Talking Sleep

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Faisal Ali, professor of dermatology at the University of Central Lancashire and consultant dermatologist specializing in Mohs micrographic and laser surgery, to explore the fascinating connections between sleep and skin health. Drawing from recent research published in Clinical and Experimental Dermatology, Dr. Ali explains how sleep serves as a critical regulator of skin physiology, affecting everything from skin surface pH and transepidermal water loss to blood flow and temperature regulation. The conversation delves into the complex interplay of circadian rhythms, hormones, and inflammatory cytokines that govern both sleep patterns and skin homeostasis. The discussion covers how sleep deprivation accelerates skin aging as an extrinsic factor alongside sun exposure and pollution, with compelling evidence from studies showing that good sleepers have significantly better skin aging scores and improved recovery from UV exposure. Dr. Ali explores the bidirectional nature of this relationship—while poor sleep worsens skin conditions, dermatological disorders like atopic dermatitis, psoriasis, and rosacea can severely disrupt sleep through mechanisms including the itch-scratch cycle and inflammatory processes. The episode addresses practical clinical concerns including the higher prevalence of sleep disorders in patients with conditions like hidradenitis suppurativa and rosacea, the role of obstructive sleep apnea in various skin conditions, and evidence-based approaches to breaking the itch-scratch cycle that disrupts sleep in dermatological patients. The conversation also tackles common sleep treatment-related skin issues, from CPAP mask irritation and "maskne" to headgear-induced hair loss, providing practical guidance for managing these complications. Dr. Ali discusses proper skincare routines for CPAP users, including the safety of retinol use under masks and strategies for preventing pressure-related skin breakdown. Whether you're a sleep medicine practitioner encountering dermatological complaints, a dermatologist treating patients with sleep disruption, or simply interested in optimizing both sleep and skin health, this episode provides evidence-based insights into this often-overlooked connection. Join us for this comprehensive discussion that bridges dermatology and sleep medicine to enhance patient care and understanding.

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Imran Iftikhar and Dr. Rami Khayat to discuss groundbreaking research on adaptive servo-ventilation (ASV) and the newly released AASM clinical practice guidelines for central sleep apnea treatment. Dr. Iftikhar presents his innovative approach to analyzing ASV data through meta-analysis combined with trial sequential analysis, offering fresh insights into the statistical reliability of existing research beyond traditional systematic reviews. His work addresses lingering questions about ASV efficacy and safety that have persisted since the controversial SERVE-HF trial results challenged previous assumptions about this therapy. Meanwhile, Dr. Khayat, who served as vice-chair of the AASM task force, walks through the comprehensive evidence-based recommendations covering the full spectrum of central sleep apnea treatments. The guidelines address critical clinical decisions: When should CPAP be used over no treatment? Who requires BPAP with backup rates? Why does the task force recommend against BPAP without backup rates for central sleep apnea? What role do oxygen, acetazolamide, and transphrenic nerve stimulation play in treatment algorithms? The conversation delves into practical considerations including differences between ASV device algorithms from various manufacturers, the clinical impact of current device availability issues, and findings from Dr. Parthasarathy's bench study. The experts tackle the complex question of ASV use in patients with reduced ejection fraction and clarify important distinctions between primary central sleep apnea and treatment-emergent central sleep apnea (TECSA). This episode addresses the evolving landscape of central sleep apnea management, helping clinicians navigate evidence-based treatment decisions in an era of changing technology and updated safety considerations. Whether you're treating patients with heart failure, complex sleep-disordered breathing, or emerging central events during PAP therapy, this episode provides essential guidance for optimizing care. Join us for this comprehensive update that translates complex research findings into practical clinical applications.

