Selecting Medical Conditions Relevant to Exploration Spaceflight to Create the IMPACT 1.0 Medical Condition List.

INTRODUCTION: Medical conditions occurring in spaceflight pose risks to the crew and the mission and these risks will be exacerbated during exploration-class missions. Probabilistic risk assessment is a method used at NASA to quantify this risk for low-Earth orbit operations. Informing Mission Planning via Analysis of Complex Tradespaces (IMPACT) is a next-generation tool suite that will perform these assessments for exploration-class missions. It will require a robust list of medical conditions of significant likelihood and/or consequence to exploration-class missions to accurately inform the tool suite.METHODS: The IMPACT 1.0 Medical Condition List (ICL 1.0) contains 120 conditions selected in the context of a 210-d cis-lunar, Mars analog design reference mission. The conditions were selected via a systematic process that preserved institutional knowledge from nine prior condition lists. Conditions were prioritized for inclusion in the ICL 1.0 based on history of occurrence in spaceflight, concurrence among the nine source lists, and concurrence among subject matter experts.DISCUSSION: The ICL 1.0 has notable advantages over its predecessor lists in that it is more specific to exploration-class missions, contains a greater number, breadth, and depth of conditions, and was derived via consensus across multiple medical specialties.Kreykes AJ, Suresh R, Levin D, Hilmers DC. Selecting medical conditions relevant to exploration spaceflight to create the IMPACT 1.0 Medical Condition List. Aerosp Med Hum Perform. 2023; 94(7):550-557.

The value of a spaceflight clinical decision support system for earth-independent medical operations.

As NASA prepares for crewed lunar missions over the next several years, plans are also underway to journey farther into deep space. Deep space exploration will require a paradigm shift in astronaut medical support toward progressively earth-independent medical operations (EIMO). The Exploration Medical Capability (ExMC) element of NASA's Human Research Program (HRP) is investigating the feasibility and value of advanced capabilities to promote and enhance EIMO. Currently, astronauts rely on real-time communication with ground-based medical providers. However, as the distance from Earth increases, so do communication delays and disruptions. Moreover, resupply and evacuation will become increasingly complex, if not impossible, on deep space missions. In contrast to today's missions in low earth orbit (LEO), where most medical expertise and decision-making are ground-based, an exploration crew will need to autonomously detect, diagnose, treat, and prevent medical events. Due to the sheer amount of pre-mission training required to execute a human spaceflight mission, there is often little time to devote exclusively to medical training. One potential solution is to augment the long duration exploration crew's knowledge, skills, and abilities with a clinical decision support system (CDSS). An analysis of preliminary data indicates the potential benefits of a CDSS to mission outcomes when augmenting cognitive and procedural performance of an autonomous crew performing medical operations, and we provide an illustrative scenario of how such a CDSS might function.

Enabling Human Space Exploration Missions Through Progressively Earth Independent Medical Operations (EIMO).

Goal: Current Space Medicine operations depend on terrestrial support to manage medical events. As astronauts travel to destinations such as the Moon, Mars, and beyond, distance will substantially limit this support and require increasing medical autonomy from the crew. This paper defines Earth Independent Medical Operations (EIMO) and identifies key elements of a conceptual EIMO system. Methods: The NASA Human Research Program Exploration Medical Capability Element held a 2-day conference at Johnson Space Center in Houston, TX with NASA experts representing all aspects of Space Medicine. Results: EIMO will be a process enabling progressively resilient deep space exploration systems and crews to reduce risk and increase mission success. Terrestrial assets will continue to provide pre-mission screening, planning, health maintenance, and prevention, while onboard medical care will increasingly be the purview of the crew. Conclusions: This paper defines and describes the key components of EIMO.

Multisystem inflammatory syndrome in children and adults (MIS-C/A): Case definition & guidelines for data collection, analysis, and presentation of immunization safety data.

