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BACKGROUND: The Focused Assessment with Sonography for Trauma (FAST) examines for fluid in gravitationally dependent regions. There is no prior experience with this technique in weightlessness, such as on the International Space Station, where sonography is currently the only diagnostic imaging tool. STUDY DESIGN: A ground-based (1 g) porcine model for sonography was developed. We examined both the feasibility and the comparative performance of the FAST examination in parabolic flight. Sonographic detection and fluid behavior were evaluated in four animals during alternating weightlessness (0 g) and hypergravity (1.8 g) periods. During flight, boluses of fluid were incrementally introduced into the peritoneal cavity. Standardized sonographic windows were recorded. Postflight, the video recordings were divided into 169 20-second segments for subsequent interpretation by 12 blinded ultrasonography experts. Reviewers first decided whether a video segment was of sufficient diagnostic quality to analyze (determinate). Determinate segments were then analyzed as containing or not containing fluid. A probit regression model compared the probability of a positive fluid diagnosis to actual fluid levels (0 to 500 mL) under both 0-g and 1.8-g conditions. RESULTS: The in-flight sonographers found real-time scanning and interpretation technically similar to that of terrestrial conditions, as long as restraint was maintained. On blinded review, 80% of the recorded ultrasound segments were considered determinate. The best sensitivity for diagnosis in 0 g was found to be from the subhepatic space, with probability of a positive fluid diagnosis ranging from 9% (no fluid) to 51% (500 mL fluid). CONCLUSIONS: The FAST examination is technically feasible in weightlessness, and merits operational consideration for clinical contingencies in space.

The NASA Space Medicine program is now developing plans for more extensive use of high-fidelity medical Simulation systems. The use of simulation is seen as means to more effectively use the limited time available for astronaut medical training. Training systems should be adaptable for use in a variety of training environments, including classrooms or laboratories, space vehicle mockups, analog environments, and in microgravity. Modeling and simulation can also provide the space medicine development program a mechanism for evaluation of other medical technologies under operationally realistic conditions. Systems and procedures need preflight verification with ground-based testing. Traditionally, component testing has been accomplished, but practical means for "human in the loop" verification of patient care systems have been lacking. Medical modeling and simulation technology offer potential means to accomplish such validation work. Initial considerations in the development of functional requirements and design standards for simulation systems for space medicine are discussed.

The objectives of this work are: (1) Be able to recognize characteristic symptoms of intermittent claudication (2) Diagnose PAD on the basis of history, physical exam, and simple limb blood pressure measurements (3) Recognize the significance of peripheral artery disease as a marker for coronary or cerebrovascular atherosclerosis (4) Provide appropriate medical management of atherosclerosis risk factors-- including use of antiplatelet therapy to reduce risk of myocardial infarction, stroke and death (5) Manage symptoms of intermittent claudication with program of smoking cessation, exercise, and medication The diagnosis of intermittent claudication secondary to peripheral artery disease (PAD) can often be made on the basis of history and physical examination. Additional evaluation of PAD is multi-modal and the techniques used will vary depending on the nature and severity of the patient's presenting problem. Most patients can be appropriately managed without referral for specialized diagnostic services or interventions.

Performing a surgical procedure during spaceflight will become more likely with longer duration missions in the near future. Minimal surgical capability has been present on previous missions as the definitive medical care time was short and the likelihood of surgical events too low to justify surgical hardware availability. Early demonstrations of surgical procedures in the weightlessness of parabolic flight indicated the need for careful logistical planning and restraint of surgical hardware. The consideration of human ergonomics also has more impact in weightlessness than in the conventionall-g environment. Three methods of surgical instrument restraint - a Minor Surgical Kit (MSK), a Surgical Restraint Scrub Suit (SRSS), and a Surgical Tray (ST) were evaluated in parabolic flight surgical procedures. The Minor Surgical Kit was easily stored, easily deployed, and demonstrated the best ability to facilitate a surgical procedure in weightlessness. Important factors in this surgical restraint system include excellent organization of supplies, ability to maintain sterility, accessibility while providing secure restraint, ability to dispose of sharp items and biological trash, and ergonomical efficiency.

