INTRODUCTION: Sex-specific responses to heat stress are not well characterized in women with different training backgrounds. This study examined physiological and perceptual responses to moderate-intensity exercise in the heat among endurance-trained (ET) and resistance-trained (RT) women.

METHODS: In a counterbalanced crossover design, 17 (8 ET, 9 RT) healthy, well-trained, heat-unacclimatized women performed a 75-min walking exercise session at 60% $\dot{\mathrm{V}}$ o _2peak (maximum volume of oxygen consumption) in both Hot (33°C, 50% relative humidity) and Neutral (21°C, 50% relative humidity) conditions. Rectal temperature (T_rec), heart rate (HR), minute ventilation ( $\dot{\mathrm{V}}$ _e), blood lactate, urine specific gravity, and body mass loss were assessed. Perceptual measures included overall, central, and local ratings of perceived exertion (RPE), thermal sensation, thermal comfort, thirst, and the Environmental Symptoms Questionnaire.

RESULTS: Across both groups, T_rec, HR, $\dot{\mathrm{V}}$ _e, and perceptual responses were significantly elevated in Hot vs. Neutral. No group differences were observed in T_rec, HR, $\dot{\mathrm{V}}$ _e, or perceptual ratings. RT women exhibited significantly higher post-exercise lactate levels in Hot, but this did not correspond to higher RPE or Environmental Symptoms Questionnaire scores. $\dot{\mathrm{V}}$ o _2peak was a significant predictor of RPE responses in Neutral but not Hot. No moderation effect of training group was observed.

DISCUSSION: ET and RT women experienced comparable physiological and perceptual strain during prolonged exercise in the heat. Despite metabolic differences, perceptual responses were consistent across training backgrounds. These findings highlight the role of training stimulus over $\dot{\mathrm{V}}$ o _2peak in thermoregulatory outcomes and support inclusive heat tolerance recommendations for active women across training disciplines.

Sanchez BN, Soufi S, Saenz C, Kraemer WJ, Lee EC, Volek JS, Maresh CM. Exercise heat stress responses in unacclimatized endurance- and resistance-trained women. Aerosp Med Hum Perform. 2025; 96(10):872–883.

INTRODUCTION: Cervical spine degeneration occurs naturally, often has biomechanical effects on spinal function, and can be accelerated by daily loading environments such as whole-body vibration. Military fighter pilots routinely experience high-magnitude G_z loading with added helmet mass and head-neck in nonneutral orientations. This study characterized spinal degeneration in fighter pilots and identified functional consequences.

METHODS: A total of 18 fifth-generation fighter pilots received cervical spine MRI scans with secondary clinical reviews. Type and location of degenerative changes were noted. Cervical spine range of motion (CROM) was measured before flight and as soon as possible postflight. Cervical spine degenerative changes were correlated to preflight CROM and changes in postflight CROM.

RESULTS: All enrolled pilots had 2 or more cervical spine disc bulges (average 3.5 per pilot), foraminal stenosis occurred in 17/18 pilots (average 2.8 cervical spine levels), and uncovertebral hypertrophy was evident in 17/18 pilots (average 2.4 cervical spine levels). Spinal degenerative findings were not correlated to preflight CROM. Total incidence of degenerative findings was strongly negatively correlated to postflight reductions in extension, lateral bending, and axial rotation CROM.

DISCUSSION: The pattern of degenerative changes in fighter pilots was remarkably different from that of civilians and was characterized by much higher incidence of degenerative changes and degenerative changes biased toward the upper cervical spine, despite the severity of individual degenerative findings being relatively modest. Correlation to postflight CROM changes, but not preflight CROM, implies a pain-mediated mechanism as opposed to altered biomechanics associated with degeneration of spinal tissues.

Stemper BD, Muftuler LT, Cutlan R, Strother C, Sherman KA, Meier TB, Raff H, Yoganandan N, Gerds B, Dooley C, Le P, Hainsworth KR, Vedantam A. Abnormal pattern of spondylosis and postflight neck flexibility in fifth-generation fighter pilots. Aerosp Med Hum Perform. 2025; 96(10):884–893.

INTRODUCTION: This study investigated the prevalence and risk factors of metabolic-associated fatty liver disease (MAFLD) in the Korean Air Force population (2020–2022), comparing nonpilot and pilot groups.

