BACKGROUND: Maintaining psychologically adaptive relationships among team members operating in an isolated, confined, and extreme (ICE) environment for an extended period continues to be a challenge, with relevance for long-duration missions to the Moon and beyond.METHODS: Two male architects were studied who lived and worked over a 60-d period in a polar ICE environment in a lunar analog habitat they designed and helped construct. Psychological measures were completed at different points of the mission, including a post-mission debriefing interview.RESULTS: Team members were highly different from each other on a number of personality traits, personal values, and stress and coping factors. Marked differences were noted on NEO-PI-3 Agreeableness and Extraversion personality traits, and Portrait Values Questionnaire (PVQ) Stimulation, Power, and Achievement values. Team Effectiveness Questionnaire (TEQ) findings showed consistency between team members with high ratings on the Passion and Commitment and Purpose and Goals scales, and low ratings on the Roles scale. The leveling influence of decision authority and its deleterious effect on interpersonal interactions and work performance was evident. The interior design with attention to materials that made it more Earth-like and the circadian lighting system were associated with ease of work performance and promotion of relaxation and privacy.DISCUSSION: The study findings demonstrated the impact of incompatibility in personality traits and values on team performance, challenges regarding decision authority in a long-term dyadic relationship, and highlighted the human factors components of the habitat that facilitated effective individual and team functioning.Kjærgaard A, Leon GR, Chterev K. Team effectiveness and person-environment adaptation in an analog lunar habitat. Aerosp Med Hum Perform. 2022; 93(2):70–78.

BACKGROUND: Head tracking movements are common in interceptive tasks. The benefits of these movements are unclear. The purpose of this study was to compare coincidence anticipation timing (CAT) responses for a simulated approaching object when the eyes were used in tracking the object and when the head was used in tracking the object.METHODS: A total of 29 subjects participated. A Bassin Anticipation Timer consisting of a track of sequentially illuminated lights was used to simulate an approaching object at velocities of 223 cm · s⁻¹ to 894 cm · s⁻¹. Each velocity was used 10 times under 2 conditions. In one condition, subjects were told to turn the eyes with the stimulus. In the other condition, subjects viewed the stimulus through apertures and were told to turn the head with the stimulus. Subjects pushed a button to coincide with illumination of the final light on the track.RESULTS: Signed CAT errors, unsigned CAT errors, and variable CAT errors were compared between the head movement (HM) and eye movement (EM) conditions. No significant differences were noted for the signed errors (mean signed error at 894 cm · s⁻¹; 10.3 ± 75.4 ms (HM), −16.1 ± 51.0 ms (EM). However, the unsigned and variable errors were significantly larger at some stimulus velocities in the head movement condition [mean unsigned error at 894 cm · s⁻¹: 82.6.0 ± 45.9 ms (HM), 59.0 ± 22.4 ms (EM); mean variable error at 894 cm · s⁻¹; 78.0 ± 37.8 ms (HM), 49.2 ± 17.1ms (EM)].DISCUSSION: Head movement did not result in improved CAT performance compared to eye movements. Further work will be required to determine whether these results are generalizable to situations where head tracking is required but apertures are not worn.Ross E, Kinney M, Fogt N. Coincidence anticipation timing responses with head tracking and eye tracking. Aerosp Med Hum Perform. 2022; 93(2):79–88.

INTRODUCTION: Precision medicine is an approach to healthcare that is modifying clinical management by leveraging technological advances in genomics that assess a patient’s genetic information to identify unique predispositions. While the civilian sector is integrating genomics widely to personalize diagnosis and treatment, the military medical environment has reacted more slowly. The operational requirements of military service encourage a tailored approach for focusing military precision medicine on occupation-specific conditions. Here, we present a survey of the genomic landscape related to military aerospace medicine.METHODS: We collated observations from genome-wide association studies (GWAS) relating genetic markers to conditions that may negatively influence flight operations and for which the U.S. Air Force School of Aerospace Medicine’s Aeromedical Consult Service (ACS) provides aeromedical waiver guidance. Our sources for identifying relevant literature were the GWAS Catalog, the Atlas of GWAS Summary Statistics, and PubMed/Google Scholar searches.RESULTS: Using the ACS guidance as a starting point, we found 1572 papers describing 84 clinical conditions with genetic associations. The earliest aeromedical GWAS publication was in 2006, increasing to 225 publications in 2019. We identified 42,020 polymorphisms from more than 84 million participants across the studies.CONCLUSION: Our study revealed areas where deeper investigations into how genetic markers manifest in clinical diagnosis, prevention, or risk management could lead to increased medical readiness. Additionally, our results show those clinical areas for which guidance could include genetic risk considerations.Chapleau RR, Regn DD, de Castro MJ. Surveying the genomic landscape supporting the development of precision military aerospace medicine. Aerosp Med Hum Perform. 2022; 93(2):89–93.

