Impact of sleep deficiency on surgical performance: a prospective assessment.

STUDY OBJECTIVES: Sleep deficiency can adversely affect the performance of resident physicians, resulting in greater medical errors. However, the impact of sleep deficiency on surgical outcomes, particularly among attending surgeons, is less clear. METHODS: Sixty attending surgeons from academic and community departments of surgery or obstetrics and gynecology were studied prospectively using direct observation and self-report to explore the effect of sleep deprivation on patient safety, operating room communication, medical errors, and adverse events while operating under 2 conditions, post-call (defined as > 2 hours of nighttime clinical duties) and non-post-call. RESULTS: Each surgeon contributed up to 5 surgical procedures post-call and non-post-call, yielding 362 cases total (150 post-call and 210 non-post-call). Most common were caesarian section and herniorrhaphy. Hours of sleep on the night before the operative procedure were significantly less post-call (4.98 ± 1.41) vs non-post-call (6.68 ± 0.88, P < .01). Errors were infrequent and not related to hours of sleep or post-call status. However, Non-Technical Skills for Surgeons ratings demonstrated poorer performance while post-call for situational awareness, decision-making, and communication/teamwork. Fewer hours of sleep also were related to lower ratings for situational awareness and decision-making. Decreased self-reported alertness was observed to be associated with increased procedure time. CONCLUSIONS: Sleep deficiency in attending surgeons was not associated with greater errors during procedures performed during the next day. However, procedure time was increased, suggesting that surgeons were able to compensate for sleep loss by working more slowly. Ratings on nontechnical surgical skills were adversely affected by sleep deficiency. CITATION: Quan SF, Landrigan CP, Barger LK, et al. Impact of sleep deficiency on surgical performance: a prospective assessment. J Clin Sleep Med. 2023;19(4):673-683.

Risk assessment of road traffic accidents related to sleepiness during driving: a systematic review.

Background: Injuries due to accidental crash are the 8th leading cause of death worldwide. Sleepiness results in disrupted neurological function and is a major risk factor for road traffic accidents. Aims: This systematic review assessed the relationship between sleepiness during driving and road traffic accidents. Methods: A systematic review was conducted using online databases such as Wiley Online Library, JSTOR, Medline, and PubMed. Full-text, English language articles published between May 2000 and November 2020 were retrieved. Road traffic accident was set as the outcome of interest and sleepiness during driving as the exposure. The review included studies containing adjusted risk estimates (95% confidence interval). Ten cross-sectional studies (N = 55,945), 5 case-control studies (N = 3821), and 2 cohort studies (N =16,875) were included. Results: Over 50% of the participants in the different studies experienced sleep deprivation ranging from 3.5% to 67.3%. Abe et al. reported the highest (58%) frequency of sleepiness during driving in their cross-sectional study in Japan, and Nabi et al. reported the lowest (1.1%) in their cohort study in France. Conclusion: Sleepiness and sleep deprivation were related to road traffic accidents; and sleep deprivation was the main contributor to drowsiness while driving.

Association of high profile football matches in Europe with traffic accidents in Asia: archival study.

OBJECTIVE: To investigate the association between popular football games played in Europe and the incidence of traffic accidents in Asia. DESIGN: Study based on 41 538 traffic accidents involving taxis in Singapore and 1 814 320 traffic accidents in Taiwan, combined with 12 788 European club football games over a seven year period. SETTING: Singapore and Taiwan. PARTICIPANTS: The largest taxi company in Singapore, with fine grained traffic accident records in a three year span; all traffic accident records in Taiwan in a six year span. EXPOSURE: Days when high profile football games were played or not played. MAIN OUTCOME MEASURE: Number of traffic accidents. RESULTS: Regression based and time series models suggest that days with high profile European football matches were more positively associated with traffic accidents than days with less popular European football matches. For an approximate €134.74m (£120.25m; $159.76m) increase in average market value for matches played on a given day, approximately one extra accident would occur among Singapore taxi drivers, and for an approximate €7.99m increase in average market value of matches, approximately one extra accident would occur among all drivers in Taiwan. This association remained after control for weather conditions, time of the year, weekend versus weekday effects, driver demographics, and underlying temporal trends. It was also stronger for daytime traffic accidents than for night time traffic accidents, suggesting that the association between high profile football matches and traffic accidents cannot be attributed to night time celebration or attention deficits while watching and driving. Annually, this increased rate of traffic accidents may translate to approximately 371 accidents among taxi drivers in Singapore and approximately 41 079 accidents among the Taiwanese public, as well as economic losses of approximately €821 448 among Singapore taxi drivers and approximately €13 994 409 among Taiwanese drivers and insurers. The total health and economic impact of this finding is likely to be much higher because GMT+8 is the most populous time zone, encompassing 24% of the world's population. CONCLUSIONS: Days featuring high profile football matches in Europe were associated with more traffic accidents in Taiwan and Singapore than were days with lower profile football matches. A potential causal mechanism may be Asian drivers losing sleep by watching high profile European matches, which are often played in the middle of the night in Asia.

