Systematic screening for unsafe driving due to medical conditions: Still debatable

<p>Abstract</p> <p>Background</p> <p>Assessing people's ability to drive has become a public health concern in most industrialized countries. Although age itself is not a predictive factor of an increased risk for dangerous driving, the prevalence of medical conditions that may impair driving increases with age. Because the implementation of a screening for unsafe driving due to medical conditions is a public health issue, its usefulness should be judged using standardised criteria already proposed for screening for chronic disease. The aim of this paper is to propose standardised criteria suitable to assess the scientific validity of screening for unsafe driving due to medical conditions, and identify potential issues to be clarified before screening can be implemented and effective.</p> <p>Discussion</p> <p>Using criteria developed for screening for chronic diseases and published studies on driving with medical conditions, we specify six criteria to judge the opportunity of screening for unsafe driving due to medical conditions. This adaptation was needed because of the complexity of the natural history of medical conditions and their potential consequences on driving and road safety. We then illustrate that published studies pleading for or against screening for unsafe driving due to medical conditions fail to provide the needed documentation. Individual criteria were mentioned in 3 to 72% of 36 papers pleading for or against screening. Quantitative estimates of relevant indicators were provided in at most 42% of papers, and some data, such as the definition of an appropriate unsafe driving period were never provided.</p> <p>Summary</p> <p>The standardised framework described in this paper provides a template for assessing the effectiveness (or lack of effectiveness) of proposed measures for screening for unsafe driving due to medical conditions. Even if most criteria were mentioned in the published literature pleading for or against such a screening, the failure to find quantitative and evidence-based estimates of relevant indicators provides useful insight for further research.</p

Inaptitude médicale à la conduite automobile (évaluation de l'opportunité d'un programme de dépistage)

L'évaluation médicale de l'inaptitude à la conduite est devenue un axe majeur de la sécurité rourière dans les pays industrialisés. L'objectif de cette thèse était d'évaluer, par une approche de santé publique, l'opportunité d'un dépistage de l'inaptitude médicale à la conduite. La première étape a été d'analyser les conditions d'efficacité et les obstacles potentiels à un tel dépistage : 1) en étudiant, à partir de données d'assurance québécoises, l'opportunité de détecter, lors de visites médicales, des conducteurs âgés atteints d'affections médicales les plaçant potentiellement à plus haut risque d'accident ; 2) en adaptant les critères existants d'indication d'un programme de dépistage de maladies chroniques à la problématique d'un dépistage dans le cadre de la sécurité routière. Ce cadre conceptuel nous a permis de conclure qu'un dépistage de l'inaptitude à la conduite n'était pas indiqué pour le moment, en l'absence de données probantes. Ce résultat a motivé le développement d'un modèle décisionnel pour évaluer l'utilité et l'efficacité potentielles de trois stratégies envisageables pour la prévention de l'inaptitude à la conduite. Cette analyse de décision, fondée sur un modèle de Markov, nous a permis de conclure que, quels que soient l'inaptitude évaluée, l'âge ciblé et le rythme du dépistage, l'absence de dépistage était toujours meilleure qu'un dépistage avec un seul test. En définissant mieux la problématique de l'inaptitude médicale à la conduite, ce travail nous a permis de souligner la nécessité d'organiser une expertise collective pour développer des recommandations d'action et des recherches prioritaires pour répondre aux questions émergentes non résolues.Assessing fitness to drive of individuals with medical conditions has become a major road safety issue in most industrialized countries. The aim of this thesis was to assess, from a public health point of view, the opportunity of screening for inability to drive. The first step was to examine potential issues to be solved before screening can be implemented and effective : 1/ demonstrating, using insurance data from Quebec, that there might be an opportunity to detect, during usual medical visiits, medical conditions that potentially put older drivers at higher risk of collision ; 2/ adaptating criteria proposed to judge the indication of screening for chronic diseases to the issue of screening in the ontext of road safety. Using this framework allowed us to conclude that screening for inability to drive was not indicated now, given the lack of evidence. This result has justified developing a decision analysis model to assess the potential effectiveness and feasibility of three possible strategies to deal with individuals potentially unfit to drive. From this decision analysis, based on a Markov model, we concluded that, whatever the medical condition, the age when detection starts, and the rythm of screening, a no-screening strategy was always better than a single-test screening strategy. By providing a better understanding of the issue of screening for inability to drive, this work underlines the need for the organization of a task force to develop recommendations for possible actions and researches to answer unresolved emerging questions.BORDEAUX2-BU Santé (330632101) / SudocSudocFranceF

Effectiveness of prenatal treatment for congenital toxoplasmosis: a meta-analysis of individual patients' data

