Medical factors and road accidents

Discrepancy between medical conditions self-reported by bus drivers and medical records

BACKGROUND

Medical incapacity at the wheel is a rare but high-profile factor in accident causation. The UK Driver and Vehicle Licensing Agency (DVLA) does not require a review of medical records on the application for a bus licence, but applicants sign a self-declaration of medical history. There is debate over what, if any, verification of medical information is required for doctors who complete the medical assessment.

AIMS

To assess how self-declaration compares against General Practitioner (GP) patient records for a series of bus drivers undergoing driver licensing assessment in a 12-month period.

METHODS

Review of GP reports received for bus driver medicals undertaken in a 12-month period between 1 July 2022 and 30 June 2023.

RESULTS

Of the 145 medicals undertaken, 12 (8.3%) GP reports contained undeclared medical conditions that required further evaluation and may have impacted on fitness to drive.

CONCLUSIONS

Studies into the contribution of medical incapacity at the wheel to vehicle accidents are sparse, as, thankfully, are the events themselves. Nevertheless, given the updated General Medical Council guidance to doctors on confidentiality and public protection responsibilities, and evidence to suggest that doctors' knowledge of the DVLA guidelines is poor, it might be pertinent for the DVLA to reconsider its approach to driver self-reporting in some circumstances, given the discrepancy highlighted here.

Health and Economic Impact of Atrial Fibrillation of Workers in Italy: Social Security Benefits

BACKGROUND

The aim of this research was to analyze trends in social security applications in Italy as a result of the onset of atrial fibrillation, analyzing data pertaining to the classification of professions and assessing the economic impact on the social security system.

METHODS

We analyzed all applications for invalidity allowances and invalidity pensions throughout Italy over a 10-year period from 01.01.2009 to 31.12.2019, giving specific attention to all reports indicating atrial fibrillation as the principal diagnosis (Cod. ICD-9-CM 427.31). We then extracted the relative expenditure data for said benefits. The results of all analyses have been collated in tables.

RESULTS

Over the period in question, a total of 3468 applications for assistance were filed throughout Italy indicating a diagnosis of atrial fibrillation, of which 58% were rejected, 41% qualified for an invalidity allowance, and only 1.1% qualified for a pension. On average, every year, 1100 workers received social security benefits as a result of a diagnosis of atrial fibrillation, which equates to an average annual expenditure of EUR 10 million. A comparison of the data from the first observation year (2009) with data from the last (2019) shows a rising trend in the number of beneficiaries and consequently in expenses.

CONCLUSIONS

The social security assistance provided by the Italian government by means of the National Institute of Social Security is fundamental to social cohesion and to those who are either permanently disabled from working or those with a significantly diminished earning capacity. This assistance is associated with a significant financial cost, which requires careful monitoring.

Effectiveness of an intervention to reduce accidents in bus drivers

BACKGROUND

Medical incapacity at the wheel is a small but significant factor in accident causation. To mitigate against this, in July 2017 a UK-based bus operator changed its medical assessment policy, requiring all future medicals to include a request to the General Practitioner (GP) for information about any conditions in the medical record which could affect fitness to drive.

AIMS

To evaluate the impact of the change in policy on accident rates.

METHODS

Accident data were obtained over a 5-year period, with information on age and length of service of drivers, from three bus depots. Monthly accident rates, before and after the change in policy were compared with the Wilcoxon matched pairs test, and a line of best fit/R2 obtained via a scatter graph.

RESULTS

Although a general downward trend in accident rates was seen, there was no statistically significant difference between the overall accident rates in the 12 months before and after the policy change in July 2017 (P-value = 0.519, significance level P < 0.05).

CONCLUSIONS

The downward trend in accident rates observed over the study period could not be attributed to the change of policy. However, this intervention warrants further scrutiny due to the potential consequences of passenger service vehicle accidents. Evidence suggests that professional awareness of the UK Driver and Vehicle Licensing Agency fitness to drive standards can be limited, so requesting GP input into driver medicals may raise awareness of these standards from an occupational health perspective.

Dissociation between red and white stimulus perception: A perimetric quantification of protanopic color vision deficiencies

Significance

Horizontal visual field extension was assessed for red and white stimuli in subjects with protanopia using semi-automated kinetic perimetry. In contrast to a conventional anomaloscope, the “red/white dissociation ratio” (RWR) allows to describe protanopia numerically. For the majority of subjects with protanopia a restriction for faint red stimuli was found.

