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INSIDE HEALTH

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Programme 7. 鈥� Charles Bonnet syndrome, Co-proxamol, Meningitis B vaccine, Smart tablets

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TX:听 23.02.16听 2100-2130

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PRESENTER:听 MARK PORTER

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PRODUCER:听 FIONA HILL

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Porter

Coming up in today鈥檚 programme:听 Meningitis B 鈥� and the question that seems to be on lots of parents鈥� lips: How do I get my child vaccinated? I will be discussing the unprecedented demand with fellow GP Margaret McCartney.

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Smart tablets 鈥� how hospitals in Oxford have swapped the paper chart at the end of the bed for a computerised system that can help doctors and nurses spot when a patient is going downhill.

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And a blast from the past 鈥� Co-proxamol, or Distalgesic as most people will remember it. Why is the NHS still spending millions of pounds on a painkiller that was withdrawn a decade ago because it was deemed too dangerous?

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Green (Clip)

The big problem with it is that it鈥檚 very, very good at suppressing your central nervous system.听 What that means is if you take too much of it you stop breathing and it鈥檚 particularly prone to do that if it鈥檚 taken in combination with other medications as well.听 Now the one that most concerned us was alcohol because what was happening is that people were getting distressed or depressed, they would take perhaps just a handful or so of these tablets and unfortunately they were dying from it, in quite large numbers.

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Porter

More on Co-proxamol later.

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But first Charles Bonnet syndrome 鈥� the most common eye related problem that you and possibly your doctor and optometrist have never heard of.听 Those affected have vivid visual hallucinations associated with failing eyesight, a combination that could be experienced by as many as half a million people in the UK.

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Bonnet was a Swiss philosopher who first documented the syndrome in 1760 in his elderly grandfather who had advanced cataracts and was nearly blind, but still regularly reported seeing people, birds, wall tapestries and even horse drawn coaches that weren鈥檛 there. And all crystal clear 鈥� at least to him.

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Judith Potts noticed a change in her mother, Esme, when her eyesight started to get worse.

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Potts

She was in her early 鈥�90s, she was very independent.听 She had failing eyesight but she managed the Telegraph crossword every day and enjoyed life.听 But I did start to notice that her confidence was beginning to wane and I couldn鈥檛 work out why.听 And then one day she said 鈥� I do wish these people would get off my sofa.听 And of course there wasn鈥檛 anybody on her sofa.听 And then she went on to describe a goblin-like creature that jumped from table to chair, just out of reach and what she described as a Victorian street child, tear-stained, which for my mother, who鈥檇 been a children鈥檚 nurse all her life, was particularly distressing.听 This child came all day every day.听 Sometimes she looked out of the window and the garden turned into something like an Edwardian funeral with plumed horses, clergy in red cassocks.

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Porter

It鈥檚 all very odd.

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Potts

Very, very odd and鈥�

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Porter

What did you think, what was your initial thought when she said?

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Potts

Well I鈥檓 afraid the word dementia immediately came into my mind.听 I asked her how long it had been going on for and she said a few months, which knowing my mother probably meant longer.听 And I said why didn鈥檛 you say anything and she said because I think I鈥檓 probably developing dementia and I鈥檓 terrified.

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Porter

So what did you do about it?

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Potts

Well I just tried to reassure her and I thought well we鈥檒l have to call the doctor.听 But with an amazing stroke of luck that very day I picked up the newspapers on the way home and in one of them there was a tiny, tiny paragraph which could have been written by my mother and it explained the Charles Bonnet syndrome and I thought great, this is marvellous, now we have the name and we have the cause 鈥� her loss of eyesight.听 So I rang her ophthalmologist but he wouldn鈥檛 speak to me about it.听 And her GP had never heard of it and when I explained it was 鈥� said well I think that鈥檚 very unlikely.听 And her optometrist had never heard of it.听 And the only thing that we could do for her was reassurance.听 But she was plagued by it for the rest of her life and of course the fact that her eyesight was going, she was seeing images, as she called them, hallucinations, that were so sharp and clear suddenly these things loomed up.听 So in a way it was like a horror film.

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Porter

Well listening to that is Dr Dominic Ffytche, who鈥檚 clinical senior lecturer at King鈥檚 College London.

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What鈥檚 actually happening in people with Charles Bonnet syndrome?

