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All sourcesNASA NTRSDOE OSTI
NASA NTRS2020

Use of Otoacousticemission Phase Change to Evaluate Countermeasures for Spaceflight-Associated Neuro-Ocular Syndrome

Spaceflight-associated neuro-ocular syndrome (SANS) is a human spaceflight risk recognized by NASA. Elevated intracranial pressure (ICP) has been implicated as a root cause of many SANS signs and symptoms, yet there is no reliable noninvasive means of monitoring ICP. We have developed a noninvasive method of monitoring ICP change that exploits ear canal acoustic and otoacoustic emission (OAE) measurements. Changed ICP alters pressure in the inner ear, leading to changes in the tension and position of middle ear (ME) components; tension of these components determines the phase of the stimulus in the ear canal and the OAE response sound transmission back through the ME. The OAE method has been validated in several studies, including our own experiments as part of the NASA Fluid Shifts study. Systematic OAE phase changes demonstrating increased ME tension (an ICP indicator) are observed as posture is changed from seated to supine to head-down tilt (HDT). This effect can be substantially mitigated by lower body negative pressure (LBNP). The OAE technique has also been used on International Space Station (ISS) crewmembers, providing evidence that ICP in microgravity is similar to that seen on the ground in the supine position. The OAE method is also a rapid and noninvasive means of assessing the effectiveness of SANS countermeasures. Here we report results from two studies which used OAEs. In the most recent study (Venous Congestion Countermeasures - VCCM), three promising countermeasures [LBNP, an impedance threshold device (ITD), and veno-occlusive thigh cuffs (VTC)] were applied individually and in combination. In our previous ITD-only study, ITD was investigated for its ability to reduce ICP and cephalic venous congestion in supine and various HDT postures. Internal jugular vein (IJV) ultrasound showed a clear decongestive effect at all postures, however OAE data showed that ITD only caused a phase decrease (tension decrease) in HDT postures. In supine, ITD appeared to INCREASE tension. This paradox leads us to hypothesize that the OAE method is not accurately representing ICP changes with countermeasures (CM), which can alter ME tension through other means, such as ME pressure (MEP) changes. More generally, the exact mechanism for observed OAE response and stimulus phase shifts are not clearly understood, specifically with regard to the effects of MEP. The VCCM study examined the effects of externally-applied MEP on OAE recordings to document the relationship between these parameters. Analysis of these data provide new insights to these OAE mechanisms, in addition to results on CM effectiveness.

Kemp, D.↗
NASA NTRS2020

Development and Comparison of an Artificial Gravity Concept for Human Spaceflight

This Internship served as a resource to find specific research about the many facets of artificial gravity. With three main areas to be addressed in detail: the negative health effects of microgravity and how current mitigation methods fall short, the knowns and unknowns of artificial gravity as a countermeasure, and past artificial gravity habitat concepts. This report primarily focuses on the negative health effects of microgravity and how current mitigation methods fall short. Through NASA resources such as the NTRS, and external sources such as the AIAA, research papers were gathered that were pertinent to the topic. Each paper was uploaded to a NASA SharePoint and abstracts were drafted to highlight the important information. The expected results were to build a library of easily accessible information that would allow for Ryan Joyce and Gabe Merrill to easily get up to speed on relevant information. This process should allow for a faster period of understanding with high relevancy material. The ability to quickly reference data will help to build an informed and detailed case for any future proposals on artificial gravity. This also prevents the need to spend many hours searching for relevant documentation, allowing for more time to be dedicated to the creation process. The project has successfully met expectations and is continuing to add pertinent documentation. Current research shows great potential for artificial gravity as a countermeasure on long duration missions. The gravity like forces created in an artificial gravity ship could help to prevent serious problems such as muscle loss, bone fractures, vision loss due to increased intracranial pressure, and would allow for transition to other gravity environments with little to no recovery period. These conditions are highly favorable for long duration missions as current mitigation methods have yet to be proven beyond one year in space and often only slow symptoms instead of preventing them.

