Hello? Can you hear me, Brandon? Yeah, I can hear you. Good. Awesome.
How are you doing today? Doing fantastic. Just enjoying the perfect edit. Today is awesome.
Quickly here. Let’s see if I can just see what my camera sees up. My look is that turn camera on.
For some reason, it’s not letting me turn on my camera. That’s not a bad thing, but don’t worry about it. Usually it’s on the year end.
Hey, Matt, is it sharing my slideshow? It is. Okay, let me make sure that was working before. Where are you at on the planet? I’m at our office in Hopkins, Minnesota.
It’s about 20 minutes south of Minneapolis. Is a year. What’s that was the ice fishing this year.
It was good. I went once, caught one walleye. I’m not an expert at ice fishing, but still a good experience.
Yeah, it’s definitely crazy year for you guys this year. Yeah, it’s starting to get nicer now, but I like the cold. Absolutely.
It’s really nice here today. But for us, I like my favorite weather’s. Rain.
It could rain every day. I’d be happy. Well, you’re at JBLM, correct? Yeah.
You’re in the right place. Yeah, you’re in the right place. So, Matt, what do you do? The chief commercial officer.
Oh, nice. I’ve been with the company since 2020, actually. Since before COVID believe it or not.
It’s kind of like all things, the process pre entertained. Yes. Hello again.
Let me go see if I can get my tech guy to see if you can figure out the camera situation. Sounds good. Sounds good usually about these things.
All right, how are we doing here? Dr. Pal’s here. Hi, Dr.
Powell. How are you doing? I’m doing fine, thank you. How are you doing today, sir? Fine.
I had clinic this morning over at Walter Reed and Sleep. They just introduced Genesis. And so I’m spending a lot of time last week, this week, and the next week.
Kind of getting my handle on it. I think I figured it out very good. I think today was the day when I was like, okay, I get it.
All right. Is it showing the first slide? It is now. It is.
Okay, thanks. Yeah. Well, you’ve been using it, Dr.
Pi. You’ve been using it for a while, I think, haven’t you? Since January. Since January? Yeah.
Finding someone that was at another base that had used it before and then having that doctor tell you what to do. That was the keyboard. Dr.
Powell, I’m glad you’re going to be here, because I have a couple of example patients that comes up, and one of them is your patient that we talked about. Oh, very good. Excellent.
Hope you don’t mind. I’m eating my lunch as we talk. Yeah, don’t worry.
Stories, okay? We don’t want anybody to be thinking on an empty stomach, that’s for sure. I ran upstairs and scrounged for a little lunch myself. All right.
So we got a hard stop at 02:00, 02:00 Eastern. I’m not sure everybody is, but we’re going to kind of go ahead and get going. And I’m going to start by introducing thank you for coming to the meeting.
This is the first of what we hope to be many meetings of doctors that have prescribed this device Nightwear. And so I’m going to introduce you to our team, and then if you guys could all just do a quick introduction, who you are, where do you work, that would kind of help facilitate the discussion. So on our call here, we have Brant Newman, who is coordinating the efforts to set up these meetings.
So he’s our right hand man there in Minneapolis at our home office. And so Brant’s been with us for the last few months, and we’ve enjoyed having him here. Ken Rail is in charge of our research program, so he’s our director of our clinical research programs, and he’s coordinating all of our activities related to research.
And then Matt Tucker is on matt is our chief commercialization officer, helps run all of our marketing efforts as well as our sales efforts. That’s how I think about Matt, and I usually do whatever Matt tells me to do because he’s got a lot of experience in healthcare and working with other large pharmaceutical and medical device companies in the past. And then you guys know me, I know all three of you, but I want you to introduce yourselves to each other so you know who they are.
So, Dr. Powell, do you want to start? Sure, of course. I’m just a clinical psychologist.
I’m working at Fort Hood, and the hospital’s name is Cr Damsey. Carl R. Darnell.
Army Medical Center is what it stands for. Dr. Savage? Absolutely.
I’m Paul Savage. Background is 25 years Navy medical officer. Mostly internal medicine is my background.
And what I do now since 2007, is working concussion care, even though it’s at JBLM Federal Court in Common, washington really is for me. I retired in 2008, and really, this has just been my pond. So what I do is I take care of just all kinds of I’m grateful to be here.
I have just a background. I probably got about twelve, I think, more than ten people. But I’ve not seen one patient yet that has used it and has any benefit.
So I’m kind of one of those users that’s waiting for those first ten to come back and let me know how it works. I’m looking forward to hearing what your experience is with NightWare. Great.
Thank you, Doctor, for that. Yeah. And we’re hoping to learn, hopefully.
We want people like yourself who have just started prescribing, and then people have used it for a little longer and have had the patients follow up, and so they got some feedback. Both so it’s important we have everybody here. Melissa, I don’t know, maybe you’re still muted.
Yeah. Melissa, can you unmute maybe not. I think she’s frozen.
