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Aspirin, holiday sickness, ADHD

Duration:
28 minutes
First broadcast:
Tuesday 27 March 2012

Aspirin is over 100 years old, but doctors still can't agree whether the benefits of taking it to prevent heart conditions or cancer outweigh the risks.Dr Mark Porter investigates. And - you've worked flat out to get on holiday, then come down with a stinking cold - is there any science behind why so many of us get sick on vacation. Plus ADHD - not in children, but ADULTS - why is it so hard for grown-ups to get a diagnosis.

Producer: Erika Wright.

  • Programme Transcript - Inside Health

    THE ATTACHED TRANSCRIPT WAS TYPED FROM A RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT. BECAUSE OF THE RISK OF MISHEARING AND THE DIFFICULTY IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS COMPLETE ACCURACY.


    INSIDE HEALTH

    TX: 27.03.12 2100-2130

    PRESENTER: MARK PORTER

    PRODUCER: PAULA MCGRATH


    Porter
    Hello and welcome to Inside Health. In today's programme: An aspirin a day keeps the doctor away - or does it? If you are confused by the latest news, rest assured you are not alone. Ever since the news that aspirin can protect against cancer, GPs have been dealing with perplexed patients. I will be asking two leading lights in cancer prevention whether they think more of us should be taking the drug.

    There could be nearly a million adults in the UK with Attention Deficit Hyperactivity Disorder (ADHD). Most of whom won't know it - although they are likely to have some idea that they are different from their peers. Could you be one of them?

    Kewley
    In Europe there are probably around two and a half per cent in the population which is huge if you think about that.

    Porter
    One in 40.

    Kewley
    Yes.

    Porter
    So a million people at least, we're talking about, in adults in the UK?

    Kewley
    So where's it been all this time and what is it that has made us so incredibly blind about it?

    Porter
    And, if you have ever wondered why so many so many people fall ill with coughs and colds after flying abroad on holiday - and I am one of them - then we might just have the answer.

    But first, aspirin. It may be more than a hundred years old, but age has not withered its myriad properties - or its ability to grab headlines. Over the last few years British doctors have been more cautious about recommending daily low dose aspirin to thin the blood and reduce the likelihood of heart attack and stroke because of the risks of side effects - potentially life threatening bleeds, mainly into the gut.

    But new research suggesting that the drug can protect against cancer, and slow its spread, could see the pendulum swing the other way. It has certainly piqued the public's interest - as GP Margaret McCartney has discovered.

    Margaret, these latest findings made the headlines last Wednesday, how long was it before patients were asking your advice?

    McCartney
    Not very long at all, I think shortly after the Today programme ended my surgery began and it's certainly a hot topic I think among people who would like to discuss this and wonder what the research means for them.

    Porter
    It's difficult as a GP to stay abreast of these stories, isn't it, we have to be right on the ball, I mean how aware were you of this research and how critical were you of it?

    McCartney
    Yeah I mean usually I do get press releases put through to me but I missed this one, so I was on the Lancet website trying to find out what this study was and really what it meant. And I think the problem that I have is that often we do get a lot of media coverage about one particular piece of research but it's much more difficult to find out the whole breadth of research. This was a positive finding, we thought there was a benefit from aspirin, what about all the trials that showed no benefits or potential harms? And I think it's much more difficult to kind of put all those trials together and then make a judgement based on the enormity of the evidence, as it were, and trying to make a holistic judgement I think about all the research that's been, not just one little bit of it.

    Porter
    So if I was to come in as a 49-year-old male, otherwise healthy and say look Dr Margaret should I be taking aspirin or not, I mean what were you saying to them on Wednesday?

    McCartney
    Well I think that we know that there's an awful lot of risk factors for cancer that are quite amenable to probably much more dramatic impressive improvements in terms of your risk than taking aspirin, for example not smoking, exercising, not being overweight - those things haven't changed, they're still the best things of all. But we also know that we actually have to put an awful lot of people on to aspirin to get even this reported effect, so I mean the authors had to find, I think, that you could reduce three cancer diagnoses out of a thousand people that were taking aspirin over a year. So that's quite a small amount all things in perspective and I just wonder whether in the meantime until we get more definitive statements about what the entire field of this evidence is whether we should be concentrating on the bigger risk factors that we all have.

