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INSIDE HEALTH

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TX:Ìý 19.03.13Ìý 2100-2130

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PRESENTER:Ìý MARK PORTER

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PRODUCER:Ìý ERIKA WRIGHT

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Porter

Coming up in today's programme:Ìý Babies' hips - and concerns that the resurgence of swaddling is leading to hip dysplasia.Ìý Friendly viruses - could harnessing the power of phages - naturally occurring viruses that prey on bacteria - help fight the threat posed by growing resistance to antibiotics?Ìý Cervical smears follow up - if women in their late 60s are among those most likely to develop cancer of the cervix why aren't they included in the national screening programme?Ìý And the space age hospital bed that can detect everything from infections to some types of cancer.Ìý But this one isn't in the sick bay of the Star Ship Enterprise - it's in a hospital in Leicester.

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But first, the budget and minimum pricing of alcohol.Ìý Should alcoholic drinks in England and Wales have a minimum price - equivalent to around 45p a unit - to stem drink related problems?Ìý The move, which would roughly double the price of some of the cheaper strong lagers and ciders, remains the subject of fierce political debate but does it actually work?Ìý Inside Health's resident sceptic Margaret McCartney has been examining the evidence behind the plans - and Margaret this is a public health initiative you actually believe in. I never thought I would see the day….

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McCartney

Well this is the day and it has come.Ìý I am actually full committed to the idea that this sounds like a really good evidence based public health intervention that could actually save people harm and prevent lives being damaged or ended early.

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Porter

So persuade me - what's the evidence?

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McCartney

Well there is actually a fair bit of evidence in different places in the world.Ìý The strongest evidence, I think, comes from a province called Saskatchewan in Canada who building up over a couple of decades decided to have an effective minimum price of alcohol in 2010 and they raised the prices by about 10%, so there's a minimum price per unit of alcohol.Ìý And they looked to see what happened before and after.Ìý And they basically found a reduction in total consumption of alcohol by about 8.4% but in particular they found that cheap strong drinks were the ones that were being purchased less.Ìý And they also found when they went to look at the health benefits or otherwise of what happened next they found there was a mass of difference basically in the amount of alcohol related deaths and harm that had been caused by alcohol that were changed after this new policy came into place by about a 32% reduction in deaths which were wholly due to alcohol and about a 20% reduction in acute problems related to alcohol, chronic problems related alcohol - things like foetal alcohol syndrome, things like heart disease related to alcohol - and there were benefits in all of those areas.

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Porter

Because this is a concern isn't it that by increasing the price of alcohol, so say doubling the price of the cheapest strong cider in the supermarket, that it will reduce consumption but actually it won't stop the people who've got a problem drinking as much.Ìý But you're saying that it does?

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McCartney

Well that's what the evidence is saying.Ìý I think it's really interesting when you look at the distribution of alcohol consumption across the population - so 45% of alcohol consumed in the UK is consumed by just the heaviest 10% of drinkers and the lightest - 40% - of drinkers account for just 2% of our total alcohol consumption.Ìý So you can see there's not an even distribution here, it's not that there's a slow increase, really the vast majority of alcohol is consumed at the top end.

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Porter

And at what level do you set the minimum pricing?Ìý I mean they've muted - I've heard figures varying between 40 and 50p per unit, so a can of lager might be a minimum price, a strong one, of £1.50?

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McCartney

Yeah so in Scotland they're proposing that the minimum price should be 50p which means that an own brand vodka will go from costing £8.72 just now to £13.13 after.Ìý And there's been evidence done, for example, in Edinburgh they went and they looked at people - they asked people who had problem drinking who'd been admitted to hospital what it was that they drunk and they found that mean price of the alcohol they were drinking was 43pence, so it tended to be cheap strong lagers.

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Porter

Minimum alcohol pricing will impact on anyone who drinks - but there is another, more targeted initiative, aimed at people who fall foul of the law as a result of their drinking - sobriety orders.Ìý We are joined now by Sally Marlow, alcohol researcher at the Institute of Psychiatry to explain more. Sally, what is a sobriety order?

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Marlow

A sobriety order is very simple, people who are violent offenders are asked to stop drinking and they're monitored by wearing a tag round their ankle but they're also monitored by coming in for breathalysers twice daily.