Purpose

Comparing the horizontal visual field extensions for red and white stimuli in subjects with protanopia and those with normal trichromacy and assessing the related intra-subject intra-session repeatability.

Methods

The subjects were divided into groups with protanopia and with normal trichromacy, based on color vision testing (HMC anomaloscope, Oculus, Wetzlar/FRG). Two stimulus characteristics, III4e and III1e, according to the Goldmann-classification, were presented with semi-automated kinetic perimetry (Octopus 900 perimeter, Haag-Streit, Köniz/CH). They moved along the horizontal meridian, with an angular velocity of 3°/s towards the visual field center, starting from either the temporal or nasal periphery. If necessary, a 20° nasal fixation point offset was chosen to capture the temporal periphery of the visual field. For each condition the red/white dissociation ratio (RWR); Pat Appl. DPMA DRN 43200082D) between the extent of the isopter for red (RG610, Schott, Mainz/ FRG) and white stimuli along the horizontal meridian was determined.

Results

All data are listed as median/interquartile range: Five males with protanopia (age 22.1/4.5 years) and six males with normal trichromacy (control group, age 30.5/15.2 years) were enrolled. The RWR is listed for the right eye, as no clinically relevant difference between right and left eye occurred. Protanopes’ RWR for mark III4e (in brackets: control group) was 0.941/0.013 (0.977/0.019) and for mark III1e 0.496/0.062 (0.805/0.051), respectively.

Conclusions

In this exploratory “proof-of-concept study” red/white dissociation ratio perimetry is introduced as a novel technique aiming at assessing and quantifying the severity of protanopia. Further effort is needed to understand the magnitude of the observed red-/white dissociation and to extend this methodology to a wider age range of the sample and to anomalous trichromacies (protanomalia) with varying magnitude.

Fitness to Drive in Cardiovascular Disease

BACKGROUND

Medical students are taught little or nothing about the medical considerations related to the driving of motor vehicles. Physicians treating patients with cardiovascular disease need to acquire competence in traffic medicine in order to be able to advise them about their fitness to drive.

METHODS

We present the current governmental regulations and recommendations concerning fitness to drive in patients with cardiovascular disease. We also review pertinent publications that were retrieved by a selective search in PubMed with the search terms "cardiovascular disease and traffic accidents" and "cardiovascular disease and traffic deaths" for the decade 2007-2016, as well as further publications collected by us individually.

RESULTS

Cardiovascular disease can make a driver lose control of a vehicle without warning and thereby lead to an accident. The main pathophysiological mechanisms of sudden loss of control are disturbances of brain perfusion (e.g., syncope with or without cardiac arrhythmia, sudden cardiac death due to ventricular fibrillation or asystole, stroke, aneurysm rupture) and marked general weakness (e.g., after major surgery or in cardiac insufficiency).

CONCLUSION

Patients with cardiovascular disease should be advised by their physicians about their fitness to drive, and the discussion should be documented in writing. Because of the German law on the confidentiality of medical data, only the affected patient should receive this information, with very few exceptions.

Autopsy Cases of Motorcyclists Dying of Trauma or Disease

We aimed to provide a better estimation of health-related motorcycle fatalities by comparing the backgrounds, mechanisms of injuries, and injury severity of victims who died of collision versus those who died of disease. We retrospectively analyzed autopsy records of 29 motorcyclists (mean age, 61.0 ± 21.0 years), none of whom had been driving under the influence of alcohol. Altogether, 22 (75.9%) had died of trauma, and 7 had died of disease. The disease-death victims were significantly older and had a significantly higher prevalence of a medical history compared with those with trauma-related death (100% vs 45.5%, P = 0.01), especially of lifestyle diseases (100% vs 13.6%, P < 0.001) and heart or cerebrovascular disease (57.1% vs 13.6%, P = 0.02). All of the victims who were affected by disease and 50% of trauma-death victims had fallen on the road without a vehicle collision (P = 0.02). Mean Injury Severity Score of the trauma-death group was significantly higher than that of the disease-death group (48.1 vs 9.1, P < 0.001). A forensic autopsy should be performed for all motorcyclist fatalities to diagnose a disease-related death during motorcycle riding. To reduce the incidence of these accidents, motorcyclists should maintain a good physical status.

