Jumat, 23 Juni 2017

inhaled glucocorticoids side effects

inhaled glucocorticoids side effects

asthma uk works for all people with asthma works for all people with asthma, andprovides an enormous range of patient information to support people with asthma on aday-to-day basis we also have our asthma nurse advice line, which is an invaluable resource that people with asthma can call in ifthey have any queries to talk to our specialist asthma nurses we're also very heavily involved infunding research into looking at asthma treatments and managements andso we we have a very comprehensive overviewand we hope that we

work as advocates for people with asthma our asthma nurse advice line is open from nine to five, monday to friday and all details of that can be found onour website at asthma.org.uk the types of callls that we get varyenormously we may get calls from people withasma have just had a diagnosis made and they feel uncertain, they feel scared, they need some more reassurance we have calls from people with asthmawho want a better understanding of the treatmentsthat they're taking

treatments fall broadly into twocategories: so you have reliever treatments whichdo exactly what they say, they relieve the symptoms of asthma when you have them and there are preventive treatments which you take on a regular basis but won't have any impact on coughingand wheezing when you actually have it the relievers can be taken on as required basis and some people may need to take them just simply whenthey've got a cold

or perhaps before they exercise butthe preventive treatments which are inhaled corticosteroids taken regularlyin the morning and the evening all the time even when you have nosymptoms and that keeps all the inflammation and swelling within the airways at bay

inhaled glucocorticoids for asthma

inhaled glucocorticoids for asthma

greetings. it's eric bakker, naturopath fromnew zealand, author of candida crusher and formulator of canxida, the candida dietarysupplements. thanks for tuning into my video. i'm going to talk a bit about steroid usetoday and patients that i see with yeast infection. i've seen way too many people over the yearswho take different kinds of steroid preparations. whether it be for asthma, they'll inhale asteroid. whether it be for dermatitis or a skin condition, they'll put it on their handsor different parts of their body. maybe they're taking prednisolone, a stronger one, for differentkinds of diseases, autoimmune diseases, for example. i've seen no good outcomes with peopleon steroids, particularly long term. i get many cases of patients in. all the time,i see people who take these kinds of preparations.

whether it's creams or ointments or pills,sometimes for years on end. and then come to seek my advice regarding overcoming somekind of chronic illness, which they've developed over time.i had a patient recently yesterday who's been taking a steroid cream now probably for about30 years with quite a bad urinary problem. and this poor guy has been to so many differentpractitioners to try and work out what's wrong with his urinary system. and there's no doubtabout it, no family history on either side with this poor young guy. there are no realclear-cut causes or reasons why he should have this problem apart from using steroidcream for 30 years, a very powerful steroid he's been using. you can see what's happened.he's suppressed his adrenal gland. he's suppressed

his ability to make cortisol properly. he'seven showing some signs of cushing's disease already, which is just too much steroid inthe body. if you're watching this video and you're takinga preparation for say psoriasis or dermatitis and it involves a topical application of asteroid, maybe you're swallowing some prednisone tablets on a regular basis for some conditionthat you've got. or perhaps you're inhaling steroids for asthma. the long-term consequencesof these drugs can be devastating for your cardiovascular system, for your musculoskeletalsystem, for your immune system, it just doesn't make sense long term to take a hormone inthat your body itself produces. you'll only end up in serious problems doing this. justlike you will be by continuing to borrow money

all the time from banks. eventually, you'llget to a point where you just can't pay the debt anymore. and that's what i see with peoplewith long-term steroid use. to me some of the two worst drugs i've everseen patients use repeatedly would have to be antibiotics and steroids. so if this ringsa bell for you, stop and think about what you're doing. go and see a health care practitionerand tell them that you're concerned about steroid use. or maybe go and see someone likeme or another health care professional who can guide you on how you can get off thisstuff. because what you're presenting with right now could very well be linked to thelong-term use of that steroid that you're using right now.thanks for tuning in.

inhaled glucocorticoids examples

inhaled glucocorticoids examples

having a hypersensitivity means that someone’simmune system has reacted to something in such a way that it ends up damaging them,as opposed to protecting them. there are four different types of hypersensitivities,and in the first type or type one, the reactions rely on immunoglobulin e, or ige antibody,which is a specific type of antibody - the other major ones being igg, iga, igm, andigd. so because ige is involved with type one hypersensitivityreactions they are also called ige-mediated hypersensitivities. this type of reaction is also sometimes calledimmediate hypersensitivities, because the reaction happens super fast—on the orderof minutes.

so most allergic reactions are ige-mediated,and therefore most allergies are type i hypersensitivity reactions. “allergy” comes from the greek allos whichroughly means “other” and ergon which means “reactivity”. essentially, allergies are reactions to moleculesfrom outside your own body that most people don’t react to—and these are specificmolecules from things you might breathe or take in like foods, animal dander, bee stings,mold, drugs or medications, and pollen. you can also mount an allergic reaction tothings you come in contact with on your skin like latex, lotions, and soaps.

these specific molecules are also called antigens,and when they cause an allergic reaction, they’re called allergens. an allergic reaction happens in two steps,a first exposure, or sensitization, and then a subsequent exposure, which is when it getsa lot more serious. people that react to these allergens usuallyhave a genetic predisposition to having over-reactions to unknown molecules or allergens. this means that these people have certaingenes that cause their t-helper cells to be more hypersensitive to certain antigens. since the production of these t-helper cellsis genetically linked, allergies to things

tend to run in families. so let’s say this person breathes in someragweed pollen, that person happens to have t-helper cells that can bind to a specificmolecule on the pollen, making that molecule an allergen. first off, that antigen gets picked up byimmune cells hanging out in the membranes along the airways, which then grab the moleculeand migrate to the lymph nodes, which happens regardless of if the person is allergic ornot. these cells are antigen-presenting cells,since they carry the antigen to the lymph nodes and present it to the t-helper cellsliving there.

dendritic cells and macrophages are examplesof antigen-presenting cells. when the person is allergic, the antigen presentingcell will also express costimulatory molecules, which are needed to mount an effective immuneresponse. before the t-helper cell sees the antigenthough, it’s called a naive t-helper, since, even though it’s built to recognize theantigen, it hasn’t actually seen it before. when the t-helper gets its hands on the antigenthough, and also binds the costimulatory molecule, it’s now been primed, and the naive t-helperchanges into a different sort of t-helper cell. usually in type i hypersensitivity it differentiatesinto a type 2 t helper cell, or just th2 cell,

and this step happens in response to varioussmall proteins or interleukins that might be floating around at the time. some interleukins that sway the t-helper cellinto turning into a th2 cell are interleukin 4, interleukin 5, and interleukin 10, andthese are all cytokines - and they’re given numbers because it’s easier to keep trackof them that way. at any rate, the excited th2 cells releasea bit of their own interleukin 4 and get the b cells to undergo antibody class-switching,and so the b cell switches from making igm antibodies to making ige antibodies whichare specific to ragweed pollen in our example. th2 cells also release some interleukin 5,which stimulates production and activation

of eosinophils, a granulocyte, which is atype of white blood cell that degranulates or essentially releases a whole bunch of toxicsubstances that can damage both invading cells and nearby host cells. these ragweed-specific ige antibodies havea high affinity for, or basically really like fc epsilon receptors on mast cells, anothertype of granulocyte, so they quickly attach themselves to the surface of mast cells. these antibodies are also called cytotropicantibodies, since they can bind to cell surfaces. at this point it’s like the mast cell’sbeen geared up for combat, and is ready for action, and therefore we’re finished withthe sensitization phase.

now let’s say that that same person breathesin the ragweed pollen again, maybe a few months later - a second exposure. well, the suped up mast cells, using theircoat of antibodies, binds to the antigen. actually, it takes two or more bound antigensto cross-link the ige antibodies, which signals the mast cell to degranulate and release abunch of pro-inflammatory molecules called mediators that ultimately causes the effectsseen in an allergic reaction. one of the major mediators released in anallergic reaction is histamine. histamine binds to h1 receptors and causesthe smooth muscles around the bronchi to contract, which means the airways get smaller, makingit more difficult to breathe.

it also causes blood vessel dilation and increasedpermeability of the blood vessel walls, meaning that, while blood vessel diameter increasesand blood flow to the affected area increases, fluid is allowed to more easily leak out theblood vessel walls and get into the interstitium, the spaces between cells, which causes edemaand swelling, and urticaria, or hives. in addition to histamine, mast cells releaseother pro-inflammatory mediators including some that activate eosinophils and proteaseswhich chop up large proteins into small peptides. the effects of these molecules are called“early phase reactions”, and they happen within minutes of the second exposure. there are also “late phase reactions”though, which happen 8-12 hours after that

second exposure, where even more immune cellslike th2 cells, eosinophils, and basophils, yet another type of granulocyte, are recruitedto the site where the allergen is located because of the cytokines and pro-inflammatorymolecules produced during that early phase. these include some of those same interleukinsagain, interleukin 4, interleukin 5, and interleukin 10, but also leukotrienes which are smallermolecules made out of fatty acids and facilitate communication between a local group of cells. two leukotrienes in particular, ltb4 and ltc4,can not only cause smooth muscle contraction and damage to the epithelium like histamine,but they can attract immune cells - like neutrophils, mast cells, and eosinophils to their locationeven after the allergen is long-gone.

a lot of people with allergic reactions experiencemild symptoms, like hives, eczema, allergic rhinitis—which is inflammation of the nose,as well as asthma. certain people though, when exposed to a largeload of specific allergens, like bee stings, seafood, or peanuts, can have a really severeand potentially life threatening allergic reaction. the increased vascular permeability, alongwith the constriction of airways can be severe enough such that the body can’t supply thevital organs—like the brain, with enough oxygen-rich blood, a condition known as anaphylacticshock. treatment for type one hypersensitivity caninvolve a variety of medications.

antihistamines, act to block the effects ofhistamine, which reduces vascular permeability and bronchoconstriction. also there’re corticosteroids, which canbe used to reduce the inflammatory response, as well as epinephrine, which is sometimesgiven during severe reactions via intramuscular injections through an epipen or intravenousinjection. epinephrine can help constrict blood vesselsand prevent anaphylactic shock. if there’s ever a serious type one hypersensitivityreaction that requires something like steroids or epinephrine, it’s super important toget medical attention because type 1 hypersensitivity reactions can be serious and can sometimesget slightly better before getting worse again.

inhaled corticosteroids

inhaled corticosteroids

pulmicort turbuhaler is a prescription medicationused in maintaining asthma control and preventing asthma attacks. pulmicort turbuhaler belongsto a group of drugs called corticosteroids which help to decrease inflammation to relievesymptoms. this medication comes as a dry powder inhaler,and it is typically used twice daily. common side effects of pulmicort turbuhalerinclude respiratory infection, pharyngitis, and headache.

inhaled corticosteroids side effects

inhaled corticosteroids side effects

mometasone is a prescription medication usedto treat asthma, allergies, and skin conditions. mometasone is in a class of medications calledcorticosteroids. it works by decreasing swelling and irritation in the airways to allow foreasier breathing. mometasone comes in several forms, including an inhaler, a nasal spray,a cream, a lotion, and an ointment. the nasal spray and inhaler are used once or twice daily.mometasone cream, lotion, and ointment are applied to the skin, usually once daily. commonside effects include headaches, viral infections, sore throat, and nosebleeds. for more informationon this medication and all other medications, explore the rxwiki encyclopedia on the webor on your mobile device.

