Early safety outcomes of laparoscopic one anastomosis gastric bypass in patients with class III, IV, and V obesity.

BACKGROUND: The extremely obese patient deserves special consideration: significant comorbidities, technical difficulties, and increased postoperative morbidity and mortality are all expected in this patient population. The study compared early postoperative complications (≤30-day) following one-anastomosis gastric bypass (OAGB) morbidity in patients with morbid obesity class IV obesity, body mass index (BMI) ≥50-59.9 kg/m2, and class V obesity, BMI ≥60 patients. METHODS: We retrospectively reviewed perioperative OAGB outcomes in three BMI groups. Operative time, length of stay (LOS), and overall early postoperative complication rates were studied. Patient-reported complications were ranked by Clavien-Dindo Classification (CDC). RESULTS: Between January 2017-December 2021, consecutive patients with obesity class III (n = 2950), IV (n = 256), and V (n = 23) underwent OAGB. BMI groups were comparable in sex, age, and associated comorbidities. Mean operative time was significantly longer in the higher BMI groups: class III (66.5 ± 25.6 min), IV (70.5 ± 28.7 min), and V (80.0 ± 34.7 min), respectively (p = 0.018); no difference in LOS. In respective BMI classes, ≤30-day complication rates were 3.2%, 3.5%, and 4.3% (p = 0.926). The respective number of patients with CDC grades of one to two were 45 (1.5%), 6 (2.3%), and 1 (4.3%), p = 0.500; and in grade ≥3a, 25 (0.8%), 1 (0.4%), 0 (0.0%), p = 0.669. There was 0.06% mortality (n = 2 in 3229), both in BMI class III. CONCLUSIONS: OAGB is a safe BS procedure in patients with class III, IV, and V obesity in the perioperative term with comparable ≤30-day morbidity in the three BMI groups.

Reconsidering policy of casualty evacuation in a remote mass-casualty incident.

OBJECTIVES: Inappropriate distribution of casualties in mass-casualty incidents (MCIs) may overwhelm hospitals. This study aimed to review the consequences of evacuating casualties from a bus accident to a single peripheral hospital and lessons learned regarding policy of casualty evacuation. METHODS: Medical records of all casualties relating to evacuation times, injury severity, diagnoses, treatments, resources utilized and outcomes were independently reviewed by two senior trauma surgeons. In addition, four senior trauma surgeons reviewed impact of treatment provided on patient outcomes. They reviewed the times for the primary and secondary evacuation, injury severity, diagnoses, surgical treatments, resources utilized, and the final outcomes of the patients at the point of discharge from the tertiary care hospital. RESULTS: Thirty-one survivors were transferred to the closest local hospital; four died en route to hospital or within 30 minutes of arrival. Twenty-seven casualties were evacuated by air from the local hospital within 2.5 to 6.15 hours to Level I and II hospitals. Undertriage of 15% and overtriage of seven percent were noted. Four casualties did not receive treatment that might have improved their condition at the local hospital. CONCLUSIONS: In MCIs occurring in remote areas, policy makers should consider revising the current evacuation plan so that only immediate unstable casualties should be transferred to the closest primary hospital. On site Advanced Life Support (ALS) should be administered to non-severe casualties until they can be evacuated directly to tertiary care hospitals. First responders must be trained to provide ALS to non-severe casualties until evacuation resources are available.

Early outcomes of one-anastomosis gastric bypass in the elderly population at high-volume bariatric centers.

The increasing rate of obesity and life expectancy will lead to increasing numbers of bariatric procedures in the elderly. We aim to report the early (≤ 30 days) adverse events of One-Anastomosis Gastric Bypass (OAGB) in this patient population. Assuta Bariatric Centers in Israel. Retrospective review of perioperative OAGB outcomes between elderly group (≥ 65 years) and non-elderly group (18-64 years) at high-volume bariatric centers between January 2017-December 2021. Operative time, length of stay (LOS), and overall ≤ 30 days complication rates, as ranked by the Clavien-Dindo Classification (CDC) were compared. There were 6618 patients (non-elderly group) and 104 (elderly group) who underwent OAGB. Gender and preoperative BMI were comparable between the two age groups. The elderly group had significantly higher rate of ischemic heart disease and chronic renal failure. The number of patients with LOS ≥ 3 days was significantly higher in the elderly group [19.4% (n = 20) vs. 6.6% (n = 331), respectively; p < 0.001]. The total early adverse events were higher in the elderly group with no statistical significance [7.7% (n = 8) vs. 3.8% (n = 250), respectively; p = 0.062]. The rate of minor and major adverse events and reoperation rate was comparable between the two groups. The rate of readmissions was significantly higher in the elderly group 5.8% (n = 6) vs. 1.9% (n = 124), respectively p = 0.015. There was 0.06% mortality (n = 2) in the non-elderly group. OAGB is a relatively safe metabolic and bariatric surgery for elderly obese patients with early (≤ 30 days) morbidity rates similar to the non-elderly population.

