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Objective The objective of this study was to understand the relationship between some of the most common diseases that are known to contribute to excessive daytime sleepiness (EDS) and traffic injury crashes. Specific focus was on the relationship between disease and crash type (single-vehicle or multiple-vehicle crash) and between disease and injury severity. Methods This registry-based study considered all passenger car drivers involved in a crash in Sweden between 2011 and 2016 who were 40 years or older at the time of the crash (n = 54,090). For each crash-involved driver, selected medical diagnoses registered from 1997 until the day before the crash were extracted from the National Patient Register. The drivers were assigned to 1 of 4 groups, depending on prior diseases: sleep apnea (SA; group 1, n = 2,165), sleep disorders (group 2, n = 724), Parkinsons or epilepsy (group 3, n = 645) and a reference group (group 4, n = 50,556). Logistic regression analysis compared single-vehicle crashes with multiple-vehicle crashes and moderately/severely injured drivers with slightly/uninjured drivers. Results Drivers with EDS-related diseases (groups 1-3) had higher probability of a single-vehicle crash than a multiple-vehicle crash compared to the reference group. The most sizeable effect was found for Parkinsons/epilepsy with an odds ratio (OR) of 2.5 (confidence interval [CI], 2.1-3.0). For multiple-vehicle crashes, the probability of a moderate/severe injury was higher for drivers with other sleep disorders (OR = 1.5; CI, 1.0-2.2) and Parkinsons/epilepsy (OR = 1.6; CI, 1.1-2.3) compared to the reference group. Conclusions This study has made first steps toward understanding the relationship between some of the most common diseases that are known to contribute to EDS and crashes. Having Parkinsons/epilepsy, in particular, elevated the probability of a single-vehicle crash compared to a multiple-vehicle crash. A single-vehicle crash was seen as indicative of causing a crash; thus, having Parkinsons/epilepsy could be interpreted as a risk factor for crash involvement. Having Parkinsons/epilepsy, as well as other sleep disorders, was also related to more severe outcomes in multiple-vehicle crashes, given that a crash occurred. This was not identified in single-vehicle crashes. Funding Agencies|project ADAS&ME - European Unions Horizon 2020 research and innovation program [688900]; Swedish Transport Agency

The objective of this exploratory study is to investigate if lane departures are associated with local sleep, measured via source-localized electroencephalography (EEG) theta power in the 5-9 Hz frequency range. Thirty participants drove in an advanced driving simulator, resulting in 135 lane departures at high levels of self-reported sleepiness. These lane departures were compared to matching non-departures at the same sleepiness level within the same individual. There was no correspondence between lane departures and global theta activity. However, at the local level an increased risk for lane departures was associated with increased theta content in brain regions related to motor function.

Suffering a stroke might lead to permanent cognitive and/or physical impairment. It has been shown that these impairments could have an impact on an individual's fitness to drive. In Sweden, as in many other countries, there are regulations on driving cessation post-stroke. Information on driving cessation should be given to all patients and noted in the journal. The present study sought to determine physician's compliance to driving regulations post-stroke as well as follow-up and gender aspects.A retrospective study of medical records on stroke patients was carried out. The study covered all of the medical records on stroke incidents (n = 342) during a year at a typical medium to large-sized hospital in Sweden.A journal entry on driving cessation post-stroke was missing in 81% of the medical records. Only 2% of the patients were scheduled for a follow-up meeting specifically concerning fitness to drive. Significantly more men than women had an entry on driving in the journal.We conclude that the Swedish regulations on driving cessation post-stroke were not followed at the participating hospital. It is crucial that all stroke patients receive information on driving cessation because their condition might affect fitness to drive. Analysis of follow-up records showed that there was no consistent method for assessment of a patient's fitness to drive. There was also a gender difference in the material, which warrants further investigation.

Objective: Driver fatigue is considered to be a major contributor to road traffic crashes. Cardiac monitoring and heart rate variability (HRV) analysis is a candidate method for early and accurate detection of driver sleepiness. This study has 2 objectives: to evaluate the (1) suitability of different preprocessing strategies for detecting and removing outlier heartbeats and spectral transformation of HRV signals and their impact of driver sleepiness assessment and (2) relation between common HRV indices and subjective sleepiness reported by a large number of drivers in real driving situations, for the first time. Methods: The study analyzed >3,500 5-min driving epochs from 76 drivers on a public motorway in Sweden. The electrocardiograph (ECG) data were recorded in 3 studies designed to evaluate the physiological differences between awake and sleepy drivers. The drivers reported their perceived level of sleepiness according to the Karolinska Sleepiness Scale (KSS) every 5 min. Two standard methods were used for identifying outlier heartbeats: (1) percentage change (PC), where outliers were defined as interbeat intervals deviating >30% from the mean of the four previous intervals and (2) standard deviation (SD), where outliers were defined as interbeat interval deviating >4 SD from the mean interval duration in the current epoch. Three standard methods were used for spectral transformation, which is needed for deriving HRV indices in the frequency domain: (1) Fourier transform; (2) autoregressive model; and (3) Lomb-Scargle periodogram. Different preprocessing strategies were compared regarding their impact on derivation of common HRV indices and their relation to KSS data distribution, using box plots and statistical tests such as analysis of variance (ANOVA) and Student’s t test. Results: The ability of HRV indices to discriminate between alert and sleepy drivers does not differ significantly depending on which outlier detection and spectral transformation methods are used. As expected, with increasing sleepiness, the heart rate decreased, whereas heart rate variability overall increased. Furthermore, HRV parameters representing the parasympathetic branch of the autonomous nervous system increased. An unexpected finding was that parameters representing the sympathetic branch of the autonomous nervous system also increased with increasing KSS level. We hypothesize that this increment was due to stress induced by trying to avoid an incident, because the drivers were in real driving situations. Conclusions: The association of HRV indices to KSS did not depend on the preprocessing strategy. No preprocessing method showed superiority for HRV association to driver sleepiness. This was also true for combinations of methods for frequency domain HRV indices. The results prove clear relationships between HRV indices and perceived sleepiness. Thus, HRV analysis shows promise for driver sleepiness detection.

