in your genes, is rare as hen鈥檚 teeth, the reason for that is that the ankle joint moves in a beautiful very clever way that doesn鈥檛 wear out unless you mess up God鈥檚 good work.听 There certainly is and historically been an attitude that ankle arthritis is a very difficult thing to treat and therefore the best treatment perhaps is just painkillers and getting on with it.听 That said we now have two very well established treatments, both that have good outcomes and both of them are available on the NHS.

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So typically in arthritis the shock absorbing cartilage, that鈥檚 sort of the gristle that you see at the end of a chicken drumstick, is worn away and you end up having bone rubbing against bone and that鈥檚 painful, it causes stiffness and pain, especially on weight bearing. 听So in arthritis the idea is to take away two painful surfaces rubbing against each other, either you replace the surfaces which is what a joint replacement is or you connect the two bones together so there is no movement and that鈥檚 what a joint fusion is.

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Timms

My decision to go for the replacement rather than a fusion I think was based in a way on a sort of a perception of the fusion being permanent and the feeling of immobility.听 This may not be the case of course, I鈥檝e understood subsequently there is some mobility in a lot of cases but the joint replacement I just felt more comfortable with, being able to have that extra degree I hoped of flexibility, which I have now got.

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Goldberg

The interesting thing about the foot and ankle is there鈥檚 30 mobile joints in the foot and so if you fuse the ankle joint you still have a significant amount of motion.听 So the real answer is that some patients don鈥檛 like the concept of having fusion and some patients have stiff adjacent joints or the other joints are stiff and in those situations you would like to think that a joint replacement or an ankle replacement is the right sensible route to have.听 The fact is that although we offer both treatments there鈥檚 never been a clinical trial out there to compare an ankle replacement against ankle fusion so what we don鈥檛 know is which treatment patients prefer, now which is more effective or cost effective for the NHS.听 The National Institute for Health Research has agreed to invest close to 拢2 million to finally answer the question of which treatment is better for patients and so we鈥檙e carrying out a randomised controlled clinical trial and we鈥檙e looking for 340 patients nationally, over 鈥� around 18 centres in the NHS to enter into the trial to have either an ankle replacement or ankle fusion as part of the trial and we鈥檒l follow them up very closely and able hopefully to answer for future patients which treatment鈥檚 better for them.

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Timms

I was very pleased to wake up and think that I鈥檇 got this fresh start.听 The work I had to do was really physiotherapy at the time, I took it a little further off my own bat by going to my local gym and I feel I鈥檓 back to normal now except for one rather laughable situation in which six weeks ago I had an accident on the stairs and slipped down the stairs and broke a bone in the same foot.听 Except for my wife no one up to this point has said that I鈥檓 accident prone but I鈥檓 starting to believe her.

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Porter

You said it Peter, Peter Timms. And recruiting for that ankle surgery trial is about to start - details are on our page of the Radio 4 website.

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Now back to Fascinating Aida.

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Music 鈥� Fascinating Aida

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Hot flushes, the butt of many a joke, but no laughing matter for lots of menopausal women.听 Twenty years ago, when HRT was regarded by some as a panacea for middle age, it was second nature to reach for the prescription pad.

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But a decade ago the pendulum swung violently the other way following the publication of research suggesting that HRT had more serious side effects than previously thought. It quickly fell out of favour.

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But in recent years opinion appears to changing again. Like most of my colleagues I have noticed more women are coming in to ask for help with troublesome symptoms of the menopause - in particular hot flushes. So what should I be offering them?

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Mary Ann Lumsden is Professor of Medical Education and Gynaecology at the University of Glasgow.

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Lumsden

A flush is more than just going red, you only need a tiny change in temperature to lead to a heat loss response and it鈥檚 due to lack of the hormone oestrogen.听 When it becomes severe it will often be associated with sweating which causes severe embarrassment and also with feelings of tension and anxiety.

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Porter

How often do these flushes occur?

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Lumsden

It鈥檚 very variable, some women will have them two or three times but if it鈥檚 in the middle of the night then that can be very significant.听 But others will get upwards of 10 or 20 a day, it is something which really does impair their quality of life.

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Porter

What treatments can we offer women?

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Lumsden

The most effective treatment is hormone replacement therapy and this will be effective in 85% say of women with flushing.听 However, for those who can鈥檛 take or don鈥檛 want to take hormones then there are other alternatives which I think we have to say are more effective than placebo, always remembering that placebo will work in 30-40% of women.听 So it鈥檚 really complicated as to what is useful.

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Porter

And the sort of drugs you鈥檙e talking about are what?