All right. Not sure if she’s there. Dr.
Dubik, would you like to introduce yourself to the other doctors here? Dr. Dubik, I don’t think we’re able to hear you. I don’t know.
Do you have a microphone problem? Having trouble with it? Well, I’ll introduce Dr. Dubai because I know for years yeah, you might have to butte, I think. I don’t think it’s working.
That’s okay. Maybe there’s a chat function where there’s a little bubble with fake lines in it on your Microsoft team’s toolbar, and there’s a meeting chat, and maybe you can put messages in there. But Dr.
Dubik is a sleep medicine doctor. He is a retired Navy captain, and he is at Portsmouth. He’s been there for quite some time.
He has used night wear at least one year of use. I think he’s been using it. But he has some feedback.
I think he might be able to share at least some insights. And then, Melissa, I don’t know if you were able to yeah, can you hear me now? I can. Okay, good.
So I’m Melissa. I’m a nurse practitioner. I’m actually also a reservist.
I’m actually home on orders this week, or at least for the next couple of months, but I work at Fort Belvor Sleep Medicine Clinic, so Dr. Robinson was one of my mentors as I came into this process a couple of years ago. Have only ordered nightwear a couple of times.
Haven’t had much success with it. I’ve gotten sometimes it works, sometimes it doesn’t. So I think just getting more background information on how people are utilizing and how they’re selecting their patients will definitely help me in this aspect.
All right, great. Okay, so we’ll go ahead and get started. I want to kind of move through the discussion.
Brandt, you put the slides up. Okay, great. So a few housekeeping notes.
We’re going to record the meeting. What we’re going to do is we want a kind of a frank discussion, and what we will do is summarize the meeting, and then we’ll send it to our users. But we won’t be naming names or anything like that.
Our goal is to get feedback about the device. Go to the next slide. So what we want to do is, when you have a new device, you need to understand in the real world how it’s being applied and what are some special situations that you might not have known about from the research that has been done on the device.
In just the real world, there may be use cases that we had not anticipated or certain kinds of patients where it works very well in or doesn’t work very well in. And learning those kind of things through feedback is very important. We also want to identify any kind of gaps in directions, both for you, the prescriber, and then for the patients.
So do they have enough information to set up the device without getting a lot of extra help. Do you have enough information so that you’re able to quickly explain the device to the patient where they can understand it? And then finally just learning about the disease state and how nightmares can sometimes be missed. And so what steps can we take to help raise awareness in general about the disease state among practitioners, among sleep doctors, sleep practitioners, and then mental health providers in particular? Go to the next slide.
Okay, so our agenda date with these sessions we have kind of four different sessions. We’re going to be repeating this session actually again today at 05:00 p.m.. But what we want to do with this session is just look at these four items and starting with patient identification and patient selection, like, who’s a good candidate.
I want to talk a little bit about the PTSD diagnosis because that has come up in some of my conversations with doctors in the past, and I wanted to get your opinion on that. And then also about assessment tools that you can use when you prescribe night wear. Let’s go to that next slide.
Patient identification is really, like just what I really want to talk about is how you find patients with nightmares. And if you go to the next slide right, so how we pick the right patients, we know that there can be an under diagnosis problem with nightmares because if the doctor doesn’t ask about the condition, then the patients may not mention it. This happened to me several times in my career where a patient would come in with insomnia and then I would find out about the nightmares, but only because I asked, not because the patient volunteered that as the reason that they were having insomnia, they just said they couldn’t stay asleep.
And then identifying the kinds of patients that you need to ask about nightmares, I think that’s an important thing to do. And then educational opportunities for patients themselves. Like what is there a population of patients that we need to do some sort of public health type outreach to talk about nightmares? So I guess I’ll just kind of throw out my first question, which is has anybody had seen this problem of under diagnosis of nightmares where it was missed initially by either maybe the primary care doctor or even a specialist that they saw? And then it later came to light that this was actually the problem that was driving a lot of their sleep issues.
I don’t know if anybody yeah, feel free to comment off. I think your mic is still messed up. It’s all right.
You can go ahead and just type any comments you have in if you don’t mind, I’ll be glad to see those. I was going to suggest that in terms of the nightmare disorders, the first things that we look at is something called the BHDP, which most of the I would assume most of you would have access to. Behavioral health data portal.
And one of the questions on it has to do with the amount of sleep and sleep disturbance and problems. And that is what leads me into talking with people about sleep and then diagnosing the nightmare disorder. I actually learned about that database just recently, and I’m wondering if maybe dr.
Savage, do you use that same database with your patients in the Intrepid Spirit Center? Yeah, I’ve had access to those databases for a long time, but what I found in general in my population is that all my patients have nightmares or disruptive dreams to some extent, but they’re not always willing to talk about or really get into it unless you ultimately come back to them and really use the Nightmare severity index. That specific. They don’t like to say they’re nightmares, but if they say well remembered, disturbing, disruptive dreams, they’ll all generally turn out ends up being a challenge for some of our patients because they don’t sleep.
