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Xiaoshan Z, Huan C, Zhilin G, Liwen M, Yan Z, Yue C. Hypoxia-inducible factor-1α attenuates renal podocyte injury in male rats in a simulated high-altitude environment by upregulating Krüppel-like factor 4 expression. Exp Physiol 2024; 109:1188-1198. [PMID: 38774964 PMCID: PMC11215487 DOI: 10.1113/ep091443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 04/12/2024] [Indexed: 07/02/2024]
Abstract
Previous studies have shown that podocyte injury is involved in the development of proteinuria in rats under hypobaric hypoxia conditions. Prolyl hydroxylase inhibitors (PHIs) may reduce proteinuria. This study aimed to further investigate whether the protective effects of hypoxia-inducible factor 1α (HIF1α) on podocyte injury induced by hypobaric hypoxia are related to Krüppel-like factor 4 (KLF4). Rats were housed in a low-pressure oxygen chamber to simulate a high-altitude environment (5000 m), and a PHI was intraperitoneally injected. Urinary protein electrophoresis was performed and the morphology of the podocytes was observed by electron microscopy. Rat podocytes were cultured under 1% O2, and siRNA was used to interfere with KLF4 expression. The protein expression levels of HIF1α, KLF4, CD2-associated protein (CD2AP) and nephrin were determined by western blotting. Compared with those in the experimental group, the rats in the intervention group on day 14 had lower urinary protein levels, increased protein expression levels of CD2AP and nephrin, and reduced podocyte injury. The results of in vitro experiments showed that the protein expression levels of KLF4, CD2AP and nephrin were greater in the PHI intervention group and lower in the HIF1α inhibitors group than in the low-oxygen group. The protein expression of CD2AP and nephrin in the siKLF4-transfected podocytes treated with PHI and HIF1α inhibitors did not differ significantly from that in the low-oxygen group. HIF1α may be involved in reducing progressive high-altitude proteinuria by regulating KLF4 expression and contributing to the repair of podocyte injury induced by hypobaric hypoxia.
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Affiliation(s)
- Zeng Xiaoshan
- College of MedicineSouthwest Jiaotong UniversityChengduPR China
| | - Cheng Huan
- College of MedicineSouthwest Jiaotong UniversityChengduPR China
| | - Gan Zhilin
- College of MedicineSouthwest Jiaotong UniversityChengduPR China
| | - Mo Liwen
- Department of NephrologyGeneral Hospital of Western Theater Command of PLAChengduPR China
| | - Zeng Yan
- Department of NephrologyGeneral Hospital of Western Theater Command of PLAChengduPR China
| | - Cheng Yue
- College of MedicineSouthwest Jiaotong UniversityChengduPR China
- Department of NephrologyGeneral Hospital of Western Theater Command of PLAChengduPR China
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2
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Vizcarra-Vizcarra CA. Letter to the Editor: Some Considerations on the Article "High-Altitude Renal Syndrome". High Alt Med Biol 2024. [PMID: 38742993 DOI: 10.1089/ham.2024.0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024] Open
Affiliation(s)
- Cristhian A Vizcarra-Vizcarra
- Nephrology Division, Honorio Delgado Regional Hospital, Arequipa, Peru
- Faculty of Medicine, Santa Maria Catholic University, Arequipa, Peru
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3
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Aoun M, Chelala D. Where do you live and what do you do? Two questions that might impact your kidney health. FRONTIERS IN NEPHROLOGY 2022; 2:1011964. [PMID: 37675017 PMCID: PMC10479685 DOI: 10.3389/fneph.2022.1011964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 09/13/2022] [Indexed: 09/08/2023]
Abstract
In many cases the social determinants of health need to be assessed through their interaction with environmental factors. This review looks at the impact of physical location and occupation of individuals on their kidney health. It examines the effect of living at high altitude on kidney function and the relationship between extreme cold or hot temperatures and the incidence of kidney injury. It reviews as well the many occupations that have been linked to kidney disease in high-income and low-and-middle-income countries. As a conclusion, this overview proposes preventive recommendations that could be individualized based on weather, altitude, socio-economic level of the country and occupation of the individual.
