Bingham: We are in Seattle with Sleep 2009, a joint ...



A Conversation with

Eric Dyken

Bingham: We are in Seattle with Sleep 2009, a joint meeting of the American Academy of Sleep Medicine and the Sleep Research Society and we’re with Eric Dyken, Director of the Sleep Disorder Center at the University of Iowa Hospitals and Clinics and is an expert on obstructive sleep apnea and narcolepsy, epilepsy. Eric, last time we met, two years ago, at that point, we were bemoaning the fact that according to the National Sleep Foundation, there are forty million Americans with some form of sleep disorder. I hope things are getting better, at least awareness has been raised or something. Is there, sort of, a stake the Science Report can give us? Have we moved forward?

Dyken: I think that awareness has been increased, especially for the public and I believe, for example, the International Stroke Conference, there was a specific lecture that Dr. Antonio Culebras brought in regard to the association between untreated sleep apnea, stroke, a variety of problems including cardiac dysrhythmia, and possible, even, death. So I think scientific meetings are starting to recognize sleep as a specific subset of medicine and especially the lay population, at least from the numbers I am seeing in my clinic.

Bingham: So, most people obviously don’t get enough sleep. Is that a fair statement?

Dyken: I wonder if it’s most people, and it’s relative, isn’t it. I’m sure infants do. ultradian rhythm. But as we age, sleep demands are a little bit different. When you go to sleep early in the day, early at night, late in the morning, circadian rhythm problems with shift work. I would say we probably, in this society, western industrialized society that works on the twenty four hour clock, we probably don’t get enough sleep because if we work harder, burn the candle at both ends, we are more successful in a westernized, industrialized society. So I believe in America, in the United States, we probably, on average, don’t get enough sleep. That seven to nine hours that Grandma said you always needed.

Bingham: How do you change the situation? So that you are getting more sleep? If you are talking about burning the candle at both ends, at one end, lets say, is the time it takes you to get to work, unlikely to be able to change that because you’ve got to drive, that we are industrialized, and so on. So do you have to go to bed earlier, and that means you get less relaxing time? It’s a complicated equation.

Dyken: It is complicated and I think the answer, at least an approach to treating the problem of not getting enough sleep depends on the individual, whether they’re a shift worker, whether they’re in the military, whether they’re on an on-call basis on a regular response time, so I think that’s dependent on the individual. A marathoner that’s trying to make it from one end of the United States to the other on a record time. When is the efficient time to sleep? So I believe that that’s probably a very variable answer. For children who have to get to sleep early but they’re phase delayed and they’re used to staying up later and have a need to sleep in later I know we are trying to address that on many levels. So I think, again, that the answer is being addressed, for example, Mark Maholwald and Mary Carskadon have encouraged certain areas where the children actually get to go to sleep later because young children, adolescents, often are phase delayed. And in some areas, I believe in Kentucky, Lexington, they actually found that there were less deaths from teenage motor vehicle accidents in the areas where these children were allowed to come to school later, rather than the early time where they may not naturally be more accommodating, feeling more rested or less sleepy, so safer drivers. So I think a lot of these issues are slowly being addressed and that’s one example.

Bingham: You’re a father, you’ve got a family, you work in medicine, you’ve been through medical school where all the doctors look tired and sleep deprived.let’s put you in control now, you can change the system. What would you do to make people get enough sleep and yet be able to go to school enough and be able to go and socialize enough and go to work on time. To accommodate ideal solutions for sleep medicine, obviously means it gets intimately involved with the entire structure of the family and the education system.

Dyken: If they actually implemented what is hypothesized, would be the best waking time, sleeping time for the children, it would destroy me. I drive my kids to school. I have to drive early because that’s when I need to be at work. And I think that’s exactly what you’re alluding to. A societal change for me would be devastating. How could I possibly drive my kids to school and that would be devastating psychologically, maybe physiologically, but they are all finding that they need to follow my schedule, for the most part and if they change that schedule, I would have to adjust and I don’t know if I could accommodate that well. So one simple change in waking time and sleeping time for just the group of children, just the adolescents could make major societal changes cost an awful lot of money and an awful lot of controversy in making those changes. And that’s just one issue. Getting my kids to school on time, at the right time and again, shift workers, you had mentioned that our people addressing these issues.