Kamis, 22 Juni 2017

inhaled corticosteroids side effects long term

inhaled corticosteroids side effects long term

emphysema means “inflate or swell”, whichmakes sense because in the lungs of people with emphysema, the alveolar air sacs, whichare the thin walled air spaces at the ends of the airways where oxygen and carbon dioxideare exchanged, become damaged or destroyed. the alveoli permanently enlarge and lose elasticity,and as a result, individuals with emphysema typically have difficulty with exhaling, whichdepends heavily on the ability of lungs to recoil like elastic bands. emphysema’s actually lumped under the umbrellaof chronic obstructive pulmonary disease (or copd), along with chronic bronchitis. they two differ in that chronic bronchitisis defined by clinical features, like the

productive cough, whereas emphysema is definedby structural changes, mainly enlargement of the air spaces. that being said, they almost always coexist,probably because they share the same major cause—smoking. with copd, the airways become obstructed,the lungs don’t empty properly, and that leaves air trapped inside the lungs. for that reason, the maximum amount of airpeople with copd can breath out in a single breath, known as the fvc, or forced vitalcapacity, is lower. this reduction is especially noticeable inthe first second of air breathed out in a

single breath, called fev1—forced expiratoryvolume (in one second), which typically is reduced even more than the fvc. a useful metric therefore is the fev1 to fvcratio, which, since the fev1 goes down even more than fvc, causes the fev1 to fvc ratioto go down as well. alright so say normally your fvc is 5 l, andyour fev1 is 4 l, your fev1 to fvc ratio would end up being 80%. now, someone with copd’s fvc might be 4l instead, which is lower than normal, but the volume of air that he or she can expirein the first second is only 2 l, so not only are both these values lower, but their ratiois lower as well—and this is a hallmark

of copd. all that had to do with air breathed out right? conversely, for air going in, the tlc, ortotal lung capacity, which is the maximum volume of air that can be taken in or inspiredinto the lungs, is actually often often higher because of the air trapping. alright, so emphysema is a form of copd, that’sbased on structural changes in the lung, specifically a destruction of the alveoli. normally, though oxygen flows out of the alveoliand into the blood while carbon dioxide makes the reverse commute, but when the lung tissueis exposed to irritants like cigarette smoke,

it triggers an inflammatory reaction thatupsets the delicate alveolar walls and affects the flow of gases. inflammatory reactions attract various immunecells which release inflammatory chemicals like leukotriene b4, il-8, and tnf alpha,as well as proteases, like elastases and collagenases. these proteases break down key structuralproteins in the connective tissue layer like collagen, as well as elastin, which is a proteinthat gives the tissue elasticity, and this leads to the problems seen in emphysema. in healthy lungs, during exhalation, air whizzesthrough the airways with high velocity, creating a low pressure environment in the airway.

this is due to the bernoulli principle, where,as a fluid—which includes air—moves at higher velocity, it must have lower pressure. now this lower pressure tends to pull thetiny airway inward. strong healthy airway walls full of elastincan withstand that pressure and don’t collapse; they hold the airway open and allow air tofully escape during exhalation. with emphysema though, that elastin’s lost,which makes the airway walls weak and allow that low pressure system to pull the wallsinward and collapse during exhalation. this ultimately leads to air-trapping becausethe collapsed airway traps a tiny bit of air distal to the point of collapse.

also, this loss of elastin makes the lungsmore compliant, meaning that when air blows into them, they easily expand and then holdonto that air instead of expelling it during exhalation, and so the lungs start to looklike large thin plastic bags. the loss of elastin also leads to a breakdownof the thin alveolar walls called septa. without these walls, neighboring alveoli coalesceinto larger and larger air spaces, which means the surface area available for gas exchangeis reduced (relative to the expanding volume), which affects oxygen and carbon dioxide levels. this process all happens in the acinus, whichis the endings of the lung airways where those clusters of alveoli are located.

different types of emphysema affect the acinusslightly differently. the first pattern of emphysema is called centriacinaremphysema, or centrilobular emphysema, and this is the most common pattern and it reallyonly damages the central or proximal alveoli of the acinus. this is the pattern seen with cigarette smokingand is thought to happen because the irritants from smoke aren’t able to make it all theway to the distal alveoli. centriacinar emphysema typically affects theupper lobes of the lungs. there is also panacinar emphysema, where theentire acinus is uniformly affected, and this is often associated with the genetic conditionalpha-1 antitrypsin deficiency.

now in healthy individuals, macrophages arealways letting out some proteases to help clear the debris that occasionally finds itsway into the acini, but those proteases break down proteins, right? so these can damage the tissue. alpha-1 antitrypsin is a protease inhibitorgenerated by the body, to protect against unintended collateral damage from the proteases. people with alpha-1 antitrypsin deficiencydon’t have these protective proteases inhibitors, and so they end up with damaged air sacs,that affect the entire acinus. panacinar emphysema typically affects thelower lobes of the lungs.

a third and final type of emphysema is calledparaseptal emphysema in which the distal alveoli of the acinus are most affected, and thistype typically affects the lung tissue on the periphery of the lobules, near the interlobularsepta, that separate each lobule. the thing to keep in mind about paraseptalemphysema is that the ballooned out alveoli on the lung surface can rupture and causea pneumothorax. people with emphysema typically experiencesymptoms like dyspnea, which is a shortness of breath, due to the air trapping and diminishedgas exchange. to help counteract this, people sometimesexhale slowly through pursed lips, which increases pressure inside the airways and preventingthem from collapsing as easily.

this way of breathing explains the nickname“pink puffers”, since individuals are able to oxygenate their blood, but have topurse their lips to do so. all of this constant energy spent on breathingcan even cause weight loss. over time, though, as more and more lung tissueis affected, emphysema can lead to hypoxemia, or low oxygen in the blood. there can also be a cough with a small amountof sputum from inflammation in the small bronchioles that causes excess mucus production via gobletcells, but this is a lot different from the productive cough with lots of sputum seenin chronic bronchitis. over time, air-trapping and hyperinflationof the lungs can cause individuals to develop

a barrel-shaped chest, and on x-ray, individualsmight have an increased anterior-posterior diameter, a flattened diaphragm, and increasedlung field lucency. alright, so in normal physiology there isa process called hypoxic vasoconstriction, where if, for some reason, one area of thelungs has poor gas exchanges, then the blood vessels going to that area undergoes vasoconstrictionin an attempt to shunt blood to an area with better gas exchange. this works great if the hypoxia is localizedto one area of the lungs, but when a large proportion of the lungs aren’t exchangingoxygen effectively, then that vasoconstriction starts involving too many blood vessels andthis leads to pulmonary hypertension.

over time, this increases the work that hasto be done by the right side of the heart to pump blood to the lungs, causing it toenlarge, a process called cor pulmonale, which eventually to right-sided heart failure. treatment of emphysema largely involves reducingrisk factors and managing associated illnesses. since smoking’s a major player in causingemphysema, stopping smoking is a major player in reducing mortality. supplemental oxygen, as well as certain medicationslike bronchodilators, inhaled steroids, and antibiotics to control secondary infectionsare all helpful in managing emphysema. alright as a quick recap, emphysema is a typeof chronic obstructive pulmonary disease or

copd, where where exposure to irritants—likesmoking—causes elastin in the small airways and alveolar walls to be broken down, andthis leads to air trapping and poor gas exchange, both of which eventually lead to hypoxemia. thanks for watching, you can help supportus by donating on patreon, or subscribing to our channel, or telling your friends aboutus on social media.

inhaled corticosteroids pregnancy

inhaled corticosteroids pregnancy

[music playing] [chattering] director (offscreen):[inaudible] [starting pitches givenby keyboard] [music - "si hei lwli mabi"] interviewer (offscreen): howold were you when started taking drugs? amy protheroe (offscreen): wheni first started taking dope and valium and thingslike that, i was 12.

cornelius collins (offscreen):i was 11 when i started smoking dope, then valiumand eggs and speed. amy protheroe (offscreen):when i started taking heroin i was 14. my mother startedgiving it to me. cornelius collins (offscreen): iwas 15 when i started taking heroin and crack. i was dealing by the timei was 16 with my father. amy protheroe (offscreen): iwas homeless when i was 12.

and when i was 14, i went backto live with my mother, and within three months of goingback to my mother, i was taking heroin. she sent me to work in aparlour-- do you know a massage parlour-- when i was 14, wasn't it? cornelius collins (offscreen):it was not a parlour. it was a fucking whore house,not a massage parlour. amy protheroe (offscreen):yeah.

when i was 14, she sent meto work in one of them. cornelius collins (offscreen):that's the posh word for them, isn't it? amy protheroe (offscreen): andall the money that i was earning, i was giving toher and her boyfriend. cornelius collins (offscreen):that's because people like us grow up with parents who areselling drugs and doing drugs, you learn where you live. amy protheroe (offscreen):you end up copying.

cornelius collins (offscreen):right. you end up kind of doing whatyour parents did, because you think that's what's the norm. that's what normalityis to you. amy protheroe: oh, oh. amy protheroe loves corneliuscollins forever, 2008. cornelius collins: it's just alittle reminder to the world that she loves me. amy protheroe: he's my baby.

i loves him. we've been together nearlyfour years, haven't we? cornelius collins: yeah. well, three years, 9 months. amy protheroe: i lied about myage when i got with him. i told him i was 16. i was only 15. i wrote that. cornelius collins: she didit when i was in jail.

interviewer (offscreen): 2008,october last year. amy protheroe: i wason suicide watch. 24/7, they made sure someonewas with me all the time, because i was depressed. i used to sleep with his red gapjumper and cuddle into it. i never washed it. i'd smell him, yeah? cornelius collins: don't-- hey.

amy protheroe: but we've hadsome hard times, haven't we? we've had a lot of trouble. we recently lost a baby. didn't we, corneil? we recently lost our baby. cornelius collins: sort meout with a glug of that. amy protheroe: didn't we? cornelius collins: let's talkabout better things, amy. amy protheroe: no, wait.

but i'm explaining, that's howwe went downhill so rapidly. cornelius collins: well,whatever, innit. amy protheroe: i was eight anda half months pregnant. my baby was born stillborn. i had a little boy. and after that happened, we juststarted drinking really heavily, didn't we, babes? because we neverused to drink. you hated drinking,didn't you?

cornelius collins: yep. i did. amy protheroe: we started offdrinking a little bit, and then when the baby died, thatwas it, our heads went. cornelius collins: give us aglug on that, babes, please. amy protheroe: i don'twant to, shove off. cornelius collins: no, man. oh, this one's fucking dirty. [inaudible].

andrew williamson: lighter? the lighter? where's that filter? you're a dozy fucker. lighter. it's like talking tothe fucking wall with you lot, man. cornelius collins: haven'tgot a lighter. andrew williamson: amy, haveyou got a lighter?

[whistles] andrew williamson: yeah, that'snice as fuck, that is. lovely gear, that is. andrew williamson (offscreen):i wish i'd said this when i was sober. i'm having to maintain myself ona seriously addictive drug. just make sure youwait for me. i'll come into townwith you, innit? cornelius collins: we'llmeet you round the

back of the ym, yeah? derek james: i heard adefinition many years ago about the difference a northwalian and a south walian. and the difference was betweenbelt and braces. the south walian always worea belt slung under his beer belly, and was a roistering,boisterous taffy. whereas a north walian alwayswore braces and hunched them forward as if he were foreverplodding uphill. most of the coal that was minedin the swansea area and

up the swansea valleywas used in swansea for the metal refining. swansea was then, at one time,the major metal refining center for the entire world. that's an example from the olddays, when children were underground. and it was only about 1840- oddthat they raised the age of children workingunderground to 12. but no, mrs. thatchershut the lot down.

it's awful when you think thatthe amount of skill and the amount of knowledge that washere, the knowledge base that they had, and it alljust withered away. employment after the heavyindustry went as not good. there was a short period in the'60s when there was quite a lot of work around. but that declined all throughthe '70s and the '80s, until the late '90s. yeah, that's played a part inthe present drug problem, i

think, in swansea, andthe alcoholism. of course, the system underwhich we live-- the capitalist system--is so competitive. and it's a continual stresson the individual. and younger people, i feel, whocan't get into the stream and compete and can't getwork just lose heart. and then they descend into adrug culture, which is almost a subculture now. danielle gray: (singing)swansea, oh

swansea, swansea city. living on the lamppostuntil the day i die. (speaking) something likethat, isn't it? josie: my name's josie. danielle gray: my nameis danielle gray and i'm from swansea. we're stepsisters. josie: we're stepsisters. danielle gray: that we are.

interviewer (offscreen):stepsisters. danielle gray: there's 12of us all together. interviewer (offscreen):right. danielle gray: there's me,rachel, ciaran, becca, teagan, gemma, emma, then it's ryan,reagan, brandon, and timmy and teagan. and my daughter's namedcourtney-lee-- 28th of the fifth-- it's a bit fadedat the moment.

josie: "dad", i put there. danielle gray: they're prisontattoos, they are. josie: i got "mum" there. danielle gray: you'vegot her ex-missus named leanne up there. that's fucked it off. josie: fucked off. my ex-girlfriend's name there. i've got my ex-boyfriend'sname--

danielle gray: on thatside, isn't it? yeah, mark. i got a daughter. she's three years old now. and if you look there, i got acesarean, from there to there. i sees her every tuesday between10:00 and 12:00. she's brilliant. she goes, mummy, dani,where's my daddy? i goes, working away.

but he was in prison. he came out the other day. no, she doesn't want tosee him and that. two days ago, my mother was abit drunk, and she hit me. i hit her back. and she bit my nose fromthere to there. interviewer (offscreen): whathappened to your face there? josie: oh, i was jumpedby two girls, i was. in swansea?