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Ffytche

Charles Bonnet syndrome is the name that we give to people that have visual hallucinations in the context of eye disease.听 In people that have moderate visual loss there are changes in the brain, so the brain adapts to the loss of visual input coming in and causes excitability and it鈥檚 that excitability and spontaneous firing of visual parts of the brain that leads to the hallucinations.

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Porter

So when you say moderate loss, these people can still see but what the brain is doing is filling in the gaps, if you like, is that what you鈥檙e鈥�?

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Ffytche

Yes, so moderate loss means halfway down the eye chart at the optometrist.

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Porter

And the sort of conditions that would cause that degree of loss?

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Ffytche

Well the commonest cause is Age Related Macular Degeneration, so a very common disease in the elderly, but in fact any eye disease can cause it and if you blindfold someone with a perfectly intact visual system for long enough they will get Charles Bonnet syndrome as well.

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Porter

But many listeners won鈥檛 even have heard of this.听 I mean as Judith hadn鈥檛 heard of the condition before in her own mother.听 Why don鈥檛 we know more about it?

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Ffytche

Well it鈥檚 a bit of an orphan condition because it sort of straddles different specialties.听 So it sits between ophthalmologists who are not really primarily concerned with the hallucination experiences, psychiatrists who never see it because they don鈥檛 necessarily see people with eye problems and geriatricians and GPs 鈥� everyone will have a sort of familiarity with it potentially but no one has a sort of overview of the problem as a whole and that鈥檚 may be why it鈥檚 less well known.听 A survey that we carried out a couple of years ago looked at all the people that had been to a medical professional, so it鈥檚 not just doctors, it could be optometrists or clinic nurses, and about a third of them that had revealed their symptoms felt that the doctor or the medical professional didn鈥檛 鈥� hadn鈥檛 heard of it, didn鈥檛 know what to say.听 So there鈥檚 a big awareness problem amongst the medical professionals as well as amongst the patients themselves in being forewarned that this might happen.

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Porter

This varies obviously from individual to individual but if somebody starts getting these hallucinations what can they expect going forwards, how long are they likely to last?

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Ffytche

So the typical story is a sudden visual loss or a gradual reaching of a particular threshold of visual loss, so as I say if you lose vision and then within a few weeks, maybe a few months, you start to have very florid visual hallucinations.听 So that means they will last a long time or they鈥檒l be very frequent throughout the day.听 And that will go on for several months and it will gradually reduce in frequency and so you鈥檒l have periods without hallucinations.听 And then it sort of will trickle on for 鈥� we used to say 18 months but we now know they go on for much longer than that and maybe even for life, maybe once you鈥檝e had Charles Bonnet syndrome you will always be susceptible because you鈥檝e got a certain type of brain response to changes in vision.听 And at a later date if you develop a chest infection or urinary infection or start various medications the hallucinations may came back again.

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Porter

How graphic are these hallucinations 鈥� are they confined to visual, I mean if you see a dog that鈥檚 barking do you hear the dog barking?

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Ffytche

No, so the definition of Charles Bonnet is that it鈥檚 isolated visual hallucination, so no other sense is involved.听 And it鈥檚 an important discriminator for some of the other conditions where you get hallucinations.听 So if someone is seeing and hearing the figure talking to them, it鈥檚 not going to be Charles Bonnet, and it鈥檚 important that people realise that, just because you鈥檝e got eye disease not every hallucination is Charles Bonnet syndrome, so having a sound, a smell, a feeling of touch on the skin, that makes it unlikely to be Charles Bonnet syndrome.

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Porter

Judith, tell me about the effect that your mother鈥檚 problems had on you and what you鈥檙e doing now.

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Potts

Well after she died I decided to launch, in memory of my mum, Esme鈥檚 Umbrella.听 And since then we now have a website and people have emailed me and telephoned the helpline with their stories.

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Porter

Can you give us some examples of the sort of problems that people have been having?

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Potts

I have to say that absolutely everybody who鈥檚 been in touch with us nobody has ever been warned that this might happen.听 People talk about again goblin like creatures or the room disappearing.听 Somebody talked to me about getting to the top of the stairs, was just about to go down and the whole staircase turned into a giant waterfall.

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Porter

Dominic, let鈥檚 assume that your GP or optometrist or whoever you consult is very aware of this and makes the correct diagnosis, what can we do about it?

