Chronic medical conditions and traffic safety: review of the California experience

Distribution and association of road traffic accident with depression among Indian population aged 45 years and above: nested multilevel modelling analysis of nationally representative cross-sectional survey

INTRODUCTION

The prevalence of important public health problems like road traffic accidents (RTA) and depression are surging. This study was aimed to estimate distribution and determine the association between RTA and depression among Indian population aged 45 years and above: overall and stratified into age group, gender and across states/union territories as aspirants, achievers, and front runners.

METHODS

Using Longitudinal Aging Study in India (LASI) dataset (April 2017-December 2018), we have conducted this study among middle aged (45-59 years) and older adults and elderly (≥ 60 years) Indians. Bivariate analysis was conducted to estimate the prevalence of RTA and depression nationally and across aspirants, achievers, and front runner states. States and union territories were categorised as low, medium, and high as per RTA and depression prevalence, which were further cross tabulated. Spatial distribution maps were created using Microsoft Excel. We have documented the association of RTA with depression. To reduce the confounding effects of demographic and socioeconomic; health related and behavioural covariates; propensity score matching (PSM) was conducted. Nested multilevel regression modelling was analysed using STATA version 17.

RESULTS

Prevalence of RTA was 1.84% (1.74-1.94) nationally, highest among achiever states [2.04% (1.82-2.30)]. Prevalence of depression was 6.08% (5.90-6.26) nationally, highest among aspirant states [7.02% (6.74-7.30)]. The adjusted odds of having RTA was significantly among depressed [aOR (95% CI) 1.76 (1.45-2.15)] than non-depressed participants; which was much higher among females [aOR (95% CI) 1.93 (1.43-2.62)] than in males [aOR (95%CI) 1.67 (1.29-2.16)] and much higher among middle aged [aOR (95%CI) 2.08 (1.63-2.65)]. Odds of RTA was highest across front runners [aOR (95%CI) 1.86 (1.26-2.72)] followed by aspirant states [aOR (95%CI) 1.79 (1.37-2.33)].

CONCLUSION

This study established the positive association between depression and road traffic accidents among middle aged, older adults and elderly. Therefore, efforts must be taken to address mental health issues in them with proper policy implication more focused on females and middle aged. Front runner's states should get the limelight followed by aspirant states.

Schizophrenia, antipsychotic treatment adherence and driver responsibility for motor vehicle crash: a population-based retrospective study in British Columbia, Canada

OBJECTIVE

To examine the relationship between schizophrenia, antipsychotic medication adherence and driver responsibility for motor vehicle crash.

DESIGN

Retrospective observational cohort study using 20 years of population-based administrative health and driving data.

SETTING

British Columbia, Canada.

PARTICIPANTS

Licensed drivers who were involved in a police-attended motor vehicle crash in British Columbia over a 17-year study interval (2000-16).

EXPOSURES

Incident schizophrenia was identified using hospitalisation and physician services data. Antipsychotic adherence was estimated using prescription fill data to calculate the 'medication possession ratio' (MPR) in the 30 days prior to crash.

PRIMARY OUTCOME MEASURES

We deemed drivers 'responsible' or 'non-responsible' for their crash by applying a validated scoring tool to police-reported crash data. We used logistic regression to evaluate the association between crash responsibility and exposures of interest.

RESULTS

Our cohort included 808 432 drivers involved in a police-attended crash and for whom crash responsibility could be established. In total, 1689 of the 2551 drivers with schizophrenia and 432 430 of the 805 881 drivers without schizophrenia were deemed responsible for their crash, corresponding to a significant association between schizophrenia and crash responsibility (66.2% vs 53.7%; adjusted OR (aOR), 1.67; 95% CI, 1.53 to 1.82; p<0.001). The magnitude of this association was modest relative to established crash risk factors (eg, learner license, age ≥65 years, impairment at time of crash). Among the 1833 drivers with schizophrenia, near-optimal antipsychotic adherence (MPR ≥0.8) in the 30 days prior to crash was not associated with lower crash responsibility (aOR, 1.04; 95% CI, 0.83 to 1.30; p=0.55).

CONCLUSIONS

Crash-involved drivers with schizophrenia are more likely to be responsible for their crash, but the magnitude of risk is similar to socially acceptable risk factors such as older age or possession of a learner license. Contemporary driving restrictions for individuals with schizophrenia appear to adequately mitigate road risks, suggesting more stringent driving restrictions are not warranted.

Differences in shift and work-related patterns between metropolitan and regional/rural healthcare shift workers and the occupational health and safety risks

OBJECTIVES

To explore if there are differences in shift patterns and work-related factors between metropolitan and regional/rural healthcare shift workers and their risk of poor sleep and mental health. Furthermore, explore whether these factors impact on medical errors, workplace and car/near car accidents.

DESIGN

A cross-sectional study.

SETTING

An anonymous online survey of healthcare shift workers in Australia.

PARTICIPANTS

A total of 403 nurses, midwives and paramedics completed the survey.

MAIN OUTCOME MEASURES

Sample characteristics, employment location, shift work-related features, sleep and mental health measurements, workplace accidents, medical errors and car/near car accident post shift.

RESULTS

Regional/rural healthcare shift workers were significantly older, had more years' experience, worked more nights, on-call and hours per week. Those in metropolitan areas took significantly longer (minutes) to travel to work, had higher levels of anxiety, increased risk of shift work disorder, reported significantly more workplace accidents and were more likely to have a car/near car accident when commuting home post shift. Both groups reported ~25% having a medical error in the past year. Workplace accidents were related to more on-call shifts and poor sleep quality. Medical errors were associated with fewer years' experience, more evening shifts and increased stress. Car accidents were associated with metropolitan location and increased depression.

CONCLUSION

Differences in work-related factors between metropolitan and regional/rural healthcare shift workers were observed. Some of these factors contributed to occupational health and safety risks. Further exploration is needed to understand how to reduce occupational health and safety risks, and improve employee and patient safety both in both regional/rural and metropolitan areas.

A Systematic Review of the Risks of Motor Vehicle Crashes Associated with Psychiatric Disorders

OBJECTIVE

Psychiatric disorders and their treatments have the potential to adversely impact driving skills. However, it is unclear to what extent this poses a public health risk by increasing the risk of motor vehicle crashes (MVCs). The aim of this systematic review was to synthesize and critically appraise evidence on the risk of MVC for drivers with psychiatric disorders.

METHOD

We conducted a systematic review of the MVC risk associated with psychiatric disorders using seven databases in November 2019. Two reviewers examined each study and extracted data. The National Heart, Lung, and Blood Institute Quality Assessment tools were used to assess each study's quality of evidence.

