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Coughs, vocal cord dysfunction and athletes, taste and smell, waiting room toys

Duration:
28 minutes
First broadcast:
Tuesday 10 July 2012

Dr Mark Porter debates whether the recent lung cancer awareness campaign on TV, radio and the internet, hits the spot or is scaremongering. He discovers new research suggesting some people with exercise induced asthma are being given the wrong diagnosis and treatment. And GP Margaret McCartney investigates rumours this week that children's toys are to be thrown out of the doctors surgery in the on going battle against infection.

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

    Cough, VCD and Athletes

    TX DATE: 10.07.12 2100-2130

    PRESENTER: MARK PORTER

    PRODUCER: ERIKA WRIGHT


    Porter
    Hello and welcome to Inside Health. In today's programme: As we approach the 2012 Olympics, I'll be finding out how breathing exercises are helping some top athletes go for gold - and they are not the only ones who might benefit.

    Clip
    Asthma's very common in the UK, up to five million people have asthma, so we often assume that if a young person says their breathless on exertion that it must be asthma and it's not the right diagnosis for them.

    Porter
    GP Margaret McCartney investigates rumours that toys in the waiting room are the latest victims in the on-going battle against healthcare associated infections - could magazines be next?

    And why apples taste like onions if you can't smell properly - I track down one of the UK's leading experts on taste to answer a listener's query.

    But first:

    Clip: Cough ad
    If you've had [coughing] for over three weeks you should go and see your doctor. A [coughing] can be a sign of lung cancer....

    Porter
    One of a number of different lung cancer awareness ads put out by the Department of Health on TV, radio and internet over the last couple of months. A campaign that has attracted criticism from some doctors. GP Margaret McCartney is one of them. Margaret, what do you think is wrong with the ads?

    McCartney
    Well I'd love to see patients who've got worrying symptoms and I'm delighted to do that, that's my job. What I'm really worried about though is that these kinds of campaigns don't get the right patients to come and see me. And I'm afraid to say that that's what the evidence would also say - that there might be more people who are prompted to come along to the doctor because of a cough but they're not the right people that have got serious underlying causes.

    Porter
    Well Professor Sir Mike Richards is the national cancer director for England, he also joins us. Mike, how would you reply to that?

    Richards
    Well the first thing is to say where are we on lung cancer in this country? We have poor survival from lung cancer, we have lots of evidence that that's because of late diagnosis. And so we need to take action to get people diagnosed earlier. We estimate that if we do that we could save 1300 lives a year in England. And for these campaigns we've started at a local level, we've tested things at a local level, we've then moved on to a regional level where we get the benefit of the media and we've evaluated as we've gone. Our evidence is that it's the right people that are coming to the doctor, it's about an average of two to three patients more per practice per week, just during the campaigns, and they are the people in the right groups that are most likely to get lung cancer.

    McCartney
    If I can come to that because it's really not true that we're increasing our diagnoses of lung cancer via these campaigns...

    Richards
    No, no I'm just saying is it the right patients - that's what you were saying was wrong.

    McCartney
    No, well it's not, there may be high risk but they're not the patients with lung cancer, that's the point.

    Richards
    Well the point is this - we are trying to change the culture towards people coming forward early with symptoms, we're never saying this is going to happen overnight but what we do know is that GPs are clearly thinking there is something wrong with these patients because they are referring more patients on to hospital, they wouldn't be doing that if they thought it was always the wrong patients that are coming through. And indeed at the hospital they're often then getting CT scans which wouldn't be being done if they didn't think these were the right patients. And what we know, if you look at what's happened in Leeds where they've run one of these local campaigns, the proportion of people who come with lung cancer as an emergency has fallen very rapidly and very markedly. Now that is the first really good sign we're getting that we're getting to the right patients.

    McCartney
    We obviously want to get people the necessary help and to investigate people promptly, that's absolutely clear, but what - the point is of an intervention like an awareness campaign is is it that that's making the difference or not and we don't think - I mean there's no evidence so far to say that they are making a difference and that they're meaningfully making diagnoses earlier of lung cancer. And if you actually look at the cough campaign itself, the literature, I mean it's actually quite hectoring - it says if someone you know has had a cough for three weeks or more make them go to their doctor, don't take any excuses, they're needing a chest x-ray even if they have had one before, it infers that chest x-ray is all that they'll need, it's quick and easy, when actually we know that around a quarter of the time lung cancer will not be detected despite it being present via a chest x-ray. So this is not a panacea, it's not a quick fix all, it's something that really has to be looked at very, very carefully.

