Levels of evidence for human system risk evaluation

NASA uses a continuous risk management process to seek out new knowledge of spaceflight-induced risk to human health and performance. The evidence base that informs the risk assessments in this domain is constantly changing as more information is gleaned from a continuous human presence in space and from ongoing research. However, the limitations of this evidence are difficult to characterize because fewer than 700 humans have ever flown in space, and information comes from a variety of sources that span disciplines, including engineering, medicine, food and nutrition, and many other life sciences. The Human System Risk Board (HSRB) at NASA is responsible for assessing risk to astronauts and communicating this risk to agency decision-makers. A critical part of that communication is conveying the uncertainty regarding the understanding of the changes that spaceflight induces in human processes and the complex interactions between humans and the spacecraft. Although the strength of evidence grades is common in the academic literature, these scores are often not useful for the problems of human spaceflight. The HSRB continues to update the processes used to report the levels of evidence. This paper describes recent updates to the methods used to assign the level of evidence scores to the official risk postures and to the causal diagrams used by the HSRB.

Causal diagramming for assessing human system risk in spaceflight

For over a decade, the National Aeronautics and Space Administration (NASA) has tracked and configuration-managed approximately 30 risks that affect astronaut health and performance before, during and after spaceflight. The Human System Risk Board (HSRB) at NASA Johnson Space Center is responsible for setting the official risk posture for each of the human system risks and determining-based on evaluation of the available evidence-when that risk posture changes. The ultimate purpose of tracking and researching these risks is to find ways to reduce spaceflight-induced risk to astronauts. The adverse effects of spaceflight begin at launch and continue throughout the duration of the mission, and in some cases, across the lifetime of the astronaut. Historically, research has been conducted in individual risk "silos" to characterize risk, however, astronauts are exposed to all risks simultaneously. In January of 2020, the HSRB at NASA began assessing the potential value of causal diagramming as a tool to facilitate understanding of the complex causes and effects that contribute to spaceflight-induced human system risk. Causal diagrams in the form of directed acyclic graphs (DAGs) are used to provide HSRB stakeholders with a shared mental model of the causal flow of risk. While primarily improving communication among those stakeholders, DAGs also allow a composite risk network to be created that can be tracked and configuration managed. This paper outlines the HSRB's pilot process for this effort, the lessons learned, and future goals for data-driven risk management approaches.

Updates to the NASA human system risk management process for space exploration

This paper describes updates to NASA's approach for assessing and mitigating spaceflight-induced risks to human health and performance. This approach continues to evolve to meet dynamically changing risk environments: lunar missions are currently being designed and the ultimate destination will be Mars. Understanding the risks that astronauts will face during a Mars mission will depend on building an evidence base that informs not only how the humans respond to the challenges of the spaceflight environment, but also how systems and vehicles can be designed to support human capabilities and limitations. This publication documents updates to the risk management process used by the Human System Risk Board at NASA and includes changes to the likelihood and consequence matrix used by the board, the design reference mission categories and parameters, and the standardized evaluation of the levels of evidence that the board accepts when setting risk posture. Causal diagramming, using directed acyclic graphs, provides all stakeholders with the current understanding of how each risk proceeds from a spaceflight hazard to a mission-level outcome. This standardized approach enables improved communication among stakeholders and delineates how and where more knowledge can improve perspective of human system risks and which countermeasures can best mitigate these risks.

Viability of internal comparisons for epidemiological research in the US astronaut corps

This study aims to determine whether astronauts who have not flown in space can provide an unbiased comparison to astronauts who have flown in space when analyzing long-term health outcomes such as incidence of chronic disease and mortality. Various propensity score methods failed to achieve good balance between groups, demonstrating that even with sophisticated rebalancing methods the group of non-flight astronauts cannot be demonstrated to be an unbiased comparison group for examining the effect of the hazards of spaceflight on incidence and mortality from chronic diseases.

Validating Causal Diagrams of Human Health Risks for Spaceflight: An Example Using Bone Data from Rodents

As part of the risk management plan for human system risks at the US National Aeronautics and Space Administration (NASA), the NASA Human Systems Risk Board uses causal diagrams (in the form of directed, acyclic graphs, or DAGs) to communicate the complex web of events that leads from exposure to the spaceflight environment to performance and health outcomes. However, the use of DAGs in this way is relatively new at NASA, and thus far, no method has been articulated for testing their veracity using empirical data. In this paper, we demonstrate a set of procedures for doing so, using (a) a DAG related to the risk of bone fracture after exposure to spaceflight; and (b) four datasets originally generated to investigate this phenomenon in rodents. Tests of expected marginal correlation and conditional independencies derived from the DAG indicate that the rodent data largely agree with the structure of the diagram. Incongruencies between tests and the expected relationships in one of the datasets are likely explained by inadequate representation of a key DAG variable in the dataset. Future directions include greater tie-in with human data sources, including multiomics data, which may allow for more robust characterization and measurement of DAG variables.

Contrapositive logic suggests space radiation not having a strong impact on mortality of US astronauts and Soviet and Russian cosmonauts

Space travelers are exposed to unique forms of ionizing radiation that pose potentially serious health hazards. Prior analyses have attempted to quantify excess mortality risk for astronauts exposed to space radiation, but low statistical power has frustrated inferences. If exposure to deep space radiation were causally linked to deaths due to two particular causes, e.g., cancer and cardiovascular disease, then those cause-specific deaths would not be statistically independent. In this case, a Kaplan-Meier survival curve for a specific cause that treats deaths due to competing causes as uninformative censored events would result in biased estimates of survival probabilities. Here we look for evidence of a deleterious effect of historical exposure to space radiation by assessing whether or not there is evidence for such bias in Kaplan-Meier estimates of survival probabilities for cardiovascular disease and cancer. Evidence of such bias may implicate space radiation as a common causal link to these two disease processes. An absence of such evidence would be evidence that no such common causal link to radiation exposure during space travel exists. We found that survival estimates from the Kaplan-Meier curves were largely congruent with those of competing risk methods, suggesting that if ionizing radiation is impacting the risk of death due to cancer and cardiovascular disease, the effect is not dramatic.

