AUGUST 2014NewsletterImproving health through understanding

In the wake ofthe hugelysuccessful25thAnniversaryScientificMeeting last year in Edinburgh, thecommittee has been very busy,particularly in regard to twoprojects. Firstly, we have bookedan iconic venue, Sage Gateshead,for our next scientific meeting in2015 (22-24 October 2015). Thisstriking building, designed primarilyas a music centre, is in the middleof Newcastle-Gateshead on thebanks of the Tyne and is trulyworld-class. The scientificprogramme is almost finalised andwe are confident the success ofEdinburgh will be echoed. The second major developmentis the hiring of a professionalcompany, Executive BusinessSupport (EBS), to run all theadministrative needs of the Societyfrom membership issues to thewebsite and beyond. Severalinterested parties were interviewed

President’s Message

AUGUST 2014

BSS Hands On shines onthe Sunshine Coast

The newly-rebranded BSSHands On meeting was held inEastbourne in May 2014.Although the Sunshine Coastfailed to live up to its nameweather-wise, delegates weretreated to an illuminatingprogramme of talks andworkshops that shone despitethe rain.

Day 1 provided some sunshine– direct from Spain – when asombrero-toting Simonede Lacy opened the conferencewith an excellent session onremote scoring of PSG. Adiverse range of topics werecovered, from the very basicsof why we sleep to ENTexamination, sexsomnia andpublic engagement in science.

The historic Hydro Hotelprovided the perfect backdropfor the evening’s Great Gatsbythemed gala dinner, withflappers, gangsters and mollsreviving the Roaring Twentiesin style (see photo).

Despite the roaring headachesthat may have followed theevening’s festivities, the 62delegates returned for a busyday 2. Diagnosis of sleepdisorders using actigraphy andpolysomnography werediscussed, the latterhighlighting the differences andsimilarities between paediatricand adult sleep studies.Treatment topics were alsocovered, with very practicalsessions on CPAP complianceand CBTi for insomnia.

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AUGUST 2014

Welcome to the summeredition of your BSS Newsletter. Youjoin us at a very exciting time for theSociety, with preparations for theBSS2015 Scientific Meeting wellunderway. After the success ofBSS2013 in Edinburgh, we can lookforward to another fine programme

of international speakers and homegrown talent onthe “Geordie Shore”. Read on for a first taste, andto find out how you and your team can be part ofwhat promises to be the 2015 highlight for UK sleep,and also to hear from winner of the BSS2013 YoungInvestigator Prize. Next year, it could be you! Lookout for more information soon, including a stand atthe upcoming ESRS meeting in Tallinn, Estonia,where we will not only promote this fantasticmeeting, but also introduce the European Sleepcommunity to the delights of Newcastle Brown Ale.

Of course, the Scientific Meeting is not the onlyconference run by the BSS, and I must congratulateJill Meeres on putting together an excellent BSSHands On Meeting earlier this year. This practicalclinical conference, held in a charming, 1920s-stylevenue in Eastbourne, had us learning by day andCharleston-ing by night and was well-received byall. A full review is featured in this edition.

Back in Tallinn, the ESRS meeting inSeptember hosts the first sitting of the EuropeanSomnologist-Technologist exam, a new Masterslevel qualification for sleep technologists. A numberof UK “grandparents”, including myself, will besitting the exam – good luck to you all, and I lookforward to sharing your experiences in the nextNewsletter!

Finally, some thank yous. Jackie Bennett haskindly supplied her RPSGT Tips column since I tookover as Newsletter Editor in 2012, and has nowdecided to take a break. Thanks, Jackie, for all yourhard work contributing to the Newsletter, and wehope to hear from you again in future.

Also, as you will know, Jill Dellar has left theBSS after many years of service as the SocietyAdministrator. Since I joined the BSS in 2000, Jillhas been a constant presence at conferences,online and on the phone. She has always been amine of help and information, particularly, for me,since I joined the Executive Committee and took onthe Newsletter. Despite my constant emailing andpestering, she has always been supportive andhelpful, as well as always having time for a friendlychat at meetings. I will miss her, and would like totake this opportunity to thank her for everything.

Finally, thank you to all the contributors to thisNewsletter. As always, I welcome articles from allBSS members and others working in sleep. Thisedition features some regular contributors as wellas some new, and has the first in a new series ofarticles, “How do YOU sleep?”. I hope this willinspire you to put pen to paper (or fingers to keys)and write your own piece for an upcomingNewsletter – please send your article (200-1200words) to lizzie.hill@ed.ac.uk.

Lizzie Hill – BSS Newsletter

Editor’s Message

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President’s message continued

Hands-on workshops onrespiratory scoring, scientificwriting and oximetry were well-received, providing directly-applicable skills whichdelegates can readily put intopractice. Not only thedelegates benefit from thesesessions – for a presenter’sperspective, see page 3 of thisnewsletter.

Hands On ConferenceOrganiser Jill Meeres shouldbe congratulated on puttingtogether an excellent meeting.

Feedback from attendees wasvery positive:

“Great meeting! GoodVenue and content.”

“Everyone was friendly andapproachable. Course welldelivered!”

“Overall excellent,informative and usefulscientific meeting. Facilitiesand venue very good!”

“Fantastic two days!”

Preparations now start inearnest for the next BSSmeeting, which was unveiledin Eastbourne – to find outabout the BSS2015 ScientificMeeting, please read on...!

for the post of SocietyAdministrators, and EBS stoodout with their proven track recordin a number of similarly-sizedsocieties and charities. As anaside, we are very hopeful thatour ties with the ARTP willbecome even closer as they havehad EBS running their affairs formany years. Of course, thismeans saying farewell to JillDellar who stood down in the latesummer. To many, over the years,Jill has been the face of the BSS,always there to help withenquiries and BSS-related issueswith unfailing patience anddedication. I’m sure we would alllike to thank her for the tirelesswork she has put in over theyears, too many to mention...Thanks also to the media

department at Papworth Hospitalfor their helpful input to thewebsite when it was re-developed4 years ago and for their handlingof the numerous media enquiriesthat come through to the BSS.So, with the various majordevelopments taking place behindthe scenes, please be patient if ittakes some time for the handoverto find its feet. We continue withour aims at improving thewebsite, in particular.For those of you attending theESRS meeting in Tallinn inSeptember, please visit our stallthat will be advertising theSociety and its forthcomingmeeting in 2015. Offers of helpwill not be refused!Dr Paul Reading – BSS President

AUGUST 2014

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Oximetry WorkshopBSS ‘Hands On’ Meeting

n some ways, running aworkshop is moredaunting than deliveringa presentation at a

conference. Instead ofstanding in front of a group ofpeople, talking for 30 minutes,answering a couple ofquestions and then sitting backdown again, you are up therefor 90 minutes, deliveringinformation and fieldingquestions for the whole time,hoping that the group you arewith will be able to take awaysomething of value from theexperience. By its very nature,running a workshop impliesthat you are an expert in thatarea and will be passing onvaluable knowledge and skillsto whoever attends. This iswhy, the day before theconference, franticallypreparing for what was ahead,I was wondering what an earthI was thinking saying yes torunning a workshop onoximetry!

