Hi, good evening and welcome. We're going to wait just a few more minutes for everyone to log on and then we'll begin our webinar. Good evening and thank you for joining us for the second in our webinar series of addressing pediatric respiratory issues. Tonight's webinar focuses on obstructive sleep apnea in children. When is snoring a problem? I'm Cassie Pulse, position liaison with the University of Maryland Children's Hospital. Before I introduce our speaker, I have a few housekeeping items. You may submit your questions at any time during the presentation using the chat box feature. Erin Rummel, our pediatric marketing manager, will be monitoring the chat box and Dr. Lasso will answer all of your questions at the end of the presentation. Please note that this seminar will be recorded and an email with a link to this recording will be sent out next week. Our speaker this evening is Dr. Anna Lasso. Dr. Lasso is an assistant professor of pediatrics for the University of Maryland School of Medicine and division head of pediatric pulmonology, allergy, and sleep. She went to medical school at the University of Panama School of Medicine and did her pediatric residency at Monmouth Medical Center in New Jersey. She went on to complete her pediatric pulmonary fellowship at St. Christopher's Hospital for Children in Philadelphia, Pennsylvania. Dr. Lasso has been with us at the University of Maryland Children's Hospital since 2006. Dr. Lasso, the floor is yours. I'm not sure if you see the slides properly. Cassie, can you just make sure that the screen looks good before I get started? Yes, there we go. So what I would like to do tonight is give you basically an overview of pediatric sleep apnea, but really trying to focus really on a practical approach and thinking, you know, get snore, but when is snoring a problem? So we can come up with hopefully some recommendations on when to refer, when to send patients for a sleep study. Basically, you know, when to worry about the patient. So starting with simple definitions, obstructive sleep apnea is considered a syndrome. The definition is one where a patient has prolonged partial or intermittent complete obstructions of the upper hairway. And this obstructions or the problem basically causes disruption of normal ventilation and sleep continuity. It is a spectrum of disease that goes from primary snoring that we really don't consider harmful and can be present in up to 13% of preschool and school children and goes all the way to what we consider the true presentation of the disease, which is the obstructive sleep apnea that causes pathology. And it's present depending on the literature you review somewhere between 1 to 5% of preschool children and kind of changes as the kids get to be in the adult group. Big prevalence is between two to eight years and this peak really has to do with the time when kids have enlarged tonsils and abnormalities. When you get to the pre-prevital male-female ratio, it's about the same. But by the teenage years, the pathology starts to resemble more that pathology that's seen in adults, where it's more common in boys. Risk factors. It's important to think of sleep apnea in all kids, but it's more common, if you will, in kids that have a family history of sleep apnea, in kids that have recurrent wheezing, kids with a history of recurrent sinusitis, premature babies have a 3 to 5 times the risk of a full-term baby. Babies and kids with poor tone. So all syndromes, if you will, that cause hypotonia can cause obstructive sleep apnea. Kids that have upper airway and make basal-oficial anomalies, children with syndromes that affect the face and the midline in particular are at a higher risk for OSA. It appears that African Americans have a higher risk and obesity, I highlight it because it is definitely a risk and it's something that we see more and more these days. So it's something to think about for sure in patients that have gained weight quickly. We think of the consequences of OSA as neurobehavioral growth-related and cardiovascular sequelae and it's felt to be related to under diagnosis or under treatment, if you will, of the condition. It appears that there is an association with hyperactivity, aggressiveness, destructibility, and learning problems, and this has been shown in multiple studies over the years. A study that was published in 1988 was a while ago by David Guzall who is an expert in the topic of pediatric OSA showed that in kids in first grade that were not performing well, the incidence of OSA was six to nine fold compared to kids that were doing well. It is such an important cause of neurobehavioral growth and problems that we should think of considering the sleep study in kids that are being evaluated for conditions like ADHD and other behavioral and attention problems before medications are started. The best predictors for thought problems, phonological processing problems, externalizing problems, aggressive behavior, verbal comprehension problems are two things. One is the apnea-hypotnea index, which is the number of apneas and hypotenias per hour of sleep during the sleep study and the needier saturation during that sleep study. So those two factors or those two signals, if you will, in a sleep study are the best predictors of the list that I showed below where there is definitely significant findings. I apologize because there is a lag time between my advancing the slides and Erin, it's not responding. Would you be able to advance the slide there? Erin, if you don't mind, I might ask you to advance the slides for me because it seems to not be responding very well to my keyboard. No problem. Thank you. So the other thing that we have to think about is, the concept I think that is interesting and important to think about is that perhaps snoring, not by itself, but the association with sleep apnea and school performance issues in the early years might actually have a long-lasting effect or perhaps with Dr. Gozall in a pediatrics article in two dozen ones suggested, which is a learning depth where kids that have this problem early in life develop neurocognitive morbidity that if not treated properly might actually cause long-lasting effects with school performance. He also looked at kids in middle school and the opposite looked at what he'd looked at if the patients in first grade were also looked then at kids in middle school where he saw that kids that were not performing well in middle school were more likely to have snored as younger kids and have had a tonsillectomy and an endectomy. So again, showing that perhaps there is this long-lasting effect of having OSA in early life. Next slide.  It's been felt for years that OSA causes cardiovascular sequelae, but this is driven mostly by adult data. In fact, a recent study published by one of our Dr. Peria, Kevin Peria from the University of Maryland and Dr. Amal Isaiah from the University of Maryland showed that pre-operatively right before a TNA, when patients had an echocardiogram, it didn't actually show even in kids that had CBROS, say, significant abnormalities. So the concern that we have had does not appear to materialize, at least not in the pre-op echocardiograms. And so it's something that we consider not doing, which we were doing pretty consistently before in our institution. There is also another study that looked at the prevalence of pulmonary hypertension in pediatric OSA and also found low end and low incidence. So again, it's a concern that we have had that untreated or under-treated OSA causes cardiovascular sequelae, but in pediatric, which would actually be a good thing, that it doesn't seem to materialize early in life. So perhaps it's not something that occurs quickly, but perhaps over a long time and that is why we see it born in adults. So this is something to think about, we don't see it, doesn't mean that we shouldn't worry that in the long term it'll cause problems. Erin, next slide, please. So piece of information that's a really important point that I like to always remind people of is that your exam awake doesn't predict airway obstruction with sleep. So on the right hand side here, you can see that patient awake will have perhaps good tone and have good airflow into the airway, but that same patient that awake might maintain, the patent airway might block their airway when they lose their tone secondary to sleep. So to remember that what you see in the office during your visit might not truly help you understand if the patient has OSA and how severe it is. The other thing that also doesn't correlate is the size of the tonsils and adjuvants. So a patient might have large tonsils and very minimal if any OSA and the opposite industry might have a patient who has very small tonsils with significant OSA. So that's something to remember. Next slide. Another thing that's interesting is that in the past we have talked a little bit about scores where you could try to figure out if a patient that was snoring had OSA and how severe it was and there's been studies looking at a few questions, if you will, that could help with this. In fact, those scores tend to misclassify patients at least a quarter of the time. And here you have a list of the things that typically used to be asked that do not seem to be very helpful. So is the patient having daytime math breathing? You know, is that helpful? Doesn't seem to be the P values or not significantly affected, observed apnea, parent shaking the child to try to wake them because they look scary, child struggling to breathe, parent afraid of the apnea that they observe. None of those things seems to be good enough if you will to give you significant data. So they're not something we recommend. We ask them on physical and during our Asian peace, but they're not by themselves enough to give us the data that we require without a sleep study. So as a statement, if you will, it's basically said at this point that the clinical history and physical examination are not reliable for diagnosing OSAs by themselves. Next slide. So there's practice guidelines that have tried to help pediatricians and providers on how to think of sleep apnea and who to treat. The first one was in 2002. And the second one in 2012 both were published by the pediatric journal. The first one is, I think, very clear to all of us that we should be screening all children and adolescents for snoring that complex high-risk patients like the ones that I mentioned before that have bit line abnormalities, low tone, down syndrome, preemies. Any of those kids, if there is a concern for OSA should be referred to a specialist that the history, if you will, is not good enough in really differentiating primary snoring from sleep apnea. So polysomnography is what