Mortality Among International Astronauts

INTRODUCTION: Research on the mortality of space explorers has focused exclusively on U.S. astronauts and Soviet and Russian cosmonauts. However, other nations have organized space programs over the last 40 yr and the European Space Agency, the Canadian Space Agency, the China National Space Administration, and the Japan Aerospace Exploration Agency all offer an opportunity for further study of the mortality of space explorers.METHODS: We used biographical and vital data abstracted from public sources for European, Canadian, Chinese, and Japanese astronauts. Using general population mortality rates from the Human Mortality Database and mortality rates derived from the cohort of U.S. astronauts, we computed standardized mortality ratios.RESULTS: The groups displayed different preferences in selection of astronauts. As there were no deaths in any of the four groups, the point estimates for standardized mortality ratios were all 0. However, the European cohort experienced a statistically significant reduction in all-cause mortality risk in comparison to the European general population as well as in comparison to U.S. astronauts.DISCUSSION: The healthy worker effect predicts that all study cohorts should have lower all-cause mortality risk in comparison to their general populations. The general population of Japan has mortality rates low enough that any reduction in mortality risk may remain undetectable in the Japanese cohort. Continued surveillance of these populations in the coming decades will make them a useful addition to the evidence base for astronaut mortality.Reynolds RJ, Day SM. Mortality among international astronauts. Aerosp Med Hum Perform. 2019; 90(7):647-651.

Mortality Rates and Excess Death Rates for the Seriously Mentally Ill

OBJECTIVES

-To compute mortality rates and excess death rates for patients with serious mental illness, specific to categories of gender, age and race/ethnicity.

BACKGROUND

-People with serious mental illness are known to be at greatly increased risk of mortality across the lifespan. However, the measures of mortality reported for this high-risk population are typically only summary measures, which do not provide either the mortality rates or excess death rates needed to construct life tables for individuals with serious mental illness.

METHODS

-Mortality rates were computed by dividing the number of deaths by the amount of life-years lived in strata specific to gender, age and race/ethnicity. Age-specific excess death rates were determined as the difference between the study population rate and the corresponding general population rate in each stratum. To compute excess death rates beyond observed ages in the cohort, a method with documented reliability and validity for chronic medical conditions was used.

RESULTS

-For the cohort with mental illness, mortality rates for Black and White females were mostly equal, and consistently greater than those for Hispanic females; excess death rates for females displayed a similar pattern. Among males, mortality rates were highest for Whites, with Hispanics and Blacks close in magnitude at all ages. Excess death rates for males showed more divergence between the categories of race/ethnicity across the age range.

CONCLUSIONS

-Mortality rates specific to categories of gender, age and race/ethnicity show sufficient differences as to make them the preferred way to construct life tables. This is especially true in contrast to broader summary measures such as risk ratios, standardized incidence rates, or life expectancy.

Mortality of US astronauts: comparisons with professional athletes

Objective

Studies of mortality among US astronauts are complicated by the healthy worker effect, which predicts lower mortality for astronauts than the general population based solely on the ability to become and remain an astronaut. We attempt to evaluate astronaut mortality risk while accounting for the healthy worker effect.

Methods

We compare mortality rates of male US astronauts with those of professional athletes from Major League Baseball and the National Basketball Association between January 1, 1960 and May 31, 2018.

Results

Both athlete cohorts and astronauts had significantly lower-than-expected mortality in comparison with the general population. For the overall study period, there were no significant differences in all-cause mortality rates between astronauts and athletes. Astronauts were at greater risk of death from external causes (SMR=583; 95% CI 377 to 860) and reduced risk of death from cardiovascular disease (SMR=39; 95% CI 18 to 73) and all natural causes (SMR=67; 95% CI 47 to 93).

Conclusions

The data presented here do not support increased mortality for astronauts due to unique exposures received in space. The mortality experience of astronauts as compared with professional baseball and basketball players should be re-examined periodically as part of the ongoing surveillance of astronaut mortality in years to come.

The effect of competing risks on astronaut and cosmonaut mortality

Astronauts and cosmonauts have been reported to be at substantially lower age-specific risk of death from chronic disease (primarily heart disease and cancers) in comparison to the general populations of the United States and Russia, respectively. Yet, both groups have been at greater age-specific risk of death from external causes, mainly due to plane crashes and spacecraft accidents. In this study we tested the hypothesis that the reported reductions in mortality from natural causes result, to some degree, from survival bias created by early deaths from external causes. Statistical comparisons of baseline characteristics between cause-of-death groups showed no significant differences. Cause-specific survival curves showed no difference in long-term mortality from external causes among either astronauts or cosmonauts compared to Kaplan-Meier curves with censoring for competing causes. Cause-specific survival curves for natural causes suggested a possible upward bias in mortality estimates published thus far for both groups of space explorers. Differences in survival between Kaplan-Meier curves and the cause-specific survival curves were 7% and 5% for astronauts and cosmonauts respectively after 55 years. The data do not support the hypothesis that observed reductions in mortality from natural causes are due in whole or in part to bias created by deaths from external causes at young ages. The data imply that reports of cause-specific mortality for astronauts and cosmonauts may in fact systematically overestimate mortality rates, though these findings should be interpreted with caution as the data are thin at the extremes of follow-up time.

Mortality Due to Cardiovascular Disease Among Apollo Lunar Astronauts

INTRODUCTION

Recent research has postulated increased cardiovascular mortality for astronauts who participated in the Apollo lunar missions. The conclusions, however, are based on small numbers of astronauts, are derived from methods with known weaknesses, and are not consistent with prior research.

METHODS

Records for NASA astronauts and U.S. Air Force astronauts were analyzed to produce standardized mortality ratios. Lunar astronauts were compared to astronauts who have never flown in space (nonflight astronauts), those who have only flown missions in low Earth orbit (LEO astronauts), and the U.S. general population.

RESULTS

Lunar astronauts were significantly older at cohort entry than other astronaut group and lunar astronauts alive as of the end of 2015 were significantly older than nonflight astronauts and LEO astronauts. No significant differences in cardiovascular disease (CVD) mortality rates between astronaut groups was observed, though lunar astronauts were noted to be at significantly lower risk of death by CVD than are members of the U.S. general population (SMR = 13, 95% CI = 3-39).

