Thematic Review Series 2009
Sleep Apnea: Traffic and Occupational
Accidents – Individual Risks,
Socioeconomic and Legal Implications

Pneumology Department and Center for Sleep Medicine, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels , Belgium Key Words
These are all but uniform, especially concerning sleep apnea. Sleep apnea ؒ Motor vehicle accidents ؒ Sleep medicine ؒ Even within the European Union, where a minimum set of rules is mandatory for all countries, sleep apnea is not in-cluded in the minimum. Therefore, drivers are left in a very uncomfortable position, behaving according to the law in Abstract
one country but being unlawful once the border with the Obstructive sleep apnea has been associated with a high risk neighbor country is crossed. Physicians are also in a very dif- for motor vehicle accidents, probably the highest of all risks ficult position if they have to counsel their patients on the due to medical conditions. Treatment of sleep apnea with best attitude when travelling by car. The situation is even nasal continuous positive airway pressure appears to reduce worse for commercial drivers, for whom the legislation is the risk of traffic accidents to the one of the general popula- more severe but leaves sleep apnea uncovered in many tion. The risk for accidents may also be increased in untreat- countries. This is all the more disturbing if one considers that ed patients in the home and work environment. The in- sleep apnea can be suspected, screened and diagnosed with creased risk seems unrelated to the symptom of daytime relative ease, and that once diagnosed the adequate treat- excessive sleepiness, and in many studies lacks a clear dose- ment allows for safe driving. The inclusion of sleep apnea in response relationship with respect to the severity of apneas the European traffic license regulations would represent a and hypopneas. The association of sleep apnea, chronic step forward towards safe routes for patients and healthy sleep deprivation and consumption of hypnotics or alcohol has not been thoroughly studied, although alcohol has been considered as a confounding variable in some studies. The cost of traffic accidents due to sleep apnea has been esti-mated to be so high that diagnosing and treating all drivers Previous articles in this series: 1. Riha RL: Genetic aspects of the
obstructive sleep apnoea/hypopnoea syndrome – is there a com-
with sleep apnea in the USA would be cost saving and result mon link with obesity? Respiration 2009;78:5–17. 2. Verbraeck- in a decrease in society costs related to the disease. Driving en JA, De Backer WA: Upper airway mechanics. Respiration 2009; licenses are delivered according to national legislations. DOI: 10.1159/000222508. Tel. +32 2 764 2886, Fax +32 2 764 2831, E-Mail Introduction
Table 1. Examples of everyday questions without easy answers
Irrespective of the presence and intensity of the symp- Can I drive if I stop CPAP for a weekend? tom ‘sleepiness’, patients suffering from obstructive sleep Can I drive if I stop CPAP for one night? apnea (OSA) are at increased risk of motor vehicle acci- For how long should I be on treatment before I can drive safely? dents (MVA) when driving. The body of evidence on this issue is large and independent of cultural, topographic How many hours of CPAP per night will allow me to drive and traffic density backgrounds. Increased risks have been found in countries as dissimilar as Japan, Canada, Can I still safely transport my neighbour’s children to school?the USA, Germany, Spain, Switzerland, the UK, France My sleep clinic report states that I have an apnea/hypopnea index and Australia. Across all studies, the risk of MVA for pa- of 6 (or 10, 12, etc.) per hour. They state that I need no treatment tients, compared to the general population, is increased with CPAP. Can I safely continue driving?by about a factor of 3.
Work and home accidents have been much less stud- ied, and only scarce data have been published. Though scant, these data point, again, to an increased risk for pa- externally detectable somnolence and MVA risk. It is not clear that sleepiness is the OSA-associated trait that is re- The other concordant information coming from sev- sponsible for MVA increased risk. It could as well be in- eral countries is that the treatment of OSA with continu- termittent hypoxia, through unknown mechanisms, that ous positive airway pressure (CPAP) applied during sleep, determines a dysfunction of executive functions and cog- if adequately used by patients, reduces the increased risk nitive integration.
of MVA to the one seen in the general population.
