ICAM 2024 Trip report

Trip report from the International Congress of Aerospace Medicine ICAM in Lisbon, Portugal, 3 – 5 October 2024,  the trip report is mainly covering specific lectures providing new insights and overviews, picked for you by Ann Bovin.

Opening lecture – by Duncan Hughes

Commercial space travel: Clearing passengers for space travel – challenges and solutions

Commercial space flights are a reality, and the first launches have been successful.

The Galactic Delta fleet plans to expand its capacity to send thousands of persons into space annually.

Commercial space flights are a rapidly expanding business. Recently the number of passengers launched into space could be counted in tens but is expected soon to reach 2000 annually.

The current technology allows one flight per month, however new technology may allow 6 launches per week per shuttle. Additional plans of establishing multiple (6) international space ports may cause space tourism to expand rapidly, urging the need for guidance material on medical clearance for passengers on space flights.

We have sparce data and no database for the medical risk assessment for commercial space flights.  The speaker is requesting to establish a medical space flight database.

Prior data had indicated 18 medical emergencies per 1 million and 0.2 deaths per 1 million however the total number of persons and the criteria used were not clear. Regardless of the statistical uncertainty the risk is presumably quite low.

What are the current requirements? Right now, only a written, informed consent is required by law to go on a space flight. However, Galactic is conducting a thorough examination incl. a full Class 1 medical examination.

Special items of particular interest are:  Established ASCVD (AtheroSclerotic CardioVascular Disease) and a ASCVD risk evaluation, age, body and mobility, medications, hearing aids, glasses, and a psychological evaluation. Then the knowledge is limited, like how does a hearing aid react to the G force, and does it stay in the ear – these are all new questions to be addressed when launching often elderly passengers on commercial space flights.

Clinical aviation medicine – by Eddie Davenport

Cardiology

Fundamentals of aerospace medicine – on update on cardiology

Routine screening of pilots with resting ECG has limited prognostic evidence.

There are data on ECG as a primary screening tool for example in the ESC guidelines for Sports Cardiology, but in regards of aeromedical practice we still lack evidence, international guidelines, and consensus in this field.

Prior all US Airforce pilots also had a screening echocardiography performed, however in the absence of a cardiac murmur and symptoms the evidence is sparce for this practice, and it is not mandatory any longer. You might find valve abnormalities like a bicuspid aortic valve, or a mitral valve prolapse, but with normal valve function those would not be expected to cause symptoms for decades, and in that case a cardiac murmur and symptoms would appear. The US army are approving pilots with these heart valve abnormalities provided there is no valvular dysfunction.

More important than echocardiography is a thorough familiar history and a clinical screening for cardiac murmurs; if one of these is present, an echocardiography is indicated.

ASCVD screening is also mandatory. Extreme G-forces impact coronary blood flow and would cause hazard to the pilots in case of obstructive coronary blood flow.

MPI and resting ECG are not useful tools for screening purposes due to its low sensitivity and specificity. Exercise stress ECG also has a poor sensitivity and specificity and should not be part of guidelines as a tool for screening purposes for ASCVD. It has been removed from the ESC guidelines on this behalf in favor of more sensitive, more specific, non-invasive, prognostic tests. The exercise ECG is considered obsolete and new diagnostic tools should be considered for the scheduled update of the EASA regulation.

The recommend screening tool for ASCVD is without doubt a CT Coronary Calcium Score (CAC) as the best prognostic marker for ASCVD risk stratification. It has proven a strong prognostic tool for future ASCVD events – regardless of – and more powerful than – traditional risk factors like smoking, lipids, diabetes, etc.

A Coronary Calcium Score (CAC) of 0 (zero) is equivalent to ab estimated risk of an ASCVD event of only 1% per 10 years, while on the other end of the spectrum a CAC of 1000 or above is equivalent to a risk of an ASCVD event similar to persons with established obstructive coronary disease, prior MI or revascularization – even without obstructive lesions.

Coronary calcium scoring would provide the AMEs with the most powerful predictive tool for future coronary events, and at the same time guide AMEs to initiate appropriate preventive therapy for those at risk to maintain pilots’ health.

João Lousada

Presentation of ISS, the project, the team, the life and some of the experiments on ISS.

Planning of a journey to Mars pose further considerations:

-exposure to radiation.

-duration of the mission (at least 2 years).

-delay of communication at least 20 min at the speed of light?

-testing of equipment and isolation studies on earth performed as simulation training in the desert.

Clinical aviation medicine – by Pedro Pinto

Cardiology

Navigating the skies with septal defects

20-25% of a population have a PFO (persistent foramen ovale). No screening is performed routinely.

