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All sourcesNASA NTRSDOE OSTI
NASA NTRS2007

Renal Stone Risk During Space Flight: Assessment and Countermeasure Validation

NASA has focused its future on exploration class missions including the goal of returning to the moon and landing on Mars. With these objectives, humans will experience an extended exposure to the harsh environment of microgravity and the associated negative effects on all the physiological systems of the body. Exposure to microgravity affects human physiology and results in changes to the urinary chemical composition during and after space flight. These changes are associated with an increased risk of renal stone formation. The development of a renal stone would have health consequences for the crewmember and negatively impact the success of the mission. As of January 2007, 15 known symptomatic medical events consistent with urinary calculi have been experienced by 13 U.S. astronauts and Russian cosmonauts. Previous results from both MIR and Shuttle missions have demonstrated an increased risk for renal stone formation. These data have shown decreased urine volume, urinary pH and citrate levels and increased urinary calcium. Citrate, an important urinary inhibitor of calcium-containing renal stones binds with calcium in the urine, thereby reducing the amount of calcium available to form calcium oxalate stones. Urinary citrate also prevents calcium oxalate crystals from aggregating into larger crystals and into renal stones. In addition, citrate makes the urine less acidic which inhibits the development of uric acid stones. Potassium citrate supplementation has been successfully used to treat patients who have formed renal stones. The evaluation of potassium citrate as a countermeasure has been performed during the ISS Expeditions 3-6, 8, 11-13 and is currently in progress during the ISS Expedition 14 mission. Together with the assessment of stone risk and the evaluation of a countermeasure, this investigation provides an educational opportunity to all crewmembers. Individual urinary biochemical profiles are generated and the risk of stone formation is estimated. Increasing fluid intake is recommended to all crewmembers. These results can be used to lower the risk for stone formation through lifestyle, diet changes or therapeutic administration to minimize the risk for stone development. With human presence in microgravity a continuing presence and exploration class missions being planned, maintaining the health and welfare of all crewmembers is critical to the exploration of space.

Whitson, P. A.↗
NASA NTRS2007

Sensitive Quantitative Assessment of Balance Disorders

Computerized dynamic posturography (CDP) has become a standard technique for objectively quantifying balance control performance, diagnosing the nature of functional impairments underlying balance disorders, and monitoring clinical treatment outcomes. We have long used CDP protocols to assess recovery of sensory-motor function in astronauts following space flight. The most reliable indicators of post-flight crew performance are the sensory organization tests (SOTs), particularly SOTs 5 and 6, which are sensitive to changes in availability and/or utilization of vestibular cues. We have noted, however, that some astronauts exhibiting obvious signs of balance impairment after flight are able to score within clinical norms on these tests, perhaps as a result of adopting competitive strategies or by their natural skills at substituting alternate sensory information sources. This insensitivity of the CDP protocol could underestimate of the degree of impairment and, perhaps, lead to premature release of those crewmembers to normal duties. To improve the sensitivity of the CDP protocol we have introduced static and dynamic head tilt SOT trials into our protocol. The pattern of postflight recovery quantified by the enhanced CDP protocol appears to more aptly track the re-integration of sensory-motor function, with recovery time increasing as the complexity of sensory-motor/biomechanical task increases. The new CDP protocol therefore seems more suitable for monitoring post-flight sensory-motor recovery and for indicating to crewmembers and flight surgeons fitness for return to duty and/or activities of daily living. There may be classes of patients (e.g., athletes, pilots) having motivation and/or performance characteristics similar to astronauts whose sensory-motor treatment outcomes would also be more accurately monitored using the enhanced CDP protocol. Furthermore, the enhanced protocol may be useful in early detection of age-related balance disorders.

Paloski, Willilam H.↗
NASA NTRS1978

Infant Transport Monitoring

The photo sequence illustrates the movement of an ill infant to a special care hospital by means of a new Pediatric Monitoring and Transport System, in which NASA technology and technical assistance are being applied to an urgent medical problem. Development of the system is a collaborative effort involving several organizations, principally, NASA Ames Research Center and Children's Hospital Medical Center, Oakland, California. Key to the system's efficacy is a custom-designed ambulance-to-hospital and hospital-to-hospital communications network, including two-way voice capability and space-derived biotelemetry; it allows a specialist at the destination hospital to monitor continuously the vital signs of the patient during transit.