To make things more complicated, it has to be recalled Seen from a distance, the summary of this informa- that MVA are generally the final consequence of multiple tion leads to a seemingly simple situation: drivers with causes. From a simple decrease in attention, to bad weath-untreated OSA have about a threefold increased risk for er conditions modifying the braking distances, to bad MVA, whereas drivers with CPAP-treated OSA have no road conditions, to the motor vehicle maintenance level, increased risk. From a closer viewpoint, however, the pic- to the tire pressure and state, to blood alcohol levels, to ture gets blurred. Many investigators have not found a previous night sleep duration and quality, to mood, med-relation between the severity of the disease and the size ications and drugs consumption, and to circadian aspects of the risk (although a minority of studies showed such (that is, time of day), all these aspects will ultimately, an effect). This is quite disturbing. Indeed, one would ex- alone or in combination, explain why an MVA has taken pect that if it is the consequences of OSA that produce place.
MVA, the more severe the disease, the greater the risk. When a diagnosis of OSA is made in a given patient, it This dose-response relationship has great practical value, is reasonable to assume that the patient will be informed since it may help to grade the risk and identify highest that he is at increased risk for MVA, and that he should risk groups. In addition, it is a robust argument support- react in an appropriate way to this new information. The ing the causal role of OSA in explaining the increased rate problem arises when the patient starts asking questions, of MVA. Thus, the absence of a dose-response relation- which will be very specific and very important for the ship makes the OSA-MVA relation less convincing.
patient, and for which physicians will not have precise, Moreover, MVA risk seems to be unrelated to exces- satisfactory and clear answers. Examples of such ques- sive daytime sleepiness, one of the consequences of OSA tions are given in table 1 . Although it should be acknowl-that is a logic culprit in accounting for MVA risk. This is edged that drivers spend most of their time blocked in also worrying, but less so. Sleepiness is a self-perception traffic jams, driving a private car enables most of us to that can be influenced by the disease itself, so that sleepy live far from where we work, from our children’s school, patients may be partially unaware of their degree of sleep- from our families and friends or from shops and grocer- iness and fill in questionnaires of sleepiness with answers ies. Being deprived from driving a car because one could that deny sleepiness. On the other hand, measuring sleep- have an MVA (although one has in fact never had one) iness with external tests that do not rely on the patient’s may be devastating. Having an actual MVA may be trag-own perception has proved difficult to apply on a large ic. Physicians will not escape easily from the need to face scale, and data are simply lacking on any relation between these questions and try to honestly answer them despite uncertainties and lack of information. The matter is even and prompted the inclusion of questions on sleepiness more dramatic for someone making his living out of driv- while driving and of MVA into the usual questions to be ing. It has been calculated that more than 10% of the considered in patients with OSA. Many reports have been workforce in Western societies are drivers, whether of published since then, using different methodologies, person transport vehicles, from taxis to buses, trains or from epidemiologic studies to cohort studies, case-con-planes or of small and large goods transport vehicles.
trol studies and follow-up studies. Several investigators From the society point of view, diseases imply costs, relied on patient’s responses to these questionnaires (sub- both because the patient may decrease his earning ca- jective data), whereas many others turned to official da- pacities and because health care for the patient will need tabases of MVA (in general more serious accidents in-expenses. In the case of MVA due to OSA, society will volving personal injuries or significant financial conse-face costs that are beyond the health care budget. Usu- quences). Several papers have reported on the effects of ally, these costs will not be considered when assessing the treatment (usually with CPAP) on MVA, comparing, in a economic impact of a disease. In OSA, these costs should cohort of patients, the rate of MVA for a given time before be taken into account to understand the global economic and after the institution of therapy. Patients were fre- implications of the disease and its treatment.
