The White Noise Podcast

The White Noise Podcast

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The White Noise Podcast episodes

  • Episode #12 Even More Restless Legs
    We welcome back Dr. Andy Berkowski to discuss more restless legs, including updated guidelines, and also get into a brief discussion of concierge sleep Medicine. Show Notes Thing of the month 4:00-The investiGATORS, Mouse, The Watchmen , 48 Laws of Power, Cloud Cuckooland, The last of UsRLS recap of previous RLS episode 8:422021 Mayo Clinic Proceedings RLS 10:00Alcoholism induced by dopamine agonist 14:30Think/check Iron first 15:30Parkinson’s patients 16:15Initial management & Serum Iron Brain Iron mismatch and iron dosing 21:30Iron supplementation: 23:5026:00 Transferrin Saturation28:30 HepcidinOral iron approaches 29:30Gabapentin side effects 30:45When symptoms continue despite iron repletion 32:15Gabapentin Encarbil 33:30 Clonazepam and…
    1 hr 12 min
  • Episode #11 - Hypoglossal Nerve Stimulation
    In this months episode we will be discussing all things Inspire with Dr. Paul Hoff, an ENT at Michigan Medicine.  What is Hypoglossal Nerve Stimulation? Who can get it? Does it Even work? Listen as we answer all your burning questions. 
    Show Notes
    3:00 get to know you questions
    9:20 Favorite Book
    Best Advice 10:00
    The Inspire Case 11:00
    What type of sleep study? 18:20
    AHI Cutofffs: 18:55
    Goals of Care? 21:50
    What is considered effective therapy? 24:30
    Star Trial link: Upper-Airway Stimulation for Obstructive Sleep Apnea | NEJM
    Adhere Registry Link: Results of the ADHERE upper airway stimulation registry and predictors of therapy
    efficacy - Thaler - 2020 - The Laryngoscope - Wiley Online Library
    Define CPAP failure? 26:00
    Nasal obstruction causing CPAP failure 28:00
    Floppy Epiglottis causing Aerophagia? 28:30
    Surgery for Aerophagia 29:30
    Risks and medical contraindications 33:00
    MRI compatibility? 33:30
    Surgery description/length 34:30
    ICD compatibility? 35:00
    Avg Voltage ranges? 37:00
    Removing devices 39:00
    Recovery time 39:40
    Incision size 40:45
    Back to the case, parameters for referral 43:00
    Drug Induced Sleep Endoscopy (DISE) 43:45
    What percentage of patients fail DISE? 47:00
    Management after Inspire placement 48:15
    Inspire sync: 49:15
    Battery life 11 years: 51:00
    Explant 51:30
    Surgical options other than Inspire 53:15
    Does UPPP work? 56:00
    What can we expect from surgery? 57:00
    When to refer for large tonsils 59:00
    Closing comments 1:01:00
    1 hr 5 min
  • Episode #9 Patient Centered View of Narcolepsy

    In this months episode we discuss narcolepsy with Matthew Horsnell. Matt is a narcolepsy patient and advocate, and we discuss his journey of living with narcolepsy. 

     

    SHOW NOTES

    1. Introduction of Guest: (5:00)
    2. Matt’s Best Advice (11:00)
    3. Matt’s Role in the sleep community (12:40)
    4. Matt’s symptoms onset (15:00)
    5. Matt’s additional symptoms (19:00)
    6. Matt’s onset of cataplexy (23:00)
    7. Cataplexy triggers (24:45)
    8. Delayed diagnosis: (27:00)
    9. Nightmares and sleep paralysis onset (31:30)
    10. One more question about sleep paralysis (34:15)
    11. Partial cataplexy (37:50)
    12. Diagnosis and Management: (39:00)
    13. Pitolisant (43:45)
    14. Strategic Napping (44:15)
    15. Bitter Pills (45:15)
    16. AASM revised Guidelines (47:22)
    17. Sodium Oxybate and Cataplexy (49:00)
    18. Finding a sleep physician to manage narcolepsy (55:00)
    19. Sleep apnea (60:30)
    20. MSLT (62:15)
    21. Treat Clinically (65:00)
    22. 4 pillars of management (66:00)
    23. Patient request/feedback (68:00)
    24. Academic vs private practice (71:30)

      25.  