    Porter
    Mike, I'm intrigued by the three week cut off, I mean here on the one hand as GPs we're telling people with viral coughs that they don't need antibiotics and that they may last two or three weeks and that's perfectly normal, was there any science behind choosing coughs that lasted more than three weeks?

    Richards
    There is not very good evidence about what the right length of time should be, how long it takes for coughs that are going to subside to subside. We went out to expert opinion on this and talked to a great number of experts about it and this was what everybody was saying to us feels about right to them.

    Porter
    Professor Sir Mike Richards, Margaret McCartney, we must leave it there, I think we all agree on the fact that prolonged cough, whatever the cause, is never normal and should not be regarded as so. Thank you both very much.

    Now on to a less sinister, but much more common cause of cough - and one that is often confused with asthma. New research by a team from the Royal Brompton Hospital in London suggests that lots of people diagnosed as having exercise induced asthma are being misdiagnosed because they've actually got a problem with their voice box, not their lungs. And unlike asthma, this vocal cord dysfunction does not respond to inhalers. Essentially lots of people may be getting the wrong drugs for the wrong condition.

    The only way to confirm the diagnosis is to monitor what is happening to the voice box during exercise using an endoscopic camera passed through the nose. Something the team at the Royal Brompton has been using on athletes who have been told they have asthma to see what proportion actually has vocal cord dysfunction.

    Time for me to change in to some sports kit and see how my voice box reacts to a spell on an exercise bike - but first Dr James Hull has to get the camera in.

    Hull
    So I tend to ask people to start by blowing their nose. Are there any problems with the anaesthetic - local anaesthetic?

    Porter
    No.

    Hull
    Good. The first thing I'm going to do is I'm going numb the nostrils in gel, novocaine gel, it's a local anaesthetic which will make it nice and numb. It takes about two minutes to work so I just take my time with this bit because if it is nicely numb that it will be very much more comfortable.

    Porter
    Oh I want it nicely numb.

    And while my nostril was going numb I caught up with Dr Andrew Menzies-Gow, consultant respiratory physician at the Royal Brompton and the man leading the research. So how big a problem is exercise induced cough and wheeze?

    Menzies-Gow
    Well it's a big problem and the reason this is is that there's no good diagnostic test for what's causing the cough or what's causing the wheeze. Now asthma's very common in the UK - up to five million people have asthma - so we often assume that if a young person says they're breathless on exertion or they're coughing after doing some exercise that it must be asthma and because there's no gold standard test for asthma often people end up on asthma treatment and it's not the right diagnosis for them.

    Porter
    Indeed, in general practice we would probably regard that as the test, we would give them reliever inhalers to see if their symptoms get better.

    Menzies-Gow
    Yes and that's the right thing for some people but often it's very hard for the doctor to tell and often we're seeing patients when they're sitting down in front of us comfortable at rest and they're not actually doing any exercise and the symptoms will be very similar because regardless of where the airway tightens up you'll feel breathless and you might well feel wheezy. One of the easier ways to tell is often if it's the voice box that's closing up people will be wheezy when they breathe in rather than when they breathe out and with asthma it tends to be a problem on breathing out.

    Porter
    But otherwise the symptoms essentially are shortness of breath when they exert themselves and cough are much the same.

    Menzies-Gow
    Absolutely right.

    [Blowing nose]

    Hull
    The next thing we're going to do is pass the scope - your nostril will be nice and numb now.

    Porter
    The fibre optic scope goes in through my left nostril - it's about the size of a large straw isn't it, it's not very big.

    Hull
    Exactly that. When it passes through the back of your nostril it sits at the very top of the back of the nose so that we can view down on to the voice box from there.

    Porter
    So it's got an aerial view - it's looking down on top.

    Hull
    Exactly.

    Porter
    Not a view I've seen before actually - if you can get it in.

    Hull
    So [indistinct word] your eyes again for this. So that's it passed through the nose now. We're looking at the very back of the top of your throat and we can see now one of the main structures which protects your airway when you swallow called epiglottis. If you say eeeeee now continuously.

    Porter
    Eeeeeeeeeeeeeeeeeeeeeeeeeee. Right so I can see my cords coming - the folds coming together. Eeeeeeeeeeeeeeee.

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

    [Cough]

    Porter
    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.

