Sleep disorders, medical conditions, and road accident risk

Association between sleep problems and functional disability in community-dwelling older adults

BACKGROUND

Sleep problems are frequently observed in older adults. They can lead to changes in the individual's physical, occupational, cognitive, and social functioning, compromising the performance of activities of daily living and contributing to the occurrence of functional disability. This study evaluated the association between sleep problems and functional disability in community-dwelling older adults.

METHODS

This was a cross-sectional study with data from 10,507 Brazilian community-dwelling older adults participating in the 2013 National Health Survey. The exposure variable was self-reported sleep problems in the last two weeks. The outcome measure was functional disability assessed from self-reported questionnaires, categorized into basic activities of daily living (BADL) and instrumental activities of daily living (IADL), and defined as not being able to perform or having little or a lot of difficulty in at least one of the activities investigated in the domain of interest.

RESULTS

Older adults who reported sleep problems had 1.53 (95%CI: 1.34; 1.75) and 1.42 (95%CI: 1.26; 1.59) greater odds of having a disability in BADL and IADL when compared to individuals who reported having no sleep problems.

CONCLUSIONS

Older adults with sleep problems were more likely to have a functional disability, both in BADL and IADL. Thus, it is important to implement strategies to screen for sleep problems in older adults in primary health care as a preventive strategy for functional disability.

Prevalence of fatigue while driving among two-wheeled vehicle drivers and associated factors: Exploratory approach from secondary analysis based on hospital data, Benin

Fatigue while driving is one of the risk factors of road crashes. It's still poorly considered in interventions because of insufficient literature. In addition, the literature on this issue doesn't focus on two-wheelers, the most frequent users in the Benin context. The study examined the prevalence of fatigue while driving among two-wheeled vehicle drivers and the related factors. It's a secondary baseline data analysis from a cohort of road crash victims recruited from five hospitals in Benin. Data were collected from July 2019 to January 2020. Patients who identified themselves as drivers during the accident were included. Data on individual characteristics, including fatigue status in the moments preceding the collision, and other risk factors and environmental settings, were extracted. We used multivariate logistic regression. Among the respondents, 12.20% (95% CI=10.20-14.53) reported fatigue in the moments preceding the collision. The odds of fatigue while driving were significantly higher in male drivers (aOR=3.60; 95% CI=1.08-11.98), during professional trips (aOR=2.09; 95% CI=1.30-3.37), in non-helmet wearers (aOR=1.85; 95% CI=1.09-3.13), in users of stimulants (aOR=3.13; 95% CI=1.50-6.54), in those with a history of chronic diseases (aOR=1.95; 95% CI=1.16-3.27), at dusk (aOR=4.22; 95% CI=2.22-8.02), at night (aOR=6.90; 95% CI=3.95-12.05), and on Inter-State National Roads (aOR=2.01; 95% CI=1.18-3.43). Fatigue is a risk factor for road crashes in Benin, associated with other risk factors that highlight particularly vulnerable profiles and groups. Integrating prevention policies based on these cumulative risk factors will result in efficiency improvements.

The short-term impact of a referendum on motor vehicle collisions casualties

OBJECTIVE

A referendum took place in Greece on the 5th of July 2015 to decide whether the suggested bailout would be accepted. Since this was the first one since 1974, the period between the referendum and the subsequent national elections was characterized by increased uncertainty and had spillover effects in many aspects of everyday life. We take advantage of this quasi-experiment to investigate the short-term impact of the referendum on vehicle collisions casualties.

METHODS

We use data from the daily number of injuries and fatalities caused by vehicle collisions in 2015 and employ a difference-in-differences approach, comparing trends before and after the referendum.

RESULTS

We reveal that the referendum had a short-term impact on road traffic casualties (4.14 more casualties per day), compared to what would have been expected in the absence of the referendum.

CONCLUSIONS

The study provides evidence that negative emotions and anxiety, due to uncertainty, could promote dangerous driving behavior. Preventive and traffic control measures may need to be considered by policy makers during periods of uncertainty.

The Association Between Fatigue and Adult Atopic Dermatitis: A Cross-Sectional Study

Background: There is currently limited insight into the broader impact of atopic dermatitis (AD) on mental health. Although studies indicate that AD patients may experience fatigue, no study has so far examined fatigue in more granular detail, for example, occurrence of general fatigue, physical fatigue, reduced activity, reduced motivation, and mental fatigue, or correlated fatigue measures with AD severity and symptoms intensity. Objectives: To examine fatigue subtypes and their prevalence in adults with AD, as well as their possible association with AD severity. Methods: A survey was conducted in adults with AD who had been managed in a hospital setting. The Patient-Oriented SCORing Atopic Dermatitis was used to determine AD severity. Patient reported outcomes, including multidimensional fatigue inventory, were included. Results: Data from 2729 adults with AD were analyzed. The total and individual fatigue scores increased consistently with lower socioeconomic scores, higher AD severity, Dermatology Life Quality Index, itch, pain, and sleep scores. Increased fatigue scores were associated with AD severity in adjusted analyses. Conclusions: Among adults with AD, fatigue scores increased with disease severity as well as intensity of AD symptoms. Fatigue is a hitherto underappreciated symptom of AD that clinicians should be cognizant about.

Prevalence of sleep disturbance in patients with cervical radiculopathy and an analysis of risk factors: a cross-sectional study

OBJECTIVE

Previous research has shown that many patients with musculoskeletal diseases suffer from sleep disturbances. However, the sleep quality of patients with cervical radiculopathy (CR) has yet to be fully investigated. This study aims to investigate the prevalence and status of sleep disturbances in patients with CR and identify the mechanisms and risk factors associated with this condition.

METHODS

We conducted a cross-sectional study of patients diagnosed with CR. The Pittsburgh Sleep Quality Index (PSQI) and Insomnia Severity Index (ISI) were used to evaluate the sleep quality of patients and determine whether patients experience sleep disturbances. In addition, we analyzed the clinical and radiological risk factors of sleep disturbance and determined the key risk factors related to sleep disturbance by multivariable analysis.

RESULTS

According to specific inclusion and exclusion criteria, 186 patients with CR were finally included, with a mean age of 59.1 ± 14.3 years, of which 113 (60.8%) were female. Sleep disturbance was defined as a PSQI score ≥ 6 and was identified in 56.5% of patients (105/186). By performing multivariate analysis, we determined that sleep disturbance was closely related to the female gender, a higher Beck Depression Inventory (BDI) score, a reduction in cervical mobility, an increase in C2-C7 sagittal vertical axis (C2-C7 SVA), and severe asymmetry of the paravertebral muscle at C5 and C6 levels.

CONCLUSION

In this study, we identified the high prevalence and potential high-risk factors of sleep disturbance in patients with CR. Clinicians should closely evaluate and monitor such patients and consider appropriate treatment strategies.

LEVEL OF EVIDENCE

IV.

