Hypertension and Acute Mountain Sickness in Himalayan Trekkers in Nepal: An Observational Cohort Study.

INTRODUCTION: A history of preexisting hypertension is common in people participating in mountain activities; however, the relationship between blood pressure (BP), preexisting hypertension, and acute mountain sickness (AMS) is not well studied. We sought to determine these relationships among trekkers in the Everest region of Nepal. METHODS: This was a prospective observational cohort study of a convenience sample of adult, nonpregnant volunteers trekking in the Everest Base Camp region in Nepal. We recorded Lake Louise Scores for AMS and measured BP at 2860 m, 3400 m, and 4300 m. The primary outcome was AMS. RESULTS: A total of 672 trekkers (including 60 with history of preexisting hypertension) were enrolled at 2860 m. We retained 529 at 3400 m and 363 at 4300 m. At 3400 m, 11% of participants had AMS, and 13% had AMS at 4300 m. We found no relationship between AMS and measured BP values (P>0.05), nor was there any relation of BP to AMS severity as measured by higher Lake Louise Scores (P>0.05). Preexisting hypertension (odds ratio [OR] 0.16; 95% CI 0.025-0.57), male sex (OR 0.59; 95% CI 0.37-0.96), and increased SpO2 (OR 0.93; 95% CI 0.87-0.98) were associated with reduced rates of AMS in multivariate analyses adjusting for known risk factors for AMS. CONCLUSIONS: AMS is common in trekkers in Nepal, even at 3400 m. There is no relationship between measured BP and AMS. However, a medical history of hypertension may be associated with a lower risk of AMS. More work is needed to confirm this novel finding.

Cerebral oxygenation using near-infrared spectroscopy in the beach-chair position during shoulder arthroscopy under general anesthesia.

PURPOSE: To examine the risks of shoulder arthroscopy in the beach-chair position (BCP) as opposed to the lateral decubitus position. The challenge during general anesthesia, particularly with the patient in the BCP, has been to ascertain the lower limit of blood pressure autoregulation, correctly measure mean arterial pressure, and adequately adjust parameters to maintain cerebral perfusion. There is increasing concern about the BCP and its association with intraoperative cerebral desaturation events (CDEs). Assessment of CDEs intraoperatively remains difficult; the emerging technology near-infrared spectroscopy (NIRS) may provide noninvasive, inexpensive, and continuous assessment of cerebral perfusion, offering an "early warning" system before irreversible cerebral ischemia occurs. METHODS: A systematic review was undertaken to determine the incidence of intraoperative CDEs as measured by NIRS and whether it is possible to risk stratify patients for intraoperative CDEs, specifically the degree of elevation in the BCP. RESULTS: Searching Medline, Embase, and the Cochrane Central Register of Controlled Trials from inception until December 30, 2013, we found 9 studies (N = 339) that met our search criteria. The Level of Evidence was III or IV. CONCLUSIONS: There remains a paucity of high-level data. The mean incidence of CDEs was 28.8%. We found a strong positive correlation between CDEs and degree of elevation in the BCP (P = .056). Emerging evidence (Level IV) suggests that we may be able to stratify patients on the basis of age, history of hypertension and stroke, body mass index, diabetes mellitus, obstructive sleep apnea, and height. The challenge remains, however, in defining the degree and duration of cerebral desaturation, as measured by NIRS, required to produce measureable neurocognitive decline postoperatively. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Sex Disparity in the Effect of Obesity in Hospitalized COVID-19 Patients: A Retrospective Cohort Study From the New York City Metropolitan Area.

