Blood glucose monitoring by insulin-treated pilots of commercial and private aircraft: An analysis of out-of-range values.

AIM: To examine blood glucose measurements recorded as part of the diabetes protocol operated by the UK, Ireland and Austria, which allows commercial airline pilots with insulin-treated diabetes to fly. METHODS: An observational study was conducted in pilots with insulin-treated diabetes, granted medical certification to fly commercial or noncommercial aircraft, who recorded pre-flight and hourly in-flight blood glucose measurements. These values were correlated to a traffic light system (green 5.0 to 15.0 mmol/L; amber 4.0 to 4.9 mmol/L and 15.1 to 20.0 mmol/L; and red <4.0 mmol/L or >20.0 mmol/L) and studied for trends in glucose concentrations, time course within flight and any consequences. Pilot demographics were also analysed. RESULTS: Forty-four pilots (90%) recorded one or more blood glucose value outside the green range during the 7 years of the study. Pilot age, diabetes type and duration, and follow-up period were comparable among subgroups, and mean glycated haemoglobin did not differ before and after certification in a way which would indicate poorer glycaemic control in any subgroup. A total of 892 blood glucose values (2.31%) were outside the green range, with half reported in-flight at various time intervals. There were 48 (0.12%) low red range values recorded, 14 (0.04%) of which occurred in-flight; all but four were restored to within the green range by the time of the next measurement. Appropriate corrective action was taken for all out-of-range values, with no reports of pilot incapacitation from any cause. CONCLUSIONS: The traffic light system appears effective in identifying and reducing the frequency and severity of out-of-range values.

Surgery for women with posterior compartment prolapse.

BACKGROUND: Posterior vaginal wall prolapse (also known as 'posterior compartment prolapse') can cause a sensation of bulge in the vagina along with symptoms of obstructed defecation and sexual dysfunction. Interventions for prevention and conservative management include lifestyle measures, pelvic floor muscle training, and pessary use. We conducted this review to assess the surgical management of posterior vaginal wall prolapse. OBJECTIVES: To evaluate the safety and effectiveness of any surgical intervention compared with another surgical intervention for management of posterior vaginal wall prolapse. SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Register of controlled trials, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) (searched April 2017). We also searched the reference lists of relevant articles, and we contacted researchers in the field. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing different types of surgery for posterior vaginal wall prolapse. DATA COLLECTION AND ANALYSIS: We used Cochrane methods. Our primary outcomes were subjective awareness of prolapse, repeat surgery for any prolapse, and objectively determined recurrent posterior wall prolapse. MAIN RESULTS: We identified 10 RCTs evaluating 1099 women. Evidence quality ranged from very low to moderate. The main limitations of evidence quality were risk of bias (associated mainly with performance, detection, and attrition biases) and imprecision (associated with small overall sample sizes and low event rates).Transanal repair versus transvaginal repair (four RCTs; n = 191; six months' to four years' follow-up)Awareness of prolapse is probably more common after the transanal approach (risk ratio (RR) 2.78, 95% confidence interval (CI) 1.00 to 7.70; 2 RCTs; n = 87; I2 = 0%; low-quality evidence). If 10% of women are aware of prolapse after transvaginal repair, between 10% and 79% are likely to be aware after transanal repair.Repeat surgery for any prolapse: Evidence is insufficient to show whether there were any differences between groups (RR 2.42, 95% CI 0.75 to 7.88; 1 RCT; n = 57; low-quality evidence).Recurrent posterior vaginal wall prolapse is probably more likely after transanal repair (RR 4.12, 95% CI 1.56 to 10.88; 2 RCTs; n = 87; I2 = 35%; moderate-quality evidence). If 10% of women have recurrent prolapse on examination after transvaginal repair, between 16% and 100% are likely to have recurrent prolapse after transanal repair.Postoperative obstructed defecation is probably more likely with transanal repair (RR 1.67, 95% CI 1.00 to 2.79; 3 RCTs; n = 113; I2 = 10%; low-quality evidence).Postoperative dyspareunia: Evidence is insufficient to show whether there were any differences between groups (RR 0.32, 95% CI 0.09 to 1.15; 2 RCTs; n = 80; I2 = 5%; moderate-quality evidence).Postoperative complications: Trials have provided no conclusive evidence of any differences between groups (RR 3.57, 95% CI 0.94 to 13.54; 3 RCTs; n = 135; I2 = 37%; low-quality evidence). If 2% of women have complications after transvaginal repair, then between 2% and 21% are likely to have complications after transanal repair.Evidence shows no clear differences between groups in operating time (in minutes) (mean difference (MD) 1.49, 95% CI -11.83 to 8.84; 3 RCTs; n = 137; I2 = 90%; very low-quality evidence).Biological graft versus native tissue repairEvidence is insufficient to show whether there were any differences between groups in rates of awareness of prolapse (RR 1.09, 95% CI 0.45 to 2.62; 2 RCTs; n = 181; I2 = 13%; moderate-quality evidence) or repeat surgery for any prolapse (RR 0.60, 95% CI 0.18 to 1.97; 2 RCTs; n = 271; I2 = 0%; moderate-quality evidence). Trials have provided no conclusive evidence of a difference in rates of recurrent posterior vaginal wall prolapse (RR 0.55, 95% CI 0.30 to 1.01; 3 RCTs; n = 377; I2 = 6%; moderate-quality evidence); if 13% of women have recurrent prolapse on examination after native tissue repair, between 4% and 13% are likely to have recurrent prolapse after biological graft. Evidence is insufficient to show whether there were any differences between groups in rates of postoperative obstructed defecation (RR 0.96, 95% CI 0.50 to 1.86; 2 RCTs; n = 172; I2 = 42%; moderate-quality evidence) or postoperative dyspareunia (RR 1.27, 95% CI 0.26 to 6.25; 2 RCTs; n = 152; I2 = 74%; low-quality evidence). Postoperative complications were more common with biological repair (RR 1.82, 95% CI 1.22 to 2.72; 3 RCTs; n = 448; I2 = 0%; low-quality evidence).Other comparisonsSingle RCTs compared site-specific vaginal repair versus midline fascial plication (n = 74), absorbable graft versus native tissue repair (n = 132), synthetic graft versus native tissue repair (n = 191), and levator ani plication versus midline fascial plication (n = 52). Data were scanty, and evidence was insufficient to show any conclusions about the relative effectiveness or safety of any of these interventions. The mesh exposure rate in the synthetic group compared with the native tissue group was 7%. AUTHORS' CONCLUSIONS: Transvaginal repair may be more effective than transanal repair for posterior wall prolapse in preventing recurrence of prolapse, in the light of both objective and subjective measures. However, data on adverse effects were scanty. Evidence was insufficient to permit any conclusions about the relative effectiveness or safety of other types of surgery. Evidence does not support the utilisation of any mesh or graft materials at the time of posterior vaginal repair. Withdrawal of some commercial transvaginal mesh kits from the market may limit the generalisability of our findings.

