Defining the Core Content for Transport Physician Training Programs.

In many parts of the world, emergency medical services (EMS) clinical care is traditionally delivered by different levels or types of EMS clinicians, such as emergency medical technicians and paramedics. In some areas, physicians are also included among the cadre of professionals administering EMS-based care. This is especially true in the interfacility transport (IFT) setting. Though there is significant overlap between the knowledge and skills necessary to safely and effectively provide care in the IFT and prehospital settings, the IFT care environment requires physicians to develop several additional competencies beyond those that are expected of traditional EMS clinicians. NAEMSP first published recommendations regarding what some of these competencies should be in 1983 and subsequently updated those recommendations in 2002. This document is an updated work, given the evolution of the field.

Direct Versus Video Laryngoscopy for Prehospital Intubation: A Systematic Review and Meta-analysis.

OBJECTIVES: The use of video laryngoscopy (VL) for intubation has gained recent popularity. In the prehospital setting, it is unclear if VL increases intubation success rates compared to direct laryngoscopy (DL). We sought to conduct a systematic review and meta-analysis of studies comparing VL to DL in the prehospital setting to determine whether the use of VL increases overall and first-pass endotracheal intubation success rates compared to DL. METHODS: A systematic search was performed of the PubMed, Embase, and SCOPUS databases through May 2016 to include studies comparing overall and first-pass success for VL versus DL in patients requiring intubation in the prehospital setting. Data were abstracted by two reviewers. A meta-analysis was performed using a random-effects model. RESULTS: Of a potential 472 articles, eight eligible studies were included. Considerable heterogeneity (I2  > 90%) precluded reporting an overall pooled estimate across all studies. When stratified by provider type, the pooled estimates for overall intubation success using VL versus DL were a risk ratio (RR) of 0.05 (95% confidence interval [CI] = 0.01-0.18) in studies of physicians and RR = 2.28 (95% CI = 1.00-5.20) in nonphysicians. For first-pass intubation success the pooled RR estimates for using VL versus DL were 0.32 (95% CI = 0.23-0.44) and 1.83 (95% CI = 1.18-2.84) among studies using physicians and nonphysicians, respectively. There was moderate to significant heterogeneity between studies when stratified by provider. CONCLUSIONS: Among physician intubators with significant DL experience, VL does not increase overall or first-pass success rates and may lead to worsening performance. However, among nonphysician intubators with less experience with DL, VL may provide benefit in the prehospital setting.

Chest Pain of Suspected Cardiac Origin: Current Evidence-based Recommendations for Prehospital Care.

INTRODUCTION: In the United States, emergency medical services (EMS) protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of chest pain of suspected cardiac origin and to compare these recommendations against the current protocols used by the 33 EMS agencies in the state of California. METHODS: We performed a literature review of the current evidence in the prehospital treatment of chest pain and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the chest pain protocols of each of the 33 EMS agencies for consistency with these recommendations. The specific protocol components that we analyzed were use of supplemental oxygen, aspirin, nitrates, opiates, 12-lead electrocardiogram (ECG), ST segment elevation myocardial infarction (STEMI) regionalization systems, prehospital fibrinolysis and ß-blockers. RESULTS: The protocols varied widely in terms of medication and dosing choices, as well as listed contraindications to treatments. Every agency uses oxygen with 54% recommending titrated dosing. All agencies use aspirin (64% recommending 325 mg, 24% recommending 162 mg and 15% recommending either), as well as nitroglycerin and opiates (58% choosing morphine). Prehospital 12-Lead ECGs are used in 97% of agencies, and all but one agency has some form of regionalized care for their STEMI patients. No agency is currently employing prehospital fibrinolysis or ß-blocker use. CONCLUSION: Protocols for chest pain of suspected cardiac origin vary widely across California. The evidence-based recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols.

Association of a nonsynonymous single-nucleotide polymorphism of matrix metalloproteinase 9 with giant cell arteritis.