This is a Brighton Collaboration Case Definition of the term "Multisystem Inflammatory Syndrome in Children and Adults (MIS-C/A)" to be utilized in the evaluation of adverse events following immunization. The case definition was developed by topic experts convened by the Coalition for Epidemic Preparedness Innovations (CEPI) in the context of active development of vaccines for SARS-CoV-2. The format of the Brighton Collaboration was followed, including an exhaustive review of the literature, to develop a consensus definition and defined levels of certainty. The document underwent peer review by the Brighton Collaboration Network and by selected expert external reviewers prior to submission. The comments of the reviewers were taken into consideration and edits incorporated into this final manuscript.

A programme to treat chronic hepatitis B in Kiribati: progress and challenges.

PROBLEM: Over 290 million people worldwide suffer from chronic hepatitis B (CHB), with the highest prevalence in the Pacific islands. Mortality attributable to this disease exceeds that from HIV, tuberculosis and malaria combined in this region. CONTEXT: CHB is a major health problem in the Pacific island nation of Kiribati. Medical care is complicated by vast expanses of ocean separating population centres in its constituent islands. Birth-dose hepatitis B immunization rates need improvement. High rates of obesity, metabolic syndrome, and co-infection with hepatitis B and hepatitis D in Kiribati make treatment less effective. Staff allocation, training and retention are difficult. Limited infrastructure creates challenges in training, communications, laboratory testing and record-keeping. ACTION: We have established a CHB treatment programme in Kiribati based on World Health Organization (WHO) guidelines and local needs. It includes direct patient care; laboratory, radiology and pharmacy support; public education; training; and data management. Thousands of individuals have been screened, and 845 hepatitis B-positive patients have had blood sent to Australia for molecular testing. Patient education pamphlets, medical training programmes and treatment protocols have been developed. Seventy-nine patients have started treatment. Regular onsite visits by technical experts are scheduled throughout the year. LESSONS LEARNT AND DISCUSSION: This is the first national CHB treatment programme established in the Pacific islands region. Unique challenges exist in Kiribati, as they do in each nation affected by CHB. Close engagement with local partners, knowledge of the barriers involved, flexibility, advocacy, and support from WHO and volunteer technical experts are key attributes of a successful treatment programme.

A Program to Treat Hepatitis B in North Korea: A Model of Antiviral Therapy in a Resource-Poor Setting.

Despite the well-proven, safe and effective therapies for hepatitis B infection, delivery of treatment remains a significant challenge in resource-poor settings. Geopolitical and economic restrictions present additional difficulties in providing care in North Korea. However, treatment of patients with chronic hepatitis B remains a top priority for both the North Korean Ministry of Public Health and international agencies working in North Korean hepatitis healthcare facilities. Working in partnership, a path was created to institute this much-needed program. A consortium of United States and Australian humanitarian non-governmental organizations along with generous individual and corporate donors working in concert with local and national health authorities have succeeded in establishing the first hepatitis B treatment program in North Korea. The essential elements of this program include renovation of existing hepatitis hospitals, access to antiviral medications, establishment of laboratory facilities, creation of medical documentation and record-keeping, training of local health care professionals, and quarterly visits by international volunteer physicians and laboratory experts. Management and treatment decisions are made bilaterally. To date, nearly 1,500 patients have been evaluated, and over 800 have been started on long-term antiviral therapy. It is envisioned that this program will eventually be managed and funded by the Democratic People's Republic of Korea Ministry of Public Health. This program's success demonstrates a potential model for delivery of antiviral therapy for patients suffering from hepatitis B in other developing countries.

A Micronutrient Fortified Beverage Given at Different Dosing Frequencies Had Limited Impact on Anemia and Micronutrient Status in Filipino Schoolchildren.

