Steroids, the killing season, telehealth, Dupuytren's

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: 07.08.12 2100-2130

PRESENTER: MARK PORTER

PRODUCER: PAULA MCGRATH

Porter
Hello. In today's programme: It's has been dubbed the Killing Season by some sections of the media - but what is the truth behind claims that August is a particularly risky time to be in hospital? Dr Margaret McCartney investigates.

After our critical report on the impact of telehealth on long term problems like diabetes in the community, I will be finding out how technology is being used to bring patient to specialist to transform emergency services in hospital.

And everything you need to know about a condition that affects the palms and fingers of as many as one in 10 of us to some degree - Dupuytren's contracture - including a new alternative to surgery.

But first a widely ignored, yet burgeoning type of drug abuse. Aggressive testing of athletes, and state of the art facilities like the 2012 anti-doping lab in Harlow, may now mean that the use of anabolic steroids is rare amongst those in the Olympic village. But the same cannot be said for the rest of the UK where abuse has exploded.

Anabolic steroids are naturally occurring hormones, like testosterone, that influence growth, physical development and the workings of the reproductive system. Abuse allows athletes to train harder for longer so they become bigger, stronger and faster. But what do anabolic steroids do for the rest of us, and who is using them?

Jim McVeigh is Deputy Director at the Centre for Public Health at Liverpool John Moores University.

McVeigh
We know that the vast majority of people who use anabolic steroids are not engaged in top level sport and not even engaged in what we class - most people class as any form of competitive sport. What we are seeing is people use them purely for cosmetic purposes to enhance musculature, to get a more defined physique or to just look a lot bigger.

Porter
Do we have any idea how many people?

McVeigh
We have some indications but we're unable to put a firm figure on it. The British Crime Survey, which is used by the government to identify prevalence of use of drugs, came up with a figure of 52,000 who'd used in the last 12 months. All the indications are that it's much higher than that. The British Crime Survey involves representatives from the Home Office knocking on people's doors and asking people to declare if they use drugs or not and you could perhaps see why people may be reluctant to do that. What we do know is data from needle and syringe programmes, we've been collecting data in Cheshire and Merseyside. What we've seen is from 1990 a couple of dozen people who were using steroids to now we have 3,000 people being seen in the last year. What we've seen over the last four years is over five and a half thousand new clients who are using anabolic steroids and other performance enhancing drugs.

Porter
Have you seen any change in the profile of your average steroid injector, I mean who is he or she if you had to give me a typical picture?

McVeigh
I know when I was working in needle and syringe programmes the majority of steroid users that you would encounter would be men in their 30s, experienced weight trainers, some of them would be competitive body builders, the majority of them aspiring body builders and also you would see some doormen and other occupations where size, strength and bravery are at a premium. Certainly in recent years we're seeing youngsters in their late teens, predominantly, and quite often they won't be training properly, in some cases they're not training at all.

Porter
So what you're saying is today's users are more likely to be sitting on the sofa hoping that the drug will do the work for them whereas previous users realised that all steroids do effectively is they help you train harder but you have to put the work in to get the reward.

McVeigh
Many of them won't appreciate exactly what is required to get that muscle growth and that is a lot of dedication, a lot of calories, a lot of work, sleeping at the right times, avoiding recreational drugs and intense partying - all the things that many young men would think is their raison d'etre and also tied in with the reasons why they may want to look with a chiselled physique and attractive on the dance floor - the two aren't compatible.

Porter
Using steroids alone won't help you - you get that - but how are they actually taking them - these are all injections presumably?

McVeigh
No, the vast majority of people use injectables and will also use oral anabolic steroids as well. They'll use them in combinations referred to as stacks, there's a lot of myths and folklore about the synergistic effects of anabolic steroids but it's quite hard to counter this because we haven't done the legitimate research to actually prove this wrong. So it's influenced heavily by steroid gurus often who are - have incredible physiques and therefore their opinion carries a lot of weight, they'll use them usually for a set period of time and then an off-cycle where they won't use, although in recent years this off-cycle has got shorter and shorter. The vast majority of steroid users will use a whole range of other drugs in conjunction - these will be things like growth hormone or some of the growth hormone promoters to stimulate growth hormone production - to work together with the steroids to increase muscle mass. But then a whole range of drugs to counter the side effects.

Porter
What sort of problems do we see as a result of this form of abuse?