       

      Links to articles and guidelines referenced in this episode are included 

      Trotti LM. Central Disorders of Hypersomnolence. Continuum (Minneap Minn). 2020 Aug;26(4):890-907.

      Treatment of central disorders of hypersomnolence: an American Academy of Sleep Medicine clinical practice guideline

      1 hr 12 min
    26. Episode 7 - OSA and cardiovascular disease

      Join us this month as we discuss OSA and cardiovascular disease with Dr. Peter Farrehi, a cardiologist at the University of Michigan. We focus on arrhythmias, but do delve into other topics as well. We hope you enjoy!

      Time Stamps

      00:45 intro
      3:00 best advice
      6:50 pick of the month
      12:12 discussion begins
      12:30 What should we be looking for on a sleep ECG?
      14:00 See the patient or do the sleep study first?
      16:38 should every patient with afib get a sleep study?
      17:15 STOP BANG screening and afib
      19:30 arrhythmia and auto-cpap
      21:30 heart failure and preserved EF
      22:50 why does OSA predispose to atrial fibrillation
      26:00 anti arrhythmic drugs for afib with co-morbid sleep apnea
      29:00 minutes coughing can be edited if you want
      29:30 rate or rhythm control for afib?
      31:00 fatigue or sleepiness?
      32:20 Other sleep related arrhythmias
      32:36 Non sustained ventricular tachycardia
      33:00 Sustained ventricular tachycardia
      36:00 arrhythmia and management on the sleep end
      37:40 Long QT
      38:00 Chronic afib
      38:30 sinus pause
      39:30 AV block
      42:00 2 Lead ECG problems
      43:00 medicare games
      44:30 positional therapy
      47:15 virtual visits discussed vs face to face

      48:30 screening afib for OSA
      50:33 compliance and non compliance - sleep heart health study
      51:00 Meta –review JAMA
      52:40 arrhythmia and cpap, when will my arrhythmia improve?
      54:30 treat sleep apnea prior to cardioversion?
      58:50 PVC’s
      1:01:00 7 pvc/minute
      1:02:00 PACs?
      1:03:00 bigeminy or trigemini?
      1:04:20 oxygen nadir and oxygen desaturation index
      1:12:30 using oxygen nadir to reach the patient
      1:15 wrap up

      1 hr 17 min
    27. Episode #6 - Sleep and ADHD

      Join us as we talk with Dr. Barbara Felt about the management of ADHD in children with sleep disorders,

      37:14 – Second-line medications for ADHD

      38:08 – How late in the day can stimulant medications be given without risk of sleep disruption?

      38:28 – How to approach the evaluation of night terrors in the patient from our case

      40:22 – What is a “normal” ferritin in children?

      41:15 – What is average ferritin in pre-school children?

      41:40 – How do you approach a vague history provided by children regarding RLS symptoms?

      43:12 – What dose of iron should be used to treat children with RLS?

      44:00 – If treatment of OSA improves ADHD symptoms, is it reasonable to wean stimulant medications?

      45:57 – How frequently should one re-evaluate medication doses for children with ADHD?

      47:23 – Can ADHD resolve over time? Is ADHD a life-long disease?

      50:32 – How commonly do children with ADHD have difficulty falling asleep?

      52:15 – Discussion about behavioral insomnia of childhood, limit-setting type and combined type

      54:35 – What sort of behavioral treatments are useful for children with insomnia?

      56:20 – Are children with ADHD more likely to have circadian rhythm disorders?

      59:00 – On the importance of sleep routines for children with ADHD

      59:47 – Opportunities for research in the field of ADHD and sleep

      1:02:42 – What dose of melatonin should be recommended for children?

