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Measurements: Self-rated fatigue and sleepiness, simple reaction time before and after each session, number of inappropriate line crossings from the driving simulator and from video-recordings of real driving.

Results: Line crossings were more frequent in the driving simulator than in real driving (P < .001) and were increased by sleep deprivation in both conditions. Reaction times (10% slowest) were slower during simulated driving (P = .004) and sleep deprivation (P = .004). Subjects had higher sleepiness scores in the driving simulator (P = .016) and in the sleep restricted condition (P = .001). Fatigue increased over time (P = .011) and with sleep deprivation (P = .000) but was similar in both driving conditions.

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Conclusions: Fatigue can be equally studied in real and simulated environments but reaction time and self-evaluation of sleepiness are more affected in a simulated environment. Real driving and driving simulators are comparable for measuring line crossings but the effects are of higher amplitude in the simulated condition. Driving simulator may need to be calibrated against real driving in various condition.

Hybrid electric vehicles (HEVs) are perceived to be more energy efficient and less polluting than conventional internal combustion engine (ICE) vehicles. However, increasing evidence has shown that real-driving emissions (RDE) could be much higher than laboratory type approval limits and the advantages of HEVs over their conventional ICE counterparts under real-driving conditions have not been studied extensively. Therefore, this study was conducted to evaluate the real-driving fuel consumption and pollutant emissions performance of HEVs against their conventional ICE counterparts. Two pairs of hybrid and conventional gasoline vehicles of the same model were tested simultaneously in a novel convoy mode using two portable emission measurement systems (PEMSs), thus eliminating the effect of vehicle configurations, driving behaviour, road conditions and ambient environment on the performance comparison. The results showed that although real-driving fuel consumption for both hybrid and conventional vehicles were 44%-100% and 30%-82% higher than their laboratory results respectively, HEVs saved 23%-49% fuel relative to their conventional ICE counterparts. Pollutant emissions of all the tested vehicles were lower than the regulation limits. However, HEVs showed no reduction in HC emissions and consistently higher CO emissions compared to the conventional ICE vehicles. This could be caused by the frequent stops and restarts of the HEV engines, as well as the lowered exhaust gas temperature and reduced effectiveness of the oxidation catalyst. The findings therefore show that while achieving the fuel reduction target, hybridisation did not bring the expected benefits to urban air quality.

Starting in 2017, the Real-Driving Emissions (RDE) test became part of the type-approval procedure for all new passenger cars and vans. The RDE test is an on-road emissions test meant to complement laboratory tests to ensure vehicle emissions are similar during normal, real-world operating conditions as they are during laboratory testing. The RDE regulation was adopted in four packages between 2015 and 2018.

bExtended driving conditions are still allowed to count towards a valid trip, but the pollutant emissions (excluding CO2) measured must be divided by 1.6 before evaluating compliance with emissions limits

Where CF is a conformity factor and EURO-6 is the Euro 6 emission limit in mg/km. The conformity factor allows for vehicles to emit by a certain factor above the Euro 6 emission limit when driving on the road. Conformity factors are shown in the table below:

In addition to specifying the trip characterization, other defined boundary conditions include ambient conditions, stop times, maximum speed, and altitude. A set of additional dynamic boundary conditions has been added for the second RDE legislative package to exclude driving that could be regarded as too smooth or too aggressive, based on indicators such as speed and acceleration. The table shows the dynamic boundary conditions for the RDE tests.

Even though epidemiological studies show associations between behavioral sleep deprivation or sleep disorders and accident risk, experimental studies are needed to confirm the relationship between sleepiness and risk of accidents. One such study11 demonstrated that patients with narcolepsy and OSAS have impaired driving performance on a simulated driving task compared to controls.

Countermeasures to sleepiness exist and their effect on driving risk has been demonstrated. Naps, caffeine intake, or exposure to continuous blue light have a positive effect on real-life driving performance in sleep deprived healthy subjects,12,13 and continuous positive airway pressure improves driving skills in patients with OSAS.14,15 Modafinil is a first-line pharmacological treatment for daytime sleepiness in narcolepsy and IH. One study investigated its beneficial effects on simulated driving performance in patients with narcolepsy,16 and no study has demonstrated in on-road conditions the efficacy of alerting drugs, used in narcolepsy or IH, on driving performance.