is recommended. That's what it's meant by diagnostic evaluation. But that if that's not available, a referral to a specialist for more extensive evaluation may be considered. That a TNA or adenotensilectomy is a treatment of choice for children with adenotensilore hypertrophy. That high-risk patients should be monitored after surgery in the hospital. And that includes kids under the age of three or kids that have severe sleep apnea reported by the sleep study. So more than more people or more than 10 obstructions per hour or an oxygen saturation need year of less than 80% or both. Patients should be followed. So we should be thinking of checking on our patients after surgery and reordering a sleep study if there is if the patient was severe at baseline or if there is significant symptomatology after surgery. CPAP is recommended if the TNA is not performed or if the symptoms persist after surgery and weight loss should be recommended for all kids and adolescents who are overweight or obese. Next slide. So diagnosis basically what we think or how we call it an obstructive apnea is a complete cessation of air flow with respiratory effort. An obstructive hypopnea is when there is a partial obstruction in a central apnea as you well know is no respiratory effort so no central signal to breathe if you will. Next slide. So another way to think of it is the way that ENT if you will thinks of it. And I think that that's useful in primary care because you might not really have the opportunity to do a sleep study in all your patients that have snoring and so I think it is important to think of if you have a child with tonsill hypertrophy what do the guidelines say and this is a guideline by ENT in 2019 that tells us that if a patient has tonsill hypertrophy clinicians should be asking about comorbid conditions that might improve after tonsillatomy. So they would like to know if the patient has had growth or a tradition if they have poor unspeakable performance, if they have aneurysies, if they are asthmatics, if they're presenting with behavioral problems. They will in that guideline they're recommending a sleep study for kids with tonsill hypertrophy if they're very young less than two years of age. The other guideline talks about less than three. If they're obese, if they have Down syndrome, if they have craniofacial abnormalities, neuromuscular disorders, sickle cell disease, and the full cycle reduces. And that is because that list of kids is much more likely to have severe disease that they would like to know about before surgery. So ENT is recommending not to do surgery on kids without a sleep study in that age group because of the risk of having severe OSA without knowing about it. Next slide. So sleep studies in children are commonly done. They're not fine if you will, but kids tolerate them pretty well. And pediatric sleep labs are well equipped to deal with kids. Kids, the technicians typically will train in treatment or how to deal with younger kids. And it is all about the environment. So one thing that I will say is that when ordering a sleep study, it is important to consider where you're ordering your study to make sure that the facility that you use has experience with kids. Because it's not the same to do a sleep study in a facility that deals with mostly adults. Because one is that the night in the lab that is different, the experience that the technician feels comfortable with kids, that the parents feel comfortable there in how their kids are handled. But also who's reading your study, do they have experience with pediatric sleep studies? And are they reading according to guidelines for pediatrics? The guidelines tend to call, if you will, kids below the age of 13. And 13 and above gets read as an adult. So for older teenagers, it's, I think, safer to send them to an adult lab. I think for younger kids, it's really important to think of the pediatric lab. Next slide. So I'm giving you a couple of cases here just to highlight what we're talking about. This is a five-year-old with history of snoring, respiratory pauses, history of chronic nasal congestion, morning headaches, difficult to arouse, has been underweight and is referred for a PSG. So here, just to show you, you know, this kid had a apnea, hypopnea index that, to remind you, is again at the index of the number of apneas and hypopneas per hour. So 35 obstructions per hour with a knee deer in the oxygen saturation to 72 and saturation under 90% for 20, 27 minutes. So this is a kid who's having an obstruction very, very frequently, you know, more than every two minutes they're having an obstruction. So the quality of sleep for this patient is very poor. And as you can see, this kid's frequently in that age group don't grow well because they're really having significant work of reading if you will every night. Next slide. And I'll show you, I believe my next slide has just might be a little bit hard to see. But basically, the idea is this is the epaulom that you get from a sleep study where you're tracking also symmetry at the top, you track the movement, basically, chest movement, abdominal movement, and then you get flow. So you can see there is nasal flow or not and then an entitled CO2 level. So when you have a pause, like over here, you see a pause. And this is about 20 second pause. You can see, you know, this is probably a little bit small for you. But basically, when there is a pause in the lab, the reading you get will tell you one if it's central or not. And if it is in central, you'll know if it's a complete obstruction or a partial obstruction called a hypopnea. And then what happens with that, you know, is the entitled CO2 increasing during the pause? Are you having deceptorations during the pause? And how long is the period, if you will, that that there is a problem? It also gives you a heart rate. So you'll also see sometimes radiocardia in response to the pause. So there is patients like this one that we talk about a five year old with 35 obstructions per hour, they're having 35 obstructions every hour of their sleep with naps with nighttime sleep. So obviously, those kids don't grow well, they do poorly, they basically don't sleep. So they have a lot of behavioral problems that tend to show, like I said, with learning issues and also hyperactivity. One thing to remember is that in adult medicine, sleep apnea tends to cause fatigue and sleepiness in younger kids. We see the opposite, we tend to see hyperactivity. So they're usually kind of wired up, they're not really, they don't look fatigued, they just don't stop. Next slide. So here's 10 year old girl, she's referred to us after having a TNA and actually had a pretty large surgery, a Google of plastic, which is basically a surgery where the soft palate and the uvula is removed. And so for the rest of surgery, with the idea of opening up the upper airway, she clearly failed that surgery, still falling asleep at school, had an eresis, and she gets a PSG, and that's one of the little bit easier, I think, for you guys to see. She has multiple pauses.  So she kept doing that. She had frequent obstructions, also due to the secretions and entitles you to in the mid-50s, so significant hypoxia with her events. She was treated with positive airway pressure, did well with resolution of symptoms. In this case, surgery definitely wasn't enough, and she required CPAP basic. Next slide. So just to touch a little bit more on the interpretations, if you get a report from a sleep lab, you're going to get basically what we use the most is the hypopnea index, which is normal. It's considered 1 to 1.5 per hour. Some labs will give you just the obstructive apnea index that doesn't include hypopneas, and then there is the respiratory disturbance index that will add apnea, hypopneas, and arousals. Like I said, we typically use, in Hopkins, that's the same, the apnea hypopnea index, which is really counting the number of apneas and hypopneas. They'll also give you a saturation nadir, an oxygen saturation nadir. They'll also give you the amount of time that the patient is spending under 90%. They'll give you the number of arousals, and when you're checking your results, you need to make sure that the patient had REN sampled and that the patient slept at least 80% of the night to make sure that it was a good quality sleep study. Next slide. So the same in a table form, and you guys will receive this in the link later on, but basically this is a simple table to just show that normal on the left mild would be 1.5 to 5 structures per hour, saturation somewhere in the high 80s, I'm sorry, and entitled CO2s in the mid 50s. Moderate OSA 6 to 10, a little bit lower sets, and higher entitled CO2, and severe OSA is more than 10 structures per hour, less than 75 equal or less than 75 in the saturation index and the entitled CO2 above 65. What we tell people is that say that you have, for example, 6 to 10 obstructions per hour, but your CO2 is over 65, I would place that patient in the severe category, even though by the number of obstructions you're not having, you're not meeting criteria to be in the severe category, the fact that you have significant difficulties with gas exchange makes you a more severe patient.  