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Conference ReportThe Neurosurgical PerspectiveClinical Neurosciences 2005 was hosted by theDepartment of Clinical Neurosciences,Peninsula Medical School. The meeting openedwith a Trainees teaching session, entitled‘Getting out of trouble’. This was a great success– firstly, because it was free, and secondly,because the trainees had not previously knownthat their consultants had ever been in trouble.However, the topics remained professional, andsome useful insights and experiences were eloquentlypassed on to the next generation. Thissession occurred in parallel with aNeurosciences Nurses Session, a first and longoverdue addition to the SBNS meetings. Withthe increasing role that nurses are playing in theclinical and academic neurosciences, we anticipatethat this successful session will set a precedentfor future meetings.Delegates then were welcomed to the meetingproper by Mr James Palmer and ProfessorJohn Zajicek, with a historical perspective coveringthe naval connections and developmentof Neurosurgery in the region. The move fromlectures towards debate has become a trend inrecent meetings that continued here with a livelysession on ‘Neurologists should look afterpatients with subarachnoid haemorrhage’.Voting involved each member of the audiencepointing to a yes or no section of the stage witha laser pointer. Some interesting points wereenergetically made, but the only clear conclusionwas that neurosurgeons had steadier handswith laser pointers.The second plenary session was a high qualitycombination of four talks representingNeurosurgery and Neurology from the UK andHolland. Mr Richard Kerr, Oxford, presentedthe latest data from the InternationalSubarachnoid Aneurysm Trial (including 7 yearmortality data) and Dr Martin van den Bent,Rotterdam, presented the results of a phase IIIstudy of combination chemotherapy foranaplastic oligodendroglioma.The sponsored satellite symposia were a greatsuccess, with Professor David Miller chairingdevelopments in the treatment of MS, andProfessor John Pickard presiding over currentopinions on normal pressure hydrocephalusand its management. The delegates were thenwitness to the delights of Torquay by night, andthe sponsors’ contributions were both enjoyedand appreciated.The third plenary session provided an excellentsynopsis of the current management oflow-grade glioma with contributions from bothsides of the Atlantic. Professor Peter Black,Boston, USA, provided a contemporary view onthe surgical management of low-grade gliomas,where important advances in technology,notably intra-operative MRI scanning, weredemonstrated. Clearly this intervention willhave a significant impact on whether and howpatients are treated early with radical resectionover watchful waiting.The breakout SBNS sessions comprised neurovascular,neuro-oncology, spine/trauma,movement disorder and audit. There was a livelysession chaired by Mr Richard Nelson(Bristol) and Mr Peter Whitfield (Plymouth)on neurovascular developments in the managementof subarachnoid haemorrhage, while MrJames Palmer (Plymouth) and Mr MichaelPowell (London) looked over advances intumour management with a particular focus onadjuvant therapies. Mr Robin Johnston(Glasgow) and Mr Lou Pobereskin (Plymouth)chaired an eclectic session that could have beentitled ‘pain in the neck’, covering topics such asthe role of neuronavigation in cervical surgeryto the problems we face in getting neurotraumapatients to appropriate centres quickly. Finally,Mr Ken Lindsay (Glasgow) and Miss AnneMoore (Plymouth) chaired an interesting sessionon the surgical management of movementdisorder.The meeting concluded with a debate onphysician assisted dying with arguments presentedby Deborah Annetts from the VoluntaryEuthanasia Society, Dr Bert Keizer discussingphysician assisted dying in Holland, and DrHelen Watt, ethicist. As anticipated, strongviews were expressed by both speakers andaudience. The pros and cons of the Joffe Bill,due to go before the House of Lords, inNovember were discussed at length.Overall, Clinical Neurosciences 2005 was ahugely successful meeting with healthy interactionbetween surgeons / physicians and Dutch /British alike. An enjoyable social programme,the pinnacle of which was a Gala Banquet at theBritannia Naval College, Dartmouth, supportedits strong scientific content.PJ Hutchinson and RJ Mannion,Derriford Hospital, Plymouth, UK.AcknowledgementsMany thanks to the local organising committee comprisingJames Palmer, Peter Whitfield, Anne Moore, John Zajicek,Martin Sadler, Simon Edwards, Louise Davies, Jo Henleyand Tracey Holman.The 17th Annual Scientific Meeting of the British Sleep SocietyCambridge, UK, 25-27 September, 2005.Having previously been a peripateticsymposium, the 2005 BSS scientificmeeting was held for a fifth consecutiveyear at Robinson. A negative view mightsuggest this implies (small ‘c’) conservatismand a fear of change. However, the