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1Department of Radiation Medicine, Radiobiology Program, and 2Department of Microbiology and Molecular Genetics, Loma Linda University School of Medicine and Medical Center, Loma Linda, California 92354
Submitted 5 December 2003 ; accepted in final form 9 February 2004
| ABSTRACT |
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increased, whereas interferon-
decreased. These findings, although not identical to those reported for spaceflight, indicate that altered gravity can influence both hematological and functional variables that may translate into serious health consequences during extended missions. centrifugation; immune; cytokine; erythrocyte
The spaceflight environment includes at least three factors that likely influence immunity. These include mission-related psychological stress, low-dose-to-low-dose rate radiation, and changes in inertial condition (i.e., microgravity and hypergravity) (43, 54). In the worst case, these environmental factors might act synergistically, compromising the ability of astronauts to mount an immune response to infection and possibly other diseases (18, 54). Clearly, the influence of the spaceflight environment, as well as any potential synergy between the various factors inherent to that environment, must be carefully considered when coordinating long-term missions (i.e., Mars or Lunar missions, International Space Station).
Despite the important pioneering work of earlier investigators, scientifically relevant and consistent immunological data are somewhat limited. However, there have been reports of spaceflight-induced changes noted in total body mass (1, 7, 9, 16, 43, 55, 59), thymus and spleen mass (16, 43), circulating corticosterone (7, 59), mitogen-induced lymphocyte proliferation (7, 28, 49), cytokine production and reactivity (16, 28, 31), and lymphocyte subpopulations (2, 22, 42, 43, 48, 49).
Due to the logistic difficulties involved and limited opportunity for these experiments, ground-based models have been developed to simulate many aspects of spaceflight. For example, low-dose-to-low-dose rate irradiation has been used to model the spaceflight radiation environment. The present investigators have demonstrated with C57BL/6 mice that low-dose radiation can also have dramatic short- and long-term effects on immunity. Low-dose
-ray (20, 40), proton (15, 17, 38, 39, 41), iron, and silicon ion (21) irradiation can have profound effects on immune parameters.
In the present study, the purpose was to model chronic changes in the inertial environment (as opposed to acute loads such as launch and landing) by using centrifugation. The early time points (days 17) were meant to explore the adaptation phase that astronauts undoubtedly experience soon after launch. Ideally, this study would be conducted in true spaceflight "microgravity." However, given the constraints of spaceflight research, we chose to use centrifugation to model a similar, although not identical, change in the gravitational environment.
To date, there have been very few reports on the effects of centrifugation on immunity in vivo. Sonnenfeld et al. (50) found no significant difference in response of bone marrow cells from control rats and rats continuously exposed to 2 G for 14 days when the cells were incubated with granulocyte-monocyte colony-stimulating factor. In the same study, little or no significant change was noted in leukocytes from bone marrow and spleen, based on expression of surface markers for T, B, and natural killer cells and IL-2 receptor. The investigators concluded that hypergravity did not greatly affect the same immunological parameters that were affected by spaceflight in the Cosmos 2044 mission. However, there were several differences between this study and the present investigation, including different animal species, times of assay, and inertial conditions.
Centrifugation, similar to antiorthostatic tail suspension, simulates many of the chronic stressors inherent to all current spaceflight experiments: exposure to a novel environment, changes in loads placed on the limbs, cephalic fluid distribution shifts, and orthostatic intolerance. The effects of these various stressors on physiological parameters have already been shown.
Circulating corticosterone generally increased (57, 59) or remained constant (10) in rats flown on the space shuttle. Similar results were found after tail suspension (37, 60) and centrifugation (37). That these are real stress-induced changes and are not simply due to handling or readaptation is supported by corresponding changes in stress-sensitive adrenal (5, 37, 59) and spleen (3, 4, 7, 9, 16, 19, 60) mass seen under all three gravitational conditions.
However, thymus mass, another indicator of stress, either did not change (7, 9) or increased (5, 6) in rats flown on the space shuttle. Adrenalectomy and basal corticosterone replacement increased this flight-induced change in thymus mass even further (5), suggesting that stress is not a factor in this increase. Because thymus mass decreased in rats after suspension (51) and remained unchanged after centrifugation (47), this measure may be more sensitive to fluid shifts and/or loading rather than psychological stress. This is further indicated by decreases in this measure in mice exposed to both spaceflight (16) and centrifugation (19). The fluid shifts and unloading in the much smaller mouse model are likely to be less severe than those of the larger rat model, thus making it more sensitive to psychological, rather than physical, stressors.