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Ffytche

Well the standard treatment is not evidence based, so we don鈥檛 really know, but the practice is that we educate and inform people, so you explain that this is a normal response of the brain, that the likelihood is it will reduce over time.听 Now it doesn鈥檛 necessarily go away, we used to tell people 18 months was the magic number that you鈥檒l probably be hallucination free in 18 months, we now know that鈥檚 not the case, that most people will have hallucinations for more than five years, although they鈥檒l be relatively infrequent.听 So it won鈥檛 be troubling you all the time and they may be very brief.听 You need to know things like that if you develop a medical condition on top of that 鈥� urinary infection, chest infection 鈥� the hallucinations are going to get a lot worse, or a change in your eye problem or indeed starting new medication, so a lot of medications can exacerbate the hallucinations as well.

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Porter

Dr Dominic Ffytche and Judith Potts, founder of the awareness group Esme鈥檚 Umbrella. And there is more information about Charles Bonnet syndrome on the Inside Health page of the Radio 4 website.

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Now from a centuries old syndrome to a blast from the more recent past. Do you remember the painkiller co-proxamol, or Distalgesic as it was better known? When I first entered general practice in the early 鈥�90s this combination of paracetamol and a weak synthetic opioid was commonly prescribed for mild to moderate pain.

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But all that changed just over 10 years ago when a review deemed that the benefits of the drug did not outweigh the risks. In a nutshell 鈥� it wasn鈥檛 a good painkiller and it had some worrying side effects.听 Co-proxamol鈥檚 licence was withdrawn.

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So, why then is the NHS still using it a decade later, with 100,000 prescriptions issued for the drug in England alone during 2014?

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Dr Andrew Green is Chair of the Clinical and Prescribing arm of the GP Committee at the British Medical Association.

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Green

Now the difficulty is that co-proxamol is a combination of paracetamol, which we all know, and an opioid medication called Dextropropoxyphene.听 And that鈥檚 the ingredient that鈥檚 the problem.听 The big problem with it is that it鈥檚 very, very good at suppressing your central nervous system, what that means is if you take too much of it you stop breathing.听 And it鈥檚 particularly prone to do that if it鈥檚 taken in combination with other medications as well.听 Now the one that most concerned us was alcohol because what was happening is that people were getting distressed or depressed, they were drinking, that made them more depressed, it affected their judgement, they鈥檇 take perhaps just a handful or so of these tablets and unfortunately they were dying from it, in quite large numbers, probably between 300-400 deaths a year was caused by co-proxamol.听 And that was the background as to why the committee on safety of medicines decided that it should no longer generally be used.

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Porter

So that was back in 2005, what happened immediately afterwards?

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Green

Well GPs had a couple of years to phase this in 鈥� between 2005 and 2007 鈥� and over that period I think most GPs stopped prescribing it to new patients.听 And as patients had their medication reviews they were changed off co-proxamol on to safer painkillers.

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Porter

And by safer painkillers what sort of drugs would be equivalent to this?

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Green

It tends to be the co-codamols, that鈥檚 a combination of paracetamol and codeine, that has similar efficacy.听 And of course one of the interesting things about co-proxamol is not only is the Dextropropoxyphene dangerous in overdose but it also didn鈥檛 seem to be contributing to the analgesic properties of the medication.听 So both for short term pain relief and long term pain relief it was no more effective than plain paracetamol but much more dangerous.

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Porter

Although its licence has been withdrawn doctors can still prescribe co-proxamol on a 鈥渘amed patient鈥� basis where they feel there is a special need and are prepared to shoulder the responsibility. And quite a few doctors seem to be doing just that given that thousands of patients are still taking the drug. Bedfordshire GP John Lockley is one of those doctors.

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Lockley

My feeling is very strongly 鈥� if I have a patient that genuinely doesn鈥檛 seem to be able to go away from using co-proxamol and if they are a sensible and sane and balanced person who is not likely to go and do silly things like getting drunk or even having alcohol with it, if they鈥檙e not going to do things like taking overdoses, then I don鈥檛 see why a person who is balanced, sane, sensible and practical should be told that you can鈥檛 have this because the alternative is unfortunately that they may be in pain for a very, very long time.听 It would be lovely if we could get these people off it, I would love more than anything else, then everybody would know that we haven鈥檛 got them on a drug that was being looked at a little bit askance.听 But life unfortunately is not quite as simple and easy as that.听 I鈥檓 thinking about the patients, I don鈥檛 want to ban things across the board, simply when it鈥檚 because other people are using it inappropriately.听 What I want to do is to say to the patient 鈥� you use this carefully and appropriately and with a bit of luck there will be no problems whatsoever and at least we鈥檒l get rid of this pain that we can鈥檛 do by any other means.