BACKGROUND: The coronavirus epidemic originated in China, having its epicenter in Wuhan. This was the first place in the world to adopt social distancing measures to contain the disease on January 23^rd, 2020. After the initial isolation, several countries started making diplomatic plans to evacuate and repatriate their citizens, with the permission of the Chinese authorities. Due to the high risk of exposure of the transported passengers, evacuations were conducted with preventive measures against contamination by biological agents.CASE REPORT: We report the air evacuation of 39 passengers from China to Brazil. Five passengers were transported to Poland and the remaining 34 went to Brazil, where they remained in quarantine for 14 d. The mission was triggered on February 4^th, named “Operation Return to Brazil” (Operação Regresso à Pátria Amada Brasil), and conducted by military personnel of the Brazilian Air Force. The mission was accomplished in 6 days; the flight from Wuhan lasted 25 h 20 min; and, additionally, there were on-ground preparations.DISCUSSION: Only with adequate isolation and protective measures was it possible to air evacuate the potentially contaminated passengers in the initial phase of the pandemic. Specific protective equipment (Personal Protective Equipment – PPE) is mandatory for missions in which the properties of the potentially contagious biological agent are not fully known, as was the case. Due to the risk of contamination of passengers and the likely evolution of the transport into an aeromedical evacuation, protocols stating the minimum safety conditions for this kind of patient transport must be followed, with consideration for the patient as well as the crew.Gomes ED, Ronconi MABR, Santos MB, Júnior PP, Franco AZP, Haberland DF, Borges LL. Air evacuation of citizens during the COVID-19 epidemic. Aerosp Med Hum Perform 2022; 93(2):94–98.

INTRODUCTION: In the event of decompression using an isobaric differential cockpit pressurization system, oxygen concentration breathed pre-decompression must be greater than required for the given cockpit altitude in order to prevent hypoxia. The model for determining oxygen concentration requirements advanced by Dr. John Ernsting, when graphed against cockpit altitude, creates a hypoxia safety “notch” which has become a standard requirement for aircraft oxygen systems. Although variables in the Ernsting notch model are not fixed, they are often presented as such.METHODS: Model equations are presented to evaluate the effects of different cockpit pressurization, oxygen regulator PBA schedules, and changes to the physiological state of the aircrew.RESULTS: Increased cockpit differential pressure, regulator breathing pressure, and aircrew respiratory quotient decreased pre-decompression oxygen concentration requirements by up to 6%, eliminating the hypoxia safety “notch.” Although effects were small, reducing alveolar carbon dioxide pressure decreased oxygen concentration requirements while reducing respiratory quotient increased oxygen concentration requirements. A 10-mmHg increase in the minimal oxygen hypoxia threshold increased the pre-decompression oxygen concentration requirement 8 to 12% depending on cockpit altitude.CONCLUSION: Variation in cockpit and regulator pressure schedules which stray outside the parameters used by Ernsting need to be independently calculated. During flight, an individual’s physiological “notch” will be dynamic, wavering in response to changes in metabolic load, respiratory dynamics, and environmental conditions. Consideration of aircrew activity should be factored in when considering minimal oxygen concentration for pre-decompression hypoxia protection in the design of aircrew life support systems.Dart TS, Morse BG. Variations on Ernsting’s post-decompression hypoxia prevention model. Aerosp Med Hum Perform. 2022; 93(2):99–105.

BACKGROUND: Fighter pilots undergo extensive medical screening but may still miss rare diseases like latent autoimmune diabetes in adults (LADA). LADA patients have circulating autoantibodies directed against pancreatic beta cell antigens and present with frank diabetes late in life which may elude conventional military flight screening.CASE REPORT: Two fifth-generation fighter pilots, a 38-yr-old man (patient 1) and a 27-yr-old man (patient 2), with no significant past medical histories developed symptoms of fatigue, weight loss, episodic polyuria, and arthralgia. Patient 1’s symptoms were initially thought to have been caused by COVID-19, but he subsequently tested negative for viral infection. Lab work instead showed elevated TSH, HgbA1C 11.4%, positive GAD-65, anti-TPO, and anti-islet cell antibodies. Patient 2 developed symptoms following a military deployment and a 72-h diarrheal illness. Due to flight status, patient 2 did not seek expert medical attention for several months, but lab work found HgbA1C of 10.4%, positive GAD-66, and ZnT8 antibodies. Both patients were started on insulin therapy. Patient 1 was also started on levothyroxine for hypothyroidism and retired from flying duties. Patient 2 eventually transitioned to metformin without insulin and returned to flying duties with an aeromedical waiver.DISCUSSION: Our patients maintained peak physical fitness throughout their selection and aviation careers, which likely delayed their clinical presentation. Current USAF flight rules prohibit insulin use with flying fighter aircraft. Early antibody screening during pilot selection may be a cost-effective means of diagnosis as traditional screening techniques are unlikely to detect LADA.Zhang JX, Berry J, Kim NM, Gray JJ, Fotheringham S, Sauerwein TJ. Two fifth-generation fighter pilots discovered with latent autoimmune diabetes. Aerosp Med Hum Perform. 2022; 93(2):106–110.