Distracted driving behavior in patients with insomnia

Insomnia is one of the most common sleep disorders and is characterized by a subjective perception of difficulty falling asleep. Drivers with insomnia are vulnerable to distraction and exhibit higher levels of risk while driving. This study investigated the effect of two sources of in-vehicle distractions on the driving performance of drivers with insomnia and good sleepers by analyzing different driving behavior measures. Twenty-one drivers with insomnia and twenty-one healthy volunteers were recruited to complete simulated driving dual tasks. The primary task required the participants to perform: (a) a lane-keeping task, and (b) a lane-change task. The secondary task required the participants to deal with: (a) baseline (non-task), (b) internal distraction task, and (c) external distraction task. The internal distraction task required participants to complete quantitative reasoning tasks, while the external distraction task was a 0-back test. The relationship between distracted driving ability and cognitive function was also investigated. The results demonstrate that for lane-keeping tasks, drivers with insomnia had significantly higher standard deviations (SD) for speed, throttle position, acceleration, and lateral position than healthy drivers under internal distraction, but the driving performance did not differ significantly between groups under internal distraction or baseline. In the lane-change task, drivers with insomnia had higher SDs for steering wheel angle, steer angular velocity, lateral acceleration, and lateral speed than healthy drivers under external distraction. Moreover, external distraction impaired driving behavior in the healthy group, while internal distraction impaired driving ability in both groups. Healthy drivers with cognitive impairment displayed impaired lane-keeping abilities under internal distractions and impaired lane-changing abilities under external distractions. Driving performance in the insomnia group was not significantly associated with cognitive function. The results demonstrate that insomnia and distraction impair driving ability, and driver performance is affected differently by the distraction source (internal or external). The driving ability of healthy drivers with decreased cognition was impaired, but not that of insomniacs.The findings of this study provide new insights for preventing and estimating the potential influence of distracted driving behavior in individuals with insomnia.

Fatigue performance in patients with chronic insomnia

Insomnia is associated with fatigue and poor driving performance, thus increasing the risk of traffic accidents. This study aimed to evaluate the effect of fatigue on driving in patients with chronic insomnia in a free-flow traffic scenario and car-following scenario, and to investigate the relationships between driving performance, cognitive function, and insomnia. The Trail Making Test (TMT), Stroop Color and Word Test (SCWT), Symbol Digit Modalities Test (SDMT), and Digit Span Test (DST) of 15 participants with mild-to-moderate chronic insomnia and 16 healthy participants were assessed. During the fatigue driving task, drivers completed simulated driving tasks under free-flow traffic and car-following scenarios. The mean speed (MS), mean acceleration (MA), mean lateral position (MLP), and standard deviation of lateral position (SDLP) were measured to assess driving performance. During fatigued tasks, the MA and MLP in the free-driving scenario were higher than those in the car-following scenario (P < 0.01), the SDLP was higher in the insomnia group than in the healthy group (P = 0.02), and the interaction effect was significantly different for MLP between the groups (P = 0.03). MS was negatively correlated with TMT score, SDMT score, and DST score, and positively correlated with time to complete TMT, errors in SCWT, and time to complete SCWT. SDLP was negatively correlated with DST score and positively correlated with time to complete SCWT. Furthermore, the insomnia group had poorer lateral vehicle control ability than the healthy group. The insomnia group had a more impaired driving performance in the free-driving scenario than in the car-following scenario. Drivers with impaired cognitive function exhibited impaired driving performance.

Bioheat Transfer Basis of Human Thermoregulation: Principles and Applications

Thermoregulation is a process that is essential to the maintenance of life for all warm-blooded mammalian and avian species. It sustains a constant core body temperature in the face of a wide array of environmental thermal conditions and intensity of physical activities that generate internal heat. A primary component of thermoregulatory function is the movement of heat between the body core and the surface via the circulation of blood. The peripheral vasculature acts as a forced convection heat exchanger between blood and local peripheral tissues throughout the body enabling heat to be convected to the skin surface where is may be transferred to and from the environment via conduction, convection, radiation, and/or evaporation of water as local conditions dictate. Humans have evolved a particular vascular structure in glabrous (hairless) skin that is especially well suited for heat exchange. These vessels are called arteriovenous anastomoses (AVAs) and can vasodilate to large diameters and accommodate high flow rates. We report herein a new technology based on a physiological principle that enables simple and safe access to the thermoregulatory control system to allow manipulation of thermoregulatory function. The technology operates by applying a small amount of heating local to control tissue on the body surface overlying the cerebral spine that upregulates AVA perfusion. Under this action, heat exchangers can be applied to glabrous skin, preferably on the palms and soles, to alter the temperature of elevated blood flow prior to its return to the core. Therapeutic and prophylactic applications are discussed.

Prevalence of fatigue and associated factors among clinically stable patients with chronic obstructive pulmonary disease in Guizhou, China: A cross-sectional study

INTRODUCTION

Fatigue is important, but ignored symptom among COPD patients. At present, there is very limited data are available for the prevalence of fatigue and its risk factors among COPD patients in China.

OBJECTIVE

The purpose of this study is to determine the prevalence of fatigue and to investigate the factors associated with fatigue among clinically stable patients with COPD in China.

METHODS

This is a cross-sectional study using a questionnaire to collect data on sociodemographic, related to COPD disease, and exercise habits. Multidimensional fatigue inventory (MFI-20) was used to assess the prevalence of fatigue. Independent samples t test, bivariate correlation, one-way ANOVA test, and test for several independent samples were used to compare the sociodemographic factors with MFI-20 scores of COPD patients. Multiple stepwise linear regression was performed to estimate influencing factors related to the MFI-20 of COPD patients.

RESULTS

Among the participants, the prevalence of fatigue was 88.62%. Negative correlations were found between FEV_1% and multidimensional fatigue (r = -0.40, p < 0.01), general fatigue (r = -0.20, p < 0.05), reduced activity (r = -0.20, p < 0.01), and physical fatigue (r = -0.10, p < 0.01). A multiple linear regression models revealed that age (p < 0.05), BMI (p < 0.05), FEV₁ % (p < 0.01), exercise times (p < 0.01), and the times of hospitalization in the past 12 months (p < 0.05) were associated with multidimensional fatigue scores.

CONCLUSIONS

The prevalence of fatigue is high among clinically stable patients with COPD. Keeping exercise, prevention obesity, and exacerbation should be an effective intervention strategy to reduce COPD-related fatigue.

Fatigue as the Chief Complaint – Epidemiology, Causes, Diagnosis, and Treatment

BACKGROUND

Fatigue is a main or secondary reason for 10-20% of all consultations with a primary care physician.

METHODS

This review is based on pertinent publications retrieved by a comprehensive, selective literature search on the epidemiology, etiology, and diagnostic evaluation of fatigue as a leading symptom of disease, as well as on the treatment of its common causes. Information was also included from the literature search we conducted for the German clinical practice guideline on fatigue that was issued by the German College of General Practitioners and Family Physicians (Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin, DEGAM).

RESULTS

Fatigue can be due to any of a broad spectrum of diseases, including decompensation of already known conditions. Sleep disorders and sleep-related disorders of breathing, depression (18.5%), and excessive psychosocial stress are the most common causes of persistent fatigue. Previously undiagnosed cancer is a rare cause, accounting for only 0.6% of cases (95% confidence interval [0.3; 1.3]). Anemia and other organic causes are rare as well (4.3% [2.7; 6.7]). Investigations beyond the history, physical examination, and simple laboratory tests are needed only in the presence of additional symptoms or findings. If the diagnosis remains unclear, watchful waiting and regularly scheduled follow-up help prevent an excessive focus on somatic causes, leading to overdiagnosis. Irrespective of specific causes, psychoeducative and psychotherapeutic approaches should be discussed with the patient, as well as an individually adapted exercise program.