This study evaluated the effects of a multi-micronutrient fortified juice drink given in different frequencies of consumption on hemoglobin (Hb) concentration of schoolchildren. Hb was measured in 2423 schoolchildren aged 6- to 9-years-old at baseline. All anemic children (n = 246) were randomly allocated into groups: Daily dose (HD: high dose), 5X/week (MD: Moderate Dose), 3X/week (LD: Low Dose) and unfortified (Control). Pre- and post-study measurements of micronutrients were collected from 228 children. At the endpoint, significant Hb increases were observed in all groups, but there was no significant difference between groups. There was a significant reduction in anemia prevalence in all groups from 100% to 36% (Control), 30% (LD), 23% (MD) and 26% (HD). No dose-response effect was observed in Hb in this population. Most likely, this resulted from better than expected micronutrient status and lower than expected severity of anemia and micronutrient deficiencies in this cohort. It is unlikely that the addition of a fortified beverage to school feeding programs in this population would have a positive impact. Whether such an intervention would be cost-effective as a preventative approach needs to be assessed. This study demonstrates the importance of targeting such interventions to appropriate populations.

Neighborhood disparities in access to healthy foods and their effects on environmental justice.

Environmental justice is concerned with an equitable distribution of environmental burdens. These burdens comprise immediate health hazards as well as subtle inequities, such as limited access to healthy foods. We reviewed the literature on neighborhood disparities in access to fast-food outlets and convenience stores. Low-income neighborhoods offered greater access to food sources that promote unhealthy eating. The distribution of fast-food outlets and convenience stores differed by the racial/ethnic characteristics of the neighborhood. Further research is needed to address the limitations of current studies, identify effective policy actions to achieve environmental justice, and evaluate intervention strategies to promote lifelong healthy eating habits, optimum health, and vibrant communities.

Prevalence of metabolic syndrome and obesity in adolescents aged 12 to 19 years: comparison between the United States and Korea.

This study compared the prevalence of metabolic syndrome (MetS), its risk factors, and obesity in adolescents in the United States (US) and Korea. Data were obtained from 2003-2004 US National Health and Nutrition Examination Survey (NHANES) and 2005 Korea NHANES for adolescents aged 12-19 yr in the US (n=734) and in Korea (n=664). The 2007 International Diabetes Federation (IDF) pediatric definition for diagnosis of MetS and the 2000 US Growth Charts and 2007 Korea Growth Charts for assessment of obesity were utilized. The prevalence of metabolic syndrome in US and Koreans was 5.5% and 2.5%, respectively. The prevalence of obesity was 18.1% in US compared to 9.0% in Koreans. The prevalence of abdominal obesity, hyperglycemia, and hypertriglyceridemia were higher in the US, whereas that of low HDL-C levels was higher in Korea. Despite the doubled prevalence for the single entities of MetS and obesity in the US, the prevalence of MetS in obese US and Koreans did not differ (20.8% and 24.3%, respectively). In conclusion, there are differences in the prevalence of MetS, obesity, and the individual MetS risk factors between the US and Korean adolescents; however, the risk of MetS among obese adolescents is similar in both countries.

A comparison of the prevalence of the metabolic syndrome in the United States (US) and Korea in young adults aged 20 to 39 years.

This study estimated and compared the prevalence of the Metabolic Syndrome and its individual components in young adults (ages 20-39 years) in the US and Korea using 2003-2004 US and 2005 Korean National Health and Nutrition Examination Survey data. The mean body mass index and rate of metabolic abnormalities in the US were significantly higher than in Korea. The prevalence of the Metabolic Syndrome in the US was nearly three times higher than in Korea using National Cholesterol Education Program-Adult Treatment Panel III and Inter-national Diabetes Federation criteria (21.6% vs. 6.9% and 23.0% vs. 6.9%, p <0.001). The prevalence of abdominal obesity, hyperglycemia, and hypertriglyceridemia was higher in the US while the prevalence of low high density lipoprotein-cholesterol level was higher in Korea. The rate of hypertension showed no significant difference while mean systolic blood pressure and diastolic blood pressure varied between the two countries. The proportion of subjects having at least one component of Metabolic Syndrome was similar in both countries; however, multiple abnormalities were more common in the US. These findings indicate the need for the development of race/ethnic-based norms for components of the Metabolic Syndrome and detailed analysis of the risk factors for the Metabolic Syndrome in the two countries. National health policies designed to prevent the Metabolic Syndrome, its individual abnormalities, and its complications using population-based characteristics of each nation will generate improved outcomes.

