About Health – Inside Medicine

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Treating abnormal blood fat can prevent serious health problems

In a series focusing on medical specialties, the BBC News website meets lipidologist Dr Dermot Neely.

Lipidology is the study of fats which play a key role in the body.

By recognising the metabolic problems underlying abnormal blood fat levels and then treating them, a lipidologist can then prevent serious health problems.

I am a consultant in clinical biochemistry and metabolic medicine at Newcastle-upon-Tyne Hospitals NHS Trust.

I am also chairman of the medical and scientific research committee of Heart UK, a heart-health charity.

I need to know if a patient gets extremely nervous, or whether they’ve been widowed, or if there’s something else bothering them. Anne Storey

My main clinical activities are in lipidology, a sub-specialty of metabolic medicine, which deal with problems in the biochemical processes which take place inside the body.

Lipid is a technical term for a fat, and lipidology is the study of fats which play a key role in the body.

Two of the best known are cholesterol and triglyceride (ordinary fat). High levels of either in the blood are significant risk factors for heart disease and diabetes.

By recognising the metabolic problems underlying abnormal blood fat levels and treating them – when necessary – by diet and exercise, the lipidologist can prevent serious health problems, principally cardiovascular disease – heart attacks, stokes and lower limb amputations and deaths.

These are patients with a mixed increase of cholesterol and triglycerides in the blood.

Very often this is the pattern we see in patients who have ischaemic heart disease.

Triglyceride – or "ordinary fat" is the principal form of fat absorbed from the food for energy storage and it is transported through the blood in globules or particles mixed with cholesterol.

Problems with delivery and or inefficient storage of triglyceride can contribute to "traffic jams" in the blood fat transport system and can delay removal of left-over cholesterol and contribute to cholesterol deposits in the arteries.

Delayed clearance of triglyceride and high blood levels of triglyceride are also linked to diabetes, fatty liver disease and occasionally pancreatitis, which is potentially fatal

We carry out more detailed investigations of lipoproteins to define precisely what lipid disorder lies behind the patient’s high cholesterol or triglycerides.

There are a number of primary and secondary causes of this and we need to distinguish which one is at the root of the problem.

Now we are also able to make a firm diagnosis of familial hypercholesterolaemia (FH), an inherited form of high cholesterol, by using DNA testing.

At the moment trying to get family screening or cascade testing implemented, as recommended by the National Institute for health and Clinical Excellence (NICE) guidance.

We have been successfully piloting this form of testing in Newcastle since 2005 and now need to get it commissioned across the mainstream NHS service.

Lipidologists study fat levels

FH is caused by a defect in one of the genes required for the LDL-cholesterol removal system.

Two sets of genes, one from each parent, is required for the left-over, LDL-Cholesterol ("bad cholesterol") to be removed at normal speed in order to maintain normal blood cholesterol levels.

If a fault is inherited from either parent, the removal system doesn’t work properly and cholesterol deposits and artery blockages can build up around the heart.

This causes early heart attacks and deaths in affected families and although FH occurs in only one person in 500, if one member of a family has the gene causing the condition, we know that half of their siblings and children will carry the same gene.

"Cascade testing" uses this knowledge to test other family members who might also have inherited the gene to ensure that they are offered advice and treatment with a statin which can bring cholesterol back down to normal and prevent early heart disease death.

My most satisfying case has to be one of my patients with FH who recently participated in the DNA testing arm of the cascade screening study.

She was found to be a carrier of a mutation in the APOB gene, a recognised genetic cause of FH, and was referred to our regional clinical genetics centre and had family cascade testing.

I was greatly relieved as she had eight siblings and between them 32 first and second degree relatives at greater than 25% risk were identified.

So far 10 members of the family have been tested and five have been found to have the same mutation – exactly as predicted – and all five have been referred back to my clinic for assessment, advice and treatment by their GPs when the DNA test results came through.

I very much doubt if these previously undiagnosed relatives would have been picked up and referred in without the cascade screening initiative. It is such a powerful tool.

When I was a medical student I was offered the opportunity to take a BSc in either physiology, anatomy or biochemistry.

I chose biochemistry because it was the subject I found to be the hardest to understand.

But despite having to work harder than ever before, I had a wonderfully stimulating year and having heard about lipoproteins for the first time I was hooked!

Lipids and lipoproteins still fascinate me and we have much more to learn about them.

For instance, I have been involved in exciting research with my colleagues in hepatology which has revealed how the Hepatitis C virus hides in lipoproteins to infect the liver and cause chronic infection.

