Gender X; Diabetes diagnosis; Trigeminal Neuralgia; Oesophageal cancer

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As Germany becomes the first country in Europe to pass a law allowing newborn babies to be registered as being of indeterminate sex - neither male nor female - should the UK follow suit?

The incapacitating facial pain that feels like an electric shock - a world expert explains Trigeminal Neuralgia.

And recurrent indigestion - should more be done to investigate the millions of people troubled with heartburn?

Plus a new test for diagnosing diabetes that's causing some confusion.

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28 minutes

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Wed 6 Nov 2013 15:30

Programme Transcript - Inside Health

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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

           

Programme 7.

 

TX:  05.11.13  2100-2130

 

PRESENTER:  MARK PORTER

 

PRODUCER:  ERIKA WRIGHT

 

 

Porter

Coming up today:  Heartburn – should we be doing more to investigate the millions of people in the UK troubled by recurrent indigestion? I meet a surgeon who thinks we should.

 

A pain in the face:

 

Clip

You’d dread every meal, you can’t actually eat you have to puree your food and just put it in – sort of shovel it in with a teaspoon at one side – you can’t…

 

Because the chewing action just triggers…

 

Absolutely.  So just dropping your head down to read – that can trigger it off.  I mean it’s just unbelievable.  It seriously impedes your life.

 

Porter

We answer a listener’s query about trigeminal neuralgia – with a little help from a world expert.

 

And diagnosing diabetes – we take a closer look at a new diagnostic test that’s causing some confusion, not least among GPs like me.

 

But we start with news that Germany has become the first country in Europe to allow newborn babies to be registered as being of indeterminate sex - neither male nor female.

And it’s a move that has been welcomed by Inside Health’s Margaret McCartney, who’s on the line from our studio in Glasgow.

 

Margaret, how common is it for a newborn baby to neither obviously be a boy nor a girl? 

 

McCartney

Yeah I mean it is far more common I think than we would know about probably because it’s not talked about very often.  But the normal – the figure that’s quite often given is one in 2,000 births are of a child who is of indeterminate or intersex.

 

Porter

Just to be clear – I mean basically doctor, midwife or even parent can normally take a quick ganders between the child’s legs and say immediately whether it’s a boy or a girl?

 

McCartney

Yeah that’s right.

 

Porter

What’s actually happening inside the womb – what determines whether we become a baby boy or a baby girl?

 

McCartney

So when we’re conceived until about eight weeks old in the womb our gender [indistinct words] is unambiguous – our genitals are neither male nor female and the default position is that everyone will develop into a girl unless there are male hormones to influence that and turn the labia into a scrotum, to turn the ovaries into testicles, to turn the clitoris into a penis.

 

Porter

So if all goes well I mean you have an obvious girl or an obvious boy but it’s quite a complicated process and what you’re saying is that one in 2,000 might be caught somewhere twixt the two?

 

McCartney

Absolutely and the problem can be is that a child is a born and it can be unclear whether that child is male or female, what their sexual characteristics are most like and how that child should be named and brought up.

 

Porter

Do you think it’s useful to have this new indeterminate sex, so called gender X, because presumably one of the things you don’t want to do is rushing into making the wrong decision?

 

McCartney

I think it’s a fantastic idea and I wish we had the same thing in the UK.  I think that we’ve come a long way I think in recognising that our gender is not always as fixed as we would have it believe – yes we’ve got our x and y chromosomes but there’s an awful lot of ambiguity in between.  I think it’s far kinder and far more humane to say look, we’re not quite sure what’s going on here, we need some time to step back and work out what’s going on, we need to get scans and other tests done, take things from there, rather than putting pressure on parents as soon as they’ve had a child – the weight and the sex at the same time.

 

Porter

Thank you Margaret and stay with us because our next item is about the confusion surrounding a new way of diagnosing diabetes. The World Health Organisation advocates the use of haemoglobin A1C – known as HBA1C - to test for the condition but more than two years later its adoption in the UK has proved slow and somewhat patchy.

 

Unlike conventional testing which measure blood sugar levels on the day, HBA1C reflects average sugar levels over the preceding couple of months.

 

Eric Kilpatrick is Professor of Clinical Biochemistry at Hull York Medical School.