The associations between different sleep patterns and osteoporosis based on the Osteoporosis Self-Assessment Tool for Asians.

Based on the use of Osteoporosis Self-Assessment Tool for Asians (OSTA) to assess osteoporosis risk, we found that short sleep duration and taking a daytime nap had an increased risk of osteoporosis. PURPOSE: To explore the associations between different sleep patterns with osteoporosis. METHODS: 3659 postmenopausal women (average age of 60 years) were divided into low, middle, and high osteoporosis risk categories based on the Osteoporosis Self-Assessment Tool for Asians (OSTA). After having collected by a standard questionnaire, total and nocturnal sleep duration was collapsed to form categories of ≤ 6 h, > 6 h and ≤ 7 h, > 7 h and ≤ 8 h, > 8 h and ≤ 9 h, > 9 h, and daytime nap duration of 0 h and > 0 h. RESULTS: As a categorical variable, the total sleep duration of ≤ 6 h per day (OR = 1.34, 95% CI 1.04-1.72), nocturnal sleep duration of ≤ 6 h per night (OR = 1.65, 95% CI 1.24-2.18), and taking a daytime nap (OR = 1.33, 95% CI 1.09-1.64) had higher osteoporosis risk after adjustment for covariates. As a continuous variable, after the adjustment for covariates, both longer total (OR = 0.86, 95% CI 0.78-0.94) and nocturnal sleep duration (OR = 0.83, 95% CI 0.76-0.91) had lower risk of osteoporosis risk while taking longer daytime nap (OR = 1.10, 95% CI 1.02-1.19) had higher osteoporosis risk. CONCLUSIONS: Postmenopausal women with both short total and nocturnal sleep duration (6 h or less) and taking a daytime nap had increased osteoporosis risk as assessed by OSTA.

Adolescent Sleep: Challenges and Solutions for Pediatric Primary Care.

As pediatricians, we can all recall an adolescent patient who presents with fatigue. She is groggy in the morning before school, sometimes nods off in class, and then drinks a caffeinated beverage in the afternoon. She sends text messages to friends before going to bed shortly after midnight. After getting a bit of history from her, the parents complain that she has poor sleep habits while the teenage yawns and then rolls her eyes at being outed. For many adolescents, sleep restriction is a conscious choice that is made, as teens are juggling school responsibilities, extracurricular activities, and social interactions. This article is intended to help primary care pediatricians understand the causes of insufficient sleep in teenagers and gives tips on how to address common sleep issues. There is serious morbidity associated with poor sleep in adolescents, including mood disorders such as depression and anxiety, increased obesity risk, and higher rates of drowsy driving. It is my hope that a few tips from this article will help prevent some of these serious sequelae. [Pediatr Ann. 2019;48(8):e292-e295.].

Disparities in Hypertension Among African-Americans: Implications of Insufficient Sleep.

PURPOSE OF REVIEW: Sleep deficiency has been proposed as a potential contributor to racial disparities in cardiovascular health. We present contemporary evidence on the unequal burden of insufficient sleep in Blacks/African-Americans and the repercussions for disparate risk of hypertension. RECENT FINDINGS: The prevalence of insufficient sleep is high and rising and has been recognized as an important cardiovascular risk factor. Presumably due to a constellation of environmental, psychosocial, and individual determinants, these risks appear exacerbated in Blacks/African-Americans, who are more likely to experience short sleep than other ethnic/racial groups. Population-based data suggest that the risk of hypertension associated with sleep deficiency is greater in those of African ancestry. However, there is a paucity of experimental evidence linking short sleep duration to blood pressure levels in African-Americans. Blacks/African-Americans may be more vulnerable to sleep deficiency and to its hypertensive effects. Future research is needed to unequivocally establish causality and determine the mechanism underlying the postulated racial inequalities in sleep adequacy and consequent cardiovascular risk.