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Porter

Andrew, Johh Lockley there makes the point that you often hear raised when defending co-proxamol that some patients find it鈥檚 the only painkiller that works for them.听 What would you say to that?

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Green

It is absolutely true that the individual response to painkillers is very variable.听 We all know that red painkillers, for some reason, seem to work better than white ones.听 But I think the sort of conversations that we should be having with our patients is that this is a drug which has significant problems, I appreciate that you鈥檙e distressed with your hip or your knee pain but let鈥檚 try and find some other way to deal with it, that doesn鈥檛 involve the prescription for this drug.听 And if I could just pick up on a particular thing there.听 It is unfortunately desperately difficult to predict who is going to run in to mental health problems, none of us are immune from this sort of difficulty.听 And you can have, for example, an elderly man who suddenly becomes widowed, his son can have a divorce or problems in their personal life, and all of a sudden someone who you thought was very stable emotionally can have difficulties.

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Porter

Dr Andrew Green and listening to that in our Glasgow studio is GP Dr Margaret McCartney. Margaret, do you still prescribe co-proxamol?

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McCartney

I do not and I haven鈥檛 prescribed co-proxamol for many years.听 It鈥檚 what I would term 鈥渁 manky drug鈥� as in it鈥檚 dirty, it鈥檚 got lots of side effects, it has lots of unintended consequences and I haven鈥檛 had to use it for a good nine, 10 years now.

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Porter

One of the reasons, as we鈥檝e heard, that co-proxamol鈥檚 still being used is that patients feel it鈥檚 the only thing that helps them 鈥� nothing else works doctor 鈥� is a cry familiar to many prescribers I suspect.听 And it can be difficult, can鈥檛 it, to refuse patients who demand a particular treatment.

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McCartney

It鈥檚 difficult for doctors.听 In general doctors like to be people pleasers, it鈥檚 much easier to do your job when you鈥檙e making people happy and giving people what they want rather than saying no.听 But that鈥檚 not what doctors are there for, we鈥檙e also there to first do no harm and to protect people against the adverse effects of medication that is being used unwisely.听 And the question is when is something being used wisely and when is not 鈥� that鈥檚 a bit of a judgement of Solomon in many cases.听 But certainly for co-proxamol it鈥檚 pretty clear.听 Other things like antibiotics, I鈥檓 sure all doctors have had the situation where a person comes in and says I want antibiotics for my sore throat, nothing else ever works for me, this is what I want and what I need, what鈥檚 a doctor to do when faced with the evidence that actually this is a viral infection, antibiotics will not help, they will only cause harm and they will contribute towards resistance within the community.听 So the good doctor in that situation should say no, antibiotics are not warranted, let鈥檚 look at other ways to help you through this illness.听 But we know that there is evidence of association between doctors who prescribe less antibiotics and patient satisfaction 鈥� so fewer patients seem to be happy with their doctor when their surgery prescribes less antibiotics, compared with surgeries that prescribe more.听 Now we can鈥檛 demonstrate cause and effect but when doctors are being judged so frequently on questionnaire surveys of satisfaction, on feedback online how good your doctor is, what your opinion is, I think doctors might well feel quite vulnerable in these situations.

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Porter

So how do we resist that sort of influence?

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McCartney

Well first of all I think we should be absolutely honest about what we know and what we don鈥檛 know about the treatment that鈥檚 under question.听 And if something doesn鈥檛 work we should not be afraid to say so and to discuss that with patients.听 In general I think most people are pretty sensible and they come to their doctor because they want a discussion about what would be best for them.听 In the end doctors are responsible prescribers who have to justify their decisions to not only their patients but their peers, their colleagues and the General Medical Council, their local prescribing advisors, the wider community.听 So I think doctors are in a difficult position, I don鈥檛 think it鈥檚 very easy but I don鈥檛 think we can prescribe solely to keep our patients happy, I think there鈥檚 far more to it than that.

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Porter

Well talking of patient pressure the Meningitis B vaccine is at the forefront of many parents鈥� minds this week with GPs and private clinics receiving an unprecedented number of calls, I don鈥檛 know if you have, we certainly have, from people trying to get their children vaccinated.听 And a petition calling for the vaccine to be offered to all children under the age of 11 has now just attracted over 700,000 signatures, how do you feel about that?