RESULTS

We identified 24 studies that met the inclusion criteria, including eight cohort, 10 case-control, and six cross-sectional designs. Quality assessment ratings were "Good" for four studies, "Fair" for 10, and "Poor" for 10. Self-report or questionnaires were used in place of objective measures of either MVC, psychiatric disorder, or both in 12 studies, and only seven adjusted for driving exposure. Fifteen studies reported an increased risk of MVC associated with psychiatric disorders, and nine did not. There was no category of disorder that was consistently associated with increased MVC risk.

CONCLUSION

The available evidence is mixed, not of high quality, and does not support a blanket restriction on drivers with psychiatric disorder. An individualized approach, as recommended by international guidelines, should continue. Further research should include objective assessments of psychiatric disorders and MVC risk and adjust for driving exposure.

Seizure-Related Injuries in People with Epilepsy: A cohort study from Saudi Arabia

Objectives

Patients with epilepsy have a high risk of accidents and injuries, resulting in minimized physical activity and social withdrawal. Therefore, we surveyed the prevalence and the types of injuries that patients with epilepsy may endure, and the factors that may increase the risk of injuries.

Methods

In this cohort study, adult and pediatric patients diagnosed with epilepsy (age ≥ 7 years) and a close family member (parents/guardian) attending the outpatient epilepsy clinics at King Fahd Medical City (Riyadh, Saudi Arabia) were interviewed by neurologists. They reviewed the patients' medical records and administered a structured questionnaire to identify and compare several variables, including injury frequency versus seizure type and seizure frequency, number of antiseizure medications used, medication compliance, and work and social limitations.

Results

Out of 200 patients, 86 (43%) sustained injuries during an attack of their habitual seizures. Almost half of this group showed a tendency for recurrent injuries. The most common traumas were soft tissue injury (36.5%), head injury (32%), dental injury (8.5%), burns (7%), dislocation (7%), fractures (6.5%), and submersion (2%). Two‐thirds of the patients had their injury at home. 64% of patients who had seizures for more than 10 years sustained multiple injuries (P = .003). Injury frequency was higher among patients with daily or monthly seizures (P = .03). 76% of patients who suffered injuries more than twice had generalised tonic‐clonic seizures, and genetic generalised epilepsy was encountered more in injured patients (P = .02). Also, patients on polytherapy were more likely than those on monotherapy to have an injury (P = .003).

Significance

Two‐fifths of the patients reported seizure‐related injuries. The most common were soft‐tissue injuries and head traumas, while homes were the most frequent site. In addition, longer epilepsy duration, generalized tonic‐clonic seizures, and polytherapy were associated with a higher prevalence of injuries. Therefore, injury prevention strategies should be developed for PWE, especially for those at higher risk.

Driving performance of euthymic outpatients with bipolar disorder undergoing real-world pharmacotherapy

OBJECTIVE

Medications for the treatment of bipolar disorder (BD) could affect patients' cognitive function. Patients with BD present with neurocognitive impairment even in a remission state. Little research is available on the daily functioning, especially driving performance, of stable outpatients with BD under pharmacological treatment.

METHODS

In total, 58 euthymic outpatients with BD undergoing real-world pharmacotherapy and 80 sex- and age-matched healthy controls (HCs) were enrolled. Three driving tasks using a driving simulator-road-tracking, car-following, and harsh-braking-and three cognitive tasks-Continuous Performance Test, Wisconsin Card Sorting Test, and Trail-Making Test-were evaluated. Symptom assessment scales-Young Mania Rating Scale, Structured Interview Guide for the Hamilton Depression Rating Scale, Beck Depression Inventory-II, Social Adaptation Self-evaluation Scale, and Stanford Sleepiness Scale-were also completed.

RESULTS

Car-following and road-tracking performance were significantly impaired in patients with BD compared with HCs after adjusting for demographic variables, but these performances generally overlapped. Broad neurocognitive functions were significantly lower in the patients with BD compared to HCs, but car-following performance was significantly negatively correlated with sustained attention only. Although most patients received multiple medications rather than monotherapy, no relationship between prescriptions and driving performance was found.

CONCLUSION

Euthymic patients with BD under steady-state pharmacotherapy had impaired driving performance compared with HCs, but the overlapping distributions of driving performance suggested that driving performance is not always deteriorated in patients with BD. Therefore, attentional function may be a useful clinical feature for judging driving aptitude in patients with BD.

Cannabis and Driving

As more states in the U.S legalize recreational and medicinal cannabis, rates of driving under the influence of this drug are increasing significantly. Aspects of this emerging public health issue potentially pit science against public policy. The authors believe that the legal cart is currently significantly ahead of the scientific horse. Issues such as detection procedures for cannabis-impaired drivers, and use of blood THC levels to gauge impairment, should rely heavily on current scientific knowledge. However, there are many, often unacknowledged research gaps in these and related areas, that need to be addressed in order provide a more coherent basis for public policies. This review focuses especially on those areas. In this article we review in a focused manner, current information linking cannabis to motor vehicle accidents and examine patterns of cannabis-impairment of driving related behaviors, their time courses, relationship to cannabis dose and THC blood levels, and compare cannabis and alcohol-impaired driving patterns directly. This review also delves into questions of alcohol-cannabis combinations and addresses the basis for of per-se limits in cannabis driving convictions. Finally, we distinguish between areas where research has provided clear answers to the above questions, areas that remain unclear, and make recommendations to fill gaps in current knowledge.

The Impact of Two MMPI-2-Based Models of Personality in Predicting Driving Behavior. Can Demographic Variables Be Disregarded?

The driver’s personality is a key human factor for the assessment of the fitness to drive (FTD), affecting driving decisions and behavior, with consequences on driving safety. No previous study has investigated the effectiveness of Minnesota Multiphasic Personality Inventory (MMPI)-2 scales for predicting the FTD. The present study aimed to compare two MMPI-2-based models of normal and pathological personality traits (i.e., Inventory of Driving-related Personality Traits (IVPE)-MMPI vs. Personality Psychopathology Five (PSY-5) scale) in predicting the cognitive FTD. One hundred young and eighty-seven adult active drivers completed the MMPI-2 questionnaire as a measure of personality and a computerized driving task measuring for resilience of attention (Determination Test (DT)), reaction speed (Reaction Test (RS)), motor speed (MS), and perceptual speed (Adaptive Tachistoscopic Traffic Perception Test (ATAVT)). The effects of age, gender, and education were also controlled. Results showed that the models controlled for demographics overperformed those neglecting them for each driving outcome. A negative effect of age was found on each driving task; the effect of gender, favoring males, was found in both the RS and the MS, and the effect of education was found on the DT and the ATAVT. Concerning personality traits, significant effects were found of sensation seeking (IVPE-MMPI) on each outcome; of anxiety (as a measure of emotional instability; IVPE-MMPI) and introversion (PSY-5) on the measures of MS; and of psychopathic deviation (as a measure of self-control; IVPEMMPI) on the DT. The study confirmed the key role of demographic factors in influencing the FTD, further suggesting the usefulness of some MMPI2-based personality scales in the assessment of driving-related personality determinants.

