that a look now at day-to-day operations in the house and senate with role call senior editor, david hawkings. joining us to talk to the people and positions that make the day toi day activities of the house and senate run is b&xn hawkings of role call, he is their seniorçhf+> editor. good morning. >> tell us a little bit about these positions that we see all the time. what purpose do they serve in the day-to-day running of things? >> as you can -- on both the house side and the senate side, there are a team of bureaucratic functionaries that keep operations running smoothly and according to parliamentary procedure and making sure records are kept properly, completely, accurately and quickly. there are teams of people you season the rosters of both the house and the senate who make that happen in ways that that if they're doing their jobs properly the public never notices and the members never notice. that's kind of the way it's

supposed to work. >> talk about the people behind them. who are we seeing on this side starting. >> sure, the person you see right under the mace and that's important to note that the mace is carried into the house whenever the house is in -nárááátpá predictably, the person who sits right under, no, i'm wrong, i'm sorry the person who sits under the mace is the parliamentarian n and the parliamentarian wants to stay close to the speaker. he or she has a sheath of scripted papers he can h!;he presiding officer or the speaker pro tem to read the script. people often ask how do the presiding officers know that formal language? that's because it's written down on the sheets of paper and the parliamentarian hands him tf right sheet of paper or if things become rough going in a parliamentary way the parliamentarian have there is to give advice to the speaker

saying you should rule this way (hvuç or that way or the president of the house says this is the right ruling or that is the right ruling. >> on the opposite side what are these positions? >> that would be the formal spot for the clerk of the house, a woman named karen haas, and i should note for people watching today, i said a couple minutes ago if they're doing their jobs right, people never notice who they are. this is the one day of the year where karen haas or her predecessor as the clerk of the house become tv stars for a few hours, because the way the house works is when the house convenes at noon today, in a parliamentary sense it won't really exist. none of the members will have been sworn in yet so for a while karen haas is the presiding officer and you'll see her in the speakers chair until the election of a speaker has taken place and then the new speaker presumably john boehner will take the rostrum and karen haas

will go back to relative anone anonymity to the speaker's left. >> the sergeant at arms, what is the job? >> the sergeant at arms is the chief security officer for the 6x house and supposed to maintain good order and discipline, is supposed to assure that the chamber is secure and members are secure, and that the house chamber is in good working order, and is actually in charge of that mace i mentioned a couple days ago. the sergeant at arms, now that i think about it, a little bit surprising right where your pen is, sits down by the door, brings the mace in and then goes to sit down there, but if there were a hubbub on the floor, a disruption on the floor there's occasionally historically been some periods of violence or members getting so heated in their discussion the sergeant at arms has to intervene. it's the sergeant at arms who does that. right in front of the sergeant at arms the two people in the lowest tier of the dais are the bill clerks.

when you talk about a member introducing a bill or put it in the hopper that's where the hopper is. going around the front, going up to the two chairs above that. those two chairs empty in this picture in part because i'm getting this is not a moment where a vote is about to happen, one of those people is the so-called tally clerk who is in charge of the voting procedures. sometimes if you're watching a recorded vote in the house toward the end of the vote you might be hearing somebody trying to switch their vote. the way it works actually it's electronic voting almost all the time. members get credit cards, they put their credit cards in the machines that you don't see on tv, they vote yes or no. if it gets towards the end of the vote and they want to change their vote they actually have to hand a red card to vote no or a green card to vote yes to one of the clerks in the empty chairs. the woman in the red shirt some people see when they watch c-span, she's called a reading clerk, there's a republican reading clerk and democratic reading clerk.

the chair that's empty at the moment, they're the ones that the presiding officer says announce the amendment announce what bill we're going to do next, they're the ones who are in charge of keeping that paperwork flow going and of course down in front, way down t" áj áráting on either sides of the lovely dining room table with the red and green cards on it are the people transcribing the debate, old school transcribers. i think they're all gone now, for years when i covered congress there were men and women doing it with shorthand with thick pencil. i think they're gone now replaced -- >> the machines. >> they use court reporting machines that type in a weird way that only they can decipher. >> so the senate has a little bit of a different configuration but some of the similar positions but let's start with the presiding officer. >> the presiding officer in that picture is ed markey, a member of the majority party who has minimal seniority, because unlike in the house where the speaker of the house has enormous power and how he or she

rules from the chair, it has an enormous amount to do with how the day goes. in the senate, the rules are so fundamentally different that the presiding officer has minimal power, and so it's sort of a scut job, a thankless task assigned to members of the majority party who are brand new. for the next two years we'll see all the freshmen, the new freshman senators, i think there are 11 freshmen republican senators assigned to take turns sitting up there. they can't really do anything else other than sign letters or sign autographs, can't work their phones, can't work their blackberries. >> helps them learn the process. >> they do learn the process and several say they've become procedural experts by sitting up in the chair and it's an invaluable thing. in that close-in shot you see the man right to ed markey's front, right there, looking as though he's trying to get mr. markey's attention. he is the senatorial equivadslt> of the parliamentarian, he is the parliamentarian and just like we talked about in the house, he has some script sheets

and he'll hand the officer scripted announcement, here comes the vote or here's what we're voting on and advises the presiding officer on what to do next, what is the next thing in proper parliamentary order. >> to his right? >> and to his right i believe that is the journal clerk who helps keeps the proceedings and runs the system by which the transcription of the senate again this is a picture, this is a picture when no vote is about to happen, so again the empty chair would be the tally clerk, the person who calls out the role, you know, you always hear g sonerous tones whenever they go into a quorum call. the person first in the alphabet, i don't know who it will be in the new congress, i haven't stopped to think about that, gets his or her called out and they slowly, slowly, slowly call the roll. when an actual vote is happening they're in charge of the hubbub

of calling the role. and simultaneous to calling the role members can go and get that person's attention and vote even when their name isn't being called. that's a high stressed job in the parliamentary business. and i think he is the assistant to that job. and down in front you see, you'll see these two tables, oner'c is run by the republicans, one run by the democrats. it's where the republicans and democrats go to ask their own partisan people, what are we voting on and how am i supposed to vote? >> how do these people get their jobs? who appoints them? >> all kinds of different ways. some bubble up within some of the bureaucratic system of the clerks' office and they need to be willing to spend long hours sitting on television and behaving themselves. it's consider z%uj )t)áuáh job so some of the lesser jobs are people who are careerists in the bureaucratic sellers of congress, and some of them, like miss haas, the clerk of the house and the secretaries of the majority and the minority who have those desks at either side fz of the rostrum are political

jobs who have gotten to know the leaders and have gotten the trust of the leaders and might have worked as their chiefs of staff or legislative councils and it's again sort of a capstone position. >> walking us through the various places of the house and senate is david hawkings, senior editor of "roll call." thank you very much. >> thanks, pedro. >> the 114th congress gavels in tomorrow at noon eastern. we'll be live to speak with elected members. and we'll take your phone calls and comments on facebook and twitter. live on c-span from 7:00 a.m. eastern until the house gavels in at 12:00 p.m. and in addition to watching the house on c-span and the senate on c-span2 you can watch live coverage here on c-span3 with the ceremonial swearing in of members. that begins at 1:00 p.m. eastern tp#s he old senate chamber with

vice president biden and incoming senators. 3:00 p.m., we'll see the swearing in of house members live from capitol hill. with live coverage of the u.s. house on c-span and the senate on c-span2, here on c-span3, we compliment that coverage by showing you the most relevant congressional hearings and public affairs events. weekends c-span3 is the home to american history tv. the civil war 150th anniversary visiting battlefields and key events. >> american artifacts, touring museums and historic siekts to discover what they reveal about america's past. history book shelf with the best known american history writers. the presidency. looking at the policies and legacies of our nationsp commanders in chief. lectures in history. top college professors devilling into america's fast. our new series archival

government and educational films from the 1930s through the 3!'70s. c-span3 created by the cable tv industry and funded by your local cable or satellite provider. watch us in hd, like us on facebook and follow twitter. >> the national transportation safety board held a summit on the dangers of drowsy driving. vehicle safety advocates. this first panel looked at the issue of sleep deprivation among teens. it's an hour. welcome back, everybody. we're here for our third panel. we expanded the audience and sitting in the back there everybody, is a group from the national organization for youth safety. noise. there you go. what perfect timing because our