I’m not an expert on oximetry,however, with a scientificbackground and a goodgrounding in how to usephysiological software, as wellas having had about 60oximetry studies fall onmy desk each week for the lastfour years, I have picked upone or two things along theway. I ran three 90 minuteworkshops over the two dayswith about 20 or so people ineach group. After talking aboutthe principles of oximetry ingeneral and giving a bit ofbackground to what we do atthe James Cook UniversityHospital in Middlesbrough, Iwent into detail about how torecognise and account forartefacts that may affect thequality of oximetry data. Thencame the fun bit; it was over tothe group to spend a bit of timediagnosing disorders based

on some classic oximetrystudies and patient symptoms. Thanks to the enthusiasmand willing involvement ofthose that attended the 2014BSS ‘Hands On’ meeting, Ireally enjoyed running theoximetry workshop. We hadsome great discussions;ranging from the different waysin which centres carried outand used oximetry, to thedangers of interpreting solelyfrom any device ormeasurement without takinginto account the patientsymptoms. I felt that everyonewho attended fully took part theworkshop and left knowingsomething that they didn’tbefore, including me, so thanksfor making it such a success!

Dr Charlotte Kemp – JamesCook Hospital, Middlesbrough;BSS Executive Committeemember

I8-9th May 2014

AUGUST 2014

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Save the date! BSS2015 Scientific Meeting,Sage Gateshead, 22-24 October 2015

Following on from the

huge success of our 25th

Anniversary Scientific Meeting

in Edinburgh last year, the BSS

is delighted to announce that

BSS2015 will be held on 22-24

October 2015 at the stunning

Sage Gateshead. Expect an

excellent and varied

programme, featuring

established international

speakers, local talent and

early-stage researchers;

submit an abstract, and this

programme could include you!

The confirmed

keynote speakers are profiled

below. Other highlights will

include Hands-On workshop

sessions each morning,

special interest lunches and

symposia on the role of tele-

monitoring in device

adherence, treatment of

insomnia and updates in

clinical sleep medicine.

Responding to delegate

feedback from BSS2013, the paediatric

sleep content of the meeting has been

expanded to include a special

symposium on the Impact of Sleep

Disorders in Children. This session will

feature Dr Sameer Zuberi (Glasgow)

reviewing developments in the genetics

of sleep related epilepsies, James Di

Pasquale (London) discussing sleep

dysfunction associated with eczema,

food allergies and asthma, and Dr

Cathy Hill (Southampton) talking on

sleep and Down syndrome in children.

BSS President, Dr Paul

Reading, will chair a pro/con debate

between Dr Ian Morrison (Edinburgh)

and Dr Guy Leschziner (London) on the

topic MSLT is an extremely important

and useful investigation in the diagnosis

of narcolepsy, which promises to be a

lively and informative session.

Registration opens on 01 November

2014. But rather than just attending,

why not be part of the programme?

With awards for the Best

Abstract and Best New

Investigator, BSS2015 is a

great opportunity to share

your latest research, clinical

audit, interesting case study

or other piece of work as a

poster or talk. Whether you

are a first-time author or

seasoned investigator, the

meeting is the perfect forum

to present your work to a

multidisciplinary sleep

professional audience and

highlight your contribution to

UK sleep.

Please note that, due to aclash with the rugby worldcup, the meeting date hasbeen changed from thatpreviously advertised (01-03 October 2015).

So don’t miss out – save the date now, and register at

www.newcastlesleep2015.co.uk!

Photo credit: Mark Savage

Meet the KeynotesPage 5…

AUGUST 2014

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25th Anniversary Scientific MeetingYoung Investigator Award winner

Customised and ‘off-the-shelf’ mandibularadvancement appliances in sleep apnoea:

a randomised cross-over trialPriya Haria (nee Shah) -

Post-CCST in Orthodontics, Royal London Hospital,Barts Health NHS Trust

haria_priya@hotmail.co.uk

uring my training as a Specialist Registrar in Orthodontics, under thesupervision of Dr Ama Johal, I conducted a randomised cross-over trialcomparing customised (Fig. 1) and ‘off-the-shelf’ (Fig. 2) mandibularadvancement appliances (MAAs) in obstructive sleep apnoea/hypopnoea

syndrome (OSAHS). The abstract for this research was put forward to be presentedat the 25th Anniversary meeting of the British Sleep Society in 2013 and I washonoured to receive the Young Investigator award.

The role of MAAs in the management of OSAHS is already well recognised (Kushidaet al 2005). A literature review when the trial was planned identified that there wereno well designed studies comparing customised and ‘off-the-shelf’ MAAs in subjectswith OSAHS alone. It was also noted that information regarding the effects of suchappliances on the quality of life of sufferers of OSAHS was lacking (Lim et al 2009). This study aimed tocompare customised and ‘off-the-shelf’ MAAs in subjects with OSAHS, with respect to subjective daytimesleepiness, quality of life and disease severity.

Continued on page 6…

D

Professor Jan Born, Director of the Department of Medical Psychology and Behavioral Neurobiology at the University

of Tübingen, Germany will speak on ‘Sleep’s role for memory’ at BSS2015. Dr. Born's primary research interests are in

the dynamics of memory formation in biological systems, particularly in the central nervous and immune systems. We

look forward to his State of the Art Presentation that will open our conference.

Professor Terri E. Weaver, PhD, RN, FAAN, Dean of University of Illinois at Chicago College of Nursing was the first to describe

the dose-response relationship between hourly duration of CPAP use and normalization of clinical outcomes for obstructive sleep

apnoea. Professor Weaver’s title is: ‘Treatment adherence: Does 4 hours fit all?’

