The Clinical Impact of Flash Glucose Monitoring-a Digital Health App and Smartwatch Technology in Patients With Type 2 Diabetes: Scoping Review.

BACKGROUND: Type 2 diabetes has a growing prevalence and confers significant cost burden to the health care system, raising the urgent need for cost-effective and easily accessible solutions. The management of type 2 diabetes requires significant commitment from the patient, caregivers, and the treating team to optimize clinical outcomes and prevent complications. Technology and its implications for the management of type 2 diabetes is a nascent area of research. The impact of some of the more recent technological innovations in this space, such as continuous glucose monitoring, flash glucose monitoring, web-based applications, as well as smartphone- and smart watch-based interactive apps has received limited attention in the research literature. OBJECTIVE: This scoping review aims to explore the literature available on type 2 diabetes, flash glucose monitoring, and digital health technology to improve diabetic clinical outcomes and inform future research in this area. METHODS: A scoping review was undertaken by searching Ovid MEDLINE and CINAHL databases. A second search using all identified keywords and index terms was performed on Ovid MEDLINE (January 1966 to July 2021), EMBASE (January 1980 to July 2021), Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library, latest issue), CINAHL (from 1982), IEEE Xplore, ACM Digital Libraries, and Web of Science databases. RESULTS: There were very few studies that have explored the use of mobile health and flash glucose monitoring in type 2 diabetes. These studies have explored somewhat disparate and limited areas of research, and there is a distinct lack of methodological rigor in this area of research. The 3 studies that met the inclusion criteria have addressed aspects of the proposed research question. CONCLUSIONS: This scoping review has highlighted the lack of research in this area, raising the opportunity for further research in this area, focusing on the clinical impact and feasibility of the use of multiple technologies, including flash glucose monitoring in the management of patients with type 2 diabetes.

An Update to Aircrew Grounding Periods After Ketamine Use.

INTRODUCTION: Ketamine is a rapidly acting general anesthetic which is globally used in surgical analgesia, as well as in the management of pain. It is also used as a recreational drug. Because of its widespread use in surgical settings, the use of this drug presents an aeromedical problemin addition, of course, to the underlying condition for which it has been used. The literature around the mechanisms and side effects of ketamine is reasonably mature, and it is possible to make fairly dependable risk management decisions about return to flying based on the information available. Accordingly, following ketamine use it is recommended that aviators be grounded for 48 h following Aviation Medical Examiner review. If review is unavailable, the aviator should be grounded for 1 wk to allow sufficient time to identify the existence of prolonged side effects, such as psychomimetic effects or cognitive changes.Boyd NL, Navathe PD. An update to aircrew grounding periods after ketamine use. Aerosp Med Hum Perform. 2021; 92(8):670-675.

Aircraft-Assisted Pilot Suicides in the General Aviation Increased for One-Year Period after 11 September 2001 Attack in the United States.

Pilot aircraft-assisted suicides (AAS) are rare, and there is limited understanding of copycat phenomenon among aviators. The aim of this study was to evaluate the possible effect the 11 September 2001, terrorist attacks had on pilot AASs in the U.S. Fatal aviation accidents in the National Transportation Safety Board (NTSB) database were searched using the following search words: "suicide", "murder-suicide" and "homicide-suicide". The timeline between 11 September 1996, and 11 September 2004, was analyzed. Only those accidents in which NTSB judged that the cause of the accident was suicide were included in the final analysis. The relative risk (RR) of the pilot AASs in all fatal accidents in the U.S. was calculated in order to compare the one, two, and three-year periods after the September 11 terrorist attacks with five years preceding the event. The RR of a fatal general aviation aircraft accident being due to pilot suicide was 3.68-fold (95% confidence interval 1.04⁻12.98) during the first year after 11 September 2001, but there was not a statistically significant increase in the later years. This study showed an association, albeit not determinate causal effect, of a very specific series of simultaneous terrorist murder-suicides with subsequent pilot AASs.

Copycats in Pilot Aircraft-Assisted Suicides after the Germanwings Incident.

Aircraft-assisted pilot suicide is a rare but serious phenomenon. The aim of this study was to evaluate changes in pilot aircraft-assisted suicide risks, i.e., a copycat effect, in the U.S. and Germany after the Germanwings 2015 incident in the French Alps. Aircraft-assisted pilot suicides were searched in the U.S. National Transportation Safety Board (NTSB) accident investigation database and in the German Bundestelle für Flugunfalluntersuchung (BFU) Reports of Investigation database five years before and two years after the deliberate crash of the Germanwings flight into the French Alps in 2015. The relative risk (RR) of the aircraft-assisted pilot suicides was calculated. Two years after the incident, three out of 454 (0.66%) fatal incidents were aircraft-assisted suicides compared with six out of 1292 (0.46%) in the prior five years in the NTSB database. There were no aircraft-assisted pilot suicides in the German database during the two years after or five years prior to the Germanwings crash. The relative aircraft-assisted pilot suicide risk for the U.S. was 1.4 (95% CI 0.3-4.2) which was not statistically significant. Six of the pilots who died by suicide had told someone of their suicidal intentions. We consider changes in the rate to be within a normal variation. Responsible media coverage of aircraft incidents is important due to the large amount of publicity that these events attract.