next panel is specifically on novice drivers. so mr. bragg, whenever you are ready. >> thank you, member rosekind. as a reminder for our panelists, please push the button on the microphone to activate. bring it close to you. when done speaking, turn off the microphone by again depressing the button. once again our next panel is on concerns for novice drivers. bradley hospital and professor of psychiatrist and human behavior brown university. and we also have dr. nate watson. president elect of the academy of sleep medicine and professor of neurology and co-director of sleep centers at the university of washington. >> thank you.bkm thank you very much for the invitation to speak here today. thank you, member rosekind. and thank you for making some noise back there. i'm very excited that high school students are here this morning for my presentation. because i'm going to be talking

about why teens are susceptible to driving fatigue and what's happening to them that's making them susceptible. so i'm going to talk about the biology of teen sleep and what's going on during adolescent development in terms of regulating sleep than teen behaviors that affect sleep as well as societal restrictions. and then what's going on with teen driving and sleep. the biology of sleep, when we talk about the regulation of sleep biology, we talk about two systems. one is the circadian timing system, and the other the sleep/wake static system. both of these systems undergo changes during the adolescent years so the circadian timing system just a reminder what we're looking at here in the context of sleep pressure is this 24-hour pattern of higher

and lower sleep pressure as a function of the internal biology1it of our daily clock. what happens to that daily clock during adolescent development. one way of looking at it is asking what is the -- how are you timing your sleep when you don't have anything else going on in the day. and so weekend sleep timing, if we look at the mid point of that, you can see on the vertical axis, the mid points ranging from 2:30 a.m. in 10 year-olds and rising to as late at 5:00 a.m. in 20 year-olds. so this second decade, the adolescent phase, is where we see a rapid delay in this marker of the biological system. we can also look at it by

measuring the biology itself. so by looking at the timing of the hormone that marks the start of the biological night each day. so we've done that and looked at this. it's called the onset phase of melatonin secretion. if you look at it as a function of the stage of puberty -- so the high school students in the back of the room here are probably at puberty stage 5. so the latest progression on this, you can see clearly a pattern that the more mature an adolescent is, the later is the timing of this biological signal. so just a quick summary then. the timing of the rhythms get later across adolescents, and as a result, sleep is favored later in the day. of course, waking up is favored later in the morning as well, but we'll see. there is a problem for adolescents on that end side of

the program. so the second part of the system is the sleep/wake homeostatic drive. so the longer you are awake, the sleep pressure rises and, as we sleep, this sleep pressure falls, is dissipated, recovers from being awake. so we have again this pattern that's occurring on a daily basis, although we alter this significantly many times. we measure this by looking at the type of sleep in a qualitative way, just assessing the brain wave patterns. we can also measure and quantitatively look at this by looking at the slow wave activity. this one child prepubertal the first time she was studied and a mature adolescent the second time she was studied.

the amount of slow wave sleep declined markedly and the amount of power of the slow wave activity during sleep also declined markedly. what didn't change, however, was this decay of the sleep pressure across the night. and we can look at it in this light in a different way where model systems are given showing that across puberty, this recovery process is not changed.+"a8q but the rate that sleep pressure builds slows down in the more mature adolescent. so we look at that, it sort of a jives nicely, with some perspective, with the sir cade yan process. we see that recovery process doesn't change. so one interpretation of that is that the need for sleep stays the same in a 10-year-old and a 17-year-old. but the pressure builds a little slower in the 17-year-old so it

is a little bit easier to stay awake longer. again, the result of this is that late nights are favored. here nowpda3ñ in a permissive way, more than driven, as we saw in the circadian system, but the key point is the same amount of sleep is needed. so what else is going on with ]jç teens. yes, we have the biology, but there is a lot of other stuff that happens during adolescent development. there is a psycho/social context. we could go around the room and everybody could give a point on this.:/y but we see one of the major goals of adolescent development behaviors and in regulating your lives. there are a lot of adolescents who have jobs. a lot of adolescents who are using all kinds of substances, caffeine being a major one, one of my mantras is that no child needs caffeine or should need

caffeine, but we see much caffeine used in adolescents. now in the 21st century, screen time at night has become a big deal. social networking is also now very highly available and available at night. of course, one of the major things that happens during adolescent developments are romantic attachments and the loss of those attachments. and there is a ton more things. but one of the key parts of the psycho/social context is the context that society puts on adolescents with the school schedule. so the school start time is a major issue and a major thorn in the side of adolescent sleep. schools in the u.s. start early. middle schools, grade 6 through 8, more than half start before 8:00 a.m. high schools, looking at different school districts, we see, again, more than half

starting before 8:00 a.m. this is a problem when sleep is delayed due to the biology of the system. and here's a view of that problem. so this slide is showing that tenth-graders -- so these are our young people on the verge of getting their driving licenses, in a school that started at 7:20 in the morning, the kids were sleeping about seven hours a night. and we monitored that. we can see when we had them in the lab, sleeping that amount at night, and we testedw5úh#ast they fall asleep in the morning, that at 8:30 a.m., which would be second period in their school, they're falling asleep in under five minutes. and some of them were falling asleep essentially when their head hit the pillow.

recently, in august of this year, the american academy. pediatrics actually has now acknowledged that the school start time is a problem in adolescents. i've just highlighted here one of the comments and recommendation of this group was that most school districts, middle and high schools, should aim for a start time of no earlier than 8:30 a.m. if kids are not getting adequate sleep, there are many consequences. i've highlighted some here from a study showing that the reduction of sleep leads to a number of things that could be thought of as risk-taking activities. and so you see in these slides from texting while driving to drinking in excess, or drinking at all. i guess at this age in the united states drinking at all is excess.

but there are problems and there are consequences for behavior as teens get less and less sleep. we've also seen some data showing that school start time changes have an impact on driving crashes in teens. not necessarily directly attributed to drowsy driving, but sort of statistically attributed to the school start change. so in lexington county, kentucky, one of the first such studies showed that in the year after the school district changed their start time from 8:00 a.m. to 9:00 a.m., the crash rate in teenagers went down 16.5%, and in the rest of kentucky, the crash rate in teenagers went up nearly 8%. another study looked at two towns in southeastern virginia that were very similar.

in this study one of the towns, the school started at 7:25. the teen crash rate was 65, almost 66 crashes per 1,000 drivers. in another town, chesapeake, with a school start time of 8:40 to 8:45, the crash rate was significantly lower. less than 50 crashes per 1,000 drivers. new data coming out from work that was done by kyla walstrom's group for the cdc showed again that in school districts where the start time was shifted to a later time, in general the crash rate was reduced. you can see in the minnesota and wyoming school districts, it was incredibly big shift in the crash rate for teen drivers. so, a, many teens don't get enough sleep. i didn't emphasize this, but a recent poll by the national

sleep foundation showed that the average amount of sleep in grades 11 and 12 in the united states on school nights was seven hours or less. that's the average. so if you think about it, that means many teens are well below seven hours a night. this means they're fatigued. they're especially fatigued in the early morning, after school,o and late at night. and the short sleep and fatigue has many consequences that include consequences for driving safety. >> thank you, dr. carskadoiv. our next presenter is nate washington from the american academy of sleep medicine and university of washington. dr. watson. >> mr. bragg, member rosekind, and the board of the national transportation safety board, i want to thank you for inviting me today to be here to speak

with you on this important topic. and my goal today is to be a representative of the american academy of sleep medicine to let you know about some of our concerns in regards to novice drivers, drowsy driving, and to present to you a proposal that we're going to be undertaking in regards to how we are going to nphéñ so i wanted to share with you our vision and mission. you can see here that clearly, when you look at our vision, that if we achieve optimal health through better sleep, we make people more alert. if people are more alert, they're going to be more alert behind the wheel and we're going to have safer roadways. if you look at our mission, we focus on a broa including advocacy, education, strategic research and practice standards. so i think this really 0 summarizes our strengths that we bring to the table as we work together to overcome dangers of drowsy driving. i'd also like to let you know that we're currently engaged in a five-year grant from the cdc with multiple other stakeholders

shown here to help advance the agenda of the four sleep health objectives from healthy people 2020. one of those objectives is to reduce the rate of drowsy x!k driving accidents for 100 miles million miles traveled. this forum today and the efforts that we'll be putting forth dovetail nicely with the agenda that we have for this healthy sleep awareness project. as we got to work on that project, we decided to focus much of our efforts on teen drivers, because we acknowledge that accidents are the leading cause of death among teens and motor vehicle accidents are the leading cause of these accidental deaths. this represents over one-third of deaths to all teenagers. so as a result we want to tailor

or messaging to teenage drivers. you can see here as an example of what we feel is some effective messaging that will resonate with teenagers. this is from the utah teen driving task force. they highlight what they call the five deadly behaviors. you can see drowsy driving is included here, as well as impaired driving, distracted driving, and reckless or aggressive driving, along with seatbelt use. as we go forward with this talk, what i'll be bringing up again and again is the fact that none of these things are happening in a vacuum, that there's substantial overlap between all f of these factors when we consider safety on the roadways with our novice drivers. we also want to focus on novice drivers because we know from research that drowsy driving prevalence is highest amongst younger drivers. so you can see here between the 16 to 24-year-old age group.