Next slide. Do remember that a TNA is a treatment of choice in pediatrics, but that there is a risk, you know, that has to do with surgery. So it is important that patients that have severe OSA be treated with CPAP or BiPAP around surgery that anesthesia is involved. So for patients with severe OSA, it is important to make sure that they are known by anesthesia as having severe OSA prior to surgery. Precustomy and uvaloplasticity, as I said, are very rare procedures for OSA. I have seen them done. We are always trying to avoid them. And in fact, these days we have a much more, we have a larger group of options, if you will, for PAP therapy. So we really in the last five years have not sent anybody for a three-calistomy for OSA. Next slide. Systemic steroids in OSA, not recommended. So years ago, there was an open legal study looking at five days of prednisone in a few children with OSA, no improvement in sleep measures, the risk of thinking oral steroids, as you know, is significant. So definitely not recommended. Just wanted to make a point to say that. Next slide. Much more commonly used those days, intranasal steroids. However, I wanted to make a point to say that there is a recent cocaine database review of 2020 that says that there is really insufficient evidence to be, you know, for the efficacy of intranasal steroids. So not something I would recommend at this point. It's something that we used to do. But at this point, I don't think it makes a lot of sense to go for it. And I would not waste time treating patients with intranasal steroids if they have clear OSA, I would just send them for therapy. That's helpful. So next slide. So spending a little bit of time on the complications after a TNA. In a study of 44 children that was done a while ago in the 1980s. But it is important to realize that in that study, 32% of a third of the kids had complications and significant complications in 16% of the patients. So to remember that even though TNA is the treatment of choice, it's not risk free. So patients that have red flags, if you will, young age, then have it as severe OSA with low CO2, low oxygen and high CO2, or syndromic features like we talked about, down syndrome patients. Anybody who is raising the flag as having a severe case of OSA should be done in a pediatric hospital where there is pediatric anesthesia and stay in the hospital overnight after surgery. Next slide. Another study basically showing the same thing. In this case, 23% of patients had severe respiratory compromise after a TNA. And some of them had shown during the procedure of having significant dysenteration and hypercapnia and or hypercapnia requiring intervention. So again, this is another study, the same idea, craniofacial abnormalities, young age, severe OSA. So to remember that if a vision has this factors that they should never be done in a community facility where they won't have the ability to be in a pediatric ICU if there is a problem. Next slide. So current guidelines are pretty clear on recommending inpatient monitoring of high risk groups. Just to remember that. Next slide. Now, if TNA, if the TNA fails or if the patient is not a candidate for a TNA because they do not have large dumpsoles and adenoids or because the family refuses surgery, I actually recently had a case of that. We then should consider continuous positive air with pressure or CPAP. It is well tolerated and safe in infants and children. It's frequently used. It is more common to need it in children with congenital facial abnormalities. Its studies showed that CPAP therapy for about 15 months minus plus minus three months with a pressure of 7.9 centimeters water eliminated the signs of OSA in 90% of the children's studies. So very effective therapy when used properly. Another study to show that the respiratory disturbance index decreased from 27 plus minus 20 to 2, it gets treated with CPAP. So patiently proven symptoms, the findings on the sleep study also improve. And to remember that compliance with CPAP is actually better in children than adults. So it's a therapy that's used. It's not first line, but it's definitely second line in an option. I would definitely consider referring to specialty care if patients fail PNAs because the management of their CPAP tends to be by specialty teams. Next slide. So when or why do we order a polysommogram? So I would think of it if we have to confirm OSA if clinically suspected, particularly in high risk groups. So if you have a patient who has enlarged tonsils, clinical history, if you will, for OSA and is not in one of the high risk groups, I think you could go directly to surgery. This is a little bit controversial because the guidelines aren't very clear. And not everybody has the option of the average sleep study is not available everywhere or at least not close by. So I would not worry too much about kids that are healthy otherwise. I would definitely think of a sleep study if there is concerns for a very severe disease or if the patients are in a high risk group. Like we said, young kids, kids with syndromic features, kids that are morbidly obese, have low tone. In those patients, we do it because we want to know the severity because like we said, the management won't be the same by the pediatric anesthesia team if the patient has moderate OSA or if they have severe OSA. It's also an option for us to test the efficacy of the surgical interventions for patients where there's been a TNA. It can be considered if there is still symptomatology or if the patients were extremely severe to start with and we want to make sure there has been significant improvement. And then PSGs are also used for titration of non-invasive support to see if happen by then. Next slide. We consider referral for a specialty appointment if your patient has moderate to severe OSA, particularly if they have comorbid conditions. They'll be children, kids with chronic facial abnormalities, very young children or if patients are not candidates for surgical intervention. Next slide. Quickly touching on parasomias. I think you guys know more about it than I do, but I just wanted to make a point that it's been shown that a lot of kids with parasomias have OSA. In fact, the study done a while ago published in pediatrics in 2003 showed that 61% of kids with parasomias had a diagnosis of an additional sleep disorder and more than 50% of those kids their disorder or their additional sleep disorder was OSA. To think about it, so if you have a kid who has night terrors, sleepwalking, disorders of arousal, it can be normal. It's something that may be triggered by fatigue or illness and still be considered normal. But to remember that if it's an unusual case that there is an association with OSA and so to think about it, those patients might need a sleep study to check on that. Next slide. So I think we're close to the end of the lecture, but I just wanted to tell you that the topic is pretty controversial. So not everything is written in stone in pediatrics sleep. There's some confusing data and there'll be more to come in the future about this. A recent study showed that if you had a sleep study to start in seven months later, about almost half the kids had actually normalized without therapy. So that's quite a large number, you know, about half the kids just got better on their own. And so it is important to think as a pediatrician that this does happen, that about half the kids just improves. So I think it's safe if a kid is pretty healthy and doesn't have a lot of other problems that you give them some time before you commit to a PSG and therapy. So I think it's safe to think about this, but not act on it right away if there isn't significant concerns other ways. The other thing that is difficult is that there's study, a recent study actually, showing that the treatment, so the improvement that we see in symptoms in patient's treated with a TNA is not always measurable in a sleep study. So it isn't always very clear. So you might get a history that the parents give you that major improvement in clinical symptomatology, but when you look at a sleep study before and after, you don't always see that much of a difference. So again, sleep studies are not perfect. They're worked in progress, I would say. For some patients, they're very clear. For some, they're not. And so more to come on that, if you will. And the last thing that I wanted to say, because it hasn't been used as standard of care, but it might become more common in the next few years, is that there is a pretty clear picture, if you will, that an abnormal pulse oximetry highly predicts the indication for a TNA. So we could potentially be using home pulse oximetry to predict the need for surgery instead of sending patients for a sleep study. This is something that isn't fully clear and written in stone. It's definitely something that has been shown recently. I think there's gonna be more to come on that because clearly, pulse oximetry at home is a lot cheaper than a sleep study. So there'll be, I think over the next few years, more people looking at this more seriously, particularly for areas where there isn't quick access to a pediatric sleep lab. Next slide. So to conclude, OSA is common in children and adults. Peak prevalence for OSA in childhood is early. It is typically associated with enlargement of the tonsils and adenoids. There is, we think, long-term neurocognitive consequences if OSA is undying, is un-treated. The most common therapy can be effective, is it tonsillectomy and adeninectomy. The procedure isn't risk-free. There is comparative risk of surgery. Remembering that watchful waiting is an option, particularly for your patients that are not at high risk or that have no other comorbidity. And that home oximetry might actually become a tool to diagnose OSA in the near future, in particular for children with tonsillar hypertrophy and in the context where PSG is not readily available. It might actually become standard of care, but it's definitely more likely to become standard of care quickly, if you will, in areas where PSGs are difficult to obtain for pediatric patients. And I think that's all I have to review, so if anybody has a question. Thank you, Dr. Lasso. Again, as a reminder, please feel free to type your questions into the chat box and Erin will read the questions for Dr. Lasso. Okay, great. If you have any questions, please feel free to submit them now. Okay, great. What degree of OSA requires a TX? What degree of OSA requires... Lee Norton has asked, what degree of OSA requires a TX? Therapy, probably. What degree of OSA, I think that's what we're trying to say, right? So, it is a good question and a controversial question to answer. I think we all agree that severe OSA needs treatment. So, 10 obstructions per hour or more, we should be thinking of treatment. Mild OSA, most people at this point would recommend waiting, watchful waiting and not going for therapy because like I highlighted, things aren't that clear. I think the gray zone is in the moderate group that has 5 to 10 obstructions per hour, 6 to 10 obstructions per hour. So, my suggestion or the way I think of it is, if the patient is having moderate OSA, so 5 to 10 obstructions per hour, but they're also dropping their oxygen saturation, they're also potentially retaining CO2 and have symptoms, I would treat. If they're not having a lot of symptoms and their gas exchange is pretty normal, I would wait. I would give them at least 7 months to see if things settle down. A lot of this isn't set in stone, unfortunately, because a lot of those things over the years have changed and I think over the last 5 years there's a lot of data saying that we don't know for sure what to do with some of those kids. So, that's the kind of population where I would follow closely with families and make sure that symptomatology isn't getting worse and potentially consider a repeat slave study over time. Thank you, Dr. Lasso. Are there any other questions? That is all that we have today. All right. So, this will conclude our webinar. Thank you for joining us this evening and we hope that you found the webinar series informative. Thank you again for attending and have a great rest of your evening. Take care. Thank you.


