The Untapped Potential of Narrative as a Tool in Aviation Mental Health and Certification.

INTRODUCTION: Work-related stress is common in pilots, with broad implications, including the potential development of mental health symptoms and sometimes even psychiatric disease. This commentary argues for the use of narrative as a tool to promote preventive health behaviors in pilots and combat misinformation about aeromedical certification related to mental health.Hoffman WR, McNeil M, Tvaryanas A. The untapped potential of narrative as a tool in aviation mental health and certification. Aerosp Med Hum Perform. 2024; 95(3):165-166.

Factors That Influence Health care-Seeking Behavior and Health Information Disclosure Among U.S. Air Force Pilots.

INTRODUCTION: The reality of pilot health care avoidance behavior is often common knowledge to both pilots and aeromedical physicians, but the underlying factors leading to this behavior are less understood. In the current study, we conducted a qualitative assessment of a sample of U.S. Air Force (USAF) pilots to gather firsthand perceptions of the factors that encourage and discourage disclosure during aeromedical screening and use of mental and physical health care services, as well as recommendations to improve the USAF aeromedical health care system. MATERIALS AND METHODS: We conducted interviews with 21 USAF pilots on their perceptions of seeking medical care to identify factors that uniquely discourage or encourage disclosure and health care utilization to understand factors that aid the aeromedical provider/aviator relationship and to elicit interventions that could be prospectively researched. This work was reviewed by the Air Force Research Laboratory Institutional Review Board at Wright-Patterson Air Force Base and designated as exempt research, FWR20220103E. RESULTS: The most reported factors that discourage military pilot health care disclosure and health care utilization overall were medical revocation, stigma, and lack of trust in providers. Unit-embedded services, ease of access, and severity of condition were the most reported factors encouraging disclosure and utilization. Factor descriptions and exemplary quotes from pilots and pilot recommendations to encourage health care utilization and disclosure are provided. CONCLUSIONS: Results from firsthand interviews with pilots provide valuable information for flight surgeons to focus on building trust with their pilots to reduce health care avoidance.

Feasibility Assessment of Rapid Response EEG in the Identification of Nonconvulsive Seizures During Military Medical Air Transport.

INTRODUCTION: Traumatic brain injury often requires neurologic care and specialized equipment, not often found downrange. Nonconvulsive seizures (NCSs) and nonconvulsive status epilepticus (NCSE) occur in up to 30% of patients with moderate or severe traumatic brain injury and is associated with a 39% morbidity and an 18% mortality. It remains difficult to identify at bedside because of the heterogeneous clinical manifestations. The primary diagnostic tool is an electroencephalogram (EEG) which is large, requires an external power source, and requires a specialized technician and neurologist to collect and interpret the data. Rapid response EEG (rr-EEG) is an FDA-approved device that is pocket sized and battery powered and uses a disposable 10-electrode headset. Prior studies have demonstrated the noninferiority of rr-EEG in the identification of NCSE and NCS as compared to conventional EEG in hospitals. An unanswered question is whether rr-EEG could be used in the identification of NCSE and NCS by medics. MATERIALS AND METHODS: In conjunction with the Critical Care Air Transport (CCAT) team, a simulation was created and implemented on a CCAT training mission. The simulation team included a neurology resident, who oversaw the simulation, a pulmonary critical care fellow, an intensive care unit nurse, and a respiratory therapy. A survey was provided before and after the simulation. The team was expected to review the rr-EEG to make clinical decisions during ground transport, takeoff, and landing. The neurology resident monitored and recorded the team's ability to distinguish between NCS and a normal EEG. In between, the neurology resident monitored the quality of the EEG for potential interference and loss of quality. RESULTS: The CCAT team was able to efficiently set up the rr-EEG on a patient manikin, correctly identify visual EEG wave forms of a patient in NCS, and utilize the proprietary audio program of a simulated patient in NCS. The team reported that the device was easily set up in the environment, and the data were interpretable despite vibration, aircraft auditory and electrical noise, and the ergonomics of the aircraft medical section. CONCLUSIONS: This pilot study has validated a potentially revolutionary technology in medical transport. The rr-EEG technology is measurably user-friendly and will improve patient outcomes. This device and simulation can reduce time to an EEG by hours to days allowing for immediate treatment and intervention, which can significantly reduce morbidity and mortality.

