Factors associated with serious vehicular accidents: A cross-sectional study in hospital emergency rooms.

AIMS: Pictograms on medicine boxes warn of potential drug-related driving hazard; we studied their association with serious accidents. METHODS: Prospective study in emergency departments of the hospitals in Bordeaux and Périgueux (France), of drivers with serious (admitted at least 24 hours) or nonserious vehicular accidents. Minors, passengers, pedestrians or subjects incapable of answering an interview were excluded. Interviews ascertained driver and accident characteristics, use of drugs with or without pictograms, use of alcohol and abuse substances, sleepiness, distractions, and mind wandering at the time of the accident, RESULTS: Between 18 October 2016 and 26 December 2018, 1200 of the 6212 drivers admitted to the hospital emergency rooms, 741 nonserious, 459 serious, were interviewed. Serious accidents were associated with male sex (odds ratio 1.89, 95% confidence interval [1.36-2.64]), age above 60 years (3.64 [2.21-6.00]), driving on local roads (3.34 [2.34-4.76]), driving a motorcycle (3.39 [2.29-5.00]), having drunk alcohol within 6 hours (2.89 [1.85-4.51]) and using a drug with a pictogram during the 24 hours previous to the accident (1.57 [1.06-2.32]). From 207 police reports, 101 drivers were not responsible, and 106 were responsible, associated with age below 40 years, driving in overcast or rainy weather (2.62 [1.29-5.33]), on local roads (3.89 [1.90-7.95]), and use of at least 1 pictogram drug in the previous week (3.12 [1.31-7.41]). CONCLUSION: The known risks of alcohol and pictogram drugs, of riding motorcycles and using local roads were confirmed. As measured, behavioural sleepiness did not predict accidents.

The Bordeaux Sleepiness Scale (BOSS): a new questionnaire to measure sleep-related driving risk.

STUDY OBJECTIVES: Sleepiness is a well-known risk factor for traffic accidents. Our study presents a new questionnaire, the Bordeaux Sleepiness Scale (BOSS), specifically designed to evaluate sleep-related driving risk in patients with sleep disorders. METHODS: The BOSS was designed by gathering data on sociodemographics, sleepiness, driving items, and traffic accident exposure (kilometers driven) in the past year of 293 patients followed for sleep disorders at a French sleep clinic. It was then validated on data from a large population-based cohort of 7,296 highway drivers. Its performance was compared to the Epworth sleepiness scale and to self-reported episodes of severe sleepiness at the wheel. Receiver operating characteristic curves were computed. RESULTS: The sensitivity and specificity of the BOSS (cutoff = 3) to predict sleep-related near-misses or accidents was, respectively, 82% and 74%, with an area under the receiver operating characteristic curve of 0.83. In a cohort of patients and a large population-based cohort, the area under the curve of the BOSS was significantly larger than that of the Epworth sleepiness scale (P < .001). Although the areas under the curve were equivalent between the BOSS and sleepiness at the wheel, the specificity of the BOSS was higher. CONCLUSIONS: The BOSS scale combining exposure (kilometers driven) and self-perception of situational sleepiness provides a simple and reliable evaluation of sleep-related driving risk. This short, specific questionnaire should be promoted as a first-line tool to evaluate the risk of traffic accidents in sleepy patients. CITATION: Philip P, Micoulaud-Franchi J-A, Taillard J, et al. The Bordeaux Sleepiness Scale (BOSS): a new questionnaire to measure sleep-related driving risk. J Clin Sleep Med. 2023;19(5):957-965.

From improved sleep regularity to reduced sleep complaints and mental health conditions: a population-based interventional study using a smartphone-based virtual agent.

