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Shingles vaccine; Energy drinks; Liver function tests; Anorexia

Margaret McCartney reports on confusion around the new shingles vaccine, including how old you have to be to qualify and why there's a lack of supply in some GP surgeries.

Margaret McCartney reports on confusion around the new Shingles Vaccine - including how old you have to be to qualify and why there's a lack of supply in some GP surgeries.

Why readymade drinks combining caffeine and alcohol have been banned in America.

Are the tests GP's use to screen for liver damage falsely reassuring?

And a leading authority dispels myths surrounding the causes of anorexia.

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28 minutes

Programme Transcript - Inside Health

Downloaded from www.bbc.co.uk/radio4 

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 3.

 

TX:  08.10.13  2100-2130

 

PRESENTER:  MARK PORTER

 

PRODUCER:  ERIKA WRIGHT

 

 

Porter

Hello.  Coming up in today’s programme:  Wide awake drunks - we look at the hazards of mixing alcohol with energy drinks like Red Bull, Monster and Full Throttle.  Eating disorders - we talk to a leading authority about the latest thinking on anorexia nervosa.

 

Clip

For so long parents have been blamed for bringing on anorexia in their children, there is no evidence whatsoever that parents can create anorexia nervosa – that evidence has never been shown.

 

Porter

And testing your liver - why the standard blood tests used to screen for liver damage are not a reliable indicator of whether you have been drinking too much.

 

But first the new shingles vaccine which was introduced into the routine immunisation programme last month - at least it was supposed to be.

 

Judging by the emails and tweets we have had from Inside Health listeners it has not got off to the best start. Not least because the criteria for eligibility are rather confusing and when you do work out if you are eligible, there is a good chance your practice won’t have enough jabs to go round. 

 

Dr Margaret McCartney is our Glasgow studio.

 

Margaret, why is it so confusing?

 

McCartney

There are problems.  It doesn’t work very well in people aged over 80, so it’s not aimed at them because it doesn’t work very well and there isn’t enough vaccine to go around for everyone aged over 70 or between 70 and 79 just now.

 

Porter

And this is the confusing bit and this is what we’ve had all the e-mails about because people don’t understand why it’s being offered in such a strange way.  Can you explain how it’s being offered at the moment?

 

McCartney

Okay.  So it’s being offered in a way that in a decade’s time everyone between 70 and 80 will have been vaccinated.  Because there isn’t enough vaccine to go round it’s being offered in a way that only certain parts of that age group are getting it in the first round.  So the first round this year depends on what age you were on 1st September 2013.  If on the 1st September 2013 you were aged either 70 or 79 - nothing in between - you can get the shingles vaccine, that’s the only two age groups that are being offered it this year.

 

Porter

And the idea being that they’re catching everybody at the beginning of the cohort that they want to vaccinate and of course the people who are 79 who are about to leave it?

 

McCartney

That’s right.

 

Porter

Looking at the Department of Health argument with regard to the upper cut off, at 80, what the Department of Health has said is that it’s uneconomic to vaccinate this group.  Is it basically a cost benefit thing?

 

McCartney

Well I would say it’s more cost effectiveness, so it’s not that effective, you don’t get a very good result from it so I think if you’re planning an immunisation programme you have to think where are you going to get most bang for your buck, as it were, and if it’s not going to work very well in the over 80s well try and aim it at an age group that are more likely to benefit and will hopefully carry their immunity forward.  So the 79 year olds this year are being seen as the catch up group and the age 70s are the ideal group to give it in.

 

Porter

Right.  And as more supplies come in that might well change but that’s the situation at the moment.  Now about supplies - we’ve had a number of tweets and e-mails from listeners saying that their surgery hasn’t got any, actually my surgery hasn’t got any, that’s not completely the suppliers’ fault but that’s another story.  What’s the situation with your practice?

 

McCartney

We’ve got enough, we’ve got enough to go round, so we’re okay.  But I mean overall I mean the risks of getting shingles are pretty low overall, I mean we’re talking about - about 1% of the population aged over 70 a year, so I mean the risks are overall low.  And the vaccine isn’t 100% effective, I mean it is pretty good – it will reduce your risk of shingles by just over half and it will reduce your risk of getting nerve pain as a cause of the shingles by about two-thirds.  So it is pretty good but it’s not perfect.

