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Artificial gravity as a countermeasure in long-duration space flight

Long-duration exposure to weightlessness results in bone demineralization, muscle atrophy, cardiovascular deconditioning, altered sensory-motor control, and central nervous system reorganizations. Exercise countermeasures and body loading methods so far employed have failed to prevent these changes. A human mission to Mars might last 2 or 3 years and without effective countermeasures could result in dangerous levels of bone and muscle loss. Artificial gravity generated by rotation of an entire space vehicle or of an inner chamber could be used to prevent structural changes. Some of the physical characteristics of rotating environments are outlined along with their implications for human performance. Artificial gravity is the centripetal force generated in a rotating vehicle and is proportional to the product of the square of angular velocity and the radius of rotation. Thus, for a particular g-level, there is a tradeoff between velocity of rotation and radius. Increased radius is vastly more expensive to achieve than velocity, so it is important to know the highest rotation rates to which humans can adapt. Early studies suggested that 3 rpm might be the upper limit because movement control and orientation were disrupted at higher velocities and motion sickness and chronic fatigue were persistent problems. Recent studies, however, are showing that, if the terminal velocity is achieved over a series of gradual steps and many body movements are made at each dwell velocity, then full adaptation of head, arm, and leg movements is possible. Rotation rates as high as 7.5-10 rpm are likely feasible. An important feature of the new studies is that they provide compelling evidence that equilibrium point theories of movement control are inadequate. The central principles of equilibrium point theories lead to the equifinality prediction, which is violated by movements made in rotating reference frames. Copyright 2000 Wiley-Liss, Inc.

Review Literature↗

Effect of Exercise Training and +Gz Acceleration Training on Men

Countermeasures for reduction in work capacity (maximal oxygen uptake and strength) during spaceflight and enhanced orthostatic intolerance during re-entry, landing and egress from the return vehicle are continuing problems. The purpose for this study was to test the hypothesis that passive-acceleration training; supine, interval, exercise plus acceleration training and exercise combined with acceleration training would improve orthostatic tolerance in ambulatory men; and that addition of the aerobic exercise conditioning would not alter this improved tolerance from that of passive-acceleration training. Seven men (24-38 yr) underwent "Passive" training on the Ames human-powered centrifuge (HPC) for 30 min, "Exercise" training on the cycle ergometer with constant +Gz acceleration; and "Combined" exercise training at 40% to 90% of the HPC +Gz(max) exercise level. Maximal supine exercise loads increased significant (P<0.05) by 8.3% (Passive), 12.6% (Exercise), and by 15.4% (Combined) after training, but their post-training maximal oxygen uptakes and maximal heart rates were unchanged. Maximal time to fatigue (endurance) was unchanged with Passive was increased (P<0.05) with Exercise and Combined training. Thus, the exercise in the Exercise and Combined training Phases resulted in greater maximal loads and endurance without effect on maximal oxygen uptake or heart rate. There was a 4% to 6% increase (P<0.05) in all four quadriceps muscle volumes (right and left) after post-Combined training. Resting pre-tilt heart rate was elevated by 12.9% (P<0.05) only after Passive training suggesting that the exercise training attenuated the HR response. Plasma volume (% Delta) was uniformly decreased by 8% to 14% (P<0.05) at tilt-tolerance pre- vs. post-training indicating essentially no effect of training on the level of hypovolemia. Post-training tilt-tolerance time and heart rate were increased (P<0.05) only with Passive training by 37.8% and by 29.1%, respectively. Thus, addition of exercise training appeared to attenuate the increased Passive tilt-tolerance.