danielle gray: yeah. it's gone down. rough area. josie: rough, yeah. danielle gray: realrough area. interviewer (offscreen): why? josie: because of the drugs. danielle gray: but now you'vegot kids at ages 12 and 13-- josie: taking heroin.

danielle gray: they'retaking heroin. josie: there's dealersselling it to them-- danielle gray: exactly. josie: and they don't reallycare about them, as long as they get their money. danielle gray: they won't careif a 12-year-old or an 11 goes, oh, have you gota bag and that? oh, yeah, have yougot a tenner? yeah, here's a bag and that.

do you know what i mean? josie: they just don't care. danielle gray: no. they should have more respect. cornelius collins: right, you'vegot sands, which is for over-18s, and sandpit, down innash house, for under-18s. this is a drug agency. they offer counseling. they can help you get onopiate prescribing--

methadone, subutex, suboxoneneedle exchange. they do a men's day on awednesday, when you go in and have some toast and tea, andjust have a chat with all the boys in there. john frith: thanks, lynn. is everybody here? this is another counselingroom, which we'd call a family room. first point of call wouldnormally be the needle

exchange, where we'dfirst engage with-- interviewer (offscreen):why's that? john frith: a lot of them wouldactually come here and be asking for clean needles. and so we've got thecookers, then. this is the most populartype of needle. so this is a 1 mil syringe. you hear about people drawingup water from puddles. we have got water ampules aswell, which you can put in the

cooker and mix withthe heroin. people will still use whetherwe were here or not. where there's a way,they'll find a way. you can actually inject intoyour anus, where there's lots of blood vessels closeto the surface. people are beginning toinject crack now. most people are stillactually smoking it. andrew williamson: this is howcomplicated it is to get drugs, but this isto get crack.

basically, i've gotto get there. i'll ring him on the way--say i'm in a taxi. i meet him by a certain shop. hello? yeah? righto. no, i will. i will comply. at 11:30.

and what's the time now? right. ok. ok, i'll be there at 11:30. my drug worker, that was. i got a phone call about mymedication, because i'm banned from the building, dueto an incident. i've got to meet the ladyoutside there at half past 11. and she'll go throughthings with me.

and it's involving my methadoneprescription, it is. i'm on my way up in a taxinow, mate, yeah? i've got to be back by theymca at ha;f past 11. so, step on it, driver, asthey say in the films. yeah, i take crackrecreationally. it's not something i makea habit of doing. it's not physically addictive,so it's-- interviewer (offscreen):you don't think so? andrew williamson: well,textbook, it's

not physically addictive. i have come off it before. and i have vomited blood. i drank 60 mil of methadone. and then an hour later, iinjected 2 mil of subutex. and i tell you what, it was oneof the worst cold turkeys i've ever been throughin my entire life. any users who watch thisprogram, never ever do that. i don't want to be vulgar,yeah, but you could have

fitted a watermelon up myasshole, that's how disg-- it came out of me like piss. and i laid on my bed with myeyes like 50 pence pieces-- the old 50 pence pieces. i'm there now, yeah. interviewer (offscreen):you all right? andrew williamson: yeah,safe, sorted. interviewer (offscreen): good. andrew williamson:that's the crack.

kim, it's andrew, it is. right, love, i'm going to beabout 10 minutes later, is that all right? yeah, i know, i know. but i've got to pick up acounter payment from the job center, see? yeah, no. this won't happen again. this is a one off.

yeah, i know, love,but please. i promise you i'll be 10minutes, at the most, late. i didn't realize i was going toget a phone call saying to be at the job center. i got a phone call afteri spoke to you, you know what i mean? i didn't realize thiswas going to happen. ok, my love, i'll be there. ok, thanks.

bye. ooh. she weren't happy. she bought it. oh, jesus. christ. ah, shit. i haven't got a lighter. fucking frank [inaudible].

right, this is the wire wool. you've got to burn this first toget the toxicity out of it. [accompanist plays choir'sbeginning pitches offscreen] [dunvant male voice choirsinging "si hei lwli madi"] andrew williamson: the goodthing about a glass pipe is residue collects, and youcan clean it out. and what you clean out is betterthan what you smoked the first time round. one more pipe, boys,and we're away.

fuck it. aw, i left your lighter,didn't i? ah, for fuck's sake. if it was better stuff, i'dstill be rushing my tits off, i'd still be-- [panting] [deep exhalation] andrew williamson: it's a bitof a double-edged sword, me arriving late.

she might have someone-- i was wondering, they might havesomeone waiting there to maybe arrest me for the theftof the magazines. ah, come on, mate. please. get out of the fucking way. oh my god, what'sthis traffic? it's driving me nuts. well, mate, i'm going toget out and run, yeah?

lee dennis: well, we've knowneach other years. i mean, we always used to bumpinto each other and talk. rachel rees: we used to havea nice chat, didn't we? lee dennis: i mean, she'sa tidy girl, like. rachel rees: my ex was givingme a few hidings here and there, like. dennis is there. have a chat with dennis-- this,that, and the other. tidy guy.

and that's how weclicked, really. lee dennis: i mean, i'vealways had a little soft spot for her. rachel rees: we'll see how itgoes from here now, isn't it? lee dennis: yeah. rachel rees: just take it day byday and help each other out as much as we can. lee dennis: february 27,i got out of jail. but when i moved in here,it was stinking.

this is my bedroom. i'm gonna put mybed down here. put the bed down here-- i got my bedside cabinet-- and lay the carpet and put mywardrobes down here and my chest of drawers behindthe door. rachel rees: you can't putit in your ear, can he? lee dennis: it's allright like that. that's my first ever swanseacity tattoo--

the proudest ever. i've been to a few prisons, aswell, and i always wear it with pride, always walk aroundwith my top off. and i want to get clean. i'm starting treatment now onthe 26th of this month. because i tattooed myself injail, i had test results done. i had a letter then fromthe nurse, saying come down and see me. i need to see you urgently.

and when i went down, she says,i'm very sorry, but you have got hep c. i'm gonnatry a cupboard, put a cupboard up on here. i'm gonna paint the ceiling. i'm gonna paint that. it'll probably be tomorrow. and look, there'sbits of blood. when you're cooking upand that, you draw the blood into yourself.

and when you draw so much in,there's a little bit of blood left in, and theyjust squirt it. there was some onhere as well. i put a bit on there. my stereo's in my mum's it is. what kind of musicdo you like? lee dennis: i like all differenttypes of music. i got loads of music here. r&b, garage, r&b, fleetwoodmac seven wonders--

if i live to see theseven wonders. rachel rees: therewas an abscess. i had to go in for an operationon that, because i missed there. you know, basically, myveins are kaput now. that's going intoanother abscess. that one's not too bad. if i wasn't on the heroin, i'dcry my eyes out for my kids now, you know?

don't get me wrong, i lovethem all to bits, but you know, i can't really see themwhile i'm in this predicament. lee dennis: this is gonnago up in my bedroom. rachel rees: otherway round, babes. lee dennis: is that all right? rachel rees: the otherway, babes. lee dennis: (singing) when i wasjust a little boy, i asked my mother, what shall i be? shall i be swansea?

shall i be scum? this is what she said to me. take your father's gun, andshoot the cardiff scum. forever will be, my son. you'll always be swansea. who are we? jack army! lee anderson: lee anderson, inswansea, like, in a shared flat, with smackheads,down and outs.

clint ryan jones: aye. all right? this is clint, the oldfamous clinty. this is a friend's bedsit,as they call it. he said i could stay here for acouple of days, so i've made myself a room. [farting] lee anderson: oh, had tocome out, didn't it? clint ryan jones: i started aprogram now with methadone.

it's done me a world of good. for some people, it'llmake them worse. and then they have aheroin habit on top of a methadone habit. lee anderson: it's peoplelike clint are stupid. they think it's the answer. but it's not. interviewer (offscreen):you disagree with him? clint ryan jones: it's goingagain in a minute.

clint ryan jones: right. better out than in, isn't it? you know what i mean? because i went off the heroin,and when i get to that point when it's making me better, i'llstop using heroin, and then eventually, in a couple ofmonths, gradually come off the methadone. and i'll be a brand new, squeakyclean person again. lee anderson: withrotten teeth.

kristian evans: i've been onit since i can remember-- 14, which is the bestpart of my life. clint ryan jones: anyway,i'm just doing about my day to day thing. come on, let's go downthe shop now. kristian evans: is it? lee anderson (offscreen):come along if you want. kristian evans: hm? well, if it's all about him--he's a fucking idiot.

clint ryan jones: before i hadthe bedsit, this is where we used to go up to have a dig. "dig up" means inject yourheroin and what have you. bish, bash, bosh. lee anderson: look,there's pin tops. look, there, wherehe's standing. clint ryan jones: this is wherewe used to go for a pipe, down here. this is where we used to go.

lee anderson: we started-- we get the needles from there. kristian evans: it'sour fault why the needles are down there. lee anderson: yeah. people should clean up. kristian evans: theygive us things-- clint ryan jones: hang on, letme put this camera right now. hang on.

it's not our fault the needlesare down there. we clean up whatwe used to use. kristian evans: yeah, yeah. clint ryan jones: months ago,when i used to come here, i always used to take my doingswith me and put them in the same bin and take them backto the drug project. the dirty smackheads that arearound that leave needles about then and what have you-- we are the clean smackheads,the user.

we are users, not smackheads. whoa, watch you don't sit onany fucking needles, mate. kristian evans: i would havethought the heroin consumption-- considering that 90% of heroincomes from afghanistan, how much has come into the country,considering a our british troops-- clint ryan jones: but it'snot all about fucking afghanistan, really.

why are we using it, you know? kristian evans: yes, i know. but the documentary'sabout how there's been such an increase. clint ryan jones: yeah, butthey want to know about swansea and things-- why are we using it so much? and basically, at theend of the day-- kristian evans: well, i wasn'ttalking about that.

clint ryan jones: why? because there's boredom. kristian evans: i think thata lot of heroin addicts are using the actual, "oh, i'maddicted to heroin" to get away with the way that they'relooking, the way that they talk to people, and theactual way that they live their lifestyle. i like to think that i'veproven them all wrong. i've been a heroin addict sincei was 18 years of age,

which is nearly 10 years. yeah, i'm well known around townfor shoplifting to fund for my habit. but fingers crossed, that ifsomeone walked past me in the street, they wouldn'tthink that i was a dodgy-looking bastard-- excuse my french-- and consider me to look like atypical smackhead like you see off trainspotting, you know?

i can't see any reason why ican't turn my life around. lee anderson: [inaudible]. clint ryan jones: ok, wehaving a dig, are we? man (offscreen): yeah. clint ryan jones: positivemental attitude, as i put underneath. you know, i wake up in the bedin the morning, and i thought, i see the sign that'son the wall. so i look and i think, right.

pma, pma-- positive mental attitude. so, at the end of the day,positive mental attitude. right, what am i goingto do today? straight to the chemist--they'll have my methadone-- positive mental attitude. there's one. number two, go and scorea fucking bag. positive mental attitude,yeah?

my spelling's not toogood, though. sorry. i just want to be part of mykids and my ex-wife, you know? i just want the chanceto be a daddy, yeah? i love my babies. i said to myself, pma. i'm going to stop using any typeof drug before i get in touch with my children everagain, because it wouldn't be fair on my children if iwas to go, oh, that's

my daddy, that is. ah, but your daddy's a junkie. cornelius collins (offscreen):my old man's never been on the streets, homeless. he's just been a junkie and adrug dealer most of his life, and a burglar, and inand out of jail. he's not selling drugs at themoment or committing crime, but he's still using drugs. sean collins: pleasedon't litter or

urinate on the stairs. they want to put with that "oruse needles." that's for them to have a boot, smoke the heroinon the foil that's probably two days,between three. interviewer (offscreen): so howmany do you drink a day? sean collins: about 12 each. about 12 each, yeah. come on. come on, celine.

libby collins (offscreen): no,you can't have a joint. male speaker (offscreen):of course we can. male speaker: yeah, you can. libby collins (offscreen):where's my can, then? hang on, let me have a can. carlo: can you just get onebetween me and you? libby collins: why? dad. sean collins (offscreen):i put it on top of

there, right by you. libby collins: four cans, dad! cornelius collins:yeah, no, it is. sorry, i've picked yours up. libby collins: dad, come here. dad, just come here a sec. it's in your hand. sean collins: it's not. i just opened it.

libby collins: yeah, and you'vegot one in the fridge. come here. sean collins: no, i haven't. libby collins: yes, you have. that one in the fridgeis yours, daddy. cornelius collins: that's carlo,my sister's boyfriend. this is my sister, libby. libby collins: hi. cornelius collins (offscreen):my old man, sean.

