Vicky

Once again. Good evening, and a very warm welcome to our webinar on respiratory medicine. My name is Vicky, and I'll be your host this evening. I'm delighted to be joined by our expert speaker, Dr Sandip Banerjee, Consultant Respiratory, and Sleep Physician here at Benenden Hospital.

Tonight's session will begin with a presentation followed by a live Q&A If you have any questions at any point, please feel free to submit them using the Q&A icon at the bottom of your screen.

You're welcome to ask anonymously or include your name. But just a quick note that the session is being recorded. So any name shared may be visible in the recording.

If you're interested in booking a consultation, we'll share all the relevant contact details at the end of the session.

So I'm going to hand over to Dr Banerjee, and you'll hear from me again later.

Dr Sandip Banerjee

Evening, everyone. So let me start off by introducing myself. I'm Dr Sandip Banerjee. I'm a Consultant, Respiratory Physician for Medway Maritime Hospital and today's conversation or discussion is purely to introduce respiratory and sleep services that have been started here at Benenden Hospital, and I thought, I shall give you a brief flavor of what our service looks like.

So what I've included in today's session is to talk about sleep for a brief period of time, and then we'll talk a little bit about asthma, which seems to be a condition that is affecting lots of people here, especially in the southeast of England.

So we frequently ask ourselves, how do we define what is good quality sleep? And I suspect our perception of a good night's sleep is when one can fall asleep easily, we do not wake up through the night, we don't wake up too early, and we feel fairly refreshed when we wake up in the morning.

Now that is our perception. But for that to happen, something happens in the background, and that is very important to understand, and that is where I would be using my expertise in helping you understand sleep a bit better.

So this is a simplistic way of trying to understand what our brains do when we sleep. As you can see, when we are awake, our brain has certain type of activity, and then, as we start drifting into sleep, we first go into light sleep, then we spend some time in deep sleep, and then gradually progress to the line in red that we call as REM sleep.

And as you can see from this schematic diagram that the period of deep sleep keeps reducing as we go through the night, and the period in REM sleep keeps increasing as we go through the night.

Now you may be asking, okay, so that is what our brains do but what is really important as part of our sleep.

Now we have to understand that we have to have a good period of time in deep sleep, because that is the most restorative phase of sleep that our brains go through. It is in this period that our brain has the opportunity to replenish itself physically as well as to help promote immune cells to improve and increase our immunity.

The REM phase of sleep helps us to replenish our emotional regeneration within our brain.

And so clearly we need a good combination of deep sleep and REM sleep to feel fairly refreshed when we wake up in the morning.

If you're asking for numbers, then we roughly need to have at least 25 to 30% of our sleep time in deep sleep, to feel fairly refreshed physically and mentally in the morning, on waking up.

So the question that I would be asking is quantity important, or is quality important?

Of course, quality is what is most important for us, but duration is also important, so most adults would require between seven to 9 hours of sleep, with equitable distribution of deep sleep and REM sleep.

Anything that interrupts this pattern of brain activity through the night can impair your quality of sleep.

So some of the common conditions that can lead to sleep disruptions are sleep disorders. So something that you've come across quite often, especially with your partners, complaining, maybe, about snoring or sleep, apnoea, and in some individuals you may develop restless legs.

There are other conditions that can also affect your sleep quality, and that includes pain, you know, if you are a young mother looking after young children or a carer, then caregiving responsibilities means that you're constantly very active, and your brain is constantly racing, not allowing you the opportunity to relax and sleep.

If you're menopausal or perimenopausal, and you have night sweats that can also affect and disrupt your sleep. If the environment within your room is not comfortable, and that can affect sleep. And of course Noctua or nighttime trips to the bathroom can also affect sleep quality.

That is what the role of a sleep physician is to try and understand if the quality of sleep that you're having is good and what are the factors that may be affecting your sleep quality.

Now, if you have good quality, sleep, there are significant benefits. Your mood is happier. You're able to cope with stress a little better. And you find that at work you have extra energy. You're able to focus and concentrate for longer periods of time, and almost certainly you find that memory is definitely getting significantly better.

Now there is evidence to suggest that having good quality, sleep definitely makes people more efficient and productive at work, but also results in fewer accidents at work, and therefore associate with fewer injuries.

Now, as I mentioned that if you have good quality of deep sleep. It does have a positive impact on your immune system, and that very often leads to a significantly better or reduced prevalence or incidence of health problems, such as hypertension diabetes, and other issues that are associated with poor quality sleep.