Effects of various antipsychotics on driving-related cognitive performance in adults with schizophrenia

The aim of this study was to determine whether the driving-related cognitive performance differs among adults with schizophrenia taking different types of antipsychotics. Neurocognitive performance was assessed using the Cognitive Perceptual Assessment for Driving (CPAD), a computerized battery of tests of visual perception, attention, working memory, reaction time, and inhibitory control for driving ability. One hundred and two adults with schizophrenia who were on antipsychotic monotherapy participated in the study. Of these, 15 were on haloperidol, 28 on risperidone, 14 on olanzapine, 28 on aripiprazole, and 17 on paliperidone. Sixty-four (63%) of the 102 subjects were regarded as competent to drive. Of the subjects taking haloperidol, 33% passed the CPAD, while the passing rates of subjects taking risperidone, olanzapine, aripiprazole, and paliperidone were 57%, 57%, 75%, and 82%, respectively, with a significant difference between the haloperidol and aripiprazole groups (p = 0.005) and between the haloperidol and paliperidone groups (p = 0.001). Additionally, scores on CPAD depth perception (number of correct responses), divided attention, digit span test, and trail-making test B subtests were significantly better for the aripiprazole and paliperidone groups than for the haloperidol and risperidone groups. In this cross-sectional design study, adults with schizophrenia treated with aripiprazole or paliperidone antipsychotic monotherapy demonstrated superior driving-related cognitive performance than those treated with haloperidol or risperidone antipsychotic monotherapy.

Associations of serum low-density lipoprotein and systolic blood pressure levels with type 2 diabetic patients with and without peripheral neuropathy: systemic review, meta-analysis and meta-regression analysis of observational studies

BACKGROUND

Compositional abnormalities in lipoproteins and cardiovascular risk factors play an important role in the progression of diabetic peripheral neuropathy (DPN). This systematic review aimed to estimate the predicting value of low-density lipoprotein (LDL) and systolic blood pressure (SBP) level in type-2 diabetes mellitus (T2DM) patients with and without peripheral neuropathy. We also tried to determine whether LDL and SBP are associated with an increased collision risk of DPN.

METHODS

A systematic search was conducted for eligible publications which explored the LDL and SBP level in T2DM patients with and without peripheral neuropathy. The quality of the included studies was assessed by the QUADAS-2 tool. The standardized mean difference (SMD) with 95% CI of LDL and SBP level were pooled to assess the correlation between LDL and SBP level with DPN. We performed random effects meta-regression analyses to investigate factors associated with an increased collision risk of DPN.

RESULTS

There was a significant association between LDL and SBP with poor prognosis of DPN in those included studies (I₂ = 88.1% and I₂ = 84.9%, respectively, Both P < 0.001). European T2DM patients have higher serum level of LDL in compare with the European DPN patients (SMD = 0.16, 95% CI: - 0.06 - 0.38; P < 0.001). SBP level was associated with a 2.6-fold decrease in non-DPN patients of T2DM (SMD = - 2.63, 95% CI: - 4.00 - -1.27, P < 0.001). Old age European T2DM patients have significantly high risk for diabetes drivers. Furthermore, the results of the case-control study design model are more precise to show the accuracy of SBP in Asian T2DM patients.

CONCLUSION

Our finding supports the LDL and SBP status could be associated with increased risk of peripheral neuropathy in T2DM patients.

Comparing executive functioning and clinical and sociodemographic characteristics of people with schizophrenia who hold a driver's license to those who do not

BACKGROUND.

Community engagement requires driving. However, there is paucity of research focusing on the potential to drive for people with schizophrenia.

PURPOSE.

This study aimed to characterize people with schizophrenia by comparing clinical signs, executive functions (EF), and sociodemographic aspects of those holding a driver's license to those without one.

METHOD.

This cross-sectional study used convenience sampling to select 60 ambulatory individuals to participate: 31 with a driver's license and 29 without one. They completed the Wisconsin Card Sorting Test (WCST) for evaluation of EF and the Positive and Negative Syndrome Scale (PANSS) for symptoms severity evaluation. Data were analyzed using multivariate analyses of covariance and logistic regression models.

FINDINGS.

Participants with a license had less severe negative symptoms and general psychopathology and better EF and sociodemographic aspects compared to those without a license. Logistic regression revealed significant odds ratios (OR) in general psychopathology (PANSS; OR = 0.963, p = .011) and in the WCST (OR = 0.504, p = .027).

IMPLICATIONS.

This study offers occupational therapists a data-driven perspective on evaluating potential fitness to drive to enable participation in daily life and well-being of people with schizophrenia.

Risk of traffic accidents after onset of vestibular disease assessed with a surrogate marker

OBJECTIVES

To determine if the risk of traffic accidents increases after disease onset in patients with acute vestibular disorders. That could provide a valid rationale for guidelines on driving restrictions.

METHODS

5,260,054 patient data (> 18 years of age) from a statutory health insurer were used to identify traffic injuries in incident cases of Menière's disease (MD) and vestibular neuritis (VN) in 2010-2013. Incident diagnoses were defined as the absence of such diagnoses in the preceding 5 years. Comparators were insured individuals with no such diagnoses throughout 2005-2017. The surrogate for traffic injuries were whiplash injuries coded in ICD-10 as diagnosis of sprain of ligaments of the cervical spine without structural changes.

RESULTS

We identified 4509 incident patients with Menière's disease and 25,448 with vestibular neuritis and 5,102,655 controls with no such diagnoses throughout the observation period. The incidence of traffic injuries was increased for both vestibular disorders prior to the time point of diagnosis-MD 0.72 [0.47; 0.97] and VN 0.66 [0.56; 0.76] compared to controls (0.46 [0.46; 0.47]). The temporal course of incidence in whiplash injuries showed no increase and was 0.64 [0.41; 0.88] for MD at diagnosis and 0.73 [0.48; 0.98] after diagnosis, for VN it was 0.81 [0.70; 0.92] at diagnosis and 0.65 [0.55; 0.74] after diagnosis.