Yes, definitely!

Because I always like to have a new challenge – to do something completely different would be great.

However, I doubt I would enjoy doing anything else so much. I wouldn’t mind having a go at keyhole brain surgery though!

I would hope to see the balance between clinical, laboratory, research and management work change.

Currently clinical work represents only about one quarter of my time and I would prefer this to be my biggest commitment. To me, seeing patients is the best part of the job.

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In a series focusing on medical specialties, the BBC News website meets medical photographer Karl Southerton.

Medical photographers provide a wide range of photographic services to staff working in the medical field.

Their work can play a key role in helping to diagnose disease, and track and record treatments.

I am a head of department in medical photography at the Western Eye Hospital, London.

Now I only take photographs of the eye, but when I was a general medical photographer I might take pictures of any condition the doctors needed records of, such as a skin problem or a mastectomy.

We document things in situ. You can photograph again and again in the same position and have a photographic record of what the patient looks like before, during and after treatment.

At the moment age-related macular degeneration (AMD) is the big thing as there are now treatments which can help patients while 10 years ago when doctors would say there was not a lot they could do.

Often they would have to say ‘We will probably monitor you, but you will probably go blind’.

Now we can actually treat the patient so they can get their sight back.

Taking photographs of AMD patients.

The macular is the key part of the retina at the back of the eye where the rod and cone cells that react to light are concentrated.

If it is damaged then it can have a huge impact on the quality of your vision – particularly your central vision.

Having the aid to document helps the patient because they can see what they were like before and with the photograph you can see the difference Karl Southerton

AMD is a degeneration of this area, which can be caused by leakage from the tiny blood vessels nearby.

Doctors treat the area with drugs, and then we use photography both to see if it has stopped leakage from the blood vessels, and to measure the extent of the scarring that has taken place.

We put fluorescent dye into the patient to fill the retinal vessels to show if there is any sort of leakage or block and where they are.

We also look at the vessels underneath the retina.

We dilate the pupils of a patient – this is essential as it’s very difficult to image a patient without dilation drops as the pupil’s natural reaction to light is to close.

Dilating drops work on one of two principles: they either stimulate the iris muscle that opens the pupil (the dilator), or prevent action of the iris muscle that closes the pupil (the sphincter).

When a person is dilated the pupils remain large even if light is shone in them. This then allows a clear view of the retina.

We then use a camera, called a fundus camera, with inbuilt mirrors to take pictures of the eye.

There is a filament light within it that bounces off the back of the retina and takes a reversed image. The image is then bounced back through a series of mirrors which then turn the image the right way round so we can record it.

The hardest thing about my job is the number of patients I see – about 200 plus a month with a variety of different ophthalmic conditions. AMD probably accounts for about 50-60% of these.

Then there is also separate database, with about 7,000 patients, for diabetic patients as these are seen regularly for an eye test.

Retinal images are taken of the eyes of the diabetic patients using a ‘non-mydriatic fundus’ camera, which instead of emitting light to view the retina, instead is viewed through an infa red viewer which is better for the patient as there’s no bright light (other that when the image is taken). As diabetic patients are quite often photophobic and also don’t dilate very well, this camera is specifically used for their needs.

Most diabetic patients have a yearly screening appointment.

It is very satisfying when you have someone who is expecting to lose their sight, but they come back a couple of weeks later and you can see it is getting better and better.

The eye of a person with Age Related Macular Degeneration

It is also great to have the photographic proof to be able to show treatment is working.

Photographs can really help a patient, because they can show them how they were before and after an operation.

It can really bring home to them the difference treatment has made – for instance, a patient who undergoes surgery for a drooping eyelid.

I went to college and did an HND in commercial photography, fashion and advertising and then went to do a course in art and design, with more emphasis on audio/visual.

I did a few jobs including work with the local newspaper and a few photographers.

But there were no jobs out there because of the recession, so I looked to see what jobs were available and kept seeing medical photography and wondered what it was all about.

I made several shortlists for jobs but didn’t get them because I didn’t have the experience.

But then I offered to do two weeks work experience at Moorfields Eye Hospital, someone was leaving and I got the job.

I probably would not. I like ophthalmic work. It is very specialised and when you focus on the back of the eye it is very critical work and I like that.

I had an idea that I wanted to do sports photography because I liked following Newcastle United.

Sports photography is quite similar to our work because you are looking at something quite close up on the pitch and you have obviously got to take the photograph as quickly as possible.