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NASA NTRS1979

Cancer Therapy

The patient shown is undergoing cancer radiation treatment in a hospital-like atmosphere but he is not in a hospital. The treatment room is at NASA's Lewis Research Center, Cleveland, Ohio. It is a converted portion of the Center's cyclotron facility, originally designed for radiation studies related to nuclear propulsion for aircraft and spacecraft. Under an agreement between the Center and the Cleveland Clinic Foundation, the 50 million volt cyclotron is now being used to evaluate the effectiveness of "fast neutron" therapy in the treatment of cancerous tumors.

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NASA NTRS1977

Help for Crippled Children

Children with cerebral palsy have nervous system defects which lead to muscular spasticity and loss of coordination. Many of these children have great difficulty walking because certain muscles are in a constant state of contraction. Surgical techniques can lengthen muscles or tendons to improve the child's walking pattern, but it is vital to diagnose accurately the particular spasticity problem of each patient; the individual muscles causing the handicap vary greatly from child to child. It is difficult by physical examination alone to determine precisely which muscle groups are most involved. Biotelemetry has provided a solution. For the past two years, the Children's Hospital at Standord, assisted by NASA and the Stanford Biomedical Application Team, has been applying biotelemetry to the cerebral palsy problem.

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NASA NTRS1977

Cataract Surgery Tool

The NASA-McGannon cataract surgery tool is a tiny cutter-pump which liquefies and pumps the cataract lens material from the eye. Inserted through a small incision in the cornea, the tool can be used on the hardest cataract lens. The cutter is driven by a turbine which operates at about 200,000 revolutions per minute. Incorporated in the mechanism are two passages for saline solutions, one to maintain constant pressure within the eye, the other for removal of the fragmented lens material and fluids. Three years of effort have produced a design, now being clinically evaluated, with excellent potential for improved cataract surgery. The use of this tool is expected to reduce the patient's hospital stay and recovery period significantly.

Source record↗
NASA NTRS1977

Innovations in Medicine

NASA is planning now toward the day of long-duration flight-manned interplanetary missions for example-wherein routine health care and emergency treatment must be accomplished on-board the spacecraft over periods of months or perhaps even years. Since spacecraft design limits crew size, the medical assignment may be handled by a single astronaut-physician or by a crew member trained as a physician's assistant. In a space emergency demanding surgery, for instance, sophisticated communications equipment, backed by a computerized data processing system, would make it possible for a surgeon on Earth to "examine" the patient. He could study X-rays and other data, specify an in-flight surgical procedure, and guide the astronaut-medic step-by-step through the operation. Such a system is being evaluated now. It is called STARPAHC (Space Technology Applied to Rural Papago Health Care). NASA technology in space communications and data processing is being applied to remote health services for the Papago tribe. STARPAHC is administered by the NASA Life Sciences Directorate in the Office of Space Sciences. It is a joint program involving NASA's Johnson Space Center, the Indian Health Service of the Department of Health, Education & Welfare, and the Papago's Executive Health Council. Lockheed Missiles & Space Co. is NASA's systems support contractor.

Source record↗
NASA NTRS2007

New and Improved T-wave Morphology Parameters to Differentiate Healthy Individuals from those with Cardiomyopathy and Coronary Artery Disease

We investigated the ability of several known as well as new ECG repolarization parameters to differentiate healthy individuals from patients with obstructive coronary artery disease (CAD) and cardiomyopathy (CM). Advanced high-fidelity 12-lead ECG tests (approx. 5-min supine) were first performed on a "training set" of 99 individuals: 33 with ischemic or dilated CM and low ejection fraction (EF less than 40%); 33 with catheterization-proven obstructive CAD but normal EF; and 33 age-/gender-matched healthy controls. The following multiple parameters of T-wave morphology (TWM) were derived via signal averaging and singular value decomposition (SVD, which yields 8 eigenvalues, rho(sub 1) greater than rho(sub 2)...greater than rho(sub 8) and studied for their retrospective accuracy in detecting underlying disease: 1) Principal component analysis ratio of the T wave (T-PCA) = 100*rho(sub 2)/rho(sub 1); 2) Relative T-wave residuum (rTWR) = 100* SIGMA (rho(sub 4)(sup 2) +...+ rho(sub 8)(sup 2)); 3) Modified complexity ratio of the T wave (T-mCR) = 100*SIGMA(rho(sub 3)(sup 2) +...+rho(sb 8) (sup 2)); and 4) Normalized 3-dimensional volume of the T wave (nTV) = 100*(rho(sub 2)*rho(sub 3)/rho(sub 1)(sup 2). All TWM parameters significantly differentiated CAD from controls (p less than 0.0001), and also CM from controls (p less than 0.0001). Retrospective areas under the ROC curve were 0.77, 0.81, 0.82, and 0.83 (CAD vs. controls) and 0.93, 0.89, 0.95 and 0.96 (CM vs. controls) for T-PCA, rTWR, T-mCR and nTV respectively. The newer TWM parameters (T-mCR and nTV) thus outperformed the more established parameters (T-PCA and rTWR), presumably by putting a greater emphasis on the third T-wave eigenvalue, which in most healthy subjects has little energy compared to the first two eigenvalues. Subsequent prospective analyses have also yielded similar results, such that we conclude that diagnostic differentiation of pathology from non-pathology may be especially aided by detecting the transference of energy from the first and second T-wave eigenvalues into the third T-wave eigenvalue.