CONCLUSION

The work-up of fatigue as a chief complaint should be guided by investigating common and/or potentially dangerous disorders. Since the latter are rare, an exclusively somatic focus should be avoided in order to prevent overdiagnosis.

Sleepiness Behind the Wheel and the Implementation of European Driving Regulations

Sleep disturbance and sleepiness are established risk factors for driving accidents and obstructive sleep apnea (OSA) is the most prevalent medical disorder associated with excessive daytime sleepiness. Because effective treatment of OSA reduces accident risk, several jurisdictions have implemented regulations concerning the ability of patients with OSA to drive, unless effectively treated. This review provides a practical guide for clinicians who may be requested to certify a patient with OSA as fit to drive regarding the scope of the problem, the role of questionnaires and driving simulators to evaluate sleepiness, and the benefit of treatment on accident risk.

Algorithm for automatic detection of self-similarity and prediction of residual central respiratory events during continuous positive airway pressure

Study Objectives

Sleep-disordered breathing is a significant risk factor for cardiometabolic and neurodegenerative diseases. High loop gain (HLG) is a driving mechanism of central sleep apnea or periodic breathing. This study presents a computational approach that identifies “expressed/manifest” HLG via a cyclical self-similarity feature in effort-based respiration signals.

Methods

Working under the assumption that HLG increases the risk of residual central respiratory events during continuous positive airway pressure (CPAP), the full night similarity, computed during diagnostic non-CPAP polysomnography (PSG), was used to predict residual central events during CPAP (REC), which we defined as central apnea index (CAI) higher than 10. Central apnea labels are obtained both from manual scoring by sleep technologists and from an automated algorithm developed for this study. The Massachusetts General Hospital sleep database was used, including 2466 PSG pairs of diagnostic and CPAP titration PSG recordings.

Results

Diagnostic CAI based on technologist labels predicted REC with an area under the curve (AUC) of 0.82 ± 0.03. Based on automatically generated labels, the combination of full night similarity and automatically generated CAI resulted in an AUC of 0.85 ± 0.02. A subanalysis was performed on a population with technologist-labeled diagnostic CAI higher than 5. Full night similarity predicted REC with an AUC of 0.57 ± 0.07 for manual and 0.65 ± 0.06 for automated labels.

Conclusions

The proposed self-similarity feature, as a surrogate estimate of expressed respiratory HLG and computed from easily accessible effort signals, can detect periodic breathing regardless of admixed obstructive features such as flow limitation and can aid the prediction of REC.

Self-reported view on work capacity predicts abnormal Oxford Sleep Resistance Test results in patients with obstructive sleep apnea

STUDY OBJECTIVES

The Oxford Sleep Resistance Test is an objective vigilance test based on behavior. It is a modified version of the maintenance of wakefulness test and is considered less burdensome and less expensive than the maintenance of wakefulness test. Although professional drivers with obstructive sleep apnea in Europe must be assessed for their ability to maintain adequate wakefulness on a yearly basis, Oxford Sleep Resistance Test results are usually normal in this population. In this retrospective observational study, we searched for predictive factors of abnormal Oxford Sleep Resistance Test sleep latency.

METHODS

We included 1,071 Oxford Sleep Resistance Test results of patients with obstructive sleep apnea (95% men, aged 21-74 years). Mean sleep latency < 40 minutes was considered abnormal.

RESULTS

Sleep latency was abnormal in 12.0% of tests. Participants at risk for abnormal test results self-reported as being sleepy, depressed, on sick leave, unemployed, or retired or considered themselves unable to work. In a logistic regression model, the self-reported view on work capacity was the most important predictor of abnormal Oxford Sleep Resistance Test sleep latency (odds ratio, 3.5). Ongoing sick leave was also an important predictor for abnormal test results.

CONCLUSIONS

A self-reported good ability to work predicts that a patient with sleep apnea can maintain wakefulness in a vigilance test. This may help in reducing the increasing challenge with frequent tests.

A systematic literature review and meta-analysis of the clinical effects of aroma inhalation therapy on sleep problems

BACKGROUND

This systematic review investigated the clinical effects of inhalation aromatherapy for the treatment of sleep problems such as insomnia.

METHODS

Studies on sleep problems and inhalation aromatherapy, published in Korean and international journals, were included in the meta-analysis. Five domestic and international databases, respectively each, were used for the literature search. Keywords included sleep disorder, sleep problems, insomnia, and aroma inhalation, and the related literature was further searched. After the screening, selected articles were assessed for their quality and conducted the risk of bias using RevMan 5.0, a systematic literature review was then conducted. A meta-analysis comparing the averages was conducted on studies that reported numerical values. Additionally, meta-analysis of variance and meta-regression analyses were performed.

RESULTS

Meta-analysis of the 34 studies using the random-effects model revealed that the use of aromatherapy was highly effective in improving sleep problems such as insomnia, including quantitative and qualitative sleep effects (95% confidence interval [CI], effect sizes = 0.6491). Subgroup analysis revealed that the secondary outcomes including stress, depression, anxiety, and fatigue were significantly effective. The single aroma inhalation method was more effective than the mixed aroma inhalation method. Among the single inhalation methods, the lavender inhalation effect was the greatest.

CONCLUSION

Inhalation aromatherapy is effective in improving sleep problems such as insomnia. Therefore, it is essential to develop specific guidelines for the efficient inhalation of aromatherapy.

ETHICS AND DISSEMINATION

Ethical approval is not required because individual patient data are not included. The findings of this systematic review were disseminated through peer-reviewed publications or conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42020142120.

Non-apnea sleep disorder and its risk for all kinds of injuries: A 14-year follow-up for a nationwide population-based retrospective study

Non-apnea sleep disorder (NASD) increases the risk of motor vehicle accidents. However, systemic review of NASD and its risk for all causes of injury is lacking. The aim of the present study was to provide a detailed demographic data on NASD and all causes of injury in a 14-year follow up.Our study utilized outpatient and inpatient data from the Longitudinal Health Insurance Database between 2000 and 2013 in Taiwan. We enrolled 989,753 individuals aged ≥20 years who were diagnosed with NASD as outpatients ≥3 times or inpatients ≥1 time. We matched the study cohort with a comparison cohort by age, index date and comorbidities at a ratio of 1:4. We used Cox proportional hazards regression to analyze the association of NASD and the cause of injury.In this 14-year follow up study, patients with NASD had 12.96% increased risk of injury compared to that of the control cohort. Fall was the first place of the cause of injury with 670.26 per 105 PYs. In the stratified age group, patients aged ≧65 years had the highest risk of injury (adjusted HR= 1.381; P < .001). Kaplan-Meier analysis showed that the incidence of injury between the with- and without-NASD cohorts started from the first year and persisted until the end of the follow-up.Our study demonstrates that NASD patients were associated with higher risk of all causes of injuries, with falling being the most prevalent diagnosis. The general public should be more aware of this neglected issue of NASD.