The next item of business is consideration of business motion 1312, in the name of George Adam, on behalf of the parliamentary bureau, setting out a change to today's business. Any member who wishes to speak against the motion should press their request to speak button now. I call on George Adam to move the motion. Thank you, Presiding Officer, and formally moved. Thank you. No member has asked to speak against the motion. Therefore, the question is that motion 1312 be agreed. Are we all agreed? The motion is therefore agreed. The next item of business is topical questions. As ever, I would like to get in as many people as possible and succinct questions and responses. It would be very helpful, as I call question number 1 Emma Harper. To ask the Scottish Government whether it has assessed the impact of the increase in wholesale gas prices on food and energy availability in Scotland, particularly ahead of winter. Scottish Government ministers and officials are in regular contact with the whole of the food and drink sector, and the current assessment based on our discussions is that, while availability has stabilised, there has been a reduction in the choice of products, and the Scottish Government will continue to maintain regular contact with the sector, including on the availability of carbon dioxide, which has significant impacts for food production and animal welfare. When it comes to the security of gas supply, that is a reserved matter and one in which the Scottish Government has no formal functions. The UK gas system is subject to regular assessments of security of supply through national grids, twice yearly, outlake publications, the biennial European gas risk assessment and other ad hoc assessments. The Scottish Government works closely with national grids, as well as with the Department for Business Energy and Industrial Strategy of GEM and Scotland's gas distribution network operator, to ensure that the supply of gas to Scottish consumers remain resilient and that Scottish circumstances and priorities are taken fully into account. Emma Harper I thank the cabinet secretary for that response. As she says, CO2 is essential as a component in food supply chain. It is used in our abattoirs and to vacuum pack food products and to provide the ffizz for beer, cider and soft drinks. James Withers from Food and Drink Scotland told me that he is extremely concerned, as it is estimated that Scottish pork and poultry producers only have between five and 15 days left of CO2. In addition, Scottish small and micro breweries cannot access CO2 supplies. Without an urgent resolution, I understand that it is likely that livestock will be backed up on farms, potentially causing animal welfare issues and that many small breweries will be out of business. Given these serious food supply chain concerns, can the cabinet secretary outline what representations the Scottish Government has made to the UK Government and the industry that requires restarting fertiliser production, which is essential in the whole food supply chain? The cabinet secretary is absolutely right in raising all the concerns that she has because that is critical. As the member mentioned, the risk of a shortage of carbon dioxide has major implications for food production, as well as animal welfare, because it is used in packaging when it extends shelf life. The lack of use of it will lead to increased spoilage and waste. In relation to animal welfare, as Emma Harper highlighted, CO2 is used for slaughter with the pig plant, a brifian and the poultry plant in Ceparangus, which are both reliant on gas for slaughter. At this current point, we understand that both plants either have supplies for the time being or have alternative methods that they can use. In the longer term, we need to find more resilient supplies of gas for our industry, but I would say to the member into the chamber that I am expecting to speak to Deputy Minister Victoria Prentis later on today about a range of issues. In particular, given the latest issues that we are facing, we will add a long-term and sustainable solution of CO2 supply to that list of issues that we will be discussing. I would be grateful if both the member and the cabinet secretary could ensure that questions and answers were shorter, please. I will try to be brief. The regulator of GEMS price cap, cap surprise of the maximum suppliers can charge customers on their standard variable tariffs, and that has been set to rise by 12 per cent by the end of 1 October. Those who use repayment meters, typically the most vulnerable in our society, are likely to see an average of their energy bills rise by £1,309 a year. On top of the UK Government's callous cruel cut of the £20 per week universal credit, can I ask the cabinet secretary to outline what action the Scottish Government is taking to help to prevent fuel poverty? Will she join me in calling the UK Government to stop penalising some of the most vulnerable people in our society during the global pandemic? The member is absolutely right, and I am happy to join her in that call. The cut that we have seen to universal credit will only go to exacerbate the extreme situation that a lot of people are facing right now about a third of people live in fuel poverty and about a quarter of people live in extreme fuel poverty. Issues that we are facing right now will only go to exacerbate that, and the actions by the UK Government will do nothing to resolve it and, indeed, make that situation even more precarious. In relation to what we are doing to tackle fuel poverty, by the end of this year we will have allocated over £1 billion since 2009 to tackle fuel poverty and improve energy efficiency. That will include £114 million that has been spent this year alone. In addition to that, we are continuing to fund Home Energy Scotland to provide free and impartial advice on how to reduce bills and make homes warmer and cheaper to heat. The Scottish Government will continue to do what we can, as we always do, to mitigate against the worst of the cuts that we see from the UK Government and Westminster. With a shortage of CO2 required for the humane slaughter of pigs and the suspension of the Chinese licence due to Covid, Scottish Pig Producers are facing the perfect storm. QPL Breakin has currently, on a three-day week, with farmers choosing to divert their pigs to the north of England. Can I ask what the Scottish Government's position is on the reinstatement of the Chinese licence to help Breakin to return to full capacity and will she extend the Pig Producers fund deadline beyond 26 September? I am acutely aware of the issues that the member has just raised. Again, the QPPL plant is within my constituency. My officials have been engaging closely with QPPL to try and resolve the issues that they are facing. I personally engage with them and I will continue to do so. The member rightly raised the hardship fund, which was announced earlier on this month. We will continue to do all that we can to support our vital pig industry. As the minister has already said that she is meeting with the UK Government, she will also be aware that, with one or two factories closing, that can cripple the supplies of our CO2 across the country, which the food and drink sector and NHS absolutely rely on. Is this something that the minister and the cabinet secretary will be discussing with the UK Government and with her own Scottish Government's food resilience group? Can the minister set out what the discussions will be to ensure greater long-term resilience for the CO2 supply chain? I want to assure the member and assure other members across the chamber that we are working across Government on this. As has been highlighted in some of the questions that we have seen today, we can see the impacts not just within the food and drink sector but in relation to fuel poverty and social security. We are working across Government to do what we can to try and resolve some of the issues. As I said in a previous response to Emma Harper, I will be meeting with the Deputy Minister for Victoria and Prentis this evening. We will be discussing a range of issues, including the CO2, and not least, of course, the labour shortages, which are also a critical issue, not just for our food and drink sector, but right across society in Scotland at the moment. Willie Rennie We have already heard about welfare issues and food shortages as a result of the CO2 shorting. Will the minister consider intervening and prioritising CO2 supplies for the food sector? Cabinet Secretary? Of course, as I previously stated, we will be doing everything we can to try and resolve the situation. Again, this is one where not all the levers of this are within our control. I believe that the business secretary and the UK Government has been engaging with CF industries, the fertiliser supplier in an attempt to find a resolution to that. We would, of course, encourage these discussions because this is absolutely critical now in relation to keeping our food and drink supply chains going and to keeping the food on ourselves. Of course, we will be doing all that we can to try and help in this situation. Liam McArthur I ask the Scottish Government what its response is to research, stating that no recommendations to improve practice are made in nine out of 10 fatal accident inquiries into deaths in prison. Cabinet Secretary, Keith Brown, Any death in custody is a tragedy. As I set out in Parliament during portfolio questions last week, the Scottish Government takes very seriously the issue of death in custody. We have commissioned an independent review of how death in custody are handled, as I indicated in response to a question from Paul McNeill last week. We will consider carefully any recommendations that the independent review makes when it reports this year whether to improve the safety of prisoners or how death in custody are responded to.  The sheriff will consider the evidence that is led by all parties and determine whether any reasonable precautions were identified which might have resulted in a death being avoided or any defects in any system of working which contributed to the death. Where no matters have been identified at the inquiry, which might realistically prevent other deaths in similar circumstances, there will be no basis for the sheriff to make any recommendations. In 2020-21, there were 61 fatal accident inquiries that were held, including any FAI relating to a death in custody. There were 18 recommendations made and eight of the inquiries held, where recommendations are made. The priority is to ensure that those are acted upon. In 2018, Katie Allen and William Lindsay tragically died in Pullman. Almost three years on, the fatal accident inquiries into their deaths are still outstanding. Lessons are still to be learned. The research from Glasgow University shows that even when FAIs conclude, improvements are unlikely to follow. Two weeks ago, Jack Mackenzie died in Pullman awaiting trial. He was 20. Does the cabinet secretary still believe that the fatal accident inquiry is working properly? As a member knows, the fatal accident inquiry system that we now have was debated and agreed upon in 2016. It was also being subsequently debated by the Justice Committee who looked at those issues in depth and did not recommend, for example, mandatory time limits in terms of fatal accident inquiries. There is always the case that we can look to improve the situation. We have allocated new funding to the law officers to ensure that the FAIs, where they are held, can be conducted more quickly. The member will also know that there are very often other inquiries that have to take place prior to an FAI taking place. We will look to make any further improvements that we can. I, for my part, am more than willing to listen to any representations that are made by the Justice Committee, but in the meantime we believe that the FAI system is one that works, albeit that we should all seek to improve it. Cabinet Secretary, it is not just death and custody where fatal accidents inquiries fail. The whole system is in need of reform. The search for Scottish Liberal Democrats in 2019 found decade-long delays to investigations. The Scottish Government and the Lord Advocate promised resources, improvements and response, but reports of decade-long delays keep on coming. Why does the cabinet secretary believe that more of the same is enough? I have just said to the member that I believe that more has to be done. I have also mentioned the fact that additional resources were made available and that we have seen reductions in the length of inquiries. There has also been an increase in the number of inquiries over the course of recent years. As that happens, as the pressures can build up, it is up to the Scottish Government to make sure that we look at that fresh. Although it is not just down to the Scottish Government, we have to of course listen to what the Justice Committee who have examined the issues in depth has to say, but we will continue to look at it seriously as we know the heartbreak that it can cause to people of some of whom Liam McArthur has highlighted when a system is delayed, albeit that it may be delayed for very legitimate purposes. The bottom line, Cabinet Secretary, is that fatal accident inquiries are simply taking both too long to commence and too long to conclude. The average time is nearly three years, and that is up from two in just one year. It is a shocking statistic. Those benches support the introduction of a statutory maximum timescale for fatal accident inquiries. Why does the cabinet secretary not? As I understand it, his party did not support that back in 2016 when it was previously discussed. It may be that there is a reason for them having changed their views, and of course I am happy to listen to any representations on that. However, he will also know that, if I can just finish before Mr Kerr starts shouting again from a sedentary position, which he does on a regular basis, it is of course the case that those are conducted independently of the Scottish Government by the Lord Advocate. I am not aware that other parties, including the Conservative Party, want to change that. If they do want to change that, they can bring that forward. It is the case where it is not working as effectively as it could. Of course we and the law officers want to do all that we can to make sure that it is done as timely as possible, and we have seen improvements in recent years, partly due to the resources that have been allocated to it. However, if there are other suggestions, we should keep an open mind in relation to those.