It is very difficult to get an action shot, which is similar to getting a retinal shot because you have a patient at whom you are shining a bright light and they don’t want to keep their eyes open for too long.

Now there is foundation degree course to take medical photographs which gives students a background in what they are actually taking photos of.

This is important, because there is no use saying ‘take a picture of the optic disc,’ if you don’t know what the optic disc is.

The imagery is also becoming far more detailed, and is playing an ever more key role in helping medical staff make a diagnosis, or assess how a treatment is progressing.

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Mr Hamed also sees men with breast problems

In a series focusing on medical specialties, the BBC News website meets breast surgeon Hisham Hamed.

His speciality is treating patients, women and men, with breast problems ranging from cancers to benign conditions.

I am a full-time breast surgeon and head of the breast surgery service at Guy’s & St Thomas’ Hospital Foundation Trust and University Hospital, London.

As well as my clinical duties I also have managerial and research commitments.

Although breast disease predominantly concerns women, I also see a number of men with various breast problems – most commonly breast enlargement.

Guy’s & St Thomas’s NHS Foundation Trust is one of the largest teaching hospitals in the country, so teaching medical students and training young surgeons are a part of my regular daily activity.

It just isn’t possible to get used to breaking bad news Mr Hisham Hamed

The majority of my patients have benign conditions, or are the “worried well”.

Breast pain is one of the most common conditions affecting women.

But while breast cancer represents less than 10% of the cases I see, it takes up nearly 90% of my working time.

Most of the surgical procedures are related to breast cancer treatment.

Mastectomy used to be the most common procedure.

But with advances in breast surgical treatment, mastectomy has been replaced in a significant number of cases with less extensive surgery called a lumpectomy.

Also reconstructive surgery (rebuilding the breast) has become an integral part of breast cancer surgery and has been carried out more frequently in recent years.

Ironically, the best part of the job – the doctor-patient relationship – constitutes the hardest.

It just isn’t possible to get used to breaking bad news.

Developing breast cancer is one of the most critical life events. In most cases the lives of the patient’s whole family get turned upside down.

Away from patients, changes in the NHS and the development of a new management style have also proved to be one of the most challenging tasks of a senior clinician’s job.

In the modern NHS clinicians are now playing a significant role in running their own departments.

This can be challenging – and sometimes frustrating – but is undoubtedly rewarding because I am taking an active part in shaping the service to provide the best possible care for our patients.

I am also fortunate to be a part of an academic and research programme that gives me the chance to work in such an exciting field where so much is going on in the development of breast cancer treatment.

Consistent efforts to deliver high quality care both from physical and psychological aspects within limited resources can be hard and frustrating.

But despite all my commitments I wouldn’t change my job for anything else!

It may sound like a cliché, but truly it is seeing breast cancer patients get better and turning from desperation to hope.

It is also very satisfying to be able to support patients during one of the most difficult times in their lives.

For the worried well and those with benign conditions, it is to be able to give good news that they have no serious problem and to alleviate their anxiety.

Patients’ satisfaction and their acknowledgement that they received the best care possible do certainly keep me going.

I consider myself fortunate.

During my training I felt that learning to become a breast surgeon would provide me with the most satisfying aspect of my medical career: that is close involvement with patients’ care and getting to work with patients as people and not just interesting cases.

In the meantime there was the opportunity of a training post in one of the most prestigious Cancer Research UK breast units.

Also breast cancer provides a fertile field in research to find answers to one of the most intriguing malignancies.

I have no regrets and still enjoy my job.

There is hardly a dull moment and every day provides a new challenge. There is a lot to learn about breast cancer and its victims.

The field of breast cancer surgery is continually evolving

There are advances in our knowledge and new skills to learn.

A holistic approach to management of breast cancer has become a fundamental aspect of patients’ care and it is important for carers to embrace it.

A humane and sympathetic approach is a crucial skill needed by all breast surgeons.

Patients’ recovery depends on this as much as on physical treatment. So it is an integral part of any surgeon’s curriculum.

Reconstructive surgery and its impact on patients’ quality of life is also now a fundamental skill for the modern breast surgeon to learn.

The field of cancer genetics is growing at a rapid pace and the modern breast surgeon has to be up to date with all the latest developments. That is certainly a major challenge.

Finally, the care of patients with breast cancer is no longer the responsibility of a single doctor.

Today patients have the advantage of being looked after by a multidisciplinary team of experts who are able to provide comprehensive care.