Extended Reality Applications for Space Health.

INTRODUCTION: Spaceflight has detrimental effects on human health, imposing significant and unique risks to crewmembers due to physiological adaptations, exposure to physical and psychological stressors, and limited capabilities to provide medical care. Previous research has proposed and evaluated several strategies to support and mitigate the risks related to astronauts' health and medical exploration capabilities. Among these, extended reality (XR) technologies, including augmented reality (AR), virtual reality (VR), and mixed reality (MR) have increasingly been adopted for training, real-time clinical, and operational support in both terrestrial and aerospace settings, and only a few studies have reported research results on the applications of XR technologies for improving space health. This study aims to systematically review the scientific literature that has explored the application of XR technologies in the space health field. We also discuss the methodological and design characteristics of the existing studies in this realm, informing future research and development efforts on applying XR technologies to improve space health and enhance crew safety and performance.Ebnali M, Paladugu P, Miccile C, Park SH, Burian B, Yule S, Dias RD. Extended reality applications for space health. Aerosp Med Hum Perform. 2023; 94(3):122-130.

Crew Autonomy During Simulated Medical Event Management on Long Duration Space Exploration Missions.

OBJECTIVE: Our primary aim was to investigate crew performance during medical emergencies with and without ground-support from a flight surgeon located at mission control. BACKGROUND: There are gaps in knowledge regarding the potential for unanticipated in-flight medical events to affect crew health and capacity, and potentially compromise mission success. Additionally, ground support may be impaired or periodically absent during long duration missions. METHOD: We reviewed video recordings of 16 three-person flight crews each managing four unique medical events in a fully immersive spacecraft simulator. Crews were randomized to two conditions: with and without telemedical flight surgeon (FS) support. We assessed differences in technical performance, behavioral skills, and cognitive load between groups. RESULTS: Crews with FS support performed better clinically, were rated higher on technical skills, and completed more clinical tasks from the medical checklists than crews without FS support. Crews with FS support also had better behavioral/non-technical skills (information exchange) and reported significantly lower cognitive demand during the medical event scenarios on the NASA-TLX scale, particularly in mental demand and temporal demand. There was no significant difference between groups in time to treat or in objective measures of cognitive demand derived from heart rate variability and electroencephalography. CONCLUSION: Medical checklists are necessary but not sufficient to support high levels of autonomous crew performance in the absence of real-time flight surgeon support. APPLICATION: Potential applications of this research include developing ground-based and in-flight training countermeasures; informing policy regarding autonomous spaceflight, and design of autonomous clinical decision support systems.

Objective Measurement of Learners' Cognitive Load During Simulation-Based Trauma Team Training: A Pilot Study.

INTRODUCTION: Literature has shown cognitive overload which can negatively impact learning and clinical performance in surgery. We investigated learners' cognitive load during simulation-based trauma team training using an objective digital biomarker. METHODS: A cross-sectional study was carried out in a simulation center where a 3-h simulation-based interprofessional trauma team training program was conducted. A session included three scenarios each followed by a debriefing session. One scenario involved multiple patients. Learners wore a heart rate sensor that detects interbeat intervals in real-time. Low-frequency/high-frequency (LF/HF) ratio was used as a validated proxy for cognitive load. Learners' LF/HF ratio was tracked through different phases of simulation. RESULTS: Ten subjects participated in 12 simulations. LF/HF ratios during scenario versus debriefing were compared for each simulation. These were 3.75 versus 2.40, P < 0.001 for scenario 1; 4.18 versus 2.77, P < 0.001 for scenario 2; and 4.79 versus 2.68, P < 0.001 for scenario 3. Compared to single-patient scenarios, multiple-patient scenarios posed a higher cognitive load, with LF/HF ratios of 3.88 and 4.79, P < 0.001, respectively. CONCLUSIONS: LF/HF ratio, a proxy for cognitive load, was increased during all three scenarios compared to debriefings and reached the highest levels in a multiple-patient scenario. Using heart rate variability as an objective marker of cognitive load is feasible and this metric is able to detect cognitive load fluctuations during different simulation phases and varying scenario difficulties.

Utility of Epinephrine Levels in Determining Adrenal Vein Cannulation During Adrenal Venous Sampling for Primary Aldosteronism.

OBJECTIVE: In patients with primary aldosteronism, adrenal venous sampling (AVS) is performed to determine the presence of unilateral or bilateral adrenal disease. During AVS, verification of catheter positioning within the left adrenal vein (AV) and the right AV by comparison of AV and inferior vena cava (IVC) cortisol levels can be variable. The objective of this study was to determine the utility of AV epinephrine levels in assessing successful AV cannulation. METHODS: This was a single institution, retrospective review of patients who underwent AVS with cosyntropin stimulation for primary aldosteronism between 2009 and 2018. Successful cannulation of the AV was defined by an AV/IVC cortisol ratio selectivity index (SI) ≥3:1. Epinephrine thresholds to predict catheter placement in the AV were determined using logistic regression. The calculated epinephrine thresholds were compared with previously published thresholds. RESULTS: AVS was performed on 101 consecutive patients and, based on the SI, successful cannulation of the left AV and right AV occurred in 98 (97%) and 91(90%) patients, respectively. The calculated optimal epinephrine threshold to predict AV cannulation was 364 pg/mL (sensitivity, 92.1%; specificity, 94.6%) and the calculated optimal AV/IVC epinephrine ratio threshold was 27.4, (sensitivity, 92.1%; specificity, 91.3%). Among the 14 patients with failed AV cannulation, 3 patients would have been considered to have successful AVS using AV epinephrine levels >364 pg/mL and AV/IVC epinephrine ratio >27.4 thresholds. CONCLUSION: Obtaining 2 right AV samples routinely as well as AV and IVC epinephrine levels during AVS could prevent unnecessary repeat AVS in patients with failed AV cannulation based on cortisol-based SI <3:1.