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Porter

You say they're asked - they're told?

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Marlow

Well they're told, yeah, it's an order, it's not a request, it is an order.

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Porter

And what happens if they don't abide by that order?

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Marlow

If they don't abide by that order they go straight to jail, do not pass go, do not collect £200.Ìý They go for a day or they go for two days or they go for seven days depending on the severity of their previous offences.

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Porter

And who do you decide who gets the order, I mean you have to presumably work out that alcohol is a major feature in their problem?

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Marlow

Well I should say it's not actually happening in the UK yet, it has been happening in the US particularly in the state of South Dakota.Ìý And there they use it for people who drive while under the influence of alcohol predominantly but they also use it for violent offenders.

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Porter

So this has been used for some time in the States, it's going to be piloted here in London - is that the aim?

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Marlow

The aim is to pilot it although the legislation has stalled at the moment but the aim eventually is to pilot it.

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Porter

But presumably we've already got an evidence base from the States, I mean does it work?

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Marlow

The benefits - immediate benefits to the offenders - they stop drinking, they consume less - liver problems, blood pressure, all the usual things - but there's also the health benefits to the society around them, if you've got very violent offenders who are no longer drinking alcohol and alcohol is a trigger in their offending behaviour and their violence then we're reducing health harms to the people who are at the receiving of those violent behaviours.Ìý So one of the things they found is that in South Dakota domestic violence rates across the state as a whole decreased by 9%, so that was a kind of a good emerging prophesy from something which was supposed to deal with driving.

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Porter

And how are these order received by the people who are getting them, I mean presumably the alternative's go to prison, so...?

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Marlow

Yeah, so people get a choice, it's not you must have the order, people are given a choice - you do this or you go to prison.Ìý Compliance is really pretty high - 80% of people in the States don't test positive for alcohol, about 10% test positive two or three times, go to jail, learn their lesson and then don't test positive and there's about 10% - it depends which numbers you look at but there's about 10% that stay drinking basically and they do go to jail.

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Porter

Margaret, what are your thoughts on the idea of sobriety orders if they were to be introduced?

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McCartney

I suppose the question is of evidence, do they work or don't they work and I suppose the other thing that's tied up is that some people with problem drinking do have a problem with addiction and it's difficult to know whether that's best treated through a punitive system to do with the police and jail or whether that's best treated through mental health aspect and whether sort of groups, for example, like AA - Alcoholics Anonymous - can be very, very useful for a lot of people who need some kind of model to understand their behaviour and to help with that.

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Porter

I mean Sally I would hope that these people, as well as having the order slapped on them, are actually being given help to stop drinking?

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Marlow

Yeah I think that that's certainly the intention in the UK is that there will - and we already have a framework that does that, we have alcohol treatment requirements where people are required to go to treatment but again it's a false choice - go to jail or go to treatment or often they're attached to a community sentence.Ìý I think Margaret is absolutely right to raise the issue of addiction and needing treatment and I think this is a really strong pillar of policy that we need to strengthen, we need to strengthen the services that we offer for people who have got an addiction to alcohol.Ìý AA does work but we can't leave it to a self-help organisation, the NHS is not spending enough on alcohol treatment and with the new commissioning guidelines going forward it's really not clear how people with very severe alcohol problems are going to be treated and who's going to pay for that.

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McCartney

Yeah I completely agree with that, I think people who have got alcohol addiction issues have generally been treated pretty badly by NHS services, it always seems the first to cut, it's always the thing that it seems somehow tolerable to have very long waiting lists for whereas if that was an issue with something like cancer we would be appalled that people are having to wait for three or four months for treatment for a very severe problem that's likely to shorten their life and harm people around them as well.

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Porter

Margaret McCartney and Sally Marlow we must leave it there - thank you both very much.

Last week Margaret looked at antibiotic resistance and our report prompted a couple of you to e-mail us asking about the latest on phage technology - might it be an alternative to antibiotics?

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Phages - or bacteriophages to give them their full name - are viruses that prey on bacteria. They are the most abundant microbe on the planet and are found everywhere bacteria are. So sample your local river and you will not only find bacteria feasting on the debris in the water, but phages feasting on them too.