McVeigh
We know quite a bit about the more cosmetic or in some cases transient side effects. So the things that are quite predictable are things like acne, where there's a propensity for it accelerated male pattern baldness. One of the other side effects, which are associated with anabolic steroids, Gynecomastia, the growth of breast tissue. Another side effect would be the shrinking of testes because when you have that external testosterone in your system you no longer need to produce your own.

Porter
And as well as the physical effects does it have an effect on behaviour, I mean does it turn men into the stereotypical raging bull?

McVeigh
We have conflicting evidence around this. Certainly I think most people who've worked with steroid users would disagree with that. What we've found in particular work that's been conducted in the United States is for the vast majority of people it will have minimal effects on psychological behaviour, on mood, on aggression but for a small number of people - these are usually what we class as high responders - they may actually experience mania, they may even become aggressive. There was a systematic review conducted in Scandinavia recently where they failed to find a causal effect of anabolic steroids with aggression. What we don't do is the research around this very well and partly this is due to the ethical implications, quite rightly we're not able to give people large amounts of anabolic steroids and then poke them with a stick and see what happens. So a lot of the assumptions are drawn from clinical dosages that are used or from animal models and they're not really good enough to get a good understanding.

Porter
Jim, you know you have to ask - here we've got a group of people that you're saying in some cases are taking these drugs so they can cut a more striking shape on the dance floor and yet the side effects include - losing your hair, acne, growing breasts if you're a chap and shrinking testicles - you're not selling it well to me, I'm surprised - surprised they're so popular.

McVeigh
To a large extent those adverse effects are dose dependent. What you will see is a group of youngsters who will get advice from the more experienced steroid users and unfortunately sometimes the advice isn't around limiting the dosage, it will be to use the drugs to counteract those side effects. Of course alongside those adverse effects a range of - from a health point of view - things that we consider much more serious and that's the long term effects associated with cardiovascular disease, impacts on the liver, in particular with oral anabolic steroids it's associated with some cases of kidney damage as well. So those are the sort of things which are real concerns but of course for a lad of 19 or 20 those things only happen to other people and they're indestructible.

Porter
Jim McVeigh. And just to be clear, although they share the same umbrella term - steroids - the anabolic variety we have been talking about are very different from the corticosteroid family used therapeutically in lots of different forms. The corticosteroid family includes prednisolone tablets, cortisone joint injections, and the ingredients in some types of creams for eczema, nasal sprays for hayfever and inhalers for asthma - none of which have anything to do with anabolic steroids. You will find more clarification on our website - go to bbc.co.uk/radio4 and just follow the links to Inside Health.

Last Tuesday was the first day at work for thousands of new doctors and their arrival prompted a flurry of scary headlines highlighting the risks involved for anyone unlucky enough to end up under their care. And it is not just sections of the media who seem concerned - the dangers of going into hospital in August have long been part of medical folklore - but is the situation really as worrying as everyone makes out? Dr Margaret McCartney has been investigating.

McCartney
It's August and so, it's the 'killing season'. Yes, a fresh crop of junior doctors are unleashed onto the sick and ill of our nation and the newspapers howl.

So we have the headlines, happy to infer that droves of patients will suffer in the fallout of baby medics who don't know where the dangly bits of a stethoscope are meant to go. 'A danger to our patients' - said one newspaper, claiming that juniors started on 'Black Wednesday' and that death rates for the week in August when junior doctors typically start are '...8% higher than at other times of the year'.

So should we steer clear of hospitals in August? I don't think so. The belief that we are in this month in the valley of death has even made Sir Bruce Keogh, the Medical Director of the
NHS, announce that junior doctors are to shadow senior colleagues for their first week in the job and from next year, four days of being under the wing will be compulsory.

But are we sure that there's an increased death rate at all?

The study which is often cited as 'proving' this truth was published in the Public Library of Science in 2009. The authors looked at records of all patients admitted as an emergency on the last Wednesday in July - when the juniors have been in post for a year - and the first Wednesday in August - when they are newbies. There were around 150,000 emergency admissions between 2000 and 2008. And the death rate? Well, if these are directly compared, there isn't much in it. The risk of death was 1.43% in July admissions compared with 1.50% in August, which isn't statistically significant - in other words, this small difference was more likely due to chance than a real harmful effect of new doctors.

But the figures get even more complex. The researchers tried to adjust the numbers to even out the differences between the groups of patients, by accounting for age and other illnesses that they had. When they did this, they found that the risk of death rose by 6% in the patients admitted in August. This was 'statistically significant'.