BACKGROUND: Arrhythmogenic right ventricular cardiomyopathy (ARVC) results in progressive replacement of right ventricular myocardium with fibrofatty tissue. This condition commonly presents with sudden cardiac death, cardiac arrest, or sustained ventricular tachycardia among young adults. Considering the likelihood of sudden incapacitation, a diagnosis of ARVC usually signals the end of a career in aviation. However, the morbidity pattern among those diagnosed later in life may differ as compared to the young.CASE REPORT: A private pilot, in his 60s, applied for renewal of an ICAO Class 2 medical certificate a decade after his previous medical certificate had expired. He declared history of hospitalization due to a heart-related condition. Further information revealed that he had been diagnosed as a case of ARVC and that he had declined to be implanted with an implantable cardioverter-defibrillator. Recent clinical examination and related cardiovascular investigations were normal except echocardiogram findings of left ventricular hypertrophy and left atrial enlargement. The treating cardiologist, in the absence of history of syncope and evidence of right ventricular dysfunction or sustained ventricular tachycardia, considered this condition to be stable with minimal risk of malignant arrhythmia.DISCUSSION: This case report discusses aeromedical decision making in a pilot found to have ARVC late in life. Despite the progressive nature of the condition with its attendant risk of incapacitation, considering the age at diagnosis and absence of any high-risk features of ARVC, the regulator decided to issue the medical certificate with safety pilot restriction to enable this pilot to return to aviation activities.Sharma S. Arrhythmogenic right ventricular cardiomyopathy in an older private pilot. Aerosp Med Hum Perform. 2022; 93(2):111–115.

INTRODUCTION: After traumatic brain injury (TBI), cognitive, behavioral alterations and seizures frequently occur. Beside instrumental examinations, neuropsychological testing is the common clinical practice for detecting cognitive deficits. However, in highly skilled individuals, subtle changes with a large impact on fitness to fly may be neglected.CASE REPORT: A 28-yr-old Italian Air Force pilot with almost 700 flying hours suffered a TBI. After 2 yr of cognitive retraining programs, as the neuropsychological evaluation executed in a public hospital was within the standards and repeated EEGs had all been normal, the pilot was allowed to resume flying duties. During the refresh flight training, he was not considered proficient for solo flight and was again referred to the Institute of Aerospace Medicine (IMAS), where, due to the absence of a neuropsychologist, the pilot was referred to a public hospital. Again, he was within the normal range and received a fitness to fly with limitations. Nevertheless, the flight instructors noticed the presence of cyclic errors. Consequently, he was sent for a third time to the IMAS, where the cooperation between a neuropsychologist and a flight surgeon allowed a tailored testing.DISCUSSION: With a proper evaluation, the subject showed deficits in topographic visuospatial learning and in prospective memory. After 5 yr, he was finally declared permanently unfit to fly. Specific neuropsychological batteries, simulated flight tests, and aeromedical evaluations are described here.Verde P, Guadagno AG, D’Angelo A, Vitalone R, Di Vita A, Piccardi L. A controversial assessment of fitness to fly after a traumatic brain injury. Aerosp Med Hum Perform. 2022; 93(2):116–122.

INTRODUCTION: As NASA and private spaceflight companies push forward with plans for missions to cis-lunar and interplanetary space, the risk of surgical emergency increases. At latencies above 500 ms, telesurgery is not likely to be successful, so near-real-time telementoring is a more viable option. We examined the effect of a 700-ms time delay on the performance of first year surgical residents on a simulated task requiring significant feedback from a mentor in a pilot study.METHODS: A simulated surgical task requiring precision and accuracy with built-in error detection was used. Each resident underwent two trials, one with a mentor in the same room and one with the mentor using a teleconference with time delay. Outcomes measured included time to complete task, game pieces successfully removed, number of errors, and scores on the NASA Task Load Index by both mentor and operator. Data were analyzed using paired t-tests.RESULTS: The time delay group removed significantly fewer pieces successfully than the real time group (3.0 vs. 1.6, P = 0.02). There was no difference in the NASA Task Load Index (TLX) scores for the operators between the two groups, but the mentor reported significantly higher scores on Mental Demand (5.6 vs. 12.0, P = 0.04) and Effort (6.2 vs. 11.8, P = 0.05) during the time-delayed trials.DISCUSSION: A 750-ms time delay significantly degraded performance on the task. Though operator TLX scores were not affected, mentor TLX scores indicated significantly increased mental load. Telementoring is viable, but more onerous than in-person mentoring.Kamine TH, Smith BW, Fernandez GL. Impact of time delay on simulated operative video telementoring: a pilot study. Aerosp Med Hum Perform. 2022; 93(2):123–127.