Clinical outcomes and resource utilisation in patients with major burns treated with NovoSorb® BTM.

INTRODUCTION: Patients with major burns can undergo temporary coverage while skin graft donor sites heal, where dermal templates have an emerging role. The aim of this study was to evaluate the clinical outcomes and resource utilisation in patients with major burns treated with a bilayer biodegradable synthetic matrix (NovoSorb BTM). METHOD: This retrospective cohort study included patients admitted to the Royal Brisbane and Women's Hospital Adult Burn Unit with burns to at least 40 % TBSA who survived their acute admission. Patients treated from July 2017 to June 2022 with BTM were compared with patients with similar injuries treated using cadaveric allograft as temporising full thickness wound coverage between January 2013 and June 2017. Outcomes measures included number of operations, total operative time, hospital and intensive care unit (ICU) length of stay (LOS), cadaveric allograft and BTM use, and blood product use. Unadjusted comparisons were made with Wilcoxon Rank-Sum tests and Fisher's exact tests. Multivariate linear regression was used to adjust for the effect of TBSA on each outcome. RESULTS: Fifty-five patients were included (78 % male), 22 of whom were treated with BTM. We found no significant differences in age, sex, or TBSA between groups. One patient had half of the BTM removed due to infection and replaced with allograft. Patients treated with BTM had significantly less operative theatre time (median 1361.5 min [BTM] vs 1768 min [no BTM], P = 0.044). Number of operations, allograft use, hospital and ICU LOS, and blood product use were similar between groups. Adjusted models accounting for TBSA supported unadjusted models. CONCLUSION: Resource utilisation and clinical outcomes were similar in patients with at least 40 % TBSA treated with BTM and those who were treated with allograft before the introduction of BTM. Patients treated with BTM had significantly less total operative time and no difference in number of operations, allograft use and ICU LOS.