application for 56 College Street. Come up, have a seat, and I think we all know you're Jeff next, so you don't need to introduce yourself.  Sure, so this is that old former headquarters of the New England Calling Institute, and back in 2004 I believe we renovated the old house and resurrected the old carriage barn and moved it and put on a new foundation and connected it with this vector wing here, which is where the elevator main entrance are, and we have second floor offices up above in that wing there. And at the time we really would have liked to put a dormer there, and discussions with the city never got to a hearing when we discussed with the city they were in favor of it as was the state because this was a historic renovation. Somebody in the federal office in Washington said no to the dormer, and we were unable to put the dormer on. Do they give you a reason? They just didn't like it. They said it wasn't in keeping with the historic character and we and Jay Ansel gave a number of photographs of similar buildings in Montilio with dormers, but it didn't seem to win them over. Beyond that time frame they also installed a dormer. They said they'll do it anyway. They said they'll eat it out. Yes, oh everything about the project is acceptable. At the time the one guy in Washington didn't like the dormer idea. Everybody up here did. And if you look at the floor, if you're in, if you've been up there, the floor plan just doesn't play out. We've got a very nice, you know, we've retended the building with Vermont Legal Aid and the National Wildlife Federation, but that second floor the way it lays out just doesn't make much sense as a standalone unit. And Necky made it work, but it's just, you know, the ceiling height and the on this side of the, I mean I'm sure your floor plan, but it's like seven feet until your shoulder hits the slope ceiling and just give us an extra two and a half feet make it very comfortable to lift the roof line up a little bit. So that's what we're hoping to let us do. So this is the same dormer that you proposed back then? You know, I don't know. Jay produced this for me, so I've forgotten what it was. Jay was kind of leading the charge back when we were doing it 2004, yeah. Yeah, I don't know why. Well, that's still on there from 2004. I guess you didn't take that off. Good question. There you windows on the dormer are a one over one as opposed to the six over one that are on the second floor of the main building and the ones that were on either side of the old garage and on the garage doors. Was there any reason for that? Well, Jay, because these two below are one over one, he chose that. That's what's there currently in the wing. We're happy to do whatever you would like, but that's the reason he did that. Okay, I was just asking questions. I think the six over one would be better. I don't think you actually, in the photograph, you don't see the one over one being hidden behind both the bush and the porch. And the porch. Like it reads more in the drawing, but I don't think you actually, going down the street, you will see these in relation to those a lot more than those. Yeah, I think the one over ones I know from my experience with working with the state and with Washington. When you have a new addition, they often want the new addition details to be a little different than the historic sections of the building. So you don't, I mean, it's, most people would never really think about this, but the new additions read a little different. You don't want to give what they call a false sense of history. So, you know, to make that look old when it's really not. Yeah. Yeah. Okay. That makes any sense. So you're suggesting the six over one? No, I'm suggesting keeping them the way they are there. Yeah. The one over ones, in my opinion. Okay. Now, the carriage house is original to the original building. Yes. Was that center section and filled was that? Yes. Catched. That was in film. The actual garage barn was probably, I think 10 feet this way. We lifted it up, put it on a new foundation, put it back down. Yeah. Okay. It's a tough call because I know it's a new infill, but it follows the, it follows the lines of the carriage house so close that it looks like it could, and that's the nice thing about it. Yeah. It's like it could have always been there. It's a nice, nicely done, I think, nicely designed. Sure. We always thought it looked a little odd, but it's just all, all roofline, you know, all the way across it. We always thought it would better breaking up the roofline, that massive roof there. With the door, I think we'll actually do that. Yeah. Yeah. I like the idea of the six over ones too, just because I think that you're not consistent with what we're gonna see as we look at the building. I understand what you're saying about this, but my own impression, I'd like to see six over ones. Just in terms of pure aesthetics, it looks like it has always been there, and frequently carriage houses were attached to older buildings by breezeways, open sheds, sort of in the nature of the old farmhouse where the barn was attached to the house with a shed or a garage or a wood shed or whatever. Right. And again, it was a new addition between the two, but it looks like, I mean, passing down the street and looking at it looks like it could have always been there. Right. Because it's not atypical. And again, I guess that's a, a mixed. Right. Yeah. And then again, we could give them the option of doing either which, whichever you think would look the best. Well, Jay and I batted around the six and the one over one and Jay went with the one over one because that was what was below it. So that's how we arrived at this. I think that the one over ones follow the Secretary of Interior's standards, which do say you shouldn't give a false, you know, false sense of history with your new additions. They should be compatible, but you don't want them to look like they've always been there necessarily. You want them to work and be sympathetic with what's historic. Yeah. So. And actually, if you use a insulated glass with an exterior screen on it, the darkness of the screen will help. If you look at some of the other windows that have that, that will help that blend in so that it's not going to be as conspicuous as it would just glass sitting there reflecting the morning sun, which hits that, that building morning and late morning. Right. The one over ones are probably a little cheaper, too. What are the windows? Are they marvins or what do you use? I've, that's been a while since we've, whatever we use on the molasses, we'll probably use again. Yeah, we'll pick a good one. It's like a wood window. I'm interested in the sort of rhythm between siding window, siding, double window, siding window, siding that they're unequal. And whether that is what the intention is. It almost looks like he matched. Oh, I see. He matched the bump out on the second story of the main building. You know, you have a single on the, on either side and then that double in the front. Well, also just that there's more than that. There's a lot more siding on the far side. No, okay. And it looks like the space is, the space between the two windows is unequal on the right and left. Oh, okay. Now, whether there is some intentionality that I don't understand. It might have to do with the floor plan. I would think, yeah. Yeah, but it may be that that we were hitting the floor plan. There's a, there's a wall here and we're going to move it here to make this right. Right. A little more generous. This office will be small. I'm guessing that wall is there. Right. I'm thinking that's what you do. I like the balance of that. I think it works fine. Yeah. Yeah. This is the existing floor plan. I'm certain there's good reasons for it. And I think we wanted to move this wall or cross out the existing wall. This wall here is going to be the new wall. And I'm guessing Jay married up the, the split in the window. Yes. With that wall. Yeah. Copy of that just for class? Yeah. Awesome. Thank you. I'm certain Jay is sensitive to what it looks like for me. Right. Yeah. Well, maybe we, the, the window on the, you know, it's funny that far right hand window as you're looking at the building. If you slid that over, that would make it more equal because it's long. Yeah. I see what you're saying. Rather than move the middle one is move this one that way. Right. Or if you move this one that way. Yeah. That makes sense. I think the middle one was lined up on that wall, but I think the two outer ones, we can make those equally distant if you'd like to. I feel like that would give it a little, everything else is pretty well proportioned and sort of stepped on the building. Right. Yeah. We'll make the windows equidistant. Yeah. As much as possible based on the floor. Yeah. It's a beautiful building. Yeah. Thanks. Yes. A little more painting to do up there and a little more roofing and painting and then the storm or it would be done. Yeah. I assume it'll, look, you've already redone this roof since this photograph. Yes. Yeah. And so this door will have an ascolchial roof to match whatever. To match. Yeah. It was just put it in as an option that you may position the windows equidistant spacing or aesthetic balance if it can be accomplished with a proposed interior floor plan. We'll do it. There are comments, questions, suggestions. Alternative depending on what the other windows are. Some mix of wood. I think on the front there would. They may be clad on the back, but I'm pretty sure they would. It just indicated that they wanted to replace some on the hand. I can go through the criteria unless anybody has anything else. Here's a set of criteria. You've been through this before. I'll just read quickly through that. Yeah. Evaluation criteria number one. Preservation of reconstruction of the appropriate historic style of the proposed projects in the historic district involves an historic structure. This addition of the adornment is acceptable. Harmony of exterior design with other properties in the district acceptable. Compatibility of proposed exterior materials with other properties in the district acceptable. Compatibility of proposed landscaping. None proposed in this application. Prevention of the use of incompatible designs, buildings, color schemes or exterior materials. Acceptable. Location and appearance of all utilities. No change in any lighting or other utilities. None the outside. Recognition of and respect for view quarters and significant visitors including gateway views of the city and state house. Acceptable. All in favor of the application is proposed. Raise your hand. Just signed that one right above my name. I'm a little out there. You have a pen. Okay, thank you. So did we go to go one over one or six over one? It's your option. I didn't write it down. I didn't write it. You have it listed as a one over one. Okay. Unless you want the option of doing a six over one. No, I think we're good with a one over one. Yeah. Okay. Again, I think the screens on the outside are usually dark enough that they'll make it more subtle whichever way you go. Yeah. Great. All right. Thanks everybody. Thank you. Okay. Thank you. Yep. Check and see if I pray for him. Okay. We'll talk amongst ourselves. Whoa. It's really good. It's a little bright. I'm hoping that the color is a little darker and a little more subtle, maybe a little gray in it or something to tone it down. Yeah, it's pretty bold. I already have a green one on the state street that takes your breath away.  