French mobile neurosurgical unit: a retrospective analysis of 22 years of mission.

INTRODUCTION: The French mobile neurosurgical unit (MNSU) is used to provide specific support to remote military medicosurgical units deployed in foreign theatres. If a neurosurgical casualty is present, the Role 2 team may request the MNSU to be deployed directly from France. The deployed neurosurgeon can then perform surgery in Role 2 or decide to evacuate the casualty and perform surgery in Role 4 in France. We provide an epidemiological analysis of MNSU missions between 2001 and 2023 and investigate the value of the MNSU for the French Armed Forces. METHODS: We conducted a retrospective case series that included patients managed by the MNSU from 1 January 2001 to 31 January 2023. We collected epidemiological data (eg, age, military or civilian status, delay between transmission and takeoff, origin of the injury and mission location), clinical records (aetiologies of the injury and disease), data on surgical intervention (operator nature and type of surgery) and data on postoperative outcomes recorded at the time of discharge from hospital. RESULTS: 51 patients were managed by the MNSU. 36 (70.5%) and 3 (5.8%) patients underwent surgery on Role 2 and Role 4, respectively. 39 (76.9%) interventions were due to traumatic injury, 4 (7.8%) due to hydrocephalus, 4 (7.8%) due to vascular causes, 3 (5.9%) due to tumour and 1 (2%) due to spine degeneration. In 30 (76.9%) of these cases, the first operator was a neurosurgeon from the MNSU, whereas in the remaining 9 (23.1%) cases, procedures were initially performed by a non-neurosurgeon. CONCLUSION: The MNSU contribution to D1 casualties' strategic evacuation (STRATEVAC) is important. The MNSU provides additional support for STRATEVAC during the reorganisation of French Armed Forces engaged in several fronts. With the return of high-intensity wars, the French MNSU must develop and adjust for the management of massive influxes of casualties.

Perception, confidence, and willingness to respond to in-flight medical emergencies among medical students: a cross sectional study.

BACKGROUND: In-flight medical emergencies (IMEs) are expected to increase as air travel normalized in the post-COVID-19 era. However, few studies have examined health professions students' preparedness to respond to such emergencies. Therefore, this study aimed to investigate medical students' knowledge, confidence, and willingness to assist during an IME in their internship program. METHODS: This cross-sectional survey utilized an online, self-administered questionnaire-based survey targeted at medical students at two medical colleges in Saudi Arabia. The questionnaire comprised three parts: sociodemographic characteristics, knowledge about aviation medicine (10 items), and confidence (7 items)/willingness (4 items) to assist during an IME. Odds Ratios (OR) and 95% Confidence Intervals (95%CI) were computed to detect potential associations between the knowledge levels and the other independent variables. Responses to confidence and willingness questions were scored on a 5-point Likert scale. RESULTS: Overall, 61.4% of participants had inadequate knowledge scores for providing care during an IME, and the proportion of participants did not differ between those who had or had not attended life support courses (60.4% vs. 66.7%, p > 0.99). Only frequency of air travel ≥ two times per year was associated with higher odds of adequate knowledge score [OR = 1.89 (95%CI 1.14-3.17), p = 0.02]. In addition, 93.3% of the participants had low, 6.3% had moderate, and 0.8% had high willingness scores, while 86.3% had low, 12.2% had moderate, and 1.5% had high confidence scores. There were no differences in the proportion of participants with low, moderate, and high willingness or confidence scores by attendance in life support courses. CONCLUSION: Even though over 8 in 10 students in our study had previously attended life support courses, the overwhelming majority lacked the knowledge, confidence, and willingness to assist. Our study underscores the importance of teaching medical students about IMEs and their unique challenges before entering their 7th-year mandatory general internship.

Determining the Best Approach: Comparing and Contrasting the Impact of Different Coping Strategies on Work-Related Stress and Burnout Among Saudi Commercial Pilots.