Professor Eus JW Van Someren, Head of the Dept. Sleep & Cognition, Netherlands Institute for Neuroscience and VU University

Medical Center investigates how sleep affects brain function during subsequent wakefulness, and how experiences during

wakefulness affect subsequent sleep. Professor Van Someren’s keynote presentation will review: ‘The neuroscience of individual

differences in sleep vulnerability and insomnia’.

Dr Philip Gehrman, PhD, CBSM is assistant Professor of Psychology in the Department of Psychiatry and a member of the

Sleep Center at the University of Pennsylvania. Dr. Gehrman’s clinical work focuses on the treatment of insomnia and other

sleep disorders. He has an active telehealth program where he delivers insomnia treatment to Veterans using videoconferencing

technology. At BSS2015 Dr. Gehrman will draw on these experiences to discuss 'cognitive behavioral and chronotherapeutic

interventions for insomnia’.

Meet the Keynotes…

AUGUST 2014

Full ethical approval was in place at the start ofthe project and I was involved in conducting arandomised prospective cross-over trial, undertakenat the Royal London Hospital. Referred subjects,meeting the selection criteria (Table 1), wererandomised to an initial appliance for three months,with a two week washout period, prior to crossover tothe alternative appliance, for a further three months.The Epworth Sleepiness Scale (Johns 1991) was usedto measure subjective daytime sleepiness. The impactof treatment on quality of life was measured with theFunctional Outcomes of Sleep Questionnaire (Weaver1997) and Medical Outcomes Study 36-Item Short-Form Health Survey (Ware and Sherbourne 1992).Subjects also completed a questionnaire regardingappliance experience (Johal and Battagel 1999).Limited overnight, unattended sleep studies were usedto monitor disease severity and objectively assessbreathing disturbances, through recording the apnoea/ hypopnoea index (Fig. 4).

Since the number of subjects needed to meetthe sample size calculation (n=48) have not yet beenrecruited, early trends may be observed, butconclusions should be interpreted with caution. Atinterim analysis, 34 subjects were randomised, 8dropped out and 20 completed the trial. Objectively,both appliances led to a reduction in disease severityand subjective daytime sleepiness; a slightly greaterchange was observed with the customised MAA. Aslight increase in some parts of the quality of lifequestionnaires suggested some subjectiveimprovement after use of both appliances. Subjectsreported better compliance with the customised MAAsthan the ‘off-the shelf’ appliances, with more subjectscontinuing to use the customised appliance for agreater number of hours per night and nights per week.

The interim analysis suggests the customisedMAA may offer advantages over the ‘off-the-shelf’ MAAin terms of objective improvement in OSAHS,reduction in subjective daytime sleepiness andcompliance in wear. The effects upon quality of life arenot yet clear. The final results of study will be publishedupon completion.

Through my recent research and training I have cometo understand the significance of OSAHS, its impactupon an individual’s quality of life and the potentialbenefits they may receive from oral appliances.Although CPAP is still the gold standard for treatmentof OSAHS, in circumstances where oral appliancesare indicated, they are a relatively simple and effective

Fig. 1 Customised MAA

Fig. 2 Off-the-shelf MAA

Fig. 3 Overnight sleepmonitor equipment

1 ‘Visi-Lab Greyflash’ reader2 Chest strap and case for reader3 Microphone4 Nasal airway cannula5 Pulse Oximeter probe

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AUGUST 2014

strengthened at events such as the BSS and ESRSmeetings. I would also encourage all trainees totake opportunities to become involved in well-conducted research, in order to both understandthe research process and add to our currentknowledge base. Attending the British SleepSociety meeting was a fantastic opportunity tomeet other colleagues who work in the field ofsleep medicine and to learn about new

developments in the field of OSAHS. I particularlyenjoyed listening to other speakers discuss theircurrent trials. I am looking forward to attending theEuropean Sleep Research Society Meeting inTallinn later this year, as part of the YoungInvestigator Award prize. I am currently completingmy training towards becoming a consultantorthodontist and foresee the management ofOSAHS becoming an ever-more significant part of

Inclusion Criteria Exclusion Criteria

· Previously diagnosed with OSAHS by aspecialist sleep physician and referred for oralappliance therapy.

· Over 18 years of age.

· Fluent in English.

· Satisfactory dental health.

· Prepared to wear an oral appliance.

• Prepared to spend 2 weeks without an appliance.

· History of poorly controlled epilepsy.

· Taking narcotics, sedatives or anypsychoactive medication.

· Significant pulmonary or cardiac disease, forexample, chronic obstructive pulmonarydisease, uncontrolled hypertension ormyocardial infarction within the past 12 months.

· Previous oral appliance therapy for OSAHS.

· Edentulous or had inadequate tooth substanceto support an intra-oral device.

• Evidence or a reported history oftemporomandibular joint dysfunction.

Johal, A, Battagel J. An Investigation into the Changes in Airway Dimension and the Efficacy of Mandibular AdvancementAppliances in Subjects with Obstructive Sleep Apnoea British Journal of Orthodontics. 1999; 26 (3): 205-210

Johns MW. A new method for measuring daytime sleepiness: The Epworth sleepiness scale. Sleep. 1991; 14: 540-545.

Lim J, Lasserson TJ, Fleetham J, Wright JJ. Oral appliances for obstructive sleep apnea (Review). Cochrane Database ofSystematic Reviews. 2006. Issue 1. Art No.: CD004435. DOI: 10.1002/14651858.CD004435.pub3.

Kushida CA, Morgenthaler T, Littner M, Alessi C, Bailey D, Coleman J, Friedman L, Hirshkowitz M, Kapen S, Kramer M,Lee-Chiong T, Owens J, Pancer J. Practice parameters for the Treatment of Snoring and Obstructive Sleep Apnoea withOral Appliances: An Update for 2005. An American Academy of Sleep Medicine Report. Sleep. 2006; 29 (2): 240-243.

Ware JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and itemselection. Med Care. 1992; 30 (6): 473-483.

Weaver TE, Kribbs NB, Pack AI, Kline LR, Chugh DK, Maislin G, Smith PL, Schwartz AR, Schubert NM, Gillen KA, DingesDF. Night to night variability in CPAP use over the first three months of treatment. Sleep. 1997; 20: 278-283.