STUDY OBJECTIVES: To explore the effect of sleep regularity on sleep complaints and mental health conditions (i.e. insomnia, fatigue, anxiety, and depressive symptoms) in a population-based interventional study using a smartphone-based virtual agent. METHODS: A populational cohort based on the Kanopée application, which provided interactions with a virtual companion to collect data on sleep and make personalized recommendations to improve sleep over 17 days. A pre-intervention sleep diary and interview were used for cross-sectional analysis (n = 2142), and a post-intervention sleep diary and interview were used for longitudinal analysis (n = 732). The intra-individual mean (IIM) and standard deviation (ISD) of total sleep time (TST) were calculated to measure sleep quantity and sleep regularity. RESULTS: The mean age at baseline was 49 years, 65% were female, 72% reported insomnia, 58% fatigue, 36% anxiety, and 17% depressive symptoms. Before the intervention, irregular and short sleep was associated with a higher likelihood of insomnia (Relative risk [RR] = 1.26 [1.21-1.30] for irregular TST and RR = 1.19 [1.15-1.23] for short TST), fatigue, anxiety, and depressive symptoms. After the intervention, the IIM of the TST increased while the ISD of the TST and sleep complaints and mental health conditions decreased. More regular TST was associated with reduced insomnia and depressive symptoms (RR = 1.33 [1.10-1.52] and RR = 1.55 [1.13-1.98], respectively). CONCLUSIONS: Our results reveal a longitudinal association between sleep regularity and sleep complaints and mental health conditions. Policymakers, health professionals, and the general population should be aware that, beyond its positive effect on sleep health, regular sleep could promote mental health.

Validity and diagnostic performance of a virtual reality-based supermarket application "MEMOSHOP" for assessing episodic memory in normal and pathological aging.

Objective: MEMOSHOP is a virtual reality (VR)-based supermarket application for assessing episodic memory in aging. The aim of this study was to examine its construct validity against the gold standard paper-and-pencil neuropsychological test for clinical memory assessment in mild cognitive impairment (MCI) in older adults. Methods: Patients with isolated subjective cognitive complaints (SCCs) or MCI were recruited in the Bordeaux Memory Clinic (MEMENTO cohort). Cognitively normal elderly controls were also recruited. MEMOSHOP allows a near-ecological evaluation of episodic memory during a usual daily life activity, i.e. shopping at the supermarket. MEMOSHOP and the gold standard Free and Cued Selective Reminding Test (FCSRT: French adaptation) were administered to all participants to assess episodic memory. Non-parametric tests and receiver operating characteristic curves were computed to compare their performances. Results: Twenty-nine patients (21 females, age = 71 years ±7) and 29 matched controls were evaluated. The performance trends observed with MEMOSHOP and FCSRT on free and cued recall were associated (p < .01) and comparable (p < .0001), without any participants' groups interaction. Although easier than FCSRT in free recall for participants, MEMOSHOP demonstrated better diagnostic performance based on cued recall in isolated SCCs/MCI patients (p < .05). Conclusion: MEMOSHOP demonstrated its reliability and validity for VR-based episodic memory assessment in the early stage of MCI and is potentially of interest for use in memory clinic settings.

Predictors of users' adherence to a fully automated digital intervention to manage insomnia complaints.

OBJECTIVE: Fully automated digital interventions show promise for disseminating evidence-based strategies to manage insomnia complaints. However, an important concept often overlooked concerns the extent to which users adopt the recommendations provided in these programs into their daily lives. Our objectives were evaluating users' adherence to the behavioral recommendations provided by an app, and exploring whether users' perceptions of the app had an impact on their adherence behavior. MATERIAL AND METHODS: Case series study of individuals completing a fully automated insomnia management program, conducted by a virtual agent, during December 2020 to September 2022. Primary outcome was self-reported adherence to the behavioral recommendations provided. Perceptions of the app and of the virtual agent were measured with the Acceptability E-Scale and ECA-Trust Questionnaire. Insomnia was evaluated with the Insomnia Severity Index at baseline (phase 1), after 7 days of sleep monitoring (phase 2) and post-intervention (phase 3). RESULTS: A total of 824 users were included, 62.7% female, mean age 51.85 (±12.55) years. Of them, 32.7% reported having followed at least one recommendation. Users' trust in the virtual agent and acceptance of the app were related to a pre-intervention effect in insomnia severity (phase 2). In turn, larger pre-intervention improvements predicted better adherence. Mediational analyses showed that higher levels of trust in the virtual agent and better acceptance of the app exerted statistically significant positive effects on adherence (ß = 0.007, 95% CI, 0.001-0.017 and ß = 0.003, 95% CI 0.0004-0.008, respectively). DISCUSSION: Users' adherence is motivated by positive perceptions of the app's features and pre-intervention improvements. CONCLUSIONS: Determinants of adherence should be assessed, and targeted, to increase the impact of fully automated digital interventions.

Efficacy of a Smartphone-Based Virtual Companion to Treat Insomniac Complaints in the General Population: Sleep Diary Monitoring Versus an Internet Autonomous Intervention.

