INTRODUCTION: The aviation occupational environment may expose a developing fetus to intermittent hypoxia, high gravitational force, toxic materials, loud noise, high frequency vibrations, and galactic cosmic radiation. These exposures in animal models are associated with adverse neonatal outcomes. We sought to investigate whether a maternal military aviation career was associated with adverse neonatal health outcomes.

METHODS: We performed a retrospective cohort study of female officer’s children born in the Military Health System from October 2002 to December 2019. Female fixed-wing aviation officers were identified by the presence of an aviation occupation code prior to birth. Adverse neonatal outcomes were identified by International Classification of Diseases codes in in-patient medical records. Binomial regression was used to estimate the adjusted relative risk (aRR) of neonatal health outcomes.

RESULTS: We identified 27,033 eligible births, with 1144 children born to female fixed-wing aviation officers and 25,889 to female nonaviation officers. Children of fixed-wing aviation officers had a significantly lower adjusted risk of overall neonatal growth abnormalities compared to children of nonaviation officers [aRR 0.74 (95% Confidence Interval 0.57–0.99)], but did not have significant differences in low birth weight [aRR 0.78 (0.56–1.10)] or small for gestational age [aRR 0.72 (0.46–1.10)] diagnoses. There were no statistically significant adverse neonatal outcomes.

DISCUSSION: Children of female military fixed-wing aviation officers were at decreased risk of neonatal growth abnormalities compared to children of nonaviation officers and had no significant adverse neonatal health outcomes. Further research is needed to determine how flight impacts neonatal health outcomes.

Stark CM, Sorensen IS, Royall M, Dorr M, Brown J, Dobson N, Salzman S, Susi A, Hisle-Gorman E, Huggins BH, Nylund CM. Neonatal health risks among children of female military aviation officers. Aerosp Med Hum Perform. 2024; 95(11):815–820.

INTRODUCTION: Undiagnosed depression in the aviation industry can have catastrophic consequences such as aircraft-assisted suicide. Depression is often underreported, especially when subjects are aware they are reporting on depression. The aim of the present study was to investigate whether scores on a depression screening tool would vary if it was disguised as a “life stress” questionnaire in a sample of Australian commercial pilots.

METHODS: A total of 109 subjects were assigned into either a “Life Stress” survey or a “Depression” survey, both containing the Depression, Anxiety, Stress Scales depression screening tool among other questions relating to either depression or stress to determine any variation in depression scores.

RESULTS: A statistically significant difference was found in which the covert group that completed a “life-stress” survey scored higher average depression scores than the control group completing an overt depression inventory. Prevalence of depression was consistent with the general population, with 25% of pilots meeting the threshold for depression within the control group, and this number increased to 41% when using a covert measure to assess depression.

DISCUSSION: This research adds further weight to the potential underreporting of depression in pilots as a function of stigma and fear associated with the label “depression”. Regulators and organizations must proactively minimize exposure to psychological harm, negating the reliance on self-reporting to control psychological risk and recruitment methods must aim to reduce bias against those with disabilities. Nonpunitive environments for pilots to self-assess and report psychological issues will allow better outcomes from expedited treatment.

Minnock SDT, Thomas MJW. Underreporting of depression in Australian commercial pilots. Aerosp Med Hum Perform. 2024; 95(11):821–825.

INTRODUCTION: Flight attendants are constantly exposed to high-stress environments that could lead to the development of depression. The COVID-19 pandemic brought out new risk factors that could affect flight attendants’ mental health, such as reduced flight hours and fear of the disease itself, which other studies have shown was associated with depression. We aimed to find out whether reduced flight hours, fear of COVID-19, and other factors were associated with depression in flight attendants during the COVID-19 pandemic.

METHODS: This cross-sectional study was conducted at the Directorate General Civil Aviation Medical Center Indonesia and Garuda Sentra Medika in 2022. We included flight attendants who were still employed before and after the start of the pandemic. Data were collected using several questionnaires, including the General Health Questionnaire-12 to screen for depression and Fear of COVID-19 for fear levels.