References

Table 1: Summary of Selection Criteria

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AUGUST 2014

Spotlight on…

Dr Paul Reading has been President of the British Sleep Societysince 2011, Having previously held the posts of Secretary andTreasurer.

Paul completed his medical training in Cambridge and Londonbefore returning to Cambridge to undertake a PhD in the behaviouralassessment of embryonic neural grafts in models of Parkinson’s andHuntington’s diseases. Involvement in the neurobiology of reticularactivating systems fuelled a later clinical and academic interest insleep disorders such as narcolepsy.

After neurological training in Edinburgh and Newcastle, Paulmoved to the James Cook University Hospital in Middlesbrough totake up a new neurology post. He has been running a weekly (now bi-weekly) Neurology SleepClinic for over a decade, attracting referrals from the Northern region and beyond. His particularinterests are narcolepsy, abnormal sleep in neurodegenerative disease (particularly Parkinsoniansyndromes) and parasomnias.

Firstly, thank you for taking the time to chat with us. You are currently a consultantneurologist and President of the British Sleep Society. How did your interest in sleep firstdevelop, and how did you progress to your current position?

When I was trying to decide an area of specialist interest in the year before I was due to qualify asa consultant neurologist, I recall a lecture that inspired me. Briefly, data were presented that thenewly developed drugs for Alzheimer’s were actually probably more effective in dementia due toParkinson’s disease. Somehow, this got me thinking about cholinergic processes in the brain,including REM sleep, and how Parkinson’s disease could resemble narcolepsy. The ideasnowballed into how fascinating and unexplored sleep medicine was and how virtually no-one inneurology seemed particularly interested. Simply raising my hand, showing interest and offeringto undertake a “sleep clinic” allowed me to learn “on the hoof” with referrals coming from all areas,particularly respiratory physicians trying to make sense of sleep disorders that were not breathing-related. Given the lack of career pathways in UK sleep medicine, my route to my current positionhas been a fairly random process. Roughly a third of my week is supposed to be “sleep-related”

Paul Reading

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AUGUST 2014Sleep neurology is growing field. What have been the key moments so far, and, in youropinion, what have been the landmark publications?

I was just “getting into sleep” when the seminal finding from Stanford that narcoleptic Dobermanshad a receptor mutation related to an obscure hypothalamic neuropeptide, hypocretin, waspublished in 1999. The results came from blue sky and led to the amazing discovery that full-blownhuman narcolepsy was caused by losing a pin-head of neural tissue in the hypothalamus, leadingto a specific neurochemical deficiency. That such a disabling life-long condition can come fromsuch subtle damage never ceases to amaze me.

The ultimate question of sleep function may well be answered by the amazing technology thatallows the analysis of active genetic transcripts from the entire genome of flies, rats and humans.The activity profile in differing states of wake, sleep and sleep deprivation is already providingfascinating information helping to confirm and refute current sleep theories.

The British Sleep Society held its 25th anniversary meeting in Edinburgh last year. Whatdo you think the next 25 years of UK sleep holds? What will be the key areas/discoveries?Where would you hope the field/the society will be by its30/40 /50th anniversary?

The UK has particularly strong sleep research interests inchronobiology and genetic aspects of sleep. Dissecting sleepat the level of protein expression will hopefully answer theultimate question of why every animal (with a brain) has anabsolute need for sleep. In subsequent BSS anniversaries, Isuspect the importance of good sleep for optimal health will bebetter defined and acknowledged by all medical practitionersand not just those involved in this evolving discipline.

What has been the highlight of your career so far, the most significant event or theachievement you are most proud of?

Neurology is often criticised for a having a “diagnose and discharge” ethos with treatments eithernot available or, at best, minimally helpful. Looking back, therefore, the moments that have givenme most satisfaction are clinical interactions with patients where my interventions have made auseful difference. On my wall, I have a poem that never fails to lift my mood. It was written to meby a 7 year-old whose narcoleptic mother we had managed to treat successfully, “re-uniting” herwith the family.

Conversely, what has been your most embarrassing/amusing professional moment?

My most embarrassing moment was early in my sleep career when, in a particularly eager state,I agreed to host an all-night live radio insomnia session for the BBC. The fresh-faced DJ introducedme as a national expert on “necrophilia” which, as you might imagine, spawned a few weird callers...!

Whose contribution to sleep do you most admire, and why?

Emmanuel Mignot from Stanford is a role model in many ways. Apart from his pivotal role infurthering the neurobiological basis of narcolepsy and dissecting the complex immunologicalaspects, he is a thoroughly pleasant and unassuming chap!

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AUGUST 2014And who is your inspiration outside of sleep? Who would be your dream dinner party guest(s)?

I’m not sure my sources of inspiration, one of whom is a militant vegetarian, would make particularlycompatible dinner guests. However, from musical, sporting and academic circles respectively, I wouldpick Nigel Blackwell (lead singer and lyricist of witty Scousers Half Man Half Biscuit), Rob Fahey (worldchampion Real Tennis player for the last 24 years) and Richard Dawkins.

Your love of Morrissey and The Smiths is well documented. Which one album, single and bookshould everyone have in their collection? Which Morrissey lyric has been most valuable to you?What would be your karaoke song?

Album choice: Rank by The Smiths (the band in full bombastic flow, one of their last live performances).

Single choice: Jeanne by The Smiths (first single by the band – generally overlooked, simple and brilliant).

Book choice: Cloud Atlas by David Mitchell (book and the filmof it blew me away).

Best Morrissey lyric: “I dreamt about you last night and I fellout of bed twice” – a description of REM sleep behaviourdisorder a full 2 years before Mahowald and Schenk! Karaokesong: I once tried “How Soon Is Now” by The Smiths in akaraoke bar in Kyoto – murdered it, but would fancy anothershot even though it’s a tricky one!

What 3 things would you like to banish to “Room 101”?

Management speak, especially acronyms. Voice recognitionsoftware that I’m currently trying to master, unsuccessfully. Cold calls on mobile phone about PPI orsimilar.

What one piece of advice would you give to anyone – medics, researchers, technologists ornurses – starting out in sleep?

The one bit of advice is to stick with sleep through thick and thin – it’s still a Cinderella area of medicineand research that has a long way to evolve but the inherent interest and mystery around the state ofsleep continues to fascinate.

What do you hope will be your lasting legacy as President of the British Sleep Society? Whathas the experience of being President been like, and what have you learned from the experience?

