Cardiovascular Risk Factor Modification in Asymptomatic Adults and Implications for Pilots.

This study aims to examine the available evidence that supports a more aggressive approach to managing asymptomatic people with low to intermediate cardiovascular risks; to evaluate the appropriate threshold for initiating pharmacologic interventions to treat hyperglycaemia, hyperlipidaemia, and hypertension; and to describe the implications for airline pilots. A systematic search was performed employing an OvidSP interface, including all EBM Reviews, EMBASE, and Ovid MEDLINE databases. Data, including sixteen randomised controlled trials, on the appropriate threshold for initiating pharmacologic interventions were extracted. Studies on the treatment of hyperlipidaemia indicated that the threshold for initiation of intervention in intermediate-risk people is a LDL-C level of 3.36 mmol/l (130 mg/dl). There was no lower limit or optimal LDL-C level below which further reduction was no longer beneficial. Studies on the treatment of hyperglycaemia suggested that a threshold of fasting plasma glucose of ≥5.3 mmol/l (95 mg/dl) and 2-hour postprandial glucose level of 7.8 mmol/l (140 mg/dl) is reasonable for initiating pharmacologic intervention. Initiating treatment to people with a blood pressure of ≥130/≤89 mmHg or ≤139/≥85 mmHg significantly reduced the risk of developing stage 1 hypertension. Multifactorial intervention studies showed that, in hypertensive patients (BP ≥160/≥100 mmHg), initiating treatment to those with a total cholesterol of 6.5 mmol/l (251.35 mg/dl) or higher resulted in a significant reduction in the risk of developing fatal and non-fatal cardiovascular events. The available evidence from large quality trials supports a more aggressive approach to managing hyperglycaemia, hyperlipidaemia, and hypertension in asymptomatic pilots with a 5-year CVD risk of 5-10% and 10-15%.

Cardiovascular Tests for Risk Assessment in Asymptomatic Adults and Implications for Pilots.

BACKGROUND: This study aims to examine which marker or testing protocols have been suggested for cardiovascular disease (CVD) risk assessment in asymptomatic populations, at which CVD risk level, and how this can be implemented for CVD risk assessment in pilot populations. METHODS: A systematic search was performed using Systematic Reviews Subset on PubMed; the OvidSP interface, including all EBM reviews and EMBASE databases; and the G-I-N International Guideline Library. From each recommendation, we extracted data on consideration of the use of a marker or test for cardiovascular risk assessment in asymptomatic populations. RESULTS: Included were 45 guidelines, systematic reviews, or meta-analyses relevant to cardiovascular risk assessment in asymptomatic populations. The majority (9/12) of the citations recommend coronary artery calcium score (CACS) for CVD risk assessment in intermediate-risk (10-yr CVD risk score of 10-20%) asymptomatic adults. Other cardiac and vascular tests that may also be considered include the measurements of carotid-intima media thickness, supplemented by carotid plaque, and the ankle brachial index for prevention of peripheral artery disease and stroke. Stress myocardial perfusion scan is the potential cardiac functional test to be used with pilots with 5-yr risk of ≥15%. Among laboratory markers, only hs-CRP has a potency to be used in CVD risk assessment in intermediate-risk asymptomatic adults; however, the strength of the recommendation is not adequate. DISCUSSION: Among the cardiac and vascular testing available, CACS is the most frequently suggested test. The implications of findings for CVD risk assessment in airline pilots are highlighted in this paper.Wirawan IMA, Griffiths RF, Larsen PD. Cardiovascular tests for risk assessment in asymptomatic adults and implications for pilots. Aerosp Med Hum Perform. 2018; 89(7):648-656.

Fatigue in Air Medical Clinicians Undertaking High-acuity Patient Transports.