NASA's vision for space exploration includes missions of unprecedented distance and duration. However, during 30 years of human space flight experience, including numerous long-duration missions, research has not produced any single countermeasure or combination of countermeasures that is completely effective. Current countermeasures do not fully protect crews in low-Earth orbit, and certainly will not be appropriate for crews journeying to Mars and back over a three-year period. The urgency for exploration-class countermeasures is compounded by continued technical and scientific successes that make exploration class missions increasingly attractive. The critical and possibly fatal problems of bone loss, cardiovascular deconditioning, muscle weakening, neurovestibular disturbance, space anemia, and immune compromise may be alleviated by the appropriate application of artificial gravity (AG). However, despite a manifest need for new countermeasure approaches, concepts for applying AG as a countermeasure have not developed apace. To explore the utility of AG as a multi-system countermeasure during long-duration, exploration-class space flight, eighty-three members of the international space life science and space flight community met earlier this year. They concluded unanimously that the potential of AG as a multi-system countermeasure is indeed worth pursuing, and that the requisite AG research needs to be supported more systematically by NASA. This presentation will review the issues discussed and recommendations made.

This document is an outline of a presentation about the determination of minimum allowable concentrations in spacecraft. The presentation reviews the type of toxins and mechanisms to determine the acceptable concentrations of these toxic substances. The considerations for the unique situation that spaceflight entails including zero gravity, and the intense scrutiny are reviewed. The current measurement hardware is reviewed. The spacecraft atmospheres on the Shuttle, airflow, the Space Station and the EMU in respect to airflow, pressure, constituents are also summarized. Contingency situations and potential hazards are also discussed.

Our previous studies showed that modeled (MMG) and true (USA Space Shuttle Missions STS-54 and STS-56) microgravity (MG) inhibit human lymphocyte locomotion, Modeled MG also suppressed polyclonal and antigen-specific lymphocyte activation. Activation of PKC by phorbol myristate acetate (PMA) restored the microgravity-inhibited lymphocyte locomotion as well as activation by phytohaemagglutinin (PHA), whereas calcium ionophore (ionomycin) was unable to restore these functions. Based on these results we hypothesized that MG-induced changes in lymphocyte functions are caused by a fundamental defect in signal transduction mechanism. This defect may be localized either at the PKC level or upstream of PKC, most likely, at the cell membrane level. In this study we examined the expression of PKC isoforms alpha, epsilon and delta in PBMC cultured in rotating wall vessel bioreactor, developed at NASA JSC, which models microgravity by sustaining cells in continuous free fall. The assessment of the isoforms was performed by FACS analysis following cell permeabilization. A decrease in the expression of isoforms epsilon and delta, but not isoform a, was observed in PBMC cultured in microgravity conditions. These data suggest that MMG might selectively affect the expression of Ca2+ independent isoforms of PKC Molecular analysis confirm selective suppression of Ca2+ independent isoforms of PKC.

The space environment contains radiation and chemical agents known to be mutagenic and carcinogenic to humans. Additionally, microgravity is a complicating factor that may modify or synergize induced genotoxic effects. Most in vitro models fail to use human cells (making risk extrapolation to humans more difficult), overlook the dynamic effect of tissue intercellular interactions on genotoxic damage, and lack the sensitivity required to measure low-dose effects. Currently a need exists for a model test system that simulates cellular interactions present in tissue, and can be used to quantify genotoxic damage induced by low levels of radiation and chemicals, and extrapolate assessed risk to humans. A state-of-the-art, three-dimensional, multicellular tissue equivalent cell culture model will be presented. It consists of mammalian cells genetically engineered to contain multiple copies of defined target genes for genotoxic assessment,. NASA-designed bioreactors were used to coculture mammalian cells into spheroids, The cells used were human mammary epithelial cells (H184135) and Stratagene's (Austin, Texas) Big Blue(TM) Rat 2 lambda fibroblasts. The fibroblasts were genetically engineered to contain -a high-density target gene for mutagenesis (60 copies of lacl/LacZ per cell). Tissue equivalent spheroids were routinely produced by inoculation of 2 to 7 X 10(exp 5) fibroblasts with Cytodex 3 beads (150 micrometers in diameter). at a 20:1 cell:bead ratio, into 50-ml HARV bioreactors (Synthecon, Inc.). Fibroblasts were cultured for 5 days, an equivalent number of epithelial cells added, and the fibroblast/epithelial cell coculture continued for 21 days. Three-dimensional spheroids with diameters ranging from 400 to 600 micrometers were obtained. Histological and immunohistochemical Characterization revealed i) both cell types present in the spheroids, with fibroblasts located primarily in the center, surrounded by epithelial cells; ii) synthesis of extracellular matrix; and iii, mitotic cells located throughout the spheroids. Spheroidal integrity and cell viability were retained for the 30-day test period after removal of spheroids from the bioreactor. Potential utility of this three-dimensional, transgenic model for genotoxicity was initially assessed by exposure of spheroids to 0-2 Gy neon at dose rates of 0.3 to 1.5 Gy/min (National Institute of Radiological Sciences, Chiba, Japan). Quantification of mutation at the lacl gene revealed a linear dose response for mutation induction. Limited sequencing analysis of mutant clones revealed higher frequencies of deletions and multiple base sequence changes with increasing dose. These results suggest that our three-dimensional, transgenic model is applicable to a wide variety of studies involving the quantification, identification, and characterization of genotoxicity incurred in space and on Earth. This model uniquely allows investigation of the interaction of relevant factors, namely cell-to-cell interactions and the mechanistic interaction of microgravity with radiation insults and DNA repair. Using this three-dimensional model will allow us to obtain dual genotoxic information (i.e., mutation rate plus chromosome aberration data) from the same system so that one endpoint can be used to reference the other, thereby increasing the fidelity of the data set. Moreover, the tissue-equivalent nature of the three-dimensional model provides high confidence for relevance of risk assessment, i.e., the establishment of quality factors directly applicable to the microgravity environment.