We have clearly shown that untreated patients with OSAS have altered performance in real driving conditions,17 and that Maintenance of Wakefulness Test (MWT) can predict this driving impairment. However, no study has yet evaluated the relationship between MWT scores and real driving performance in patients with hypersomnia.

Each patient received modafinil (400 mg/day) or placebo for 5 consecutive days in a randomized double-blind placebo-controlled crossover design (Figure 1). The placebo was of the same appearance (color and size of the capsule) and taste as the trial medication; it was prepared by the Central Pharmacy of the University Hospital Center of Bordeaux. Modafinil and placebo administrations were separated by a 3-week washout period. Treatment was administrated at 08:00 (modafinil 2100 mg) and 12:30 (modafinil 2100 mg). For the first 3 days, the subjects stayed at home where they were instructed to maintain their habitual sleep/wake schedules assessed by actigraphy and sleep diary. The length of this period was choosen due to the half-life of modafinil (15 h); 3 days are required to eliminate the drug. Prior to the start of the study, all patients were treated with modafinil when taking a stimulant medication except one patient treated with modafinil and methylphenidate; during the entire protocol, this patient received only modafinil to match the other patients. At the beginning of the protocol, all patients received either modafinil (400 mg) or placebo for a 3-day period before entering the test sessions the next 2 days. At the end of the day 3, patients were called back in the laboratory to perform an overnight polysomnography (PSG) (night 4). The next day (day 4) patients underwent an MWT to assess their level of objective sleepiness and a second overnight PSG (night 5). The last day (day 5), patients performed an on-road driving session. Patients were paid 400 euros for their involvement in the study.

Overview of protocol design. A placebo condition (top panel) and a modafinil condition (400 mg/day) (lower panel) for 5 consecutive days separated by a 3-week washout period were administered in a randomized crossover double-blind placebo-controlled design in patients with narcolepsy and idiopathic hypersomnia (IH). The length of the 3-day period at home was chosen due to the half-life of modafinil (15 h); 3 days are required to eliminate the drug. Treatment was administrated at 08:00 (modafinil 2100 mg) and 12:30 (modafinil 2100 mg). In each condition, a period of 3 days at home with actigraphic recordings and sleep diary was followed by successive 36 h with 2 polysomnography (PSG) nights (nights 4 and 5) and 2 days to perform a 4 40-min Maintenance of Wakefulness Test (MWT) (day 4) and a 2-h on-road driving session (day 5).

Schematic representation of the on-road driving test. A Continental system continuously records the actual position of the car within the traffic lane by tracking the relative distance of the car from the delineated stripe in the right of the road. Primary outcomes are Inappropriate Line Crossings (ILC) and Standard Deviation of Lateral Position (SDLP) (cm).

Mean number of Inappropriate Line Crossings (ILC) with on-road driving in patients with narcolepsy and idiopathic hypersomnia (IH) under placebo and modafinil and in healthy controls (mean standard error). *P < 0.05.

Patients with narcolepsy have continual fluctuations of vigilance with attention difficulties22,23 that affect a wide variety of activities of daily living,24 including automobile driving. Modafinil has been shown to significantly improve cognitive performance including executive functions in healthy subjects in normal and sleep deprived conditions.25 Our study is the first to investigate the benefit of a reference wake-promoting drug, i.e., modafinil, on real driving condition in patients suffering from narcolepsy or IH. Modafinil caused a substantial reduction in the number of ILC and SDLP of the vehicle on the highway. This result confirms the beneficial effect of modafinil on driving skills in patients with narcolepsy and IH using validated criteria of driving performance.26

Regarding the limitations of the current study, different cognitive processes can be involved in specific situations of automobile driving. The vigilance component is usually involved during a prolonged and monotonous situation of driving on highway. If the situation requires more attention (i.e., increased traffic), the driver is then in condition of sustained attention. The driving conditions in our experiment were stimulant though involving a high cognitive load due to heavy traffic. Additional studies will have to verify that patients with hypersomnia do not experience more difficulty in monotonous driving situations involving the vigilance component. It is possible that the vigilance component is more affected than the sustained attention component in these patients during driving. Another limitation of our study is the small sample size. More studies are needed to determine the reproducibility of data. Finally, our control group was not matched in age with the patient group but was older. However, no degradation of driving performance has been observed between young and middle-aged drivers on the highway;27 therefore, our conclusions remain valid. ff782bc1db