I was asked to give a lecture at the casino. Twenty four-seven. And the owner of the casino, he had noted that there were some lawsuits because people were falling asleep on the shift work trying to go home. They were steadily sleepy and he wanted to address this issue and he formally had us come in, give a lecture on sleep hygiene to all of his shift workers. We gave them some tricks, how they could get better sleep and how they could stay up easier on those night shifts and when they went home they did a variety of things like the blackout lights. Judicious use of melatonin, making sure that they kept their schedule of sleeping during the day seven nights a week and sometimes they even selected for the appropriate person for shift work. Generally younger people, night owls and there are specific questionnaires that you can take that show your tendency to be a better night owl or shift worker. So as you asked earlier, are things being addressed? I think they are being addressed slowly, in a piecemeal fashion and based on a little bit of science, but then addressing an awful lot of major societal issues that changes would be expensive to make and are the risks of not sleeping enough really worth the benefits to society as a whole.

I don’t know about you, but some of the best work I ever did, when I got my tenure, I hardly ever slept. I think I could do two or three days in a row with no sleep. Dead tired, then, when I reached my forties, I remember falling asleep going to pick my children up from school and pulling off to the side of the road, calling my wife on the cell phone and saying you go get the kids, this is dangerous, and doing a very bright thing, driving myself home another thirty miles. Still, those societal issues, and knowing that sometimes burning the midnight oil makes us successful. And we see it in medical school, and for our medical residents, they’re limited because of the Libby Zion Case, limiting their hours to eighty-hour work weeks and made further and further cuts. If they had made that cut to me I wouldn’t be as successful as I am. If they made demands where I had to sleep, and I believe in sleep, what a tough world it is. So, I think, to become a great athlete, to become a great academician, it takes a little bit of pain, but how much pain can we take? How much sleep deprivation can we take? Because the last thing a truck driver remembers before falling asleep behind the wheel of a forty ton rig is being wide awake. So when does that happen, just like that. And you only get one chance to fall asleep behind the wheel of a forty ton rig, they tell me, for the most part.

Bingham: How serious is the sleepless driver issue?

Dyken: I believe it’s very serious. I remember Dr. Dement, when he started looking at apnea in truck drivers.

Bingham: This is William Dement at Stanford?

Dyken: Dr. William Dement helped me get my tenure, good friend, I would say. And, in fact, Dr. Dinges from Pennsylvania had said we have the best, safest truck drivers in the world. Remember that, they are the best, safest truck drivers in the world, probably because of a lot of this early work. When they fall asleep at work, I think he said 4.2, 4.6 people go with them to the grave because you don’t slow down in the early stages of sleep, you just keep right on going through what ever is in front of you. And because of a lot of that early research, Dr. Dement had done and through Stanford colleagues, a lot of people are a lot safer on the road because the truck drivers are following very strict rules and again if you talk to a lot of them, maybe too strict. That Machiavellian limitations on what they can do doesn’t fit everybody’s schedule, but probably the safest truck drivers on the road, but still, on a weekly basis, even in Iowa, there’s someone who falls asleep, not just truck drivers, just every day people.

That little girl many years ago who fell asleep driving home, working in the summer, trying to save money for college, she took a wrong turn off a back country road, upside down, under water in a drainage ditch for a few days, lost both legs. Now she is a spokeswoman for orthopedics because she was given new legs. I think she should have been a spokesperson for the sleep societies because she was pathologically sleepy and that could have ended her life. It’s not just truck drivers. It’s our children, it’s our truck drivers, it’s me, and my thought is, it’s probably underreported. Because when there is a death on the road, there are a lot of signs that can suggest someone fell asleep, but when they are looking at that individual on a pathology slab, it’s awful difficult to tell was this person in this situation because the fell asleep behind the wheel. I think it’s underreported, I think it’s a major problem.

Bingham: This is a bazaar question, I know, but are there any industries where people are actually monitored while they’re at work so that there are video records of them actually falling asleep on the job?

Dyken: I wonder about that. There was in my profession and it led to the dismissal of an individual, but it was, sort of, serendipitous because it was part of the job, there was video monitoring going on, and just happened to catch someone falling asleep.

Bingham: Just what you said, someone falling asleep just like that, so and I thought you mentioned that you had some videos of it.

Dyken: Well, we do have some video and I got to get you that permission, but they’re doing a lot of work right now with a driving simulator and two of my colleagues, Matt Rizzo and John Tippin have been working with people with obstructive sleep apnea and residual sleepiness that is associated with that prior to being treated with, generally, continuous positive airway pressure therapy. So you’ve taken a group of people, highly suspected of having sleep apnea, and we’ve monitored them for sleepiness using a driving simulator to see how their performance changes pre and post therapy, and a lot of that data is presently pending for publication but there is some indication and as I’ll show you on that film, the individual falls asleep, then a nice place to wreck on a driving simulator, but goes off the road and has a wreck. Sort of a proof in the pudding kind of thing.