Work-related factors, fatigue, risky behaviours and traffic accidents among taxi drivers: a comparative analysis among age groups

The main purpose of this study was to investigate the effect of work-related factors, fatigue, risky behaviours on accident involvement among different age groups of taxi drivers in China. A total of 2391 taxi drivers were selected to complete a self-reported questionnaire about their demographic data and information on working conditions, fatigue, risky behaviours, as well as involvement in traffic accidents between 2014 and 2016. The drivers were divided into three categories according to their age. Then, a set of comparative analyses and three structural equation models were used to analyze the samples of specific age groups. The results indicated that taxi drivers in the younger group rest the least with the most dissatisfaction with income while those in the mid-age group worked the longest time and were charged the most management fee, but the older taxi drivers more frequently engaged in risky behaviours and traffic accidents. Furthermore, two mediating chain processes were confirmed (i.e. 'work-related factors - fatigue - accidents' and 'work-related factors - risky behaviours - accidents') across the three age groups. However, the causes of fatigue, risky behaviours and accidents in different age groups are not exactly the same. These findings suggest that the regulation of the taxi industry should be carefully improved. Incentive policy and education aimed at taxi drivers may also hold promise.

Age-Related Diseases and Driving Safety

Due to demographic changes, the number of older drivers is steadily increasing. Mobility is highly relevant for leading an independent life in the elderly. It largely depends on car driving, which is a complex task requiring a multitude of cognitive and motor skills vulnerable to age- related functional deterioration. The almost inevitable effects of senescence may be potentiated by age-related diseases, such as stroke or diabetes mellitus. Respective pharmacological treatment may cause side effects, additionally affecting driving safety. The present article reviews the impact of age-related diseases and drug treatment of these conditions on driving fitness in elderly drivers. In essence, we focus on diseases of the visual and auditory systems, diseases of the central nervous system (i.e., stroke, depression, dementia and mild cognitive disorder, and Parkinson's disease), sleep disorders, as well as cardiovascular diseases, diabetes mellitus, musculoskeletal disorders, and frailty. We will outline the role of functional tests and the assessment of driving behavior (by a driving simulator or in real traffic), as well as the clinical interview including questions about frequency of (near) accidents, etc. in the evaluation of driving fitness of the elderly. We also address the impact of polypharmacy on driving fitness and end up with recommendations for physicians caring for older patients.

European Respiratory Society statement on sleep apnoea, sleepiness and driving risk

Obstructive sleep apnoea (OSA) is highly prevalent and is a recognised risk factor for motor vehicle accidents (MVA). Effective treatment with continuous positive airway pressure has been associated with a normalisation of this increased accident risk. Thus, many jurisdictions have introduced regulations restricting the ability of OSA patients from driving until effectively treated. However, uncertainty prevails regarding the relative importance of OSA severity determined by the apnoea–hypopnoea frequency per hour and the degree of sleepiness in determining accident risk. Furthermore, the identification of subjects at risk of OSA and/or accident risk remains elusive. The introduction of official European regulations regarding fitness to drive prompted the European Respiratory Society to establish a task force to address the topic of sleep apnoea, sleepiness and driving with a view to providing an overview to clinicians involved in treating patients with the disorder. The present report evaluates the epidemiology of MVA in patients with OSA; the mechanisms involved in this association; the role of screening questionnaires, driving simulators and other techniques to evaluate sleepiness and/or impaired vigilance; the impact of treatment on MVA risk in affected drivers; and highlights the evidence gaps regarding the identification of OSA patients at risk of MVA.

Evaluation of the Effectiveness of the Risk Minimization Measures of Sodium Oxybate in the European Union

BACKGROUND

Sodium oxybate (Xyrem^®), approved by the European Medicines Agency (EMA) for narcolepsy with cataplexy, is only available through risk mitigation programs due to potential adverse effects including respiratory and central nervous system depression, neuropsychiatric events, and misuse.

OBJECTIVE

We report findings from a survey evaluating effectiveness of the European Union Xyrem^® Risk Management Plan (RMP).

PATIENTS AND METHODS

A cross-sectional, online, multiple-choice survey was distributed to randomly selected healthcare professionals (HCPs) from six European countries (April 2016-May 2018). Eligibility criteria: current/potential Xyrem^® prescriber and/or sleep disorder specialist; contact information available; on the Xyrem^® RMP educational materials mailing list.

PRIMARY OUTCOME

proportion of respondents answering each question correctly (< 50% responses correct = unsatisfactory comprehension, 50% to < 70% = satisfactory, ≥ 70% = excellent), with precision assessed using 95% confidence intervals (CIs).

RESULTS

Of the 709 HCPs contacted, 601 did not agree to take part, 108 were screened with 35/108 eligible for inclusion; 31 HCPs completed the survey. Of the 31 respondents, 29 (93.5%; 95% CI 84.4-100.0) reported receiving Xyrem^® safety information, commonly from a sales representative, EMA Summary of Product Characteristics (SmPC), or educational meeting; only 9/31 (31.0%; 14.3-50.0) recalled receiving mailed educational materials. The number of HCPs answering dosing-related questions correctly ranged from 24/31 to 31/31. All Xyrem^® contraindications were correctly identified by 26/31 (83.9%; 70.0-96.7) respondents. All respondents 'always' or 'sometimes' completed SmPC recommended activities upon treatment initiation. The majority indicated signs of abuses/misuse/diversion (23/31; 74.2%; 58.6-88.0) and criminal use (23/31; 74.2%; 59.4-89.3) should be monitored at follow-up.

CONCLUSIONS

These data demonstrate the importance of providing a range of educational materials. However, the low sample size limits interpretation; increased HCP engagement would improve understanding of how best to develop educational materials.

EUROPEAN POST-AUTHORIZATION STUDY (PAS) REGISTER NUMBER

EUPAS15024.

Correlation between the Epworth Sleepiness Scale and the Maintenance of Wakefulness Test in Obstructive Sleep Apnea Patients Treated with Positive Airway Pressure

BACKGROUND

The Epworth sleepiness scale (ESS) is often used to evaluate the impact of treatment in patients with obstructive sleep apnea hypopnea syndrome (OSA). We aimed to evaluate the correlation between ESS and the Maintenance of Wakefulness Test (MWT) in a population of OSA patients treated with positive airway pressure (PAP).

METHODS

We retrospectively included all patients during a 2-year period who were diagnosed with OSA in our sleep clinic and required PAP therapy. ESS was evaluated at baseline and after PAP therapy for all patients, and all had a concomitant MWT. Correlation between final ESS, change in ESS, and MWT were evaluated using Spearman's correlation. Given that MWT is considered as the gold standard, the diagnostic performance of ESS was evaluated against MWT.

RESULTS

Hundred thirty-four OSA patients were included. At the time of MWT, 89.6% of the patients were compliant (PAP use ≥4hours/night), and only 9 (6.7%) had persistent sleepiness despite PAP treatment (mean sleep latency at MWT<19.4min). Moderate correlation was observed between final ESS and MWT (Spearman's correlation coefficient=-0.42), but no correlation was found between change in ESS and MWT. Diagnostic performance was as follows for final ESS: sensitivity=55.6%, specificity=84.8%, PPV=20.8%, and NPV=96.4%.

CONCLUSIONS

ESS was moderately correlated with MWT in a population of OSA patients compliant with PAP therapy. In this population, ESS showed poor diagnostic performance in identifying patients with persistent excessive daytime sleepiness. CLINICALTRIALS.

GOV IDENTIFIER

NCT03629834.

Safety implications of fatigue and sleep inertia for emergency services personnel

Emergency services present a unique operational environment for the management of fatigue and sleep inertia. Communities request and often expect the provision of emergency services on a 24/7/365 basis. This can result in highly variable workloads and/or significant need for on-demand or on-call working time arrangements. In turn, the management of fatigue-related risk requires a different approach than in other more predictable shift working sectors (e.g., mining and manufacturing). The aim of this review is to provide a comprehensive overview of fatigue risk management that is accessible to regulators, policy makers and organisations in the emergency services sector. The review outlines the unique fatigue challenges in the emergency services sector, examines the current scientific and policy consensus around managing fatigue and sleep inertia, and finally discusses strategies that emergency services organisations can use to minimise the risks associated with fatigue and sleep inertia.