(1) Background: Insomnia is the most prevalent sleep disorder worldwide and cognitive behavioral therapy is the front-line treatment. Digital health technologies have a role to play in screening and delivering interventions remotely and without the need for human intervention. The KANOPEE app, which provides a screening and behavioral intervention for insomnia symptoms through an interaction with a virtual agent, showed encouraging results in previous studies during and after the COVID-19 lockdown, but has not yet been evaluated in a controlled study. This study aims at comparing the benefits of KANOPEE, a smartphone application dealing with insomnia complaints, with another application proposing an electronic sleep diary named "My Sleep Diary". The acceptance and potential benefits of these digital solutions are tested in real-life settings (i.e., without soliciting human medical resources) and in the general population. (2) Methods: Subjects were included if they downloaded one of the apps between December 2020 and October 2021, and were of legal age. Both apps were available on downloading platforms in France. Primary outcome was Insomnia Severity Index (ISI), and secondary outcomes were total sleep time (TST), sleep efficiency (SE) and wake time after sleep onset (WASO). (3) Results: A total of 535 users completed the intervention with KANOPEE and 489 users completed My Sleep Diary, both for 17 days. KANOPEE users improved their ISI score significantly more than sleep diary users (interaction Time*Group: F(2,2002) = 17.3, p < 0.001). Similar results were found for nocturnal sleep parameters (TST) (KANOPEE users gained 48 min of sleep after intervention, while My Sleep Diary users gained only 16 min of sleep), and particularly in the population with moderate to severe initial sleep complaints (F(4,1980) = 8.9, p < 0.001). Other sleep markers (SE and WASO) were significantly improved in the KANOPEE users compared to the sleep diary ones (p < 0.001). (4) Conclusions: KANOPEE provides significantly greater benefits than an electronic sleep diary regarding reduction of insomnia complaints and estimated nocturnal sleep characteristics in a self-selected sample of the general population. Population with the most severe initial ISI score (≥15) benefited the most from the KANOPEE App compared to filling up a simple sleep diary.

Fear and stop: a role for the amygdala in motor inhibition by emotional signals.

Rapid interruption of ongoing motor actions is crucial to respond to unexpected and potentially threatening situations. Yet, it remains unclear how motor inhibition interacts with emotional processes. Here we used a modified stop-signal task including an emotional component (fearful faces) to investigate whether neural circuits engaged by action suppression are modulated by task-irrelevant threat-related signals. Behavioral performance showed that reaction times were prolonged in the presence of incidental threat information, and this emotional slowing was enhanced when incorrect responses were made following stop signals. However, the speed and efficacy of voluntary inhibition was unaffected by emotion. Brain imaging data revealed that emotional cues during stop trials interacted with activity in limbic regions encompassing the basal amygdala and sublenticular extended amygdala region, as well as with the supplementary motor area (SMA). In addition, successful motor inhibition to threat signals selectively recruited a region in lateral orbitofrontal cortex, distinct from areas in inferior frontal gyrus typically associated with voluntary inhibition. Activity in primary motor cortex was lower when incorrect responses were made on stop signal trials accompanied by a fearful face, relative to neutral, in parallel with the slower response times observed behaviorally. Taken together, our findings suggest that the amygdala may not only promote protective motor reactions in emotionally-significant contexts (such as freezing or defensive behavior) but also influence the execution of ongoing actions by modulating brain circuits involved in motor control, so as to afford quick and adaptive changes in current behavior.

Prolonged nocturnal driving can be as dangerous as severe alcohol-impaired driving.

In industrialized countries one-fifth of all traffic accidents can be ascribed to sleepiness behind the wheel. Driver sleepiness can have many causes, including the use of medicinal drugs or prolonged driving. The present study compared the effects of prolonged highway driving at night with driving impairment caused by alcohol. A cross-over balanced design tested 14 healthy young men who drove three sessions during night-time on the open road. The driving sessions were of 2, 4 and 8 h (03:00-05:00, 01:00-05:00 and 21:00-05:00 hours) duration. Standard deviation of lateral position (SDLP, cm), measuring the weaving of the car in the last driving hour of each session, was the primary parameter. Only 2 h of continuous nocturnal driving were sufficient to produce driving impairment comparable to a blood alcohol concentration (BAC) of 0.05%; after 3 h of driving impairment corresponds to a BAC of 0.08%. In conclusion, a maximum of two continuous nocturnal driving hours should be recommended.