CONCLUSIONS

Although these data were not originally collected to address the research question, they provide a valid body of evidence. There is no rationale for driving restrictions, which substantially interfere with the individuals' quality of life, in patients with incident MD and VN.

Auras and the risk of seizures with impaired consciousness following epilepsy surgery: implications for driving

OBJECTIVE

To calculate the chance of a seizure in the next year (COSY) for seizures with impaired awareness in those experiencing auras only, those with no seizures and those with continuing seizures. Epilepsy surgery is an effective treatment for refractory focal epilepsy. Driving is an important factor affecting quality of life. In the UK, driving is not permitted if focal seizures with no impairment of awareness (auras, simple partial seizures) continue, if there is a prior history of seizures with impaired awareness, as will invariably be the case in those having epilepsy surgery. Current UK driving regulations allow driving if COSY is less than 20%.

METHOD

We calculated COSY in 819 epilepsy surgery patients with up to 25 years follow-up. Each patient year was graded on the The International League against Epilepsy surgery outcome scale.

RESULTS

Patients who were entirely seizure-free for 1, 2 and 3 years had COSY of 4.9%, 3.5% and 2.4% respectively. Patients with only auras within the last 1, 2 or 3 years had a COSY of 11.3%, 9.2% and 7.8% respectively.

CONCLUSIONS

Individuals with auras only after epilepsy surgery had a higher COSY than those who were seizure-free. If a COSY of below 20% is regarded as an acceptable risk, it may be suggested that those with auras only in a given year be allowed to drive. The relative risk of these patients causing accidents is lower than population groups such as those aged <25 or >75 years, who are permitted to drive.

Psychiatry, the law and death on the roads

The motor vehicle on the road has a history of only just over 100 years. It is a major form of personal and public transport, but is also associated with hazards and risks. Many more people are killed on the roads each year in Britain than are the victims of homicide. General and forensic pyschiatric evaluation of offenders charged with or convicted of motoring offences is, however, infrequent, despite the presence of mental health problems in some of them. I describe psychiatric, criminological and legal factors associated with driving of motor vehicles, as many psychiatric patients have driving licences and have access to a vehicle or, indeed, may decide to drive unlicensed.

A systematic review of evidence for fitness-to-drive among people with the mental health conditions of schizophrenia, stress/anxiety disorder, depression, personality disorder and obsessive compulsive disorder

BACKGROUND

Limited evidence exists regarding fitness-to-drive for people with the mental health conditions of schizophrenia, stress/anxiety disorder, depression, personality disorder and obsessive compulsive disorder (herein simply referred to as 'mental health conditions'). The aim of this paper was to systematically search and classify all published studies regarding driving for this population, and then critically appraise papers addressing assessment of fitness-to-drive where the focus was not on the impact of medication on driving.

METHODS

A systematic search of three databases (CINAHL, PSYCHINFO, EMBASE) was completed from inception to May 2016 to identify all articles on driving and mental health conditions. Papers meeting the eligibility criteria of including data relating to assessment of fitness-to-drive were critically appraised using the American Academy of Neurology and Centre for Evidence-Based Medicine protocols.

RESULTS

A total of 58 articles met the inclusion criteria of driving among people with mental health conditions studied, and of these, 16 contained data and an explicit focus on assessment of fitness-to-drive. Assessment of fitness-to-drive was reported in three ways: 1) factors impacting on the ability to drive safely among people with mental health conditions, 2) capability and perception of health professionals assessing fitness-to-drive of people with mental health conditions, and 3) crash rates. The level of evidence of the published studies was low due to the absence of controls, and the inability to pool data from different diagnostic groups. Evidence supporting fitness-to-drive is conflicting.

CONCLUSIONS

There is a relatively small literature in the area of driving with mental health conditions, and the overall quality of studies examining fitness-to-drive is low. Large-scale longitudinal studies with age-matched controls are urgently needed in order to determine the effects of different conditions on fitness-to-drive.

Driving skills in unmedicated first- and recurrent-episode schizophrenic patients

The present study was designed to examine driving skills according to regulations of the German guidelines for road and traffic safety in unmedicated schizophrenic inpatients. A total of 13 first-episode (FES) and 13 recurrent-episode (RES) schizophrenic inpatients were included in the analysis and compared with a group of 20 healthy controls (HC). Data were collected with the computerised Wiener Testsystem measuring visual perception, reactivity and stress tolerance, concentration and vigilance. Analysis of data indicates that a great proportion (58 %) of schizophrenic patients were impaired in psychomotor functions related to driving skills. FES and RES significantly differed with respect to driving ability with a greater proportion in the FES (38 %) showing severe impairments when compared with RES (25 %). Differences with respect to HC performance were most pronounced in concentration and for the FES additionally in visual perception. Analysis of our data indicates that a great proportion of schizophrenic patients are impaired in psychomotor functions related to driving skills that cannot be attributed to adverse side effects of psychopharmacological treatment. Besides, we cannot confirm a chronical decline of psychomotor functions related to driving skills at least in the early course of schizophrenic illness.

A simulated driving evaluation for patients with Alzheimer's disease

A prospective study concerning the driving ability of 41 patients with the diagnosis of Alzheimer's disease (AD) was performed. Using a simulated driving test we evaluated the predictive value of the MMSE,'4ADL,5-7and IADL&9to determine the ability of a person with Alzheimer's disease to drive. All patients were driving at the time of the evaluation.

There was no correlation between driving performance and functional status evaluated by ADL and IADL. When comparing driving performance with cognitive evaluation by MMSE, a significant number of patients with MMSE c 22failed the test, compared to patients with MMSE > 22 (P = 0.01, Fisher's exact test).

No patient with a MMSE < 20 passed the driving test. The authors recommend that health care professionals who are caring for people with Alzheimer's disease with a MMSE of22 or less should request a driving evaluation.

Automobile driving and Alzheimer's disease

Automobile driving surveys designed for drivers, nondrivers, and caregivers were mailed to 70 patients with a diagnosis of probable Alzheimer's disease and to their caregivers. The MMSE score of patients who were driving (n=16) was significantly higher (23.9 vs. 11.7 p < .001) than that of nondrivers. Other factors such as age, accident rate, and caregiver driving status did not differ. Caregiver surveys were utilized not only to validate patient responses, but also to identify their concerns. Actual behind the wheel test reports of 12 Alzheimer patients demonstrated serious deficiencies in judgement and in performance.