Therefore, it appears that the effects of spaceflight on immune parameters may fall into two separate categories: those induced by spaceflight-related psychological stressors (e.g., exposure to a novel environment), and those induced by spaceflight-related shifts in physical parameters (e.g., fluid shifts and unloading). Those parameters that are influenced primarily by physical stressors may have very different responses to the inertial environment (i.e., responses to hypergravity are opposed to those of microgravity). In contrast, those parameters that are influenced primarily by psychological stressors will likely have similar responses to changes in inertial condition (i.e., similar responses to both hyper- and microgravity).
In an effort to further characterize the effects of inertial condition on immunity, female C57BL/6 mice were exposed to up to 3 G on the 24-ft-diameter centrifuge at the Ames Research Center (Center for Gravitational Biology Research) for up to 21 days. Previously, reports from this study focused on population distributions in the spleen and blood (19). The parameters described herein will provide insight on the energy balance of the animal, red blood cell (RBC), and platelet characteristics, and the ability of the immune system to respond to a mitogenic challenge in terms of proliferation and cytokine expression. These findings provide a wide spectrum of immunological and hematological information regarding the suitability of hypergravity as a model for the chronic inertial component of the spaceflight environment.
| MATERIALS AND METHODS |
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Centrifugation. Mice were subjected to hypergravity at Ames in the 24-ft-diameter centrifuge designed for small-animal research. The centrifuge has 10 radial arms, each holding two large gondolas (23.5 in. high x 39.5 in. wide x 22 in. deep) capable of holding four polycarbonate cages (n = 5 mice/cage). The gondolas swing freely with centrifugation, ensuring that the gravitational force vector was perpendicular to the cage floor.
Control animals were housed in stationary gondola-like enclosures that are located in the same room as the centrifuge. Three smaller enclosures were located in the center of the centrifuge for rotation control animals. These animals experienced slow rotational effects but minimal centrifugal force.
All enclosures were illuminated by fluorescent lighting on a 12:12-h light-dark cycle. Several centrifuge gondolas were fitted with video cameras to allow in-cage TV monitoring of animals during centrifugation.
In the present study, mice were subjected to a maximum of 3 G for up to 21 days. Food and water were available ad libitum. The centrifuge was stopped daily each morning for
1 h on the request of the veterinarian who assessed animal health by visual inspection. Experimental gravitational forces were achieved within
12 min after initiation of centrifugation. Provision of clean bedding two to three times each week and selection of animal subsets for euthanasia were synchronized as closely as possible with the times of health inspection to minimize downtime.
Euthanasia and tissue collection. On days 1, 4, 7, 10, and 21, subsets of animals in each group were removed from the centrifuge and euthanized with 100% CO2 (44). Whole blood was collected immediately by cardiac puncture with K2-EDTA-coated syringes. To protect the tissues during transport from the Ames Research Center to LLU, spleens were removed, cut into four pieces, and placed in sterile screw-capped tubes containing complete RPMI-1640 medium (with 20% heat-inactivated bovine calf serum) on wet ice. The samples were shipped with ice packs by overnight express to LLU for evaluation. At LLU, single-celled suspensions of spleen leukocytes were obtained, as described previously (17, 40).
Hematological analysis. Hematological parameters were quantified by using an ABC Vet Hematology Analyzer (Heska, Waukesha, WI). Parameters characterized include RBC, platelet, and white blood cell counts, Hb concentration, and mean corpuscular volume (MCV, mean volume per RBC). Based on these measurements, standard formulas were used to obtain Hct (percentage of whole blood consisting of RBC), mean corpuscular Hb (MCH; mean mass of Hb per RBC), MCH concentration (concentration of Hb per RBC), RBC distribution width (RDW; width of the RBC histogram produced by cell number x cell size), and the mean platelet volume (size of the average platelet).