 

Porter

What happens if I am 65 or 81 and I actually think that there’s a good reason why I should have this vaccine but I lie outside that cohort, can I talk to my GP about it?

 

McCartney

Yeah, this is a really interesting one.  I’ve spoken to Public Health England who say that GPs can prescribe the shingles vaccine on the NHS for individual patients if they believe it’s clinically indicated out with the current two age groups.  However, they say, only vaccine for the national programme, i.e. individuals aged 70 or 79 on the 1st September 2013 can be ordered from the centrally purchased stock.  So that means that if you are out with that age group you’re not entitled to get it from the central stock and it will need to be obtained from elsewhere and we know there are shortages.

 

Porter

Thank you very much Margaret.  And if that’s still as clear as mud, you will find some useful links on the new vaccine on our page of the Radio 4 website - go to bbc.co.uk/radio4 and click on I for Inside Health.

 

Now Margaret, you may not have tried a Red Bull and vodka, mixed your gin with Relentless or downed a Skittle or Jager bomb, but you will be familiar with the current vogue for mixing alcohol and caffeine rich energy drinks.

 

A mixture that has earned a formidable reputation on the party and club circuit - boosted, no doubt, by a ban in the United States of all ready-made mixes of the two that came into force in 2010 amid concerns about the effect of combining caffeine and alcohol.

 

Mary Claire O’Brien is Associate Professor of Emergency Medicine at Wake Forest University Baptist Medical Center in North Carolina/

 

O’Brien

There was significant concern in the scientific community that these beverages were associated with increased risk for alcohol related harms.  There’s concern that caffeine masks some of the subjective intoxication associated with alcohol and of course the problem here’s the alcohol, the problem is not the caffeine.  But there is a neurochemical interaction in the brain and it turns out that the interaction of caffeine and alcohol is very complex in the brain and it’s actually possible for the caffeine - and there is strong animal evidence to suggest this and there is good report evidence among humans to suggest this - that what the caffeine does is change how sleepy you get when you drink alcohol.  So in other words alcohol makes you sleepy if you drink too much of it and what the caffeine does is make you less sleepy.  What it doesn’t do is change the extent to which your judgement is impaired or your motor function would be impaired following the consumption of alcohol.  So basically a person who drinks caffeine and alcohol a lot, at the same time, becomes a wide awake drunk - that’s what happens when you get a lot of caffeine and a lot of alcohol at the same time.

 

Porter

So he or she is just as drunk but they’re awake and likely to carry on drinking and get into even more trouble?

 

O’Brien

Exactly, that’s the issue.

 

Porter

And do we have any evidence about what’s safe and what’s not safe when it comes to taking them both at the same time in terms of absolute levels?

 

O’Brien

No and that’s the whole focus of the problem is that we don’t know what’s safe.

 

Porter

I can see the basis of this from a physiological argument but do we have data to show - have we looked at this, have we studied the effects of this combination?

 

O’Brien

The data are very difficult to obtain for a couple of reasons and a large part of it has to do with scientifically how do you measure the doses and the administration, the timing.  So if you and I went out to a pub together and we both had a couple of drinks and maybe I had a caffeinated alcoholic beverage and perhaps you had coffee afterwards none of that would still be adequate to explain the differences in our responses because you’re a man and I’m a woman and we metabolise alcohol differently - I don’t know what medications you’re taking - and so there’s significant variability in alcohol tolerance and also sensitivity to caffeine.  The other problem with the laboratory tests and I say this as a person coming from the point of view that caffeine has no place in alcoholic beverages but also as a person who enjoys both alcohol and caffeine, to be clear, just not at the same time, you cannot in the laboratory setting ethically reproduce the manner of consumption or the level of intoxication that’s typical in young adults in the real world.  But the weight of scientific evidence here are sufficient for the Food and Drug Administration to conclude that the safety is not established.

 

Porter

Margaret McCartney, in Scotland I gather there are plans that are being muted to introduce a similar ban?

 

McCartney

Yeah that’s right, so there is at the moment a proposal that would ban drinks with more than 150 milligrams of caffeine per litre but that’s a proposal, it’s not a bill and it’s not been passed.  But of course we’ve also got the minimum alcohol pricing that’s still pending.  And to be honest with you I suspect that that will make more of a difference because what I think might happen is that you ban caffeinated alcohol drinks but then there’s nothing to stop people using caffeinated products to mix in with other drinks which means that you really can get the same effect but just not in the same bottle.