The Association Between Cardiovascular Disease Risk Factors and Motor Vehicle Crashes Among Professional Truck Drivers

OBJECTIVE

This study assesses relationships between the Framingham cardiovascular disease risk (CVD risk) score and prevalence of US Department of Transportation (DOT)-reportable crashes in commercial motor vehicle (CMV) drivers, after controlling for potential confounders.

METHODS

Data were analyzed from CMV drivers (N = 797) in a large cross-sectional study. CVD risk was calculated for each driver. Adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) between CVD risk and DOT-reportable crashes were calculated.

RESULTS

Drivers in the two highest CVD risk groups had significantly higher likelihood of crash (OR = 2.08, 95% CI = 1.20 to 3.63 and OR = 1.99, 95% CI = 1.05 to 3.77, respectively) after adjusting for confounders. There was a significant trend of increasing prevalence of crashes with an increasing CVD risk score (P = 0.0298).

CONCLUSION

Drivers with a high CVD risk had a higher likelihood of a crash after controlling for confounders.

Diabetes and collision risk. A meta-analysis and meta-regression

AIMS

The main objective of this study was to see whether diabetes is associated with an increased collision risk and to test the effect of age and gender on the overall collision risk for diabetes drivers.

MATERIALS AND METHODS

Twenty-eight studies were included in meta-analysis, using mean age, gender, continent and the prevalence of fatal road incidents as covariates.

RESULTS

The collision risk for diabetes drivers was small and not statistically significant - RR = 1.11 (1.01-1.23) with a prediction interval (PI) or 0.77-1.65. Age and gender were not associated with an increased overall risk. Insulin-dependent diabetes patients had a slightly increased effect size compared with the overall diabetes population, but the effect was not statistically significant. European diabetes drivers had a lower collision risk compared with their North American counterparts, the main cause being the difference of collision risk in the countries in which the studies were performed.

CONCLUSIONS

Overall, diabetes patients do not have a statistically significant increased risk for unfavourable traffic events. Old age and insulin-dependent patients tend to have a higher risk. Advances in diabetes care, associated with advances in road safety regulations, and automotive industry have not decreased significantly the collision risk in the last 50 years for drivers with diabetes.

Knowledge of Driving Vehicle Licensing Agency guidelines among NHS doctors: a multicentre observational study

Objectives

Over half of the UK population holds a driver's licence. The DVLA have produced guidelines to ensure drivers with medical conditions drive safely. Doctors should ensure that patients are given appropriate information and advice if they have a medical condition affecting their driving. We sought to evaluate doctors' knowledge of DVLA guidelines.

Design

A 25-point questionnaire was designed from DVLA guidelines (‘The DVLA Questionnaire’). Five questions were included for each of neurology, cardiology, drug and alcohol abuse, visual, and respiratory disorders.

Setting

Ealing Hospital, Northwick Park Hospital, Watford General Hospital, Norfolk and Norwich University Hospital and Leeds Teaching Hospitals Trust.

Participants

140 UK doctors.

Main outcome measures

Questionnaire scores assessing knowledge of DVLA guidelines in five specialty areas.

Results

The median overall questionnaire score was 28%, interquartile range 20–36% and range 0–100% [Watford 28%, Leeds 30%, Norfolk and Norwich 36%, Ealing 30%, Northwick Park 28%]. There were no significant differences between the scores for each centre (p = 0.1332), Mean scores for specialty areas were: neurology 33.1%, standard deviation 22.1; cardiology 35.6%, standard deviation 26.9; drug and alcohol abuse 30.6%, standard deviation 23.8; visual disorders 33.9%, standard deviation 23.5 and respiratory disorders 20.3%, standard deviation 24.8; overall score 30.7%. There was no significant difference between the scores of the specialty areas (p = 0.4060).

Conclusions

Knowledge of DVLA guidelines in our cohort was low. There is a need for increased awareness among hospital doctors through focused education on driving restrictions for common medical conditions. Improving physician knowledge in this area may help optimise patient safety.

Epilepsy and Driving

The risk of losing consciousness while driving a motor vehicle and the need to drive a car in today's society are opposing forces at play in determining the fitness and ability of people with epilepsy to drive. We must remember that until some 20 years ago, in Canada and in many other countries people with epilepsy were not allowed to drive. A movement by Canadian neurologists to establish guidelines which would enable people with controlled or remitted epilepsy to drive was headed by the late Dr. Francis McNaughton and by Dr. Guy Courtois. At present, legislation allowing people with controlled epilepsy to drive exists in every province or state of Canada and the United States and in many other countries. The International League Against Epilepsy, the professional society concerned with research, teaching and patient care, has a standing committee devoted to the problems of driving a motor vehicle. The Canadian League Against Epilepsy, the national branch of the International League, has carried the issues raised by driving and by the legislation governing it on the agenda of its annual meetings for the past several years. A committee headed by Dr. Guy Rémillard has compared pertinent laws and rules in different provinces with a view to establishing universally acceptable criteria and guidelines.

Acute medical impairment among elderly patients involved in motor vehicle collisions

BACKGROUND

The association between acute medical illness and motor vehicle collisions (MVCs) among elderly emergency department patients is unclear. We sought to determine the prevalence of acute medical conditions that might impair driving ability among the elderly involved in MVCs and determine if there was an increased risk of the driver having an acute medical condition compared to similarly aged passengers.

METHODS

We reviewed charts of patients aged 65 years or older whose emergency department visit was prompted by a motor vehicle collision between 1 July 2000 and 30 June 2010 at two Level 1 trauma centres. The exposure of interest was occupancy status (driver vs. passenger), and the outcome measure was the presence of any predefined acute medical illness that might impair driving ability.

RESULTS

Final analysis included 871 drivers (cases) and 307 passengers (controls). An acute medical illness was recorded in 107 patients (9%): 97 drivers (11%) and 10 passengers (3%). Compared to passengers, drivers had significantly higher odds of presenting with acute medical illness (OR 3.7, 95% CI 1.9-7.2). After controlling for potential confounders, the adjusted odds ratio was 5.5 (95% CI 2.3-13.0).

CONCLUSION

Acute medical conditions are a moderately common diagnosis among elderly drivers, presenting in about one in ten patients. A difference in the risk of finding an acute medical illness when comparing elderly drivers and passengers evaluated in the emergency department after a collision suggests the need for considering additional diagnostic investigation and post-discharge surveillance in this population.

Do drivers with epilepsy have higher rates of motor vehicle accidents than those without epilepsy?

OBJECTIVE

We sought to understand the magnitude of the risk that drivers with epilepsy (DWE) contribute to motor vehicle accidents (MVAs) compared to other drivers.

METHODS

We performed an evidence-based, systematic review using the American Academy of Neurology (AAN) guideline methodology.