Spontaneous and mitogen-induced blastogenesis. The spontaneous and mitogen-induced blastogenesis assays were performed as previously described (14). To determine spontaneous blastogenesis of peripheral blood leukocytes, a 50-µl aliquot of whole blood from each mouse was dispensed in triplicate into wells of 96-well flat-bottom microtiter plates. RPMI medium (150 µl) supplemented with 10% FCS (Hyclone), antibiotics, mercaptoethanol, and [3H]thymidine (specific activity = 46 Ci/mmol; ICN Radiochemicals, Irvine, CA) was immediately added to each well (1 µCi/50 µl). The plates were incubated for a total of 4 h at 37°C in 5% CO2. Single-cell splenocyte suspensions (after RBC lysis) were treated similarly except that leukocyte counts were first adjusted to 2 x 106 cells/ml.
For mitogen-induced blastogenesis in the spleen, 100-µl aliquots of 2 x 106/ml leukocytes were dispensed into wells of microtiter plates and 100 µl of phytohemagglutinin (PHA), concanavalin A (ConA), or LPS (Sigma Chemical, St. Louis, MO) were added; control wells with no mitogen were included (no stimulation). Mitogens were pretitrated for optimal response. After 44 h, [3H]thymidine (1 µCi/50 µl/well) was added, and cells were allowed to incubate for an additional 4 h.
For both assays, cells were harvested into a 96-well format filter with a Harvester 96 Mach III-m (Tomtec, Hamden, CT), and the incorporated radioactivity was quantified on a 1450 Microbeta Trilux Liquid Scintillation and Luminescence Counter (EG&G-Wallac, Turku, Finland). Spontaneous blastogenesis results for blood leukocytes were adjusted to account for the cell counts, based on the white blood cell counts obtained with the hematology analyzer (see above). Stimulation index (SI) for each mitogen was calculated as follows: SI = [counts per minute (cpm) with mitogen cpm without mitogen]/(cpm without mitogen).
Quantification of cytokines.
Spleen leukocytes were quantified and diluted with supplemented RPMI-1640 medium (Irvine Scientific) to 2 x 106 cells/ml. Aliquots (0.1 ml) were placed into wells of 96-well microculture plates. PHA (Sigma) was immediately added (0.1 ml/well), and the cells were incubated for 48 h. Supernatants were then aspirated, cells and debris were removed by centrifugation, and the levels of IFN-
, TNF-
, IL-2, IL-4, and IL-5 were quantified by using the Cytometric Bead Array Assay (CBA Assay, Becton Dickinson Biosciences, San Diego, CA), according to the manufacturer's instructions via flow cytometry. Supernatants from nonstimulated cells were collected from three mice/group and tested for background cytokine levels. Cytokine concentrations in each test sample were interpolated from the appropriate standard curve.
Statistical analysis. Data were normalized to the controls on each day of euthanization (actual control means given in Table 1) and evaluated by using two-way ANOVA with Tukey's pairwise multiple-comparison test (Systat, Systat Software, Richmond, CA). P values of <0.05 and <0.1 were selected to indicate significance and a trend, respectively. Main effects of gravity and day, as well as interactions between these variables, are reported. A significant main effect of gravity suggests that there was an overall effect of the inertial condition independent of the day the assay was performed. Similarly, a main effect of day suggests that there was an overall effect of day independent of gravitational condition. Finally, an interaction between gravity and day suggests that the effect of gravity depended on the day the assay was performed.
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| RESULTS |
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There were main effects of both day and gravity on RDW (P values <0.001; Fig. 3D). In general, the 3-G group was significantly lower than both the 1-G controls and 2-G animals (P < 0.005 and P < 0.01, respectively). However, compared with 1-G controls, there were significant decreases in the 3-G group on only days 4 and 7 (P values <0.05) and in the 2-G group on day 4 (P < 0.05). This led to a significant day x gravity interaction (P < 0.05).
Platelet parameters were only acutely influenced by centrifugation. There was a significant main effect of day (P < 0.001), and a trend for an effect of gravity, on platelet counts (Fig. 4A). After 1 day of centrifugation, the 3-G animals had elevated platelet counts. Counts in these animals returned to control levels by day 4, and there were no significant differences in any group throughout the rest of the run. This resulted in a significant day x gravity interaction (P < 0.05). However, there was only a trend for a main effect of day on mean platelet volume (Fig. 4B).
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At first glance, it appears that the response in the unstimulated cells was actually greater than that of the stimulated cells. However, this is simply due to normalization, with the means for the 1-G controls set at 1. Before normalization, the cpm for the mitogen-induced responses were much higher for the stimulated than for the unstimulated cells. Ultimately, this meant that even a slight inertia-dependent change in the response for the unstimulated cells could result in a large proportional change. For a similar proportional increase in the stimulated cells, there would have to be a considerably larger gravity response.
