High-Altitude Exposure and Cerebral Venous Thrombosis: An Updated Systematic Review.

Kharel, Sanjeev, Suraj Shrestha, Samriddha Raj Pant, Suman Acharya, Amit Sharma, Santosh Baniya, and Sanjeeb S. Bhandari. High-altitude exposure and cerebral venous thrombosis: an updated systematic review. High Alt Med Biol. 24:167-174, 2023. Background: High altitude (HA) may increase the risk of cerebral venous thrombosis (CVT). Differentiating it from other HA illnesses is crucial for prompt treatment and better outcomes. We aimed to summarize the clinical data, etiology, and risk factors of this poorly understood entity at an HA. Materials and Methods: A systematic literature search of various databases, including PubMed, Embase, and Google Scholar, was done using relevant keywords; cerebral venous thrombosis; HA, up to May 1, 2022. Results: A total of nine studies, including 75 cases of CVT at HA (3,000-8,848 m), with 66 males and 9 females, were included in this review. Headache and seizure were the most common clinical presentations. Smoking, drinking habits, and the use of oral contraceptive pills (OCP) were the most common risk factors for the development of CVT. Similarly, various underlying hypercoagulable states were also present among cases of CVT associated with HA exposure. Conclusion: Our review concludes that HA exposure can predispose individuals with risk factors such as preexisting hypercoagulable states, smoking, drinking habits, and use of OCP to an increased risk of CVT.

Metabolic Syndrome among Stable Chronic Obstructive Pulmonary Disease Patients Visiting Outpatient Department of a Tertiary care centre: A Descriptive Cross-sectional study.

Introduction: Metabolic syndrome; a constellation of obesity, hypertension, and disturbances of lipid and carbohydrate metabolism is a common phenomenon in chronic obstructive pulmonary disease. Systemic inflammation plays an important role in both conditions. The aim of this study was to find out the prevalence of metabolic syndrome among stable chronic obstructive pulmonary disease patients visiting the outpatient Department of a tertiary care centre. Methods: A descriptive cross-sectional study was done in the outpatient Department of Pulmonology and General Practice from 1 August 2019 to 31 December 2020. Ethical approval was obtained from Institutional Review Committee [Registration number: 5/(6-11)E2/076/077]. Convenience sampling method was used. Point estimate and 95% Confidence Interval were calculated. Results: Among 57 patients with stable chronic obstructive pulmonary disease, the prevalence of metabolic syndrome was 22 (38.59%) (27.48-49.70, 90% Confidence Interval). The prevalence of metabolic syndrome in patients with Global Initiative for Obstructive Lung Disease stages 1, 2, 3, and 4 were 6 (27.27%), 9 (40.90%), 6 (27.27%) and 1 (4.54%) respectively. Conclusions: The prevalence of metabolic syndrome was similar to the other studies done in similar settings. The screening of metabolic syndrome is necessary and stratification for cardiovascular disease risk is important for timely intervention to prevent and decrease morbidities and mortalities. Keywords: chronic obstructive pulmonary disease; c-reactive protein; metabolic syndrome.

Metabolic Syndrome among Stable Chronic Obstructive Pulmonary Disease Patients Visiting Outpatient Department of a Tertiary care centre: A Descriptive Cross-sectional Study.

Introduction: Metabolic syndrome; a constellation of obesity, hypertension, and disturbances of lipid and carbohydrate metabolism is a common phenomenon in chronic obstructive pulmonary disease. Systemic inflammation plays an important role in both conditions. The aim of this study was to find out the prevalence of metabolic syndrome among stable chronic obstructive pulmonary disease patients visiting the outpatient Department of a tertiary care centre. Methods: A descriptive cross-sectional study was done in the outpatient Department of Pulmonology and General Practice from 1 August 2019 to 31 December 2020. Ethical approval was obtained from Institutional Review Committee [Registration number: 5/(6-11)E2/076/077]. Convenience sampling method was used. Point estimate and 95% Confidence Interval were calculated. Results: Among 57 patients with stable chronic obstructive pulmonary disease, the prevalence of metabolic syndrome was 22 (38.59%) (27.48-49.70, 90% Confidence Interval). The prevalence of metabolic syndrome in patients with Global Initiative for Obstructive Lung Disease stages 1, 2, 3, and 4 were 6 (27.27%), 9 (40.90%), 6 (27.27%) and 1 (4.54%) respectively. Conclusions: The prevalence of metabolic syndrome was similar to the other studies done in similar settings. The screening of metabolic syndrome is necessary and stratification for cardiovascular disease risk is important for timely intervention to prevent and decrease morbidities and mortalities. Keywords: chronic obstructive pulmonary disease; c-reactive protein; metabolic syndrome.

