INTRODUCTION: Decompression sickness (DCS) can occur during unpressurized flight to altitudes >18,000 ft (FL180; 5486 m). To our knowledge, this has not been studied in general aviation (GA). This knowledge gap may have public health and safety implications because the most popular models of GA aircraft by sales volume are capable of flying >FL180.METHODS: Data from a 1-yr period in a commercial flight tracking database were analyzed to identify flights >FL180 in unpressurized, piston aircraft in the United States. Peak altitude and duration at that altitude were used to calculate DCS risk employing the U.S. Air Force (USAF) Altitude Decompression Sickness Risk Assessment Computer (ADRAC). Registration numbers were cross referenced in publicly available federal databases to identify any events that might be attributable to impairment due to DCS. A web-based survey of practices and associated symptoms was also made available to GA pilots through an online discussion forum.RESULTS: During the data collection period, 1696 flights occurred. The DCS risk was calculated to be 1.9 4.2%. There were 42 responses to the survey. Of these, 25 (59.5%) pilots reported having flown at altitudes >FL180 and 21 (84%) of them reported symptoms possibly attributable to DCS. None sought medical attention. No safety events were identified for any of the aircraft during the study period.CONCLUSION: The risk of DCS in the GA community is not zero. As GA aircraft performance profiles advance and sales increase, this may have significant implications from a public health and safety perspective. Further study is warranted.Harrison MF, Butler WP, Murad MH, Toups GN. Decompression sickness risk assessment and awareness in general aviation. Aerosp Med Hum Perform. 2021; 92(3):138145.

INTRODUCTION: Incidental findings in brain and spine MRI are common. In aerospace medicine, pilot selection may be affected by improved sensitivity of modern MRI devices. We investigated the occurrence of medically unfit rates caused by incidental findings in military pilot applicants using a 3-Tesla scanner as compared to the outcomes of a lower field strength 1-Tesla device based on similar screening protocols.METHODS: A total of 3315 military pilot applicants were assessed by a standardized German Air Force Imaging Screening Protocol and retrospectively subdivided into two cohorts, one of which was assessed by 1-Tesla MRI (2012-2015; N 1782), while in the second cohort (2016-2019; N 1808), a 3-Tesla MRI was used. Cohorts were statistically analyzed relating to three entities of incidental findings: 1) intervertebral disc displacements, 2) intracerebral vessel malformations, and 3) other abnormal findings in the brain.RESULTS: Pooled prevalences of incidental findings in medically unfit applicants significantly increased by use of 3-Tesla MRI as compared to lower resolution 1-Tesla MRI. Regarding the spine, prevalences more than doubled (1.46 vs. 4.99%; P < 0.05) for intervertebral disc displacements. Similarly, prevalences of cerebral vessel malformations as well as other abnormal CNS incidental findings considerably increased by use of 3-Tesla MRI (0.28 vs. 1.67%; P < 0.05, and 5.12 vs. 9.80%; P < 0.05). Effect sizes and correlations were substantial in all conditions analyzed (Cohens d > 0.8; Pearsons r > 0.75).CONCLUSIONS: Our data suggest a strong dependency of incidental cerebrospinal findings on image resolution and sensitivity of MRI devices used for screening, which is enhanced by refined imaging protocols and followed by increased medical unfit rates in prospective aviators. Adjusted strategies in the assessment of such lesions are needed to redefine their natural history and physiological impact, and to optimize screening protocols for future pilot selection.Snksen S-E, Khn SR, Nobl H-J, Knopf H, Ehling J, Jakobs FM, Frischmuth J, Weber F. Incidental finding prevalences in 3-Tesla brain and spine MRI of military pilot applicants. Aerosp Med Hum Perform. 2021; 92(3):146152.