positivealternative is true. There exists a growing andcompelling seasonal urge that keeps the eclecticBritish sleep community returning to thiscorner of Cambridge. Some propose this has abasis in melatonin secretion and breedinghabits, others are probably attracted by thesuperb Robinson cuisine. One not altogetherfanciful reason for return is that the BSS meetinginvariably coincides with a visit from a funlovinggroup of Portuguese proctologistsfamed for their disinhibited dancing techniques.Rather more soberly, however, theexcellent nearby parking probably provides themain rationale. Whatever the reasons for coming,the meeting invariably provides the delegatewith a veritable pot pourri of reviews andnew data, relating to every conceivable aspectof sleep medicine. This year was certainly noexception with a stated theme of ‘FromGenotype to Phenotype: what’s sleep got to dowith it?’The programme kicked off with an eveningsymposium chaired by Jonathan Bird thataddressed sleep from a psychiatric perspective,stretching from cradle to grave. It is a soberingthought that psychiatrists receive even lesstraining than neurologists in sleep medicine,yet probably see a greater proportion ofpatients with significantly disordered sleep.Distinguishing between the deleterious effectsof mood disorder on sleep and the consequencesof a defined sleep disorder on mood isa minefield within which even those experiencedin sleep medicine tread carefully. This isparticularly true at the extremes of age.Professor Gregory Stores, an acknowledgedexpert in adolescent sleep problems, addressedthe area with an overview of those sleep disordersfrequently mistaken for psychiatric or psychologicaldistress. Dr Chris Hawley thenaddressed the issue of excessive daytime sleepiness,as opposed to fatigue, in a general psychiatricpopulation, emphasising a much neededsystematic approach to assessment and treatment.This meat of the symposium wasenclosed by two entertaining and enlighteningpersonal reviews by Dr Paul Gringras and DrAvi Dhariwal. The former discussed how herbs,hormones and hypnotics are used (andabused) in children, the latter how sleep problemsmay severely affect the elderly, yet remaincompletely off the radar of the physicians incharge.The first day of the meeting proper startedwith a superb overview of gene research in thefield of intracellular clock mechanisms bySimon Archer from Surrey University. Havingleapt to popular fame on a recent RobertWinston sleep documentary, Simon gave anauthoritative and particularly comprehensiveaccount of ‘clock’ genes, highlighting the surprisingextent to which humans remainhostage to our internal clocks. He focused particularlyon how polymorphisms in certain keyclock genes may determine whether we are‘night owls’ or ‘’morning larks’ and thereforebetter suited to careers as croupiers or milkmen.Cyclical production and degradation of asmall number of proteins as they pass between30 I ACNR • VOLUME 5 NUMBER 6 • JANUARY/FEBRUARY 2006
Conference Reportthe nucleus and cytoplasm provides the basisof circadian timing. The tightly orchestratedmechanism is essentially the same in fruit fliesas it is in humans and represents a truly fascinatingarea of biology. We are only just beginningto comprehend the effects these primitiveprocesses have on functions such as repair,metabolism and the immune system. Thepotential application of such knowledge iscolossal.The second keynote speaker was PatrickLevy from Grenoble whose pivotal work inunravelling the unholy trinity of (visceral)obesity, the metabolic syndrome and obstructivesleep apnoea is widely acknowledged. Thetalk focused on how intermittent hypoxia dueto OSA may independently lead to impairedglucose tolerance and leptin (the ‘satiety’ peptide)gene dysregulation. One current theme ofsuch research is that OSA sufferers will gainvisceral fat independently and directly becauseof their fragmented sleep, thereby worseningtheir OSA. Whether appropriate treatment ofOSA can offset this proposed vicious cycleremains an area of debate. Subsequent talksthrough the morning addressed these issuesfurther, broadening the topical discussion toinclude the potential damaging effects ofincreased cytokines and oxidative stress secondaryto severe OSA.The first afternoon was dominated by furtherinsights into the metabolic consequencesof OSA, followed by the ‘free communications’session. The latter included talks on topics asdiverse as CRP levels in sleep-disorderedbreathing and the effects of behavioural interventionfor sleeplessness in autistic children.There then followed a relatively painless AGMbefore the feverishly anticipated gala dinner.With so much education in the previous 10hours on matters germane to sleep hygiene andthe metabolic syndrome, one might haveexpected a sober and reflective evening. Ofcourse, the adage ‘do what I say, not what I do’applied with the inevitable consequences ofoverindulgence and sleep deprivation