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McCartney

It鈥檚 great that people are interested in wanting to do something good for their community and they want to try and improve the chances of children not getting Meningitis, who would not support that, you would have to be a monster to disagree with the premise that we don鈥檛 want children to die of Meningitis, that鈥檚 absolutely good and right that people want to make their opinions known.听 However, this is a question of what we spend our money on in the NHS.听 So this vaccine has lots of uncertainties attached to it, it鈥檚 not fully effective, we don鈥檛 know how long it鈥檚 going to work for, it鈥檚 unclear about who would get most benefit from it as well.听 Some people think it鈥檚 not cost effective, other people using different calculations think it is cost effective and opinion on that has changed over time.听 The real issue is what happens when you make funding decisions, really difficult funding decisions, a popularity contest.听 I hear from child psychiatrists every week or two who tell me that they鈥檝e had to send children to the other end of the country for a mental health bed when they have become unwell and need hospital care.听 We don鈥檛 see big petitions about that.听 We absolutely should.听 So my issue is really about equity and I think if we鈥檙e a lot of children getting this from private providers we鈥檙e probably going to see the least well off children in our community at higher risk and that really can鈥檛 be fair.

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Porter

But once again it鈥檚 the GP that鈥檚 put in the difficult position because the patient who鈥檚 sitting in front of you doesn鈥檛 really care about cost benefit when it comes to their own child, I mean their children are priceless, so it鈥檚 quite hard for the doctor to explain that face to face during a 10 minute consultation.

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McCartney

I think that鈥檚 why we have to have these cost effect decisions taken out of the consultation room and put into a public domain with full transparency, public discussion and debate about what we鈥檙e going to spend our money on.听 It鈥檚 unfair, I think, to make this into an individual decision that one doctor and one patient, it鈥檚 our entire country isn鈥檛 it that has to try and reach some kind of consensus about what we do here.听 Of course there are other ways forward, this is about cost effectiveness, and if something is not cost effectiveness you can either reduce the cost or increase the effectiveness to make it viable for NICE or we could decide to put more money into the NHS to fund these kind of interventions.

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Porter

Thank you very much Margaret. And to be clear on the Meningitis B vaccine situation:

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We are aware of no plans to extend the programme to older children, although, as we have previously reported on Inside Health, work is being done to look at the possible benefits in another high risk group 鈥� teenagers.

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As for paying for your child to be vaccinated: GSK, who manufactures the vaccine, has asked all private clinics in the UK to STOP immunising any new children as it cannot guarantee ongoing supply due to the severe shortage.

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The NHS however has been prioritised and the immunisation of all babies is unaffected.

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Now from injections to a tablet 鈥� not the type you swallow, but the computer variety which hospitals in Oxford are using instead of the traditional paper chart to record and monitor patients鈥� vital signs - things like temperature, blood pressure, pulse rate and oxygen levels.

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The project is the result of collaboration between the University of Oxford and the Oxford University Hospitals NHS Foundation Trust which includes The Churchill and John Radcliffe hospitals.

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The idea is simple. By recording and collating all the patients鈥� data electronically software can be used to highlight worrying trends that might be harder to spot on paper. And that data can be accessed from anywhere across the hospital network.

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It is called SEND 鈥� System for Electronic Notification and Documentation 鈥� and has so far been used by 4,000 staff to record over two million vital signs on 12,000 patients. I went to The Churchill Hospital to see it in action.

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Ward Sister Anna

Hi Clare, hello, are you okay?

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Clare

Yes I鈥檓 fine thank you.

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Ward Sister Anna

I鈥檓 just going to track your blood pressure, is that alright?听

听

We have the monitor and we have the iPads on.听 So what I do first is I check in my name and then what we do is we scan the patient鈥檚 wristband as well.听 So then patients鈥� details come up, latest observations as well.听 So what we do is we click on the machine, check the blood pressure.

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Watkinson

So I鈥檓 Pete Watkinson, I鈥檓 an intensive care physician at the Oxford University Hospitals鈥� NHS Trust.

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Porter

Pete, just explain to me what we鈥檙e looking at because some of it will be familiar to our listeners, some of it won鈥檛.

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Watkinson

We have a vital signs trolley which probably will be familiar to many people, where the equipment for taking say your blood pressure and your temperature are all gathered together on a trolley.

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Porter

That鈥檚 what the nurse wheels from bed to bed.