it is also highest among some male drivers. as we move forward and consider about lou to tackle this problem, i think we get the most traction if we gear our message towards teen boys and young men as the primary target, but clearly we will be addressing driving issues in all teenagers. one of the other things that we need to acknowledge as we try to tackle this problem is the fact eiñx that the teenage brain is not yet fully developed. i think anybody here who has a teenager will probably -- this will resonate for them. but we know that through the teenage years, in an area ever of the brain called the prefrontal cortex, there's on going developmental process in order to develop this brain area and this area is really crucial to aspects of judgment, decision making and moderation of social behavior. so if it's not fully developed, then what you have is that teenagers are more apt to not really be able to correctly assess risk and perhaps engage in more risk taking behavior than adults would.

another challenge is the fact that teenagers and young adults are baltimore susceptible and more vulnerable to sleepiness. so here is a study by fitness in 2012. on your left, you can see what they did was they sleep deprived these individuals to five hours the night before a simulated driving task that took two hours. the younger age group had an average age of 23 years. the older age group had an average age of 67 years. you can see that there were substantially more episodes where all four tires would go out of the intended lane in the younger age group than the older age group. this is after the same amount of sleep deprivation. on the right, you can see they were measuring the electro encephalogram. a way to measure brain waves and can indicate whether someone is asleep or not. they found, you can see in the younger age group, more what we call power in alpha and theta ranges. really that means a greater propensity to fall asleep and

more sleep occurring in the younger age groups. so there is another challenge as we try to address this in the younger group. teenagers are also prone to [p distraction and risky behaviors, and here on the left is some nhtsa data that showed that for crashes in teenagers that are 15 to 18-year-old drivers, that driver error was the cause in more than 95% of crashes. what i'd like you to appreciate is that, recognition errors, decision errors and performance errors make up most of this. so actually falling asleep only made up 1.2% of critical teen driver errors resulting in accidents. however, this study did not assess crashes occurring betweengbc0n midnight and 6:00 a.m. which may1[fj0 have artificially reduced that number. nevertheless recognition errors involve things like distracted driving or inattention.

decisional errors involve driving too fast or aggressive driving. those things clearly can be influenced by sleep deprivation and drowsiness. so i think that that's a big issue. on the right, you can see a survey of -- population-based survey of over 500 young licensed drivers showed an increase odds ratio of crash involvement in two conditions. one was being a current smoker. the second was driving drowsy while alone. there's also overlap between drowsy driving and driving while impaired. that's highlighted here. when 11th grade students were surveyed, 13% admitted to driving while impaired at least once in the past 30 days. 24% admitted to riding while impaired, at least once in the past year. you can see if you look at the odds ratios that the odds are increased over eight-fold of driving while impaired if you were sleepy or drowsy. you can also see that driving after midnight also increased

the odds substantially of driving while impaired. not only that, we also have evidence that individuals and teenagers that are using cell phones while they're driving, either texting or on the phone, are more apt to drive while drowsy as well. so i'd like to turn our attention now to the american academy of sleep medicine strategy to try to address this issue. we're going to mostly do this through advocacy and education. we recognize the widespread prevalence of drowsy driving and its association with fatal motor vehicle accidents especially amongst novice drivers. what we're going to be doing is creating a transportation safety task force in order to address this issue. education is a big part of this. we know that it can be effective. here is a study out of yale from last year which utilized a quick computer-based educational program about risky driving behaviors in emergency rooms and showed that when you assess

these individuals one month later, you find that all of these risky driving behaviors were reduced, as well as drowsy driving being reduced by 16%. so at the u=ijá educational initiative will be efforts to partner with states to promote standardized evidence-based drowsy driving education within the local driver education system. we've done a preliminox assessment and found that at least 17 states currently include drowsy driving education in their curricula. what we have found is that there is high variability in the )fox1%qeze)q ontent. one exemplar is montana which has power point presentations, videos, and faqs sheets. we'd like to access this space and improve it where we can. we are also looking at state drivers manuals. we have found that 48 tkqxz jurisdictions out of 51, including washington, d.c., currently have information about drowsy driving in their drivers

manuals. only iowa, south carolina and hawaii do not currently have this. so it is fairly prevalent. however, what we find is that the quality of what's there rf#tr(t&háhp &hc% often can vary quite a bit. some of it is fairly superficial. here's an example of what's in the arkansas state driver's manual. we will address this by drafting model language that states can adopt and include in their manuals to equip drivers with more comprehensive information about drowsy driving. we also want to address state driver's license examples and ensure that not only is the content being taught, but it's also being tested. and so here's an example of a practice question from new york. but what we'll propose to do is write questions and then offer them to states to include in

their driver's license exams related to the perils of drowsy driving. another approach that we plan to take will be to engage with another important stakeholder which is the insurance industry. and what we see is that when we've looked at this space, thatv there is some things being done, particularly by state farm, to try to address this issue with their celebrate my drive and steer clear discount program, if young drivers go through these modules, they can actually save money on their insurance rates. and so we're going to seek to partner with auto insurers to make drowsy driving education a part of their existing discount programs or collaborate and develop new discount programs that address drowsy driving. as part of our national healthy sleep awareness project we'll

have a public safety campaign and we have to be mindful that if we want to get some traction with teenage drivers that we have to have messaging that is going to resonate with them. these are some examples of messaging that is from the utah teen driving safety task force that we think will resonate with younger drivers and be compelling and be something that might motivate behavior change. so this forum is happening at a very advantageous time. it is actually teen driver safety week 2014. transportation safety is really an issue that can unite a diverse coalition of interest groups from both the public and private sectors. the academy's transportation safety task force and our healthy sleep project will seek to develop strategic partnerships with a variety of stakeholders, including federal and state agencies, safety foundations, medical institutions, professional societies, insurers, driving educators, and the auto industry.á%t;÷ i want to finish with an example of success. this is the state graduated driver's license laws that are out there. this shows how strategy and targeted initiatives can lead

significant improvements in driver safety. so all states and the district of columbia have a three-stage gdl system which really gives young drivers the opportunity to develop the expertise and competency to drive while keeping them away from situations that would be unsafe. one of the major tenets is limiting driving hours so they are not driving at night. also limit being the number of passengers that can be in the car and whether or not they can have their cell phones with them when they are in the car. and this initiative has been tremendously successful. you can see here on the right that the change in per capita fatal crash rates by driver age has reduced substantially, over 70%, in the 16-year-old age group. so this is a true example of success. however, we have to be mindful that there's work still to be done. the overall teen crash rates remain elevated compared to middle aged drivers. is going to be doing is

convening the aasm transportation safety task force. we're going to be assessing driver's education curricula, drowsy driving material for driver's manuals and craft questions for drooin's license exams. we want to look at all these material and ensure that's accuracy and consistency in the program. we want to develop a strategy for safety campaign with some elements of that being targeted to the novice driver and develop partnerships as well. in closure, i want to remind everything that research without action is merely an academic pursuit. thank you. >> thank you, dr. watson. dr. watson touched on this briefly and we have young people here so i'd like to expand on it. would you discuss how prolonged n( chronic sleep deprivation affects the cognitive development of adolescents. >> how it affects their cognitive development? >> yes.

>> well, there's not a lot of data on how it affects the development but it is clear that sleep deprivation affects thinking in a lot of different ways. it also affects learning and the ability to learn. you think about it on three levels we have it now. if you're too sleepy, you have trouble with the acquisition phase of learning. paying attention, not being distracted, being motivated to get the information in. so we hear education, education, education. well, if you're too sleepy, you're not going to be absorbing the education. secondly, sleepiness is going to impact how one retrieves the information.

so you can acquire the information, but then you have to be able to use it. so if you're too sleepy, too tired, distracted, unmotivated, that's a problem as well. and the third factor, in the last decade or so we've learned a huge amount about, is that sleep itself helps to ;á÷ substantiate those things you learn during the daytime. it actually improves learning. so the students who get plenty of sleep get a bonus in their learning purely from having a good night's sleep. and one of the things particularly maybe related to driving is the motor skills learning is particularly advantaged by having a good night's sleep. and a lot of what we do when we drive is sort of repeated motor skills. oh, you press this pedal and do you this turn and you turn that. so the quality and quantity of sleep are affecting the learning and the ability to perform at a number of different levels.