While road safety in the United States (U.S.) has been continually improving since the 1970's, there are indications that these improvements are becoming increasingly difficult to sustain. Strategic Highway Safety Plans (SHSPs) are prepared by States to guide road safety management, however assessing the appropriateness of these plans remains a significant challenge, especially for the future in which they are to be applied. This study developed a new methodology to assess SHSPs from the perspectives of comprehensive system-based safety management and relevant future issues that can be applied before SHSPs are implemented, thereby avoiding long periods after implementation before assessing the appropriateness of the plans. A rating scale was developed and applied to assess 48 U.S. SHSPs against two key criteria: 1. a comprehensive framework for road safety, and 2. the anticipated changing, difficult and unpredictable nature of future transport and its context. The analysis concluded that current SHSPs have good national oversight with several strengths but were weak in some areas of content and did not address future challenges. Improvements are suggested to strengthen the plans' thoroughness by being consistent with systems theory and practice, as well as ways that these SHSPs can be more resilient to future circumstances. Implementing the recommendations in this paper provides the opportunity to adopt a system-based safety management practice that has been successful in other hazardous industries. Doing so is expected to most efficiently and effectively continue the recent improvements to road safety, which is likely to be increasingly difficult otherwise.

The objective of this study was to compare the development of sleepiness during manual driving versus level 2 partially automated driving, when driving on a motorway in Sweden. The hypothesis was that partially auto-mated driving will lead to higher levels of fatigue due to underload. Eighty-nine drivers were included in the study using a 2 ? 2 design with the conditions manual versus partially automated driving and daytime (full sleep) versus night-time (sleep deprived). The results showed that night-time driving led to markedly increased levels of sleepiness in terms of subjective sleepiness ratings, blink durations, PERCLOS, pupil diameter and heart rate. Partially automated driving led to slightly higher subjective sleepiness ratings, longer blink durations, decreased pupil diameter, slower heart rate, and higher EEG alpha and theta activity. However, elevated levels of sleepiness mainly arose from the night-time drives when the sleep pressure was high. During daytime, when the drivers were alert, partially automated driving had little or no detrimental effects on driver fatigue. Whether the negative effects of increased sleepiness during partially automated driving can be compensated by the positive effects of lateral and longitudinal driving support needs to be investigated in further studies. Funding Agencies|ADASME [688900]; Mediator projects - European Unions Horizon 2020 research and innovation programme [814735]; Autoliv Development; SmartEye AB

Objective: Appropriate preprocessing for detecting and removing outlier heartbeats and spectral transformation is essential for deriving heart rate variability (HRV) indices from cardiac monitoring data with high accuracy. The objective of this study is to evaluate agreement between standard preprocessing methods for cardiac monitoring data used to detect outlier heartbeats and perform spectral transformation, in relation to estimating HRV indices for drivers at different stages of sleepiness. Methods: The study analyzed more than 3,500 5-min driving epochs from 76 drivers on a public motorway in Sweden. Electrocardiography (ECG) data were recorded in 3 studies designed to evaluate the physiological differences between awake and sleepy drivers. The Pan-Tompkins algorithm was used for peak detection of heartbeats from ECG data. Two standard methods were used for identifying outlier heartbeats: (1) percentage change (PC), where outliers were defined as interbeat interval deviating >30% from the mean of the 4 previous intervals, and (2) standard deviation (SD), where outliers were defined as interbeat interval deviating >4 SD from the mean interval duration in the current epoch. Three standard methods were used for spectral transformation, which is needed for deriving HRV indices in the frequency domain; these methods were (1) the Fourier transform; (2) an autoregressive model; and (3) the Lomb-Scargle periodogram. The preprocessing methods were compared quantitatively and by assessing agreement between estimations of 13 common HRV indices using Bland-Altman plots and paired Student's t-tests. Results: The PC method detected more than 4 times as many outliers (0.28%) than SD (0.065%). Most HRV indices derived using different preprocessing methods exhibited significant systematic (P Conclusions: The standard preprocessing methods for HRV data for outlier heartbeat detection and spectral transformation show low levels of agreement. This finding implies that, prior to designing algorithms for detection of sleepy drivers based on HRV analysis, the impact of different preprocessing methods and combinations thereof on driver sleepiness assessment needs to be studied.

City bus drivers spend hours driving under time pressure, in congested traffic and in a monotonous sitting position. This leads to unhealthy working conditions, especially in terms of physical and psychological stress. The aim of this study is to investigate whether an active steering system can alleviate the musculoskeletal stress involved in manoeuvring a bus. Twenty bus drivers drove a city bus equipped with the Volvo dynamic steering (VDS) support system in real traffic. Steering effort was evaluated with electromyography and with a questionnaire. Compared to baseline, VDS significantly reduced the required muscle activity by on average 15–25% while turning, and up to 68% in the part of the manoeuvre requiring maximum effort. The bus drivers believed that VDS will help reduce neck and shoulder problems, and they expressed a desire to have VDS installed in their own bus.