    Porter
    Well that is strange isn't it you do see patients do that a lot - I mean they come in they put a packet of cigarettes on the table and they say well tell me about this aspirin or statin or whatever to reduce my chances - where lifestyle is key.

    The other thing I wanted to ask you about was the way that opinion seems to sway - aspirin's been around for a very long time, it's been used for the prevention of heart disease and stroke but even without we've said put everybody on it, don't put everybody on it, oh it's good, no it's not as good as we thought - does this worry you the way we seem to swing from black and white when in fact most of medicine's grey?

    McCartney
    Yeah I mean it definitely is grey and it's all sort of shades of grey, there's very few sort of definitive things out there. But I think what - I'm absolutely for the evidence if the evidence changes then we should change practice, that's absolutely clear but I'm not sure we've ever really got there with aspirin and I think what we're really missing is the kind of prospective trials - the trials looking forward - where we can know people from now and work out what best to do. And I'm not sure we really have that kind of quality of evidence so far and I think probably the best thing is for the researchers to come back to us and tell us where the gaps are in evidence and then we can all work together to try and fill those gaps.

    Porter
    Well talking of the researchers Margaret let's see if the experts can provide any clarity.

    Yanush Yankofski is the Sir James Black Professor at St Mary's, University of London and joins us from a conference into cancer in Switzerland. And, from his outpatients clinic, Peter Rothwell who's Professor of Clinical Neurology at Oxford and the man behind the study that put the cat among the pigeons last week.

    Peter, at the moment we generally only recommend daily low dose aspirin to otherwise healthy people deemed to be at very high risk of heart attack and stroke - because of the side effects involved. Do you think your research suggesting that it also reduces the risk of developing cancer is likely to change that?

    Rothwell
    I think we need to - we need to think clearly about quite how to do this and the guidelines don't take into account at all the effect of aspirin on risk or spread of cancer and they clearly need to be updated. But I think we do need to think carefully about which groups of the population it is that has a sufficient chance of benefiting and also the least chance of being harmed by taking aspirin long term.

    Porter
    Professor Yankofski, you're not quite so convinced.

    Yankofski
    Well I think the benefit is unproven so if I were a man in the street or a lady in the street, for that fact, I would ask myself three questions: do we have hard evidence that aspirin has a benefit? And we can answer that - yes it has, unquestionably it has a benefit. The magnitude of that benefit we could quibble over but I think most people would say 20-25%, it maybe take you 20 years to get that, so if we take that...

    Porter
    Twenty, Twenty five per cent of what?

    Yankofski
    Of those people who take aspirin 20-25% of people will have some sort of reduced mortality or cancer end point, so approximately one in five to one in four may have a benefit from taking aspirin over 20 years. The second question the person in the street should say: Does it have any risks? Now that is the big question here. The older you are the more likely you are to have complications and these complications, particularly in the GI tract, will be serious. And the last question we need to ask ourselves, which is probably the detail is: How long do I take it, when do I take it, in what dose do I take it and what are the potential good and bad combinations? In fact we don't really know the answers to that to be frank with you.

    Rothwell
    Yanush is absolutely right, we do need to look at this in detail but I think the problem so far is that people haven't looked at bleeds in detail - they haven't looked a severity of bleeds, no one's considered the time course of bleeds because what we're trying to do is to predict the risks and benefits of taking aspirin for 20 years and so we need to understand how that risk evolves over time, how severe those bleeds are.

    Porter
    To put this in simple terms, perhaps I could come to both of you and say what would you explain to a patient who is perhaps - me, I'm 50 years old, sitting opposite you, in terms of what the risks of taking aspirin might be versus the benefits - I mean how would you quantify that in an easy way for me to understand? Yanush would you like to have a go?

    Yankofski
    Yes, if you're going to have to take a drug for up to 20 years, might be shorter but let's say 20 years for the sake of argument, that means your risk of GI bleeds will also accumulate too. And if you look at the published data and if you're a patient out there the range of risks is from 1% to .1% and if it's .1% there really is no big issue here, your risk of having a GI bleed, a serious one, is probably one in 50, most patients would probably take that. If it's 1% and that can be the case, particularly in people who are elderly, then your risk of GI bleed is after 20 years surprisingly 20%, so your risk benefit ratio is remarkably small. And in medicine we always like to use the Hippocratic Oath - first do no harm before you try to do some good - so therefore while we still think there's advantage, and there probably still is, it's marginal.

