professor at the Faculty of Medicine of the University of Lisbon, and clinical director of occupational health services at the Municipality of Lisbon in Portugal. Our second presenter is Dr. Chumbai Zhang. He's an internist, occupational medicine, and sleep medicine specialist. His occupational sleep related research has focused on how sleep disorders affect job related performances. Dr. Zhang currently serves as the medical director and section chief of employee occupational health service as the VA budget sound health care system. He's an assistant professor of medicine at the School of Medicine and an adjunct assistant professor at the School of Public Health both at University of Washington. And yours truly, Dr. Vlad Bakarios, medical director of Center for Occupational Health and Mental Health Practice, which provides treatment and med legal evaluation of injured workers in San Francisco Bay Area, California. All right, so before I pass the baton to Dr. Diaz, let me first say a couple of words. Why do we present together? And this is kind of multicultural panel of experts, and we decided to present together actually nearly three years ago, but due to COVID the presentation was postponed twice. So finally we have an opportunity and we present together not only because we have our mutual clinical interests, but also because of the inextricably connection between alcohol use and tobacco, obesity, and sleep. And as you can see on this slide, these connections are bi-directional. Use of alcohol and tobacco, as well as obesity, affects sleep, and insomnia in its turn affects weight and use of both substances. So let me pass the word to Dr. Diaz, who will be the first to start, and if we can turn him on. There he is. Georgi, you're on? Yes, yes, I am. Are you listening? I'm okay? It's okay. Thank you very much. Well, I have here a delay of sounds. Maybe I can mute this. I don't know how to do it. Well, let's see. Are you listening to me? Okay. Well, thank you very much. It's a pleasure to be online. I prefer to be present, but COVID test doesn't allow me to travel to you. So anyway, it's a pleasure to present this with my colleagues. Well, we are talking about these important subjects, about alcohol, tobacco, obesity, and sleep in workplace, and we divided a little bit these subjects. I will talk more about alcohol, tobacco, and obesity, and my friends will talk more about sleep. So I will talk about some facts, evidence base, some recommendations, and diagnostic criteria, and screening tools. But I address this question. Are alcohol, tobacco, and obesity, and sleep, occupational health issues? Is our matter also or not? Well, let's see. In fact, tobacco, obesity, and sleep, and alcohol are very, very important public health contaminants. Sorry. And so the deaths in the ages between 50 and 70 in 69 years for both sex in Portugal, but also in other countries. The risk factor most important for death attribute, different for these risk factors are, first of all, the tobacco, the high pressure, the overweight, the alcohol, and excessive consumption of salt. This is very the same in the old world. So we can say that alcohol is linked to over 200 health conditions, including liver diseases, road injuries, violence, cancer, cardiovascular diseases, suicides, tuberculosis, and AIDS with avoidable behaviors. So also we know that less developed countries has higher burden of alcohol. And also we know that the highest consumptions of alcohol makes even higher burden and more heaviest burden of these problems. So in America is the second highest consumption, and in Europe is the biggest one, as we say, in comparison. Also, we know that it's estimated that 4.9 of adult world population has suffered for alcohol-related problems. So it's a big, big issue. The alcohol is so around us and so in our culture that we even forget to think about it. So the conclusion is that tobacco and alcohol consumptions are by far the most prevalent addictive behaviors and cause the vast majority of harm of non communicable diseases. So in the agenda of WHO, we have for sustainable developed goals that we want to reduce the premature mortality in one third of non communicable diseases. And for these, we need to address the universal access to health services. And this, I give, and I add this, that is the importance of the occupational health services. In this way, I said, yes, alcohol, tobacco, and obesity and sleep are issues of occupational health services. And also the control of non communicable diseases and risk factors are connected with alcohol, tobacco. So we need to, yes, to address these risk factors. So the question for this psychological risk factor as an alcohol consumption, as an example of behavior risk factor at work, the question is why? And Sir Michael Marmot says that the people turn to alcohol, drugs, and tobacco to numb the pain of harsh economic and social conditions. So we have in the workplace for burden, we have that 25% of work accidents are connected with alcohol and 60% of fatal accidents are connected with alcohol. So in Europe also, we have this as a priority area of intervention. So the prevention of harmful effects of alcohol in adults, and also the reduction of negative repercussions in workplace. And this is statistics about road safety. So mortal victims, serious injuries, and minor injuries in Portugal, but the other countries, at least in Europe, is not so different. And we can see here that weekdays has less accidents and burden than weekend days. So Friday, Saturday, and Sunday has more accidents and more burden and important burdens. So we can say also that the consumption of alcohol is a socializing consumption that goes in our organizations. So this is the population that we can, for the country or for our companies or wherever. But anyway, for a country, we say the alcohol consumption has different levels of consumption in the population from abstinence to low, going to low risk until severe dependence. And also, this is connected with the levels of risk from none, low, moderate, and high risk. And also for health services, we have different levels of interventions. When we are here, the operational health services are here in the level one, and we need to address this level one and level two to try that in our organizations, our workers are more safety in this alcohol consumption. And this is very important, very important concept, the continuum factor. We need to know that everyone can go to other level. It depends on something that happened in his life that makes it. So we need to address always to stop the continuous to go up until the biggest consumption. And so the operational population, what we see in most is mostly the dependence. And what we do is more about the dependence. But we should do more to address more those consumption, the socialized and that maintain the going to the dependence and maintain the culture of consumption and going to the dependence. So the companies ask us to make testing, excluding the heads, but maintain the consumer culture. And we need to be careful about that. About tobacco, of course, everybody is a fact. 21% of deaths globally is connected with tobacco in non-communicable diseases. Tobacco is the world's largest preventable cause of premature death. And what about the smoking cessations? Smoking cessations are in some programs of health services and companies is beneficial at any age, reduce the risk of premature death and can add as much as one decade of life expectancy. Smoking is a substantial financial burden for smokers, for health care systems and for society. On the other hand, the smoking cessation give us, reduce this burden. And smoking cessation reduce risk for many adverse health effects, including repetitive health outcomes, cardiovascular diseases, chronic obstructive pulmonary diseases and