>> address that question briefly, too. i think that there's some research out there in animal models that showmlq that sleep deprivation can affect cells in the brain called b&0talgodendra sites. so getting back to frontal lobe development, you know, it would be a possibility, i suppose it is yet unproven, that there could be some affect there as well. and we also know that sleep is important for many things clearly, but that sleep is a time when the by-products of neuro transmission get cleared out of the brain and so if you're not sleeping that's not happening and there's some suggestions that that can create some issues with protein deprivation in the brain. >> thank you. oured a le our adolescents, are they as

likely to become aware as adults? >> no. the short answer is no. you know what the adolescent brain is just wired differently as has already been alluded to and the the part that's turned on seems fully ñ functional is the emotional part. and it's that executive part that's not turned on and not helping to gauge the situations and keep you aware of what's going on. one of)hizç my colleagues has alluded to this situation in adolescents -- since we're at a driving forrum, as the accelerator is fully the brake is not. and so, you have this part of adolescent brain development where all of the emotional regular -- all the emotional activity is there but the regulation of that activity, the foresight, the controls are not fully engaged yet.

>> another comment i would like to make so we do something in sleep medicine to test their ability to stay awake where they may be prone to fall asleep. what researchers have shown that if you ask individuals to press a button and4÷ younger individuals to press a button as they get drowsier, as they feel sleep is eminent, 60% of the time they fall asleep without pressing the button. and even if you incentivize it you still get a substantial percentage of individuals that just fall asleep without signalingzk it. so i think that it's quite often people, they're not good -- they cannot judge how sleepily they are. they cannot judge that sleep is imminent, and obviously that has implications for transportation safety. >> okay. dr. watson, as a parent of a child, that by some measure is now an adult, when i think back

to when he was learning how to drive and i tried to do -- implement all these things to make him safe, it never occurred to me warn him about drowsy driving. are we doing enough to teach parents and sleep snelt. >> i would argue we're not doing enough to teach parents about sleep health. i think sleep iq in this country is low right now.wfppu and i think that, you know, that's one of our great challenges is to get people to reprioritize sleep in their lives. a forrum such as this is one way to get the message out because really ultimately the sleep habits that these children develop when they're in homes with their parents are going to be the ones that they'll carry throughout theiri=!] lives. so in some sense, you know, having parents that enforce bedtimes, that get technology out of the bedroom you know, that limit caffeine use,

parental involvement is really crucial to good sleep health and good sleep habits in the youth of this country. you know sleep education is not only limited to the general public but unfortunately it's also limited within the medical schools out of our country. at the academy we've been trying for years to try to increase the amount of sleep medicine education and haven't had a lot of success because curricula are already so stuffed with so many other things, but we find that many medical schools only have two or three hours worth of sleep medicine education and unfortunately we end up with many physicians out in the world that never think of sleep illness or sleep problems when their patients come to see them and that's also a problem. >> i think one of the really nice points of the american academy of pedoiatrics comments on school start time was advice to pediatricians to get involved in thisq for teenagers and really i think

it's the pediatricians who can help empower the parents to help guide and put limits on the sleep and electronic activities of teenagers. and younger children as well. >> okay. thank you. i have nothing else. dr. price? >> thank you. fascinating presentations as the mom of a middle schooler, i'm listening very carefully. so speaking of parents and because we have a lot of youth leaders in our audience today doctor, you mentioned the concept of later school start times. i would like to know if you have any advice or suggestions to people who may be trying to advocate for later school start times? any kind of words of wisdom for those individuals? >> it's a challenge. in the united states there are

thousands of school districts. every town every you know, village has its own school district. and every school district has its own organizational style and own, you know catchment area for students. some may have a commute of five minutes, some may have a commute of an hour or more, so the challenges are individual for each district. there are things to help though, those who are advocating. there are actually some nice websites now that have where parents have put together materials that are useful. the national sleep foundation also has modules on how to go about advocating for later school start times. and i think one of the big flags that now can be waved since august 25th 2014 is that advice from the american academy of pediatrics which is backed up by another paper which includes

the data that supports this move. so it's a hard task. but what's always fascinated me has been in school districts that make the change the commitment that they shownkq to the health and well being of the teenagers in their schools is just staggering to me. i mean, it really is so impressive that what they do how they arrange it, the steps that they take to bolster this situation are just so impressive. and that tells me that it really does take a commitment in a big way to the health, the safety and the educational needs of teenagers for schools to make this>&5 kind of change. >> you know, i'm in seattle and there have been a group of concerned parents and professionals that have been working to try to get a later school start time now for about a year and a half.

and observing that process, i think that what i've that the doctor is saying, it's really about education. you need to educate the school board about the issue. and what we find is that once you begin to do that, i mean, the argument that you make is so strong that because you're talking about their well being, you're talking about their being prepared to learn when they show up to school that it's really hard to be opposed to it once you understand the issue. >> thank you. that's very helpful. my final question is just a bit of a curiosity thing. i read recently this term that i thought was very interesting. it was social jet lag and the concept even people who aren't using -- going on long-distance air travel can have sir cade yan disruption or q.zdisrit mia just by their lifestyles. it strikes me well-intentioned adolescents who are trying to do

right on school nights might have very different schedules1v on weekends. i'm wondering if you're observed that in your work and if you can comment on that. >> it's really a huge issue especially for adolescents because there's this biological comment. >> it's a huge issue because there is this biological pressure to stay up later. it's almost as[1

>> thank you both. dr. malloy. >> and as a father of a young man in high school whose county has considered moving the start time back an evakhour, which i would like, i'm waking my son up to get him ready, unfortunately the school board would like it. the costs are too great r. there any studies that look at the costs associated with not moving the school time. we've seen the crash rates are higher, learning, you mentioned learning, is there anything that quantifys r) >> there's one paper that comes to mind. it was written in a, the psychological economics journal about comparing improvements in middle schoolers test

performance by changing the school start time an hour later, the cost of that versus getting the same improvements in their test taking by reducing can class size and it was a 7-to-1 zimpls. so it costs seven times more to get the same you know, bang for your buck in terms of the performance outcomes by reducing class sizes as by changing the school start times. so yes, there are economic costs but there are also ways to work around it and it is a complex situation and complex - issues but part of what's gone on is we've decided that the little children can't ride on the same buses as the big children, which i was at one

forum where some high school student says but those are our little brothers and sisters, what's the problem? and i think, you notice, there are some interesting thinking on these things that maybe need to be readjusted. >> i think when you consider costs, you know the similar question was asked of dr. flowers in his panel. i'm just thinking in a similar way to him, this is really a social issue and how do you figure up the cost of, you know, the safety of our children. they're learning preparedness, their mental health him all of these things are at stake here. i think cost is obviously an important argument. but i think there are many elements of this that clearly go beyond the cost assessment. >> thank you. i have three questions i'd like a competent from each of you so we'll try and stay focused.