quently compared with a control sample, either limited There are legal questions linked to the MVA risk in in number and matched to the patient group on several OSA. One of the most important is the legal framework aspects or including all the population in a given geo-for driving license regulations. In many European coun- graphical area (an island, a state). In most studies, many tries (as well as for instance in many Australian regions) factors that could influence the comparisons were ac-OSA is specifically considered in the national driving li- counted for in the calculations. These include, for in- cense regulations. In others it is not. European rules try stance, distance driven per year, visual troubles, medica-to harmonize national rules and set minimal standards tions and alcohol consumption, body mass index, smok-to which all EU countries must comply. Unfortunately, ing, work schedule, and comorbidities. Most studies have OSA is not mentioned in the medical sector of the Euro- probed the possible relationships between the severity of pean Driving License Regulations (Annex III of the Eu- the disease, assessed either through the apnea/hypopnea ropean Directive 91/439/EEC). Physicians are usually not index (AHI) or the desaturation index, or the severity of at ease with legal questions. Nevertheless, they may be the the disease-related sleepiness, usually assessed with the only ones that can advise a patient with OSA driving Epworth Sleepiness Scale, or some index of sleep frag-abroad about the fact that driving regulations may differ, mentation such as the Movement Arousal Index on the and greatly so, from one country to another, at least until one hand, and the rate of MVA on the other hand. Table 2 the EU decides to harmonize rules concerning OSA and shows summary data of many such studies.
driving. It is worth mentioning that OSA is not the only Whatever the population sample considered, whatever medical condition having a deleterious influence on driv- the methodology of the study, whatever the follow-up ing ability. But it should also be mentioned that of all length, whether studies rely on self-reported MVA rate or medical conditions leading to an increase in MVA risks, on official databases, the results are concordant: there is OSA carries by far the greater risk increase, which makes an increased risk for MVA in patients with OSA, either it all the more necessary to homogenize driving license for MVA in general or for serious MVA only, and this ex-regulations in a continent where crossing borders has be- cess is cancelled when patients start and remain on treat- come commonplace for millions of drivers.
ment with CPAP. The average increase in risk across all The following pages will review in more detail some studies is in the range of 3-fold with respect to the gen- of the above mentioned aspects of OSA, that although not related to health, are worth knowing for physicians inter- As previously stated, only about half the published studies have found some relationship between the sever-ity of OSA and the risk for MVA. When this is the case, the relationship is generally not linear, but rather there is OSA and MVA: The Evidence
a kind of threshold above which the risk increases. For instance, in the study by Horstmann et al. [10] , patients The first reports of an increased number of MVA in with MVA had an AHI 1 34. In the study by George and patients with sleep apnea were published in the late 1980s Smiley [14] , the threshold was an AHI of 40. In other [1, 2] . These reports brought MVA to the medical realm, studies, the limit is just an AHI of more than 5 events per Table 2. Main studies on obstructive sleep apnea and MVA
experience and km driven, age, drugs, HTA increased risk, that was cancelled in treated patients near miss) before CPAP; after CPAP the proportion fell to 0 and 9%, respectively BMI = Body mass index; HTA = arterial hypertension; NA = not applicable.
hour, just above the figure defining the limit of normal- MVA, from visual refraction troubles, to cardiac arrhyth- ity in sleep studies. Concerning sleepiness, most studies mias, neurological diseases like epilepsy, hearing trou-show a lack of relationship between MVA and the usual bles, rheumatic diseases and the like. A recent meta-anal-way of assessing sleepiness, that is, the Epworth Sleepi- ysis compared the risks for MVA in all medical condi- tions reported in the literature [15] . The summary of this It is interesting at this point to remind the reader that meta-analysis is that most medical conditions confer a OSA is not the only medical condition leading to an in- risk increased between 1.2- and 2-fold with respect to a crease in MVA risk. Many diseases are known to result in healthy population (meaning that the disease increases the MVA rate by 20–100%). OSA had the highest in- drugs with sedative effects, sleep-prone effects, antipsy- creased risk, with a relative risk of 3.71, which is second chotic drugs and antidepressants. To these categories, only to age and gender as a general risk factor for MVA.
one should add narcotic pain killers and antihistamine For home and work accidents, the data are very poor. drugs. All these medicines decrease fitness to drive, not Only Krieger et al. [5] have systematically assessed these only shortly after their intake but many hours later, de-questions in their cohort of 893 patients followed up for pending on the compound [20, 21] .