Continuous Glucose Monitoring by Insulin-Treated Pilots Flying Commercial Aircraft Within the ARA.MED.330 Diabetes Protocol: A Preliminary Feasibility Study.

Background and Aims: A preliminary study compared the use of continuous glucose monitoring (CGM) with the use of self-monitored blood glucose (SMBG) by aircraft pilots with insulin-treated diabetes in the United Kingdom, Ireland, and Austria, certified to fly commercial aircraft within the European Aviation Safety Agency ARA.MED.330 protocol. Methods: SMBG and simultaneous interstitial glucose measurements using CGM (Dexcom G6®) were recorded during pre- and in-flight periods. Results: Eight male pilots (seven with type 1 diabetes and one with type 3c diabetes), median age of 48.5 years and median diabetes duration of 11.5 years, participated. The correlation coefficient (R) between 874 contemporaneously recorded SMBG and CGM values was 0.843, P < 0.001. The mean glucose concentration was 8.78 mmol/L (standard deviation [SD] 0.67) using SMBG compared with 8.71 mmol/L (SD 0.85) recorded using CGM. The mean absolute relative difference was 9.39% (SD 3.12). Conclusions: CGM using Dexcom G6 systems is a credible alternative to SMBG for monitoring glucose levels when insulin-treated pilots fly commercial aircraft. The study was registered with Clinical Trials.gov NCT04395378.

Diminishing lengths of subsequent bowel resections in the surgical management of ileal Crohn's disease.

BACKGROUND: Crohn's disease is a chronic inflammatory bowel disease that most commonly affects the ileum. As a result, it is associated with a high lifetime risk of one or more surgical resections. The surgical paradigm is to preserve intestinal length. This study aims to assess the length of ileum resected at the index operation and at subsequent ileocolic resections for Crohn's disease. METHODS: This is a retrospective study assessing the clinical and pathological data of patients undergoing ileocolic resection for the management of Crohn's disease over the period 01/01/2002 to 31/07/2020 in two metropolitan Australian hospitals. RESULTS: One hundred and seventy-six patients were analysed: 130 underwent a single resection; 31 underwent two resections; and 15 underwent three resections. The median age at the first operation was 37.2 years (range 18-69) with 60% of patients female. The median length resected at the first surgery was 17.8 cm (IQR 12.0) for small bowel, and 5.0 cm (IQR 1.0) for large bowel. The length of ileum resected at the first surgery was significantly greater than that of the second (P = 0.0001), without significant differences between the second and third resections (P = 0.49). The time interval from diagnosis to the first surgery had no significant impact on the length of intestine resected at the index ileocolic resection. CONCLUSION: In Crohn's disease, the length of ileum removed at first resection is the greatest, with subsequent resection lengths less than the first.

Leisure pilot license proposed for Europe: do you want such pilots crossing your flight path?

In a Notice of Proposed Amendment, the European Aviation Safety Agency proposes to introduce a Leisure Pilot License (LPL). Holders of a LPL for airplanes will be allowed to fly single-engine piston airplanes with a maximum takeoff mass of 2000 kg or less, carrying a maximum of three passengers. In this commentary paper, we express significant concern about the flight safety consequences of the proposed aeromedical requirements of the LPL. We argue that the proposed minimum age, validity period of the medical certificate, and issuance of certificates by general practitioners may increase the flight safety risk. Major revision of the proposed LPL regulation is recommended.

Asymmetric acyl-transfer promoted by readily assembled chiral 4-N,N-dialkylaminopyridine derivatives.

The development of a new class of chiral 4-N,N-dialkylaminopyridine acyl-transfer catalysts capable of exploiting both van der Waals (pi) and H-bonding interactions to allow remote chiral information to stereochemically control the kinetic resolution of sec-alcohols with moderate to excellent selectivity (s = 6-30). Catalysts derived from (S)-alpha,alpha-diarylprolinol are considerably superior to analogues devoid of a tertiary hydroxyl moiety and possess high activity and selectivity across a broad range of substrates.

Kinetic resolution of sec-alcohols using a new class of readily assembled (S)-proline-derived 4-(pyrrolidino)-pyridine analogues.

We report the development of a new class of readily prepared chiral 4-(pyrrolidino)-pyridine catalysts capable of exploiting both van der Waals (pi) and H-bonding interactions, thus allowing remote chiral information to stereochemically control the kinetic resolution of sec-alcohols.