OBJECTIVE: Giant cell arteritis (GCA) is the most common type of primary vasculitis. Matrix metalloproteinase 9 (MMP-9) is present in arterial lesions of GCA and may be involved in its pathogenesis. We investigated whether certain genotypes of 4 single-nucleotide polymorphisms (SNPs) of MMP-9 are overrepresented in patients with histologically confirmed GCA. METHODS: Four SNPs of MMP-9, rs3918242 in the promoter region and 3 nonsynonymous coding SNPs (rs3918252, rs17576, and rs2250889) were genotyped by polymerase chain reaction-restriction fragment length polymorphism analysis in 58 white patients for whom there was a clinical suspicion of GCA. Thirty of these patients had histologically confirmed GCA (group 1), and 28 patients had negative results of a temporal artery biopsy for GCA (group 2). Estimates of the genotype distributions of each of these SNPs in a white population were determined using publicly available genotype data for a panel of 23 individuals (group 3). RESULTS: Although 1 SNP was monomorphic in all 3 groups, we observed statistically significant differences in the genotype distributions for rs2250889 between group 1 and group 2 (P = 0.005) and between group 1 and group 3 (P = 0.009), but not between groups 2 and 3 (P = 0.965). CONCLUSION: These data derived from a sample of patients with GCA suggest that the G allele of MMP-9 polymorphism rs2250889 is overrepresented in patients with histologically confirmed GCA. Clearly, larger sample sizes will be necessary to confirm this suggestive association and better characterize a possible linkage disequilibrium structure among polymorphisms.

Multifocal ERG in ethambutol associated visual loss.

AIM: To determine the anatomical site and extent of electrophysiological dysfunction in patients with ethambutol associated visual loss. METHODS: A comparative case series. Four patients with ethambutol associated visual loss underwent multifocal electroretinography (mERG). Two patients had advanced visual loss while two had early signs of toxicity. The N1-P1, N1, P1 amplitudes, N1, and P1 latencies were compared to 10 age and sex matched controls. RESULTS: mERG abnormalities were detected in the ethambutol treated patients. The N1 amplitude was significantly lower in the ethambutol treated patients than in the control group. CONCLUSION: Ethambutol is possibly toxic to the retina, and not only the optic nerve. The multifocal ERG may be of value to diagnose and monitor patients taking ethambutol.

Fractionated stereotactic radiotherapy for parasellar meningiomas: a preliminary report of visual outcomes.

BACKGROUND/AIM: Fractionated stereotactic radiotherapy (FSRT) is a new treatment for brain tumours that are close to critical structures, such as the visual apparatus. This study aims to assess the visual outcomes for patients with parasellar meningioma following FSRT. METHODS: A retrospective, non-comparative case series of 13 patients with parasellar meningiomas who were treated in one institution with FSRT between January 1995 and January 2001. RESULTS: 13 patients (26 eyes) were followed for a mean of 2 years. Visual acuity improved in four eyes (12.5%), remained stable in 18 eyes (75%), and worsened in three eyes (12.5%). Visual field improved in 15 eyes (57%), remained stable in six eyes (23%), and worsened in four eyes (15%). No adverse visual outcome occurred as a result of radiation. CONCLUSION: These preliminary findings suggest that FSRT is a safe and effective treatment for parasellar meningiomas.

Amiodarone induced optic neuropathy.

AIM: To determine the clinical features of amiodarone induced optic neuropathy, which may help distinguish it from non-arteritic anterior ischaemic optic neuropathy. METHODS: Retrospective observational case series of patients diagnosed with amiodarone induced optic neuropathy at the neuro-ophthalmology service from March 1998 to February 2001. Amiodarone was discontinued after discussion with the patient's cardiologist. Visual acuity, colour vision, automated perimetry, and funduscopy were performed on initial and follow up examinations. RESULTS: Three patients with amiodarone induced optic neuropathy presented with mildly decreased vision, visual field defects, and bilateral optic disc swelling. Upon discontinuing the medication, visual function and optic disc swelling slowly improved in all three patients. CONCLUSION: Amiodarone induced optic neuropathy can present with visual dysfunction, and is typically a bilateral process. Upon discontinuation of amiodarone, slow resolution of optic disc swelling occurs and visual function improves in some patients.

Image-guided transorbital roof craniotomy via a suprabrow approach: a surgical series of 72 patients.