That somehow didn't look. I just. It was represented. It'll probably fade over a couple of years. 20 years. It's too bad because there's a depth in certain colors that you try to achieve that makes a building look really rich and really, really nice. Someone didn't quite make it. No. No. I'm not sure. It's unfortunate. Yeah. I don't know. Some people see that. Some people don't. Some of the better designers are really good with colors. I think people don't realize really what it's going to look like until they get it out. I think it's pretty hard to go from a peas watch or a chip. Yeah. You have to do a big sample. Well, they painted samples on the side of the building and why they had people thinking that was the one that kept going myself. I wonder if she has an actual color swatch of the true color. I hope so because I don't think I can vote for that one. That one's really not an accurate federal blue. Right. Did they give you an actual color chip other than that? No. That and saying it's federal blue. You want an actual color? It's good that they're here. We'd like an actual color chip. Okay. Perfect. Professor, that's a bit bright. I'm not sure if that's what they were truly attempting. And again, that's a sample color. I'm an entirely different building. Yeah. No, I know. I'm not sure. What's the siting on the building now? Is that a wood siting? I don't think so. What's that aluminum to me? I don't know. Or is that aluminum? I think it's aluminum. I'm looking at the corners and there's not a corner board on there. But I also don't read the little aluminum caps in there either. There's no like, you know, like that or trim around the windows. I was also looking at the corners here. Yeah. And usually if it's wood. And the windows. Sometimes they will do a miter cut. But more often than not, they do a corner board. So what kind of siting? What color? Concurrent or color trim? An actual color chip. Some of the corners daily. Just before you go on the bridge. In state. In state, yeah. That's the gas station. Right. On the river side. Okay. Yeah, it's kind of an odd view. Has anybody had a chance to look at the minutes? On February the 4th? I did. And they looked good to me. Anybody have anything else to add or change? I was not present. Okay. I think it was good. No apology necessary. Do I hear a motion to approve the minutes? Okay. All in favor of approving minutes. Raise your hand. And it's far approved by four votes. Any other business other than the fact the next meeting's Monday, April Fool's Day. I have a question. Because I have obviously have too much time in my hands and I was reading all of our regulations. Why has the one more time sign not been removed from that's an abandoned sign? Probably because I have a backlog of sign enforcement that I haven't gotten to. You still have Lewinstein's address. Is there anybody? Is there anybody older? Yes, that's Lewinstein. It's not a Jacobs building. Not yet. Lewinstein wants to sell the building but it needs a lot of work. It's uninsulated and much of it. There's single pane windows. I'm not sure if the heating system is ever replaced. The heating system belongs in the Smithsonian. And he wanted, last time knew, they wanted 1.3 as is. I just caught my eye. So anyway, but you're right. Yeah, no, it needs to come down. There's other signs that have popped up around the city that have a couple of things that I need to follow up on. Do I hear a motion to adjourn? I move to adjourn. Second? I'll adjourn. All in favor of adjournment, raise your hand. Meeting is adjourned. That was quick. That was tough.


Safety is the top priority of the Department of Transportation. I'm Dick Landis. I used to be a Highway Patrol commander. Now I'm the Associate Administrator for Motor Carriers at the Federal Highway Administration. That safety statement was contained in the National Transportation Policy that was announced by President Bush and Secretary Skinner at the White House in March of 1990. In that statement, safety applies to all modes of transportation. Trucks, buses, airplanes, trains, ships, all modes. We're particularly concerned about motor carriers, trucks and buses. They are so numerous and they're so important that we apply a great deal of resources to their safety. Ensuring truck and bus safety as they share the road with other vehicles on the highway is the responsibility of the Federal Highway Administration. The methods that are used to regulate this industry will be the subject of this film for the next few minutes. It's a story we're proud of. It's a story you will appreciate. Regulation of truck and bus safety is not something new. The first regulations were issued in the late 1930s when the industry and the highway system were just developing. Today the truck and bus safety function is carried out by the Department of Transportation's Office of Motor Carriers. There is an important sizable universe under its jurisdiction. There are more than 200,000 trucking operations in interstate commerce, ranging from a few giant carriers with thousands of rigs to many, many more companies with as few as three or four trucks. There are four higher carriers, which hold themselves out to serve anyone, private carriers, which operate trucks as an adjunct to their primary non-transportation business, and countless owner operators, individuals who own one or several trucks and who often lease their services to motor carriers. Plus, there are 3,000 interstate bus companies that provide regular route, charter and special services. All told, these freight and passenger carriers operate some 3.5 million trucks and buses. And somewhere in the neighborhood of 5.5 million men and women drive those trucks and motor coaches for a living. The Office of Motor Carriers oversees the safety of those operations in the three principal areas shown in this roadmap, the driver, the vehicle and the carrier. This video will take us through the separate routes shown for each of the three and show how they all come together at the end in one coordinated program, the master plan for safe trucks and buses. First, because there are so many of them, 5.5 million, let's take drivers. Prior to a law enacted by Congress in 1986, there were some unscrupulous and unsafe commercial drivers who obtained licenses fairly easily from a handful of states. Thus, they spread out violations and convictions using those various licenses, and they continued to work without losing their driving privileges. No longer. Now, each individual commercial driver is allowed to have just a single license issued only by the state of residence. No more multiple licenses or unlimited violations will be possible because of a new nationwide computer hookup that states check before issuing new licenses or renewals. Acquiring the new license isn't automatic either. Before that 1986 law, people could get commercial type licenses in a lot of states without taking special tests or even having to show they could drive a truck or bus. No more. Under the new commercial license program, drivers have to do two things. Pass a comprehensive knowledge test and demonstrate their ability to handle the vehicle they intend to drive safely and skillfully. There are other qualifications as well. Among them, drivers must be in good health and pass a thorough physical examination every two years. They cannot use or be addicted to drugs and are subject to regular drug testing. They cannot be an alcoholic. They cannot have any condition that might cause fainting or blackouts. They must have an annual review of their driving record. And before employment, they must provide a ten-year job history. The aim is to make absolutely sure they are physically and professionally qualified. The focus of the second of the three areas of regulation is the vehicle. How all three and a half million of them can be made as safe as humanly possible. The Federal Highway Administration provides millions of dollars in grants to the states to enforce the safety regulations through the Cooperative State Federal Motor Carrier Safety Assistance Program. This has taken the form primarily of state personnel being specially trained to perform roadside inspections of vehicles and driver records. A total every year nationwide of about one and a half million. These are effective in getting potentially unsafe equipment and drivers off the road. Vehicles and drivers are put out of service on the spot until defects or deficiencies, usually brakes that need adjusting or excessive driving hours, can be corrected. The third area of emphasis is the motor carriers. Those 200,000 entities that operate or control the trucks and buses. Along with a number of state personnel, some 450 federal safety specialists visit these carriers at their headquarters. They conduct systematic reviews of carriers' safety procedures