None of my patients sleep. And a lot of your patients, just from my conversations with you and with other Intrepid Spirit Center doctors, they have TBI, but a large percentage of them also have PTSD or most maybe even that’s absolutely true. But again, I will just pick on my Special Forces population.
They don’t want the diagnosed PTSD, so there’s a lot of they don’t even want the diagnosis of nightmare disorders, but they would be happy to take the night wear without having answering questions. It’s kind of one of the 15 populations. But I don’t want to digress what we’re trying to do today.
Just to say that most of my patients have these challenges and it’s really opening them up to that idea is really just what’s the best way to go about it. But back to what Dr. Powell had definitely that we have access to those questionnaires, but it doesn’t always get to us.
It always gets to you. Okay. And I guess my next question is about, like, hidden nightmare issues.
Grant, could you go to the two slides from here? Just go jump forward two slides. I’ll show them this. I think this might be helpful.
When I talk about nightmares, of course, there’s the PTSD patients, and then there’s insomnia, depression, and anxiety, and those are the ones that I focus on. And when I am in my clinic, that if I find that they have one of these diagnoses, then that prompts me to ask about nightmares, right. So that’s kind of how I approach it myself.
One other question I had go back one slide, Grant. So, this study, jim Kramer is one of our sleep colleagues. She’s at Walter Reed right now as the Chief of Sleep at the moment.
And she did this study a few years ago looking at patients that came into the military sleep clinic, and what they found was that about 4% of the patients mentioned nightmares as the reason why they were getting a sleep evaluation. But about 30% of them indicated on a questionnaire that they had clinically significant nightmares at the same time. So there’s a huge disconnect between what the patients were telling the doctors, but then when you directly ask them the question on the questionnaire, they would indicate that they had this issue.
One question I always wonder about this is how common you think this issue of nightmare is in the general military population and then at your base and then even just in your clinic, kind of three different scenarios there. Do you think it’s close to 30%? Less. More? How common do you think you actually see that the problem is actually there? So this is Melissa at Fort Belvore.
That’s an automatic question we ask on nightmares. And when someone says yes, I usually will ask, well, how many days a week does it occur? How many times a night does occur? But I would say more people say nightmares. But then when they go to describe it, as you said earlier, it’s more stressful like type dreams, not trauma based events kind of thing.
But I say it’s a significant amount that we also have. We see all the TBI patients. We see a majority of the behavioral health patients.
So our population is very heavily in behavior health or via TBI that probably have an alternate diagnosis of either TBI or some type of behavioral health diagnosis to go with it. So a significant amount of our patients do say, yes, I have nightmares. And then I usually focus on anybody that’s like, three times or more a week.
And then I look at when I review their notes, they never tend to mention it with their behavior health counterparts or anything like that. Over. Okay, that’s helpful.
And Mike mentioned here that he’s seen this issue of under diagnosis. What he says that he thinks people tend not to think of nightmares as a medical issue per se. Dr.
Dubik and I have talked about this before, and I think one of the things I’ll give you his example. He said that nightmares are it’s an issue where nobody had a hammer, so he didn’t look for any nails. Right? And so if you don’t have a tool to address the problem, what’s the point of bringing it up? And I think that may be part of it.
And then also, he mentioned, too, it’s just seen as simple as still having issues with it. Dr. Dubai? Dr.
Dubai, I think there’s a call in number you can use. There should be a call in number on the invite, and you may have to call in. I think that’s what Smitrovich did.
Okay. You asked about the percentage, and if mine is the clinic that I work with is a general outpatient clinic and the multid clinic. It’s not a specialty clinic, but I would say 30% is at least 30% of the people that I deal with have sleep disturbances and most often it’s nightmares or distressing sleep.
Even if they don’t call it nightmares, where they’re not getting the sort of rest they need. That’s very common among a high percentage of my people only get three, four, or 5 hours sleep a night on is what their estimates are, a very high percentage across all diagnoses. And then, particularly when you look at the PTSD, the rate of those with what I would classify as nightmares goes up tremendously.
Okay, yeah, I think that’s about right. Yeah. And that’s actually an interesting point, is defining a nightmare for the patient and selecting the patient that’s had it.
Why don’t you skip forward a couple of slides, Brent? Let’s go to sorry, slide ten here. Yeah. And that kind of goes into this next topic, which is who is a good candidate for night wear? Right.
So obviously these patients that are having sort of unsettled sleep that might not be the best candidate for it for the device. Go to the next slide. And you guys, I know that we have talked to everybody about sympathetic activation symptoms and how you really need the right kind of patient for the device.
How’s your experience been finding these patients? Is there, like, a shorthand one question you asked to kind of get at the issue, anything like that? I worked with a psychologist. Her shorthand to get to nightmare disorder was, do you wake up with nightmares? Right? So if they wake up with nightmares, then that was a clue that they were clinically significant and she would dive into it further. I don’t know if you have anything like that that you use.
