Clinical Conundrum: Return to High Altitude After Cerebral Venous Sinus Thrombosis.

Luks, Andrew M., Thomas G. DeLoughery, Jeffrey H. Gertsch, and Suzy Stokes. Clinical conundrum: return to high altitude after cerebral venous sinus thrombosis. High Alt Med Biol. 00:00-00, 2024.

Management of high altitude pulmonary edema in the Himalaya: a review of 56 cases presenting at Pheriche medical aid post (4240 m).

OBJECTIVE: The purpose of this study was to review the patient characteristics and management of 56 cases of high altitude pulmonary edema at the Pheriche Himalayan Rescue Association Medical Aid Post, and to measure the use of medications in addition to descent and oxygen. METHODS: In a retrospective case series, we reviewed all patients diagnosed clinically with high altitude pulmonary edema during the 2010 Spring and Fall seasons. Nationality, altitude at onset of symptoms, physical examination findings, therapies administered, and evacuation methods were evaluated. RESULTS: Of all patients, 23% were Nepalese, with no difference in clinical features compared with non-Nepalese patients; 28% of all patients were also suspected of having high altitude cerebral edema. Symptoms developed in 91% of all patients at an altitude higher than the aid post (median altitude of onset of 4834 m); 83% received oxygen therapy, and 87% received nifedipine, 44% sildenafil, 32% dexamethasone, and 39% acetazolamide. Patients who were administered sildenafil, dexamethasone, or acetazolamide had presented with significantly lower initial oxygen saturations (P ≤ .05). After treatment, 93% of all patients descended; 38% descended on foot without a supply of oxygen. CONCLUSIONS: A significant number of patients presenting to the Pheriche medical aid post with high altitude pulmonary edema were given dexamethasone, sildenafil, or acetazolamide in addition to oxygen, nifedipine, and descent. This finding may be related to perceived severity of illness and evacuation limitations. Although no adverse effects were observed, the use of multiple medications is not supported by current evidence and should not be widely adopted without further study.

Practical psychosocial care for providers of pre-hospital care: a summary of the report 'valuing staff, valuing patients'.

BACKGROUND: Caring for people who are ill or injured in pre-hospital environments is emotionally draining and physically demanding. This article focuses on the Psychosocial and Mental Health Programme commissioned by the Faculty of Pre-Hospital Care (FPHC) at the Royal College of Surgeons of Edinburgh (RCSEd) in 2018 to investigate the experiences and needs of responders to pre-hospital emergencies and make recommendations. It summarises the report to FPHC published in 2022, and adds material from research published subsequently. METHOD: FPHC appointed a team to undertake the work. Team members conducted a literature review, and a systematic review of the literature concerning the impacts on the mental health of pre-hospital practitioners. They conducted fieldwork, participated in training and had conversations with trainees and established practitioners, and took evidence from the Pre-hospital Emergency Medicine Trainees Association (PHEMTA). RESULTS: The Results summarise the evidence-based theoretical background derived from the programme and practical guidance for practitioners, professional organisations, and employers who deliver pre-hospital care on the implications of, preventing and intervening with pre-hospital providers who experience psychosocial and mental health problems. CONCLUSION: This paper summarises the outputs from a multidisciplinary programme of scholarship, research, and fieldwork. The authors condense the findings and the guidance developed by the Programme Team to provide a summary of the report and guidance on implementation. They believe that the recommendations are applicable to all healthcare organisations and particularly those that employ responders to emergencies and provide pre-hospital care.

Managing anaphylaxis in a jungle environment.

Anaphylaxis is a medical emergency requiring prompt action to prevent death from cardio-respiratory collapse. It can be a biphasic, unpredictable, and challenging reaction to deal with even in a hospital environment. The wilderness environments afforded by expeditions, remote health posts, and military exercises pose additional challenges often involving casualty evacuation. This article identifies and addresses some of these points using a case report from the Costa Rican jungle.

The effect of angiotensin-converting enzyme genotype on acute mountain sickness and summit success in trekkers attempting the summit of Mt. Kilimanjaro (5,895 m).

