Performance during simple and complex military psychomotor tasks at various altitudes.

BACKGROUND: The purposes were to determine the following: 1) the threshold between 2500-4300 m at which simple and complex military task performance is degraded; 2) whether the degree of degradation, if any, is related to changes in altitude illness, fatigue, or sleepiness at a given altitude; and 3) whether the level of hypoxemia, independent of altitude, affects simple and complex military task performance. METHODS: There were 57 lowlanders (mean +/- SD; 22 +/- 3 yr; 79 +/- 12 kg) who were exposed to either 2500 m (N = 17), 3000 m (N = 12), 3500 m (N = 11), or 4300 m (N = 17). Disassembly and reassembly of a weapon (DsAs, simple), rifle marksmanship (RM, complex), acute mountain sickness (AMS), fatigue, sleepiness, and arterial oxygen saturation (SaO2) were measured at sea level (SL), and after 8 h (HA8) and 30 h (HA30) of exposure to each altitude. RESULTS: DsAs did not change from SL to HA8 or HA30 at any altitude. RM speed (target/min) decreased from SL (20 +/- 1.5) to HA8 (17 +/- 1.5) and HA30 (17 +/- 3) only at 4300 m. AMS, fatigue, and sleepiness were increased and SaO2 was decreased at 2500 m and above. Increased sleepiness was the only variable associated with decreased RM speed at 4300 m (r = -0.67; P = 0.004). Greater hypoxemia, independent of altitude, was associated with greater decrements in RM speed (r = 0.27; P = 0.04). CONCLUSIONS: Simple psychomotor performance was not affected by exposures between 2500-4300 m; however, complex psychomotor performance (i.e., RM speed) was degraded at 4300 m most likely due to increased sleepiness. Greater levels of hypoxemia were associated with greater decrements in RM speed.

Challenges in closing the gap between evidence and practice: International survey of institutional surgical stabilization of rib fractures guidelines.

BACKGROUND: Surgical stabilization of rib fractures (SSRF) has gained increasing interest over the past decade, yet few candidates who could benefit from SSRF undergo operative management. We conducted an international survey of institutional SSRF guidelines comparing congruence between practice and contemporary evidence. We hypothesized that few guidelines reflect comprehensive evidence to facilitate standardized patient selection, operation, and postoperative management. METHODS: A request for institutional rib fracture guidelines was distributed from the Chest Wall Injury Society. Surgical stabilization of rib fractures-specific guideline contents were extracted using a priori-designed extraction sheets and compared against 28 SSRF evidence-based recommendations outlined by a panel of 14 international experts. Fisher's exact test compared the proportion of strong and weak evidence-based recommendations specified within a majority of institutional guidelines to evaluate whether strength of evidence is associated with implementation. RESULTS: A total of 36 institutions from 3 countries submitted institutional rib fracture management guidelines, among which 30 had SSRF-specific guidance. Twenty-eight guidelines (93%) listed at least one injury pattern criteria as an indication for SSRF, while 22 (73%) listed pain and 21 (70%) listed impaired respiratory function as other indications. Quantitative pain and respiratory function impairment thresholds that warrant SSRF varied across institutions. Few guidelines specified nonacute indications for SSRF or perioperative considerations. Seven guidelines (23%) detailed postoperative management but recommended timing and interval for follow-up varied. Overall, only 3 of the 28 evidence-based SSRF recommendations were specified within a majority of institutional practice guidelines. There was no statistically significant association ( p = 0.99) between the strength of recommendation and implementation within institutional guidelines. CONCLUSION: Institutional SSRF guidelines do not reflect the totality of evidence available in contemporary literature. Guidelines are especially important for emerging interventions to ensure standardized care delivery and minimize low-value care. Consensus effort is needed to facilitate adoption and dissemination of evidence-based SSRF practices. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.