Implementation of a teaching programme to improve doctors' awareness of DVLA guidelines: a multicentre study

INTRODUCTION

Over half of the UK population holds a driver's licence. Driver and Vehicle Licensing Authority (DVLA) guidelines are available for conditions from most specialties. Despite this, no focused training occurs in the undergraduate or postgraduate setting. We evaluate the impact of a teaching programme to improve guideline awareness.

METHODS

A 25-point questionnaire was designed using the current DVLA guidelines. Five questions were included for the following fields: neurology, cardiology, drug and alcohol abuse, visual disorders and respiratory. This was distributed to doctors in training at five hospitals. Four weeks later, a single-session teaching programme was implemented. The questionnaire was redistributed. Preintervention and postintervention scores were compared using the Wilcoxon rank sum test.

RESULTS

139 preteaching and 144 post-teaching questionnaires were completed. Implementation of a single-session teaching programme significantly improved the knowledge of DVLA guidelines in all five areas explored. Median scores: neurology, preteaching 40%, post-teaching 100%, p<0.001; cardiology, 0%, 100%, p<0.001; drug and alcohol misuse, 0%, 100%, p<0.001; visual disorders, 40%, 100%, p<0.001; respiratory disorders, 20%, 100%, p<0.001; and overall, 28%, 92%, p<0.001.

CONCLUSIONS

Knowledge of DVLA guidelines among our cohort was poor. Implementation of a single-session teaching programme can significantly improve guideline knowledge and awareness, serving as a cost-effective intervention.

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.

Bias in counseling of seizure patients following a transient impairment of consciousness: differential adherence to driver fitness guidelines

PURPOSE

To determine primary care physicians' counseling as well as patients' driving behaviors following seizure and non-seizure events impairing consciousness in the community.

METHODS

Patients attending a rapid-referral first seizure clinic were entered into the study if they were deemed medically-unfit to drive according to national guidelines for driving licensure: had experienced a seizure or an unexplained episode of lost consciousness, and had a valid driver's license at the time of their index event. Risk of physician counseling in the community regarding driving cessation in the interval between initial primary care assessment and neurological consultation was examined as a primary outcome, and patient driving cessation was examined as a secondary outcome.

RESULTS

106 of 192 (55%) patients attending clinic met guideline criteria requiring driver fitness counseling in the primary care community, and 89 patients (46%) were deemed medically-unfit to drive following the initial specialist consultation appointment. Among medically unfit driver cases, 73% were ultimately deemed to have experienced a seizure and 27% had experienced a non-seizure event (e.g. syncope, PNES). Driver fitness counseling was more likely for seizure than non-seizure cases (unadjusted odds ratio: 4.14, p<0.05), as was patient driving cessation (5.10, p<0.05).

CONCLUSION

Physician compliance with clinical practice guidelines appears strongly biased when counseling about driving following an episode of transient impairment in consciousness. The failure of the primary care medical community to apply driver fitness counseling equitably to both seizure and non-seizure drivers may have ramifications upon public safety or conversely disease-related quality-of-life.

Medical conditions, medication use, and their relationship with subsequent motor vehicle injuries: examination of the Canadian National Population Health Survey

PURPOSE

To examine the effects of various medical conditions and medications on subsequent motor vehicle injuries (MVIs).

METHOD

The National Population Health Survey, a large, nationally representative, longitudinal study of Canadians, included self-reported medical conditions of asthma, arthritis/rheumatism, back problems excluding arthritis, high blood pressure, migraine headaches, diabetes, heart disease and distress, and medication use during the past month for asthma, high blood pressure, diabetes, heart, codeine/pethidine (Demerol)/morphine, other pain relievers, antidepressants, tranquilizers, and sleeping medication. Path analyses were used to examine the odds of subsequent MVI for different medical conditions and medication use reported prior to the MVI (in the previous wave of the survey) while controlling for age and sex.

RESULTS

Increased odds of subsequent MVIs were found for asthma (odds ratio [OR]: 1.864, 95% confidence interval [CI]: 1.281, 2.713), arthritis/rheumatism (OR: 1.659, 95% CI: 1.163, 2.365), back problems (OR: 2.169, 95% CI: 1.624, 2.895), and migraines (OR: 1.631, 95% CI: 1.125, 2.364) but not for high blood pressure (OR: 1.435, 95% CI: 0.944, 2.181), diabetes (OR: 1.479, 95% CI: 0.743, 2.944), heart disease (OR: 2.627, 95% CI: 0.941, 7.334) or distress (OR: 1.153, 95% CI: 0.840, 1.581). Except for migraine with codeine/pethidine/morphine, this effect persisted regardless of whether medication was used to treat the condition. Respondents who reported using certain medications, namely, codeine/pethidine/morphine (OR: 2.215, 95% CI: 1.274, 3.850), other pain medication (OR: 1.630, 95% CI: 1.242, 2.139), antidepressants (OR: 2.664. 95% CI: 1.602, 4.429), and sleeping medication (OR: 2.059, 95% CI: 1.161, 3.651), had increased odds of subsequent MVI, independent of related medical condition, whereas tranquillizers showed no increased odds of subsequent MVIs.