cancer. So also the chronic obstructive pulmonary diseases and heart disease is something that is very important to remember when we are trying to address and to try that our workers go to smoking cessation. So we need to also there is other issues about smoking cessation difference, different that is different from from countries. But of course, we need to address also the price, also the the pharmacy of medications approved and behavioural counselling. There is a lot of techniques and it is different from country to country. Well, I say this is we have we talk about the alcohol, we talk about the tobacco and we need to maintain in our companies, in our interventions, some campaigns to help the workers. We can use programs, we can use some some information that is free for them. And we need also, for instance, to address this too. And what about overweight and obesity in United States? Here I took this information from 1990 to 2016. We had an increase of almost 30 percent of early deaths and disability in 2016. Overweight and obesity was linked to deaths of cardiovascular diseases, diabetes, genital, blood and endocrinal diseases, cancer, Alzheimer's disease. So, yes, is an important issue. And this is also very interesting. Obesity and inequities. There is a strong relationship between obesity and low socioeconomic status, especially for women. Overweight and obesity in women for educational level. You can see here this graphic for countries in Europe. You can see that low level education is always bigger, have bigger obesity and obesity in these populations, the low level education than those that have high level education. So we need also to address these differences and be careful about in our professions, inside our companies, why we have this, why we have obesity from others and not for others, for the high level. So we need also to address this factor to think about the interventions that could be different. The communication should be different. So I had the first question about the if this is occupational health issues or not. And the second question could be, do the different professions and the different occupational risk factors cause differences in avoidable behaviours of workers in relation to alcohol, tobacco, obesity and sleep? Well, let's see. In the municipality of Lisbon, we address a bigger research, trying to use the screening tools that could allow us to make comparisons with other companies, with other municipalities in other countries so that we have indicators, occupational health indicators that give us opportunity to work together and networking these problems. And let's see here, we address these dependent factors and also the professional factors. So about the alcohol we use, it is very common, the audit, the audit C and the audit and the tobacco, the Fagerstrand enrichment and the obesity, the body mass index, that's common, but also the abdominal perimeter and cervical perimeter. And for sleep, my colleagues will talk about also Pittsburgh Sleep Quality Index, sleepless care, mostly for drivers, but also the stop and questionnaire that is a small and very easy questionnaire for apnea syndrome. So the first results that compare urban cleaning workers, urban cleaning workers with firefighters, we found differences. So C, no consumption, low consumption or risky consumption. In urban cleaners, we find that there is more urban cleaners that don't drink, but also has more dependence. And in firefighters, we have less people that don't drink at all, but also we don't have so much dependence. So what we have is, in fact, is a kind of consumption more connected with the socializing consumptions. And so, as I said before, the socializing consumption is connected with our culture, culture of consumption. And so continues with this study. Now we have 6,840 workers in our study in this moment and for a universe of 10,000 and is growing. And we have an infography, but I'm not talking about all the infography, but just about some some issues, the sport and the eatings. We had some people that has practiced exercise and about 40 percent is less than three times a week. And also we get the habits of eating for this. We didn't find so many things, but I talk about this 10 percent of drink carbonated and sugar drinks daily. We tried that people drink less, drink sugar carbonate. About the sleep, my colleagues will talk about the sleep is 40 percent of for the older for our study, not for professions, but for that I speak later is 40 percent of less sleep, less than seven hours. 20 percent feel sleepy, 29 percent sleep. The sleep is not restorative, is not sufficient. And 11 percent take pills for two to 12 percent fall asleep when sitting inactive. And six percent have fallen asleep while driving. So also the blood pressure, the criteria of Framingham, we say that 10 percent of the men for so 500 has risk of cardiovascular events. Five percent of women. So about this risk factors, obesity, smoking, risk consumption and sleep problems. Yes, we see that we have here problems to address and to give again like a mirror to our workers. And they can see these indicators as problem of us as professional professionals, but a problem of behavior that they need to change and need to to be aware about this. See that here in sleep, in the problems of sleep, we have a lot of drivers with risky situation about obstructive sleep apnea syndrome. And so but continue with the question, the differences between them here also we address about the smokers and connection about other habits. And we see, as in other studies, that those that smoke more have less sports, also have drink, drink, have more consumption of drugs and also has the most most those that are smokers also drink more, have more alcohol consumption. So when this is the the figure about our our connective risk risk behaviors and we we can address more these kind of populations that are more connect with all or have intervention for just one of the subjects. And here we have the comparison in between police, firefighters, drivers, gardeners, human cleaners, right diggers and school school assistants. And we see that, in fact, they have different levels of risk. Also, and the different here I hit the age, the average of age are not so different, but we have different differences between them. Sleep here, see that the police and firefighters has a lot has higher risky about sleep. And this is connected with the night shifts and also about the stress. But we are still working and studying this. So I'm not talking about all those factors and differences, but just in red light letters, you see the drivers here with a big risk of a mayor. Sorry, the risk of a mayor and the obesity in gardeners and also the smokers and consumptions are high in grave diggers. So this give us questions how to address interventions, how to talk with them, how to arrive to some reduction of this risk. And so the question is, what intervention are the most appropriate, most appropriate for my worker population, how to adapt interventions to our working population, how to organize occupational health services for better results. And universal workers health services, sorry, universal workers health surveillance for better outcomes. How can we do? Is universal surveillance needed? Well, we should say that we don't learn for those who know better. When we want changing in behaviors, we learn from whoever connect with us. And we all, as occupational physicians, but as health professionals, to arrive to some interventions in these fields is very important to know how to connect and then try to change, use all the techniques and all the models to change behaviors. And so we have in the occupational services several professions, several ways to address the safety and occupational health. And also, and then we have activities fit to work, return