[Sleep and accidents]. / Sommeil et accidents.

The evolution of society and labor organization (24/7 working) has significantly changed our lifestyles and increased the number of workers with sleep debt and staggered hours. Populations are particularly at risk of excessive sleepiness due to sleep deprivation (professional obligations), circadian factors (e.g. night driving) and sleep disorders (e.g. obstructive sleep apnea syndrome and hypersomnia). Excessive daytime sleepiness (i.e. difficulty staying awake) is estimated to affect about 5 % of the population. Public health studies have shown that sleepiness at the wheel and other risks associated with sleep are responsible for 5% to 30% of road accidents, depending on the type of driver and/or road. Strategies to reduce accidents related to sleepiness include--reliable diagnosis and treatment of sleep disorders,--management of chronobiological conflicts,--adequate catch-up sleep, and--countermeasures against sleepiness at the wheel.

Sleep timing, chronotype and social jetlag: Impact on cognitive abilities and psychiatric disorders.

Sleep timing is controlled by the subtle interplay between circadian and homeostatic oscillators which, according to their endogenous properties, allow beings to feel spontaneously that it is time to go to bed or wake up in synchrony with the earth's light/dark cycle. In humans, however, social time and nocturnal artificial light modify sleep timing. Our modern lifestyle and artificial nocturnal light delay our bedtime, make us wake up, and lead to a greater intraindividual variability in sleep timing. Depending on the constraints that social time places on us, our sleep timing may be in or out of phase with the internal circadian timing determined by the circadian clock. When a person's social time is out of phase with their circadian time, they may be considered to suffer from circadian disruption or 'social jetlag'. There are interindividual differences in sleep timing that are known as morningness-eveningness preferences or chronotype, e.g. late chronotypes go to bed later. Chronotype may be assessed in terms of differences in kinetic homeostatic sleep pressure, intrinsic circadian period (ICP) and/or phase angle entrainment. In addition, chronotype depends on genetic and age-related factors, e.g. it gets earlier as people grow older. The social time of late chronotype individuals during week days is not adapted to their circadian time, unlike on free days. This results in social jetlag and circadian disruption, which in turn induces a chronic sleep debt due to a late bedtime and an early wake time, which is compensated on free days but only partially. Sleep and circadian clock disruption generally alter cognitive performance (alertness, attention, memory, higher-order executive functions such as response inhibition and decision-making) but their impact remains to be clarified. When subjects adopt their preferred sleep timing, a "synchrony effect" often appears with chronotypes performing better during daytime at optimal than at suboptimal timing (late chronotypes perform better in the evening, early chronotypes in the morning). Evening types appear to be cognitively more vulnerable to suboptimal times than morning types, probably because they have to deal with social jetlag and the "wake effort" period after awakening. Circadian disruption, but not chronotype, may impact attentional/inhibitory performance (more impulsivity and inattention). Strong associations have been found between mood disorders or attention deficit hyperactivity disorder (ADHD) and chronotype, with these psychiatric disorders typically being overrepresented in evening types. The association between social jetlag and these psychiatric disorders is less obvious. Social jetlag can be corrected by reducing exposure to evening light, although eveningness may be considered as a lifelong factor predisposing to depression or inattention.

Sleep in Normal Aging, Homeostatic and Circadian Regulation and Vulnerability to Sleep Deprivation.

In the context of geriatric research, a growing body of evidence links normal age-related changes in sleep with many adverse health outcomes, especially a decline in cognition in older adults. The most important sleep alterations that continue to worsen after 60 years involve sleep timing, (especially early wake time, phase advance), sleep maintenance (continuity of sleep interrupted by numerous awakenings) and reduced amount of sigma activity (during non-rapid eye movement (NREM) sleep) associated with modifications of sleep spindle characteristics (density, amplitude, frequency) and spindle-Slow Wave coupling. After 60 years, there is a very clear gender-dependent deterioration in sleep. Even if there are degradations of sleep after 60 years, daytime wake level and especially daytime sleepiness is not modified with age. On the other hand, under sleep deprivation condition, older adults show smaller cognitive impairments than younger adults, suggesting an age-related lower vulnerability to extended wakefulness. These sleep and cognitive age-related modifications would be due to a reduced homeostatic drive and consequently a reduced sleep need, an attenuation of circadian drive (reduction of sleep forbidden zone in late afternoon and wake forbidden zone in early morning), a modification of the interaction of the circadian and homeostatic processes and/or an alteration of subcortical structures involved in generation of circadian and homeostatic drive, or connections to the cerebral cortex with age. The modifications and interactions of these two processes with age are still uncertain, and still require further investigation. The understanding of the respective contribution of circadian and homeostatic processes in the regulation of neurobehavioral function with aging present a challenge for improving health, management of cognitive decline and potential early chronobiological or sleep-wake interventions.