RESULTS

Contributory evidence consisted of six Class II studies and one Class III study. Two articles reported a trend toward a decreased rate of overall MVA rates for DWE when compared with the general population with a relative risk (RR) of 0.86 (95% CI: 0.65-1.14) (Class III) and a RR of 1.00 (95% CI: 0.95-1.06) (Class II); both studies used patient report to ascertain MVA rates. Three Class II studies reported either a trend toward or an increased risk of MVA rates for DWE when compared with the general population with a RR of 1.62 (95% confidence interval (CI): 0.95-2.76), as ascertained by insurance, emergency department, and physician reporting databases, a RR of 1.73 (95% CI 1.58-1.90), as ascertained by police reports, and a RR of 7.01 (95% CI 2.18-26.13), as ascertained by casualty department visits. One Class II study showed that, compared to fatal crashes with DWE, fatal crashes were 26 times more likely to occur because of other medical conditions and 156 times more likely to occur because of alcohol abuse. Motor vehicle accident crashes due to seizures in DWE occurred in one out of every 2800 MVAs, as reported in another Class II study.

CONCLUSIONS

The evidence for the difference in MVA rates in DWE compared to the general population is inconsistent, and no conclusion can be made. Important methodological differences across the studies contribute to the imprecision. Future research should be performed using objective measures rather than self-reporting of MVAs by DWE and "miles driven" as the denominator to calculate MVA rates.

Epilepsy and driving: potential impact of transient impaired consciousness

Driving is an important part of everyday life for most adults, and restrictions on driving can place a significant burden on individuals diagnosed with epilepsy. Although sensorimotor deficits during seizures may impair driving, decreased level of consciousness often has a more global effect on patients' ability to respond appropriately to the environment. Better understanding of the mechanisms underlying alteration of consciousness in epilepsy is important for decision-making by people with epilepsy, their physicians, and regulators in regard to the question of fitness to drive. Retrospective cohort and cross-sectional studies based on surveys or crash records can provide valuable information about driving in epilepsy. However, prospective objective testing of ictal driving ability during different types of seizures is needed to more fully understand the role of impaired consciousness and other deficits in disrupting driving. Driving simulators adapted for use in the epilepsy video-EEG monitoring unit may be well suited to provide both ictal and interictal data in patients with epilepsy. Objective information about impaired driving in specific types of epilepsy and seizures can provide better informed recommendations regarding fitness to drive, potentially improving the quality of life of people living with epilepsy.

Hypoglycaemia and accident risk in people with type 2 diabetes mellitus treated with non-insulin antidiabetes drugs

AIMS

To assess associations between hypoglycaemia and risk of accidents resulting in hospital visits among people with type 2 diabetes receiving antidiabetes drugs without insulin.

METHODS

People with type 2 diabetes who were not treated with insulin were identified from a US-based employer claims database (1998-2010). Following initiation of an antidiabetes drug, the occurrence of accidents resulting in hospital visits was compared between people with, and without, claims for hypoglycaemia using multivariable Cox proportional hazard models adjusted for demographics, comorbidities, prior treatments and prior medical service use. Additional analyses were stratified by age 65 years or older.

RESULTS

A total of N = 5582 people with claims for hypoglycaemia and N = 27,910 with no such claims were included. Accidents resulting in hospital visits occurred in 5.5 and 2.8% of people with, and without, hypoglycaemia, respectively. After adjusting for baseline characteristics, hypoglycaemia was associated with significantly increased hazards for any accident [hazard ratio (HR) 1.39, 95% CI 1.21-1.59, p < 0.001], accidental falls (HR 1.36, 95% CI 1.13-1.65, p < 0.001) and motor vehicle accidents (HR 1.82, 95% CI 1.18-2.80, p = 0.007). In age-stratified analyses, hypoglycaemia was associated with greater hazards of driving-related accidents in people younger than age 65 and falls in people aged 65 or older.

CONCLUSIONS

In people with type 2 diabetes receiving antidiabetes drugs without insulin, hypoglycaemia was associated with a significantly higher risk of accidents resulting in hospital visits, including accidents related to driving and falls.

Epilepsy awareness in a Jamaican community: driven to change!

There are relatively few published studies on epilepsy-related knowledge, attitudes, and practices (KAP) from developing countries and none from Jamaica. A questionnaire-based, cross-sectional study of 320 individuals was performed in a small community in Kingston. Residents and employees were comparable in age, sex, and personal and family history of epilepsy, but differed in attained education and occupation. Persons with postsecondary education were less likely to believe that epilepsy is a mental disorder (9% vs 24.8%, P<0.001), is due to demonic possession (8% vs 18.2%, P<0.01), or is contagious (2.5% vs 23%, P<0.001). Overall, 73% felt that people with epilepsy should not drive. The results of this Jamaican KAP study differ from those in other developing countries. There appears to be less societal stigma in Jamaica; however, there is widespread reluctance to allow PWE to drive. This represents a substantial challenge to the current initiative to change existing driving regulations that currently bar people with epilepsy from driving.

Association of waterpipe smoking and road traffic crashes

Background

The purpose of this research was to examine whether waterpipe smokers experience increased risk of motor vehicle crashes.

Methods

In a telephone survey, a random sample of Iranian drivers were asked to report their age, gender, vehicle age, whether their vehicles were equipped with anti-lock braking system (ABS), average daily drive time (DDT), whether they smoked cigarette or waterpipe, whether they had diabetes mellitus (DM), number of traffic crashes during the last calendar year and whether the crash involved a pedestrian or another vehicle.

Results

A total of 2070 motor vehicle owners with the mean age of 41.6 ± 11.45 were interviewed. The annual incidence of Road Traffic Crashes (RTC) was 14.9%; 14.0% involved a collision/s with other vehicles and 0.9% with pedestrians. There was an association between the RTC and male gender, DDT, being a cigarette smoker, being a waterpipe smoker and DM in univariable analysis. The association between RTC and being a waterpipe smoker and also cigarette smoker was significant in multivariable analysis after adjustment for DDT.

Conclusions

Being waterpipe and/or cigarette smoker and DDT were the independent predictors of the number of traffic crashes in Poisson regression model. If the increased risk of RTC among waterpipe or cigarette smokers is seen in other studies, it would be beneficial to promote tobacco cessation and control strategies through injury prevention initiatives.