Greenleaf, John E.↗

Flight controller alertness and performance during MOD shiftwork operations

Decreased alertness and performance associated with fatigue, sleep loss, and circadian disruption are issues faced by a diverse range of shiftwork operations. During STS operations, MOD personnel provide 24 hr. coverage of critical tasks. A joint JSC and ARC project was undertaken to examine these issues in flight controllers during MOD shiftwork operations. An initial operational test of procedures and measures was conducted during STS-53 in Dec. 1992. The study measures included a background questionnaire, a subjective daily logbook completed on a 24 hr. basis (to report sleep patterns, work periods, etc.), and an 8 minute performance and mood test battery administered at the beginning, middle, and end of each shift period. Seventeen Flight controllers representing the 3 Orbit shifts participated. The initial results clearly support further data collection during other STS missions to document baseline levels of alertness and performance during MOD shiftwork operations. These issues are especially pertinent for the night shift operations and the acute phase advance required for the transition of day shift personnel into the night for shuttle launch. Implementation and evaluation of the countermeasure strategies to maximize alertness and performance is planned. As STS missions extend to further extended duration orbiters, timelines and planning for 24 circadian disruption will remain highly relevant in the MOD environment.

Kelly, Sean M.↗

Effects of the 8 psia / 32% O2 Atmosphere on the Human in the Spaceflight Environment

Extravehicular activity (EVA) is at the core of a manned space exploration program. There are elements of exploration that may be safely and effectively performed by robots, but there are critical elements of exploration that will require the trained, assertive, and reasoning mind of a human crewmember. To effectively use these skills, NASA needs a safe, effective, and efficient EVA component integrated into the human exploration program. The EVA preparation time should be minimized and the suit pressure should be low to accommodate EVA tasks without undue fatigue, physical discomfort, or suit-related trauma. Commissioned in 2005, the Exploration Atmospheres Working Group (EAWG) had the primary goal of recommending to NASA an internal environment that allowed efficient and repetitive EVAs for missions that were to be enabled by the former Constellation Program. At the conclusion of the EAWG meeting, the 8.0 psia and 32% oxygen (O2) environment were recommended for EVA intensive phases of missions. As a result of selecting this internal environment, NASA gains the capability for efficient EVA with low risk of decompression sickness (DCS), but not without incurring additional negative stimulus of hypobaric hypoxia to the already physiologically challenging spaceflight environment. This paper provides a literature review of the human health and performance risks associated with the 8 psia/32% O2 environment. Of most concern are the potential effects on the central nervous system including increased intracranial pressure, visual impairment, sensorimotor dysfunction, and oxidative damage. Other areas of focus include validation of the DCS mitigation strategy, incidence and treatment of acute mountain sickness (AMS), development of new exercise countermeasures protocols, effective food preparation at 8 psia, assurance of quality sleep, and prevention of suit-induced injury. As a first effort, the trade space originally considered in the EAWG was re-evaluated looking for ways to decrease the hypoxic dose by further enriching the O2% or increasing the pressure. After discussion with the NASA engineering and materials community, it was determined that the O2 could be enriched from 32% to 34% and the pressure increased from 8.0 to 8.2 psia without significant penalty. These two small changes increase alveolar O2 pressure by 11 mmHg, which is expected to significantly benefit crewmembers. The 8.2/34 environment (inspired O2 pressure = 128 mmHg) is also physiologically equivalent to the staged decompression atmosphere of 10.2 psia / 26.5% O2 (inspired O2 pressure = 127 mmHg) used on 34 different shuttle missions for approximately a week each flight. Once decided, the proposed internal environment, if different than current experience, should be evaluated through appropriately simulated research studies. In many cases, the human physiologic concerns can be investigated effectively through integrated multi-discipline ground-based studies. Although missions proposing to use an 8.2/34 environment are still years away, it is recommended that these studies begin early enough to ensure that the correct decisions pertaining to vehicle design, mission operational concepts, and human health countermeasures are appropriately informed.