INTRODUCTION: Exposure to microgravity reduces muscle mass, volume, and performance. The ingestion of protein, especially combined with carbohydrate intake and exercise after ingestion, improves net muscle protein synthesis and increases muscle mass. However, there are few studies on this relationship during and after a long-term spaceflight. The objective of this study was to investigate the influence of protein and the combined effects of carbohydrate intake on muscle performance following long-term spaceflight.METHODS: This study is a retrospective cohort study involving secondary analysis of data stored in the NASA Lifetime Surveillance of Astronaut Health Repository. Multivariable analysis was performed to evaluate the impact of protein intake on physical performance by considering covariates potentially associated with each model.RESULTS: After adjusting for sex, age, flight week, energy intake, and preflight physical performance, protein intake was found to be significantly associated with concentric measurements for knee extension ( 51.66), ankle plantar flexion ( 32.86), and eccentric measurements for ankle plantar flexion ( 79.85) at 5 d after landing. Significant associations remained after controlling for exercise effect. No significant interaction between protein and carbohydrate intake was observed in either model.DISCUSSION: Protein intake during spaceflight was related to physical performance for knee extension and ankle plantar flexion, even after taking exercise effect into consideration. However, protein and carbohydrate intake provided no synergetic benefit. This suggests that high protein intake, about twice the current average intake, may serve as a countermeasure to offset the negative effects of long-duration spaceflights.Nozawa Y, Wagatsuma Y. Protein intake and physical performance following long-term stay on the International Space Station. Aerosp Med Hum Perform. 2021; 92(3):153159.

BACKGROUND: The first skin physiological pilot experiment (SkinA) on a single astronaut showed a deterioration of the skin. In a follow-up experiment (SkinB) we showed that skin physiological parameters improved on average. However, it is well known that sports have positive effects on the skin, that astronauts prefer special sports devices, and do sports with different intensity. The aim of this study was to analyze the different sports activities of SkinB astronauts and to find out whether they have an influence on the skin physiological parameters.METHODS: The cumulative distance covered on the treadmill and on the cycle ergometer as well as the repetition of arm-related exercises have been calculated and possible correlation between sports activities and skin physiological parameters have been analyzed.RESULTS: The average distance covered for all six astronauts per day is 1364 AU on the treadmill T2, and 11,077 AU on the cycle ergometer CEVIS. In addition, the astronauts performed an average of about 73 repetitions of all arm-related exercises daily. Here, we were able to show very well how differently the astronauts on the ISS train. In addition, a decreasing trend in skin volume can be observed in astronauts with increasing activity on the bicycle and more repetitions on arm-related exercises.CONCLUSION: Increased activity on the cycle ergometer and increased arm-related exercises have a medium negative impact on the parameter skin volume and thus reflects more fluid content in the skin. No correlations between sports activities and skin moisture/skin barrier function could be found.Braun N, Hunsdieck B, Theek C, Ickstadt K, Heinrich U. Exercises and skin physiology during International Space Station expeditions. Aerosp Med Hum Perform. 2021; 92(3):160166.

INTRODUCTION: Pilots are more aware of drugs and self-medication in the internet age. However, they are unaware of the effects of self-medication, which may impede their cognitive and decision-making performance. The aim of this study was to determine the awareness levels of ab initio (student) pilots on self-medication and factors contributing to the prevalence of self-medication among them. To the best of the authors knowledge, this is the first study examining ab initio pilots knowledge on medication use and the causality of self-medication among them.METHODS: A 17-item questionnaire was developed and administered online to 500 students across 5 flight training organizations (FTO) in Turkey. The response rate was 97/500. For the descriptive analysis of the data, SPSS (the Statistical Package for the Social Sciences) was used.RESULTS: Based on the results, fear of medical disqualification and job loss is the most significant factor resulting in the prevalence of self-medication among ab initio pilots. Most of the ab initio pilots (88.7%, N 86) were aware of self-medication and its threat to flight safety. Furthermore, three factors influencing the level of awareness and knowledge of ab initio pilots on this subject were evaluated.DISCUSSION: All flight training organizations should educate ab initio pilots on the consequences of self-medication. Furthermore, ab initio pilots should be encouraged to consult an aeromedical examiner with any ailment before a flight.Kilic B. Self-medication among ab initio pilots. Aerosp Med Hum Perform. 2021; 92(3):167171.