Alice Elberfeld↗
NASA NTRS2020

Quantitative Magnetic Resonance Image Assessment of the Optic Nerve and Surrounding Sheath after Spaceflight

A subset of long-duration spaceflight astronauts have experienced ophthalmic abnormalities, collectively termed spaceflight-associated neuro-ocular syndrome (SANS). Little is understood about the pathophysiology of SANS; however, microgravity-induced alterations in intracranial pressure (ICP) due to headward fluid shifts is the primary hypothesized contributor. In particular, potential changes in optic nerve (ON) tortuosity and ON sheath (ONS) distension may indicate altered cerebrospinal fluid dynamics during weightlessness. The present longitudinal study aims to provide a quantitative analysis of ON and ONS cross-sectional areas, and ON deviation, an indication of tortuosity, before and after spaceflight. Ten astronauts undergoing ~6-month missions on the International Space Station (ISS) underwent high-resolution magnetic resonance imaging (MRI) preflight and at five recovery timepoints extending to 1 year after return from the ISS. The mean changes in ON deviation, ON cross-sectional area, and ONS cross-sectional area immediately post flight were−0.14 mm (95% CI:−0.36 to 0.08, Bonferroni-adjusted P=1.00), 0.13 mm2(95% CI−0.66 to 0.91, Bonferroni-adjusted P=1.00), and−0.22 mm2(95% CI:−1.78 to 1.34, Bonferroni-adjusted P=1.00), respectively, and remained consistent during the recovery period. Terrestrially, ONS distension is associated with increased ICP; therefore, these results suggest that, on average, ICP was not pathologically elevated immediately after spaceflight. However, a subject diagnosed with optic disc edema (Frisen Grade 1, right eye) displayed increased ONS area post flight, although this increase is relatively small compared to clinical populations with increased ICP. Advanced quantitative MRI-based assessment of the ON and ONS could help our understanding of SANS and the role of ICP.

Jesse Rohr↗
NASA NTRS1996

Cardiovascular adaptation to spaceflight

This article reviews recent flight and ground-based studies of cardiovascular adaptation to spaceflight. Prominent features of microgravity exposure include loss of gravitational pressures, relatively low venous pressures, headward fluid shifts, plasma volume loss, and postflight orthostatic intolerance and reduced exercise capacity. Many of these short-term responses to microgravity extend themselves during long-duration microgravity exposure and may be explained by altered pressures (blood and tissue) and fluid balance in local tissues nourished by the cardiovascular system. In this regard, it is particularly noteworthy that tissues of the lower body (e.g., foot) are well adapted to local hypertension on Earth, whereas tissues of the upper body (e.g., head) are not as well adapted to increase in local blood pressure. For these and other reasons, countermeasures for long-duration flight should include reestablishment of higher, Earth-like blood pressures in the lower body.

Review, Tutorial↗
NASA NTRS1993

Cerebral blood flow velocity in humans exposed to 24 h of head-down tilt

This study investigates cerebral blood flow (CBF) velocity in humans before, during, and after 24 h of 6 deg head-down tilt (HDT), which is a currently accepted experimental model to simulate microgravity. CBF velocity was measured by use of the transcranial Doppler technique in the right middle cerebral artery of eight healthy male subjects. Mean CBF velocity increased from the pre-HDT upright seated baseline value of 55.5 +/- 3.7 (SE) cm/s to 61.5 +/- 3.3 cm/s at 0.5 h of HDT, reached a peak value of 63.2 +/- 4.1 cm/s at 3 h of HDT, and remained significantly above the pre-HDT baseline for over 6 h of HDT. During upright seated recovery, mean CBF velocity decreased to 87 percent of the pre-HDT baseline value. Mean CBF velocity correlated well with calculated intracranial arterial pressure (IAP). As analyzed by linear regression, mean CBF velocity = 29.6 + 0.32IAP. These results suggest that HDT increases CBF velocity by increasing IAP during several hours after the onset of microgravity. Importantly, the decrease in CBF velocity after HDT may be responsible, in part, for the increased risk of syncope observed in subjects after prolonged bed rest and also in astronauts returning to Earth.