CONCLUSIONS

This study suggests that the relationship between medical conditions, medications, and MVIs is complex but consistent with other studies.

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.

Observational failures/distraction and disease attack/incapacity as cause(s) of fatal road crashes in Finland

OBJECTIVE

To study the incidence of health-related conditions and observational failures/distraction (OFD) as an immediate cause for fatal motor vehicle accidents (FMVA) and to correlate them with driver's age.

METHODS

Retrospective study of all FMVA in Finland secondary to OFD from January 1995 to December 2005 and FMVA secondary to a disease attack/incapacity (DA) from January 2003 to December 2004. The data were based on the final investigation reports of the Finnish Motor Insurers' Centre. The cases were categorized into the three following groups: 1) vehicle crashes due to OFD of the driver, 2) pedestrian-vehicle accidents due to the driver's OFD, and 3) pedestrian-vehicle accidents due to the pedestrian's OFD. In the second part, 54 autopsy reports from FMVA resulting from a DA of the driver between the years 2003-2004 were revisited and the health-related causes of the accident were investigated.

RESULTS

Oldest age group (> 65 years) had the highest prevalence of FMVA secondary to an OFD. We estimated that in 20-30% of all FMVA affecting subjects > 65 years an impairment of cognitive functions might have played a role. Analysis of the DA that the inspection teams had concluded to have been the immediate risk factor for the FMVA revealed that these accidents accounted for 10.3% of all FMVA in 2003-2004. Cardiovascular diseases were most often involved.

CONCLUSIONS

OFD as an immediate cause of FMVA began to play a role from the age of 60 years onwards. The role of health conditions as a cause of FMVA was higher than expected. Cardiovascular disease (70%) was found to be the leading medical condition that inhibited the driving task among the DA related to FMVA in Finland.

Diseases and motor vehicle fatalities in Finland in 2001 and 2002

OBJECTIVES

The possible connection between diseases among drivers and traffic accidents was examined for traffic safety purposes.

METHODS

We studied medical conditions of drivers and passengers in all motor vehicle crashes with fatalities in Finland in 2001 and 2002 by using reports of road accident investigation teams, including autopsy reports. We analyzed a total of 542 crashes with 640 fatalities. Findings were also compared with available epidemiological data in Finland.

RESULTS

An insignificant difference in the number of reported diseases was present between the different parties involved in crashes. However, among killed key drivers, so-called A-parties, psychiatric diseases, especially alcoholism, depression, and unspecific mental disorders, were diagnosed more often than in the groups of other drivers or passengers. In addition, A-parties were reported to more frequently suffer from cerebral arteriosclerosis and arterial hypertension.

CONCLUSIONS

Drivers' diseases can be a risk factor for traffic accidents. Fitness to drive should therefore be considered in medical practice, particularly in patients with alcoholism and other psychiatric disorders.

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.

Driving and patients with brain tumours: a postal survey of neurosurgeons, neurologists and radiation oncologists

This study was aimed at evaluating the consistency of driving advice given by treating clinicians to patients diagnosed with brain tumours. Secondary aims include assessing the awareness of current driving guidelines and whether or not there was a need for more specific guidelines in this group of patients. This was undertaken utilizing a scenario-based postal survey. The results show an overall poor consistency in the answers provided for each case scenario. 73.1% respondents were not aware of any current driving guidelines. Of those who were aware of driving guidelines, 67.7% wanted more specific guidelines to be developed. Possible explanations for this are a lack of awareness of the existence of any driving guidelines and a lack of objective criteria in the current driving guidelines. The authors recommend that the current driving guidelines be comprehensively distributed to clinicians who treat patients with brain tumours, as well as forming a multi-disciplinary working party to develop more specific and objective driving guidelines.