 

Professor Kilpatrick, is this test a step forward?

 

Kilpatrick

Yes and so you can’t help but feel that a test that gives you an idea of someone’s average sugar over the past few weeks or months would be a more reliable test than a single one off glucose measurement.

 

Porter

You say we can’t help but feel but are we sure?

 

Kilpatrick

Well one of the reasons that there’s – you can say there’s been a delay in introducing haemoglobin A1C as a diagnostic test is because we weren’t completely sure about that and it’s only in recent years that we’ve been able to establish that actually haemoglobin A1C is a useful test for diagnosing diabetes, just in the same way that fasting glucose measurements are useful.

 

Porter

From a practical point of view is this a simpler more reliable test than using blood glucose?

 

Kilpatrick

Well starting from the patient point of view it certainly is a simpler test because one of the disadvantages of measuring glucose for diagnosis was the patient had to be fasted overnight, so they weren’t able to eat any food from about 10.00 p.m. onwards.  And some people think that’s one of the reasons why there’s so many people with undiagnosed diabetes because of the difficulty in catching those individuals after they haven’t eaten.  Whereas with haemoglobin A1C it doesn’t matter whether you’ve eaten or not, the test will be equally reliable.  As far as the laboratory’s concerned it is a bit more complex to measure haemoglobin A1C and because of that it’s slightly more expensive but compared to all the problems there can be with glucose measurement – and there’s other tests we have to do with glucose like glucose tolerance tests which means getting someone in fasting, giving them a sugary drink and measuring how high their sugar goes two hours later on – it’s actually more cost effective or at least as cost effective as it would be for using glucose.

 

Porter

Do you think this test is going to pick up people with diabetes?

 

Kilpatrick

That’s the hope.

 

Porter

Well listening to that is Inside Health’s Dr Margaret McCartney.  Margaret, what’s happening in your area – in my part of the world we are being recommended to move over to this test, is it the same in your part of the world?

 

McCartney

Well certainly I have tried on several occasions but we got a letter from our local department asking us not to do anymore in people who we’re trying to diagnose them for the first time with diabetes.

 

Porter

So you’re being asked not to do it and I’m being asked to do it – what reason have they given for not doing it up in Scotland?

 

McCartney

I’m still waiting and I think it’s really cost related to be honest with you, I think the test is more expensive than doing a simple blood glucose, which is the standard one up till now.

 

Porter

But what do diabetes specialists think? John Pickup is Professor of Diabetes and Metabolism at King’s College London.

 

Pickup

I was at a meeting recently which was devoted to HBA1C and its uses and I would say that a good half of the doctors there were very enthusiastic about this new way of diagnosing diabetes.  But the other half were concerned and an experienced diabetologist next to me leant across and said – I’m not sure that we really know what diabetes is any longer and maybe we should start again.  Because of course one of the problems with diagnosing diabetes using HBA1C is that it identifies a different population of people from the plasma glucose diagnosis.  And in fact now you have a situation in which there are three or four ways of diagnosing diabetes – the fasting state after the glucose drink, the HBA1C and if you’ve got symptoms and a fantastically high blood glucose.  And they all seem to identify different populations, although they overlap. 

 

Porter

In my part of the world, I practice in Gloucestershire, we’re being actively encouraged to move across to this as using it as our diagnostic test – are you happy with that?

 

Pickup

I think it’s a useful step forward but I think there are many issues that need to be resolved.  You know when any new test or treatment is introduced there’s a period in which doctors get used to knowing how to use it best, the appropriate patients to use it on, what the limitations are and I think that’s the period we’re moving into at the moment.

 

Porter

I’m quite unfamiliar with using the test in this way, so who should I be careful and what sort of patients are likely to be misdiagnosed or missed using this sort of test?

 

Pickup

Well there’s a group of patients, first of all, that you shouldn’t be using this to diagnose diabetes on – that’s Type 1 diabetes, young people, those who are pregnant, those where the glucose in fact is changing rapidly – this is not a good test for those people.  Then there are groups of patients where there’s an interference with the HBA1C result – the anaemias for example, in particular iron deficiency anaemia…

 

Porter

Which is quite common.