DISCUSSION

The differences in age structure between lunar and nonlunar astronauts and the deaths of LEO astronauts from external causes at young ages lead to confounding in proportional mortality studies of astronauts. When age and follow-up time are properly taken into account using cohort-based methods, no significant difference in CVD mortality rates is observed. Care should be taken to select the correct study design, outcome definition, exposure classification, and analysis when answering questions involving rare occupational exposures.Reynolds RJ, Day SM. Mortality due to cardiovascular disease among Apollo lunar astronauts. Aerosp Med Hum Perform. 2017; 88(5):492-496.

The relationship of life expectancy to the development and valuation of life care plans

BACKGROUND

A life care plan often analyzes needs up to a person's life expectancy. Expected present value of necessary funding for such a plan is likewise based on the fixed survival time. If a client should live beyond or die before the life expectancy, a shortfall or excess of funding may seem inevitable. The life table, of which life expectancy is a summary measure, clarifies these issues.

OBJECTIVES

We explain life expectancy and how it is used in tort litigation, economic calculations, and life care planning. We examine the life table, of which life expectancy is one output. We illustrate how a life table provides age-specific probabilities of death and survival, life expectancies, and median survival times, and other information and that every life expectancy must be associated with a life table. We consider the implications for life care planners, forensic economists, and others.

CONCLUSIONS

Life expectancy is a summary of more detailed information provided in a life table. The full life table provides better information for planning purposes. Whether life expectancy or a full life table should be used in developing and valuing a life care plan is not well understood. A multi-disciplinary approach may help clarify these issues.

Extrapolating published survival curves to obtain evidence-based estimates of life expectancy in cerebral palsy

Studies reporting long-term survival probabilities for cohorts of persons with cerebral palsy provide evidence-based information on the life expectancy of those cohorts. Some studies have provided estimates of life expectancy based on extrapolation of such evidence, whereas many others have opted not to do so. Here we review the basic methods of life table analysis necessary for performing such extrapolations, and apply these methods to obtain evidence-based estimates of life expectancy from several studies that do not report such estimates themselves.

The role of genetic variants in CRP in radiographic severity in African Americans with early and established rheumatoid arthritis

This study investigates the association of CRP (C-reactive protein) single-nucleotide polymorphisms (SNPs) with plasma CRP levels and radiographic severity in African Americans with early and established rheumatoid arthritis (RA). Using a cross-sectional case-only design, CRP SNPs were genotyped in two independent sets of African Americans with RA: Consortium for the Longitudinal Evaluation of African Americans with RA (CLEAR 1) and CLEAR 2. Radiographic data and CRP measurements were available for 294 individuals from CLEAR 1 (median (interquartile range (IQR) 25-75) disease duration of 1 (0.6-1.6) year) and in 407 persons from CLEAR 2 (median (IQR 25-75) disease duration of 8.9 (3.5-17.7) years). In CLEAR 1, in adjusted models, the minor allele of rs2808630 was associated with total radiographic score (incident rate ratio 0.37 (95% confidence interval (CI) 0.19-0.74), P-value=0.0051). In CLEAR 2, the minor allele of rs3093062 was associated with increased plasma CRP levels (P-value=0.002). For each rs3093062 minor allele, the plasma CRP increased by 1.51 (95% CI 1.15-1.95) mg dl(-1) when all the other covariates remained constant. These findings have important implications for assessment of the risk of joint damage in African Americans with RA.

Comparative Mortality and Risk Factors for Death among US Supreme Court Justices (1789-2013)

Objectives .- To compare the mortality experience of 112 justices of the US Supreme Court with that expected in the general population. To identify variables associated with mortality within this cohort. Background .- Supreme Court justices are a select occupational cohort. High socio-economic status, advanced education, lifetime appointment, and the healthy worker effect suggest lower mortality. Sedentary work, stress, and a tendency to work beyond typical retirement age may attenuate this. Methods .- Standardized mortality ratios compare the observed mortality rates of justices with those expected in age- and sex-matched contemporary general populations. Poisson regression analyzes variables associated with mortality within the cohort. Results .- From 1789 to 2013, 112 justices (108 male) contributed 2,355 person-years of exposure. Mean age (standard deviation) at appointment was 53.1 years (6.7); at retirement 69.7 years (9.9); at death (n = 100) 74.4 years (10.3); and at end of the study for those alive (n = 12) 72.1 years (11.8). Standardized mortality ratios (95% ci) were: overall 0.87 (0.70-1.05); prior to 1950 0.92 (0.61-1.33); and from 1950 to 2013 0.66 (0.42-0.99). Variables in the final Poisson model and their associated mortality rate ratios (95% ci) were: age 1.06 (1.03-1.09); calendar year 0.99 (0.99-1.00); active status 0.41 (0.25-0.68); career length 1.04 (1.01-1.07); and chief justice 1.08 (0.59-1.84). Conclusions .- Supreme Court mortality was lower than that of the general population in the period from 1950 to the present, but was on par prior to 1950. Increasing age and career length were associated with greater mortality, while active status and later calendar year with lower. These results may add to a body of knowledge that may help to develop or refine models of mortality risk in increasingly aged working populations.

Mortality among Soviet and Russian cosmonauts: 1960-2013

INTRODUCTION

Though the mortality of U.S. astronauts has been studied repeatedly in the last 20 yr, little is known about the long-term mortality trends of Soviet and Russian cosmonauts.

METHODS

Using data from 266 cosmonauts accepted into cosmonaut training from 1960 to 2013, we document the causes of death and crude death rates among cosmonauts. Using standardized mortality ratios (SMR), we compared cosmonauts to the general populations of Russia and Ukraine, and to 330 U.S. astronauts.

RESULTS

Cosmonauts experienced significantly lower all-cause mortality risk compared to the general population. However, cosmonauts were at almost double the risk of all-cause mortality in comparison to U.S. astronauts (SMR = 190, 95% C.I. 154-239). Cosmonauts were also at greater risk of circulatory disease (SMR = 364, 95% C.I. 225-557) and cancer (SMR = 177, 95% C.I. 108-274) compared to U.S. astronauts. Though not statistically significant, cosmonauts experienced fewer fatal accidents (SMR = 88, 95% C.I. = 54-136) than their U.S. counterparts.