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Lumsden

The antidepressants, the SSRIs鈥�

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Porter

The Prozac family of drugs then?

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Lumsden

Yes, Venlafaxin is the one that we use and as long as you are really careful to start it slowly, because women will feel very sick initially, but if they get through the first couple of days it can work really, really well.

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Porter

And what about self-help measures, looking at things like diet and lifestyle?

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Lumsden

Diet, we often encourage people to think about, they may be able to avoid the triggers, such as curry and wine.听 And there are some data that possibly exercise helps flushing.

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Porter

A lot of women like to self-medicate and a number of herbal products over the years have been claimed to help hot flushes, what鈥檚 your stance on that?

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Lumsden

It may well work because we know that placebo will work in 30-40% of women.听 And the herbal preparations are usually as effective as placebo.听 May be slightly more.听 And so it may well be that they will work and if they work that鈥檚 fine but people need to recognise that particularly if people take excessive amounts they may not be quite as harmless as they appear and so women should always let us know if they鈥檙e on herbal preparations.

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Porter

So if we use hormone replacement therapy all we鈥檙e doing is artificially elevating and stabilising, if you like, the oestrogen levels in the woman鈥檚 body but there鈥檚 got to come a time when we鈥檝e got to withdraw that oestrogen, presumably the hot flushes are likely to come back are they not?

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Lumsden

I think the honest answer is yes but they don鈥檛 come back with the same severity in most women.

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Porter

What advice would you give to GPs like me then when we鈥檙e prescribing for hot flushes?听 A, how long should women ideally be on the HRT for and how should we get them off it?

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Lumsden

The length of time is rather arbitrary.听 We usually go for five years because it is I think becoming more accepted that at five years there is a statistically significant increase in the risk of breast cancer.听 And so I think people feel that this is a safe duration for people to be on.听 However, I certainly. and all the doctors I know with an interest in the menopause, will have quite a number of women who want to stay on for longer and with careful and appropriate counselling I think this is absolutely fine and I would certainly stop people gradually.

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Porter

Faced with a patient in my consulting room, the woman鈥檚 likely to ask me a couple of questions, first of all she鈥檚 going to be worried about the side effects, so assuming that we use HRT up to five years what would you be telling her about her risks of breast cancer, blood clots and strokes and other complications?

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Lumsden

I would tell her about the increased risk of blood clots with the oral therapy, which is really pretty well absent with patches and gels and there are some very nice studies from France, in particular, where they use a lot of patches, it鈥檚 shows that there is virtually no impact on clotting at all.听 So for women who are at increased risk, possibly those who are overweight, it鈥檚 well worth a thought.听 I mention the increase or probable increase in the risk of breast cancer and I say also that it has a bone protective effect and for anybody who lives and works in Glasgow heart disease is very important and I say there is no evidence of harm in women using it around the age of the menopause, up to sort of 60ish.听 Stroke is more complex because the likelihood of having a stroke at 50 is so low that it鈥檚 almost impossible to see a numerical change, although it is likely that there is a small increase.听 But that becomes significant when they鈥檙e 70, when women are more likely to have their strokes.

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Porter
HRT comes in myriad forms and I鈥檓 intrigued by your reference there to the fact that we might not have so many serious side effects from the patches and gels, on that do you think we should be using patches more here in the UK?

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Lumsden

I think we鈥檒l be able to answer that question in about a year.听 A NICE guideline is being produced on menopause.听 I don鈥檛 know what they will find to be honest, so we鈥檒l have to wait and see.

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Porter

Professor Mary Ann Lumsden.

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You are listening to Inside Health, I am Dr Mark Porter, and this is the part of the programme where you set the agenda.

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We have a tweet from a listener concerned about a friend who has been admitted to hospital with a rare type of paralysis called Guillain Barre Syndrome. Could Inside Health please explain what it is, and how it is treated? Questions I put to consultant neurologist Jane Pritchard.听 But first someone who knows all too well what your friend is going through.

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Ide Smith

My name is Sue Ide Smith and I am a Guillain Barre survivor.听 Yes I used to work in advertising in a media advertising agency and I was a managing partner, and so I ran quite a big team working on major corporate clients and yes, so I was doing that when I got taken ill.听 And so basically I had no choice in the matter I couldn鈥檛 carry on with work when I got ill because it was a very sudden onset, the illness, and it basically took me from 鈥� I had flu but it took me from having flu and being off work with flu to being in intensive care within 48 hours.