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Each phage preys on a specific type of bacterium - they have no interest in anything else, and that includes us. Before killing the bacterium the virus takes over and forces it to make and release hordes of new phages.Ìý A self-propagating weapon - the most deadly type.

A documentary in the '90s about the successful use of phages in a hospital in Georgia helped put them on the map here in the UK, but things seem to have gone a bit quiet ever since.

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Dr Martha Clokie is Reader in Microbiology at the University of Leicester.

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Clokie

Any environment that you go to anywhere you will generally find there are between 10 and a hundred times more phages than there are bacteria, so if you're walking home from work and you look in the puddles on the road they'll be full of bacteria happily living on the dead bits of leaf in that puddle and controlling those bacteria, even in that setting, you will have bacteriophages.

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Porter

I mean the obvious conclusion is - and I remember the story first being muted in the '90s that you could harness the power of the phage to help us fight bacterial infections but it seems to have disappeared, what's happened to the story?

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Clokie

Well really it was, as you say, there were people who talked about it in the '90s it was muted as an idea but actually it goes - the story goes way back before that so people developed bacteriophages as a therapeutic in the '20s and '30s in France and in Georgia but then in the West very little happens because of the antibiotics coming online and becoming widely available.Ìý So antibiotics were seen as being easier.Ìý So if you want to use a phage you really have to know what you're treating, so you need a link between - you need to know the bacteria that's causing the infection and then you need to make sure you're using the right phage for it.Ìý With antibiotics you don't need that level of knowledge, so antibiotics were seen as the panacea so there was really no motivation in the West to develop them as a therapeutic.Ìý And then it's more recently when we were just realising there are so many bacteria now that we're only one antibiotic or two antibiotics ahead of that we're realising actually we need to perhaps revisit bacteriophages and see how we can use them.

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Porter

So when we use antibiotics it's a bit like throwing a bomb into a room whereas using a phage is sending in an assassin to take out the person who's causing the trouble?

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Clokie

Yeah - yeah that's perfect, bacteriophages are almost like the sharp shooters, they will go in and just take that one bacteria out.

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Porter

How have they been used successfully?

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Clokie

Well they've been used successfully where you have a strong link between bacteriophage researchers and doctors, so where they use them in Georgia as patients come in with a bacterial infection they'll take a swab, the doctors will give the swab to the phage researchers who will find then - see what that bacteria is and find appropriate phages for it and then deploy that back to the doctor to treat the patient.Ìý Where they've been used, for example, quite effectively is in things like diabetic leg ulcers which - where people have had open wounds for perhaps two years and they haven't healed despite the normal wound management practices but after the deployment of bacteriophages applied probably to a dressing which will be wrapped around the wound the infection gets better much more rapidly.

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Porter

It sounds like a field that's full of potential, why do you think it's not really taken off?

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Clokie

I think until recently there's just been little motivation - antibiotics were seen as the answer so because of the complexities involved with actually having to find the appropriate phages and then how to develop them as a product, how to patent them and protect them and regulate them and do all the necessities of clinical trials I think there's been huge barriers there as people not knowing the best way to move forward.

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Porter

Yes because presumably it must be tricky to patent a bacteriophage, something that occurs in nature?

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Clokie

Yes it's possible but difficult. And I think because of that there's been very little funding from companies to develop bacteriophages.Ìý And I think as well it was seen I think certainly in the West it was seen as a sort of strange crazy idea that people tried and failed, it definitely suffered a certain amount of prejudice.

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Porter

Do you detect a change in the winds that might mean that more money might be heading this way?

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Clokie

Yes I think that there are a lot of research groups now all over the world who are focusing on different bacteria and trying to understand the sort of basic phage biology and there's also a much more increased engagement with doctors, doctors I think until recently have been in a way a little bit sniffy about using bacteriophages but at phage meetings you can see there's more and more doctors coming to these meetings who are interested and who are really motivated by the very applied aspects of bacteriophage research.

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Porter

Dr Martha Clokie on the rise of the phage.

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And don't forget if there is a health issue that is confusing you and you'd like us to try and clarify, then please do get in touch. We are particularly keen to hear any questions you may have about the NHS reforms which really start to kick in at the end of the month when GPs take over the budget for commissioning care on your behalf.Ìý Whether you have concerns or comments as a patient, or someone who works for the NHS - either as a clinician or an administrator - we would like to hear from you. E-mail me at insidehealth@bbc.co.uk

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Last week's item on cervical smears prompted this anonymous question from a 59 year old woman.

