Evidence-Based Guidelines for Prehospital Airway Management: Methods and Resources Document.

INTRODUCTION: Emergency airway management is a common and critical task EMS clinicians perform in the prehospital setting. A new set of evidence-based guidelines (EBG) was developed to assist in prehospital airway management decision-making. We aim to describe the methods used to develop these EBGs. METHODS: The EBG development process leveraged the four key questions from a prior systematic review conducted by the Agency for Healthcare Research and Quality (AHRQ) to develop 22 different population, intervention, comparison, and outcome (PICO) questions. Evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework and tabulated into the summary of findings tables. The technical expert panel then used a rigorous systematic method to generate evidence to decision tables, including leveraging the PanelVoice function of GRADEpro. This process involved a review of the summary of findings tables, asynchronous member judging, and online facilitated panel discussions to generate final consensus-based recommendations. RESULTS: The panel completed the described work product from September 2022 to April 2023. A total of 17 summary of findings tables and 16 evidence to decision tables were generated through this process. For these recommendations, the overall certainty in evidence was "very low" or "low," data for decisions on cost-effectiveness and equity were lacking, and feasibility was rated well across all categories. Based on the evidence, 16 "conditional recommendations" were made, with six PICO questions lacking sufficient evidence to generate recommendations. CONCLUSION: The EBGs for prehospital airway management were developed by leveraging validated techniques, including the GRADE methodology and a rigorous systematic approach to consensus building to identify treatment recommendations. This process allowed the mitigation of many virtual and electronic communication confounders while managing several PICO questions to be evaluated consistently. Recognizing the increased need for rigorous evidence evaluation and recommendation development, this approach allows for transparency in the development processes and may inform future guideline development.

Evidence-Based Guidelines for Prehospital Pain Management: Recommendations.

This project sought to develop evidence-based guidelines for the administration of analgesics for moderate to severe pain by Emergency Medical Services (EMS) clinicians based on a separate, previously published, systematic review of the comparative effectiveness of analgesics in the prehospital setting prepared by the University of Connecticut Evidence-Based Practice Center for the Agency for Healthcare Research and Quality (AHRQ). A technical expert panel (TEP) was assembled consisting of subject matter experts in prehospital and emergency care, and the development of evidence-based guidelines and patient care guidelines. A series of nine "patient/population-intervention-comparison-outcome" (PICO) questions were developed based on the Key Questions identified in the AHRQ systematic review, and an additional PICO question was developed to specifically address analgesia in pediatric patients. The panel made a strong recommendation for the use of intranasal fentanyl over intravenous (IV) opioids for pediatric patients without intravenous access given the supporting evidence, its effectiveness, ease of administration, and acceptance by patients and providers. The panel made a conditional recommendation for the use of IV non-steroidal anti-inflammatory drugs (NSAIDs) over IV acetaminophen (APAP). The panel made conditional recommendations for the use of either IV ketamine or IV opioids; for either IV NSAIDs or IV opioids; for either IV fentanyl or IV morphine; and for either IV ketamine or IV NSAIDs. A conditional recommendation was made for IV APAP over IV opioids. The panel made a conditional recommendation against the use of weight-based IV ketamine in combination with weight-based IV opioids versus weight-based IV opioids alone. The panel considered the use of oral analgesics and a conditional recommendation was made for either oral APAP or oral NSAIDs when the oral route of administration was preferred. Given the lack of a supporting evidence base, the panel was unable to make recommendations for the use of nitrous oxide versus IV opioids, or for IV ketamine in combination with IV opioids versus IV ketamine alone. Taken together, the recommendations emphasize that EMS medical directors and EMS clinicians have a variety of effective options for the management of moderate to severe pain in addition to opioids when designing patient care guidelines and caring for patients suffering from acute pain.

Evidence-Based Guidelines for Prehospital Pain Management: Literature and Methods.

INTRODUCTION: Emergency Medical Services (EMS) clinicians commonly encounter patients with acute pain. A new set of evidence-based guidelines (EBG) was developed to assist in the prehospital management of pain. Our objective was to describe the methods used to develop these evidence-based guidelines for prehospital pain management. METHODS: The EBG development process was supported by a previous systematic review conducted by the Agency for Healthcare Research and Quality (AHRQ) covering nine different population, intervention, comparison, and outcome (PICO) questions. A technical expert panel (TEP) was formed and added an additional pediatric-specific PICO question. Identified evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework and tabulated into Summary of Findings tables. The TEP then utilized a rigorous systematic method, including the PanelVoice function, for recommendation development which was applied to generate Evidence to Decision Tables (EtD). This process involved review of the Summary of Findings tables, asynchronous member judging, and facilitated panel discussion to generate final consensus-based recommendations. RESULTS: The work product described above was completed by the TEP panel from September 2020 to April 2021. For these recommendations, the overall certainty of evidence was very low or low, data for decisions on cost effectiveness and equity were lacking, and feasibility was rated well across all categories. Based on the evidence, one strong and seven conditional recommendations were made, with two PICO questions lacking sufficient evidence to generate a recommendation. CONCLUSION: We describe a protocol that leveraged established EBG development techniques, the GRADE framework in conjunction with a previous AHRQ systematic review to develop treatment recommendations for prehospital pain management. This process allowed for mitigation of many confounders due to the use of virtual and electronic communication. Our approach may inform future guideline development and increase transparency in the prehospital recommendations development processes.

Evidence of association between sleep quality and APOE ε4 in healthy older adults: A pilot study.

BACKGROUND: It has been estimated that the prevalence of Alzheimer disease (AD) and related dementias will triple by 2035, unless effective interventions or treatments are found for the neurodegenerative disease. Understanding sleep changes as a marker for both AD risk and progression is a burgeoning area of investigation. Specifically, there is emerging evidence that both sleep disturbances and the APOE ε4 allele are associated with increased dementia risk. Previous research has suggested that in AD, individuals carrying the APOE ε4 allele have decreased sleep quality compared to individuals without the APOE ε4 allele. This observational trial aimed to determine if healthy older adults with the risk allele (APOE ε4+) have more sleep complaints or evidence of objective sleep disruption compared to healthy older adults without the risk allele (APOE ε4-). METHODS: Within the larger Brain in Motion study, a subset of participants completed at-home polysomnography (PSG) and actigraphy sleep assessment. Subjective sleep complaints were determined using the Pittsburgh Sleep Quality Index. RESULTS: This investigation found a significant relationship between presence of APOE ε4 allele and objective sleep disturbances measured by both actigraphy and PSG, but not subjective sleep complaints in a healthy population screened for dementia. CONCLUSIONS: These data suggest that the influence of APOE ε4 allele on objective sleep quality may precede subjective sleep complaints in individuals at increased risk for dementia.