METHODS: Participants over 40 yr were classified into MAFLD or non-MAFLD groups. MAFLD was defined as hepatic steatosis on ultrasonography plus one of the following: overweight/obesity, type II diabetes, or metabolic deregulations. Variables analyzed included body mass index (BMI), alanine aminotransferase (ALT), uric acid, fasting plasma glucose, lipid profile, triglycerides, albumin, and exercise habits.

RESULTS: Among 1044 participants (667 pilots, 377 nonpilots), MAFLD prevalence was 30.3%, significantly lower in pilots (27.7%) than in nonpilots (34.7%). For nonpilots, BMI [odds ratio (OR) = 3.41], diabetes (OR = 8.32), and ALT (OR = 1.91) were significant factors, although the small sample size limited broader conclusions. Among pilots, BMI (OR = 3.77), uric acid (OR = 1.83), ALT (OR = 1.98), triglycerides (OR = 1.50), and dyslipidemia (OR = 7.97) were strongly associated with MAFLD. Uric acid levels had a greater association with MAFLD in pilots compared to nonpilots.

DISCUSSION: This study highlights the distinct prevalence and risk factors of MAFLD in pilots vs. nonpilots. Uric acid, in particular, emerged as a significant risk factor for pilots, suggesting its potential use for targeted risk assessment in this group. The findings underscore the importance of tailored preventive strategies for MAFLD in occupational groups.

Song DH, Ku B. Prevalence and risk factors of metabolic-associated fatty liver disease in the Korean Air Force. Aerosp Med Hum Perform. 2025; 96(10):894–902.

INTRODUCTION: Pilots are undoubtedly among employees who undergo rigorous medical evaluations to ensure they are fit to fly. However, accidents like the Germanwings Flight 9525 highlight that medically unfit individuals can still end up in the cockpit.

METHODS: This study sought to investigate Greek pilots’ attitudes toward medical reporting, given that the available national research is very limited. Semistructured interviews were conducted and analyzed through Thematic Analysis with subjects (N = 18) from general, military, and commercial aviation in Greece during the first quarter of 2024. Cross-sectoral differences were identified through Content Analysis.

RESULTS: The primary barrier to medical reporting, identified by 16 out of 18 subjects (88% of the sample), was the fear of losing their pilot license, which would have major consequences for their income and way of life. Additionally, concerns about the perceived damage to professional identity and a deep passion for flying contributed to their reluctance to disclose medical issues. A general tendency to conceal medical problems from the Aeromedical Examiner during the annual medical certificate renewal was identified, particularly when such issues were considered of minor importance (61% of the sample).

DISCUSSION: Although the findings align with international research, this study identified a more pronounced tendency among subjects to conceal medical issues they perceived as unimportant. The establishment of compulsory loss-of-pilot-license insurance was the major mitigation measure proposed by the interviewees. Nonetheless, its effectiveness remains questionable according to the literature, and further research is recommended in this area.

Kioulepoglou P, Makris I. Medical reporting behavior of military, commercial, and general aviation pilots. Aerosp Med Hum Perform. 2025; 96(10):903–910.

INTRODUCTION: Human factors are responsible for 80% of accidents and 50% of serious incidents. The Human Factor Analysis and Classification System allows the identification of contributing factors, including pilot preconditions, as the imminent layer prior to errors. This study aimed to investigate the association of pilot preconditions and errors to accidents and serious incidents from 2007–2024 in Indonesia.

METHODS: This was a cross-sectional study design with secondary data from the investigation reports published by the National Transport Safety Committee (NTSC) from 2007–2024 in Indonesia, downloaded from the NTSC website, August 12–31, 2024. The study focused on pilot-error-related investigation reports, analyzing preconditions and errors. Internal validation was conducted with the NTSC investigators. Statistical analysis using nonparametric tests was carried out to assess the association between preconditions, errors, and incident severity (Accidents and Serious Incidents).

RESULTS: A total of 245 investigation reports were downloaded, amounting to 253 aircraft, with 8 aircraft involved in near collisions, and 186 pilot-error-related investigations selected as subject analysis. The study found that pilots with Adverse Mental States had a 3.87 times higher risk [95% confidence interval (CI) = 1.77–8.47] for accidents, while pilots with Physical Mental Limitation had a 3.35 times higher risk (95% CI = 1.50–7.45). In addition, pilots with Skill-Based Errors had a 3.07 times higher risk (95% CI = 1.38–6.83) for accidents.