 

Pickup

… which as you know is very, very common and that can increase the HBA1C level falsely, so it’ll go a little bit higher reading than you would expect.  Then there are increases with age, increases in certain ethnic groups – for example, those from the South Asian community and the AfroCaribbean community in the UK have a little bit higher levels than you would expect for their glucose levels, which is interesting of course because they’re the groups where diabetes is particularly common.  Then there are certain drugs which affect the glycation of the haemoglobin molecule, Vitamin C reduces it a bit, aspirin has rather complicated effects.  There are chronic diseases like renal disease which have a variable effect.

 

Porter

I mean listening to you reel all of these off that’s quite a significant proportion of our patients may well have a factor that could compromise the accuracy of the test?

 

Pickup

It might be and sometimes you know that that’s a compromise for your patients don’t you and sometimes you don’t.

 

Porter

Well Margaret McCartney’s been listening to that too.  Margaret, that long list from Professor Pickup there – you can’t use it, you shouldn’t be using it in young people, it’s  not for diagnosing Type 1 Diabetes, you have to interpret it with caution in people with anaemia – and these are extremely common conditions that we’re seeing in general practice and if you and I aren’t familiar with when this test works and when it doesn’t work it’s not going to get interpreted properly is it?

 

McCartney

Well absolutely, so I think in many ways it can seem superficially to be a much better test to do but I think the problems of running it in the real world do add an extra layer of complexity to it which means I think we should be cautious about throwing our arms around it and embracing this as the new best thing.

 

Porter

People are listening to this I mean they’re just going to be worried that this test is being used to diagnose them as having diabetes or indeed not having diabetes, are you happy that it’s being used properly?

 

McCartney

It’s difficult, so there’s two situations, one, would be a diagnostic test where you are trying to make a definitive diagnosis about whether someone has or has not got diabetes and it’s quite important to bear in mind does that person have symptoms or not, do they have symptoms of diabetes – are they tired, are they losing weight, are they thirsty, are they peeing more than usual.  So that group of patients I would probably say it’s more accurate to do a fasting blood glucose on them because they’re symptomatic, it’s a better diagnostic test.  The other time that the test is being done I think a lot more often is in people who are perceived to be at higher risk of getting diabetes or being at high risk for developing it in the future.

 

Porter

So using it as a sort of screening if you like?

 

McCartney

Absolutely.  And I think this is where we get into a little bit of difficulty because sometimes the test is going to produce a false positive and sometimes it’s going to produce a false negative, so you’re either falsely reassured or you’re falsely alarmed.  So it’s not quite as accurate a test as a fasting blood glucose but it sometimes can give a bit of a hint that there’s something amiss.  So I think there’s a balance of risks and benefits in there.  And I think it’s really important if the test is being done that patients know what test is being done and that it may be that you need to get further tests done if it comes out as being abnormal, as in a fasting blood glucose, to work out whether or not you do actually have a problem.

 

Porter

Margaret McCartney thank you very much. And if you would like more information on using HBA1C to diagnose diabetes then you will find some useful links on our page of the Radio 4 website. Where you will also find details about how you can contact Inside Health.

 

Amanda e-mailed us to ask about trigeminal neuralgia. She was diagnosed with this comparatively rare but nasty condition that causes severe shooting pains across the side of the face back in February. Her GP’s put her on the standard treatment - carbamazepine - to help but, while it helps the pain, it has left her feeling sick and wobbly. And if she stops the drug the pains come back.

 

 An all too familiar story to Ann Eastman who developed trigeminal neuralgia a few years ago:

 

Eastman

I was brushing my teeth and I suddenly had this absolutely unbelievable pain, it was a combination of an electric shock and an electric drill going into my head.  And I was just standing there screaming and screaming because the pain was so unbelievable.  And then it subsided and I had no idea what it was.  The next morning at breakfast it started again.

 

Zakrzewska

My name is Professor Joanna Zakrzewska, they all know me as Zak for short because it’s too difficult to pronounce and my area of particular expertise is the facial pain.  Trigeminal neuralgia, luckily, is a rare disease that causes an electric shock to go through one half of your face.  In most of the patients it’s due to a vessel pressing on the nerve and this causes the myelin sheath, which is the protective cover of nerves of different types, to get worn away and as a result of that you get cross talk between a nerve that transmits light touch and one that transmits sharp pain.  And then as the myelin tries to heal itself so the nerve can regenerate and therefore get a period of pain remission.

