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GI bleeds, pregnancy and working, frozen shoulder, patient surveys

Duration:
28 minutes
First broadcast:
Tuesday 03 July 2012

50,000 people end up in hospital every year in the UK because of bleeding from the top end of the gut - an upper gastrointestinal bleed. Around 1 in 10 of them will die. Gastrointestinal or GI bleeds are often due to ulcers - a side effect of taking aspirin and other non-steroidal anti-inflammatory drugs like ibuprofen and diclofenac. The bleeding can occur in the gullet, stomach or the first part of the intestine, the duodenum. Other causes include cancers and liver disease. The location of the bleed can be pinpointed by using an endoscope - a camera to look inside the gut - and treatments include stopping the bleeding with clips, heat or injections of adrenalin.

The National Institute for Health and Clinical Excellence hopes to change that with new guidelines on managing GI bleeds - guidelines which, as of last month, hospitals in England, Wales and Northern Ireland will be expected to follow. Scotland has had similar guidance in place for the last few years. David Patch is a Consultant Hepatologist at the Royal Free Hospital in London and has a special interest in this type of bleeding. He says that patients whose needs cannot be met at smaller hospitals should be transferred to specialist units where they can be treated promptly.

Tariq Iqbal who's a consultant gastroenterologist at the University of Birmingham is evaluating a new kind of treatment called Hemospray. This is a powder that can sprayed over the bleeding area to stop or slow any bleeding by accelerating the natural clotting process.

New research appears to show that standing at work for long periods in pregnancy can affect the unborn child. Research in the journal Occupational and Environmental Medicine, followed 4,680 mothers throughout their pregnancies. Some of the women had jobs where they were on their feet a lot - such as hairdressing, sales and working with toddlers. Women who stood for a long time had babies with smaller heads. It's thought that standing for long periods of time causes blood to "pool" in the legs, limiting the blood supply to the rest of the body including the uterus and therefore the developing foetus. The study also showed that working up to 36 weeks of pregnancy had no impact on birth weight, size or prematurity. Previous studies have shown that heavy lifting increased the risk of babies being born early - but this study showed no such link.

Many people with pain and stiffness in the shoulder are told they have a frozen shoulder. But the label is often incorrect as a truly frozen shoulder means restricted movement in all directions, accompanied by pain. It's not known what causes it but it is commoner in people with diabetes. During the very painful initial phase it's best to rest the shoulder and use analgesia to help relieve the pain, especially at night time when it can be at its worst. TENS and acupuncture can help sometimes. The tissues in the shoulder "capsule" appear to be thickened and rubbery - and some relief can be gained from surgery, to let the shoulder move more freely. If left alone about half of patients still have discomfort after 7 years - so the common belief that it lasts 2 years is a myth. As the pain starts to recede physiotherapy can be helpful and if there is inflammation - eg with calcified tendonitis - then steroid injections can relieve pain.

Producer: Paula McGrath.

  • Programme Transcript - Inside Health

    INSIDE HEALTH

    TX: 03.07.12 2100-2130

    PRESENTER: MARK PORTER

    PRODUCER: PAULA MCGRATH



    Porter
    Hello and welcome to a new series of Inside Health - in today's programme: We go behind headlines suggesting that pregnant women who spend a lot of time standing could be slowing their baby's growth. Our resident sceptic, Dr Kamran Abbasi, digs a little deeper.

    Another member of the Inside Health team, Dr Margaret McCartney, investigates GP surveys. Since 2006 nearly £50 million has been spent collating feedback about GPs, but just how helpful are the results?

    And we answer your queries, this week it's frozen shoulder - what is frozen shoulder, and what is the best way to treat it?

    But first a condition that hospitalises around 50,000 people every year in the UK, 5,000 of whom will not survive the ordeal. Upper gastrointestinal bleeds - potentially catastrophic bleeding from the gullet, stomach or the first part of the intestine, the duodenum.

    There are lots of underlying causes for the GI bleeds, including cancers and liver disease, but the lion's share is due to ulcers - which often result as a side effect of taking aspirin and other non- steroidal anti-inflammatories like ibuprofen, naproxen and diclofenac.

    Traiq Iqbal is a consultant gastroenterologist at the University of Birmingham.

    Iqbal
    The usual presenting symptom is that the patient feels very lousy, first of all - they feel very tired and faint as a result of blood loss. And usually the stool changes colour, so they get loose black stools which is an indication of bleeding. If the bleeding is very active then they can also vomit blood as well. So they either - either vomit blood and have black stools or they may just present with black loose stools.

