Recent developments in the diagnosis and management of N1 penile cancer.

PURPOSE OF REVIEW: This article presents a critical review of the current literature to provide a brief update on the contemporary advances in diagnosing and managing N1 penile cancer. RECENT FINDINGS: Penile squamous cell carcinoma (pSCC) has evolved from being an orphan field for cancer innovation. Advances in the understanding tumour biology have enabled sophisticated diagnostics and predictive modelling to better characterize inguinal disease. Minimally invasive inguinal lymph node dissection is emerging as a technique that reduces morbidity while maintaining oncological safety. Furthermore, robust clinical trials are underway ,which will provide level one evidence to guide treatment decisions. Exciting advances in the field of immune-oncology offer promise as adjuvant therapies. International collaboration and centralisation of care will be essential to driving translational research and equitable evidence-based care. SUMMARY: Improving outcomes for men with pSCC remains a global challenge. Radical inguinal lymph node dissection remains the gold standard for diagnosing and curing N1 disease. Although many promising developments are on the horizon, high-level evidence is required to guide therapy.

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

OBJECTIVE: Psychiatric disorders and their treatments have the potential to adversely impact driving skills. However, it is unclear to what extent this poses a public health risk by increasing the risk of motor vehicle crashes (MVCs). The aim of this systematic review was to synthesize and critically appraise evidence on the risk of MVC for drivers with psychiatric disorders. METHOD: We conducted a systematic review of the MVC risk associated with psychiatric disorders using seven databases in November 2019. Two reviewers examined each study and extracted data. The National Heart, Lung, and Blood Institute Quality Assessment tools were used to assess each study's quality of evidence. RESULTS: We identified 24 studies that met the inclusion criteria, including eight cohort, 10 case-control, and six cross-sectional designs. Quality assessment ratings were "Good" for four studies, "Fair" for 10, and "Poor" for 10. Self-report or questionnaires were used in place of objective measures of either MVC, psychiatric disorder, or both in 12 studies, and only seven adjusted for driving exposure. Fifteen studies reported an increased risk of MVC associated with psychiatric disorders, and nine did not. There was no category of disorder that was consistently associated with increased MVC risk. CONCLUSION: The available evidence is mixed, not of high quality, and does not support a blanket restriction on drivers with psychiatric disorder. An individualized approach, as recommended by international guidelines, should continue. Further research should include objective assessments of psychiatric disorders and MVC risk and adjust for driving exposure.

Interrogating the Impassable: A Case Series and Literature Review of Unilateral SPECT-CT Groin Visualization in Men With Penile Cancer.

Penile squamous cell carcinoma (SCC) is a rare malignancy, which is known to invade local inguinal lymph nodes prior to progressing to the pelvis. Dynamic sentinel lymph node biopsy (DSLNB) is a standard for the minimally invasive assessment of lymphadenopathy in patients with subclinical groin metastasis. Hybrid 99mTc Single-Photon Emission Computed Tomography (SPECT-CT) has been shown to increase the accuracy of identifying first draining "sentinel" nodes (SN). Unilateral inguinal visualization on SPECT-CT is a rare presentation, which may increase the likelihood of a false negative SN biopsy. Retrospective analysis from three-penile cancer uro-oncologists in Melbourne, Australia identified 78 groins undergoing DSLNB for intermediate/high risk primary disease. Unilateral SPECT-CT results were observed in four patients suggesting a functional pattern of lymph diversion. Analysis confirmed malignancy (n = 2), sarcoidosis (n = 1), and evidence of local inflammation in SPECT-CT negative groins. Findings re-iterate the role of SPECT-CT a pre-operative adjunct. Experienced multimodal groin assessment using palpation, SPECT-CT, lymphoscintigraphy, and blue dye tracking remains paramount. Unilateral SN on pre-operative SPECT-CT in men with intermediate/high-risk penile SCC should elicit a higher degree of clinical suspicion. We recommend a low threshold for recommending radical inguinal lymph node dissection (ILND) for groins refractory to minimally invasive assessment.

Dynamic Sentinel Lymph Node Biopsy for Penile Cancer: Accuracy is in the Technique.