Surprisingly, there were unexpected effects of both day (P < 0.001) and gravity (P < 0.05) in unstimulated blastogenesis. In general, cpm values for the 2-G (P < 0.001) and 3-G (P < 0.1) groups were increased compared with those for 1-G controls. The pattern of these effects was similar to both spontaneous and mitogen-induced blastogenesis, peaking on day 10 (P < 0.001 for 2 G and P < 0.01 for 3 G).
Because of this unexpected result, we are also presenting blastogenesis data in the form of stimulation indexes (Table 4). In this form, there were no significant effects of day on the ability of any of these mitogens to induce blastogenesis. However, there was a significant effect of gravity on PHA (P < 0.05), with trends in ConA and LPS. For both of the T-cell mitogens, this appears to be due to overall increases in the 2-G group compared with 1-G controls (P > 0.05 for PHA and P < 0.1 for ConA). For LPS, this was due to overall decreases in the 3-G group compared with 1-G controls. However, post hoc Tukey's test did not indicate that the centrifuged groups were significantly different from 1-G controls on any of the test days.
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expression. In general, the 3-G group was significantly lower than both 1-G controls (P < 0.01). Tukey analysis indicated that there were significant differences between 3-G and 1-G controls on day 1 (P < 0.05), and between 3-G and 2-G on day 21 (P < 0.05). There was a significant effect of day (P < 0.05), as well as a significant day x gravity interaction (P < 0.005), on TNF-
expression. This was due to an increase in the 3-G animals on day 7 compared with both 2-G and 1-G controls (P < 0.001 and P < 0.01, respectively).
In the plasma, there were main effects of gravity (P < 0.05) on the level of transforming growth factor (TGF)-
. The effect of day was reduced to a trend. In general, TGF-
concentration was low in the 3-G group compared with 1-G controls and 2-G animals (P < 0.05 and P < 0.1, respectively). However, in post hoc Tukey's test, the 3-G group only trended toward a decrease compared with 1-G controls on days 1 and 4.
| DISCUSSION |
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The overall decreases in RBC, Hct, and Hb across the 21 days may reflect adaptation. The lack of early centrifugation effects on Hct is consistent with past mouse studies under similar conditions (47). Furthermore, the pattern of effects is similar, although not identical, to that of the spaceflight environment. After 7 days aboard an orbiting space shuttle, rats had higher RBC, Hct, and Hb values compared with ground controls (27). After 9 days, these differences were no longer present (1, 55). We found a slight increase in RBC count but no change in Hct or Hb in mice after 12 days on the shuttle (16). The initial increases in these parameters likely reflect an acute decrease in water intake as the animals adapt to new inertial conditions. The opposing long-term results between hyper- and hypogravity may reflect the long-term adaptation to opposing physical stressors.
Centrifugation consistently decreased the MCV, whereas the MCH response was bimodal. These results do not match what has been seen after spaceflight, suggesting a response to physical rather than psychological stressors. There was no change in either MCV or MCH in rats flown on the space shuttle for 79 days compared with ground controls (27, 55). Similarly, although we found a slight decrease in MCV, there were no changes in MCH in mice flown for 12 days on the shuttle compared with ground controls (16). It is possible that the apparent disparity between spaceflight and centrifugation is a result of the analysis technique. This is particularly true for MCV. The values produced by the hematology analyzer for MCV are strictly integers, forcing the data to be artificially "quantized." With relatively small sample sizes, this may influence statistical analysis by artificially minimizing variation between samples. However, because the
2% decreases seen in MCV were consistent across the entire 21-day run (Fig. 3) and involve
30 animals per centrifuge condition, the possibility exists that this difference is biologically relevant. If this is indeed the case, such a result would be consistent with a response to physical, rather than psychological, stressors.