Greco, E. C.↗
NASA NTRS2007

Multi-channel System for Beat to Beat QT Interval Variability and its Use in Screening for Coronary Artery Disease and Cardiomyopathy

We investigated the ability of beat-to-beat QT interval variability (QTV) and related parameters to differentiate healthy individuals from patients with obstructive coronary artery disease (CAD) and cardiomyopathy (CM). For this purpose we developed a PC-based ECG software program that in real time, acquires, analyzes and displays QTV in each of the eight independent channels that constitute the 12-lead conventional ECG. The system also analyzes and displays the QTV from QT interval signals that are derived from multiple channels and from singular value decomposition (SVD) to substantially reduce the effect of noise and other artifacts on the QTV results. It also provides other useful SVD-related parameters such as the normalized 3-dimensional volume of the T wave (nTV) = 100*(rho(sub 2)*rho(sub 3)rho(sub 1^2). Advanced high-fidelity 12-lead ECG tests (approx. 5-min supine) were first performed on a "training set" of 99 individuals: 33 with ischemic or dilated CM and low ejection fraction (EF less than 40%); 33 with catheterization-proven obstructive CAD but normal EF; and 33 age-/gender-matched healthy controls. All QTV parameters that were studied for their accuracy in detecting CM and CAD significantly differentiated both CM and CAD from controls (p less than 0.0001). Retrospective areas under the ROC curve (AUC) of SDNN-QTV, rmsSD-QTV, and QTV Index (QTVI) for CM vs. controls in the lead V5 were 0.85, 0.90, and 0.99, respectively, and those for CAD vs. controls in the lead II were 0.82, 0.82, and 0.89. Other advanced ECG parameters, such as HFQRS RAZ score, LF Lomb of RRV or QRS-T angle, differentiated both CM and CAD from controls less significantly, with the respective AUC values of 0.89, 0.88 and 0.98 for CM vs. controls, and 0.73, 0.71 and 0.80 for CAD vs. controls. QTV parameters (especially QTVI, which is QTV as indexed to RRV) were, diagnostically speaking, amongst the best performing of the advanced ECG techniques studied thus far.

Starc, V.↗
NASA NTRS2007

Chromosome Aberrations in Normal and Ataxia-Telangiectasia Cells Exposed to Heavy Ions

Although cells derived from Ataxia Telangiectasia (AT) patients are known to exhibit abnormal responses to ionizing radiations, its underlying mechanism still remains unclear. Previously, the authors reported that at the same gamma-irradiation dose AT cells show higher frequencies of misrepair and deletions compared to normal human fibroblast cells. In this study, we investigated the effects of heavy ions beams on chromosomal aberrations in normal and AT cells. Normal and AT fibroblast cells arrested at G0/G1 phase were irradiated with 2 Gy of X-rays, 490 MeV/u Silicon (LET 55 keV/m), 500 MeV/u Iron (LET 185 keV/m) and 200 MeV/u Iron (LET 440 keV/m) particles, and then cells were allowed to repair for 24 hours at 37 degrees before subculture. Calyculin-A induced PCC method was employed to collect G2/M chromosomes and whole DNA probes 1 and 3 were used to analyze chromosomal aberrations such as color-junctions, deletions, simple exchanges (incomplete and reciprocal exanges) and complex-type exchanges. The percentages of aberrant cells were higher when normal and AT cells were exposed to heavy ions compared to X-rays, and had a tendency to increase with increasing LET up to 185 keV/m and then decreased at 440 keV/m. When the frequency of color-junctions per cell was compared after X-ray exposure, AT cells had around three times higher frequency of color-junctions (mis-rejoining) than normal cells. However, at 185 keV/m there was no difference in the frequency of color-junctions between two cell lines. It was also found that the frequency of simple exchanges per cell was almost constant in AT cells regardless LET levels, but it was LET dependent for normal cells. Interestingly, the frequency of simple exchanges was higher for AT cells when it was compared at 185 keV/m but AT cells had more complex-type exchanges at the same LET levels. Heavy ions are more efficient in inducing chromosome aberrations in normal and AT cells compared to X-rays, and the aberration types between normal and AT fibroblast appeared different probably due to difference in the ATM gene function.