OBJECTIVES: To demonstrate an operative standard for dynamic sentinel lymph node biopsy (DSLNB). Long-term survival in men with penile squamous cell carcinoma (SCC) depends on accurately staging lymph node metastases. European Association of Urology (EAU) and National Comprehensive Cancer Network (NCCN) guidelines recognize DSLNB as a standard for staging men with intermediate to high-risk tumors and clinically absent inguinal lymphadenopathy. DSLNB accuracy has been linked with pre-operative planning and surgical technique, yet no peer-reviewed video exists to establish an operative standard. Here we present a narrated video of our technique and discuss the accuracy of this approach using retrospective patient data. METHODS: Ethics approval and patient consent was obtained. Retrospective analysis was performed on patients undergoing DSLNB for inguinal lymph node staging of histologically proven penile SCC. Data was included from 2 experienced uro-oncologists with subspecialty training in penile cancer working in Victoria, Australia between January 2015 and July 2021. Variables collected included Primary tumour histology, DSLNB pathology, progression to radical inguinal lymph node dissection (RILND) and recurrence patterns. DSLNB sensitivity and proportion of groins spared RILND is calculated. RESULTS: DSLNB was performed on 127 groins (64 patients) during the study period. Within the cohort, 44% (n = 28) of patients had a pre-operative lymphoscintigraphy with single-photon emission computed tomography (SPECT/CT). Analysis of primary tumor intervention demonstrates that 82.8% (n = 53) of men underwent penile sparing surgery. Tumor histology in 88% of patients (n = 56) demonstrated pT1-pT2 disease. Overall n = 19 groins undergoing DSLNB were positive for malignancy and n = 108 were negative. 36 groins progressed to RILND during a mean follow up of 29 months. Only 2 groins that previously had a negative DSLNB were positive on RILND, one in the groin and one in the pelvis. We observed a false negative rate of 1.9% and a sensitivity of 90.5%. In our cohort DSLNB allowed 71.7% of groins to proceed for surveillance instead of prophylactic radical ILND. CONCLUSIONS: DSLNB is a safe and accurate method for assessing inguinal lymphadenopathy in men with intermediate to high-risk penile SCC and impalpable groins. This video study establishes an operative standard for DSLNB with oncological outcomes are consistent with international expectations. Standardized use of DSLNB by an experienced team will reduce morbidity while maintaining oncological safety for men with intermediate to high-risk penile cancer and cN0 disease.

IID 2021: towards context-specific protein interaction analyses by increased coverage, enhanced annotation and enrichment analysis.

Improved bioassays have significantly increased the rate of identifying new protein-protein interactions (PPIs), and the number of detected human PPIs has greatly exceeded early estimates of human interactome size. These new PPIs provide a more complete view of disease mechanisms but precise understanding of how PPIs affect phenotype remains a challenge. It requires knowledge of PPI context (e.g. tissues, subcellular localizations), and functional roles, especially within pathways and protein complexes. The previous IID release focused on PPI context, providing networks with comprehensive tissue, disease, cellular localization, and druggability annotations. The current update adds developmental stages to the available contexts, and provides a way of assigning context to PPIs that could not be previously annotated due to insufficient data or incompatibility with available context categories (e.g. interactions between membrane and cytoplasmic proteins). This update also annotates PPIs with conservation across species, directionality in pathways, membership in large complexes, interaction stability (i.e. stable or transient), and mutation effects. Enrichment analysis is now available for all annotations, and includes multiple options; for example, context annotations can be analyzed with respect to PPIs or network proteins. In addition to tabular view or download, IID provides online network visualization. This update is available at http://ophid.utoronto.ca/iid.

Impact of COVID-19 on motor vehicle injuries and fatalities in older adults in Ontario, Canada.