Bingham: I read a paper, recently, by Immanuel Mignot about narcolepsy, which is a rather unusual thing. I’ve actually seen dogs with narcolepsy just running along in a field and then poof, they’re straight over on their sides. It turns out that narcolepsy affects one in every two thousand people, which is quite a significant number. And the suggestion is that it might be an autoimmune disease. Does that have any resonance with you?

Dyken: I think that’s the present thought in regard to etiology. It makes sense, the term heuristically pleasing. It just fits a whole package. You live in maybe the more northern hemisphere, you might be more exposed, or be of a genetic lineage that is more susceptible to a certain viral entity, let’s say, and you get that bad cold, that bad flu and at that time, your autoimmune system reacts in a rather aberrant fashion, hits these latter nuclear cells and the hypothalamus and recognizes them as being abnormal, and with repeated flues or colds or immune susceptibility periods, you gradually destroy those cells, which we believe is the cause of narcolepsy with cataplexy. And those cells have a very specific neurotransmitter chemical protein called orexin, hypocretin, named two different names because it was simultaneously discovered by two different groups, but that paucity of an awaking neurotransmitter is the cause, we believe, of narcolepsy with cataplexy. But it fits in a very pleasing way with an autoimmune phenomena and that it generally occurs in adolescent period, and we’ve got a few cases, just my anecdotes, of young kids, bad flu, afterwards falling asleep in class, funny jokes, cataplexy, fall to the ground, and in fact, I’ve saved some CSF, cerebral spinal fluid, that I’m holding, Dr. Kushida says he’ll let me know when they start to run the CSF levels of orexin, hypocretin, but I’ll bet you money that she’s developed narcolepsy right after this flu like period. But again, I bet there will be more case reports, anecdotal and retrospectively looking for these cases because of some of that work that hopefully, in the future, the research will show cause and effect with some specific entity, possibly viral, that you’re predisposed to infection in that specific area of sleep/wake mechanism.

Bingham: Suppose I put you in charge of the system. Put you in the cabinet, maybe, so that your task was to get people enough sleep, but allow them to still go to work and still go to school. What would you do?

Dyken: That’s why I vote. I don’t want that job. I think it would be horrific. It is tough times, we are all in the red, but what I would propose, as we’ve suggested, I would go to the experts. I know that Mark Mahowald, Mary Carskadon, in regard to the adolescents may be going to school and hour or so later then they are presently going and then trial areas, where we can do studies to scientifically show that there’s some evidence that the children perform better, that they are safer on the road when they are coming to and from school. I think in regard to the military, there’s some indication with Dr. Dinges, etcetera. A lot of the people from Pennsylvania, I’d go to the expert and look at some small level plans, pilot studies and see if implementing certain changes in, for example, the military, leads to safer, healthier, more productive soldiers. I think the same thing with shift work. I think a lot of that, Dr. Czeisler, etcetera, from Harvard, if they could take a video camera into the people of the shift work in the powerplant, and implement certain therapeutic recommendations, whether it’s melatonin use, bright light therapy, but I think that would be the way to start. Look at the experts. Look at small pilot studies in a variety of different ways and I think data driven scientific evidence is going to be expensive to come up with, but is what’s going to change public policy, not just my long white coat, saying that I run a sleep laboratory and I think everybody should, because I have a bias. I think everybody should sleep very well and I think that it’s good for business for me, so I obviously have a bias and I think that’s why science needs to be done. It’s expensive to do. The small studies need to start before the big expensive ones but public policy will change with data driven science.

Bingham: Doctors, as portrayed on television, are not the best. They all look haggard and drawn and in deep need of sleep.

Dyken: You know, I honesty believe, if I hadn’t sleep deprived, I wouldn’t be a doctor because I’m not that smart and I had to work hard. When I was an undergrad, I drank so much coffee. I remember I was beating a hundred beats per minute. It’s down to forty now. I almost died, I told you, driving my car. But my thought is, I’m happy to be a doctor. I’m lucky to be alive and I’m glad no one said you must sleep this many hours. Actually, we can’t even do that with the medical students. We tell them they can only work this many hours, but what does a type A personality do? They go back home and do five million other things. They play guitar, they sing in the choir, they have research projects, and they do clinical work. They look at their family members and play with them on the weekends. They still burn the candle at both ends. Does it necessarily mean and how do you mandate this? And you even suggest this: ok kids, this Christmas Eve, let’s get to bed early. I’ll give you this candy bar, you’ll get extra presents, there will be some money it, just get to bed. They’re going to be so excited. You ever try to get a kid to go to sleep early on Christmas Eve? It cannot be done. My thought is, how do you mandate enough sleep? And as you know, there’s a broad spectrum of sleep necessity and most of us think about seven to nine hours for most adults but there are some short sleepers and some long sleepers. And physiologically, what is best for any given individual? That comes tough.