I’d love to hear it if you do. I don’t have a specific question or single question asked like that, but I always ask the people about pain issues. I ask them about sleep issues on almost all of the questionnaires or responses that we get.
Whenever they’ve indicated they’re having sleep problems, I’ll go into the type of sleep disruption they have, and that’s when it gets into nightmare. It just seems to naturally follow the questions about how much sleep are you getting? Right? Yeah. How much sleep are you getting? That’s a good point.
I see Jessica Richards is here. Dr. Richards is a psychologist that works at Walter Reed.
Jessica, can you be able to introduce yourself? Yeah, I’m a clinical psychologist specializing in pain management. So I’m embedded in a physical medicine or rehab clinic. And, yeah, my my bread and butter is like, CBT for pain and biofeedback treatment for pain.
But in our clinic, large portion of the population has co occurring PTSD and or TBIs and or other certainly other sleep disorders, sleep apnea, insomnia. And so in my background, my fellowship training was in the co occurrence of chronic pain and sleep disorders. So I’m always asking about starting with basic insomnia criteria, do you have difficulty falling or staying asleep? And then when I determine that they do on a significant basis, it’s disrupting functioning.
I ask kind of like, what percentage of your sleep issues are due to pain in particular? And then those questions about sleep typically come after PTSD symptom evaluation. So then I’ll ask what percentage of those issues are nightmare related if they’ve endorsed nightmares already, and then might go into more detail about the frequency of nightmares. And that kind of gets me down the path of maybe thinking about nightmare for them.
Yeah, that’s a good point. One question I have, too, is, like, I guess, important patient characteristics to consider when prescribing night wear, like, what makes you want to use it, and also what makes you not want to use this particular device? Is there anything that kind of sticks that you remember from your conversations with patients that prompted you to use it or prompted you not to use it? I found that it’s an extremely effective device. I love using it.
The only question has to do with the frequency of the disruptive dreams. If they’re having less than one nightmare a week, I’m very hesitant to go ahead and use it because I just don’t think it’s going to be sufficient. I don’t know if that’s the proper way to evaluate this or not, but if it’s less than once a week, you generally do not recommend it.
Okay. Yeah. I feel like my gauge is usually like, if it’s at least three times a week or more that their sleep is disrupted by nightmares, they have difficulty falling back to sleep.
And also if there’s any functional or daytime impairment or even just bed partner stress, because the bed partner is like, gosh, you had a nightmare again, and you’re disrupting my sleep. So if it’s three times a week or more, I can’t fall back to sleep. Some kind of disruption to their life.
Yeah, that’s interesting. So the bed partner is actually prompting the patient to come in. Yeah, that’s a lot.
A lot of the time in my population, definitely. Okay. The other thing I also am always very I have a low threshold for a sleep clinic referral to rule out sleep apnea if someone hasn’t had a sleep study before, because folks with chronic pain have higher rates of all kinds of sleep disorders, including including sleep apnea.
So if someone is having also just like strong physiological arousal at night, not always associating it with nightmares per se. And if they’re having some of the other stop bang kind of indicators that there may be a sleep apnea going on, I would recommend a sleep clinic consult first to rule out or diagnose and treat that before I necessarily consider this. Yeah.
Especially when both might be present and you’re trying to sort out which is which makes sense. Okay. I know they’re not on here, but some of our colleagues at the Walter Reid Sleep Clinic have said the same thing, that sometimes they’ll see a patient and they have nightmares, but it’s not clear.
Maybe they don’t have a PTSD diagnosis, or it’s not clear that they have another major risk factor for having nightmare disorder like insomnia or depression, and they’ll evaluate them for sleep apnea first before they pursue this. So I think that’s reasonable. Bad candidates for nightmare.
I think Dr. Savage kind of hit on this point a little earlier with having patients that are just having sort of generally disturbed sleep, but it’s not clear that they’re having nightmares. I guess that would be kind of a bad candidate.
Do you agree with that? What I’m trying to do is advise other doctors on, like, this is the kind of patient you need to use this in, because one of the things I don’t want to do is I don’t want to use this device in patients that won’t benefit from it. We want success stories as many as we can. Right.
So the goal is for us is to do that. So figuring out, like, if you have a patient that didn’t respond well, if you can think of one like that, was there something about that patient that is different than the other patients that did respond? Yeah. I mean, my kids and I’ve only prescribed it for a handful, actually, just recently I had my fifth patient start using it.
And anecdotally it seems so far that the folks who are who don’t have so I want to say all five of them have meet criteria for PTSD and have been treated for that to varying degrees. But the ones that are least successful it’s nightmares, maybe unsurprisingly, are the ones who have had the least success with managing getting their PTSD symptoms optimally managed. More broadly, the folks who have had a lot of different medication trials, who have maybe even tried and failed, so to speak, at trauma focused psychotherapy, the ones who just have the really treatment resistant PTSD symptoms generally seem to be the ones who are having the least beneficial response to night wear.