BACKGROUND: Older adults constitute the group most vulnerable to COVID-19 mortality. As a result, in North America and elsewhere, older adults have been strongly advised to shelter in place. Older adults also represent the fastest growing segment of licensed drivers. OBJECTIVE: We examined the change in injuries and fatalities sustained by younger and older drivers and pedestrians during the first month of the COVID-19 pandemic. We hypothesized that adults ages 80 years and over would have a proportionally larger reduction than the other drivers and pedestrians. METHODS: Using a cohort design, we compared the proportion of drivers and pedestrians involved in injuries and fatalities attributable to individuals aged 80 years and over, as recorded in the Ministry of Transportation of Ontario (Canada) database, between the 30 days prior to shelter-in-place related to the COVID-19 pandemic and the subsequent 30 days. By way of comparison, we conducted a similar comparison for younger age cohorts (16-24 years, 25-34 years, 35-54 years, 55-64 years, and 65-79 years). RESULTS: Drivers aged 80 years and over represented 21 per 1000 injuries and fatalities in the 30 days prior to March 17, 2020 (95 % CI: 15-29), and 8 per 1000 injuries and fatalities in the 30 days beginning on that date (95 % CI: 2-20), a 64.7 % reduction (exp (ß) post 0.353, 95 % CI 0.105-0.892). Drivers in the 35-54 year age range underwent a significant but smaller reduction of 22.9 %; no significant changes were seen for drivers in other age groups, or for pedestrians of any age. CONCLUSIONS AND RELEVANCE: The physical distancing measures that aimed to reduce the spread of COVID-19 resulted in a marked reduction in driver injuries and fatalities in the oldest old, illustrating the impact of physical distancing recommendations in this population. The excess mortality burden faced by the oldest adults during the COVID-19 pandemic, by direct exposure to the virus, may be indirectly mitigated by the reduction in road-related deaths in this cohort.

Influence of Multiple Sclerosis on Spatiotemporal Gait Parameters: A Systematic Review and Meta-Regression.

OBJECTIVE: To quantify the effect of multiple sclerosis (MS) on spatiotemporal gait characteristics accounting for disability severity and fall classification. DATA SOURCES: MEDLINE (1946-August 2018), Allied and Complementary Medicine Database (1985-2018 August), and PsycINFO (1806-August 2018) were searched for terms on MS and gait. STUDY SELECTION: Dual independent screening was conducted to identify observational, cross-sectional studies that compared adults with MS grouped according to Expanded Disability Status Scale (EDSS) level or fall history, reported on spatiotemporal gait characteristics, and were published in English. The search retrieved 5891 results, of which 12 studies satisfied the inclusion criteria. DATA EXTRACTION: Two authors worked independently to extract and verify data on publication details, study methodology, participant characteristics, gait outcomes, conclusions, and limitations. Risk of bias was assessed using the QualSyst critical appraisal tool. A random-effects meta-regression and meta-analysis were conducted on pooled data. DATA SYNTHESIS: All studies received quality ratings of very good to excellent and collectively examined 1513 individuals with MS. With every 1-point increase in EDSS, significant changes (P<.05) were observed in gait speed (-0.12 m/s; 95% confidence interval (CI), 0.08-0.15), step length (-0.04 m; 95% CI, 0.03-0.05), step time (+0.04 seconds; 95% CI, 0.02-0.06), step time variability (+0.009 seconds; 95% CI, 0.003-0.016), stride time (+0.08 seconds; 95% CI, 0.03-0.12), cadence (-4.4 steps per minute; 95% CI, 2.3-6.4), stance phase duration (+0.8% gait cycle; 95% CI, 0.1-1.5), and double support time (+3.5% gait cycle; 95% CI, 1.5-5.4). Recent fallers exhibited an 18% (95% CI, 13%-23%) reduction in gait speed compared with nonfallers (P<.001). CONCLUSIONS: This review provides the most accurate reference values to-date that can be used to assess the effectiveness of MS gait training programs and therapeutic techniques for individuals who differ on disability severity and fall classification. Some gait adaptations could be part of adopting a more cautious gait strategy and should be factored into the design of future interventions.

Optimal surgical margin for penile-sparing surgery in management of penile cancer-Is 2 cm really necessary?

Introduction: Classical teaching of a 2 cm macroscopic surgical margin for surgical treatment of primary penile cancer is overly aggressive. Contemporary evidence suggests narrow but clear margins have similar survival outcomes for localized disease. This study aims to determine the oncological outcome of using a risk-adapted algorithm to selection of macroscopic surgical margin based on biopsy grade of disease: 5 mm margin for grade 1, 10 mm margin for grade 2, and 20 mm margin for grade 3. Methods: This is a retrospective case series of patients who underwent penile-sparing surgery for biopsy-proven penile SCC by a single surgeon from May 2010 through to January 2019. Clinicopathological data were extracted from medical records. Primary outcome was the positive margin rate. Secondary outcomes were overall survival (OS), cancer-specific survival (CSS), metastasis-free survival (MFS), and local recurrence-free survival (RFS). Kaplan-Meier survival analysis was used to determine survival outcomes. Results: A total of 21 patients were included in this study. The median age was 65. Pre-operative biopsy grade was grade 1 in 19.1% of patients, grade 2 in 47.6%, and grade 3 in 33.3%. The median size of tumor on examination was 20 mm. Using a grade-stratified algorithm for macroscopic surgical margin, only one patient (4.8%) had a positive margin. This patient had G1T3 disease and proceeded to have a total penectomy for oncological clearance. The median margin clearance was 7 mm. The 12-month OS, CSS, MFS, and local RFS were 94.6%, 94.6%, 81.0%, and 92.3%, respectively. Conclusion: This study suggests that using a grade-stratified approach to aim for a narrower macroscopic surgical margin does not appear to significantly alter the oncological outcome, with a negative margin rate of 95.2% in our this series. This enables more men to be eligible for organ preserving surgery and thereby improve their quality of life in the urinary function and sexual function domain. Larger prospective studies are warranted to confirm these findings.