So, putting all of this together, if you are trying to ensure that you have good quality sleep. There are quite a few things that together lead to you, having better quality. Sleep at night, for instance, ensuring that the sleep environment is conducive to sleeping, it is generally stated, having a cooler room. Darker room tends to help you sleep better, having a fixed routine.

So you go to bed at a fixed time, you wake up at a fixed time, tends to be very helpful. We know that you should be off phones and devices for at least 60 to 90 minutes before your scheduled bedtime. Try and relax at the time before bedtime. So if you're stressed, you need to try and de-stress yourself.

We definitely suggest that avoid caffeine after 3pm. Because it tends to have an impact with sleep quality and avoid large meals just before bedtime.

Now, if you've seen this thing I've written here napping for greater than 30 minutes, there is some evidence to suggest that if you nap for very long during the daytime your Melatonin surge reduces, and melatonin is our main sleep hormone, and so, having a good surge of melatonin, actually always helps with having good quality sleep.

So I hope I've given you a good background of what sleep is and what is good quality sleep at night, and so then I'll start speaking about something that I specialize, and we have started offering this service here at, sorry, at Benenden Hospital.

So sleep apnoea. Now what is sleep apnoea, sleep apnoea is a condition where you transiently stop breathing. These cessations of breathing efforts can last from between 10 seconds to 59 seconds.

The vast majority of cases are obstructive. But you can have this central etiologies for breathing cessation as well. We'll keep central sleep apnoea out of today's discussion. But obstructive sleep apnoea is fairly common in this country.

And basically, what happens if you can see from this diagram is that the muscles at the back of your throat collapse and cause this blockage of air moving towards your lung.

This is associated with a drop in oxygen levels, and that causes a stress response within your body, causing your brain to partially wake up and send signals to these muscles. So they contract again, and your airway reopens. So in essence. That is what sleep apnoea is, and trying to understand why you have sleep apnoea is fairly important.

Now, did you know that there are probably a billion people with sleep apnoea in the world and almost half of them have moderate to severe sleep apnoea that have been associated with significant cardiac metabolic conditions, such as diabetes, and also been associated with dementia.

So it has significant consequences, and being able to diagnose this early and instituting the correct treatment, is quite, quite useful.

Now, you know, there are several studies that talk about a range of sleep apnoea in the population. But a simplistic way of putting this is one in three adult males, and probably one in four adult females are likely to have some form of sleep apnoea.

Now, almost 85% of these cases currently in the Uk remain undiagnosed, and so, therefore, looking at identifying sleep, apnoea early is, is extremely useful.

Now let's look at this the other way around. So we know that almost 80% of people who have hypertension that are requiring multiple drugs for the correction of their hypertension have sleep apnoea, and even other conditions, such as heart failure, obesity, irregular heartbeat diabetes are associated with a high prevalence of sleep apnoea in these patients in this population, and so, if you have these conditions, and you are waking up feeling unrefreshed, or if partners have suggested that you snore in your sleep, then there is a high possibility that you do indeed have sleep apnoea.

Now these are the risk factors that I mentioned but the most important thing to take away from this slide is that a 10% weight gain is associated with nearly a 30% increase in the risk of sleep apnoea.

Now, there is some research to suggest that if your neck circumference is over 17 inches in men and 16 inches in women, and there is a slight higher risk of sleep apnoea. But there is no conclusive proof of the same and the other thing to take home here is that if there are other members in your family who have sleep, apnoea, it is very likely that you would have sleep apnoea as well, because the anatomical dysmorphisms are generally hereditary, and so those same reasons for the sleep apnoea are likely to exist in other members as well.

So let's say you do decide to come to my clinic, or you go to your GP. The two main questionnaires. That they would be asking you is something called as a stop bang questionnaire, and the Epworth sleepiness, questionnaire. And these essentially try and identify what is the risk of sleep apnoea.

So if you see from the data, the stop bank question has a fairly good positive, predictive value of sleep apnoea. If your history is strongly suggestive of sleep apnoea.

The other things that we would be doing when we examine you is to look at the back of your throat, and if we can't see the back of your throat and the risk of sleep, Apnoea again is fairly high.

Now when you do come to a sleep clinic. What we tend to do is a sleep study, and essentially, as you can see from this slide, we have a little probe around your nose, where we are trying to see the flow of air through your nose and mouth.

We have a chest probe, and an abdominal sensor, and then a little oximeter on your finger, and essentially using these four devices, we can then determine whether you have sleep apnoea, or whether you just have simply snoring or a normal sleep study.