DISCUSSION

Cosmonauts are at much lower risk of all-cause mortality than the general populations of Russia and Ukraine, yet are at greater risk for death by cardiovascular disease and cancer than are U.S. astronauts. This disparity may have common roots with decreases in life expectancy in Russia in recent decades. Further research is needed to understand these trends fully.

Causes of death and comparative mortality in Texas public mental health clients, 2006–2008

Seriously mentally ill patients are known to have rates of mortality much greater than those of the general population. Prior research in Texas has shown inpatient Public Mental Health Clients (PMHCs) treated in in-patient settings were subject to greatly increased mortality, but little is known about the mortality of PMHCs in an outpatient setting in Texas.

For this study outpatient service records for PMHCs treated in Texas were combined with death data from the Texas Department of State Health Services for 2006–2008. Frequencies of causes of death, age-adjusted death rates, standardized mortality ratios, and life expectancies were calculated from these data.

The most frequent causes of death were external causes, followed by circulatory disease, and then neoplasms. Examination of the outcomes suggests that substance abuse plays a major role in the mortality of PMHCs in Texas in the form of drug overdoses, tobacco-related cancers, and alcoholic liver disease. Prevention efforts should therefore aim at integrating mental health services, substance abuse services, and careful medical and pharmacological monitoring, including medication monitoring to prevent suicides and accidental overdoses.

Coordination and management of multicenter clinical studies in trauma: Experience from the PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) Study

AIM

Early death due to hemorrhage is a major consequence of traumatic injury. Transfusion practices differ among hospitals and it is unknown which transfusion practices improve survival. This report describes the experience of the PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) Study Data Coordination Center in designing and coordinating a study to examine transfusion practices at ten Level 1 trauma centers in the US.

METHODS

PROMMTT was a multisite prospective observational study of severely injured transfused trauma patients. The clinical sites collected real-time information on the timing and amounts of blood product infusions as well as colloids and crystalloids, vital signs, initial diagnostic and clinical laboratory tests, life saving interventions and other clinical care data.

RESULTS

Between July 2009 and October 2010, PROMMTT screened 12,561 trauma admissions and enrolled 1245 patients who received one or more blood transfusions within 6h of Emergency Department (ED) admission. A total of 297 massive transfusions were observed over the course of the study at a combined rate of 5.0 massive transfusion patients/week.

CONCLUSION

PROMMTT is the first multisite study to collect real-time prospective data on trauma patients requiring transfusion. Support from the Department of Defense and collaborative expertise from the ten participating centers helped to demonstrate the feasibility of prospective trauma transfusion studies. The observational data collected from this study will be an invaluable resource for research in trauma surgery and it will guide the design and conduct of future randomized trials.

A Cytoplasmic Regulatory Mutant of Euglena: Constitutivity for the Light-Inducible Chloroplast Transfer RNAs

An ultraviolet-induced cytoplasmic mutant (G(1)BU) of Euglena gracilis Klebs var. bacillaris Pringsheim is described. G(1)BU, in addition to being golden in color and containing smaller amounts of chlorophyll than wild type when grown in the light, is a regulatory constitutive mutant for the light-inducible chloroplast isoleucine and methionine tRNAs; i.e., these two tRNAs are present in dark-grown G(1)BU cells at approximately the levels present in light-grown wild-type cells. Six other mutants were also examined for normal control of plastid tRNA biosynthesis; all four of the aplastidic mutants (lacking appreciable plastid structures and detectable plastid DNA) are incapable of chloroplast tRNA biosynthesis, whereas two other color mutants that do contain plastids and chloroplast DNA have normal plastid tRNA regulation.

Change in ambulatory ability of adolescents and young adults with cerebral palsy

This study aimed to determine the probability that a child with cerebral palsy (CP) will lose or gain ambulatory ability through adolescence and young adulthood. We analyzed retrospectively data from 1987 to 2002 on Californians with CP initially aged 10 years (SD 0.9y; n=7550 [4304 males, 3246 females]) and 25 years (SD 0.8y; n=5721 [3261 males, 2460 females]) who had varying levels of ambulatory ability (initial Gross Motor Function Classification System Levels I-IV). We used the Aalen-Johansen estimator to estimate probabilities of transition to other levels of ambulatory ability in the future. Those who walked and climbed stairs without difficulty at age 10 had only a 23% chance of decline (to requiring a handrail to manage stairs, or worse) 15 years later. Those who ambulated with some difficulty but did not use a wheelchair had a significant chance (33%) of improvement (to being able to walk unsteadily alone at least 3m or better) and only a small chance (11%) of becoming non-ambulatory. Those who used a wheelchair were more likely to lose ambulatory ability (34%) or die (6%). Those who walked and climbed stairs well at age 25 were likely to maintain that ability 15 years later (76%), while those needing support to climb stairs were more likely to lose ability. Improvement in ambulation after age 25 was unlikely. Children and young adults with CP are likely to maintain their ambulatory ability during their next 15 years. Some who ambulate with difficulty at age 10 may improve through adolescence, but those who use a wheelchair are more likely to decline. By age 25 improvement in ambulation is unlikely and decline more likely. Most, however, will not change over the next 15 years.

Causes of death in remote symptomatic epilepsy

OBJECTIVE

To determine the causes of death of individuals with developmental disabilities that occur more frequently among those with remote symptomatic epilepsy (i.e., epilepsy occurring in persons with developmental delay or identified brain lesions) than for those without.

METHODS

The authors compared causes of mortality in persons with (n = 10,030) and without (n = 96,163) history of epilepsy in a California population of persons with mild developmental disabilities, 1988 to 2002. Subjects had traumatic brain injury, cerebral palsy, Down syndrome, autism, or a developmental disability with other or unknown etiology. There were 721,759 person-years of data, with 2,397 deaths. Underlying causes of death were determined from the State of California's official mortality records. Cause-specific death rates and standardized mortality ratios (SMRs) were computed for those with and without epilepsy relative to subjects in the California general population. Comparisons were then made between SMRs of those with and without epilepsy, and CIs on the ratios of SMRs were determined.