and controls to determine whether the carriers have safety systems in place to comply fully and properly with all applicable regulations. The basic review questionnaire consists of close to 60 areas of inquiry. Does the carrier have a copy of the Federal Motor Carrier Safety Regulations at hand? Does the carrier have the prescribed amount of accident insurance all the way up to five million dollars for hazardous materials? Complete up-to-date driver medical records, current maintenance and repair records, and so forth. The questions are more numerous and tougher for hazardous materials and passenger carriers. The result is that each carrier is given a rating, satisfactory, conditional or unsatisfactory. Those in the latter two groupings get follow-up educational assistance and technical advice from the specialists to help them improve their performance and practices. It is an education mentality rather than a penalty mentality, although there are severe penalties and sanctions on the books up to and including a shutdown of operations that can be assessed for continued willful disregard of the regulations. So to return to the master roadmap, at the top are the three main elements, again the vehicle, the carrier and the driver. Vehicles that pass inspection continue in service safely. Carriers that earn satisfactory ratings carry on their business safely and drivers who pass the tests and meet the other qualifications get their commercial licenses and go about their day-to-day work. On the other hand, there are sanctions ranging from fines to permanent disqualification for serious traffic violations or drug or alcohol usage while on duty. A complete record on every driver is filed away and is available in the commercial driver's license information system. Vehicles that can't pass either a roadside inspection or a required annual inspection must have the required repairs before they can resume service. The Motor Carrier Safety Information Network, called SafetyNet, allows the Federal Highway Administration and the states to manage and share the data collected during vehicle safety inspections. Carriers that do not get satisfactory ratings get assistance to help them get upgraded. But in the meantime, they could well lose business because of their rating, plus having to pay fines or even shut down all or part of their operation pending improvement. All the elements, the driver, the vehicle and the carrier, come under surveillance through the driver testing and record checking by roadside inspections, by examination of accident data and by visits to carrier facilities. The computer networks allow close monitoring so safety problems can be detected and resolved quickly. That's how the whole system works. Coupled with numerous other cooperative activities at the federal and state levels, the commercial motor vehicle safety effort described in the past few minutes is an effective one, one that helps prevent accidents by keeping unsafe vehicles and unqualified drivers off the road, the road that's shared by everyone every day. The record speaks for itself. The fatality rate for truck and bus accidents has been on a steady decrease over the past several years. We may not ever get to zero, but we are making excellent headway. As I said, I used to be with the highway patrol. In my many years in Arizona, it taught me a lot about highway safety. I am very proud to be part of the team that is moving us into the 21st century safely. Won't you please join me? If you would like further information about the truck and bus safety programs right to the Federal Highway Administration, 407th Street, Southwest, room 3103, Washington, D.C. 20590.


Heshi miwa? Yes, myself. I am very good. I am just enjoying the pressure of the world. I am just enjoying the cool breezes. I am enjoying the freedom that was finally arrived. I am just enjoying the good environment. Hey, how are you? I hope you are doing well. My name is Ndenya and welcome to yet another episode of Crazy 11. Today I spotted Mahesh Mwenyewe. They call him Mahesh. Let's approach him. We talk to him and we'll get to know who it is. Heshi miwa? Yes, myself. I am very good. I am just enjoying the pressure of the world. I am just enjoying the cool breezes. I am enjoying the freedom that was finally arrived. I am just enjoying the good environment. Okay, can we take a stroll as we catch up a bit? No problem. KK, how are you? I am a content creator. So, I just created the content. So, I just created the content. So, I just created the content. So, I just created the content. So, I just created the content. So, I just created the content. So, I just created the content. So, I just created the content. I just created the content. Ok, let's finish the video eki. I interact withised challenge. If anyone from my family lives, that can always do something and be a problem okay. I try two tiktokивi in텐ittifu za Peanutunido o cub Gorne. If anyone come up and say that he is a last resort trud. and in trapping people inragon I confirm that I can change it. your graniva, who else can you immediate apart from him? ah I am, I am sorry na jari boku fa niya researche ki dogo but for now hwacha khwaza ni fokasina uyo Naya uyo kwa na okay, now I meant to ask you some questions to get to know you better so money or love? money or love money or love, e m uha ma ande hwacha kwa na se waza squeeze hi without money you cannot have love So... Bati na dependi huni nani unapenda. Unaji kuna maali kuna mani ingine, iyesinu nua. Kuna mapenzingi ingine, iyesinu nua na mani. Kama ya mizazi ui yos, iwa off yesu ta prefer love. Bata na ekifika ni ingine yadunia, aafadali pesa. Adi yadunia. So what keeps you up at night? What keeps me up at night? At night what keeps... Ah, mi researching for new content. Yondo ni fanyanga tu ni kwa on at night. Amma ni ki research, amma ni ki fanyafanya. Tukazitu hangu maybe editing, afrandime shoot, shoot. Ya, that's what... Amma yako keep up at night. Amma kuna kitu ingine ina keep up at... At a visit, you know where I'm going, Lisa? Mi kupangu, ni kukua busy. Ya, yondo ni keep up at night. So what keeps you up at night? Nara rangabibas na kama yako busy.  Is it true? Of course I am. What do you study? Nafanya applied computer science. No kuna brain sapa? Ah, wei, wei. Nakuwa nga nazo ni vidasosa na. Nakuwa nga ni mezi feature tu wa tu hezi ya na. Na isu, ya mi am a student at Kisi University. Magadia, pursuing bachelor of science in applied computer science. Ya. Ah, nice. Are you a shu person or accessory person? Accessory. Shu, aja nazo. Muna mefkiri eba. Muna naluku, bura eba. Una jua, yo nava jula. Lakin isada ikifikani accessories. Una jua isi bitu. Zat jubi su naski aminim tu wa ni ni wa computer science. So I prefer accessories ju. Zinani sa idea nakuwa na fikiri ya. Mbibi kusimama mbaya computer na ni ni nasi imu na ni ni hezo. Ya. Fever 8 mil? Fever 8 mil. Mimi nakuwa nga kila kitu, lakin kikama ikuwa na kuku. Mimi kitu skulangi labda chuma na ikisi ya goa na eza fikiri ya kitu ingine. But sasa na prefer kuku na penda kuku. Best music? Best music. Gaya yata skuizi yata sinaba best. Nasi kuni kuna skiza rege, alafu ni kafika maali. Ni kawkoka. So... Mwadza? Otwa mwako kwa skiza rege? Wana skiza nga like iyo siku. Like siku wa ni mwako kwa masahi. Sahi sana sana skiza goa spare. Zagot God, but I still love reggae music very much. Okay, do you believe in marriage? I believe, of course I believe in it. Why should I not? My mum is married. My father married my mum. Why should I not believe?  Why not? I'm going to get married very soon. Kwebam tuyuko? Ni pesa zina. Pesa una, lakini mutu yuko? Pesa na mutu lakini. Nasa aw. Pesa una jua marriage kwa zi ni expensive kwa zi kama una pesa. Wei, abu hachana na. Ile maisha, una angali yanga from the past experience ni ume piti ya piti ya iwi kwa watu, na angali ya tu watu. Hei, una linganisha. So, dazi ma kwa zi utafute pesa vizuri na ukwa na fukomu zuri. Mareji na kujangana vitu zake. Yuki kuja, mareji yuki kuja waza awa, toto wada kuja utaitaji kuja. So, kazi mingi bati. Yuki kuja nisa awa. Yuki kuja nisa awa? Dreamka? Dreamka? Ah manze jagua. Mi na penda yo gali sana. Mi na yuki penda. Tuki maliza? What is the last Google? The last thing of Google? The last thing I Google, iliku wa ni ni manza. Angali ya, suko nasimu? Niza angali ya watu ni angali ya mi. Ah, iliku wa ni kisi University Student Poto. Nima kumbuka this morning by the way. Of course. Uniza kono farm. Niza watu wa mi ni tu. Lakin ni thank you so much. I enjoy your content. I like your content. Thank you. Welcome. Nimi wome ni umbiya thank you, sir. Welcome. Okay, now tell me. Na ebu ni kulize? Ukapata na agasha guwale. Niza mombiya ni ni? Ah, iliku wa ni watu wa mi niluza. Lakin ni sasa. Una juwa sasa ni aje. Ni kama... Ni kama... Ita kuja tu. Waja ni kuwa. Mi siyesi panga. Siyesi yandika script ni seme. Ati juicy juwa raka manta patana. Una na. Una na. Una niki yandika script ni seme. Tuki patana yanta mombiya iwi na iwi na iwi na iwi. But ni kifika apu. I know I'll have the power to tell him what I would like to have. Ama kitunita mombiya tu. Tuta. Do you look up to him in any way? Yes. Ako hard working. Una na. Lik. Abuangali. Abuangali. Imi kitu imagine. The first yandi. Siju kama ni the first time kama kushaiku wa na kitu kama yoko history ya Kenya. Ako 2. Ame kuwa 2 MP. In maybe 2017 for the first time. And now he's the deputy president. Why should not I admire him? Why should I not? Ya sunona. So he's a good model of course. Ya. Okay. Now tell my people to like, share, subscribe to Crazy Eleven. Oh Crazy Eleven. Oh, thank you. Thank you. People, people, people. Here he is Mr. KK Mwenyevena. Like and subscribe to Crazy Eleven. Ya. Crazy Eleven. Make sure you subscribe. And make sure you subscribe to Mr. KK Mwenyevena too. Thank you. Thank you so much KK. You're the people of Kenya. The people of the Hasra Nation. Every person of the Republic of Kenya. I want to ask you this time to subscribe to SPM bus. And this is the best online platform. Where you get all the type of news. Make sure you subscribe. Make sure you like. Make sure you follow all the pages. And I am very sure that you are going to enjoy. Thank you.