to work, workplace assessment. Also, we have campaigns, prevention for all these that we are talking, and also other issues. And so my question is, who decides the occupational health needs for workers? Who is the best, who knows more what the workers needs? I say that it's us, not the employer. We need to address these risk factors, all the risk factors, and decide all that. So this is connected with health surveillance or not, or teamwork just with all connected services, or just a part, some that do fitness work, and others do return to work, work assessments. Who should decide? Well, this is our model for our municipality of Lisbon. And we here, in the center, we have the worker. And we want for the organization cohesion and health. And also, the worker is middle inside the organization and outside the organization, the community. And of course, we want all well-being. About, around him is occupational professionals, occupational and safety. And around, we have all as a team, but inside and connected, and also articulated for interventions individually, and also collective, but multidisciplinary interventions. And also with the safety professionals. Around is the entities out of the community that audit us. And I say that we are important, but the most important is those for the culture of safety and health. We need also to address the group, the organization, the culture inside. So the management, the work colleagues, the social network, and the family are very important to address as a way to get the solutions and interventions. And so this is my last question. What kind of occupational health our organization should have? And I'll let you with this last question for your organization. Thank you very much, and welcome in Lisbon anytime. Thank you. Thank you, Dr. Dias. And the next in line is Dr. Chumba Ejeng. We will accept the questions and try to answer them after all the presentations are done. So we have allocated time for that. No worries. You're on. Okay. Good morning, everybody. It's George. Great job. So glad that you could join us from Lisbon, despite the COVID situation. I, too, are talking to you from Seattle, where I am currently in the employee occupational health at the VA Puget Sound. Let me try to put this on the presentation mode. Can everybody see this? Go to slideshow. Yeah, slideshow. Hold on. Okay. So briefly, I think, just to piggyback on George's talk, I'm going to focus my talk slightly on the non-insomnia and non-sleep apnea issues, since sleep apnea and insomnia will be covered in other sessions also by Vlad a little later. So first slide, I wanted to tell you briefly about the duration of sleep. So this is a slide from the National Sleep Foundation indicating the ideal amount of sleep we need, and as we progress from our infantry to the older age, we do need less and less sleep. And in the adult populations, you see seven to nine hours is probably ideal for us. Any longer or any shorter than that, sometimes possible, maybe appropriate for a different individual, depending on their genetic disposition, but not recommended for any longer and shorter. Both are associated with higher morbidity and mortality. A brief slide on the sleep stages and architecture. This is a typical slide in a sleep study indicating various stages of sleep. So this addresses the quality of sleep. We have the wakeful hours in the W on the left side of the W indicates the wakeful hours, followed by REM sleep, which is a dark bar in the middle, rapid eye movement stage where you have active dreaming and your bodies are actually locked up, so you don't act out your dream. In some rare cases, people can break through REM sleep and they move. Those are actually not very good signs. In the non-REM sleep, they're divided into the stage one, two, and three. The higher the number, the more deep it is. Stage three sleep is associated with a restoratory sleep. The body will repair itself during the deep sleep. So you want to have a lot of REM sleep and deep sleep during your sleep, but not too much of a stage one or two sleep. And there's a periodicity in the cycle. Every 90 minutes or so, people go back into REM sleep. As the night progresses, the REM sleep usually gets longer and longer, and that's the reason why most people wake up remembering their dreams. And some individuals may not remember their dream, not because they don't dream, but because they didn't wake up in the REM sleep stage. And the next slide is about just the change of sleep architecture as we age, as we indicated before. As we age, our REM sleep duration tends to drop further. By the age of 85, we can see that duration is a lot shorter than age five year old. On the other hand, the stage two remains fairly stable. Slow wave sleep, which is stage three sleep, also reduces in volume as we progress. So there's some natural progression of our sleep architecture being different as we age. Next slide is, I want to show you a typical kind of a sleepy, typical United States college student, I would say. It's not the greatest sleep pattern. The black bars are the hours that they're awake, and they tend to have very irregular sleep pattern and then nap very often. And this is the example of just terrible sleep hygiene. I want to shift quickly to chronobiology and jet lag, since this is a part that deals with a shift work syndrome, and we need to understand a little bit of the biology behind that. The circadian rhythm we talk about is approximately 24 hour long, but interestingly, I want to point out that most individuals, our sleep cycle is actually 24.2 hours. And that explains why we tend to have better time delaying our sleep than advancing our sleep. So meaning if you are traveling westward and you're arriving at a place where it's slightly earlier in time, but you could stay up a little bit later, it's generally a little bit more difficult to shift depending on which direction you fly. And the core temperatures, cortisol level, blood pressure, heart rate, all these factors, exercise, hunger, all these factors actually play into how we feel, whether we're subjectively sleepy or not. And there's a part in the hypothalamus called the suprachiasmatic nucleus or SCN, which is the Zeitgeber in German, which meant time giver for our circadian rhythm. So people with rare pituitary tumors sometimes will have those time givers being in disorder. Interestingly, blind people have preserved SCN center. So even for people who are born blind, they do have their intrinsic rhythm as well. And sunlight obviously is the most powerful time giver. So I will talk a little bit later about how light therapy can help us to shift our circadian rhythm forward or backward. Also social cues and whether you have dinner at six o'clock or in Portugal where Georgia is, maybe you have dinner at nine o'clock. So those are different social cues may set different circadian rhythm for different culture. We are very familiar with biological rhythms. We have, as I mentioned before, a 90-minute cycle, four-hour sleep cycle, even during one night. And 24-hour cycle is generally an intrinsic, endogenously regulated cycle with our internal clock at a cellular level. Monthly rhythm, we're familiar with the menstrual cycle and also seasonal rhythm in places where the latitude is very high in Norway and Norwegian countries, Canadian countries where it's well-described that people have seasonal affective disorder. In Seattle, we actually see a fair share given how high the latitude is in the continental US. So I want you to jump around. Let's look at this slide. I want to emphasize the importance of the slide. This is a slide that explains our circadian rhythm and how various factors like light, exogenous melatonin or moderate exercise can help us shift our circadian rhythm. So at the bottom panel in the gray background represents the