Objective It is generally believed that professional drivers can manage quite severe fatigue before routine driving performance is affected. In addition, there are results indicating that professional drivers can adapt to prolonged night shifts and may be able to learn to drive without decreased performance under high levels of sleepiness. However, very little research has been conducted to compare professionals and non-professionals when controlling for time driven and time of day. Method The aim of this study was to use a driving simulator to investigate whether professional drivers are more resistant to sleep deprivation than non-professional drivers. Differences in the development of sleepiness (self-reported, physiological and behavioral) during driving was investigated in 11 young professional and 15 non-professional drivers. Results Professional drivers self-reported significantly lower sleepiness while driving a simulator than nonprofessional drivers. In contradiction, they showed longer blink durations and more line crossings, both of which are indicators of sleepiness. They also drove faster. The reason for the discrepancy in the relation between the different sleepiness indicators for the two groups could be due to more experience to sleepiness among the professional drivers or possibly to the faster speed, which might unconsciously have been used by the professionals to try to counteract sleepiness. Conclusion Professional drivers self-reported significantly lower sleepiness while driving a simulator than non-professional drivers. However, they showed longer blink durations and more line crossings, both of which are indicators of sleepiness, and they drove faster. Funding Agencies|FFI-Vehicle; Traffic Safety Program, Vinnova

Vehicle crashes lead to huge economic and social consequences, and one non-negligible cause of accident is driver sleepiness. Driver sleepiness analysis based on the monitoring of vehicle acceleration, steering and deviation from the road or physiological and behavioral monitoring of the driver, e.g., monitoring of yawning, head pose, eye blinks and eye closures, electroencephalogram, electrooculogram, electromyogram and electrocardiogram (ECG), have been used as a part of sleepiness alert systems. Heart rate variability (HRV) is a potential method for monitoring of driver sleepiness. Despite previous positive reports from the use of HRV for sleepiness detection, results are often inconsistent between studies. In this work, we have re-evaluated the feasibility of using HRV for detecting drivers’ sleepiness during real road driving. A database consists of ECG measurements from 10 drivers, driving during morning, afternoon and night sessions on real road were used. Drivers have reported their average sleepiness level by using the Karolinska sleepiness scale once every five minutes. Statistical analysis was performed to evaluate the potential of HRV indexes to distinguish between alert, first signs of sleepiness and severe sleepiness states. The results suggest that individual subjects show different reactions to sleepiness, which produces an individual change in HRV indicators. The results motivate future work for more personalized approaches in sleepiness detection.

Contains fulltext : 131970.pdf (Publisher’s version ) (Open Access) The majority of individuals appear to have insight into their own sleepiness, but there is some evidence that this does not hold true for all, for example treated patients with obstructive sleep apnoea. Identification of sleep-related symptoms may help drivers determine their sleepiness, eye symptoms in particular show promise. Sixteen participants completed four motorway drives on two separate occasions. Drives were completed during daytime and night-time in both a driving simulator and on the real road. Ten eye symptoms were rated at the end of each drive, and compared with driving performance and subjective and objective sleep metrics recorded during driving. 'Eye strain', 'difficulty focusing', 'heavy eyelids' and 'difficulty keeping the eyes open' were identified as the four key sleep-related eye symptoms. Drives resulting in these eye symptoms were more likely to have high subjective sleepiness and more line crossings than drives where similar eye discomfort was not reported. Furthermore, drivers having unintentional line crossings were likely to have 'heavy eyelids' and 'difficulty keeping the eyes open'. Results suggest that drivers struggling to identify sleepiness could be assisted with the advice 'stop driving if you feel sleepy and/or have heavy eyelids or difficulty keeping your eyes open'. 8 p.

A large number of accidents are due to the driver falling asleep at the wheel, but details of this link have not been studied on a real road. The purpose of the present study was to describe the development of sleepiness indicators, leading to the drive being terminated prematurely by the onboard expert driving instructor because of imminent danger. Eighteen individuals participated during a day drive and a night drive on a motorway (both 90 min). Eight drivers terminated (N) prematurely (after 43 min) because of sleep-related imminent danger [according to the driving instructor or their own judgement (two cases)]. The results showed very high sleepiness ratings (8.5 units on the Karolinska Sleepiness Scale) immediately before termination (7 at a similar time interval for those 10 who completed the drive). Group N also showed significantly higher levels of sleep intrusions on the electroencephalography/electro-oculography (EEG/EOG) than those who completed the drive (group C). The sleep intrusions were increased in group N during the first 40 min of the night drive. During the day drive, sleep intrusions were increased significantly in group N. The night drive showed significant increases of all sleepiness indicators compared to the day drive, but also reduced speed and driving to the left in the lane. It was concluded that 44% of drivers during late-night driving became dangerously sleepy, and that this group showed higher perceived sleepiness and more sleep intrusions in the EEG/EOG.

Driver sleepiness contributes to a considerable proportion of road accidents, and a fit-for-duty test able to measure a driver’s sleepiness level might improve traffic safety. The aim of this study ...

Contains fulltext : 161962.pdf (Publisher’s version ) (Closed access) Driving while sleepy is associated with increased crash risk. Rumble strips are designed to alert a sleepy or inattentive driver when they deviate outside their driving lane. The current study sought to examine the effects of repeated rumble strip hits on levels of physiological and subjective sleepiness as well as simulated driving performance. In total, 36 regular shift workers drove a high-fidelity moving base simulator on a simulated road with rumble strips installed at the shoulder and centre line after a working a full night shift. The results show that, on average, the first rumble strip occurred after 20 min of driving, with subsequent hits occurring 10 min later, with the last three occurring approximately every 5 min thereafter. Specifically, it was found that the first rumble strip hit reduced physiological sleepiness; however, subsequent hits did not increase alertness. Moreover, the results also demonstrate that increased subjective sleepiness levels, via the Karolinska Sleepiness Scale, were associated with a greater probability of hitting a rumble strip. The present results suggest that sleepiness is very resilient to even strongly arousing stimuli, with physiological and subjective sleepiness increasing over the duration of the drive, despite the interference caused by rumble strips. 7 p.

This study investigated the effects of two very commonly used countermeasures against driver sleepiness, opening the window and listening to music, on subjective and physiological sleepiness measures during real road driving. In total, 24 individuals participated in the study. Sixteen participants received intermittent 10-min intervals of: (i) open window (2 cm opened); and (ii) listening to music, during both day and night driving on an open motorway. Both subjective sleepiness and physiological sleepiness (blink duration) was estimated to be significantly reduced when subjects listened to music, but the effect was only minor compared with the pronounced effects of night driving and driving duration. Open window had no attenuating effect on either sleepiness measure. No significant long-term effects beyond the actual countermeasure application intervals occurred, as shown by comparison to the control group (n = 8). Thus, despite their popularity, opening the window and listening to music cannot be recommended as sole countermeasures against driver sleepiness.