DISCUSSION: Aviation accidents and serious incidents are caused by multiple contributing factors, and the complexity of human factors emphasizes the need for a multifaceted approach to mitigating pilot error.

Yuliawati I, Sampurna B, Wiguna T, Subekti I, Kekalih A, Mustopo WI, Diatri H, Mulyawan W. Pilot preconditions and errors identified in indonesian aviation accident investigation reports. Aerosp Med Hum Perform. 2025; 96(10):911–918.

INTRODUCTION: Magnesium is essential for numerous physiological processes. Changes in magnesium homeostasis during spaceflight could impact astronaut health, particularly as mission durations increase. This review examines trends in serum, urine, and intake-based magnesium data from published human spaceflight studies.

METHODS: A systematic search was conducted using scientific and government agency databases. Inclusion criteria were English studies of adult astronauts in spaceflight reporting magnesium measurements (serum, urine, or intake). Magnesium data were extracted across in-flight, landing day, and postflight time points. Percent change from baseline was calculated and regression analyses evaluated trends over time.

RESULTS: A total of 20 studies were included. In-flight data showed an early increase in urine magnesium (+19.3% ± 3.6%) without significant trends over time, while serum magnesium remained stable initially but increased with longer flight duration (β = 0.03). On landing day, serum magnesium was similar (−3.92% ± 0.94%) with a nonsignificant trend toward baseline thereafter (β = 0.15), whereas urine magnesium decreased significantly (−30.01 ± 6.74%), followed by a significant trend toward baseline over time (β = 1.16).

DISCUSSION: Microgravity may be associated with early renal magnesium losses and a progressive increase in serum magnesium. This could be a result of initial fluid shifts and neurohormonal changes, followed by progressive loss from bone and muscle, potentially exacerbated by insufficient dietary intake. Data are limited to missions less than 6 mo, leaving long duration consequences unknown. Further research is needed to confirm trends and explore underlying mechanisms.

Diaz TE, Sullivan RD, Ashworth ET, Buesking SC, Haggarty AM, Carmichael BDM, Singh G. Magnesium alterations in human spaceflight. Aerosp Med Hum Perform. 2025; 96(10):919–930.

INTRODUCTION: One crucial aspect of flight safety is being able to detect medical or neuropsychological conditions during aeromedical examinations. However, subtle but safety-significant post-COVID-19 neurocognitive impairments may go unreported or undetected. The Trail Making Test (TMT) and Symbol Digit Modalities Test (SDMT) can detect these impairments in domains essential to pilot performance, though further investigation is needed to assess their effectiveness and clinical utility in routine pilot aeromedical examinations. This short communication presents preliminary findings for using these tests.

METHODS: A study identified the TMT and SDMT as appropriate screening tools for evaluating pilot neurocognitive performance after COVID-19. Mixed methods were then used to compare the screening tools’ performance between post-COVID-19 cases and healthy controls, while also assessing their acceptability and feasibility in routine aeromedical examinations for pilots.

RESULTS: Post-COVID-19 neurocognitive disorders affect skills that are essential for pilot performance. Receiver operating characteristic curve analyses showed the diagnostic accuracy of the screening tests, with area under the curve values of 0.853 for TMT Part B, 0.817 for the SDC version of SDMT, and 0.769 for TMT Part A, indicating their effectiveness in identifying cognitive impairments. Airline pilots considered screening an important flight safety intervention.

DISCUSSION: Airline pilots, together with international aviation psychologists and aviation medicine experts, endorsed the safety-critical importance and value of screening pilots for post-COVID-19 impairments. Given the numerous practical implications of implementing such a strategy, we recommend that pilots be screened for potential post-COVID-19 neurocognitive impairments. A larger study is necessary to validate these preliminary findings and recommendations.

Beka SG, Griffiths RF, Myers JA, Skirrow PM. Post-COVID-19 neurocognitive screening in routine pilot aeromedical evaluations. Aerosp Med Hum Perform. 2025; 96(10):931–935.

BACKGROUND: The syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL syndrome) consists of migraine-like headache episodes with >4 h of hemiparesthesia, dysphasia, and/or hemiparesis plus cerebrospinal fluid lymphocytic pleocytosis. While the rarity of HaNDL syndrome often precludes reassurance of the nature of this syndrome, it has consistently been identified as a benign condition that lasts no longer than 3 mo.

