Extreme Tele-Echocardiography: Methodology for Remote Guidance of In-Flight Echocardiography Aboard the International Space Station

Methods: In the year before launch of an ISS mission, potential astronaut echocardiographic operators participate in 5 sessions to train for echo acquisitions that occur roughly monthly during the mission, including one exercise echocardiogram. The focus of training is familiarity with the study protocol and remote guidance procedures. On-orbit, real-time guidance of in-flight acquisitions is provided by a sonographer in the Telescience Center of Mission Control. Physician investigators with remote access are able to relay comments on image quality to the sonographer. Live video feed is relayed from the ISS to the ground via the Tracking and Data Relay Satellite System with a 2- second transmission delay. The expert sonographer uses these images, along with twoway audio, to provide instructions and feedback. Images are stored in non-compressed DICOM format for asynchronous relay to the ground for subsequent off-line analysis. Results: Since June, 2009, a total of 27 resting echocardiograms and 5 exercise studies have been performed during flight. Average acquisition time has been 45 minutes, reflecting 26,000 km of ISS travel per study. Image quality has been adequate in all studies, and remote guidance has proven imperative for fine-tuning imaging and prioritizing views when communication outages limit the study duration. Typical resting studies have included 27 video loops and 30 still-frame images requiring 750 MB of storage. Conclusions: Despite limited crew training, remote guidance allows research-quality echocardiography to be performed by non-experts aboard the ISS. Analysis is underway and additional subjects are being recruited to define the impact of microgravity on cardiac structure and systolic and diastolic function

Extreme Tele-Echocardiography: Methodology for Remote Guidance of In-flight Echocardiography Aboard the International Space Station

Echocardiography is ideally suited for cardiovascular imaging in remote environments, but the expertise to perform it is often lacking. In 2001, an ATL HDI5000 was delivered to the International Space Station (ISS). The instrument is currently being used in a study to investigate the impact of long-term microgravity on cardiovascular function. The purpose of this report is to describe the methodology for remote guidance of echocardiography in space. Methods: In the year before launch of an ISS mission, potential astronaut echocardiographic operators participate in 5 sessions to train for echo acquisitions that occur roughly monthly during the mission, including one exercise echocardiogram. The focus of training is familiarity with the study protocol and remote guidance procedures. On-orbit, real-time guidance of in-flight acquisitions is provided by a sonographer in the Telescience Center of Mission Control. Physician investigators with remote access are able to relay comments on image optimization to the sonographer. Live video feed is relayed from the ISS to the ground via the Tracking and Data Relay Satellite System with a 2 second transmission delay. The expert sonographer uses these images along with two-way audio to provide instructions and feedback. Images are stored in non-compressed DICOM format for asynchronous relay to the ground for subsequent off-line analysis. Results: Since June, 2009, a total of 19 resting echocardiograms and 4 exercise studies have been performed in-flight. Average acquisition time has been 45 minutes, reflecting 26,000 km of ISS travel per study. Image quality has been adequate in all studies, but remote guidance has proven imperative for fine-tuning imaging and prioritizing views when communication outages limit the study duration. Typical resting studies have included 12 video loops and 21 still-frame images requiring 750 MB of storage. Conclusions: Despite limited crew training, remote guidance allows research-quality echocardiography to be performed by non-experts aboard the ISS. Analysis is underway and additional subjects are being recruited to define the impact of microgravity on cardiac structure and systolic and diastolic function

A Broadly Implementable Research Course in Phage Discovery and Genomics for First-Year Undergraduate Students

Engaging large numbers of undergraduates in authentic scientific discovery is desirable but difficult to achieve. We have developed a general model in which faculty and teaching assistants from diverse academic institutions are trained to teach a research course for first-year undergraduate students focused on bacteriophage discovery and genomics. The course is situated within a broader scientific context aimed at understanding viral diversity, such that faculty and students are collaborators with established researchers in the field. The Howard Hughes Medical Institute (HHMI) Science Education Alliance Phage Hunters Advancing Genomics and Evolutionary Science (SEA-PHAGES) course has been widely implemented and has been taken by over 4,800 students at 73 institutions. We show here that this alliance-sourced model not only substantially advances the field of phage genomics but also stimulates students’ interest in science, positively influences academic achievement, and enhances persistence in science, technology, engineering, and mathematics (STEM) disciplines. Broad application of this model by integrating other research areas with large numbers of early-career undergraduate students has the potential to be transformative in science education and research training

A Broadly Implementable Research Course in Phage Discovery and Genomics for First-Year Undergraduate Students