Observer-rated sleepiness (ORS) based on video recordings of the driver’s face is often used when analysing naturalistic driving data. The aim of this study is to investigate if ORS ratings agree with subjective self-reported sleepiness (SRS). Forty raters assessed 54 video-clips showing drivers with varying levels of sleepiness. The video-clips were recorded during a field experiment focusing on driver sleepiness using the same cameras that are typically used in large-scale field studies. The weak results prompted a second test. Ten human factors researchers made pairwise comparisons of videos showing the same four participants in an alert versus a very sleepy condition. The task was simply to select the video-clip where the driver was sleepy. The overall average percentage of video segments where ORS and SRS matched was 41 % in Test 1. ORS 0 (alert) and ORS 2 (very sleepy) were easier to score than ORS 1 and it was slightly harder to rate night-time drives. Inter-rater agreement was low, with average Pearson’s r correlations of 0.19 and Krippendorff’s alpha of 0.15. In Test 2, the average Pearson’s r correlations was 0.35 and Krippendorff’s alpha was 0.62. The correspondence between ORS and SRS showed an agreement of 35 %. The results indicate that ORS ratings based on real road video recordings correspond poorly with SRS and have low inter-rater agreement. Further research is necessary in order to further evaluate the usefulness of ORS as a measure of sleepiness.

This paper addresses the problem of detecting sleepiness in car drivers. First, a variety of sleepiness indicators (based on driving behavior) proposed in the literature were evaluated. These indicators were then subjected to parametric optimization using stochastic optimization methods. To improve performance, the functional form of some of the indicators was generalized before optimization. Next, using a neural network, the best performing sleepiness indicators were combined with a mathematical model of sleepiness, i.e., the sleep/wake predictor (SWP). The analyses were based on data obtained from a study that involved 12 test subjects at the moving-base driving simulator at the Swedish National Road and Transportation Research Institute (VTI), Linkoping, Sweden. The data were derived from 12 1-h driving sessions for each test subject, with varying degrees of sleepiness. The performance measure (range [0,1]) for indicators was taken as the average of sensitivity and specificity. Starting with indicators proposed in the literature, the best such indicator, i.e., the standard deviation of the yaw angle, reached a performance score of 0.72 on previously unseen test data. It was found that indicators based on a given signal gave essentially equal performance after parametric optimization, but in no case was it better than 0.72. The best generalized indicator (the generic variability indicator) obtained a performance score of 0.74. SWP achieved a score of 0.78. However, by nonlinearly combining SWP with the generic variability indicator, a score of 0.83 was obtained. Thus, the results imply that a nonlinear combination of a measure based on driving behavior with a model of sleepiness significantly improves driver sleepiness detection.

Studies of driving and sleepiness indicators have mainly focused on prior sleep reduction. The present study sought to identify sleepiness indicators responsive to several potential regulators of sleepiness: sleep loss, time of day (TOD) and time on task (TOT) during simulator driving. Thirteen subjects drove a high-fidelity moving base simulator in six 1-h sessions across a 24-h period, after normal sleep duration (8 h) and after partial sleep deprivation (PSD; 4 h). The results showed clear main effects of TOD (night) and TOT but not for PSD, although the latter strongly interacted with TOD. The most sensitive variable was subjective sleepiness, the standard deviation of lateral position (SDLAT) and measures of eye closure [duration, speed (slow), amplitude (low)]. Measures of electroencephalography and line crossings (LCs) showed only modest responses. For most variables individual differences vastly exceeded those of the fixed effects, except for subjective sleepiness and SDLAT. In a multiple regression analysis, SDLAT, amplitude/peak eye-lid closing velocity and blink duration predicted subjective sleepiness bouts with a sensitivity and specificity of about 70%, but were mutually redundant. The prediction of LCs gave considerably weaker, but similar results. In summary, SDLAT and eye closure variables could be candidates for use in sleepiness-monitoring devices. However, individual differences are considerable and there is need for research on how to identify and predict individual differences in susceptibility to sleepiness.

Young drivers are over-represented in nighttime traffic accidents and several studies have suggested that many accidents are associated with elevated sleepiness levels. It has been suggested that there may be a connection between lowered wake capacity and functional sensory motor skills on the one hand and sleep deprivation at the circadian low in young drivers on the other. Performance during a 45/min evening and night drive among young (n=10, age range 18-24 years) and elderly (n=10, age range 55-64 years) subjects was studied using a moving base driving simulator. EEG was measured continuously. Every 5 min, subjects were rated on the Karolinska Sleepiness Scale (KSS). Saliva cortisol was assessed before and after each drive. The results showed that sleepiness increased across each drive and was higher among young drivers at night. Relative EEG power increased among older drivers for frequencies of 10-16Hz. The sigma 1 frequency band (12-14Hz) proved particularly sensitive to sustained driving, and was elevated among subjects in the elderly group. Cortisol levels before and after the evening and night drive showed higher mean levels for elderly subjects. The present study has demonstrated that young drivers were more sleepy while driving at night. The effects could represent a mobilization of effort and a reorganization of brain firing pattern among older subjects, possibly reflecting better ability and effort to resist sleepiness.