Background Many physiological, psychological, and environmental stressors can be experienced by pilots throughout their careers, which may affect their mental and psychological health and their performance consequently. Stressing factors of aviation and commercial operations can result in pilots' burnout, which is a description of the response to chronic emotional exhaustion and loss of motivation. Objective The objective of this study was to determine the prevalence of burnout and compare the effects of different coping strategies on burnout levels among commercial pilots in the Kingdom of Saudi Arabia, 2023 Methods The study was a cross-sectional survey utilizing an online form of a validated questionnaire administered to pilots of Saudi commercial airlines in the Kingdom of Saudi Arabia. The study targeted on-duty Saudi commercial pilots, excluding retired and in-training pilots, with an estimated population of around 2000. A sample size of 311 was determined using an equation considering a 5% margin of error, 95% confidence level, and a 60.3% burnout prevalence rate. Non-probability snowball sampling method was used to achieve sample size. Results A total of 321 pilots were included, mostly Saudis. The participants had a median age of 47, and the majority were married with one to two children. BMI classifications showed high percentages of overweight and obese individuals. The study found that most pilots experienced medium levels of burnout (70.1%). Nationality, marital status, and shorter sleeping duration were significantly associated with higher burnout levels. Common challenges included long duties (79.4%), irregular working hours (72.3%), and time away from home (55.5%). Coping strategies included rest and sleep (81%), exercise (59.2%), and relaxation behaviors (50.5%). Stressors such as long duties, irregular working hours, and work conflicts were significantly associated with higher burnout levels. However, no significant associations were found between coping strategies and burnout levels. Conclusion The study found that most pilots experienced medium levels of burnout. In addition, common challenges included long duties, irregular working hours, and time away from home. The study emphasizes the need to address work-related stressors, implement interventions, and support pilots' mental health. Promoting healthy coping strategies and understanding individual resilience is important. Further research and organizational efforts are required to mitigate burnout and enhance the quality of life for aviation professionals, benefiting both individuals and the industry.

Degenerative cervical spine changes among early career fighter pilots: a 5-year follow-up.

INTRODUCTION: Degenerative changes of the cervical spine often cause disability and flight duty limitations among Finnish Air Force (FINAF) fighter pilots. We aimed to study the effect of +Gz exposure on degenerative changes in the cervical spine by comparing cervical MRIs of FINAF fighter pilots and controls. METHODS: At baseline, the volunteer study population consisted of 56 20-year-old FINAF male fighter pilots (exposure group) and 56 21-year-old Army and Navy cadets (control group). Both groups underwent MRI of the cervical spine at the baseline and after 5 years. Degenerative changes evaluated using MRI included intervertebral disc (IVD) degeneration (Pfirrmann classification), disc herniations, uncovertebral arthrosis, Schmorl's nodes, Modic changes, spinal canal stenosis, kyphosis and scoliosis. RESULTS: The degree of IVD degeneration in the whole cervical spine increased significantly in both populations with no between-group differences. The prevalence of disc herniations also tended to increase in both populations with no difference in the incidence over the follow-up. However, pilots proved to have more disc herniations at the baseline and at the follow-up. There were virtually no between-group differences in other assessed degenerative changes. DISCUSSION: We found that IVD degeneration and the prevalence of disc herniations increased at a similar rate for fighter pilots and non-flying military students when all cervical levels were summed up. The lack of difference may be explained by the relatively low cumulative +Gz exposure during the first 5 years of a pilots' career.

Collective aeromedical evacuations of SARS-CoV-2-related ARDS patients in a military tactical plane: a retrospective descriptive study.

After the appearance of the COVID-19 pandemic in France, MEROPE system was created to transform the military tactical ATLAS A400M aircraft into a flying intensive care unit. Collective aeromedical evacuations (aero-MEDEVAC) of patients suffering from SARS-CoV-2-related acute respiratory distress syndrome was performed from June to December 2020. A total of 22 patients were transported during seven missions. All aero-MEDEVAC was performed in safe conditions for patients and crew. No life-threatening conditions occurred during flight. Biohazard controls were applied according to French guidelines and prevented crew contamination. Thanks to rigorous selection criteria and continuous in-flight medical care, the safe transportation of these patients was possible. To the best of our knowledge, this is the first description of collective aero-MEDEVAC of these kinds of patients using a tactical military aircraft. We here describe the patient's characteristics and the flight's challenges.

Comparison of injuries between US Army paratroopers and their non-paratrooper soldier counterparts.