dad's mate, darren. and my missus, amy, whoyou've met already. carlo: well, i've known her foryears, but we recently got to meet on the streets, yeah? libby collins: yeah, wemet drinking in town. carlo: in town. drinking in town. interviewer (offscreen):in the last four years, everyone's said there's been alot more heroin in swansea.

is that true? libby collins: oh, yeah. sean collins: lots of it. you've got to go backfrom the '60s. you've got to take it fromthe '60s, really. you could do chemists,and it'd be amazing. you know, it's be wooden-- male speaker (offscreen):morphine and-- sean collins: shut up.

shh. shut up. libby collins (offscreen):people of these days, they're just growing up-- carlo (offscreen): they'regrowing up around it. yeah. libby collins (offscreen):everybody's doing gear, because everybody's doing it. you know, people just don't carenow, because their mother

or their father or theirbrother or their cousin is doing it. they're all doing it. sean collins: it don't make nodifference about your mother or your father-- male speaker (offscreen):of course it do. sean collins: it's about you. it's about you. it's your brain.

libby collins (offscreen):look at kids now. 10, 20 years ago, itwas different. look at them now. sean collins: and yet my-- libby collins (offscreen):[inaudible] no, hang on. i'm not saying it's the parents'responsibility. what i'm saying is, if you'reround people doing it. if your mother and your father,your aunt and your

uncle, or anybody that's aroundyou 24/7 is on heroin, obviously, you're goingto take it. i'm not blaming youor mammy, dad. i'm just saying, i got suckedinto the wrong circle. darren: [inaudible]. sean collins: right. hang on, now. how did you get suckedinto it? i never used in front of you.

your mother never usedin front of you. cornelius collins: right. as a kid, i did catch you dosedup on the toilet with the works in your arms. shit like that. sean collins: yeah. cornelius collins:right, started smoking fags and drinking. then i went to smoking dope.

then i went to smokingdope with you. seeing you smoking dope oncei'd started smoking dope. but that's part ofit, isn't it? drink and drugs. that's the circle you're in. libby collins (offscreen): heshouldn't have been should he? cornelius collins: not now,i've got an abscess. sean collins: i know. i've never laid afinger on him.

i think once i hityou, didn't i? one time. libby collins (offscreen):don't get into this now. speak to these questions. sean collins: and thatwas in another house. amy protheroe: how long wasyou homeless for, carlo? carlo: i'm luckyat the moment. i've got a girlfriend witha flat at the moment. so god knows what's gonna happenif she kicks me out.

libby collins: well, if you werea bit nicer, you wouldn't be worrying, would you, love? cornelius collins: how manytimes have you been into detox and rehab and whatever? sean collins: detox. i've been to detox about-- cornelius collins:10, 12 times? sean collins: 10, 12 times. i didn't stay that long.

cornelius collins: my motherand father split up-- amy protheroe: ask if hismother got clean. cornelius collins: when i 13. my mother got clean. i stayed with dad. sean collins: not myfault, i said. look at her, stickingher oar in. cornelius collins: in and outof detox, rehab, whatever. libby collins (offscreen): mammyand daddy fought fucking

and got clean for 8 weeks. sean collins: it'll belike jeremy kyle now. cornelius collins:i just pissed a whole day on that one. sean collins: let me tellyou something now. she's one bitch. cornelius collins: ah, dad,give it up now, will you? don't speak abouther like that. it's not nice.

sean collins: all right,she's not a bitch. i didn't mean to insultdogs, sorry. amy protheroe: it'sa long story. sean collins: no, it's not. it's a short story. if i have a minute with my son,amy seems to think that that little bit of love in thatminute, she's losing. she won't allow us aboutfive minutes together. amy protheroe: you're thesame, though, sean.

sean collins: quiet. hurry up, because you've gotone minute now, right? [music - dunvant malevoice choir singing] sean collins: i used tobeat you when you were a little baby. libby collins: shut up, dad. sean collins: all i'msaying is the truth. she's one evil person. [all chattering]

libby collins: come on,then, sit up here. cornelius collins: cheese. it's a chaotic familyi got, isn't it? libby collins: there'llbe no chaos. excuse me, you've gota loving family. [choir singing] male speaker (offscreen): in theold days, the way to get out of a situation was boxing. if you wanted to earn a bit ofmoney, you wanted to become a

professional, you wanted toget a bit of money, people went into boxing. so it was physical. the working environmentwas more physical. now we look around, andthere's no jobs left for the kids. and, same as anything else, theywant to make a few bob. and then you've got the peoplewho've got these drugs. right, ok, go and sell these.

take them into schoolyards,where, i know from personal experience, 11 year olds havebeen given cannabis and things in schoolyards. and it comes down to an economicclimate, if you like. that person will grow up to be18, 19, perhaps meet a girl, get married-- drug problem is still there. the children see the parentswith a drug problem, and it's just a never-ending circle.

when the factories closed downand the docks closed down, and you've got the coal tippersgone from the docks. bp closed down. then the steel companycut back. and then you got all thebuilding firms that were pulling out. depression can do a lot ofthings to a lot of people. i can understand why these kidsget so depressed and turn to something like drugs,alcohol, whatever.

it's a sad indictment of oursociety that at 30 years of age, you're on therubbish heap. male speaker: it's not thatthe city was changed. it's the people that's changedit's all about derelict warehouses on the backof the strand down there, for instance. they're now about to be takenover by a lap dancing company. so, showing your knickers offin a club for a couple of quid-- that's ok, is it?

i don't think so. all i can say is only a totalidiot would pay money at the door to go in and watchcrap like that. and if i had a grandchild-- and i've got a couple ofgranddaughters, actually, well, three-- i would hammer them with that. female speaker (offscreen): thisis just basically my job at the moment, whichis really good.

it's good fun, pouring alcoholdown each other's necks, getting wet, breathingfire, stripping off. like, trying something differentand wearing really sexy, beautiful clothes. female speaker: myparents know. yeah, they thinkit's brilliant. it gives me confidence. i wasn't normally aconfident person. it's given me a worldof confidence.

i really enjoy it. female speaker (offscreen):yeah, my parents think it's awesome. my nan actually thinksit's amazing. she said if she was like 60years younger, she'd do it. but, yeah, she's abit old to do it. but they love it. female speaker (offscreen): mymum wants to come do it too. she wants to come and dancearound the poles.

female speaker (offscreen): ithink they're actually proud of the fact that we're goingout there, and we're independent females who can dothis kind of thing and just be amazingly proud of it. we have a really good time. [dog barking] male speaker: i've been livinghere for 12 years. interviewer (offscreen): yeah,and how old are you now? male speaker: 13.

interviewer (offscreen): ok. and how old are you? male speaker: 14. male speaker: prostitutesall the way down there. male speaker: in thoseflats there. male speaker: goofy as hell. they've got [inaudible]all over-- one girl, all over her teeth. she hadn't got none.

they were false. loads of boys speak abouther and that-- like loads of junkiesand all that. interviewer (offscreen): whatdo they do, the junkies? male speaker (offscreen):inject themselves on the street. male speaker (offscreen): coupleof them died the other day up there, didn't they? male speaker: yeah.

a boy, he took valium,isn't it? and he died then. male speaker (offscreen): no,i don't like the muslims. interviewer (offscreen):you don't like them. why not? male speaker: becausethey wouldn't like it if we all emigrated. they wouldn't like it if we allemigrated over to their countries, so why should theycome over to our country?

male speaker: yeah, and theycomes down here, works, gets the money, and thengoes back to their country and spends it. they don't spend it here. taha idris: when somebody hasgot no job, no income, et cetera, and you go and tellthem, have you seen the people out there, the black peopletaking our jobs? people tend to believethat sort of thing. swansea's a verypeaceful place.

you know, it has always beena very peaceful place. i've lived here for almost 40years, and i can honestly say that there has never beenany major discord. the only time i've ever seen abig protest, demonstration in swansea, where people actuallyjoined in thousands, was protesting against the killingof kala kawa karim, or anything of that nature. female speaker: hey! who is it?

who are you? taha idris: goodness me. female speaker: abdul! taha idris: why? taha idris: yeah,come on through. interviewer (offscreen):who are you? female speaker (offscreen):abdul! interviewer (offscreen):"abdul." taha idris: there we are.

that's what happens. you get used to it, honestly. you get used to it. and you start thinking, well,if there is that sort of attitudes around, you can'tdo anything about it. cornelius collins: a mosque? fuck. are you taking the piss, man? why do they want toopen another--

a wosque-- a mosque, whenthere's one opposite? there's one across the road. amy protheroe: i got arrestedfor being racist, right? but he said somethingbehind my back. cornelius collins: he calledher white trash, so she slapped him and smasheda window. he says to her, show me yourtits, and i'll give you free kebab meat. cheeky cunt, innit he?

male speaker: fuck off. all chanting: nazi scum,off our streets! male speaker: what, then? what, then? police officer: i wantyour full name. [chanting and shouting] male speaker: justcharge forward. give it some of that. male speaker: swansea'sa good town.

it's a good town. as long everybody gets on. if you don't get on, well, youcan't make it, can you? i say there's enough room inthe world for everybody, as long as somebody givessome space. cornelius collins: hey, hey. what's happening, boys? oh, a lot of old billabout, isn't it? fucking filth everywhere, man.

oh, they're doing a-- there's my old man, look! amy protheroe: there he is. that's his-- cornelius collins:mr. collins. sean collins: how's it going? how's things? cornelius collins: rememberthis one, do ya? sean collins: where's the bin?

cornelius collins: youall right, man? sean collins: well, i went tothat bnp thing, and i thought, well, it's a load of fucking-- what's going on? but we do need the jobsfor our boys. and most of them areillegal immigrants. there's no black onthe union jack. there is no white on thestars and stripes. amy protheroe: [inaudible].

cornelius collins: oy, it'd benice if we was working again, dad, wouldn't it? get him off the drugs. amy protheroe: oh, look what hebought me for my birthday. cornelius collins: i'm tryingto get back on the big issue, i am. sean collins: i don't wantthem two to get married. cornelius collins: why? sean collins: would you?

too many-- cornelius collins:we're in love. sean collins: yeah, right. sean collins: i reallydon't want my son to marry this girl. cornelius collins:come on, then. sean collins: she dragshim down, man. since he's been withher, it's like he's gone into the gutter.

she drags him down, man. i don't know why he loves her. love is blind, so they say. i don't know. and it's a sad thing. i'm really sorryfor my son now. i'm sorry for her, forwhat happened-- what she said, you know? that she was abused and that.

amy protheroe: he's notjust my boyfriend. he's my soulmate, my bestfriend, and he's the love of my life. sean collins: i loves him. he loves me. amy protheroe: iloves him, too. sean, why don't weget on, darling? sean collins: whatdo you reckon? amy protheroe: wedo and we don't.

sean collins: you'rea bitch, man. cornelius collins: shutit, you, you cunt. sean collins: well,you asked me why. i'm telling the truth. you are a bitch. eh? you are a bitch, you know. interviewer (offscreen): hepulled your hair out? amy protheroe: yeah.

and he smashed the phone up. sean collins (offsreen):i did, yes. i shouldn't have, but i did. i am very sorry. you know that, don't you? cornelius collins:the collins clan. the collins clan. clint ryan jones: hello. how are you?

interviewer (offscreen):how are you? clint ryan jones: allright, thank you. interviewer (offscreen):good to see you. clint ryan jones:i've cleaned up. i'm clean. interviewer (offscreen):you are? clint ryan jones:yeah, i'm clean. i've sorted my head out sincethe last time you've seen me. i went on a detox.

and then, that didn'twork for me. i relapsed. and then they put me ona methadone program. ah, that's better, isn't it? i've come a long way since youlast seen me, you know? interviewer (offscreen): yeah. clint ryan jones: it's nice tosee you fellows, anyway. you too, man. you too.

positive mental attitude. clint ryan jones: yeah. pma. clint ryan jones:it does work. clint ryan jones (offscreen):i've really improved and things. i'm much happier. like, i want to go back tocollege and study social-- is it care?

i'm saving up now for mydaughter, for when i get to see her, to give her a loadof presents and things. because i don't want to bedependent on methadone. no, no way. liquid handcuffs,they call it. that's what they call it--liquid handcuffs, because you've got to stay in the areato take that liquid every day to stop you from being ill. it's impossible.

it's every other door aroundhere is selling it. or if they haven't got it, youknow, it's only down around the corner have got it. you know, it's easy to geta hold of-- so easy to get a hold of. it is. it's getting really worse. it's getting terrible. because of the demand?