Decreases in RBC characteristics would be consistent with anemia, a condition frequently reported in flight personnel (45). However, these measurements depend, at least in part, on a constant blood volume. Fluid shifts due to altered gravitational conditions typically result in blood volume changes. A decrease in MCV suggests a possible iron deficiency and/or passage of cells from the portal to the systemic core due to hepatic insufficiency. In addition, both MCV and MCH have been shown to be negatively correlated with transport ATPase activity (25). As gravity-dependent changes in muscle ATPase activity have been reported (11, 29), the disparity between models may be related to similarly dependent changes in muscle mass and protein. Finally, there may be a hypergravity-induced decrease in Hb production during erythropoiesis or an increase in its degradation. Both of these mechanisms would be consistent with decreased oxygen and/or energy consumption. However, because immature RBCs are larger than their mature counterparts, a significant increase in erythropoiesis should result in increased MCV. Because MCV decreased after centrifugation, it is unlikely that enough new RBCs were produced to cause a shift in cellular Hb. The low RDW is similar to what we found in mice flown on the space shuttle for 12 days (16). This suggests a burst of cell death or apoptosis in reticulocytes, initiated shortly after a change in inertial condition (i.e., launch or placement on the centrifuge). Platelet counts and volume were relatively unaffected by hypergravity. This is similar to what has been shown in rats exposed to 8 days of spaceflight (7). However, we found that, after 12 days on the shuttle, platelet counts were increased in mice (16).
After an early, slight decrease, spontaneous blastogenesis in the spleen was increased in the centrifuged animals on day 10. The temporal changes may reflect an initial insult, followed by overcompensation. The reason for lack of similar shifts in blood is not clear. However, because of these compartmental differences, it seems unlikely that this was simply an effect of dehydration. The early decrease is in agreement with the hypergravity-dependent decreases that we previously reported in splenic lymphocyte numbers (19). Hence, the subsequent increase in DNA synthesis may well reflect reconstitution following splenocyte apoptosis (19). There are reports that spontaneous blastogenesis of lymph node lymphocytes is not significantly different between controls and rats exposed to the spaceflight environment or suspension for 14 days (35). However, as we found differences between the blood and spleen, the lack of spaceflight effects on lymph node lymphocyte spontaneous blastogenesis may not be surprising.
As with spontaneous blastogenesis in spleen, T-cell mitogen-induced proliferation initially exhibited a downward trend followed by a significantly increased responsiveness on day 10. It is noteworthy that a similar pattern, with the peak shifted to day 7, was seen in the splenic helper, but not cytotoxic, T cells (19). These two phenomena suggest a temporal relationship between helper T cells, which provide activating cytokines, and T-cell blastogenesis.
In contrast, experiments using blood from astronauts and cosmonauts have shown that spaceflight leads to decreased mitogen-induced proliferation (52, 53). Similarly, results from spaceflight rodents are different from those of centrifugation. ConA-, but not PHA-, induced splenocyte blastogenesis trended toward an increase in rats flown on the shuttle for 4 days (36). Other studies show normal levels after 8 days (7) and depression after 10 days (6) and 14 days (28) on the shuttle. A similar pattern has been reported for lymph node lymphocytes (6, 7). Unlike centrifugation, results from rat antiorthostatic tail suspension models are remarkably similar to those of spaceflight. ConA- and PHA-stimulated proliferation either decreased or remained constant after 7 days of suspension in lymphocytes from rat blood, lymph nodes, or spleen (34). This suggests that blastogenic responses to changes in gravitational loads in rats may be due more to the loading of the limbs and fluid distribution shifts, rather than a general stress response. In mice, tail suspension results are much closer to those of centrifugation than those of spaceflight. Splenic T-cell blastogenesis decreased after 7 days (60) and increased after 11 days (26) of tail suspension. Although there are no comparable spaceflight blastogenesis results for mice, a species-dependent response to gravity is possible.
With the B-cell mitogen LPS, we found a peak in activity on day 10, followed by a decrease on day 21, when expressed as cpm. However, these variations were no longer evident when the data were presented in the form of an SI, which takes into account the background cpm without mitogen. While the lack of a B-cell response to gravity is similar to results found with rat (34, 35) and mouse (60) tail suspension models, the increased activity on day 10 once again opposed that of spaceflight. LPS-induced blastogenesis in splenocytes from rats flown on the shuttle remained unchanged after 8 days (7) and decreased after 10 days (6), compared with controls. A similar pattern was reported in the lymph nodes (6, 36). Combined with the T-cell mitogen data, this further suggests that the influence of gravity on overall blastogenic responses is more likely due to loading and fluid redistribution than a generalized stress response.