    Hull
    So if we could get you safely on to the bike now, what I suggest is that you hold on with the handlebars in case you lose your footing. So what we'll do is we'll start you off now.

    Menzies-Gow
    One of the studies we're actually doing is not only looking at elite athletes but patients with very severe asthma, so five per cent of the asthmatic population despite all our best treatments have daily severe symptoms and we think that some of these patients may have the vocal cord problem as well as having bad asthma.

    Porter
    And looking at your work what sort of proportion of the people previously labelled as having asthma do you think might well have a vocal cord issue?

    Menzies-Gow
    Well we've certainly done enough in our severe asthma population to suggest that it may be up to 40-50% have in combination with bad asthma this problem on top, which is certainly worth addressing.

    Porter
    So these are people who've got a problem with their airways but it's compounded by the fact that they've also got a problem with their vocal cords?

    Menzies-Gow
    Correct. And treating their vocal cords mean that they feel better and their asthma is better without giving them more medicine.

    Porter
    But equally there are people out there who are labelled as having asthma that don't actually have a problem with their airways at all and it's all in their voice box?

    Menzies-Gow
    Absolutely correct and you're going to talk to someone who had that label and we've corrected the diagnosis and now she's able to perform to a much higher level than previously.

    Hull
    How are you feeling?

    Porter
    I feel fine, yes, quite easy yeah.

    Hull
    Okay, let's put it up then.

    Rebecca
    My name's Rebecca and I'm a rower, I row in a quad and I did Junior England two years ago.

    Porter
    And a quad is?

    Rebecca
    Four people rowing with two oars each.

    Porter
    When did you notice that you had a problem?

    Rebecca
    I started training properly in my upper sixth year and I started - every time we were racing I'd have problems breathing and sort of get rushed off to an ambulance at the end of every race.

    Porter
    And the feeling is of shortness of breath, are you coughing?

    Rebecca
    Shortness - coughing, shortness of breath. It felt almost like someone was strangling me or like choking me - it just really hurts. I went to my GP who referred me to a chest specialist who tried me on pretty much every combination of asthma medicine.

    Porter
    The presumption was at this stage that you had asthma?

    Rebecca
    Yeah I was diagnosed with asthma at 15, so they just assumed it was the same problem. The last race that I did got to the end and I took all my asthma medicine and it didn't help and then they put me on an oxygen tank and it took like two hours almost to calm it down.

    Porter
    But outwardly to other people presumably it looks like a classic asthma attack?

    Rebecca
    Yeah.

    Hull
    So you can see now as you're exercising a little bit harder your heart rate will be going up, you're breathing a little bit quicker and you can start to see that those airways structures are starting to stay more open, your vocal cords are opening up out of the way to allow lots of airflow to go in and out without any resistance. And these little structures around them as well are opening up nicely now.

    Porter
    And what actually do you see with the cords themselves when they're not performing as they should do?

    Hull
    Well you'll see once we get you up to a little bit more intensive exercise the cords they should stay completely out of the way, so they open right up and they stay right out of the way and they shouldn't close at all. And what we see is in contrast to that is that when patients we see develop their symptoms those cords actually can almost completely close and they're closing when an individual's breathing in and so that generates a lot of wheeze, it generates a lot of turbulence, it generates a lot of discomfort and breathing difficulties. And of course when they then go and see one of the medical doctors and tell them about their symptoms they say well I was breathless, I was wheezy and I couldn't get my breath at all, I was struggling, and people say well that sounds like asthma, that's asthma and in fact you can see that actually this is a completely different area and it's nowhere near the kind of airway tubes that are much lower down that are affected by asthma.

    Porter
    And the medication that we use to treat the asthma won't help this either, has no effect?

    Hull
    Exactly that and I mean - and one of the other things which is potentially harmful for athletes is that we know now that if athletes use a lot of the blue type of inhaler that people would routinely treat exercised induced asthma with over time that can actually make your airways respond less well to treatments. So getting the diagnosis right is very important if you want to help any individual but certainly athletes.

    Menzies-Gow
    What we see sometimes is that the vocal cords shut when they should stay open. Now that means that the patient will feel breathless, they'll feel wheezy and they'll feel as if - sometimes they tell you that they're trying to breath in and out through a straw and you can see, from seeing the pictures yourself, that clearly those vocal cords are meant to be open in a wide V and if they're shutting right down it would be very hard to breath in and out and will impact on people's maximum exercise capacity.