Self-perceived sleep during the Maintenance of Wakefulness Test: how does it predict accidental risk in patients with sleep disorders?

STUDY OBJECTIVES: To determine whether the feeling of having slept or not during the Maintenance of Wakefulness Test (MWT) is associated with the occurrence of self-reported sleep-related traffic near misses and accidents in patients with sleep disorders. METHODS: This study was conducted in patients hospitalized in a French sleep center to perform a 4 × 40 min MWT. Relationship between mean sleep latency on the MWT, feeling of having slept or not during MWT trials and sleep-related near misses and accidents reported during the past year was analyzed. RESULTS: One hundred and ninety-two patients suffering from OSAS, idiopathic hypersomnia, narcolepsy, restless leg syndrome or insufficient sleep syndrome were included. One hundred and sixty-five patients presented no or one misjudgment of feeling of having slept during MWT trials while 27 presented more than two misjudgments. Almost half of the latter (48.1%) reported a sleepiness-related traffic near miss or accident in the past year versus only one third (27.9%) for the former (p < 0.05). Multivariate logistic regression showed that patients with more than two misjudgments had a 2.52-fold (95% CI, 1.07-5.95, p < 0.05) increase in the risk of reporting a sleepiness-related near miss/accident. CONCLUSIONS: Misjudgment in self-perceived sleep during the MWT is associated with the occurrence of self-reported sleepiness-related traffic near misses and accidents in the past year in patients suffering from sleep disorders. Asking about the perception of the occurrence of sleep during the MWT could be used to improve driving risk assessment in addition to sleep latencies.

Does Homeostatic Sleep Pressure Buildup Explain Objective Excessive Daytime Sleepiness in Adults With ADHD? An Exploratory Study.

Background: Excessive daytime sleepiness (EDS) is central in Attention deficit hyperactivity disorder (ADHD) but its causes remain unclear. The aim of this study was to explore objective EDS and homeostatic sleep pressure buildup, evaluated by power theta-alpha frequency (PTAF), in drug-free sleepy adults with ADHD and controls. Methods: Participants were placed during a 36-h period of extended wakefulness under constant routine protocol to strictly control sleep time, sleep duration, and circadian zeitgebers. Results: Eight drug-free sleepy patients with ADHD and 7 matched controls were included. The ADHD group had significantly shorter sleep latency on the Maintenance of Wakefulness Test (MWT) throughout extended wakefulness than the control group. There was no significant difference between the groups in PTAF evolution during extended wakefulness and in kinetic sleep pressure buildup, evaluated by the time constant of saturating exponential function. Limitations: The sample was small, so the findings cannot be generalized. Moreover, psychiatric comorbidities and circadian regulation should be taken into account in future studies. Conclusion: In very controlled conditions, mean sleep latency on the MWT during the whole extended wakefulness was significantly shorter in sleepy patients with ADHD than in control subjects. However, the difficulty to remain awake during soporific circumstances observed in these patients with ADHD cannot be explained by changes in the kinetic of sleep pressure buildup. Clinical Trials Registration: www.clinicaltrials.gov/, Identifier: NCT02217371.

Maintenance of wakefulness test: how does it predict accident risk in patients with sleep disorders?