Kawai, Y.↗
NASA NTRSDate not supplied

Intracranial Effects of Intermittent Lower Body Negative Pressure with Head Down Tilt Bed Rest: Comparison to Upright Posture

INTRODUCTION Spaceflight-associated neuro-ocular syndrome (SANS) affects a majority of astronauts during long-duration spaceflight. SANS is hypothesized to result from an unrelenting headward fluid shift that occurs in the microgravity environment. Altered intracranial structure and physiology documented in spaceflight and head-down tilt (HDT) experiments(1, 2) are also theorized to be related to chronic headward fluid shift and thereby can provide an independent quantitative assessment related to this mechanism. As a potential countermeasure, lower body negative pressure (LBNP) applied in the supine posture has shown efficacy in reducing headward fluid shift(3). However, it remains unknown if intermittent LBNP simulating daily upright posture fluid redistribution can mitigate SANS and intracranial changes associated with long-duration spaceflight. The goal of this study was to quantify the effects of daily application of LBNP or daily exposure to the upright posture on intracranial structure and physiology during long-term HDT in order to evaluate the potential efficacy of LBNP as a countermeasure to SANS. METHODS 22 healthy volunteers (11 men; 11 women; mean age = 35 years (SD=9.2)(age range = 24 to 52 years); mean BMI = 24.0 kg/m2 (SD=2.8)) completed an MRI study performed at the German Aerospace Facility in Cologne, Germany. Strict six-degree head-down tilt (HDT) bedrest was used as a spaceflight analog to induce a continuous headward fluid shift for 30 days. The subjects were divided equally into two groups of interventions: 1) LBNP for 3-hour sessions twice daily and 2) seated position for 3-hour sessions twice daily. Interventions were divided into morning and afternoon sessions for both groups. The LBNP intervention was maintained at 25 mmHg  2 mmHg. Pulse-gated MRI phase-contrast flow imaging was used to quantify cerebral artery stroke volume (CASV) and peak-to-peak cerebral spinal fluid (CSF) velocity (CSFVp-p) within the cerebral aqueduct. A 3D T1-MPRAGE sequence was used to quantify volumetric changes of the brain and intracranial CSF spaces using MRI Cloud software. MRI acquisitions were obtained at baseline (BDC, supine posture), 15 days into HDT (HDT15), 29 days into HDT (HDT29), and 12 days after recovery (R12, supine posture). The data were analyzed by a mixed model, which included intervention, time (four nominal levels BDC, HDT15, HDT29, R12), and intervention-time interaction as the fixed effects and included subject as a random effect. RESULTS Compared to BDC there was no statistically significant difference in CASV and CSFVp-p during HDT except for CASV at HDT29 (seated group) where there was a 1.7 mL (12%) decrease (P<0.01). Compared to BDC there was a statistically significant increase in intracranial volume (ICV; ICV = white matter + gray matter + CSF) for both interventions at HDT15 (Δ13 mL, 0.9 % (LBNP group); Δ15 mL, 1.0%, (seated group)) and HDT29 (Δ19 mL, 1.2%, (LBNP group); Δ23 mL, 1.5%) (seated group)) (All Ps<.001). Compared to baseline, lateral ventricular volume increased at HDT15 (Δ0.9 mL, 5.5%) and HDT29 (Δ1.8 mL, 10%)) for LBNP only (P=.001 for each). During HDT, white matter volume remained stable compared to baseline for both interventions. There were no significant intervention effects in the overall response to HDT (All Ps >.2). CONCLUSION LBNP had a similar response to the seated posture during 29 days of HDT. Although there was an increase in ICV and lateral ventricular volume with HDT there was no change in intracranial physiological parameters with LBNP suggesting an overall diminished response to the long-term effects of HDT. The lack of any significant increase in white matter volume during HDT with LBNP suggests maintenance of cerebral interstitial fluid transport. Final conclusions are pending the data collection for the control group (no intervention) which will be completed in 2023.

Larry A Kramer↗
NASA NTRS1995

Measurement of Transcranial Distance During Head-Down Tilt Using Ultrasound

Exposure to microgravity probably elevates blood pressure and flow in the head which may increase intracranial volume (ICV) and pressure (ICP). Due to the slightly compliant nature of the cranium, any increase of ICP will increase ICV and transcranial distance. We used a noninvasive ultrasound technique to measure transcranial distance (frontal to occipital) during head-down tilt. Seven subjects (ages 26-53) underwent the following tilt angles: 90 deg. upright, 30 deg., 0 deg., -6 deg., -10 deg., -6 deg., 0 deg., 30 deg., and 90 deg. Each angle was maintained for 1 min. Ultrasound wave frequency was collected continuously and transcranial distance was calculated (Delta(x) = x(Delta)f/f, where x is path length and f is frequency of the wave) for each tilt angle. Frequency decreased from 503.687 kHz (90 deg. upright) to 502.619 kHz (-10 deg.). These frequencies translated to an increased transcranial distance of 0.403 mm. Although our data suggest a significant increase in transcranial distance during head-down tilt, this apparent increase may result, in part, from head-down tilt-induced subcutaneous edema or cutaneous blood volume elevation. In three subjects, when the above protocol was repeated with an ace bandage wrapped around the head to minimize such edema, the increased transcranial distance from 90 deg. to -10 deg. was reduced by 0.174 mm. Further development of the technique to quantify bone-to-bone expansion unconfounded by cutaneous fluid is necessary. Therefore, this ultrasound technique may provide measurements of changes in cranial dimensions during microgravity.