      1:05:01 – Take-home points from Dr. Felt

      1 hr 8 min
    29. Episode #4 Restless Legs Syndrome

      Legs bothering you? Well join the The White Noise Podcast as we pick the brain of Dr. Andy Berkowski, clinical associate professor and restless leg expert at the University of Michigan. Learn all about the diagnosis and management of restless legs syndrome. There is also a guest appearance by hepcidin, the bouncer at Club Ferritin.

      CME credit link will be here when available

      Show Notes – Season 1, Episode 4 – Restless legs syndrome

      Time stamps

      0:30

      – Introduction

      2:30

      – Interview starts

      7:40

      – Picks of the month

      12:50

      – Case

      13:50

      – Initial thoughts on case

      14:00 – Diagnosis of restless legs syndrome

      16:50 – Diagnostic criteria for restless legs syndrome

      17:40

      – Difficulties in diagnosis

      22:20

      – Key questions to ask in taking history

      24:00 – Periodic limbs vs restless legs syndrome

      28:30 – Pathogenesis of restless legs syndrome

      31:00

      – History of Willis-Ekbom disease

      35:50

      – Case

      36:40 – Medications for restless legs syndrome

      38:30

      – Dopamine agonists

      43:30

      – Alpha-2-delta-ligands

      45:00

      – Iron therapy

      50:10

      – PO vs IV iron supplementation

      58:45

      – IV iron formulations

      1:00:30

      – Narcotics

      1:05:03

      – Augmentation

      1:09:00

      – Non pharmacologic therapies

      1:11:10

      – Medications that worsen restless leg syndrome

      1:16:00 – Screening for restless legs syndrome

      1:18:00 – Follow-up of restless legs syndrome patients

      1:18:50 – Sleep apnea and restless legs syndrome

      1:20:10

      – Take home points

      1:22:00

      – Interview end

      Definitions

      Augmentation: The process by which the symptoms of restless legs syndrome occur earlier in the day, become more severe, are less responsive to treatment, and spread to other parts of the body (e.g. arms and trunk), usually due to treatment with escalating doses of dopaminergic medications.

      Restless legs syndrome: A condition characterized by an urge to move one’s legs (often accompanied by unpleasant sensations in the legs) that is most prominent at rest, partially or totally relieved by movement, and classically worse in the evening. The symptoms must not be better explained by another condition such as peripheral neuropathy.

      Periodic limb movements of sleep: Periodic, repetitive, stereotyped limb movements that occur during sleep. American Academy of Sleep Medicine (AASM) scoring criteria require a minimum of 4 limb movements in series with 5-90 seconds between movements. Periodic limb movements of sleep are seen in the majority of patients with restless legs syndrome who undergo polysomnography.

      Periodic limb movement disorder: A disorder characterized by more than 15 periodic limb movements per hour of sleep in adults (greater than 5 in children) that cause a significant sleep disturbance and/or functional impairment not better explained by a different disease entity.

      Akathisia: An inner sense of restlessness and desire to move that is often caused by dopamine antagonist medications, is usually generalized (not limited to the legs), and is unlikely to be totally relieved by movement.

      Clinical Pearls

      1. Restless legs is a clinical diagnosis
      2. The hallmark of the disease is a SENSATION  of the need to move.
      3. There must be a circadian component to make a diagnosis.
      4. Augmentation will almost inevitably occur with dopamine agonists.
      5. Target ferritin >75 and transferrin saturation greater than 20% for iron repletion.
      6. Obtain fasting ferritin levels.
      7. Some times less iron is better than too much; if supplementing with daily PO iron and there is no improvement to ferritin levels consider cutting dose in half or switching to every other day dosing.
      8. Vitamin C supplementation increases iron absorption.
      9. Clinical practice is trending away from starting with dopamine agonists as first line agents.
      10. Making sure that iron is at adequate levels is the first step in management.
      11. Judicious use of opiates may be of benefit to the patient: This decision should be made after thorough risk benefit discussion with the patient.
      12. If patient has been stable on medication and RLS symptoms recur, check ferritin levels first.