but starting on the last panel, even before that there has been a lot of discussion about culture and a lot of need for changing attitudes and behaviors. so it seems a lot of since its education, education, education here. not just about drowsy driving but all these+ucñissues. it seems like there is a generational opportunity here by focusing on teenagers. dr. watson you started on that a little bit. i'd like each of to you kind of comment. if we want 2015 to be the year there is no more sleep problems, it's not going to happen. it's going to take us a while. it seems like this focus on teenagers, maybe driving is the hook. it gives us this generational opportunity to give us this cultural change we keep talking about. could both of you make a comment about that? >> well what was most exciting for me today was to see these youth leaders in the audience here and i think, you know we can as grown-ups can talk until we are blue

at these young people but it's the leaders of these who i think really have the opportunity to get these messages akroscross to their fellow teen agers and to have some impact. i think if we can convince those young people that get their parents on board get the pediatricians on board. get the school districts on board and really shift the mindset to where keep e sleep is no longer the forgotten country but a part of our health behaviors. it's going to take work. it's going to take time. as you say, i have been trying to send this message for decades now and it really seems like our society may be at a point where the commitment is there to do the things that will push this message forward and the younger

we can get it you know into the family life the better we will all be. to start at teenagers i think is hard for many parents. if they haven't started in their 9 and 10-year-olds and keep the bed time setting and thinking of planning for sleep, not just letting sleep be the last thing in the day, it's so much easier to keep that going as the kid get a little older. >> i think deliberate or not there are some powerful interests that don't want us to sleep in this country. there are some that i refer to as the caffeine industrial complex out there and i'm from seattle but, you know, if you look at what the stock has done on starbucks, you don't have to look very far to see that when there is a need for caffeine

there is economic benefit that's out there.huáu know, you also can't consume things when you are sleeping. so, you eno, i think we have to act knowledge these challenges that we have but, yet, you know we also have to also propose the what the value of sleep is to teenagers. i mean, they're pretty savvy. i think they'll hear the message, you know, when we let them know, you know, there is a lot of experimental and epidemiological studies shows sleep deprivation and obesity those kind of things will get their attention. what we also see if teenagers obviously, they're embracing technology. there's lots of sleep health focused technology that's out there that i think is a real opportunity in order to engage people. what that tells me is people are interested in their sleep. they want to know more about their sleep. i think if we can take eight

step further to say to encourage them to get more of it. then we'll definitely be making progress so you know i think it's going to be an educational effort. i think we need to convince people on a case by case basis to prioritize their sleep and see how they feel. i do that all the time. it's a simple experiment to prioritize sleep for a few weeks. going to bed when you are sleepy b0f waking up spon toewstaneously and see how people feel and focus on8 quality-and-than the quantity of the wakeful experience, if we get those messages out there, i think they will eventually resonate. >> thank you both. you had one message on screen time. if you could make a brief comment about technology, it seems to be a part ofç creating the risk and a part of the

solution. if you could sort of give us a little bit more about the role of technology again both as part of the problem but also maybef helping us out. >> hih well, as part of the problem there is a paper i have in my bag now that just came out showing thatxjv light from technology in the evening you actually willmz/ have better melatonin onset phase. the signal of nighttime is established better. the problems with technology if you are using technolo?[pí@ you are not asleep. if you have it in bed with you, your phone is ringing or pinging, you will not be able to sleep as well. so that's very clear. to the extent that apps are made

or, you know, well, my fantasy for technology was always a rolling jc&2÷blackout of the internet for people whose brains are of a certain age. you know that's obviously not going to happen17szz anymore. it's something we have to live with and something we have to begin to understand better and begin to use thoughtfully and not, not use it so much so late to avoid sleeping. >> yeah, you know this is a really difficult issue. like you say, is it the solution or is it the problem? i mean technology has been interfering with sleep ever since the invention of the alarm clock. so in my ideal world everybody weaks up spontaneously now. that's clearly not the world we live in. but, you know, i do think that

you know as a sleep lq medicine prak tickserpractitioner, is to have good sleep]df regular habits and a wind down period of time where you allow your body to prepare for sleep and i think we have problems when people view sleep as something they need to do. those are the people that have trouble. the people that sleep well are the ones that let it happen in the right circumstances. and so generallyn8" think we need to keep technology out of the bedroom and5 kind of preserve the bedroom environment for sleep. >> so this is the last issue. i'd like both of you to address. that is when you think of the conversation around start time schools, a lot is about learning. dr. seisler has done work with medical interns and residents that's hours of work for learning. yet, in both situation we can

also focus on the car crashes. so we're here at the national transportation safety board, health well being maybe soviet goes under well being. we are all about safety. we are focused on this because lives get lost and people injured. it seems that that piece. it shows the data that when you change the start time of schools, crashes goes down safety improves. i'm wondering how often again, there has been a lot of health focused on the learning part, but really one of the at least equally important hook here is the safety of these at any level of our education system for us to be focusing on the safety element as health well being or learning anything else we want to be talking about here. . >> well, you know,í vku&h?i think that we're really going to enact change through education here. you know, i listen to the radio.

i listen to a radio qyik a bit. here, so many public health announcements from nitsa in regard to distracted driving and impaired driving. i'd like to hear some about drowsy driving. i think the academy through the healthy awareness project is going to get the word out. but i think there is going to come a point where everyone will be aware of this. i don't think we're there yet, but we have to keep knocking on the door in order to get our message heard. >> i think that there has to be a way to incentivize young people to get better sleep in for their health and for their safety and for the safety of their friend and people they don't know on the road. one of the first stories iq]u ever heard about a teen fall asleep crash is a tragedy that is

repeated many, many times in this country and we just. we aren't hearing them. we're not listening. we aren't telling our children about them. this first crash is a young manuel on his way to college. he had gone to visit this college that he wanted to attend. he had stayed up late. he had driven tooúvr&a early in the morning and he fell asleep his car drifted and crashed head-on with a car killing both of them. i mean, it's just that kind of story and that kind of, you know again, it's the let's wake 'em up by telling them the worst that can happen. because they're not hearing that. they're not seeing that. they're not. it's just not a part of what is the message that they're getting. >> that might help implement some change. >> great. thank you both for a great u$wq

panel. mr. bragg your leadership we're keeping up this high level of excellence here.b@k to all of our safety leaders in the back. dr. carstadt8tq)q''t know you were coming. you made her day. she was talking to both of you not onlymjk you got the information to be educated. we may have prevented an injury or saved a life. we are about to break for lunch. i will take a prerogative. i took it out of my opening remarks, i will do it now. one of the things you just heard about the doctor discussed was a sleep latency test, the physiological way to measure how sleepy people are. it took two stanford professors to figure this out. i mention this, i was post-doc out of brown i mentioned that, do i know sleepiness alertness in that test? i have tattoos, i know it i mentioned this part of my career was working at nasa and

working a petite correspondent measures program. the first was a call saying mark what's this petite stuff? nobody knows sleep alertness better than you do. i'm bringing this up our conversation was around specifically how people tuque u talk about sleep, alertness drowsiness fatigue, et cetera. i noticed fatigue was in the title of your talk today t. doctor said this i want to include this, you will hear a lot of words fatigue, drowsiness alertness, et cetera, we are all talking about the same thing. we want to point out we do not want to get pulled into a semantic discussion because we are talking about the same thing. wex have heard those differently throughout the day. i want to highlight, whether fatigue, sleepy inside, drowsiness, they're all dangerous and a part of the rickbomg÷ now. we will adjourn for lunch. we will see you back here starting at 1:15.

. >> we recommend all of us who are here to meet us here at this time. . more now from the national transportation safety board summit on drowsy driving with a discussion on sleep disorders and the effects of mixing prescription medication with over the counter drug. this is just over an hour. >> we are going to begin our fourth panel of the day and the chair of that is dr. mary pat mccay. whenever you are ready. >> thank you very much. as a reminder for the panel, when you push the buttonco microphone, a green light will indicate the microphone is on. when speaking, bring your microphone close to you. when finished, please turn off the mic. in this (@!!, we will discuss

issues, the chief of the division of public mental health and uponlation sciences at stanford university. a doctor, associate professor in the division of sleep medicine at the university of pennsylvania and the director of the sleep disorders the philadelphia veterans administration medical center. and finally, dr. ronald fargas, lead medical officer in a division of neurologist products at the u.s. food and drug administration. >> i am a member of rosskind and the enterprise. thank you very much to have invited me to this forum. so i will speak today about drowsy drivers in the generratical situation. so this data is coming from the usa survey that was realizedd3hrr

in 2013. this today very recent and i am trying, i will try to present you with what are the research we found 99ç about the drowsy driver and the link with the mental disorder and. b also the med kalical condition so in fact the number of drowsiness and accidents. generically, they are coming from police report and the agency and from insurance report from clinical study for specific disease, all these ones are with numbers that are focusing on accidents also

sleepiness and rarely from populationriú studies. the checking the data, the correlation with the death toll because, in fact, we find in general population these people about the life and for just reason. the population of the general population are difficult to do but are one of the best ways to assess sleepiness at 3-11ñ without any consequences with the police or with any kind of physical implication. the people are spontaneously reporting what is happening and like that, we can see the impact on traffic accident marginally. >> so the present study is based on the large representative sample of the american engineeringlqf/z population.