One Anastomosis Gastric Bypass in 6722 Patients: Early Outcomes from a Private Hospital Registry.

BACKGROUND: One-anastomosis gastric bypass (OAGB) is an emerging metabolic bariatric surgery (MBS) type used in both primary OAGB (pOAGB) and revisional OAGB (rOAGB). We studied ≤30-day outcomes of pOAGB and rOAGB and identified predictors of early complications. METHODS: Electronic medical records of all OAGBs performed between January 2017 and December 2021 at a high-volume bariatric clinic in Israel comprising four hospital centers were scanned retrospectively using specialized data software (MDClone software, version 6.1). Data gathered were patients' characteristics, surgical procedure, and ≤30-day complications with Clavien-Dindo Classification (CDC). Multivariate logistic regression analyses were used to identify factors related to early complications of pOAGB and rOAGB. RESULTS: A total of 6722 patients underwent a pOAGB (n = 5088, 75.7%) or rOAGB (n = 1634, 24.3%) procedure at our institution. Preoperative mean age and body mass index (BMI) were 40.6 ± 11.5 years and 41.2 ± 4.6 kg/m2, respectively. Early complications occurred in 258 (3.8%) patients (176 pOAGB and 82 rOAGB) and included mainly bleeding (n = 133, 2.0%), leaks (n = 31, 0.5%), and obstruction/strictures (n = 19, 0.3%). CDC complications for grades 1-2 and grades 3a--5 were 1.5% and 1.6%, respectively. The overall mortality rate was 0.03% (n = 2). Age, operative time ≥3 h, and any additional concomitant procedure were independent predictors of early complications following pOAGB, while a diagnosis of diabetes mellitus and operative time ≥3 h were independent predictors of early complications following rOAGB. CONCLUSIONS: OAGB was found to be a safe primary and revisional MBS procedure in the ≤30-postoperative day term. The most common complications were gastrointestinal bleeding, leaks, and obstruction/stricture.

Addressing the important error of missing surgical items in an operated patient.

BACKGROUND: We aim to analyze the characteristics of incidences of missing surgical items (MSIs) and to examine the changes in MSI events following the implementation of an MSI prevention program. METHODS: All surgical cases registered in our medical center from January 2014 to December 2019 were retrospectively analyzed. RESULTS: Among 559,910 operations, 154 MSI cases were reported. Mean patient age was 48.67 years (standard deviation, 20.88), and 56.6% were female. The rate of MSIs was 0.259/1000 cases. Seventy-seven MSI cases (53.10%) had no consequences, 47 (32.41%) had mild consequences, and 21 (14.48%) had severe consequences. These last 21 cases represented a rate of 0.037/1000 cases. MSI events were more frequent in cardiac surgery (1.82/1000 operations). Textile elements were the most commonly retained materials (28.97% of cases). In total, 15.86% of the cases were not properly reported. The risk factors associated with MSIs included body mass index (BMI) above 35 kg/m2 and prolonged operative time. After the implementation of the institutional prevention system in January 2017, there was a gradual decrease in the occurrence of severe events despite an increase in the number of MSIs. CONCLUSION: Despite the increase in the rate of MSIs, an implemented transparency and reporting system helped reduce the cases with serious consequences. To further prevent the occurrence of losing surgical elements in a surgery, we recommend educating OR staff members about responsibility and obligation to report all incidents that are caused during an operation, to develop an event reporting system as well as "rituals" within the OR setting to increase the team's awareness to MSIs. Trial registration Clinicaltrials.gov (NCT04293536). Date of registration: 08.01.2021. https://clinicaltrials.gov/ct2/show/NCT04293536 .

Benefit versus risk of chromosomal microarray analysis performed in pregnancies with normal and positive prenatal screening results: A retrospective study.