    Porter
    Because this is a natural bottleneck - where the vocal folds are - I mean when they're closed it's very, very tight.

    Menzies-Gow
    Absolutely right, so they're there - so as I'm talking, you're talking that they're generating the noise and they're also there as a protection mechanism if we swallow the wrong way to stop fluid or food from going down on to the lungs. But you can imagine when you're maximally exercising you want to get the air in and out as quickly as possible.

    Porter
    Now this can be a problem for anyone who's doing any form of exercise but obviously for an elite athlete entering the Olympics it can be the difference between a gold medal and no medal.

    Menzies-Gow
    Absolutely correct.

    Porter
    And presumably the importance of getting the diagnosis correct is so that we can treat them and the treatment is different?

    Menzies-Gow
    Yes correct, so clearly if it's asthma you need to give the right inhalers and if it's a vocal cord problem asthma therapies won't work and a much better way forward is physiotherapy intervention. So our physiotherapists teach people how to breathe properly, how to open up their upper airway and prevent the spasm from happening on exertion.

    Johnston
    So Rebecca, so today we're going to focus on some of your breathing re-training techniques.

    My name is Rachel Johnston and I'm a respiratory physiotherapist at the Royal Brompton Hospital.

    When you're pushing yourself hard and you feel like you have physical obstruction in your upper airway the natural thing is to breathe faster, breathe harder and then panic does set in. So it's about educating the patient as well as teaching breathing re-training.

    Porter
    How quickly can you see a noticeable change in somebody's breathing habits?

    Johnston
    We would expect to see a change within three to four sessions. We would actually expect to see a change acutely in the first session...

    Porter
    Almost immediately.

    Johnston
    Yes because the vocal cords, when they come in, you normally hear an inspiratory wheeze, you normally get your symptoms very acutely, and so educating the patient, teaching them breathing control, can very often stop those symptoms very quickly.

    Porter
    How do the patients that you're looking after respond? These people have often been told they've had asthma, they've been given lots of different drugs by doctors that haven't really worked are they convinced that you're right this time?

    Johnston
    I think that coming here and having the test where they can visualise the vocal cords it helps them to have confidence in their diagnosis from that point on and then it helps to give them confidence in the treatment.

    Porter
    And presumably it gives them a lot of understanding, so once you've seen your own vocal cords coming together you can understand why you can't get breath.

    Johnston
    Absolutely.

    Porter
    It's very strange - so I'm sitting on the bike, I'm facing the screen, I can see my own voice box really, is what you call it, at the bottom of the picture is the epiglottis, which is like a big leaf that falls over the area to protect it, so that food doesn't go down the wrong way effectively and then below that I can see my vocal cords and they're open at the moment as I'm starting to get breathless, as I'm sure you can hear. It's very strange, actually of course the voice I'm making coming from there as well, it's all moving as I speak and it seems to be working so far so good.

    Hull
    So you're up to 150 watts now and you can hear that you're starting to get a little bit breathless and now the structures really out of the way and the vocal cords you can see now are completely open.

    Porter
    And what is about the exercise that makes the cords close abnormally in some people?

    Hull
    That's the sort of million dollar question really and a lot of people are looking at that in detail. Whether it's a response to try and hydrate the air as it's going in or whether it actually reflects the process where there's an abnormal neural control of that area is still being looked at and it's one of the areas we're very interested in.

    Porter
    Are mine behaving themselves?

    Hull
    Yeah, they look perfectly fine. So if you feel you've done enough then we can wind it down.

    Porter
    Yeah that'll do for me.

    Hull
    You're sweating quite hard now so that was a good test.

    Porter
    Dr James Hull putting me through my paces at the Royal Brompton Hospital in London. That type of testing is not yet widely available but vocal cord dysfunction is a diagnosis worth considering in anyone who coughs and wheezes when they exercise, and in whom conventional asthma inhalers don't seem to be working. And you will find some useful links on our website - go to bbc.co.uk and follow the link to Inside Health.

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

    Roger got in touch from Hong Kong with a query about taste and smell - a question we put to an expert on the subject over a coffee and cake in a café in Bristol.

    Melikar
    My name is Jan Melikar and I'm a doctor who does clinical research at the University of Bristol into taste and smell which I've been doing for over a decade.

    Porter
    Jan, we've had an e-mail from Roger who evidently around two years ago, after a bout of cold or flu, lost his sense of taste and smell and he wants to know why and why not a lot is being done about it basically.