RESULTS: We obtained data from 159 respondents, of whom 25.2% of them had depression. Multivariate analysis showed that the reduction of flight hours 1 yr after the start of the pandemic and fear of COVID-19 were found to significantly increase the likelihood of depression by 2.3 times and 3.9 times, respectively.

DISCUSSION: During the pandemic, depression was found to be highly prevalent among flight attendants and was associated with the reduction of flight hours and fear of COVID-19.

Sutrisno AB, Agustina A, Sosrosumihardjo D, Sugiharto A, Zulaecha SI, Khoe LC. Flight hours and depression in flight attendants during the COVID-19 pandemic. Aerosp Med Hum Perform. 2024; 95(11):826–830.

INTRODUCTION: As next-generation space exploration missions require increased autonomy from crews, real-time diagnostics of astronaut health and performance are essential for mission operations, especially for determining extravehicular activity readiness. An augmented reality (AR) system may be a viable tool allowing holographic visual cueing to replace physical objects used in traditional assessments.

METHODS: In this study, 20 healthy adults were compared in an Ingress and Egress Task and Obstacle Weave Task with holographic and physical objects to determine the effect of AR on performance. Subjects performed each task three times within each modality.

RESULTS: AR exhibited increased task completion times with greater head pitch angles across the two tasks. The head and torso angular velocity showed a reduction in magnitude in both tasks within AR, while decreased magnitudes of head and torso acceleration were observed for the Obstacle Weave Task. The subjects were more deliberate and careful in their task completion during the Ingress and Egress Task within AR, stepping higher and lowering their heads further.

DISCUSSION: Subjects successfully completed both tasks using AR and meaningful assessments of their performance were obtained. The increased head pitch observed supported the hologram visualization with the reduced AR field of view. The increased task time and reduced torso angular velocity were compared to strategies used by astronauts postflight while experiencing sensorimotor impairments. AR may be a useful instrumentation solution for assessing in-flight performance, providing embedded sensors and onboard computations; however, thresholds for assessing extravehicular activity readiness must be developed.

Weiss H, Stirling L. Augmented reality assessments to support human spaceflight performance evaluation. Aerosp Med Hum Perform. 2024; 95(11):831–840.

INTRODUCTION: When a pilot is referred for nasal polyposis, his/her flight fitness may be questionable. The objective of this retrospective study was to describe a case series of barotrauma in a pilot population exhibiting nasal polyposis and to discuss the decisions about their flight fitness.

METHODS: There were 17 pilots with nasal polyposis who were referred to the Head and Neck Department of the National Pilot Expertise Center. The study was declarative on the occurrence of ear and sinus barotrauma during the last 5 yr. Nasofibroscopy was performed to determine the stage of the nasosinus polyposis.

RESULTS: Out of 17 pilots, 1 did not obtain flight fitness clearance. Among the 16 who received fitness clearance to fly, 2 had restrictions on their flight fitness. Out of 17 patients, 8 had sinus barotrauma and 13 had middle ear barotrauma. A total of 21 cases of sinus barotrauma were reported, 17 involving the frontal sinus and 4 involving the maxillary sinus. Also reported were 48 cases of middle ear barotrauma.

DISCUSSION: Flight fitness was based on the recurrence of barotrauma episodes, their severity, in-flight incapacitation due to hyperalgesic sinusitis or otitis, and the failure of medical and/or surgical treatments. In our series, nasal polyposis did not seem to be a risk factor for severe barotrauma. The results made it possible to determine a patient’s fitness to fly and any restrictions. The published studies on the resumption of flight for patients who have nasal polyposis and our experience suggest that nasal polyposis may allow a safe pursuit of aviation activity.

Crambert A, Marchi Y, Pons Y, Podeur P, Allali L, Ballivet de Régloix S. Nasal polyposis and fitness to fly. Aerosp Med Hum Perform. 2024; 95(11):841–844.