BACKGROUND: Most studies on chromosomal microarray analysis (CMA) and amniocentesis risks have not evaluated pregnancies with low risk for genetic diseases; therefore, the efficacy and safety of CMA and amniocentesis in this population are unclear. This study aimed to examine the benefits and risks of prenatal genetic diagnostic tests in pregnancies having low risk for chromosomal diseases. METHODS AND FINDINGS: In this retrospective study, we used clinical data from a large database of 30,830 singleton pregnancies at gestational age 16-23 weeks who underwent amniocentesis for karyotyping with or without CMA. We collected socio-demographic, medical and obstetric information, along with prenatal screening, CMA and karyotyping results. Fetal loss events were also analysed. CMA was performed in 5,837 pregnancies with normal karyotype (CMA cohort). In this cohort, 4,174 women had normal prenatal screening results and the risk for identifying genetic abnormalities with >10% risk for intellectual disability by CMA was 1:102, with no significant difference between maternal age groups. The overall post-amniocentesis fetal loss rate was 1:1,401 for the entire cohort (n = 30,830) and 1:1,945 for the CMA cohort (n = 5,837). The main limitation of this study is the relatively short follow-up of 3 weeks, which may not have been sufficient for detecting all fetal loss events. CONCLUSION: The low risk for post-amniocentesis fetal loss, compared to the rate of severe genetic abnormalities detected by CMA, suggests that even pregnant women with normal prenatal screening results should consider amniocentesis with CMA.

Interventricular septum thickness predicts future systolic hypertension in young healthy pilots.

Left ventricular hypertrophy (LVH) has been associated with hypertension, although debate exists as to whether LVH is caused by elevated blood pressure (BP) or is a risk factor for its development. The present study evaluates the association between left ventricular structure and the development of hypertension in a young healthy population. We followed young healthy Israeli Air Force aviators from initial echocardiography at the start of their military service to a mean of 7.5+/-3.0 years. Data collection included annual BP measurements, height, weight, smoking habits, and lipid profile. We monitored 500 Air Force men with a mean age of 20.5+/-3.3 (range, 17-40) years and baseline BP of 125+/-13/74+/-8 mmHg. Systolic BP during follow-up was associated with baseline systolic BP, interventricular septum (IVS) thickness, and ejection fraction, whereas diastolic BP was associated only with baseline diastolic BP and body mass index. The probability that the systolic BP during follow-up would be higher than the median was twice that in those with an IVS thickness greater than the median. In conclusion, IVS thickening was associated with long-term elevation of systolic BP. Therefore, it seems that IVS thickening is not merely a result of long-term BP elevation, but may predict the development of systolic hypertension.

Physical examination and ECG screening in relation to echocardiography findings in young healthy adults.

BACKGROUND AND AIMS: Cardiovascular screening in young adults is an important tool in many occupational settings. Our aim was to test whether screening physical examination and ECG influence the rate of abnormal echocardiogarphic findings in young healthy subjects. METHODS: Consecutive echocardiography results of 18- to 20-year-old flight candidates were analyzed retrospectively. Echocardiographies were performed as part of a screening protocol, which includes ECG, physical examination and referral for echocardiography for any positive finding. A second stage includes universal echocardiography for all candidates. RESULTS: 1,066 subjects were evaluated; 489 subjects underwent echocardiography following referral because of abnormal auscultatory or ECG findings. Findings (mostly mild valvular insufficiencies) were demonstrated in 12.7%, with only 0.6% of subjects disqualified. In subjects who underwent universal echocardiography (n = 577), findings (mostly mild valvular insufficiencies) were detected in 18%, with only 0.5% of subjects disqualified. CONCLUSIONS: The rate of significant echocardiography findings is extremely low in this young and healthy population. The presence of abnormal findings on either physical examination or ECG screening was not demonstrated to alter the rate of abnormal echocardiographic findings. We suggest that the low yield of screening should be weighed against the cost of an unidentified congenital cardiac lesion in the specific setting.

Effect of G-force on bicuspid aortic valve in aviators.