Kawata, T.↗
NASA NTRS2007

Association between Randall's Plaque and Calcifying Nanoparticles

Randall's plaques, first described by Alexander Randall in the 1930s, are small subepithelial calcifications in the renal papillae (RP) that also extend deeply into the renal medulla. Despite the strong correlation between the presence of these plaques and the formation of renal stones, the precise origin and pathogenesis of Randall s plaque formation remain elusive. The discovery of calcifying nanoparticles (CNP) and their detection in many calcifying processes of human tissues has raised hypotheses about their possible involvement in renal stone formation. We collected RP and blood samples from 17 human patients who had undergone laparoscopic nephrectomy due to neoplasia. Homogenized RP tissues and serum samples were cultured for CNP. Scanning electron microscopy (SEM) and energy dispersive X-ray spectroscopy (EDS) analysis were performed on fixed RP samples. Immunohistochemical staining (IHS) was applied on the tissue samples using CNP-specific monoclonal antibody (mAb). Randall s plaques were visible on gross inspection in 11 out of 17 collected samples. Cultures of all serum samples and 13 tissue homogenates had CNP growth within 4 weeks. SEM revealed spherical apatite formations in 14 samples, with calcium and phosphate peaks detected by EDS analysis. IHS was positive in 9 out of 17 samples. A strong link was found between the presence of Randall s plaques and the detection of CNP, also referred to as nanobacteria. These results suggest new insights into the etiology of Randall's plaque formation, and will help us understand the pathogenesis of stone formation. Further studies on this topic may lead us to new approaches on early diagnosis and novel medical therapies of kidney stone formation.

Ciftcioglu, Neva↗
NASA NTRS2007

Simulated Microgravity Regulates Gene Transcript Profiles of 2T3 Preosteoblasts: Comparison of the Random Positioning Machine and the Rotating Wall Vessel Bioreactor

Microgravity of spaceflight induces bone loss due in part to decreased bone formation by osteoblasts. We have previously examined the microgravity-induced changes in gene expression profiles in 2T3 preosteoblasts using the Random Positioning Machine (RPM) to simulate microgravity conditions. Here, we hypothesized that exposure of preosteoblasts to an independent microgravity simulator, the Rotating Wall Vessel (RWV), induces similar changes in differentiation and gene transcript profiles, resulting in a more confined list of gravi-sensitive genes that may play a role in bone formation. In comparison to static 1g controls, exposure of 2T3 cells to RWV for 3 days inhibited alkaline phosphatase activity, a marker of differentiation, and downregulated 61 genes and upregulated 45 genes by more than two-fold as shown by microarray analysis. The microarray results were confirmed with real time PCR for downregulated genes osteomodulin, bone morphogenic protein 4 (BMP4), runx2, and parathyroid hormone receptor 1. Western blot analysis validated the expression of three downregulated genes, BMP4, peroxiredoxin IV, and osteoglycin, and one upregulated gene peroxiredoxin I. Comparison of the microarrays from the RPM and the RWV studies identified 14 gravi-sensitive genes that changed in the same direction in both systems. Further comparison of our results to a published database showing gene transcript profiles of mechanically loaded mouse tibiae revealed 16 genes upregulated by the loading that were shown to be downregulated by RWV and RPM. These mechanosensitive genes identified by the comparative studies may provide novel insights into understanding the mechanisms regulating bone formation and potential targets of countermeasure against decreased bone formation both in astronauts and in general patients with musculoskeletal disorders.