Right. So if other treatments for PTSD aren’t working, they tend not to do as well with this treatment too. Right.
So sometimes we call it the healthy user effect, where if you have patients that take their medicines and do what they’re supposed to do, they tend to do. If you prescribe a new treatment to them, they tend to use that treatment like you tell them to do also. I think I understand that.
Okay, that’s a good point. One other question that comes up sometimes is about the cause of trauma. So these patients that have PTSD have different reasons for having PTSD.
It might be combat trauma, of course, but certainly sexual trauma, other an accident, or medical problems that have led to the PTSD. I know we have a limited amount of patients like this, but have you seen patients let me put it this way is the cause of the trauma influence how you prescribe night wear, and that answer might be no, but I’m going to go ahead and throw the question out. Yeah, me either.
You haven’t noticed anything like patients? It doesn’t either. My answer would be no. Okay.
Their physiological response to what happened? Pretty good after having all dr. Savage, we’re having a little trouble hearing you there. At least I am.
No worries. Is that right there? Yeah, that’s better. That’s better with a microphone.
Just that patient selection for me has been more their physiologic response to the disturbing disruptive brain. But again, I haven’t had anyone come back yet with it. I just saw a patient yesterday who had it, but she hadn’t applied it yet.
Okay. Yeah, well, I’ll keep asking that question. Maybe we get more people involved and we’ll see if we can dig into that more.
One question I have is about dream enacting behavior. One of our contraindications is if the patient’s been acting out their dreams, you’re not supposed to use NightWare. I know of at least four cases where doctors have used it and prescribed it despite that contraindication.
The reason we have the contraindication is because I lack safety data in that particular group of patients. But I have been told by some psychologists that they actually think that these patients that have PTSD have nightmares and enact their dreams might actually be really good candidates for the treatment. And I’m wondering if any of you have prescribed it to a patient that says that they act out their dreams.
You haven’t done that? Okay. No, sir. That’s fine.
Yeah. I’m going to keep looking for those patients, but I definitely wanted to ask that question, and we’re going to keep trying to get more information about that. Our colleague, Dr.
Kramer at the Walter Reed Sleep is particularly interested in that group of patients that act out dreams and have PTSD. So I told her we’d make sure we asked about that and see if it’s being used in those patients. What about patients that we’ve had a couple of anecdotes where patients have PTSD and they have very disruptive sleep, so they’re screaming in their sleep, things like that, but then they deny having nightmares.
And we’ve had a few instances where the clinician prescribed nightmare anyway, and the patients reportedly did very well with it. So I guess there’s another question, is have you ever prescribed it to a patient that denied having nightmares? It would be off label, of course, but have you considered doing that, or can you think of patients like that? I find that more people don’t know the difference between a night terror and a nightmare and what people describe as night tears, when you start asking them about it, it turns out to actually be a nightmare. So I don’t see many very few night tears, or at least that they admit to it in our clinic.
Dr. Richards, I can’t hear you. I think you’re.
Talking, but yeah, sorry, I didn’t mute. Yeah. My most recent patient started using it.
He only remembers a fraction of his nightmares. Like, if you ask his wife, I think he did. When I was initially assessing how many times a week do I have nightmares, she said four to five.
He remembers one, maybe two a week. And so a lot of times when she’ll say, wow, you really have a nightmare last night, he doesn’t remember it, but sometimes he does. It’s just not as often as she remembers it.
Yeah. So it’s interesting getting the spouse’s or bed partner’s opinion about what’s happening sometimes that can help clarify things. One of the problems when patients are asleep, they’re not aware of what’s happening, really.
And even their ability to recall nightmares can be sometimes limited. And he happens to be one who so far I’ve had two follow ups with him since he started using it. And in the last two follow ups, he said he’s not had any nightmares and his wife has not complained about his nightmares since he started using.
Okay. So he seems to be a remarkable patient so far in terms of his benefit. That may be one that’s been my experience with several of my patients, too.
I’ve used it maybe with about 30 or 35 people at this point. And I’ve have a number of them, when I ask them if they have nightmares, they’ve said they don’t recollect it. And then when I ask them about their partners, they’ll say, well, yes, my wife says I scream all the time and I pit her and she had to move out of the bed and go to another room.
But I don’t remember the nightmares. And I take that as indications that they’re having nightmares, but they’re just not recollecting them the next morning. They don’t remember about having it.
And so I’ve used it with them and with good effect. I’ve had several spouses that have been able to come back into the bedroom with their husbands. I look at not just the statements of the person, but particularly the spouses or the partners.
That’s very interesting. Yeah. I sometimes wonder if that’s a good marker for success.
Can someone sleep next to this person without being beaten up? Yes. Right. That’s interesting.
No, thank you. One other group of patients that I thought about is patients that have rim behavior disorder. We’ve had a couple of patients with rim behavior disorder use this device with success, like it helped them.