 

O’Brien

I will agree with Margaret with enthusiasm that cost is a very big part of the issue and in fact that was one of the major problems with the pre-packaged caffeinated alcoholic products here was that you could buy a can of a caffeinated alcoholic beverage that was effectively a six pack and two cups of coffee for under three dollars and naturally these products were sold in areas where young people frequent.

 

Porter

How were those products being sold to the young people in America at the time?

 

O’Brien

It’s interesting, the pre-packaged products capitalised on the marketing of the regular energy drink companies and so using names that are taboo, that attracted youth, with an emphasis on sexual prowess and physical endurance, the idea that alcohol is stimulating and would give you strength and success in sporting events and then a lot of corporate sponsorship of events where the caffeinated products were handed out in venues where alcohol would be served as well.

 

Porter

What about anecdotal evidence?  I mean you’re somebody who works in emergency medicine, do you see this first hand in a department like yours?

 

O’Brien

Oh absolutely and in fact that’s how I became first interested in it.

 

Porter

Well paint me a picture of the sort of problem that you might see.

 

O’Brien

A young man came in after an evening of enthusiastic partying with his college buddies and he was drunken and in such a stupor that he barely avoided going to the intensive care unit on a ventilator.  When he awoke many, many hours later after supportive care in the emergency department I said why would you do that, why do you drink alcohol to get drunk and then caffeine to stay aware, that makes no sense?  He said so you can stay drunk longer before you pass out.

 

McCartney

I think the issue is that the risk of drinking - binge drinking - or heavy alcohol intake is borne in the vast majority by these drinkers themselves, so a lot of people worry about antisocial behaviour and things like that but actually the risks of violence, the risks of sexual violence, all these things these are risks that are carried by the individuals themselves that are drinking in excess.  And I think there is a bit of a cultural issue in that some people, particularly younger people I think, they’re very much encouraged to drink to get drunk because these drinks are sweet, they are cheap, they are readily available.  There’s some work going on in Scotland where they’re trying to find out whether the sale has actually been legal or not, so certain retailers were asked to put a tag on bottles and then they could be traced back where they found in possession of an under-aged drinker, for example.  So I think it’s really important not to demonise the young people who end up carrying the problem of the advertising to them that’s going on at the moment.

 

Porter

But equally - equally Mary Claire it’s important we don’t demonise the drink.  I accept that this combination may be particularly dangerous for people who are drinking but that’s not the whole problem, is it, it’s only just part of the problem and actually a relatively small part?

 

O’Brien

I would have no problem demonising the manufacturers and their marketing techniques and so I agree with Margaret, I think youth is a period that’s characterised by experimentation and risk taking and that to capitalise upon that with products that are potentially dangerous and to sell them at very low prices I have no problem with demonising that behaviour.

 

Porter

Dr Mary Claire O’Brien and Margaret McCartney thank you both very much.

 

You don’t have to be young, or mix caffeine with alcohol, to be at risk of alcohol related liver disease. Indeed you don’t even need to drink too much - just being overweight, as an increasing number of us are, can lead to long term damage.

 

But how much do you really know about the state of your liver? Maybe you’ve been reassured by a recent liver function blood test taken during a medical. Surely if you feel okay, and the test results came back as normal, then all must be well? Mustn’t it?

 

Consultant liver specialist Nick Sheron - who’s developed a more accurate test at his busy liver unit at Southampton General Hospital - might beg to differ.