    Rothwell
    When we've tentatively suggested that people might consider taking aspirin what we've said is that you might think about starting it at around 45 and you'd probably stop it at 65, at which point the bleeding risk starts to rise.

    Porter
    Well how did you quantify the risks over that period? So let's assume you're talking to the 45 year old, I mean how would you put those - the risk and benefit, in simple terms?

    Rothwell
    Well if you look at the trials the risk was for the first three years in these trials of relatively healthy middle aged people, the risk of a major GI bleed, the sort of bleed that might take you to hospital, was one per thousand patients per year and that risk actually fell with time. We've also got to bear in mind that there's no excess of fatal bleeds, GI bleeds, there's no evidence that aspirin increases the risk of you dying of a stomach bleed. So you're weighing up these non-fatal bleeds against potentially fatal heart attacks, potentially disabling strokes, potentially fatal cancers and I think the risk calculations we're doing so far are just too crude, we need to look more at death and disability - we're comparing apples and pears as it were with bleeds versus strokes and bleeds versus cancers.

    Porter
    Well not only are they too crude but I mean there's a huge variation in the figures - I mean one in 50 to one in five is a vast difference - and presumably we would all agree that the truth probably lies somewhere twist those two. But my question is for the man in the street, the person who's been reading the headlines that have been out this week, he's an otherwise healthy middle aged man, like myself, with no particular history, when do you think we'll know enough to be able to recommend to them whether they should be on aspirin or not, that's the key question for most people who are listening?

    Yankofski
    Five years probably.

    Porter
    Okay, more research needed. Until then, Professor Yanush Yankofski and Professor Peter Rothwell, thank you both very much.

    GP Margaret McCartney's been listening to that. Margaret, are you any the wiser?

    McCartney
    Well I think it was very interesting that they were talking about mortality - deaths - and whether or not taking aspirin would reduce your death risk or not because quite clearly the Lancet paper that was out was quite clear that they didn't find that taking aspirin reduced deaths when taking it. What it did seem to do was reduce cancer diagnoses, I mean the big bottom line are the ones we need to know about. We need to know whether we're going to live longer or not when we take aspirin compared with when we don't and I find it amazing that you know aspirin's one of these drugs that's been around for how long?

    Porter
    Over a hundred years yeah.

    McCartney
    Yeah and we still don't know the answers to really pretty fundamental questions - do you get more benefit or harm?

    Porter
    And that's the bottom line isn't it Margaret - we just don't know yet.

    McCartney
    Absolutely right.

    Porter
    Thank you very much. Oh by the way your don't call me dear item last week, on how healthcare professionals should address their patients, prompted a few listeners to get in touch.

    Keith Taylor from Scarborough has been in and out of hospital over the last two years and says that he has always been treated with respect and courtesy - despite being called dear, sweetheart and luv. He says there shouldn't be any hard and fast rules, as it's all down to the background and personality of the individuals, both patient and carer.

    But Jane Lewis is not so happy: "What annoys me intensely is being asked "How are we today"? Why WE? What on earth does it mean?"

    If you would like to get in touch - like Keith and Jane - maybe to ask the team to look into an issue that is confusing you, then send a tweet to @bbcradio4 including the hashtag insidehealth or e-mail us via insidehealth@bbc.co.uk.

    Airport actuality

    It has taken you ages to save up for an Easter holiday in the sun, but no sooner do you start to relax by the pool than you go down with a cough or cold. I blame the plane and sharing such a small space with hundreds of others, at least one of whom is bound to be carrying some form of virus. But is there any evidence to support this theory? Our resident investigator Dr Kamran Abbasi, Editor of the Journal of the Royal Society of Medicine, has been doing some digging. What did you find Kamran?

    Abbasi
    Well Mark I found there were two separate questions to answer here. The first one is if you get on an aeroplane are you at higher risk of catching an infection? That's the first thing. The second one is also interesting in that there's some concern about the ventilation systems on aircraft - people and the media have raised concerns that they might be adding to the infection risk.