Seventeen healthy and eight vestibular deficient subjects were exposed to an interaural centripetal acceleration of 1 G (resultant 45 deg roll tilt of 1.4 G) on a 0.8 meter radius centrifuge for a period of 90 minutes in the dark. The subjects sat with head fixed upright, except every 4 of 10 minutes when instructed to rotate their head so that their nose and eyes pointed towards a visual point switched on every 3 to 5 seconds at random places (within +/- 30 deg) in the Earth horizontal plane. Motion sickness caused some subjects to limit their head movements during significant portions of the 90 minute period, and led three normal subjects to stop the test earlier. Eye movements, including directed saccades for subjective Earth- and head-referenced planes, were recorded before, during, and immediately after centrifugation using electro-oculography. Postural stability measurements were made before and within ten minutes after centrifugation. In normal subjects, postural sway and multisegment body kinematics were gathered during an eyes-closed head movement cadence (sway-referenced support platform), and in response to translational/rotational platform perturbations. A significant increase in postural sway, segmental motion amplitude and hip frequency was observed after centrifugation. This effect was short-lived, with a recovery time of several postural test trials. There were also asymmetries in the direction of post-centrifugation center of sway and head tilt which depended on the subject's orientation during the centrifugation adaptation period (left ear or right ear out). To delineate the effect of the magnitude of the gravito-inertial vector versus its direction during the adaptive centrifugation period, we tilted eight normal subjects in the roll axis at a 45 deg angle in the dark for 90 minutes without rotational motion. Their postural responses did not change following the period of tilt. Based on verbal reports, normal subjects overestimated roll-tilt during 90 minutes of both tilt and centrifugation stimuli. Subjective estimates of head-horizontal, provided by directed saccades, revealed significant errors after approximately 30 minutes that tended to increase only in the group who underwent centrifugation. Immediately after centrifugation, subjects reported feeling tilted on average 10 degrees in the opposite direction, which was in agreement with the direction of their earth-directed saccades. In vestibular deficient (VD) subjects, postural sway was measured using a sway-referenced or earth-fixed support surface, and with or without a head movement sequence. 'Me protocol was selected for each patient during baseline testing, and corresponded to the most challenging condition in which the patient was able to maintain balance with eyes closed. Bilaterally VD subjects showed no postural decrement after centrifugation, while unilateral VD subjects had varying degrees of decrement. Unilateral VD subjects were tested twice; they underwent centrifugation both with right ear out and left ear out. Their post-centrifuation center of sway shifted at right angles depending on the centrifuge GIF orientation. Bilateral VD subjects bad shifts as well, but no consistent directional trend. VD subjects underestimated roll-tilt during centrifugation, These results suggest that orientation of the gravito-inertial vector and its magnitude arc both used by the central nervous system for calibration of multiple orientation systems. A change in the background gravito-inertial force (otolith input) can rapidly initiate postural and perceptual adaptation in several sensorimotor systems, independent of a structured visual surround.