High Altitude Illness among Rapidly Ascending Pilgrims to Kailash Mansarovar.

BACKGROUND: High altitude pilgrims typically ascend rapidly, are not well prepared for the austere environment and tend to have multiple co-morbidities. Here, we list the trend of altitude and other illnesses who visited Humla district hospital (2,950 meters) following very rapid ascent to Kailash Mansarovar (4,500 meters). METHODS: A prospective study was conducted among 55 patients at the Humla District Hospital from September 2019 - August 2022. Patients who fell ill during pilgrimage and brought to the hospital were included. The patients were assessed with medical history and clinical examination. Lake Louise Score Acute Mountain Sickness Score (2018) was used for the diagnosis of Acute Mountain Sickness. RESULTS: A total of 56 evacuees visited the hospital which included 55 patients and 1 brought dead. The mean age was 50.63 ± 10.91 years. Sixteen patients (29.1%) developed symptoms within 24 hours and 15 patients (27.3%) within 48 hours of ascent. Headache 42 (76.4%) was the most common complain. Mild acute mountain sickness (30.9%; 17 patients) was the most common altitude related illness while 14 patients (25.4%) were diagnosed with non-altitude related illnesses. Twelve patients (21.8%) had co-morbidities like hypertension and diabetes mellitus. CONCLUSIONS: In the rapidly ascending pilgrims, majority of travelers requiring medical attention are suffering from some form of altitude illnesses. Hence, proper planning and public awareness about slow and gradual ascent profile is necessary to make the travel safer.

Diclofenac induced anaphylaxis: A case report from Nepal.

Introduction: Diclofenac is considered a generally safe medication, and cause few side effects like dyspepsia, diarrhea/constipation, nausea, and vomiting, stomach bleeding, rash, urticaria, photosensitivity reactions, acute renal failure, analgesic nephropathy, bone marrow and liver diseases. Rarely, it causes anaphylactic reaction. Case presentation: We report a case of 40 years male who developed anaphylactic reaction after intravenous infusion with diclofenac. Discussion: Both the pulmonary embolism and anaphylaxis guidelines emphasize the importance of a thorough evaluation when making a diagnosis. Mast cells secrete tryptase, a neutral protease that is specifically concentrated in the secretory granules of human mast cells (but not basophils), along with histamine, as a marker of mast cell activation. Conclusion: Although intravenous diclofenac sodium is a safe and often used medicine, it can cause severe and perhaps fatal anaphylactic responses.

A case report on atypical spindle cell lipomatous tumor: A rare entity.

Introduction: Atypical spindle cell lipomatous tumor (ASPLT), a separate entity for the group of benign/low grade adipocytic neoplasm that is characterized by adipocyte adequacy and the presence of lipoblast-like cells and spindle cells at varying degrees. Case presentation: Here, we report a rare case of 60 years old male with atypical spindle cell lipomatous tumor in the anterior abdominal wall. Discussion: Histopathology is the gold standard for establishing the diagnosis and grade of soft tissue tumor and consistent radiology-pathology correlation is essential to avoid any diagnostic pitfalls [1]. Ultrasound is preferred as an initial investigation for superficially located lesions. Conclusion: ASPLT show a wide variety of microscopic features, and differential diagnosis is important and difficult. Recognition of morphologic clues and immunohistochemistry/molecular tests to confirm the diagnosis.

Bell's palsy as a possible complication of mRNA-1273 (Moderna) vaccine against COVID-19.

Introduction: Vero Cell, AstraZeneca, Janssen, mRNA-1273 (Moderna), and Pfizer COVID-19 vaccines have been authorized for emergency use in Nepal. These vacines have been linked to some adverse effects, including fever, myalgia, and headache. Furthermore Bell's Palsy a rare adverse effect was also reported to be associated with the use of mRNA-1273 (Moderna) vaccine in some patients. Case presentation: In this case report we present a 17-year-old female who acquired Bell's Palsy following the administration of mRNA-1273 (Moderna) COVID-19 vaccination. Discussion: The possible etiology of BP that has been suggested is infection by reactivated viruses, such as the varicella-zoster virus (VZV), herpes simplex virus type 1 (HSV-1), human herpesvirus 6, and the Usutu virus, [1] the most accepted hypothesis is the one with reactivation of latent Herpes Simplex Virus type 1 in the geniculate ganglia of the facial nerves, an autoimmune mechanism through the mimicry of host molecules by the antigens of the vaccines. Conclusion: Though the extent of association between the mRNA vaccination and the development of Bell's Palsy has yet to be confirmed, this example highlights the need to closely monitor side effects and repercussions after receiving a new vaccine.