Now I can already see questions coming up, but the treatment of choice. So the gold standard is always CPAP therapy, and what CPAP therapy does is that it is a little compressor. It sucks in air and blows air at high velocity through your nose and mouth to the back of your throat and tries to obstruct the back of your throat, preventing freer flow of air down your lung, and drowning your breathing tube into your lungs.

Studies have conclusively shown that improves health and vitality, and improves performance in in the vast majority of individuals.

Now, if CPAP has been unsuccessful what we do recommend is that a mandibular advancement device, and these are simply gum shields that look at

thrusting forward your lower jaw by as much as possible, so that it takes the tongue that collapses and causes that obstruction at the back of your throat. Generally most dentists have to achieve a jaw thrust of between eight to a centimeter.

Now the advice would be to make bespoke gum shields simply because they are more comfortable. You do get generic ones online, but because they're generic, they can lead to jaw pain and dental issues. So it's generally advisable always to seek advice and guidance from either a specialist dentist or from an orthodontist.

Now, obviously, as I explained in my previous slides, that a 10 kg. A 10% weight gain is associated with an increased risk. Similarly, if you lose 10% of your body weight, there's almost a 50% chance of reduction of your mild sleep apnoea, it does not have the same effect for those with moderate to severe, but definitely in mild sleep apnoea, it definitely reduces the presence of sleep apnoea. Obviously there are bariatric surgeries available, and as you lose weight after bariatric surgery, it reduces the risk of sleep apnoea.

obviously the latest drug that is now quite fashionable, is Monjaro. This is a weight reduction drug. A competitor by the name of wegovy is also now available in the market, and what these studies have shown is that as individuals lose weight, it reduces the prevalence of sleep apnoea, and does indeed, in some individuals improve sleep quality.

And of course we need longer term studies, because that's not being available at the moment.

Now, if you remember, I mentioned about associations, and all that I wanted to say is that individuals with sleep apnoea have a higher prevalence of high blood pressure. They have a higher prevalence of irregular heartbeats and heart attacks and strokes seem to be more common in these individuals. There's also a higher percentage of people who develop dementia and cognitive decline in the presence of sleep apnoea.

Now, I won't waste too much time on this, but I've already spoken about the higher risk of cardiac diseases in individuals who have sleep apnoea.

I suppose I've spent enough time on sleep and sleep apnoea, and I also wanted to give you a flavor of what we could do with chronic respiratory diseases.

So bronchial asthma is fairly common. We know that there are almost five million people with bronchial asthma in the United Kingdom. It's mostly related to the higher prevalence of allergies, and that's potentially a genetic trait. So obviously, therefore, asthma tends to be more common because of the higher exposure to pollens in this country

Most individuals present with breathlessness or wheezing. Some individuals may have chest tightness and obviously others present with coughing. Now one of the characteristic things about asthma is, the symptoms tend to be variable, so you may have good days and bad days, and they also tend to be seasonal.

So symptoms tend to be worse in Spring and Autumn months, and you seem to have some relief during the summer months, or when you go away on holiday away from the shores of the UK.

A characteristic thing about asthma is that asthma is chronic, heavy inflammation and what you see in the vast majority of patients is just inflammation, which is triggered by some environmental triggers, such as a virus pollens, house dust, mite pets. It could be a large number of triggers.

So if you look at this slide, what you can see to the left of the slide is a normal airway where you have a muscle. You have the yellow bit, which is the mucosa, and then you have a patent airway that takes the air from your nose and mouth into your lungs, and then subsequently through your lungs into the deeper sections of your lungs.

Now, what happens when you have airway inflammation is that there is swelling of that mucosa, so you can see thickening of the yellow bits on the lining. You can see that the muscles also become more edematous. You can see mucus within your airways, and you can see the muscles causing more bronchospasms sequentially.

So, all in all that leads to a narrow tube breathing tube, and which is what leads to the difficulty in breathing and the recurrent episodes of wheezing. And the mucus is what creates the recurrent coughing that many individuals with asthma develop, and these symptoms will obviously resolve, and you tend to keep going around in this cycle of steady state, followed by inflammation, followed by repair.

Now, if this is not controlled well with the appropriate treatment, then you tend to get this progressive deterioration, and then eventually, you develop more persistent asthma symptoms which can obviously lead to more fixed airway pathology which requires more regular usage of inhalers.