    Melikar
    Yes, it's an area that falls between two stools. So on the one hand you've got dental specialists in oral medicine, you've got the ear, nose and throat specialists and it sort of falls in the middle.

    Porter
    There isn't a taste specialist.

    Melikar
    There isn't a taste specialist, no.

    Porter
    How common a problem is it?

    Melikar
    We don't actually know because it's one of those loses that people tend not to report because they'll go to their GP or talk to their friends about whether they should see their GP and their friends or their GP will say well no actually you've lost it, there's no one really to refer to, it'll probably get better and then there's the confusion of is it taste or is it smell.

    Porter
    Because they're very closely linked?

    Melikar
    Yes, a way of looking at it is taste provides sort of base notes to everything, you've only got five main tastes - sweet, sour, salt, savoury and bitter - with the sense of smell providing all the rest. So there's various ways of fooling the brain, if you have a blocked nose all food tastes relatively bland because you're not hitting all that smell sensation. And I can illustrate that now by chopping up an onion and an apple and apples and onions have very much the same texture and the same taste but it's the sense of smell that differentiates them and you go ah lovely for the apple and oh disgusting to eat a raw onion.

    Porter
    So actually as far as the taste buds in the mouth are concerned apple and onion are basically the same?

    Melikar
    They're the same - it's sweet and it's a little bit bitter and a little bit sour. So you must block your nose...

    Porter
    So if I pinch my nose just to do that.

    Melikar
    Just pinch your nose and then we find a spoon and you close your eyes and I feed you one of them, okay? And when you've finished eating that we'll feed you the other.

    Porter
    Onion, apple?

    Melikar
    Yes that's right.

    Porter
    But actually to be honest that was mainly a texture thing. I think if you liquidised them - I could just get a slight appleness - I mean hardly any difference at all.

    Melikar
    Yes, yes, isn't that impressive and yet....

    Porter
    For someone with no smell at all couldn't tell the difference.

    Melikar
    No but they would say they've lost their sense of taste.

    Porter
    Right. Which takes us back to Roger, so what I suspect has happened here, based on that experiment, is he's not lost his sense of taste, he's probably lost his sense of smell has he?

    Melikar
    Probably because that's the common loss.

    Porter
    And what sort of things can - I mean talking about an episode of cold or flu, I've seen patients with a very similar story...

    Melikar
    That is one of the classic causes. So you have a strong bout of flu which the patient will express outright saying this happened and I had it...

    Porter
    It happened then doctor.

    Melikar
    It happened then, I had it, it blew out my - if you like it blew out my nasal epithelium where the sensory cells of smell were and for some reason they haven't regrown, poked back through.

    Porter
    So the virus associated with colds and flu is actually permanently damaging the lining?

    Melikar
    Well we think so, we haven't got any specific absolute categorical proof, apart from there is this lovely link that you have this awful cold or you have this permanent inflammation in the sinuses of your nose and that nicely links to you've lost your sense of smell and we can't find any other reason for it.

    Porter
    What about looking forward, what's the outlook for people like this?

    Melikar
    Okay, they've done studies of that where they've said right, we'll investigate fully, this is mainly in Europe, and what they found is it doesn't really matter what the cause is but the things that make your sense of smell come back, if you keep following people up in the clinic, is the younger you are, the less you smoke and the more female you are.

    Porter
    Well I don't know if Roger's a smoker or not but you can influence that obviously but we can't do anything about our age or our sex.

    Melikar
    No, no, no, unfortunately no, so I mean these are the things they picked up following people through. Various treatments have been tried, so if you've got particularly inflamed sinuses then sometimes steroids put in there to reduce the inflammation can stop the cause, if you like, whether it solves the problem that's still....

    Porter
    But the outlook is - I mean if you've lost your sense of smell for weeks or months is there any chance of it coming back?

    Melikar
    Yes, yes, about 30-40% of people continue to improve, so they go from having no sense of smell, to altered sense of smell, to it comes back but it's a slow process, it doesn't happen to everyone.

    Porter
    Give us some idea of how that loss of sense of smell might affect what they perceive as their taste, what sort of things might they not be able to tolerate that they would have previously enjoyed?

    Melikar
    They - put simply - they just don't enjoy food, food is totally bland, they have no idea what the flavours are, they may over salt food abysmally, they won't know if it's gone off or not, it just tastes bland and so you can then fall into a sort of deep, almost clinical, depression because actually you don't realise until your sense of smell and taste have gone just how dull life can be.