And it did two things. One, it made the patient they seemed to not have as many dream enacting behavior events, and the nightmares seemed to go away too. But the other thing was the effect on their spouse.
So the spouse actually benefited from it because they felt more secure that they didn’t have to watch their spouse, the patient that the device was doing that for them. And so I’m curious if maybe this is aimed more at my sleep colleagues. If you have a patient with rim behavior disorder that you’ve thought about using the device in, maybe not that’s.
Okay. Mike says he has, but he don’t have much feedback yet, so we’ll table that one. I’ll keep it on my list of questions to ask about.
The other question I have is about sleepwalking. I’m unaware of patients. That is, again, one of our contraindications.
Like, if you have a history of sleepwalking, you shouldn’t use this device. Any experience? Anybody have any experience with a patient that sleepwalks in this particular device? Night wear? Not me, sir. Okay.
All right. And then using night wear and patient with sleep apnea. I think we kind of touched on that earlier.
Have you found success using both devices at the same time, CPAP and night wear or any issues with doing that? I don’t understand the correlation very well, but I’ve had three of my patients that once they started using the night wear device and we got some resolution to the nightmares, found that they no longer used their CPAP machines, and they were sleeping quite well. Now, that’s just a small sample, and it’s just a handful of people, and I don’t understand the connection. I don’t understand why that should be so, but apparently they are not having the sleep apnea problems that they had before.
But that’s just, like I said, only three people that I know out of. Okay. Yeah, I wonder about that, too.
I know you had mentioned that to me before, Dr. Powell. Reason I put this in my list of questions to ask about.
Yeah. I don’t know what the connection is there. I’ve seen patients with sleep apnea that complained about choking or drowning dreams that seem to be sort of a theme when you ask the patients what dreams they’re having.
But why would night wear somehow treat their symptoms of sleep apnea? A little puzzled. That’s something we may have to explore a little farther. One other use case for night wear is an acute stress disorder.
So directly after a trauma event, before they have a diagnosis of PTSD, they just have nightmares. And either giving it to them sort of preemptively on the assumption that after a trauma that nightmares are very prevalent and we may want to prevent those. Or once nightmares have started, like, as soon as you can afterwards seeing that patient and then starting the device on them, would you consider doing that? Is that like, an acute stress disorder? I mean, how do you guys feel about using it in that sort of situation? I hadn’t actually considered that before, but that’s interesting.
It’s something that we might want to look at might be beneficial. I haven’t done it and have not had any patients, so I don’t know the experiences they would have, but that’s a possibility. Okay.
Yeah. It does make me wonder if treating that the nightmares acutely might decrease the risk of going on to develop to meet criteria for PTSD. Because I do know some data that when people have more severe sleep disruptions like in the acute phases after trauma and especially if they have REM disruptions in their early stages after trauma, that those seem to increase risk of going on to develop PTSD.
So treating some of those things earlier on maybe could reduce the risk. Okay. Yeah, I think it’s something I’ve thought about, and it’s on my mental list of things I want to look into.
Dr. Dubik and Colonel Mitrovich, they don’t see patients acute setting, which I understand. That’s funny.
Good. All right. Anything else about patient selection? Like things you think about when you’re deciding to use this device that maybe you haven’t mentioned yet? I think for me, a lot of it’s going to be is the ability, one, can the patient follow up with me? Because, as you know, for someone to come back, it’s like three months down the line.
Two, what treatment have they had for nightmares? I would tend to use it more. So on those that probably haven’t been successful with ProsIn or treatment because they’ve tried everything else. I mean, if someone is stable with their nightmares on medicine, then obviously I wouldn’t probably give it to them.
But again, I haven’t done and I haven’t seen enough to know if it’s actually the few cases that I’ve had. One it worked, one it didn’t. So it’s still to be determined kind of thing for us.
Okay. I think that’s fair. Brand let’s move on to the next section.
So this was something I’m throwing this topic in here because it’s come up a few times where the patients are resistant. I think Dr. Savage kind of sort of led into this a little bit, but the patients resist the diagnosis.
Go to the next slide. Brand they resist the diagnosis of PTSD, and what it really comes down to is if they get the diagnosis of PTSD, either it’s real or imagined, but that might threaten their military career. So, one, have you seen patients like this where they had a military career? They’re doing fine.
They got a PTSD diagnosis, and that sent them to a Med board or that was the final straw or something like that, that sent them to a Med board. I’m just trying to figure out if this is like, a perception issue or is it a reality? Yeah, no, I mean, just simply getting a diagnosis of PTSD, I’ve not seen as like, all right, you’re up for MedBoard. That’s it.
But certainly people do get med boarded for PTSD. But that’s typically if they are folks who have quite severe symptoms that have been again, their symptoms have been resistant to treatment, they’re not getting better, maybe even so severe that they’re experiencing suicidal ideation or they’re seen as some kind of risk to the mission or command because of their level of symptoms. That are not being effectively managed by treatment then.