Studies of devices detecting sleepiness need reference points of physiological sleepiness. The present study sought to validate the Karolinska drowsiness score (KDS) as an indicator of physiological sleepiness against driving impairment and eye blink duration during a 45-minute drive in an advanced moving-base driving simulator.Data from 19 persons were used in the analysis. Electrooculography, electroencephalography, and electromyography were administered continuously. Physiological sleepiness was quantified by scoring the percentage (0-100%) of the scoring epoch with alpha and theta activity and slow eye movements (KDS). Lateral position and speed were used as measures of driving behavior. Lane departure was defined as two wheels touching the lane markers. Blink duration was used as a secondary indicator of sleepiness.The results showed that, for young drivers, sleepiness increased with time in the task with higher levels. The variability of the lateral position and the mean and variability of the blink duration significantly changed when sleepiness increased to KDSor =20%. Furthermore, there was an increase in the risk of lane departure for KDSor =30%.The results suggest that KDS scoring is a reasonable procedure for estimating physiological sleepiness under conditions of driving. The results also indicate that a younger age is associated with greater sensitivity to sleepiness at the wheel.

The aim of the present national questionnaire study was to relate the use of sleepiness countermeasures among drivers to possible explanatory factors such as age, sex, education, professional driving, being a shift worker, having experience of sleepy driving, sleep-related crashes, problems with sleep and sleepiness in general and sleep length during working days. Also the attitude to countermeasures related to information or driver support system was studied. A random sample of 3041 persons was drawn from the national register of vehicle owners. The response rate was 62%. The most common countermeasures were to stop to take a walk (54%), turn on the radio/stereo (52%), open a window (47%), drink coffee (45%) and to ask passengers to engage in conversation (35%). Logistic regression analysis showed that counteracting sleepiness with a nap (a presumably efficient method) was practiced by those with experience of sleep-related crashes or of driving during severe sleepiness, as well as by professional drivers, males and drivers aged 46-64 years. The most endorsed means of information to the driver about sleepiness was in-car monitoring of driving performance providing drivers with information on bad or unsafe driving. This preference was related to experience of sleepy driving, not being a professional driver and male gender. Four clusters of behaviours were identified: alertness-enhancing activity while driving (A), stopping the car (S), taking a nap (N) and ingesting coffee or other sources of caffeine (C) (energy drinks, caffeine tablets). The participants were grouped according to their use of any of the four categories of countermeasures. The most common cluster was those who used activity, as well as stopping and drinking caffeine.

The present study aimed to provide subject-specific estimates of the relation between subjective sleepiness measured with the Karolinska Sleepiness Scale (KSS) and blink duration (BLINKD) and lane drifting calculated as the standard deviation of the lateral position (SDLAT) in a high-fidelity moving base driving simulator. Five male and five female shift workers were recruited to participate in a 2-h drive (08:00-10:00 hours) after a normal night sleep and after working a night shift. Subjective sleepiness was rated on the KSS in 5-min intervals during the drive, electro-occulogram (EOG) was measured continuously to calculate BLINKD, and SDLAT was collected from the simulator. A mixed model anova showed a significant (P < 0.001) effect of the KSS for both dependent variables. A test for a quadratic trend suggests a curvilinear effect with a steeper increase at high KSS levels for both SDLAT (P < 0.001) and BLINKD (P = 0.003). Large individual differences were observed for the intercept (P < 0.001), suggesting that subjects differed in their overall driving performance and blink duration independent of sleepiness levels. The results have implications for any application that needs prediction at the subject level (e.g. driver fatigue warning systems) as well as for research design and the interpretation of group average data.

Driving in the early morning is associated with increased accident risk affecting not only professional drivers but also those who commute to work. The present study used a driving simulator to investigate the effects of driving home from a night shift. Ten shift workers participated after a normal night shift and after a normal night sleep. The results showed that driving home from the night shift was associated with an increased number of incidents (two wheels outside the lane marking, from 2.4 to 7.6 times), decreased time to first accident, increased lateral deviation (from 18 to 43 cm), increased eye closure duration (0.102 to 0.143 s), and increased subjective sleepiness. The results indicate severe postnight shift effects on sleepiness and driving performance.

The main consequence of insufficient sleep is sleepiness. While measures of sleep latency, continuous encephalographical/electro-oculographical (EEG/EOG) recording and performance tests are useful indicators of sleepiness in the laboratory and clinic, they are not easily implemented in large, real-life field studies. Subjective ratings of sleepiness, which are easily applied and unobtrusive, are an alternative, but whether they measure sleepiness sensitively, reliably and validly remains uncertain. This review brings together research relevant to these issues. It is focused on the Karolinska Sleepiness Scale (KSS), which is a nine-point Likert-type scale. The diurnal pattern of sleepiness is U-shaped, with high KSS values in the morning and late evening, and with great stability across years. KSS values increase sensitively during acute total and repeated partial sleep deprivation and night work, including night driving. The effect sizes range between 1.5 and 3. The relation to driving performance or EEG/EOG indicators of sleepiness is highly significant, strongly curvilinear and consistent across individuals. High (>6) KSS values are associated particularly with impaired driving performance and sleep intrusions in the EEG. KSS values are also increased in many clinical conditions such as sleep apnea, depression and burnout. The context has a strong influence on KSS ratings. Thus, physical activity, social interaction and light exposure will reduce KSS values by 1-2 units. In contrast, time-on-task in a monotonous context will increase KSS values by 1-2 units. In summary, subjective ratings of sleepiness as described here is as sensitive and valid an indicator of sleepiness as objective measures, and particularly suitable for field studies.

The aim of the present study was to explore if observer rated sleepiness (ORS) is a feasible method for quantification of driver sleepiness in field studies. Two measures of ORS were used: (1) one for behavioural signs based on facial expression, body gestures and body movements labelled B-ORS, and (2) one based on driving performance e.g. if swerving and other indicators of impaired driving occurs, labelled D-ORS. A limited number of observers sitting in the back of an experimental vehicle on a motorway about 2 hours repeatedly 3 times per day (before lunch, after lunch, at night) observed 24 participant’s sleepiness level with help of the two observer scales. At the same time the participant reported subjective sleepiness (KSS), EOG was recorded (for calculation of blink duration) and several driving measure were taken and synchronized with the reporting. Based on mixed model Anova and correlation analysis the result showed that observer ratings of sleepiness based on drivers’ impaired performance and behavioural signs are sensitive to extend the general pattern of time awake, circadian phase and time of driving. The detailed analysis of the subjective sleepiness and ORS showed weak correspondence on an individual level. Only 16% of the changes in KSS were predicted by the observer. The correlation between the observer ratings based on performance (D-ORS) and behavioural signs (B-ORS) are high (r = .588), and the B-ORS shows a moderately strong association (r = .360) with blink duration. Both ORS measures show an association (r>0.45) with KSS, whereas the association with driving performance is weak. The results show that the ORS-method detects the expected general variations in sleepy driving in field studies, however, sudden changes in driver sleepiness on a detailed level as 5 minutes is usually not detected; this holds true both when taking into account driving behaviour or driver behavioural signs.

