Talking Sleep

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Binal Kancherla, Associate Professor of Pediatrics and Medical Director for the Sleep Program at Texas Children's Hospital, to discuss how sleep medicine practitioners can thoughtfully expand their practice to include pediatric patients.

Many adult sleep medicine clinicians have considered adding pediatrics to their practice but weren't sure where to start. Dr. Kancherla has created a comprehensive educational series addressing exactly this question—providing the clinical knowledge and practical framework needed to confidently treat children and adolescents with sleep disorders.

The landscape of pediatric sleep medicine has evolved significantly. Diagnostic approaches now include home sleep testing for appropriately selected adolescents, wearable technology, and refined polysomnography protocols specific to developmental stages. Sleep-disordered breathing in children presents differently than in adults, with updated assessment and treatment strategies. Meanwhile, insomnia and behavioral sleep issues in younger children are now understood through a more sophisticated lens that goes beyond simple behavioral management.

Pharmacotherapy in pediatrics raises important questions that clinicians treating adults may never encounter: How do you approach melatonin and magnesium supplementation that parents frequently use? What FDA-approved hypnotics exist for children, and when are they appropriate? These practical decisions require understanding pediatric-specific evidence and developmental considerations.

Pediatric sleep medicine encompasses conditions rarely seen in adult practice—parasomnias, circadian rhythm disorders in adolescents, restless leg syndrome in children, and pediatric narcolepsy. Recent advances in narcolepsy treatment create new clinical opportunities, though current approvals remain limited to adults, raising questions about future options for children.

Beyond disease-specific knowledge, Dr. Kancherla emphasizes building a pediatric sleep-informed practice—understanding workflow differences, family-centered communication, developmental considerations, and how to effectively partner with pediatric specialists and families.

Whether you're considering expanding into pediatrics, curious about how pediatric sleep medicine differs from adult practice, or seeking to deepen your understanding of conditions you may encounter, this episode provides clinical guidance and inspiration for professional growth.

Join us for this practical conversation about expanding your sleep medicine practice to serve the youngest patients.

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Carrie Mahoney, a neuroscientist and faculty member in the Department of Neurology at Harvard Medical School and Beth Israel Deaconess Medical Center, to discuss her groundbreaking research on how oxytocin may regulate social cataplexy in narcolepsy.

With FDA approval of new narcolepsy medications, understanding the neural mechanisms underlying cataplexy has never been more clinically relevant. Dr. Mahoney's research began with a simple but profound clinical observation: cataplexy attacks occurred reliably when patients laughed with close friends and family members, but rarely when joking with coworkers or strangers. This pattern of emotion-triggered muscle weakness in social contexts prompted investigation into whether oxytocin—the hormone associated with bonding and social connection—might play a role.

Dr. Mahoney explains social cataplexy and discusses whether most cataplexy episodes occur in social contexts. She traces how she came to hypothesize oxytocin's involvement, moving from clinical observation to basic science investigation. The research explores how the amygdala—typically associated with fear—also processes other emotional responses including the joy and bonding feelings that characterize close relationships.

The episode walks through her research methodology. Using orexin knock-out mice (which model narcolepsy), Dr. Mahoney observed increased cataplexy during social interactions. She then systematically investigated oxytocin signaling in the amygdala to understand the mechanism. She employed advanced neuroscience techniques including chemogenetics and optogenetics—tools that allow precise manipulation and observation of specific neural circuits. The conversation clarifies what these approaches reveal about oxytocin's role in triggering muscle atonia during emotional social situations.

A crucial ethical question emerges: If oxytocin facilitates social bonding but also triggers cataplexy, would blocking oxytocin eliminate this important neurochemical? Dr. Mahoney addresses whether targeted intervention might be possible without sacrificing the neurochemical foundation of human connection and social behavior.

The research faced significant setbacks during COVID-19, affecting experimental timelines and animal studies. Dr. Mahoney discusses how she navigated these disruptions and the collaborative nature of validating complex neuroscience findings. She co-published this work with John Peever, highlighting how competitive yet collaborative the field must be to advance understanding.

An intriguing comparison emerges: Just as AI models solving previously unsolved math problems require human validation, complex neuroscience discoveries need replication and independent confirmation. Dr. Mahoney explains how her research will be validated and what the competitive landscape looks like in basic sleep neuroscience.

The ultimate goal is translation to clinical benefit. Would oxytocin-targeted therapy be preventive medication taken before social events, or a daily medication to modulate cataplexy susceptibility? Dr. Mahoney discusses how she communicates detailed scientific findings to patients and clinicians in understandable language, acknowledging the collaboration with science communicators like Kara Weaver.

Her research extends beyond cataplexy—orexin knock-out mice are also being used to investigate menopause-related sleep changes, suggesting broader applications of her findings.

Whether you're interested in narcolepsy pathophysiology, basic neuroscience approaches to understanding sleep disorders, or how fundamental research translates to clinical treatments, this episode illuminates the meticulous work underlying next-generation narcolepsy therapies.

