Evolution of telemedicine in the space program and earth applications.

Remote monitoring of crew, spacecraft, and environmental health has always been an integral part of the National Aeronautics and Space Administration's (NASA's) operations. Crew safety and mission success face a number of challenges in outerspace, including physiological adaptations to microgravity, radiation exposure, extreme temperatures and vacuum, and psychosocial reactions to space flight. The NASA effort to monitor and maintain crew health, system performance, and environmental integrity in space flight is a sophisticated and coordinated program of telemedicine combining cutting-edge engineering with medical expertise. As missions have increased in complexity, NASA telemedicine capabilities have grown apace, underlying its role in the field. At the same time, the terrestrial validation of telemedicine technologies to bring healthcare to remote locations provides feedback, improvement, and enhancement of the space program. As NASA progresses in its space exploration program, astronauts will join missions lasting months, even years, that take them millions of miles from home. These long-duration missions necessitate further technological breakthroughs in tele-operations and autonomous technology. Earth-based monitoring will no longer be real-time, requiring telemedicine capabilities to advance with future explorers as they travel deeper into space. The International Space Station will serve as a testbed for the telemedicine technologies to enable future missions as well as improve the quality of healthcare delivery on Earth.

Design and current status of the longitudinal study of astronaut health.

BACKGROUND: Information has been collected regarding the immediate physiological effects of spaceflight on humans. However, little is yet known regarding long-term effects. The purpose of this paper is to describe the Longitudinal Study of Astronaut Health (LSAH) and report current mortality data. METHODS: All astronauts selected for the United States Space Program are followed from selection throughout their lifetime or until the end of the study. Comparisons are ground-based Johnson Space Center (JSC) employees matched to the astronauts at a 3:1 ratio by sex-specific age and body mass index. They are followed in the same manner as astronauts. Morbidity and mortality data are obtained from medical records supplemented with study questionnaires. Checks for death certificates are made to ascertain death of participants who miss routine examinations. RESULTS: Current cause-specific mortality rates for astronauts selected from 1959 through 1991 are not statistically different from rates for comparison participants for cardiovascular (p = 0.8112), cancer (p = 0.2382), or other disease (p = 0.5040) mortality. Astronauts have a significantly higher mortality rate due to accidents and injuries (p < 0.0001). CONCLUSIONS: Astronauts have a similar risk of death due to chronic diseases as ground-based participants, but are at greater risk for occupational-related accidental death.

Applications of telemedicine in the United States space program.

Since the beginning of human space flight, NASA has been placing humans in extreme and remote environments. There are many challenges in maintaining humans in outer space, including the provision of life-support systems, radiation shielding, and countermeasures for minimizing the effect of microgravity. Because astronauts are selected for their health, among other factors, disease and illness are minimized. However, it is still of great importance to have appropriate medical care systems in place to address illness and injury should they occur. With the exception of the Apollo program, exploration of space has been limited to missions that are within several hundred miles of the surface of the Earth. At the drawn of the 21st century and the new millennium, human exploration will be focused on operation of the International Space Station (ISS) and preparation for human missions to Mars. These missions will present inherent risks to human health, and, therefore, appropriate plans must be established to address these challenges and risks. Crews of long-duration missions must become more independent from ground controllers. New systems, protocols, and procedures are currently being perfected. Application of emerging technologies in information systems and telecommunications will be critical to inflight medical care. Application of these technologies through telemedicine will provide crew members access to information, noninvasive procedures for assessing health status, and guidance through the integration of sensors, holography, decision-support systems, and virtual environments. These technologies will also serve as a basis to enhance training and medical education. The design of medical care for space flight should lead to a redesign of the practice of medicine on Earth.

The Spacebridge to Russia Project: internet-based telemedicine.