A Systematic Review of the Risk of Motor Vehicle Collision in Patients With Syncope.

BACKGROUND: Drivers at risk of sudden incapacitation from syncope pose a potential threat to themselves and to society. The purpose of this systematic review is to synthesize the risk of motor vehicle collisions (MVCs) for patients with a history of syncope. METHODS: We systematically searched Medline (1946-2019) as well as Cinahl, Embase, Psychinfo, and the Transportation Research Information Documentation (1806-2017) for articles on MVCs and drivers with vasovagal syncope (VVS), arrhythmic syncope, or syncope not yet diagnosed (NYD). Quality ratings were assigned by team consensus. RESULTS: Eleven studies of moderate quality were included (n = 42,972). Compared with the general populations of Canada, the United States, and the United Kingdom (0.49%-2.29% per driver-year), the prospective MVC risk was lower for VVS (0.0%-0.31% per driver-year; 3 studies; n = 782) and higher for arrhythmic syncope (1.9%-3.4% per driver-year; 2 studies; n = 730). The results were more variable for syncope NYD (0.0%-6.9% per driver-year prospectively; 6 studies; n = 41,460). Patients with syncope NYD had an almost 2-fold increased MVC risk in the largest study, although the smaller studies showed contradictory findings. CONCLUSIONS: VVS patients appear to be at very low risk for MVCs, supporting current guidelines which do not recommend driving suspension for these patients in most cases. Although the data for other forms of syncope are too limited for definitive conclusions and must be improved, arrhythmic syncope appears to be associated with nontrivial risk.

Impact of medical fitness to drive policies in preventing property damage, injury, and death from motor vehicle collisions in Ontario, Canada.

INTRODUCTION: Drivers with medical conditions and functional impairments are at increased collision risk. A challenge lies in identifying the point at which such risk becomes unacceptable to society and requires mitigating measures. This study models the road safety impact of medical fitness-to-drive policy in Ontario. METHOD: Using data from 2005 to 2014, we estimated the losses to road safety incurred during the time medically-at-risk drivers were under review, as well as the savings to road safety accrued as a result of licensing decisions made after the review process. RESULTS: While under review, drivers with medical conditions had an age- and sex-standardized collision rate no different from the general driver population, suggesting no road safety losses occurred (RR = 1.02; 95% CI: 0.93-1.12). Licensing decisions were estimated to have subsequently prevented 1,211 (95% CI: 780-1,730) collisions, indicating net road safety savings resulting from medical fitness to drive policies. However, more collisions occurred than were prevented for drivers with musculoskeletal disorders, sleep apnea, and diabetes. We theorize on these findings and discuss its multiple implications. CONCLUSIONS: Minimizing the impact of medical conditions on collision occurrence requires robust policies that balance fairness and safety. It is dependent on efforts by academic researchers (who study fitness to drive); policymakers (who set driver medical standards); licensing authorities (who make licensing decisions under such standards); and clinicians (who counsel patients on their driving risk and liaise with licensing authorities). Practical Applications: Further efforts are needed to improve understanding of the effects of medical conditions on collision risk, especially for the identified conditions and combinations of conditions. Results reinforce the value of optimizing the processes by which information is solicited from physicians in order to better assess the functional impact of drivers' medical conditions on driving and to take suitable licensing action.

Renal colic causing Boerhaave syndrome.