Self-Reported Health Care Avoidance Behavior in U.S. Military Pilots Related to Fear for Loss of Flying Status.

INTRODUCTION: U.S. military pilots are required to meet certain medical standards in order to maintain an active flying status. Military pilots face potential temporary or permanent loss of flying privileges in the setting of a new condition or symptom that does not meet required standards, which could result in negative social and occupational repercussions for the pilot. For this reason, it has been proposed that U.S. military pilots participate in health care avoidance behavior, but little evidence exists to characterize such a trend in this population. MATERIALS AND METHODS: We conducted a non-probabilistic Internet survey of the general population of U.S. pilots from November 1, 2019 through August 1, 2021. The current study is a sub-analysis of military pilots. RESULTS: A total of 4,320 pilots answered the informed consent question, and 264 selected one military pilot type and were included in this sub-analysis. There were 72% of military pilots who reported a history of health care avoidance behavior (n = 190), and no statistical difference was found between age groups, gender, and military pilot types. There were 55.5% of pilots who reported a history of seeking informal medical care (n = 147), 33.7% of pilots who have flown despite a new symptom they felt required medical evaluation, 42.5% of pilots who reported withholding information on aeromedical screening (n = 111), and 11.4% of pilots who reported a history of undisclosed prescription medication use (n = 30). CONCLUSIONS: U.S. military pilots may participate in health care avoidance behavior because of fear for loss of flying status.

Health Care Avoidance Among Canadian Pilots Due to Fear of Medical Certificate Loss: A National Cross-Sectional Survey Study.

OBJECTIVE: Canadian pilots may avoid health care and report inaccurate medical information due to fear of medical invalidation. We sought to determine if health care avoidance due to fear of certificate loss exists. METHODS: We conducted an anonymous 24-item Internet survey of 1405 Canadian pilots between March and May 2021. Responses were collected using REDCap, and the survey was advertised through aviation magazines and social media groups. RESULTS: Seventy-two percent of respondents (n = 1007) have felt worried about seeking medical care because it may impact their career or hobby. Respondents participated in various health care avoidance behaviors with the most common being having actually avoided or delayed medical care for a symptom (46%, n = 647). CONCLUSION: Canadian pilots fear medical invalidation and consequently, avoid health care. This may be severely impacting aeromedical screening effectiveness.

Aviator Occupational Behavior Surrounding COVID-19 Infection and Vaccination in the United States: A Cross-Sectional Population-Based Survey.

Introduction The coronavirus disease 2019 (COVID-19) pandemic has precipitated change across the aviation industry, including aeromedical standards. U.S. pilot occupational behavior regarding COVID-19 infections and vaccinations have not been well-studied. Methods We conducted an anonymous survey of 661 U.S. pilots from September 1, 2021, through December 15, 2021. Results We found 23.8% of pilots reported a history of COVID-19 infection but only 20.5% of infected pilots reported this history to an aeromedical examiner (AME)/flight surgeon. Of uninfected pilots, 50.5% reported being either extremely unlikely or somewhat unlikely to disclose a new infection to an AME/flight surgeon. Seventy-nine point six percent (79.6%) of pilots received at least one dose of any COVID-19 vaccine and 89.6% of those who received a vaccine complied with the 48-hour no-flying policy. Of the unvaccinated pilots, 74.5% reported being either extremely unlikely or somewhat unlikely to receive a vaccine.

Healthcare Avoidance in Aircraft Pilots Due to Concern for Aeromedical Certificate Loss: A Survey of 3765 Pilots.