Assessment of the Risks of Occupational Diseases of the Passenger Bus Drivers

Background

The working conditions of bus drivers are difficult; they lead to occupational diseases and require careful study, particularly in Ukraine. The objective of the article is the description of occupational health risks of passenger bus drivers that lead to deteriorating health.

Methods

The risk assessment was performed using a modified Risk Score method, which allowed determining the generalized level of danger to the driver's health. The hygienic hazards level was assessed as based on Stevenson's law, which was generalized later.

Results

Based on the modification of the Risk Score method, it was possible to depart from expert assessments method of the risk level and calculate the general indicator based on the degree of dependence of the impact on the human body on its intensity, proposed by V. Minko. This allows objective determining of the impact of hygiene hazards on the health of the driver and to predict the occurrence of occupational diseases associated with the cardiovascular system, musculoskeletal system, and partial or complete disability due to the accumulation of emotional fatigue. The hazard assessment was carried out for three brands of passenger buses common in Ukraine, in which the driver is exposed to the dangers of fever, vibration, noise, harmful impurities in the bus cabin, and emotional load.

Conclusion

The health of drivers in the cabins of passenger buses is most affected by hygiene hazards: fever, vibration, and emotional stress. The generalized level of risk is calculated by the modified method of Risk Score is 0.83; -0.99, -0.92 respectively.

Brief digital sleep questionnaire powered by machine learning prediction models identifies common sleep disorders

INTRODUCTION

We developed and validated an abbreviated Digital Sleep Questionnaire (DSQ) to identify common societal sleep disturbances including insomnia, delayed sleep phase syndrome (DSPS), insufficient sleep syndrome (ISS), and risk for obstructive sleep apnea (OSA).

METHODS

The DSQ was administered to 3799 community volunteers, of which 2113 were eligible and consented to the study. Of those, 247 were interviewed by expert sleep physicians, who diagnosed ≤2 sleep disorders. Machine Learning (ML) trained and validated separate models for each diagnosis. Regularized linear models generated 15-200 features to optimize diagnostic prediction. Models were trained with five-fold cross-validation (repeated five times), followed by robust validation testing. ElasticNet models were used to classify true positives and negatives; bootstrapping optimized probability thresholds to generate sensitivities, specificities, accuracies, and area under the receiver operating curve (AUC).

RESULTS

Compared to reference subgroups, physician-diagnosed sleep disorders were marked by DSQ evidence of sleeplessness (insomnia, DSPS, OSA), sleep debt (DSPS, ISS), airway obstruction during sleep (OSA), blunted circadian variability in alertness (DSPS), sleepiness (DSPS and ISS), increased alertness (insomnia) and global impairment in sleep-related quality of life (all sleep disorders). ElasticNet models validated each diagnosis with high sensitivity (80-83%), acceptable specificity (63-69%), high AUC (0.80-0.85) and good accuracy (agreement with physician diagnoses, 68-73%).

DISCUSSION

A brief DSQ readily engaged and efficiently screened a large population for common sleep disorders. Powered by ML, the DSQ can accurately classify sleep disturbances, demonstrating the potential for improving the sleep, health, productivity and safety of populations.

A randomized study of solriamfetol for excessive sleepiness in narcolepsy

Objective

Solriamfetol (JZP‐110) is a selective dopamine and norepinephrine reuptake inhibitor with wake‐promoting effects. This phase 3 study (NCT02348593) evaluated the safety and efficacy of solriamfetol in narcolepsy.

Methods

Patients with narcolepsy with mean sleep latency <25 minutes on the Maintenance of Wakefulness Test (MWT), Epworth Sleepiness Scale (ESS) score ≥10, and usual nightly sleep ≥6 hours were randomized to solriamfetol 75, 150, or 300 mg, or placebo for 12 weeks. Coprimary endpoints were change from baseline to week 12 in MWT and ESS. Improvement on the Patient Global Impression of Change (PGI‐C) was the key secondary endpoint.

Results

Safety and modified intention‐to‐treat populations included 236 and 231 patients, respectively. Solriamfetol 300 and 150 mg were positive on both coprimary endpoints. Least squares mean (standard error [SE]) changes from baseline were 12.3 (SE = 1.4) and 9.8 (SE = 1.3) minutes for solriamfetol 300 and 150 mg on the MWT, respectively, versus 2.1 (SE = 1.3) minutes for placebo, and −6.4 (SE = 0.7) for 300 mg and −5.4 (SE = 0.7) for 150 mg on the ESS versus −1.6 (SE = 0.7) for placebo (all p < 0.0001). At week 12, higher percentages of patients treated with solriamfetol 150 mg (78.2%) and 300 mg (84.7%) reported PGI‐C improvement relative to placebo (39.7%; both p < 0.0001). Adverse events ≥5% across all solriamfetol doses included headache (21.5%), nausea (10.7%), decreased appetite (10.7%), nasopharyngitis (9.0%), dry mouth (7.3%), and anxiety (5.1%).

Interpretation

Solriamfetol has the potential to be an important therapeutic option for the treatment of impaired wakefulness and excessive sleepiness in patients with narcolepsy. ANN NEUROL 2019;85:359–370.

Expert-level sleep scoring with deep neural networks

Objectives

Scoring laboratory polysomnography (PSG) data remains a manual task of visually annotating 3 primary categories: sleep stages, sleep disordered breathing, and limb movements. Attempts to automate this process have been hampered by the complexity of PSG signals and physiological heterogeneity between patients. Deep neural networks, which have recently achieved expert-level performance for other complex medical tasks, are ideally suited to PSG scoring, given sufficient training data.

Methods

We used a combination of deep recurrent and convolutional neural networks (RCNN) for supervised learning of clinical labels designating sleep stages, sleep apnea events, and limb movements. The data for testing and training were derived from 10 000 clinical PSGs and 5804 research PSGs.

Results

When trained on the clinical dataset, the RCNN reproduces PSG diagnostic scoring for sleep staging, sleep apnea, and limb movements with accuracies of 87.6%, 88.2% and 84.7% on held-out test data, a level of performance comparable to human experts. The RCNN model performs equally well when tested on the independent research PSG database. Only small reductions in accuracy were noted when training on limited channels to mimic at-home monitoring devices: frontal leads only for sleep staging, and thoracic belt signals only for the apnea-hypopnea index.

Conclusions

By creating accurate deep learning models for sleep scoring, our work opens the path toward broader and more timely access to sleep diagnostics. Accurate scoring automation can improve the utility and efficiency of in-lab and at-home approaches to sleep diagnostics, potentially extending the reach of sleep expertise beyond specialty clinics.

Effect of Positive Airway Pressure Therapy on Drowsy Driving in a Large Clinic-Based Obstructive Sleep Apnea Cohort

STUDY OBJECTIVES

Drowsy driving related to obstructive sleep apnea (OSA) represents an important public health problem with limited data on the effect of positive airway pressure (PAP) therapy. We hypothesize that PAP therapy will reduce self-reported drowsy driving in a large clinic-based OSA cohort.