Now, to avoid getting very complex, some of you may have difficult asthma and may find that your symptoms are continuing despite being on inhalers, and I've enumerated a few of the common causes why your asthma control might be poor. Now, very often individuals with asthma will also have allergic rhinitis, and unless that has been treated, individuals will continue to have poor control of their asthma.

You may also have gastric reflux disease, which causes acid reflux to the back of your throat, and then that can cause further inflammation of the airways, causing poor control of your asthma.

Inhaler technique is of paramount importance. So if your inhaler technique is poor, then all the drug is not being delivered into your lungs, and that can lead to poor control of your asthma.

If you're a smoker, then cigarette smoking acts as a stimulant, and the same goes with vaping as well, so the materials and chemicals that are used in wipes could be a trigger and sensitizer to inflammation in your airway.

Of course the diagnosis could be wrong. You may have something else that is causing you the breathlessness and reviewing that diagnosis. If your symptoms aren't control is quite, quite useful.

Now, asthma is a lifelong condition. It doesn't just disappear in the vast majority of people, especially in adulthood.

And so sometimes individuals do not like to take their inhalers, or do not like to take their inhalers regularly, and that is what then leads to recurrence of symptoms in many, many individuals. And so, being regular with your treatment and being consistent with your inhaler technique, really helps control your asthma much better.

So based on what I've shown you. Logically speaking, you've got to target the inflammation, and if you've targeted inflammation, then your asthma control will always be much better, and you wouldn't require to use your blue reliever puffer on a regular basis.

However, across the world, and especially here in the UK, asthma deaths have been quite high, and it's been attributed to increased usage of the blue puffer instead of using your inhaled steroid.

And so the national body here, which is called as nice, including the British Thoracic Society, have suggested some changes to the asthma management as we go forward and the suggestion is that we move to a inhaler that contains an inhaled corticosteroid, but also contains a bronchodilator.

so such as your pink or the red puffers, and these should also be used as a reliever instead of the blue puffer and if you are very bedded to your blue puffer, then you should always utilize it along with your brown puffer to ensure that you're giving anti-inflammation when you're using the blue puffer.

So in essence, the cornerstone or the central most important thing, as far as asthma care is concerned, has to be targeting inflammation and making sure that you use your inhaled steroids regularly.

Just for our understanding. I've shown various types of inhalers that are available. So you get the MDI inhaler or you can get the dry powdered inhaler. These are the two common ones that most GPS would prescribe in cases of asthma, but you also have a soft mist inhaler that tends to be more commonly used in COPD, but have some use in asthma as well.

We increasingly feel that inhaler technique is so important that if you can't get your technique correct, then it's better to use a spacer because a spacer reduces inhaler errors significantly.

You can also use nebulizers in an emergency, but my advice to you would be to not use a nebulizer at home leave it, for when you are in the emergency department.

So I'll conclude by saying, you know, we need to treat each individual as an individual so that we can personalize their treatment, we must focus on symptom control and inflammation and getting the right drug in the right device at the right dose is paramount to getting success as far as asthma management is concerned.

You must insist with your respiratory nurse that you would like to have a self-management plan, because, knowing what to do when your breathing gets worse, really helps reassure you, relaxes you, and gives you confidence in managing when you have an outbreak of symptoms, or you have a sudden exacerbation, so that you can deal with that competently.

What is important in self-management is knowing when is the right time to call for an ambulance when it is life threatening, and once that self-management plan is in place, you will fly with managing your asthma care.

So I suppose I've spoken enough. I don't want to overburden you, but I hope you all have found this interesting. Thank you very much.

Vicky

Thanks, Dr Banerjee. So now we've got some time for your questions. So the first one is from Dorothy, and Dorothy says that she's got a persistent, dry, tickly cough, which started with a chest infection in March 2024. She's in good health, no breathing problems, but it's constantly disturbing her sleep. What would you recommend?

Dr Sandip Banerjee

So particularly cough that that started following a chest infection is potentially likely to indicate that you have some sort of postnasal drip and that is what is causing your cough when you lie down in the supine position. And so it's the constant coughing that is actually disturbing your sleep.

It is unlikely to be sleep apnoea. In some instances acid reflux could cause the same issues. If you have a mild hiatus hernia, so I would suggest that you should look at dealing with your nose. If you have nasal congestion or post nasal drip or acid reflux first, before you delve deeper into to investigating further for sleep apnoea.

Vicky

Lovely thanks, Dorothy. I hope that was useful. And next question, can Benenden Hospital offer a surgical solution to sleep? Apnoea, instead of using the CPAP machine?