INTRODUCTION: Military studies have investigated acute injuries associated with parachute jumps, but the literature does not address paratroopers' cumulative microtraumatic (CMT) injury risk, nor does it compare injury risks between paratroopers and the rest of the military population. This study determined whether US active duty Army paratroopers experienced greater injury risks than their non-paratrooper soldier counterparts and whether their injuries cost more to treat suggesting greater injury severity. METHODS: This retrospective study evaluated electronic medical records (2016-2018) for 31 621 paratroopers and a randomly selected comparison group of 170 715 non-paratrooper soldiers. Analyses included univariate and multivariate regression to quantify odds of injuries associated with risk variables and additional descriptive statistics. RESULTS: Paratroopers had a 57% increase in the odds of experiencing one or more injuries (OR=1.57, 95% CI: 1.52 to 1.62) after controlling for sex, race and age, with a greater proportion of acute injuries (OR=1.38, 95% CI: 1.34 to 1.42), relative to comparison group soldiers. Injury types proportionally higher among paratroopers included head trauma and shoulder injuries. Average injury cost among paratroopers was 13% lower than for non-paratroopers ($2470 vs $2830 per injury). Among both populations, acute injury costs were notably higher than for CMT injuries (paratroopers, $1710/$630; non-paratroopers, $1860/$880 per injury). CONCLUSIONS: Paratroopers were more likely to incur injury, especially an acute injury, than non-paratroopers. However, paratroopers' average injury costs were less. This may be due to higher return-to-duty motivations, fitness levels, and/or facility-specific cost of care. Future studies should investigate causes of injuries found to be proportionally higher among paratroopers.

Cardiovascular risk profiles in German Air Force pilots.

INTRODUCTION: Cardiovascular disease (CVD) is the leading cause of death in western industrial countries and one of the most frequent causes of sudden incapacitation in flight for pilots. There are limited data available on cardiovascular risk profiles of pilots, and especially military pilots. The aim of this study was to assess the prevalence of cardiovascular risk factors (CVRF) in German military pilots. METHODS: The changing prevalence of CVRF in active military pilots was studied using a cross-sectional survey during two distinct periods, 2007-2009 and 2016-2018. Data collected included sex, body mass index (BMI), smoking status, resting blood pressure, total cholesterol, high density lipoprotein (HDL), low density lipoprotein (LDL), triglycerides and glucose. The use of antihypertensive drugs, diagnosis of diabetes mellitus and positive family history of myocardial infarction were also captured. Based on these data, the PROCAM (Prospective Cardiovascular Münster) score was calculated. RESULTS: Data from 5353 flight medical examinations were analysed, 3397 from 2007 to 2009, and 1959 from 2016 to 2018. Between the cohorts, age, BMI, total cholesterol, HDL, LDL, glucose and triglycerides increased significantly. The number of pilots on antihypertensive medication decreased significantly. The PROCAM score increased between cohorts from 18 to 23 points predicting a 10-year risk of an acute coronary event of <1% and 1.3%, respectively. CONCLUSION: The German military pilot population has become older with increased CVRF. CVD will be a future challenge for the German Armed Forces and probably other military forces. However, there was only a mild increase of the PROCAM score over time.

Trans-Atlantic aeromedical repatriation of multiple COVID-19 patients: a hybrid military-civilian model.

Here, we report the first known transcontinental aeromedical evacuation of a large number (55) of patients with known and suspected positive COVID-19. These patients were evacuated from Havana, Cuba, to the UK through MOD Boscombe Down as part of Operation BROADSHARE, the British military's overseas response to COVID-19. We describe the safe transfer of patients with COVID-19 using a combined military-civilian model. In our view, we have demonstrated that patients with COVID-19 can be aeromedically transferred while ensuring the safety of patients and crew using a hybrid military-civilian model; this report contains lessons for future aeromedical evacuation of patients with COVID-19.

Negative impact of high-performance flights on aviators with mitral valve prolapse.