Abstract Background. Fatigue is likely to be a significant issue for air medical transport clinicians due to the challenging nature of their work, but there is little published evidence for this. Objective. To prospectively assess the levels and patterns of fatigue in air medical transport teams and determine whether specific mission factors influenced clinician fatigue. Methods. Physicians and flight nurses from two intensive care interhospital transport teams routinely completed fatigue report forms before and after patient transport missions over a 4-month period. Data collected included subjective ratings of fatigue (Samn-Perelli and visual analog scale), mission difficulty and performance. Multivariate hierarchical logistic and linear models were used to evaluate the influence of various mission characteristics on post-mission fatigue. Results. Clinicians returned 403 fully complete fatigue report forms at an estimated overall return rate of 73%. Fatigue increased significantly over the course of missions, and on 1 of every 12 fatigue reports returned clinicians reported severe post-mission fatigue (that is, levels of 6 or 7 on the Samn-Perelli scale). Factors that impacted significantly on clinician fatigue were the pre-mission fatigue level of the clinician, night work, mission duration, and mission difficulty. Poorer self-rated performance was significantly associated with higher levels of fatigue (r = -0.4, 95% CI -0.5 to -0.3), and for the 6-month period leading up to the study clinicians reported a total of 22 occasions on which they should have declined a mission due to fatigue. Conclusions. These results suggest that clinicians undertaking interhospital transports of even moderate duration experience high levels of fatigue on a relatively frequent basis. In the unique and challenging environment of air medical transport, prior fatigue, long or difficult missions, and the disadvantageous effect of night work on normal circadian rhythms are a combination where there are minimal safety margins for clinicians' performance capacity. Fatigue prevention or fatigue resistance measures could positively affect air medical clinicians in this context.

Cardiovascular investigations of airline pilots with excessive cardiovascular risk.

BACKGROUND: This study examined the prevalence of airline pilots who have an excessive cardiovascular disease (CVD) risk score according to the New Zealand Guideline Group (NZGG) Framingham-based Risk Chart and describes their cardiovascular risk assessment and investigations. METHODS: A cross-sectional study was performed among 856 pilots employed in an Oceania based airline. Pilots with elevated CVD risk that had been previously evaluated at various times over the previous 19 yr were reviewed retrospectively from the airline's medical records, and the subsequent cardiovascular investigations were then described. RESULTS: There were 30 (3.5%) pilots who were found to have 5-yr CVD risk score of 10-15% or higher. Of the 29 pilots who had complete cardiac investigations data, 26 pilots underwent exercise electrocardiography (ECG), 2 pilots progressed directly to coronary angiograms and 1 pilot with abnormal echocardiogram was not examined further. Of the 26 pilots, 7 had positive or borderline exercise tests, all of whom subsequently had angiograms. One patient with a negative exercise test also had a coronary angiogram. Of the 9 patients who had coronary angiograms as a consequence of screening, 5 had significant disease that required treatment and 4 had either trivial disease or normal coronary arteries. CONCLUSION: The current approach to investigate excessive cardiovascular risk in pilots relies heavily on exercise electrocardiograms as a diagnostic test, and may not be optimal either to detect disease or to protect pilots from unnecessary invasive procedures. A more comprehensive and accurate cardiac investigation algorithm to assess excessive CVD risk in pilots is required.

A study of airline pilot morbidity.

INTRODUCTION: It has long been believed that airline pilots are healthier than the general population. There are a number of reasons why this should be the case. However, there is very little evidence to support this belief as fact. This study investigates the health of the pilot population of an Oceanic based airline compared to the health of the general population. METHODS: Pilots who conducted their medical certificate renewal at the airline's medical unit between 1 November 2009 and 31 October 2010 were included. A medical questionnaire was completed by each pilot at the time of their medical certificate renewal. Data from the questionnaire was entered into a database as well as the pilot's BMI, blood pressure, lipid profile, and blood glucose level. The comparison population was the population who completed the New Zealand Health Survey (NZHS) between 2006-2007. Demographic, lifestyle characteristics, and health status data from the pilots was compared to the NZHS using a Chi-squared test. RESULTS: Included in the study were 595 pilots. With respect to most medical conditions, pilots had a lower prevalence when compared to the general population. Pilots had a higher prevalence of kidney disease (3.3% vs 0.6%) and melanoma skin cancer (19 per 1000 vs 0.4 per 1000). DISCUSSION: This study suggests that pilots in New Zealand are healthier than the general population with respect to most medical conditions. The two medical conditions that were identified as being overrepresented in pilots may be the result of the occupational environment.

Cardiovascular risk score and cardiovascular events among airline pilots: a case-control study.

BACKGROUND: A cardiovascular risk prediction score is routinely applied by aviation authorities worldwide. We examined the accuracy of the Framingham-based risk chart used by the New Zealand Civil Aviation Authority in predicting cardiovascular events among airline pilots. METHODS: A matched case-control design was applied to assess the association of 5-yr cardiovascular risk score and cardiovascular events in Oceania-based airline pilots. Cases were pilots with cardiovascular events as recorded on their medical records. Each case was age and gender matched with four controls that were randomly selected from the pilot population. To collect data before the events, 5-yr retrospective evaluations were conducted. RESULTS: Over a 16-yr study period we identified 15 cases of cardiovascular events, 9 (60%) of which were sudden clinical presentations and only 6 (40%) of which were detected using cardiovascular screening. There were 8 cases (53%) and 16 controls (27%) who had a 5-yr risk of > or = 10-15%. Almost half of the events (7/15) occurred in pilots whose highest 5-yr risk was in the 5-10% range. Cases were 3.91 times more likely to have highest 5-yr risk score of > or =10-15% than controls (OR = 3.91, 95% CI 1.04-16.35). The accuracy of the highest risk scores were moderate (AUC = 0.723, 95% CI 0.583-0.863). The cutoff point of 10% is valid, with a specificity of 0.73, but low sensitivity (0.53). CONCLUSION: Despite a valid and appropriate cutoff point, the tool had low sensitivity and was unable to predict almost half of the cardiovascular events.