clint ryan jones: well, it'snot so much as that. it's the money that's beingmade off it, you know? people are making thousandsupon thousands of pounds off it. i'm ashamed to say iused to sell it. i used to make, easy,1,500 pounds a day. and i'd still be livinglike a scruff. i'd do a snowball,as they call it-- mix heroin with crack andhave one hell of a

fantastic head on. but you've still got to wakeup to the same shit the following day, you know? i've turned my life aroundnow, and i've sorted myself out. and i wouldn't dare touchanother bag of it in my life. cornelius collins: hey, cat. guess what we done yesterday? interviewer (offscreen): whathappened yesterday?

cornelius collins: lostour fucking money. amy gets paid on a wednesday. i get paid on thursday. she's coming. said she had the car. there she is. she's crying. cornelius collins: amy, wouldyou be nice and not hit me? you poured cider allover my hair, man.

cornelius collins: what? why? amy, why? because you fucking-- amy protheroe: youfucked my mother. cornelius collins: i didn'tfuck your mother. amy. amy protheroe: i'm homeless. look what you've done.

cornelius collins: lookwhat i've done. hold on. right, amy? it's either do that, right,or hit you back? what do you want me to do? do you want a punch? or do you want a fuckingdribble of cider chucked at you? i'm not having it, amy.

amy, your mother and fogeyyesterday, right, told me and you you're lucky i haven'tfucking hit you. that's what they said. you're lucky you haven'thad a fucking hiding. do you know if you weren'tmy girlfriend-- cornelius collins: amy,fuck off, right? amy protheroe: he's alwaysabandoning me. i've fucked my own mother. her lips are long, man.

don't they sag down a bit? cornelius collins (offscreen):i know you've fucked your own mother, amy. you've told me, man. amy protheroe: don't theysag down a bit? cornelius collins: fuck off. you knows i wouldn'tshag your mother. would you risk shagging yourgirlfriend's mother when your girlfriend's on the settee,you're out in the kitchen

looking for cider with yourgirlfriend's mother. and her boyfriend-- no, her mother's boyfriend--is upstairs, who's fucking loopy, who's been to jail forkidnapping and smashing people's toes off. and he's fucking psychoto the max. would you risk shagginghis missus downstairs while he's upstairs? would you?

interviewer (offscreen):i wouldn't. cornelius collins:would you, adam? interviewer (offscreen):mm-mm. cornelius collins: would do? interviewer (offscreen): no. cornelius collins:so fuck you. i wouldn't neither. you knows i don'tlike violence. you knows i don'tlike fighting.

so am i gonna risk havingmy fucking hand chopped off with an axe? cornelius collins:not my problem. i'll give you one glassand that's it. i'm not having you takea piss ut of me. telling me i shagged yourfucking mother. how are you so insecure? amy protheroe: corneil, i paidthe money [inaudible]. cornelius collins: why don'tyou go do a punter?

quicker than begging,isn't it? amy protheroe: i hadto beg for the 17 pounds my mother robbed. and i'm only allowedto have one. can i have the cider? it's just gonna make me ill. cornelius collins: fuckingfill your glass up, and shut up. you're being dopey.

cornelius collins: oh, wellfuck off then, if you're gonna go. i just don't know whyyou're being nasty. amy protheroe: fillit up, will you? fuck's sake. cornelius collins: look atthe way you're talking. get off my-- hey. kick my glass on the floor. get all dirt all over it.

thanks. i'm in agony, right? yesterday, she punched me fourtimes in the bollocks. and she's fucked my other--she's fucked my only decent bollock up. one's fucked already from 11years ago, as she knows, and she's gonna fucking punchme four times. and i've got a pain in mystomach at the moment. my bollocks are fuckingkilling.

amy protheroe (offscreen):you're fucking lying. cornelius collins: i'm lying? did you know i had a fuckingdodgy bollock, then? cornelius collins: was is muchbigger than the other one? amy protheroe (offscreen):don't know. you don't know. amy protheroe: why can'tyou give me some cider? cornelius collins (offsreen):i just gave you a glass. amy protheroe: i want youto give me some more.

cornelius collins: all right,[inaudible], huh? are you going toknock it over? cornelius collins(offsreen): amy. cornelius collins: what amy protheroe (offscreen):[inaudible] cornelius collins: oh, phwor. poor little amy. lee dennis (offscreen): i feela lot better in myself. i mean i've been cleannow a good few weeks.

there's a few boys on thebikes by here, look. [engines revving] lee dennis (offscreen):little kids, eh? some mad times we used tohave up here as kids-- setting cars on fire. good boy. the rabbits and the hares andthat-- many times we'd come up here, early hours of themorning, and you could see eyes running everywhere.

we used to try to chasing themin a stolen car and try killing them and stuffyou know what i mean? off our face, drunk and stuff,you know what i mean? many times, the farmer used tocome out with his rice gun and shoot us with his rice-- rice cartridges. and they used to sting likehell, especially if they catch you on the arse, like. you know, i wish i'd stuck withthe old crowd, instead of

all the heroin usersand stuff. years ago, i could count a goodfew friends on my hand. but now, they disowned me, typeof thing, for the heroin. if i'd known how bad heroin was,i wouldn't have tried it. it's a bad drug. it' a dirty drug. but it's a nice drug as well. it's a nice feeling off it. now, i wake up in the morning, igo down to get my methadone,

i drink my methadone, and i tryto keep myself occupied then by going over to mysister's or my mum's that i made when i was inprison before. interviewer (offscreen):you did? lee dennis: yeah, gypsy caravanout of matches. nodding head-- when i put my reggae on, hishead rocks back and forth. drug testing kit that i done yesterday, which is a negative.

they test you for heroinand crack cocaine. and there's two lines-- negative. now i just want to be normalnow, try and get myself a decent job. interviewer (offscreen):when you look back on it, how do you feel? lee dennis: tell youthe truth, man, i think i'm an asshole.

put my family through somuch shit and trouble. many a times, i said i've loveto move away and that, but really, i won't. it's my hometown, and all myfamily are in swansea. i don't think i'veever move away. amy protheroe: if i didn't havecorneil, i think i would have killed myself by now. he's what keeps me going. you're my rock, aren't you?

cornelius collins: oh, baby. amy protheroe: he's my rock. well, we loves each otherto bits, don't we? cornelius collins:we do, yeah. cornelius collins: welove each other. amy protheroe: we're engaged. he got me an engagementring for my 18th birthday, remember? cornelius collins: just founda bottle of wine.

that is when i had student ofthe year award in swansea college, tychoch college, fornvq level 1 business studies. or was it level 2? i can't remember now. level 2, i think it was. no, gnvq foundation level 1. and i look like igot lipstick on. amy protheroe: he done acatering course, business studies course.

cornelius collins:what's that say? amy protheroe: haveyou got fucking lip balm on or something? cornelius collins: don't i looklike i got lipstick on? i look weird, don't i, man? amy protheroe: i love you. see, look at that. look at all that-- all stale blood.

cornelius collins: seethis bit here? that was all up the wall. it was a shit hole. amy protheroe: lookat my pillow case. there's blood on it. he got me all of my shampoos. these shampoos-- he didn'tget me cheap ones. he got me that. he got me perfume.

cornelius collins:do you like that? from next, but i didn't actuallyhave it in next. it was three or four quid inone of the charity shops. amy protheroe: hebought me that. i haven't worn it yet. look, al the tagsare still on it. cornelius collins (offscreen):knickers amy protheroe: my pajama set-- my minnie mouse.

i'd love to be pretty. cornelius collins (offscreen):you are pretty. amy protheroe: me? i looks like a fucking dog. cornelius collins (offscreen):shut up, twat. amy protheroe: i'm fat. look at the size of me. look how fat i am. cornelius collins: she'snot fat, is she?

amy protheroe: aren't i fat? my ass is huge. cornelius collins: you'remore of a twat than fat. turn around and showthem your feet. cornelius collins: no, idon't want to do that. amy protheroe: don'tbe a big baby. turn around. if you love me, you will. cornelius collins: stop it.

look, look. they're not well, are they? lift your foot up. cornelius collins: no way. stop it, man. it's embarrassing. amy protheroe: please. cornelius collins: the red'sburning right there. it's all burning.

amy protheroe (offscreen):he's been crying. every time he walks, it's likehe's just been bum raped. cornelius collins: it'scalled trench foot. they used to get in the war. yeah, i bought the trainers. was it me that boughtthe trainers? cornelius collins: she wokeup, and somebody had taken them off her fuckingfeet, man. amy protheroe: mylittle zebra.

what's he do now? how do you do it? [cowboy-like shoutingfrom toy] cornelius collins (offscreen):woohoo. amy protheroe: my mothersent me to live with this bloke, right? he was 31 and i was 13. he used to make me sleep withhis friends and that. they used to know whatwas going on.

they used to watchhim beat me up. and they used to watchhim send me to the bedroom with other men. and my mother did nothing,because he used to give her 50 pounds' worth of heroinfor free. i had to have sex withmy mother and her partner as well. so it hasn't been a reallygood life, but-- it's tough, isn't it?

cornelius collins (offscreen):let's talk about something else, amy. amy protheroe: the first timehis father ever hit me, his father misplaced 20 pounds. and we didn't have it. i had my maternity grant. i was six months pregnant. his father threw me on thefloor, ripped my hair out, slapped me in the face, spat onmy face, and within three

weeks, the baby died. [music - dunvant malevoice choir singing "si hei lwli mabi"] female speaker (offscreen):are you ready, boys? clint ryan jones: this is theone now, "don't do drugs." some of my friendssang some of it. female singer (offscreen): i wassitting on a log and along came a frog. he said, do you wantto smoke some pot?

i said, i'd rather not. he said he slung hash, comeon and give me your cash. you mean you want my money? you must be tryingto be funny. i don't do drugs. clint ryan jones: i relapseda fortnight ago. so i went to put a needlein, and i missed. and it went in to an abscess. i've lost my wife,my three kids.

now, all i want in life is tobe a family and to be loved. i've never been loved. i've never had a mother orfather that loved me. basically, i was abused. instead of having a cutch,i'd be fucking punched around, you know? but i am going to be the bestdaddy going when i get to the stage i can say, fuck it. i don't want no more.

that was me demonstrating on thevery last fucking bag i'll ever do in my wholeentire life. i missed a bit. but there's the fucking hole itleft me with, which isn't a fucking pleasurable sight,as you can see. mums, dads, don't turn yourback on your children. always be there. give them plenty of loveand attention. once chance you haveof living.

don't blow it. that's all for now. nice one. clint ryan jones. thank you. clint ryan jones: clean andserene for 30 days. clean and serenefor six months. interviewer (offscreen):how did you get the six months one?

clint ryan jones: because iwas clean for six months. interviewer (offscreen): when? clint ryan jones: when wasi clean for six months? no, three months iwas clean for. they gave me thewrong keyring. [music - dunvant malevoice choir]

inhaled corticosteroids names

inhaled corticosteroids names

hello, i'm norman swan. welcome to this programon breathlessness in the older adult, asking the question, 'is it asthma?' we're coming to you liveacross australia through the rural health educationfoundation's satellite network. some older people think that breathlessness isa natural consequence of ageing, unaware that's not the case, even though the prevalence of asthma

and chronic obstructivepulmonary disease, copd, both increase with age. in this program, we'll talk about the differentialdiagnosis of breathlessness, with special referenceto asthma and copd. the distinction between asthmaand copd is important, even when they coexist,as there are significant differences in the care of peoplewith each condition. as always,we have a number of useful resources

on the rural health educationfoundation's website - as usual, the broadcast is interactive, and we want your phone calls and faxeswhen you want to ask a question. you can even drop us an email. we've already had one question inahead of time. we look forward to yours. the numbers to call in on are - fax numbers - or you can drop us an email,

and somebody will be hangingon the computer, waiting for it - now let's meet our panel. christine mcdonald is deputy directorof the austin hospital's department of respiratory and sleep medicine, and a director of the institutefor breathing and sleep medicine at the same institution. - welcome, christine.- thanks very much. as a clinician/researcher, christine'sspecial research interests include airways diseases, asthma, copdand lung cancer.

she's a member of the australianlung foundation's copd executive. gary kilovis a solo general practitioner, currently practising in clarinda,in melbourne, with over 25 years' experience in bothmetropolitan and regional practice. - welcome, gary.- thank you. toni riley is a community pharmacistwith 30 years' experience, currently practisingin bendigo, victoria. a victorian evening this evening. - welcome, toni.- thank you.