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Greg Burek, a psychiatrist and former Marine, and Dr. Dmitriy Kogan, associate professor of medicine at the Medical College of Wisconsin and program director for the sleep medicine fellowship program, to discuss the unique sleep challenges facing military veterans and first responders. The conversation explores how military and first responder training fundamentally changes individuals, creating an "adrenaline-focused" mindset that profoundly impacts their relationship with sleep and health. Dr. Burek provides insider insights into the stages of military service and the concept of "sacrifice" as a unifying characteristic among veterans, while explaining why many veterans may minimize or dismiss their service experiences. The guests introduce the BRAVE program, an innovative initiative designed specifically for military veterans and first responders to address the "invisible wounds of service"—PTSD and TBI—and their complex interactions with sleep disorders. Unlike traditional VA programs, BRAVE takes a specialized approach to understanding how military culture and experiences create unique sleep medicine challenges. The discussion covers critical clinical topics including insomnia management in veterans, the frequent use of clonidine as a treatment option, REM behavior disorder presentations that may differ from civilian populations, and the intricate relationships between PTSD, TBI, sleep-disordered breathing, and nightmare disorders. The experts address whether these sleep disturbances stem from combat trauma, brain injury, or the military experience itself. This episode provides essential insights for healthcare providers treating veterans, including practical approaches to asking about TBI history, understanding military culture's impact on patient care, and recognizing when specialized referrals may be beneficial. Whether you're a sleep medicine practitioner, mental health professional, or healthcare provider serving veteran populations, this episode offers valuable perspectives on culturally competent care for those who have served. Join us for this enlightening discussion that bridges military culture and sleep medicine to improve care for our veterans and first responders.

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Gulcin Benbir, professor of neurology and sleep researcher from Turkey, and Dr. Lourdes Del Rosso, sleep physician and professor at UCSF who served on the task force for updated AASM RLS guidelines, to discuss groundbreaking research on periodic limb movements in sleep (PLMS) that persist after successful sleep apnea treatment. Following the recent updates to RLS guidelines, this conversation addresses the often-overlooked condition of periodic limb movement disorder (PLMD). The guests reveal surprising findings that challenge traditional teaching: while sleep medicine practitioners have long been taught that PLMD improves with PAP therapy, their research shows that 30% of patients continue to experience significant periodic limb movements even after successful OSA treatment. The discussion explores critical clinical questions: Are PLMs innocent bystanders or pathological processes requiring treatment? When do PLMs become PLMD? How should we evaluate residual hypersomnolence in well-treated OSA patients—should we screen for persistent PLMs before prescribing wake-promoting agents? The experts also delve into the complex relationship between RLS and PLMs, examining whether they represent interconnected sensory and motor phenomena or distinct processes. Practical treatment strategies are covered extensively, including the role of iron supplementation, appropriate diagnostic testing, IV iron protocols, and evidence-based pharmacological interventions. The conversation also addresses how the shift toward home sleep testing may impact our ability to detect and treat this important cause of continued sleep disruption. Whether you're treating OSA patients with persistent daytime sleepiness or managing complex sleep disorders, this episode provides essential insights into recognizing and treating PLMD as a potential contributor to ongoing symptoms. Join us for this clinically relevant discussion that may change how you approach residual hypersomnolence in your practice. 

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Luca Baldelli, a neurologist from the University of Bologna and Treasurer-Elect of the International REM Sleep Behavior Disorder Study Group, to discuss breakthrough research on predicting which RBD patients will develop neurodegenerative diseases. Building on the AASM's updated RBD guidelines, Dr. Baldelli presents compelling evidence for using simple autonomic reflex testing to identify patients at highest risk for phenoconversion to conditions like Parkinson's disease and dementia with Lewy bodies. His research demonstrates that objective autonomic testing, particularly orthostatic assessments, can reveal early neurogenic orthostatic hypotension that precedes overt neurodegeneration by years. The conversation explores practical clinical applications: How can sleep medicine practitioners implement these screening protocols? What constitutes abnormal autonomic function in RBD patients? How do we interpret changes over time, and when should patients be referred for neurological evaluation? Dr. Baldelli shares his longitudinal monitoring framework that could transform how we counsel RBD patients about their future risk. This episode addresses critical questions about biomarker development in prodromal neurodegeneration, the timeline of autonomic changes, and evidence-based approaches to patient discussions about prognosis. Dr. Baldelli also discusses current research initiatives and potential therapeutic interventions for high-risk patients. Whether you're a sleep medicine physician, neurologist, or researcher interested in neurodegenerative diseases, this episode provides essential insights into improving early detection and patient care in RBD. Join us for this informative discussion that bridges sleep medicine and neurology to enhance clinical decision-making and patient outcomes.