BACKGROUND: Mass, moment of inertia, and amplitude of neck motion were altered during a reciprocal scanning task to investigate how night vision goggles (NVGs) use mechanistically is associated with neck trouble among rotary-wing aircrew.METHODS: There were 30 subjects measured while scanning between targets at 2 amplitudes (near and far) and under 4 head supported mass conditions (combinations of helmet, NVGs, and counterweights). Electromyography (EMG) was measured bilaterally from the sternocleidomastoid and upper neck extensors. Kinematics were measured from the trunk and head.RESULTS: Scanning between the far amplitude targets required higher peak angular accelerations (7% increase) and neck EMG (between 1.24.5% increase), lower muscle cocontraction ratios (6.7% decrease), and fewer gaps in EMG (up to a 59% decrease) relative to the near targets. Increasing the mass of the helmet had modest effects on neck EMG, while increasing the moment of inertia did not.DISCUSSION: Target amplitude, not head supported mass configuration, had a greater effect on exposure metrics. Use of NVGs restricts field-of-view, requiring an increased amplitude of neck movement. This may play an important role in understanding links between neck trouble and NVG use.Healey LA, Derouin AJ, Callaghan JP, Cronin DS, Fischer SL. Night vision goggle and counterweight use affect neck muscle activity during reciprocal scanning. Aerosp Med Hum Perform. 2021; 92(3):172181.

BACKGROUND: Middle ear (ME) barotraumas are the most common condition in aviation medicine, sometimes seriously compromising flight safety. Considering this and the ever-increasing amount of commercial aviation, a detailed overview is warranted.METHODS: In this survey study, an anonymous, electronic questionnaire was distributed to commercial aircrew of the three major commercial airlines operating in Finland (N 3799), covering 93% of the target population (i.e., all commercial aircrew operating in Finland, N 4083). Primary outcomes were self-reported prevalence, clinical characteristics, and health and occupational effects of ME barotraumas in flight. Secondary outcomes were adjusted odds ratios (OR) for frequency of ME barotraumas with respect to possible risk factors.RESULTS: Response rate was 47% (N 1789/3799), with 85% (N 1516) having experienced ME barotraumas in flight. Of those affected, 60% had used medications, 5% had undergone surgical procedures, and 48% had been on sick leave due to ME barotraumas (40% during the last year). Factors associated with ME barotraumas included a high number of upper respiratory tract infections [3 URTIs/yr vs. 0 URTIs/yr: OR, 9.02; 95% confidence interval (CI) 3.9920.39] and poor subjective performance in Valsalva (occasionally vs. always successful: OR, 7.84; 95% CI 3.9715.51) and Toynbee (occasionally vs. always successful: OR, 9.06; 95% CI 2.6730.78) maneuvers.CONCLUSION: ME barotraumas were reported by 85% of commercial aircrew. They lead to an increased need for medications, otorhinolaryngology-related surgical procedures, and sickness absence from flight duty. Possible risk factors include a high number of URTIs and poor performance in pressure equalization maneuvers.Lindfors OH, Ketola KS, Klockars TK, Leino TK, Sinkkonen ST. Middle ear barotraumas in commercial aircrew. Aerosp Med Hum Perform. 2021; 92(3):182189.

INTRODUCTION: Fatigue is a common problem in aviation. The identification of efficacious fatigue countermeasures is crucial for sustaining flight performance during fatigue-inducing operations. Stimulants are not recommended for consistent use, but are often implemented during flight operations with a high risk of fatigue. As such, it is important to evaluate the efficacy of approved stimulants for sustaining flight performance, alertness, and mood.METHODS: Four electronic databases (PubMed, PsycInfo, SPORTDiscus, Web of Science) were systematically searched to identify research on the effects of caffeine, dextroamphetamine, and modafinil during simulated or in-flight operations.RESULTS: There were 12 studies identified that assessed the effects of at least 1 stimulant. Overall, dextroamphetamine and modafinil were effective for sustaining flight performance and pilot mood during extended wakefulness. Results with caffeine were inconsistent.DISCUSSION: Dextroamphetamine and modafinil appear to sustain flight performance and mood during extended wakefulness. However, most studies have used flight simulators and short operation durations. Additional research is needed in realistic settings and during longer duration operations. Caffeines effects were inconsistent across studies, possibly due to differences in study methodology or individual caffeine responses. Despite fatigue being a common problem in civilian aviation as well, only one study in this review included civil aviators. More research should be conducted on the effects of caffeine during civil operations.CONCLUSION: Dextroamphetamine and modafinil appear to be effective fatigue countermeasures but should be further evaluated in more ecologically valid settings. The effects of caffeine are unclear at this time and should continue to be evaluated.Ehlert AM, Wilson PB. Stimulant use as a fatigue countermeasure in aviation. Aerosp Med Hum Perform. 2021; 92(3):190200.