The National Aeronautics and Space Administration (NASA) has been a pioneer in telemedicine since the beginning of the human spaceflight program in the early 1960s. With the rapid evolution in computer technology and equally rapid development of computer networks, NASA and the Department of Surgery in Yale University's School of Medicine created a telemedicine testbed with the Russia Space Agency, the Spacebridge to Russia Project, using multimedia computers connected via the Internet. Clinical consultations were evaluated in a store-and-forward mode using a variety of electronic media, packaged as digital files, and transmitted using Internet and World Wide Web tools. These systems allow real-time Internet video teleconferencing between remotely located users over computer systems. This report describes the project and the evaluation methods utilized for monitoring effectiveness of the communications. The Spacebridge to Russia Project is a testbed for Internet-based telemedicine. The Internet and current computer technologies (hardware and software) make telemedicine readily accessible and affordable for most health care providers. Internet-based telemedicine is a communication tool that should become integral to global health care.

Telemedicine and international disaster response: medical consultation to Armenia and Russia via a Telemedicine Spacebridge.

UNLABELLED: The Telemedicine Spacebridge, a satellite-mediated, audio-video-fax link between four United States and two Armenian and Russian medical centers, permitted remote American consultants to assist Armenian and Russian physicians in the management of medical problems following the December 1988 earthquake in Armenia and the June 1989 gas explosion near Ufa. METHODS: During 12 weeks of operations, 247 Armenian and Russian and 175 American medical professionals participated in 34 half-day clinical conferences. A total of 209 patients were discussed, requiring expertise in 20 specialty areas. RESULTS: Telemedicine consultations resulted in altered diagnoses for 54, new diagnostic studies for 70, altered diagnostic processes for 47, and modified treatment plans for 47 of 185 Armenian patients presented. Simultaneous participation of several US medical centers was judged beneficial; quality of data transmission was judged excellent. CONCLUSION: These results suggest that interactive consultation by remote specialists can provide valuable assistance to on-site physicians and favorably influence clinical decisions in the aftermath of major disasters.

Telemedicine and international disaster response. Medical consultation to Armenia and Russia via a Telemedicine Spacebridge.

UNLABELLED: The Telemedicine Spacebridge, a satellite-mediated, audio-video-fax link between four United States and two Armenian and Russian medical centers, permitted remote American consultants to assist Armenian and Russian physicians in the management of medical problems following the December 1988 earthquake in Armenia and the June 1989 gas explosion near Ufa. METHODS: During 12 weeks of operations, 247 Armenian and Russian and 175 American medical professionals participated in 34 half-day clinical conferences. A total of 209 patients were discussed, requiring expertise in 20 specialty areas. RESULTS: Telemedicine consultations resulted in altered diagnoses for 54, new diagnostic studies for 70, altered diagnostic processes for 47, and modified treatment plans for 47 of 185 Armenian patients presented. Simultaneous participation of several US medical centers was judged beneficial; quality of data transmission was judged excellent. CONCLUSION: These results suggest that interactive consultation by remote specialists can provide valuable assistance to on-site physicians and favorably influence clinical decisions in the aftermath of major disasters.

The space life sciences strategy for the 21st century.

In the past, space life sciences has focused on gaining an understanding of physiological tolerance to spaceflight, but, for the last 10 years, the focus has evolved to include issues relevant to extended duration missions. In the 21st century, NASA's long-term strategy for the exploration of the solar system will combine the assurance of human health and performance for long periods in space with investigations aimed at searching for traces of life on other planets and acquiring fundamental scientific knowledge of life processes. Implementation of this strategy will involve a variety of disciplines including radiation health, life support, human factors, space physiology and countermeasures, medical care, environmental health, and exobiology. It will use both ground-based and flight research opportunities such as those found in current on-going programs, on Spacelab and unmanned biosatellite flights, and during Space Station Freedom missions.

Development of countermeasures for medical problems encountered in space flight.