BACKGROUND: Despite three decades of prenatal screening for congenital toxoplasmosis in some European countries, uncertainty remains about the effectiveness of prenatal treatment. METHODS: We did a systematic review of cohort studies based on universal screening for congenital toxoplasmosis. We did a meta-analysis using individual patients' data to assess the effect of timing and type of prenatal treatment on mother-to-child transmission of infection and clinical manifestations before age 1 year. Analyses were adjusted for gestational age at maternal seroconversion and other covariates. FINDINGS: We included 26 cohorts in the review. In 1438 treated mothers identified by prenatal screening, we found weak evidence that treatment started within 3 weeks of seroconversion reduced mother-to-child transmission compared with treatment started after 8 or more weeks (adjusted odds ratio [OR] 0.48, 95% CI 0.28-0.80; p=0.05). In 550 infected liveborn infants identified by prenatal or neonatal screening, we found no evidence that prenatal treatment significantly reduced the risk of clinical manifestations (adjusted OR for treated vs not treated 1.11, 95% CI 0.61-2.02). Increasing gestational age at seroconversion was strongly associated with increased risk of mother-to-child transmission (OR 1.15, 95% CI 1.12-1.17) and decreased risk of intracranial lesions (0.91, 0.87-0.95), but not with eye lesions (0.97, 0.93-1.00). INTERPRETATION: We found weak evidence for an association between early treatment and reduced risk of congenital toxoplasmosis. Further evidence from observational studies is unlikely to change these results and would not distinguish whether the association is due to treatment or to biases caused by confounding. Only a large randomised controlled clinical trial would provide clinicians and patients with valid evidence of the potential benefit of prenatal treatment

Association between road vehicle collisions and recent medical contact in older drivers: a case‐crossover study

International audienceOBJECTIVE: To estimate the association between past medical contacts and the risk of vehicle collision in a population of older drivers from the province of Quebec, Canada. DESIGN: Case-crossover study. SETTING: Quebec. PARTICIPANTS: 111 699 older drivers involved in at least one vehicle collision between January 1988 and December 2000. MAIN OUTCOME MEASURES: For each driver, the risk of having a vehicle collision while exposed and not exposed to a medical contact was compared. Separate conditional logistic regression analyses were conducted for all drivers and in four diagnostic-specific subgroups. RESULTS: The study found a weak but statistically significant increased risk of all collisions being associated with a medical contact within 1 month before the collision, for all drivers (OR=1.10, 95% CI 1.08 to 1.11) and for drivers with diabetes (OR=1.07, 95% CI 1.03 to 1.11). CONCLUSION: Older drivers who have a collision are more likely to have been in contact with a physician shortly before the collision. These findings suggest that there might be an opportunity to detect medical conditions that put older drivers at higher risk of collision; however, further research is needed to assess the potential effectiveness and practical modalities of screening

0053: Incidence of cardiovascular events following myocardial infarction in France: an observational analysis using a claims database

ObjectivesTo describe the characteristics and treatments of patients having a myocardial infarction (MI) and estimate the incidence of cardiovascular events following the index MI, in the French Health Insurance database.MethodA cohort of patients who had a MI in France between 2007 and 2011 was extracted from a claim database: the Echantillon Généraliste de Bénéficiaires (a 1% representative sample of subjects covered by the general health insurance (?600,000 patients). The incidence of cardiovascular events following the index MI was estimated using the Kaplan Meier method.Results1,977 subjects were identified with an index myocardial MI: 2/3 were males, mean age=67.2 y, 20.6% had diabetes, 37.6% hypercholesterolemia and 82.4% hypertension. Cumulative incidence rates for outcomes are shown in the table. All cause mortality at 3 years (including in-hospital death) was 27% (95% CI: 25.8-29.1). This incidence was high in the 3 months following the index MI stabilized thereafter.ConclusionDespite high prescription rates of post-MI treatments, rates of all-cause mortality and CV events remained high following MI. This underscores the need to improve secondary prevention.Abstratct 0053 – Table% patients treated6 months before index MI6 months after index MIStatins30.7%91.1%Ezetimibe3.6%4.9%Aspirine (Alone)59.9%11.6%Aspirine+P2Y12-I*23.9%76.0%Class III Antiarrhytmic2.4%8.4%Oral Anticoagulant5.1%10.1%Non-Thiazide Diuretics19.1%32.9%ACE Inhibitors18.6%71.0%Beta-Blockers26.5%86.0%Nitrates9.9%46.4%Other Antihypertensives**40.2%30.3%Cumulative incidence rate (95%CI)1 year2 year3 yearAll cause deaths***17.8% (16.0%;19.5%)21.6% (20.7%;23.5%)27.0% (25.8%;29.1%)Recurrent MI3.1% (2.3%;3.8%)4.1% (3.2%;5.0%)4,7% (3.7%;5.7%)Stroke orTIA1.9% (1.3%;2.5%)3.1% (2.3%;3.9%)4.1% (3.1%;5.0%)Composite of death***/ reinfarction/stroke20.7% (18.9%;22.5%)26.0% (24.0%;28.0%)32.1% (29.8%;34.3%)*mostly clopidogrel**thiazide diuretics, angiotensin II receptor blockers, CCBs***including in-hospital death

Plasma 17-hydroxyprogesterone/cortisol ratio is not a predictor of systemic hypotension in extremely premature infants