Attention-Deficit/Hyperactivity Disorder and Fatal Accidents in Aviation Medicine.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder with symptoms of inattention and/or hyperactivity-impulsivity that interfere with functioning and/or development. ADHD occurs in about 2.5% of adults. ADHD can be an excluding medical condition among pilots due to the risk of attentional degradation and therefore impact on flight safety. Diagnosis of ADHD is complex, which complicates aeromedical assessment. This study highlights fatal accident cases among pilots with ADHD and discusses protocols to detect its presence to help to assess its importance to flight safety. METHODS: To identify fatal accidents in aviation (including airplanes, helicopters, balloons, and gliders) in the United States between the years 2000 to 2015, the National Transportation Safety Board (NTSB) database was searched with the terms ADHD, attention deficit hyperactivity disorder, and attention deficit disorder (ADD). RESULTS: The NTSB database search for fatal aviation accidents possibly associated with ADHD yielded four accident cases of interest in the United States [4/4894 (0.08%)]. Two of the pilots had ADHD diagnosed by a doctor, one was reported by a family member, and one by a flight instructor. An additional five cases were identified searching for ADD [5/4894 (0.1%)]. Altogether, combined ADHD and ADD cases yielded nine accident cases of interest (0.18%). DISCUSSION: It is generally accepted by aviation regulatory authorities that ADHD is a disqualifying neurological condition. Yet FAA and CASA provide specific protocols for tailor-made pilot assessment. Accurate evaluation of ADHD is essential because of its potential negative impact on aviation safety.Laukkala T, Bor R, Budowle B, Sajantila A, Navathe P, Sainio M, Vuorio A. Attention-deficit/hyperactivity disorder and fatal accidents in aviation medicine. Aerosp Med Hum Perform. 2017; 88(9):871-875.

Bipolar Disorder in Aviation Medicine.

BACKGROUND: One of the most difficult challenges in aviation medicine is to diagnose, as early as possible, pilots with psychiatric disorders that may impair pilot performance and increase the risk of incidents and accidents. This diagnosis applies particularly to bipolar disorder (BD), where return to flying duty is not an option in the majority of cases. BD is a long-term mental disorder presenting remittent depressive, hypomanic, manic, or mixed episodes between low symptomatic or asymptomatic intermediate periods. Onset in most cases is in late teen or early adult years. Suicidal intentions and suicide risk are significantly elevated in individuals with BD compared to the general population. METHODS: A systematic literature search was performed of BD and aviation accidents and the National Transportation Safety Board database of fatal general aviation accidents was searched. One case report and two database reports of interest from 1994 to 2014 were identified. RESULTS: The findings set a minimum frequency of BD in general aviation fatalities to be approximately 2 out of 8648 (0.023%) in the United States. DISCUSSION: The reported incidence may underestimate the real number of BD cases for several reasons, including the fact that the medical history of pilots is not always available or is sometimes not the primary interest of a safety investigation. This study suggests that the demarcation of psychiatric disorder related to fitness to fly is an important step in safety.Vuorio A, Laukkala T, Navathe P, Budowle B, Bor R, Sajantila A. Bipolar disorder in aviation medicine. Aerosp Med Hum Perform. 2017; 88(1):42-47.

Identifying Pilots with Parkinson's Disease.

BACKGROUND: In 2012 the Australian Institute of Health and Welfare produced a report titled 'Dementia in Australia.'(2) The report noted that the number of people with dementia in Australia would reach almost 400,000 by 2020. Australia is a jurisdiction which does not impose a mandatory retirement age for pilots. With an aging population it was hypothesized that conditions such as Parkinson's disease (PD) were likely to be seen more commonly by the Civil Aviation Safety Authority (CASA). It was decided that this was an appropriate time to retrospectively study the data held by CASA. METHODS: An interrogation of CASA databases was undertaken. Data was produced comparing percentage of Class 1 certificate holders over 60 yr of age against time. A cohort of pilots and controllers with PD was identified. The history of the cases was reviewed. RESULTS: The study confirms that the pilot population is aging in line with population trends. Over a period from 1992 to 2012, 22 cases of pilots and controllers with PD were identified. DISCUSSION: The study confirmed that PD will be of increased relevance over the next decade. Gaps between policy and practice managing past cases were identified. Updated guidelines have been published aiming to address the deficiencies identified in the study. Historically pilots and controllers have been able to maintain certification for an average of 3.75 yr. This information should be of benefit to clinicians, pilots, and controllers when considering occupation and treatment options.