nighttime. So generally if we don't do any shift work, we'll have our evening time where the sinusoidal curve actually indicates the core body temperature. So we're generally most sleepy at the nadir of that core body temperature, usually around 4 a.m. as most people who have not been trained with other systems should have that natural circadian rhythm because of the day and night shift. And that's probably why most of the military operations starts around 4 a.m. when you want to attack your enemy. You want to make sure you attack during the time they're most sleepy. And in the middle of the black bar represents the habitual bedtime. Most people go to bed around 11 o'clock at night and wake up around 7 in the morning. And you notice the M in front of the black bar represents the evening endogenous melatonin production. So this is something, a tool that we could mimic if we use exogenous melatonin to induce sleep. I'll talk a little bit just in a bit about how we do that. So that's when the endogenous melatonin is excreted. And so most people, if you want to shift to their circadian rhythm from this black bar to go towards the right side, which meaning you want them to be more awake earlier in the evening and shift their sleep a little bit later, what you can do is expose them to light in the evening portion, early evening portion of the night. And that would actually push their sleep time a little later. So in people who travel to a different time zone, light exposure at a local time, especially in the afternoon, can help you shift your sleep circadian rhythm slightly earlier. On the other hand, if you expose your light in the early morning, you actually shift your circadian rhythm backwards. So if you do have, you know, blinds are not working, if you live in an area where there's a lot of environmental ambient light early in the morning, it can shift your sleep time earlier. Melatonin does the opposite. So the dosing actually tends to be somewhat linear. And depending on how high the dose you give, you could shift your sleep cycle slightly earlier or later. Interestingly, if you dose it, we want to want you to dose them approximately four hours before desired bedtime to have the circadian rhythm effect of the melatonin. And it doesn't have to be a high dose. In a lower dose, much, sorry, in a much higher dose, you use that for lay people, they use that for a soporific effect, but a much lower dose can be used to change the circadian rhythm forward and backward. Similarly, if moderate exercise at a certain time can also push your bedtime a little later, moderate exercise in the early evening is actually fine, but it can push your to here slightly later. And also if you, just a little factoid on the side, most Olympic track and field records are broken in the late afternoon, early evening time. That's when the performance is the best among our athletes. Let me just advance this forward. So to summarize what I was just describing, light therapy exposure or avoidance can help us achieve certain rhythm better. And some, in some services, a very detailed life therapy instruction will be given to a company CEOs who travel to help them to get over gel lag and start negotiating contract more effectively. Melatonin exogenously can be used as well as exercise. And this is just a brief summary of how a detailed software can be used to help us regulate our sleep cycle when people travel. University of Michigan has an in-train app that you can use to help doing that. And I'm not affiliated with the product. I'm just introducing that as a, as a, as a way of saying that there are multiple online resources out there to help us in train our sleep. In Boston, Boston Celtics actually consulted with the Boston sleep group. And the recommendation they were given was, you know, eliminate morning practice time to allow the professional basketball players to sleep longer. They have a 2 a.m. rule. So if the players are traveling to a hotel to, for a game away game, if they cannot get to the hotel by 2 a.m., then they stay put in the same place to get an eight hour sleep versus traveling. As you know, many of the professional players who play for one team may not actually live there. They have their private jets and they have a very different lifestyle from laymen. And so the result is they found that these measures actually increase their reaction time and it decreased players' irritability. And during that, seasons after that, I think the Celtics did pretty well in their performance. I'm going to probably in the interest of time, skip or just skim through the sleep app near screening for drivers. Unlike the FAA, the Federal Aviation Administration, the current regulatory agencies don't have a mandate for that. But it's up to the clinicians to have the final determination. If there are some risks, the clinicians suspect sleep apnea, they should refer them to get a sleep study. But there are certainly concerns for incurred costs for diagnostics testing. Sometimes it's a long wait. Sometimes the test itself is not accurate. Sometimes the test is certainly costly. And so that can serve as a problem for the drivers. And also compliance monitoring can be an issue people are not comfortable with. You know, the Big Brother issue. Certain companies are monitoring through Bluetooth live when drivers are on the road. And there are certainly some concerns about privacy invasion from the drivers. And also accommodation. If there's a poor compliance for positive airway pressure, CPAP usage, how do we deal with those accommodations, whether they can use oral compliance or the appliance to achieve the same result, or sometimes surgical outcome can be, can be, surgical intervention can be entertained. And also the challenges, communication between occupation and sleep specialists are often not very, not very smooth. So the, you know, when the driver comes in for a DOT exam, their sleep compliance report sometimes is not available. Occupational specialists may not have access to that quickly. Very quickly, I want to just mention that this slide, the goal of this slide is to ask, to inform people who are not in sleep medicine, that the, the way we calculate apnea hypopnea index, which are defined here as, you know, complete cessation of airflow for 10 seconds or more versus hypopnea, which is less, which is not complete cessation, but some reduction of airflow, but with a resulting oxygen saturation of more than 4%. Those are those are kind of, there's a variation of that calculation and called RDI, respiratory disturbance index, which is often used in a home sleep study to, to serve as a surrogate measure for true apnea hypopnea index. And when I wanted to this group to recognize that the RDI estimate is some, sometimes it can be an overestimate of the true AHI, but it's being used for home studies. A distinction of OSA sleep apnea syndrome versus objective sleep apnea. One is the diagnosis with AHI or RDI more than five events per hour, meaning apnea or hypopnea index for more than five episodes per hour on average over the whole night, but also with the documented symptoms of excessive daytime sleepiness, sleepiness. This is OSA syndrome, OSA itself. People may have OSA, but then they may not have syndrome. They may just have a objective diagnosis of these events, but they may not have any symptoms. In fact, what we see in, in I think there's a study in, in I think I eliminated that slide. And there is a study in Israel showing that a hundred percent of the truck drivers deny they have any sleepiness in their subjective report. So they may have subjective sleep apnea, but whether they have sleepiness or not, it's a much harder question to answer. But we do know that untreated sleep apnea is associated with, with metabolic syndrome, as George mentioned before, obesity, diabetes, hypertension, hypercholesterolemia. It