Environmental control↗

Risk of Performance Decrements and Adverse Health Outcomes Resulting from Sleep Loss, Circadian Desynchronization, and Work Overload

Sleep loss, circadian desynchronization, and work overload occur to some extent for ground and flight crews, prior to and during spaceflight missions. Ground evidence indicates that such risk factors may lead to performance decrements and adverse health outcomes, which could potentially compromise mission objectives. Efforts are needed to identify the environmental and mission conditions that interfere with sleep and circadian alignment, as well as individual differences in vulnerability and resiliency to sleep loss and circadian desynchronization. Specifically, this report highlights a collection of new evidence to better characterize the risk and reveals new gaps in this risk as follows: Sleep loss is apparent during spaceflight. Astronauts consistently average less sleep during spaceflight relative to on the ground. The causes of this sleep loss remain unknown, however ground-based evidence suggests that the sleep duration of astronauts is likely to lead to performance impairment and short and long-term health consequences. Further research is needed in this area in order to develop screening tools to assess individual astronaut sleep need in order to quantify the magnitude of sleep loss during spaceflight; current and planned efforts in BHP's research portfolio address this need. In addition, it is still unclear whether the conditions of spaceflight environment lead to sleep loss or whether other factors, such as work overload lead to the reduced sleep duration. Future data mining efforts and continued data collection on the ISS will help to further characterize factors contributing to sleep loss. Sleep inertia has not been evaluated during spaceflight. Ground-based studies confirm that it takes two to four hours to achieve optimal performance after waking from a sleep episode. Sleep inertia has been associated with increased accidents and reduced performance in operational environments. Sleep inertia poses considerable risk during spaceflight when emergency situations necessitate that crewmembers wake from sleep and make quick decisions. A recently completed BHP investigation assesses the effects of sleep inertia upon abrupt awakening, with and without hypnotics currently used in spaceflight; results from this investigation will help to inform strategies relative to sleep inertia effects on performance. Circadian desynchrony has been observed during spaceflight. Circadian desynchrony during spaceflight develops due to schedule constraints requiring non-24 operations or 'slam-shifts' and due to insufficient or mis-timed light exposure. In addition, circadian misalignment has been associated with reduced sleep duration and increased medication use. In ground-based studies, circadian desynchrony has been associated with significant performance impairment and increased risk of accidents when operations coincide with the circadian nadir. There is a great deal of information available on how to manage circadian misalignment, however, there are currently no easily collected biomarkers that can be used during spaceflight to determine circadian phase. Current research efforts are addressing this gap. Work overload has been documented during current spaceflight operations. NASA has established work hour guidelines that limit shift duration, however, schedule creep, where duty requirements necessitate working beyond scheduled work hours, has been reported. This observation warrants the documentation of actual work hours in order to improve planning and in order to ensure that astronauts receive adequate down time. In addition to concerns about work overload, ground based evidence suggests that work underload may be a concern during deep space missions, where torpor may develop and physically demanding workload will be exchanged for monitoring of autonomous systems. Given that increased automation is anticipated for exploration vehicles, fatigue effects in the context of such systems needs to be further understood. Performance metrics are needed to evaluate fitness-for-duty during spaceflight. Although ground-based evidence supports the notion that sleep loss, circadian desynchronization and work overload lead to performance impairment, inconsistency in the measures used to evaluate performance during spaceflight make it difficult to evaluate the magnitude of performance impairment during spaceflight. Work is underway to standardize measures of performance evaluation during spaceflight. Once established, such performance indicators need to be correlated with operational performance. Individual differences in sleep need and circadian preference, phase shifting ability and period have been documented in ground-based studies. Individual differences in response to sleep loss and circadian misalignment have also been documented and are presumed to be associated with genetic polymorphisms. No studies have systematically reported individual differences in sleep or circadian-related outcomes during spaceflight. More work is needed in this area in order to identify genetic or phenotypic biomarkers that predict resilience or vulnerability to sleep loss in order to personalize countermeasure strategies and mitigate performance impairment during spaceflight. Two laboratory and field investigations specific to this topic are currently ongoing; additional efforts, including an effort to mine existing biological data from spaceflight relative to sleep and circadian outcomes, are planned. Sex differences in sleep need and circadian period and phase have been reported in ground-based studies. The impact of these sex differences on performance is unclear. Sex differences in sleep need and circadian rhythms have not been systematically studied during spaceflight, presumably due to the small number of women that have flown in space. More research is needed in this area to evaluate whether any of the observed sex differences in physiology lead to altered performance in spaceflight and on the ground.