BACKGROUND: While it appears not to affect healthy aviators' hearts, there are scarce data regarding the impact of high-performance flights on aviators with mitral valve prolapse (MVP). METHODS: A retrospective, comparative cohort study of military aviators with MVP. Subjects were categorized to either high-performance (jet fighter) or low-performance (transport and helicopter) aviators. The primary outcomes were the rates of mitral interventions and of adverse cardiovascular events since being an aircrew candidate and up to the end of flying career. Additional outcomes were echocardiographic measurements and the cumulative proportion of mitral valve interventions over time. RESULTS: Of 33 male aviators with MVP, 18 were high-performance aviators. On average, follow-up started at age 18.5 years and lasted 27.8 ±â€¯10.1 years. Baseline characteristics were similar between the study groups. Aviators of high-performance aircraft had increased rates of mitral valve surgery (33 % vs. 0, p = 0.021), MVP-related complications (39 % vs. 6.7 %, p = 0.046), and a higher incidence of mitral valve repair over time (p = 0.02). High-performance flight was associated with increased intraventricular septum thickness (IVS, 9.7 mm vs 8.9 mm, p = 0.015) and IVS index (p = 0.026) at the last echocardiographic assessment. High-performance aviators tended to develop worsening severity of mitral regurgitation. CONCLUSIONS: High-performance flight may be associated with an increased risk for valvular deterioration and need for mitral surgery in aviators with MVP.

Lateral Epicondylitis of the Elbow in an Airline Pilot Regarding Throttle Lever Operation.

Lateral epicondylitis is a degenerative condition affecting the origin of the extensor tendon in the forearm. It is the primary etiology of elbow pain in adults and is also a frequently reported ailment in various occupational sectors. Herein, we present a case of lateral epicondylitis in an airline pilot. The etiology was supposed to be the frequent and prolonged use of throttle levers in the at-risk limb position, i.e., forearm pronation and wrist dorsiflexion. Despite limited treatment options due to aeromedical standards, the patient recovered after approximately one month, primarily by means of physical therapy and improving the working posture. In general, pilots are subject to strict medical standards and may not receive standard treatments. There are also reports of treatment withdrawal and concealment of disease due to fear of losing their license. The treatment of pilots requires special consideration based on doctor-patient trust and occasionally collaboration with experts in aviation medicine, such as aeromedical examiners.

Impact of flight and equivalent short-term high-altitude exposure on ocular structures and function.

Background: Exposure to high-altitude conditions during flight or similar activities affects many aspects of visual function, which is critical not only for flight safety but for any altitude-related activity. We aimed to summarize the available literature pertaining to ocular changes during flight or equivalent short-term high-altitude exposure (e.g., hypobaric chamber, effortless ascent lasting ≤ 24 h) and to highlight future research priorities. Methods: Using the PubMed/MEDLINE and Web of Science/ISI Web of Knowledge databases with structured search syntax, we conducted a systematic review of the literature spanning a 40-year period (January 1, 1983, to October 10, 2023). Articles pertaining to ocular changes during flight or flight-equivalent exposure to altitude were retrieved. The reference lists of retrieved studies were also searched, and citations of these references were included in the results. Results: Of 875 relevant PubMed and ISI publications, 122 qualified for inclusion and 20 more were retrieved from the reference lists of initially selected records, for a total of 142 articles. Reported anterior segment changes included deterioration in tear film stability and increased dry eye incidence, increased corneal thickness, discomfort and bubble formation in contact lens users, refraction changes in individuals with prior refractive surgery, decreased intraocular pressure, and alterations in pupillary reaction, contrast sensitivity, and visual fields. Photoreceptor-visual pathway changes included alterations in both photoreceptors and neuro-transduction, as evidenced in dark adaptation, macular recovery time, reduction in visual field sensitivity, and optic neuritis (likely an element of decompression sickness). Retinochoroidal changes included increases in retinal vessel caliber, retinal blood flow, and choroidal thickness; central serous chorioretinopathy; and retinal vascular events (non-arteritic ischemic optic neuropathy, high-altitude retinopathy, and retinal vein occlusion). Conclusions: The effect of short-term high-altitude exposure on the eye is, in itself, a difficult area to study. Although serious impairment of visual acuity appears to be rare, ocular changes, including tear film stability, contact lens wear, central corneal thickness, intraocular pressure, contrast sensitivity, stability of refractive surgeries, retinal vessels, visual fields, and macula recovery time, should be considered in civilian aviators. Our report provides guidance to climbers and lowlanders traveling to altitude if they have pre-existing ocular conditions or if they experience visual symptoms while at altitude. However, key outcomes have been contradictory and comprehensive studies are scarce, especially those pertaining to the choroid and retina. Such studies could not only deepen our understanding of high-altitude ocular pathophysiology, but could also offer valuable information and treatment possibilities for a constellation of other vision-threatening diseases.