is associated with a cognitive skill decline over time. That's because of during night, if you're obstructed, your oxygen level in the brain drops. And sometimes it can be down there, you know, in the sixties and fifties, even for up to 10 seconds or longer. And over time, those causes cerebrovascular constriction and vasculature problems over time. And so it increases your stroke risk as well over time. And cardiopulmonary risk is also very high. And they're also sort of associated with shorter duration of sleep. Okay. This is a slide I was, I was said that I thought I missed, but Dagan et al in 2006, look, there is really truck driver population, a hundred percent sleep apnea. Sorry. And, and, you know, even though their, their PSG, their polysomnography shows a very high prevalence of sleep apnea. Anyway, I don't want to go much detail into it, given the time and just, just want to emphasize that the, the sleep, the commercial driver also have a fairly high BMI on average. And it's they're on average, they're more obese than the average American population, which is already very obese. So we need to just make sure that in our driver population I want to emphasize there's a stop band questionnaire which stands for you know whether they snore, whether they're tired, they have observed apnea, whether they have blood pressure issues which are subjectively reported and gets combined with the objective components which are blood you know body mass index measurement, their age, neck size, their gender. It's a slightly better tool to screen for sleep apnea than the Epworth sleep unit score which is completely subjective reporting. So I think in an occupational setting we do want to use some sort of objective component to screen for sleep apnea in addition to in a general population we use just the subjective reporting okay. However the you know diagnostic choices home study versus in-lab study is still being debated in home study has you know less bottleneck access issue but they don't often most of them don't measure the brain wave so they don't have a way to really look at sleep and pin down the sleep stages so they're doing the estimate of sleep time which is sometimes reported by the tester itself so the chain of custody is an issue with home study but the technology is improving and there's some home studies that does monitor brain wave now and there's a cost issue as I mentioned and then the follow-up enforcement issue as I mentioned. I just want to quickly Dr. Schneider. Five minutes. Okay great thanks. Schneider being a good truck company that actually screen their own population they show some safe there that's why return to investment is shown here. Quickly to close up on occupational sleep program workplace. I agree with George it's a overall you need to engage everybody employer, supervisor, employee and all this work safety people including psychologists, safety people, industrial hygienists, occupational sleep specialists, everybody involved and we need to build that into the wellness program. Now I'm going to COVID related sleep problems. There's basically multiple issues with coronavirus related that makes us sleep even more of an issue in our workforce. Lack of interaction often induce stress, combined role at home and work make people more stressful, overeating, isolation. All these are a problem with coronasomnia as I call it. You know people have to give care at home, they have disrupted daily routine and infection also causes disruption in sleep. There are some positive maybe less commute time, more family time but overall it's a challenge. Anyway I want to just highlight at the end that there's a group in Oregon, Oregon Healthy Workforce Center and their work is started here. They try to do a randomized clinical controlled trial using psychologists and workplace intervention designed to increase family support and also supervision by the managers as well as the family to improve employees sleep and they've actually shown that the actigraphies objectively measure sleep quantity and quality actually improve. So please take a look at their work in 2018. They do involve multiple managers and employees altogether so this is a very thorough engagement. The other thing I want to point out is the study actually the effectiveness is shown in 18 months so the annual cycle most people are familiar with you know looking at the outcome in 12 months may not be sufficient to look at the outcome for sleep related issues. Just to summarize, this is the second to last slide, we need multiple level multi-level support from the CEO or the chief of the hospital to the frontline staff by in to get an occupational sleep program running. Support for dedicated time off is important for training and education, foster cultural wellness with nutrition sleep and all sorts of holistic approach that George had mentioned and also measurement outcome beyond annual basis is important. Okay this is the end of my talk, this is a picture of where I work in Puget Sound in Seattle. I give you my floor to Vlad next. Thank you. Thank you Dr. Zhang. All right. I'm coming back to the slide because I didn't tell you the most important thing about the slide. You can see that sleep is in the middle here. Why? Of course because it's in my presentation on sleep. So Dr. Zhang already spoke about the importance of sleep. We all know from the childhood you need to be in bed at certain time, you need to take a daytime nap, everything must must must it's all around sleep. Why? The answers were already heard from Dr. Zhang. You need to sleep a certain amount of hours and you need to go through certain architecture phases of sleep. If either of them, either one is not achieved, then you have impairment and functioning of pretty much all what is on the slide. So there is, oops sorry, Arthur Bayer, an American journalist said evaluating insomnia in one person that his insomnia was so bad he couldn't sleep during office hours. Well fortunately enough our president does not suffer from this disorder based on this definition. On a serious note, I'm a psychiatrist. I'm board certified in psychiatry and pain medicine. So DSM-5, Diagnostic Statistical Manual of Health Disorders is my bible, right? So this is the definition of insomnia, right? That actually speaks in criterion A, the necessary criterion that there are two, three types of insomnia. Difficulty initiating sleep, early insomnia, difficulty maintaining sleep, middle insomnia, and early morning awakening with inability to go back to sleep. The patient usually say I would like to but I can't. That's late insomnia. It should cause a significant distress in daytime functioning, any type of functioning. You can see the examples here. And it should be, the sleep difficulty should occur at least three days per week for at least three months and continues to occur despite the adequate time given for sleep. A lot of patients of mine come to me and say, oh, I can't sleep at all. I sleep like four, five hours. And when you start to collect the history, and we'll be talking about the importance of that, they say, oh, I have a twin. I have twins, newborn. So I can't sleep, right? So there is no adequate time of sleep, cannot be counted as an insomnia. So it's not better explained by psychological or medical problems and not better explained by using of any type of substances, illicit drugs or medications. All right. As you can see, and again, Dr. Zhang presented some of those, insomnia is associated with marked increased risk for pretty much everything. Actually, including longevity, not insomnia per se, but insomnia in conjunction with sleep apnea, obstructive sleep apnea is independent risk for decreased longevity, which is also important is that insomnia is associated with increased occurrence of collisions, which pose the most