First-generation H1 antihistamines found in pilot fatalities of civil aviation accidents, 1990-2005

INTRODUCTION: First-generation H1-receptor antagonists are popularly used for alleviating allergy and cold symptoms, but these antihistaminics cause drowsiness and sedation. Such side effects could impair performance and, thus, could be the cause or a factor in accidents. Therefore, the prevalence of these antagonists was evaluated in aviation accident pilot fatalities. METHODS: The Civil Aerospace Medical Institute's (CAMI's) Toxicology Database was examined for the presence of the first-generation antihistamines in pilot fatalities of civil aircraft accidents that occurred during a 16-yr (1990-2005) period. RESULTS: Of 5383 fatal aviation accidents from which CAMI received specimens, there were 338 accidents wherein pilot fatalities (cases) were found to contain brompheniramine, chlorpheniramine, diphenhydramine, doxylamine, pheniramine, phenyltoloxamine, promethazine, and triprolidine. Of the 338 accidents, 304 were general aviation accidents, and 175 of the 338 pilots held private pilot airman certificates. Antihistamines were detected alone in 103 fatalities (1 antihistamine in 94 and 2 antihistamines in 9), while other drug(s) and/or ethanol were also present in an additional 235 fatalities. The antihistamines were found in approximately 4 and 11% of the fatalities/accidents in 1990 and in 2004, respectively. The use of antihistamine(s) was determined by the National Transportation Safety Board to be the cause of 13 and a factor in 50 of the 338 accidents. CONCLUSIONS: There was an overall increasing trend in the use of antihistamines by aviators during the 16-yr span. Blood levels of the antihistaminics were in the sub-therapeutic to toxic range. Findings from this study will be useful in investigating future accidents involving antihistamines.     

Antiemetic and sedative levels found together in 26 civil aviation pilot fatalities, 2000-2006

INTRODUCTION: Antiemetics and sedatives are two drug classes that may have harmful side effects when mixed. This is especially dangerous for pilots. Although many of these compounds are considered disqualifying by the FAA, their use occurs. Some pilots may be unaware of the danger of combining compounds from these two drug classes. Our laboratory was interested in evaluating the circumstances surrounding accidents in which the pilot was found positive for drugs from each of these two classes. METHODS: Epidemiological, toxicological, and aeromedical findings from pilots involved in such accidents were collected for the 7-yr period from 2000 through 2006. Case histories, accident information, and the probable cause of the aviation accidents were obtained from the National Transportation Safety Board (NTSB). Toxicological information was obtained from the Civil Aerospace Medical Institute's (CAMI's) Forensic Toxicology Research Laboratory. RESULTS: Of the 2184 fatal aviation accidents over this time period, 26 were found positive for compounds from both the antiemetic and the sedative drug classes. All 26 aircraft were operated under 14 CFR Part 91 as general aviation. All pilots were male; 21 tested positive for a disqualifying substance that may have affected their ability to control the aircraft. CONCLUSION: Although the percentage of accidents in which the pilot tests positive for a compound from each class is small, it is important for all pilots to understand the dangers of self-medicating and concomitant use of such substances. Under-reporting of medications by pilots during their certification process occurs; education is the key to preventing inadvertent drug-drug interactions.     

Selective serotonin reuptake inhibitors and rhabdomyolysis after eccentric exercise

PURPOSE: The purpose of this report was to review three cases of clinically significant rhabdomyolysis that developed in research subjects after completing an eccentric exercise protocol. All three cases occurred in subjects who reported use of selective serotonin reuptake inhibitors (SSRI). METHODS: Sixty-three subjects enrolled in the study. Subjects performed 15 sets of 15 repetitions of maximal eccentric contractions of the elbow flexors. Subjects were then monitored on a daily basis for development of delayed onset muscle soreness (DOMS). Subjects received either microcurrent electrical neuromuscular stimulation (MENS) or sham treatment. RESULTS: Three subjects developed clinically significant rhabdomyolysis after performing this exercise protocol. Affected subjects were the only subjects who reported use of SSRI during the study period. CONCLUSION: This report raises suspicion of SSRI use as a predisposing factor to muscle injury after eccentric exercise.     