 

Porter

And are the changes in the outside covering of the nerve – I mean is that age related, is that why it’s something that happens generally to slightly older people?

 

Zakrzewska

It could be, it’s also that the brain tends to shrink with time, we also develop high blood pressure with time so the vessels can become more tortuous and the relationship between the blood vessels and the nerves may change with time.  But we still are struggling with trying to find out what really causes this dreadful condition.

 

Porter

What’s the natural history of this disease – I mean looking at our listener who’s had it for six months now, what can you tell her about her likely future?

 

Zakrzewska

This is something that all patients ask us and it’s very difficult because we have no cohort studies, that is studies that are looking at patients over a period of time.  I have started one and some patients get long remission periods and have no pain for quite a long time, get short episodes of recurrence of pain and it goes away and they can go on like this for 10, 20 years.  Others it gets very severe very quickly and within five years we’re already doing operations on them.

 

Porter

In your experience as a specialist in this field, looking at the patients that you’ve seen come in, what are the common mistakes that are made by GPs or maybe dentists that are seeing patients with this condition?

 

Zakrzewska

Very often in fact the patient first goes to the dentist because the pain presents more typically in the lower part of the face rather than the upper part of the face and of course both the patient and the dentist feel convinced it’s a dental pain.  And then when they go to the medical practitioners then they’re at a loss as well, they will often send their patients to the dentist, also thinking it’s a dental problem.  In fact quite a high proportion of patients will lose teeth as a result of misdiagnosis.

 

Eastman

I rang up my dentist and said I’ve got the most terrible pain and it seems to be manifesting itself from my temple down to my lower jaw.  And so he said come in straightaway.  And he couldn’t see anything wrong but he said it looked to him as though the nerves were beginning to – in that tooth – were beginning to fuse and he said I think you’ll probably have to have that out.  The effect of the injections wore away and then the pain was still there, there was no tooth but the pain was still there in that exact spot.  You dread cleaning your face because when you clean your face it triggers it off.  You dread cleaning your teeth, so you end up just sort of giving them a quick rinse with mouthwash.  It seriously impedes your life and it’s not because you’re thinking about it because you think every time it goes away you think oh it’s gone, it’s gone and then it comes back.

 

Zakrzewska

They can become quite socially isolated because they can’t talk, can’t socialise, can’t go out anywhere, can’t eat and drink, can lose weight.  In a very rare proportion of cases it could be due to a tumour sitting there as well and so we need to do MRI scans on patients to pick up any of these tumours.  But to begin with we start with treatment straight away.

 

Porter

And that treatment is?

 

Zakrzewska

An anticonvulsant called carbamazepine and there’s no doubt that this drug just turns off this diseases immediately, at least at the start on the first episode.

 

Porter

Our listener who e-mailed us in has been on carbamazepine for six months and is struggling – two fold really – with quite a few side effects and not got good control of her pain.  When she’s been on the drug for that long what happens next?

 

Zakrzewska

Well firstly we have to find out how responsive they’ve been to it and therefore potentially rethink the diagnosis because there could be variations on this condition.  And of course we know that this drug causes significant side effects.  So the next drug of choice is a daughter drug of this drug called oxcarbazepine, which works very well and seems to have fewer side effects.  I think once we’ve tried one or two drugs, to which they have initially been responsive but now are no longer responsive because they’ve had to increase the dose and the side effects are stopping it and the quality of life has significantly impaired then we will consider surgical options.

 

Eastman

My dentist rang me up and he said I’ve just tracked down somebody in the Eastman Dental Clinic, who is a specialist in facial pain and might be able to help.  Just as I walk through the door I had the most terrible episode and I just sat there whimpering as she was sitting there holding my hand and she said classic case, classic case.  I was put on the drug and pretty much 12 months afterwards it came back again but this time I knew what it was, I had the medication at the ready so I wasn’t frightened anymore.

 

Zakrzewska

Fear is a big driver and some studies done in France at the moment have shown that patients with trigeminal neuralgia may be triggering their fear centres in the brain.  And so we’re running a programme just exclusively for patients with trigeminal neuralgia to help them cope with flare ups, decide on some strategies, looking at other ways of relaxing, mindfulness – as ways of trying to manage some of these fears of pain.