Who can drive home from the emergency department? A questionnaire based study of emergency physicians' knowledge of DVLA guidelines

OBJECTIVE

To determine whether doctors working in emergency departments are aware which of the common conditions seen have driving restrictions associated with them and whether they routinely advise patients of these restrictions.

METHODS

200 questionnaires were distributed to all grades of doctor currently working in 15 emergency departments in Wessex and the south west. The survey was anonymous so follow up of non-responders was not possible. Doctors were asked to indicate which of the 20 commonly seen conditions listed had DVLA guidelines restricting driving activity at least temporarily, and in which of these conditions they actually advised patients appropriately about their driving. In addition the MDU, GMC, and the Department of Transport web site were contacted to establish what they considered to be good medical practice regarding issuing advice about driving.

RESULTS

102 doctors (51%) responded to the survey. Knowledge regarding restrictions for various conditions varied, with 87.5% responding correctly about a first fit to only 7.8% regarding a collapse query cause. With regard to advising patients, 79.4% of doctors responding said that they routinely advised patients about stopping driving after a first fit, 32% advised patients after a single transient ischaemic attack, and only 7% after a collapse query cause.

CONCLUSIONS

Doctors working in emergency departments are aware of conditions that lead to an inpatient admission that have driving restrictions. However, knowledge of conditions where patients are likely to be discharged was not as complete and advice was less likely to be given to patients. Emergency department doctors need to be more aware of restrictions that apply to conditions where patients are to be discharged.

Resumption of driving after life-threatening ventricular tachyarrhythmia

BACKGROUND

Although the privilege of driving must be respected, it may be necessary to restrict driving when it poses a threat to others. The risks associated with allowing patients with life-threatening ventricular tachyarrhythmias to drive have not been quantified.

METHODS

The Antiarrhythmics versus Implantable Defibrillators (AVID) trial compared antiarrhythmic-drug therapy with the implantation of defibrillators in patients resuscitated from near-fatal ventricular arrhythmias. In the current study, we sent patients who participated in the AVID trial a questionnaire, to be completed anonymously, requesting information about driving habits and experiences.

RESULTS

The questionnaire was returned by 758 of 909 patients (83 percent). Of these, 627 patients drove during the year before their index episode of ventricular tachyarrhythmia. A total of 57 percent of these patients resumed driving within 3 months after randomization in the AVID trial, 78 percent within 6 months, and 88 percent within 12 months. While driving, 2 percent had a syncopal episode, 11 percent had dizziness or palpitations that necessitated stopping the vehicle, 22 percent had dizziness or palpitations that did not necessitate stopping the vehicle, and 8 percent of the 295 patients with an implantable cardioverter-defibrillator received a shock. Fifty patients reported having at least 1 accident, for a total of 55 accidents during 1619 patient-years of follow-up after the resumption of driving (3.4 percent per patient-year). Only 11 percent of these accidents were preceded by symptoms of possible arrhythmia (0.4 percent per patient-year).

CONCLUSIONS

Most patients with ventricular tachyarrhythmias resume driving early. Although it is common for them to have symptoms of possible arrhythmia while driving, accidents are uncommon and occur with a frequency that is lower than the annual accident rate of 7.1 percent in the general driving population of the United States.

Diabetes and driving: towards equitable, evidence-based decision-making

In January 1998, the British government introduced new restrictions on licensing of people with insulin-treated diabetes mellitus to drive. These restrictions were based on the second EU driver licensing directive (91/4389) and looked to be costing insulin-treated diabetic individuals their entitlement to drive light goods and small passenger-carrying vehicles. In response to concerns expressed by the diabetes community in Britain, the British Diabetic Association commissioned a report examining and interpreting the available evidence of accident risk in insulin-treated diabetic patients, particularly that related to unexpected hypoglycaemia. The following article is drawn from that report.

Resumption of motor vehicle operation in vasovagal fainters

This study surveyed current practice patterns with respect to the manner by which cardiac arrhythmia specialists advise patients with vasovagal syncope regarding resumption of motor vehicle operation. Among 66 physician-respondents from 9 countries, 98% indicated that they rely on tilt-table testing to establish a diagnosis, and, if an effective treatment is found based on serial tilt-table testing, they recommend a 6- to 7-week symptom-free waiting period before advising return to driving.