Prevalence of chlorpheniramine in aviation accident pilot fatalities, 1991-1996.

BACKGROUND: Chlorpheniramine is known to cause drowsiness, and this side effect has a potential to impair performance and could be a factor in accidents. METHODS: Therefore, to establish the prevalence of this drug in pilot fatalities of aviation accidents, a postmortem toxicology database--maintained at the Civil Aeromedical Institute--was examined for the presence of chlorpheniramine in the fatalities, occurred during 1991-1996. RESULTS: There were 47 (2.2%) accidents involving chlorpheniramine. Of these, 16 had only chlorpheniramine at 109 ng.ml-1 (n = 4) in blood and 1412 ng.g-1 (n = 12) in liver. Other drugs were also present in the remaining 31 cases, wherein chlorpheniramine concentrations were 93 ng.ml-1 (n = 18) in blood and 747 ng.g-1 (n = 12) in liver. Ninety-five percent of all quantitated blood values were at or above the therapeutic level (10 ng.ml-1), giving a 100 ng.ml-1 (n = 21) mean blood value. The drug's mean liver concentration from all cases was 1080 ng.g-1 (n = 24). The average blood value was approximately 10 times higher than the therapeutic value. CONCLUSIONS: The presence of other drugs did not appear to significantly alter the blood chlorpheniramine level, but no such correlation could be established with the hepatic value. The approximate 10-fold increase in the liver concentration was consistent with the general trend of drug distribution in the hepatic compartment. However, the contribution of postmortem redistribution of the drug to alter its concentration cannot be entirely ruled out. This study suggests that chlorpheniramine was present in some aviation fatalities at levels higher than therapeutic levels.     

Toxicological findings in fatal civil aviation accidents, fiscal years 1968-1974.

Toxicological findings in 1,345 fatal general aviation accidents from fiscal year 1968 through 1974 are summarized. Methods used in examination of specimens for alcohol, drugs, carbon monoxide, cyanide, and cholinesterase activity are described. Blood ethanol levels in excess of 0.050% were found in 117 of the 1,345 pilots (8.7%). Drugs were found in 16 cases (1.2%). These and other toxicological findings indicate that in more than 40% of the cases, information worthy of consideration in developing the human-factors history of an accident or the cause of death from survivable crashes was obtained.     

Characteristics and toxicological processing of postmortem pilot specimens* from fatal civil aviation accidents

INTRODUCTION: Autopsied biosamples from civil aviation accident pilot fatalities are submitted to the Civil Aerospace Medical Institute (CAMI) for toxicological evaluation. However, such evaluation is dependent on types and amounts of submitted samples, and obtaining suitable samples is governed by the nature of the accident. Characteristics of those samples and associated toxicological processing have not been well documented in the literature. METHOD: Therefore, the CAMI Toxicology Database was searched for these aspects. RESULTS: CAMI received samples from the pilot fatalities (CAMI cases) of approximately 80% of the 1990-2000 aviation accidents reported by the National Transportation Safety Board. Accidents and cases during June-September were higher than the other months, and more than half of the received cases had multiple samples in sufficient amounts. For example, out of 1891 cases processed for the 1996-2000 accidents, 1211 had at least adequate amounts of blood, urine, and/or vitreous humor; 324 had inadequate amounts of blood and urine; and 356 had no blood or urine. Muscle, liver, lung, and/or kidney samples were submitted in 90% of the cases, while cerebrospinal fluids were submitted in only 8% of the cases. The toxicologically preferred samples, blood and urine, were available in 78% and 56% of the 1891 cases, respectively. Out of 51 cases containing only one sample type, 46 had muscle and the remaining 5 had other sample types. Samples were primarily analyzed for combustion gases, alcohol/volatiles, and drugs. Generally, the presence of analytes is demonstrated in at least two different sample types by using two different analytical techniques for reporting a particular case as "positive." An effective quality-assurance/quality-control is maintained throughout the process. CONCLUSION: In the majority of the aviation accidents, sufficient amounts and types of biological samples were submitted for toxicological evaluation.     