I wouldn’t like to speculate on legacies but my main aim has been to involve and possibly inspireneurologists to become more involved in sleep – it’s all about the brain!

Finally, tell us something we don’t know about Dr Paul Reading…

I like to think I’m an open book, so no secrets! In my family, one of the most interesting facts is that mydad, in his days as a professional saxophonist, played the (in)famous theme tune, Yakkety-Sax”, for theBenny Hill Show – unfortunately, his musical bent was not passed on…

Thank you very much for taking the time to share your thoughts with us. I hope the BSS karaokeorganisers have taken note...

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AUGUST 2014

Location: Ashurst Education Centre, AshurstHospital, Lyndhurst Road, Southampton, SO407AR. Ashurst sits on the edge of The New Forest.

Dates: October 2014 and Jan 2015

Cost: This is a modular course allowing GPs andpaediatricians to attend the first three days of thecourse only, if they wish to do so at a cost of £495.The full five day course for all other practitionerscosts £795 per person. Please contact EvelynStewart if you are unsure which you would like todo.

Lunch, tea and coffee will be provided each day

About the teaching team

We are a multi-disciplinary team working within awell established children’s sleep disorder servicewith a track record in providing high quality training.

Who is the course designed for?

The course is designed for individuals working withchildren and adolescents who wish to develop theskills to manage common childhood sleepproblems.

Course Content

● The science of sleep

● Cutural and family perspectives

● Sleep hygiene

● Specific sleep disorders (includingbehavioural insomnia, parasomnias,

● circadian rhythm disorder)

● The psychology of sleep

● Medical aspects of sleep (includingmedication, epilepsy and snoring)

● Techniques for measuring sleep

● Managing sleep disorders in children inchildren with ADHD and autism

● Completing a sleep assessment

● Crafting and managing a sleep programme

● How to run a sleep service

● Flexible models of working

Places on these courses are limited. To find out moreor reserve a space please contact:

Evelyn Stewart on

evelyn-sleep@hotmail.co.uk

Sleep Practioner Training

he British Society of Dental Sleep Medicine (BSDSM)was founded in 2005, by Dr Roy Dookun and AdrianZacher, to encourage, support and educate dentists tobecome involved in the field of dental sleep medicine.

The BSDSM provides regular training courses at introductory andadvanced levels and has produced an accredited protocol fordentists to use to screen for obstructive sleep apnoea (OSA).Trained dentists are able to provide custom-made snoringappliances which are comfortable and adjustable, after firstscreening the patient for OSA. Snoring appliances, often knownas MADs or MRDs, can be suitable for non-apnoeic snorers or formild/moderate OSA snorers and as an alternative for CPAPintolerant patients.

The society promotes a multi-disciplinary approach, encouragingdentists to work with sleep physicians, ENT specialists and otherclinicians involved in sleep medicine. It is a non-commercialsociety and does not promote any one particular product.However, it enjoys support from several laboratories andcompanies involved in provision of appliances, screening systemsand monitoring equipment.

The BSDSM has, as its ambition, the desire to advance this fieldof work by training and educating dentists to help patients withsleep-disordered breathing and, additionally, to inform othermedical professionals of the invaluable contribution traineddentists can bring to this ever-growing field of medicine.

The next BSDSM training course will be held in London on 18October 2014. For further information and to register, please visitour website: www.dentalsleepmed.org.uk

Adrian Zacher – Co-Founder, Non-executive Director andWebmaster, British Society of Dental Sleep Medicine

T

The British Society of Dental SleepMedicine

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The International Academy of Law and Mental Health have approachedme about having a session in their next conference devoted to forensicparasomnias. The conference is on 12-17th July 2015, in Vienna. Ifanyone is interested in presenting, please contact themon admin@ialmh.org.

You can find out more about the conference here:http://www.ialmh.org/template.cgi.This would be a great opportunity to introduce the topic to a wideraudience, so I would be grateful if anyone is able to present.Dr John Rumbold, PhD candidate, Keele University

AUGUST 2014

Dr Lisa Genzel MD is a Society inScience Branco Weiss fellow at theMorris Lab, Centre for Cognitive andNeural Systems (BMS), University ofEdinburgh. Her background is based inhuman sleep and memory researchwith a focus on sex differences, patientswith psychiatric diseases and fMRIapproaches. She is also interested in translationalresearch approaches of how to bridge the gap betweenbasic animal research and human application.

Miscommunication between animaland human sleep researchers

hen asking a question in research it is importantto tackle the issue with multiple methods andapproaches to be able to gain a deeperunderstanding into the mechanisms and effects.Everyday relevance and a few techniques e.g.

repeated in vivo imaging is only possible with humansubjects, while for most interventional methods animalmodels are needed. However, most researchers are onlyfamiliar with the techniques of one field e.g. humanresearch and sometimes miscommunication and adifferent terminology creates difficulties or evenmisconceptions when translating basic animal researchto human application. In particular in sleep research thisseems to be the case. One fundamental differencebetween the fields is that human researchers name onlythe deep sleep during NREM as slow wave sleep (SWS)while many if not most animal researchers call all NREMtogether SWS. A case were this has impeded theoreticalunderstanding is sleep related memory consolidation.

When we learn something new, it is initially encodedas episodic memories with information represented indifferent cortical modules (vision, olfaction etc.) that are

W

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Temporarily interconnected via the hippocampus – an area deep within the brain. Over timethese memories undergo a systems consolidation process, which results in the strengtheningof direct intracortical connections and, according to one major theory, creating hippocampus-independent memory networks. The prefrontal cortex seems to play an important role in thisinterconnection process. Consolidation takes several forms, but one role is to extractstatistical overlap of events and eliminate non-salient aspects of memory, and in this wayepisodic memory can lead to semantic memory – a process that may occur covertly duringsleep. Two mechanisms have been proposed: (1) 'Sleep replay', the active potentiation ofrelevant synaptic connections via reactivation of patterns of network activity that had occurredduring previous experience. Overlapping replay - orchestrated by cortical slow oscillationsand executed during SWRs and followed by cortical processing during sleep spindles –enables propagation to the cortex and reprocessing there to extract statistical overlap (Genzelet al., 2014;Battaglia et al., 2012). Alternatively (2) sleep has been suggested to non-specifically, but homeostatically regulate synaptic weights by ‘downscaling’, thereby improvingsignal-to-noise ratio of memory traces. The push-pull action of replay (potentiating ‘important’traces such those fitting the current cortical networks) and downscaling (weakening irrelevanttraces) may play a role in memory network construction and updating (Lewis and Durran t,2011;Genzel et al., 2014;Diekelmann and Born, 2010).