    Porter
    Do these patients have warning signs that they're heading towards a serious bleed?

    Iqbal
    No, most people would associate ulcers with pain and most often there's no pain at all, the first sign is of the black - loose black stools really when they go to the toilet.

    Porter
    So the key message is not to ignore that and why is it black - that's altered blood is it?

    Iqbal
    It's altered blood. Blood is a fantastic laxative so not only does it cause loose stools it causes frequent stools and the stools are described as tarry and they've got a very distinctive smell and I think once this has happened once the patient knows what's going to happen next time. The problem is, is it can be four or five days before they realise there is a problem and by that time they come to hospital and they're quite compromised by the extent of bleeding.

    Porter
    Do you think there's enough awareness of the dangers of gastric bleeds?

    Iqbal
    No I think it is a neglected area to be honest. A lot of people take aspirin and painkillers like aspirin, for example profen and such painkillers and I'm not sure people are aware of the risks.

    Porter
    And what proportion of patients that you're seeing are coming to the unit because they're taking aspirin or an anti-inflammatory drug like aspirin?

    Iqbal
    I would say about 30% - 30-40%.

    Porter
    Despite major advances in the management of gastrointestinal bleeds over the last 50 years - not least the development of the fibre optic endoscope, a camera that allows doctors to look inside the gut - there's been hardly any improvement in survival rates. You are about as likely to die from an acute upper GI bleed today as you would have been back in the early sixties.

    The National Institute for Health and Clinical Excellence hopes to change that with new guidelines on managing GI bleeds - guidelines which, as of last month, hospitals in England, Wales and Northern Ireland will be expected to follow. Scotland has had similar guidance in place for the last few years.

    David Patch is a Consultant Hepatologist at the Royal Free Hospital in London and has a special interest in this type of bleeding.

    Patch
    Within the UK we've generally had a good reputation worldwide for managing these conditions but I think there's room for further improvement. If you vomit 200 mils of blood onto the kitchen floor I think there's only one place that you're going to go and that's hospital. The care and management at that point needs to be absolutely as good as it can be and there are variations in practice in the UK. I think somebody who's had a significant bleed should be endoscoped as soon as resuscitation has been completed. So that would be endoscopy within six hours. And we know from the British Society of Gastroenterology audit that around 50% of hospitals in the UK, who have accident and emergency units, don't offer an on-call bleeding rota. I think we now need to get the network sorted so that patients who go into let's say a smaller hospital which doesn't have full access to all the different services can then link in with a large hospital and patients can follow a fairly seamless pathway whereby they can be endoscoped, if the bleeding's not stopped they can be offered interventional radiology etc.

    Salva
    My name is Salva, I'm a sister in endoscopy unit Queen Elizabeth Hospital. When they come to the unit our job is to assess them, the initial assessment, because especially someone bleeding inside they will be poorly and ensure they are safe and their observation - which is the blood pressure and pulse - they are okay and make them comfortable and get them ready for the procedure.

    Porter
    They're not done under anaesthetic - these...?

    Salva
    No they work under sedation.

    Porter
    So sedation which means - what - they're given a bit of jungle juice?

    Salva
    Yes gin and tonic they normally call it, yeah. A little bit of valium kind of medication to make them nice and relaxed. They can't remember what's happened to them but they can remember the surroundings - that's the effect of the drug.

    Porter
    And are you watching the whole operation on a video screen so you can see exactly what's going on?

    Salva
    Yes, yes.

    Porter
    Sister Salva from the endoscopy unit at Queen Elizabeth Hospital in Birmingham, where the team is testing a new approach to tackling bleeds. At the moment the bleeding's often stopped by placing a metal clip onto the leaking vessel, but it can be hard to find the culprit when everything is swamped in blood. Which is where Hemospray is proving useful - it's a powder that can be sprayed over the bleeding area to stop or slow bleeding by accelerating the natural clotting process.

    Tariq Iqbal

    Iqbal
    This is a very exciting new avenue. It's entirely new technology which allows us, for the first time, to attack the bleeding site without having to get right up to it, which can be very difficult anatomically. Quite often these patients have ulcers which are bleeding from vessels right at the back of the duodenum, which is the bit the stomach empties into, and it can be really hard to get there with the conventional endoscopic technique. So this is a very exciting new development which allows you to apply a treatment to the area rather than to actually get right up to the ulcer.

    Porter
    How do you actually deliver it?