STUDY OBJECTIVE: To determine whether the objective level of alertness measured by the Maintenance of Wakefulness Test (MWT) is associated with the occurrence of self-reported sleepiness-related traffic near misses and accidents related to sleepiness in patients with sleep disorders. METHODS: This case-control study was conducted over a three-year period in four French sleep centers during a 4∗40 min MWT in patients driving more than 5000 Km/year. Relationship between mean sleep latency on the MWT (MWT latency) and age, sex, driving, sleepiness-related near misses and accidents reported during the previous year, and sleep disorder characteristics was analyzed. RESULTS: Of 377 patients suffering from OSAS, idiopathic hypersomnia, narcolepsy, restless leg syndrome or insufficient sleep syndrome, 176 were included. 74 cases reported an accident or near miss related to sleepiness at the wheel in the past year, and 102 reported no accident/near miss (control patients). Thirty-one (37.8 %) cases and 9 (8.8 %) controls reported being sleepy at the wheel more than once a week (p < 0.0001). After adjusted regression analyses, patients with MWT latency between 19 and 33 minutes had a 3.2- (CI 95%[1.5; 6.8], p < 0.0001) fold increase in risk of reporting a near miss/ accident and patients with MWT latency <19 min had a 5.5- (CI 95%[2.2; 13.8], p = 0.003) fold increase in this risk, compared to the referent group (MWT latency>33 min). CONCLUSIONS: MWT latency is associated with self-reported, sleepiness-related near misses and accidents related to sleepiness in the past year in patients routinely investigated in sleep clinics. The MWT could be used to assess driving risk together with clinical interviews assessing sleepiness at the wheel.

Sleepiness, near-misses and driving accidents among a representative population of French drivers.

Study objectives were to determine the prevalence of sleepy driving accidents and to explore the factors associated with near-miss driving accidents and actual driving accidents in France. An epidemiological survey based on telephone interviews was conducted on a representative sample of French drivers. The questionnaire included sociodemographics, driving and sleep disorder items, and the Epworth sleepiness scale. Of 4774 drivers (response rate: 86%), 28% experienced at least one episode of severe sleepiness at the wheel (i.e. requiring to stop driving) in the previous year; 11% of drivers reported at least one near-miss accident in the previous year (46% sleep-related); 5.8% of drivers reported at least one accident, 5.2% of these being sleep related (an estimate of 90,000 sleep-related accidents per year in France). Sleepy driving accidents occurred more often in the city (53.8%), during short trips (84.6%) and during the day (84.6%). Using logistic regression, the best predictive factor for near-misses was the occurrence of at least one episode of severe sleepiness at the wheel in the past year [odds ratio (OR) 6.50, 95% confidence interval (CI), 5.20-8.12, P < 0.001]. The best predictive factors for accidents were being young (18-30 years; OR 2.13, 95% CI, 1.51-3.00, P < 0.001) and experiencing at least one episode of severe sleepiness at the wheel (OR 2.03, 95% CI, 1.57-2.64, P < 0.001). Sleepiness at the wheel is a risk factor as important as age for traffic accidents. Near-misses are highly correlated to sleepiness at the wheel and should be considered as strong warning signals for future accidents.

Excessive Daytime Sleepiness Measurements in Children With Attention Deficit Hyperactivity Disorder.

Attention deficit hyperactivity disorder (ADHD) is the most commonly diagnosed neurodevelopmental disorder in childhood. It is a heterogeneous disorder in terms of clinical presentation that is probably due to the frequent occurrence of comorbidity. Children with ADHD more frequently report sleep disorders (notably delayed sleep phase syndrome) and excessive daytime sleepiness (EDS) than typically developing children. The aim of this article is to propose a narrative review of the assessment of EDS in the context of ADHD with first a summary of the subjective and objective tools used to measure it. Secondly, perspectives in terms of electroencephalogram (EEG) markers and neurofeedback are proposed. Then, possibilities for new kinds of evaluation are discussed (virtual reality, ecological momentary assessment, etc.). Lastly, we discuss specific clinical situations with EDS in the context of ADHD as links with narcolepsy, the comorbidity with other psychiatric disorders, and the context of sluggish cognitive tempo.

Virtual Remediation Versus Methylphenidate to Improve Distractibility in Children With ADHD: A Controlled Randomized Clinical Trial Study.

Objective: Virtual environments have been used to assess children with ADHD but have never been tested as therapeutic tools. We tested a new virtual classroom cognitive remediation program to improve symptoms in children with ADHD. Method: In this randomized clinical trial, 51 children with ADHD (7-11 years) were assigned to a virtual cognitive remediation group, a methylphenidate group, or a psychotherapy group. All children were evaluated before and after therapy with an ADHD Rating Scale, a Continuous Performance Test (CPT), and a virtual classroom task. Results: After therapy by virtual remediation, children exhibited significantly higher numbers of correct hits on the virtual classroom and CPT. These improvements were equivalent to those observed with methylphenidate treatment. Conclusion: Our study demonstrates for the first time that a cognitive remediation program delivered in a virtual classroom reduces distractibility in children with ADHD and could replace methylphenidate treatment in specific cases.