Flynn-Evans, Erin↗

Female Astronauts Exhibit Greater Reductions in Aerobic Peak Power Following Long-Duration Space Flight than Males

BACKGROUND: Long-duration exposure to microgravity during space flight causes cardiovascular deconditioning, ultimately reducing aerobic fitness. While sex-based differences play an integral role in health on Earth, there is a paucity of data to inform space flight-induced health and performance implications for female astronauts, which may be critical to ensure health, safety, and mission success. Therefore, this retrospective investigation characterized aerobic capacity in female and male astronauts to inform whether sex differences exist from pre to postflight. METHODS: A NASA historical database (n=47 crew; 11 female, 36 male) of International Space Station (ISS) crewmembers was used to characterize sex differences in aerobic capacity changes from pre to postflight to update the NASA Aerobic and Muscle Risk Evidence Report. Aerobic capacity (VO2pk; ml/kg/min) and peak power (W) were assessed using a graded cycling exercise protocol that included a 3-min warmup at 50 W, with stepwise increases in resistance (25 W/min) until volitional fatigue. Group differences in baseline demographics and the percent change in aerobic capacity from preflight (~90 days before launch) to postflight (~3 days after return) were compared using independent t-tests. Significance was set at P<0.05 (Mean ±SD). RESULTS: At preflight, females were younger (44.5±6.6 vs 48.6±5.6 yrs; p=0.041), weighed less (68.8±10.0 vs 81.0±8.8 kg; p< 0.001), with lower VO2pk (32.8±5.9 vs 37.8±6.0 ml/kg/min; p=0.021) and aerobic peak power (229±42 vs 299±52 W; p< 0.001) than males, but had similar heart rate at VO2pk (176.0±7.3 vs 173.0±10.8 beats/min; p=0.406). ISS flight durations (F: 205.0±58.3 vs M: 176.0±40.5 days; p=0.061) and reductions in VO2pk from pre to postflight were comparable between sexes (F: -11.8±10.7%; M: -8.8%±7.9%; p=0.32). However, females had a greater reduction in aerobic peak power than males (−13.3%±8.9% vs −4.9%±8.8%; p < 0.01). CONCLUSIONS: These data indicate that some indicators of fitness (i.e., aerobic peak power) are more impacted in female astronauts compared to males after long-duration space flight missions. Future investigations with larger sample sizes are necessary to identify the physiological basis of sex-based differences and develop effective countermeasure approaches for both sexes.

Nicole C Strock↗

Effects of illumination on human nocturnal serum melatonin levels and performance

In humans, exposure to bright light at night suppresses the normal nocturnal elevation in circulating melatonin. Oral administration of pharmacological doses of melatonin during the day, when melatonin levels are normally minimal, induces fatigue. To examine the relationship between illumination, human pineal function, and behavior, we monitored the overnight serum melatonin profiles and behavioral performance of 24 healthy male subjects. On each of three separate occasions subjects participated in 13.5 h (1630-0800 h) testing sessions. Each subject was assigned to an individually illuminated workstation that was maintained throughout the night at an illumination level of approximately 300, 1500, or 3000 lux. Melatonin levels were significantly diminished by light treatment, F(2, 36) = 12.77, p < 0.001, in a dose-dependent manner. Performance on vigilance, reaction time, and other tasks deteriorated throughout the night, consistent with known circadian variations in these parameters, but independent of ambient light intensity and circulating melatonin levels.