A randomized, double-blind, placebo-controlled, parallel-group, phase III multicenter trial was performed to evaluate the relative efficacy and safety of cilostazol and pentoxifylline. The study included 54 outpatient vascular clinics, including sites at Air Force, Veterans Affairs, tertiary care, and university hospitals in the United States. Of 922 consenting patients, 698 met the inclusion criteria, were randomized, and received treatment with either cilostazol 100 mg P0 twice a day, pentoxifylline 400 mg PO 3 times a day, or placebo. Treatment was double-dummy to ensure study blindness. Efficacy was primarily established by maximal walking distance (MWD), measured with constant-speed, variable-grade treadmill testing, assessed at baseline and at 4, 8, 12, 16, 20, and 24 weeks. Mean MWD of cilostazol-treated patients (n=227) was significantly improved at every visit compared with patients who received pentoxifylline (n=232) or placebo (n=239). After 24 weeks of cilostazol, mean MWD increased 53.9% (107.3 m) from baseline, and the effect had not plateaued. This was better (P < 0.001) than the 30.4% (64.4 m) MWD improvement with pentoxifylline. MWD improvement with pentoxifylline was similar (P = 0.82) to that of placebo (64.7 m). Deaths and serious adverse event rates were similar in each group. Common side effects included headache (27.8% with cilostazol, 11.2% with pentoxifylline, 11.7% with placebo), palpitations (17.2% with cilostazol, 2.2% with pentoxifylllne, 1.3% with placebo), and abnormal stools. Cilostazol was significantly better than pentoxifylline or placebo for increasing walking distances; pentoxifylline was no better than placebo.

Adaptational response of human cell populations to microgravity is investigated using simulation, short-term Shuttle experiments, and long-term microgravity. Simulation consists of a clinostatically-rotated cell culture system. The system is a horizontally-rotated cylinder completely filled with culture medium. Low speed rotation results in continuous-fall of the cells through the fluid medium. In this setting, cells: 1) aggregate, 2) propagate in three dimensions, 3) synthesize matrix, 4) differentiate, and 5) form sinusoids that facilitate mass transfer. Space cell culture is conducted in flight bioreactors and in static incubators. Cells grown in microgravity are: bovine cartilage, promyelocytic leukemia, kidney proximal tubule cells, adrenal medulla, breast and colon cancer, and endothelium. Cells were cultured in space to test specific hypotheses. Cartilage cells were used to determine structural differences in cartilage grown in space compared to ground-based bioreactors. Results from a 130-day experiment on Mir revealed that cartilage grown in space was substantially more compressible due to insufficient glycosaminoglycan in the matrix. Interestingly, earth-grown cartilage conformed better to the dimensions of the scaffolding material, while the Mir specimens were spherical. The other cell populations are currently being analyzed for cell surface properties, gene expression, and differentiation. Results suggest that some cells spontaneously differentiate in microgravity. Additionally, vast changes in gene expression may occur in response to microgravity. In conclusion, the transition to microgravity may constitute a physical perturbation in cells resulting in unique gene expressions, the consequences of which may be useful in tissue engineering, disease modeling, and space cell biology.

We previously reported that a NASA-developed bioreactor that simulates microgravity environment and creates the unique environment of low shear force and high-mass transfer is conducive for maintaining long term 3-D cell cultures of functional hepatocytes (60 days). However, significant further expansion of liver mass, or the remodeling of liver in vitro was jeopardized by the appearance of apoptotic zones in the center of large cell aggregates. To optimize oxygenation and nutritional uptake within growing cellular aggregates we cultured primary human liver cells (HLC) in a bioreactor in the presence or absence of microcarriers and biodegradable scaffolds. Also, to promote angiogenesis, HLC were cultured with or without microvascular endothelial cells. HLC were harvested from human livers by collagenase perfusion. While microcarriers did not affect cell growth, HLC cultured with biodegradable scaffolds made from polyglycolic acid (PGA) formed aggregates up to 3 cm in length. Culturing cells with PGA scaffolds increased the efficiency of cell self-assembly and the formation of larger cell aggregates. Based on histological evaluation it appears that the degree of apoptotic cells was diminished as compared to cultures without scaffolds. Histology of HLC with PGA-scaffolds revealed cell distribution between the fibers of the scaffolds, and cell-cell and cell-fiber interactions. Analyses of HLC spheroids revealed tissue-like structures comprised of hepatocytes, biliary epithelial cells and/or progenitor liver cells that were arranged as bile duct-like structures along nascent vascular sprouts. Electron microscopy revealed groups of cohesive hepatocytes and bile canaliculi with multiple microvilli and tight cellular junctions. Hepatocytes were further organized into tight clusters surrounded by complex stromal structures and reticulin fibers. Also, we observed higher levels of albumin mRNA expression when hepatocytes were co-cultured with endothelial cells. To evaluate viability and microsomal deethylation activity of hepatocytes we assessed the metabolism of midazolam by gas chromatography. Samples that were collected from HLC cultured in the bioreactor contained higher levels of midazolam metabolites (1-OH-midazolam and 4-OH-midazolam) than samples collected from conventional cultures. In summary, we have shown that co-culture of HLC with endothelial cells and/or culturing in the presence of PGA scaffolds provides additional advantages in maintaining functional activity of 3-D hepatocyte cultures that resemble liver tissue. This cell culture system may facilitate studies of liver regeneration and cell-to-cell interactions that occur in vivo and suggest the feasibility of using this approach for pre-clinical metabolic screening of novel drug candidates.