CASE REPORT: In the first week of a viral illness, a 29-yr-old male helicopter pilot experienced acute-onset “stumbling” when walking, “nonsensical speech,” migraine-like headache, scintillating scotomata, and paresthesias of the tongue and bilateral extremities that lasted for 4–6 h. Work-up included lumbar puncture, revealing lymphocytic pleocytosis. A week later, he experienced word-finding difficulty, right-sided numbness/paresthesia, and severe occipital headache lasting 3 h. A third episode with sensory symptoms involving the tongue and right arm and leg occurred for a few hours 25 d after the onset of the first episode. Symptoms resolved spontaneously. A month following initial discharge, he denied symptom recurrence. Repeat lumbar puncture 4 mo later showed resolution of his pleocytosis. He was considered neurologically recovered 3 mo after symptom onset.

DISCUSSION: This patient’s transient episodes were consistent with HaNDL syndrome. His symptom resolution involving three episodes within 25 d reflects the transient nature of this condition. It is critical to recognize HaNDL syndrome as a benign, monophasic disorder that resolves within a maximum of 3 mo so that future pilots with a recent history of HaNDL syndrome may safely and expeditiously return to work.

Wetmore EL, Haddon R, Robertson CE, Cowl CT, Elkhatib WY, Garza I. Headache and neurological deficits with cerebrospinal fluid lymphocytosis in a helicopter pilot. Aerosp Med Hum Perform. 2025; 96(10):936–939.

BACKGROUND: Optimal visual function is essential in aviation to ensure flight safety and mission effectiveness. Pachychoroid neovasculopathy is a relatively recently recognized clinical entity of choroidal neovascularization, belonging to the pachychoroid spectrum, for which intravitreal therapy (IVT) is the standard of care. The main aeromedical considerations are degradation of visual function from disease progression, which could preclude aircrew from flying duties, and the compatibility of IVT with flying.

CASE REPORT: A trained Republic of Singapore Air Force aircrew operator on board the Fokker-50 first presented with a reduction in visual acuity at his annual aircrew medical examination, for which he was restricted from flying duties for further evaluation. He was diagnosed with central serous chorioretinopathy and treated conservatively, but subsequently developed pachychoroid neovasculopathy. He was started on monthly IVT for 3 mo before being placed on a treat-and-extend regimen. After 10 mo of treatment totalling five doses of aflibercept IVT, he achieved resolution of subretinal fluid and recovery of visual acuity, stereopsis, and color vision. He was returned to flying duties upon full recovery, with a close follow-up regimen with his attending ophthalmologist and flight surgeon.

DISCUSSION: Pachychoroid neovasculopathy can cause degradation of visual function and visual incapacitation, posing differential threats to flight safety and mission success based on an aircrew’s vocational roles. The aviation environment could also influence disease progression. Furthermore, aeromedical considerations for IVT are increasingly relevant as IVT becomes the standard of care for prevalent conditions, including neovascular age-related macular degeneration and diabetic macular edema.

Yang WYL, Chay IWJ, Lim HB, Tan MCL, See B, Low JW. Pachychoroid neovasculopathy, intravitreal injection, and implications for aeromedical decision making. Aerosp Med Hum Perform. 2025; 96(10):940–946.

INTRODUCTION: As international efforts in space exploration continue, spaceflight dermatology is a critical field for ensuring the health of astronauts. Microgravity, limited hygiene, and radiation uniquely impair skin integrity, contributing to issues such as dermal atrophy, xerosis, and increased infection risk during spaceflight. This commentary highlights practical strategies and potential research avenues for preventing and addressing the array of dermatologic changes during spaceflight. There are multiple promising interventions, including retinoids, vitamin-A derivatives, calcitriol, L-asparaginase, advanced dressings, telemedicine, and immune-system enhancement strategies which may help mitigate skin-thinning, dermatitis, and slow wound-healing. Continued interdisciplinary collaboration, more human data, and real-time data collection will refine and validate strategies, improving skin health in space. Routine consideration of novel dermatologic therapies may benefit spaceflight and overall mission success as humans venture farther into space.

Henke J, Kamboj S, Barrett D, Idris H, Gangal A, Blalock T. Therapeutic and diagnostic perspectives for advancing spaceflight dermatology. Aerosp Med Hum Perform. 2025; 96(10):947–949.