serious health risk. And it is significant, independent predictor of permanent work disability, which is important for this audience. Okay. There are some biopsychosocial risk factors that I put on the table. Those are just examples, of course, and they're grouped by categories. As you can see, like in social environmental categories, I personally liked the first one, right? So it definitely may disturb your sleep to the point of complete insomnia. But for this audience, since we are in occupational health, I put a separate slide for professional risk factors. And again, Dr. Zhang already spoke about some of them. This is definitely not an exhaustive list, but those are some good examples that do happen a lot. All right. Insomnia is costly. Billions of dollars per year in lost productivity and in treatment costs are incurred by the United States per year. And this is because about a quarter of workers suffer from insomnia. There are definitely differences in gender and age, and the number of cases keeps increasing. So I'm in practice treating injured workers since 2011, and I did some calculations. Those are not any statistic things, just based on my electronic database. How many of my patients complain of insomnia? Your estimate. And my practice is psychiatric practice. I don't do pain management in workers' comp arena. Any numbers? Five? Okay. Okay. Close. The majority of people are either with mental problems or with chronic pain, so insomnia is a big deal. All right. Now, how many patients with insomnia already had sleep aids prescribed? What's the percentage? 20. Okay. You win the motor torpedo boat. You picked, right? You picked inside of the handouts, right? Okay. I don't think there are numbers in handouts. Anyway, yes, some sleeping aid. And this is pretty low in my understanding. Anyway, how many were prescribed FDA-approved medications for insomnia? Five. Anybody? More? Five? Okay. Five percent. Finally, five wins. Okay. How many underwent non-pharmacological treatment for insomnia? One or two percent. Good. Less. Less than one. It's a rare occasion that people, even being in psychotherapy for pain, for depression, for anything, got specific cognitive behavioral psychotherapy for insomnia. So, less than one. All right. The last question, and you cannot be wrong with that. How many improved after receiving appropriate treatment in our practice? How did you guess? I don't want to say that they all improved to the preexisting level, but improved, reported better sleep, reported better functioning during the daytime. Okay. I'm a first-generation physician. I do believe in history-taking. If you took a good history-taking, you're golden. You understand not only the diagnosis and what to treat, you understand the cause of insomnia, which is extremely important, right? You come up with the right diagnosis. You come up with the right treatment. If you ask those questions, which is minimal questions, you're golden. You don't need any additional assessment tools. That would be it. However, I understand that it's time-consuming. We're all busy. We need to complete a lot of paperwork, right? I'm not talking about talking to the patient, but at least completing everything that we need to complete. That is required by the insurance company. You need to get paid for that. So, you have no time. So, you can incorporate simple assessment tools. Those that are here, the self-reported measures, there are four tests that are actually easy to reach. They're free. They're very short. It's easy to incorporate them in any paperwork that you give to the patient. It takes virtually no time. And you get a snapshot of the severity of insomnia, of the daytime sleepiness, depression, and anxiety. And I'm pretty sure that most of you are familiar with this test. The good thing about them, you can repeat them at the intervals and actually get the feeling of the progress that your patient makes or doesn't make at all. My personal favorite is the DSM-5 Level 2 sleep disturbance. It's not because this is the best sleep test, but this is because it actually has the space for clinician use. So, whenever a patient tells you something and does self-assessment, you have a chance to clarify the questions, because I believe it's so important. I'm not talking about faking patients. That's a different story. But even the patients who are very reliable, they have difficulties, especially if it's a chronic condition, difficulty to understand the extent of their poor sleep. They dramatize it. They overemphasize it and tell you, five, five, five, five, five, five, five. When you ask them, so, for example, how much time does it take for you to fall asleep? And they already marked five. They tell you, oh, about 30 minutes. And how often does that happen? Oh, that happens about three, four times a week. So, what you make out of that, this is not five, right? This is three or four. Why is it important? First of all, you understand the severity, right? It's important for the treatment. How do you treat the patient? And it's also very important in our profession, treating injured workers, to understand their needed accommodation, restrictions, and finally, the disability in regards to insomnia. I threw some codes. Just if you don't use any, there are some codes that can be used. ICD-9 codes, easily accessible. The only thing that I would like to underline on this slide is the primary insomnia that is a diagnosis of exclusion and usually is not given in the primary settings. All right. We will discuss now pharmacological treatment, non-pharmacological treatment, and referrals, when the referrals are appropriate. So, in pharmacological treatment nowadays, there are plenty of medications that help with sleep. Those are just clustered by groups, and there are multiple medications in each group. The number grows each year. They become better and better and better. And you can notice that the ones that have the star after them are not FDA approved. So, what's important here, what I would like to draw your attention to, all GABA agonists, with exception of azopiclon, Lunesta, are only approved for short-term use. What is short-term use? Weeks. Those are weeks. Maybe a month. How many patients come to your offices or to my offices with years of benzodiazepines? Not that they are like bad medications. They're okay medications, but they have their niche. How many patients come to you with a combination of benzodiazepines and opioids, which is a clear ban? How many patients with obstructive sleep apnea come in this beautiful combination? And they are clearly suppressing the breathing center. I don't want to even go to numbers here, but it may be interesting. You will see a lot of patients who come on four big benzos, alprazolam, lorazepam, clonazepam, and diazepam. They are not FDA approved for insomnia. Never been, and never will be, I hope. All right. Anyway, there are plenty of medications that are very safe, have very safe profiles, and orexin antagonists win. They continue to develop. Dariodexin is already FDA approved, will be in pharmacies probably this May and this month. And celtorexin, well, diaderexin, what is interesting about it, the half-life is much shorter than for balsomra or davigo, right? So patients have less sedation side effects during the daytime. And celtorexin, which is currently in research, will have even shorter half-life. It's about four hours half-life. So maybe a very good choice, safe choice for treating insomnia. No, I'm not representing any pharmaceutical company. I have no, zero interest, zero conflict. It's just from use in the office. How do you choose the medication? Well, it's technically, I go with comorbidities. Let's say patients have mental comorbidities, anxiety or depression, I would rather use sedating antidepressants in this case. If the patient comes with chronic pain, I