Dr Sandip Banerjee

Unfortunately not so. As far as surgical options go. There are two or three surgical options. Obviously, if you've got very enlarged tonsils that are causing an obstruction of your upper area of course an ENT surgeon here at Benenden could remove those tonsils, and that would provide you with significant benefit.

But most of the other surgeries have not proven to be very successful. More recently a surgery called as a hypoglossal nerve stimulation is being offered by a few centers, but not in the private sector, so you would have to be referred to specialist ENT units, mostly in London that could potentially offer you this surgical option.

Vicky

Okay, lovely. Thank you very much.

Next question is from Patricia, and she asks, does sleep Apnoea cause one to wake up suddenly, gasping for breath. I've had this, and also the feeling that I'm not going to be able to breathe properly.

Dr Sandip Banerjee

Yes, the long and short answer is, yes. There are two main causes for somebody to wake up suddenly gasping for air. The first cause is acid reflux. So in a sudden bolus of acid, if it gets pushed up from your stomach into the back of your throat, it causes all the muscles in your upper airway to go into a spasm.

So you wake up with this sudden gasping episode and then what you find is that you're really struggling to breathe for around 30 to 40 seconds, and then the breathing starts improving. You need to rush to a window, open the window and get some fresh air.

If that is not the case, then obviously the condition that causes you to wake up gasping for air could be indeed sleep apnoea, and if you are not refreshed from sleep or feeling fatigued, or you have a background of the cardiovascular risk that I indicated, then the advice and guidance would be to go ahead and get a sleep study done.

Vicky

Okay, hope that was reassuring, Patricia.

Next question is from Betty, and Betty says, I don't do well on the full mask for sleep, apnoea, so is given the nose machine instead. Is it as effective as the full mask?

Dr Sandip Banerjee

Yes, Betty, of course. Ultimately what is important is for the pressure to be delivered down to the back of your throat. Now, even if you sleep with your mouth open, a nasal mask should be as effective as a full face mask.

The machines these days that are offered are adaptive machines so they can deliver higher pressures if needed, to ensure that the obstruction is unblocked. So the long and short answer is that the nose mask is just equally effective as compared to the full face mask.

Vicky

Okay, thank you very much. Next question is from Mary, and she asks, Does Benenden Hospital offer a gum shield type solution? Or is this only available via a specialist dentist.

Dr Sandip Banerjee

So, Mary, unfortunately, we've only just started the respiratory and sleep service. Currently, it's not available here at Benenden.

If you want to have a bespoke device. Yes, you do need to go to a specialist dentist, especially dentists who have some expertise with making a bespoke mandibular advancement device for you.

My advice to you would be to go online and look up, bespoke mandible advancement devices common ones that people tend to look at are somnodent flex or pro sonus and they should give you a good idea of what I'm talking about.

Vicky

I hope that was helpful, Mary.

And next question, do you offer the nitric oxide test or spirometry to help with asthma diagnosis as per the updated guidelines?

Dr Sandip Banerjee

Yes, indeed, we will be offering pheno spirometry and a full pulmonary function test with reversibility testing as per the latest updated guidelines. So yes, if  your patients need them, please do refer them to me.

Vicky

Okay, thank you.

And next question comes from Tracy. Tracy doesn't like using her blue Ventolin. But has the pink for stare? She's asked. Can I use that on the odd time. I don't like how Ventolin makes my heart race.

Dr Sandip Banerjee

Well, Tracy, you've already beaten the guidelines in that instance. So the current guidelines suggest that if you are on Fostair we would recommend whatever one or two puffs twice a day. But you can take add-on puffs as the reliever instead of the blue puffer up to eight times in a day. So if you're feeling sudden episode of shortness of breath, or wheezing, or you're having a bout of paroxysmal cough.

then the suggestion would be to take one puff of the Fostair. Now the additional doses of Fostair are on the 100 by six, not the 200 by six. So if you are on the 200 by six that you take on a regular basis, my advice would be to seek advice from your GP to be given the additional 100 by six, which you can take up to eight puffs in a day.

Vicky

Okay, lovely. Thank you.

So it looks like our final question. Here I have chronic asthma and nasal polyps suffer from sudden and severe coughing fits. How can I stop this I’m 75 years of age.

Dr Sandip Banerjee

Yeah so I suspect your symptoms of sudden and severe coughing fits, unless proven otherwise, is probably occurring because of your nasal polyps that cause nasal congestion that cause a post-nasal drip and sudden sensitization of the back of your throat.