the followingmorning for the majority.The second day of the meeting was dominatedby matters paediatric, from womb to adolescence,a much neglected area of sleep medicineparticularly in the UK. Fascinating materialwas presented concerning the activity-restcycles of the foetus and their relations to autonomicfunction and dysfunction. It is extremelyinteresting to reflect that the foetus in its latterstages of development spends well over50% of its existence in a state akin to REMsleep, a fact rarely incorporated into theories ofREM (dream) sleep. Moving into the first yearof life, a lecture by Dr Helen Ball, an anthropologistfrom Durham University, was equallyenlightening and somewhat leftfield to those ofus working in more conventional areas of medicine.It mostly dealt with how we sleep, or,rather, don’t sleep, with our infant offspring.Since Victorian times or a little before, it can beargued that humans in Westernised societieshave fought an evolutionary and naturalinstinct to sleep along side our infants.Certainly in ‘underdeveloped’ cultures, it is thenorm to sleep with the very young and breastfeed through the night. Interesting video datawere shown, outlining how the maternal positionis generally stereotyped in the shared bed.When deviations from this pattern wereobserved, accompanying problems with sleepfor the mother and infant became evident. Acogent argument was made that having infantssleeping in distant beds or rooms to the parentwas often the primary cause of psychosocialproblems and disrupted sleep. The final talk ofthe paediatric session was an inspirational andwide-ranging discourse from Ron Dahl, a professorfrom Pittsburgh, on ‘Sleep and EmotionRegulation in Children and Adolescents’.Combining ‘hard’ data with psychological theory,he addressed the myriad of potential sleepproblems and associated behavioural difficultiesthat can affect teenagers.The final session of the meeting was devotedto 3 case studies from different areas ofsleep medicine, each of which had a ‘message’.We heard from Sophie West about a patientwith dreadful OSA, diabetes and extreme obesity(BMI > 50) whose long term managementwas helped immensely by gastric (bariatric)surgery. Renata Riha presented an interestingparasomnia case with videos showing a youngman exhibiting a so-called ‘rhythmic movementdisorder’ of sleep. This is thought torepresent the persistence into adulthood of adisorder akin to ‘head banging’, a commonchildhood sleep phenomenon, usually atsleep-wake transition. The rhythmical movementscan involve various body parts andaffect the patient in any sleep stage, includingREM. Invariably it is the bed partner who suffersin this situation. Indeed, one commonlyheld theory is that the movements are, in asense, gratifying to the subject and bestviewed as a form of sleep-related tic. Thethird case from Ron Dahl was a teenager withdelayed sleep phase syndrome, a not uncommoncircadian rhythm disorder, usually misdiagnosedas ‘lazyitis’. Good evidence suggestthat sufferers have an inherent phase delay intheir circadian timing such they are compelledto sleep a few hours later than average,the resulting lay-in often causing major upsetwith parents and educators alike. Cultural andsociological factors are also clearly importantin fuelling the abnormal sleep-wake pattern.The case study described one behavioural wayof treating this problem which, paradoxically,involved sequentially delaying sleep further by3 hours each night over 6 days until a conventionalsleep onset time was achieved. Thistight schedule appeared successful in thepatient discussed and the need for medicationobviated.In conclusion, speaking as a veteran of thelast 6 annual BSS meetings, I think this wasprobably the most rewarding to date, despiteconcentrating on areas largely foreign to myclinical practice. Particular credit must go toDr Mary Morrell from the National Heart andLung Institute who was the main driving forceon the scientific committee that organised themeeting. It never ceases to amaze me howbroad are the horizons for sleep medicine.Although it is still very much a ‘Cinderalla’discipline in the UK, even compared to continentalEurope, the enthusiasm generated bymutli-disciplinary meetings such as thoseorganised by the BSS bodes well for thefuture. A working knowledge of sleep biologyand the wide-ranging consequences of whenit goes wrong should surely be essential to allhealth practitioners dealing with the brainand mind.Paul Reading,James Cook University Hospital,Middlesbrough, UK.Additional web content www.acnr.co.ukEuroYapMeet - European Conference for Younger People with Parkinson’s disease, was held in Dublin, 7-9 October 2005.For a report on this event see www.epda.eu.com/For a report on ‘Innovations in Brain Injury Rehabilitation’ (Manchester, September 28-30 2005),see www.acnr.co.uk/events.htmACNR • VOLUME 5 NUMBER 6 • JANUARY/FEBRUARY 2006 I 31
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