A prospective study of loss of consciousness in epilepsy using virtual reality driving simulation and other video games

Patients with epilepsy are at risk of traffic accidents when they have seizures while driving. However, driving is an essential part of normal daily life in many communities, and depriving patients of driving privileges can have profound consequences for their economic and social well-being. In the current study, we collected ictal performance data from a driving simulator and two other video games in patients undergoing continuous video/EEG monitoring. We captured 22 seizures in 13 patients and found that driving impairment during seizures differed in terms of both magnitude and character, depending on the seizure type. Our study documents the feasibility of a prospective study of driving and other behaviors during seizures through the use of computer-based tasks. This methodology may be applied to further describe differential driving impairment in specific types of seizures and to gain data on anatomical networks disrupted in seizures that impair consciousness and driving safety.

Driving issues in epilepsy: past, present, and future

Driving restrictions for people with seizure disorders are intended to ensure the public's safety, but driving is of such great importance in the United States that the imposed restrictions also may unduly harm the welfare of these individuals. Because driving restrictions historically have been based more on expert opinion than sound scientific evidence, the appropriateness and application of standards for licensing drivers with seizures continue to raise questions and concerns, as does the role physicians should have in the process. Driving is an important and complex practical concern for physicians who care for people with epilepsy or who may serve as consultants to regulatory authorities, requiring them to be well informed about the relevant issues to properly manage their patients and to protect themselves against lawsuits.

Driving simulator performance and psychomotor functions of schizophrenic patients treated with antipsychotics

The objective of the study is to compare schizophrenic inpatients under antipsychotic monotherapy regarding simulated driving behaviour and psychomotor functions related to driving ability. Schizophrenic inpatients (n = 80) were tested before discharge to outpatient treatment. Data were collected with the computerized Act & React Testsystem and the Wiener Testsystem measuring visual perception, reaction time, attention, vigilance and stress-tolerance. Besides, patients underwent various driving simulations on a static driving simulator (FT-SR 200). Before discharge to outpatient treatment, about 25% of schizophrenic patients must be considered as severely impaired with respect to driving skills. Differences between treatment groups could be shown both in psychomotor measures and in driving simulator performance with a better test performance of patients treated with atypical antipsychotics. Controlling for age, psychopathologic symptoms and extrapyramidal signs, differences in psychomotor measures were most pronounced in concentration and vigilance. As mental disorders itself pose an increased risk of accidents, counselling patients with respect to differential effects of antipsychotic treatment is of great relevance. In addition to psychomotor tests computer-simulated driving seems to be a useful tool in assessing traffic safety under pharmacologic treatment.

Injuries in epilepsy: a review of its prevalence, risk factors, type of injuries and prevention

Currently, there is intense clinical research into various aspects of the medical risks relating to epilepsy, including total and cause-specific mortality, accidents and injuries in patients with epilepsy and mortality related with seizures. Seizures occurring in precarious situations and resulting in injuries are still an important concern for patients with epilepsy, their employers and their care-givers. Submersion injuries, motor vehicle accidents, burns, and head injuries are among the most feared epilepsy-related injuries. These concerns seem valid because the hallmark of epilepsy, episodic impairment of consciousness and motor control, may occur during interictal EEG epileptiform discharges, even in the absence of a clinical seizure. In addition, psychomotor comorbidity and side effects of antiepileptic drugs may contribute to the risk of injuries in patients with epilepsy. Published risk factors for injuries include the number of antiepileptic drugs, history of generalized seizures, and seizure frequency. In general, epidemiological information about incidence of injuries has been conflicting and sparse. In general, studies focusing on populations with more severe forms of epilepsy tend to report substantially higher risks of injuries than those involving less selected populations. On the other hand, studies based on non-selected populations of people with epilepsy have not shown an increased frequency of injuries in people with epilepsy compared with the general population. Some studies have shown that patients with epilepsy are more frequently admitted to the hospital following an injury. Possible explanations include: more cautious attitude of clinicians toward injuries occurring in the setting of seizures; hospitalization required because of seizures and not to the injuries themselves; and hospitalization driven by other issues, such as comorbidities, which are highly prevalent in patients with epilepsy. Potentially the high rate of hospitalizations could be related with the severity of the injury. This article reviews the best available epidemiological information about injuries, including incidence and risk factors. Also this article reviews information about specific types of injuries such as fractures, burns, concussions, dislocations, etc. Information about accidents in people with epilepsy is also discussed.

Accidents and injuries in patients with epilepsy

People with pilepsy are thought to be at an increased risk of accidents and injuries. This results in stigmatization of patients with epilepsy and contributes to a number of limitations in their daily living activities. However, even with differing results, several observational studies (including a large multicenter European survey) report that most accidental injuries are minor and are mostly caused by an epileptogenic clinical condition, an associated handicap or the recurrence of seizures. Domestic, street and work accidents are, in decreasing order, the most common places for such injuries to occur. Contusions and wounds are the most common injuries, followed by abrasions, fractures, brain concussions, sprains/strains and burns. Associated handicaps and comorbidity, where present, as well as antiepileptic drugs, may cause accidents and injuries by impairing cognitive functions and increasing the patient's susceptibility to suffer from the complications of injuries. Patients with epilepsy are also at a slightly higher risk of accidental death than the general population; accidental causes include fires and flames, drowning, suffocation, foreign bodies, falls, suicide and transport accidents. When epileptogenic conditions and seizure-related events are excluded, patients with epilepsy are only at a slightly greater risk of accidents and injuries than the general population.

Road traffic accidents and diabetes: insulin use does not determine risk

AIMS

Progressive restrictions placed on insulin-treated patients with diabetes exclude them from driving group 2 and class C1 and D1 vehicles. This reflects an assumption that an increased risk of hypoglycaemia in these patients will cause road traffic accidents. These restrictions have been implemented without any consistent evidence that this is the case. The aim of the study was therefore to investigate whether the rate of road traffic collisions in insulin-treated patients was higher than that of the non-diabetic population using a population register-based study.

METHODS

A historical cohort study combined information from the Devon and Cornwall Constabulary database on road traffic collisions with the district wide retinal screening database, to provide an anonymized matched database of road traffic collisions in the diabetic population. Accident rates were calculated in the diabetic population and compared to rates in the non-diabetic population using relative risks.

RESULTS

The estimated overall annual accident rate for the non-diabetic population was 1469 per 100,000 vs. 856 per 100,000 for the diabetic population as a whole (Chi-squared, P < 0.001). On stratification of the groups by age, within the insulin-treated group there was no significant difference in the accident rate compared to the non-diabetic population, with relative risks between 0.51 [confidence interval (CI) 0.25-1.05] and 1.13 (CI 0.88-1.46).

CONCLUSIONS

Our findings suggest that insulin-treated patients as a group do not pose an increased risk to road safety. They reiterate the need for an individualized risk-based assessment when considering driving restrictions.

