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Interview with Spanish Doctor Javier Puertas

November 23, 2017

Dr. Javier Puertas eng

NN: The Sleep Unit of Hospital Universidad La Ribera is a reference point for sleep in Spain. How does it work and what makes this unit different from other sleep units?

Dr. Puertas: The sleep unit at Hospital La Ribera was started 18 years ago, in 1999.  From the beginning,  with the will to collaborate with different specialties like in other European countries, here in the United States,  sleep labs are the physical place with the beds and the polysomnography studies.  It is  an environment of collaboration of specialties, mostly of the pulmonology,  neurophysiology, and pediatrics specialties.  This is a place patients would visit every week or every other week.  A  place in which patients would be analyzed together by other colleagues.  A place in which sleep studies would be one more component of the diagnosis and treatment of patients. The patient could then start on one test and go back to the doctor for coordination and follow-up comments by the specialists.  This, and the fact that this was one of the biggest units in Europe when it opened, with four beds working every weeknight, distinguishes us from the rest.

NN: What is your opinion of the professional development of sleep medicine in Europe?

Dr. Puertas:   Of course in Europe, Germany in the 90s, there was already an acknowledgement of sleep medicine as a subspecialty.   It is true however, that this aspect was not developed in Europe afterwards. The United States acknowledged it as a subspecialty in 2007.  Recently in Europe, especially France, as well as other countries,  sleep medicine has also been recognized as a subspecialty. Like Germany and the United States, a subspecialty that can be accessed from other specialties is born. Specialties such as neurology, psychiatrics, pulmonology, internal medicine, pediatrics, otolaryngology, etc.  I believe this gives way to a second plan, enabling a European country like France to meet sleep medicine needs, following Germany’s success.  This can also be a very important aspect for other European countries, such as Spain, Italy, etc. as well as health authorities, to recognize sleep studies as a need based subspecialty area.  In other words, as a medical discipline.  This discipline will gain acceptance, and will have a comprehensive vision of the sleep disorders of patients, beyond the partial vision some specialties might have.  I am confident that in Spain, and in other European companies, especially countries in the European Union, there is a quick advance in acknowledging sleep medicine as a subspecialty.

NN: Back to the sleep unit in Hospital La Ribera, you have conducted thorough studies, clinical trials to contribute to the development of medications for sleep disorders such as insomnia, the restless legs syndrome, etc. What are the most recent results of those trials you have conducted? And have you seen the results on the medications being currently approved?

Dr. Puertas:  We have fortunately been able to collaborate in various clinical trials on medications for some sleep disorders.  The truth is that we are seeing how, after some years, there has always been a certain reduction in speed concerning the solution in the development of medications. There is again another group of molecules in medications which is in study stage.  Truly, we have been able to prove that both insomnia levels, and the restless legs syndrome, as well as narcolepsy,  apathy and hypersomnia, both in trials from a few years ago and in trials with which we have had more experience recently, there is an important group of molecules of new medications which can really help patients with sleep disorders.  For example, in the insomnia spectrum, due to the creation of molecules that work with mechanisms different to the gamma effect,  such as the hypocretin antagonists, in the case of the restless legs syndrome, we find an important group of clinical trials that are studying how intravenous iron is helping patients who respond poorly to other medications.  We have also helped develop some epilepsy antagonists.  Currently there is a series of trials on new medications to improve sleepiness in narcolepsy, such as the inverse antagonists of the histamine H3 receptor, and that can help patients with narcolepsy that have a partial response. That can work as a complement to other medications for narcolepsy.

NN:  You are a member of the World Sleep Medicine Association – well, besides other associations like the European one – a great specialist in sleep. What is your opinion about the evolution of studies and treatments on sleep disorders around the world? Is there a kind of study that is used  more frequently, and is there a specific specialty?