Perchance to Dream: Pathology, Pharmacology, and Politics in a 24-Hour Economy.

The lack of sleep is a significant problem in the modern world. The structure of the economy means that 24 hour working is required from some of us, sometimes because we are expected to be able to respond to share-price fluctuations on the other side of the planet, sometimes because we are expected to serve kebabs to people leaving nightclubs, and sometimes because lives depend on it. The immediate effect is that we feel groggy; but there may be much more sinister long-term effects of persistent sleep deprivation and disruption, the evidence for which is significant, and worth taking seriously. If sleeplessness has a serious impact on health, it represents a notable public health problem. In this article, I sketch that problem, and look at how exploiting the pharmacopoeia (or a possible future pharmacopoeia) might allow us to tackle it. I also suggest that using drugs to mitigate or militate against sleeplessness is potentially morally and politically fraught, with implications for social justice. Hence, whatever reasons we have to use drugs to deal with the problems of sleeplessness, we ought to be careful.

Partial Sleep Deprivation Reduces the Efficacy of Orexin-A to Stimulate Physical Activity and Energy Expenditure.

OBJECTIVE: Sufficient sleep is required for weight maintenance. Sleep deprivation due to noise exposure stimulates weight gain by increasing hyperphagia and reducing energy expenditure (EE). Yet the mechanistic basis underlying the weight gain response is unclear. Orexin-A promotes arousal and negative energy balance, and orexin terminals project to the ventrolateral preoptic area (VLPO), which is involved in sleep-to-wake transitions. To determine whether sleep deprivation reduces orexin function in VLPO and to test the hypothesis that sleep deprivation would attenuate the orexin-A-stimulated increase in arousal, physical activity (PA), and EE. METHODS: Electroencephalogram, electromyogram, distance traveled, and EE were determined in male Sprague-Dawley rats following orexin-A injections into VLPO both before and after acute (12-h) and chronic (8 h/d, 9 d) sleep deprivation by noise exposure. RESULTS: Orexin-A in the VLPO significantly increased arousal, PA, total EE, and PA-related EE and reduced sleep and respiratory quotient before sleep deprivation. In contrast to after acute sleep deprivation in which orexin-A failed to stimulate EE during PA only, orexin-A failed to significantly increase arousal, PA, fat oxidation, total EE, and PA-related EE after chronic sleep deprivation. CONCLUSIONS: Sleep deprivation may reduce sensitivity to endogenous stimuli that enhance EE due to PA and thus stimulate weight gain.

Effects of Sleep Loss on Subjective Complaints and Objective Neurocognitive Performance as Measured by the Immediate Post-Concussion Assessment and Cognitive Testing.

OBJECTIVE: This study examined the effects of total and partial sleep deprivation on subjective symptoms and objective neurocognitive performance, as measured by the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) in a sample of healthy adults. METHOD: One-hundred and two, right-handed, healthy participants (between ages 18 and 30 years old) completed three consecutive nights in the sleep laboratory with concurrent continuous polysomnography monitoring. Night 1 served as a baseline night. Prior to Night 2, they were randomly assigned to one of three sleep conditions: undisrupted normal sleep (N = 34), sleep restriction (50% of habitual sleep, N = 37), or total sleep deprivation (N = 31). Participants slept undisturbed on Night 3. ImPACT was administered on three separate occasions. RESULTS: Sleep loss was associated with increased severity of subjectively reported affective, cognitive, physical, and sleep symptoms. Although objective neurocognitive task scores derived from the ImPACT battery did not corroborate subjective complaints, sleep loss was associated with significant differences on tasks of visual memory, reaction time, and visual motor speed over time. CONCLUSIONS: While self-report measures suggested marked impairments following sleep loss, deficits in neurocognitive performance were observed only on three domains measured with ImPACT. ImPACT may capture subtle changes in neurocognitive performance following sleep loss; however, independent and larger validation studies are needed to determine its sensitivity to acute sleep loss and recovery sleep. Neurocognitive screening batteries may be useful for detecting the effects of more severe or chronic sleep loss under high-stress conditions that mimic high-risk occupations.