To our knowledge, this is the first report of cytokine expression after centrifugation. Overall, the greatest effect on splenic PHA-induced cytokines was noted for IFN-
, which tended to be low for the entire 3-wk period. The early increases in IL-2 (needed for T-cell proliferation) and IL-4 (a promoter of B-cell differentiation) may be in response to the significant drop in T and B cells noted in these animals (19). The depression in IFN-
that was noted in conjunction with an increase in IL-4 suggests a shift in the balance between the T-helper type 1 (Th1) and type 2 (Th2) lymphocyte subsets. Under normal conditions, activated Th1 cells secrete IFN-
and other cytokines that promote cell-mediated immune responses important in the control of viral infections. Similarly, the Th2 cells secrete IL-4 and other cytokines that facilitate humoral immunity (e.g., antibody production). IFN-
is also well known to be a potent activator of cells of the monocyte-macrophage lineage that function in removal of bacteria and present antigen to lymphocytes. Thus compromised ability to secrete a sufficient amount of IFN-
may result in increased risk for infections of various types. By days 10 and 21, the total Th cell population, as well as the B cells, had either rebounded above controls, or returned to within the normal control range (19), as did IL-2 and IL-4 expression. The slight decrease in plasma TGF-
1 during the first week of centrifugation is consistent with these observations. A reduction in this highly immunosuppressive cytokine could enhance the probability of lymphocyte proliferation. Except for an acute increase in mitogen-induced IL-2 secretion after exposure to flight for 4 days (36), splenic cytokine expression has generally either remained constant or decreased after spaceflight (7, 16, 28) or suspension (34, 60). This again suggests that fluid shifts and limb unloading may influence some immune parameters more than psychological stressors.
These shifts in cytokines, and hence changes in the ability to respond to disease, are consistent with the antiorthostatic tail suspension literature. When mice were inoculated with Listeria monocytogenes 2 days before, or on the day of, initiation of antiorthostatic tail suspension, bacterial clearance was no different from that of controls. However, when mice were inoculated 2 or 4 days into a 7- to 9-day suspension, clearance was actually enhanced. When mice were suspended for 7 days before inoculation, clearance was still enhanced but not to the extent seen for days 2 and 4 (30, 32). Furthermore, EL-4-stimulated splenocytes from animals exposed to 4 days of suspension had significantly higher levels of IL-1 activity compared with vivarium controls in both naive and Listeria inoculated mice (30). In contrast, Gould et al. (13) found that mice inoculated with a normally resisted dose of encephalomyocarditis virus on day 0 began to die within 4 days of suspension. This was reported to be coordinated by changes in IFN production (13).
Clearly, changes in inertial condition can have effects on multiple hematological and immune parameters. However, a factor that must be taken into consideration when interpreting the results presented here is the daily "stop and start" of the centrifuge. This was done on the request of the veterinarian at the Ames Research Center so that a general health assessment could be performed by visual inspection of all mice, rather than by visualization of animals in selected cages by video camera. It is possible that the frequency of inertial changes exacerbated the differences observed between the centrifuged and noncentrifuged control groups.
By comparing results across spaceflight, centrifugation, and antiorthostatic tail suspension experiments, potential mechanisms may be further elucidated. However, this effort must be coordinated to be of value. Furthermore, results from in vitro studies must be verified in in vivo models. For example, Cogoli (8) has summarized potential mechanisms by which gravitational changes could affect cells of the immune system. These mechanisms include those that function in signal transduction pathways involving cell activation and/or cytokine secretion, synthetic pathways leading to expression of receptors for growth factors and other immunoregulatory molecules, and interactions between lymphocytes and accessory cells that present antigen (e.g., dendritic cells and monocyte-macrophages). However, these conclusions are based primarily on cells in culture, and it is not yet clear whether many of the in vitro observations hold true in vivo.
Finally, the immunological significance of these gravity-dependent phenomena must be characterized by utilizing pathogenic-challenge and transgenic models. Whereas there has been some progress in these areas with antiorthostatic tail suspension, there is very little data available for spaceflight or centrifugation. Similarly, to more closely simulate the interplanetary spaceflight environment, these gravitational models must be combined with low-dose-to-low-dose-rate irradiation. Until these goals are met, astronaut risk assessment paradigms will be less than complete.
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| ACKNOWLEDGMENTS |
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| FOOTNOTES |
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The costs of publication of this article were defrayed in part by the payment of page charges. The article must therefore be hereby marked "advertisement" in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.
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