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Pritchard

Guillain Barre Syndrome is named after two French neurologists who described the condition in 1916 in two First World War soldiers who were taken ill at the front when they developed weakness.

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Porter

You鈥檇 have thought those French neurologists would have had better things to do during the First World War, it must have been a pretty awful time.

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Pritchard

Yes it was just after the Battle of the Somme and they found these soldiers who had developed weakness and they took the time to do a lumbar puncture on them to demonstrate that the protein was high and yet there weren鈥檛 cells which meant it wasn鈥檛 polio, it wasn鈥檛 other infectious conditions.听 And to do basically research, electrical studies, to confirm the problem was in the nerves after the spinal cord.听 It鈥檚 astonishing.

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Porter

How does a typical case present?

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Pritchard

Often at the beginning people develop a little bit of tingling, perhaps in the hands and feet, and then gradually they develop weakness and that weakness can progress very quickly in some cases, some people can barely move within 48 hours, other people the weakness progresses over a number of weeks, and they can become paralysed in their arms and legs, they can have difficulty with breathing, difficulty with swallowing and even difficulty with moving their eyes in the most extreme case.

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Porter

As a medical student I was taught this was an ascending paralysis, so it starts, if you like, at the feet and works its way up, is that true?

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Pritchard

That鈥檚 the classical presentation but something that sometimes catches us out is that often there can be weakness around the movement of the tops of the legs.

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Porter

And what鈥檚 actually happening to the nerves?

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Pritchard

Let鈥檚 be clear, it鈥檚 not the central part of the nervous system that鈥檚 the problem here, the brain and the spinal cord are fine, the nerves after they鈥檝e left the spinal cord are not conducting the signals properly.听 And what鈥檚 happening at the microscopic level is that we think the immune system is attacking the nerves, so it鈥檚 a combination of block of signal and damage to the nerve.

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Porter

And so it鈥檚 an example of what we would call an autoimmune disorder, where the immune system is attacking鈥�

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Pritchard

That鈥檚 right.

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Porter

鈥�instead of attacking an invader it鈥檚 attacking our own body, what triggers it?

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Pritchard

Well we know from epidemiology 鈥� that鈥檚 the study of populations 鈥� that people have reported an increased incidence of infections often before Guillain Barre Syndrome begins.听 So two-thirds of patients describe an infection, perhaps in up to four weeks before the onset of their neurological symptoms, may be flu like illness, may be viral illness, that they didn鈥檛 really even think much of, they may not have even needed to take time off work and then in the weeks following they develop Guillain Barre Syndrome.

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Porter

How do you manage it?

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Pritchard

When the patient first presents the first thing is to recognise that that鈥檚 the problem, so your average GP might only encounter one case in their whole lifetime.

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Porter

Well I鈥檝e never seen a case.

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Pritchard

So that鈥檚 the first thing.听 Similarly getting through casualty, a lot of patients get turned away from casualty the first time that they present because they鈥檙e just describing tingling and nobody can detect any weakness.听 Once it鈥檚 been diagnosed or suspected the patient would be admitted and carefully monitored because of the problems with the breathing and because of the problems that can develop with heart rhythm.听 And then to try to stop the immune process from going on there are two main treatments 鈥� the first one that was described was called plasma exchange but it鈥檚 been shown that another treatment, called immunoglobulin, is equally effective and immunoglobulin is taken from blood donors, the immunoglobulin faction is pulled together and then administered to the patient over a course of five days.听 And that is much easier to give than the plasma exchange that used to be the first line treatment, so nowadays immunoglobulin would be first line treatment but they both work equally well.

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Ide Smith

When I came to in ICU my family told me that I had been totally paralysed, I was still 95% paralysed.听 When I was totally paralysed I had no expression in my face and I couldn鈥檛 move my mouth, so I couldn鈥檛 even mouth words at them.听 And I couldn鈥檛 speak because I had a tracheotomy.听 So it鈥檚 an incredibly 鈥� and your brain is 100% operational.听 So you are trapped inside your body.听 It is like a temporary version of locked in syndrome and it鈥檚 absolutely terrifying.听

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I had been in neuro-ICU for about three weeks when I realised where I was.听 The first time when I knew I was getting better was when I realised I fancied my physio 鈥� that was a good thing.听 And gradually things changed, like my fingers started to move or my toes started to move but it was excruciatingly painful.听 And then I was in ICU for two months and then I got moved to a ward.听 The first time I stood up and I thought I鈥檇 been standing for about two minutes and I was sweating buckets, it was so much work, it was so hard.听 Then the physio said 鈥� that was 20 seconds, that鈥檚 fantastic.听 And I was like 鈥� Only 20 seconds!听 That鈥檚 so annoying.