Prediagnosis Sleep Duration, Napping, and Mortality Among Colorectal Cancer Survivors in a Large US Cohort.

Study Objectives: Prediagnosis lifestyle factors can influence colorectal cancer (CRC) survival. Sleep deficiency is linked to metabolic dysfunction and chronic inflammation, which may contribute to higher mortality from cardiometabolic conditions and promote tumor progression. We hypothesized that prediagnosis sleep deficiency would be associated with poor CRC survival. No previous study has examined either nighttime sleep or daytime napping in relation to survival among men and women diagnosed with CRC. Methods: We examined self-reported sleep duration and napping prior to diagnosis in relation to mortality among 4869 CRC survivors in the NIH-AARP Diet and Health Study. Vital status was ascertained by linkage to the Social Security Administration Death Master File and the National Death Index. We examined the associations of sleep and napping with mortality using traditional Cox regression (total mortality) and Compositing Risk Regression (cardiovascular disease [CVD] and CRC mortality). Models were adjusted for confounders (demographics, cancer stage, grade and treatment, smoking, physical activity, and sedentary behavior) as well as possible mediators (body mass index and health status) in separate models. Results: Compared to participants reporting 7-8 hours of sleep per day, those who reported <5 hr had a 36% higher all-cause mortality risk (Hazard Ratio (95% Confidence Interval), 1.36 (1.08-1.72)). Short sleep (<5 hr) was also associated with a 54% increase in CRC mortality (Substitution Hazard Ratio (95% Confidence Interval), 1.54 (1.11-2.14)) after adjusting for confounders and accounting for competing causes of death. Compared to no napping, napping 1 hr or more per day was associated with significantly higher total and CVD mortality but not CRC mortality. Conclusion: Prediagnosis short sleep and long napping were associated with higher mortality among CRC survivors.

Role of sleep and circadian disruption on energy expenditure and in metabolic predisposition to human obesity and metabolic disease.

Weight gain, obesity and diabetes have reached alarming levels in the developed world. Traditional risk factors such as over-eating, poor nutritional choices and lack of exercise cannot fully account for the high prevalence of metabolic disease. This review paper examines the scientific evidence on two novel risk factors that contribute to dys-regulated metabolic physiology: sleep disruption and circadian misalignment. Specifically, fundamental relationships between energy metabolism and sleep and circadian rhythms and the impact of sleep and circadian disruption on metabolic physiology are examined. Millions of individuals worldwide do not obtain sufficient sleep for healthy metabolic function, and many participate in shift work and social activities at times when the internal physiological clock is promoting sleep. These behaviours predispose an individual for poor metabolic health by promoting excess caloric intake in response to reduced sleep, food intake at internal biological times when metabolic physiology is not prepared, decreased energy expenditure when wakefulness and sleep are initiated at incorrect internal biological times, and disrupted glucose metabolism during short sleep and circadian misalignment. In addition to the traditional risk factors of poor diet and exercise, disturbed sleep and circadian rhythms represent modifiable risk factors for prevention and treatment of metabolic disease and for promotion of healthy metabolism.

Fatigue in Emergency Services Operations: Assessment of the Optimal Objective and Subjective Measures Using a Simulated Wildfire Deployment.

Under controlled laboratory conditions, neurobehavioral assays such as the Psychomotor Vigilance Task (PVT) are sensitive to increasing levels of fatigue, and in general, tend to correlate with subjective ratings. However, laboratory studies specifically curtail physical activity, potentially limiting the applicability of such findings to field settings that involve physical work. In addition, laboratory studies typically involve healthy young male participants that are not always representative of a typical working population. In order to determine whether these findings extend to field-like conditions, we put 88 Australian volunteer firefighters through a multi-day firefighting simulation. Participants were required to perform real-world physical and cognitive tasks under conditions of elevated temperature and moderate sleep restriction. We aimed to examine changes in fatigue in an effort to determine the optimum objective and subjective measures. Objective and subjective tests were sensitive to fatigue outside laboratory conditions. The PVT was the most sensitive assay of objective fatigue, with the Samn-Perelli fatigue scale the most sensitive of the subjective measures. The Samn-Perilli fatigue scale correlated best with PVT performance, but explained a small amount of variance. Although the Samn-Perelli scale can be easily administered in the field, the wide range of individual variance limits its efficacy as a once-off assessment tool. Rather, fatigue measures should be applied as a component of a broader fatigue risk management system. Findings provide firefighting agencies, and other occupations involving physical work, guidance as to the most sensitive and specific measures for assessing fatigue in their personnel.