These conditions should be considered as normal variants without further implications for flying duties for cabin crew (CC) without prior embolic events.

An exercise stress test with pulse oximetry and Holter is recommended to rule out arrhythmias in these cases.

EASA research activities overview – by Pedro Caetano   

-MESAFE (MEntal SAFEty of pilots) – large EASA project with the objective to provide recommendations

-Diabetes mellitus treated with insulin – research ongoing.
-Announcing the upcoming CaVD & Diabetes event 13-14/11 2025.

-VISION (color vision) – recommendations for pilots & ATCOs.

-Health aircraft surface study – solutions testing for antibacterial use on aircrafts.

-Proposed future studies: OSA (obstructive sleep apnea) & HAO (higher airspace operations).

EASA Medicine research activities – by Gerd Köhler

Diabetes mellitus in pilots and ATCOs

Testing scheme for insulin treated DM for commercial pilots was developed – with a traffic light system.

CHMs and traditional insulin pumps are impacted by the changes in atmospheric pressure (Boyles Law and Henles Law) thus affecting the solution in the insulin pump and the effective dosage.

Experimental research was done with insulin pumps; this revealed that during climb, an over-delivery of insulin was measured, whilst during decent an under-delivery of insulin was measured.

Then AID systems (automatic insulin delivery systems) were tested; those optimized delivery, tested at ambient pressure and in a hypobaric chamber; all pumps delivered reliable dosage regardless of pressure.

The results will be discussed further at a meeting coming up; CaVD & Diabetes event 13-14/11 2025.

EASA Medicine research activities – by Ries Simons

CaVD-PACE project (ESAM)

CaVD-PACE project; to find evidence and recommendations providing guidance for updating EASA regulations. The literature search included the thorough literature reviews in the current and recent ESC, EAPC, ACC, and AHA guidelines.

The new ESC SCORE2/OP is recommended for ASCVD risk stratification (ESC App calculator available).

Exercise ECG is recommended not to be used as a routine testing method to exclude CAD due to its low sensitivity, low specificity, and low predictive value, in accordance with the prior speech by Dr Eddie Davenport.

Coronary CT angiography is recommended for moderate to high risk of ASCVD as first line screening.

A risk evaluation maze was developed (CaV-PACE Matrix, ref. https://www.easa.europa.eu/en/research-projects/new-treatments-and-diagnostic-measures-cardiovascular-diseases-pilots-and-atcos)

For further evaluation, a combination of anatomical and functional methods may be indicated (coronary CT angiography, stress echocardiography, MPI (myocardial perfusion imaging, PET perfusion imaging, etc.). However, the sensitivity and specificity of traditional MPI are not particularly good, and PET or MRI should be preferred when a perfusion scan is recommended.

Regarding atrial ablation techniques, pulse field ablation is preferred to thermos catheter ablation due to lower risk of complications and collateral damage when this technique is applicable.

For coronary stenting (percutaneous coronary stenting) 3rd generation DES (drug eluting stents) are preferred, however an individual evaluation of stent type and risk is required in each case.

Regarding systolic heart failure (CHF), modern treatment with ACE inhibitors, BB, MRS, and GLP-1 (Semaglutide) provides increasingly better prognosis for CHF patients. These recent advances in medical therapy and prognosis may make recertification possible for some of these pilots in due time, provided on optimal medical therapy and in NYHA class 1 (asymptomatic). However, not applicable for Class 1.

Clinical aviation medicine – by Paola Tomasello

Mental health

MESAFE study: https://www.easa.europa.eu/en/research-projects/mesafe-mental-health

MESAFE (MEntal SAFEty of pilots:  44 recommendations made to EASA)

A large project though seems to be based on already published evidence and largely made by consensus.

Results:

  1. Glossary developed for examinations of pilots – 30 cards published
  2. MIRAP; Mental Incapacitation Risk Assessment Process. A stepwise tool for AMEs and Mas (guidance & information material provided).

Clinical aviation medicine – Anthony S Wagstaff

Mental health

MESAFE (MEntal SAFEty of pilots – recommendations made to EASA)

Key points:

To avoid yes/no questionnaires – prefer an open interview

In difficult cases: An aeromedical operational board is recommended (incl. the pilot) – with participation of the AME, MHS, MA, operational experts, a specialist, and the pilot.

Non-disclosure is an issue due to lack of trust in the assessment system & inadequate tools.

Different questionnaires and tools are presented though not any revolutionary to clinical practice nor safety.

Clinical aviation medicine -color vision

Christian Ionut Panait

VISION (color vision study)

Screening with Ishiharas is rather sensitive, but the specificity is low.

Then anomaloscope and CAD test is recommended. The lantern test has a low sensitivity.