    Iqbal
    It's a powder which is delivered by carbon dioxide canister which jets this powder through a plastic catheter which you put down the endoscope.

    Porter
    So it's a bit like a dry powder fire extinguisher - effectively you're hosing down the area where you think the bleeding's coming from?

    Iqbal
    Exactly right, I think that's a very good analogy actually, it's like a dry powder fire extinguisher. It does - it seems to be very effective. Just the last week there was an 85 year old lady who'd been in three times bleeding from a duodenal ulcer and she'd had endoscopic treatment three times and also radiological treatment as well to try and plug the vessels, we then used the Hemospray and it stopped and she went home a week later, so we've had some great success with it really.

    Porter
    So this - put it in very simple terms - might be the equivalent of powdered styptic pencil, it encourages the formation of a blood clot?

    Iqbal
    That's right, it seems to act in two ways: First of all it provides a barrier, it absorbs water and it also encourages the accumulation of blood clotting factors around the bleeding site, so it encourages coagulation. So it's like a safety blanket really - you just spray it on and it does stop the bleeding.

    Porter
    So the Hemospray would be generally used as your first line treatment?

    Iqbal
    When there is a visible bleeding spurting vessel the priority is to get control of the vessel, that's where the Hemospray comes in because if we can achieve blood clotting without having to fiddle around with a clip then you're in the position of being able to make a decision as to whether to go on and apply the clips as belt and braces...

    Porter
    The pressure's off a bit.

    Iqbal
    The pressure's off, it's a safety blanket.

    Porter
    Consultant gastroenterologist Tarig Iqbal. And you will find a link to the new NICE guidance on managing GI bleeds on our website - go to bbc.co.uk/radio4 and follow the links to Inside Health.

    Dr Kamran Abbasi, Editor of the Journal of the Royal Society of Medicine is here. Kamran you've come in to talk to us about pregnancy and the effect on working on baby's health but while I've got you here you used to be a rheumatologist did you not?

    Abbasi
    Yes I worked in rheumatology for a while yes.

    Porter
    So presumably you're quite familiar with using non-steroidal anti-inflammatories - the aspirin, ibuprofen family...

    Abbasi
    Yes very much so.

    Porter
    ... of drugs? I mean my concern is people will listen to that and they'll be worried that if they're on these drugs, as millions of people are, that they're going to have a bleed but there is an interesting association with age isn't there?

    Abbasi
    Yes there is, I mean if we look at a simple age cut off - let's take 55 years - anybody below that on a non-steroidal you'd be surprised to find people on non-steroidal regularly.

    Porter
    The risk is they will be regarded, if they're otherwise healthy, as low risk?

    Abbasi
    Yeah low risk, yes definitely. Above 55 years of age I think there's an interesting stat whereby with every decade you put on after that you double your risk. So, for example, the risk is roughly one per one thousand person per year.

    Porter
    At 55?

    Abbasi
    At 55, yeah, then that goes to two one thousand person at 65 and doubles again at each decade.

    Porter
    And that just shows that the vast majority of people on these drugs do not have bleeds. There are other steps that doctors take, I mean just looking at the guidelines here, we avoid non-steroidals if simple painkillers and paracetamol will do and that applies to the public buying over-the-counter?

    Abbasi
    Yes.

    Porter
    Try and avoid them if people are taking aspirin at the same time, use the weakest possible and for most cases that will be ibuprofen, that's probably the safest. And in people who are at risk - and most people are probably aware of this - we use antacid drugs like omeprazole. But as I say that's not why you're here. You're here to talk about this study that looked - it was published last week - that looked at the effects of working during pregnancy on babies health. At first glance this is a little worrying, it suggested that if you stood for long periods - so say you had a job where you were standing for long periods - that it could lead to restricted foetal growth, where did the story come from?

    Abbasi
    Yes it was published in a journal called Occupational and Environmental Medicine and it was published last week. It was a study of nearly 5,000 mums to be from early pregnancy onwards and it was done in the Netherlands. And what they were - what the researchers were looking at was the effect of lifting, standing for long periods, working long hours on various pregnancy outcomes. Now what they found was - were two findings essentially one was that if you worked for longer than 40 hours a week, compared with somebody who worked less than 25 hours a week, your baby might be smaller at birth. The second finding, main finding, was that if you worked shall we say in a demanding job and stood for a long time there was a chance that your baby would have a smaller head.

    Porter
    So a smaller head, lighter weight baby - that's - the suggestion is that baby's not thriving so well, that somehow the working is detracting from baby's growth and development?