Various parameters of immune suppression are observed in astronauts during and after spaceflight, and in isolated immune cells in true and simulated microgravity. Specifically, polyclonal activation of T cells is severely suppressed in true and simulated microgravity. These recent findings with various polyclonal activators suggests a suppression of oligoclonal lymphocyte activation in microgravity. We utilized rotating wall vessel (RWV) bioreactors that simulate aspects of microgravity for cell cultures to analyze three models of antigen-specific activation. A mixed-lymphocyte reaction (MLR), as a model for a primary immune response; a tetanus toxoid (TT) response and a B. burgdorferi (Bb) response, as models of a secondary immune response, were all suppressed in the RWV bioreactor. Our findings confirm that the suppression of activation observed with polyclonal models also encompasses oligoclonal antigen-specific activation.

To understand the mechanism of immunity impairment in space it is important to analyze the direct effects of space-related conditions on different lymphocytes functions. Since 1992, we are investigating the effect of modeled and true microgravity (MG) on numerous lymphocyte functions. We had shown that modeled (MMG) and true microgravity inhibit lymphocyte locomotion through type I collagen. Modeled microgravity also suppresses polyclonal and antigen-specific lymphocyte activation. Polyclonal activation of lymphocytes prior to exposure to MMG abrogates the MG-induced inhibition of lymphocyte locomotion. The relationship between activation deficits and the loss of locomotion in MG was investigated using PKC activation by phorbol ester (PMA) and calcium ionophore (ionomycin). Direct activation of PKC by PMA substantially restored the MMG-inhibited lymphocyte locomotion and PHA-induced lymphocyte activation lonomycin by itself did not restore either locomotion or activation of the lymphocytes, indicating that these changes are not related to the impairment in the calcium flux in MMG. Treatment of lymphocytes with PMA before exposure to MMG prevented the loss of locomotion. It was observed that DNA synthesis is not necessary for restoration of locomotion since mitomicin C treated and untreated cells recovered their locomotion to the same level after PKC activation. Our recent data indicate that microgravity may selectively effect the expression of novel Ca2+ independent isoforms of PKC, in particularly PKC sigma and delta. This provides a new insight in understanding of the mechanisms of MG-sensitive cellular functions.

For the first four decades of human space flight NASA's priorities in life sciences and medical programs have been preventative medicine (astronaut selection and training); assessment of the physiologic effects of microgravity and other unique aspects of space flight, implementation of countermeasures to protect against adverse effects, and amelioration of these adverse effects. Because most of the U.S. space flight experience has been on short duration missions, the need for medical and diagnostic treatment capabilities have been limited.The first long-term crews will arrive on the International Space Station (ISS) in early 2000. This will usher in a new era, an era of sustained human presence in Low Earth Orbit. One of the principal purposes of the ISS program is to increase the knowledge of the effects of long duration space flight on humans, a pre-requisite to future exploration class missions beyond Low Earth Orbit (e.g., a return to the Moon or an exploration of Mars). Areas of particular interest include protection from radiation, muscle atrophy, bone loss, cardiovascular alterations, immune dysfunction, adverse psychological response to hazards and confinement, and neurovestibular alterations. In addition, long duration space flight requires the development of autonomous medical care capabilities, as the distances involved eliminate the possibility of real-time telemedicine or robotic intervention, and prevent a mission abort and a rapid return to Earth. The objectives of this presentation include: 1. A description of the International Space Station project, including its research facilities and on-orbit medical capabilities; 2. An overview of the physiological and medical problems associated with microgravity in space flight; 3. A review of NASA's biomedical research priorities and ongoing work to develop clinical care capabilities for space flight crews (including surgical interventions) and; 4. An overview of current and proposed research priorities for NASA Research Announcements, NASA Space Biomedical Research Institute, Small Business Innovation Research Grant, and other funding sources.

Quantitative analyses of a 77 year old astronaut's balance control performances on a standardized test battery revealed few differences between his neuro-adaptive responses to space flight and those of a group of younger astronauts tested following missions of similar duration. This finding suggests that the physiological changes associated with age do not necessarily impair adaptive plasticity in the human following removal and subsequent reintroduction of gravity.