Join us for this fascinating discussion about how curiosity-driven neuroscience research may transform how we treat cataplexy and understand the biology of narcolepsy.

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes three patient advocates who are reshaping how sleep medicine is practiced and funded. Matt Horsnell, living with two sleep disorders and active as an author and panelist; Emma Cooksey, a patient-advocate and host of the Sleep Apnea Stories podcast; and Julie Flygare, a lawyer, author, and founder of Project Sleep, share their transformative advocacy work.

While clinicians often think of advocacy as writing letters or making donations, these three demonstrate that patient advocacy encompasses far more complexity and impact. They explain the multiple dimensions of advocacy work: legislative advocacy that influences policy and funding, educational advocacy that raises awareness and understanding, and research advocacy that shapes the scientific agenda.

The conversation begins with personal stories—what brought each advocate to this work and how living with sleep disorders motivated their commitment to systemic change. Matt shares insights as someone navigating two sleep conditions, while Emma and Julie discuss how legal training informed their approaches to advocacy and systems change.

Legislative advocacy receives detailed exploration. The guests explain how patient voices influence congressional action, regulatory decisions, and funding priorities. They discuss educational advocacy—raising public awareness, changing misconceptions, and helping people recognize sleep disorders they might otherwise dismiss or normalize.

Project Sleep, Julie's organization, serves as a centerpiece for discussion. While Project Sleep doesn't fund research directly, the conversation addresses which organizations do fund sleep medicine research and how clinicians and patients can access federal funding mechanisms. The guests provide insights into how disease-specific organizations like Wake-up Narcolepsy secure funding and the lessons applicable to sleep medicine more broadly.

Project Sleep's helpline receives attention—what it offers, who it serves, and the critical challenge of sustainability when grant funding ends. The guests discuss Rising Voices, an initiative amplifying patient narratives and lived experience in policy and clinical discussions.

A particularly valuable discussion addresses how clinicians can meaningfully engage with patient advocacy. Is this space exclusively for people living with sleep disorders, or can healthcare providers contribute? The conversation explores collaboration opportunities without appropriating patient voices or experiences.

The guests address practical questions: How do you sustain advocacy work without becoming discouraged? What does advocacy look like at local versus federal levels? What's on the wish list for sleep medicine advocacy? A recurring theme emerges: sustained funding remains elusive despite growing recognition of sleep disorders' impact on public health.

The episode acknowledges that patients bring irreplaceable perspectives to clinical practice, research prioritization, and policy development. Their lived experience of navigating diagnoses, treatments, and healthcare systems provides insights clinicians cannot access through clinical practice alone.

Whether you're interested in supporting patient-led advocacy, seeking to collaborate with patient organizations, curious about how to engage in legislative efforts, or simply wanting to understand the power of patient voices in healthcare transformation, this episode provides essential perspectives and practical guidance.

Join us for this important conversation with patient advocates who are leading meaningful change in sleep medicine.

Episode Correction: During the audio recording, federal funding for circadian research was misspoken as $60 Million. The correct amount is $600 Million.

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In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Sahil Chopra to discuss research challenging a fundamental assumption: that residual AHI measurements from PAP device downloads accurately reflect whether patients' sleep apnea is adequately treated.

Sleep medicine clinicians routinely rely on residual AHI from PAP downloads to determine treatment success, typically targeting an AHI under 5. But what if this metric significantly underestimates untreated sleep apnea? Dr. Chopra's study comparing PAP-determined residual AHIs to cardiopulmonary coupling (CPC)-derived AHIs reveals striking discrepancies: mean residual AHI was 2.4 via PAP download versus 12.1 via objective testing. Even more concerning, 85% of nights showing residual AHI under 5 on PAP downloads had elevated AHI based on objective CPC measurement.

Dr. Chopra explains why he chose cardiopulmonary coupling as the comparator metric, using a PPG-based wearable ring worn for 7-10 nights. He clarifies why PAP devices may systematically underestimate residual disease through mask leak, unstable breathing, and periodic breathing patterns.

A particularly concerning finding involves residual hypoxia. Dr. Chopra discovered significant hypoxic burden in many patients considered "well-treated" by PAP standards—important since hypoxic burden, not just AHI, drives cardiovascular risk.

Dr. Chopra's conclusion isn't that PAP-derived AHI is "bad"—rather, that it shouldn't be the sole metric for assessing treatment efficacy. Even patients with good symptoms may have significant residual respiratory events and hypoxia that PAP downloads fail to detect.

Clinical applications are discussed, including when to pursue objective testing and what interventions to consider when objective testing reveals inadequate control despite acceptable AHI.

Whether you rely on PAP downloads to assess treatment efficacy, manage patients with residual symptoms, or seek emerging objective metrics, this episode provides essential perspectives on optimizing PAP therapy.

Join us for this important discussion that challenges current assumptions about measuring treatment success in sleep apnea.