民航飞行员肾上腺皮质腺瘤两例

一、临床资料 例1，男，24岁，波音737副驾驶，1999年年度体检发现血压升高，波动于135～140／90～110mmHg，送武汉协和医院检查双肾MRI提示左肾上腺皮质腺瘤，24h尿游离皮质醇431nmol／L（参考值55．2-276nmol／L）增高，血醛固酮正常，24h动态血压监测平均血压122／84mmHg，观察10d血压波动于临界值之间，诊断为：①功能性左侧肾上腺腺瘤；②皮质醇增多症。出院经地面观察3个月，血压波动于临界水平，准予观察飞行。执行飞行任务两班后监测血压升高（140／100mmHg），送武汉同济医院治疗，医院建议手术治疗，本人拒绝手术。体检结论飞行不合格。     

Selective serotonin reuptake inhibitors and isoniazid: evidence of a potential adverse interaction.

BACKGROUND: Recognizing a potential interaction between isoniazid (INH), a weak monoamine oxidase inhibitor, and serotonin reuptake inhibitors (SSRIs), we assessed medication discontinuation rates in human immunodeficiency virus-infected individuals taking an SSRI, INH, or both. METHOD: We retrospectively reviewed treatment records to determine if patients on an SSRI, INH, or both completed drug therapy in accordance with a treatment plan (e.g., 12 months of INH therapy). Patients on both medications constituted the study group; patients taking either an SSRI or INH alone constituted comparison groups. RESULTS: There were no significant differences between the groups based on age, gender, CD4%, or CD4 count. Seven of the 10 patients (70%) in the study group discontinued therapy, which was significantly greater than the 2 of 14 (14%) in the SSRI group (P = 0.01) and the 4 of 18 (22%) in the INH group (p = 0.02) who discontinued therapy. CONCLUSION: Medication discontinuation rates for patients prescribed an SSRI coincident with INH were significantly higher than for individuals prescribed these medications separately. These differences cannot be accounted for on the basis of age, gender, or CD4%, but they may be attributable to increased side effects caused by interactions between these medications.     

民航飞行员亚急性甲状腺炎一例

一、临床资料患者男性 ,40岁 ,MD- 82飞机驾驶员 ,飞行时间 46 0 0 h。 1999年 4月出现咽痛、发热脉搏增快等呼吸道感染症状 ,对症治疗无效入院。查体 :体温 38.6℃ ,咽部红肿 ,扁桃体已手术切除。甲状腺轻度肿大 ,弥漫性 ,质地稍硬 ,触痛明显 ,心率 96次 / min,血 T3 6 .2 4m mol/ L ,T434 0 .5 m mol/ L ,血沉 5 8m m/ h,诊断为亚急性甲状腺炎。给予泼尼松 ,P-转移因子等治疗 30余天 ,症状消失 ,血 T3 、T4和血沉恢复在正常范围内出院。地面观察 3个月 ,康复疗养 1个月 ,查 T3 、T4正常。体检结论 :飞行合格。二、讨论亚急性甲状腺炎…     

美国民用航空器事故医学调查简介

20 0 0年 7月 15日作为中美双方航空医学交流的一部分 ,由民航总局飞行标准司组团 ,前往位于美国俄克拉荷马城的美国联邦航空局 (Federal AviationAdministration,FAA)和民用航空医学研究所 (Civilian Aviation Medicine Insti-tute ,CAMI)接受为期两周的“民用航空器事故医学调查 "的培训。现将有关美国航空器事故医学调查的梗概介绍如下。一、航空器事故医学调查的组织管理1.航空器事故率 :1998年美国运输发生死亡性事故 4390 2起 ,其中高速路事故占 94.2 % ,航空性事故占 2 .4% ,航海和铁路事故各占 1.7%。航空事故发生的时段分布…     