Objective Level of Alertness and Inhibitory Control Predict Highway Driving Impairment in Adults With ADHD.

Objective: It remains unclear whether daytime impairments in ADHD patients are better explained by an altered level of alertness and/or by cognitive deficits. The aim of this study was to determine the respective contribution of these factors on driving performance in ADHD adults. Method: ADHD adults (n = 39) and healthy controls (n = 18) underwent a nocturnal polysomnography (PSG) followed by a Maintenance of Wakefulness Test (MWT), a simulated driving task, and a neuropsychological evaluation. Results: ADHD patients had shorter mean sleep latency on the MWT and worse driving performance than controls. They also made more errors on attention and executive functioning tests. Logistic regression analyses showed that inhibition deficits and objective daytime sleepiness predicted highway driving performance in ADHD. Conclusion: Our study shows that not only inhibitory control deficits but also pathological level of alertness independently contribute to highway driving impairment in ADHD patients, providing a better understanding of the pathophysiological mechanisms involved in ADHD.

Maintenance of Wakefulness Test, obstructive sleep apnea syndrome, and driving risk.

OBJECTIVE: Sleepiness at the wheel is a major risk factor for traffic accidents. Because of the potential medical and legal implications, in this study, we evaluated the correlation between subjective and objective measures of sleepiness and driving performances in patients suffering from excessive daytime sleepiness. METHODS: Thirty-eight untreated sleep apnea patients (mean age +/- standard deviation, 51 +/- 9 years; mean apnea-hypopnea index +/- standard deviation, 41 +/- 25), and 14 healthy control subjects (mean age +/- standard deviation, 46 +/- 9 years) were included in the study. Nocturnal polysomnography, mean sleep latency as measured by four 40-minute Maintenance of Wakefulness Test (MWT) trials, Epworth Sleepiness Scale, Karolinska Sleepiness Scale, and the number of inappropriate line crossings during a 90-minute real-life driving session were analyzed. RESULTS: The number of inappropriate line crossings correlated with MWT scores (Spearman's Rho: r = -0.339; p < 0.05), Karolinska Sleepiness Scale scores measured at halfway in total driving distance (Rho: r = 0.367; p < 0.01), and Epworth Sleepiness Scale (Rho: r = 0.389; p < 0.01). We found a significant difference in the number of inappropriate line crossings among the four groups defined by MWT scores (very sleepy [0-19 minutes], sleepy [20-33 minutes], alert [34-40 minutes], and controls) (Kruskal-Wallis test: H = 11.319; p < 0.01). Very sleepy and sleepy patients had more inappropriate line crossings than the control drivers (p < 0.05). INTERPRETATION: In addition to subjective sleepiness scales, the MWT can be used to assess driving ability in untreated sleep apnea patients.

Confinement and sleep deprivation effects on propensity to take risks.

INTRODUCTION: The impact of confinement and sleep deprivation on risk-taking propensity is a key issue in crew management. We investigated both confinement and gender effects on risk propensity and performance during up to 36 h of extended wakefulness. METHOD: We studied 4 groups of 3 men and 3 women [N = 24, mean age (+/- SD) = 32.9 +/- 5.8 yr] for 10 consecutive days: a 7-d confined period (CONF) or a 7-d baseline (BASE) condition preceding one control night of normal sleep, one night of sleep deprivation, and one recovery night in the laboratory. Risk propensity (EVAR scale) and simple reaction time task (SRTT) performances were monitored every 2.25 h (0930-1945) during CONF and every 2.11 h (0930-0745) during the sleep deprivation condition. RESULTS: Overall risk propensity during extended wakefulness showed a variation in both conditions with two diurnal peaks separated by a nocturnal minima. After the confinement period, no second peak was found. Number of lapses (reaction time > 500 ms) on the SRTT varied daily in both conditions. In the normal sleep schedule, subjects increased their level of impulsiveness between the first day and the end of confinement (P < 0.05). DISCUSSION: During the night of sleep deprivation, risk-taking propensity decreases and remains stable the following day in the confinement condition while it increases after the baseline period. In a confined environment under a normal sleep-wake schedule, impulsiveness increases in men and women.