    Porter
    This is the theory that the airlines are economising by cutting back on the aircon, circulating the same air and we're all breathing each other's air and catching the bugs. We'll come on to that in a minute but first of all did you find any evidence that my theory that you catch things on a plane is true?

    Abbasi
    Okay, to cut a long story short: There isn't much evidence.

    Porter
    No you mean.

    Abbasi
    But, but, but let's say you require two things: First of all there's a plausible mechanism and I think you described that well - you're in a confined space with several other hundred people, one of whom, perhaps many of whom, have got a cough or a cold or some other infection. So it's entirely plausible that sitting next to them you've got a chance of a catching something. The second element of our evidence based analysis is that are there any studies that have shown this, unfortunately it's quite a difficult area to study. There isn't much evidence to support it but it's entirely plausible. And if we look at something a bit more serious, like tuberculosis, there has been quite a bit of work looking into people catching TB from other people on the plane who have that illness. And that showed rather interestingly that if you're sitting within two rows of somebody with TB for about eight hours you've got an increased chance of catching that infection.

    Porter
    So proximity and duration is important.

    Abbasi
    Yeah.

    Porter
    What about this theory then that if I'm - I've got flu and I'm sitting at the back of the plane and I'm breathing flu viruses up into this air that's being recirculated - tell me about this recirculation, that's what I'm interested in.

    Abbasi
    Yes, yes so don't sit at the back because you might get everybody else's bugs. Well interesting the ventilation systems, the way they work, is that they direct air downwards and out to the sides to try and minimise the number of people that would be exposed to each other's air...

    Porter
    And that's done on purpose?

    Abbasi
    That's deliberate - it's to cut down airborne infections. So the second issue is do these ventilation systems increase the risk of infection? Well all the evidence, and there's a bit more evidence on this, suggests that they probably reduce the risk of infection on aeroplanes and one particular example where a plane was stuck - was grounded - for quite a while with a ventilation system that wasn't working and there was an influenza outbreak amongst those passengers.

    Porter
    So being in a confined space is not great for spread of infectious diseases, it makes it easier and more likely, but actually being in a plane, because of the type of ventilation system they've got, because of the airflow and filters - are they using filters?

    Abbasi
    They are using filters and these are very sophisticated filters so when you're in the air about 50% of the air is recirculated but it's pumped through filters which take out dust, vapours, bacteria, fungi and viral particles - so these are highly efficient. And they create an environment that is probably safer than any building you might work in or other transportation.

    Porter
    So okay we'll give them the benefit of doubt, if I catch my cough and cold it's likely to be in the departure lounge, we think, it could be in the departure lounge rather than on the plane itself.

    Abbasi
    Yeah probably.

    Porter
    But I would urge you that if you're flying with a cough or a cold please don't sit next to me.

    Kamran Abbasi, thank you very much.

    And don't forget if you would like Kamran to look into something that is confusing you then tweet your message to @bbcradio4 including the hashtag insidehealth - or e-mail us at insidehealth@bbc.co.uk.

    Listener Rohan did just that about Attention Deficit Hyperactivity Disorder - ADHD - a well-recognised condition in children but not in adulthood.

    Rohan
    Millions of adults and that includes me suffer the misery of ADHD but trying to get actual treatment for it is proving to be really, really difficult. A lot of GPs I've spoken to don't acknowledge that the condition exists, I mean I've suffered things like self-doubt, self-hate, depression, even though I've got quite a high IQ, I've got a lot of skills, but at the age of 47 I'm a horrendous under-achiever. It's really difficult to face the barriers that the medical profession seem to put up.

    Porter
    ADHD is something most children will never grow out of so it is little surprise that the latest estimates suggest that as many as one in 50 adults in the UK could have some degree of ADHD too - the vast majority of whom remain undiagnosed. Dr Geoff Kewley is a Consultant Paediatrician at the Learning Assessment and Neurosense Centre is Horsham West Sussex.

    Kewley
    Prior to about 1990 ADHD was hardly recognised in children let alone in adults, it was present obviously but it was often called other things, such as personality disorder or poor parenting and the like. So that it wasn't recognised and wasn't treated and there's now a huge cohort of adults who have gone through life untreated. In many areas of the country there are still a significant shortfall in service provision for adults.