Aircraft-Assisted Pilot Suicides: Lessons to be Learned.

Aircraft assisted suicides were studied in the United States, United Kingdom, Germany, and Finland during 1956-2012 by means of literature search and accident case analysis. According to our study the frequency varied slightly between the studies. Overall, the new estimate of aircraft assisted suicides in the United States in a 20-yr period (1993-2012) is 0.33% (95% CI 0.21-0.49) (24/7244). In the detailed accident case analysis, it was found that in five out of the eight cases from the United States, someone knew of prior suicidal ideation before the aircraft assisted fatality. The caveats of standard medico-legal autopsy and accident investigation methods in investigation of suspected aircraft assisted suicides are discussed. It is suggested that a psychological autopsy should be performed in all such cases. Also the social context and possibilities of the prevention of aviation-related suicides were analyzed. In addition, some recent aircraft assisted suicides carried out using commercial aircraft during scheduled services and causing many casualties are discussed.

Aeromedical decision making: from principles to practice.

While there is literature which describes aeromedical decision making (ADM), there is not much which describes a process identifying the steps to be taken in arriving at such decisions. A five-step algorithm is proposed to clarify the ADM process. The five steps are: 1) determine the likelihood of a clinically significant event from the health condition; 2) determine the likelihood of an undesirable aviation event from the health condition; 3) determine the acceptability of the combined risks (#1 and #2); 4) determine the risk level after clinical intervention for the health condition; and 5) determine the risk level after operational restrictions for the health condition. There are several factors which can affect the various steps in the algorithm, such as uncertainty, difficulty in generalization, power and "fit" of the studies, etc. Notwithstanding these issues, the algorithm serves a useful purpose in providing a pathway for ADM.

Aeromedical certification of aircrew and controllers with renal calculi.

Acute renal colic is an incapacitating condition. Advances in understanding the pathogenesis of calculi and their detection and treatment require a new approach to aeromedical risk assessment. Can this new information support the stratification of aeromedical risk into "High" and "Low" categories, and fulfill the paramount responsibility of the Civil Aviation Safety Authority, Australia's aviation regulator, which isthe maintenance of aviation safety? This article reviews the epidemiology of calculi and finds 2-10% annual risk of a symptomatic event following incidental detection of a calculus. While calculi 4 mm or less in size may not require surgical intervention, this does not equate to a pain-free passage. Similarly, calculus recurrence rates may vary in different anatomical locations, but no location can be considered "safe." The recognition of parenchymal calcification and Randall's plaques as precursors to the development of calculi places such individuals at elevated risk of developing calculi. More recently evidence has supported a link between metabolic syndrome and calculus formation. In an occupational group where there is potential for elevated radiation exposure, appropriate imaging is of particular importance. CT, X-ray, and ultrasound modalities are reviewed with recommendations presented for aeromedical assessment and surveillance based on identification of those at high risk of colic and minimization of investigational radiation exposure.

Major depression and fitness to fly by different aviation authorities.

Safety issues are paramount in aviation and careful treatment protocols have been developed to ensure fitness to fly among aviators recovering from major depressive episodes (MDE). Aeromedical examiners (AMEs) do not necessarily treat depressive patients frequently, so they often consult psychiatrists; however, psychiatrists are rarely familiar with aviator treatment protocols. U.S., Canadian, and Australian regulations allow several choices among antidepressant drugs for flying pilots recovering from an MDE. Symptom stability times before the possible return to flying duties vary from 4 wk to 12 mo. So far European regulations have not allowed antidepressants, but the situation may change.

Aeromedical decision making in attention-deficit/hyperactivity disorder.

Attention-deficit/hyperactivity disorder is a problematic diagnosis in the context of aeromedical certification. Certain characteristics of the disorder such as impaired attention potentially affect the safe conduct of flying. Pharmacological treatment with stimulants also has issues surrounding short half-lives and effects on the recognition of fatigue. This article gives a broad overview of the issues involved and provides certification guidelines as adopted in the Australian Civil Aviation Safety Authority which may be helpful if adopted by other certification bodies.

Insulin-dependent diabetes and aeromedical certification - the Australian perspective.

Whether pilots with insulin-dependent diabetes should be allowed to fly has long been a controversial issue. Hypoglycaemia remains a significant threat to flight safety, and a barrier for pilots with insulin-dependent diabetes to overcome. Some countries allow recreational pilots to fly while treated with insulin under strict conditions. Recent changes in aeromedical certification in Australia will give pilots with diabetes more freedom to exercise the privileges of their licence, while adopting mechanisms to ensure the safety of air navigation.