Figure 1: Hippocampal recording in a rat (left) and a human scalp surface recording (right).During sleep stage 2, nestled between the K-complexes and spindle oscillations, sharp waveripples occur in the hippocampus and initiate the replay of memory traces in the hippocampusand cortex which hypothetically leads to consolidation processes (Genzel et al., 2014).

Research in sleep and memory is currently at an exciting stage; both studies in humansand animals provide us with compelling though arguably not yet definitive evidence of theputative processes of replay and downscaling. However, during the translation process ofanimal and human research different use of semantics has led to a misunderstanding betweenresearchers investigating humans and animals, since these two processes both are nowthought to occur during deep Non-REM sleep (slow wave sleep) leaving 75% of all sleepunaccounted for. As mentioned above researchers investigating human and animal sleepuse different terminology; while slow wave sleep contains only deep sleep (Non-REM stages3+4) in humans, it is customary to use this term in animals to describe all Non-REM sleep.Thus, when human sleep researchers translated the replay findings – only conclusivelymeasurable in animals – they read that it occurred during “SWS” while the animal esearchersmeant NREM. Even more so, based on what can be judged from published traces, rodentstudies investigating replay are likely to mostly contain light sleep, in part because of thetypically short duration of the sleep sessions.

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Another issue are unclear semantics and word definitions.Electrophysiological studies in animals and humans could showthat there seems to be a common temporal order of slowscillations, sharp wave ripples and sleep spindles , withhippocampal and cortical replay being associated with sharpwave ripples. Sharp wave ripples and spindles are clearly definedoscillatory phenomena, however slow oscillations by name aloneare not as clear. The name derives from the fact that theseoscillations are slow (0.5-1Hz)alterations between states ofgeneralised cortical excitation anddepolarised membrane potentials (UPstates) and states of relative neuronalsilence (DOWN states). The questionarises how these slow oscillations areexpressed and visualized in thesurface EEG. Initially, humanresearchers automatically associatedthe slow oscillation with slow waveactivity dominating SWS, however slowwave activity (a.k.a. delta waves) isactually a faster component (0 - 4Hz)of the EEG than pure slow oscillations.Further, while slow oscillations areglobal phenomena occurring multiplesites simultaneously and travelingacross many cortical regions, slowwave activity is a very local oscillation(Nir et al., 2011). Instead the globalslow oscillation synchronising replayevents during SWR seems to be theK-complex, which occurs throughoutNREM (Nir et al., 2011;Steriade andAmzica, 1998;Amzica and Steriade,1998;Genzel et al., 2014), while slowwave activity has been associated withdownscaling (Binder et al., 2014).

All together this shows that muchcloser communication between animaland human researchers is needed todevelop correct theories and answerquestions in a conclusive way. Further,to be able to make progress in the fieldof sleep and memory research futureresearch should incorporate bothanimal and human methods withdirectly comparable paradigms.

Reference List

Amzica F, Steriade M (1998)Electrophysiological correlates of sleep deltawaves. Electroencephalogr Clin Neurophysiol107:69-83.

Battaglia FP, Borensztajn G, Bod R (2012)Structured cognition and neural systems: Fromrats to language. Neuroscience & BiobehavioralReviews 36:1626-1639.

Binder S, Rawohl J, Born J, Marshall L (2014)Transcranial slow oscillation stimulation duringNREM sleep enhances acquisition of the radialmaze task and modulates cortical network activityin rats. Front Behav Neurosci. 7:220.doi:10.3389/fnbeh.2013.00220.

Diekelmann S, Born J (2010) The memoryfunction of sleep. Nat Rev Neurosci 11:114-126.

Genzel L, Kroes M, Dresler M, Battaglia FP(2014) Light sleep vs. slow wave sleep in memoryconsolidation: A question of global vs. localprocesses? Trends in Neurosciences 37:10-19.

Lewis PA, Durrant SJ (2011) Overlappingmemory replay during sleep builds cognitiveschemata. Trends Cogn Sci 15:343-351.

Nir Y, Staba R, Andrillon T, Vyazovskiy V,Cirelli C, Fried I, Tononi G (2011) Regional slowwaves and spindles in human sleep. Neuron70:153-169.

Steriade M, Amzica F (1998) Slow sleeposcillation, rhythmic K-complexes, and theirparoxysmal developments. J Sleep Res 7:30-35.

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As you may know, the three year project that the BLF has been running to raiseawareness of OSA and campaign for improved service provision has come toan end. Judy Harris, who led the project, looks back on three years of work andasks if the project was successful.

Awareness of OSANationally, awareness levels of OSA amongst peoplewho snore, or whose partner snores, has improved from57% in spring 2011 to 62% in spring 2014, which is astatistically significant rise. These results obtained fromonline surveys of a sample of 2,000 representative adults.The highest increase by farwas in the North east ofEngland, where awarenessrose by 17%. In 2011,awareness here was one ofthe lowest in the UK, and rose

to 72%, the second highest in 2014. This area also scored highest for thepercentage of people who snore, people who stop breathing when asleepand people who are sleepy when awake. This was where the BLF’stargeted OSA awareness campaign took place in 2013 – the area waschosen as it was highlighted as an OSA hotspot in our mapping exercise2012.The BLF’s awareness campaign included press and media work, and intotal, 215 pieces were placed – this includes television, radio and writtenpieces, in national and local media. Our online Epworth Sleepiness Scalewas completed by over 40,000 people, with 7% overall scoring 19 or over, indicating severe levelsof excessive sleepiness. We have a suite of awareness materials including posters and bannersfeaturing our “Triple S” symptoms, and a guide for GPs.

We’ve developed a suite of patient informationand campaign resources. Patient informationincludes the website information, including theaward winning OSA in children information, plushard copy resources such as the OSA leaflet,three part OSA pack, and OSA in childrenbooklet.

Campaign information includes the OSA charterand the burden of OSA infographic, as well asthe results of our OSA risk and service provisionmapping exercise, which we are using toprovide reports for MPS and health areas.

The BLF’s OSA project – did it work?