 

Sheron

If you look at the mortality from pretty much every disease you care to mention over the last 30 or 40 years - cancer, heart disease, chest disease, the lot - they’ve all gone down by between 20 and 70%.  If you look at mortality from liver disease, deaths from liver disease, they’ve gone up about 400%.  In addition to that, since I’ve been in Southampton, about 20 odd years now, the survival rates for people admitted with liver disease have not improved.  Now I don’t think that’s something special about Southampton because I’ve got data from Copenhagen and I’ve got data from Plymouth which says the same thing.  So we’ve got increasing numbers of people dying from liver disease being driven, by the way, by cheap alcohol - that’s the key driver, that’s what’s changed - and we’re not doing any better at keeping them alive.  And I think the fundamental problem is that they’re coming in too late.  So I know that of our admissions around about 4,000 admissions - patients with cirrhosis - 75% of them have never been referred to a liver clinic, we’ve never seen them before.  And I’m making the assumption that their GPs haven’t picked up their liver disease either.  And liver disease develops silently, it has no symptoms, the liver has no pain fibres in it and it becomes diseased through a process of scarring, gradual scarring or fibrosis, as we call it, which could take 10 years for alcohol or 50 years for obesity related liver disease.  Even the tests that GPs currently do do not pick up that scarring or fibrotic process.

 

Porter

Well let’s look at those tests because most people will be familiar - I get a lot of patients themselves coming in and saying I know I’ve been drinking a bit too much or I’ve been doing this, that and the other can you check my liver doctor and we do this, what we call, LFTs - the conventional liver function test.  And what you’re saying is that they’re not much cop.

 

Sheron

Well that’s exactly true.  So first of all the term liver function test isn’t a very accurate term because of the five or six different tests we do some of them measure liver function but probably the two most commonly used tests aren’t tests of liver function at all they’re enzymes which normally sit inside liver cells and where liver cells are being damaged, broken open, they’re released into the blood stream and then they can be detected.  So they’re not tests of liver function, they’re tests of liver damage.  And they’re quite useful in diseases like viral hepatitis where liver cells are being broken open by the immune system.  But in, for example, liver disease associated with alcohol or liver disease associated with obesity, which is probably more than 80% of mortality from liver disease, then these enzymes give you no indication of the underlying liver problem.

 

Porter

Even worse they may well be falsely reassuring you, me as a GP, and the patient that they don’t need to change their lifestyle or that there isn’t anything sinister going on.

 

Sheron

That’s exactly what happens.

 

Porter

So what does is the test that you’ve devised, how does that differ?

 

Sheron

So the separate way to do it and the way that we use to do it is to do a blood test and to measure chemicals within the blood which are released as part of the scarring process.  And because the liver is the biggest organ in the body if your body is becoming scarred you’re much more likely to find these breakdown products of the scarring process in the bloodstream.  But we’ve found that just using these two markers of fibrosis we were missing some people with cirrhosis and so what we did was we added one of the routine tests, the platelet count, which gives us three tests and those three together are much more accurate than just the two fibrosis markers.

 

Porter

And this is a simple blood test - it can be all done on one blood test?

 

Sheron

It’s a simple blood test, it’s done in the routine NHS labs here, it costs about 50 quid.  And rather than giving the readout as a number - and you have to be an expert to interpret what the number means - we’ve just converted that number to a simple traffic light, so the patient gets an amber, red or green traffic light and the GP gets the same thing and that frankly is intuitively understandable.

 

Porter

I could be doing that in general practice, doesn’t require any expert interpretation.

 

Sheron

No, no that’s exactly correct and that’s the entire point of the study.  So we’ve been using these tests in the clinic here for 10 years now, which is why we’ve got 10 year follow up data.  But by the time people come to us in hospital it’s too late and we’ve already discussed how these people just aren’t being sent to liver clinics, they’re out there in communities and they don’t know about their liver disease.  It’s a very simple and straightforward test to do and it could be easily available to all GPs everywhere frankly.

 

Moore

I’m Michael Moore, I’m a GP and I was a partner with Dr Nick Sheron undertaking this research.

 

Porter

What are the implications for your practice as a GP?

 

Moore

We know that the risk factors for liver disease are prevalent in the population, they’re common in the population, and the existing tests don’t help us very much, as you’ve just heard.

 

Porter

But we think they do, that’s the problem, the general perception is, both amongst the public and doctors, is that well your liver tests were okay, that’s reassuring, but we’ve heard that you could have quite advanced liver disease and still have perfectly normal tests.

 

Moore

And I think this is going to be news for a lot of GPs, they probably were working under the false assumption that if they did those liver tests they could give a clean bill of health.  So I guess that people need to be more aware that it can be falsely reassuring to do the routine tests and then say to somebody well your liver’s healthy.