        13. Diagnosis of restless legs syndrome:

        • Obtaining a thorough history the the cornerstone to making a correct diagnosis of restless leg syndrome. Things to elicit are whether the patient endorses a sensory component vs just a motor component.
        • Diagnosis may be difficult when there are other co-morbid conditions such as peripheral neuropathy, or chronic pain. The sensory component and urge to move will help in distinguishing restless leg from other conditions.
        • This is a clinical diagnosis; there are no tests that need to be done.
        • International restless leg syndrome study group diagnostic criteria.

          • Treatment of restless legs syndrome:

          • Treatment begins with checking ferritin and transferrin levels. Ferritin levels of less than <75 ng/ml, and/or transferrin saturation of less than 20% may indicate that iron supplementation is warranted.
          • Typically PO iron supplementation is started, unless there is a contraindication to oral therapy (poor absorption, gastric bypass ect).
          • Supplementation of PO iron with PO vitamin C is recommended; lower doses of iron may be more beneficial then higher doses.
            • "Oral iron supplements increase hepcidin and decrease iron absorption from daily or twice-daily doses in iron-depleted young women"
            • If IV supplementation is needed, see formulation list below. Newer formulations are safe, and the side effect profile is low.
              • Sample iron supplementation algorithm
                • If symptoms persist despite adequate supplementation of iron then initiation of therapy with an alpha-2-delta-ligand is recommended.
                  • "Comparison of Pregabalin with Pramipexole for Restless Legs Syndrome"\
                  • Due to risks of augmentation dopamine agonists are not recommended, unless other forms of therapy are contraindicated.
                    • Guidelines for the first-line treatment of restless legs syndrome/Willis–Ekbom disease, prevention and treatment of dopaminergic augmentation: a combined task force of the IRLSSG, EURLSSG, and the RLS-foundation

                      • Goals and objectives

                      Goals

                      Listeners of this episode will able to recognize restless legs syndrome in the clinic and be familiar with treatment strategies.

                      Objectives

                      After listening to this episode, listeners will be able to…

                      1. Recognize patients with restless legs syndrome disorder based on history.

                      2. Compare the different forms of iron supplementation, and formulate a therapeutic plan for the patient. 

                      3. Describe the various treatments for restless legs syndrome. 

                      4. Implement a treatment plan based on a patient’s specific needs. 

                      5. Recognize patients undergoing augmentation, and formulate treatment plans. 

                      6. Be familiar with the opioids used in management of restless legs syndrome.

                      7. Discuss the risks and benefits of different pharmacologic treatment options with the patient.

                      Dr. Berkowski's Suggested reading list.

                      1. "A 10-year, longitudinal assessment of dopamine agonists and methadone in the treatment of restless legs syndrome"
                      2. "Comparison of Pregabalin with Pramipexole for Restless Legs Syndrome"
                      3. "Clinical efficacy of ferric carboxymaltose treatment in patients with
                        4. restless legs syndrome"
                      4. White Paper on prevention and treatment of RLS by IRLSSG
                      5. "Evidence-based and consensus clinical practice guidelines for the iron treatment of restless legs syndrome/Willis-Ekbom disease in adults and children: an IRLSSG task force report"

                        6. Patient resources

                        1. Restless Legs Syndrome Foundation
                        2. Restless Legs Syndrome, National Sleep Foundation
                        3. Restless Legs Syndrome, American Thoracic Society Patient Education/Information Series

                          4. Picks of the month

                          1. The Big Fat Surprise by Nina Teicholz
                          2. Glass
                          3. Game of Thrones

                            4. Disclosures

                            The authors of The White Noise Podcast do not have any relevant financial disclosures. 

                            1 hr 24 min

                          About The White Noise Podcast

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                          The aim of this sleep medicine podcast is to provide health care professionals who deal with sleep related issues with the most up to date clinical information when. We use expert interviews with…