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Read

If, as your guest suggested last week, women in their sixties are among those most likely to get cancer of the cervix, why does the national screening programme stop before they are out of this danger zone?

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Porter

A question we put to that guest - Dr Anne Szarewski, Senior Lecturer at the Wolfson Inistitue of Preventive medicine.

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Szarewski

You only stop if you've had normal smears, so that's the important thing, but if you have an abnormal smear - this lady's 59 - so if she was to have an abnormal smear now she wouldn't be stopping at 64, she'd have to have three normal smears.Ìý And in England we stop at the age of 64 and the same happens in Wales.Ìý In Scotland they stop at the age of 60.Ìý But basically she wouldn't just be allowed to stop or just told to stop if she'd had an abnormality.

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Porter

But if you've had normal smears right up until the upper age limit the chances are you're never going to run into trouble?

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Szarewski

Well that's the point, that's why we do stop because if you catch HPV it's going to take at least 10 years to develop an abnormality, develop cervical cancer, and so if you've got a normal smear at 64 then you're covered until you're at least 74 and so the chances that anything is going to go wrong at that stage are very, very, very small.

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Porter

So this second peak that occurs in women in their 60s we would be picking signs of that up as abnormal smears in women in their 50s?

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Szarewski

Exactly.

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Porter

Anne Szarewski.

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And we've had another e-mail on the subject from a slightly different perspective:Ìý "I was told at my last smear, aged 61," writes the anonymous listener, "that ladies in our practice over 60 didn't have sex, so no more tests for me. Confirmed by a letter from the PCT."

All I can say is your practice must be very different to mine, perhaps the right advice for the wrong reason.

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Now do you have a newborn baby in the family? If so are they ever swaddled? It may be an old fashioned practice, but swaddling has made something of a comeback in recent years - some midwives and health visitors recommend it as a way of soothing a distressed child, and it has become a popular method for calming children with colic.

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But there is a downside Ìý-Ìý straightening a baby's legs and holding them together, which is happens when they are swaddled,Ìý can hinder the development of a healthy hip joint leading to hip dysplasia and arthritis later in life.

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Paediatric orthopaedic surgeon Professor Nicholas Clarke is all too familiar with the results of the resurgence of swaddling among the children he sees in his busy clinic at Southampton General Hospital.

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Clarke

Swaddling is where the baby is swaddled with blankets with their legs straight and the arms restrained so that it's comfortable and quiet.Ìý The hips need to be apart, the legs need to be apart for the hips to develop particularly in the first six months.

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Porter

The first six months.Ìý So what's the downside from your perspective?

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Clarke

Well the downside is that we're seeing that resurgence and we are seeing in our hip screening clinics babies with hip dysplasia exacerbated by swaddling.Ìý And frankly this is shocking for us.

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Actuality

Did you swaddle her?

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Did I swaddle her as a baby - baby baby?Ìý Sometimes.

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Porter

At least one in a hundred children in the UK will develop some degree of hip dysplasia and it accounts for a third of all hip replacements done in adults under the age of 60.Ìý If caught early the hips can be repositioned and encouraged to develop normally by putting the baby in a special harness.Ìý But if missed or picked up late more extreme measures are required and the outlook is nowhere near as good.

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Patient

The only thing I knew was what the midwife told me when the babies are born that they like to be swaddled because obviously being in the mummy's tummy they're all comfy and warm and cosy so that's kind of how they suggest to keep the baby calm and definitely swaddled at birth.Ìý So the hips would be towards each other rather than out as they should be, they kind of pushed together as it were.

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Porter

Girls are at particular risk of developing hip dysplasia, as are babies that are born upside down in the breech position - and it also tends to run in families.

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Patient

My niece also had a problem and also Greg's brother had it when he was young but none of them have had it as bad as our son has but there is a family history on both sides which they think contributes to it as well.Ìý We had a few too many risk factors unfortunately.

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Patient's husband

Grandad's just had a double hip replacement so...

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Patient

Yeah grandma needs a hip operation, dad's got a dodgy hip, hips aren't particularly strong in our family.