International audienceBackground/aims: To determine whether the 17-hydroxyprogesterone (17-OHP)/cortisol ratio as a marker of immature11-beta hydroxylase activity can predict severe systemic hypotension in preterm neonates. Methods: Serum cortisol and 17-OHP concentrations were measured in capillary blood deposited on blotter paper on day 3 post-natal age (Day 3) in infants less than 32 weeks postmenstrual age (PMA). The predictive value of 17-OHP/cortisol ratio for a first episode of systemic hypotension occurring after Day 3 (FESH) was evaluated. Results: Of 105 infants included, 14 patients (13%) presented a FESH. Neither the 17-OHP/cortisol ratio, nor the 17-OHP or cortisol concentrations were associated with the occurrence of a FESH when adjusted for potential confounding factors. 17-OHP and cortisol were inversely associated to PMA (r = ﹣0.36 and ﹣0.40, respectively). Cortisol, but not 17-OHP, was associated with the type of hospitalization unit, the respiratory support and the presence of a patent ductus arteriosus. The 17-OHP/cortisol ratio was associated with the type of hospitalization unit only. Conclusions: The 17-OHP/ cortisol ratio at Day 3 did not predict the occurrence of a first episode of systemic hypotension after Day3 inpreterm neonates

Does adherence to inhaled corticosteroids predict asthma-related outcomes over time? A cohort study

Inhaled corticosteroids (ICS) adherence is important for asthma management. Current evidence on the impact of ICS adherence on outcomes is mostly based on correlational analyses of between-person data. Although it is widely acknowledged that asthma outcomes fluctuate over time, evidence on predictors of within-person change is scarce. We aimed to quantify these fluctuations and the longitudinal relationships between ICS adherence and outcomes at both between- and within-person levels.A prospective cohort of persistent asthma patients in France and the UK (n=847, age 6-40 years) provided 3756 reports over up to 2 years via computer-assisted telephone interviews and text messages on ICS adherence, asthma control, reliever medication use and exacerbations. We examined adherence-outcome relationships via longitudinal models, controlling for confounders, including severity.Considerable within-person variability was found for exacerbations (91%), asthma control (59%) and reliever use (52%); 431 (11.5%) reports signalled exacerbations and 2046 (54.5%) poor control. At between-person level, patients with higher average adherence were more likely to report asthma control (OR 1.25, 95% CI 1.06-1.47), but not asthma exacerbations (OR 0.99, 95% CI 0.87-1.12) or lower reliever use (b -0.0004, 95% CI -0.089-0.088). At within-person level, higher-than-usual adherence was associated with higher concomitant reliever use (b 0.092, 95% CI 0.053-0.131) and lower subsequent reliever use (b -0.047, 95% CI -0.005- -0.088); it was unrelated to asthma control (OR 0.93, 95% CI 0.84-1.02) or exacerbations (OR 1.04, 95% CI 0.94-1.16).Patients maintaining high ICS adherence over time have better asthma control. Temporarily increasing ICS adherence tends to be simultaneous to higher reliever use and reduces reliever use later on. Causes of within-person variation in outcomes require more investigation

Long-acting beta-agonists plus inhaled corticosteroids safety: a systematic review and meta-analysis of non-randomized studies

Background: Although several systematic reviews investigated the safety of long-acting beta–agonists (LABAs) in asthma, they mainly addressed randomized clinical trials while evidence from non-randomized studies has been mostly neglected. We aim to assess the risk of serious adverse events in adults and children with asthma treated with LABAs and Inhaled Corticosteroids (ICs), compared to patients treated only with ICs, from published non-randomized studies. Methods: The protocol registration number was CRD42012003387 (http://www.crd.york.ac.uk/Prospero webcite). Literature search for articles published since 1990 was performed in MEDLINE and EMBASE. Two authors selected studies independently for inclusion and extracted the data. A third reviewer resolved discrepancies. To assess the risk of serious adverse events, meta-analyses were performed calculating odds ratio summary estimators using random effect models when heterogeneity was found, and fixed effect models otherwise. Results: Of 4,415 candidate articles, 1,759 abstracts were reviewed and 220 articles were fully read. Finally, 19 studies met the inclusion criteria. Most of them were retrospective observational cohorts. Sample sizes varied from 50 to 514,216. The meta-analyses performed (69,939-624,303 participants according to the outcome considered) showed that odds ratio of the LABAs and ICs combined treatment when compared with ICs alone was: 0.88 (95% CI 0.69-1.12) for asthma-related hospitalization; 0.75 (95% CI 0.66-0.84) for asthma-related emergency visits; 1.02 (95% CI 0.94-1.10) for systemic corticosteroids; and 0.95 (95% CI 0.9-1.0) for the combined outcome. Conclusions: Evidence from observational studies shows that the combined treatment of LABAs and ICs is not associated with a higher risk of serious adverse events, compared to ICs alone. Major gaps identified were prospective design, paediatric population and inclusion of mortality as a primary outcome.Financial support for this study was provided by the Health Research Fund (European Union FP7, ASTROLAB project EC HEALTH-F5-2011-282593); the Agency for Management of University and Research Grants AGAUR (2012FI_B1 00177); and a Fundación Carolina Fellowship