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 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.

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Andrea Matsumura, a sleep physician with specialized certification in menopause medicine and national advisor for Monarch MD, to discuss how sleep clinicians can better support patients struggling with perimenopausal sleep disturbances.

Since the FDA removed the black box warning on hormone replacement therapy, more patients are inquiring about medications to treat perimenopausal sleep symptoms. Dr. Matsumura, who left traditional practice to pursue menopause certification and now works at the intersection of sleep medicine, mental health, and women's midlife health, provides practical guidance on this increasingly important clinical area.

The conversation begins with Dr. Matsumura's career evolution. After training as an internist with a leadership role at Kaiser Permanente and practicing sleep medicine in a group setting, she pursued specialized menopause certification—a credentialing process explained in detail. Dr. Matsumura discusses what menopause certification encompasses, who can pursue it, and her own path into this specialty. She also discusses her work developing specialized supplements for perimenopausal sleep support.

The episode systematically addresses how perimenopause disrupts sleep. Rather than focusing solely on hot flashes, Dr. Matsumura explains the full spectrum of sleep-related changes. She clarifies the timeline of perimenopause—when it starts and ends—and discusses less commonly recognized phenomena like menstrual hypersomnia that clinicians may not immediately associate with menopause.

A critical discussion addresses patient expectations around hormone replacement therapy. Many patients expect sleep clinicians to prescribe HRT, which raises legitimate concerns for providers unfamiliar with menopause management. Dr. Matsumura provides practical guidance on these conversations and clarifies the role of hormone level testing—addressing the debate between treating symptoms versus checking levels before initiating therapy.

The conversation explores the complex relationship between sleep apnea and menopause. Dr. Matsumura explains why and how obstructive sleep apnea may worsen during perimenopause, how to have these conversations with patients, and when referral to OBGYN colleagues is appropriate for collaborative care.

Additional topics include the role of hypnotics in perimenopausal sleep disorders, absolute contraindications to hormone replacement therapy, how to initiate HRT when appropriate, and whether restless leg syndrome worsens with perimenopause.

Dr. Matsumura addresses common misconceptions about menopause and sleep, helping clinicians understand what practitioners and patients frequently get wrong about this life stage. The episode emphasizes that sleep medicine clinicians don't need to become menopause specialists, but understanding these connections enables better patient care and appropriate referrals.

Join us for this important conversation about supporting women's sleep health through midlife transitions.

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Laura Donahue, an assistant professor of sleep medicine at Vanderbilt University with a background in internal medicine and a researcher in sustainable healthcare, to discuss the environmental impact of sleep medicine practice and practical strategies for reducing carbon footprint and medical waste.

Recent environmental challenges—heat waves exacerbating insomnia, wildfires affecting respiratory and sleep health—highlight how climate directly impacts patient wellbeing. But do sleep medicine clinicians have an obligation to reduce their own environmental footprint? Dr. Donahue explores this question, examining the waste generated by sleep testing, PAP therapy, and ongoing supplies.

The conversation begins with foundational concepts: How does climate change impact sleep health? What exactly constitutes medical waste, and how does it differ from carbon footprint? Dr. Donahue explains methods for calculating carbon footprint and how the US healthcare system compares globally. She introduces life cycle analysis—a comprehensive tool for understanding environmental impact across product lifecycles.

Sleep lab waste assessments receive detailed attention. Dr. Donahue walks through how to conduct a waste audit of sleep facilities and why examining both carbon footprint and waste matters, acknowledging that these metrics don't always move directionally. Her research on PAP device waste, conducted with Dr. Morgenthaler, revealed substantial environmental costs associated with standard OSA therapy—findings that prompted examination of alternatives.

Telemedicine emerges as a potential sustainability strategy. Dr. Donahue compares carbon footprints of virtual versus in-person sleep consultations, exploring how practice model choices affect environmental impact. However, the analysis doesn't focus solely on PAP therapy—hypoglossal nerve stimulators and other non-PAP treatment options receive consideration as alternatives with potentially different environmental profiles.

SHAPE, an organization dedicated to helping healthcare providers examine their carbon footprint and waste generation, receives discussion. Dr. Donahue explains SHAPE's mission and practical resources available to sleep medicine programs. She provides concrete guidance on reducing environmental impact: waste audits, supply chain evaluation, and transitioning to circular economy models where possible.

A particularly relevant discussion addresses plastic waste from CPAP devices and consumable supplies. Dr. Donahue explains how waste audits serve as the first step toward identifying reduction opportunities and discusses strategies for minimizing single-use plastics in sleep medicine practice.

The episode acknowledges that sustainability requires institutional commitment and individual awareness. Dr. Donahue emphasizes that small changes—from supply selection to practice model design—accumulate to meaningful environmental impact.

Whether you're interested in sustainable healthcare, concerned about medical waste, seeking to reduce your sleep practice's carbon footprint, or wanting to better understand climate impacts on sleep health, this episode provides practical guidance and evidence-based approaches.

Join us for this important conversation about environmental responsibility in sleep medicine practice.

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Karin Johnson, Professor of Neurology at UMass Chan School of Medicine–Baystate and expert on circadian rhythm policy, to discuss two competing legislative bills addressing permanent time change in the United States.

Two bills currently before Congress present starkly different solutions: the Sunshine Protection Act for permanent daylight saving time and the Sunshine for Our Kids Act for permanent standard time. Both campaigns use compelling language that makes their position sound obvious, complicating decisions for policymakers and clinicians alike.