Accumulation of insoluble (i.e., aggregated, cross-linked) protein is proposed to be a major cause of aging of the budding yeast cell Saccharomyces cerevisiae. This may give rise to the Lansing effect—precocious aging of parthenogenetically propagated daughters from old mothers—and to the genomic instability observed in old cells.

Prolonged wakefulness greatly decreases nocturnal driving performance. The development of in-car countermeasures is a future challenge to prevent sleep-related accidents. The aim of this study is to determine whether continuous exposure to monochromatic light in the short wavelengths (blue light), placed on the dashboard, improves night-time driving performance. In this randomized, double-blind, placebo-controlled, cross-over study, 48 healthy male participants (aged 20–50 years) drove 400 km (250 miles) on motorway during night-time. They randomly and consecutively received either continuous blue light exposure (GOLite, Philips, 468 nm) during driving or 2*200 mg of caffeine or placebo of caffeine before and during the break. Treatments were separated by at least 1 week. The outcomes were number of inappropriate line crossings (ILC) and mean standard deviation of the lateral position (SDLP). Eight participants (17%) complained about dazzle during blue light exposure and were removed from the analysis. Results from the 40 remaining participants (mean age ± SD: 32.9±11.1) showed that countermeasures reduced the number of inappropriate line crossings (ILC) (F(2,91.11) = 6.64; p

Study Objectives: Most studies of sleepy driving have been carried out in driving simulators. A few studies of real driving are available, but these have used only a few sleepiness indicators. The purpose of the present study was to characterize sleepiness in several indicators during real driving at night, compared with daytime driving. Design: Participants drove 55 km (at 90km/h) on a 9-m-wide rural highway in southern Sweden. Daytime driving started at 09: 00 or 11: 00 (2 groups) and night driving at 01: 00 or 03: 00 (balanced design). Setting: Instrumented car on a real road in normal traffic. Participants: Eighteen participants drawn from the local driving license register. Interventions: Daytime and nighttime drives. Measurement and Results: The vehicle was an instrumented car with video monitoring of the edge of the road and recording of the lateral position and speed. Electroencephalography and electrooculography were recorded, together with ratings of sleepiness every 5 minutes. Pronounced effects of night driving were seen for subjective sleepiness, electroencephalographic indicators of sleepiness, blink duration, and speed. Also, time on task showed significant effects for subjective sleepiness, blink duration, lane position, and speed. Sleepiness was highest toward the end of the nighttime drive. Night driving caused a leftward shift in lateral position and a reduction of speed. The latter two findings, as well as the overall pattern of sleepiness indicators, provide new insights into the effects of night driving. Conclusion: Night driving is associated with high levels of subjective, electrophysiologic, and behavioral sleepiness.

The aim of this study was to describe the effects of sleep loss on behavioural and subjective indicators of sleepiness on a road containing a milled rumble strip in the centre of the lane. Particular attention was paid to behavioural and subjective indicators of sleepiness when using the centre lane rumble strip, and to possible erratic driving behaviour when hitting a rumble strip. In total 9 regular shift workers drove during the morning hours after a full night shift and after a full night sleep. The order was balanced. The experiment was conducted in a moving base driving simulator on rural roads with a road width of 6.5 and 9 meters. Out of the 1,636 rumble strip hits that occurred during the study, no indications of erratic driving behaviour associated with the jolt caused by making contact with the centre lane rumble strip could be found. Comparing the alert condition with the sleep deprived condition, both the standard deviation of lateral position (SDLP) and the Karolinska Sleepiness Scale (KSS) increased for sleepy drivers. For the two road widths, the drivers drove closer to the centre line on the 6.5-meter road. The KSS and the SDLP increased with time on task. This simulator study indicates that rumble strips in the centre of the lane may be an alternative to centreline and edgeline rumble strips on narrow roads.

Sleepiness has been identified as one of the most important factors contributing to road crashes. However, almost all work on the detailed changes in behavior and physiology leading up to sleep related crashes has been carried out in driving simulators. It is not clear, however, to what extent simulator results can be generalized to real driving. This study compared real driving with driving in a high fidelity, moving base, driving simulator with respect to driving performance, sleep related physiology (using electroencephalography and electrooculography) and subjective sleepiness during night and day driving for 10 participants. The real road was emulated in the simulator. The results show that the simulator was associated with higher levels of subjective and physiological sleepiness than real driving. However, both for real and simulated driving, the response to night driving appears to be rather similar for subjective sleepiness and sleep physiology. Lateral variability was more responsive to night driving in the simulator, while real driving at night involved a movement to the left in the lane and a reduction of speed, both of which effects were absent in the simulator. It was concluded that the relative validity of simulators is acceptable for many variables, but that in absolute terms simulators cause higher sleepiness levels than real driving. Thus, generalizations from simulators to real driving must be made with great caution.