    Porter
    Can it be a sign of anything worrying?

    Melikar
    Occasionally yes because the way smell and taste go up into the brain, it's a long route and many things could impede or press down on those nerves.

    Porter
    A brain problem could potentially cause it?

    Melikar
    Yes, yes but that's very rare small print.

    Porter
    How did you get into this field?

    Melikar
    Well myself and a colleague were drinking a glass of wine and we realised that the chemicals in the brain that I was interested in researching were the identical chemicals that were involved in taste. So we thought ah there's a link, can we look at taste as a sort of marker of other things going on in the brain. And it sort of followed on from there.

    Porter
    And looking at your field nationally across the UK are you one of many or is this a Cinderella speciality?

    Melikar
    I'm it.

    Porter
    Dr Jan Melikar - one of a rare breed. And, please, if there is a confusing health issue you would like us to investigate do get in touch - you can e-mail me via insidehealth@bbc.co.uk

    And talking of confusion - could waiting room toys be the latest victim in the battle against healthcare acquired infections? Rumours have been swirling around GP surgeries that the forthcoming need for all practices in England to register with the Care Quality Commission will mean much more rigid infection control policies. The CQC wrote to doctors last week to start the process, and infection control officers are already visiting practices, in some cases banning toys from the waiting room.

    Margaret McCartney has been investigating further.

    McCartney
    I became aware that there was a Dr Martin Brunett down in Surrey who had a beautiful wooden train set on a wooden table in his surgery, which he's had for a decade or more, and he was visited by an infection control nurse employed by his primary care trust who told him that he had to get rid of the train and the train set in order to be CQC compliant.

    Porter
    So what's been happening in Dr Brunett's surgery is probably being mirrored in practices across the country. I know from our perspective in Gloucestershire, my practice manager, I've got a hole in my carpet and needed new carpet for the consulting room, my practice manager's told me I can't have one and my curtains are going to have to go as well. But you've been to talk to the CQC and it's not the case.

    McCartney
    Well it's a load of rubbish, I'm delighted to say, so I got in touch with the Care Quality Commission and asked them where on earth this had come from and if it was true that they wanted Martin Brunett's lovely wooden train set to be sent to the fire and they said absolutely not, they said that these are rumours, they have no basis in fact, they don't think that carpets or soft furnishings should be thrown out and further more they would like to know who is spreading the rumours. So if you're a GP and you've been told to get rid of your toys tell them.

    Porter
    So Margaret where's the confusion come from?

    McCartney
    Well it seems that the primary care trusts have sent out their infection control nurses into general practices to ensure that they are compliant with the CQC and when I asked the infection control nurse who visited Dr Brunett's surgery they said that because toys do carry a risk of infection and therefore need to be cleaned every day and as a recommendation it is of course for the practice to choose whether or not to make any changes. Now they claim that this is based on the National Patients Safety Agency National Specifications for Cleanliness in the NHS but when you go and look at that, page 30 I think it is, it quite clearly says that cleaning frequencies are offered only by way as a guide.

    Porter
    So Dr Brunett's train is safe for the moment.

    McCartney
    Hurrah.

    Porter
    But this has been a on-going debate, hasn't it, about toys in the waiting room and whether they pose any significant risk, is there any hard data to suggest that they transmit infections?

    McCartney
    Yeah, I mean lots and lots of people have looked quite hard for bugs on all sorts of things and it is quite clear that we are hoching [sic] with bacteria, all of us, it's the normal state of being, there's lots of scientists who will say that we have more bacterial cells in our body than we do human cells. And there was a fantastic study from America where they swabbed people's hands and found an average of 3,200 bacteria on their hands from a 150 different species. So it's quite clear that we have lots of bugs on us and that's our normal natural healthy state. The big question is: what is harmful and what is not? And I think we can say quite safely that there have been no demonstrable harms caused by toys carrying bugs in normal general practices.

    Porter
    Margaret McCartney thank you very much for clearing that up.

    Just time to tell you about the next programme when, amongst other things, we will be investigating the pros and cons of screening for heart problems. In light of Fabrice Muamba's cardiac arrest on the pitch earlier this year, should we be screening all young people taking part in vigorous sports? Join me next week to find out.

    ENDS

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    Inside Health

    Demystifying the health issues of the day that confuse us. Inside Health, with Dr Mark Porter, will…

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