So it’s usually like, if anything, getting the diagnosis of BTSD, if there are available treatments that can help them, is a great thing. It keeps them fit for duty. Just getting the diagnosis, I think, is an unfounded fear that people have because you still have the symptoms regardless if we give you the diagnosis, that’s going to open up more treatment opportunities for you, which is going to be better for your fitness for duty.
Does that make sense? I think more people are probably more concerned about having PTSD in their security clearance, even though that percentage rate is less than 1%, that you’re going to lose it. And it’s usually those ones that have been resistant for over a year and end up being med boarded. But it’s still a very sensitive topic about a behavior health diagnosis, and a security clearance is more of an issue than having the diagnosis and being med boarded, at least from my perspective.
Yeah. As well. I don’t know that much about that.
I should mention that Melissa is also Colonel Mitrovich, who is tell me your job again in the reserves. I’m sorry? I’m a brigade commander. Yes, thank you.
Brigade commander in the reserves. So she has some experience with this sort of thing? Yeah, I guess I just haven’t really gotten into that with the patients. And even with other things like diagnoses, I make a lot like sleep apnea.
No one seems really threatened by that one, of course, but I’m just worried that one of the reasons that it’s difficult maybe to prescribe this device or get the treatments is that the patients are resisting the diagnosis. Sounds like that does happen from time to time. Is that right? With all the people that I’ve seen when I talk about PTSD, they are worried to death that this is going to be the end of their military career, or that they’re going to lose their clearance, or they’re going to have stigma with them.
And I have to spend quite a bit of time working with them on that. It doesn’t but there’s not a person yet that I’ve brought in that hasn’t had fears that if they had PTSD, it was going to end their military career. It hasn’t.
And my people but it is the sort of thing that I get. Quite a number of people come in, have been in the military for 1819, even beyond 20 years, they’re about ready to get out, and they said, okay, I’m going to come in now and work on my PTSD, because basically my career is ending and it can’t hurt me anymore, and I just hate that. Okay.
I wish that they’d come in years before, but the stigma of coming to behavioral health at all is still very much out there, despite all the lectures and presentations and everything we’ve done. And the substigma of having PTSD is very much out there. And people think of it, it’s going to be the knife of death if they have PTSD and I try to reinsure them and I spend quite a bit of time talking about them.
And normalizing. I think Dr. Dubai is agreeing with you in the chat.
He also says he wants to see the resident AirView, like data collection and presentation. I have one of the sessions, we are going to do that, and Dr. Dubik, I will get with you and let you know exactly when we’re going to do that.
And I have a whole session planned about looking at the data and how we can make that data more compelling and useful to you as the clinician. But I kind of want to move on because I know it’s 145. So let’s move on to the next topic, which is, like, clinical assessment tools.
And really, I guess this question. Go to the next slide. Brand the question I have here is, how are you assessing the response to treatment? And I’ve thrown up a few questionnaires that I’m going to throw those suggestions, but if you have a tool you like to use, I would love to hear about it.
Is there any formal tool, or do you just talk to them about their nightmares and how maybe get an idea of the frequency and the severity in general, just through normal conversation with your patient for night wear? Specifically, I’ve been using the Nightmare Disorder Index and Readministering it about monthly. Anyone else? I follow up by just talking with them rather than using a questionnaire response, and I ask them to bring in their phone or their watch or both and look at the data that they’ve got and the number of interventions, whether they’re going up or down, what their overall impression is, what the impression is of spouses. And so I just do all that with questioning, but I’m using the device itself and the data from there.
Okay, yeah, go to the next slide. I think it’s the nightmare disorder index. So this is a nightmare disordered index.
I talked to the authors that did the validation study on this tool, and about a year and a half ago, we went through all of the existing nightmare questionnaires that are out there that have been validated in some way. This one was by far one of the simpler ones, and I’ve been mentioning it to doctors for a while because I think it would be easy to use clinically. Right.
Some of the questionnaires are three or four pages. They involve narrative sections. It’s difficult to use clinically, but this one seems pretty easy.
And except for question number five, which is how long you’ve been bothered by nightmares, the other four questions can be useful to you clinically. I think we’re not going to affect question five, but we should be able to affect questions one through four there, and so that might be a good tool. I like that.
Questionnaire there. There’s others, though, that I think could be helpful too, and I just want to kind of get everybody’s opinion on that. When you prescribe night wear, when do you want to see them back? How long do you want to wait? Usually all the other things being equal, like, you don’t have to see them back earlier for something else.
But how long would you wait to I generally want to see them have used the device for at least two to three weeks before I have them back. Part of it is dependent upon my schedule, just to schedule return times and return visits. We have so many patients here, it’s very hard to get people in on an every other week basis.