METHODS

Drowsy driving (self-reported near-accidents/accidents) incidents from baseline to after PAP therapy (stratified by adherence) were compared in a cohort of 2,059 patients with OSA who initiated PAP therapy from January 1, 2010 to December 31, 2014. Multivariable logistic regression models evaluated the dependence of change in drowsy driving incidents on other factors, including change in Epworth Sleepiness Scale (ESS) and Patient Health Questionnaire-9 (PHQ9) scores.

RESULTS

In the entire cohort (age 56.0 ± 13.1 years, 45.4% female, 76.0% white, average follow-up 124.4 ± 67.3 days), drowsy driving incidents reduced from 14.2 to 6.9% after PAP therapy (P < .001). In subgroups, drowsy driving incidents reduced from 14% to 5.3% (P < .001) in patients who self-reported adherence to PAP therapy and 14.1% to 5.3% (P < .001) in patients objectively adherent to PAP therapy. For each one-point improvement in Epworth Sleepiness Scale score, the odds of drowsy driving decreased by about 14% (odds ratio 0.86, 95% confidence interval 0.82 to 0.90).

CONCLUSIONS

In this clinic-based cohort, drowsy driving improved after adherent PAP usage, with greater drowsy driving risk for those with greater sleep propensity. This highlights the importance of and need for routine drowsy driving assessments and careful clinical attention to PAP adherence and sleep propensity in this population. Our findings should be confirmed and may be used to provide support for initiatives to address the public health issue of drowsy driving.

Analytical observational study of nonfatal motor vehicle collisions and incidents in a light-vehicle sales and service fleet

Motor vehicle crashes (MVCs) are a significant cause of lost-workday injuries, and consistently the leading cause of work-related fatalities in the United States for all industries combined. Prevention research has focused mainly on collisions fatal to the drivers of large trucks. This analytical observational study addresses gaps in the literature by: conducting a descriptive analysis of motor vehicle claim events involving light-vehicle drivers in a large health care industry fleet; identifying risk factors for work-related MVCs and injuries based on vehicle miles traveled; and providing details on circumstances of these events. The study examined 8068 motor vehicle events resulting in vehicle damage, property damage, or injury reported by 6680 U.S.-based drivers in a light-vehicle sales and service fleet operated by a health care company over a 4 ½-year period (January 2010 through June 2014). Thirty-three percent (n = 2660) of the events were collisions. Collisions were segmented as recoverable or non-recoverable according to whether the company could recover costs from another party, and mileage-based collision and injury rates were calculated by gender, age, tenure, and vehicle type. Differences in collision and injury rates between groups of interest (for example, tenure and age categories) were assessed with Poisson regression techniques adjusted using generalized estimating equations (GEE) for repeated observations on the same employee over time. Age, gender, and job tenure were significant collision risk factors, and risk patterns for recoverable and non-recoverable collisions were similar to those for total collisions. Collisions per million miles (CPMM) were significantly higher for drivers 21-24.9 years of age compared to drivers age 25-54.9 years (9.58 CPMM vs 4.96 CPMM, p = .025), drivers employed for less than 2 years compared to those employed 2 or more years (6.22 CPMM vs 4.82 CPMM, p < .001), for female drivers compared to male drivers (6.37 CPMM vs 4.16 CPMM, p < .001), and for drivers of passenger cars compared to all other vehicles (5.27 CPMM vs 4.48 CPMM, p < .001). Among collisions between the employee's vehicle and another vehicle in transport, those where the front of one vehicle hit another vehicle at an angle were the most likely to result in injury to the employee driver or another party (26%), followed by rear-end collisions (25%). Special attention should be given to preventing collisions among newly-hired employees, and to preventing angle and rear-end collisions, which were the most common types of collisions and also were most likely to result in injury than all other collisions combined.

From Nanowarming to Thermoregulation: New Multiscale Applications of Bioheat Transfer

This review explores bioheat transfer applications at multiple scales from nanoparticle (NP) heating to whole-body thermoregulation. For instance, iron oxide nanoparticles are being used for nanowarming, which uniformly and quickly rewarms 50-80-mL (≤5-cm-diameter) vitrified systems by coupling with radio-frequency (RF) fields where standard convective warming fails. A modification of this approach can also be used to successfully rewarm cryopreserved fish embryos (∼0.8 mm diameter) by heating previously injected gold nanoparticles with millisecond pulsed laser irradiation where standard convective warming fails. Finally, laser-induced heating of gold nanoparticles can improve the sensitivity of lateral flow assays (LFAs) so that they are competitive with laboratory tests such as the enzyme-linked immunosorbent assay. This approach addresses the main weakness of LFAs, which are otherwise the cheapest, easiest, and fastest to use point-of-care diagnostic tests in the world. Body core temperature manipulation has now become possible through selective thermal stimulation (STS) approaches. For instance, simple and safe heating of selected areas of the skin surface can open arteriovenous anastomosis flow in glabrous skin when it is not already established, thereby creating a convenient and effective pathway to induce heat flow between the body core and environment. This has led to new applications of STS to increase or decrease core temperatures in humans and animals to assist in surgery (perioperative warming), to aid ischemic stress recovery (cooling), and even to enhance the quality of sleep. Together, these multiscale applications of nanoparticle heating and thermoregulation point to dramatic opportunities for translation and impact in these prophylactic, preservative, diagnostic, and therapeutic applications of bioheat transfer.

Can real-life driving ability be predicted by the Maintenance of Wakefulness Test?

Objective: Drowsy driving is a profound road safety issue. In patients with excessive daytime sleepiness (EDS), the Maintenance of Wakefulness Test (MWT) is commonly used to evaluate driving ability. However, there is little evidence that MWT predicts driving performance, and several sleep latency cutoffs have been suggested. Methods: Based on a retrospective chart analysis of patients with an MWT and a driving ability assessment between January 2006 and November 2014, we identified 63 studies in 60 patients. The driving ability assessment judged the patients as qualified or disqualified for commercial driving. MWT latencies to 3 s of alpha activity, 3 s of drowsiness (microsleep), and sleep onset were compared between qualified and disqualified patients and their validity to identify driving qualification was evaluated. Results: Disqualified patients had shorter alpha, microsleep, and sleep latencies, but the latency distributions were widely overlapping. MWT accuracy to predict driving performance was poor: two thirds of short sleep latencies were false positives. Adding information from alpha and microsleep latencies added little extra accuracy. Conclusions: MWT results correlate poorly with driving performance in a 2-h test irrespective of sleep latency cutoff or added alpha/microsleep latency data. Better diagnostic tools are needed to evaluate driving performance in patients with EDS.

The Risk of Hospitalization for Motor Vehicle Accident Injury in Narcolepsy and the Benefits of Stimulant Use: A Nationwide Cohort Study in Taiwan

STUDY OBJECTIVES

To examine the risk of hospitalization for motor vehicle accident injury (MVAI) in patients with narcolepsy and the effects of stimulant use on MVAI occurrence in patients with narcolepsy.

METHODS

This is a population-based, retrospective cohort study using Taiwan's National Health Insurance Research Database between 2000 and 2013. We included patients with narcolepsy based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, 347. The case and matched control participants were selected in a ratio of 1:3, and the traffic accident (ICD-9-CM codes: E810-E819) plus injury codes (ICD-9-CM codes: 800.xx-999.xx) due to MVAI following hospitalization were used for the study outcome. The type of injury, causes, intentionality, and the effects of stimulant use on patients with narcolepsy were also assessed.