BACKGROUND AND AIMS: Bicuspid aortic valve (BAV) is a common congenital cardiac malformation. The major complications are aortic stenosis (AS), aortic regurgitation (AR), infectious endocarditis and aortic dissection. This paper aims to assess the hemodynamic importance of incidentally-found BAV in military aviators and evaluate the effect of high G-force on disease progression. METHODS: Aviators with BAV were detected by reviewing all cardiac assessment records between 1987 and 2005. All aviators underwent annual flight surgeon examination. Echocardiography was performed as recommended by our cardiologists and flight surgeons. RESULTS: Eight newly diagnosed cases of BAV were found. All of the aviators continued active aviation throughout the study period. Repeat echocardiography demonstrated progressive widening of the aortic diameter in five of the eight aviators. No worsening of valve dysfunction was seen in those with mild aortic regurgitation at diagnosis. Left ventricular dimensions and function did not deteriorate. No new valve complications, including infectious endocarditis, were seen. The age at diagnosis strongly correlated with the root diameter change; both total (r = 0.74, p = 0.02) and annualized (r = 0.78, p = 0.02) change. Over a mean follow-up period of 12.1 years, no difference was seen in the progression of BAV in high-performance as compared to low-performance aviators. CONCLUSIONS: Exposure to G-force and anti-G maneuvers does not appear to worsen cardiac and valve function in aviators with BAV.

Posturography as an indicator of fatigue due to sleep deprivation.

BACKGROUND: Fatigue is one of the main causes for accidents in transportation. This study was designed to assess the efficacy of a short objective posturographic test as an indicator of fatigue due to sleep deprivation. OBJECTIVES: To assess the efficiency of a short objective posturographic test as an indicator of fatigue due to sleep deprivation. METHODS: Postural control was measured using four-plate posturograhy with eyes open and eyes closed. Over a period of 26 h of sleep deprivation (from 08:00 to 10:00 the following day) 12 subjects were studied 10 times. The posturographic data were correlated with a subjective fatigue assessed by means of the Stanford Sleepiness Score. RESULTS: Stability and sway intensity while eyes were closed showed a statistically significant circadian pattern with a peak at early morning hours and a recovery at 10:00 the following day. When eyes were open, only changes within the medium-low frequency band (0.1-0.05 Hz), believed to be linked with vestibular function, reached statistical significance. The Subjective Feeling Scale pattern was similar to the postural parameters, but with an absence of recovery at 10:00 the following day. Excluding this point, significant correlations were found between posturography with eyes closed and this scale. CONCLUSIONS: Fatigue caused by sleep deprivation can be objectively assessed by a short, non-invasive, postural test. The vestibular function appears to be relatively more strongly affected by fatigue than the visual and somato-sensory sub-systems. Occlusion of vision appears to enhance the effect of fatigue on postural performance. Our results may imply that this test could be used as an efficient screening tool for detection of fatigue.

Pre-hypertension as a predictor of hypertension in military aviators: a longitudinal study of 367 men.

BACKGROUND: Recently, the seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure introduced the term "pre-hypertension" for systolic blood pressure (BP) levels of 120-139 and diastolic BP levels of 80-89 mmHg. Our aim was to establish the prevalence of this novel entity among young subjects, and to assess the rate of progression to hypertension. METHODS: We retrospectively analyzed the data of a group of 367 male aviators who were examined at the age of 18 and who were followed for an average of 18 +/- 7 yr (range 3-37 yr). Systolic and diastolic BP, heart rate, and body mass index (BMI) were measured at the age of 18 and at the end of the follow-up. RESULTS: At the age of 18, 176 subjects (48%) had pre-hypertension. Subjects with pre-hypertension had higher BP levels (132 +/- 6/76 +/- 8 vs. 115 +/- 6/72 +/- 7 mmHg; p < 0.001), heart rate (71 +/- 12 vs. 65 +/- 12 bpm; p < 0.001) and BMI (22.4 +/- 2.9 vs. 21.7 +/- 2.5 kg x m(-2); p < 0.05) than the subjects with normal BP. During the follow-up period, 110 subjects (30%), 77 with pre-hypertension and 33 with normal BP, developed hypertension. Pre-hypertensive subjects had an odds ratio of 3.7 (95% CI; 2.3-6.2) to develop hypertension as compared with subjects with normal BP. CONCLUSIONS: Pre-hypertension is common and it predicts the development of frank hypertension. Thus, subjects with pre-hypertension should be closely followed and encouraged to begin lifestyle modification in order to prevent future complications.

PET scan as an aid for the return of a head-injured aviator to flying duty.