Torikoshi, Shigeyo↗
NASA NTRS2017

Advancing Translational Space Research Through Biospecimen Sharing: Amplifying the Impact of Ground-Based Studies

Biospecimen Sharing Programs (BSPs) have been organized by NASA Ames Research Center since the 1960s with the goal of maximizing utilization and scientific return from rare, complex and costly spaceflight experiments. BSPs involve acquiring otherwise unused biological specimens from primary space research experiments for distribution to secondary experiments. Here we describe a collaboration leveraging Ames expertise in biospecimen sharing to magnify the scientific impact of research informing astronaut health funded by the NASA Human Research Program (HRP) Human Health Countermeasures (HHC) Element. The concept expands biospecimen sharing to one-off ground-based studies utilizing analogue space platforms (e.g., Hind limb Unloading (HLU), Artificial Gravity) for rodent experiments, thereby significantly broadening the range of research opportunities with translational relevance for protecting human health in space and on Earth. In this presentation, we will report on biospecimens currently being acquired from HHC Award Head-Down Tilt as a Model for Intracranial and Intraocular Pressures, and Retinal Changes during Spaceflight, and their availability. The BSP add-on to the project described herein has already yielded for HHC-funded investigators more than 4,700 additional tissues that would otherwise have been discarded as waste, with additional tissues available for analysis. Young (3-mo old) male and female rats and Older (9-mo old) male rats are being exposed to HLU for either 7, 14, 28, or 90 days. Additional groups are exposed to 90 days of unloading followed by either 7, 14, 28 days or 90 days of recovery (normal loading). Comparisons are made with non-suspended controls. Unused tissues are: Skin, Lungs, Thymus, Adrenals, Kidneys, Spleen, Hindlimb Muscles (Soleus, Extensor Digitorum Longus, Tibialis Anterior, Plantaris Gastrocnemius), Fat Pads, Reproductive Organs, and Intestines. Tissues are harvested, weighed, preserved then archived (with metadata) using a sample tracking system (CryoTrack). Preservation techniques include snap-freezing and RNALatersnap-freezing. Specimens were weighed at the time of dissection, and organ mass: body mass ratios analyzed to determine unloading effects across conditions and durations. The results corroborate previously reported effects of short-term exposure to microgravity or unloading exposure on various organs, and provide new insights into adaptation to long-duration unloading relevant to sustained spaceflight exposures on ISS. Supported by the Human Research Program (HRP) Human Health Countermeasures (HHC) Element and NASA Grant NNX13AD94G (CAF).

rodent↗
NASA NTRS2017

Advancing Translational Space Research Through Biospecimen Sharing: Amplified Impact of Studies Utilizing Analogue Space Platforms