Bingham: You would imagine, if you were a Martian, just arriving, isn’t that something that people just do normally? Just sleep. That’s what they do at the end of the day, they sleep. But it is more complicated than that isn’t it?

Dyken: There’s another question, like the martians, if you watch family members burn to death in a trailer fire, do you think you are going to get a good sleep that night? What do you think the response would be on a questionnaire? I think 99.9 would say you have insomnia. You will not sleep well. We know it. Why is that? What we could do, after a horrific event like that, is we could deep sleep for days, maybe months. Oh my goodness, trauma, everybody’s going to be asleep. Biggest problem in the military is all the sleeping soldiers. They saw a great big explosion, now they are all falling asleep, but we know it’s not that way because of catecholamine, central nervous system cracks, the hypothalamus, autonomic systems that have biochemical concomitants that make us stay awake. But, just as fascinating are the people with Seasonal Affective Disorder who can have that same kind of depression and maybe even to a suicidal extent, decrease light exposure and they sleep all the time instead of having the insomnia we just had with a different kind of an affective problem, if you will.

So it is interesting, the martians can come down and say well, yes, they sleep because it’s restorative isn’t it? And do we have to sleep? I was reading about that, some of our colleagues, in the great Kryger, Dement and Roth principle and practice that all of medicine, that all our students have to read before they take the sleep. We know that if you sleep deprive an animal, the great studies of [unintelligible] in Chicago many years ago, and I know that’s a bit of a controversy, because animals died. You sleep deprive them for fifteen, sixteen, twenty some days, they die. The core body temperature goes way, way down, basal metabolic rate goes way, way up, they get neurogenic lesions across the back and they look horrific. They just burn themselves up and they die. We’re really not sure why they die, but there is something necessary about sleep. And, maybe more specifically, REM sleep, that keeps them alive. Restorative, if you will.

And I know at the last meeting, they showed that kid out in California, it was a Stanford project, what did he get? Eleven, twelve, thirteen days, and at day eleven he was shooting baskets. He was still alive. And I don’t know, unless there’s a pathology, like fatal familial insomnia, if we really have someone who has been pushed beyond the limits, who has died of sleep deprivation, and I know it’s a big controversy now with the Guantanamo Bay, now they have let it known that sleep deprivation, for two or three days, I’ve done that, but I did it because I wanted to. No one was scraping their fingernails on a chalkboard or threatening to water board me, or telling my family may suffer detriment but the question is, do people, and I think some of the experts said maybe a person, a human being’s metabolism and body mechanisms are such that maybe they wouldn’t need sleep at all. Maybe they could actually sleep deprive for long periods of time, I don’t know that. That would be an unethical study to actually do. I mean that’s where the clinical research is very limited. But does a rat necessarily correlate, parallel, the fineness you see with the human. Although we do know that people who sleep much, much less than that seven to nine, or much, much more, tend to have, in general, higher morbidity and mortality rates and probably are not going to live as long as you and I are because we are sleeping seven to nine hours a night every night.

Bingham: Now the interesting thing, just to follow up on your thing about how productive you can be with screen culture, and I understand that. It makes a lot of sense, it’s just that you also said that you didn’t need to go to a meetings anymore, and that’s one of the things that comes out of this, which is people don’t necessarily have as much social interaction.

Dyken: Yeah, that’s why I’m here today. I think it is an important element, and it is very interesting with all the cut backs, the concern is that you are just going to socialize, but a wise old sage told me that it’s important to meet your colleagues, it is important to see people face to face. It is important to bring your data and in general when we are presenting, when we are inviting speakers, when we do have research to present, that’s very, very important to have the face to face. I think that there is something about the face to face that the screen can’t replace, but I’m not sure how well to define it. But the economics are taking care of that for me, because in many of our departments, you are given one lecture or none because we just can’t afford it. I think, again, we can’t oversimplify. I think it’s helped me to become more economic and more efficient with my meeting attendants so that I save money for the department. I don’t know if that’s necessarily a good thing either.

