INTRODUCTION: As NASA and its international partners, as well as the commercial spaceflight industry, prepare for missions of increasing duration and venturing outside of low-Earth orbit, mitigation of medical risk is of high priority. Gynecologic considerations constitute one facet of medical risk for female astronauts. This manuscript will review the preflight, in-flight, and postflight clinical evaluation, management, and prevention considerations for reducing gynecologic and reproductive risks in female astronauts.METHODS: Relevant gynecological articles from databases including Ovid, Medline, Web of Science, various medical libraries, and NASA archives were evaluated for this review. In particular, articles addressing preventive measures or management of conditions in resource-limited environments were evaluated for applicability to future long-duration exploration spaceflight.RESULTS: Topics including abnormal uterine bleeding, anemia, bone mineral density, ovarian cysts, venous thromboembolism, contraception, fertility, and health maintenance were reviewed. Prevention and treatment strategies are discussed with a focus on management options that consider limitations of onboard medical capabilities.DISCUSSION: Long-duration exploration spaceflight will introduce new challenges for maintenance of gynecological and reproductive health. The impact of the space environment outside of low-Earth orbit on gynecological concerns remains unknown, with factors such as increased particle radiation exposure adding complexity and potential risk. While the most effective means of minimizing the impact of gynecologic or reproductive pathology for female astronauts is screening and prevention, gynecological concerns can arise unpredictably as they do on Earth. Careful consideration of gynecological risks and potential adverse events during spaceflight is a critical component to risk analysis and preventive medicine for future exploration missions.Steller JG, Blue RS, Burns R, Bayuse TM, Antonsen EL, Jain V, Blackwell MM, Jennings RT. Gynecologic risk mitigation considerations for long-duration spaceflight. Aerosp Med Hum Perform. 2020; 91(7):543–564.

BACKGROUND: This research aimed to analyze the body composition (BC) of different military units in the Spanish Armed Forces.METHODS: We studied 179 male aircrew members (86 airplane pilots, 15 helicopter pilots and 78 transport aircrew) using bioimpedance.RESULTS: Airplane pilots (AP) had higher means than transport aircrew (TA) in height (179.56 cm vs. 173.90 cm), total body water (46.72 L vs. 42.96 L), intracellular body water (29.45 L vs. 26.89 L), extracellular body water (17.27 L vs. 16.07 L), proteins (12.72 kg vs.11.63 kg), minerals (4.50 kg vs. 4.15 kg), soft lean mass (60.21 kg vs. 55.29 kg), fat free mass (63.95 kg vs. 58.74 kg), skeletal muscle mass (36.41 kg vs. 33.07 kg), and lower means in body mass index (24.01 kg vs. 25.49 kg), body fat mass (BFM) (13.53 kg vs. 18.81 kg) and percentage of body fat (PBF) (16.83 kg vs. 23.79 kg). Helicopter pilots also had significantly lower means in BFM (13.21 kg vs. 18.81 kg) and PBF (17.11 kg vs. 18.81 kg) than TA.DISCUSSION: The different types of activity between AP (active coping with G forces) and TA (inactive) during operational flights negatively affects the body composition of TA. These results suggest differences in aircrews training and job tasks. Specific training is needed for each unit: it should be individualized, prevent injuries, and be directed by qualified personnel.Bustamante-Sánchez Á, Clemente-Suárez VJ. Body composition differences in military pilots and aircrew. Aerosp Med Hum Perform. 2020; 91(7):565–570.

BACKGROUND: Loss of spacecraft atmosphere (LOA) during Earth-Moon transit may require up to 144 h of pressure suit operations. This work investigates the feasibility of DCS treatment in this paradigm and discusses the operational and engineering implications.METHODS: Three scenarios of LOA-induced DCS were considered: a permanent LOA secondary to a 0.25-in (0.64 cm) hole (unrecoverable cabin leak), a transient LOA, and a permanent LOA with early suit over-pressurization (beyond suit specification). Each was simulated in the context of the current Orion spacecraft operational concept with regards to atmosphere and anticipated cabin depress profile. Probability of DCS symptom resolution (P(SR)) was estimated using the previously derived Hypobaric DCS Treatment Model, with ΔP calculated from a Three Region Well-Stirred Tissue (3RWT) bubble dynamics model. Analysis was conducted and analogies drawn from experiences with the development and testing of the Orion Crew Survival System (OCSS).RESULTS: Maintaining 8 psia at 100% F_io₂ following LOA resulted in an eventual halt and regression of bubble growth with a P(SR) of 87% (at 8 h, time to symptom onset (T_s) = 105 min, with ambulation). If cabin atmosphere was not restored and psia dropped to 4.3, bubble growth returned, but again eventually slowed and regressed over time (P(SR) = 75% at 21 h). If the leak is repaired within the 8-h period, 8 psid (psia = 22.7) resulted in P(SR) of greater than 95%. Similarly, if the suit was over-pressurized (12 psid/psia) within 3 h after LOA, P(SR) exceeded 95%.DISCUSSION: A launch/entry pressure suit represents a contingency option for DCS management in the event of LOA.Greene MR, Jacobs SE. Decompression sickness treatment using a pressure suit after loss of spacecraft atmosphere. Aerosp Med Hum Perform. 2020; 91(7):571–577.