    Alan
    Hello I'm Alan, I suffer from ADHD but I wasn't diagnosed until I was aged 61, I'm now 67. The main characteristics I tend to have are severe memory problems, not that it's not in my memory but there's a great difficulty in getting things out, especially names. I also have a problem with procrastination, I start tasks, leave them, I forget. I also have a problem with interrupting people, behaviour problems, some of the problems can be quite dangerous. I just didn't know what it was all about.

    Clinic actuality
    Badat
    Good evening everyone, it's me Dr Badat. You may or may not know me, maybe you're on the waiting list to see me for which I apologise profusely. But in any case...

    Porter
    Consultant psychiatrist Ovaze Badat is involved in a local support group and works at a specialist adult ADHD clinic in Bristol.

    Badat
    Some of them have crazy risk taking behaviours which just - they are almost addicted to and one of the useful theories is people with ADHD, if they lack dopamine, the sort of excitatory hormone, they're going to find it somewhere and what they tend to do is live on a brinksmanship kind of way, so they drive in a really reckless way, so people with ADHD tend to have a litany of driving offences - that's at the lowest level. The other thing that I can say is takes risks in relationships - they find themselves arguing and curiously almost spurred on by the argument and they can get moments of clarity and then regret. What appears to be happening is they're actually exciting their own adrenals. When you're in an anxious state and you have ADHD what you get is a short burst of adrenalin which actually is a sort of body self-medication, you get clarity. So these people live on the edge because they're just using their own body, their own hormonal profile, to treat themselves. Always catching themselves out in jobs, always seeking stimulation, unable to do mundane things because they're simply - they cannot commit their mind to those mundane things because it just isn't enough excitatory hormone to just get them through life.

    Porter
    Sounds a dangerous recipe - if you're unlucky you get caught out at work, you get caught out in your relationship and you get caught out driving or breaking the law in other ways and you can end up in quite a lot of trouble.

    Badat
    Indeed you can. You get huge numbers of people in prison who really are unable to just stop themselves from saying or doing things out of turn and they're really embarrassed about it. This leads to all sorts of problems in their life - they can't hold down a job, their relationships fail, they also seek help for something which they don't know the shape of.

    Jill
    Hello my name's Jill, I'm Alan's partner of three years, although I have known him for about 15 years because we sing in the same choir. What I can't get over to him is I know he's got it, I understand part of it, I never understand what's going on in his brain, he puts this barrier up and we always end up arguing.

    Alan
    I lost a lot of friends, I gave up a lot of friends because I didn't feel I could be a true friend. I don't think I'm worthy of their friendship, you just get worn out mentally and physically sometimes, you get worn out. I've got quite a good IQ and because of that I had a good education.

    Badat
    Typically the picture is this child did very well at school and so well that they seemed to never need to revise for exams, they were just extraordinarily bright - that's a particular subset we get. And then when they arrive at university it just falls out and they just arrive with this serious sense that something has gone wrong. Clearly they haven't lost all their intelligence, they just can't coordinate their heads and the analogy I sometimes use is that they feel as if they're at an airport which just has one plane landing a day - is able to cope. But suddenly they feel like an airport with air traffic controller who have gone on strike and the planes - which are thoughts if you like - are just landing in a chaotic way - they're landing anyway, life moves on, you need to press on but the place is a mess and they feel why can't I coordinate my own head.

    Porter
    Because this concept of an adult presenting with ADHD being quite a high achiever, having a good school record, probably goes against the grain of what most doctors would think of an adult with undiagnosed ADHD, I mean the stereotype might be of a child who's caused chaos throughout their school life but never been picked up and ends up in trouble as an adult and is quite a low achiever but you're saying that that's not always the case.

    Badat
    No indeed not.

    Susan
    I'm Susan and I'm 60. Why I am hyperactive - I'm not really physically hyperactive, I'm mentally hyperactive. I change interests really fast. I have a lot to say but I've only got one mouth and it's really hard to get a lot of ideas that are buzzing around my head at the same time out through one mouth. One of the worst impacts of not being diagnosed with this is that I have learnt to be extremely cruel to myself and beat myself up all the time for making mistakes, for forgetting things and for upsetting other people. In part it's because I was diagnosed late and have very low self-esteem as a result, although I manage to hide that but it means that I'm constantly doubting myself.