RESULTS

Death rates for persons with epilepsy were elevated for several causes. The greatest excess was due to seizures (International Classification of Diseases-9 [ICD-9] 345; SMR 53.1, 95% CI 28.0 to 101.0) and convulsions (ICD-9 780.3; SMR 25.2, 95% CI 11.7 to 54.2). Other causes occurring more frequently in those with epilepsy included brain cancer (SMR 5.2, 95% CI 2.2 to 12.1), respiratory diseases (SMR 1.7, 95% CI 1.2 to 2.5), circulatory diseases (SMR 1.3, 95% CI 1.0 to 1.7), and accidents (SMR 2.7, 95% CI 1.9 to 3.7), especially accidental drowning (SMR 12.8, 95% CI 7.0 to 23.2).

CONCLUSIONS

Remote symptomatic epilepsy is associated with an increased risk of death. Seizures, aspiration pneumonia, and accidental drowning are among the leading contributors.

Mortality and causes of death in persons with Down syndrome in California

This study investigated mortality and causes of death between 1988 and 1999 in 14781 persons (6702 female) with Down syndrome in California, comparing age, sex, ethnicity, and other factors. Mean age at the start of follow-up was 14 years 8 months (SD 14y 10mo). During the study period 600 persons died. The standardized mortality ratio (SMR) for the population was 5.5. Blacks were at greater risk than whites, Hispanics, or Asians (relative risk = 1.5). Mortality declined during the period, especially for children with congenital heart defects. Leukemia (SMR = 17), respiratory illnesses (SMR = 27), congenital anomalies (SMR = 72), and circulatory diseases (SMR = 5.3) accounted for most of the excess mortality. With the exception of leukemia, cancer mortality was not different from that of the general population.

Accretion of low-metallicity gas by the Milky Way

Models of the chemical evolution of the Milky Way suggest that the observed abundances of elements heavier than helium ('metals') require a continuous infall of gas with metallicity (metal abundance) about 0.1 times the solar value. An infall rate integrated over the entire disk of the Milky Way of approximately 1 solar mass per year can solve the 'G-dwarf problem'--the observational fact that the metallicities of most long-lived stars near the Sun lie in a relatively narrow range. This infall dilutes the enrichment arising from the production of heavy elements in stars, and thereby prevents the metallicity of the interstellar medium from increasing steadily with time. However, in other spiral galaxies, the low-metallicity gas needed to provide this infall has been observed only in associated dwarf galaxies and in the extreme outer disk of the Milky Way. In the distant Universe, low-metallicity hydrogen clouds (known as 'damped Ly alpha absorbers') are sometimes seen near galaxies. Here we report a metallicity of 0.09 times solar for a massive cloud that is falling into the disk of the Milky Way. The mass flow associated with this cloud represents an infall per unit area of about the theoretically expected rate, and approximately 0.1-0.2 times the amount required for the whole Galaxy.

Evidence for an Additional Heat Source in the Warm Ionized Medium of Galaxies

Spatial variations of the [S ii]/Halpha and [N ii]/Halpha line intensity ratios observed in the gaseous halo of the Milky Way and other galaxies are inconsistent with pure photoionization models. They appear to require a supplemental heating mechanism that increases the electron temperature at low densities, ne. This would imply that in addition to photoionization, which has a heating rate per unit volume proportional to n2e, there is another source of heat with a rate per unit volume proportional to a lower power of ne. One possible mechanism is the dissipation of interstellar plasma turbulence, which, according to Minter & Spangler, heats the ionized interstellar medium in the Milky Way at a rate of approximately 1x10-25ne ergs cm-3 s-1. If such a source were present, it would dominate over photoionization heating in regions where ne less, similar0.1 cm-3, producing the observed increases in the [S ii]/Halpha and [N ii]/Halpha intensity ratios at large distances from the galactic midplane as well as accounting for the constancy of [S ii]/[N ii], which is not explained by pure photoionization. Other supplemental heating sources, such as magnetic reconnection, cosmic rays, or photoelectric emission from small grains, could also account for these observations, provided they supply approximately 10-5 ergs s-1 per square centimeter of the Galactic disk to the warm ionized medium.

A comparison of calcium phosphate coprecipitation and electroporation. Implications for studies on the genetic effects of DNA damage

Plasmid-based transfection assays provide a rapid means to measure homologous and nonhomologous recombination in mammalian cells. Often it is of interest to examine the stimulation of recombination by DNA damage induced by radiation, genotoxic chemicals, or nucleases. Transfection is frequently performed by using calcium phosphate coprecipitation (CPP), because this method is well suited for handling large sample sets, and it does not require expensive reagents or equipment. Alternative transfection methods include lipofection, microinjection, and electroporation. Since DNA strand breaks are known to stimulate both homologous and nonhomologous recombination, the induction of nonspecific damage during transfection would increase background recombination levels and thereby reduce the sensitivity of assays designed to detect the stimulation of recombination by experimentally induced DNA damage. In this article, we compare the stimulatory effects of nuclease-induced double-strand breaks (DSBs) on homologous and nonhomologous recombination for molecules transfected by CPP and by electroporation. Although electroporation yielded fewer transfectants, both nonhomologous and homologous recombination were stimulated by nuclease-induced DSBs to a greater degree than with CPP. Ionizing radiation is an effective agent for inducing DNA strand breaks, but previous studies using CPP generally showed little or no stimulation of homologous recombination among plasmids damaged with ionizing radiation. By contrast, we found clear dose-dependent enhancement of recombination with irradiated plasmids transfected using electroporation. Thus, electroporation provides a higher signal-to-noise ratio for transfection-based studies of damage-induced recombination, possibly reflecting less nonspecific damage to plasmid DNA during transfection of mammalian cells.

