ALBERT

Description: Investigative procedures were approved by Henry Ford Human Investigation Committee and NASA Johnson Space Center Committee for Protection of Human Subjects. Informed consent was obtained. Authors evaluated ability of nonphysician crewmember to obtain diagnostic-quality musculoskeletal ultrasonographic (US) data of the shoulder by following a just-in-time training algorithm and using real-time remote guidance aboard the International Space Station (ISS). ISS Expedition-9 crewmembers attended a 2.5-hour didactic and hands-on US training session 4 months before launch. Aboard the ISS, they completed a 1-hour computer-based Onboard Proficiency Enhancement program 7 days before examination. Crewmembers did not receive specific training in shoulder anatomy or shoulder US techniques. Evaluation of astronaut shoulder integrity was done by using a Human Research Facility US system. Crew used special positioning techniques for subject and operator to facilitate US in microgravity environment. Common anatomic reference points aided initial probe placement. Real-time US video of shoulder was transmitted to remote experienced sonologists in Telescience Center at Johnson Space Center. Probe manipulation and equipment adjustments were guided with verbal commands from remote sonologists to astronaut operators to complete rotator cuff evaluation. Comprehensive US of crewmember's shoulder included transverse and longitudinal images of biceps and supraspinatus tendons and articular cartilage surface. Total examination time required to guide astronaut operator to acquire necessary images was approximately 15 minutes. Multiple arm and probe positions were used to acquire dynamic video images that were of excellent quality to allow evaluation of shoulder integrity. Postsession download and analysis of high-fidelity US images collected onboard demonstrated additional anatomic detail that could be used to exclude subtle injury. Musculoskeletal US can be performed in space by minimally trained operators by using remote guidance. This technique can be used to evaluate shoulder integrity in symptomatic crewmembers after strenuous extravehicular activities or to monitor microgravity-associated changes in musculoskeletal anatomy. Just-in-time training, combined with remote experienced physician guidance, may provide a useful approach to complex medical tasks performed by nonexperienced personnel in a variety of remote settings, including current and future space programs. (c) RSNA, 2004.

Description: BACKGROUND: Ultrasound imaging is a successful modality in a broad variety of diagnostic applications including trauma. Ultrasound has been shown to be accurate when performed by non-radiologist physicians; recent reports have suggested that non-physicians can perform limited ultrasound examinations. A multipurpose ultrasound system is installed on the International Space Station (ISS) as a component of the Human Research Facility (HRF). This report documents the first ocular ultrasound examination conducted in space, which demonstrated the capability to assess physiologic alterations or pathology including trauma during long-duration space flight. METHODS: An ISS crewmember with minimal sonography training was remotely guided by an imaging expert from Mission Control Center (MCC) through a comprehensive ultrasound examination of the eye. A multipurpose ultrasound imager was used in conjunction with a space-to-ground video downlink and two-way audio. Reference cards with topological reference points, hardware controls, and target images were used to facilitate the examination. Multiple views of the eye structures were obtained through a closed eyelid. Pupillary response to light was demonstrated by modifying the light exposure of the contralateral eye. RESULTS: A crewmember on the ISS was able to complete a comprehensive ocular examination using B- and M-mode ultrasonography with remote guidance from an expert in the MCC. Multiple anteroposterior, oblique, and coronal views of the eye clearly demonstrated the anatomic structures of both segments of the globe. The iris and pupil were readily visualized with probe manipulation. Pupillary diameter was assessed in real time in B- and M-mode displays. The anatomic detail and fidelity of ultrasound video were excellent and could be used to answer a variety of clinical and space physiologic questions. CONCLUSIONS: A comprehensive, high-quality ultrasound examination of the eye was performed with a multipurpose imager aboard the ISS by a non-expert operator using remote guidance. Ocular ultrasound images were of diagnostic quality despite the 2-second communication latency and the unconventional setting of a weightless spacecraft environment. The remote guidance techniques developed to facilitate this successful NASA research experiment will support wider applications of ultrasound for remote medicine on Earth including the assessment of pupillary reactions in patients with severe craniofacial trauma and swelling.

Description: INTRODUCTION: The performance of complex tasks on the International Space Station (ISS) requires significant preflight crew training commitments and frequent skill and knowledge refreshment. This report documents a recently developed "just-in-time" training methodology, which integrates preflight hardware familiarization and procedure training with an on-orbit CD-ROM-based skill enhancement. This "just-in-time" concept was used to support real-time remote expert guidance to complete ultrasound examinations using the ISS Human Research Facility (HRF). METHODS: An American and Russian ISS crewmember received 2 h of "hands on" ultrasound training 8 mo prior to the on-orbit ultrasound exam. A CD-ROM-based Onboard Proficiency Enhancement (OPE) interactive multimedia program consisting of memory enhancing tutorials, and skill testing exercises, was completed by the crewmember 6 d prior to the on-orbit ultrasound exam. The crewmember was then remotely guided through a thoracic, vascular, and echocardiographic examination by ultrasound imaging experts. RESULTS: Results of the CD-ROM-based OPE session were used to modify the instructions during a complete 35-min real-time thoracic, cardiac, and carotid/jugular ultrasound study. Following commands from the ground-based expert, the crewmember acquired all target views and images without difficulty. The anatomical content and fidelity of ultrasound video were adequate for clinical decision making. CONCLUSIONS: Complex ultrasound experiments with expert guidance were performed with high accuracy following limited preflight training and multimedia based in-flight review, despite a 2-s communication latency. In-flight application of multimedia proficiency enhancement software, coupled with real-time remote expert guidance, facilitates the successful performance of ultrasound examinations on orbit and may have additional terrestrial and space applications.