Driving issues related to arrhythmic syncope

The safety of driving in patients with cardiac arrhythmias is a common concern. Although the risk of driving in these patients cannot be reduced to zero, available data and expert consensus suggest that most patients with arrhythmias can return to driving with a relatively low risk of harm to themselves and others, that is, a risk within the limits deemed acceptable by society. Specific recommendations for allowing patients with various cardiac rhythm abnormalities to drive are reviewed in detail.

Quality of life and driving in recipients of the implantable cardioverter-defibrillator

The efficacy of a treatment is primarily based on objective criteria, such as mortality and morbidity. Besides these criteria, the interest in measuring quality of life (QOL) in relation to health care has increased in recent years. Although the concept of patients' QOL is inherently subjective, and definitions vary, it can be assessed on a basis of 3 major components: physical condition, psychological well-being, and social activities. The basic requirements of QOL assessments are: multidimensional construct, reliability, validity, sensitivity, responsiveness, appropriateness to question or use, and practical utility. The instruments to assess QOL can be disease specific or generic, depending on the context. In 1991 a prospective and systematic evaluation of QOL in implantable cardioverter-defibrillator (ICD) recipients was started at the University of Bonn: psychological profile and patient acceptance were assessed in 57 consecutive patients using a specifically designed questionnaire. The results of this pilot study demonstrated that the acceptance of the ICD was remarkably high. Restrictions on driving a vehicle may have a substantial impact on QOL in patients with ICDs. A specifically designed questionnaire was addressed to 47 European national delegates in order to determine their present practices and criteria utilized when advising driving restrictions to patients after ICD implantation. Of the 39 (83%) respondents, 22 (56%) cardiologists advised all patients to abstain from driving--13 (33%) advising permanent abstinence, while 26 (67%) recommended temporary driving abstinence for periods of 3-18 months (mean 9 +/- 4 months). Despite medical advice not to drive, one third of the patients resume driving; half of the patients resumed driving after 6 months, with the vast majority driving within 12 months after ICD surgery. Two patients experienced ICD discharges while driving, but no motor vehicle accident occurred. Another patient had a motor vehicle collision with a fatal outcome, which was not caused by loss of consciousness or ICD discharge.

CONCLUSIONS

(1) Fatal accidents or ICD discharges while driving are a rare finding in ICD patients. (2) About half of the physicians always advise their patients to cease driving for a period of 9 +/- 4 months. Despite this medical advice, the majority of the patients resume driving within 6 months of ICD implantation. (3) Criteria used in advising driving abstinence are not uniform among physicians.

Epilepsy and driving: an international perspective. Joint Commission on Drivers' Licensing of the International Bureau for Epilepsy and the International League Against Epilepsy

Individuals with a history of seizures may be granted driving privileges if the risks of future seizure while driving are relatively low. Different nations have defined these risks in a wide variety of ways. Some countries, e.g., Japan, Greece, Brazil, India, and Russia, preclude driving after a single seizure. Other countries, such as Canada and the United States, allow driving < or = 3 months after certain types of seizures. A Joint Commission of the International Bureau for Epilepsy/International League Against Epilepsy has summarized regulations in several countries. From a consideration of medical literature and existing practices, a series of proposed guidelines for driving and epilepsy is recommended. In general, these guidelines suggest use of a seizure-free interval, generally 1-2 years but less in particular instances, to determine fitness to drive. Required physician reporting is discouraged, but physicians should report patients whom they believe pose a danger to themselves and to public safety. Individualized consideration should be given to special circumstances that may modify a general driving prohibition. Education and information programs are necessary for medical and regulatory authorities to develop a rational approach to driving and epilepsy worldwide.

Legal and ethical aspects of driving and working in patients with an implantable cardioverter defibrillator

Automobile driving is essential to work and leisure for many people, and patients with implantable cardioverter defibrillators (ICDs) are no exception. Whether patients who may suffer sudden incapacitation should be allowed to drive raises important ethical and legal issues. The opinion of physicians regarding when or if it is safe to drive with an ICD varies, and most countries have no regulations to assist such decisions. Such regulations can best be developed by actuarial analysis of the risks involved, although the limited volume of published data on the ICD hinders this process. A policy based on very low levels of social risk from driving by patients with ICDs or a comparison with epileptic patients suggests a ban on driving for 12 to 24 months after ICD implantation. Patients who have received therapy from the ICD within this period would not be granted a driver's licence. As further data from actuarial studies become available, these guidelines could be relaxed for patients at low risk of therapy delivery.