toni has a major focus in her pharmacy as a provision of pharmacy servicesto residential care facilities, and is also on the national asthmacouncil pharmacist asthma group. last but not least, vanessa mcdonald, who's a respiratory and sleep-medicineclinical nurse/consultant with hunter new england healthin newcastle in new south wales and has 15 years' experiencein asthma and respiratory education. - welcome, vanessa.- thanks, norman. vanessa's current phd studies

are in obstructive-airways diseasein older people. sounds like her special intereststonight are in mastermind. we'll sit back and have a spotlightgoing on you all. welcome to you all. what are the major issues from a general practice point of view,gary? we see a number of patients who maypresent with shortness of breath or some respiratory symptom. the issue is really to try and tease outthe potential causes, the differential diagnosis,

and then to stratify those in terms of potential seriousnessand potential urgency. - a common walk-in, though, isn't it?- it is indeed. it may often be evenan incidental finding, when somebodypresents with something else. they may present withan upper respiratory tract infection, and when one delves a bit deeperinto the history, they may explain that they routinelyneed several courses of antibiotics, they get more frequent infectionsthan other people.

it's somethingthat we can then explore further. do you ever get a surprise diagnosiswhen you go through the differential? we do. we do indeed. and i think,particularly with the older patient, because the existence often of multiplediagnosis, multiple pathology, even if one is fairly certain aboutone's diagnosis, one has to be vigilant not to miss something else. by the time you get tothe back of the pharmacy, a few must be breathless, toni? you're probably correct.

norman: your head's buried in thecomputer screen. you wouldn't know. no, not at all. the reality is we do get the oddbreathless patient in the pharmacy that perhaps hasn't been to the doctorat that stage. it would be our normal procedure to endeavour to make sure that personwas seen by the doctor. we might even ring the doctor firstand ensure that that was facilitated. if it was urgent, obviously,we'd be calling an ambulance... what are the common medication issues?

as in drug interaction-type things,you're thinking along the lines? we need to be very careful aboutbeta-blockers and people with asthma - not only beta-blockers treatingcardiovascular conditions but beta-blockersthey're using in eye drops. oftentimes, ophthalmologists don'tget to know the rest of their condition. they may not know this isa contraindication for this person. there is another part of the bodythan the eye. there is, yes, yes. vanessa, you'd imagine these days,when smoking rates,

particularly in the over-50s,are incredibly low, that the problems of copd, et ceteraand asthma must be disappearing. we're certainly seeing a decreasingtrend in asthma admissions into the acute setting. however, we're not seeingthe same trend with copd admissions. the prevalence of asthma and copdin this country and internationally is in fact increasing. - really?- mm-hm. christine,why aren't the rates going down?

in copd, we're seeing peoplein the older age group who started off as a cohortwho might have been smokers. we're still seeing the effectsof the smoking down the track. in terms of asthma and copdin the older age group, as we're here to talk about tonight, it can be difficult to tease outone from the other, particularly if they have been smokers. although smoking rates are going down,smoking rates among asthmatics are not dissimilarfrom the rest of the community.

it's still around 17% to 20%. that's why we're still seeing peopleadmitted to hospital with copd, and asthma in the older age group - because, probably,many of them have coexistent disease. i understand that asthma deathsthese days are in the older age group? yes, they are. again, part of that may bethat they're copd patients, partly to do with the fact that we're underdiagnosing asthmain the elderly population.

why is that? possibly not thinking of it as much. in fact, there's data to suggest that - that patients who are oldermay not be tested, or diagnosis may not be thought ofas much as in a younger person. there's also male-female discrepancy. if you see a woman presenting withbreathlessness, you're more likely to think of asthma. if you see an older man,you're more likely to think of copd.

whereas that doesn't always follow. there's a burdenof undiagnosed copd? undoubtedly there is, yes. have people done the epidemiologyof a mixed picture, even if you add incoronary heart disease? not very well, norman. that hasn't been done very well. a lot of the epidemiology, the asthmaprevalence and the copd prevalence, there's probably an interactionbetween the two.

there have been paperslooking at the number of patients who are co-diagnosedwith both asthma and copd. this is quite high. patients themselves will say,'one doctor told me i had asthma, the other one said i had emphysema.what have i got?' often it is difficult to tease that out.they may have both. is there an inordinate focus on theheart, being a respiratory condition? yes, i do think so. as hospital specialists, of course,we see the patients,

they've normally had the investigationsfor the cardiac disease. so they've had their echocardiogram,they've had their ecg. then someone thinks, maybethey should have a breathing test. and the penny drops. do you find that as well, vanessa? yes. in fact, the prevalenceof this overlap and this mixed disease is being increasingly recognised. there was a paper this month in thoraxfrom a group in new zealand that studied a large group of peoplewith airways disease.

they found that only 19% could bedefinitively defined as copd alone. the rest of the populationhad some kind of overlap, whether it be asthma and copd or whether that be chronic bronchitis,emphysema or some other mix. which, gary,must complicate management? absolutely.i know this is a respiratory evening, but as a gp, i am perhaps defendingthe cardiac perspective a little bit. we're holistic here. we can cope. cardiovascular death still - despiteall the advances that have occurred -

it still takes the lion's shareof mortality. there is a mindset among gps that if there is a possibilityof this being cardiac, that's going to be the focus. to some extent, as you mentioned,we don't think about copd enough. the risk factors, or the pathogenesis,of some of these conditions overlap. once the gp has perhaps excludedwhat they perceive might be a cause of sudden deathor of much greater urgency, sometimes the drive to continueto explore the causes is lessened.

hopefully this evening,we can change that a little bit. let's try. we've got a few case studies.let's take a look at our first one. max is a 65-year-old man,new to your surgery, gary. he comes in complaining of increasingbreathlessness with some activities. he's finding it hardergoing to the shops, climbing stairs, walking any distance. he's not too worried. he sayshe's not as young as he used to be. what's your approach to max?

this is a fairly common scenario - a patient who presentsnew to the practice. they may have moved into the areaor their gp may have retired. they'll often minimise the symptoms because they've been coming on over...sometimes decades. they'll attribute it to ageing,to perhaps putting on a little weight or giving up the golf. because it's insidious, people are able to adjust remarkablywell to their declining lung function.

from the gp's perspective,you have undifferentiated disease. we're looking broadly, i suppose, atcardiac causes, respiratory causes, and of coursethere's an overlap of both. then of course there are thenon-cardiac, non-respiratory causes, such as perhaps anaemia, even anxiety. we are seeing more of our patientsbecoming obese and deconditioned. it can be difficult to tease out on the basis of the limited informationwe have at present. anything to add tothe differential diagnosis, christine?

just thinking of thyroid disease.there's a bit of a differential. in terms of respiratory diseases, there are other respiratory diseases,such as pulmonary fibrosis. i mean, much rarer. but, again, in terms of yourdifferential with cardiac diseases - with crackles, for example. if you go into max's history, he's had a run ofupper respiratory infections, but he tells youhe was always a chesty child.

he does talk aboutwheezing and coughing, particularly on exercisefirst thing in the morning. he is mildly obese, with a bmi of 30. he's taking half an aspirin a dayon the advice of his last doctor and atorvastatin, 20mg daily. between the ages of 17 and 50he smoked a pack a day, and he saysthat he's now an ex-smoker. he tells you that his last doctordid an ultrasound of his heart, but he's never had a lung test.

what are you going to do for him now? this focuses our attention now moreon the respiratory side. he's had someof the cardiological investigations, though there's certainly room for more. the previous gp would haveexcluded things like heart failure, but there could still besilent ischaemia. we would like to do other investigationslooking at anaemia and we would like to do spirometry. anybody who presentswith any respiratory symptom

should have spirometry. max would be a candidate for that. and a chest x-ray looking for a tumour? yes, a chest x-ray as well. is it going to take much elseother than a tumour, christine, a reason for an x-rayin a man like this? if you see a major degreeof hyperinflation, you could be thinking asthma or copd. you'd be looking for cardiac signs,as you say.

but tumour, and pulmonary fibrosis, but on examinationyou would have found some crackles. this is presuming we would have skippedover examination. - you have laid a hand on him, gary?- absolutely. assuming there's not much to find. gary, what's your view of the roleof spirometry in general practice? i think spirometry is very important. in a situation like this, it can give usan enormous amount of information, and can possibly obviate the need

for more complicated and expensiveinvestigations. it's an effective wayof picking up obstructive lung disease. we can also pick up restriction, which,as christine said, is less common. it will also help us in terms ofdefining the severity of the disease, if there is any. it's a good baseline to determinethe response of medication. if there's an improvement, we can also track the progressionof the disease as well. spirometryis an absolutely essential part

of any respiratory historyand examination. an essential part of general practice. some people have argued that if you'vegot a stethoscope in general practice, you should have a spirometer. diagnosing respiratory diseasewithout doing it with spirometry is a bit like managing diabeteswithout looking at the blood sugar as far as i'm concerned,but i am a respiratory physician. we need to be doing it morein general practice. what are you looking foron the spirometry, christine,

to differentiate between asthmaor copd in someone like max? we're looking for airflow obstructionto diagnose either of them. in asthma there's variability andreversibility of airflow obstruction. in most patients,that reversibility is complete. post-bronchodilator,you'll get normal spirometry. in copd, by its definition, you have an irreversible or poorlyreversible degree of airflow obstruction and post-bronchodilator spirometry will still showa persisting obstructive defect.

vanessa, what would be the issues,if you're thinking ahead and dealing with max, in terms ofself-management and other things, you'd want to be preparingyourself or him for? with max, despite whetherthis might be asthma or copd, it will be a new diagnosis. he's going to need to understandthe process of the disease and how it's managed in terms ofthe actions of these medications, the side effects that might happenand how they're delivered - most likelythey'll be inhaled medications.

that would be the first thingsto deal with with max. he has been a past smoker,so we'd need to revisit whether or not he is currently smokingor has been smoking recently. just because someonegave up previously doesn't meanthey're still a current smoker. whether max is diagnosed with asthmaor copd, we'd need to look at whether or not he needsexercise rehabilitation. as gary said, he's deconditioned,he's overweight. that would be an effective formof treatment for him

with his decreased lung function, that's if he has decreased lungfunction, after we do the spirometry. the final thing would be developingsome kind of management plan with him so that he knows what to doshould his symptoms deteriorate. christine, is there any evidencethat reducing weight improves respiratory symptomsin asthma or copd? there is limited evidence, norman,that that is the case, yes. but it's very difficultto get people to lose weight, so the studies are difficult to do.

we know from the sleep apnoea world,whenever we try and do such studies, the majority of patientsdon't lose the weight. but i would agreethat an exercise program and a weight-reduction program would be an important partof this man's management. although often with copd,you're thin rather than fat. toni: oftentimes. that used to be the case, although we're finding now,with the obesity epidemic...

you're getting the same paradoxyou get with heart failure - you're more likely to get heart failureif you're obese, but once you're obese,you're more likely to survive it. certainly in copdthere is that obesity paradox, in that if you're obeseyou're protected against mortality. many studies have shown that. it's difficult to know what to doin that situation, i suppose. is there much difference insymptomatology between, say, somebody in their 30s or 40sversus max, in his late 60s?