By the turn of this century, long-duration space missions, either in low Earth orbit or for got early planetary missions, will become commonplace. From the physiological standpoint, exposure to the weightless environment results in changes in body function, some of which are adaptive in nature and some of which can be life threatening. Important issues such as environmental health, radiation protection, physical deconditioning, and bone and muscle loss are of concern to life scientists and mission designers. Physical conditioning techniques such as exercise are not sufficient to protect future space travellers. A review of past experience with piloted missions has shown that gradual breakdown in bone and muscle tissue, together with fluid losses, despite a vigorous exercise regimen can ultimately lead to increased evidence of renal stones, musculoskeletal injuries, and bone fractures. Biological effects of radiation can, over long periods of time increase the risk of cancer development. Today, a vigorous program of study on the means to provide a complex exercise regimen to the antigravity muscles and skeleton is under study. Additional evaluation of artificial gravity as a mechanism to counteract bone and muscle deconditioning and cardiovascular asthenia is under study. New radiation methods are being developed. This paper will deal with the results of these studies.

Cardiovascular function in space flight.

Changes in orthostatic heart rate have been noted universally in Soviet and U.S. crewmembers post space flight. The magnitude of these changes appears to be influenced by mission duration, with increasing orthostatic intolerance for the first 7-10 days of flight and then a partial recovery in the orthostatic heart rate response. Fluid loading has been used as a countermeasure to this postflight orthostatic intolerance. Previous reports have documented the effectiveness of this technique, but it has also been noted that the effectiveness of volume expansion diminishes as flight duration exceeds one week. The response of carotid baroreceptor function was investigated utilizing a commercially available neck collar which could apply positive and negative pressure to effect receptor stimulation. Bedrest studies had validated the usefulness and validity of the device. In these studies it was shown that carotid baroreceptor function curves demonstrated less responsiveness to orthostatic stimulation than control individuals. Twelve Space Shuttle crewmembers were examined pre- and postflight from flights lasting from 4-5 days. Plots of baroreceptor function were constructed and plotted as change in R-R interval vs. carotid distending pressure (an orthostatic stimulus). Typical sigmoidal curves were obtained. Postflight the resting heart rate was higher (smaller R-R interval) and the range of R-R value and the slope of the carotid sigmoidal response were both depressed. These changes were not significant immediately postflight (L + O), but did become significant by the second day postflight (L + 2), and remained suppressed for several days thereafter. It is hypothesized that the early adaptation to space flight involves a central fluid shift during the initial days of flight, but subsequent alterations in neural controlling mechanisms (such as carotid baroreceptor function) contribute to orthostatic intolerance.

Medical considerations for extending human presence in space.

The prospects for extending the length of time that humans can safely remain in space depend partly on resolution of a number of medical issues. Physiologic effects of weightlessness that may affect health during flight include loss of body fluid, functional alterations in the cardiovascular system, loss of red blood cells and bone mineral, compromised immune system function, and neurosensory disturbances. Some of the physiologic adaptations to weightlessness contribute to difficulties with readaptation to Earth's gravity. These include cardiovascular deconditioning and loss of body fluids and electrolytes; red blood cell mass; muscle mass, strength, and endurance; and bone mineral. Potentially harmful factors in space flight that are not related to weightlessness include radiation, altered circadian rhythms and rest/work cycles, and the closed, isolated environment of the spacecraft. There is no evidence that space flight has long-term effects on humans, except that bone mass lost during flight may not be replaced, and radiation damage is cumulative. However, the number of people who have spent several months or longer in space is still small. Only carefully-planned experiments in space preceded by thorough ground-based studies can provide the information needed to increase the amount of time humans can safely spend in space.

Earth benefits from space life sciences.

Contributions of space exploration which are widely recognized are those dealing with the impact of space technology on public health and medical services in both urban and remote rural areas. Telecommunications, image enhancement, 3-dimensional image reconstructions, miniaturization, automation, and data analysis, have transformed the delivery of medical care and have brought about a new impetus to the field of biomedicine. Many areas of medical care and biological research have been affected. These include technological breakthroughs in such areas as: (1) diagnosis, treatment, and prevention of cardiovascular diseases, (2) new approaches to the understanding of osteoporosis, (3) early detection of genetic birth defects, (4) emergency medical care, and (5) treatment of chronic metabolic disorders. These are but a few examples where technology originally developed to support space medicine or space research has been applied to solving medical and health care delivery problems on Earth.