ly go very fast on it. it has objective to determine sleepiness right at the wheelhâw of the matter. to identify what are the characteristics of this individual in term of social or medical condition secondly disorder and the treatment that are very important for these people sleepy at wheel. so the sample the size of the sample is more than 19,000 people. we have a participation rate. i gave the participation rate only to say how much right could be as the reason we are presenting 83.2% participation rate. the age range is between 18 and 100 years. the location 15 states we took

15 states and for each state we are a representative according to usa. we have l reporting driving ir vehicle at the moment. so it's 83.8% of the sample and i will present you will see are peoplely tell you. only to put inr)dy position the problem with the sleeping at wheel, let me say according to ought generic population study ( the american population is sleeping around 6 hour 45. it is the$6ñ number that is reptively found inside of thes7dm population by fight. so comparativelféq, the sleep in europe is around 7

hour. with one exception in u.k. where we found a number around 6 hour 50 minutes. 28% of the general population of america is experiencing day time aií(ñ sleepiness. this is for everyone really a big number with sleepiness as the first reason to have an accident but also something is disturbing the social relationship, family at work et cetera. so the consequence that of all of that is in our study we areã feeding to coll information about this sleepiness disorder causing we have it so the sleep disorder

diagnosis and ics 2 according to icd 10ened psychotropic consumption of the chemical compounds. so i go with sleepiness at wheel by age and gender. imwp can tell you that the difference between men and women are as important at any kind of age and generally speaking, we find 10% of the' population are concerned when further it's practically =c7&!1 the traffic accident by age and gender. i don't say sleep at wheel. i am saying on1zp! the traffic accident by age and)yb/ñ gender and you see that for the category of ag ut &n and 24 we have the highest prevalence.

we have another at 2534 but for the rest. it's comparable. it is no significant difference between all the group the traffic accident with or withouthy sleepingj)!g at the wheel in the past year. as you see if red, i am sleeping at wheel in the great. i have without sleeping at wheel. if you look at our graph, you have inside the men and the women and you see the men have more traffic accidents in the past year than the women and you see that without sleeping at the wheel, so in red, sleeping at the wheel, do you see that we are practically for the men around 15% and when we go with the women around 10% and you are

cooperating with the accident without sleeping at the wheel. sleeping at the wheel by the time of the accident, very interesting thing inside the generation of america, you see the number are for nighttime like the speaker was vxhwpsaying nighttime is really the biggest problem and i must add we nund the early morning is >+jdzconcerned i have not here, but who will come back on the next slide. the sleeping at wheel by fight time sleep duration. that is)hçr something that everyonú@ñ has said i will go very fast on saying that less more you sleep, less you have sleeping at the wheel him so this is a very interesting thing. it's only a confirmation that

what the speaker the previous speaker was saying. sleeping at the wheel by severity, this isñu4$v more interesting and you see that we vhave many significant difference between the group we have severe and you see that we have a lot of people that are of concern around 15 person. the prevalence of sleeping at the wheel an accident by autáb

the people.x you see 15% for the people that are sleepy and we have the cary֍ so accidents and great so you see that sleepiness is not totally recovering. the car accident. we have praktctically something like have more of sleepy people. these people are driving. they are not all accident. so tol appreciate>a

>> excuse me the sleepiness by sleep disorder and here is very interesting, because we have sleepgnç apnea exiting withá a great strength. you see we have always seen the same kind of design flaws in red the presence of the disorder the essence of the disorder. when you have sleepdv.j apnea you see you have around 18 persons that are concerned and you see on the side great withoutáii@ñ sleep apnea. you see that insomnia is less powerful to give a sleeping at the wheel. surprisingly, it's doing more problem of sleepiness inside of the dob)xsample but here the difference is not significant.

theeh:"@ prevalence of sleepiness at the wheel by disorder and you see that the disorder is exiting and exiting in comparison of the people without sleeping disorder. it is so coming and on site disorder could be there but again, what is reallyla?s without the disorder. the prevalence of sleepiness at the wheel by col consumption and here youq áç see, if you take the number of drink the people are taking, you would say six zrimpgs not so much different because in my opinioná9co they are in the bed/pñ not moving anymore. if you look at your category it's more exact at what we have. for the prevalence of

medication here a big surprise anti-arrhythmic exiting strongly and the anti-psychotropic also and something very surprising but not so surprising for the people of the da is the otc drug because of the presence of anti- -- inside of the project i verify is really this project that are responsible of that. the anti-depressant, you see, they have a wparticipation. but not so high i'm seeing there. so what are the best predictor; of sleepiness at wheel for a man 35-years-old. you see here

that daily alcohol the fact you are fatigued and you have sleep apnea. this is explaining participant. when es we are taking the best predicter of the people, the man more than 35 here you find agu lot of'918z explanation to the1 ásqq( disorder. out there, they are ordered by frequency- the time i must go faster. the best predicter of sleepiness at wheel for nm>÷women, you see that. there, we have, for example something that is more present for women. the otc and this is explaining all this four factors, 26%. we have for the best predicter for the women more than 35 and

here or so, we have sl%85x apnea that is exiting with 45%. again, sleep apnea has a big presence that we can find for this presentation. the best predictç;&e of traffic accidents, that is interesting. i hope you have again a sleep apnea and you see that 41% is explained. again, it's a predicter, they are very strong and best predicter of traffic accidents for men more than 35-years-old. i will go through directly to the conclusion for finishing time. so sleepiness while driving is relatively frequent affecting;o 9% of men and 35% of the women representing and thatñl number 13% of american > ndrivers.

the sleepy individuals at the wheel have nearly two times more chances to beñbz traffic accident in the past year. the factor associated with sleepiness at the wheel sleep stepryvation alcohol and medication including thank you very much for that.. thank you. >> dr. >> i appreciate the opportunity to be here.!q$b >> so i'm going to be talking about the health economics that lead to day time sleepiness and that the doctor illustrated so

beautifully in her talk. what determines how alert we aresl( in any given 24-hour period, our alertness fluctuates over the course of the day. it's determined by two different processes. one is called the home static spat says or process h, indicated by the downward pointing aarrows on9 the slide.ólx÷ after we fall asleep, the longer we have been asleep the less our drive to continue to sleep. now that process is counterbalanced by another process, an alerting process, driven by an indogenous÷ añ pace-maker. there is a dip in the middle afternoon, that's our bkv time. but that process also drives at the incredible sleepiness that we feel in the early morning hours and of course our behavior capablyhmmuz operate a

motor vehicle varies according to our level of sleepiness. in real life things are never this clean and easy. there are always other factors that can modify our level aalert inside, they can be internal to us or external to so whether we are feeling stressed or anxious whetherjfm the situation is urgent.bjú we are highly motivated aboutoc5 something, we will be more alert and if we've consumed alcohol or taken certain typesñd p?d,m medications, or for being sedentary, then we may be less7 alert. so the disorders that cause sleepiness can impact any of these processes, there can be disorders when we're awake people with insomnia have problems falling asleep, patients with sleep hygiene issues, there can be sir cadium disorders, or jet lag and then there is the group of disorders that directly affect the duration and quality of sleep. that includes sleep apnea,

restless legs as dr.'qvjzj!÷kj alluded to artie disorders, gasping or breathing disorders at fight, anxiety or ocd, where people have afó hard time sleigh staying asleep angúrp certainly medications. i'm going to focus today on sleepr:3x apnea and itsd epidemiologically a huge problem. it's very importantöx it has a very important association with drowsiness while we drive. so i will cover what is it, who is is it? what are the usual symptoms? what are the consequence surface can we diagnose it quickly and at low cost?á' can it be :" wztreated? does treatment help? discuss it maine make sense? let's go. i have 11 minutes. here we have a picture of an airway. the blue arrows represent air moving through the nose and mouth down the wind pipe3-ñ into the lungs. so when we are awake, we are

breathing, getting plenty of air. so sleep apnea does not happen when we are awake. it ogk happens when we are asleep. the upper airway collapses it blocks the progressive air into the throat and down into the b táip r(t&háhp &hc% so why does that happen when we're asleep? what is different? people with sleep apnea can have a airway that's narrowed because of excess fatty tissue back in a minute up in the area. ú strongest, it is one of the strongest rick factors we know of. airways can be crowded with large on the sills or if there is apc÷ç large tongues"< or if the jaw is recessed and set back like donzknots instead of jay leno, her redties and other risk factors and airways can be. sloppier as we get older. everything gets sloppier as we get older. the airway is no exception. men are also at higher risk and