Dr. Puertas:   I believe that the vision, in relation to sleep disorders, has changed in recent years.  What was once a concern considered to be weird or strange in hospitals, has now a feeling of seriousness that sleep disorders have in the general population, and in primary assistance physicians.  I am currently seeing many patients in my practice with sleep disorders, which have been referred by primary assistance physicians. Sometimes with symptoms that have appeared very recently.  This leads me to believe that primary physicians are asking more and more about sleep disorders in the general population.  What may be happening here could be a good aspect and a bad aspect.  The good aspect is that sleep is starting to be seen as an important health issue.  Because sleep is an essential factor in the quality of life and health in general, it is also true that, such disorders as insomnia, sleep apnea syndrome, and restless legs syndrome, we are starting to see that in the sleep units of public hospitals, there is an important assistance pressure. This involves various aspects. As sleep disorder facilities, large and small, we need to start a campaign to train primary care physicians to better treat sleep disorders.  The bad aspect is that it is impossible to have in our units, everyone who is suffering from a sleep disorder.  I believe this is going to make health authorities realize sleep is a health issue which requires assistance and it is true, that even though it is difficult for sleep units to grow in Europe, as has been the case in the United States where there are sleep units with 20 beds or 20 rooms, I believe that telemedicine in Europe is going to be able to facilitate both the diagnosis and follow-up to patients.  We honestly cannot have bigger sleep units in the hospital, and therefore we need to look for ways to work in a network with primary care physicians, to be able to do a diagnosis and follow-up to patients.  I believe that those of us who work in sleep medicine hope that telemedicine, information and communication technologies, are able to facilitate the ability to reach more patients and to conduct follow-up better. Therefore, the companies working on new diagnostic technologies will have to get a little bit away of diagnosis in the hospital field, and seek other parameters.  Diagnoses such as algorithms, help us see heart rate, body temperature and other signs, that is why we have  technologies, to allow us to better handle this data, and we are able to integrate them to sleep studies to have a better understanding of what healthy sleep is to patients.

NN: In terms of percentage, in Spain principally, what is the percentage of people who are still suffering from sleep disorders but who have never been diagnosed because their primary physician never referred them to a specialist?

Dr. Puertas:  Our impression, and we believe Spain´s impression is similar, is that we do not have reasons or elements to think that it is different for other countries. Basically, half the general population suffer from a sleep disorder, and that half of the general population in the last year has required continuous medical assistance.  We are talking roughly 20% of the population.  It is very unlikely that we are given access  to less than 2, 3, 4, and  5% of the hospital population, including patients suffering from insomnia, sleep apnea, narcolepsy, parasomnias, therefore we have a 15 or 20% of the population expecting to be given an opportunity to be assisted regarding their sleep condition.

NN: Is there any type of disorder which is more frequent in a specific region of Spain?

Dr. Puertas:  We have conducted some studies with data from the Ministry of Health.  For example, we have found that in certain regions of northern Spain, people use more hypnotics than in the southern regions. We still do not know whether this is due to the lack of light or because it is colder.  We do not know the reason why the regions show a consumption of sleep medications, which is one third, almost double the one in the regions in the South. They are also from regions that are more developed in socioeconomic terms, that is why we do not know whether there is more stress and it is easier to access primary care. The fact that Spain is not very different from other Western countries, leads us to the conclusion, stress is the common factor.  The cities and the crisis have obviously generated more insomnia.  It is also true, that in terms of obesity of the general population, since we cannot only see it in adults but in children, we have a percentage of potential patients with sleep apnea associated to overweight and beyond. We see it in developing countries.  Mexico especially has the highest percentage of child obesity in the world.  Of course, we see that sleep apnea in children has migrated from a hypertrophy and tonsils profile, to an obese child profile.  Treatment and risk factors for each of these children are different, because clearly, a child younger than 6 years with hypertrophy will be operated on if there is an indication, because there are apneas. Of course we also see that a 7, 8, 9, and 10 year old obese child, with many apneas, sometimes needs to use a CPAP.

NN:  It is known that more developed societies have a higher rate of people suffering from sleep disorders, do you think there is an explanation for this?