INTRODUCTION:  Obesity has been recognized as a risk factor for poor outcomes in coronavirus disease 2019 (COVID-19) illness. We analyzed the impact of patient characteristics including obesity on hospital mortality and specifically analyzed the effect of obesity by body mass index (BMI) class and by sex. METHODS:  This retrospective case series included adult patients consecutively hospitalized with confirmed COVID-19 illness between March 12, 2020 and May 13, 2020, at a teaching hospital in the New York City (NYC) metropolitan area. Data were manually extracted from electronic health records by the authors and included demographics, comorbidities, laboratory parameters, and outcomes (hospital mortality or discharge). We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. RESULTS:  Some 348 patients were included in this study, of whom 207 were discharged and 141 died in the hospital. Multivariable regression showed increasing odds of in-hospital death with older age and excess weight. Interestingly obesity increased mortality in women [odds ratio (OR) 4.4, confidence interval (CI) (1.4-13.5) p=0.01] but not among men [OR 1.4, CI (0.5-3.6) p=0.5]. Among women, the effect of excess weight on mortality was seen in a "dose-effect" fashion, with increasingly higher odds of mortality from progressively worsening obesity (OR ranging between 2.7 and 6.9). Out of all the comorbidities, only obesity positively correlated with peak levels of C-reactive protein (CRP). CONCLUSION:  Advancing age is a risk factor for in-hospital death during COVID-19 illness. Obese women could be at a higher risk for mortality due to COVID-19 and should take extra precautions to prevent contamination by social distancing and other measures. Immunomodulators may be more effective in obese women affected by COVID-19. Further studies are needed to help elucidate this association.

Analysis of Male Sex as a Risk Factor in Older Adults With Coronavirus Disease 2019: A Retrospective Cohort Study From the New York City Metropolitan Region.

Background Advancing age and male sex have been identified as risk factors for poor outcomes in coronavirus disease 2019 (COVID-19). However, there is a dearth of data investigating the impact of age on the risk reported with male sex. We aimed to determine the risk associated with male sex in people of different age groups, that is, in people younger or older than 65 years of age. Methods This is a retrospective cohort study that included 370 adult patients hospitalized with COVID-19 between March 12, 2020, and May 13, 2020, at a 242-bed teaching community hospital in the New York City metropolitan region. Patients were classified into younger (age<65 years, n=132) and older individuals (age>=65, n=238). We calculated odds ratios for poor outcomes in men compared to women separately in these two groups. Results Among older individuals, there was no difference in the odds of poor outcomes between men and women. In contrast, among younger people, men had higher odds of severe pneumonia, need for high oxygen support, acute kidney injury and acute liver injury when compared to women. Conclusions Among people older than 65 years, sex did not impact disease severity and outcomes in COVID-19. Thus, older women were equally likely to have severe COVID-19 when compared to age-matched men. In contrast, among younger middle-aged adults (29-64 years), men had higher odds of end-organ damage from COVID-19 compared to women. Based on these observations, age is a more important driver of poor outcomes in COVID-19 than sex. Public health policies need to create awareness for the increased risk of older individuals to COVID-19, regardless of sex.

Incidence and Risk Factors for Acute Kidney Injury and Its Effect on Mortality in Patients Hospitalized From COVID-19.

OBJECTIVE: To determine the incidence of and risk factors for the development of acute kidney injury (AKI) and investigate the association between AKI and mortality in patients hospitalized with coronavirus disease 2019 (COVID-19) infection. PATIENTS AND METHODS: This retrospective case series includes the first 370 patients consecutively hospitalized with confirmed COVID-19 illness between March 10, 2020, and May 13, 2020, at a 242-bed teaching hospital. To determine independent associations between demographic factors, comorbid conditions, and AKI incidence, multivariable logistic regression models were used to estimate odds ratios adjusted for clinical covariates. RESULTS: Median age of patients was 71 (interquartile range, 59-82) years and 44.3% (145 of 327) were women. Patients with AKI were significantly older with a higher comorbid condition burden and mortality rate (58.1% [104 0f 179] vs 19.6% [29 of 148]; P<.001) when compared with those without AKI. Increasing age, chronic kidney disease, hyperlipidemia, and being of African American descent showed higher odds of AKI. Patients with AKI had significantly higher odds of mortality when compared with patients without AKI, and this effect was proportional to the stage of AKI. Increasing age and acute respiratory distress syndrome also revealed higher adjusted odds of mortality. CONCLUSIONS: Acute kidney injury is a common complication among hospitalized patients with COVID-19 infection. We found significantly higher odds of AKI with increasing age and among patients with hyperlipidemia, those with chronic kidney disease, and among African Americans. We demonstrate an independent association between AKI and mortality with increasingly higher odds of mortality from progressively worsening renal failure in hospitalized patients with COVID-19 infection.