Service Improvement

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We’ve contacted every MP,have run an e-action whereconstituents have contactedtheir parliamentaryrepresentative (400 times), andhave hosted two parliamentaryreceptions on OSA in Englandand Northern Ireland. Wepresented at a recent freighttransport and obesity All PartyParliamentary Group meetingon OSA, and have produced apolicy report called “NextSteps”.

Our project ended with aconference for health careprofessionals who identifiedwhat needs to be done toensure OSA is a priority in thefuture. The report from theconference and the year threereport from the project can bedownloaded here:www.blf.org.uk/Page/Obstructive-Sleep-Apnoea

Finally, our patient survey,the largest ever under taken,has been completed. 53 clinicsfrom across the UK gave outsurvey questionnaires to their

OSA patients and nearly 3,000were returned for analysis.

Headline results of the OSApatient survey - The 44% whohad heard of OSA beforediagnosis sought medical helpon average 10 months earlierthan those who had not. 11% ofdrivers said they had fallenasleep driving and 2% admittedhaving a road traffic accidentcaused by sleepiness but atdiagnosis only 62% of driverswere told of the requirement toinform the UK Driver andVehicle Licensing Authority(DVLA). 62% had positiveemotional reactions to receivingtheir diagnosis, the mostcommon one being relief. Only56% received writteninformation about OSA atdiagnosis. 92% were treatedwith continuous positive airwaypressure (CPAP), which almostall said was the best treatmentfor them. Treatment had ahighly significant positiveimpact on well being for allpatient groups, butimprovements were significantlygreater for those who: had more

severe OSA; reacted positivelyto diagnosis; were using CPAPfor more hours per night; hadweight problems; were younger.These results highlight theneed: to raise awareness ofOSA in the general population;for a positive patient experienceat diagnosis and the importanceof providing mechanisms toencourage CPAP compliance.They also identify gaps inproviding patient informationabout OSA, and advisingpatients about informing theDVLA. Full results will beavailable on request from thesummer.

Thank youThanks to our funders Philips Respironics and ResMed, and also themany partner organisations who have helped us, particularly the BSSand ARTP.

What nextSo, did it work? We’re proud of what’s been achieved, but there is stillmuch to do. The BLF’s work in OSA does not stop here – in 2014, we’llcontinue to campaign and will be writing a health economics report onOSA and producing a toolkit for commissioning OSA services.

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This is a joint publication by theBSS and ARTP

AUGUST 2014

Review of The European Sleep School,Orehuela, Spain.

Several months ago, I asked Simone de Lacy to design a bespoke course in PSG for myselfand two other colleagues. How delighted were we when our Trust gave us the go ahead to attendthe European Sleep School in January.

We choose to go out in January, booking the cheapest flights we could! On arrival at 10am atthe airport, Phil, Sim’s husband , was waiting where he had arranged to meet us and drove us backto the house in Orehuela. We quickly settled in after refreshments, starting straight away, with thefirst of several modules. Sim explained the course content, running through the order of subjectsalong with the weeks timetable. It was agreed that we would wire up one Tech the following nightand so on, until each had undergone their own PSG. We would also be scoring them! Sim haddesigned a comprehensive course that covered in detail, the topics we needed.

The first night saw us all collapsed into bed by 11pm but looking forward to the week ahead.Each morning, following breakfast, we studied until lunchtime, in the purpose laid out school, with abrief break for coffee before the remainder of the session, until about 5pm. During classes, Sim wasvery patient and gave us plenty of time to answer the many questions we had. Learning in a relaxedatmosphere, without the pressure of phones and clinical demands, was perfect. The course, speciallydesign ed for us, encompassed all we asked for and more. I worried that as a mixed skill set, ourTeacher would find it difficult to teach at different levels but this wasn’t a problem. Her professionalismcomes across along with her extensive knowledge of the subject matter, (some 30 years or more)which makes this school, a must for all.

Sim’s sister was in charge of catering and kept us supplied with homemade goodies for ourelevenses’ and excellent meals throughout the week. Each night after dinner, we went back downto the lab and wired each other up. Although they were long days, we were more than happy to belearning from someone so accomplished and respected in the world of Sleep Medicine. By the middleof the week, we had an evening off and attended the famous ‘Quiz Night’ (and won, I might add) atthe local tavern! Needless to say, no one was wired up on this particular occasion!

By the end of the week, we had covered several modules and wired each other up for a fullPSG. We would certainly recommend the European School for training inPolysomnography/Oximetry/Actigraphy/etc. The following week, one of our Consultants went outto the school also for his bespoke 4 day course. The relaxed, hands-on approach made all thedifference and her positive and caring attitude was very encouraging. We all wish her well andthank her for a great experience! Muchas Gracias Maestra!

By Jill Meeres - Principal Sleep Technologist and Unit Manager,Sleep Studies Unit, Conquest Hospital, Hastings

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AUGUST 2014How Do YOU Sleep?We’ve all been asked, “Wow, sleep – how did you get into that?”, and

nearly all of us will have a different answer. In a specialty which still lacks adefined training pathway and crosses over so many different disciplines and

job types, how do those working in sleep get there? And what do theyactually do in their many diverse roles? In this new feature, we explore thevariety of roles and career pathways of people working in sleep today, andthe wide range of opportunities for those looking to broaden their horizons

in sleep. Share your story by emailing lizzie.hill@ed.ac.uk

or me the title should be‘falling into sleep’, as itwasn’t planned. Afterflunking my physics ‘A’

level, I lost my place atEdinburgh University VetSchool. Edinburgh looked nicewhen I went for the interview soI decided, as an 18 year old, tosee what I could get throughclearing. I accepted a place todo Agriculture, but latertransferred to Life Sciences andstudied microbiology,immunology, evolution,physiology, pharmacology andpopulation biology. The thirdyear was more specialised. Ichose physiology, anatomy,pharmacology &pharmacological physiologybased on the fact that theselectures were closer to my flat,so I could have longer in bed –perhaps a career in sleep wasinevitable!

At this point everythingchanged and I becamecaptivated with the amazinghuman body and with research.Unlike my other subjects, which

were traditional lectures,tutorials and practical’s,Pharmacological Physiologywas a small class of about 12who met up twice a week. At thebeginning of the week we weregiven a recent publication on ahot topic. Our week’s work wasto totally dissect the paperbefore presenting it to the rest ofthe group later that week. Myinitial enthusiasm for this modulewas probably because itsounded very low maintenance!However, I became hooked onpresenting researchmethodology and critical review.Physiology was the topic for meand I chose this for my honoursyear.