Good day everybody. Dr. Sanjay Sanyal, Professor, Department Chair. Welcome to our section of the phase. This time I'm going to demonstrate a few of the muscles of facial expression. But before I start demonstrating the muscles, I need to tell you a few general things about these muscles. First of all, these muscles are all derived from the second bronchial arch, or the second pharyngeal arch, and therefore they are all supplied by branches of the facial nerve. And the facial nerve supplies them through five principal branches, which are as per the distributionation by my fingers. Temporal, zygomatic, buccal, marginal mandibular, and cervical. The second point about these muscles of facial expression is that even though the textbooks show them in vivid clarity, in real life they are not so clear. They are very thin, they are almost like fibers. And more importantly, these muscles, because they have to keep the facial skin mobile, one end of the muscle is attached to the bone, the other end of the muscle is attached to the skin. And therefore, while dissecting them, it is quite possible that we may have to remove some of the fibers. And not only that, the facial artery and the facial vein sometimes they run deep to some muscles, and sometimes they run superficial to muscles which we shall see. So therefore, we cannot see all the muscles in as clarity as we can see them in the pictures. Having mentioned these points, let's start off with whatever muscles we have been able to dissect out here. The first muscle that we can see here, this is a part of the frontalis muscle. The frontalis muscle takes origin from the gallia aponeurotica, and that is shown here, or the epicranial aponeurosis. And it gets inserted, as you can see here, on the skin of the forehead. And the function of this is when it contracts it produces horizontal wrinkles of the forehead. Now, this function of the frontalis is facilitated by another opposing muscle and that is the occipitalis muscle. The occipitalis muscle takes attachment from the superior nuclear line and it gets inserted onto the gallia aponeurotica. And when this occipitalis muscle contracts, it tenses the gallia aponeurotica and therefore, it increases the functionality of the frontalis muscle. Because the frontalis muscle is the opposite, it takes origin from the gallia and gets inserted onto the skin. Incidentally, whenever there is any injury of the scalp, this layer that we see here, this is the layer number 4 of the loose aerial tissue layer of the scalp, which separates the gallia aponeurotica from the periosteum. Blood can track on this loose aerial tissue layer and it tracks under the frontalis muscle and it then spreads under the skin of this upper eyelid and the lower eyelid, around the auricularis oculi producing what is known as the black eye or the racoon eye. Now, let's come to the next muscle that we can see here. For that, I have lifted up the skin on the nasal side of the face and we can see this muscle here. This is the proceder's muscle. One side is attached to the under surface of the skin, other side gets attached to the bone and it moves from lateral to medial. And this is the one which produces the disdainful appearance. Now, let's take a look at the fibres which are just deep to the proceder's and that is these fibres here. We can see some of these fibres here. These are the fibres of the auricularis oculi and we can see some of the fibres of the auricularis oculi in this also. These are the fibres of the auricularis oculi. The auricularis oculi has got three parts. One portion is the orbital part which is the more peripheral part and that is the one which is responsible for closing the eyelids tightly. Then we have a few fibres which are closed over the eyelids and they are the ones which are responsible for gentle closure of the eyelids. And finally, there are a few small fibres which are located right on the nasal side of the eye which are in contact with the lacrimal sac and they are responsible for facilitating drainage of the tears. Next muscle that we can see here, actually it's a group of muscles, we can see some of these fibres here. These are the fibres of the levator labiae superioris alec nasi and we can see some of the fibres are going down and some of the fibres are coming from the nose. They are the ones which elevate one side of the nose when the person is making a sneering expression. Next, we have some other muscle fibres and incidentally when I am dissecting this out, you would have noticed that the facial artery is running partly under the muscles and partly superficial to the muscles. These are the fibres of the zygomaticus major, the lateral fibres, and the zygomaticus minor are the medial fibres. Zygomaticus major, when it acts on one side, it produces a sneering appearance and when it acts bilaterally, it produces a smiling appearance. Deep to the zygomaticus major and zygomaticus minor, we have the levator anguli oris and the levator labiae superioris. The levator anguli oris produces a grin or a grimace expression. This is the buccanator muscle which takes origin from the alveolar process of the maxilla medial and from the terico medibular raffae and inserts with the fibres of the orbicularis oris. This is also known as the trumpeter's muscle which the trumpeter uses to blow out his cheek. It also acts as an accessory muscle of mastication. Importantly, we notice that the buccanator muscle is pierced by this structure here. This is the perotid or the stensin duct which pierces the buccanator and it opens on opposite the crown of the upper second molar tube. I would like to draw your attention to this cavity here.  This buccal pad of fat actually has got multiple extensions. One extension goes above the zygomatic arch to the temporal region and the bulk of it fills up this region.  This buccal pad of fat is supposedly useful for suckling in children. When a person undergoes starvation or when the person is bedridden and malarished, then the sunken cheeks appearance is produced by loss of this buccal pad of fat. And finally, cosmetic surgeons use this buccal pad of fat for various cosmetic and reconstructive beautification surgery. That is about the buccal pad of fat which is located here superficial to the buccanator but deep to the other facial muscles. Let us continue with what other muscles that we can see here. We can see some of the fibres of the orbicularis oris here, the circular fibres which completely encircle the upper and the lower lip. In this correction, I would like to draw your attention to yet another structure which is located just about 1 cm lateral to the angle of the mouth and that is here where my finger is located. There is a fibromuscular condensation here that is known as the modulus of the face. The modulus of the face is like the hub of a wheel. Three muscles from the top, three muscles from below, one muscle from lateral side and one muscle from medial side. All of them meet at the fibromuscular condensation that is the modulus. The three from the top are the zygomaticus major, the levator angulari oris and the levator labisuperioris. The muscle from the side is the buccanator, the muscle from the medial side is the orbicularis oris and the three muscles from below are the depressor angulari oris. Some of those fibres we can see them here. The risorius which we can see some of the fibres here and the depressor labi inferioris. So these are the three muscles from below. All these eight muscles meet at the modulus and in facial palsy when the injury to the facial nerve. One of the common findings is flattening of the nasal labial furrow that is this furrow here as well as drooping of the angle of the mouth. And that is because of this fibromuscular condensation, the modulus dropping down because it is no longer supported by these muscles. And finally as I mentioned already these are some of the fibres of the risorius. These are some of the fibres of the platysma and these are some of the fibres of the mentalis muscle. The platysma is also a muscle of the face but it is located more in the neck. It is a subcutaneous muscle and that is located here. And just to complete the story though it is not a muscle of facial expression we can see this strong muscle here on the lateral surface of the ramus of the mandible. This is the masseter muscle which is a very important muscle of mastication. So these are the muscles which are related to the muscles of facial expression and which are all supplied by branches of the facial nerve. When a person has got injury to the facial nerve which travels through the parotid gland then there can be paralysis of the muscles of facial expression. And which can produce a whole host of manifestations some of which I already mentioned. One important manifestation apart from drooping of the angle of the mouth is inability to close the upper eyelid. And therefore when the person tries to close his upper eyelid the eyeball moves up and that is known as Bell's Phenomenon. Thank you very much for watching. Ladies and gentlemen if you have any questions or comments please put them in the comment section below. Have a nice day. Dr. Sanjay Sanyal signing out. Don't forget to like and subscribe.