But just because we think we can see a pattern doesn't mean that we can be sure about what has caused it. Neither do we know what deaths were potentially avoidable; we would need far more detailed analysis for that. Another study published in the BMJ in 1994 looked at causes of mortality that could possibly be avoided by prompt medical attention in hospitals - like asthma - and found no difference in July or August. And the most recent data in the Public Library of Science study found no statistically significant difference in mortality in July or August for either the raw or adjusted data for the two most recent years. And it would have been far better to look for fluctuations in death rates all the way through the year and not just cherry pick two dates.

So are we unnecessarily alarming people who need to go into hospital in August? I think so. It seems a shame for new doctors to face such harsh accusations of their abilities after five years of exams - and with many medical schools making good provision for shadowing already. The evidence for a 'killing season' is much more fragile than the headlines insist - and a term I'll be saving for my next box set in front of the telly with Nordic noir.

Porter
Margaret McCartney.

More senior supervision is often cited as the best way to improve outcomes in emergency hospital care, but there is a limit to how many consultants can be employed by any one hospital, or how many hours they can work. And no doctor can be in two places at once - or can they?

A new initiative to improve emergency stroke care in the North of England uses telehealth technology to do just that, enabling more people who have had strokes to receive lifesaving treatment.

Dr Paul Davies is Consultant Stroke physician at the Cumberland Infirmary in Carlisle.

Davies
Thrombolysis is the only effective treatment for stroke and it is a clot dissolving treatment, so it only works for those patients with stroke who have a blood clot and that can only be defined by a CT scanner. So to increase the amount of patients that were getting thrombolysis we had to get patients to CT scans quickly and then get expert advice on providing the treatment. Being a very strong treatment, this clot busting thrombolysis treatment, there is a risk of bleeding with it and you need an expert to try and define which patients are more likely to benefit. In the past we've been able to provide this treatment, nine to five, five days a week, office hours, with our resident staff within the hospitals, each hospital in Cumbria and Lancashire has one or two stroke physicians, but we've not had enough physicians on any one site to provide an out-of-hours service. And what Telestroke has provided for the first time in Cumbria and Lancashire is an out-of-hours service.

Actuality - Telestroke
Hello Mr Warbank, my name's Paul Davies, I'm a stroke consultant in Carlisle. I've been asked to give some advice to the doctors in your unit.

What I need you to do now is just do some assessments.

In our area around about 3,000 patients have strokes a year and in the last year we have thrombolysed 130 patients out-of-hours using the Telestroke service.

Porter
So these are 130 patients that would have otherwise missed out?

Davies
They wouldn't have had any thrombolysis treatment no.

Porter
And practically how does it actually work - the patients obviously still have to get to the scanner, that remains the same but the scan result can then be sent to wherever the specialist happens to be?

Davies
Yes that's absolutely right. The treatment can only be given up to four and half hours after the onset of symptoms. In our area hospitals are widely spread, there's over an hour's travel time between a number of the hospitals, so time in an ambulance travelling to a single centre is time wasted, it's brain cells lost, so we try and ensure the patient goes to their nearest hospital that has a CT scanner. We can see the patients through a high definition camera and they can see the physician on a screen placed underneath the camera and you can have quite a good conversation and you can assess visually the strength in their arms, the strength in their legs but you do need support from a nurse or a doctor at the other end to check things like sensation and their visual fields.

Actuality - Telestroke
Right Mr Warbank I'm just going to have a look at your eyes now, so I'm just going to zoom in with the camera a little bit. Staff nurse can you just check his eye movements for me - can you just get him to follow your finger from left to right, right across, fantastic - all the way and all the way to other side. Could you just check his visual fields now? I just need you to look at the staff nurse's nose and she'll wiggle her fingers.

Tell me when you see my fingers moving.

Any difference.... that was alright okay. Thank you.

You can make an accurate diagnosis of stroke and the severity of the stroke that way. When they've had their CT scan the images are sent to the on-call clinician who can then view those images and see whether there's been a bleed or whether the stroke is caused by a blood clot. And then with all the information from the assessment and from the CT scans the on-call stroke physician can advise the local doctors whether thrombolysis is appropriate or not.

Porter
And this is important because if the patient has one of the rarer forms of stroke - the bleed version - and you give them a clot buster - a thrombolytic drug - then it'll make them worse presumably?

Davies
It would probably make that life threatening.

Actuality - Telestroke
And can I just see if you can do the same with your left hand? Just give a little bit of help there staff nurse. Just see if you can hold that.