Mycoplasma pneumoniae: a frequent cause of pneumonia among U.S. Marines in southern California

From August 1993 through April 1994, U.S. Marines (98% male, median age 20 years) who were hospitalized with radiographically confirmed pneumonia were prospectively studied for evidence of acute Mycoplasma pneumoniae infection. Overall, 32 (36.4%) of the 88 patients with paired sera had evidence of acute infection by an elevated immunoglobulin M titer (22.7%), a 4-fold rise in immunoglobulin G titer (9.1%), a positive polymerase chain reaction result (11.1%), and/or a positive culture (5.8%). No specific symptoms or clinical findings were strong predictors of M. pneumoniae infection. Among patients with evidence of acute M. pneumoniae infection, admitting clinicians chose other pathogens as more likely etiologic agents 46.4% of the time, and over the course of the hospitalization, 10% of patients failed to receive appropriate antibiotics. These data indicate that M. pneumoniae may cause a high proportion of pneumonias among military personnel and should be considered in empiric treatment and prophylaxis.

Fabry-Perot CCD annular-summing spectroscopy: study and implementation for aeronomy applications

The technique of Fabry-Perot CCD annular-summing spectroscopy, with particular emphasis on applications in aeronomy, is discussed. Parameter choices for optimizing performance by the use of a standard format CCD array are detailed. Spectral calibration methods, techniques for determining the ring pattern center, and effects imposed by limited radial resolution caused by superpixel size, variable by on-chip binning, are demonstrated. The technique is carefully evaluated experimentally relative to the conventional scanning Fabry-Perot that uses a photomultiplier detector. We evaluate three extreme examples typical of aeronomical spectroscopy using calculated signal-to-noise ratios. Predicted sensitivity gains of 10-30 are typical. Of the cases considered, the largest savings in integration time are estimated for the day sky thermospheric O(1)D case, in which the bright sky background dominates the CCD read noise. For profile measurements of faint night sky emission lines, such as exospheric hydrogen Balmer-α, long integration times are required to achieve useful signal-to-noise ratios. In such cases, CCD read noise is largely overcome. Predictions of a factor of 10-15 savings in integration time for night sky Balmer-α observations are supported by field tests. Bright, isolated night sky lines such as thermospheric O(1)D require shorter integration times, and more modest gains dependent on signal level are predicted. For such cases it appears from estimate results that the Fabry-Perot CCD annular-summing technique with a conventional rectangular format may be outperformed by a factor of 2-5 by special CCD formats or by unusual optical coupling configurations that reduce the importance of read noise, based on the ideal transmission for any additional optics used in these configurations.

Patterns of morphological variation within myelin internodes of normal peripheral nerve: quantitative analysis by confocal microscopy

Knowledge of variations in the morphology of normal myelinated peripheral nerve fibres is fundamental to subsequent interpretation of neuropathology. It would be advantageous for structural analysis of normal variations to be based on entire myelin internodes, but acquisition of such data via the classic approach of nerve fibre teasing has been hindered by limitations in optical resolution and specimen preparation. This study addressed these limitations through a new confocal imaging method which permits detailed visualisation of individual myelinated fibres in intact peripheral nerve trunks, and quantitated previously unrecognised patterns of morphological variation within normal internodes. The study focused particularly on Schmidt-Lanterman incisures, the narrow cytoplasmic channels which traverse normal compact myelin and provide foci for disruption of the compact sheath in a number of peripheral neuropathies. Analysis was based on confocal fluorescence images of multiple sequential internodes, traced within posterior tibial nerve trunks of adult male Sprague-Dawley rats. The strength of relationships between internodal size variables (length, fibre diameter, myelin sheath thickness) and total number of incisures per internode were documented. Each internode was divided into 4 regions of equivalent length (regions 1-4), and variations in the distribution of incisures and Schwann cell nuclear location were evaluated. Regional variations were consistent, irrespective of differences in fibre diameter, myelin sheath thickness, and internodal length. Expressed in terms of proximodistal orientation, there was a unimodal distribution of incisures within internodes of this fibre population (diameter range 5-9 microns), with region 3 containing the highest number of incisures and region 4 the lowest (P < 0.05). The Schwann cell nucleus was located more frequently in region 3 than in region 2 (P < 0.01). Contrary to previous reports, an incisure was found in close association with the nucleus in at least 50% of internodes. Documentation of frequent incisure-nuclear association and consistent patterns of variation within internodes extends knowledge of the microanatomy of normal peripheral nerve, and may provide insight into the functional role of incisures. Demonstration of such patterns in normal nerve may contribute to the understanding of pathological change, for example progression of ovoid formation from midinternodal regions during wallerian degeneration.

Characterization of a mammalian cell line that exhibits spontaneous and ultraviolet light-induced hypermutability while retaining resistance to cell killing by ultraviolet light

Chronic exposure of V79 cells to 80 daily doses of 150 J/M2, 290-330-nm ultraviolet light (UVB) produced a mixed cell population that was found to be generally more resistant to cell killing by both UVB and UVC (254 nm) than the wild-type cells. Several subclones from this population were studied for their survival and mutation responses and then one was chosen for further characterization based on this data. The studies carried out on this subclone, designated N806, show that its spontaneous HPRT mutation rate is approximately 10 times higher than that of wild-type V79 cells and it is almost three times more mutable than the wild-type cells when both are induced by UVB or UVC. The mutation responses of N806 and MI2G cells to 50-kVp X-rays are different, but the N806 cells do not appear to be hypermutable as they are with UV. N806 cells are also moderately more resistant to the cytotoxic effects of UV radiation but are more sensitive than MI2G cells when exposed to X-rays. Assays to measure the removal of cyclobutane pyrimidine dimers (CPDs) and the incision step of nucleotide excision repair have revealed no detectable difference in the repair capacities of N806 and parental V79 cells. These results suggest that chronic, protracted UV irradiation may be able to induce a 'mutator phenotype' in a subpopulation of the progenitor cells.