- in terms of...- asthma. copd, you're not going to expectin the younger person. but asthma? if the person is younger, it's usually more clear-cutthat they have asthma. but the symptoms will be the same. in this instance, the patient'smain symptom is breathlessness. in the younger age group, certainlyteens and children and younger adults, we'll probably see wheezemore frequently rather than the insidious onsetof breathlessness.

it's the older patient whoattributes this to the ageing process that we see commonly, whereas younger peoplewould be usually more energetic, doing more exercise,and this is not normal, so they'll go along perhaps earlier. gary, let's assume for a momentthat max is pure copd, the 1 in 5, the 20% who have got copdrather than the mixed picture. how would you manage him? it would be important to quantifythe degree of obstruction.

that would determinethe choice of medication. say if he had mild copd,we may find that simple prn use of a short-acting bronchodilatormay be enough. even if there's not much reversibility? yes. it has been shown to improveexercise tolerance and quality of life. if he was a little more severe, we mightadd a long-acting bronchodilator such as tiotropium. if it was getting into the more moderateto severe level, we might then add inhaled steroids

and perhaps a long-acting beta-agonistcombination. and the role of antibiotics? the role of antibiotics is importantin intercurrent infection. it can be difficult thoughto differentiate between... norman: an acute exacerbation.- yeah, and also viral versus bacterial. even with a viral infection,they may cough up discoloured sputum. we do know thatuntreated intercurrent infection does in fact further damage the lungs. so early and aggressiveappropriate management

is important with antibiotics. anything to add or change, christine? on the antibiotic question, depending onhow much sputum this man has, another differentialwe haven't discussed is bronchiectasis. quite a large number of patientswith copd, when you go to do hrcts,may have bronchiectasis. that's muddying the water, butwe haven't mentioned it, and we should. norman: if it was bronchiectasis,a chest physio? chest physiotherapy would be posturingand flutter valves

and, again, prompt use of antibioticsfor infections. would you change anythingto gary's management? no, i don't think so. vanessa has mentionedthe pulmonary rehabilitation, but i think that's really importantto emphasise. in this manand in all patients with copd, pulmonary rehabilitationis level-1 evidence to support its use in terms of improvement inexercise capacity and quality of life, and potentially also some reductionin hospital admissions.

as far as my understandingthrough the lung foundation's work, about 2% of patients with copdin australia has access to pulmonary rehab,so it's really inadequate. and i guess the message should be that there's a toolkit available onthe australia lung foundation website. people who are interestedcan go to that. in the rural community, we need to bethinking about setting up groups to assist these patients, as well as... it's easy in melbourne or sydney.

vanessa? absolutely. i agree. the access that people have to rehabis appalling, really, when you look at the population. is this the sort of stuff a local physioor ot could get involved with? it's not complicated,it's just doing it. absolutely. pulmonary rehabilitationprograms that combine exercise together with self-management are those that have been shownto be the most effective.

doing that in the local community centreis easy enough to do if you've got the resources. adherence is pretty important, toni? absolutely.from the pharmacist's perspective, understanding what disease this patientactually has is important. oftentimes we're not privywith that diagnosis. that makes it difficult for pharmacists. going through the adherence programwith the patient, making sure they knowhow to use their devices,

and understanding why andwhat they're doing is really important. we probably see themmore than anyone else does, so it's an opportunity. a question from a general practitionerin rural victoria to you, gary - what would be the recommended antibioticfor acute exacerbations? i'd probably look at a combinationof amoxicillin and clavulanic acid. we know that there's an increasingincidence of atypical organisms, so one may consider macrolide as wellif the initial response isn't adequate, or sometimes in combination.

do you agree with that, toni? it's certainly what we see in practice. norman: that's a diplomatic answer. it's an honest answer. the thing we see a lot in practicewith older patients being put on those groups of antibioticsis the resultant diarrhoea, which is a bit of an issue. you've got the compliance problem,so what happens next? maybe they stop taking the antibioticsand don't tell anybody,

or maybe they do stop taking theantibiotics and get something else. that is an issuewe see quite frequently. christine, the antibiotic question? i suspect gary's thinking about thatthey may have a patch of pneumonia. that combination of therapy would bevery appropriate in that situation. if it's a simple bronchitic illness, some rulide or some amoxicillinmight be enough. a question from a gp in queensland asks, how often would you repeat respirometry

in somebody with, say, copd to look at whether or notyou're maintaining or declining? there's no level-1 evidence for that. this is really level 4. norman: in your opinion. expert opinion, yes. i would be repeating it firstlyin terms of a trial of medication in someone that i might suspecthas coexistent asthma, where i'm expecting to seea significant improvement.

otherwise, probably if the patientis not doing well and the breathlessness is deterioratingdespite my best attempts, to see whether there's any significantchange in spirometric indices. in fact though,spirometry doesn't correlate very well with level of dyspnoeain copd in general. oftentimes,an mrc breathlessness score or a quality-of-life score might bemore useful to monitor the patient. a gp in south australia asks - you think there's coexistingcoronary heart disease.

you want to do a stress test to see ifyou can elicit significant ischaemia, but there's copd as well. how do you get through all thatto not muddy the stress test? you're often usinga dobutamine stress test or something, because you can't exercise the patientenough. what we do in our hospital is a combinedcardio-pulmonary exercise test, where we use a cycle ergometer. we've got cardiac response,we're looking at ecg,

we can also look atwhat's happening to ventilation. that can give a nice pictureof the lungs and heart. - it's a specialist thing?- yeah. in terms of a stress test, dobutaminestress tests are the way to go if the patient cannot exert themselves. do you want to comment, gary? i agree, absolutely. let's go to our next case study,and keep those questions coming in. andrew is 55 years old.he presents with breathlessness.

there's no history of asthma, buthe's been a smoker for 41 pack years. let's have a look at his baseline pulmonary function test. do you want to walk us through these? christine: sure. firstly, on the left-hand side - i'm sure many of you are familiar with spirometric indices, but just to go through them -

the forced expiratory volume in one second. the forced vital capacity - the amount of air you can take in and fully breathe out. the vital capacity, done not as a forced manoeuvre but a slow manoeuvre. the forced expiratory ratio - the ratio

of the forced expiratory volume over vital capacity. in this case, we've also got a measure of gas-exchange capacity, the tlco, or carbon monoxide-diffusing capacity. he's got severe airflow obstruction. he's got an fev1 of less than a litre, 25% i think it is, of predicted. there's an improvement

post-bronchodilator, so it's post-mdi, probably salbutamol, i imagine. he's left with a significant, persisting, obstructive ventilatory defect, even post-bronchodilator. so looking like copd, particularly with that gas-exchange abnormality, but still could be asthma.

there's a 27% improvement in fev1 post-bronchodilator - only a couple of hundred mils, right on the borderline. you'd be thinking about copd. what would you do for him, gary? as christine has mentioned, you're trying to tease outwhether this is copd or asthma or probably a combination of both,

given that there has beena reasonable amount of reversibility. i would look at a steroid challenge,either oral steroid, perhaps prednisolone,25mg a day for four weeks, or inhaled steroids. to some extent,the choice would depend on how symptomatic the patient is. i would then repeat the spirometry and see whether we were able to achievesignificant improvement. what would you do, christine?

exactly the same thing. oral steroids or inhaled? you know what? i know this patient. i know that i gave him oral steroids. this patient was really quite unwell. i take gary's pointthat in a particularly unwell person, probably oral,to get that response quickly. let's see what his pulmonary functiontests were after three weeks. christine?

i'm delighted to say that there's been a significant improvement in the fev1. remembering that it was under a litre in the previous table,and now 2.4 litres, which is 68% of predicted normal. so a significant improvementin baseline ventilatory function, with a forced-expiratory ratiopost-bronchodilator now of 66%. he still has a persisting degree of airflow obstruction,but really an asthmatic-type response,

i would say,to this course of prednisolone. norman: it's a mixed picture? it's a mixed picturein that he still has a persisting degreeof airflow obstruction even after our maximum treatment. gary, how are you going to manage him,going forward? he's on oral steroids.you got a good response. he's ready to run a marathon -a very limited one, given his copd. i would certainly look to transfer himonto inhaled steroids,

probably in combinationwith a long-acting beta-agonist. this fella has quite significant asthma. he's probably got either remodellingfrom undertreated or untreated asthma, but he's also of course a smoker,so he's got the double whammy. norman: how are you going toget him off his smoking? oh, i wish i knew the answer. one of the things that i find works is really to show him the resultof his spirometry. i find that quite powerful

because you can show the patientwhat they achieved - this is the best that you could do,this is what you should be doing, this is as a result of your smoking. there's randomisedcontrol-trial evidence to suggest that telling them their lung agemakes a difference to motivating them. quite a number of spirometers nowinclude that as an option in the print-out. norman: you've got85-year-old lungs, andrew. yes. this is one of the rare situationswhere we can wind time backwards.

we can get your lungs younger. we can't often offer that. toni, what are the pbs issues herein terms of andrew moving forward, given this transition? given the transition, initially,andrew's going to need to try a plain, inhaled steroidbefore he can go on. that needs to be successful before the beta-agonist can be added into a combination. initially he could be havingtwo inhalers.

norman: a short-acting reliever? plus steroid.you know, your inhaled steroid. and the dose of steroid? it would probably be the 250mcg-typedose, i should think, i would imagine. i'd have to defer to myrespiratory physician and gp, of course. well, probably he'd be starting higherat that stage, wouldn't he, because he's been on his oral. so it does depend a biton what the physicians are feeling. from the pharmacist's perspective,there's a lot of other issues

around complianceand understanding the disease stage and the willingness to treat. especially in a younger person, the willingness to treatand accept that that's essential is often the challenge that we're faced, and i should imagine peoplelike vanessa deal with every single day. what about the dosageof corticosteroids, because we're still going too high. it's high. it's difficult, isn't it?

if he's purely got asthma, we've certainly moved awayfrom those very high doses that were used to be usedsort of a decade or so ago. on the other hand,if we think he has copd and we know he's got someirreversible airflow obstruction... it's a moot point, isn't it, whetherit's the remodelling you talked about or whether it truly is the copd. you'll be aware that the studiesthat have been done on copd have used higher doses,fixed doses of inhaled corticosteroid

and long-acting beta-agonistof 1,000mcg in the large studies, such as the torch study, and800mcg of budesonide in studies by... that might have been engineered by the pharmaceutical companyto flog more drugs. indeed so, but the trouble is,we have those studies and we don't have the studiesof the lower doses in copd. in asthma, we know we can use quite lowdoses of inhaled corticosteroids and that there's a plateau effect. norman: are you hamstrung by the pbsrules if you've got copd and asthma?

- um...toni: not necessarily. no. so, but the temptation... i'm trying toget the picture of the mixed picture and how that changes your management. with titration of dose, followingthe national asthma guidelines, the asthma action plans and so on, it's fairly straightforwardhow you teeter up, teeter down. but with copd, teetering down, titratingdown, might be more of an issue. that's right.thinking about this particular man,

i'd be treating him fairly aggressivelyfor his asthma and i'd probably be wantingto back-titrate. if, however, he was a different patient,with severe copd, having recurrent exacerbations, i'd probably be sticking him oncombination therapy, leaving him on that, and getting benefitin terms of quality of life and hopefully reductionsin exacerbation. those are the differences. you don't back-titrate with copd

if you're aiming at reducing hospitaladmissions in that severe group. this man... he started off severe,but we've converted him to moderate. would you expect that spirometryto change much in a month's time? well, not if he's got copd. if he's truly got asthma, we may seesome further benefit, i suppose. as i know the patient, i shouldknow that, but i can't remember. i think his airflow obstructionstayed fairly fixed, so i truly did believehe had two diseases. what would you do for him, vanessa?

there's a range of different thingsthat andrew needs. firstly, one of the best treatments for someone with copd,or asthma for that matter, is to get him to stop smoking. we need to build a partnership with him in terms of getting himto see the things that he needs to do in order to change his behaviour. in terms of his smoking cessation,we'd need to do counselling, but also offer some pharmacotherapy,

either usingnicotine-replacement therapy or some varenicline if necessary, and make a commitmentto continue to see him in terms of his smoking cessationto provide some support. and do referrals to other support lines,such as the quitline, et cetera. but again, with andrew,this is a new diagnosis. he's come in. he's got a new diagnosis.he's been told to stop smoking. he's been givena couple of new devices. he needs to make somesubstantial changes to his behaviour.

he needs to understand why, and how these treatmentsare going to work for him and what he will get out of it. we talked briefly about ways of gettinghim to consider stopping smoking. but he's only 55. if he can see the advanceshe'll get from stopping smoking now, then that might give him some keysto change his smoking behaviour. the fletcher-peto chartis always very useful when you're trying to get peopleto stop,

because they can see the damage thatthey don't do to their lung function by stopping at an earlier age. but it's never too late. so that's his smoking cessation. again, if he's got copdand his tlco is reduced, he would also benefitfrom some pulmonary rehabilitation. but he does have that elementof asthma, so a written action plan for himwould be effective in terms of avoiding exacerbations,et cetera.

finally, we need to just make surehe's using his inhalers correctly. a question from tasmaniaasks to explain more fully what a pack year is. a pack year is smoking 20 cigarettesper day for one year. norman: as simple as that?intuitively, that's what it is. a question from cairns - 'is there any truth in the needto change the spiriva machine yearly? - six-monthly.- six-monthly, ok. let's go to our next case study.

denise is 63, and has lived with asthmafor most of her adult life. she also has seasonal rhinitisand gastro-oesophageal reflux. she's on budesonide, 100mcg, and eformoterol, 6mcgon the smart regime. tell us what the smart regime is,christine. - are we allowed to use drug names?- we are. we have to in this case. it's symbicort used as maintenanceand reliever therapy. the patient would taketwice-daily symbicort,

then use that as their reliever as wellthrough the day. - instead of a short-acting?- correct. don't you riskgetting an overdose of steroids on that? work has been done - the steroid loadseems to be lower in the patient group when smart was comparedto a regular bd plus short-actingbronchodilator regimen. you're effectively treatingmini attacks, i suppose, exacerbations of asthmathrough the day, by nipping them in the budwith the inhaled steroid

as well as the bronchodilator. denise has come inwith increased breathlessness. what are you going to do for her? the idea, of course, isto try and ascertain the cause of that. does she havean intercurrent infection? does she have another diagnosis? is she using her medication correctly,or at all? we often find patientsdiscontinue medications because of something they may have seenon a current affair program.

