MANAGEMENT OF DIABETES DURING AIR TRAVEL: A SYSTEMATIC LITERATURE REVIEW OF CURRENT RECOMMENDATIONS AND THEIR SUPPORTING EVIDENCE.

OBJECTIVE: Individuals with diabetes are increasingly seeking pretravel advice, but updated professional recommendations remain scant. We performed a systematic review on diabetes management during air travel to summarize current recommendations, assess supporting evidence, and identify areas of future research. METHODS: A systematic review of the English literature on diabetes management during air travel was undertaken utilizing PubMed and MEDLINE. Publications regarding general travel advice; adjustment of insulin and noninsulin therapies; and the use of insulin pumps, glucometers and subcutaneous glucose sensors at altitude were included. Gathered information was used to create an updated summary of glucose-lowering medication adjustment during air travel. RESULTS: Sixty-one publications were identified, most providing expert opinion and few offering primary data (47 expert opinion, 2 observational studies, 2 case reports, 10 device studies). General travel advice was uniform, with increasing attention to preflight security. Indications for oral antihyperglycemic therapy adjustments varied. There were few recommendations on contemporary agents and on nonhypoglycemic adverse events. There was little consensus on insulin adjustment protocols, many antedating current insulin formulations. Most publications advocated adjusting insulin pump time settings after arrival; however, there was disagreement on timing and rate adjustments. Glucometers and subcutaneous glucose sensors were reported to be less accurate at altitude, but not to an extent that would preclude their clinical use. CONCLUSION: Recommendations for diabetes management during air travel vary significantly and are mostly based on expert opinion. Data from systematic investigation on glucose-lowering medication adjustment protocols may support the development of a future consensus statement. ABBREVIATIONS: CSII = continuous subcutaneous insulin infusion (device) DPP-4 = dipeptidyl peptidase 4 EGA = error grid analysis GDH = glucose dehydrogenase GOX = glucose oxidase GLP1 = glucagon-like peptide-1 NPH = neutral protamine Hagedorn SGLT2 = sodium-glucose cotransporter-2.

Hypertension screening of commercial divers from an occupational medicine perspective.

Hypertension is one of the most common chronic diseases in the world: in the United States, it affects one-third of the adult population. Most cases are primary hypertension - with no identified cause - and significantly increase risk for cardiovascular disease and stroke. At NASA's Neutral Buoyancy Laboratory (NBL), there is a cadre of professional divers who provide underwater support during extravehicular activity training (EVAs, commonly referred to as "spacewalks") for astronauts. The NBL occupational health program requires regular "work-site" physical exams, including blood pressure checks, on at least a weekly basis. Although some blood pressures measured during such regular checks were elevated, the diagnosis and management of blood pressure was outside the scope of that occupational medicine program. As a result, there was no protocol to analyze and manage asymptomatic elevated blood pressure if and when it warranted physician follow-up. We therefore analyzed the blood pressure data from all divers in 2015, vetted the worksite physical and developed a referral pathway to ensure divers have access to effective management of their blood pressure while minimizing impact of such a program on daily operations.

Subject anxiety and psychological considerations for centrifuge-simulated suborbital spaceflight.

INTRODUCTION: Anxiety and psychological concerns may pose a challenge to future commercial spaceflight. To help identify potential measures of anxiousness and indicators of flight-related stress, the psychiatric histories and anxiousness responses of volunteers exposed to G forces in centrifuge-simulated spaceflight acceleration profiles were examined. METHODS: Over 2 d, 86 individuals (63 men, 23 women), 20-78 yr old, underwent up to 7 centrifuge runs. Day 1 consisted of two +G(z) runs (peak = +3.5 G(z)) and two +Gx runs (peak = +6.0 G(x)). Day 2 consisted of three runs approximating suborbital spaceflight profiles (combined +G(x) and +G(z)). Hemodynamic data were collected during the profiles. Subjects completed a retrospective self-report anxiety questionnaire. Medical monitors identified individuals exhibiting varying degrees of anxiousness during centrifuge exposure, medical histories of psychiatric disease, and other potential indicators of psychological intolerance of spaceflight. RESULTS: The retrospective survey identified 18 individuals self-reporting anxiousness, commonly related to unfamiliarity with centrifuge acceleration and concerns regarding medical history. There were 12 individuals (5 men, 7 women, average age 46.2 yr) who were observed to have anxiety that interfered with their ability to complete training; of these, 4 reported anxiousness on their questionnaire and 9 ultimately completed the centrifuge profiles. Psychiatric history was not significantly associated with anxious symptoms. DISCUSSION: Anxiety is likely to be a relevant and potentially disabling problem for commercial spaceflight participants; however, positive psychiatric history and self-reported symptoms did not predict anxiety during centrifuge performance. Symptoms of anxiousness can often be ameliorated through training and coaching. Even highly anxious individuals are likely capable of tolerating commercial spaceflight.

Tolerance of centrifuge-simulated suborbital spaceflight by medical condition.