Sedentary Behavior and Sleep Duration Are Associated with Both Stress Symptoms and Suicidal Thoughts in Korean Adults.

Prolonged sedentary time and sleep deprivation are associated with mental health problems such as depression and stress symptoms. Moreover, mental illness is linked with suicidal thoughts and suicide attempts. However, it is not clear whether sedentary time and sleep duration are associated with stress symptoms and suicidal thoughts independent of physical activity. Thus, our study aimed to identify if sedentary time and sleep duration were associated with both stress symptoms and suicidal thoughts. The participants in present cross-sectional study were 4,674 general Korean adults (1,938 male; 2,736 female), aged ≥ 20 years. Prolonged sedentary time (≥ 420 min/day) was significantly associated with the increased risk of stress symptoms (OR, 1.30; 95% CI, 1.04-1.62) compared with sedentary time of < 240 min/day. The OR for stress symptoms was significant for individuals who had ≤ 5 h/day of sleep time (OR, 1.88; 95% CI, 1.48-2.38) compared with sleep duration of ≥ 7 h/day. Moreover, prolonged sedentary time (OR, 1.55; 95% CI, 1.01-2.42 in ≥ 420 min/day vs. < 240 min/day) and short sleep duration (OR, 1.75; 95% CI, 1.17-2.62 in ≤ 5 h/day vs. ≥ 7 h/day) were significantly associated with an increased risk for suicidal thoughts after adjusting for confounding factors including physical activity. Thus, prolonged sedentary time and sleep deprivation are independently associated with both the risk of stress symptoms and suicidal thoughts. From a public health perspective, reducing sedentary time and improvement of sleep deprivation may serve as an effective strategy for preventing mental illness.

Residents' and attendings' perceptions of a night float system in an internal medicine program in Canada.

BACKGROUND: The Night Float system (NFS) is often used in residency training programs to meet work hour regulations. The purpose of this study was to examine resident and attendings' perceptions of the NFS on issues of resident learning, well-being, work, non-educational activities and the health care system (patient safety and quality of care, inter-professional teams, workload on attendings and costs of on-call coverage). METHODS: A survey questionnaire with closed and open-ended questions (26 residents and eight attendings in an Internal Medicine program), informal discussions with the program and moonlighting and financial data were collected. RESULTS AND DISCUSSION: The main findings included, (i) an overall congruency in opinions between resident and attendings across all mean comparisons, (ii) perceptions of improvement for most aspects of resident well-being (e.g. stress, fatigue) and work environment (e.g. supervision, support), (iii) a neutral effect on the resident learning environment, except resident opinions on an increase in opportunities for learning, (iv) perceptions of improved patient safety and quality of care despite worsened continuity of care, and (v) no increases in work-load on attendings or the health care system (cost-neutral call coverage). Patient safety, handovers and increased utilization of moonlighting opportunities need further exploration.

Sleep as a potential fundamental contributor to disparities in cardiovascular health.

Optimal sleep is integral to health but is commonly not obtained. Despite its wide-ranging public health impact, sleep health is considered only rarely by policy makers, employers, schools, and others whose policies and structures can adversely affect sleep. An inadequate duration of sleep and poor-quality sleep are prevalent in minority and low-income populations, and may be fundamental to racial and socioeconomic status inequities that contribute to a range of health conditions, including cardiovascular disease (CVD). This review examines the relationship between sleep and disparities in CVD. We describe the public health importance of sleep and the role of sleep duration, as well as the two most common disorders (sleep apnea and insomnia) as risk factors for a number of chronic diseases. We use a multilevel model focused on population health and health disparities, which is based on the notion that individual behaviors, such as sleep, are influenced by complex and dynamic interrelations among individuals and their physical and social environments. We also describe modifiable factors that contribute to insufficient sleep and circadian misalignment, propose potential interventions in various sectors (e.g., neighborhoods, schools, workplaces) that can address social structures that contribute to disparities, and recommend areas for future research. Integrating sleep into public health research will identify novel approaches for closing gaps in health disparities.

