Archived Columns
Sleep Medicine on the Eve of the Third Millennium
October 23, 2000
I recently attended a very special International Congress, Sleep Medicine on the Eve of the Third Millennium, which took place in Bologna, Italy, September 7-9, 2000. Scientists and clinicians who pioneered the development of sleep medicine and those to whom the torch will be passed, met to review the accomplishments of our field and to envisage the future for sleep researchers, sleep professionals and millions of sleep disorders victims. The site of the Congress was the University of Bologna, the Western Wold's oldest institution of higher learning. The Congress was organized by Professor Elio Lugaresi, one of the most important pioneers of sleep medicine, and I had the honor of serving as the co-president representing the United States.
During my long career, I have been a frequent apologist for the difficulties of diagnosing and treating sleep disorders and the relative paucity of cutting edge research. I have most often cited our late start compared to the other well established clinical / scientific disciplines. For example, Watson and Crick had discovered the double helix structure of DNA before anyone discovered rapid eye movements during sleep. Transplanting hearts was a clinical routine at Stanford University Medical Center well before we started the world's first sleep disorders clinic. At the end of the Third Millennium Congress, it was clear to me that there is no longer a need to apologize for being behind in research. Basic and clinical sleep research is no longer catching up, we are or soon will be in the lead.
The first part of the meeting was devoted to a review of the early discoveries of rapid eye movements during sleep, the duality of sleep (REM vs non-REM), narcolepsy and obstructive sleep apnea. After this came a wealth of exciting, new data. Emmanuel Mignot from Stanford University reviewed the research that has revealed the cause of both canine and human narcolepsy. He reported finding that the canine narcolepsy gene expressed an abnormal receptor for the newly discovered neuroregulator, hypocretin, and that there was a very significant deficit of this compound in the CSF of narcoleptic patients. Research groups both from Stanford and UCLA found a deterioration of hypocretin nerve cells in the brain of narcoleptic patients. These dramatic findings mean that better treatments and cures for this illness are on the horizon.
From the point of view of millions of OSA surfferers, the most important news was in the reports by Markku Partinen from Finland and Terry Young and Susan Redline from the United States. Although there has been skepticism in the scientific community that obstructive sleep apnea is involved in cardiovascular disease (CVD), these researchers reported elegant epidemiological data from very large numbers that established the association of OSA and CVD beyond the shadow of a doubt. It is now incumbent upon all health professionals to identify and treat all patients in order to prevent high blood pressure, heart attacks and strokes.
There were a number of reports of cutting edge research on the genetics of sleep, sleep deprivation and the function of sleep. For various species, it is now possible to screen several hundred genes at a time during both sleep and wake. One of the newest models for sleep research is drosophila melanogster, the common fruit fly. It has been found that there is a regular nocturnal rest period and awake activity period in the daytime. If the rest period is prevented, then there will be a rebound just as in sleep deprivation. It is possible to make rapid studies in this fruit fly and in Bologna there were several reports of approximately 1000 genes which were screened for those whose expression is increased during wakefulness and those whose expression is increased during sleep. This was also done in the mouse. At the current time, all of those genes whose expression is increased during sleep are unknown. Nonetheless, this is a mystery that technology is capable of solving in the near future. In the lifetime of most of us, we will know why we sleep.
I will conclude by stating the principle that has guided my career. Sleep research and sleep medicine are a single discipline. Although some might think otherwise, the implicit and lofty goal of all biological research is to improve the human condition - to improve the health and quality of life of human beings.
As we stand on the eve of the Third millennium, there are, in my opinion two overriding issues. The first is the new exciting science of sleep and what it will tell us, probably in the relative near future and hopefully in the lifetime of most of us. The other issue which for me has been overwhelmingly important and compelling is transferring the benefits of scientific research to millions of our fellow human beings. Those of us who have experienced the miraculous relief and restoration that sleep medicine has given to a few are passionately concerned that similar benefits are unavailable to millions more. I fear that many of our colleagues take it for granted that the mechanisms inherent in the health care system, wellness, and society in general will take care of this final step now that they have done all the work to create the possibilities.
In the United States, our National Institutes of Health have conceptualized this in the famous NIH arrow. With regard to the final goal of sleep research, it remains a broken arrow in the United States and around the world as well. Nonetheless, those for whom this is a consuming passion must continue. It may be that it is only our lack of experience and ineptitude that has caused success to elude us.
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