In this episode of Talking Sleep, host Dr. Seema Khosla sits down with Dr. Natalie Hauglund to discuss a groundbreaking mouse study on how the popular sleep medication zolpidem affects the brain’s natural cleaning system during sleep. Building on Dr. Maiken Nedergard's award-winning work on the glymphatic system, Dr. Hauglund's latest study published in Nature reveals surprising findings about how sleep medications may interfere with the brain's ability to clear waste products. Through innovative mouse studies using advanced imaging techniques, her research demonstrates that zolpidem reduces glymphatic clearance by 30%, raising important questions about long-term cognitive health.  The conversation explores fascinating discoveries about micro arousals during sleep—are these brief awakenings actually beneficial for brain clearance rather than disruptive? Dr. Hauglund explains the delicate balance between sleep quality and the brain's cleaning mechanisms, and how different neurotransmitters orchestrate these crucial overnight processes.  This episode addresses critical clinical questions: Should we reconsider our prescribing practices for sleep medications? How do we weigh the benefits of medicated sleep against potential impacts on brain health? What are the implications for patients using zolpidem long-term, particularly regarding neurodegenerative disease risk?  Whether you're a sleep medicine practitioner, researcher, or interested in understanding how sleep affects brain health, this episode provides essential insights into the complex relationship between sleep medications and neurological well-being.  Join us for this thought-provoking discussion that may reshape how we think about treating insomnia and protecting long-term brain health. 

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Jared Saletin, a sleep researcher investigating the complex relationship between sleep and Attention-Deficit/Hyperactivity Disorder (ADHD).  While ADHD diagnostic criteria don't currently include sleep assessment, Dr. Saletin's groundbreaking research reveals how sleep quality and timing may significantly impact attention, particularly in children. Through fMRI studies and clinical observations, he explores whether sleep loss exacerbates ADHD symptoms or might even present as ADHD-like behavior in some cases.  The conversation delves into fascinating questions: Are people with ADHD more sensitive to sleep deprivation? Can improving sleep habits reduce ADHD symptoms? How do common sleep disorders like obstructive sleep apnea intersect with attention disorders? Dr. Saletin shares practical strategies for protecting sleep in children with attention challenges, including potential educational accommodations.  Whether you're a healthcare provider, parent, educator, or simply interested in understanding the sleep-attention connection, this episode offers valuable insights into how addressing sleep might be a crucial component in managing ADHD effectively.  Join us for this enlightening discussion as we explore how sleep might be a modifiable risk factor in ADHD, providing new hope for better management strategies. 

In this episode, Dr. Seema Khosla examines the complexities of central sleep apnea  (CSA) with sleep medicine experts Dr. Vaishnavi Kundel, Dr. Rami N. Khayat, and Dr. Aneesa Das. The discussion moves beyond basic definitions to explore the critical limitations of home sleep apnea testing in accurately detecting CSA and when in-lab polysomnography becomes essential.  The conversation addresses important clinical distinctions between post-arousal, transitional, and mixed apneas, challenging common assumptions about their significance and treatment approaches. The panel provides clarity on various CSA etiologies, including heart failure-related periodic breathing, medication-induced central apneas, treatment-emergent CSA, and neurological disorders.  Discover evidence-based perspectives on treatment strategies, including updated views on adaptive servo-ventilation since the SERVE-HF trial, indications for phrenic nerve stimulation, and the potential of combination therapies. Learn when to consider alternative approaches like dead-space ventilation, supplemental oxygen, and acetazolamide, either alone or as part of hybrid treatment plans.  The discussion also examines practical clinical questions: Does distinguishing between obstructive and central apnea matter if treatment approaches overlap? When should patients with suspected CSA undergo in-lab studies versus home testing? What guidance should clinicians follow for patients with ejection fractions below 45%? Whether you're managing complex sleep disorders or encountering CSA in primary care, this episode provides essential insights for optimizing patient outcomes through accurate diagnosis and appropriate treatment selection. 

In this episode, Dr. Seema Khosla explores the critical issue of clinician burnout with Dr. Venktesh Ramnath, Associate Clinical Professor at UC San Diego. Moving beyond typical wellness advice, Dr. Ramnath offers practical strategies for addressing burnout at its systemic roots rather than treating it as an individual failure.  The conversation examines how to recognize true burnout versus temporary fatigue and challenges the common rhetoric about "resilience" that shifts responsibility from broken systems to individuals. Dr. Ramnath shares his personal burnout experience and discusses whether dramatic career changes are necessary before making meaningful improvements to professional satisfaction.  Discover actionable steps for reducing burnout, including negotiating with leadership, establishing horizontal professional networks, and eliminating low-value work. Learn how coding efficiency relates to burnout and understand the emerging role of "health architects" in creating sustainable medical workplaces.  The discussion also addresses Dr. Ramnath's public response to demands for federal employee productivity reporting, techniques for constructive workplace conversations, and practical advice for saying "no" effectively—a crucial skill rarely taught in medical training. Whether considering a job change or trying to improve a current position, this episode provides essential guidance for creating a more sustainable medical career. 