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Clarke

Hip dysplasia is under-development of the joint, it's a spectrum of abnormality - at one end you've got the tricky hip which you see in general practice and screening and at the other end you've got babies who have got dislocated hips and then you've got children who are untreated walk into the clinic at the age two with a dislocated hip.Ìý The thing is it's multi-factorial but if you don't allow the hip to develop normally and you assault it with these different positions, that are not physiological, you will not encourage normal hip development.

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Porter

And that normal hip development, even in mild cases, could have implications for the child, either during childhood or adulthood as well presumably?

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Clarke

Late dysplasia is associated with premature osteoarthritis and total hip replacement and there are still from the last generation lots of women undergoing hip replacement in this country.

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Porter

And do we know what sort of impact swaddling's having?

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Clarke

Well we do from the historical data.Ìý The North American Indians used to swaddle their babies for transport issues and they had a very high incidence of congenital dysplasia.Ìý The Laplanders used to swaddle their babies because they were cold and they used to put them on boards and there was a huge incidence of hip dysplasia.Ìý And in the 1980s in Japan all the babies were swaddled for comfort and warmth and they realised that there was a very high incidence of hip dysplasia and they started a campaign where they put educated grandmothers to tell their daughters not to swaddle their babies and the incidence went down by something like 10% - a huge number of cases that did not need treatment subsequently.

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Porter

So during that first six months you should not be restricting your child - legs should be bent and apart effectively is what you're saying?

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Clarke

There is a technique of safe swaddling which parents can look at and there is also the question of the positioning in car seats and in baby carriers.Ìý So having a baby in a baby carrier facing outwards in the first six months, as fathers do, and walk round the shopping centre pulling on the legs to pull them down is not physiological.Ìý And we are also trying to educate the midwives.

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Porter

Because it's important that they're the ones - and health visitors and midwives and people.

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Clarke

And these are the people that we want to get through to.

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Porter

Professor Nicholas Clarke - and you will find a link to the video showing the safe swaddling technique he mentioned on our website - go to bbc.co.uk/radio4 and click on I for Inside Health.

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Music - Star Trek theme tune

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Porter

Like most doctors I have always envied the kit that Bones McCoy had in his sick bay - particularly his scanner that told him what was wrong with everyone. Well in the busy A&E department at Leicester Royal Infirmary a team of researchers is working on a smart bed using space age technology to detect everything from infection to cancer. It's a touch more Heath Robinson - and a lot noisier -Ìý than Bones's kit,Ìý as I discovered when I went to see the Diagnostics Development Unit, the most expensive bed in the NHS.Ìý Tim Coats is Professor of Emergency Medicine at the University of Leicester and part of the team who built it.

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Coats

So what we've got here is a room that contains all the equipment and a bed next door in the emergency department in our resuscitation room that contains the patient and the sensors that are linked to this equipment to try and give us a bit more of an idea early on what's going on with each of our patients.

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Porter

So at the moment a patient comes in to a conventional bed, what sort of monitoring would they get as standard in any A&E department?

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Coats

So we'll be monitoring things such as the pulse, the blood pressure, the blood oxygen saturation - the sort of things that you would see on any of the TV shows with a patient hooked up to a monitor in the bed.

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Porter

But this bed here is the next generation, so what are you adding on top of that?

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Coats

So those measures are pretty crude in some ways.Ìý If I want to know how your heart is working just measuring your blood pressure or your pulse rate isn't really a good indication.Ìý So we're using a technique called thoracic electrical bio impedance which looks at changes in electricity in the heart, it's actually quite an old technique, was invented by Nasa to monitor astronauts, hasn't really been used in emergency care but seems a really good way of actually measuring how strongly the heart is pumping and how much blood it's pumping out with each heartbeat.

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Sims

My name is Professor Mark Sims, I'm part of the space research centre at the University of Leicester and I co-direct the Diagnostics Development Unit alongside Tim Coats.Ìý My sort of day job, if you like, is actually developing instruments to look for life on Mars.Ìý So we were sitting around one lunchtime and we were speculating what you could do with modern technology - could you go back and do what doctors did a hundred years ago, which is feel the pulse, look at the patient and smell them - and that's how diagnosis was done a hundred years ago and we said well modern technology's probably sufficiently good now you can probably do that again but from a technological point of view which would give doctors hints, it wouldn't replace the doctors but it would give them hints, it would make the whole system much more efficient.