Bingham: If sleep is so intimately connected with all the remaining functions of the body, now with gene expression, with your daily performance, and so on. You’d think, I’m playing Devil’s advocate here, but you’d think that it would be the most important thing to figure out and that by now we would have it nailed. Why are we still saying we don’t actually know what sleep is for, evolutionary? We don’t know if somebody sleep deprived actually would die whether they catch up with little naps. Why do we still not have this field nailed?

Dyken: Well, I think it’s because animals other than humans don’t really one hundred percent translate to human beings and Mangella is dead and I don’t think we used a lot of his data. There are certain things that you just can’t scientifically prove in a human, although you could, but you may not, because of the ethics of the element. And I was reading something where they talked and scientific proof in a human, compared to a quote on quote lower level mammal study is all relative, you have to look at even that with a grain of salt and I’ve had doctors call me and say Dr. Dyken, I have a patient who never sleeps. And I say bring them to my lab, I’ll monitor them in all the time they don’t sleep. That patient never comes to my office. I hear all sorts of things but I’ve never seen the animal. What would happen if you actually, and how would you devise a safe experiment to keep that person awake to see if they could really. That’s just an interesting fundamental question. Have you ever seen a person who never sleeped and lived? Or could you make a person not sleep? And I don’t think it’s ever been done.

Bingham: Assuming the reality TV shows right now where people are willing to have cameras there all day long, you would think that they would be willing to be guinea pigs for sleep research.

Dyken: But they would still fall asleep unless there was something to induce and I think the beauty of 2820 was that he was able to overcome with his animal studies the avoidance of a large hammer that came down on that rat and killed it. He had a very ethical way, he had a tub and everytime the rat would fall asleep it would push him into a little bit of water and rats don’t like to be in water that’s not their own so they would pull out and that would keep them awake without causing direct harm to the animal. But to a human being we know that right now, that Guantanamo Bay that just raised a lot of ire, how could you possibly keep someone up three days in a row? And my thought is, well, we all know, I mean it’s just what we know. But that’s far from science, isn’t it? Well you know it is, and that’s not going to change public policy and all the dollars that are implied by changing the public policy that we’ve talked about. Still a fascinating question, could you keep a human up forever?

Bingham: Tell me a little bit, just give me a paragraph about the importance of, or the destructive nature of, or cures, solutions, possibilities, and how widespread is obstructive sleep apnea?

Dyken: Some people have estimated, and those numbers may be going up, the last I recall, about seventeen million plus people in the united states running around with obstructive sleep apnea, depending on your definition of what apnea actually is. And it’s a variable definition, especially in relationship to risks for a variety of health related problems. So, you know, obstructive sleep apnea is a major, big, problem. The neat thing is you can treat it, for the most part. Little kids, the tonsils, take them out. Large problems in adults were often dealt with Continuous Positive Airway Pressure masks and with good technicians and technical support and a comfortable mask, can keep someone falling asleep and keep them awake at work and change their lives, I believe. But a lot of the long term follow up on that, some people believe that you’ll lose weight if you are a great big heavy person because your leptons will be more functioning and a lot of metabolic elements will improve but long term studies on that, there’s a paucity of those. But we’ve seen a lot of great anecdote in that regard.

There are many concomitants with untreated apnea. We know from Terry Young’s group that if you do not treat apnea, with an apnea hypopnea index of twenty events, where they stop breathing twenty or more times per hour, those patients have a statistically defined risk of developing hypertension. Same thing with stroke. That same group looked at four year aliquots over a twelve total year period and people with a hypopnea index of twenty or more per hour had a higher risk of developing stroke. Now those are cohort studies, they show a risk, but not cause and effect. And I think, clinically, it’s difficult to prove simple cause and effect in a human being. Maybe in a rat model and a lot of the work in the flies, etcetera, were learning a lot on circadian rhythmicity but how a does a fly, or even a Boston bulldog translate to apnea in a human being. I am really interested in the far end of the spectrum. I like to look at sleep apnea in critically ill patients and in the critically ill patients, it only takes a little bit of a lot of different things that could kill that patient and we simply observe in these two patients, one, we have a young man who’s come in, thin fellow, not a great big pickwickian stereotype of sleep apnea and he has viral encephalitis and he’s in a stuporous comatose state and they call us to the ICU for an EEG because one of my colleagues many years ago had shown that a temporal lobe epileptiform discharge secondary to viral infection to the brain can lead to cardiac dysrhythmia. They said, we think he is having a very strange, unique seizural phenomena where he’s seizing and the way we have the seizure evidence is cardiac asystole, no heartbeat. So, fascinating, morbidly fascinating, maybe we can come in there and adjust with an anticonvulsant.