OBJECTIVE: To study healthcare avoidance behavior in pilots related to fear of aeromedical certificate loss. METHODS: Voluntary participation in an anonymous survey distributed to U.S. pilots. RESULTS: A total of 3765 pilots were included in the analysis. There were 56.1% of pilots (n = 2111) who reported a history of healthcare avoidance behavior due fear for losing their aeromedical certificate. There were 45.7% who sought informal medical care (n = 1721) and 26.8% who misrepresented/withheld information on a written healthcare questionnaire for fear of aeromedical certificate loss (n = 994). CONCLUSIONS: Aircraft pilots may participate in healthcare avoidance behavior related to fear of losing their aeromedical certificate. Further work is necessary to address pilot healthcare avoidance.

Healthcare related aversion and care seeking patterns of female aviators in the United States.

Diagnosis of a new medical condition in pilots may precipitate the end of an aviation career or hobby. For this reason, a barrier exists for pilots to seek medical care due to fear of losing an aeromedical certificate. Females represent a growing proportion of pilots in the United States and data on healthcare seeking behavior in this cohort is sparse. We conducted an anonymous online survey of 154 female pilots and 131 female non-pilots in the United States. 83.7% of female pilots have experienced healthcare related aversion compared to 27.5% of non-pilots. 66.7% of female pilots had withheld information from a physician while 46.0% had delayed or forwent medical care due to concern for their medical status. Further studies should be conducted to inform policy change to address pilot healthcare barriers.

Interleukin-6 inhibition with tocilizumab for relapsing MOG-IgG associated disorder (MOGAD): A case-series and review.

BACKGROUND: Myelin oligodendrocyte glycoprotein-immunoglobulin G (MOG-IgG) associated disorder (MOGAD) is a CNS demyelinating disease distinct from neuromyelitis optica spectrum disorder (NMOSD) and multiple sclerosis. Some patients with MOGAD exhibit a highly-relapsing and steroid-dependent disease course for which optimal treatment is unknown. Interleukin-6 (IL-6) plays an important pathobiologic role in NMOSD with aquaporin-4 antibodies and preliminary data suggest similar mechanisms of CNS damage may occur in MOGAD. OBJECTIVE: To summarize our experience with and all current literature on the use of tocilizumab, an IL-6 inhibitor, for highly-relapsing MOGAD along with the underlying immunopathologic rationale. METHODS: This is a single-center report from a U.S. military tertiary referral hospital of all patients with clinically, radiographically, and serologically confirmed MOGAD who were treated with tocilizumab compiled with data from five other case series/reports from tertiary referral centers. The main outcomes of interest were reduction in annualized relapse rate and required dose of oral prednisone for symptomatic management. RESULTS: Ten total patients with relapsing MOGAD who were treated with intravenous or subcutaneous tocilizumab were identified. At our institution, a 20 year-old female with a 9-year history of highly-relapsing and steroid dependent MOGAD was treated with tocilizumab. In 28 months of follow up, she had no clinical relapses and was able to discontinue corticosteroids. Another 35 year-old female at our institution with a 10-year history of highly-relapsing and steroid dependent MOGAD was treated with tocilizumab for 6 months. Tocilizumab therapy was associated with relapse freedom, resolution of eye pain, and ability to discontinue corticosteroids. When compiled with data from all other case reports of relapsing MOGAD treated with tocilizumab, there have been zero clinical or radiographic relapses in 10 patients over an average treatment duration of 28.6 months. CONCLUSIONS: Tocilizumab is an IL-6 inhibitor that may be a promising therapeutic option for patients with relapsing MOGAD that has not responded to other immunotherapies. Our results support a key role for IL-6-related mechanisms in MOGAD disease activity. Its safety and tolerability profile, both in our own experience and based on its use for other FDA approved conditions, may even justify its use a first line therapy in select patients. Further research is needed to establish the safety and efficacy of IL-6 inhibition in MOGAD.