Boerhaave syndrome is the spontaneous rupture of the oesophagus, usually due to vomiting. The condition is rare but can be fatal. A 30-year-old male presented with vomiting and pain in his left flank and chest. Computed tomography scanning of the chest, abdomen and pelvic revealed a 4 mm left proximal ureteric stone and pneumo-mediastinum due to oesophageal rupture, consistent with Boerhaave syndrome. The patient underwent insertion of left ureteric stent, with staged left ureteroscopy and laser lithotripsy. The patient's oesophageal rupture was managed conservatively, and he made a full recovery. This is only the second report of renal colic causing Boerhaave syndrome.

Transurethral ventral buccal mucosa graft inlay for treatment of distal urethral strictures: international multi-institutional experience.

PURPOSE: To critically evaluate a multi-institutional patient cohort undergoing single-stage distal urethral repair using a novel transurethral buccal mucosa graft inlay urethroplasty technique (TBMGI). METHODS: A retrospective multi-institutional review of consecutive patients with fossa navicularis (FN) strictures treated with a single-stage TBMGI technique at 12 institutions from March 2014-March 2018 was performed. Patient demographics, stricture characteristics, clinical and patient-reported outcomes were analyzed. The primary outcomes were stricture recurrence and complications. Secondary outcomes were change in maximum urinary flow rate (Qmax), PVR, and changes in IPSS, SHIM and global response assessment (GRA) questionnaire responses. Descriptive statistical analysis was used for evaluation of outcomes. RESULTS: Sixty-eight men met inclusion criteria. Median age and stricture length were 60 years (IQR 48-69) and 2 cm (IQR 2-3), respectively. Most common stricture etiology was lichen sclerosus (34%). Median operative time and EBL were 72 min (IQR 50-120) and 20 mL (IQR 10-43), respectively. Fifty-seven men completed ≥ 12-month follow-up. At a median follow-up of 17 months (IQR 13-22), 54 patients (95%) remained stricture-free. Median Qmax improved from 5 to 18 mL/s (p < 0.0001), PVR 76-21 mL (p < 0.0001), and IPSS 15-5 (p < 0.0001); IPSS-QOL score: 5-1 (p < 0.0001). SHIM score did not significantly change following repair (median 22-21 p = 0.85). On GRA assessment, a majority of men reported "marked" (64%) or "moderate" (28%) overall improvement. No patient developed fistula, glanular dehiscence, graft necrosis or chordee. CONCLUSIONS: This novel minimally invasive transurethral urethroplasty technique is feasible and has demonstrated generalizable outcomes in a multi-institutional cohort with varying etiologies.

Penile sparing therapy for penile cancer.

Penile cancer is a rare malignancy with a reported incidence of 0.66-1.44 per 100,000 men, and a reported mortality of 0.15-0.37 per 10,000 men. Expert clinical examination and histological diagnosis from biopsy is required to determine the extent and invasion of disease, which is paramount in planning of appropriate treatment. Management of loco-regional penile cancer can be divided into management of primary tumour and management of regional lymph nodes. This review article will focus on the management of the primary penile tumour with particular focus on penile sparing therapies. The aim of primary penile tumour management is to completely remove the tumour whilst preserving as much organ function as possible. Preservation of the penis is important as it allows patients to maintain urinary and sexual function, as well as quality of life. With the majority of penile cancer confined to the glans and foreskin, most penile cancers can be managed with organ-preserving therapy. A wide variety of treatment options are available, and this review aims to describe each of the options including the reported oncological and functional outcome for the different therapies for penile cancer.

Glomus tumour of the male urethra: an unusual diagnostic.

A 56-year-old man was referred to a reconstructive urologist for evaluation of a tender nodule in the penoscrotal area. Penile Doppler ultrasound showed a non-compressible mass with internal vascularity within the corpora spongiosum, and MRI identified an enhancing, solid mass arising from the ventral aspect of the urethra. Surgical resection warranted partial excision and reconstruction of the urethra, which was achieved by a dorsal onlay buccal mucosal graft urethroplasty through a perineal incision with penile invagination. The histopathology report concluded to an invasive, high-grade urothelial carcinoma, for which an aggressive oncological approach was considered. However, discussion with the pathology team led to the identification of a glomus tumour for which the patient did not need additional procedures. Urethral glomus tumours are extremely rare and should be included in the differential diagnosis of urethral masses. This case exemplifies the importance of teamwork in the management of uncommon cases.