Temporal trends in anticoagulation management for US active duty personnel with atrial fibrillation.

ObjectivesThis study aims to investigate US active duty (AD) military members diagnosed with atrial fibrillation (AF) and the temporal trends of systemic anticoagulation (AC). Our secondary objective is to study the AC prescriptions in AD military members diagnosed with AF and associated military dispositions and deployment rates. DESIGN AND SETTING: A retrospective investigation of Tricare pharmacy AC prescriptions within the San Antonio Military Health System from January 2004 to July 2019 for AD individuals diagnosed with AF was performed. PARTICIPANTS: 386 AD personnel with non-valvular AF were analysed (mean age 35.0±9.4 years; mean body mass index, 28.3±4.3 kg/m2; 93% male; 57% Caucasian, 94% paroxysmal AF). OUTCOMES: The temporal trends of systemic AC prescriptions were the primary outcome measures. The association between AC prescriptions and military dispositions and deployments were secondary outcomes of interest. STATISTICAL ANALYSIS: The association between AC management, future deployments and military disposition was analysed using χ2 and Fisher's exact test for categorical variables. The t-test was used for comparison of continuous variables. RESULTS: CHA2DS2-VASc and HAS-BLED scores were low (0.39±0.65 and 0.86±0.63, respectively). 127 (33%) members received warfarin and 58 (15%) received direct oral anticoagulants (DOACs). Rates of military retention were not different between AC histories (no AC (64%) vs warfarin (75%) vs DOAC (65%); p=0.425). There was a significant trend of more recent utilisation of DOACs compared with warfarin (p<0.0001). When adjusted for temporal changes in deployment rates, there was no significant difference in deployment between AC groups (no AC (39%) vs warfarin (49%) vs DOAC (27%); p=0.9472). CONCLUSIONS: This is the first report describing AC utilisation in US AD military members with AF. Young AD personnel with low stroke and bleeding risks do not commonly receive AC prescriptions. DOAC prescription rates are increasing and predominate over warfarin for AC indications.

Evolution of military evacuation activity in French Guiana over 10 years: a retrospective observational study.

BACKGROUND: Three permanent military operations are established in French Guiana. The Cayenne medical unit is a French military search and rescue unit and provides MEDEVAC and CASEVAC for ill and injured soldiers. The main objective of this study was to describe the temporal trends of its evacuation missions over 10 years. The secondary purpose was to document the means used for these missions. METHODS: This retrospective observational study included patients who were evacuated for a medical reason or an injury during military operations in French Guiana. We collected the data from the computerised registers the medical department had stored. RESULTS: From 1 January 2010 to 31 December 2019, 1070 patients were included, representing a median annual incidence of 115 (IQR 91-122) evacuations. Of these, 602 (59%) were evacuated by helicopter, 214 (21%) by airplane, 182 (18%) by ambulance and 19 (2%) by pirogue.Reasons for evacuation were diseases in 664 (62%) patients, non-battle injuries in 389 (36%) patients and battle injuries in 17 (2%) patients. Finally, 286 (29%) evacuations were MEDEVAC and 712 (71%) were CASEVAC.Over the years, the increasing number of evacuations reached a maximum of 183 in 2018. Helicopter evacuations, once the primary mode of evacuation, have declined proportionately in favour of other means of evacuation. CONCLUSION: Evacuation missions by the Cayenne medical unit increased over the 10-year study period, while helicopter use decreased. This evolution is a response to the constraints of adapting military operations to fight against illegal gold mining in the Amazonian Forest. Improvement of the means and procedures allows provision of the best care to patients while ensuring the ongoing conduct of military operations.

Influence of atmospheric pressure changes on dentin bond strength of conventional, bulk-fill and single-shade resin composites.