So my epileptologist, who, very close to polysomnography, we use the EEGs on the head, he’s watching and since we train our colleagues in sleep apnea and everything else we do in the department, he’s watching this guy during the EEG monitoring. He says, ‘I see the asystole, I don’t see any epileptiform activity, the brain wave looks pretty good for a guy who is stuporous and that’s a good finding, but he’s doing this.’ And what he’s having is obstructive apnea and he has paradoxical respirations that we teach our students to look for and all of a sudden he goes back to sleep. And again, when you are just visualizing, you can’t tell whether he’s sleep, stupor or what, but on the EEG you can. He says, he’s having obstructive sleep apnea, he’s sucking in against the closed glottis, call that a Muller's maneuver and that’s a sympathetic response, that’s not necessarily healthy for this young man. So we brought our poly symnography equipment up. We do portable studies, because that’s the best way, in my opinion to study a critically ill person. Have the nursing group, fellows, the staff that is comfortable, knows them well, don’t drag them off to my lab, bring the lab to him. And we saw these prolonged apneas and that’s what we published and that’s what you see in the film. The little bell goes over, ding, ding, ding, the nurse goes over, see her pull up the atropine, she’s calling the code, her injecting the atropine. That’s just the strangest thing, he’s not even losing his blood pressure when his heart stops. Usually when the heart stops, there’s no blood flow to the brain.

Nurse: It actually increases, which is really weird.

Dyken: In this case, as [unintelligible] showed many years ago, often times, there’s a sympathetic response and we believe the vessels are clamping down to save the ischemic penumbra, that there’s a protective mechanism in the apneic state, which sometimes can go awry. That’s the fellow with the encephalitis and we show, as the encephalitis is resolved, the apnea resolved. What we show in the other case is what Sullivan and Grimstein in the first principle and practice bible of sleep medicine had talked about the potential for rebound sleep in under treated CPAP and we had a fellow who had a history of apnea and wasn’t using his CPAP and he had just come in for a coronary artery bypass graft. And he said the nurses have noticed that when he goes to sleep he stops breathing. He’s got sleep apnea, could you get his CPAP all tuned up before he goes home because this is an expensive procedure, want his heart to keep beating for a while. So we brought him on over, oh, he had bad apnea. So we did a split night study, we diagnose, and then we started the CPAP and we started cranking. And it’s an art on how you increase CPAP. There’s now practice parameters from the American Academy of Sleep Medicine on how you would generally increase it. We were increasing it relatively fast. Despite increasing it, it’s the deepest state of sleep in regard to apnea, in general, REM sleep, and he starts having a prolonged apnea even though she’s increasing this pressure going up his throat. And it goes for two minutes.

Then you see at the end tail of what we show on the film, the end of the REM then you see diffused slowing which is hypoxemic coma and then it flattens. Essentially, into a brain death like pattern but we know he’s not dead because eyes move, he’s still warm and there’s still a heart rate. So we know he’s probably not dead even though his EEG is flattened out. So my technician, after two minutes says I’m not getting anywhere, she rips out his CPAP, she says ‘sir? Sir?’ She shakes him around a little bit and he’s not waking up and he’s still not breathing. She says lets call a code, hyperextends his neck, breathes a few breaths, starts doing external rub, does the chest compressions and this guy has just had his chest cracked and he doesn’t flinch. He’s not doing anything. After what seemed like a minute or so, he opens his eyes, looks to the left and she’s to the right and he has no idea what’s going on. He moans and just sort of stares at her and after fifteen minutes, this encephalopathic period resolves and he does quite well for the next few years.

But I mean, there’s a lot of limitations in clinical research, but I think, again, and that’s why people are here, what we can hopefully do is prove the obvious so that more people can be saved in regard to apnea, safety on the road with circadian rhythms and good schedules for going to school and going to work. The appropriate utilization of medications and bright light therapies for people on the shift works. And maybe, as Mignot had said with the narcolepsy, if we can get these youngsters, generally adolescents, when they get that infection that is attacking that lateral nucleus wake center in the brain and treat them with an antiviral or antibacterial or an anti whatever it is, immunomodulating therapy and prevent them from having narcolepsy. Well that’s what I think the whole meeting is about. And in fact, I think you have to be here to do that, I think you have to schmooze, I think you have to meet colleagues face to face.

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