Patel, Mamta J.↗
NASA NTRS2007

Translational Research from an Informatics Perspective

Clinical and translational research (CTR) is an essential part of a sustainable global health system. Informatics is now recognized as an important en-abler of CTR and informaticians are increasingly called upon to help CTR efforts. The US National Institutes of Health mandated biomedical informatics activity as part of its new national CTR grant initiative, the Clinical and Translational Science Award (CTSA). Traditionally, translational re-search was defined as the translation of laboratory discoveries to patient care (bench to bedside). We argue, however, that there are many other kinds of translational research. Indeed, translational re-search requires the translation of knowledge dis-covered in one domain to another domain and is therefore an information-based activity. In this panel, we will expand upon this view of translational research and present three different examples of translation to illustrate the point: 1) bench to bedside, 2) Earth to space and 3) academia to community. We will conclude with a discussion of our local translational research efforts that draw on each of the three examples.

Bernstam, Elmer↗
NASA NTRS2007

Clinical Space Medicine Products as Developed by the Medical Operations Support Team (MOST)

Medical Operations Support Team (MOST) is introducing/integrating teaching practices associated with high fidelity human patient simulation into the NASA culture, in particular, into medical training sessions and medical procedure evaluations. Current/Future Products iclude: a) Development of Sub-optimal Airway Protocols for the International Space Station (ISS) using the ILMA; b) Clinical Core Competency Training for NASA Flight Surgeons (FS); c) Post-Soyuz Landing Clinical Training for NASA FS; d) Experimental Integrated Training for Astronaut Crew Medical Officers and NASA FS; and e) Private Clinical Refresher Training.

Polk, James D.↗
NASA NTRS2007

Association between Randall's Plaque and Calcifying Nanoparticles

Randall initially described calcified subepithelial papillary plaques, which he hypothesized as nidi for kidney stone formation. The discovery of calcifying nanoparticles (CNP) in many calcifying processes of human tissues has raised another hypothesis about their possible involvement in urinary stone formation. This research is the first attempt to investigate the potential association of these two hypotheses. We collected renal papilla and blood samples from 17 human patients who had undergone laparoscopic nephrectomy due to neoplasia. Immunohistochemical staining (IHS) was applied on the tissue samples using monoclonal antibody 8D10 (mAb) against CNP. Homogenized papillary tissues and serum samples were cultured for CNP. Scanning electron microscopy (SEM) and energy dispersive X-ray spectroscopy (EDS) analysis were performed on fixed papillary samples. Randall's plaques were visible on gross inspection in 11 out of 17 collected samples. IHS was positive for CNP antigen in 8 of these 11 visually positive samples, but in only 1 of the remaining 6 samples. SEM revealed spherical apatite formations in 14 samples, all of which had calcium and phosphate peaks detected by EDS analysis. From this study, there was some evidence of a link between the presence of Randall's plaques and the detection of CNP, also referred to as nanobacteria. Although causality was not demonstrated, these results suggest that further studies with negative control samples should be made to explore the etiology of Randall's plaque formation, thus leading to a better understanding of the pathogenesis of stone formation.

Citfcioglu, Neva↗
NASA NTRS2007

Subclinical Shed of Infectious Varicella zoster Virus in Astronauts

Aerosol borne varicella zoster virus (VZV) enters the nasopharynx and replicates in tonsillar T-cells, resulting in viremia and varicella (chickenpox). Virus then becomes latent in cranial nerve, dorsal root and autonomic nervous system ganglia along the entire neuraxis (1). Decades later, as cell-mediated immunity to VZV declines (4), latent VZV can reactivate to produce zoster (shingles). Infectious VZV is present in patients with varicella or zoster, but shed of infectious virus in the absence of disease has not been shown. We previously detected VZV DNA in saliva of astronauts during and shortly after spaceflight, suggesting stress induced subclinical virus reactivation (3). We show here that VZV DNA as well as infectious virus in present in astronaut saliva. VZV DNA was detected in saliva during and after a 13-day spaceflight in 2 of 3 astronauts (Fig. panel A). Ten days before liftoff, there was a rise in serum anti-VZV antibody in subjects 1 and 2, consistent with virus reactivation. In subject 3, VZV DNA was not detected in saliva, and there was no rise in anti-VZV antibody titer. Subject 3 may have been protected from virus reactivation by having zoster <10 years ago, which provides a boost in cell-medicated immunity to VZV (2). No VZV DNA was detected in astronaut saliva months before spaceflight, or in saliva of 10 age/sex-matched healthy control subjects sampled on alternate days for 3 weeks (88 saliva samples). Saliva taken 2-6 days after landing from all 3 subjects was cultured on human fetal lung cells (Fig. panel B). Infectious VZV was recovered from saliva of subjects 1 and 2 on the second day after landing. Virus specificity was confirmed by antibody staining and DNA analysis which showed it to be VZV of European descent, common in the US (5). Further, both antibody staining and DNA PCR demonstrated that no HSV-1 was detected in any infected culture. This is the first report of infectious VZV shedding in the absence of clinical disease. Spaceflight presents a uniquely stressful environment which includes physical isolation and confinement, anxiety, sleep deprivation, as well as exposure to increased radiation and microgravity. It is interesting that in our study, VZV and not HSV-1 reactivation was detected, since stress-induced HSV-1 reactivation has been reported (6). Future studies are needed to determine the specific inducer of VZV reactivation.