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Porter

And what鈥檚 the outlook, somebody鈥檚 come in they鈥檙e two weeks into their illness and they鈥檙e under your care and they say to you 鈥� doctor am I going to be alright?听 What do you say to them?

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Pritchard

It depends on quite a lot of factors.听 So probably about 80% make a good recovery, 15-20% are left with significant disability, so by that significant weakness, sometimes pain, they might need a wheelchair, they might need walking sticks.听 If you look in the world population it still has a death rate of 4%...

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Porter

One in 25.

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Pritchard

Which is quite significant.

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Porter

So the paralysis has ascended and they can鈥檛 literally breathe for themselves so they鈥檙e on a machine and that鈥檚 associated with lots of other issues.

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Pritchard

Yeah, complications of that.听 But even those who make a good recovery a significant number, probably at least 20%, are troubled by significant fatigue, ongoing tingling and perhaps are not back to full functioning as they were before they were ill.

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Ide Smith

Effectively it took me 18 months to get to a reasonable standard of living, I wasn鈥檛 working, I couldn鈥檛 have worked, I was resting every afternoon but I had a reasonable quality of life.听 We鈥檙e now nine and a half years on, I鈥檓 a lot better, I can run, I can walk, I鈥檝e got my dexterity back, I鈥檓 lucky some people don鈥檛 get that, so I am able to make jewellery, which is what I do now 鈥� I make jewellery and I sell lovely organic natural healthcare as well, so I have work that fits in around my fatigue, rather than trying to fit my fatigue around my work.听 I still have to rest every day but if that鈥檚 one of my only side effects then I don鈥檛 really think that鈥檚 a difficult thing to deal with considering I could have been left in a wheelchair or I might not have made it at all.

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It has totally changed my life but now in a way I can help other people with these illnesses, I can do more voluntary work which I really enjoy.听 I think it鈥檚 changed my life for the better because the most important thing that came out of it for me was realising how important my family and my friends were and that I certainly would not have wanted to carry on the way I was carrying on because I didn鈥檛 have enough time to spend with my family and my friends at that stage and now I do and I make that a priority.听 And so I鈥檓 very grateful for that.

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Porter

Sue Ide Smith. And thanks to neurologist Jane Pritchard from Charing Cross Hospital in London.听 You will find some useful links of GBS on our website, where you will also find details of how to contact us.

听

Oliver Jardine e-mailed insidehealth@bbc.co.uk to ask where the term hypochondriac comes from and whether it is anything to do with hypochondrium in the abdomen.

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Margaret McCartney has been looking into it.

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McCartney

Well this was a learning experience for me.听 I have to say I hadn鈥檛 linked it at all myself but it seems that the Greek doctors in the Second Century did link the areas of the left and right hypochondrium, the area under the ribs, with people who were felt to be melancholy or sad or anxious.听 And they had decided that it was to do with your four humours.听 If you had pain in these areas you were also more likely to be anxious or depressed and therefore they made the link between pain there and your mental health.听 And what鈥檚 really interesting was they didn鈥檛 see a division between your physical health and the mental health, they felt it was one and the same thing.听 And what they felt was that if you had the pain and mental health problems at the same time this was all down to do with your black bile, one of the four humours that鈥檚 meant to govern your body.

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Porter

So how did that come to the modern use of the term where we talk about a hypochondriac being someone who has excessive anxiety, they worry too much about their health?

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McCartney

I think this is down to Robert Burton when he wrote his enormous book The Anatomy of Melancholy in 1621 because he described pain in relation to mental health, he thought they were one and the same thing.听 He described sweats, heats in the bowels, wind, heaviness of the heart, troublesome dreams all as being part of this pain under the ribs, all part of the same scenario of hypochondria, excessive worry or concern about one鈥檚 symptoms.

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Porter

And the term has stuck.

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McCartney

It certainly has, it certainly has and I have to say it鈥檚 a bit of a derogatory term I think now, I think most people wouldn鈥檛 like to be described as hypochondriacs, certainly we talk about health and anxiety now, being worried about what symptoms someone鈥檚 experiencing as I think a bit of a nicer term just to try and explain it as opposed to make a judgement on someone.

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Porter

Thank you Margaret.

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And please do get in touch if you have a query that you would like us to look into. Contact details are on our page of the Radio 4 website.

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Just time to tell you about next week when I will be asking how much we really know about standards in private hospitals - increasingly relevant these days as they take on more and more NHS work. Join me then to find out.

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ENDS