 

Porter

So are you saying that fear and anticipation of this awful pain coming can actually fuel it?

 

Zakrzewska

We think that that might be true and some early studies in France are suggesting that this could be a factor as well.

 

Porter

Professor Joanna Zakrzewska talking to me at the Eastman Dental Hospital in London.

 

Now, the term “Cinderella disease” is a much abused cliché in medical circles but it is apt when describing a common cancer that most people have never heard of.  Cancer of the oesophagus or gullet now accounts for one in 30 of all cancers diagnosed in the UK. And, despite its low profile, it is becoming more common, particularly in men – this year there will be eight and a half thousand new cases. Tell-tale signs of trouble include difficulty swallowing – food may get stuck – unexplained weight loss and persistent heartburn. But why is it becoming more common?

 

Tim Underwood is an oesophageal surgeon at Southampton General Hospital

 

Underwood

There are two things that predispose to oesophageal cancer – obesity and heartburn reflux disease.  And we think one leads to the other – so people who are overweight and obese have more reflux and are more likely to get oesophageal cancer.

 

Porter

And by reflux this is the stomach acid basically ending up in the vulnerable gullet, which sits of course above the stomach.  And is that somehow damaging it and causing cancerous change?

Underwood

Yes.  The oesophagus is the pipe that connects the mouth to the stomach and acid in the stomach should stay in the stomach.  In all of us a little bit comes back up into the oesophagus but in people with reflux disease more comes up and that causes inflammation, so the cells in the lining of the oesophagus don’t like begin bathed in acid and they react to it and they change size and they change shape and by changing size and shape they become more prone to developing cancer.

 

Porter

I can imagine a lot of people listening going oops I’ve got reflux, I mean the over 40s in the UK it’s a huge problem, so how strong is the link between reflux and cancer?

 

Underwood

So answer that by saying that about 40% of people have some reflux at some point in their lives – I’ve had some, you might have had some, we’ve all probably had a little bit of reflux – that’s normal.  What’s not normal is to have long term persistent reflux and by that I mean if you’ve had reflux every day for three weeks you should see somebody about it because that is unusual and should be investigated.  And the majority of people with reflux will have nothing wrong with them but we want to make sure we find those that do.

 

Porter

What sort of age does this cancer tend to strike at?

 

Underwood

So the average age is 66 although I’ve seen patients and I’ve operated on people in their 30s with this disease, it’s not confined to middle age and elderly, young people do get this disease.

 

Porter

So say somebody’s got what we call heartburn, the typical symptom associated with reflux, so you might notice that when you swallow something you can feel it going down or after a meal get a bit of regurgitation, a bit of heartburn.  Now the majority of those people are just going to have a little bit of acid in the wrong place, they’ll be treated by their GP with an antacid pill and the symptoms settle down.  But what proportion of them are at risk in future of going on to get cancer – the fact that they’ve got reflux – should they be worried?

 

Underwood

A tiny number.

 

Porter

But so many people have reflux…

 

Underwood

They do, this is the issue with screening for these sorts of diseases, there is not a good screening test for cancer of the oesophagus, the best test we have currently is having an endoscopy, look down your gullet and that’s why we’re saying it’s not about people who have a little bit of reflux occasionally, that’s fine, it’s those people that have persistent changes.

 

Porter

But I can see, you know, the number of people who are presenting in general practice with this very common symptom, would you be happy to have your clinic swamped with people who’ve only had heartburn for three weeks?

 

Underwood

To save lives for this disease we have to take on doing endoscopies, we’re going to have to investigate these people.  And the NHS has to respond to that.

 

Porter

But Tim I understand you regard persistent reflux – which you define as more than three weeks – as being something to worry about, I’ve got my GP hat on now, we see an awful lot of people like that, and the National Institute for Healthcare and Clinical Excellence says that as long as they’re under 55 and it sounds like reflux and there’s no other red flag symptoms then just bung them on an antacid is the simple advice.

 

Underwood

Yeah it does.  Those guidelines were written a little while ago and to my mind are not currently fit for practice.  Fortunately they’re being revised at the moment and there will be new NICE guidance out which should actually bring the age down and talk about referral for persistent reflux.