BACKGROUND: Bone density loss affects astronauts in long-duration spaceflight. The OsteoStrong Company has shown increased hip (14.95%) and lumbar (16.6%) area bone mineral density (aBMD) after 6 mo of exercises with their loading devices. The devices were tested on one subject as a pilot study.CASE REPORT: The subject performed 15 min of osteogenic exercises weekly for 24 wk. Total and regional aBMD, BAP (bone formation biomarker), NTX (bone resorption biomarker), forces exerted on devices, and weekly maximum weights lifted were collected. The control data was the subjects own lifting records 1.5 yr prestudy. The subject increased forces exerted on the devices in the upper extremity (97%, 197 to 390 kg; 435 to 859 lb), lower extremity (43%, 767 to 1097 kg; 1690 to 2418 lb), and spinal compression (22%, 275 to 336 kg; 607 to 740 lb). The monthly strength gain rate increased for snatch (2.3 vs. 0.71 kg; 5 vs. 1.56 lb), clean and jerk (2.5 vs. 0.4 kg; 5.5 vs. 0.88 lb), back squat (3.74 vs. 0 kg; 8.25 vs. 0 lb), front squat (2.15 vs. 0.2 kg; 4.75 vs. 0.47 lb), and deadlift (3.97 vs. 1.09 kg; 8.75 vs. 2.4 lb). The BAP increased by 39% (10.4 to 14.5 4 ug L¹) and NTX decreased by 41% (13.4 to 7 nmol L¹ BME). aBMD increased in the head (6%), arms (4.3%), trunk (6.3%), ribs (3.8%), and pelvis (11%). There were no differences in body weight, legs, spine, and whole-body aBMD on the full-body dual-energy X-ray absorptiometry (DXA). There were no differences in lumbar, hip, and femoral neck aBMD on the regional DXA.DISCUSSION: The osteogenic loading apparatus used for 15 min weekly increased strength for the one individual in this preliminary study. Future studies on astronauts and other healthy populations are necessary.Tsung A, Jupiter D, Jaquish J, Sibonga J. Weekly bone loading exercise effects on a healthy subjects strength, bone density, and bone biomarkers. Aerosp Med Hum Perform. 2021;92(3):201206.

BACKGROUND: To date, we lack U.S. data on the effects of the long-used Russian tilt-table training protocol known as the Russian pre-launch tilt-table training protocol on internal jugular vein cross sectional area (IJV-CSA) in microgravity.CASE REPORT: A case study of a single healthy male astronaut volunteer was used for this study. The right IJV-CSA was measured using real time ultrasound at set times throughout the Russian pre-launch tilt-table training protocol, a method of physiological preparation for microgravity using tilt-table training. In microgravity, the subjects right IJV-CSA was measured again for comparison. The mean difference from in-flight right IJV-CSA for pre-tilt (0) was 0.438 cm², for 15 was 0.887 cm², for 30 was 0.864 cm², for 50 was 1.15 cm², and for post-tilt (0) the difference was 0.305 cm².DISCUSSION: The cross-sectional areas of the subjects right IJV-CSA were significantly different between in-flight values and several angles of the Russian tilt-table protocol, except for the 0 measurement. In summary, this case-study represents the first time IJV-CSA has been compared between various angles of a tilt-table training protocol and microgravity in the same astronaut subject. The findings support prior cohort studies studying the same principles. Further investigation is merited; both to better describe the relationship between the cardiovascular effects of tilt-table simulations of microgravity and their correlating in-flight values, and to evaluate and study the Russian tilt-table protocol effects on cardiovascular physiology from a training and preparation perspective.David J, Scheuring RA, Morgan A, Olsen C, Sargsyan A, Grishin A. Comparison of internal jugular vein cross-section area during a Russian tilt-table protocol and microgravity. Aerosp Med Hum Perform. 2021; 92(3):207211.