The law and medical fitness to drive--a study of doctors' knowledge

We assessed doctors' knowledge on laws and recommendations regarding fitness to drive in certain medical conditions by a questionnaire survey. A total of 646 doctors consisting of 400 general practitioners and 246 hospital doctors of all grades were circulated with the questionnaire. The survey was anonymous so non-responders could not be re-circulated. The response rate was 26% general practitioners and 32% (hospital doctors). The results show the poor knowledge of doctors on several aspects of fitness to drive. It is necessary for all doctors to have a basic knowledge on the laws and recommendations on fitness to drive so that they can advise their patients correctly. Our survey clearly shows that doctors' knowledge is poor. Many drivers may therefore be placing themselves and others at risk. It is mandatory that this subject receives more attention in undergraduate and postgraduate education and that doctors should be regularly updated on new recommendations from the Driver and Vehicle Licensing Agency.

Employment problems and diabetes

A survey of employment problems in a random sample of diabetic patients and a group of control subjects aged 17-65 years was carried out in eight centres in the UK. Data were linked to information collected from patients' diabetic clinic notes relating to the presence and treatment of any diabetic complications and quality of diabetic control. Difficulties in obtaining employment because of diabetes were reported by 13% of diabetic patients, and because of illness by 2% of control subjects (p less than 0.001). Nine percent of diabetic patients and 2% of control subjects reported having to change their job because of their illness (p less than 0.001), and 7% of people with diabetes and 2% of people without diabetes reported losing a job because of their illness (p less than 0.001). Diabetic shift workers were twice as likely as control subjects working shifts to experience problems with their job (18 vs 8%, p = 0.045). Reports of any sickness absence in the last 12 months were not significantly different for people with and without diabetes (49 vs 45%). Sickness absence in excess of 20 days in the last 12 months was more common among diabetic patients than control subjects (29 vs 16%, p less than 0.001). People with diabetes are more likely to experience problems in obtaining employment and staying employed than people without diabetes.

Motor vehicle driving among diabetics taking insulin and non-diabetics

OBJECTIVE

To determine whether rates of road traffic accidents were higher in diabetics treated with insulin than in non-diabetic subjects.

DESIGN

Controlled, five year retrospective survey.

SETTING

Diabetic, dermatology, and gastroenterology outpatient clinics.

PATIENTS

596 Diabetics treated with insulin (354 drivers) aged 18-65 attending two clinics and 476 non-diabetic outpatients (302 drivers).

MAIN OUTCOME MEASURES

Rates of accidents in diabetic and non-diabetic subjects.

RESULTS

A self completed questionnaire was used to record age, sex, driving state, and rates of accidents and convictions for motoring offences among diabetic and non-diabetic volunteers. For the diabetic volunteers further information was obtained on treatment, experience of hypoglycaemia, and declaration of disability to the Driving and Vehicle Licensing Centre and their insurance company. Accident rates were similar (81 (23%) diabetic and 76 (25%) non-diabetic drivers had had accidents in the previous five years). A total of 103 diabetic drivers had recognised hypoglycaemic symptoms while driving during the previous year. Only 12 reported that hypoglycaemia had ever caused an accident. Overall, 249 had declared their diabetes to an insurance company. Of these, 107 had been required to pay an increased premium, but there was no excess of accidents in this group.

CONCLUSIONS

Diabetic drivers treated with insulin and attending clinics have no more accidents than non-diabetic subjects and may be penalised unfairly by insurance companies.

Incidence and implications of natural deaths of road users

A prospective study was carried out over the 10 years 1978-87 to determine the incidence and implications of sudden death in road users--that is, drivers, pedestrians, cyclists, and motorcyclists. During the study period 30,000 patients were seen in the same accident and emergency departments of East Berkshire after road traffic incidents or accidents, of whom 267 either were brought in dead or died within two hours after arrival. Of these patients, 64 (24%) were found to have died of natural causes due to pre-existing disease or to have been killed in an incident that occurred as a result of a medical or psychiatric condition. Twelve of the patients sustained physical injury; all 64 came to necropsy. Only one incident resulted in the death of another person in addition to the natural death of a patient. It is concluded that sudden natural death occurring in road users does not present an appreciable hazard to other road users.