so it's a matter of teasing outwhat's changed for the patient. if we assumethat all remains much the same, then you may need to then look atother possible confounding factors. we've spoken about some of the thingsthat might aggravate asthma - reflux, rhinitis. these issues can make the controlof the asthma more difficult. norman:what are you going to do for her reflux? a fairly standard treatment now isto introduce a proton pump inhibitor. they work quickly,they work effectively.

norman: does it have to be asthma?- unfortunately, not always. it can. reflux can in itself cause respiratorysymptoms that can cause a cough. it may cause aspiration. there are a number of mechanismsby which reflux can cause respiratory symptoms. you can still have fluid coming up,it's just not as acidic with the ppi. that's right. if it's volume reflux,you may have a problem with that. you may need to add a prokinetic agent. but we know that patients may developa cough even if they're not aspirating,

from reflux effects. the question then is,'are these symptoms in fact asthma?' if it is asthma, and this is againwhere spirometry is so useful, if you have serial spirometry, whilst it's usefulto compare patients' spirometry results against predicted levelsor against lower limits of normal, it's nowhere near as useful as comparing it against their ownperformance, against themselves. and so, if you find that the spirometryhas not declined,

you may be more inclinedto seek other causes. on the other hand, if there's beena definite increase in the obstruction, a deterioration in lung function, you're going to be shifting towards concentrating onthe respiratory medicine. what about rhinitis?that could make the asthma worse. absolutely. we know that 80% of peoplewith asthma do have rhinitis. we also know that uncontrolled rhinitis does make it more difficultto control the asthma.

so we would certainly be inclinedto treat both. what about the steroid dose ifyou're starting to treat the rhinitis? if you're thinking about the dose,it's relatively small - 32mcg or 64mcg, compared to what we're talking here,in hundreds of micrograms. it's relatively small,but yes, you have to think about that. as gary said,it's important to treat the nose because of the improvementin the asthma. what you do with denise is,you treat the reflux, you give her nasal steroidsfor her rhinitis.

a month later, she's still complainingof increasing breathlessness. what are you going to do now? if we've excluded other causes - and we spoke in the case of maxabout cardiac pathology and other non-cardiacand non-respiratory pathology - if we've excluded those, then the important thingwould be to look at what's changed, what's causing this deterioration. it may be something as simple as

the patient not using their medicationcorrectly, losing some coordination. so what you decide to dois try and increase the dose, because you can't really find anything. but she comes back, and toni,she's just not taking the medication because she's getting thrush. she complains to you. she doesn't like to upset dr kilov,'cause he's trying so hard. look, sometimes that is a reality.

the other reality is too,with the nasal steroids, they're not covered by the pbs. ultimately, the person has towear the cost of that medication. commonly we find our elderly patients aren't all that happy aboutpaying a significant amount of money, or just don't have spare money to payfor that, so choose not to use it. of course, they don't wantto bother the doctor with that, because the doctorwants them to have it. they just assumethat everything will go on.

oral thrush is a significant problem, and is quite commonly told to usin the pharmacy. it's about technique,about treating that for them. we would usually let the doctor knowthat this person has had that problem, this is what we've donebecause it's over the counter, and recommended the proper wayof using their steroid inhaler - make sure they've rinsed their mouth and spit out the waterafter they've rinsed. what about drug interactions?

you alluded to beta-blocker dropsearlier. what other drug interactionsdo you need to be wary of? especially in older patients, oftentimes they're taking medicationfor arthritis or rheumatism. they may be well be takinga nonsteroidal anti-inflammatory. in a select group of people, that willcause an exacerbation of their asthma. they're probablyour biggest group of drugs, so we really need to be mindfulof the eye drops, we need to be mindful of the achesand pains that people suffer,

we need to be mindfulof the beta-blockers that they may well be usingfor their cardiovascular problems. the other thing with an older person,we need to think about osteoporosis. that's not in your direction, but it'ssomething else we need to think about. not our place to prescribe, obviously,but it's certainly our place... if somebody was doing a home-medicinesreview for this patient... would you do a baseline dexaon somebody like this, gary? again, coming back to the issue of cost, it's not pbs-reimbursedunless they've had a fracture.

that can be a problem. the other problem is that once you've determined,assuming they do have osteoporosis, again the medicationis not pbs-reimbursed unless they've hada minimal-trauma fracture. unless you're surethat you can act on that, it's probably not worth pursuing. the other alternative is, there is evidence for using calciumand vitamin d.

gary: i think we should be doing thatanyway. i know this is not,perhaps, the forum for this, but there is an epidemicof vitamin-d deficiency. they should all be tested for it, thenhopefully put on calcium and vitamin d. taking a therapeutic dose, too. improving mobility to reduce falls. there's a good point. norman: vanessa?- with denise, we mentioned earlier that older people may not be able to useturbuhalers

as effectively as younger people.this is the device... norman: denise isn't crumbling here.she's only 63. i have no answer to that. she may not be able to inspire deepenough to activate the turbuhaler. if we had established thatthe problem was adherence, that would be a consideration for her. in terms of the adherencedue to side effects, you'd also wantto think about the device, and think about converting herto maybe a puffer and a spacer,

where she's more likelyto get oropharyngeal deposition and therefore less likelyto get oral thrush. norman: christine? christine:can i just make a comment? going back to the pointabout doing her spirometry and maybe not seeing much of a change,and wondering, 'is it worsening of her asthmaor something else?' we've determined thatthere are adherence issues. we can,perhaps not so much in rural areas,

but if you do havea lung-function laboratory nearby, they can do a methacholine challengeand some sort of challenge test to determinethe bronchial hyper-responsiveness that may be still presentin this person. perhaps of interest to peoplewould be other tests that are a bit experimental, but we hope we'll bring intoregular clinical practice, such as exhaled nitric oxideas a measure of inflammation and also sputum eosinophils,again as a measure of inflammation,

can be helpful in patientswhere you're trying to determine, is it flaring of their asthma - the lungfunction is not changing very much - or is it something else, for example,vocal-cord dysfunction? we've got problemswith oropharyngeal candidiasis. that can also mimic asthma. - what about influenza vaccination?christine: in this lady? we would be recommending it,and the guidelines recommend it. irene is an 85-year-old womanwith a confirmed diagnosis of asthma. she's pretty stable on salmeterol 50mcg

and fluticasone 250mcg bd, short-acting, and salbutamol as required. she lives independently near herdaughter and her daughter's family. her mobility is limited,and she has mild macular degeneration. vanessa, take us throughwhat you think... she's come back for a routine check-up.there's nothing changed. what are the issues here for someonewe could justifiably call elderly? vanessa: the first thing to note is thatshe seems to have adequate control on the treatment that she's taking,which is pleasing to see.

but the other things that can behighlighted in terms of her management is that she's gotmild macular degeneration. that will have an effect on her abilityto use the different inhaler devices in terms of loading medicationsand loading the spacer, et cetera. and the other thingis her decreased mobility, and that may have some effecton her strength as well and her abilityto activate the different devices. so those things would need to bereviewed and considered. the other thing to think aboutwith irene

is she is an older personwith some macular degeneration. in terms of her management,or self-management, for example, we'd need to consider thingsa little bit differently. we did mention earlier in the program that the mortality ratesamong older people are increasing. we've very effectively been ableto reduce mortality in australia over the last 20 years. that highlights that maybe there arethings we need to do differently as people age.

our approach may not be workingas effectively. action plans are a major componentof treatment for people with asthma. she may not be able to read it. right. with macular degeneration, a written action planmight be ineffective for her. the size of the fontthat people are given action plans for is a problem in older people. some groups have developedwritten action plans using large fonts to try and avoid that problem.

with her, we would need to involve herfamily members in her management. she does have a daughter nearby who may be involvedin regular follow-up with her and assessment of how she's going. so i would want to involve herin her action plan and simplify the planas much as possible. i'd also want to assess irene's needsand see what the biggest problem is for herin terms of her breathing disability, and see how we could effectivelyimprove her management

based on achievinga better outcome for her and really making ita person-centred approach. gary, in your practice,who gives the patient education? i do. i would almost invariably involvean asthma educator. it's virtually impossibleto manage any chronic disease, be it asthma, diabetes, copd, without the involvementof allied health-care professionals, the pharmacist.

it is a team approach.it needs to be a team approach. it needs to be an ongoing,regularly reviewed program. it's not a set-and-forget. whilst i might educate the patient, they will get more information, they'llget reinforcement of the information, say, from an asthma educator. we know that retention ratesin a consultation are very low. we're talking aboutof the order of 10%, 20%. much of the information does need to bereinforced, does need to be repeated.

in a country town, presumably,you just find whoever you can - whoever's availablein terms of professionals... yes. and i would imaginein most country towns, at the least you'll have the gpand the pharmacist working together. christine, what's the role of spirometryand, say, pulmonary rehabilitation in someone like irene? i was just wondering that myself,norman. depending on how disabled she is...but, as you were suggesting, vanessa, she seems to bereasonably well-managed.

i would like to see all patientswith either copd or asthma having at least had some spirometry at some pointin their management process so that we know where we are. depending on her accessto a pulmonary rehabilitation program, if her daughter is able to take her, i know it would improve her qualityof life and her exercise capacity. so i'd certainly strongly berecommending both of those things. a questionfrom rural new south wales -

'what's the current thinkingon the amount of marijuana smoking needed to cause copd?' how many bong yearsare we talking about here? i don't know how many bong years. - it's a good question.- no, it is. i think it must be from the north coastof new south wales, actually. we're seeing more and more patientspresenting with copd who have really nastycystic lung disease. norman: the ageing hippiesare coming home to roost?

it really is very severe. the chest x-rays and ct scansare really quite characteristic. as you know, it's quite difficultfor these patients to stop using. often the marijuanais mixed with nicotine. it's a difficult management situation. we are seeing quite a lot of it. rhinitis - treating the nosewith nasonex to help the asthma? - yes.- what is nasonex? mometasone.

it's another nasal corticosteroid. are there copd plans,like asthma plans? yes, there are. looking atthe australian lung foundation website, there are plans available. cochrane meta-analysis suggeststhat the use of these plans isn't quite as helpful as they have beenin asthma, but i suspect that we just don't havethe evidence about them. talking about a holistic approachand a self-management approach

to management of eitherof these disease, it makes common sense to have a patientunderstanding and using a plan, for example,for flare-ups of their copd. what are your take-home messages?vanessa? one of the take-home messages is that the needs of older peopleare quite different, that we do need to definean integrated approach to the management of older peoplewith either asthma or copd, and changing our approachto be more holistic.

- toni?- i have to agree with that. i particularly think it's very importantin a rural area. the limited number of healthprofessionals there are in that area need to work together. for pharmacists, it's really important that you get to knowwho else is in your area. the other thing is thatpharmacists, i think, have a huge role in medication complianceand adherence. we probably havea more complete record.

potentially, in country areas, where there may only be one pharmacyin a town, they'll know everythingthat person is taking. there needs to be open communicationwith the prescribers. gary? errors in medicine are generallybecause of not looking rather than not knowing. we would certainly want to encouragegreater use of spirometry, particularly in rural settings,

where you may not have accessto tertiary institutions. performing office spirometrycan be very effective in helping to tease outwhat's going on with these patients. the other thing that's been mentioned,and i'd like to reinforce, is the team-based approach. this is an ideal situation for the useof a gp management plan and team-care arrangement. gps are often pressed for time. where you do a gp management planand team-care arrangement,

you are getting adequately remuneratedfor the time and effort spent, and you're involving the necessaryallied health professionals, pharmacists and so on. - christine?- they've said everything, haven't they? i really would suggest that peoplehave a look at the copd-x guidelines. they're very useful. the first step in those guidelinesis to confirm the diagnosis, so, reiterating the importanceof doing spirometry. it's hard to treat someone properlyif you don't know what you're treating.

it may be mixed disease,but it's important to know that, and educate the patient. thank you all very much. i hope you've enjoyed tonight's programon breathlessness and the older adult. if you're interested in obtaining moreinformation about the issues raised, there are a number of resource available don't forget to complete and send inyour evaluation forms, and please register for cpd points by completing the attendance sheet.

our thanks to the nationalasthma council of australia for making the program possible, with funding from the government'sdepartment of health and ageing. thanks to you for taking the timeto attend and contribute. i'm norman swan.from all of us, bye for now. captions bycaptioning & subtitling international funded by the australian governmentdepartment of families, housing, community servicesand indigenous affairs