That's as far as it'll go there.

Okay.

Just falls down.

Just falls down. Can you just touch each hand for me please and just see if you can feel the back of them?

Can you feel me touching that hand?

And the other side please?

Can you feel me touching that hand?

Yeah.

Yeah, okay. So you've got some weakness and some sensory loss on the left side.

Porter
This is of course very much a service where minutes count so presumably you're very dependent on patients themselves spotting signs of trouble and calling for help?

Davies
Absolutely and we've got quite a stoical population in Cumbria and Lancashire who often sit waiting to see if things get better. The message that I think more people are aware of because of the FAST test is if they've got facial weakness, arm weakness or a new speech deficit then they should call 999 immediately. If symptoms do happen to get better we're delighted but if they don't they'll be in hospital in time to benefit from this treatment.

Porter
Talking of the FAST test has it increased dramatically the numbers of patients that you're seeing - what's the false positive rate?

Davies
With FAST the accuracy is round about 80%, which is perfectly fine. The false positives can be worked out quite quickly.

Porter
So one in five patients don't have a stroke but you don't mind that - you'd see them so that you'd catch the other 80% that have.

Davies
We'd rather see everybody and work out then which ones don't have a stroke.

Porter
Dr Paul Davies from the Cumbria and Lancashire Stroke Network. And if you would like more information on how to spot the tell-tale signs of a stroke using the FAST test, mentioned there, then visit the website at bbc.co.uk/radio4 and just follow the links to Inside Health.

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

Which is exactly what listener Roger did. He has problems with his palms - tightening that means he can no longer straighten the ring and little fingers of both hands. A common condition called Dupuytren's contracture - and something he thinks he inherited from his father who was similarly afflicted. Roger is a keen pianist and is struggling, and wants to know whether there is any effective alternative to surgery.

Mr Mike Hayton is a Consultant Orthopaedic Hand Surgeon at Wrightington Hospital in Lancashire.

Hayton
Dupuytren's disease is more common over the age of 45, 50 and it's much more common in males than in females. We don't really truly know why but there's certainly a very strong genetic element, so many of our patients have either got a father who's passed it down and it's thought to - if you trace it back far enough - back to the Viking gene, Northern Scandinavia.

Porter
What's the natural timescale - I mean once you notice that you've got a little bit of nodular scarring in the palm, how long will it be before it progresses to something that's likely to cause you trouble?

Hayton
Some patients we see can progress very, very slowly and really never cause any significant problems but other patients we see a very rapid onset of their disease, with a rapid deterioration in their hand function and deformity. So it is very difficult to say.

Porter
Is there anything that they can do to slow that progression, I mean you often hear about people doing stretching - putting their palm flat on the table and stretching the hand out, does that help at all?

Hayton
There's no robust literature to suggest that anything can improve the patients and slow down the natural history, no, unfortunately.

Porter
When do you decide to intervene and what interventions can you offer?

Hayton
There's a broad suggestion that if a patient can't get their hand flat on the table, that's the so-called Huston table top test, is a good time when we may consider intervention. But increasingly we're seeing more and more patients who enjoy the piano that aren't able to hyper-extend and bend their knuckles back to get those stretched notes and I will intervene earlier than perhaps when they can't get their hand flat if they've got functional problems such as playing the piano. But as a rule of thumb I think if they can't get their hand flat on the table is perhaps the time to seek medical treatment.

Porter
And how do you treat it?

Hayton
There's a number of treatments available. I think the gold standard is still surgery and surgery's performed either under general anaesthetic or regional anaesthesia. We make a zigzag incision along the finger and we remove this prolificity of fibrous tissue. And then post-operatively we get the hand moving under the care of our hand therapists. It's generally performed as a day case, they're in and out in a day, and they recover very quickly and I think most patients are back to light sedentary work within a week or two and perhaps heavy demand work within four to six weeks.

Porter
And in terms of long term success rate, once you've done it is it a good cure rate?

Hayton
Well we can never cure Dupuytren's disease and we can't predict when it's going to recur - some patients get an early recurrence within one to two years but other patients it doesn't recur in their lifetime. So unfortunately again it's difficult to predict.

Porter
What other options do you have?