Biospecimen Sharing Programs (BSPs) have been organized by NASA Ames Research Center since the 1960s with the goal of maximizing utilization and scientific return from rare, complex and costly spaceflight experiments. BSPs involve acquiring otherwise unused biological specimens from primary space research experiments for distribution to secondary experiments. Here we describe a collaboration leveraging Ames expertise in biospecimen sharing to magnify the scientific impact of research informing astronaut health funded by the NASA Human Research Program (HRP) Human Health Countermeasures (HHC) Element. The concept expands biospecimen sharing to one-off ground-based studies utilizing analogue space platforms (e.g., Hindlimb Unloading (HLU), Artificial Gravity) for rodent experiments, thereby significantly broadening the range of research opportunities with translational relevance for protecting human health in space and on Earth. In this presentation, we will report on biospecimens currently being acquired from HHC Award Head-Down Tilt as a Model for Intracranial and Intraocular Pressures, and Retinal Changes during Spaceflight, and their availability. The BSP add-on to the project described herein has already yielded for HHC-funded investigators more than 4,700 additional tissues that would otherwise have been discarded as waste, with additional tissues available for analysis. Young (3-mo old) male and female rats and Older (9-mo old) male rats are being exposed to HLU for either 7, 14, 28, or 90 days. Additional groups are exposed to 90 days of unloading followed by either 7, 14, 28 days or 90 days of recovery (normal loading). Comparisons are made with non-suspended controls. Unused tissues are: Skin, Lungs, Thymus, Adrenals, Kidneys, Spleen, Hindlimb Muscles (Soleus, Extensor Digitorum Longus, Tibialis Anterior, Plantaris Gastrocnemius), Fat Pads, Reproductive Organs, and Intestines. Tissues are harvested, weighed, preserved then archived (with metadata) using a sample tracking system (CryoTrack). Preservation techniques include snap-freezing and RNALatersnap-freezing. Specimens were weighed at the time of dissection, and organ mass:body mass ratios analyzed to determine unloading effects across conditions and durations. The results corroborate previously reported effects of short-term exposure to microgravity or unloading exposure on various organs, and provide new insights into adaptation to long-duration unloading relevant to sustained spaceflight exposures on ISS.

biospecimen sharing↗
NASA NTRS1992

Mechanism of delayed intracranial hypertension after cerebroventricular infusions in conscious rats

Prior studies showed that cerebroventricular infusions of artificial cerebrospinal fluid, 8 microliter/min for 10 min, followed by a 10 min rest and a 24 h infusion of 0.5 microliters/min, raised cerebrospinal fluid pressure (CSFp) of conscious, unrestrained rats after about 2 h. Here, we report that the 10 min infusion alone evoked a delayed, prolonged rise in CSFp. Pressure during the infusion itself rose and recovered quickly, as is usually reported. Pressure/volume tests, used to calculate resistance to outflow (Ro) and compliance (C), revealed that infusions increased Ro and decreased C, after a delay (P less than 0.05). The rise in CSFp after infusion was blocked by pretreatment with acetazolamide + ouabain (P less than 0.05), but the delayed changes in Ro and C were unaffected. We suggest that the 10 min infusion of a sterile, balanced salt solution has a primary effect that increases Ro; as CSF synthesis continues, C is exhausted and the delayed rise in CSFp ensues. This non-traumatic method of raising CSFp may be a useful method to study intracranial fluid dynamics.

NASA Center ARC↗
NASA NTRSDate not supplied

Space-Cent: Studying the Physiological and Anatomical Effects of Centrifugation and Head Down Tilt: 2021 Update

BACKGROUND The objective of this study was to evaluate the cerebral and ocular physiological and anatomical effects of head-down tilt bedrest (HDBR) with and without daily artificial gravity (AG) in healthy subjects to provide novel insights into possible countermeasures for the Spaceflight Associated Neuro-ocular Syndrome (SANS). Previous long-term studies using the spaceflight analog of strict 6° HDBR for 30 days revealed changes in ocular structure, including optic disc edema. The effects of an AG countermeasure using intermittent centrifugation to restore upright hydrostatic gradients and reduce the ocular and brain anatomical effects has not been explored. METHODS The effects of 60-day exposure to simulated microgravity (6° HDBR) on the cerebral, ocular and vestibular systems with and without the intervention of daily 30 minute exposure to AG (short-arm centrifugation) was evaluated in 24 healthy subjects. Non-invasive measurements of cerebral blood flow, intracranial blood volume (near infrared spectroscopy, NIRS), cerebral and ocular structure (MRI and optical coherence tomography), internal jugular vein area (ultrasound), lateral ventricular volumes (MRI), intraocular pressure, and sensorimotor/vestibular (i.e. balance and coordination) systems were made during various time-points during the bedrest study. Additional measures with ultrasound and NIRS were made during centrifugation. RESULTS The study began in Spring 2019 and all 24 subjects completed the testing by end of 2019. Data analysis continues. We report the following updated results for 2021. MRI showed significant decreases in carotid artery flow, increases in brain and CSF volumes, and aqueductal flow velocities in all subjects in HDT compared to baseline supine, but no effects of the short duration AG. All groups showed increased posterior globe flattening during bedrest compared to baseline, without protection from AG. As previously reported we observed chorioretinal folds for the first time in a bedrest analog, as well as optic disc edema, with no protection from the short-term AG. Data from the study is now being transmitted to the NASA LSDA which will allow for future research. CONCLUSIONS The 6 degree HDBR analog produced significant changes in the anatomical and physiological functions of the brain and eye in healthy subjects. Daily 30 minute exposure to AG with short-arm centrifugation had significant transient effects on physiology of the cerebrovascular system, but was not sufficient to prevent the anatomical effects of HDBR on the brain and eye.