Dr. Puertas:  I think there is.  There are various factors that clearly have an influence, that is, the more industrialized societies have a higher percentage of people working in shifts. The more  industrialized a society is, the more demands there will be for the population to offer a 24 hours or 24/7 services.  On the other hand, the more urban societies will take more time  commuting and most jobs are many times sedentary and indoors, which are factors.  This of course, reduces sleeptime because people spend a lot time commuting.  Sleeping less has an impact on metabolism. It favors obesity. We exercise less, sleep less, spend a lot of time in the car,  and we spend a lot of time at work.  We are also less exposed to natural light, since we leave home we enter the garage at home without receiving any sunlight, we barely walk, we drive our car, go to work where there is generally a parking lot, we park our car and sometimes, without going out to the street, we go up to our workplace without getting any light, and many times we are exposed to artificial light for most of our workday. This series of habits is a tremendously dangerous set, not only for our health, but for sleep if we compare it to what is programmed for our body.  Whether we were a farming society, or a hunting society, in both cases we were societies in which we were exposed to sunlight and physical activity at work so this change in industrialized societies is also divided in places that are more noisy. We live in buildings, on streets with cars, with environmental noise.  At times in airports next to highways.  It has been proven, for example, as early as the first year of life,  that in our sleep ECG, there are various awakenings when a plane lands; during the second year, those awakenings are decreased but heart reactivity persists, and we never fully adapt to noise or to an environment which is potentially threatening because this is something physiological.  So we have a series of elements in our environment that are causing difficulties as a whole, not isolated.  Did our Paleolithic ancestors ever suffer from any stress when they were chased by a bear? But, if we consider, as a whole, the lack of exercise, the lack of exposure to sunlight, sedentarism, sleeping in a noisy environment, etc., we have a set of factors which not only have an impact on our quality of  life, but also on our quality of sleep. Therefore, I think that we need to take these factors into account if we have to live in an urban environment. We have to try to make us better the best way we can. Avoid technology, avoid lights from tablets, excess technology, television, artificial lights. We need to make sure that when we are going to sleep, we disconnect from work stress, try to  improve our relationship with the family, and more human communication in the family environment. It means, to generate a habit that goes at least a little bit against this artificial life we are living in the cities. Everyone knows how to achieve this. Sometimes a person who works shifts cannot avoid disrupting his/her sleep, but it is true that that needs to be taken into account. Avoiding alcohol before going to sleep, avoid going back to work being exposed to the light at dawn, going back home wearing sunglasses after a night shift, allows us to sleep at home in the morning with the blinds down, and a sleep mask, etc. These cases have to be personalized a little bit. In general we have acquired life habits which are harmful to our health.

NN: You recently gave an interview about the difficulties to fall asleep when it is very hot. How does weather influence sleep quality?

Dr. Puertas:  We know there is an important relation between body temperature regulation and sleep quality.  This means that our body, in order to sleep well, especially during the first half of the night, needs the body temperature to lower.  To achieve this, we need the peripheral skin temperature to increase because it is the way in which our feet and our hands work as antennas to exchange heat with the environment.  Especially the ladies.  Women know that sleeping with cold feet and hands is impossible, that is why our grandmothers slept with hot water bags in bed when there was no heating system or air conditioning.   We have a low difference in temperature between our body and the outside.  We eliminate heat in the wrong way, and as we eliminate heat in the wrong way, we sleep less deeply, it is worse. Therefore, it is more difficult to sleep at night in hot and wet environments because we have a poorer regulation of body temperature, and our sleep is therefore lighter. Winter is another issue. If our hands and feet are cold, we are not going to be able to sleep soundly.  It is also true that with age, body temperature regulation is poorer, therefore it is one of the factors we think are associated to the worsening of sleep quality as we age. On the other hand, we also know that melatonin levels decrease with age, which is a hormone related to sleep quality.  At night, the highest the peaks of melatonin are, the better sleep depth is, but melatonin also helps produce the peripheral dilation of hands and feet which aids in expelling heat.  This is the  reason why taking melatonin will help us rest.  It also helps us regulate body temperature. Therefore, there is an important relationship between body temperature regulation and room temperature. If it is close to 30° and there is an insufficient room humidity level which prevents us from expelling heat, our sleep is going to be worse.

NN:  That is in the short term, one night, two nights, but in the long term, extended heat, for example in a place like the North of Africa, or even in Florida, which is hot throughout the year, this constant heat, can it help develop a specific sleep disorder?

