Skin Pathology Prevalence in Deployed Fighter Aircrew Using Custom Molded Hearing Protection

INTRODUCTION: During a deployment of a fighter unit, aircrew began to exhibit ear discomfort and episodes of auricular irritation and ulceration. All affected were using the Attenuating Custom Communications Earpiece System (ACCES). Discomfort was previously discussed in the literature, but neither the prevalence of discomfort nor the occurrence of skin ulcerations had been previously described.METHODS: An anonymous paper questionnaire was used with three fighter squadrons while deployed in 2019. A total of 59 aircrew in the F-15C/E and F-16 airframes participated; aircrew not using ACCES were excluded.RESULTS: Response rate was 57.3%, spread evenly among airframes, with 78% being pilots. A majority of respondents (79.7%) stated they had ACCES problems in the deployed setting. Among those noting problems in the deployed setting, 89% reported ear discomfort and a smaller portion reported skin redness, erosion, and bleeding.DISCUSSION: This study was able to provide a small sample estimate of the prevalence of ear problems among fighter aircrew ACCES users while deployed. This sample exhibited an increase in prevalence of ear discomfort during the deployment. It also showed pathological features absent in home-station flying, such as skin redness and erosion. However, the sample size and study design prevented risk factor characterization, confounder control, or causal inference. While ACCES may contribute to these problems, other confounders such as air characteristics, recall bias, aircrew motivation to report problems, and baseline dermatologic pathology could not be excluded. This data should serve as a baseline for larger studies, which are better equipped for confounder control and assessment of other potential risk factors.Strawbridge PA, Steinkraus LW, Girsch RM. Skin pathology prevalence in deployed fighter aircrew using custom molded hearing protection. Aerosp Med Hum Perform. 2023; 94(5):396-399.

Professionalism and inter-communication skills (ICS): a multi-site validity study assessing proficiency in core competencies and milestones in medical learners

BACKGROUND

Interpersonal and Communication Skills (ICS) and Professionalism milestones are challenging to evaluate during medical training. Paucity in proficiency, direction and validity evidence of assessment tools of these milestones warrants further research. We validated the reliability of the previously-piloted Instrument for Communication skills and Professionalism Assessment (InCoPrA) in medical learners.

METHODS

This validity approach was guided by the rigorous Kane's Framework. Faculty-raters and standardized patients (SPs) used their respective InCoPrA sub-component to assess distinctive domains pertinent to ICS and Professionalism through multiple expert-built simulated-scenarios comparable to usual care. Evaluations included; inter-rater reliability of the faculty total score; the correlation between the total score by the SPs; and the average of the total score by two-faculty members. Participants were surveyed regarding acceptability, realism, and applicability of this experience.

RESULTS

Eighty trainees and 25 faculty-raters from five medical residency training sites participated. ICC of the total score between faculty-raters was generally moderate (ICC range 0.44-0.58). There was on average a moderate linear relationship between the SPs and faculty total scores (Pearson correlations range 0.23-0.44). Majority of participants ascertained receiving a meaningful, immediate, and comprehensive patient-faculty feedback.

CONCLUSIONS

This work substantiated that InCoPrA was a reliable, standardized, evidence-based, and user-friendly assessment tool for ICS and Professionalism milestones. Validating InCoPrA showed generally-moderate agreeability and high acceptability. Using InCoPrA also promoted engaging all stakeholders in medical education and training-faculty, learners, and SPs-using simulation-media as pathway for comprehensive feedback of milestones growth.

A Retrospective Cohort Analysis of Battle Injury Versus Disease, Non-Battle Injury-Two Validating Flight Surgeons' Experience

Today, military combat medical care is the best it has ever been. Regulated U.S. Air Force aeromedical evacuation (AE) is one important reason. The Theater Validating Flight Surgeon (TVFS) validates that a patient is ready for flight. Two TVFSs' experiences, successively deployed in 2007, are the focus of this study. A unique operational worksheet used to manage the AE queue was used for approximately 5 months. A descriptive analysis of the worksheet's 1,389 patients found the majority male (94%), median age 30 years, and mostly Army enlisted soldiers (63%). U.S. civilians made up 9%. Battle Injury (55%) surpassed Disease, Non-Battle Injury (45%); most frequently seen were extremity injuries (73%) and cardiac illness (31%), respectively. Common to both Battle Injury and Disease, Nonbattle Injury were several TVFS prescriptions including no "remain overnights" (79%), head of bed elevation (78%), cabin altitude restriction (57%), no stops (44%), Critical Care Air Transport Team (27%), and supplemental oxygen (22%). This study is a first look at the TVFS experience and it offers up an initial accounting of the TVFS clinical and prescriptive practices. It is also a jumping point for future TVFS investigations using the available AE databases.