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Porter

Looking forward 20, 30 years I mean this sort of technology to put it very simply I mean it says well actually your patient's got a breathing problem because they're not very well oxygenated, a little bit of liver failure and the kidneys aren't quite what they should be and that technically is possible now?

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Sims

It's technically possible now...

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Porter

What the data means is?

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Sims

That's the key, the real problem is what does the data mean - can you tell an ill patient from a normal patient?

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Coats

And that is exactly the question that we're trying to answer here.Ìý So what we're doing here is we're using these new techniques, we're monitoring a whole bunch of patients, some of whom are sick, some of whom are not sick, so we're getting the idea with these new techniques what is the range that you would expect in sick patients, in normal patients.Ìý Now once we've got that information we can start saying okay does this information mean anything and then can we treat patients differently depending on this new information that we're getting?Ìý So we're doing breath analysis - we're looking at the compounds that are present in the patient's breath.Ìý Now the breath reflects the internal metabolism and also something about what's going on in the lungs.Ìý So, for example, if a patient's got a pneumonia we can look at the compounds that are coming out in their breath and we can tell perhaps which type of bacteria is causing that pneumonia which will enable us to give the right treatment early on.

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Sims

This is the mass spectrometer which is the biggest piece and the noisiest piece of equipment in this equipment room and this is the equipment which does the breath analysis.Ìý Mass spectrometers were used in space research to look for organic compounds on other planets.Ìý The mass spectrometer we use here has actually come from the chemistry department where they're looking at things like atmospheric pollution, so what it's doing is continuously sampling the air from the patient's breath...

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Porter

And it's things that we're all familiar with - with smelling on people's breath - I mean alcohol's a good example, so this machine can detect tiny amounts presumably of all sorts of other things?

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Sims

It can detect parts per trillion.

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Coats

So we're looking at both what's goes on in the patient's breath, what goes on in the patient's pulse and cardiovascular system and then the look of the patient with the imaging from space science because doctors often look at the patient from the look of the patient, from the colour of a patient, from the tone of their skin - different skin tones are associated with different diseases.Ìý Well if we can get a hyper spectral camera, which analyses very carefully the colour in the patient's skin that gives perhaps an indication in a more scientific way of what doctors have been looking at for probably hundreds of years.

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Porter

I say you look a bit peaky but you can actually come up with an objective measurement of that.

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Coats

I can perhaps say what peaky is in terms of nanometres of wavelengths.Ìý So the area that's looking particular promising is in patients with sepsis - sepsis is a huge problem to the NHS...

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Porter

Serious infection.

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Coats

Serious infection, infection that's getting into the blood to be blood infection.Ìý And one of our real problems is early detection - once a patient is realised that they're septic we've got powerful antibiotics and treatments but if you look at the patients that come to harm from sepsis and don't have good outcomes a lot of the time it's that people didn't realise what was going on until quite a late stage.Ìý What we're hoping is that this sort of imaging may be an earlier detection system to detect the patients earlier on.

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Sims

What we'd like to do eventually if all this equipment pays off, if all this work pays off, is actually take these devices and miniaturise them and maybe 10 years' time, 15 years' time there'll be miniature devices in the next generation ambulance, so you can do this diagnosis on the way to the hospital and get some early warning signs of potential problems with the patient before they actually get there and may be eventually it gets into GPs' surgeries and ultimately you go to the Star Trek Tri-Corder but that's probably 20 years off...

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Porter

That's what I'd like, that's the machine that you just sort of scan the patient with and it tells you what's wrong.Ìý A few years off I believe.

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Sims

A few years off.

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Porter

Professor Mark Sims and Tim Coats.Ìý And there is a link to the work that they are doing on the Diagnostics Development Unit on our website - go to bbc.co.uk/radio4 and head for the Inside Health page.

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Next week's programme will be dedicated to the NHS reforms - and the hopes and fears of those involved in implementing them. It is not too late to take part - if there is a concern you would like aired, or simply a comment you would like to make, then e-mail us at insidehealth@bbc.co.uk.Ìý

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ENDS