probably will use amitriptyline or add gabapentin, which is not a sleeping medication per se, not a sleeping aid, but actually makes the sleep deeper, improving the architecture of sleep. So if the patient, if I don't know, I probably will start with safest, which will be either rosaram or orexin antagonists. The healthios that you see, it's actually a relatively new medication that is indicated for people who have sleep problems who are blind and blind from birth. Many physicians don't even know that psychotherapy exists to treat sleep problems. And it's actually in many studies was shown to be comparable in effectiveness with pharmacological treatment in certain insomnia groups. The problems here is a difference between research, between academic data and true world data. The patients will benefit from CBT-I only if they are highly motivated, which is not a very common occurrence. So light exposure, Dr. Zhang already mentioned that that's a viable treatment option, rarely used clinically. Repetitive transcranial magnetic stimulation, I like the method. I use it for other things in my practice, not for insomnia, because it's not FDA approved for that. It's still in the research. On the other hand, cranial electrotherapy stimulation is FDA approved, but has virtually no robust data behind that in order to use. So sometimes you tried everything and it just doesn't work. Or through the interaction with the patient you understand there is a comorbidity. So that's a good time for referral. You basically have two major choices for referral, in the sleep medicine or psychiatry. Of course, not only these two, those are the major ones, but you can definitely refer to endocrinology sometimes or other specialties. And that will conclude our sessions. Thank you for your attention. We are ready for the questions. There will be not a lot of questions from our online colleagues, because the sessions was actually not present online. Sorry. Yes. Are they available? They should be available. Oh, excellent. Hi. I'm Dr. Michael Caldwell. I'm from Meharry Medical College in Nashville, Tennessee. And I'm very interested in alcohol as well as sleep. So very informative presentation. I'm here to educate also all of us about something called Dry January. Meharry Medical College will be launching Dry January USA. So please come by poster 542 to learn more about it. And I'm really interested to know what your thoughts are about alcohol and sleep, because you didn't, I don't think, mentioned it in your lecture. And then for Dr. Barros, he had a slide 13 or 14 where he said, keeping the consumer culture. And I didn't understand what that meant. Thanks. Dr. Dias, did you hear the question about the cultural use of alcohol in Europe, which is much more common than in the United States? Yes, about that. In fact, we have that statistic. We have much more the problem. We need to address also if we, because we are producers, we have a culture of producing, a culture of consuming. But several countries also have big producers and export. But anyway, the statistic is that we have bigger consumption of mostly the wine and the beer. And but yes, we have this problem. And first it was mainly, some years ago, it was mainly the men, but the women starting to have more. And now we have the binge drinking with the young people also. Some decades ago in Portugal, we had not this problem so much, and we have now. And but in fact, is that Europe is a part of the world that has important problems. All right. The second part. I don't know if. Yes. The question it was. No, I just wanted to answer the second or the first part of the question in regards to alcohol and sleep. And they are very good friends, right? There are plenty of patients who come and say, we increased our use of alcohol because we're not sleeping well, because of pain, because of other reasons. And of course, alcohol is known to be a very good sedating medication, but it only is good for initiating sleep. Like benzodiazepine, it attach only to GABAergic receptors, right? And dissociate from them very fast. So what happens after initial satisfaction of falling asleep, they start to wake up early and can continue to sleep. So I don't treat anybody who keeps drinking at all, right? The rules in our practice is no alcohol, zero alcohol at all, otherwise no treatment, neither psychopharmacological nor psychotherapeutic, because any dose of alcohol can affect sleep. I usually tell, oh, OK, I would like you not to drink. If you want to get better, you should not drink while you're in treatment, right? If you like to drink, there is nothing wrong with consuming alcohol, right? It's not banned, at least in our country. And you can continue, restart when you're good. But this is a psychoactive substance, so it interacts with others and it interferes with your sleep. So, zero use. Go ahead. Thank you to all the speakers for the informative presentation. My name is Laura Bain. I'm with Raytheon Technologies. My question is for you, Dr. Bacarias. Do you often wait in your practice till someone meets the strict definition from the DSM-5, meaning waiting that three months for complaints of insomnia, or do you consider treating them pharmacologically a little bit earlier? And if so, what kind of, is your thought process to maybe treating them maybe at the one-month mark or two-month mark? Excellent question. Thank you very much. The trick here is that the patient comes to my practice usually much later than three months after the injury, right? Psychiatry probably is the last one for the patients to come, so usually we're not talking about three months. But let's say they come really early and they do suffer from insomnia and they do suffer like every day. They have trauma-related disorder or they have pain and they cannot sleep. I will start treating right away. DSM-5 is a guide, right? And although I mentioned this is a Bible, it is not, right? So, of course, if the patient comes and suffers primarily from sleep, of course I will treat it right away, right? And what will I use? Probably both, psychotherapy and the medications together, and then try to see if the patient does response to psychotherapy, try to minimize the use of sleep aids. Please. Would you please comment on the use of these drugs in insomnia, and do they confer any advantage? You have short half-life and, you know, short duration. Well, the drugs like benzodiazepines, they attach to GABAergic neurons in the brain. And the advantage of them, yes, as you said, relatively short half-life, still a lot of patients do feel sedated the next day. The big disadvantage of these drugs is their addictive, high addictive potential. And many patients have difficulties getting off after they've been used for months and months and months, right? As it says, there is a reason why they're recommended for short-term use. They're very addictive. In regards to architecture, there are mixed messages, but none of them promotes phase three sleep that we would like to see as being promoted in using sleep medications. So and again, why I'm saying there is a controversy, because there is a lot of parasomnia side effects in this medication, like night walking, night eating, and so on, which actually does happen in phase three, not in REM sleep. So apparently, they do bring you sometimes to the phase three, which is a good thing. But having parasomnias is a very disadvantageous effect of these medications. There is a warning on pretty much all the sleep medications, but like in clinical use and many, many years, even before treating injured workers, you really rarely see this type of side effects with medications other than Z-drugs, okay? Does it answer the question? One more thing. Do you sleep or addition history of the prescribed Z-drugs, or medication for addition? I don't prescribe Z-drugs, and I don't