INTRODUCTION: We examined responses of volunteers with known medical disease to G forces in a centrifuge to evaluate how potential commercial spaceflight participants (SFPs) might tolerate the forces of spaceflight despite significant medical history. METHODS: Volunteers were recruited based upon suitability for each of five disease categories (hypertension, cardiovascular disease, diabetes, lung disease, back or neck problems) or a control group. Subjects underwent seven centrifuge runs over 2 d. Day 1 consisted of two +G(z) runs (peak = +3.5 G(z), Run 2) and two +G(x), runs (peak = +6.0 G(x), Run 4). Day 2 consisted of three runs approximating suborbital spaceflight profiles (combined +G(x) and +G(z), peak = +6.0 G(x)/+4.0 G(z)). Data collected included blood pressure, electrocardiogram, pulse oximetry, neurovestibular exams, and post-run questionnaires regarding motion sickness, disorientation, grayout, and other symptoms. RESULTS: A total of 335 subjects registered for participation, of which 86 (63 men, 23 women, age 20-78 yr) participated in centrifuge trials. The most common causes for disqualification were weight and severe and uncontrolled medical or psychiatric disease. Five subjects voluntarily withdrew from the second day of testing: three for anxiety reasons, one for back strain, and one for time constraints. Maximum hemodynamic values recorded included HR of 192 bpm, systolic BP of 217 mmHg, and diastolic BP of 144 mmHg. Common subjective complaints included grayout (69%), nausea (20%), and chest discomfort (6%). Despite their medical history, no subject experienced significant adverse physiological responses to centrifuge profiles. DISCUSSION: These results suggest that most individuals with well-controlled medical conditions can withstand acceleration forces of launch and re-entry profiles of current commercial spaceflight vehicles.

NASA's human system risk management approach and its applicability to commercial spaceflight.

As planning continues for commercial spaceflight, attention is turned to NASA to assess whether its human system risk management approach can be applied to mitigate the risks associated with commercial suborbital and orbital flights. NASA uses a variety of methods to assess the risks to the human system based on their likelihood and consequences. In this article, we review these methods and categorize the risks in the system as "definite," "possible," or "least" concern for commercial spaceflight. As with career astronauts, these risks will be primarily mitigated by screening and environmental control. Despite its focus on long-duration exploration missions, NASA's human system risk management approach can serve as a preliminary knowledge base to help medical planners prepare for commercial spaceflights.

Musculoskeletal injuries and minor trauma in space: incidence and injury mechanisms in U.S. astronauts.

INTRODUCTION: Astronauts have sustained musculoskeletal injuries and minor trauma in space, but our knowledge of these injuries is based mainly on anecdotal reports. The purpose of our study was to catalog and analyze all in-flight musculoskeletal injuries occurring throughout the U.S. space program to date. METHODS: A database on in-flight musculoskeletal injuries among U.S. astronauts was generated from records at the Johnson Space Center. RESULTS: A total of 219 in-flight musculoskeletal injuries were identified, 198 occurring in men and 21 in women. Incidence over the course of the space program was 0.021 per flight day for men and 0.015 for women. Hand injuries represented the most common location of injuries, with abrasions and small lacerations representing common manifestations of these injuries. Crew activity in the spacecraft cabin such as translating between modules, aerobic and resistive exercise, and injuries caused by the extravehicular activity (EVA) suit components were the leading causes of musculoskeletal injuries. Exercise-related injuries accounted for an incidence of 0.003 per day and exercise is the most frequent source of injuries in astronauts living aboard the International Space Station (ISS). Interaction with EVA suit components accounted for an incidence of 0.26 injuries per EVA. DISCUSSION: Hand injuries were among the most common events occurring in U.S. astronauts during spaceflight. Identifying the incidence and mechanism of in-flight injuries will allow flight surgeons to quantify the amount of medical supplies needed in the design of next-generation spacecraft. Engineers can use in-flight injury data to further refine the EVA suit and vehicle components.

Dysrhythmias in Laypersons During Centrifuge-Simulated Suborbital Spaceflight.

INTRODUCTION: There are limited data on cardiac dysrhythmias in laypersons during hypergravity exposure. We report layperson electrocardiograph (ECG) findings and tolerance of dysrhythmias during centrifuge-simulated suborbital spaceflight. METHODS: Volunteers participated in varied-length centrifuge training programs of 2-7 centrifuge runs over 0.5-2 d, culminating in two simulated suborbital spaceflights of combined +Gz and +Gx (peak +4.0 Gz, +6.0 Gx, duration 5 s). Monitors recorded pre- and post-run mean arterial blood pressure (MAP), 6-s average heart rate (HR) collected at prespecified points during exposures, documented dysrhythmias observed on continuous 3-lead ECG, self-reported symptoms, and objective signs of intolerance on real-time video monitoring. RESULTS: Participating in the study were 148 subjects (43 women). Documented dysrhythmias included sinus pause (N = 5), couplet premature ventricular contractions (N = 4), bigeminy (N = 3), accelerated idioventricular rhythm (N = 1), and relative bradycardia (RB, defined as a transient HR drop of >20 bpm; N = 63). None were associated with subjective symptoms or objective signs of acceleration intolerance. Episodes of RB occurred only during +Gx exposures. Subjects had a higher post-run vs. pre-run MAP after all exposures, but demonstrated no difference in pre- and post-run HR. RB was more common in men, younger individuals, and subjects experiencing more centrifuge runs. DISCUSSION: Dysrhythmias in laypersons undergoing simulated suborbital spaceflight were well tolerated, though RB was frequently noted during short-duration +Gx exposure. No subjects demonstrated associated symptoms or objective hemodynamic sequelae from these events. Even so, heightened caution remains warranted when monitoring dysrhythmias in laypersons with significant cardiopulmonary disease or taking medications that modulate cardiac conduction.Suresh R, Blue RS, Mathers CH, Castleberry TL, Vanderploeg JM. Dysrhythmias in laypersons during centrifuge-stimulated suborbital spaceflight. Aerosp Med Hum Perform. 2017; 88(11):1008-1015.