NASA Program Space Physiology and Countermeasures↗

Inadequate Loading Stimulus on ISS Results in Bone and Muscle Loss

INTRODUCTION Exercise has been the primary countermeasure to combat musculoskeletal changes during International Space Station (ISS) missions. However, these countermeasures have not been successful in preventing loss of bone mineral density (BMD) or muscle volume in crew members. METHODS We examined lower extremity loading during typical days on-orbit and on Earth for four ISS crew members. In-shoe forces were monitored using force-measuring insoles placed inside the shoes. BMD (by DXA), muscle volumes (by MRI), and strength were measured before and after long-duration spaceflight (181 +/- 15 days). RESULTS The peak forces measured during ISS activity were significantly less than those measured in 1g for the same activities. Typical single-leg loads on-orbit during walking and running were 0.89 +/- 0.17 body weights (BW) and 1.28 +/- 0.18 BW compared to 1.18 +/- 0.11 BW and 2.36 +/- .22 BW in 1g, respectively [2]. Crew members were only loaded for an average of 43.17 +/- 14.96 min a day while performing exercise on-orbit even though 146.8 min were assigned for exercise each day. Areal BMD decreased in the femoral neck and total hip by 0.71 +/- 0.34% and 0.81 +/- 0.21% per month, respectively. Changes in muscle volume were observed in the lower extremity (-10 to -16% calf; -4 to -7% thigh) but there were no changes in the upper extremity (+0.4 to -0.8%). Decrements in isometric and isokinetic strength at the knee (range: -10.4 to -24.1%), ankle (range: -4 to -22.3%), and elbow (range: -7.5 to - 16.7%) were also observed. Knee extension endurance tests showed an overall decline in total work (-14%) but an increased resistance to fatigue post-flight. DISCUSSION AND CONCLUSIONS Our findings support the conclusion that the measured exercise durations and/or loading stimuli were insufficient to protect bone and muscle health.

Rice, A. J.↗

Circadian rhythms, sleep, and performance in space

Maintaining optimal alertness and neurobehavioral functioning during space operations is critical to enable the National Aeronautics and Space Administration's (NASA's) vision "to extend humanity's reach to the Moon, Mars and beyond" to become a reality. Field data have demonstrated that sleep times and performance of crewmembers can be compromised by extended duty days, irregular work schedules, high workload, and varying environmental factors. This paper documents evidence of significant sleep loss and disruption of circadian rhythms in astronauts and associated performance decrements during several space missions, which demonstrates the need to develop effective countermeasures. Both sleep and circadian disruptions have been identified in the Behavioral Health and Performance (BH&P) area and the Advanced Human Support Technology (AHST) area of NASA's Bioastronautics Critical Path Roadmap. Such disruptions could have serious consequences on the effectiveness, health, and safety of astronaut crews, thus reducing the safety margin and increasing the chances of an accident or incident. These decrements oftentimes can be difficult to detect and counter effectively in restrictive operational environments. NASA is focusing research on the development of optimal sleep/wake schedules and countermeasure timing and application to help mitigate the cumulative effects of sleep and circadian disruption and enhance operational performance. Investing research in humans is one of NASA's building blocks that will allow for both short- and long-duration space missions and help NASA in developing approaches to manage and overcome the human limitations of space travel. In addition to reviewing the current state of knowledge concerning sleep and circadian disruptions during space operations, this paper provides an overview of NASA's broad research goals. Also, NASA-funded research, designed to evaluate the relationships between sleep quality, circadian rhythm stability, and performance proficiency in both ground-based simulations and space mission studies, as described in the 2003 NASA Task Book, will be reviewed.