In this episode, Dr. Seema Khosla talks with women's sleep expert Dr. Safia Khan about women's unique sleep challenges. Dr. Khan is an editor for "A Clinical Casebook of Sleep Disorders in Women" and specializes in women's sleep health at UT Southwestern. She explains how sleep disorders affect women differently across their lives, particularly during pregnancy and menopause, and how these transitions disrupt normal sleep patterns.  Discover Dr. Khan's assessment strategies for insomnia in women, including decision-making frameworks for implementing CBT-I versus medication interventions. Learn about the underdiagnosis of sleep disorders in women, particularly during menopause, and strategies for changing this normalized narrative. The conversation explores the physiological differences in sleep-disordered breathing between men and women, explaining why sleep apnea incidence equalizes during menopause.  The discussion addresses managing hypersomnia during pregnancy, approaches to fatigue without diagnosed sleep disorders, connections between PCOS and sleep disruption, and guidance on Restless Legs Syndrome management, including the critical role of iron deficiency screening in adolescent girls.  This episode provides essential knowledge for practitioners seeking to better understand and treat the unique sleep health challenges women face across their lifespans. 

In this episode, host Dr. Seema Khosla explores a transformative development in sleep medicine: the FDA approval of tirzepatide for obstructive sleep apnea (OSA). Joined by an expert panel including Dr. Atul Malhotra, lead investigator of the SURMOUNT-OSA trial, and specialists Dr. Radhika Breaden, Dr. Jeremy McConnell, and Dr. Rafael Sepulveda-Acosta, the discussion examines how sleep clinicians can effectively incorporate this groundbreaking medication into their treatment protocols.  Discover key insights about the SURMOUNT-OSA trial results published in the New England Journal of Medicine, including the mechanisms behind AHI improvement beyond weight reduction alone. Learn practical implementation strategies for private practices, including documentation requirements for insurance approval, necessary baseline labs, and optimal patient follow-up protocols. The experts address crucial questions about Medicare coverage, long-term medication management, the need for retesting at goal weight, and considerations for transitioning patients already using GLP-1 medications like Ozempic or Wegovy.  This episode provides essential guidance for sleep medicine specialists considering expanding their treatment options beyond traditional PAP therapy, including collaborations with obesity medicine clinics and whether obtaining board certification in Obesity Medicine would benefit sleep clinicians. This timely discussion equips practitioners with the knowledge to navigate the intersection of sleep medicine and obesity treatment in managing OSA patients 

In this episode, host Dr. Seema Khosla explores a provocative question in sleep medicine: Could high pressure PAP therapy have unexpected inflammatory effects? Joined by Dr. Sanja Jelic from Columbia University and Dr. Daniel Gottlieb from Brigham and Women's Hospital, the discussion examines emerging research that challenges conventional wisdom about positive airway pressure (PAP) therapy.  Discover groundbreaking findings on how PAP settings may influence inflammatory biomarkers like angiopoietin-2 (AP2) and VEGF-A, potentially explaining why cardiovascular outcomes in clinical trials haven't consistently shown improvement with PAP therapy. Learn about pressure optimization strategies, alternatives to high-pressure PAP therapy, and implications for treating 

In this episode, host Dr. Seema Khosla tackles a critical question in sleep medicine: What defines "well-treated" obstructive sleep apnea? Joined by Dr. Barry Krakow, a pioneering sleep medicine physician, the discussion explores the nuanced approach to assessing sleep apnea treatment beyond traditional metrics.  Discover insights into clinical endpoints for evaluating OSA treatment, the complex relationship between upper airway collapsibility and anxiety, and innovative strategies for patients with challenging sleep disorders. Dr. Krakow shares his unique perspectives on PAP therapy, including approaches for patients with PTSD and the potential role of behavioral interventions. 