Imaging myelinated nerve fibres by confocal fluorescence microscopy: individual fibres in whole nerve trunks traced through multiple consecutive internodes

Current methods of morphological analysis do not permit detailed imaging of individual myelinated fibres over substantial lengths without disruption of neighbouring, potentially significant, cellular and extracellular relationships. We report a new method which overcomes this limitation by combining aldehyde-induced fluorescence with confocal microscopy. Myelin fluorescence was intense relative to that from other tissue components, enabling individual myelinated nerve fibres to be traced for distances of many millimeters in whole PNS nerve trunks. Image obtained with a Bio-Rad MRC-600 confocal laser scanning microscope clearly displayed features of PNS and CNS myelinated fibres including nodes of Ranvier; fibre diameter; sheath thickness and contour; branch points at nodes; as well as (in the PNS) Schmidt-Lanterman incisures and the position of Schwann cell nuclei. Direct comparisons using the same specimens (whole nerve trunks; also teased fibres) showed confocal imaging to be markedly superior to conventional fluorescence microscopy in terms of contrast, apparent resolution and resistance to photobleaching. Development of the fluorophore was examined systemically in sciatic nerves of young adult rats. In separate experiments, animals were perfused systemically using (1) 5% glutaraldehyde; (2) Karnovsky's solution; (3) 4% paraformaldehyde; buffered with either 0.1 M sodium phosphate or sodium cacodylate (pH 7.4). The concentration of glutaraldehyde in the fixative solution was the principal determinant of fluorescence intensity. Confocal imaging was achieved immediately following perfusion with 5% glutaraldehyde or Karnovsky's. Fluorescence intensity increased markedly during overnight storage in these fixatives and continued to increase during subsequent storage in buffer alone. The fluorophore was stable and resistant to fading during storage (15 months at least), enabling data collection over extended periods. To demonstrate application of the method in neuropathology, individual fibres in transected sciatic nerve trunks were traced through multiple successive internodes: Classical features of Wallerian degeneration (axonal swelling and debris; ovoid formation and incisure changes; variation among fibres in the extent of degeneration) were displayed. The method is compatible with subsequent ultrastructural examination and will complement existing methods of investigation of myelinated fibre anatomy and pathology, particularly where preservation of 3-dimensional relationships or elucidation of spatial gradients are required.

Human ERCC5 cDNA-cosmid complementation for excision repair and bipartite amino acid domains conserved with RAD proteins of Saccharomyces cerevisiae and Schizosaccharomyces pombe

Several human genes related to DNA excision repair (ER) have been isolated via ER cross-species complementation (ERCC) of UV-sensitive CHO cells. We have now isolated and characterized cDNAs for the human ERCC5 gene that complement CHO UV135 cells. The ERCC5 mRNA size is about 4.6 kb. Our available cDNA clones are partial length, and no single clone was active for UV135 complementation. When cDNAs were mixed pairwise with a cosmid clone containing an overlapping 5'-end segment of the ERCC5 gene, DNA transfer produced UV-resistant colonies with 60 to 95% correction of UV resistance relative to either a genomic ERCC5 DNA transformant or the CHO AA8 progenitor cells. cDNA-cosmid transformants regained intermediate levels (20 to 45%) of ER-dependent reactivation of a UV-damaged pSVCATgpt reporter plasmid. Our evidence strongly implicates an in situ recombination mechanism in cDNA-cosmid complementation for ER. The complete deduced amino acid sequence of ERCC5 was reconstructed from several cDNA clones encoding a predicted protein of 1,186 amino acids. The ERCC5 protein has extensive sequence similarities, in bipartite domains A and B, to products of RAD repair genes of two yeasts, Saccharomyces cerevisiae RAD2 and Schizosaccharomyces pombe rad13. Sequence, structural, and functional data taken together indicate that ERCC5 and its relatives are probable functional homologs. A second locus represented by S. cerevisiae YKL510 and S. pombe rad2 genes is structurally distinct from the ERCC5 locus but retains vestigial A and B domain similarities. Our analyses suggest that ERCC5 is a nuclear-localized protein with one or more highly conserved helix-loop-helix segments within domains A and B.

Electroporation-mediated gene transfer efficiency is reduced by linear plasmid carrier DNAs

Carrier DNA has generally been found to stimulate DNA-mediated gene transfer of Chinese hamster ovary (CHO) cells by calcium phosphate coprecipitation. In studies employing electroporation, however, we observed that linear plasmid DNA was inhibitory to the transfection of CHO cells. This unexpected result prompted us to explore the effects of various types and forms of plasmid, cosmid, and chromosomal DNAs on transfection efficiencies. Both carrier DNA form and type were found to influence transfection efficiencies. Circular and linear forms of plasmid carrier DNA had opposite effects: circular plasmids increased and linear plasmids decreased transfection efficiencies. These effects were independent of homology with the selected plasmid and are probably independent of homologous recombination mechanisms. Bacterial genomic DNA failed to stimulate transfection, while calf thymus and cosmid DNA consisting primarily of human sequences stimulated transfection significantly. Our results have importance for plasmid-based experiments in mammalian cells such as those involving the induction of interplasmid homologous recombination.

Transcription stimulates homologous recombination in mammalian cells

Transcription stimulates homologous recombination in Saccharomyces cerevisiae and has been implicated in the control of recombinational events during the development of mammalian immune systems. Here, we describe a plasmid-based system in which an inducible promoter from the mouse mammary tumor virus is located upstream of heteroallelic neomycin genes carried on two plasmids. Pairs of plasmids are introduced into Chinese hamster ovary cells by electroporation, and recombination is monitored by scoring colonies resistant to the aminoglycoside G418. When transcription is induced with dexamethasone, a synthetic glucocorticoid hormone, and double-strand breaks are introduced at mutation sites, recombination is stimulated sixfold over noninduced levels. Inducing transcription in circular substrates or in substrates cleaved at sites distant from the mutations has no detectable effect on recombination between neomycin genes. Results are presented that are consistent with the observed stimulation of recombination occurring before plasmids integrate into the cellular DNA. Our results are discussed in relation to molecular models for extrachromosomal recombination in mammalian cells.