One critical situation when a driver needs to have a high degree of awareness, to avoid critical situations or crashes, is when passing a school bus, stopped for boarding or de-boarding of children. With the help of an experiment in VTI’s moving base driving simulator, a scenario, using in-vehicle information before the bus was reached, was tested. The aim was to enhance drivers’ perception, in order to reduce the speed of vehicles passing by the stopped bus. Both alert and sleep deprived drivers were tested. The results showed a significant speed reduction thanks to the information given beforehand. Sleep deprivation did not seem to have an impact on speed reduction. This suggests that the warning signals are seen and followed, regardless the drivers’ state of alertness. Thus, it seems likely that this type of information may be useful as an Intelligent Transport System (ITS), to provide driver support about upcoming hazards. One step towards further research in this direction is performed within the EU project SAFEWAY2SCHOOL, the main objectives of which are presented at the end of this chapter.

Almost all studies of sleepy driving are carried out in driving simulators and with monotonous road conditions (no interaction with other cars). The present study investigated indicators of sleepy driving in a more challenging scenario after a night awake. 17 participants drove a high fidelity moving base driving simulator experiment while sleepiness was monitored physiologically and behaviourally. Short periods of situations of free driving (no other vehicles) alternated with short periods of following another vehicle (car following) with and without the possibility to overtake. The result showed that a night of prior sleep loss increased sleepiness levels at the wheel (eye closure duration and lateral variability) compared to after a night of normal sleep. Blink duration while overtaking was significantly lower compared to the other situations, it was at the same level as after night sleep. Speed when passing a stopped school bus was not significantly affected by sleepiness. However the warning caused a more rapid reduction of speed. In conclusion, a moderately challenging driving contest did not affect sleepiness indicators, but a very challenging one did so (overtaking). This suggests that it is important to monitor the driving situation in field operational tests of sleepy driving.

It is a well-known fact today that driver sleepiness is a contributory factor in crashes. Factors considered as sleepiness contributor are mostly related to time of the day, hours being awake and hours slept. Factors contributing to active and passive fatigue are mostly focusing on the level of cognitive load. Less is known what role external factors, e.g. type of road, sound/noise, vibrations etc., have on the ability to stay awake both under conditions of sleepiness and under active or passive fatigue. The aim of this moving base driving simulator study with 19 drivers participating in a random order day and night time, was to evaluate the effect of low-frequency road noise on driver sleepiness and performance, including both long-term and short-term effects. The results support to some extent the hypothesis that road-induced interior vehicle sound affects driving performance and driver sleepiness. Increased low-frequency noise helps to reduce speed during both day-and night time driving, but also contributes to increase the number of lane crossings during night time. Funding Agencies|competence centre ViP (Virtual Prototyping and Assessment by Simulation); VINNOVA (the Swedish Governmental Agency for Innovation Systems) [2007-03083]; ViP; Volvo Car Cooperation

The present study of sleepiness and accident risk in a HI-FI car simulator aimed to provide subject-level relative risks (RR) with 95% confidence intervals (CI) for different levels of subjective sleepiness measured with the Karolinska Sleepiness Scale (KSS), 1 = very alert, 9 = very sleepy, fighting sleep, an effort to staying awake. Five male and five female shift workers, mean age 37 years, participated with a 2-h drive (08:00-10:00 hours) in a dynamic high-fidelity moving base driving simulator, after a night of work and after a night of sleep. Subjective sleepiness was measured with KSS every 5 min and events of incidents (two wheels outside the right lane), accidents (two wheels off the road or four wheels in opposite lane) and crashes (four wheels off the road) were recorded. The probability of an accident was modelled with a Generalized Linear Mixed Model approach to estimate subject-specific effects, rather than group average effects, to avoid the ecological fallacy. The results showed that sleepiness was strongly related to accident risk. An average subject was estimated at 28.2 times (95% CI RR = 10.7-74.1) increased risk at KSS = 8 and at 185 times (95% CI RR = 42-316) at KSS = 9 compared with KSS = 5. There were large individual differences in event propensity that complicates the prediction of absolute accident risk for individual subjects.

Four different glycosylation approaches illustrate strategies for providing therapy in disease targets. Two of these are to develop antiviral therapies using iminosugar derivatives. The first approach involves targeting virus encoded protein(s), the second targets host cell encoded protein(s) necessary for virus survival. The latter could potentially prove more resistant to the development of viral escape mutants, a problem plaguing most conventional drug therapies. In the case of hepatitis C virus (HCV), which affects about 3% of the world population, it is possible to employ both strategies. Using bovine viral diarrhoea virus (BVDV) as a model organism for HCV we showed that inhibition of the host cell ER alpha-glucosidases I and II using the glucose analogue deoxynojirimycin (BuDNJ) leads to an antiviral activity caused by a reduction in viral secretion due to the interference with viral envelope glycoprotein folding and subsequent impairment of viral morphogenesis. However, it is also possible to target the virally encoded HCV protein p7 which can form ion channels, using long alkylchain derivatives of either DNJ or the galactose analogue deoxygalactonojirimycin (DGJ). N7oxanonyl-6deoxy-DGJ is currently in phase I clinical studies. Worldwide, more than 350 million people are chronically infected with hepatitis B virus (HBV). Glucosidase inhibitors have been shown to be antiviral against HBV in tissue culture and in the woodchuck model of chronic HBV infection. The M surface antigen glycoprotein of HBV folds via the calnexin pathway. Glucosidase

Background The current study reports on the first step towards developing quality of care for stroke patients at a hospital in western Sweden. A general critical pathway from the patient's perspective was developed by a multidisciplinary group. Aim The aim was to investigate quality of care and the effectiveness of a critical pathway. Method The study should be classified as a case study. Patients (n = 22), next of kin (n = 63) and staff (n = 91) make up the research group. Data collection was carried out through questionnaires on quality of care before testing the critical pathway. Data on the critical pathway were collected during the testing period. Findings The respondents valued some aspects of care as good, but there were some deficiencies as regards patient information and the patient's participation in his/her own care. Next of kin were less positive than the patients. The analyses of the critical pathway showed that the key events need to be more specific and that the number of key events should be reduced. Conclusion By additionally developing the critical pathway, it should be possible to further improve the quality of care for stroke patients. Keywords: quality of care, critical pathway, stroke care

Hydrogen sulfide (H2S) poisoning involves a risk of hypoxic brain damage. Six patients who lost consciousness due to H,S poisoning are described. The symptoms varied from anosmia in the patient with the shortest but highest exposure to delayed neurological deterioration in the patient with the longest exposure. The two patients with the most serious symptoms developed pulmonary edema, which may have prolonged the hypoxia. The patients were reexaminated 5 years or more after the poisoning. The five patients who had been unconscious in H,S atmosphere for from 5 to 15-20 min showed persisting impairment at neurological and neuropsychological re-examination. Memory and motor function were most affected. One patient was seriously demented. Recent reports of large groups of H,S-poisoned workers probably underestimate the risk of sequelae, due to the inclusion of cases with exposure of short duration and lack of follow-up.