Admission to hospital for road trauma in patients with diabetes mellitus

A total of 8623 patients admitted to hospital in Western Australia with a diagnosis of diabetes mellitus during 1971-9 were linked with hospital admissions for road trauma during the same period, and their admission rates compared with the whole population. Although there was no overall difference, there was a significant excess of admissions in diabetic men aged under 55, the excess being produced by those in control of a vehicle and pedestrians. There were smaller excesses in the same female age group and a corresponding deficit in older diabetics. The results are limited through being based on routinely collected data on hospital admissions both for diabetics and victims of road crashes but indicate that there is a real problem of road accidents among diabetics that should be more fully investigated with a population based study that would collect important additional information unavailable in this study.

Driving and insulin-dependent diabetes

A survey of 250 patients with insulin-dependent diabetes (IDD) holding a full motor vehicle driving licence revealed that 107 (42.8%) had not declared IDD on their application for a driving licence. 70 of these (28% of entire group) claimed that they were unaware of the statutory requirements. There was no difference in the declaration-rate between men and women. 159 patients (66%) declared IDD for their motor insurance. 86 patients (34.4%) had had severe or frequent hypoglycaemia in the preceding six months, during which they had been driving regularly. 34 patients (13.6%) admitted involvement in a driving accident since commencing treatment with insulin, and 13 of these patients were aware that hypoglycaemia had been an important causal factor. The prevalence of diabetic retinopathy and cataracts was considerable, but few patients (2.4%) had severe impairment of vision in both eyes.

Mental illness and road traffic accidents

One hundred psychiatric patients were carefully matched with 100 physically ill patients and their driving records compared. The psychiatric patients were consuming far greater quantities of psychotropic drugs and included a larger number of alcoholics and heavy drinkers. During the six months before admission there were no significant differences between the two groups of patients with respect to accident and traffic code infringements. Apart from individual patients, drugs did not appear to be influencing the outcome in statistical terms. Alcoholics and heavy drinkers showed an increased lifetime accident liability. No specific psychiatric diagnosis was otherwise associated with increased accident rates. The majority of accidents reported were relatively trivial.

Traffic accidents caused by epilepsy

During a 10-year period, 203 traffic accidents were suspected of being caused by epilepsy; 155 of them definitely caused by seizures were selected for study. The seizures of 75% were psychomotor; in 12% the seizure was the first, and only 4% of the rest had reported that they had epilepsy when they applied for a license. Traffic accidents due to epilepsy were less serious than the "average accident". They involved another vehicle much less often, and they occurred more often outside rather than inside built-up areas. Accidents caused by epilepsy were rare--1/10,000 in the 10-year period. The characteristic features of the traffic accident due to epilepsy may be due to the "random" occurrence of seizures in traffic, and to the seizure-suppressing effect of increased vigilance in city traffic.

Disability rates of bus drivers

Raffle, P. A. B. (1974).British Journal of Industrial Medicine,31, 152-158. Disability rates of bus drivers. The proposal that ordinary driving licences should be valid up to the age of 70 has stimulated much discussion on the place of medical surveillance in the prevention of road crashes.

London Transport bus drivers are medically examined on entry to the service, after absence from work attributed to sickness or accident for more than 21 days (and in certain other circumstances), and at age 50 and routinely thereafter. Average annual rates of deaths in the service and recommendations for retiral on medical grounds and for transfers to alternative work for these drivers are presented. These disability rates are low even at the older ages. Most of those drivers who recommended for work other than bus driving were considered to be fit to drive a car. Between ages 50 and 64, 85% of the recommendations for discontinuance of bus driving resulted from post-sickness medical examinations and only 15% from routine age examinations.

It is concluded that the available evidence supports the legislative proposals for ordinary driving licensing. However, licence holders will need considerable help from their doctors in discharging their legal obligation to notify their licensing authority of medical conditions likely to affect their ability to drive safely.

Aplastic anaemia following chloramphenicol therapy in Hamburg and surrounding districts

One hundred and forty-two post mortem reports of road accident deaths in the Windsor accident area have been reviewed. Although head and chest injuries accounted for the deaths of most of these victims, twelve died of inhalation asphyxia and another eighteen died of hypovolaemia due to haemorrhage from otherwise minor injuries. Some of these cases would perhaps have survived if they had received skilled medical attention at the most critical time.

Automobile accidents caused by unsuspected neurological disease

✓ Two patients admitted as cerebral trauma cases following single-car automobile accidents were found to have previously-unsuspected, surgically-treatable neurological diseases that undoubtedly caused the accidents. A left posterior communicating artery aneurysm was clipped in one patient and a right frontal lobe abscess aspirated in the other, with excellent results in both patients.