A comparison of postmortem coronary atherosclerosis findings in general aviation pilot fatalities

The autopsy reports of 710 pilots involved in fatal general aviation accidents were received by the FAA for the years 1980-82; they were reviewed to appraise the age-specific prevalence of coronary atherosclerosis among the autopsied group and to compare findings with those of an earlier study. Of the autopsies on pilots killed in aircraft accidents, 69% indicated some degree of coronary atherosclerosis, ranging from minimal to severe. This finding is higher than for a similar group of pilots studied for the years 1975-77. However, only about 2.5% of the 1980-82 study group were found to have severe coronary atherosclerosis, compared with 5% in the previous study. Prevalence of severe coronary atherosclerosis increased with age from 5.8 per 1,000 for ages less than 40 years to 73.9 for age 50 years and above, also reflecting lower age-specific rates for severe coronary atherosclerosis than were found in the previous study.     

Analysis of changes in the pilot population and general aviation accidents.

General Aviation pilots have been involved in a steadily decreasing number of accidents over the past 20 years. Changes in the age distribution, certification, and flying habits of these pilots make direct comparison of accident statistics inaccurate. This study reviews changes in the pilot population over the past 20 years to analyze their impact on accident statistics. Pilot age and certificate distributions from 1968 to 1987 were assembled from annual Federal Aviation Administration (FAA) surveys. Information about pilots involved in accidents was collected from annual National Transportation Safety Board (NTSB) reports. Trends in pilot age distribution, certification, aircraft use, flight planning, and weather were reviewed. The accident experience from the first 5 years of the study period was used to construct an adjusted plot of expected aircraft accidents. From 1968-87, the mean pilot age increased from 35 to 40 years and the number of pilots over the age of 60 increased five-fold. The number of pilots with Air Transport Pilot (ATP) certification tripled and instrument certification increased 80%. Accidents where an Instrument Flight Rules (IFR) flight plan was filed increased from 3.6% to 6.6% without a corresponding increase in the number of accidents in weather at or below instrument meteorologic conditions (IMC). The accident experience from 1968 to 1973 predicted 116,000 accidents from 1968 to 1987. The actual number of accidents was 40% less than predicted. The average pilot age has increased both due to more pilots over the age of 50 and less young student pilots.(ABSTRACT TRUNCATED AT 250 WORDS)     

民航飞行员冠状动脉内支架植入术特许合格一例

一、临床资料患者男性,52岁,A320运输机机长,总飞行时间15 000 h。因活动平板运动试验可疑阳性20 d,心电图示左心室间壁心肌可逆性心肌缺血15 d,于2003年8月19日入院。既往有高脂血症、高尿酸血症、脂肪肝、7年非特异性T波改变史,30年吸烟史(10支/d)。入院后查:血尿酸452·3μmol/L,活动平板运动试验阳性,彩超示心脏结构房室大小、瓣膜活动及血流信号未见明显异常。初步诊断:冠心病。2003年8月21日行选择性冠状动脉造影术显示:前降支近段狭窄75%,第1对角支开口狭窄50%,第2对角支开口狭窄40%,回旋支中段狭窄40%~50%。结论为:冠心病,双支病…     

Aeromedical regulation of aviators using selective serotonin reuptake inhibitors for depressive disorders

This report, prepared at the request of the Aerospace Medical Association (AsMA), reviews the present status of aeromedical regulation of depressive disorders and antidepressant medications, emphasizing the role of serotonin specific reuptake inhibitors (SSRIs). Aeromedical certifying authorities (CAs) generally prohibit pilots from flying with a diagnosed depressive disorder, and also prohibit flying while taking antidepressant medications, including SSRIs. Some CAs are reassessing these prohibitions, which are based on long aeromedical practices, in view of changing medical management of depressive disorders. Many pilots choose to fly while depressed, with or without medications, because of the long grounding periods mandated by current policies. Some SSRIs have very few aeromedically significant side effects. Modern psychiatric practice calls for long-term use of medication following clinical recovery from depressive disorders in order to prevent recurrent episodes. Given these and other factors, AsMA proposes that CAs remove the current absolute prohibitions against pilots flying while taking SSRIs, and adopt aeromedical protocols that include carefully controlled follow-up and review. AsMA urges all certificatory and regulatory authorities to consider immediately instituting a policy of using study groups to manage depressed aviators who require SSRI antidepressants. Protocols designed to aggressively manage the full spectrum of adverse possibilities related to SSRI use may enable the safe use of SSRIs in formerly depressed aviators who suffer no aeromedically significant side effects. In these closely managed cases of depressive disorders, special issuances or waivers for SSRI use are justified.     