Proficiency in identifying, managing and communicating medical errors: feasibility and validity study assessing two core competencies

BACKGROUND

Communication skills and professionalism are two competencies in graduate medical education that are challenging to evaluate. We aimed to develop, test and validate a de novo instrument to evaluate these two competencies.

METHODS

Using an Objective Standardized Clinical Examination (OSCE) based on a medication error scenario, we developed an assessment instrument that focuses on distinctive domains [context of discussion, communication and detection of error, management of error, empathy, use of electronic medical record (EMR) and electronic medical information resources (EMIR), and global rating]. The aim was to test feasibility, acceptability, and reliability of the method.

RESULTS

Faculty and standardized patients (SPs) evaluated 56 trainees using the instrument. The inter-rater reliability of agreement between faculty was substantial (Fleiss k = 0.71) and intraclass correlation efficient was excellent (ICC = 0.80). The measured agreement between faculty and SPs evaluation of resident was lower (Fleiss k = 0.36). The instrument showed good conformity (ICC = 0.74). The majority of the trainees (75 %) had satisfactory or higher performance in all six assessed domains and 86 % found the OSCE to be realistic. Sixty percent reported not receiving feedback on EMR use and asked for subsequent training.

CONCLUSION

An OSCE-based instrument using a medical error scenario can be used to assess competency in professionalism, communication, using EMRs and managing medical errors.

Prostate Cancer in Pilots

BACKGROUND

Aviation exposes pilots to various occupationally related hazards, including ionizing radiation and chemical combustion. The possibility of increased prostate cancer incidence and mortality among pilots is a subject of debate. This systematic review and meta-analysis aims to summarize the supporting evidence and determine the magnitude of association.

METHODS

All studies reporting prostate cancer incidence and mortality in pilots compared to the general population were included regardless of language or size. The comprehensive search included multiple databases and manual search. A random effect model was used to pool relative risks (RR) across studies.

RESULTS

The final search yielded nine studies with good methodological quality. Four studies reported the incidence of prostate cancer while six reported on mortality. Pilots had a small but statistically significant increase in the risk of developing prostate cancer [RR 1.20; 95% confidence interval (CI), 1.08-1.33], but not in prostate cancer mortality (RR 1.20; 95% CI, 0.91-1.60).

CONCLUSION

Pilots appear to have a very small increase in prostate cancer incidence, but not in mortality. The clinical significance of this finding is uncertain.

Complication Rates in Altitude Restricted Patients Following Aeromedical Evacuation

INTRODUCTION

Military aeromedical evacuation, especially that associated with the present Middle East conflict, is seeing increasing research. This ecological study initiates research into the validating flight surgeon by looking at cabin altitude restriction (CAR), arguably the validating flight surgeon's prescription with the highest patient-mission impact, and its association with postflight complications.

METHODS

CAR rates from January 2006 through February 2008 were determined from the U.S. Transportation Command Regulating and Command and Control Evacuation System database. Postflight complication rates-the rate of patients with postflight complications (PFC) and the postflight complications per 100 patients (PFC-100)-from January 2007 through June 2008 were calculated from the Landstuhl Regional Medical Center trauma database. CAR and complication rates were examined before, during, and after the authors' deployment. In addition, the relationship between CAR and postflight complication rates was investigated; as the rates were nonlinear, a Spearman correlation was performed.

RESULTS

CAR rates during the authors' deployments were significantly up compared to the authors' predecessors or successors; their predecessors and successors did not differ statistically. Likewise, the PFC rate during the authors' deployments was significantly lower than that of the before or after time frames. Furthermore, a statistically significant inverse relationship between CAR and PFC rates (Spearman rho = -0.587) as well as CAR and PFC-100 rates (Spearman rho = -0.568) was demonstrated.