    Abbasi
    Yeah that's the suggestion, they didn't really define that in the study but that's the suggestion with a link that if there's any failure to thrive there's lots of research evidence that suggests that the child may develop illnesses later on in life such as diabetes and heart failure.

    Porter
    But to put this in context the effect was pretty small wasn't it?

    Abbasi
    Yeah it was tiny, let's say the difference was one centimetre in size in terms of head circumference and we're talking 150-200 grams of weight.

    Porter
    Right, well I suppose they're significant differences aren't they - did they come up with a mechanism or a suggested mechanism as to what was going on, why would standing or why would working longer hours deprive baby of nutrients?

    Abbasi
    Well there are various mechanisms proposed. One related to standing is that if you stand you're blood pooled in the legs essentially and that reduces the return of the blood back to the heart and it means that your blood is pumped around your body at a lower pressure. The result of that is that there's reduced - potentially there's reduced blood flow to the uterus and hence that may have an effect on baby.

    Porter
    And of course that's delivering all of the nutrients.

    Abbasi
    Yeah precisely.

    Porter
    And what about working long hours?

    Abbasi
    Well working long hours, shall we say that's hard physical work, so the two proposed mechanisms are that first of all it may be that mother's blood pressure was reduced, which again has an effect on reducing blood flow to the uterus and secondly, because you're working for a long time mother's consuming a lot of energy, which means there might be less for baby. Now what we need to say is that your physiological mechanisms do compensate for all of that usually and you'd expect them to but people are trying to propose mechanisms to explain these findings.

    Porter
    Yeah sure and we don't know that this is what's going on, that's a possible cause. And it's quite important this because an awful lot of women work during pregnancy and work right through pregnancy.

    Abbasi
    Well precisely, that's why there's so much interest in this study and similar work that's gone previously because over half of women we know in the UK are working in paid employment during their pregnancy and 37%, according to the data that I've seen most recently, are still working within six weeks of delivery.

    Porter
    So that's more than one in three are working pretty well as far as they can?

    Abbasi
    Yeah, yeah absolutely.

    Porter
    I mean looking overall, putting this new research into context, is there any convincing evidence in your mind that women who are working till - as long as they can in a job that might be physically demanding, are they putting themselves or their babies at risk?

    Abbasi
    Well shall we say up to around 2009 we kind of didn't know the answer, then at that time the Royal College of Physicians, the NHS and the Faculty of Occupational Medicine did some quite thorough work on this, they conducted a review with an expert panel and published a national guideline, the conclusion of all that work which seemed robust - seems robust to me is that there is a small risk with certain of these occupational, shall we say, hazards. So, for example, with lifting, with heavy physical effort, in other words working - and working long hours, prolonged standing - all of these have some effect. The other issue people have looked at is shift work and there's no real evidence, at the moment, that shift work has any effect on pregnancy outcomes.

    Porter
    The overall consensus is this is pretty safe but if you avoid doing - I mean physical exertion, serious physical exertion and standing for long periods may be detrimental but probably not but maybe?

    Abbasi
    Yeah I think that's precisely right, which is why there's nothing mandatory, there's nothing saying that after a certain amount of weeks in pregnancy you must stop working because at the end of the day if there is a risk it's a small one and it's up to the mother to see how she feels in her occupation.

    Porter
    The application of common sense. Dr Kamran Abbasi, thank you very much.

    Now, time for an apology. The last edition of the last series was supposed to contain a report on frozen shoulder - a widely misunderstood condition that affects as many as one in 50 of us at some time during our lives. But we didn't have enough time to squeeze it in and its exclusion prompted quite a response. So here it is for all those who e-mailed in to complain - Olive, Terry, Julian, Ann, Ralph and numerous others - and thank you for your patience.

    Simon Lambert is a shoulder surgeon at the Royal National Orthopaedic Hospital in Stanmore and a leading expert on the condition. So what is frozen shoulder?

    Lambert
    Well what we think that the general public and often general practitioners feel it means is any shoulder that's stiff and painful. But unfortunately that can encompass a huge variety of different problems ranging from shoulders that are actually too wobbly and painful but feel stiff to the patient right the way through to the older patient who has arthritis.

    Porter
    So when you talk about frozen shoulder what are you actually referring to?

    Lambert
    Well we're talking about a condition usually in ladies, often in the sort of 50 year old age group - that decade of life - who've not had any previous history of shoulder injury, developing an insidious onset of shoulder pain, usually felt halfway down the arm in fact but associated with a gradual crescendo of pain so that any movement becomes painful even at night when they're resting. That differentiates it from something that comes after another problem and the pain can be very different.