 

Porter

Okay, so that’s not happening at the moment and the price we’re paying is what?

 

Underwood

The price we’re paying is death, there’s no way to dress that up.  The majority of people who present with oesophageal cancer present too late to be cured, about two-thirds of people have already got disease that’s spread to secondary deposits around their body and we can’t cure them when we see them.  So if they present with food sticking they’re already likely to have disease that’s spread -  I don’t won’t to worry everybody but it’s important that we get the message out that if we catch you early we can cure you, if people come too late we probably can’t.  Give you a classic example of someone I’ve just seen in my clinic who spent all of their life working manually, had reflux on and off all of their life, had it really taking Gaviscon and other antacid medications over-the-counter for the majority of their life and then presented with inoperable cancer.  So if you look back through their history there were times to intervene when we could have looked down and said ah you’ve got early changes in your gullet we need to do something about it.

 

Porter

Well explain to me these early changes – if you were to have endoscoped that person maybe 10 years previously what might you have seen that had said oh we need to keep an eye on this chap?

 

Underwood

We might have seen something called Barratt’s Oesophagus which is a changing in the lining of the gullet from flat cells to lumped up cells effectively.  And that changing in the lining is protective for acid but is more likely to become a cancer and we can see it.

 

Porter

So you know that those people are increased – what proportion of people with Barratt’s will go on to get oesophageal cancer?

 

Underwood

Once again a very, very small percentage, the risk is about point one to point 5 per cent a year, tiny numbers.

 

Porter

So one in 200 or less.

 

Underwood

Yeah tiny numbers.  But we know that they are more likely than the rest of the population to get oesophageal cancer.

 

Porter

Equally if you have heartburn and reflux persistent, you have an endoscopy and you don’t have Barratt’s that’s quite reassuring isn’t it?

 

Underwood

Yes very reassuring, yes it is.

 

Porter

Is there something I can do, as a GP, to protect my patients who have recurrent heartburn?  Can we put them on antacid medication, does that help, do we know that helps?

 

Underwood

We know that being on antacid tablets for a long time is not, we don’t think, a major risk.

 

Porter

But what you’re saying is there isn’t convincing evidence that they’re protective?

 

Underwood

No.

 

Porter

Can they mask trouble as well?

 

Underwood

Yes they can, people will take over-the-counter medication but they are still having reflux and the medication are masking the symptoms.  So what I say to people is that if you’ve had reflux every day for three weeks come and see us but if you’re taking tablets every day for three weeks to mask the symptoms of your reflux you should also come and see us.  I think people need to look after themselves first and not rely on medication.  Stop smoking, don’t drink so much, exercise regularly and be a normal weight and those are really the protective things to do to prevent oesophageal cancer.

 

Porter

Assuming I have persistent reflux, which I do incidentally, I’m then tested and found to have Barratt’s Oesophagus, then what happens to me?

 

Underwood

Then you will probably be asked to go on a surveillance programme where we endoscope you every two years, look down your gullet, take some samples of the Barratt segment to make sure it’s not undergoing changes that are heading towards a cancer. 

 

Porter

Because if you spot those can you successfully treat them at that stage?

 

Underwood

The really good thing is that now we’ve got endoscopic therapies – so therapies that can be done from inside the oesophagus down the endoscope, we can remove big areas of the lining of the oesophagus to remove precancerous changes and we can use something called radiofrequency ablation, which is sort of heating up the inside of the oesophagus to burn the cells away and then it gets relined by a normal lining. 

 

Porter

And that compares to?

 

Underwood

That compares to what I do for a living – I operate on people who have advanced cancer and for those we do an operation that involves going into the abdomen, going into the chest, removing the oesophagus and pulling the stomach up to replace it.  That I tell patients is like asking them to run a marathon without doing any training – it takes nine months to a year to recover from and their quality of life is never quite the same as it was before.  It’s a really big endeavour.

 

Porter

Consultant surgeon Tim Underwood ending this series of Inside Health. We will be back in the New Year for another run so please do get in touch if there is something that you would like us to look into. You can e-mail the team – that’s me, Dr Margaret McCartney or our producer Erika Wright - via insidehealth@bbc.co.uk.  Until then, from all of us, goodbye.

 

ENDS