DISCUSSION

CAR rate was inversely correlated to PFC and PFC-100 rates. This finding suggests that aggressive prescribing of CARs may have a salutary effect on postflight complication rates and bears further investigation.

The incidence of hypoglycemia during HBO2 therapy: A retrospective review

BACKGROUND

Hypoglycemia is concerning in patients with diabetes undergoing hyperbaric oxygen (HBO2) therapy. We aimed to estimate the incidence, risk factors and a pretreatment glucose threshold of HBO2-associated hypoglycemia.

METHODS

We retrospectively evaluated a patient cohort undergoing HBO2 therapy. We calculated the area under the curve (AUC) and odds ratio (OR) with 95% confidence interval (CI) adjusting for patients' age, gender, diabetes type, insulin use, body mass index, hemoglobin A1c and HBO2 treatment time.

RESULTS

During 77 months, 3,136 HBO2 sessions were performed on patients with diabetes. In-chamber glucose was higher than pre-HBO2 glucose in 1,708/3,136 sessions (54%). The incidence of hypoglycemia (defined as ≤ 70 mg/dL) during or immediately after HBO2 treatment was 1.5% (0.8-2.1%). Hypoglycemia that was symptomatic or severe was rare. A glucose value pre-HBO2 of 150 mg/dL best predicted the risk of subsequent hypoglycemia (AUC 0.80; 95% CI, 0.75-0.86). Type 1 diabetes was independently associated with increased risk of hypoglycemia (OR 3.69; 95% CI, 1.67, 8.19) whereas insulin use was not.

CONCLUSIONS

In patients with diabetes undergoing HBO2, severe hypoglycemia is rare and occurs more frequently in Type 1 diabetes. Pre-HBO2 glucose values may be used to predict subsequent hypoglycemia and reduce the need for routine glucose monitoring during and after HBO2.

Real-time effects of normobaric, transient near-anoxia on performance

INTRODUCTION

Recent physiological incidents involving pilots of high performance fighter aircraft have raised the question of whether inadvertent, short bursts of significantly reduced oxygen could negatively impact real-time performance. This study evaluated normobaric, real-time performance in the setting of transient near-anoxia to inform future countermeasure development.

METHODS

The study was performed on 12 healthy subjects without significant medical history. Following collection of baseline data, real-time performance changes were evaluated during sequentially increasing periods of near-anoxic gas exposure (F(I)0(2) = 1%) using a computer-based performance assessment tool. Both room air and 100% oxygen were used as the prebreathe/recovery gases. Statistical analysis was performed on the results.

RESULTS

Under normobaric conditions, subjects inspiring up to five near-anoxic breaths showed no significant performance decrement in either accuracy or effective actions per minute. Mean accuracy up to five near-anoxic breaths was 0.67 (SD = 0.01) as compared to a baseline mean of 0.68 (SD = 0.02). Hyperoxia had a protective effect on subject physiological response to near anoxia.

DISCUSSION

These normobaric findings offer an assessment of real-time performance changes in the setting of transient, near-anoxic gas exposure. Overall, the results help inform the design of increasingly complex aircraft oxygen delivery systems in terms of how tightly such systems must match the sea-level gas equivalent with increasing altitude. This is particularly relevant as such systems are being called upon to ensure safe aircrew operations across an expanding operational flight envelope.

The risk of prostate cancer in pilots: a meta-analysis

BACKGROUND

Aviation exposes pilots to various occupationally related hazards, including ionizing radiation and chemical combustion. The possible increased risk of prostate cancer among pilots in comparison to the general population is a subject of debate. This systematic review and meta-analysis aimed to determine the quality of supporting evidence and magnitude of this association.

METHODS

All studies pertaining to prostate cancer in pilots were retrieved from multiple databases and from a manual search. Any study that assessed the incidence of prostate cancer relative to the incidence in the general population was included regardless of language or size. A random effect model was used to pool relative risks (RR) across studies. Heterogeneity was assessed using the Q statistic and I².

RESULTS

Eight studies with a low risk of bias were included in the meta-analysis. Pilots had an increased risk of developing prostate cancer compared to the general population [RR 2.0; 95% confidence interval (CI), 1.5-2.7]. The analysis was associated with substantial heterogeneity (I² = 79%). Several subgroups had significantly increased risk, such as African American pilots (RR 10.00; 95% CI, 5.04-19.86) and military pilots (RR 3.30; 95% CI, 2.03-5.39).