prescribe benzodiazepines. Those are very rare situations. I definitely can count them with this number of fingers in my practice, even less, like with that number of fingers. There is a difference in when people come already on them, and I do treat Medicare patients, so if an elderly person, geriatric person comes to me with history of 20 years of taking Z-drugs, probably not. Oh, yeah, still already 20 years. Z-drugs or benzos, that's an interesting question. I try to get them off, and if they are amenable to that, I would definitely try, but sometimes it's impossible to do. Why does MedStar get the indication for long-term use? It just doesn't have an indication for short-term use, I would rather say. There is no difference, but clearly both Sonata and Ambien have indication for short-term use. Lunesta does not have this indication, but I think FDA just forgot to say that. Hi, I'm Vicky Weldon. I'm with ExxonMobil, and thank you to all the speakers for the talks. I appreciate it. One of the areas that I'm really interested in, the longer I'm in my career, is the aspect of sleep, and something that I've been looking at and wasn't maybe mentioned so much in this that I wanted to just get your insights in, and that is that I believe there's certain professions and certain industries where lack of sleep, there's a lot of reinforcement from the business. Physicians probably being the worst, where we're all trained to get by on as little sleep as possible, and one of the ways in which I'm working on this, and this is true with executives, I think, people senior in corporations, financial industry, a lot of the cognitive industry, the more you work, the better you are. You get a lot of positive feedback, and so I've been trying to incentivize people to get sleep by thinking and framing it as sleep is work also, and you need to do that work in order to do the day work better, and I'm finding that that seems to be resonating with people when you provide the science about what happens during sleep. A lot of, you know, if you're not in the medical field, you may not ever think about it, but a lot of really important things happen during sleep that help you perform better during the day. It seems to resonate well. I just wanted to share that and get your thoughts on that. Absolutely. Excellent question. Dr. Zhang? Yeah, that's a great question. Thanks for asking that. Yeah, I think, you know, sleep, we spend a third of our time in sleep, like most, you know, throughout most animal kingdoms, sleep is preserved as an essential function for us to move forward to function properly, and if you look at the amphibious, you know, amphibious animals like a turtle, sometimes you look at them, and you can't tell whether they're asleep or not, right? So they're always moving, and when they're awake, they're not completely awake, but as our cortex was developed more in a thicker cortex, we need a lot more distinctive sleep versus awake distinct, you know, functions in order to, you know, be socially acceptable and be having these executive functions run in the right place. So I think it's a very nice way to frame sleep as work. We at the VA are trying to make sleep as an essential part of the wellness program, where employees with any sleep issues can be readily answered and channeled to the right, whether it's a psychologist, referral, a sleep specialist, or some other means to support their well-being. So I definitely think that it's the right approach to address sleep holistically. Vlad, any input on that? Yeah, sure. I agree 100%, and I actually like very much that you use the example of a turtle. Since I have a degree in traditional Chinese medicine, there is a so-called turtle style. When you want to live longer, right, it's known that turtles are living hundreds of years. So if you do everything slow and kind of in sleep, you will live longer. Vlad, can I add something? Of course, of course. Go ahead. Of course. I just want to say that also we are obliged to think about the primary prevention, not only secondary or tertiary prevention. We need to try that those people that are not sick yet will be protected by us, not only to have the indicators of that. So thank you for the question, and also we already know that in some populations we will have problems. People that have no problems now will have if continues with that. And also we need to address this problem as a production problem for the organizations, and we need to address this. For this reason, I defended that not the employer is the maestro of those things. We will try to be the maestro of the health of everybody from the primary prevention and secondary to try to find who's sick and is not saying that or not even is so bad, but also to try always that the people that have no problems not have problems in the future and we'll try to work on the bad conditions of work previous than we have the burden of the diseases. Just that. You're absolutely right, Giorgi, and I think I will be right to say that you're already using sleep hygiene as a preventive measure. Is that right? Yes, yes, yes, it's that. It needs to be addressed. So if we have this burden that is the social determinants of public health, and we have the, as I said, tobacco, alcohol, obesity, sleep, for all these risk factors, we should address something in the company that avoid or protect the workers in the way that change the behaviors, change the avoidable behaviors, but also to change the culture. Our programs should address a change of behaviors or change of culture, the top to bottom in the sense that all the company, all the organization should help us in the objectives of prevent the diseases. So mainly if it's possible in the primary prevention. Thank you. We have one more question. I was just wondering your opinion on CBD products. On what? CBD. CBD? CBD. You mean marijuana? Cannabis? Yes. Okay, okay. All right. That will be my personal opinion. This is not FDA approved. We don't have any good research supporting CBD or THC as a medication, right? No dosage, no indications, no good status. The recent review of everything that they could find on CBD that worth even mentioning would be treatment of seizures in young population, in children. That seems to be like really well dosed, well researched, and can be indicated. I don't use any cannabis products in my practice. And don't allow patients to use them. In the practice. Thank you very much for your attention. Can I add just one thing? I just want to add that we have problems in the occupational accidents and injuries with people that use drugs and marijuana and ashish. So it's something that we, inside the companies, inside the organization, we try to help the people. Because some important skills of the people, to know the distances, and people feel happy and feel well, the workers. But in fact they jump for bigger spaces and have injuries. Some skills or perceptions are changed and we have problems in the work of that. But also I want here to thank very much Dr. Vladimir Bokarius for being, moderating all this, and allow us to hear with these technical problems, so many technical problems. It's a pleasure. In the swap card doesn't work, the people that are online can see us, and he's helped us to maintain the flow of our communication. Thank you very much, dear Vlad. Thank you. And thank you. Isn't it great to have professionals of different level, right? George thinks in terms of the country, I think only in terms of my practice. Thank you, George. Thank you, Vlad. Thanks, everybody. Thank you, Vlad. Thank you, Vlad. Thank you, Vlad. Thank you, Vlad. Thank you, Vlad. Thank you, Vlad. Thank you, Vlad. Thank you. Thank you, Vlad. Thank you.

alcohol

tobacco

obesity

sleep

workplace

interventions

screenings

health

quality sleep

sleep disorders

drivers

sleep apnea

workplace programs