OBJECTIVE: Many subfrontal and orbitofrontal craniotomy techniques have been developed. We present our results with the transorbital roof craniotomy, a frontal craniotomy that incorporates the orbital roof and is performed via a suprabrow incision. This technique was used in 72 patients, primarily for tumor resection. METHODS: Charts were retrospectively reviewed for all patients undergoing transorbital procedures. A total of 72 patients underwent 82 transorbital craniotomies from September 1995 to July 1999. The primary indication for the transorbital approach was mass lesion of the orbit, anterior fossa, or parasellar region. RESULTS: A total of 47 women and 25 men with a mean age of 53 years underwent 82 procedures. The primary pathological finding was meningioma, which occurred in 40 patients (55.6%), followed by craniopharyngioma (6.9%), pituitary macroadenoma (6.9%), schwannoma (5.5%), and hemangioma (5.5%). Simpson Grade I or II resection was achieved in 54% of patients, with Simpson Grade III to V resection achieved in the remaining 46%. Forty-one patients presented with visual loss in 43 cases, with 44.2% experiencing postoperative visual improvement, 46.5% remaining unchanged, and 9.3% worsening. Overall morbidity was 18.4%, with cerebrospinal fluid leak being the most common complication (6.6%). No patients died. CONCLUSION: The transorbital roof craniotomy is an evolutionary approach that provides excellent exposure to the orbit, anterior fossa, and parasellar region with little significant morbidity and, in our series, no mortality. Although we have used this approach primarily for resection of mass lesions, future directions for this procedure will likely lie in treating vascular lesions and lesions of the interpeduncular fossa.

The prevalence of cupping in end-stage arteritic and nonarteritic anterior ischemic optic neuropathy.

OBJECTIVE: To evaluate the prevalence of cupping in arteritic anterior ischemic optic neuropathy (AAION) and nonarteritic anterior ischemic optic neuropathy (NAION). DESIGN: Retrospective, observational case series. PARTICIPANTS: Three hundred one patients. METHODS: Review of clinical records and color fundus photographs. MAIN OUTCOME MEASURES: Photographic and clinical interpretation of optic nerve appearance. RESULTS: Ninety-two patients with AAION and 102 with NAION were included in the study. Disc photographs of 42 patients (48%) with AAION and 32 patients (31%) with NAION were available for reassessment. These were presented in a masked fashion along with a random sample of 27 disc pairs considered to be 'normal' and 27 disc pairs with 'established glaucoma' according to two examiners. Cupping was present in 92% of eyes with AAION secondary to giant cell arteritis and in 2% of eyes with NAION (kappa = 0.96; P < 0.001). CONCLUSIONS: The end-stage optic disc appearance in AAION secondary to giant cell arteritis is cupping, whereas segmental or diffuse pallor without cupping is the typical disc appearance after NAION.

Intraocular pressure changes after treatment for Graves' orbitopathy.

OBJECTIVE: To evaluate the change in intraocular pressure (IOP) in subjects with Graves' orbitopathy (GO) after orbital decompression, strabismus surgery, and orbital radiation. DESIGN: Retrospective case review. METHODS: The charts of 172 consecutive subjects from the Neuro-ophthalmology Service at Wills Eye Hospital (Philadelphia, PA) with GO who underwent either orbital decompression, strabismus surgery, or orbital radiation between 1994 and 1999 were analyzed. Subject age, gender, diagnosis of glaucoma in either eye, use of systemic steroids or topical glaucoma medications, procedure performed, and the preoperative and postoperative IOP (in primary position and upgaze) were evaluated. RESULTS: Of 116 eyes that underwent orbital decompression, the mean preoperative IOP was 21.6+/-4.6 mmHg (standard deviation) in primary position and 27.9+/-6.8 mmHg in upgaze. The postoperative IOP was 17.5 mmHg +/- 3.0 mmHg in primary position and 20.1+/-4.7 mmHg in upgaze, a decrease in IOP of 18.9% in primary position and 27.9% in upgaze (P<0.001). Subjects taking glaucoma medication or who had IOP greater than 21 mmHg demonstrated a significantly (P<0.001) greater reduction in IOP postoperatively. The mean preoperative IOP in the 32 subjects who had strabismus surgery was 18.5+/-2.8 mmHg (primary position), and 24.7+/-4.3 mmHg (upgaze). Postoperative IOP was 16.1 mmHg (primary position) and 16.9 mmHg (upgaze), a decrease of 2.4 mmHg (13.3%, P<0.01 in primary position) and 7.8 mmHg (31.2%, P<0.01 in upgaze). There was no statistically significant reduction in IOP after orbital radiation. CONCLUSIONS: In the selected subgroup of subjects with GO who required intervention, orbital decompression and strabismus surgery resulted in a significant reduction in IOP in the early postoperative period, especially in subjects with preoperative IOP greater than 21 mmHg.