CONCLUSION

Pilots are at least twice as likely to develop prostate cancer compared to the general population. The implications of these findings are important considering the high prevalence of prostate cancer and the large number of pilots in the workforce.

Health assessment of commercial drivers: a meta-narrative systematic review

BACKGROUND

Motor vehicle accidents associated with commercial driving are an important cause of occupational death and impact public safety.

OBJECTIVES

We summarise the evidence regarding the type, prevalence and impact of medical conditions discovered during health assessment of commercial drivers.

EVIDENCE REVIEW

We conducted a systematic review of multiple electronic databases and made a manual search for relevant studies that enrolled commercial drivers in any country and reported the outcomes of health assessment carried out in the context of commercial driving through November 2012. Data were extracted by a pair of independent reviewers and synthesised using a metanarrative approach.

RESULTS

We identified 32 studies of moderate methodological quality enrolling 151 644 commercial drivers (98% men). The prevalence of multiple health conditions was high (sleep disorders 19%, diabetes 33%, hypertension 23% and obesity 45%). Some conditions, such as sleep disorders and obesity, were linked to increased risk of crashes. Evidence on several other highly relevant medical conditions was lacking. Cost-effectiveness data were sparse.

CONCLUSIONS

Several medical conditions are highly prevalent in commercial drivers and can be associated with increased risk of crashes, thus providing a rationale for health assessment of commercial drivers.

Aeromedical decision making--it may be time for a paradigm change

Recent events in the U-2 and F-22 fleets have challenged aeromedical experts, highlighting the need for better in-flight aircrew physiologic and cognitive monitoring capability. Existing aerospace medicine risk assessment tools, while necessary, are no longer sufficient to affect positive safety changes given the evolving nature of the aerospace environment. Cognition and its sub-elements are now primary measures for the "Fit to Fly" decision. We must investigate practical methodologies for determining dynamic aircrew physiologic and cognitive function preflight (selection, retention) and in-flight (selection, retention, performance enhancement). In 2010, a panel of aeromedical experts met to address current paradigms and suggest possible solutions. This commentary briefly summarizes panel findings and recommendations.

Diabetes mellitus type 2 in aviators: a preventable disease

INTRODUCTION

The current epidemic of obesity and resultant diabetes mellitus type 2 (DMT2) is a tsunami that will impact healthcare worldwide and lap over into aerospace medicine. Metabolic syndrome (MBS) is the major link between obesity and DMT2.

METHODS

A review of U.S. Air Force Aeromedical Consult Service (ACS) records was accomplished looking at aviators with a diagnosis of DMT2. Case reports of three flyers with DMT2 are presented and discussed. Other aeromedical agencies were contacted regarding their experiences and this information was summarized. A literature review on DMT2, obesity, and metabolic syndrome was accomplished.

RESULTS

Of 70 charts for flyers identified with diabetes mellitus at the ACS between 1975 and 2000, over 95% were for DMT2. The mean body mass index for these aviators was 26.2. Currently, all services grant restricted waivers for some aviators with DMT2, none in high performance, single-seat aircraft. The FAA is currently allowing most flyers with stable DMT2 to operate aircraft in all categories with specific restrictions.

DISCUSSION

Obesity and metabolic syndrome are becoming increasingly prevalent in the aviation community. Aggressive actions to limit weight gain and identify those at risk for developing DMT2 must be considered for all populations.

Primary osteopenia in a female military flight crewmember

This report describes a case of primary severe osteopenia in a 35-yr-old female crewmember of a USAF transport aircraft. This previously healthy individual presented with musculoskeletal symptoms that led to the incidental finding of severe osteopenia on plain films of the pelvis. The subsequent evaluation, including dual energy X-ray absorptiometry (DEXA) showed a T-score of 1-2 SD below sex-adjusted expected levels for age. Work-up revealed no secondary causes and the patient was placed on alendronate sodium, vitamin D, and calcium supplementation. Within 2 yr, her bone studies were normal. The crewmember was returned to normal flight status and has had no aeromedical problems. Osteopenia and osteoporosis represent points on a continuum of bone disease. Recognizing and addressing risk factors for osteoporosis earlier may reduce the chances for fractures later in life. Aeromedical specialists must be cognizant of the increased risk for bone disease in female crewmembers.