End-Stage Renal Disease Patients on Chronic Hemodialysis Fare Better With COVID-19: A Retrospective Cohort Study From the New York Metropolitan Region.

Introduction Several comorbid conditions have been identified as risk factors in patients with coronavirus disease 2019 (COVID-19). However, there is a dearth of data describing the impact of COVID-19 infection in patients with end-stage renal disease on hemodialysis (ESRD-HD). Methods This retrospective case series analyzed 362 adult patients consecutively hospitalized with confirmed COVID-19 illness between March 12, 2020, and May 13, 2020, at a teaching hospital in the New York City metropolitan area. The primary outcome was severe pneumonia as defined by the World Health Organization. Secondary outcomes were the (1) the Combined Outcome of Acute respiratory distress syndrome or in-hospital Death (COAD), and (2) need for high levels of oxygen supplementation (HiO2). Results Patients with ESRD-HD had lower odds for poor outcomes including severe pneumonia [odds ratio (OR) 0.4, confidence interval (CI) 0.2-0.9, p=.04], HiO2 [OR 0.3, CI (0.1-0.8), p=.02] and COAD [OR 0.4, CI (0.2-1.05), p=.06], when compared to patients without ESRD. In contrast, higher odds for severe pneumonia, COAD and HiO2 were seen with advancing age. African Americans were over-represented in the hospitalized patient cohort, when compared to their representation in the community (35% vs 18%). Hispanics had higher odds for severe illness and HiO2 when compared to Caucasians. Conclusions Patients with ESRD-HD had a milder course of illness with a lower likelihood of severe pneumonia and a lesser need for aggressive oxygen supplementation when compared to patients not on chronic dialysis. The lower odds of severe illness in ESRD-HD patients might have a pathophysiologic basis and need to be further explored.

Airway inflammation and anti-protease defences rapidly improve during treatment of an acute exacerbation of COPD.

BACKGROUND AND OBJECTIVE: There are few data on the short-term natural history of airway inflammation during severe episodes of acute exacerbation of COPD (AECOPD). An observational study was performed to determine how rapidly conventional treatment improves airway inflammation in patients admitted to hospital with AECOPD. METHODS: Twenty-four consecutive patients with AECOPD were recruited and changes in sputum inflammatory indices were assessed after 2 and 4 days of treatment. The primary end-points included presence of bacteria and viruses, changes in sputum total cell counts (TCC) and polymorphonuclear leukocyte (PMN) differential counts, and levels of secretory leukocyte protease inhibitor (SLPI), IL-8 and TNF-alpha. RESULTS: All patients received oral corticosteroids and 17 (71%) were also treated with oral antibiotics. A bacterial or viral pathogen was isolated from 12 patients (50%), and Aspergillus fumigatus was isolated from one. A positive bacterial culture was associated with increased sputum TCC and PMN count (P < 0.05), as well as higher levels of IL-8 and TNF-alpha (P < 0.05), and a trend towards lower sputum SLPI levels (P = 0.06). Sputum PMN numbers fell by 70% within the first 48 h of admission (P < 0.05), accompanied by an increase in sputum SLPI (P < 0.001) and reductions in the levels of TNF-alpha (P < 0.005) and IL-8 (P = 0.06), with no further significant change at 4 days. CONCLUSIONS: Conventional treatment for severe AECOPD is associated with rapid reduction of neutrophilic inflammation and improvement in anti-protease defences.

Retinal Hemorrhage in a High-Altitude Aid Post Volunteer Doctor: A Case Report.