 

Sheron

In the context specifically of this test if you get a red traffic light it means you’ve almost certainly got a degree of progressive scarring and you may well have cirrhosis.  If you’ve got a green traffic light it means we can’t find any evidence of liver disease at this stage and that doesn’t mean that you might not have a very early part of liver disease.  But we’ve also looked at what happens to those people and we’ve shown that over a five year period pretty much nobody with a green test will die of liver disease.  And then we’re left with a group of people in between in whom we don’t really know what the status of their liver is - in the secondary care population in a liver clinic we know that half of those patients will have a degree of fibrosis.  In a community study, in a primary care population, it’s probably less than that, it might be of the order of a third, something like that.  We also know that if you follow those patients for five years the people with a red traffic light around 20% die of liver disease and about 3-4% of people with an amber traffic light die of liver disease.

 

Porter

And comparing this to current practice they might have gone in and had a conventional liver function test, a set of blood tests, which might have come back as completely normal?

 

Sheron

Well that’s absolutely true and we know that that’s the case because we measured the routine liver tests as well and actually in only 25% of people with a red traffic light were the liver enzymes increased.

 

Porter

Nick Sheron.  And there is more information on that traffic light test on our website.

 

Now we have a visitor - Claudia Hammond - from our sister programme All in The Mind. Claudia it says here that you are 25!

 

Hammond

Yeah I wish I was, it’s not my 25th birthday that’s coming up but All in The Mind’s.  It started in October 1988 and we’re going to be doing all sorts of things to celebrate the anniversary but one thing we’re keen to do is to hear from any Radio 4 listeners who heard something on All in The Mind at any point in the last 25 years which changed something in their lives.  So maybe you heard someone talking about depression and realised that this what you or a relative had been experiencing or maybe you were inspired to work with people with mental health problems or to get into psychology as a career.

 

Porter

And if people do have something they’d like to tell you what should they do?

 

Hammond

They can e-mail us at allinthemind@bbc.co.uk or they can tweet me at claudiohammond and we’re really interested to see what people have to say.

 

Porter

Thank you Claudia and I think you will be interested in our next item.

 

At least one and half million people in the UK are thought to have some degree of eating disorder. Contrary to the stereotypical image - they are not all teenage girls and young women, although these do account for a large proportion of those with the most severe form - anorexia nervosa.

 

Despite being both common and serious, anorexia remains poorly understood and surrounded by myth and prejudice. It’s only natural, for instance, for desperate parents to worry that something they have done is partly to blame but is there any evidence to support this?

 

Robert Spooner lost his daughter Melanie - who was a doctor - in 2011 after a 17 year battle with anorexia that started in her early teens.

 

Spooner

For me if you don’t put fuel into the car tank the engine stops and I used those words to Mel with tears in my eyes.  And I came across what we learnt to live with which was a complete wall - the face locked up, her face locked up, there was a battleground for a long time to come.

 

Lask

My name is Brian Lask, Emeritus Professor in Child and Adolescent Psychiatry at the University of London.

 

For so long parents have been blamed for bringing on anorexia in their children, it’s just nothing like that simple.  In fact there is no evidence whatsoever that parents can create anorexia nervosa, even in a genetically vulnerable child, that evidence has never been shown.  We believe we have got a much better understanding now and the way we see it is that there is a particular structure in the brain which is called the insular and the insular is a bit like Clapham Junction - it’s a major part of the network.  And the messages that go around the brain, many, if not most, travel through the insular.  So if the insular’s not working properly, which is what we believe is the case in anorexia, then messages get distorted or misrouted or lost on route.  There’s a knock on effect around the brain and it means that many different structures in the brain are not working properly as a result.  And to give you just a few examples of that.  One structure that’s not working properly is the frontal lobe, that’s the thinking, planning, deciding part of the brain and it means that thinking is much more difficult when you have anorexia because it’s swamped by feelings, the feelings come up from a different part of the brain, the feeling brain going up to the thinking brain, thus people with anorexia are desperately anxious.  In addition there’s another part of the brain called the basal ganglia, which is responsible for drive, for perfectionism, for exercise, for compulsion and that is over firing, it’s overactive, because the insular which would normally modulate it, regulate it, is not doing so.  So we now have very high anxiety, we have obsessional drive, we have an inability to think properly.  And another part of the brain that’s not working because the insular’s not working properly is the part of the brain that deals with visual spatial images and that’s probably why people have a distorted body image in anorexia – they see themselves as fat when actually they are extremely thin.  And all that we attribute to the failure of the insular. 