Iron incorporation and post-malaria anaemia.

BACKGROUND: Iron supplementation is employed to treat post-malarial anaemia in environments where iron deficiency is common. Malaria induces an intense inflammatory reaction that stalls reticulo-endothelial macrophagal iron recycling from haemolysed red blood cells and inhibits oral iron absorption, but the magnitude and duration of these effects are unclear. METHODOLOGY/PRINCIPAL FINDINGS: We examined the red blood cell incorporation of oral administered stable isotopes of iron and compared incorporation between age matched 18 to 36 months old children with either anaemia post-malaria (n = 37) or presumed iron deficiency anaemia alone (n = 36). All children were supplemented for 30 days with 2 mg/kg elemental iron as liquid iron sulphate and administered (57)Fe and (58)Fe on days 1 and 15 of supplementation respectively. (57)Fe and(58)Fe incorporation were significantly reduced (8% vs. 28%: p<0.001 and 14% vs. 26%: p = 0.045) in the malaria vs. non-malaria groups. There was a significantly greater haemoglobin response in the malaria group at both day 15 (p = 0.001) and 30 (p<0.000) with a regression analysis estimated greater change in haemoglobin of 7.2 g/l (s.e. 2.0) and 10.1 g/l (s.e. 2.5) respectively. CONCLUSION/SIGNIFICANCE: Post-malaria anaemia is associated with a better haemoglobin recovery despite a significant depressant effect on oral iron incorporation which may indicate that early erythropoetic iron need is met by iron recycling rather than oral iron. Supplemental iron administration is of questionable utility within 2 weeks of clinical malaria in children with mild or moderate anaemia.

Prevalence and severity of micronutrient deficiency: a cross-sectional study among adolescents in Sri Lanka.

In order to determine the prevalence of micronutrient deficiencies (iron, zinc and folate) in Sri Lankan adolescent school children and the extent to which multiple micronutrient deficiencies exist in this population, a cross-sectional survey (2003) in the Galle district of the micronutrient and anthropometric status of 945 school children of ages 12-16 years was performed. The prevalence of anemia (Hb < 120.0 g/L) was 49.5% in males and 58.1% in females (overall 54.8%, gender difference, P = 0.004). In anemic children 30.2% of males and 47.8% of females were iron deficient (serum ferritin < 30.0 microg/L). Folate deficiency (<6.80 nmol/L) was found in 54.6% and 52.5% of boys and girls respectively whereas zinc deficiency (<9.95 micromol/L) occurred in 51.5% and 58.3%. Anemic boys had a 1.5 (95% confidence interval (CI) 0.9-2.6) and 1.6-fold (CI; 1.1-2.6) greater risk of being stunted and underweight, whereas the risk among anemic girls was 1.7 (CI; 1.1-2.7) and 1.0 (CI; 0.7-1.5) for being stunted and underweight. The relative risks of having at least two deficiencies in iron, zinc and folate among anemic children were 1.6 (CI; 0.6-4.2) among boys and 0.8 (CI; 0.5-1.5) among girls. Iron deficient subjects had a significantly increased risk of 1.8 (CI, 1.1-3.0) of being deficient in folate and 1.7 (CI, 1.2-2.6) of being deficient in zinc. Zinc deficient subjects had a risk of 1.3 (CI, 1.0-1.8) being iron deficient and 1.2 (CI, 0.9-1.7) of being folate deficient. Multiple micronutrient deficiencies are prevalent in Sri Lankan adolescents.

Na2EDTA enhances the absorption of iron and zinc from fortified rice flour in Sri Lankan children.