The occupational health and safety of flight attendants.

In order to perform safety-critical roles in emergency situations, flight attendants should meet minimum health standards and not be impaired by factors such as fatigue. In addition, the unique occupational and environmental characteristics of flight attendant employment may have consequential occupational health and safety implications, including radiation exposure, cancer, mental ill-health, musculoskeletal injury, reproductive disorders, and symptoms from cabin air contamination. The respective roles of governments and employers in managing these are controversial. A structured literature review was undertaken to identify key themes for promoting a future agenda for flight attendant health and safety. Recommendations include breast cancer health promotion, implementation of Fatigue Risk Management Systems, standardization of data collection on radiation exposure and health outcomes, and more coordinated approaches to occupational health and safety risk management. Research is ongoing into cabin air contamination incidents, cancer, and fatigue as health and safety concerns. Concerns are raised that statutory medical certification for flight attendants will not benefit either flight safety or occupational health.

Symptom-based categorization of in-flight passenger medical incidents.

INTRODUCTION: The majority of in-flight passenger medical events are managed by cabin crew. Our study aimed to evaluate the reliability of cabin crew reports of in-flight medical events and to develop a symptom-based categorization system. METHODS: All cabin crew in-flight passenger medical incident reports for an airline over a 9-yr period were examined retrospectively. Validation of incident descriptions were undertaken on a sample of 162 cabin crew reports where medically trained persons' reports were available for comparison using a three Round Delphi technique and testing concordance using Cohen's Kappa. A hierarchical symptom-based categorization system was designed and validated. RESULTS: The rate was 159 incidents per 106 passengers carried, or 70.4/113.3 incidents per 106 revenue passenger kilometres/miles, respectively. Concordance between cabin crew and medical reports was 96%, with a high validity rating (mean 4.6 on a 1-5 scale) and high Cohen's Kappa (0.94). The most common in-flight medical events were transient loss of consciousness (41%), nausea/vomiting/diarrhea (19.5%), and breathing difficulty (16%). DISCUSSION: Cabin crew records provide reliable data regarding in-flight passenger medical incidents, complementary to diagnosis-based systems, and allow the use of currently underutilized data. The categorization system provides a means for tracking passenger medical incidents internationally and an evidence base for cabin crew first aid training.

Retention of knowledge and skills in first aid and resuscitation by airline cabin crew.

The study was conducted to investigate the retention of CPR and AED skills, first aid knowledge and perceived levels of confidence for a sample of 35 cabin crew 12 months after recurrent training. The 35 cabin crew undertook a mock resuscitation scenario using the AED and bag-valve-mask carried in the medical kit. Of the 35 subjects, 33 subjects failed to use the bag-mask correctly, 18 performed chest compressions at the incorrect site, only 13 achieved the correct compression depth, only 20 placed the AED pads correctly, and the average time to first shock was 110 s after commencement of the resuscitation. While theoretical first aid knowledge was high, the participants held low levels of self-confidence in their CPR and AED skills. The results of this study indicate that cabin crew may not have sufficiently high levels of skill to manage a cardiac arrest adequately. This suggests that existing approaches to training of cabin crew require further investigation and modification.

Visual conversion disorder in a harbor pilot leading to sudden loss of control of a large vessel.

We describe an accident caused by the rapid onset of visual impairment in a ship's pilot, who was subsequently diagnosed as having visual conversion disorder (hysterical blindness). This case is documented to draw attention to the unusual cause of sudden incapacitation in transport crew and the consequential threat to transportation safety. Because sudden visual impairment incidents caused by conversion disorder are isolated and rare, they may be under-reported in the scientific literature. While it is unlikely that current systems for medical screening could anticipate and/or prevent crew incapacitation due to conversion disorders, this condition should be borne in mind when consulted by crew who report otherwise unexplained physical symptoms in the context of high levels of personal stress. It should also be considered when investigating possible medical incapacitation in transportation incidents or accidents.