    Porter
    What sort of timescale are we talking about these symptoms developing?

    Lambert
    The painful phase occurs over several weeks to a crescendo maybe six, seven, eight weeks after the onset of symptoms. And then you enter a phase where the shoulder starts to stiffen and then you enter a phase some months later when the shoulder starts to ease up again. But those phases can be different in length.

    Porter
    So that story with no obvious trauma and no previous problems and this gradually developing syndrome gives you the clue - what would you do in your outpatients' clinic to confirm the diagnosis?

    Lambert
    So having got that suspicion in one's mind what do you do then? Examining the shoulder all movements of the shoulder are limited in range and all movements are painful.

    Porter
    And that's whether they're passive or active - so whether the patient does it or whether you move it?

    Lambert
    Absolutely and if the patient tries to move it's painful from the word go, if I try to move the shoulder it's painful during the movement and particularly at the end of movement. Whereas in all other conditions there's usually some movements that are more or less comfortable. So it's a global restriction of movement and all movements are painful.

    Porter
    And what's actually happening to the joint to cause the problem?

    Lambert
    Well that's the enigma. When you look inside the joint with a telescope and you take a tissue sample the tissue is abnormal - it's thickened, it's therefore - it's a bit sort of rubbery sometimes and it's therefore by being thicker it's said to contract but it's not strictly contractile but because it's thicker it limits the range of movement.

    Porter
    So do we know how to treat it?

    Lambert
    The short answer is probably no, not with great certainty.

    Porter
    First of all what happens if we don't treat it?

    Lambert
    Well it's actually said to have a natural history of improvement. The best scientific basis for that comes from a study that's seen people at about seven years after onset where about 50% of people still had some discomfort and 60% still had some restriction, particularly in outward rotation.

    Porter
    That's not great seven years on though is it?

    Lambert
    No it's not and the common concept that it returns to normal within two years is not true.

    Porter
    So what can we do about it?

    Lambert
    Well in the first painful phase it's a fairly sad state that you have to give fairly strong painkillers, rest the arm, try all manner of things including things like tens and acupuncture can be helpful in certain individuals to try and reduce the pain burden.

    Porter
    Is it important to rest the shoulder or keep it moving as much as the pain allows?

    Lambert
    Well in the first phase, the very painful phase, let's say it's kinder to the patient. In the second phase as the pain starts to settle a little then we want to try and move the arm within the limits of the comfort that the patient has.

    Porter
    What about the role of injections - steroid injections - do they help?

    Lambert
    Well again some clever chap said steroid injections work if you give them before the onset of the frozen shoulder, which of course is very unhelpful.

    Porter
    The retrospecterscope.

    Lambert
    The retrospecterscope. But in some studies and some cases they are useful, probably if there is an inflammatory pre-condition, something like calcific tendonitis or a bursitis that actually is causing a secondary frozen shoulder.

    Porter
    But you're suggesting that most of these people with frozen shoulder have no history of shoulder problems.

    Lambert
    Exactly and so steroid use is probably not very well established and giving a steroid injection into a very painful globally restricted shoulder is actually an art form that's radiology based, not I would suggest outpatient clinic based, certainly I wouldn't do it because it's too inaccurate.

    Porter
    So we can't give injections, what can we do in the second and third phases to speed it on its way?

    Lambert
    Well the old orthopaedic treatment was to manipulate the shoulder, to try and reduce the stiffness and that was...

    Porter
    Under anaesthetic.

    Lambert
    ... under anaesthetic. That was quite successful but it carried with it a risk a complications. Something like one in 10 people had a problem and they could range from a little split of the tendons of the shoulder right through to full dislocation or nerve injury. And so most of us are really abandoning that as a form of treatment and we now undertake keyhole surgery. Keyhole surgery because you can be accurate, you can make a diagnosis of any other problems and it works and it works jolly well.

    Porter
    What are you doing during the operation?

    Lambert
    Well we're actually cutting the thickened tight tissue, cutting it out, releasing it and allowing the shoulder to flow more freely. And then of course we've got to give good physiotherapeutic backup to that and that's where the challenge lies really.

    Porter
    At what stage would you consider surgery and what sort of success rate would you offer the patient?