Head injury is not a rare event in aviators, and poses a difficult dilemma for the flight surgeon regarding return to flying duty due to the fear of post-traumatic epilepsy. Positron emission tomography (PET) is a functional neuroimaging modality that provides additional localizing data in epileptic patients in the interictal phase. We describe a case of penetrating head trauma with no loss of consciousness in a military jet fighter pilot in which the magnetic resonance imaging revealed a minimal brain contusion. PET scan was used as an additional tool for predicting the epileptogenic potential of this finding, thus aiding the decision regarding the return of the aviator to flying duty.

Asthma in military aviators: safe flying is possible.

INTRODUCTION: Asthma is considered relatively incompatible with aviation. Firstly, due to the risk of sudden incapacitation, and secondly, due to cold and dry air and other asthmogenic factors characteristic of the aviation environment. The medical requirements for flying fitness of asthmatic aviators are inconsistent between different air services, and many flight surgeons are unfamiliar with the recent developments in asthma management. This study aims to describe our experience with asthmatic aviators and to discuss the medical standards required for flying fitness in chronic asthma. METHODS: The records of all aviators diagnosed with asthma between January 1988 and September 2005 were reviewed. Pulmonary function tests and examination by a pulmonary disease specialist and flight surgeon were performed at least annually. RESULTS: Nineteen Israeli Air Force aviators with asthma were studied. Most were treated with inhaled long-acting beta agonists and corticosteroids. Disease control was satisfactory in more then 90%, with significant worsening in only one case. We had no cases of sudden incapacitation or any other safety breach. One aviator was grounded 23 yr after diagnosis due to deterioration in the severity of the disease, and another aviator was permanently grounded 1 yr after diagnosis. CONCLUSIONS: Adequate asthma control is readily feasible, even in the aviation environment. Long-term inhaled corticosteroids are effective and have few side effects in aviators. Our management approach to aviators with asthma appears to be safe and effective.

Long-term survivors of childhood malignancies--aeromedical dilemmas and implications.

Survival rates from childhood cancer have dramatically improved over the past three decades; average overall 5-yr survival rates are now > 75%. However, this has been achieved by treatments associated with significant morbidity that may present many years later. This review seeks to delineate the basic information necessary to evaluate flight-training candidates with a history of childhood cancer. We performed a literature review using the Medline database with appropriate search terms related to delayed morbidity and mortality associated with childhood cancer; we did not attempt to evaluate the risk of recurrent cancer. The neurological, cardiovascular, and pulmonary systems were identified areas of aeromedical concern. Central nervous disease and treatment-related effects may increase the risk of seizures or other neurocognitive sequelae. The cardiac toxicity of chemotherapeutic agents such as anthracyclines and radiation may cause late-occurring arrhythmia, cardiac failure, and sudden death, while available screening modalities are of limited value. Pulmonary disease and related treatment effects may cause a 9-fold increase of late-occurring pulmonary fibrosis and lung cancer, with increasing prevalence as long as 25 yr following the cancer diagnosis. Additionally, second malignancies may occur in up to 12.5% of cancer survivors at 25 yr after cancer diagnosis, affecting medical clearance for flight training. In summary, this review discusses the relevant aeromedical issues, including disabilities with specific relevance to the flying environment, risk estimation of late-occurring treatment complications, and possible interactions with occupational exposures in aircrew.

Apical hypertrophic cardiomyopathy and arrhythmia in military pilots.

Apical hypertrophic cardiomyopathy (ApHCM), a subtype of hypertrophic cardiomyopathy, may be found incidentally in healthy young adults. Arrhythmias are poor prognostic signs, and are the most frequent cause of sudden cardiac death. We present two cases of military aviators with ApHCM. One was a high-performance jet weapon system operator, who had asymptomatic non-sustained ventricular tachycardia (NSVT) and subsequently a symptomatic episode of paroxysmal atrial fibrillation. The second was a helicopter pilot, who had asymptomatic NSVT. Both aviators continue their aviation duties without exposure to +Gz under a regime of regular thorough cardiac assessment.

Cervical and lumbar MRI findings in aviators as a function of aircraft type.