Bhandari, Sanjeeb Sudarshan, Pranawa Koirala, Nirajan Regmi, and Sushil Pant. Retinal hemorrhage in a high-altitude aid post volunteer doctor: a case report. High Alt Med Biol. 18: 285-287, 2017.-High-altitude retinal hemorrhages (HARHs) are seen at altitudes more than 3000 m, are usually multiple, flame shaped, and adjacent to blood vessels. Development near the macula causes blurring of vision, otherwise, they are symptomless and self-limiting. They often develop during the first few days after ascent to high altitude and subjects often suffer from acute mountain sickness (AMS) or high-altitude cerebral edema (HACE). People going to high altitude for the first time are more susceptible to retinal hemorrhages than experienced climbers and high-altitude dwellers. We present a case of a 31-year-old male doctor who developed sudden unilateral blurring of vision without any other symptoms after 6 weeks of volunteering at a high-altitude aid post in Nepal. There were no features suggestive of AMS or HACE. All examinations were normal except for fundoscopic examination in the left eye, which determined macular retinal hemorrhage. Although he was reluctant to descend, he was counseled to descend and refrained from further ascent to higher altitude, which could accentuate hypoxemia and any strenuous activities that increase intraocular pressure. He recovered his vision after few weeks in Kathmandu and his retinal hemorrhages regressed. Hypoxia exacerbated by repeated bouts of rapid ascent to further higher altitudes may have contributed to his HARH. This suggests that unilateral retinal hemorrhages can develop even after several weeks at high altitude without concomitant AMS or HACE. People going to high altitude are reluctant to retreat, before reaching their target, when they suffer from HARH. The same is shown by a physician. So it is very important for healthcare professionals working at high altitudes especially in the Himalayas of Nepal to have a good knowledge about HARH and its proper treatment.

Blood Pressure and Altitude: An Observational Cohort Study of Hypertensive and Nonhypertensive Himalayan Trekkers in Nepal.

Keyes, Linda E., Thomas Douglas Sallade, Charles Duke, Jennifer Starling, Alison Sheets, Sushil Pant, David S. Young, David Twillman, Nirajan Regmi, Benoit Phelan, Purshotam Paudel, Matthew McElwee, Luke Mather, Devlin Cole, Theodore McConnell, and Buddha Basnyat. Blood pressure and altitude: an observational cohort study of hypertensive and nonhypertensive Himalayan trekkers in Nepal. High Alt Med Biol. 18:267-277, 2017. OBJECTIVES: To determine how blood pressure (BP) changes with altitude in normotensive versus hypertensive trekkers. Secondary aims were to evaluate the prevalence of severe hypertension (BP ≥180/100 mmHg) and efficacy of different antihypertensive agents at high altitude. METHODS: This was an observational cohort study of resting and 24-hour ambulatory BP in normotensive and hypertensive trekkers at 2860, 3400, and 4300 m in Nepal. RESULTS: We enrolled 672 trekkers age 18 years and older, 60 with a prior diagnosis of hypertension. Mean systolic and diastolic BP did not change between altitudes in normotensive or hypertensive trekkers, but was higher in those with hypertension. However, there was large interindividual variability. At 3400 m, the majority (60%, n = 284) of normotensive participants had a BP within 10 mmHg of their BP at 2860 m, while 21% (n = 102) increased and 19% (n = 91) decreased. The pattern was similar between 3400 and 4300 m (64% [n = 202] no change, 21% [n = 65] increased, 15% [n = 46] decreased). BP decreased in a greater proportion of hypertensive trekkers versus normotensives (36% [n = 15] vs. 21% at 3400 m, p = 0.01 and 30% [n = 7] vs. 15% at 4300 m, p = 0.05). Severe hypertension occurred in both groups, but was asymptomatic. In a small subset of participants, 24-hour ambulatory BP monitoring showed that nocturnal BP decreased in normotensive (n = 4) and increased in hypertensive trekkers (n = 4). CONCLUSIONS: Most travelers, including those with well-controlled hypertension, can be reassured that their BP will remain relatively stable at high altitude. Although extremely elevated BP may be observed at high altitude in normotensive and hypertensive people, it is unlikely to be symptomatic. The ideal antihypertensive regimen at high altitude remains unclear.

Older age, chronic medical conditions and polypharmacy in Himalayan trekkers in Nepal: an epidemiologic survey and case series.