PURPOSE: This study was intended to determine the effect of skin cooling on breath-hold duration and predicted emergency air supply duration during immersion.METHODS: While wearing a helicopter transport suit with a dive mask, 12 subjects (29 ± 10 yr, 78 ± 14 kg, 177 ± 7 cm, 2 women) were studied in 8 and 20°C water. Subjects performed a maximum breath-hold, then breathed for 90 s (through a mouthpiece connected to room air) in five skin-exposure conditions. The first trial was out of water for Control (suit zipped, hood on, mask off). Four submersion conditions included exposure of the: Partial Face (hood and mask on); Face (hood on, mask off); Head (hood and mask off); and Whole Body (suit unzipped, hood and mask off).RESULTS: Decreasing temperature and increasing skin exposure reduced breath-hold time (to as low as 10 ± 4 s), generally increased minute ventilation (up to 40 ± 15 L · min⁻¹), and decreased predicted endurance time (PET) of a 55-L helicopter underwater emergency breathing apparatus. In 8°C water, PET decreased from 2 min 39 s (Partial Face) to 1 min 11 s (Whole Body).CONCLUSION: The most significant factor increasing breath-hold and predicted survival time was zipping up the suit. Face masks and suit hoods increased thermal comfort. Therefore, wearing the suits zipped with hoods on and, if possible, donning the dive mask prior to crashing, may increase survivability. The results have important applications for the education and preparation of helicopter occupants. Thermal protective suits and dive masks should be provided.Madu VC, Carnahan H, Brown R, Ennis K-A, Tymko KS, Hurrie DMG, McDonald GK, Cornish SM, Giesbrecht GG. Skin cooling on breath-hold duration and predicted emergency air supply duration during immersion. Aerosp Med Hum Perform. 2020; 91(7):578–585.

INTRODUCTION: There is a growing trend in the use of drugs, which could increase the likelihood of an aircraft accident. Evidence exists that pilots do not report all medications to the Federal Aviation Administration (FAA). The purpose of this study was to compare medications discovered by postaccident toxicology testing to those reported to the FAA to determine the veracity of pilot reported medications.METHODS: Medications reported on applications for U.S. medical certificates were compared to those discovered during postaccident toxicology testing. Logistic regressions were performed using Age, Gender, Type of Flight Operation, Medical Class Issued, and whether a Special Issuance (SI) medical certificate was issued as independent covariates. Truth in Reporting a medication was the outcome variable.RESULTS: Age and an SI medical certificate were good predictors of the likelihood of truthfully reporting medications. For each year of age the probability of a subject drug record being truthfully reported increased by 5%, while a pilot with an SI was 3.12 times more likely to be truthful than a pilot without an SI. When reported medications were limited to cardiovascular drugs, Age was the only good predictor of truthful reporting and, for every additional year of age, the probability of a subject drug record being truthfully reported increased by 3%.CONCLUSIONS: This study showed that the probability of a pilot truthfully reporting medication use increases with Age and an SI medical certificate. When reported medications were limited to cardiovascular drugs, Age was the only good predictor of truthful reporting.DeJohn CA, Greenhaw R, Lewis R, Cliburn K. Drug use reported by U.S. pilots, 2009–2014. Aerosp Med Hum Perform. 2020; 91(7):586–591.