[Primary headache and work: concepts of pathophysiology, occupational risk factors, health monitoring and criteria for judging causation]. / Cefalea primaria e lavoro: nozioni di fisiopatologia, fattori occupazionali di rischio, sorveglianza sanitaria e criteri per la formulazione del giudizio di idoneità.

Primary headaches account for 90% of all the forms of headache. The disease is characterized by high occurrence in the working-age population and by significant impact in countries with high economic and social development. These two epidemiological aspects carry significant economic costs that can be estimated calculating loss of working days due to illness and appreciable loss of labour productivity. In an occupational setting several circumstances are known to cause the onset of attacks in workers who already suffer from primary headache. In this sense, the following factors have an important role: interruption of the circadian sleep-wake rhythm, sleep deprivation, physical/mental distress, not ergonomic postures (mainly those involving the cervical-brachial district), prolonged use of display screen, acoustic discomfort. Among chemicals, in the current conditions of exposure, the olfactory characteristics seem of primary importance rather than the more "conventional" mechanism of toxicity. The main aim of this study is to provide useful information to occupational physicians on the management of workers suffering from primary headache, with regard either to the formulation of the judgement of suitability, or to their auxiliary role in the planning and organization of work. A second aim involves the identification of specific preventive measures in order to reduce the probability of occurrence of a headache attack. This also minimizes the risk of accidents and injuries and ensures workers' efficiency. After these considerations, we suggest guidelines for a flow chart (aimed to understand worker's suitability for his/her specific task). This guarantees not only safety and health of workers who suffer from the illness, but also safeguards any third worker from a possible consequence due to less working capacity and reduction of attention of employees working with a headache attack. In conclusion we also identify three critical factors: the diagnosis of the form of primary headache, the characteristics of the work and the effects due to pharmacological therapy. The study and characterization of these elements are a crucial step for a proper formulation of the judgement of suitability to work. We report a decision process for judgement formulation at the end of this article. It is organized with a hierarchical model, the first steps are the clinical examination and history, the last step, if necessary or advisable, is the neurological visit and a periodic verification of the adherence to treatment prescribed and the follow-up.

Managing and mitigating fatigue in the era of changing resident duty hours.

The medical establishment is grappling with the complex issue of duty hour regulations - an issue that is a natural consequence of the numerous changes in medical culture and practice that have occurred over the course of decades. Sleep deprivation resulting from long duty hours has a recognized impact on resident health and wellness. This paper will briefly outline the evolution of the concept of well-being in residency, review the specific theme of fatigue management within that context, and describe strategies that may be used to mitigate and manage fatigue, as well as approaches that may be taken to adapt to new scheduling models such as night float. Finally, the paper will call for a change in the culture in our workplaces and among our residents and faculty to one that promotes good health and ensures that we maintain a fit and sustainable medical workforce.

Driver sleepiness and risk of motor vehicle crash injuries: a population-based case control study in Fiji (TRIP 12).

INTRODUCTION: Published studies investigating the role of driver sleepiness in road crashes in low and middle-income countries have largely focused on heavy vehicles. We investigated the contribution of driver sleepiness to four-wheel motor vehicle crashes in Fiji, a middle-income Pacific Island country. METHOD: The population-based case control study included 131 motor vehicles involved in crashes where at least one person died or was hospitalised (cases) and 752 motor vehicles identified in roadside surveys (controls). An interviewer-administered questionnaire completed by drivers or proxies collected information on potential risks for crashes including sleepiness while driving, and factors that may influence the quantity or quality of sleep. RESULTS: Following adjustment for confounders, there was an almost six-fold increase in the odds of injury-involved crashes for vehicles driven by people who were not fully alert or sleepy (OR 5.7, 95%CI: 2.7, 12.3), or those who reported less than 6 h of sleep during the previous 24 h (OR 5.9, 95%CI: 1.7, 20.9). The population attributable risk for crashes associated with driving while not fully alert or sleepy was 34%, and driving after less than 6 h sleep in the previous 24 h was 9%. Driving by people reporting symptoms suggestive of obstructive sleep apnoea was not significantly associated with crash risk. CONCLUSION: Driver sleepiness is an important contributor to injury-involved four-wheel motor vehicle crashes in Fiji, highlighting the need for evidence-based strategies to address this poorly characterised risk factor for car crashes in less resourced settings.