Halfway through my finalyear, when most of myclassmates were consideringphysiotherapy or medical school,I knew I wanted to do a PhD, butdidn’t have a clue what in. Myrespiratory lecturer offered meresearch on rabbits and tobaccosmoke. Alternatively hesuggested I contact a doctorover at the Royal Infirmary who

did human sleep research.Obviously from my vet dreamdays, I was an animal lover, sothe idea of experimenting onhumans sounded much moreappropriate! I wrote to this sleepresearch medic and asked himif I could do a PhD. He wroteback and said that if I got a 2:1,I would be initially funded for ayear, and if I got a 1st, I would beawarded funding for three years.I got a 2:1 BSc Hons inPhysiology and then embarkedon the first year of a PhD withProf Neil Douglas at EdinburghUniversity. It didn’t take me longto realise that I was working witha sleep world expert! I remainedin the sleep research group forthe next 6 years doing my PhDand then post-doc work. My timespent in the Edinburgh SleepUnit was amazing. I undertook arange of research projects onsleep apnoea patients andnormal volunteers, learnt topresent at conferences, interpretand publish data and completedmy PhD. Sleep was a fast-moving field during the mid-1990’s.

F

Dr Ruth Kingshott – Sleep Physiologist, SheffieldChildren’s Hospital

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We went from paper to computerisedPSG systems; meanwhile nasalpressure, mandibular advancementsplints and auto-setting CPAP deviceswere all being developed. In 2000 myhusband got a job in New Zealand andwe moved to Dunedin. I did somedetective work and arranged a job at asleep unit there. I embarked on severalresearch projects during our 2.5 yeartrip. In New Zealand I learnt many newskills including the benefits ofcollaboration; collaborators including alocal dentist, Fisher & Paykel and thedriving authorities who provided vehiclemotor accident data. I also undertookand passed my RPSGT in Sydney in2001 in order to gain a formal sleepqualification, at that time not availablein the UK.

In 2002 we moved back to the UK,to Sheffield, as my husband had got alectureship at the University. Fourmonths after the birth of my first child,a friend mentioned there was a job atSheffield Children’s Hospital doing ‘thatsleep thing that you do’, so I embarkedon a part time job as a ClinicalPaediatric Sleep Physiologist. Not longafter I had started I realised I had finallyfound the area of sleep medicine that Ifelt totally at home with, Paediatrics! Inow have 12 years of experience in thisarea. I love working with patients acrossa large age range, and interacting withthe whole family. The huge array ofmedical conditions leading to paediatricsleep disorders ensures the workremains exciting. I also love thechallenge of the PSG itself. Myenthusiasm for research has continuedbecause there are so many unansweredpaediatric sleep questions, and now Ihave both clinical and research roles.

So in summary, my pathway intosleep was through my love of research,the luck of unknowingly contacting aworld sleep expert and following myhusband around the world! None of itwas planned.

My son modelling for the sleep unitinformation sheets

My daughter modelling for the sleep unitinformation sheets.

My husband and I doing a pilot study for DrNigel McArdle’s ‘patient vs partner’ OSA

research. Apologies for the brown bedding (itwas the 90’s)!

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Dates for your Diary…

Events and MeetingBSS Meetings

22-24 October 2015

British Sleep Society Scientific Meeting

Gateshead, UK

Other meetings and courses

06-10 September 2014

European Respiratory Society Annual Congress

Munich, Germany

15 September 2014

Sleep Scotland Paediatric sleep study day

London, UK

16-20 September 2014

22nd Congress of the European Sleep Research Society (ESRS),

including ESRS Somnologist Technologist Exam

Tallinn, Estonia

19 September 2014

Scottish Sleep Forum

Stirling, UK

30 September 2014

An introduction and update on sleep and the law - is it like threading a needle?

Royal Society of Medicine

London, UK

18 October 2014

British Society of Dental Sleep Medicine course

London, UK

27 October 2014

Sleep Scotland Paediatric sleep study day

Edinburgh, UK

17-20 November 2014

International Sleep Medicine Course

The Netherlands

19 November 2014

CBT for insomnia disorder: Evidence base and practical implementation

methods

Royal Society of Medicine Sleep Medicine Section meeting

London, UK

16-20 March 2015

Edinburgh Sleep Medicine Course

Edinburgh, UK

21-25 March 2015

World Congress on Sleep Medicine congress

Seoul, Korea

10-11 April 2015

4th Cardiosleep International Congress

Paris, France

Are you running a meeting which might be of interest to BSS

members? Please contact the Editor (lizzie.hill@ed.ac.uk) to have it

featured here.

Executive committee

British Sleep Society Committee

Dr Paul Reading PresidentDr Simon Merritt TreasurerLizzie Hill Newsletter EditorAndrew Morley SecretaryJill Meeres Hands On Meeting OrganiserMary Morrell Scientific Meeting OrganiserProf Adrian WilliamsDr Tim QuinnellDr Renata RihaDr Charlotte Kemp

Co-opted Members of the Executive Committee

Simone de Lacy Education OfficerDr John O’Reilly ISMC Meeting OrganiserRobert Royston Commercial Liaison OfficerDavid Jones PBEC/ACHS Liaison

To contact any of the above please email the BSS Office orSecretary. Your email will be forwarded immediately to theappropriate member, or if requested shared with all theExecutive Committee. The Executive Committee is of courseelected to represent our society’s membership and is thusavailable to consult on all issues relevant to its membership.

Membership

BSS Membership Fees & Bank Standing Order

To reduce BSS administration costs we ask that allmembers pay their membership by bank standing order. Ifyou would like a standing order form please contact theBSS Office. However, if you wish to pay by Bank transferplease contact the BSS Office.

BSS Contact Address

BSSc/o EBSCity WharfDavidson RoadLichfieldStaffordshireWS14 9DZ

Email: admin@sleepsociety.org.ukFax: 0121 355 2420Conference Enquiries:enquiries@newcastlesleep2015.co.uk

Ongoing

European Sleep School - bespoke training courses

The European Sleep School in Orihuela Costa, Spain, provides

bespoke training courses for medical professionals wishing to

perfect their skills in performing and interpreting

polysomnography and other sleep diagnostics.

www.sleepsociety.org.uk