BACKGROUND: The number of tourists in Nepal doubled between 2003 and 2013 is nearly 800 000. With the increased popularity of trekking, the number of those with pre-existing medical conditions requiring access to healthcare is likely to increase. We therefore sought to characterize the demographics and health status of trekkers on the Everest Base Camp route in the Solukhumbu Valley. In addition, we report cases that illustrate the potential complications of an ageing and medicated population of trekkers with underlying diseases. METHODS: Trekkers over 18 years were enrolled in a larger observational cohort study on blood pressure at high altitude at 2860 m. They answered a questionnaire regarding demographics, medical history and current medications. Acute medical problems relating to medication use that were brought to the attention of investigators were documented and are presented as case reports. RESULTS: We enrolled 670 trekkers, 394 (59%) male, with a mean age of 48 years (range 18-76). Pre-existing medical conditions were reported by 223 participants (33%). The most frequent conditions included hypertension, hypercholesterolemia, migraines and thyroid dysfunction. A total of 276 participants (41%) reported taking one or more medications. The most common medications were acetazolamide (79, 12%), antihypertensives (50, 8%) and NSAIDs (47, 7%), with 30 classes of drugs represented. Excluding acetazolamide, older trekkers (age >50 years) were more likely than younger ones to take medications (OR = 2.17; 95% CI 1.57-3.00; P <0.05). Acetazolamide use was not related to age. CONCLUSIONS: Our findings illustrate a wide variety of medical conditions present in trekkers in Nepal with wide-ranging potential complications that could pose difficulties in areas where medical care is scarce and evacuation difficult. Our cases illustrate the potential problems polypharmacy poses in trekkers, and the need for local and expedition healthcare workers to be aware of, and prepared for the common medical conditions present.

A trekker in Nepal with painful skin blisters.

The authors present a case of a 27-year-old woman trekker with painful, slightly itchy eruptions on the dorsum of both hands for 5 days. On examination, she had a papulovesicular rash with some haemorrhagic vesicles over the dorsum of her hands and thumbs.

Quality of life among people living with acquired immune deficiency syndrome receiving anti-retroviral therapy: a study from Nepal.

PURPOSE: The present study was undertaken to determine the impact of acquired immune deficiency syndrome (AIDS) on the quality of life of affected individuals in Nepal. PATIENTS AND METHODS: A cross sectional study was done among 70 individuals attending the Anti-Retroviral Therapy clinic of the University Hospital in Nepal. Quality of life (QOL) was evaluated using World Health Organization Quality of life questionnaire (WHO QOL-BREF) instrument. Statistical analysis was done using SPSS Version 17.0. RESULTS: The median scores with interquartile range (IQR) in four domains of QOL in descending order were physical (61; IQR 22), social (58; IQR 33), environmental (56; IQR 13), and psychological (54; IQR 8). Older age was associated with lower perceived overall QOL. Females were more likely to have lower QOL scores in the social and psychological domains. Higher CD4 counts and a married status were significant predictors of higher QOL scores in the environmental domain. CONCLUSION: Being older, female, single, and having advanced clinical stage is associated with lower QOL scores in people living with AIDS. Lowest QOL scores were seen in the psychological domain suggesting the need of psychological interventions.

Risk factors for surgical site infections in abdominal surgery: a study in Nepal.

BACKGROUND: Surgical site infection (SSI) remains a major clinical problem for developing countries in terms of morbidity, mortality, and hospital cost. Little is known about the epidemiology of SSI in Nepal. We conducted a study in Nepal to identify the various pre- and intra-operative risk factors for SSIs that are accessible to interventions. METHODS: The study was a prospective study done on all eligible patients who underwent abdominal surgery in the surgical wards of Tribhuvan University Teaching Hospital (TUTH) in Kathmandu, Nepal, from January 2011 to June 2011. We evaluated some patient-related as well as intra-operative variables that could be risk factors for SSIs. We assessed the association between these risk factors and SSI with the Fisher exact test and logistic regression analysis. RESULTS: Of the 230 patients included in the study, 53 were identified as having a SSI, resulting in an overall rate of SSI of 23%. Multivariable analysis identified the following factors as independent risk factors for SSI: (1) Low hemoglobin concentrations (<12 g/dL) (odds ratio [OR] 2.5; 95% confidence interval [CI] 1.1-6.1); (2) overweight (OR 7.6; 95% CI 2.1-27.0); and (3) surgery performed by residents (OR 3.4; 95% CI 1.4-8.3). CONCLUSIONS: Surgical site infection is common among patients undergoing abdominal surgery at TUTH. This study identified some preventable risk factors associated with SSI at TUTH. Identification of such risk factors is expected to help surgeons improve patient care and decrease mortality and morbidity as well as the hospital-care cost of surgical patients.