Effectiveness of low-dose radiation therapy in COVID-19 patients globally: A systematic review.

Background: Novel Corona Virus Disease 2019 (COVID-19) can affect multiple organs, including the lungs, resulting in pneumonia. Apart from steroids, other anti-COVID drugs that have been studied appear to have little or no effect on COVID-19 pneumonia. There is a well-known history of inflammatory disease, including pneumonia, treated with low-dose radiation therapy (LDRT). It reduces the production of proinflammatory cytokines, Interleukin-1a (IL-1a), and leukocyte recruitment.   Methods: A comprehensive literature search was conducted using PubMed, Scopus, Embase, CINAHL, and Google Scholar, with keywords such as "radiotherapy," "low-dose radiation therapy," "low-dose irradiation," "covid-19 pneumonia," "SARS-CoV-2 pneumonia," and "covid pneumonia." with additional filters for human studies and customized articles in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We reviewed randomized controlled trials, quasi-experimental studies, cohort, case-control, and cross-sectional studies with a clearly defined intervention, including low-dose radiotherapy alone or in combination with any therapy to treat COVID-19 pneumonia from December 2019 to May 2021. Patients receiving standard or high-dose radiotherapy, including for other diseases, were excluded. Zotero software was used to collect and organize research from various databases, remove duplicates, extract relevant data, and record decisions. Participants' demographics and baseline status were obtained from the full-text articles along with the intervention's outcome/effect on patient status.  Results: Four studies with 61 participants that met the inclusion criteria were included. One was a double-blind randomized controlled trial, one a non-randomized trial, while the other two were single-arm clinical trials. Low-dose radiation therapy did not show any significant improvement in COVID-19 patients.  Conclusion: Only two studies included in this review demonstrated an improvement in inflammatory markers; however, patients were also given steroids or other drugs. Therefore, the confounding effects must be considered before drawing conclusions. This systematic review does not support mortality benefit, clinical course improvement, or imaging changes with LDRT.

Efficacy and safety of inhaled budesonide on prevention of acute mountain sickness during emergent ascent: a meta-analysis of randomized controlled trials.

BACKGROUND: Acute Mountain Sickness (AMS) is a pathophysiologic process that occurs in non-acclimated susceptible individuals rapidly ascending to high-altitude. Barometric pressure falls at high altitude and it translates to a decreased partial pressure of alveolar oxygen (PAO2) and arterial oxygen (PaO2). A gradual staged ascent with sufficient acclimatization can prevent AMS but emergent circumstances requiring exposure to rapid atmospheric pressure changes - such as for climbers, disaster or rescue team procedures, and military operations - establishes a need for effective prophylactic medications. This systematic review and meta-analysis aim to analyze the incidence of AMS during emergent ascent of non-acclimatized individuals receiving inhaled budesonide compared to placebo. METHODS: This current meta-analysis was conducted according to the guidance of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. We searched PubMed, Google Scholar and Embase for relevant studies. The efficacy of budesonide in reducing incidence of AMS was evaluated by calculating the pooled ORs and 95% CIs. The efficacy of budesonide in maintaining hemoglobin-oxygen saturation was evaluated by calculating standard mean difference (SMD) and 95% confidence intervals. RESULTS: We found that at high altitude, inhaled budesonide was effective in reducing the incidence of mild AMS [OR: 0.37; 95% CI, 0.14 to 0.9, p = 0.042] but was ineffective in reducing the incidence of severe AMS [OR: 0.46; 95% CI, 0.14 to 1.41, p = 0.17]. Inhaled budesonide was also effective in maintaining SpO2 (SMD: 0.47; 95% CI, 0.09 to 0.84, p = 0.014) at high altitude. However, it was not effective in maintaining or improving pulmonary function at high altitude. Systematic-review found no adverse effects of budesoide in the dose used for prophylaxis of AMS. CONCLUSIONS: Our systematic review showed that prophylactic inhaled budesonide is effective in preventing mild AMS during emergency ascent but not effective in preventing severe AMS. Though statistically significant, authors recommend caution in interpretation of data and questions for further well designed randomized studies to evaluate the role of budesonide in prophylaxis of AMS during an emergent ascent.

Prevalence of Respiratory Manifestations in Chronic Kidney Diseases; A Descriptive Cross-sectional Study in A Tertiary Care Hospital of Nepal.