12 months after the start of CPAP treatment. Domestic These facts should be brought to the attention of pa- accidents decreased from 25 before therapy to 13 after tients with OSA at the time of diagnosis and during CPAP therapy, whereas near miss accidents fell from 65 to 8. treatment implementation.
Work accidents decreased from 12 to 7, and near miss work accidents from 63 to 2. Sixty patients declared an accident before treatment, whereas the figure fell to 36 MVA, Sleep Apnea and Costs
after CPAP treatment. For near miss accidents, the fig-ures were 151 and 32, respectively.
Some investigators have tried to estimate the costs at- Barbé et al. [16] have recently performed a case-control tributable to MVA related to OSA. Starting from pub- study showing that 80 patients with sleep apnea had a 2.6 lished values of OSA prevalence, an odds ratio for MVA times higher risk of traffic accidents with respect to the in patients with OSA calculated as 2.52 and the percent-control group. When studied 2 years after the start of age of drivers older than 25 years (it is assumed that there treatment, the rate of accidents had halved in patients, but are few patients with sleep apnea below this age), they also in the control group. This points to awareness as be- computed the percentage of MVA and of related fatalities ing an important stimulus for the reduction in traffic ac- that could be attributed to patients with OSA, above the cidents, at least in the control group, that knew they were one expected in the population in general [22] . They then being followed up for motor vehicle collisions.
calculated comprehensive costs related to MVA, as ob-tained from USA official sources for the year 2000. These costs included not only medical expenses but also wages MVA, Sleepiness and Sedative Drugs
and productivity losses, administrative expenses, vehicle damages and employer costs for damages to working The literature on sleepiness and MVA is large, and will drivers. They also added lost financial values due to fa- not be reviewed in any detail here. However, there are talities, and lost financial values due to a low quality of some points that are relevant when considering patients life after an MVA.
with OSA. Sleepiness is thought to be involved in 10–20% On a separate calculation, the cost of diagnosing sleep of all MVA [17] . Sleepiness is physiologically related to the apnea and instituting CPAP treatment for all American circadian rhythm in man. Thus, a report by Connor et al. drivers was computed. The authors assumed that only 1 [18] showed that among 571 car drivers involved in serious in 5 screened drivers actually would have OSA, would be MVA (with personal injuries or deaths), compared to 588 treated with CPAP and therefore would be protected control drivers, the risk of MVA was causally related to from incurring the costs related to MVA in OSA. Very sleeping less than 5 h in the previous 24 h, to driving at an conservatively, Sassani et al. [22] also assumed the effec-inappropriate circadian time, that is, between 2 and 5 a.
m., and to being subjectively sleepy at the time of the MVA The summary of the results is that OSA-related MVA [18] . Similarly, Garbarino et al. [19] among others have represent a cost of about USD 16 billion per year. Treating clearly shown an excess rate of MVA during the circadian all drivers with CPAP would reduce the cost by about peaks in sleepiness, despite the low traffic density at these USD 11 billion per year. The cost of screening, diagnosing times. These are important messages to be conveyed to and treating all drivers was calculated at USD 3.2 billion, patients with OSA when discussing ways to decrease the leading to annual savings of USD 7.9 billion. These sums risk for MVA, and to avoid other factors possibly increas- come from an estimated 810,000 collisions per year and ing this risk beyond OSA itself. The well-known effects 1,400 fatalities attributable to OSA-related MVA. Some of alcohol consumption, even in seemingly low quantities, 567,000 collisions and 980 fatalities could be avoided with Sedating drugs are among the most sold medicines in Sensitivity analysis with a number of different vari- the world. This generic word is used here to describe ables did not change the results in any significant way. This report differs from many others on similar subjects having to always be able to control the vehicle, but with [23] because it includes all costs resulting from MVA, not no specific reference to OSA as such.