INTRODUCTION: The purpose of this study was to investigate the dentin bond strength of composite resins in response to environmental pressure changes. METHODS: Ninety extracted human molar teeth were used. A mould (3 mm x 4 mm) was adapted on dentin, resin composites (conventional [n = 30] and single-shade composites [Ohmnicroma] [n = 30]) were filled in two increments of 2 mm. The bulk-fill composites (n = 30) were filled with one 4 mm increment. The specimens were stored for 30 days in artificial saliva. The specimens were exposed to hyperbaric pressure (283.6 kPa; 2.8 atmospheres absolute [atm abs]) or hypobaric pressure (34.4 kPa; 0.34 atm abs) once daily for 30 days and the control group was stored at atmospheric pressure for 30 days. The bond strength was tested with a universal testing machine and the failures were examined with a stereomicroscope and scanning electron microscope. Statistical analyses were performed using analysis of variance with post hoc tests, and the Weibull analysis. RESULTS: Regardless of environmental pressure changes, the bulk-fill composites showed the highest bond strength. There was no significant difference in bond strength between the hypobaric and atmospheric pressure (control) groups after 30 days in all resins. The hyperbaric group showed lower bond strength for bulk-fill composites than the control group. CONCLUSIONS: Dentists experienced in diving and aviation medicine should definitely take part in the initial and periodic medical examinations of divers and aircrew to give appropriate treatment. Bulk-fill composite resins can be preferred in divers and aircrew due to high bond strength values.

Return to flying duties of German military pilots after recovery from COVID-19.

BACKGROUND: Pilots are working in a unique and exacting environment with hypobaric hypoxia and acceleration forces. In military flying, missions are often challenging with possible combat scenarios and in remote areas with impaired infrastructure. METHODS: We analysed all German military pilots and pilot candidates with confirmed SARS-CoV-2 infection, who have all been evaluated prior to their return to flying duties between April 2020 and January 2022 by the German Air Force Centre of Aerospace Medicine. Symptoms, comorbidities, scope of investigations, examination results, vaccination status and aeromedical disposition are described. RESULTS: 90 pilots (82 active pilots and 8 pilot candidates) with a median age of 35 years (IQR 15 years) were included. 78 pilots (87%) reported symptoms, with median duration of 6 days. Symptoms included influenza-like symptoms (70.0%), headache (45.6%), impaired physical fitness (37.8%), anosmia/ageusia (36.7%), fever (27.8%), exertional dyspnoea (8.9%), memory and concentration disorders (4.4%), diarrhoea (3.3%) and dyspnoea at rest (2.2%). Only one pilot (1.1%) was hospitalised, two (2.2%) required outpatient treatment. All pilots were allowed to return to unrestricted flying duties after the assessment, with eight (8.9%) reporting ongoing mild symptoms. CONCLUSION: Due to their demanding working environment, pilots, and other high-hazard employees, should undergo medical evaluation prior to return to their duties to exclude ongoing symptoms and the development of post-acute COVID-19 or post-COVID-19 syndrome. The scope of examinations may depend on the severity of the disease, comorbidities, the vaccination status, the predominant SARS-CoV-2 variant and the type of aircraft flown.

The Prevalence of Cardiometabolic Health Risk Factors among Airline Pilots: A Systematic Review.

Background: The occupational demands of professional airline pilots such as shift work, work schedule irregularities, sleep disruption, fatigue, physical inactivity, and psychological stress may promote adverse outcomes to cardiometabolic health. This review investigates the prevalence of cardiometabolic health risk factors for airline pilots. Methods: An electronic search was conducted utilizing PubMed, MEDLINE (via OvidSP), CINAHL, PsycINFO, SPORTDiscus, CENTRAL, and Web of Science for publications between 1990 and February 2022. The methodological quality of included studies was assessed using two quality assessment tools for cross-sectional and clinical trial studies. The prevalence of physiological, behavioral, and psychological risk factors was reported using descriptive analysis. Results: A total of 48 studies derived from 20 different countries, reviewing a total pooled sample of 36,958 airline pilots. Compared with general population estimates, pilots had a similar prevalence for health risk factors, yet higher sleep duration, lower smoking and obesity rates, less physical activity, and a higher overall rate of body mass index >25. Conclusions: The research reported substantial prevalence >50% for overweight and obesity, insufficient physical activity, elevated fatigue, and regular alcohol intake among pilots. However, the heterogeneity in methodology and the lack of quality and quantity in the current literature limit the strength of conclusions that can be established. Enhanced monitoring and future research are essential to inform aviation health practices and policies (Systematic Review Registration: PROSPERO CRD42022308287).