INTRODUCTION: Aviation safety sensitive personnel (SSP) function in highly complex environments. SSP mental health is thought to support safety, efficiency, and overall health. Research is needed to identify how to optimize and screen mental health across aviation SSP, but no consensus exists on the research priorities that need to be met.

METHODS: The Aerospace Medical Association established the Mental Health Research Subgroup within the Mental Health Working Group comprising 53 aviation and aerospace medicine professionals representing 9 countries. A five-round Delphi method was employed to generate research priorities.

RESULTS: Research priorities were identified under the following six topic areas: 1) Safety and Performance; 2) Mental Health Initiatives, Education, and Peer Support Programs; 3) Clinical Care, Pharmacology, and Return to Duty; 4) Epidemiology and Natural History; 5) Screening, Monitoring, and Emerging Technology; and 6) Special Considerations and Underrepresented Populations [Aerospace Medical Association Mental Health Research Subgroup Research Priorities Version 1.0 (current as of January 1, 2024)].

DISCUSSION: Research is needed to identify how to optimize and screen mental health across aviation SSP. This effort identified six key research priorities to achieve that aim.

Hoffman WR, Santilhano W, Tvaryanas A, Snyder Q, Spyropoulos BP, Fahnenbruck G, O’Shaughnessy R, Trottier K, Overbo S, Brinks E, Ndoye A, Bongers H, Miranda E, Garcia D, Schroeder D; Aerospace Medical Association Mental Health Research Subgroup. Aerospace Medical Association proposed research priorities for mental health and safety in aviation. Aerosp Med Hum Perform. 2024; 95(11):845–850.

INTRODUCTION: As military environments integrate more complex technological systems, operators increasingly require more assistance from automation. When used properly, automation can significantly enhance performance; however, proper use is predicated on the operator’s trust in the automation (TIA). TIA, like trust among people, is influenced by biological, psychosocial, and behavioral aspects. While options for measuring TIA have rapidly expanded in the past decade, there has been little consideration for how well these measures perform in operational environments.

METHODS: A 10-yr literature review was conducted to identify TIA measures and rate their appropriateness for operational aeromedical environments. Articles from Google Scholar, EBSCO, and the Defense Technical Information Center databases were included, focusing on user-reported, physiological, and behavioral measures. Study quality was rated by aeromedical research scientists, while aeromedical appropriateness was evaluated by rated military pilots. Measures were categorized as High Recommendation, Cautious Recommendation, or Not Recommended based on these evaluations.

RESULTS: Of the measures reviewed, 28 were recommended for operational use, 23 received cautious recommendations, and 6 were not recommended. The recommended measures demonstrated high research quality and suitability for aeromedical environments. The cautious recommendations highlighted measures with specific limitations that need to be considered in operational settings, while the not recommended measures lacked sufficient evidence for reliable use in these contexts.

DISCUSSION: Several high-quality TIA measures appear suitable for operational aeromedical settings. While these recommendations offer a starting point for testing TIA in aeromedical settings, further research is required to test how well these measures perform in an operational environment.

Ranes B, Wilkins J, Kenser E, Caid-Loos M. Trust in automation measures for aeromedical settings. Aerosp Med Hum Perform. 2024; 95(11):851–861.

BACKGROUND: Ejection seats are designed to be a lifesaving device for aircrew in emergencies. Modern ejection seats are widely prevalent in fighter and bomber aircraft and are occasionally associated with acceleration injury from axial loading (G_z) during the catapult phase of ejection, limb flail injury due to windblast, or parachute landing fall, especially if the ejection is outside of the seat’s performance envelope.

CASE REPORT: We present the first known case in the medical literature of a military pilot who survived a low-altitude, high-angulation (>90° of bank angle) ejection where the pilot’s ejection seat parachute did not deploy due to contact with the ground before completion of the ejection sequence. The patient’s initial exam upon arrival at a trauma center was significant for a Glasgow Coma Scale of 3T, with evidence of cranial and extremity trauma. The patient presented with respiratory acidosis and required upsizing of his endotracheal tube placed in the field. The patient’s injury list included bilateral subdural and subarachnoid hemorrhages, a Hangman’s fracture, spinal burst fractures, and extensive extremity fractures. After a prolonged hospital stay, the patient was discharged to rehabilitation. The patient made a functional and neurological recovery, including return to independent completion of his activities of daily living.