Dr. Puertas:  There are no studies in the long term that indicate that sleep is affected because of living in a given climate, and in the long term regarding life expectancy or death rate.  It is certainly true, that in this life, all biological rhythms aid the contrast, because the biological rhythms were created from the rotation of the Earth, due to light-dark cycles. Therefore, the heat-cold contrast at night also helps you sleep well.  We cannot explain why yet.  We know the human body has an incredible ability to adapt. We can see from the Berbers in the Sahara, who are covered with a tunic, to the Eskimos, we are living in extreme temperature ranges but we have no evidence of any effect, and we think it is because the body is capable of adapting to almost every situation on the planet.

NN:  Is there any type of contraindication when it is very cold that may cause harm to sleep? You just mentioned that there should be a difference in body temperature. Is there any harm to sleep when it is very cold?

Dr. Puertas:  Cold produces peripheral constriction of the blood vessels.  In order for us to keep from being very cold, and not to lose heat, our skin arteries contract and prevent blood from flowing heavily towards the skin so it does not lose heat. There is no serious damage.  Sleep is going to be poorer in extreme temperature. The ideal temperature to sleep should be between 18° and 20° celsius (64-68 F), and in an environment which is not too damp. This is not always easy to achieve, but what we do recommend is to avoid sleeping with artificial air conditioning all night because it ends up causing dryness in the mucous membranes and some wake later with some problems of pharyngeal irritation. We know more and more that these ceiling fans used in certain tropical countries that rotate slowly at night make it easier for people to sleep, than those that leave the air conditioning on all night. There are no studies however.  This is empirical evidence that in these more humid and more tropical countries,  it is more frequent to see a fan on the ceiling  that moves more slowly, so the moving air helps balance body temperature a little bit.

NN:  Doctor, you organized one of the sleep congresses which took place in Valencia in 2013; this has been one of the best sleep events. How did you come up with Valencia as one of the candidates to host the event?

Dr. Puertas:  Organizing the congress was not easy to do because there were other important cities in Europe.  These were capitals of European countries, and for us, it was a pleasant surprise to be chosen by Washam to organize the congress. As the Spanish society of sleep, personally to me, as a citizen of Valencia, it was a pleasant surprise, because when you belong in a society you want to share the good things about your country and society with your colleagues.  So after going through all the stages for the city to be chosen,  of course this implies talking to the authorities, talking to the Spanish Royal House, the King was the honorary president of the congress although he was not able to attend, fortunately he accepted the offer to be the honorary presiden.   We talked to the town hall and  to the Ministry of Health.  All of this was done here in Valencia by the Spanish Society of Sleep, and in Valencia, by me.  You find yourself involved in a series of tasks that do not have to do with your everyday work at the hospital and which you do not do every day, but there were also some pleasant bits. We mostly saw with the Spanish [sleep] Society and with other Spanish colleagues, that besides a scientific program offered by World Washam, we could offer some local sessions. One of the most emblematic places in Valencia is the city of arts and sciences which is a project by a Valencian architect, Santiago de la Traba.  We had the opportunity to present an opera in the Opera House in the city of opera.  We  also had an opera school which presented a repertoire  of international and Spanish opera to us, followed by fireworks.  Behind all of these events, we realize all the work there is in talking to others, requesting budgets, because a medical congress, mainly during the crisis, has always been difficult to achieve.  Fortunately, the feedback received at the end of the congress was a very pleasant opinion of the city and the congress.  This was an important moment in which the international scientific community of sleep participated jointly  in an event to present all the sleep medicine areas at the international level, and to be a cohesive group choosing to work on the same line. I believe we achieved many of these things in Valencia.  It was taxing personally speaking, but the truth is, it was very nice to see many world-renowned sleep medicine colleagues.  Up until that moment we had an attendance of almost 1700 people from all over the world coming from more than 66 countries with more than 800 abstracts of posters and presentations, and the satisfaction of all those who attended, since Valencia is a little way out of the international airports circuit. The reason  they made an effort to attend was the importance to offer a good scientific program, and in that sense, I think that it was a congress that was worthwhile for most of the colleagues who attended.  I wish for the next congress after Korea is in Prague this year which is going to be jointly organized.   The idea is for sleep medicine to truly be an area which is given the importance it deserves, mostly in terms of the research presented at the congress being translated into our daily practice with the patients.

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