women after or menopause. nasal congestion can contribute to sleep apnea. we have to suck harder and can suck the airwaqj"ée shut. alcohol and sleeping pills can block the nerves and make it easier for the muscles to collapse. so what happens when those wallssñ2 collapse together? they start to vibrate. that's when the tells you to sleep on the couch. they hear the snoshing. at other times air can be blocked completely. that's known as apnea. sometimes it can be partially kd blocked. some air gets if not the full that's called a v"yhypopnea. the amount of oxygen in the blood drops0óñ brain has a sensor, it sends a signal for the muscles to wake up just enough to reopen the l"b?airway. >> that signal is usually a burst of adrenaline, which we all know is a stress hormone. now, during those few seconds when the airway is closed, it's not like your heart and brain take a break and go workdfiyñ ãfor

someone else, they continue to work. they're doing it without$÷ñ o, jen. oxygen. >> that causes the air flow to get reestablished0÷ and once that happens it's now the coast is clear. wedhi as soon as we do the airwayq@d closures happens again. this can continue like this all night long. when i ask my patients how do you feel the next day afternks]b spending a night like this their usual response is the way i feel right now the most important8)0yhññr'g for them to know at that point the most dangerous(p' you do" y is operate a motor vehicle.r%r there are 18 studies inñ0jy car drivers as well as two in truckpi drivers in this metta analysis that shows the odds of a crash in people with sleep apnea range from 1.21 to 4.29!. there is a 20% higher chance of having a crash up ton 4.9 fold increase.

so what happens at night in a person with sleep apnea they may senator, choke gasp. they may have to get up and urinate frequently because if the pressure swings in the chest by fool the body into thinking there is enough fluid andyq-9pá can increase urination with fluid imbalances. a lot of times they're not aware they are doing this and are told by a bed partner. they're associated with surges of adrenaline and low oxygen which can contribute to hypertension, heart disease, stroke, bedie boats anpz(ç even death. each of these events is terminated by anzf arousal and frequent arousalsu6p(ñ can lead to day time sleepybzúñ and crash risk and can move to mood ncc2qr(t&háhp &hc% disturbances, sadness forgetfulness, difficulty withó focusing, with sustaining lfnañ aattçzbw9etñ executivy@ñz decision move making. reaction time, if someone were to cut them off on the road can

take longer. they can often experience morningiehzñ headaches impotence and wdi$u$ere are studies linkingz9 r(t&háhp &hc% sleep apnel!t7÷ to reduce productivity at$rçy work and absenteeism. all of this gets worse as people gain weight as a country facing a huge epidemic a recent analysis looked at what would happen to current prevalence in sleep apnea. we know that 9% of men, 4% of women had sleep apnea when3& data were applied, x azh:. tripled. so the way we identify this disorder wasfnmx traditionally by using something called3&"mñ in lab sleep study him this required patients to come in and get hooked up and they would have wires taped to the head that measured brain waves and also eye movement and chin and leg muscle activity. all of that taken together told us were they asleep or not.

belts to measure breathing, air flow, foring sensors to tell 3gpñ is the air flowl or is it completely absent even though there is an ongoing effort and did the oxygen level drop by using a finger clip. with this technology, we know 85% of cases of sleep apnea remain undiagnosed. what is: [lt encouraging is the development recently of portable sleep studies. there, there is no eeg monitoring and instead we just used the chest and ab domal effort m=6mbells air flow snoring and oxygen sensors. there are variations to this zg$z(of model. the beautiful advantage is that a patient can assemble it themselves in their own home and they're much more convenientriv#ñ for people who are shift workers who sleep away from home a lot.; it really accessibility. so once it's diagnosed can we treat sleep apnea? i tell my patients, think of the airway like a tire when you

were a kid you had a bicycle and a tire what could you do? blow it up with air. we have this device, a continuous positive air bay pressure machine. they become so sophisticated wkñ don't need to bring patients in, in most circumstances to determine the pressure level. these machines .7baz automatic sensors that can determine it for you. directly in the home. different masks, full face masks for mouth breathers. masks that let you sleep on your ]?dáuz or your back and these machines, it's just a flow generator that measures, that blows air into thex6(pá and keeps that airway opened when the patient sleeps. with an open airway it's now possible to have a continuous flow of oxygen and with oxygen patients can finally sleep and get a break from all that adrenaline. we know with randomized trials, crash risk. it improves alertness in as little as one

drooifr driving u ñá ju can improve in two-to-seven days, ron domized trials, people feel better, heart disease and stroke risk, their mortality all improve and we know@pc that they spend less money on health care. there are other therapies including oral appliance upper airway surgeries, the body of usually tends to be the first line therapy. we also recommend that patients lose weight that they limit alcohol, sleeping pills,u narcotics to the lowest amount they can get away with. a f otherwise increase upper airway swelling and make thefbq airway more collapsable and keep the nasal passages open by controllings theyal congestion. if they need surgery we will do a devated]k4r septum in the nose.

we c'mon tore if they'rebnv using a cpap..÷÷ it allows course do whats the mask leaking?,jh9ñ so we can address thesec&2 issues as we go|o you can see night after night, on the fifth night theouvy skipped it. it was blank. in summary, i would say sleep apneaft%s is extremely xhovenlt it's been linked to sleepiness and3eç cras( outcomes. importantly, it can befñ diagnosed in the home. cpap treatment is expensivel ñ accessible shownzrz to lower crash risks and improves many conditions lowers health care costs and can be tracked in real?

time. thank you. >> thank you very much. our final panelist would be dr. >> hi, i'm ron xáúffargas, i'm èr clinical team leader in the center for drug evaluation and reason at h the food and drug, administration mths i'd like:xdv to thank the v dntsb forz#@0ñ inviting me here to talk. i'm going to start withdsilz a slide that first says that the views i'm going tonxéç÷ express are those of our m of the88questions that come up soon is what the fda is saying to patients to understand the risks from drugs as regards drowsiness and driving. so in this presentation, there are, it's a little hard to see with the yellow highlights around text. that text is from webñtc pages that the fda has that help patients

to understand@s< risk from drugs and alsocav>÷ picture on the right is from a pamphlet available tof like to learn more about the so the fda is trying to communicate=1 clearly the risks that can occur from prescription and over the counter drug to use very clear language and make vsc? clear recommendations. so leak you see here. fda ande nitsa, ntsb, sister agencies, warns patients that prescription and over the counter#a!o medications can make it unsafer to drive.t fda judges thet#pdáqáár!ility of risk of drugs. all drug have risk. what's an acceptable risk?

like drowsyx4 driving and drunk influence of alcohol@f/!qa to try to understand society tolerance from risk from drugs. so one of the things we look at is the legale%l 8÷ definition, not to give leap advice toc!"s warnéa patients aboutw= b if you take this particular drug, wouls3gñ you be impaired to the same degree that you might be from alcohol at ther , legally. for driving and i think too that normally when you think of adverse events from drugs you think about injury to your liver or skinjfrj÷ reactions that kind of thing, but certainly crashes areí@fy seriousv) adverse event and ;f #1 oõven the whole even if it's notrthvñ illegal, being stopped by the police, that would certainly be something thatp06" patients

interested in avoiding. so the car crashes are kind of right in the middle of frequent bcseuj and rare events soz$#: that if you give somebody a drug they're frequent enough you can't say:drdy necessarily the car caused the crash, yet they're rare enough if you do a clinical trial of an experimentalk:ja 6zyññx tvdrug you see a few core crashes,?mi3t you don't have the statistical power to determine most of the time if the drug increased the risk of the car crash. andfr2z studies could be designed randomized clinical trials could be,sp designed to investigate the increased risk of the car crash from the drug. they'd have to be very largedón÷p'd most of the time that's not practical and also there is some ethical considerations that&2j if

you have a suspicion that a drug would cause an increased risk of car crashes that it would be problematic to expose them to that risk.k ) again, looking to examples fromq0ñ alcohol and drowsy driving. one approach at the fda we have beenna2w looking at is the effect the drug have on driving skills this is li+ñhelpful.%6qu drug arelefvx certainly sleepx0yzll ÷ is8f complicated, but drugs are complicated. drug forp level is high, it's dangerousarvç drive. the question becomes how many hours after taking the drug would it one of thev> that is much easier:jf address in age controlled trial

and laboratory with the7e simulator in @ an interrupted caru91jt. so thishv8?÷ again is tested in an image from the fda website and stressing that snowing medications and importantly any combination of them affect"c.u your ability to drive isn safety measure. it involves the patient, their passengers and others on the road and, in fact, the seen here the traffich.v sign a)+h s% a whole list of problems that could be caused by drugs that could affect your ability to drive4hhtwx in additionú.6añ to sleepiness. some of thecn straight forward in terms of perceiveing the problems like

blurred vision or fainting. one of the decisions arejç patients are unaware ofggñ

that cause sleepiness.amd/(t&háhp &hc% theypm- increaseha& that risk in placebo controlled trials. we often see things like 10% of patients that take the drug areé sleeping versus 3%&:v on placebo. this is represented in the label for fda gives a long listz of categories. we rem people check with the health care provider and pharmacist and treed drug 32>elabels and information that comes from these drugs. this list shows a very large variety of drugs can cause sleepiness, anti-depressants,óq drugtz.n containingkejr codeine, narcotic.h4 sx÷ ÷ colorectalpq products, sleeping pims.