BACKGROUND: Remotely guided ultrasound (US) examinations carried out by nonmedical personnel (novices) have been shown to produce clinically useful examinations, at least in small pilot studies. Comparison of the quality of such exams to those carried out by trained medical professionals is lacking in the literature. This study compared the objective quality and clinical utility of cardiac and pulmonary US examinations carried out by novices and trained physicians.METHODS: Cardiac and pulmonary US examinations were carried out by novices under remote guidance by an US expert and independently by US trained physicians. Exams were blindly evaluated by US experts for both a task-based objective score as well as a subjective assessment of clinical utility.RESULTS: Participating in the study were 16 novices and 9 physicians. Novices took longer to complete the US exams (median 641.5 s vs. 256 s). For the objective component, novices scored higher in exams evaluating for pneumothorax (100% vs. 87.5%). For the subjective component, novices more often obtained clinically useful exams in the assessment of cardiac regional wall motion abnormalities (56.3% vs. 11.1%). No other comparisons yielded statistically significant differences between the two groups. Both groups had generally higher scores for pulmonary examinations compared to cardiac. There was variability in the quality of exams carried out by novices depending on their expert guide.CONCLUSION: Remotely guided novices are able to carry out cardiac and pulmonary US examinations with similar, if not better, technical proficiency and clinical utility as US trained physicians, though they take longer to do so.Dufurrena Q, Ullah KI, Taub E, Leszczuk C, Ahmad S. Feasibility and clinical implications of remotely guided ultrasound examinations. Aerosp Med Hum Perform. 2020; 91(7):592–596.

INTRODUCTION: A total ankle replacement in a jet pilot after an open, high-energy foot and ankle fracture and dislocation with talar extrusion in a plane crash was carefully evaluated before considering fitness to fly.CASE REPORT: A 33-yr-old male test pilot of the Italian Air Force was involved in a plane crash and reported an open high-energy fracture/dislocation of the right ankle, with the expulsion of the right talus due to the impact, and other fractures. A titanium replica was inserted inside the ankle. However, the patient suffered from intolerable pain and developed arthritic changes in the cartilage of the tibial plafond. For these reasons, a decision was made to perform a custom-made total ankle replacement.DISCUSSION: The 2-yr follow-up after the last operation and the evaluation of the pilot’s fitness to fly are reported in this case study. The pilot was assessed fit to fly, including high performance military aircrafts.Verde P, Guardigli S, Morgagni F, Roberts S, Monopoli D, Scala A. Total ankle replacement in a military jet pilot. Aerosp Med Hum Perform. 2020; 91(7):597–603.

BACKGROUND: While skin conditions are commonly reported in flight on the International Space Station (ISS), postflight skin complaints have generally been limited to foot sole sensitivity upon reloading after landing. In this case report, we describe the postflight skin findings in NASA’s first year-long crewmember.CASE REPORT: The crewmember was a 51-yr-old astronaut who spent 340 d in space on this mission. His in-flight course was unremarkable except for medication use for congestion, likely secondary to microgravity-induced fluid shift and elevated CO₂ levels on the ISS, and an episode of contact dermatitis from electrodes for an experiment. He had a nominal landing in Kazakhstan. During his direct return to Houston, approximately 10 h after the Soyuz landing, he developed erythema and skin sensitivity in gravity-dependent areas. The skin findings persisted for 6 d and were successfully treated with nonsteroidal anti-inflammatory drugs, gabapentin, hydrotherapy, and massage.DISCUSSION: While vascular, allergic, and immunologic causes cannot be ruled out, we hypothesize that a prolonged lack of skin stimulation over the course of the year-long mission led to the crewmember’s postflight rash and skin sensitivity. Previous studies have demonstrated alterations in cutaneous receptor feedback in the sole of the foot in spaceflight and, therefore, it is plausible that skin in other parts of the body can undergo similar changes if they are not stimulated as they normally would be on Earth. More work will be needed to better understand this phenomenon and test potential mitigations.Law J, Gilmore S, Kelly S. Postflight rash and skin sensitivity following a year-long spaceflight mission. Aerosp Med Hum Perform. 2020; 91(7):604–607.

INTRODUCTION: A readership survey was posted in our monthly newsletter, “Ever Upward”, and sent via email to members of the Aerospace Medical Association and to authors and reviewers of the journal, Aerospace Medicine and Human Performance. The reason for the survey concerned whether to publish 6 times (or perhaps 7) per year instead of 12. There were 403 respondents. Of those who responded, 30% said bimonthly publishing would affect whether they submitted to a journal; 70% said it would not impact their decision. Less than 4% strongly disapproved and 8% disapproved of moving to a bimonthly publication. While 67% were in favor and 20% didn’t care one way or the other. There were many comments and some of those are addressed in the summary.Day PC. Comments on the readership survey concerning bi-monthly publication. Aerosp Med Hum Perform. 2020; 91(7):608–610.