Ground crew injuries and fatalities in U.S. commercial aviation, 1983-2004

INTRODUCTION: Ground crew services are an essential part of airport operations. Injury hazards to ground crewmembers who are in close proximity to aircraft have not been well studied. The objective of this paper was to examine airport ground crew injuries and fatalities involving aircraft of commuter air carriers and major airlines. METHODS: Investigation reports for all ground crew injuries involving commuter and major airline aircraft that occurred at United States airports between 1983 and 2004 were obtained from the National Transportation Safety Board (NTSB) and analyzed to describe the immediate cause and pattern of injury occurrence. RESULTS: During the 22-yr study period, the NTSB recorded a total of 80 ground crew accidents involving landing, taxiing, or standing commercial airline aircraft, yielding an overall rate of 0.47 ground crew related accidents per 1 million aircraft departures. These accidents resulted in injuries to 98 ground crewmembers, including 21 fatalities. Two-thirds of the accidents took place as the aircraft was departing. Vehicular collisions with an aircraft made up 43% of accidents, 34% were caused by moving aircraft equipment such as propellers or nose gear, and 11% resulted from jet blasts or fires. CONCLUSIONS: intervention programs for airport ground personnel should emphasize the safe operation of the aircraft equipment and ground vehicles. Some of the injuries to ground crewmembers might be avoided through improved design of commonly used equipment.     

Challenges in investigation of diabetes-related aviation fatalities—an analysis of 1491 subsequent aviation fatalities in USA during 2011–2016

Diabetes mellitus (DM) could cause pilot incapacitation and result in aviation fatalities. The mechanisms could be directly as a consequence of acute hypoglycemia/subacute diabetic ketoacidosis (DKA) or indirectly as an acute cardiovascular event by contributing to the development of atherosclerosis in coronary or carotid and cerebral arteries. In this study, DM-related fatal flight accidents in the US National Transport Bureau’s database between years 2011–2016 were analyzed with special emphasis on postmortem (PM) glucose levels and correlation of toxicological reports with anamnestic information on DM. Additionally, autopsy results on coronary arteries were reviewed. In 43 out of 1491 (~ 3%) fatal accidents pilots had DM. Postmortem glucose or glycated hemoglobin percentage (Hb1Ac) was measured in 12 of the 43 cases; while antidiabetic medication was found in 14 of the cases (only two of the cases had both glucose measurements and medication). With the increasing prevalence of DM, a possibility of pilot incapacitation due to DM or complications of DM should be actively studied, even if no anamnestic information of DM was available. While PM hypoglycemia is difficult to assess, we propose a systematic investigation based on measurement of glucose, Hb1Ac%, and ketone bodies, and documentation of atherosclerotic lesions in major arteries to identify or rule out DM as a cause of pilot incapacitation.

     

2001～2005年民航飞行员高脂血症和脂肪肝的调查

血脂、肝脏B超是民航飞行人员每年年度体检的必查项目。通过观察近年来的体检结果，发现高脂血症、脂肪肝的发病人数不断增加，部分脂肪肝进一步引起谷丙转氨酶升高，成为体检暂不合格的原因之一。我们对2001～2005年度东方航空公司山东分公司飞行员高脂血症和脂肪肝的发病情况进行了调查分析，旨在为疾病的预防及航空卫生保障提供客观依据。