only related to the medical realm but also to the labour, A recent report has detailed the state of the legislation insurance and administration markets, and makes place in 25 European countries [25] . Ten countries specifically for financial equivalents for lost quality of life and for lost mention sleep apnea in their own Annex III (Belgium, Finland, France, Germany, Hungary, The Netherlands, Poland, Spain, Sweden and the UK). In some countries it is the physician’s duty to inform the authorities, whereas Sleep Apnea and Driving License: The European
in some others the physician is forbidden from doing so Landscape
(Hippocratic oath). In most countries, a patient with OSA cannot drive at all or may drive under restrictive condi- Diseases may impair the ability of the patient to exe- tions (for instance not driving at night, not driving on cute delicate motor and cognitive tasks. It has long been highways) as long as he is not treated, whereas he can recognized that operating machines and motor engines drive without restrictions if he is treated (but nothing is may be impaired not only by disease but also by medi- said on treatment compliance, duration and so on). To cines. Thus, every country has established a list of medi- this very chaotic scene, it has to be added that the dura- cal conditions that restrict or forbid altogether access to tion of the driving license can vary from one country to the driving license. This is an evolving field and different the other from lifetime (the driving license is never re- countries have issued different lists. Moreover, the list newed in Belgium for instance) to 5 or 10 years depending may differ for private drivers and professional drivers, on the age of the applicant. In the near future, the driving the latter being in general more extensive and precise.
license will uniformly be limited in the whole European Having established the list, it became necessary to des- Union. Directive 2006/126/EC will be enforced in 2013 ignate the persons able to declare whether the candidate stating that the driving license has a validity of 10 years driver did or did not have the listed diseases, whether the for private drivers (although countries may extend this to severity of the disease justified an exception to the usual 15 years) and of 5 years for professional drivers. Unfortu-attitude, and whether the decision should apply for a lim- nately, the new Annex III is as silent as far as OSA and ited time or be considered as definitive.
excessive daytime sleepiness are concerned as was the di- Depending on local history, politics and habits, the rective issued in 1991 [26] .
geographical limits of the driving license issuing board This legislative disharmony may put drivers in diffi- can go from a County (in Switzerland for instance), to a cult legal conditions. An Italian driver with untreated State (as in the USA or Australia) to a whole country (as OSA is entitled to drive without restrictions in Italy. If he in Belgium).
has an MVA in Belgium, even if he is not at fault, he is The European Union has long promoted the free cir- culation of people and goods within the 6, then 10 and There is some hope that OSA will be considered for nowadays 27 countries union. At least partly, this policy inclusion in Annex III in the next years (it was already depends on harmonization of national transport legisla- briefly introduced to the Road Safety High Level Group tions. Driving License Regulations have been the object of the European Union in 2007), although it may as well of a European text in 1991, the Council Directive on Driv- ing License Regulations. This text comprises an Annex III, listing the diseases and impairments limiting access to the driving license [24] . This is a common minimum Sleep Apnea, MVA and the Law
set of conditions that all member countries must comply with. However, individual countries can add other condi- In 2003, Desai et al. [28] published a paper on 7 MVA tions with due justification. Beyond a very limited com- resulting in fatalities, where the driver was later found to mon set of rules, individual countries remain free to de- suffer from OSA, idiopathic sleepiness, upper airway re- cide on the procedures, issuing boards, medical examina- sistance syndrome, periodic legs movement disorder or sleep deprivation, alone or in combination. These 7 driv- Concerning OSA, neither the disease nor excessive ers were brought to court, and an expert medical opinion daytime sleepiness is mentioned in the Annex III to the was requested from the authors. In 5 cases, objective tests 1991 directive. There is a general stance on the driver of sleepiness showed severe abnormal sleepiness. The fact remains rare enough, and this author is not aware of such license, 13% screened positive with the Joint Task Force demands coming from lawyers or courts elsewhere. Screening recommendations (none would have been sus-Things may change in the future, and sleep specialist may pected with the usual Commercial Driver Medical Ex- find themselves in the midst of prosecutors, defendants amination Form). Seventy percent of those screened pos-and victims.