RESULTS

A total of 1,316 participants were enrolled, including 329 participants with narcolepsy and 987 participants without narcolepsy. During a 14-year follow-up period, a total of 104 participants had MVAI, of whom 47 (1,559.54 per 100,000 person-years) belonged to the narcolepsy cohort and 57 (556.21 per 100,000 person-years) to the non-narcolepsy cohort. After adjusting for covariates, the risk of hospitalization for MVAI among participants with narcolepsy was still significantly higher than those without narcolepsy (adjusted hazard ratio = 6.725; 95% confidence interval = 4.421-10.231; P < .001). The use of modafinil or methylphenidate, as monotherapy or combined treatment, was associated with a lower risk of MVAI in the narcolepsy cohort.

CONCLUSIONS

Patients with narcolepsy may have a higher risk of hospitalization for MVAI and stimulant use could mitigate such risk.

Mental health in elite athletes: International Olympic Committee consensus statement (2019)

Mental health symptoms and disorders are common among elite athletes, may have sport related manifestations within this population and impair performance. Mental health cannot be separated from physical health, as evidenced by mental health symptoms and disorders increasing the risk of physical injury and delaying subsequent recovery. There are no evidence or consensus based guidelines for diagnosis and management of mental health symptoms and disorders in elite athletes. Diagnosis must differentiate character traits particular to elite athletes from psychosocial maladaptations.

Management strategies should address all contributors to mental health symptoms and consider biopsychosocial factors relevant to athletes to maximise benefit and minimise harm. Management must involve both treatment of affected individual athletes and optimising environments in which all elite athletes train and compete. To advance a more standardised, evidence based approach to mental health symptoms and disorders in elite athletes, an International Olympic Committee Consensus Work Group critically evaluated the current state of science and provided recommendations.

Twenty-four-hour pattern of operations-related injury occurrence and severity of off-site/on-call volunteer French firefighters

We assessed the 24-h pattern of operations-related injuries (ORI) experienced by scheduled off-site/on-call French volunteer firefighters (VFF) through analysis of an archival database. Occurrence and severity - evaluated by number of lost work days (LWD) and total medical costs (TMC) - of ORI were explored in terms of risk ratios, respectively, number of ORI/number of service operations (RR_ORI), number of LWD/number of ORI (RS_LWD,) and TMC/number of ORI (RS_TMC). Additionally, the collective work performance of all involved VFF was measured in terms of the lag time (LT) between emergency call-center firefighter-answered communication for service of observer-presumed out-of-hospital cardiac arrest (OHCA) and departure of vehicle from fire station to render aid, designated LT_OHCA. Cosinor and cross-correlation statistical methods were applied. A total of 252 ORI occurred while performing 146,479 service operations. High-amplitude 24 h variation was detected in RR_ORI (p < .003), SR_LWD (p < .001), SR_TMC (p < .012), and LT_OHCA (p < .001), all with nocturnal peak time. Coherence was found between the day/night variation of LT_OHCA and RR_ORI (r = 0.7, p < .0002), SR_LWD (r = 0.5, p < .02), and SR_TMC (r = 0.4, p < .05). This investigation verifies the occurrence and severity of ORI of scheduled off-site/on-call VFF exhibit high-amplitude 24 h patterning with nocturnal excess that closely coincides with their day/night work performance measured by LT_OHCA. These findings, which are essentially identical to ones of a previous study entailing on-site/on-call career firefighters, indicate the need for fatigue management and ORI prevention programs not yet available to VFF, who compose the majority of the field service workforce of French fire departments. Abbreviations:FF: firefighters; CFF: career firefighters; VFF: volunteer firefighters; FD: fire department; LT_OHCA: lag time (LT) response in min:sec between fire department call-center-answered communication for service of presumed out-of-hospital cardiac arrest (OHCA) and departure from fire station of vehicle to render aid; LWD: lost work days; ORI: operations-related injuries; SR_LWD: severity ratio of operations-related injuries in terms of number of lost work days, calculated as number of lost work days/number of operations-related injuries; RR_ORI: risk ratio of operations-related injuries calculated as number of operations-related injuries/number of operations; SR_TMC: severity ratio of operations-related injuries in terms of total medical costs, calculated as total medical costs/number of operations-related injuries; TMC: total medical costs.

Red Flags for early referral of people with symptoms suggestive of narcolepsy: a report from a national multidisciplinary panel

OBJECTIVE

Narcolepsy is a lifelong disease, manifesting with excessive daytime sleepiness and cataplexy, arising between childhood and young adulthood. The diagnosis is typically made after a long delay that burdens the disease severity. The aim of the project, promoted by the "Associazione Italiana Narcolettici e Ipersonni" is to develop Red Flags to detect symptoms for early referral, targeting non-sleep medicine specialists, general practitioners, and pediatricians.

MATERIALS AND METHODS

A multidisciplinary panel, including patients, public institutions, and representatives of national scientific societies of specialties possibly involved in the diagnostic process of suspected narcolepsy, was convened. The project was accomplished in three phases. Phase 1: Sleep experts shaped clinical pictures of narcolepsy in pediatric and adult patients. On the basis of these pictures, Red Flags were drafted. Phase 2: Representatives of the scientific societies and patients filled in a form to identify barriers to the diagnosis of narcolepsy. Phase 3: The panel produced suggestions for the implementation of Red Flags.

RESULTS

Red Flags were produced representing three clinical pictures of narcolepsy in pediatric patients ((1) usual sleep symptoms, (2) unusual sleep symptoms, (3) endocrinological signs) and two in adult patients ((1) usual sleep symptoms, (2) unusual sleep symptoms). Inadequate knowledge of symptoms at onset by medical doctors turned out to be the main reported barrier to diagnosis.

CONCLUSIONS

This report will hopefully enhance knowledge and awareness of narcolepsy among non-specialists in sleep medicine in order to reduce the diagnostic delay that burdens patients in Italy. Similar initiatives could be promoted across Europe.

Clinical effects of mindfulness meditation and cognitive behavioral therapy standardized for insomnia: A protocol for a systematic review and meta-analysis

INTRODUCTION

This systematic review protocol describes the methods that will be used to evaluate the efficacy and safety of mindfulness meditation and cognitive behavioral therapy programs as a psychological intervention for insomnia disorders.

METHODS AND ANALYSIS

We will search the following 11 electronic databases without language or publication status restrictions: MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE, Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature, and PsycARTICLES. Furthermore, we will also search 5 Korean-language databases (Oriental Medicine Advanced Searching Integrated System, Korean studies Information Service System, Research Information Service System, Korean Medical Database, and Korea Citation Index). The study selection and data extraction will be performed independently by 2 authors. The study quality assessment and evaluation of the quality of evidence for the main findings will be performed independently by 2 authors using the Cochrane tool for assessing risk of bias and predefined criteria (the Grading of Recommendations Assessment, Development, and Evaluation approach). Data synthesis and analysis will be performed using RevMan Version 5.3. Data will be synthesized by either a fixed effects or random effects model according to a heterogeneity test or the number of studies included in the meta-analysis. If any plan for documenting important protocol amendments changes, the researchers will have a revision agreement and then register the modification in the International Prospective Register of Systematic Reviews (PROSPERO).

ETHICS AND DISSEMINATION

Ethical approval will not be required because individual patient data are not included and because this protocol is for a systematic review. The findings of this systematic review will be disseminated through conference presentations.PROSPERO registration number: CRD42018111217.