Effect of duration of exposure to benzo(a)pyrene diol-epoxide on neoplastic transformation, mutagenesis, cytotoxicity, and total covalent binding to DNA of rodent cells

We examined the effect of different durations of exposure (20 sec to 24 hr) to (+/-) 7-beta,8 alpha-dihydroxy-9 alpha, 10 alpha -epoxy-7,8,9,10-tetrahydrobenzo(a)pyrene (BPDE I) on the induction of transformation in C3H/10T 1/2 cells and of mutations to 6-thioguanine resistance in Chinese hamster ovary cells (CHO), as well as on BPDE I-DNA binding in these two cell lines. A 20-sec exposure of the cells to BPDE I was sufficient to induce mutations and morphological transformation in vitro. However, the transformation frequency in CH3 mouse-embryo-derived 10T 1/2 cells increased twofold and the frequency of mutations in CHO cells sixfold when the exposure time to BPDE I was increased from 20 sec to 8 h. Cytotoxicity increased under similar conditions. A large number of BPDE I-DNA adducts were formed in both cell lines within the first 15-min of exposure of the cells to this ultimate carcinogen. The total covalent binding did not increase with longer than 15-min incubation times. These results suggest that in addition to its covalent binding to DNA, BPDE I may influence other cellular mechanism(s) that are responsible for the initiation of transformation and mutagenesis.

Induction and repair of closely opposed pyrimidine dimers in Saccharomyces cerevisiae

Pyrimidine dimer-DNA glycosylase activity prepared from Micrococcus luteus has been used to develop an enzyme-sensitive site assay for the detection and quantification of closely opposed pyrimidine dimers in the nuclear DNA of UV-irradiated yeast. With this assay, closely opposed dimers were found to be induced as a linear function of dose from 0 to 200 J/m2 (254 nm). Closely opposed dimer frequencies decreased during the incubation of UV-irradiated, excision repair-proficient cells under liquid-holding conditions in the dark and during post-irradiation exposure of excision-deficient cells to photoreactivating light. Incubation of excision-deficient cells in the dark had no effect on the frequency of closely opposed dimers for up to 16 h. These results indicate that closely opposed dimers in UV-irradiated yeast are subject to repair by enzymatic photoreactivation and/or by dark-repair processes dependent, at least in part, upon functions necessary for normal excision repair. The genetic and biochemical implications of these results are discussed.

DNA sequence dependence of closely opposed cyclobutyl pyrimidine dimers induced by UV radiation

Treatment of UV-irradiated DNAs with Micrococcus luteus pyrimidine dimer-DNA glycosylase results in the formation of double-strand breaks due to cleavage at closely opposed pyrimidine dimers. To determine if the induction of closely opposed dimers is significantly affected by DNA nucleotide sequence, end-labeled DNA fragments of known nucleotide sequence were UV irradiated, incubated with pyrimidine dimer-DNA glycosylase, and analyzed by electrophoresis through nondenaturing polyacrylamide gels. Distinct bands of increased electrophoretic mobility were observed, indicating that bifilar cleavage had occurred with greater probability at specific sites in each DNA sequence. In vitro enzymatic photoreactivation of dimers prior to treatment with pyrimidine dimer-DNA glycosylase prevented the appearance of bands. DNA sequence analysis revealed the presence of closely opposed runs of pyrimidines at sites of more frequent bifilar cleavage. Our results indicate that the induction of closely opposed dimers occurs with greater probability at specific sites in DNA sequences and that such sites are characterized by the presence of closely opposed pyrimidine runs.

A sensitive, enzymatic assay for the detection of closely opposed cyclobutyl pyrimidine dimers induced in human diploid fibroblasts

A sensitive, enzymatic assay has been developed for the detection of closely opposed cyclobutyl pyrimidine dimers induced in UV-irradiated human diploid fibroblasts. In this assay closely opposed dimers are detected as bifilar enzyme-sensitive sites. Single-strand incisions are made at the positions of individual pyrimidine dimers through the action of M. luteus pyrimidine dimer-DNA glycosylase. Incisions at closely opposed dimers, effectively expressed as double-strand breaks, are quantified from the resulting reduction in DNA double-strand molecular weight as determined by velocity sedimentation through neutral sucrose density gradients. The stability of the bacteriophage lambda cos site under our reaction conditions indicates that opposed incisions must be relatively close to be expressed as a double-strand break. The dose response for the induction of bifilar enzyme-sensitive sites in mammalian cells was found to be complex but can be approximated by a function that increases as the 1.2-1.4 power of UV dose. The frequency of bifilar enzyme-sensitive sites observed decreased during postirradiation incubation of excision-repair-proficient human diploid fibroblasts with less than 20% still detectable at 24 h after irradiation with 5 J/m2 (254 nm). By comparison, over 80% of the bifilar enzyme-sensitive sites induced in fibroblasts assigned to xeroderma pigmentosum complementation group A remained detectable 24 h after irradiation. The implications of these results for models addressing the induction and repair of closely opposed pyrimidine dimers are discussed.

Repair of closely opposed cyclobutyl pyrimidine dimers in UV-sensitive human diploid fibroblasts

An enzyme-sensitive site assay has been used to examine the fate of closely opposed pyrimidine dimers (bifilar enzyme-sensitive sites) in fibroblasts from individuals afflicted with various genetic disorders that confer increased cellular sensitivity to UV radiation. The disappearance of bifilar enzyme-sensitive sites was found to be normal in cells from individuals with Fanconi's anemia, Cockayne's syndrome, dyskeratosis congenita and the variant form of xeroderma pigmentosum. The rate of bifilar enzyme-sensitive site removal in XP cells assigned to complementation group C was reduced by an amount similar to that observed for the repair of isolated dimers. Our results indicate that the initiation of repair at closely opposed dimers is slow in XP-C cells but normal in all other cells examined.

Bifilar enzyme-sensitive sites in ultraviolet-irradiated DNA are indicative of closely opposed cyclobutyl pyrimidine dimers

Incubation of UV-irradiated DNA with pyrimidine dimer-DNA glycosylase in cell-free lysates prepared from Micrococcus luteus results in the appearance of double-strand breaks. It has previously been assumed that such double-strand breaks result from cleavage at closely opposed dimers. We have used hybrid molecules of bacteriophage T7 DNA comprised of two unirradiated strands, two UV-irradiated strands, or one unirradiated and one UV-irradiated strand to test this hypothesis. Bifilar cleavage was observed only with molecules consisting of two irradiated strands and no bifilar cleavage was observed after the monomerization of pyrimidine dimers by enzymatic photoreactivation. Our results indicate that at least 80% of the double-strand breaks result from cleavage at closely opposed dimers and that the induction of dimers in one strand does not influence the induction of dimers at closely opposed positions in the complementary strand of a DNA double helix.