E M Bershad↗
NASA NTRS1992

Resistance to outflow of cerebrospinal fluid after central infusions of angiotensin

Infusions of artificial cerebrospinal fluid (CSF) into the cerebroventricles of conscious rats can raise CSF pressure (CSFp). This response can be modified by some neuropeptides. One of these, angiotensin, facilitates the rise in CSFp. We measured CSFp in conscious rats with a computerized system and evaluated resistance to CSF outflow during infusion of artificial CSF, with or without angiotensin, from the decay kinetics of superimposed bolus injections. Angiotensin (10 ng/min) raised CSFp (P less than 0.05) compared with solvent, but the resistance to CSF outflow of the two groups was similar (P greater than 0.05). Because CSFp was increased by angiotensin without an increase in the outflow resistance, a change in some volume compartment is likely. Angiotensin may raise CSFp by increasing CSF synthesis; this possibility is supported, since the choroid plexuses contain an intrinsic isorenin-angiotensin system. Alternatively, angiotensin may dilate pial arteries, leading to an increased intracranial blood volume.

NASA Discipline Cardiopulmonary↗
NASA NTRS2012

Comparison of Ocular Outcomes in Two 14-Day Bed Rest Studies

Reports of astronauts' visual changes have raised concern about ocular health during long-duration spaceflight. Some of these findings include globe flattening with hyperopic shifts, choroidal folds, optic disc edema, retinal nerve fiber layer (RNFL) thickening, and cotton wool spots. While the etiology remains unknown, it is hypothesized that, in predisposed individuals, hypertension in the brain may follow cephalad fluid shifts during spaceflight. This possible mechanism of ocular changes may also apply to analogous cases of idiopathic intracranial hypertension (IIH) or pseudotumor cerebri on Earth patients. Head-down t ilt (HDT) bed rest is a spaceflight analog that induces cephalad fluid shifts. Previous studies of the HDT position demonstrated body fluid shifts associated with changes in intraocular pressure (IOP) but the conditions of bed rest varied among experiments, making it difficult to compare data and draw conclusions. For these reasons, vision evaluation of bed rest subjects was implemented for NASA bed rest studies since 2010, in an attempt to monitor vision health in subjects subjected to bed rest. Vision monitoring is thus currently performed in all NASA-conducted bed rest campaigns

Cromwell, Ronita L.↗
DOE OSTI2020

A Phenomenological Model for Cavitation

A phenomenological model of cavitation is presented, based on observations that both large relative negative pressures and large negative time derivatives of pressure are required for cavitation onset. We simulated two cavitation experiments to generate cavitation scaling parameters for relative pressure drop and rate of pressure drop. Our results show the model, while simple, is effective at reproducing results from laboratory experiments of cavitation. The parameters were then used in conjunction with a human surrogate computational model to predict, at any position within the head, the probability of intracranial cavitation caused by exposure to a blast event. The results suggest that the magnitude of blast overpressure observed in field data is sufficient to cause intracranial cavitation. Our analysis indicates that the helmeted head, when compared to the unhelmeted head configuration, results in a decrease but not elimination of cavitation exposure. When density functions of cavitation probability versus cumulative brain volume are combined with an injury severity model, the results show helmet efficacy at low and moderate risk levels. However, the convergence of unhelmeted and helmeted probability density functions at high-to-excessive risk thresholds indicates the helmet offers diminishing protection at elevated exposure levels, relative to the unhelmeted baseline. Future investigation and collaboration with neuroscience subject matter experts are needed to contextualize the current computational results. While the present work contributes specific and quantified predictions of intracranial cavitation location and severity, more research is required to apply our results to clinical settings with population-based brain injury subjects and controls. The relationship between our intracranial cavitation predictions with their anticipated clinical sequelae remains a topic in need of exploration.

60 APPLIED LIFE SCIENCES↗