Description: 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.

Description: The presentation slides review normal physiology of the right ventricle in space, general physiology of the right ventricle; difficulties in imaging the heart in space, imaging methods, tissue Doppler spectrum, right ventricle tissue Doppler, and Rt Tei Index.

Description: Background: Carotid Intima Media Thickness (CIMT) has been demonstrated to be predictive of future cardiovascular events. Within various populations, radiation exposure, stress, and physical confinement have all been linked to an increased CIMT. Recent research discovered CIMT was significantly increased in ten long duration astronauts from pre-flight to four days post flight. The relationship between spaceflight and CIMT is not understood and trends in CIMT within the larger astronaut population are unknown. Methods: In 2010, CIMT was offered as part of the astronaut annual exam at the JSC Flight Medicine Clinic using a standardized CIMT screening protocol and professional sonographers. Between 2010 and 2016, CIMT measurements were collected on 213 NASA astronauts and payload specialists. The values used in this retrospective chart review are the mean of the CIMT from the right and left. Spaceflight exposure was categorized based on the total number of days spent in space at the time of the ground-based ultrasound (0, 1-29, 30-100, 101-200, 200). Linear regression with generalized estimating equations were used to estimate the association between spaceflight exposures and CIMT. Results: 530 studies were completed among 213 astronauts with a mean of 2.5 studies (range 1-6) per astronaut over the six year period. As in other populations, CIMT was significantly associated with age; however, gender was not. While there was no significant direct correlation between total spaceflight exposure and CIMT found, astronauts with 30-100 spaceflight days and astronauts with greater than 100 spaceflight days had significantly increased CIMT over astronauts who had never flown (p=0.002 and p=〈0.0001 respectively) after adjustment for age. Conclusion: Further work is needed to fully understand CIMT and its association to spaceflight. Current occupational surveillance activities are under way to study CIMT values in conjunction with other cardiovascular risk factors among astronauts as compared to the general population.

Description: The objective of this joint U.S. - Russian project was the development and validation of an in-flight methodology to assess a number of cardiac and vascular parameters associated with circulating volume and its manipulation in long-duration space flight. Responses to modified Valsalva and Mueller maneuvers were measured by cardiac and vascular ultrasound (US) before, during, and after temporary volume reduction by means of Braslet-M thigh occlusion cuffs (Russia). Materials and Methods: The study protocol was conducted in 14 sessions on 9 ISS crewmembers, with an average exposure to microgravity of 122 days. Baseline cardiovascular measurements were taken by echocardiography in multiple modes (including tissue Doppler of both ventricles) and femoral and jugular vein imaging on the International Space Station (ISS). The Braslet devices were then applied and measurements were repeated after 〉10 minutes. The cuffs were then released and the hemodynamic recovery process was monitored. Modified Valsalva and Mueller maneuvers were used throughout the protocol. All US data were acquired by the HDI-5000 ultrasound system aboard the ISS (ATL/Philips, USA) during remotely guided sessions. The study protocol, including the use of Braslet-M for this purpose, was approved by the ISS Human Research Multilateral Review Board (HRMRB). Results: The effects of fluid sequestration on a number of echocardiographic and vascular parameters were readily detectable by in-flight US, as were responses to respiratory maneuvers. The overall volume status assessment methodology appears to be valid and practical, with a decrease in left heart lateral E (tissue Doppler) as one of the most reliable measures. Increase in the femoral vein cross-sectional areas was consistently observed with Braslet application. Other significant differences and trends within the extensive cardiovascular data were also observed. (Decreased - RV and LV preload indices, Cardiac Output, LV E all maneuvers, LV Stroke Volume). Conclusions: This Study: 1) Addressed specific aspects of operational space medicine and space physiology, including assessment of circulating volume disturbances 2) Expanded the applications of diagnostic ultrasound imaging and Doppler techniques in microgravity. 3) Used respiratory maneuvers against the background of acute circulating volume manipulations which appear to enhance our ability to noninvasively detect volume-dependency in a number of cardiac and vascular parameters. 4) Determined that Tei index is not clinically changed therefore contractility not altered in the face of reduced preload. 5) Determined that increased Femoral Vein Area indicating blood being sequestered in lower extremities correlates with reduced preload and cardiac output. 6) That Braslet may be the only feasible means of acutely treating high pressure pulmonary edema in reduced gravity environments.