Tumbling and spaceflight: the Gemini VIII experience.

A malfunctioning orbital flight attitude thruster during the flight of Gemini VIII led to acceleration forces on astronauts Neil Armstrong (commander) and David Scott (pilot) that created the potential for derogation of oculo-vestibular and eye-hand coordination effects. The spacecraft attained an axial tumbling rotation of 50 rpm and would have exceeded this had not the commander accurately diagnosed the problem and taken immediate corrective action. By the time counter-measure controls were applied, both astronauts were experiencing vertigo and the physiological effects of the tumbling acceleration. Data from the recorders reveal that one astronaut experienced -Gy of 0.92 G-units, and the other +Gy of 0.92 for approximately 46 s. Both received a -Gz of 0.89 G-units from the waist up with a +Gz of 0.05 from the waist down. A substantial increase of time and/or an increase in rpm would ultimately have produced incapacitation of both astronauts. NASA corrected the Gemini thruster problem by changing the ignition system wiring. Future space-craft undertaking long-term missions could be equipped with unambiguous thruster fault displays and could have computer-controlled automatic cutoffs to control excessive thruster burns.

Training of aerospace medicine physicians in the Soviet Union and the United States of America.

The Union of Soviet Socialist Republics and the United States of America operate major aerospace medicine programs; each country has taken specific measures to assure the development of an adequate number of trained aerospace medicine physicians. This jointly prepared paper emphasizes the training of aerospace medicine physicians related to civil aerospace activities. Those working in the field of aerospace medicine will find of interest the aerospace medical approaches taken by the U.S.S.R. and the U.S.A. in achieving their respective aerospace objectives.

[Principles of NASA longitudinal medical studies]. / Printsipy perspektivnykh meditsinskikh issledovanii NASA.

This paper describes approaches to longitudinal studies of the changes in the health status of the US astronauts. The methods include acquisition and analysis of biomedical data accumulated in one and repeated space missions, detection of potential occupational diseases inflight and evaluation of mortality cases associated with them. It is suggested to use pilots and flight controllers as controls. It is indicated that annual physical examinations can be an important source of relevant scientific information.

[Future thrusts in life sciences experimentation in space (USA)]. / Osnovnye napravleniia mediko-biologicheskikh issledovanii v kosmicheskikh programmakh (SShA).

The major physiological problem areas confronting man in space are reviewed and major research questions that remain to be answered are identified. The need for thorough ground-based studies prior to the acquisition of inflight data is emphasized. Future experiments are seen to focus on mechanistic questions and on the development of preventive measures to disturbances in neurophysiology, cardiovascular physiology, skeletal physiology and radiobiology since these areas have highest priority in future manned spacecraft operations.

Concepts for NASA longitudinal health studies.

Clinical data collected from a 15-year study of the homogeneous group of pre-Shuttle astronauts have revealed no significant long-term effects from spaceflight. The current hypothesis suggests that repeated exposures to the space environment in the Shuttle era will similarly have no long-term health effects. However, a much more heterogeneous group of astronauts and non-astronaut scientists will fly in Shuttle, and data on this group's adaptation to the space environment and readaptation to Earth are currently sparse. In addition, very little information is available concerning the short- and long-term medical consequences of long duration exposure to space and subsequent readaptation to the Earth environment. In this paper, retrospective clinical information on astronauts is reviewed and concepts for conducting epidemiological studies examining long-term health effects of spaceflight on humans, including associated occupational risks factors, are presented.

Collagen breakdown and nitrogen dioxide inhalation.

Measurements of urinary hydroxylysine glycosides indicate that considerable collagen degradation occurred during the reentry into the earth's atmosphere of the American astronauts of the Apollo-Soyuz mission. Since the crew accidentally inhaled nitrogen dioxide, a recognized pulmonary irritant, and showed clinical and roentgenographic signs of diffuse chemical pneumonitis, it is likely that collagen degradation occurred in the pulmonary parenchyma.