at thej@ pills. one thing we are concerned about isnoq>y there is the possibility ofh an increased crash from sleepy inside. some drug/l;b might

the fda arenf"zy struggling a bit with how to1yu identify-lm just the individual patients [ìáhp &hc% more ory less at mdrisk. that's really the ideal place to look. some patients are at risk and the goal would be tow[by try to identify those patients who sleepya(h from the drug. we have taken7nbñ guidance from work done by nitsa by ntsb. there have been meetings and expert panels. i apologize ifpe 9?jj this is small. it's kind of a frame for thekjxñ fda that we've been using to$l z evaluatekku ò. up in the sy>left-hand corner there is the basic pharmacology of drugs what receptor are they binding to what neurotransmiters in the brain they can give a strong {!etjt(urj)pá the drug will bexy

impairing. anxiety, those generally cause a great deal of sleepiness. up to the right, there is ñ epidemiological evidence. will is evidence that drug@+ñ can increase the risk of traffic accidents. then down at the bottom is this focus on standardized studies,8s taking a look neuropsychological tests measuring alertness and going through all the importanté functions and the brainn. functions important fore,v driving.t=]3h uáuáp&$lm8ñ sleepiness is very important. its would go on to executive function. in the¡4 drugs, again we can ask drug

developers to&pójét enroll patientss and to randomize placebo controlled trials have positive controlshirñ and have a, gets a reallyxyq2 good idea of skills important for driving and being able to stay within the lane of thev so at this point i think we're changingn4rwú to a more sophislt7ñatr(t&háhp &hc% analysis2t of drugs. previously, we were checking, of course, a lot oádata about patient's complaint of sleepiness and representing that in the label. now more÷@fjç recently,vñk2 we have labels three are listed herecnf% where they go into someq about the kind ofm-3r driving studies that were done and the kind of results and then we made recommendations about the dose and as the dosecif#í increases in some of these drugs, these are

involving sleep at the highest though we will say" essentially unless the physician and patient know the patient isn't impaired, that they don't feelm#míñ sleepy, it5-÷ might be better not to drive or maybe there is another drug for that patient. one more i'm sorry. so the,& risk mitigation really is it was talked about erlgier today and in some f)ycases$om probably many cases, patients aren't aware that they're sleepy from the drug or it has jfsrçeffects on there under judgment. certainly if they do feel sleepy or impaired they shouldn't drive. but that could be pairedv$ again from thedqc

learning to know how reacts to me$nizó+ey pharmacology, really,ñ:z tog7ñ the dose with the

you.5fjiyayu the information that's currently available to patients, directly d to patients, related to xwñ over-the-counter or prescription medications, are they getting 0" enough information to make i knowledgeable decisions? >> well, we're increasing the amount of information that's 2]60ñ available to patients.ñf so for example, in prescription ]gj insomnia drugs, there's medication guides that go to patients, and describe risks like impaired driving, and describe how the medicine should be taken, and very straightforward language. we also have information, a lot of information available to patients, they're very much saying that so0rugs, even "g3ás over-the-counter drugs, can p!aup0ñsas

impair driving, and that saying éey very clearly that if you're 9a going to drive, you should try to select a medicine that doesn't cause sleepiness, or eqfñuc5vu anyway that trying to direct 3l!d peo

room for improvement./33y3ars >> i think that in the general popub zé drug that they are taking is x.c[- >> sorry, dr. ohayon, can you speak into the microphone?d >> they are knowing the pills um:úñ are responsible for sleepiness, one is the usual medications gn that they take for the medical 3•ñ condition of psychiatric conditions they know when, they h82ñ me2 fw that if they driv must diminish or stop the l!$jv medication, but for the people ú]bsyt that are taking otc, for 0#ñzvpx example, it shows that it is an 8)4nç unusual medication and often bé they don't read the i.ifi3u)jj a"3z2÷

that are there on the medication a l&so the fact that for example you can take a pill because you have the flu, and (! rt/ inside is an anti-histamine, andlq c:his would be responsible for fkcñ sleepiness. here is the danger.zst >> so again, i think we're highlighting the complexity of this. is there enough -- have we done enough to educate health care l##é÷ providers and pharmacists to provide the correct information )@j;v'%aeg&p to patients regarding some of ye;: these side &u$at in some cases still difficult $$ for health care providers to fúmmc even interpret? >> well, i think that there are -r'formation to health care providers, in particular.ur÷ they are tuned in to the health safety communications that come out of the fda.zt!5 there's a lot of news over the past few years about the dék1lpsx/2

of drugs that impair your brain function for driving, and ñu y4! that they need to advise . patients about drugs that impair driving, although the point is nb1c certainly taken that there are u drugs available over-the-counter to patients that cause ÷w sleepiness, and the fda is l%píkçcuu studying patients' understanding of the labeling and is trying to figure out the best ways to the things that we have on the website, that if you're going topc be driving, you should select an4tnñ over-the-counter medication thatbex is less likely to cause 4 sleepiness. õ5ba think one thing that's ipy a big difference for us as providers is having # e-prescribing available so that drug/drug interactions and sedation are automatically

cross-checked for us, provided that the patient is getting all their medications from the same -

person that has that.wmvhhbzvpt tvh>÷ r have a lot of people using this medication, underlying the fact may be we must do more to give this information. >> thank you.lu ohayon. one of the interesting things

generating the sleepinkz,afor the subject out of the disease í itself, but i think that the >84z depression by itself is giving to the people some time ta[:aqp(urjju$at are more important and probably are responsible for a lot of accidents. >> thank you. one of the things that we run zef into in commercial "ó2çsqu transportation is a pretty big reluctance on the part of operators to even explore the 8úqo possibility of whether or not they might have a sleep disorder, such as sleep apnea. in my personal life, i have a +pv(÷ couple of friends who i can tell you have sleep apnea and have said to me that they don't want to know.ñaa)f can you talk a little bit about the folks who may be more or less likely to be willing to be tested and/or treated for their sleep apnea? >> yes, i'll jump in there.s3'] that's been the area of my

research, and there are certain aspects to care delivery that seem to help people come forward. definitely education is really o?pa÷ important, but even if they're aware, there is this condition called sleep apnea, a lot of people don't com h because of the employment repercussions.l!qáq it's important that the program is non-punitive.< to screen for @z59 apnea from multiple expert bodies now, the fmcsa, the trisociety task force. we have a number of published guidelines and they all agree "ñ you have to find a way to diagnose and treat people while keeping them in service, so that's really important that they don't feel their employmente@9÷ is threatenái+f& @ the other thing is, affordabil)jx"dp((qáár!ility of diagnosis and treatment and z> we've come a long way in recent years, with home sleep testing, ! % the cost has come down &#[ and more patients now have

health insurance, so i think that we can always continue to improve accessibility, but i v@(v think that's made a big dent, v8zx2tr and then the third place we can ,q."tsp)q difference is in providing ongoing support for people who are on cpap, so they don't view it as just this thing that gathers dust in their closet but something that néfñ actually has them feel better.b[mfñ the field in the past has b ñ focused heavily on diagnosis andvç(+i less so on ongoing support, and 4 i thi@ under áj transformation right now, which is all good news for patients.$bhkñz-hñúi-@ñ >> dr. farkas, you mentioned a couple of times about the fda hard to try and increase the ngfw.zmu amount o& /sormation that's ca8gìáhp &hc% available to patients and caregivers. can you talk a little bit about .;rç where people might be able to find that information? zagñ >> yes. lot of that information is available online, particularly á" for the over-the-counter medicationñ1b)er)uráh#airly