 

And one of the myths that still persists is that people with anorexia choose to go on a diet, choose to remain the way they are, choose to have all these features and that’s just as nonsensical as saying someone with pneumonia chooses to have a fever, to be short of breath, to cough and to be in pain when they breathe - none of that’s a choice and none of what happens in anorexia is a choice.  So trying to convince someone with anorexia that they are thin not fat, that they should eat, all those things, it doesn’t work because it’s like trying to tell someone with pneumonia don’t cough, don’t have a fever.  Their illness is a very manipulative and controlling illness but they are not manipulative or controlling.

 

Spooner

By the time she was 18 and leaving school my wife had worked quite a miracle with Mel - Mel looked absolutely fantastic.  And then off she went to Cambridge where she was driven and one of the things about these people is they’re perfectionists - she was…

 

Porter

Studying medicine.

 

Spooner

… studying medicine.  And she didn’t believe in herself totally and she also felt pressured by the university itself.  There was one of her supervisors told her she wouldn’t pass and that was the year that she came first.  And that was a bit of a nail in a bit of a coffin for Mel because her driven person was even more driven.  And part of the dealing with it was self-denial of food, this was where she could - there was a buzz from not eating and she was away from home.

 

Lask

Most people with anoxia are perfectionists and therefore are compulsively driven to achieve at a very high level - work extra hard to do so and that shows through in schoolwork, it also shows through in the illness because they are desperate to achieve the lowest possible weight and starve themselves as much as necessary to do so.  And when people starve they deprive themselves of essential nutrients, one of which allows us to develop the neurotransmitter noradrenaline.  Noradrenaline we do need for all sorts of things but one of the things it does is makes us anxious - if we have too much we get very anxious.  So if we starve ourselves we lose the nutrients that give us noradrenaline, our noradrenaline levels drop and we feel less anxious.  Now people who have very high levels of anxiety find themselves less anxious when they’re not eating, therefore that reinforces the pattern of not eating and then nice kind people like me come along and make these people eat and they get anxious again, then they don’t eat and we get into a cycle which is one of the reasons that anorexia is so difficult to treat, it’s one of the very few illnesses where people don’t want the treatment because they actually feel better with the illness than without it.

 

Spooner

All along the way she had problems getting help and accepting help, bearing in mind she was an extremely clever person and may even have been cleverer than those who were trying to treat her.  So she had the answers to things that were said like there’s a problem with your blood test, potassium level’s low.  No it’s not, this is the range and this is the tolerance and it’s within the tolerance.  So she had those facts to defeat anybody who was trying to help her.

 

Porter

But why wouldn’t she accept the help?  I mean she was a doctor, she was very bright, she must have known exactly what was going on.

 

Spooner

She knew absolutely what was going on, it wasn’t where she wanted to be and we spoke about - there was Mel and there was a person called Anna - the anorexia - and Anna was so often so much more powerful in her mind and just wouldn’t let her eat and drove her with an addiction.  So she wanted to be better, she wanted to have a normal life, she knew what the effects were on her body and she was already starting to have osteoporosis but she just physically couldn’t make herself eat, it just wasn’t going to happen.

 

Lask

We’ve talked about reward and addiction and so on and if you’ve got an addiction you may not be motivated to overcome it, if you’ve got a problem that rewards you every now and then, like gambling rewards you so you keep going, so anorexia gives a certain degree of reward, then there’s no motivation to overcome it.  One of the most important types of therapy is motivational therapy, where we work on the patients’ motivation to help them to gradually reverse the balance - the balance is so much in favour of the illness, the pros of the illness, and we try and help them work towards the cons outweighing the pros rather than pros outweighing the cons.

 

Porter

Brian Lask.  And you will find some useful links on anorexia on our website.

Next week we will be asking if the NHS has enough midwives to deliver the sort of care women deserve - indeed the sort of care that they’ve been promised. And we will be demonstrating how to use an asthma inhaler properly - a first for radio - not only to improve symptoms in people who need an inhaler but to cut waste and save the NHS a small fortune to boot.

 

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