When agarose is mixed with colloidal silica, beads containing a large proportion of agarose and a minor amount of silica are formed. The beads are stabilized and remain spherical by the addition of polyethylene glycol and polyvinylpyrrolidone. They can be used for gel chromatography and proteins and polysaccharides.

Purpose To identify and establish the number and aetiology behind children being killed or injured during school transport from a door-to-door perspective by using experience from Sweden and the UK. Methods Available crash data were analysed. Results In total, 361 children in Sweden during 1994–2001, i.e. 24% of the 1,515 identified children aged 6–16 who were injured or killed were identified in 256 school transport events. The predominant reason for being killed or injured when travelling on school transportation was when children were outside the bus (74%), either when passing the bus to cross the street, running in front of the bus (21%) or behind the bus (30%). Contrary to the general belief that children older than 12 are mature enough to handle traffic, more than 50% of the fatal injuries in Sweden affected children aged 13–16. Similar results were found in the UK. The afternoon school journeys, pedestrians after alighting from the bus, and those in situations that deviated from their normal routine were found to be particularly vulnerable. Conclusions The travel chain perspective/or door to door perspective offers a promising approach for understanding school transport risks and for identifying effective countermeasures; including around bus stops and on the way to/from the bus stop. Data collection needs to be revised to reflect this approach.

Nonsulfated, partially N-deacetylated, 14C-labeled polysaccharide was formed by incubation of a mouse mastocytoma microsomal fraction with UDP-[14C]glucuronic acid and UDP-N-acetylglucosamine. After 60 min at 37 degrees the incorporation of radioactivity was interrupted, and sulfation was initiated, by the addition of unlabeled UDP-glucuronic acid and 3-phosphoadenylylsulfate, respectively. After varying periods of incubation with the nucleotide sulfate, polysaccharide was isolated and analyzed by chromatography on DEAE-cellulose. During incubation with 3-phosphoadenylylsulfate, sulfated 14C-polysaccharides were formed, while the nonsulfated 14C-polysaccharide was eliminated, each type of component retaining the same elution position throughout the entire sulfation period (60 min). No accumulation of low sulfated material was observed. Fully sulfated heparin was detected after only 0.5 min of sulfation. These results suggest that the sulfation of heparin is a rapid process, involving a limited number of polysaccharide molecules at a time. Besides heparin-like products, having both N- and O-sulfate groups, and [14C]iduronic acid as predominant uronic acid constituent, an additional sulfated component was detected, having N-sulfate but no O-sulfate groups. This novel polysaccharide contained [14C]glucuronic acid but little or no [14C]iduronic acid. Previous studies have shown that L-iduronic acid residues in heparin are formed by C-5 inversion of D-glucuronic acid units, previously incorporated into the polymer; the inversion reaction requires concomitant sulfation of the polymer. The present results demonstrate that the formation of iduronic acid residues is related to the sulfation of hydroxyl groups. Pulse-chase experiments with 3-phosphoadenylyl[35S]sulfate indicated that the N-sulfated polymer, lacking O-sulfate groups, could be converted into heparin-like products by further sulfation of hydroxyl groups only. The biosynthesis of heparin may thus involve a pathway, in which the formation of N-sulfated intermediates precedes the introduction of O-sulfate groups.

1. Chondroitin sulphate was isolated from different regions of rat costal cartilage after extensive proteolysis of the tissues. The molecular weight, determined by gel chromatography, of the polysaccharide obtained from an actively growing region (lateral zone) near the osteochondral junction was higher than that of the polysaccharide isolated from the remaining portion of the costal cartilage (medial zone). 2. In both types of cartilage the molecular weight of chondroitin sulphate, labelled with [35S]sulphate, remained unchanged in vivo over a period of 10 days, approximately corresponding to the half-life of the chondroitin sulphate proteoglycan. The molecular-weight distribution of chondroitin [35S]sulphate, labelled in vivo or in vitro, was invariably identical with that of the bulk polysaccharide from the same tissue. It is concluded that the observed regional variations in molecular-weight distribution were established at the time of polysaccharide biosynthesis. 3. In tissue culture more than half of the 35S-labelled polysaccharide–proteins of the two tissues was released into the medium within 10 days of incubation. The released materials were of smaller molecular size than were the corresponding native proteoglycans. In contrast, the molecular-weight distribution of the chondroitin [35S]sulphate (single polysaccharide chains) remained constant throughout the incubation period. 4. A portion (about 20%) of the total radioactive material released from 35S-labelled cartilage in tissue culture was identified as inorganic [35S]sulphate. No corresponding decrease in the degree of sulphation of the labelled polysaccharide could be detected. These findings suggest that a limited fraction of the proteoglycan molecules had been extensively desulphated. 5. It is suggested that the initial phase of degradation involves proteolytic cleavage of the proteoglycan, but the constituent polysaccharide chains remain intact. The partially degraded proteoglycan may be eliminated from the cartilage by diffusion into the circulatory system. An additional degradative process, which may occur intracellularly, includes desulphation of the polysaccharide, probably in conjunction with a more extensive breakdown of the polymer.