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Watkinson

It鈥檚 exactly what the nurse wheels from bed to bed.听 In addition to that we have placed a computer tablet device on that trolley and a barcode scanner set up, so that the nurse doing the observations can interact.

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Porter

So traditionally what would happen is the nurse would take this to the end of the bed and enter one of those charts that you and I flick through when we come on the ward round but this all now goes into the tablet.听 Just explain how that happens.

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Watkinson

The nurse takes the trolley to the patient, they scan the wristband on the patient, which has all the patient鈥檚 details, that gives them access to the patient鈥檚 chart directly and then it checks that it鈥檚 the right patient, so they verify that, and then they鈥檙e straight into the patient chart.

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Porter

So they鈥檙e doing the measurements as they normally would, the difference is instead of recording them in that little folder at the end of the bed, it鈥檚 going straight up on to the tablet.听 And there鈥檚 something different here that we haven鈥檛 seen before and that鈥檚 鈥� we鈥檙e used to looking at trends on our pieces of paper but this helps us, can you explain how it does that?

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Watkinson

Yes, so both at the top and bottom of the chart there is colour coding of each of the vital sign sets.听 As you take a blood pressure, or a pulse, for example it compares it to the 鈥� what would be thought to be normal for a population and the further you get outside that normal the higher each vital sign scores.听 So if you had a very low blood pressure it might score up to three, for example, similarly for the pulse and the oxygen saturations and all the other vital signs.听 The machine adds those individual scores together to create a summary score which is their track and trigger score, and that鈥檚 what鈥檚 displayed at the top and bottom of the chart.

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Porter

So looking at this pretend patient you鈥檝e got up on here there are periods where he or she is scoring nought, so you鈥檇 be presumably quite happy with that and that鈥檚 colour coded green but then we get 鈥� there鈥檚 some amber bits, which are one, and then there鈥檚 red and that鈥檚 when we鈥檙e starting to be worried and what you鈥檙e looking for is a shift in that pattern.

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Watkinson

That鈥檚 exactly what we鈥檙e looking for and clinicians have found this extremely helpful because it allows you to see very quickly subtle changes, particularly when they change a little bit over time, so you can see someone gradually changing, which you wouldn鈥檛 particularly notice without the colouration and without the chart directly in front of you.

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Porter

And what about patients that you must get asked 鈥� I鈥檝e got a patient on ward four or whatever that I鈥檓 very worried about, think he or she might need intensive care?

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Watkinson

So absolutely the first bit of us making that assessment now, when we鈥檙e phoned up, is to drop into our electronic system and look at the vital signs chart and talk to the doctor who鈥檚 referring the patient with the chart in front of us, so that we can better assess what we need to do and how urgently we need to do it.

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Porter

And that鈥檚 something you do routinely now?

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Watkinson

That鈥檚 become entirely routine for us in intensive care.

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Porter

Is the system perhaps better at spotting trends than we doctors or nurses might be?

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Watkinson

I think doctors and nurses spotting trends is definitely facilitated by the system.听 We also have a nurse concern button on the chart and that鈥檚 the biggest priority above all the scores because we know that experienced clinicians can see when people are becoming unwell, often even before their vital signs start to deteriorate.听 So it鈥檚 by no means a replacement for us as clinicians but it definitely facilitates us to watch people and communicate.

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Porter

So that nurse concern would be used by a nurse who looked at the patient and said I don鈥檛 care what the traffic light says, I鈥檓 not happy about this patient, there鈥檚 something not quite right?

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Watkinson

Exactly and we know that clinicians quite often feel that a patient鈥檚 not right, although each of the observations is within the normal range.听 And it鈥檒l be the combination of those observations and the other observations, like how the patient looks, that鈥檚 giving that feeling and clinicians uniformly will tell you that they learn not to ignore that feeling.听 And so what we鈥檝e done is encode it in our system to allow them to go no I鈥檝e got that feeling, let me make this patient be recognised as unwell.

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Ward Sister Anna

Are you happy?听 Yes?听 So we take all this away and then we can log out from the system.听 Thank you very much.听 And we鈥檒l come back soon okay?

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Porter

Ward Sister Anna and Dr Peter Watkinson demonstrating their new SEND system 鈥� may be coming to a hospital near you soon.

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Just time to tell you about next week when I will be investigating a condition that causes intense itching, lack of energy, is often blamed on drinking too much alcohol, and typically affects middle-aged women. Intrigued? Join me next week to find out more.

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ENDS