[Daytime Sleepiness in Patients with Restless Legs Syndrome: A Risk Factor for Traffic Accidents?]

Daytime Sleepiness in Patients with Restless Legs Syndrome: A Risk Factor for Traffic Accidents? Abstract. Restless legs syndrome (RLS) is a symptom complex of predominantly leg-focused paraesthesias and the associated increased urge to move. Since evening exacerbations are typical, many patients suffer from sleep disorders, which can lead to increased daytime fatigue in the long term. The present retrospective data analysis investigated a potentially relevant relationship between RLS and an increased incidence of traffic accidents due to daytime sleepiness in Swiss road traffic. A direct correlation between RLS and the occurrence of traffic accidents could not be found. Nevertheless, the question of increased daytime sleepiness should not be absent from any (traffic) medical discussion.

Drowsiness and driving performance on commuter trips

INTRODUCTION

Driver fatigue is a major road safety problem. While much is known about the effects of fatigue and the factors that contribute to it, fatigue on commuter trips has received comparatively little attention in road safety. Most interventions have focused on longer trips, while investigations of commuting have typically examined particular groups, such as shift workers.

METHOD

This study examined the effects of mild sleep deprivation on driving performance in simulated driving tasks in the morning and evening. Three groups of participants with different levels of sleep deprivation (Group 1: no deprivation; Group 2: two-hour deprivation; Group 3: four-hour deprivation) drove in a simulator for 45 min in the morning and evening, following a practice session the previous day.

RESULTS

Results showed that participants reported feeling more drowsy in the afternoon, and performance impairments (increased lane deviations) were most evident in the morning for those with sleep deprivation. Measurements of eye closure did not reflect drowsiness in participants, despite performance impairments.

PRACTICAL APPLICATIONS

These results suggest that mild levels of sleep deprivation (2 h), which many people regularly experience, can result in poor on-road performance, and that these effects are present in the morning, and on relatively short trips. These results warrant follow-up in naturalistic and on-road studies.

Impact of Medical Conditions and Medications on Road Traffic Safety

Objectives

Many medical conditions and medicines with therapeutic importance have been shown to impair driving skills, causing road traffic accidents, which leads to great human and economic suffering in Oman. The primary purpose of this study was to assess retrospectively the extent of medical conditions and medications influencing road traffic safety among drivers involved in road accidents.

Methods

We conducted a retrospective study among 951 injured or non-injured drivers who reported to Khoula and Nizwa hospitals. We used the Al-Shifa database to find the drivers and contacted randomly selected patients over phone.

Results

The majority of victims were male (72.0%), involving personal cars, and reported at Khoula Hospital. The results show that 7.6% of the victimized drivers had a history of medical conditions with diabetes and hypertension (36.1% each) the most common. About 4.0% of victims were on medications of which insulin was the most common (9.4%). Loss of control was contributed to 38.5% of cases followed by dizziness (25.6%), sleep amnesia (10.3%), and blurred vision (7.7%). Other effects blamed by victimized drivers include vertigo, phonophobia, photophobia, back pain, loss of sensation, and headache accounting for 17.9% of cases.

Conclusion

Medical conditions and medications influence road traffic safety to some extent in Oman.

From Nanowarming to Thermoregulation: New Multiscale Applications of Bioheat Transfer

This review explores bioheat transfer applications at multiple scales from nanoparticle (NP) heating to whole-body thermoregulation. For instance, iron oxide nanoparticles are being used for nanowarming, which uniformly and quickly rewarms 50-80-mL (≤5-cm-diameter) vitrified systems by coupling with radio-frequency (RF) fields where standard convective warming fails. A modification of this approach can also be used to successfully rewarm cryopreserved fish embryos (∼0.8 mm diameter) by heating previously injected gold nanoparticles with millisecond pulsed laser irradiation where standard convective warming fails. Finally, laser-induced heating of gold nanoparticles can improve the sensitivity of lateral flow assays (LFAs) so that they are competitive with laboratory tests such as the enzyme-linked immunosorbent assay. This approach addresses the main weakness of LFAs, which are otherwise the cheapest, easiest, and fastest to use point-of-care diagnostic tests in the world. Body core temperature manipulation has now become possible through selective thermal stimulation (STS) approaches. For instance, simple and safe heating of selected areas of the skin surface can open arteriovenous anastomosis flow in glabrous skin when it is not already established, thereby creating a convenient and effective pathway to induce heat flow between the body core and environment. This has led to new applications of STS to increase or decrease core temperatures in humans and animals to assist in surgery (perioperative warming), to aid ischemic stress recovery (cooling), and even to enhance the quality of sleep. Together, these multiscale applications of nanoparticle heating and thermoregulation point to dramatic opportunities for translation and impact in these prophylactic, preservative, diagnostic, and therapeutic applications of bioheat transfer.

Can subjective sleep problems detect latent sleep disorders among commercial drivers?

INTRODUCTION

Long-haul truck drivers experience poor sleep health and heightened accident rates, and undiagnosed sleep disorders contribute to these negative outcomes. Subjective sleep disorder screening tools may aid in detecting drivers' sleep disorders. This study sought to evaluate the value of subjective screening methods for detecting latent sleep disorders and identifying truck drivers at-risk for poor sleep health and safety-relevant performance.

MATERIALS AND METHODS

Using cross-sectional data from 260 long-haul truck drivers, we: 1) used factor analysis to identify possible latent sleep disorders; 2) explored the construct validity of extracted sleep disorder factors by determining their associations with established sleep disorder risk factors and symptoms; and 3) explored the predictive validity of resulting sleep disorder factors by determining their associations with sleep health and safety-relevant performance.

RESULTS

Five latent sleep disorder factors were extracted: 1) circadian rhythm sleep disorders; 2) sleep-related breathing disorders; 3) parasomnias; 4) insomnias; 5) and sleep-related movement disorders. Patterns of associations between these factors generally corresponded with known risk factors and symptoms. One or more of the extracted latent sleep disorder factors were significantly associated with all the sleep health and safety outcomes.

DISCUSSION

Using subjective sleep problems to detect latent sleep disorders among long-haul truck drivers may be a timely and effective way to screen this highly mobile occupational segment. This approach should constitute one component of comprehensive efforts to diagnose and treat sleep disorders among commercial transport operators.

The short-term impact of economic uncertainty on motor vehicle collisions

Stress and anxiety lead to attention loss and sleep deprivation and may reduce driving performance, increasing the risk of motor vehicle collision. We used evidence from a natural experiment to examine whether daily changes in economic uncertainty, potentially leading to attention or sleep loss, are associated with collisions in Great Britain. Daily data from the economic policy uncertainty index, derived from analysis of daily UK newspapers, were linked to the daily number of motor vehicle collisions in Great Britain over the period 2005-2015, obtained from the Department for Transport. Exploiting daily variations in economic uncertainty, we used a GARCH approach to model daily rates of motor vehicle collisions as a function of economic uncertainty, controlling for month and day of the week, monthly unemployment rates and weekly unleaded petrol prices. A spike in the daily economic uncertainty index was associated with an immediate increase in the number of motor vehicle collisions. Results were robust to various sensitivity analyses. Overall, daily increases in economic uncertainty are associated with short-term spikes in motor vehicle collisions. Preventive and traffic control measures may need to increase during periods of economic uncertainty.