Review↗

Evidence Report: Risk of Hypobaric Hypoxia from the Exploration Atmosphere

Extravehicular activity (EVA) is at the core of a manned space exploration program. Some elements of exploration may be safely and effectively performed by robots, but certain critical elements will require the trained, assertive, and reasoning mind of a human crewmember. To effectively use these skills, NASA needs a safe, effective, and efficient EVA component integrated into the human exploration program. The EVA preparation time should be minimized and the suit pressure should be low to accommodate EVA tasks without causing undue fatigue, physical discomfort, or suit-related trauma. Commissioned in 2005, the Exploration Atmospheres Working Group (EAWG) had the primary goal of recommending to NASA an internal environment that allowed efficient and repetitive EVAs for missions that were to be enabled by the former Constellation Program. At the conclusion of the EAWG meeting, the 8.0 psia and 32% oxygen (O2) environment were recommended for EVA-intensive phases of missions. After re-evaluation in 2012, the 8/32 environment was altered to 8.2 psia and 34% O2 to reduce the hypoxic stress to a crewmember. These two small changes increase alveolar O2 pressure by 11 mmHg, which is expected to significantly benefit crewmembers. The 8.2/34 environment (inspired O2 pressure = 128 mmHg) is also physiologically equivalent to the staged decompression atmosphere of 10.2 psia / 26.5% O2 (inspired O2 pressure = 127 mmHg) used on 34 different shuttle missions for approximately a week each flight. As a result of selecting this internal environment, NASA gains the capability for efficient EVA with low risk of decompression sickness (DCS), but not without incurring the additional negative stimulus of hypobaric hypoxia to the already physiologically challenging spaceflight environment. This report provides a review of the human health and performance risks associated with the use of the 8.2 psia / 34% O2 environment during spaceflight. Of most concern are the potential effects on the central nervous system (CNS), including increased intracranial pressure, visual impairment, sensorimotor dysfunction, and oxidative damage. Other areas of focus include validation of the DCS mitigation strategy, incidence and treatment of transient acute mountain sickness (AMS), development of new exercise countermeasure protocols, effective food preparation at 8.2 psia, assurance of quality sleep, and prevention of suit-induced injury. Although missions proposing to use an 8.2/34 environment are still years away, it is recommended that these studies begin early enough to ensure that the correct decisions pertaining to vehicle design, mission operational concepts, and human health countermeasures are appropriately informed.

Norcross, Jason R.↗

Muscle sympathetic nerve responses to physiological changes in prostaglandin production in humans

Previous studies suggest that prostaglandins may contribute to exercise-induced increases in muscle sympathetic nerve activity (MSNA). To test this hypothesis, MSNA was measured at rest and during exercise before and after oral administration of ketoprofen, a cyclooxygenase inhibitor, or placebo. Twenty-one subjects completed two bouts of graded dynamic and isometric handgrip to fatigue. Each exercise bout was followed by 2 min of postexercise muscle ischemia. The second exercise bouts were performed after 60 min of rest in which 11 subjects were given ketoprofen (300 mg) and 10 subjects received a placebo. Ketoprofen significantly lowered plasma thromboxane B(2) in the drug group (from 36 +/- 6 to 22 +/- 3 pg/ml, P < 0.04), whereas thromboxane B(2) in the placebo group increased from 40 +/- 5 to 61 +/- 9 pg/ml from trial 1 to trial 2 (P < 0.008). Ketoprofen and placebo did not change sympathetic and cardiovascular responses to dynamic handgrip, isometric handgrip, and postexercise muscle ischemia. There was no relationship between thromboxane B(2) concentrations and MSNA or arterial pressure responses during both exercise modes. The data indicate that physiological increases or decreases in prostaglandins do not alter exercise-induced increases in MSNA and arterial pressure in humans. These findings suggest that contraction-induced metabolites other than prostaglandins mediate MSNA responses to exercise in humans.

Clinical Trial↗

An overview of the issues: physiological effects of bed rest and restricted physical activity

Reduction of exercise capacity with confinement to bed rest is well recognized. Underlying physiological mechanisms include dramatic reductions in maximal stroke volume, cardiac output, and oxygen uptake. However, bed rest by itself does not appear to contribute to cardiac dysfunction. Increased muscle fatigue is associated with reduced muscle blood flow, red cell volume, capillarization and oxidative enzymes. Loss of muscle mass and bone density may be reflected by reduced muscle strength and higher risk for injury to bones and joints. The resultant deconditioning caused by bed rest can be independent of the primary disease and physically debilitating in patients who attempt to reambulate to normal active living and working. A challenge to clinicians and health care specialists has been the identification of appropriate and effective methods to restore physical capacity of patients during or after restricted physical activity associated with prolonged bed rest. The examination of physiological responses to bed rest deconditioning and exercise training in healthy subjects has provided significant information to develop effective rehabilitation treatments. The successful application of acute exercise to enhance orthostatic stability, daily endurance exercise to maintain aerobic capacity, or specific resistance exercises to maintain musculoskeletal integrity rather than the use of surgical, pharmacological, and other medical treatments for clinical conditions has been enhanced by investigation and understanding of underlying mechanisms that distinguish physical deconditioning from the disease. This symposium presents an overview of cardiovascular and musculoskeletal deconditioning associated with reduced physical work capacity following prolonged bed rest and exercise training regimens that have proven successful in ameliorating or reversing these adverse effects.