DISCUSSION: This case provides evidence of favorable outcome after a low-altitude, high-angulation ejection without parachute deployment. This case details the medical and traumatic pathology medical personnel should expect from an ejection that occurs outside of the seat’s performance envelope.

Zivkovic MM, Inman BL, Figlewicz MR, Burchett JA, Nowadly CD. Polytrauma in a jet pilot after low-altitude ejection without parachute deployment. Aerosp Med Hum Perform. 2024; 95(11):862–866.

BACKGROUND: Arterial gas embolism (AGE) may occur while breathing compressed air and failing to exhale during ascent to compensate for gas expansion as pressure decreases. Trauma to the lungs from over-pressurization may result in air bubbles entering the pulmonary veins and subsequently the systemic circulation, causing obstructed blood flow and inflammatory cascades. AGEs are known to always manifest within 10 min of surfacing from depth. In underwater egress training (UET), which is mandatory for U.S. Marines, service members learn to escape from a tilt-wing or rotor aircraft after it submerges and inverts in water.

CASE REPORT: We report a case of cerebral AGE in which the victim experienced neurological symptoms more than 1 h after completing UET at a depth between only 3.28–6.56 ft (1–2 m). The patient was treated with a U.S. Navy Treatment Table 6 and experienced complete resolution of symptoms.

DISCUSSION: This case is one of only two AGEs reported with symptom onset occurring after 10 min of surfacing from depth to be published. AGE at depths between 1–2 m has only been reported on three other occasions, and dysbarism injuries during UET are also exceedingly rare. This case demonstrates a situation in which all three events occurred, highlighting the need for increased awareness and clinical consideration of delayed AGE in similar scenarios despite the commonly held belief that AGEs do not occur outside of 10 min of surfacing.

Harvey SE, Reynolds RP, Fisher JF. Delayed-onset arterial gas embolism after underwater egress training. Aerosp Med Hum Perform. 2024; 95(11):867–870.

INTRODUCTION: Hypoxia recognition training (HRT) is a requirement for many nations’ military aircrew. The aim of HRT is to enhance the ability of aircrew to recognize and recover from an unexpected in-flight hypoxic exposure; however, there is a paucity of research evaluating the efficacy of HRT and whether current training approaches are optimal. Rather, the benefits of HRT are routinely promulgated based on opinions and anecdotes. Here, we raise some of our concerns with HRT practices in order to stimulate further discussion and research. Our aim is to ensure aircrew are provided with effective training to mitigate the risks associated with hypoxia—and other physiological threats—to promote flight safety.

Shaw DM, Harrell JW, Gant N, Peacock DS. Clearing the air on the efficacy of hypoxia recognition training. Aerosp Med Hum Perform. 2024; 95(11):871–872.

BACKGROUND: Attention deficit/hyperactivity disorder (ADHD) in pilots is considered a threat to flight safety. The U.S. Federal Aviation Administration has recently revised assessment pathways for applicants with attentional problems because of an increasing recognition that ADHD is a clinical condition with a broad symptom spectrum; some individuals may have a historical diagnosis which has been in remission for several years, while others may be using psychostimulants to enhance mental focus. This commentary compares major depression as a reference and its Federal Aviation Administration certification/clearance policy with those policies associated with ADHD. Major depression can be considered a model example of a mental disorder where appropriate treatment strategies such as medication have been demonstrated not to have adverse effects upon aviation safety. We wish to highlight that when reviewing certification and assessment practice guidelines for the assessment of pilots with ADHD, decisions must be based upon robust scientific evidence that has been obtained in aviation.

Vuorio A, Bor R, Gray A, Suhonen-Malm A-S. Attention deficit/hyperactivity disorder assessment and aviation safety using major depression as a reference. Aerosp Med Hum Perform. 2024; 95(11):873–875.