Physiotherapy and related management for childhood obesity: A systematic scoping review.

INTRODUCTION: Despite targeted efforts globally to address childhood overweight/obesity, it remains poorly understood and challenging to manage. Physiotherapists have the potential to manage children with obesity as they are experts in movement and physical activity. However, their role remains unclear due to a lack of physiotherapy-specific guidelines. This scoping review aims to explore existing literature, critically appraising and synthesising findings to guide physiotherapists in the evidence-based management of childhood overweight/obesity. METHOD: A scoping review was conducted, including literature up to May 2020. A review protocol exists on Open Science Framework at https://osf.io/fap8g/. Four databases were accessed including PubMed, Embase, CINAHL, Medline via OVID, with grey literature searched through google via "file:pdf". A descriptive synthesis was undertaken to explore the impact of existing interventions and their efficacy. RESULTS: From the initial capture of 1871 articles, 263 intervention-based articles were included. Interventions included qualitative focused physical activity, quantitative focused physical activity and multicomponent interventions. Various outcome measures were utilised including health-, performance- and behaviour-related outcomes. The general trend for physiotherapy involvement with children who are obese appears to favour: 1) multicomponent interventions, implementing more than one component with environmental modification and parental involvement and 2) quantitative physical activity interventions, focusing on the quantity of bodily movement. These approaches most consistently demonstrated desirable changes across behavioural and health-related outcome measures for multicomponent and quantitative physical activity interventions respectively. CONCLUSION: When managing children with obesity, physiotherapists should consider multicomponent approaches and increasing the quantity of physical activity, given consistent improvements in various obesity-related outcomes. Such approaches are well suited to the scope of physiotherapists and their expertise in physical activity prescription for the management of childhood obesity. Future research should examine the effect of motor skill interventions and consider the role of environmental modification/parental involvement as factors contributing to intervention success.

High neutrophil-lymphocyte ratio is not independently associated with worse survival or recurrence in patients with extremity soft tissue sarcoma.

BACKGROUND: Soft tissue sarcomas are a heterogenous group of neoplasms without well-validated biomarkers. Cancer-related inflammation is a known driver of tumor growth and progression. Recent studies have implicated a high circulating neutrophil-lymphocyte ratio as a surrogate marker for the inflammatory tumor microenvironment and a poor prognosticator in multiple solid tumors, including colorectal and pancreatic cancers. The impact of circulating neutrophil-lymphocyte ratio in soft tissue sarcomas has yet to be elucidated. METHODS: We performed a retrospective analysis of patients undergoing curative resection for primary or recurrent extremity soft tissue sarcomas at academic centers within the US Sarcoma Collaborative. Neutrophil-lymphocyte ratio was calculated retrospectively in treatment-naïve patients using blood counts at or near diagnosis. RESULTS: A high neutrophil-lymphocyte ratio (≥4.5) was associated with worse survival on univariable analysis in patients with extremity soft tissue sarcomas (hazard ratio 2.07; 95% confidence interval, 1.54-2.8; P < .001). On multivariable analysis, increasing age (hazard ratio 1.03; 95% confidence interval, 1.02-1.04; P < .001), American Joint Committee on Cancer T3 (hazard ratio 1.89; 95% confidence interval, 1.16-3.09; P = .011), American Joint Committee on Cancer T4 (hazard ratio 2.36; 95% confidence interval, 1.42-3.92; P = .001), high tumor grade (hazard ratio 4.56; 95% confidence interval, 2.2-9.45; P < .001), and radiotherapy (hazard ratio 0.58; 95% confidence interval, 0.41-0.82; P = .002) were independently predictive of overall survival, but a high neutrophil-lymphocyte ratio was not predictive of survival (hazard ratio 1.26; 95% confidence interval, 0.87-1.82; P = .22). CONCLUSION: Tumor inflammation as measured by high pretreatment neutrophil-lymphocyte ratio was not independently associated with overall survival in patients undergoing resection for extremity soft tissue sarcomas.

Presentation and management of IVC and iliac vein encroachment by lumbar pedicle screws: a case-report.

Pedicle screws are commonly used in spinal surgeries and are relatively safe, with venous complications occurring rarely. We report a patient with imaging following a L4-5 fusion that showed indentation of the inferior vena cava and right common iliac vein by the right L4 and L5 pedicle screws. She underwent revision surgery in which the hardware was removed and no bleeding was observed. Intraoperative venogram confirmed vascular integrity and absence of indentation on the venous structures following screw removal. The patient recovered without complications. Venous contact by pedicle screws should be treated on a case-by-case basis in a multidisciplinary approach with vascular surgery. We discuss a treatment algorithm for the operative management of this problem.