The I-allele rather than the D-allele of the human angiotensin converting enzyme (ACE) gene has been associated with high-altitude mountaineering success. We investigated whether the I-allele was associated with summit success, and also with AMS development, in altitude-naïve trekkers. Subjects ascended from 1,860 m to the summit over 4 days (n = 34, 'direct-profile') or 5 days (n = 82, 'slower-profile'). Proportionally more II direct-profile subjects were successful than ID or DD, although the difference was not significant (100% of II subjects, 52% ID and 43% DD, P = 0.09). There was no difference in success amongst subjects on the slower-profile (50% II, 45% ID and 58% DD, P = 0.54). There was a non-significant trend for increasing AMS scores in ID/DD subjects. Amongst tourist trekkers on Mt. Kilimanjaro the I-allele is not associated with summit success. No evidence is found to support an association between ACE genotype and AMS development.

Determinants of summiting success and acute mountain sickness on Mt Kilimanjaro (5895 m).

OBJECTIVE: To determine the incidence of acute mountain sickness (AMS), the frequency of summiting success, and the factors that affect these in trekkers on Kilimanjaro, one of the world's most summitted high-altitude peaks. METHODS: The study group comprised 312 trekkers attempting Mt Kilimanjaro summit by the Marango Route. Trekkers ascended over 4 or 5 days along a fixed ascent profile, stopping at 3 huts on ascent (2700 m, 3700 m, and 4700 m) before attempting the summit. Researchers were stationed at each hut for 16 days. Each night we measured heart rate, respiratory rate, blood pressure, oxygen saturation, and Lake Louise Score. We recorded the highest altitude that trekkers reached on the mountain. RESULTS: Of 181 complete sets of data, 111 (61%) trekkers reached the summit, and 139 (77%) developed AMS. Physiological results were not related to summit success. The incidence of AMS and summiting success were similar in those on the 4- or 5-day route. Trekkers on the 5-day route who used acetazolamide were less likely to develop AMS and more likely to summit than were those not taking acetazolamide (P = <.05); this difference was not present with trekkers on the 4-day route. CONCLUSIONS: The risk of developing AMS is high on Mt Kilimanjaro. Although taking an extra day to acclimatize with the use of acetazolamide did provide some protection against AMS, ideally trekkers need a more gradual route profile for climbing this mountain.

What to Expect Working as a Doctor at a High-Altitude Aid Post.

Over the past 40 years, in an attempt to reduce the morbidity and mortality of altitude illness, a number of volunteer-run, seasonal aid posts have been established at mountain ranges across the world. As each aid post is designed for the local population and tourists at hand, the range of problems seen and services offered vary accordingly. Although each clinic differs on its funding model, the services it offers, how it is staffed, and the interventions available, there are key similarities between each of these clinics. For physicians preparing to travel from their home country to volunteer at such aid posts, there are important preparations that need to be made before embarking on such endeavors. This article describes how to prepare for such work, what to expect, and some of the challenges that one might face.

Acceptability of perinatal rapid point-of-care HIV testing in an area of low HIV prevalence in the UK.

OBJECTIVE: To determine the uptake of current antenatal HIV testing, the prevalence of risk factors for HIV in pregnant women and the acceptability of the rapid point-of-care HIV test (RPOCT) among pregnant women and their midwives. DESIGN: A retrospective review of 717 notes to determine current HIV screening practices and a cross-sectional survey using a self-completed questionnaire for pregnant women and midwives. SETTING: The antenatal clinic (ANC) and postnatal wards (PNW) at a university teaching hospital in the West Midlands. PARTICIPANTS: 486 women attending the ANC or admitted to the PNW during a fortnight in May-June 2006. 72 midwives on the delivery ward completed a second questionnaire. RESULTS: The questionnaire showed that 90.4% of those offered the standard HIV test accepted it, with 7.2% having at least one risk factor for HIV. Over half of the decliners perceived themselves as not at risk. 85.2% would accept the rapid test, including 35.6% of the decliners. 92.8% of midwives agreed/strongly agreed the RPOCT has a role on the delivery ward and 97.2% would be happy to offer the test with appropriate training and guidance. CONCLUSIONS: Midwives deem the RPOCT to be appropriate for a variety of perinatal settings. It is also acceptable to a clinically significant proportion of those who decline the standard test (21 of 59) and therefore has the potential to increase screening and detection rates. Hence, by allowing early diagnosis and the initiation of antenatal interventions, it could reduce the rate of mother-to-child transmission (MTCT) in the UK.