But when I’m working with them on PTSD, I don’t want them to go more than two weeks between visits. And then I’ll assess the night wear effects at each time that I meet with them. If I were just dealing with nightmares themselves without consideration of PTSD or depression, I would say at least two weeks and maybe three.
Yeah, that feels about right. I use sometimes I say one month. But there are certainly patients that have told me directly that they started using it and after device calibrated to them, like, within a few days, they noticed a difference.
So sometimes it can be extremely fast. Sometimes it takes longer for the patients to notice. I’ve also had patients tell me, you ask them, they’re like, Well, I use it.
And then you ask them if they’re having nightmares, and they say, well, no, but they’re not really putting together. It seems like they have trouble putting together using the device and not having nightmares and how those things are connected, because sometimes they don’t have nightmares every night. And so if the event didn’t happen, why did the event not happen? And sometimes it takes time for them to prove to themselves, I guess, that it’s working.
As far as, like, follow up plans. What I usually recommend to doctors, and I’m just going to throw this out there, and if you disagree, just let me know. But I’ve told doctors, if you’ve done that, initial follow up with them for the nightmares after, say, a few weeks or a month or maybe even two months, how often should you see them back long term? If things are going well? It seems to me like every year or perhaps just as needed would be sufficient.
But you may feel differently. I know a lot of times this is out of your hands because the patients move on and things like that, and they’re lost to follow up and things like that. But I think that’s my general advice to doctors.
But if you think that’s not exactly right, then just let me know. Let’s go to the skip forward a little bit. Yeah, go ahead.
I don’t know if this is a good place to ask this question, but I have two of the patients who’ve been prescribed to have separated from the military and either moved or are no longer eligible for care at Walter Reed. So is there a way to transfer access to their data to a civilian network provider? Yes. So if they get out of the military and they have a new provider, it’s really a matter of us knowing who that doctor is so that we can get in touch with them.
Because it’s new to everybody I talk to. Yeah, I have to talk to them, or eventually somebody else is going to have to talk to them about it. But we have to talk to them directly and tell them about the device and what they can do, get them connected to the portal.
And then one of the important tasks that we need to do is the way our portal is set up. All of the patients at Fort Hood say Dr. Powell, who is at Fort Hood, can see all of the patients that are at Fort Hood.
But if that patient moves to, say, the Washington, DC area, then we need to know that. And until we know that that patient’s moved, they’ll still remain in the Fort Hood partition. And so we can move them at any time.
As long as we know from either the clinician or from the patient that the patient’s moved, we can go ahead and adjust that. Although I think it’s not called Fort Hood anymore. I don’t know if it’s changed yet or it’s going to.
It should change this next week. Next week? Okay. I’ll have to learn a new name.
I have to have a list of names. Brandt can you skip forward to question 20 or slide 20? I want to show you this question. I think it’s useful.
So the PCL Five, which I am going to assume my behavioral health colleagues use this PCL Five sometimes in their practice. One psychiatrist pointed this one out to me. So question two is about repeated disturbing dreams of the stressful experience.
And that might be a question that’s already being collected in the normal course of managing patients with PTSD, that could be useful to you. So I guess my first question is, do the patients fill out the PCL Five on a regular basis that have PTSD? Is that something that’s used clinically at your location? It’s part of our standard procedure for everybody who comes in. Okay.
Yeah. As a pain psychologist, the Health Psychology Service, generally we don’t use the BHDP, and so I don’t use the PCL five. But in the initial intake, I go through the diagnostic criteria for PTSD and ask about repeated distressing dreams, nightmares there.
I don’t reassess it. And Dr. Savage, I think there’s a problem with this connection there, but he said, yeah, he does PCL Five s all the time on his patients, which totally makes sense in his yeah.
Everyone that I see has a PCL five. Yeah. Okay, great.
Well, okay, it’s 154. I swore that we are going to be end on time, so we’re going to end on time. You go to slide 21.
Brand I want to thank you guys all for weighing in and being part of the conversation. We’re going to keep having these conversations, and then really, my goal is that the DoD doctors, the only people that have experience with this device, and we all have to kind of learn from each other, and I’m trying to facilitate that with these sessions. And so we’ll summarize the comments that were made here, and we will distribute that and we’ll use those comments to help kind of develop for future meetings.
We have a series of them. And I know you all signed up for this meeting. If you would have time and are able to attend others, please do so.
You all have my email and you can all reach me. If there is a particular time or day of the week that works better for you for this sort of thing, please let me know that, too, because with these initial meetings, we sort of guessed when we thought people would be available. But if there’s a better time and everybody says Thursdays at 01:00 p.m..
Eastern or 05:00 p.m.. Eastern or something like that works better for you, then we would want to know that. All right, thank you.
Hey, I appreciate it. Thank you all. Bye bye.
Thanks, Brian. Thank you all. Have a great day.
Goodbye. It okay. I have them on the attendees list.
Is it a different email than okay? All right. Yeah. Okay.
Yeah, I’m going to work on that dial in thing. Okay. All right, bye