itive underwent polysomnography and 95% showed OSA. Of course, many other commercial drivers could have gone undetected by the Task Force Screening proposal Screening and Diagnosing Sleep Apnea in
(for instance the lean patients with severe OSA with little Professional Drivers
subjective daytime sleepiness). But at least this method might increase the number of undiagnosed drivers with The facts concerning OSA and MVA have for the main OSA that can be prioritized for a fast track diagnostic part been well known since the last decade of the last cen- tury. The excess risk for MVA in drivers with OSA has worried many sleep specialists for a long time. In 2006, a Joint Task Force from the American College of Chest Conclusion
Physicians, the American College of Occupational and Environmental Medicine and the National Sleep Foun- It appears that nobody can ignore any more that pa- dation published a document on sleep apnea and com- tients with OSA are at increased risk for MVA and that treatment with CPAP protects from this increased risk. their recommendations to commercial drivers and pro- The economic consequences of this increased risk for so- posed a short screening procedure. In a driver with snor- ciety are enormous, and the protective effect of CPAP ing, excessive daytime sleepiness and/or witnessed apne- treatment is such that screening, diagnosing and treating as, 2 of the following 3 criteria – a body mass index great- all drivers with undiagnosed OSA will result in net sav- er than 35, a neck circumference greater than 43.2 cm in ings rather than in increased costs. The combined effects men or 40.6 cm in women or arterial hypertension – or of OSA, sleep deprivation and sedative medications an Epworth Sleepiness Scale greater than 10, a suspicion should be much more largely publicized to the general of OSA is present and justifies a diagnostic procedure. In public. Within Europe, the harmonization of national the meanwhile, the driver can continue driving.
legislations on driving license regulations and the inclu- If the driver has observed unexplained sleepiness (he sion of OSA as a recognized medical risk for driving in is sleeping in the waiting room for instance), has had an Annex III of the new European Directive should be a pri-MVA possibly related to being asleep, has an Epworth ority. Without these moves, physicians in general and Sleepiness Scale greater than 16 or has untreated sleep sleep specialists in particular will find themselves in a apnea, driving should not be allowed until the situation very uncomfortable posture in the face of the law. And has changed.
patients with OSA, innocent bystanders and healthy driv- Very recently, a study appears to validate these recom- ers will continue to be exposed to a preventable risk. mendations [30] . Out of 1,400 drivers with a commercial References
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a b s t r a c t A Review of the Diagnosis andManagement of Fungal Skin and Nail Infections Dermatophytes are fungi that require D’Arcy Little, MD, CCFP , Lecturer and Academic Fellow, Department of Family and keratin for growth and thus are restrict- Community Medicine, University of Toronto,Toronto, ON. ed to the hair, nails and superficialskin.1 Dermatophytoses are referred to

Case 5 cuvelier - drug induced perforation of the small intestine.pages

DRUG INDUCED ULCERATION AND PERFORATION OF THE SMALL INTESTINE Claude Cuvelier, MD, PhD Academic Department of Pathology, Ghent University, This case is the strangest drug induced ulcer with perforation of the small intestinal wall that I have ever seen! The patient had taken his drug (Motilium) just like the nurse had told him to do, but as he was confused he did not remove th

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