In this episode, host Dr. Seema Khosla explores KPAP, a new PAP therapy innovation with Dr. David White, former AASM president, and Dr. William Noah, inventor of the V-com device. Learn about this new technology that promises to make positive airway pressure more comfortable while still remaining effective for sleep apnea patients. Discover the science behind KPAP, its potential advantages over traditional CPAP, and how it addresses issues like treatment-emergent central apneas and CO2 rebreathing. The discussion covers the device's development, clinical trial results, and implications for sleep apnea treatment, offering insights for clinicians and patients alike.

In this episode, host Dr. Seema Khosla explores the new Apple Watch sleep apnea screening algorithm with Dr. Matt Bianchi, a research scientist from Apple's Health Technologies team. Learn about the innovative technology that monitors sleep patterns and potentially identifies sleep apnea risk through advanced wearable device capabilities.  Discover how this algorithm uses accelerometry and breathing disturbance detection to screen for potential sleep apnea, its limitations, and implications for patient care. The conversation delves into the algorithm's performance, its role in consumer health technology, and guidance for sleep medicine professionals navigating new diagnostic tools. Whether you're a clinician or interested in sleep health technology, this episode offers critical insights into the future of sleep disorder screening. 

In this episode, host Dr. Seema Khosla examines a crucial clinical question: how reliable is the residual AHI measured by PAP devices? Experts Dr. Robert Thomas, Dr. Tavi Ioachimescu,  and Dr. Imran Iftikhar analyze the accuracy of PAP downloads, brand differences in measurement, and implications for patient care. Through meta-analysis findings and clinical research, they explore stable versus unstable breathing patterns and how this data influences treatment decisions. The discussion covers device-specific algorithms, historical development of AHI measurement, and the role of patient monitoring software like OSCAR and SleepHQ. Learn about therapeutic approaches for unstable breathing, including medication options and practical management strategies for complex sleep apnea cases.

In this episode, host Dr. Seema Khosla welcomes Dr. Maya Schenker, a postdoctoral researcher from the University of Melbourne, who has dedicated her research to understanding the complex relationship between sleep and post-traumatic stress disorder (PTSD). With a focus on the bidirectional mechanisms linking sleep and trauma, Dr. Schenker explores how sleep can be a critical intervention point for managing and potentially preventing PTSD. Discover the latest insights into how sleep impacts trauma response, including the role of REM sleep, fear conditioning, and the neurological processes that contribute to PTSD development. The conversation delves into why women are more susceptible to PTSD, the potential of sleep interventions, and breakthrough research on preventing trauma-related sleep disorders. Whether you're a healthcare professional or interested in understanding the intricate connections between sleep and mental health, this episode offers valuable perspectives on trauma, sleep, and healing.

In this episode, host Dr. Seema Khosla welcomes Dr. Danny J. Eckert, a sleep and respiratory physiologist and professor at Flinders University in Adelaide, Australia. Dr. Eckert is a leading expert in his field and the recipient of the 2023 European Respiratory Society Gold Medal in Sleep-Disordered Breathing. As the Director of the Adelaide Institute for Sleep Health, he discusses his groundbreaking work on OSA endotyping and the PALM classification system (Pcrit, Arousal threshold, Loop gain, and Muscle recovery). Discover why 70% of OSA patients have non-anatomical causes and how understanding these distinct endotypes can revolutionize treatment approaches. The conversation delves into practical applications for clinical settings, examining the roles of obesity and nasal obstruction in sleep apnea while discussing targeted therapeutic strategies, including GABAergic medications.

In this episode of Talking Sleep, Drs. John Winkelman and Andy Berkowski discuss the updated AASM clinical practice guideline for the treatment of restless legs syndrome and periodic limb movement disorder.

There was a recent consensus statement from the Society of Anesthesia and Sleep Medicine and the Society for Obstetric Anesthesia and Perinatology on the screening, diagnosis, and treatment of obstructive sleep apnea (OSA) in pregnancy. For too many, a sleep evaluation is deferred until the pregnancy is over, with the idea that pregnancy-related sleep disorders will resolve at the end of the pregnancy. This leaves so many with sleep disorders undiagnosed and untreated. Dr. Louise O’Brien has tried to bridge this gap. She works in the Division of Sleep Medicine in the Department of Neurology, as well as the Division of Maternal and Fetal Medicine in the Department of Obstetrics and Gynecology at the University of Michigan. She is here to share her experience locally, but also globally when it comes to sleep health during pregnancy.