Epilepsy and driving capability in Slovenia

PURPOSE

To compare medical evaluations of driving capability of drivers with epilepsy with the rules of Slovenian legislation.

METHODS

Our research included all drivers in Slovenia that were evaluated as epileptic between 1993 and 2002. The results were processed using the standard descriptive statistical methods.

RESULTS

During the 10-year period, the commission evaluated 541 cases and prospective drivers of motor vehicles with the primary diagnosis of epilepsy. On average, these individuals drove a third less than other drivers, moreover only 1.6% of the epileptic drivers caused traffic accidents, which is significantly lower than the percentage in general population. Medical evaluations resulted in 349 cases being recognized as capable of driving, while the legislation would issue a driver's license to only 140 of the cases.

CONCLUSION

Our research confirmed the supposition that drivers with epilepsy are safe drivers and mirror the general population in many of their driving capabilities, thus making it urgent that the obsolete Slovenian legislation is modified to conform to the recommendations of the International Bureau for Epilepsy as quickly as possible.

Impact of mandatory physician reporting on accident risk in epilepsy

BACKGROUND

In some jurisdictions, physicians are required by law to report patients with seizures to the department of motor vehicles. We assessed the hypothesis that mandatory reporting reduces the risk of automobile accidents in people with epilepsy.

METHODS

A retrospective survey of driving and accident rates was done by mailed questionnaire to two groups of subjects with epilepsy in Canada, one living in Ontario where reporting is mandatory and the other in Alberta where it is not. Responses were obtained from a control group without epilepsy for comparison.

RESULTS

The epilepsy (n = 425) and control (n = 375) groups were comparable in age and sex. Seventy-three percent of the epilepsy group were or had been licensed drivers compared to 94% of the controls (rr 0.77, 95% CI 0.73-0.83, p < 0.001). Lifetime accident rate of licensed drivers was 58% in epilepsy and 60% in controls (rr 0.99, 95%CI 0.82-1.19, ns) while 9% of the epilepsy group and 9% of the controls had an accident in the previous year (rr 1.00, 95%CI 0.95-1.06, ns). All those with epilepsy in Ontario (n = 202) and Alberta (n = 223), also comparable in age and sex, had equal lifetime accident rates of 45 and 46% (rr 0.99, 95%CI 0.67-1.47, ns) and 1-year rates of 11 and 8% (rr 1.38, 95%CI 0.59-3.27, ns). In Ontario, 20% of drivers were unlicensed compared to 9% in Alberta (rr 2.39, 95%CI 1.17-4.89, p = 0.01)

CONCLUSION

Although it is clearly dangerous for many people with ongoing seizures to drive, the findings provide no support for the hypothesis that mandatory reporting of patients by physicians reduces accident risk and suggest that concerns about the impact of epilepsy on driving compared to other medical and nonmedical risk factors may be excessive.

Opinions, attitudes and practices of Australian neurologists with regard to epilepsy and driving

INTRODUCTION

Austroads Guidelines for fitness to drive were promulgated in 2003. Epilepsy was one of the conditions included and this paper reports results of a survey of Australian neurologists regarding opinions and practices relevant to the guidelines.

METHODS

The survey was developed, piloted and Human Research Ethics Committee approved. Members of the Australian Association of Neurologists received three mailings and results were analysed.

RESULTS

Almost 70% of 236 surveyed indicated assessment of epilepsy and driving with <9% not doing so--establishing approximately 77% response for eligible neurologists. Most questions achieved 90% response. Almost 90% respondents assessed epilepsy and 70% found the guidelines helpful. Seventy-seven per cent endorsed doctor assessors although half discounted General Practitioners as insufficiently knowledgeable and half advocated that only neurologists evaluate potential drivers with epilepsy. Most respondents supported reporting recalcitrant patients; yet only <30% did so. Three-quarters favoured licences carrying a warning to self-report and two-thirds felt that product information should identify driving implications. Although many questions attracted expected responses, the surprise was the large undecided numbers, which were greater than expected. Neurologists were more lenient than prescribed by the guidelines with neither consensus for controlled epilepsy nor mandatory driving restrictions.

CONCLUSION

Respondents supplied predictable answers regarding ideal circumstances; yet most did not report recalcitrant patients. Most claimed to adhere to the guidelines and yet advocated more lenient driving restrictions that may allow preventable accidents. There was agreement between neurologists and guidelines for more rigorous restrictions for commercial drivers although again neurologists were more lenient. There is need for prospective research on epilepsy and driving.

An audit of advice on fitness to drive during accident and emergency department attendance

INTRODUCTION

Large numbers of patients attending accident and emergency (A&E) departments drive to and from the consultation. This audit set out to examine if patients attending A&E were advised about their fitness to drive.

METHOD

The authors carried out a retrospective audit over a one month period. The Driver and Vehicle Licensing Authority (DVLA) booklet "At a glance guide to the current medical standards of fitness to drive" was used to derive a list of conditions that require driving restrictions. Any condition within these guidelines was audited. If the patient was discharged and diagnosed as having a condition requiring the patient to cease driving, the notes were scrutinised for any evidence that the doctor had given advice about driving.

RESULTS

A total of 337 patients were discharged with conditions which may have required some restrictions to driving; 332 sets of notes were available. Twenty two patients needed restrictions to be placed on their driving. Only one patient had any documented evidence of the examining doctor informing them of restrictions to be placed on driving.

CONCLUSIONS

The study provides clear evidence that patients were not being informed about their fitness to drive following consultation in the authors' A&E department. Previous studies have shown that doctors' knowledge on driving restrictions is poor. Further education is needed for A&E doctors and patient information leaflets should be provided to explain the restrictions placed on a driver's licence if they have certain illnesses.

Physician reporting of medically impaired drivers

Emergency physicians frequently encounter patients whose medical conditions represent a risk of loss of control while driving, e.g., epilepsy and diabetes. In certain states, physicians are under a legal obligation to report such drivers to the motor vehicular authorities. To determine the uniformity of legislated reporting requirements for physicians caring for patients whose medical conditions represent an automotive hazard, we conducted a survey of Department of Motor Vehicles (DMV) legal departments of all the states in the United States for the academic year 1999-2000 regarding physician reporting of patients with medical conditions that might predispose them to a motor vehicle crash (MVC) and compared the results to a similar study done in 1986. Six (12%) of the states had mandatory reporting laws, 25 (49%) had permissive reporting laws, and 20 (39%) had no laws regarding physician reporting. There was a significant difference between the distribution of laws by year. There was no uniformity on a national level concerning such legislation.