Engaging large numbers of undergraduates in authentic scientific discovery is desirable but difficult to achieve. We have developed a general model in which faculty and teaching assistants from diverse academic institutions are trained to teach a research course for first-year undergraduate students focused on bacteriophage discovery and genomics. The course is situated within a broader scientific context aimed at understanding viral diversity, such that faculty and students are collaborators with established researchers in the field. The Howard Hughes Medical Institute (HHMI) Science Education Alliance Phage Hunters Advancing Genomics and Evolutionary Science (SEA-PHAGES) course has been widely implemented and has been taken by over 4,800 students at 73 institutions. We show here that this alliance-sourced model not only substantially advances the field of phage genomics but also stimulates students’ interest in science, positively influences academic achievement, and enhances persistence in science, technology, engineering, and mathematics (STEM) disciplines. Broad application of this model by integrating other research areas with large numbers of early-career undergraduate students has the potential to be transformative in science education and research training

Significantly Reduced Renal Allograft Histopathology after Single-Dose rATG Induction and Calcineurin-Inhibitor Withdrawal vs. Minimization: Final Report from a Prospective, Randomized Clinical Trial

We conducted a randomized study of single- vs. divided-dose rATG induction with early steroid withdrawal, followed by CNI minimization vs. withdrawal. 180 patients received either single-dose rATG (one 6 mg/kg dose over 24 hours) or divided-dose rATG (4 doses of 1.5 mg/kg on alternate days), and maintenance immunosuppression with tacrolimus and sirolimus, until tacrolimus was replaced with MMF after 6 months in half the patients of each group. (Maximum follow-up = 7 years; minimum = 2 years.) Demographics were not different among the four groups. Single-dose rATG associated with fewer infectious complications (p = 0.01) and quicker recovery of lymphocyte counts (p = 0.03). Patients who received deceased donor (but not living donor) kidneys had better renal function both for the first 6 months (p = 0.02) and 3 years (p = 0.04). When analyzed by induction treatment, death-censored graft survival and rejection were not different among the 4 groups, but patient survival was inferior among divided-dose rATG recipients (p = 0.02). CNI withdrawal associated with sustained improved graft function and reduced histopathology, but did not impact rejection or graft survival. Average renal function (calculated GFR, aMDRD formula) was superior for 30 months after CNI withdrawal vs. minimization (p = 0.03) without increased graft fibrosis/tubular atrophy. In a blind comparison of 12-month protocol biopsies of all four regimens, the group with the least histopathology at 12 months received both single-dose rATG induction and CNI withdrawal, (tubular atrophy, p = 0.013; cumulative Banff chronic injury score, p = 0.07). When comparing just the effect of CNI minimization vs. withdrawal on these 12-month biopsy specimens, the CNI-withdrawal patients displayed significantly less Banff score cumulative histopathology (p = 0.016). We conclude that single-dose rATG induction followed by calcineurin-inhibitor withdrawal is associated with improved patient outcomes including graft function and reduced histopathology, and may be safely undertaken in a steroid-free context

Significantly Reduced Renal Allograft Histopathology after Single-Dose rATG Induction and Calcineurin-Inhibitor Withdrawal vs. Minimization: Final Report from a Prospective, Randomized Clinical Trial

We conducted a randomized study of single- vs. divided-dose rATG induction with early steroid withdrawal, followed by CNI minimization vs. withdrawal. 180 patients received either single-dose rATG (one 6 mg/kg dose over 24 hours) or divided-dose rATG (4 doses of 1.5 mg/kg on alternate days), and maintenance immunosuppression with tacrolimus and sirolimus, until tacrolimus was replaced with MMF after 6 months in half the patients of each group. (Maximum follow-up = 7 years; minimum = 2 years.) Demographics were not different among the four groups. Single-dose rATG associated with fewer infectious complications (p = 0.01) and quicker recovery of lymphocyte counts (p = 0.03). Patients who received deceased donor (but not living donor) kidneys had better renal function both for the first 6 months (p = 0.02) and 3 years (p = 0.04). When analyzed by induction treatment, death-censored graft survival and rejection were not different among the 4 groups, but patient survival was inferior among divided-dose rATG recipients (p = 0.02). CNI withdrawal associated with sustained improved graft function and reduced histopathology, but did not impact rejection or graft survival. Average renal function (calculated GFR, aMDRD formula) was superior for 30 months after CNI withdrawal vs. minimization (p = 0.03) without increased graft fibrosis/tubular atrophy. In a blind comparison of 12-month protocol biopsies of all four regimens, the group with the least histopathology at 12 months received both single-dose rATG induction and CNI withdrawal, (tubular atrophy, p = 0.013; cumulative Banff chronic injury score, p = 0.07). When comparing just the effect of CNI minimization vs. withdrawal on these 12-month biopsy specimens, the CNI-withdrawal patients displayed significantly less Banff score cumulative histopathology (p = 0.016). We conclude that single-dose rATG induction followed by calcineurin-inhibitor withdrawal is associated with improved patient outcomes including graft function and reduced histopathology, and may be safely undertaken in a steroid-free context