Dr. Johnson reviews the AASM's official position on daylight saving time and what research reveals about time change effects—both short-term consequences of bi-annual clock transitions and long-term health impacts of permanent DST, particularly on adolescent mental health and circadian rhythm disruption. She explains what happened during the 1974 experiment with year-round daylight saving time and why that experience remains relevant today.

The conversation details both the Sunshine Protection Act and the Sunshine for Our Kids Act, including their legislative progress and specific provisions. Dr. Johnson clarifies which approach sleep medicine clinicians support and provides practical guidance on advocacy.

An intriguing discussion explores a proposed compromise to move clocks by 30 minutes and leave them there—why didn't this gain traction? Dr. Johnson also reveals how industry influence shapes policy, discussing candy companies' historical support for daylight saving time and other commercial interests that complicate what should be a health-based decision.

Dr. Johnson emphasizes that permanent standard time better aligns with human circadian biology, particularly for adolescents whose naturally delayed circadian rhythms suffer under permanent DST.

Whether you're seeking to understand these competing bills, advocate for science-based policy, or interested in how medical evidence influences legislation, this episode provides clarity on a complex issue with direct health implications.

Join us for this important conversation about how sleep medicine can influence public health policy.

In this special live episode recorded from the SLEEP 2026 annual meeting in Baltimore, host Dr. Seema Khosla welcomes Dr. Sanjay Patel, director of the clinical sleep program at University of Pittsburgh Medical Center, to discuss groundbreaking medications for sleep disorders poised for FDA approval in 2026 and 2027.

The pharmaceutical landscape for sleep medicine is undergoing unprecedented transformation. Dr. Patel surveys the emerging drug pipeline that will fundamentally change how clinicians treat obstructive sleep apnea, narcolepsy, and idiopathic hypersomnia.

For obstructive sleep apnea, Dr. Patel discusses AD-109 (atomoxetine and R-oxybutynin), explaining the mechanistic rationale and practical considerations including use with tirzepatide. The Incannex drug combining dronabinol and acetazolamide receives analysis for different patient populations, and sultiame is discussed as a carbonic anhydrase inhibitor option. A critical framework emerges: Should treatment be symptom-based or airway-focused when PAP-intolerant patients present?

Tirzepatide, the GLP-1 agonist FDA-approved for moderate-to-severe OSA, receives comprehensive coverage including muscle loss concerns, long-term use, and emerging oral GLP-1 options. Retatrutide, the triple-hormone agent combining GLP-1, GIP, and glucagon, is also discussed.

The episode's most exciting segment focuses on orexin agonists for narcolepsy. Three pharmaceutical companies—Alkemeres, Centessa (purchased by Lilly), and Takeda—are developing these mechanistically novel agents. Dr. Patel clarifies how these medications differ, discusses why one medication disrupted nocturnal sleep (suggesting continued roles for oxybates), and addresses how clinicians will choose between similar medications.

Dr. Patel emphasizes a fundamental question: Should the field prioritize symptom management versus airway patency for OSA, and mechanistic approaches versus symptom management for narcolepsy?

Whether you're interested in emerging OSA treatments, narcolepsy innovations, or the future of pharmacological sleep medicine, this live episode provides essential updates on medications that will soon reshape clinical practice.

Join us for this exciting conversation about how sleep medicine will transform in the coming years.

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Abhishek Goyal, Professor and Head of Respiratory Medicine in Dehradoon, India, and Dr. Prakhar Agarwal, a pulmonologist in private practice in Bhopal, India, to discuss their research comparing fixed CPAP versus auto-titrating CPAP (APAP) on blood pressure control and autonomic nervous system response.

For years, difficult-to-treat hypertension has been recognized as an indication for sleep studies, reflecting the assumption that treating sleep apnea improves blood pressure. But does the method of PAP therapy matter? Beyond achieving a residual AHI under 5, are there treatment nuances that could optimize cardiovascular outcomes? Dr. Goyal and Dr. Agarwal's research addresses these questions, building on landmark work by Dr. Pepin examining fixed versus auto-titrating PAP therapy.

The motivation includes both clinical and economic considerations. A 2021 Portuguese study examined cost implications, and similar economic pressures exist in India where APAP is significantly more expensive than fixed CPAP. The study used a crossover design comparing fixed CPAP to APAP, measuring blood pressure dipping patterns and autonomic response to assess cardiovascular effects.

The results have prompted Dr. Goyal to reconsider his clinical practice regarding pressure selection, raising important questions: If fixed CPAP offers superior blood pressure outcomes, should the standard practice of prescribing APAP devices be reconsidered? This challenges assumptions about adaptive algorithms and raises questions about prioritizing cardiovascular outcomes beyond AHI reduction.

The episode contextualizes these findings within India's unique healthcare landscape, exploring surprising OSA incidence data and examining whether craniofacial anatomy or arousal patterns differ from Western populations. Dr. Agarwal discusses how pressures are typically determined and the practical differences between APAP 4-20 versus narrow-range settings.

Whether you're prescribing PAP therapy for hypertension, optimizing cardiovascular outcomes, or seeking evidence-based approaches to pressure selection, this episode provides important international perspectives.

Join us for this discussion that may prompt reconsideration of how we set PAP pressures and what outcomes we should prioritize.