A systematic review of the risk of motor vehicle collision after stroke or transient ischemic attack.

BACKGROUND: Returning to driving after stroke is one of the key goals in stroke rehabilitation, and fitness to drive guidelines must be informed by evidence pertaining to risk of motor vehicle collision (MVC) in this population. OBJECTIVES: The purpose of the present study was to determine whether stroke and/or transient ischemic attack (TIA) are associated with an increased MVC risk. METHODS: We searched MEDLINE, CINAHL, EMBASE, PsycINFO, and TRID through December 2016. Pairs of reviewers came to consensus on inclusion, based on an iterative review of abstracts and full-text manuscripts, on data extraction, and on the quality of evidence. RESULTS: Reviewers identified 5,605 citations, and 12 articles met inclusion criteria. Only one of three case-control studies showed an association between stroke and MVC (OR 1.9, 95% CI 1.0-3.9). Of five cohort reports, only one study, limited to self-report, found an increased risk of MVC associated with stroke or TIA (RR 2.71, 95% CI 1.11-6.61). Two of four cross-sectional studies using computerized driving simulators identified a more than two-fold risk of MVCs among participants with stroke compared with controls. The difference in one of the studies was restricted to those with middle cerebral artery stroke. CONCLUSIONS: The evidence does not support a robust increase in risk of MVCs. While stroke clearly prevents some patients from driving at all and impairs driving performance in others, individualized assessment and clinical judgment must continue to be used in assessing and advising those stroke patients who return to driving about their MVC risk.

Substance use and internalizing symptoms among high school students and access to health care services: results from a population-based study.

OBJECTIVES: To examine co-occurring mental health problems among a population-based sample of high school students in Ontario, Canada, to understand their prevalence, associated risk factors, and relationship with mental health service access and utilization. METHODS: The data were derived from the 2013 Ontario Student Drug Use and Health Survey, a biennial survey of students attending publicly funded Ontario schools, from a subsample of students who completed both the internalizing and substance use portions of the survey (n = 2945). Rates of co-occurring problems were calculated for the previous 12 months. Service use for students with co-occurring problems was also calculated for the past 12 months. Odds ratios were estimated using binary logistic regression models correcting for the survey design. RESULTS: In an adjusted model, youth with internalizing symptoms were 2.40 times more likely and youth with substance use problems were 2.24 times more likely to have accessed mental health services during the past 12 months than youth without these problems. Youth with co-occurring internalizing and substance use problems were 6.74 times more likely (95% CI 4.66-9.76, p < 0.001) to have accessed mental health services during the past year compared with youth without co-occurring problems, but only 52.8% of youth with co-occurring problems (95% CI 45.6-59.9%) used mental health services. CONCLUSIONS: The findings suggest that just over half of Ontario students in grades 9 through 12 who have co-occurring internalizing and substance use problems are utilizing mental health services. Further research should examine the factors related to service use in this population in order to better inform policy and program development.

Risk of Motor Vehicle Collision or Driving Impairment After Traumatic Brain Injury: A Collaborative International Systematic Review and Meta-Analysis.

OBJECTIVE: To synthesize knowledge of the risk of motor vehicle collision (MVC) following a traumatic brain injury (TBI) and the associated risk of driving impairment, as measured by on-road tests, computerized simulators, and self-reported or state-recorded driving records. METHODS: Our international team searched 7 databases for studies published between 1990 and 2015 of people with TBI, controls, and data concerning either MVC or driving impairment. The included articles examined the risk of MVC among people with TBI; we excluded studies that examined the risk of having a TBI associated with being involved in an MVC. RESULTS: From 13 578 search results, we included 8 studies involving 1663 participants with TBI and 4796 controls. We found no significant difference in the risk of MVC (odds ratio = 1.24, 95% confidence interval = 0.80-1.91, P = .34). When we restricted the analysis to self-report, the risk of MVC was higher for those without a TBI (odds ratio = 1.63, 95% confidence interval = 1.21-2.22, P = .002). In contrast, participants with TBI consistently performed worse during on-road assessments and had more problems with vehicular control. CONCLUSION: Limitations of reviewed studies included small sample sizes, failure to specify TBI severity or time postinjury, and absence of objective measures of risk. Findings concerning the relationship between TBIs from non-MVC causes and crash risk are, therefore, inconclusive and do not provide evidence for major changes to existing clinical guidelines for driving with TBI.