NASA Program Space Physiology and Countermeasures↗

Caffeine Consumption Aboard the International Space Station

INTRODUCTION: Caffeine is the most widely used performance-enhancing drug on Earth and astronaut crews have access to liquid coffee. While caffeine is a potent countermeasure to improve alertness and performance, it can also interfere with sleep. This can lead to performance deficits on the following day, driving a cycle of caffeine use to counter the effects of caffeine-induced sleep disruption. Caffeine availability may be limited during future Artemis and/or Mars missions. Accordingly, it is important that we 1) determine the prevalence of caffeine use among astronauts, 2) characterize the impact of caffeine on performance, and 3) characterize the impact of caffeine on sleep. Our aim in this study is to describe the use of caffeine aboard the ISS and begin to examine the relationship between caffeine use and sleep and performance outcomes. METHODS: Daily caffeine consumption was determined from food and beverage intake tracking for 25 astronauts on 6 month International Space Station (ISS) missions. Data were recorded using the ISS Food Intake Tracker iPad App or other detailed recording technique. On average, crew recorded dietary intake on 179.7±68.6 (mean±SD) days inflight. RESULTS: Astronauts consumed 97±92 mg caffeine per day. All astronauts (25/25) in this study consumed caffeine at some point during flight, though the frequency, amounts, and regularity differed across crewmembers. Approximately a quarter of crewmembers were regular caffeine consumers (6/25), i.e., they ingested at least 90 mg caffeine (equivalent to one cup of coffee) on 90% of inflight days.

fatigue↗

Orthostatic intolerance and tachycardia associated with norepinephrine-transporter deficiency

BACKGROUND: Orthostatic intolerance is a syndrome characterized by lightheadedness, fatigue, altered mentation, and syncope and associated with postural tachycardia and plasma norepinephrine concentrations that are disproportionately high in relation to sympathetic outflow. We tested the hypothesis that impaired functioning of the norepinephrine transporter contributes to the pathophysiologic mechanism of orthostatic intolerance. METHODS: In a patient with orthostatic intolerance and her relatives, we measured postural blood pressure, heart rate, plasma catecholamines, and systemic norepinephrine spillover and clearance, and we sequenced the norepinephrine-transporter gene and evaluated its function. RESULTS: The patient had a high mean plasma norepinephrine concentration while standing, as compared with the mean (+/-SD) concentration in normal subjects (923 vs. 439+/-129 pg per milliliter [5.46 vs. 2.59+/-0.76 nmol per liter]), reduced systemic norepinephrine clearance (1.56 vs. 2.42+/-0.71 liters per minute), impairment in the increase in the plasma norepinephrine concentration after the administration of tyramine (12 vs. 56+/-63 pg per milliliter [0.07 vs. 0.33+/-0.37 pmol per liter]), and a disproportionate increase in the concentration of plasma norepinephrine relative to that of dihydroxyphenylglycol. Analysis of the norepinephrine-transporter gene revealed that the proband was heterozygous for a mutation in exon 9 (encoding a change from guanine to cytosine at position 237) that resulted in more than a 98 percent loss of function as compared with that of the wild-type gene. Impairment of synaptic norepinephrine clearance may result in a syndrome characterized by excessive sympathetic activation in response to physiologic stimuli. The mutant allele in the proband's family segregated with the postural heart rate and abnormal plasma catecholamine homeostasis. CONCLUSIONS: Genetic or acquired deficits in norepinephrine inactivation may underlie hyperadrenergic states that lead to orthostatic intolerance.

Non-NASA Center↗