Rice flour was proposed as a vehicle for iron and zinc fortification in Sri Lanka. Although widely consumed, rice flour has not been evaluated as a fortified food, and the absorption of minerals including iron and zinc from this flour is unknown. Determination of the bioavailability of these nutrients is a critical step before commencing a fortification program. We randomly divided 53 Sri Lankan schoolchildren ages 6-10 y into 4 groups that consumed a local dish prepared with 25 g of fortified rice flour labeled with one of the following: 1) (58)FeSO(4) 2) (58)FeSO(4) + Na(2)EDTA 3) (58)FeSO(4) + (67)ZnO or, 4) (58)FeSO(4) + Na(2)EDTA + (67)ZnO. The levels of iron and zinc were 60 mg/kg; the rice flour also contained folate at 2 mg/kg in each group. Na(2)EDTA was added at a Fe:Na(2)EDTA, 1:1 molar ratio. A total of 48 children completed the trial. Absorption of (58)Fe from a meal was significantly greater (P < 0.01) in the groups administered FeSO(4) + Na(2)EDTA (4.7 +/- 3.6%) than in those administered FeSO(4) without Na(2)EDTA (2.2 +/- 1.3%). Fractional absorption of zinc was 13.5 +/- 6.0% in the FeSO(4) + Na(2)EDTA group and 8.8 +/- 2.0% in the FeSO(4) group (P = 0.037). Although zinc absorption was low, our results demonstrated a benefit in using Na(2)EDTA to improve both iron and zinc absorption. We conclude that the fortification of rice flour is feasible, although additional strategies such as dephytinization or an increase in the level of iron and zinc fortification should be considered to obtain a higher proportion of the daily requirement of total absorbed iron and zinc.

Bioavailability of iron and zinc from a multiple micronutrient-fortified beverage.

OBJECTIVE: To test the hypothesis that micronutrient beverages can provide the daily iron and zinc needs of small children. STUDY DESIGN: Forty children aged 6 to 9 years were recruited (Lima, Peru). For 4 weeks, they received a daily serving of a beverage containing multiple micronutrients. Over 2 consecutive days, subjects received stable isotope-labeled servings of the beverage with and without a meal as well as an intravenous dose of zinc. Iron and zinc bioavailability were assessed using mass spectrometry. RESULTS: Iron absorption was significantly lower with a meal than without (9.8 +/- 6.7% versus 11.6 +/- 6.9%, P=.04), but zinc absorption was not (24.5 +/- 10.7% versus 22.8 +/- 7.6%, P=.2). In either case, however, a single daily serving provided most of the iron and zinc requirements for the children. CONCLUSIONS: Single daily servings of multinutrient-fortified beverages can meet much of the mineral needs for small children. Food has a small inhibitory effect on iron, but not zinc, absorption; therefore, these beverages can be efficacious even when given with a meal.

A multinutrient-fortified beverage enhances the nutritional status of children in Botswana.

Due to their widespread acceptability, multinutrient-fortified foods and beverages may be useful in reducing micronutrient deficiencies, especially in developing countries. We studied the efficacy of a new fortified beverage in improving the nutritional status of children in Botswana. We screened 311 lower income urban school children, ages 6-11 y, in two primary schools near Gaborone. Children were given seven 240-mL servings weekly of either an experimental beverage (EXP) fortified with 12 micronutrients or an isoenergetic placebo drink (CON) for 8 wk. Weight, mid-upper arm circumference, hemoglobin, retinol, ferritin, vitamin B-12, folate and riboflavin status were measured at baseline and at the end of the study. Plasma zinc and serum transferrin receptors also were measured at study end. A total of 145 children in the EXP group and 118 in the CON group completed the trial. Using multivariate analysis, the changes in mid-upper arm circumference, weight for age and total weight were significantly better in the EXP group than in the CON group (P < 0.01). Ferritin, riboflavin and folate status were significantly better in the EXP group than in the CON group at study end (P < 0.01), but serum vitamin B-12 was not. Zinc was significantly higher and transferrin receptors were significantly lower at the conclusion of the study in the EXP group than in the CON group (P < 0.001). Mean plasma retinol concentrations, which were low (<0.7 micro mol/L) in both groups, did not change. We conclude that a micronutrient-fortified beverage may be beneficial as part of a comprehensive nutritional supplementation program in populations at risk for micronutrient deficiencies.