Hayton
Well there are other treatments available - there's percutaneous needle fasciotomy where under local anaesthetic or perhaps sometimes even without local anaesthetic a small needle is passed into the diseased cord, just to break it up as a physical break and that's done in the outpatients department, and the finger's straightened immediately. I did perform that 10-15 years ago, I abandoned it because in my practice I had early recurrence, some reasonably unsatisfied patients so I went back to normal surgery. The most recent treatment for Dupuytren's disease is the collagenase injections, they've been in the UK now for probably 18 months or so and they were in the United States a year before that. So in clinical practice probably worldwide we now have two and a half years of experience with it.

Porter
And are you injecting the collagenase directly into the cord or around it?

Hayton
No it has to be into the cord itself. And this is an enzyme and it will dissolve other proteins and there are proteins and tendons, so that's one of our concerns about using it. So it has to be given by a specialist who's well trained in using this.

Porter
Can you use it in everybody with Dupuytren's?

Hayton
Well I don't think so, I think probably about 60% of the patients that I see with their Dupuytren's disease are very suitable for the collagenase injections. The more suitable patients are the ones with a very well defined cord, it's almost likes like a pencil cord, particularly of the main knuckle joint - the MCP joint - and in those I can almost guarantee that they're going to get a good result.

Porter
Miles Houghton has come to Mr Hayton's clinic to see if the collagenase could be used to dissolve his contracture.

What's happened to your hand?

Houghton
Well yeah what you can see on my ring finger is where the growth has expanded a little until it's now sort of advancing down into my ring finger.

Porter
It looks like a big knot under the skin doesn't it.

Houghton
Yes it does and dare I say it myself a little bit unsightly and so I had been conscious of that and even kept it a little bit concealed.

Porter
And you can't - just try to straightening your fingers out, that finger remains bent doesn't it, your ring finger?

Houghton
It does yes, I can't completely strai - well I can if I actually push it back but I can feel the strain and it's uncomfortable.

Porter
Have people commented on it?

Houghton
I haven't allowed them to, to be honest, because I have kept it concealed.

Porter
Have you had any functional problems at all, has it interfered with any day to day activities?

Houghton
I'd say it hasn't for me, the only time it has affected me is when I've been doing press ups in the gym, then I can feel it, but I can just sort of...

Porter
You can't lay your hand flat...

Houghton
That's right, yeah, but I can get round that and it doesn't stop me from doing press ups but it is a little bit impairing yeah.

Porter
Miles is one of the 60% suitable for injection - followed 24 hours later by manipulation by Mr Hayton to stretch and snap the weakened cord in his palm. But first the collagenase has to be injected into the right place.

Hayton
I usually put one injection through the skin then just angle it ever so slightly to three different areas to within a centimetre or so of it. Can I ask you to come over here and just take a seat on the couch. Just lean on my finger, just so it straightens out and makes the disease more taut. We can see it there. We're aiming for where the cord is most superficial, most close to the skin, and I think that's just going to be about there. Little tiny scratch - I'm really sorry about this. Oh well done. Nice and still for me now, you're doing very well. And you've got this really firm Duputyren's disease, it's got quite a gritty feel to it. I'm applying a fair bit of pressure to get the needle into the disease, you've done very well.

Houghton
Ow, ow, oh, oh.

Hayton
Sorry last one.

Houghton
Ah. Yeah just a bit of a...

Hayton
There you go, that's it. That little last one we just tweaked you a little bit, are you okay now?

Houghton
Yeah, oh yeah I am now fine yeah thank you.

Hayton
You did very well.

Porter
You felt that go in though didn't you?

Houghton
Just at the end, yeah, just a sharp prick.

Hayton
The first injection I did two areas and then I just moved it a few millimetres away - that's why you felt that again.

Porter
The following day Miles went back to have his contracture snapped, and a just over a week later, all is well.

Houghton
My Hayton pulled the finger back but he didn't have to pull the finger too hard and I certainly felt the sensation of the cord snapping. I did hear actually that the cord slightly did the night before as I was wiping my face, some water off my face, and forgot the condition that my hand was in and I heard a little cracking or crackling noise then, so the cord had already started to go. That's quite a painful experience.

Porter
Satisfied customer Miles Houghton. And you will find some useful links on Dupuytren's - including details of that new injection treatment which is just starting to become available on the NHS, albeit at around £800 per shot, not in many places as yet. Go to bbc.co.uk/radio4 and follow the links to Inside Health.

Next time on Inside Health we'll be investigating this week's claims that there are over a million people living in the UK with undiagnosed kidney disease. But are we really doing that badly, or is this just the latest example of a trend that is starting to cause international concern - the trend of over diagnosis? In medicine, can there ever be such a thing as trying too hard?

Join me next week to find out.

ENDS