Psychodynamic cultural psychiatry: a new approach to teaching residents.

This article describes a course, Psychodynamic Cultural Psychiatry, taught to PGY-3 residents at the New York Presbyterian Hospital-Weill Cornell Medical Center that uses psychodynamic theory to help deepen cultural understanding. We (Sandra Park, the instructor for the course, and Elizabeth Auchincloss, the residency training director) developed the class in 2006 in an effort to raise cultural awareness in the residency curriculum. We believe that despite an inherent Western bias, psychodynamic theory can be an effective way to teach cultural psychiatry. Additionally, cultural understanding can enhance understanding of psychodynamic principles. In this article, we argue that our course in psychodynamic cultural psychiatry helps residents to integrate these two points of view.

Early albumin use improves mortality in difficult to resuscitate burn patients.

BACKGROUND: The optimal resuscitation algorithm remains elusive for patients with a large burn injury. Recent reports from the military support that larger burns that do not respond well to ongoing lactated Ringer's solution resuscitation may improve with the use of 5% albumin and vasopressors. We hypothesized that the use of 5% albumin and vasopressors, as needed, would decrease complications of fluid resuscitation and burn mortality. METHODS: Fluid needs during the first 24 hours after burn injury, complications, and demographics were collected from all patients 12 years and older with burn size 20% or more of total body surface area admitted from 2003 to 2010. In March 2007, we changed our resuscitation to include the use of 5% albumin in the first 24 hours if the estimated fluid needs at 12 hours after burn would lead to a fluid volume of 6 mL/kg per percent burn at 24 hours. The patients treated before this change (Preprotocol) were compared with those treated after the guideline change (Postprotocol). RESULTS: The two groups were well matched for age, burn size, and inhalation injury. Ventilator days and mortality were decreased in the Postprotocol group. There was a trend toward less intravenous fluid use in the Postprotocol group where the use of albumin was higher. There was significantly less vasopressor infusion in the Postprotocol group. There was no statistical difference in the number of escharotomies performed or overall incidence of abdominal compartment syndrome, but no patient required open laparotomy in the Postprotocol group. CONCLUSION: An algorithm incorporating albumin use in the first 24 hours after burn injury was associated with the use of less vasopressor agents and lower mortality. Early albumin use was also associated with a shorter duration of mechanical ventilation in burn patients sustaining burns 20% or more total body surface area. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Pancreatic stellate cell migration: role of the phosphatidylinositol 3-kinase(PI3-kinase) pathway.

UNLABELLED: Pancreatic stellate cells (PSCs) are implicated as key mediators of pancreatic fibrogenesis and are found in increased numbers in areas of pancreatic injury. This increase in number may be due to increased local proliferation and/or migration of PSCs to affected areas from surrounding tissue. We have recently shown that PSCs can migrate and that this migration is stimulated by PDGF in a predominantly chemotactic manner [Gut 52 (2003) 677]. However, the signalling mechanisms responsible for PDGF-induced PSC migration are not known. AIMS: (i) To determine whether PDGF-induced PSC migration is mediated by the PI3-kinase pathway. (ii) To investigate whether cell migration is influenced by cell proliferation and whether an interaction exists between the PI3-kinase pathway and the ERK1/2 pathway (known to mediate cell proliferation) in PSCs exposed to PDGF. METHODS: (i) PI3-kinase activity was assessed by measuring the activation (phosphorylation) of its downstream substrate Akt in rat PSCs incubated with PDGF (10ng/mL) for 5min, 15min, 60min, and 24hr in the presence or absence of the specific PI3-kinase inhibitor wortmannin. (ii) The role of the PI3-kinase pathway in PSC migration was examined by assessing PSC migration through a porous membrane after exposure to PDGF in the presence and absence of wortmannin for 24hr. (iii) The relationship between migration and proliferation was assessed by examining migration of PSCs exposed to PDGF in the presence and absence of mitomycin C, an inhibitor of cell proliferation. (iv) The interaction between PI3-kinase and ERK1/2 was examined by incubation of PSCs with PDGF in the presence and absence of wortmannin, followed by assessment of ERK1/2 activation by western blot. RESULTS: PDGF increased Akt activation in PSCs as early as at 5min of incubation and this increase was sustained for 24hr. Inhibition of PI3-kinase by wortmannin decreased basal as well as PDGF-induced migration and also inhibited ERK1/2 activation. Inhibition of PSC proliferation with mitomycin C significantly reduced (but did not abolish) basal and PDGF-induced PSC migration. CONCLUSIONS: (i) The PI3-kinase pathway is induced in PSCs after exposure to PDGF and this induction is sustained for at least 24hr. (ii) The PI3-kinase pathway plays a role in PDGF-induced PSC migration and is partially involved in mediating ERK1/2 activation. (iii) PSC migration is dependent, at least in part, on cell proliferation.