Cohrs, Randall J.↗
NASA NTRS2007

The Use of GIS and Remotely Sensed Data in Environmental Public Health Tracking (EPHT): The HELIX-Atlanta Experience

As part of the National Environmental Public Health Tracking Network (EPHTN), the National Center for Environmental Health (NCEH) at the Centers for Disease Control and Prevention (CDC) is leading a project in collaboration with the NASA Marshall Space Flight Center (NASA/MSFC) called Health and Environment Linked for Information Exchange (HELIX-Atlanta). HELIX-Atlanta's goal is to examine the feasibility of building an integrated electronic health and environmental data network in five counties of metropolitan Atlanta, GA. Under HELIX-Atlanta, pilot projects are being conducted to develop methods to characterize exposure; link health and environmental data; analyze the relationship between health and environmental factors; and communicate findings. There is evidence in the research literature that asthmatic persons are at increased risk of developing asthma exacerbations with exposure to environmental factors, including PM(sub 2.5). Thus, HELIX-Atlanta is focusing on methods for characterizing population exposure to PM(sub 2.5) for the Atlanta metropolitan area that could be used in ongoing surveillance. NASA/MSFC is working with CDC to combine NASA earth science satellite observations related to air quality and environmental monitoring data to model surface estimates of fine particulate matter (PM(sub 2.5)) concentrations in a Geographic Information System (GIS) that can be linked with clinic visits for asthma on the aggregated grid level as well as the individual level at the geographic locations of the patients' residences.

Al-Hamdan, Mohammad Z.↗
NASA NTRS2006

Comparison of Bystander Cardiopulmonary Resuscitation (BCPR) Performance in the Absence and Presence of Timing Devices for Coordinating Delivery of Ventilatory Breaths and Cardiac Compressions in a Model of Adult Cardiopulmonary Arrest

Astronaut crew medical officers (CMO) aboard the International Space Station (ISS) receive 40 hours of medical training during the 18 months preceding each mission. Part of this training ilncludes twoperson cardiopulmonary resuscitation (CPR) per training guidelines from the American Heart Association (AHA). Recent studies concluded that the use of metronomic tones improves the coordination of CPR by trained clinicians. Similar data for bystander or "trained lay people" (e.g. CMO) performance of CPR (BCPR) have been limited. The purpose of this study was to evailuate whether use of timing devices, such as audible metronomic tones, would improve BCPR perfomance by trained bystanders. Twenty pairs of bystanders trained in two-person BCPR performled BCPR for 4 minutes on a simulated cardiopulmonary arrest patient using three interventions: 1) BCPR with no timing devices, 2) BCPR plus metronomic tones for coordinating compression rate only, 3) BCPR with a timing device and metronome for coordinating ventilation and compression rates, respectively. Bystanders were evaluated on their ability to meet international and AHA CPR guidelines. Bystanders failed to provide the recommended number of breaths and number of compressions in the absence of a timing device and in the presence of audible metronomic tones for only coordinating compression rate. Bystanders using timing devices to coordinate both components of BCPR provided the reco number of breaths and were closer to providing the recommended number of compressions compared with the other interventions. Survey results indicated that bystanders preferred to use a metronome for delivery of compressions during BCPR. BCPR performance is improved by timing devices that coordinate both compressions and breaths.

Hurst, Victor, IV↗