    Lambert
    Well I'd really only consider surgery if a patient was so restricted that they could not rotate their arm outwards more than a distance when their forearm is pointing straight forwards, in other words if they could keep their arm pointing forwards then a physiotherapist is likely to get some improvement. People who can't do that and in particular people with diabetes appear to have a much more fierce contracture are a candidate for surgery if they've still got pain.

    Porter
    And what sort of results can you claim?

    Lambert
    Well I feel I can claim good results because I'm very specific and careful who I choose. If you're conservative to the point where the patient says I've had enough those patients actually do very well because pain relief is almost universal. Maintenance of movement is not and that can be due to patient motivation and recurrent pain and the availability of a good sympathetic but firm physiotherapist.

    Porter
    Surgeon Simon Lambert.

    And if you would like us to look into a health issue that is confusing you then please do get in touch - you can e-mail me via insidehealth@bbc.co.uk or use Twitter - send a tweet to @bbcradio4 including the hashtag insidehealth.

    Resident cynic Dr Margaret McCartney is on her soap box again - and this time she is turning her withering gaze onto the thorny issue of patient surveys. Has investing £46 million asking patients about their GP practices made it easier to choose the right doctor?

    McCartney
    Since 2007 about five million patients have been annually asked about their GP. First, the surveys were about access to care - getting that appointment when and with whom you want it - but most recently the focus has been on whether the staff explain things, listen well, or involve you in making decisions about your care.

    So if your GP is kind, gentle, knowledgeable, experienced and generous with their time then - if such a doctor does exist - the idea is that everyone else can find out about this fabulous doctor via their glowing online report. Bad doctors - crabbit bad listeners, grumblers, or medics who persistently running late - that would be me I'm afraid - will be publically shamed into retribution.

    The answers will be collated into marks out of 10 and the Department of Health says that it will "drive up standards within the profession" in "another step forward in giving people more choice. Patients will now be able to see exactly what the experience of being a patient at each GP surgery is like."

    Really? Really and truly? The Patients Association have no qualms, saying it will "enable patients to compare the performance of their own GP with others." For me it does nothing of the sort. The results are collated, meaning that it is practices, not individual GPs, we get data on. If I'm looking for feedback this won't help.

    There's been loads of research on what the data means and there are major problems. For example, some groups - like younger, or South Asian patients - report lower scores compared to others from the same practice - meaning that practices with higher than average populations of these groups could score lower when there's no difference in the quality of care.

    Worse, doctors voiced dilemmas: a satisfied patient would not always infer good care. So doctors refusing a sick note might be practising good medicine but making a patient unhappy. My concern is that bad doctors will ignore the data, and good doctors might change perfectly good medical practice to try and score higher. We have so much data sometimes it seems that we're drowning in it. One year the survey cost 10 million - 10 million!

    As a patient, I wouldn't know how to use this data to help choose me a GP. As a doctor, I don't know how to respond to it. But this is what I did when I moved to a new area and I needed a GP. I asked around, I asked people whose opinion I trusted and who had the same kinds of problems that I do. Easy. And it cost nothing.

    Porter
    GP Margaret McCartney. We contacted the Department of Health and a spokesperson told us:

    Statement - Department of Health
    The GP Patient Survey looks at patients experiences of local GP services. It provides practices with an independent picture of local patients' experience of GP accessing care, allowing them to improve services and giving patients, through NHS choices, comparable information about GP services in their area. We have managed to substantially reduce the annual budgeted cost of the survey last year to £4 million, which continues for 2012-13 ensuring the best value for money for the government.

    Don't forget you can listen to the programme again - and download it as a podcast - by visiting our website. Go to bbc.co.uk/radio4 and follow the links to Inside Health.

    And please get in touch if there is a health issue that you would like the team to look into - you can e-mail me via insidehealth@bbc.co.uk or send a tweet to @bbcradio4 including the hashtag insidehealth.

    Next week we answer a listener's query about losing your sense of smell, and discover why smell is so vital for a proper sense of taste. And talking of noses - I get a camera put into mine to take a closer look at my vocal cords.

    Clip
    Can you see eeeee now continuously?

    Eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee. Right so I can see my cords coming together. Eeeeeeeeeeeee

    Then you can cough as well and you can see what happens when you do that.

    [Cough, cough] This is very weird. To think that what I'm saying now is being generated by - actually it looks a bit like a trifid - big lower leaf that's the epiglottis that protects it.

    Porter
    I know - you are none the wiser. All will be revealed, but suffice to say that if you, or a member of your family, find exercise makes you cough or wheeze then you should listen in. Join me next week to find out more.

    ENDS

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