BACKGROUND & AIMS: Neck pain and lower back pain (LBP) are frequently reported by military helicopter pilots (HP) and fighter pilots. A small number of studies have used imaging methods to evaluate spinal cervical degenerative findings in pilots exposed to high +Gz, with results indicating an increase in cervical disk protrusions in this population. We evaluated the cervical and lumbar spine with magnetic resonance imaging (MRI) to assess the prevalence of degenerative changes in three subpopulations of pilots. METHODS: Fighter pilots (FP), transport pilots (TP), and HP (10 pilots in each group) underwent cervical and lumbar MRI. Degenerative pathologic changes (disk herniation, cord compression, foraminal stenosis, and the presence of osteophytes) were evaluated in each group by two independent experienced radiologists. RESULTS: Cervical spine degenerative changes seemed to be associated with older age rather then aircraft type, affecting the older group of TP (8/10 pilots) more than the younger FP group who were exposed to high +Gz (3/10 pilots). In contrast, for lumbar spine degenerative changes, we found an uncommon pattern of lumbar spine degeneration in HP, affecting the upper part of the lumbar spine (10/13 disks found at L1-L4). CONCLUSIONS: The results of this study suggest that HP may have detectable degenerative lumbar findings. More research is needed to validate these findings as well as to explore the possible pathophysiological link between occupational exposures and the specific involvement of the upper lumbar spine.

Blood glucose awareness training helps return insulin-treated aviators to the cockpit.

Insulin-treated diabetes mellitus has traditionally been considered disqualifying for aviation duties, the major concern being the risk of hypoglycemia. This phenomenon may lead to impaired judgment and even loss of consciousness, potentially leading to a mishap. Blood glucose awareness training has been advanced as a strategy to avoid hypoglycemia by teaching individuals to use the appearance of autonomic and neuroglycopenic symptoms as indicators of decreasing blood glucose levels. We present two military aviators with newly diagnosed type 1 diabetes mellitus who were returned to flying duty in a multicrew aircraft. Blood glucose awareness training was used as a tool for the education of these aviators regarding the early signs of hypoglycemia in order to avoid development of more significant hypoglycemia. These cases attest to the importance of blood glucose awareness training in the return of diabetic patients to the cockpit.

Pneumomediastinum in student aviators: 10 cases with return to flying duty.

Pneumomediastinum (PnM) is an uncommon phenomenon, though it is one of the most common causes of chest pain in young adults. It may be particularly important among aviators, as it may result in in-flight incapacitation. Spontaneous PnM is a variant usually associated with the Valsalva maneuver, used during high-performance flight. This may increase the risk of PnM recurrence and raises concern regarding the return to flight duties of aviators after an episode of spontaneous PnM. We present 10 student aviators who experienced a single episode of uncomplicated PnM unassociated with flight. All were returned to flying duty following a normal pulmonary evaluation and are still in active duty. Follow-up was conducted for a mean period of 74.7 mo without any adverse consequences. These findings support the return of aviators to flying duty after a single episode of uncomplicated spontaneous PnM.

Laparoscopic inguinal hernioplasty in aviators.

Repair of inguinal hernias may be performed using either open surgery or laparoscopic techniques. Following surgery, a 6-wk waiting period is generally recommended before a pilot returns to active duty, including flight in high-performance aircraft. A shorter waiting period would be operationally useful and may be possible following either a trans-abdominal preperitoneal (TAPP) laparoscopic technique or a totally extra-peritoneal (TEP) approach. In this manuscript we present the cases of four aviators who underwent inguinal hernia repair via the TEP approach and were returned to the cockpit 21 d later with no evident complications. Although this sample is small, it emphasizes the potential benefit of the TEP approach in aviators.

The maintenance of wakefulness test as a predictor of alertness in aircrew members with idiopathic hypersomnia.

Aviators are required to maintain a high level of alertness during their missions. Two conditions that may disrupt this alertness are fatigue and hypersomnia. Fatigue is a physiological state, while hypersomnia is a pathologic state, also termed excessive daytime sleepiness (EDS), which is manifested by the tendency to fall asleep in inappropriate places or situations, such as during flight or driving. Hypersomnolence may be diagnosed by subjective measurements, such as the Epworth sleepiness scale, but the diagnosis is established by two objective tests: the Multiple Sleep Latency Test (MSLT) and the Maintenance of Wakefulness Test (MWT). The first consists of four 20-min sessions used to determine the time it takes the patient to fall asleep when given the opportunity and is considered positive when the sleep latency time is shorter than 5 min, although some authors use 8 min as the cut-off for the diagnosis. The Maintenance of Wakefulness Test (MWT) consists of four 40-min sessions during which the patient attempts to maintain wakefulness while seated in a dark, quiet room during the day. Herein we report 2 cases of aviators who were returned to flying duty despite a pathologic MSLT. These aviators were waivered based on a normal MWT and safety history obtained from their commanders.