Generally the advice is a combination of nasal steroids and antihistamines, or, if that is not effective, then the suggestion is an ENT surgeon who can consider whether removing the nasal Polyps may be of any benefit to you.

Of course, if you are also experiencing episodes of wheezing, then the asthma could also be having sudden severe coughing fits.

Suggestion would be that if you do have a steroid inhaler, then taking additional puffs, just as I was explaining for Tracy may be beneficial for you.

Vicky

Okay, lovely. We've got a late entrant question here. Somebody's asked, can I use Trelegy more than once a day?

Dr Sandip Banerjee

So the answer is, no. Unfortunately, Trelegy is a 24 h puffer, and so, therefore we do not recommend using Trelegy more than once a day.

If you have asthma, then based on the latest guidelines, you need to be moved on to something different. Of course trilogy would be your first line inhaler in the presence of COPD.

Vicky

Okay, lovely. And Caroline. Oh, got a couple more questions. Come in. That's fine. Caroline asks, how do you know if you need additional oxygen with CPAP? If by blood gases, blood tests via ear lobe. What reading indicates this is necessary. Caroline's had severe sleep apnoea for 25 years.

Dr Sandip Banerjee

So Caroline, the first test that I would suggest, rather than poking and prodding you is to just repeat another sleep study on the CPAP and if your oxygen levels are above 88%, or preferably above 92%. Then actually further, blood gas tests are not really necessary. If they are indeed under 92%, then we would suggest doing the capillary blood gas.

It is very rare that somebody with sleep apnoea requires additional oxygen therapy unless you have a long standing chronic lung disease that that is associated with your sleep apnoea.

Vicky

Victoria asks. She's age 40, with a lung age of 67 on spirometry possible. COPD, not needing blue inhaler. Much symptoms seem under control.

Dr Sandip Banerjee

So yeah, so, Victoria, the first thing I would say is that at age of 40 it's very unlikely for you to have had COPD, unless you've really abused yourself smoking very large quantities.

Now, the long age of 67 is controversial. Obviously it is based on a very fit, well-built average Caucasian and sometimes looking at this data based on your lung functions over a period of time, gives a better reflection of what your underlying lung functions are.

It may simply be that your lung functions are slightly lower than the average adult Caucasian, and so I wouldn't be too worried by this if you don't have much symptoms, it is most likely, in my view, based on your age and what you've mentioned, that you have asthma. And so, if that is the case. The blue puffer is not the ideal inhaler for you. You must get this investigated and identify what is the most appropriate inhaler for you.

Vicky

Okay, lovely. Thank you. Hope that's helpful, Victoria.

I've been advised to stop using a nebulizer twice a day after 40 years. What's the replacement?

Dr Sandip Banerjee

Wow, so the question here would be, why have you been prescribed a nebulizer?

If you've been prescribed this for 40 years, I'm presuming you had some childhood lung condition, such as bronchiectasis, or maybe even a variant of cystic fibrosis. And that's why you were provided with a nebulizer.

So if that was the reason why you were given the nebulizer. Then the simple answer is not the right step to take to suddenly discontinue it.

If you're asking me what is a good replacement for a nebulizer if you need it, because you have brittle asthma, or you suffer with significant symptoms. Then 10 puffs of the salbutamol through a spacer gives you a dose equivalent to a single nebulizer liquid. And so, if you were really desperate, then that is what my suggestion to you would be

Vicky

Okay, lovely. I hope that was helpful for you.

So that's all the questions. Thanks everyone for your questions, and also for being part of this evening's session.

So you see, on your screen now, as I thank you for attending, we're pleased to offer 50% off the value of your consultation for limited time, a call back from your dedicated Private Patient Advisor, an email with a recording of this session treatment, information and loyalty reward points and updates on future events and health news as well.

We'd really appreciate it if you could take a moment to complete the short survey at the end of the session, as it really helps us to tailor the sessions for your needs.

If you'd like to speak with somebody or book your consultation, our private patient teams available until 8pm this evening, and from 8am to 6pm Monday to Friday. You'll find the contact number on the screen just there.

We've got some additional upcoming webinars on a range of topics, including hip and knee surgery and enlarged prostate treatment. And you can sign up for these on our website. So on behalf of Dr Banerjee and all of us here at Benenden Hospital. Thank you ever so much for joining us. We hope to hear from you very soon. Goodbye.

Dr Sandip Banerjee

Thank you very much.