INTRODUCTION: Chronic kidney diseases affect patients with multiple respiratory complications by varied etiopathogenesis adversely affecting the outcome in them. The aim of the study is to find out the prevalence of respiratory manifestations among patients with chronic kidney disease. METHODS: The descriptive cross-sectional study was carried out tertiary care hospital from January 2019 to March 2019 after ethical approval. One hundred and sixty five patients with established chronic kidney diseases being treated in a tertiary hospital for a month were included for the study. Clinical evaluation and relevant investigations; chest x ray, pleural fluid analysis, sputum analysis, echocardiography, biochemical investigations and hematological investigations were done to assess the respiratory manifestations of the patients. Statistical Package for Social Sciences version 22 was used for the analysis of the data and point estimate at 95% Confidence interval was calculated along with frequency and proportion for binary data and the analysis was done. RESULTS: The prevalence of respiratory manifestations was 102 (61.8%) at 95% Confidence interval, range occurring between 55% to 69%. Pulmonary oedema 41 (24.84%) was the most common manifestation followed by pleural effusion 18 (10.9%). Pleural effusions were predominantly bilateral and transudative type. Pneumonia 17 (10.3%) was predominantly lobar pneumonia. Sixteen (9.7%) of the patients were screened positive for obstructive sleep apnoea syndrome. Pulmonary tuberculosis was present in 9 (5.45%) patients. CONCLUSIONS: Varieties of respiratory complications can present in varied spectrum in patients with chronic kidney diseases and this carries adverse outcome to patient management as well as affects the quality of life of patient and their family.

Status of vitamin D and parameters of calcium homeostasis in renal transplant recipients in Nepal: a cross sectional study.

BACKGROUND: Vitamin D, apart from being an important part of the "calcium-vitamin D-parathyroid hormone" endocrine axis, has diverse range of "non-calcemic" biological actions. A high prevalence of vitamin D deficiency has been observed in renal transplant recipients (RTRs) worldwide. This study aimed to determine the prevalence of hypovitaminosis D in Nepalese RTRs and interrelations between serum 25-hydroxyvitamin D [25(OH) D] and other biochemical parameters. METHODS: A total of 80 adult RTRs visiting a university hospital were enrolled in this cross sectional study. Serum 25(OH) D and intact parathyroid hormone (iPTH) were measured using Enhanced Chemiluminiscent Immunoassay. The RTR population was categorized into recent transplant recipients (≤1 year) and long term recipients (> 1 year). The vitamin D status was defined as per NKF/KDOQI guidelines. SPSS version 20.0 was used to analyze the data. Appropriate statistical tests were applied to compare variables between groups and establish correlation. P < 0.05 was considered to be statistically significant. RESULTS: The mean age of the recipients was 38.11 ± 11.47 years (68 males, 85.0%). Chronic glomerulonephritis was the leading cause of CKD. The two RTR groups (recent and long term) didn't differ in demographic and biochemical characteristics. 83.75% of the recipients had PTH levels above the upper limit of the recommended range for their stage of CKD. 57.5% had hypocalcemia and none of the recipients had hypercalcemia. The median serum 25(OH) D was 24.15 ng/ml (8.00-51.50 ng/ml). Only 27.5% had sufficient vitamin D status whereas 53.8% were vitamin D insufficient and 18.8% were vitamin D deficient, the distribution almost comparable in the 2 transplant group. The serum 25(OH) D was not significantly affected by the time post-transplant, gender and sunlight avoidance. There was a significant negative correlation between serum 25(OH) D and iPTH (Pearson's r = - 0.35, P = 0.001), but not so with the graft function. CONCLUSION: There is a high prevalence of vitamin D insufficiency in RTRs. The deficiency status is not corrected despite of nutritional improvement and normalization of GFR post-transplantation and likely exacerbates secondary hyperparathyroidism. Vitamin D supplementation coupled with sensible sun exposure could be important strategies in optimization of the vitamin D status in this population.

Reentry High Altitude Pulmonary Edema in the Himalayas.

Baniya, Santosh, Christopher Holden, and Buddha Basnyat. Reentry high altitude pulmonary edema in the Himalayas. High Alt Med Biol. 18:425-427, 2017.-Reentry high altitude pulmonary edema (HAPE), a subset of HAPE, is a well recognized, life-threatening illness documented almost exclusively in the North and South Americans, who live at high altitude (>2500 m) and return to their homes after a brief sojourn of days to months at lower altitude. This phenomenon has not been reported in Sherpas or other people of Tibetan origin in Nepal or India. And it has rarely been reported from Tibet. In this study we document a case of reentry HAPE in Manang region (3500 m) of Nepal in a 7-year-old Nepali boy of Tibetan ancestry who fell ill when he ascended to his village (Manang, 3500 m) from Besisahar (760 m) in 1 day in a motor vehicle after spending the winter (December to March) at Besisahar with his family. With more motorable road access to high altitude settlements in the Himalayas, reentry HAPE may need to be strongly considered by healthcare professionals in local residents of high altitude; otherwise life-threatening complications may ensue as in our case report.