30 November, 2008

Minute of the Symposium




Dr Douglas McLellan, President, welcomed members of the Society, guests and our guest speakers. Dr Steve Banham, based at Gartnavel General Hospital runs the Assisted Ventilation Service for the West of Scotland and is Respiratory Specialty Adviser to Greater Glasgow Health Board. Professor Colin Espie established the Glasgow Sleep Research Centre based at the Southern General Hospital. Mr Brian Bingham is an ENT Surgeon with a long interest in, and experience of, management of snoring.

Sleep Breathing Disorders and Treatments That Can Transform Lives – Dr Banham

Dr Banham briefly reviewed the physiology of breathing at night – reduced ventilation during non-REM sleep and basic patterns of change in ventilation and arterial gases seen in obstructive sleep apnoea and in hypoventilation. Obstructive sleep apnoea is common affecting perhaps 4% of men and 2% of women. The clinical problem it presents is of daytime sleepiness rather than the actual nocturnal events. There is also an association with hypertension and cardiovascular disease. The Epworth sleepiness scale is a useful screening tool. Diagnosis is by overnight sleep study with limited home studies being generally adequate – full polysomnography unnecessary. Management with CPAP overnight ventilation is very effective and successfully tolerated in upwards of 70% of appropriate patients.

He went on to describe the principles of bi-level non-invasive assisted ventilation. Unlike CPAP which overcomes upper airway obstruction, bi-level ventilation increases breath by breath ventilation and hence improves gas exchange in a situation of failing respiration. He explained the use of this support in mechanical Chest Bellows disease, neuromuscular diseases, and some patients with chronic respiratory failure. This treatment has given some patients with chest wall deformity a normal life expectancy and has increased survival in Duchenne muscular dystrophy by around 10 years. Appreciation of the effectiveness of treatment has led to elective monitoring of patients at risk of drifting into respiratory failure.

These forms of overnight ventilatory support can genuinely transform the lives of both patients and families.

Practical Interventions for Insomnia in Primary Care – Professor Espie

Insomnia is common though precisely how common depends on definition. Simple primary insomnia is defined as poor sleep with daytime distress lasting for over a month. If it lasts for six months with the patient increasingly focused on the problem, it is described as psychophysiological insomnia. Around 10% of adults probably have insomnia severe enough to result in daytime consequences. The frequency and importance of insomnia is mirrored in various surveys. Sleep problems closely followed by the commonly associated fatigue are the commonest form of psychological morbidity in general surveys. There is an association between insomnia and depression with the former seeming to pre-date and perhaps predispose to the latter. This observation includes children. Insomnia and fatigue are similarly very common problems following treatment for cancer.

Management options include sleeping tablets and sleep hygiene advice but both approaches are of limited value. Cognitive behavioural therapy techniques have increasingly been developed to manage insomnia and are now of proven success. They underlie the approach of Professor Espie's work at the Sleep Centre. His research activities have now developed to having nurses from General Practice and Cancer Support working as CBT therapists giving a programme for insomnia of five, hour-long, sessions. These programmes improve sleep pattern and symptoms of fatigue, anxiety and depression. At their core is a change in the attitude of the patient to sleep and sleep problems. There may be future drug developments in insomnia management – Circadin which is fairly new can alter the timing of sleep cycles. However he felt that CBT is proven and should be promoted. The problem is how to achieve this with no Health Service funding currently available. His hope is that opportunities for training in this approach might increasingly be taken up.

A History of Surgery and Other Techniques to Resolve Snoring – Mr Bingham

Mr Bingham reviewed the animal kingdom, variations in nasal anatomy and Bernoulli principal in discussing the question of why we snore – the latter explains the flutter mechanism which creates noise from the floppy soft palate. Nasal obstruction, whether anatomical or temporary, increases snoring by change in airflow. Alcohol and sedatives do so by reducing muscle tone and hence increasing narrowing. Is it possible that exercise could reduce snoring by improving tone in neck muscles rather than simply by weight loss?

The other side of the problem is the snoree – why does this noise disturb us when the hearing mechanism is capable of shutting off background noise such as traffic. Perhaps it is the irregularity of the noise. His approach to snoring management started with simple measures such as nasal treatment, exercise and diet. Some of his patients benefited substantially from a simple CPAP type positive pressure mask. Dental splints – mandibular advancement devices – probably only help one third of those who try them. Surgery to the soft palate in appropriate patients is successful at the expense of two weeks of pain. It is important to exclude sleep apnoea first.

The evening was closed by Dr McKean offering a vote of thanks to all three speakers and the President presenting them with the Society's engraved glasses.

D. Macintyre

Minute of the Presidential Address



Dr Douglas McLellan was introduced by last year's President Dr Watson. His address on 'Pathological Pursuits' was subtitled 'The Psychopathology of Collectomania'.

Dr McLellan did not intend describing his own collecting interests or specifically looking at particular collecting habits – books, stamps, coins, etc. He wanted to look at the characteristics which defined or were common to the habit of collecting. He provided a definition – a pursuit followed actively, selectively and passionately involving the removal from normal use into the collection of a set of non-identical objects or experiences. At times the behaviour might be seen as addictive or even manic – hence terms such as bibliomania. Often the process of acquisition was more attractive than ownership itself with collectors using any variety of excuse to pursue an object. The rarity of the object might well increase the challenge of the pursuit. Inevitably the collection or its acquisition can become a controlling factor in the collector's life.

Dr McLellan identified various characteristics driving the collecting impulse by illustration from various historical figures. Alexander the Great collected historical artefacts, apparently through longing or nostalgia for a bygone era. In Sigmund Freud's case the loss of his father seemed to trigger his drive to acquisition of around 3000 objects from antiquity. These crowded his desk and as may often be the case perhaps said a fair amount about the collector. Sir Thomas Phillips, described as a vellomaniac Victorian, was initially driven by a desire to rescue manuscripts which might otherwise have been destroyed but ended up living in what others described as uninhabitable squalor with every room in his mansion house crowded with papers of all sorts.

Perhaps in general collecting tends to be a male trait with women investing more in relationships. However the foremost collector of modern art was Peggy Guggenheim. Again loss may have been a factor – the death of her father in the Titanic. She appeared to collect not only art but men – famous for her sequence of affairs. One possible analysis is that collecting takes over when the individual cannot find what he or she is looking for – and transfers attention to something else.

Perhaps the most striking of the list was Cardinal Mazarin at the Court of Louis XIV. It was said that his collecting formed an attempt to improve his rather cold and calculating external character. He amassed a huge collection of art and books including 660 paintings. The most morbid example was the 15th Century Cardinal Albrecht von Hohenzollern, a collector of religious relics and indulgences. The former amounted to over 20,000 with 42 intact bodies among them – an observation of some passing interest given Dr McLellan’s profession. 'Indulgences' from the church authorities gave the prospect of remission from purgatory and the cardinal amassed 39 million years' worth. He funded his collecting by selling indulgences – one of the abuses of church authority which led to Martin Luther's revolt.

Dr McLellan had given us an interesting insight into patterns and examples of collecting without hinting at, or explaining, his own habits. It was left to Mr George Gray, his neighbour, in proposing a vote of thanks to comment that Mrs McLellan was probably grateful that her husband did not follow some of the excesses he had described.

D. Macintyre