    Porter
    The mainstay of therapy is treatment with the stimulant Ritalin - a drug that has attracted more than its fair share of controversy over the years.

    Badat
    The medication mostly, broadly speaking, is - the first line is stimulant medication. What it appears to do is increase something called dopamine and/or adrenalin - these are transmitters in the brain. What these things - these chemicals appear to do is allow the brain to be more adept at choosing what to focus on and what not to focus on, so you don't get this mental noise so much. So here you have these people who are normally hyperactive - physically just cannot get it together - they suddenly get the ability to pick one thing nicely and see it through to the end without this sense that it's either going to be abandoned or incomplete.

    Porter
    So paradoxically you're giving them effectively a stimulant but that stimulant works by improving the clarity?

    Badat
    Absolutely. And one of the best things I've seen is a patient who has a habit for sports cars who says doc for the first time after medication I can drive my fast car slowly. And it was a relief to him which is a paradox.

    Susan
    The only way I can describe it is that it's like putting on my glasses. I take the medication and half an hour later I can see - I know where I'm going, what I'm doing during the day and I get things done. When I don't take the medication I just get lost - a whole day goes by and I've done nothing but think thoughts. I've had ideas of things to do, I haven't done any of them. And it is really, really distressing - not to be able to get things done. And it's the only way I've been able to hold down the jobs - the large number of jobs I've had - but the only way I've been able to do it, the only way I've been able to finish university I could not have done that without the medication.

    Badat
    People come back and say where have I been my whole life - it is as transformational as that, it is probably one of the most effective medicines in psychiatry.

    Porter
    But our listener says he's struggling to get the help that he needs and I suspect that's quite a familiar problem across the country.

    Badat
    Yes it's a cross that people have to bear when they have a disorder which isn't well recognised and which is controversial, even in professional circles - GPs sometimes just simply don't think it's there, they think it's a societal construct.

    Porter
    Are we making progress?

    Badat
    Absolutely, I think there's a large amount of activism when it comes to ADHD, partly driven by patients who are so consciously positively enraged by the fact that it took so long for them to get diagnosed and of course a lot of them are very able, very high achievers, just like people with autism who then are campaigning - these are people who are saying why isn't there enough service, why is there such a big waiting list.

    Susan
    I was diagnosed about 10 years ago in America when I was at university, then I came back to England and naturally the NHS wouldn't take an America diagnosis, which was fair enough. So I thought well I'll just go to the GP and ask for a referral, well that turned into a huge problem. The partners at the GP practice didn't believe in ADHD and didn't want to refer me. So I had to get my MP involved.

    Porter
    One of the criticisms has been that this is the medical creep, is the term that's used and that drug companies are getting in on - oh we've got a product here what are we going to do with it, oh I know it works for this condition so if we can medicalise basically an extension on normality but what would you say to people who argue that?

    Badat
    Absolutely, I think it's a debate that is absolutely valid, I don't think anyone should take anything at face value. ADHD is a disorder which is neuro-developmental and a lot of it means it's so intertwined with elements of personality that you can't just say this is disorder and this isn't, so the rounded understanding that I need to develop takes necessarily long for something that superficially looks exceptionally easy - here's 18 criteria do you tick the boxes. So we do get therefore the controversy of why are you taking so long for something that somebody might be able to self-diagnose online - the key is actually it's everything else I need to rule out.

    James
    My name's James, I am in my late 30s, I was diagnosed with ADHD just over a year ago. When you meet other people who've got it you suddenly feel human again because they have so many of the same characteristics that you do. And I think once you know you've got it, it isn't the end of the world because it comes with good things as well as bad. What does the damage is not the fact you've got the thing, it's not knowing about it because not knowing about it, it can absolutely destroy you. The big thing is that there's hope that the future can be better than the past.

    Porter
    One of the members of the adult ADHD self-help group in Bristol.

    Just time to tell you about next week's programme when, among other things, we will looking at whether boys should be vaccinated against HPV and whether children should wear cycle helmets. Oh, and Dr Max Pemberton visits a tattoo parlour - hopefully he will be out in time to report back.

    ENDS

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