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Affiliation(s)
- Mabel Aoun
- Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon
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4
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Yang Y, Peng Y, He S, Wu J, Xie Q, Ma Y. The Clinical Differences of Patients With Traumatic Brain Injury in Plateau and Plain Areas. Front Neurol 2022; 13:848944. [PMID: 35547378 PMCID: PMC9081812 DOI: 10.3389/fneur.2022.848944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Traumatic brain injury (TBI) is a leading cause of death and disability, which tends to have a worse clinical recovery if it occurs in plateau areas than in plain areas. To explore the underlying cause of this outcome preliminarily, this retrospective study was conducted to compare the clinical differences of patients with TBI in plateau and plain areas. Methods In this study, 32 patients with TBI in plateau areas (altitude ≥ 4,000 m) and 32 in plain areas (altitude ≤ 1,000 m) were recruited according to the inclusion and exclusion criteria from June 2020 to December 2021. The collected data and compared parameters include clinical features, head CT presentations and Marshall classifications, hematology profile, lipid profile, coagulation profile, and multiorgan (cardiac, liver, renal) function within 24 h of hospital admission, as well as the treatment method and final outcome. Results There were no obvious differences in demographic characteristics, including gender, age, height, and weight, between patients with TBI in plateau and plain areas (all P > 0.05). Compared to patients with TBI in plain areas, the time before hospital admission was longer, heartbeat was slower, systolic blood pressure (SBP) was lower, and hospital stays were longer in patients with TBI in plateau areas (all P < 0.05). More importantly, elevated red blood cells (RBCs) count and hemoglobin (HGB) level, enhanced coagulation function, and higher rates of multiorgan (cardiac, liver, and renal) injury were found in patients with TBI in plateau areas (all P < 0.05). Conclusion Patients with TBI in plateau areas presented with altered clinical characteristics, enhanced coagulation function, and aggravated predisposition toward multiorgan (cardiac, liver, and renal) injury, compared to patients with TBI in plain areas. Future prospective studies are needed to further elucidate the influences of high altitude on the disease course of TBI.
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Affiliation(s)
- Yongxiang Yang
- Department of Neurosurgery, General Hospital of Western Theater Command, Chengdu, China
| | - Yuping Peng
- Department of Neurosurgery, General Hospital of Western Theater Command, Chengdu, China.,Department of Neurosurgery, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Siyi He
- Department of Cardiovascular Surgery, General Hospital of Western Theater Command, Chengdu, China
| | - Jianping Wu
- Department of Neurosurgery, General Hospital of Western Theater Command, Chengdu, China
| | - Qingyun Xie
- Department of Orthopedic, General Hospital of Western Theater Command, Chengdu, China
| | - Yuan Ma
- Department of Neurosurgery, General Hospital of Western Theater Command, Chengdu, China
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Scultetus AH, Jefferson MA, Haque A, Hubbell JN, Arnaud FG, Moon-Massat P, McCarron RM, Malone DL. Histopathological Evidence of Multiple Organ Damage After Simulated Aeromedical Evacuation in a Swine Acute Lung Injury Model. Mil Med 2020; 185:57-66. [PMID: 32074309 DOI: 10.1093/milmed/usz248] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Rapid aeromedical evacuation (AE) is standard of care in current conflicts. However, not much is known about possible effects of hypobaric conditions. We investigated possible effects of hypobaria on organ damage in a swine model of acute lung injury. METHODS Lung injury was induced in anesthetized swine via intravenous oleic acid infusion. After a stabilization phase, animals were subjected to a 4 hour simulated AE at 8000 feet (HYPO). Control animals were kept at normobaria. After euthanasia and necropsy, organ damage was assessed by combined scores for hemorrhage, inflammation, edema, necrosis, and microatelectasis. RESULTS Hemodynamic, neurological, or hematologic measurements were similar prior to transport. Hemodynamic instability became apparent during the last 2 hours of transport in the HYPO group. Histological injury scores in the HYPO group were higher for all organs (lung, kidney, liver, pancreas, and adrenal glands) except the brain, with the largest difference in the lungs (P < 0.001). CONCLUSIONS Swine with mild acute lung injury subjected to a 4 hour simulated AE showed more injury to most organs and, in particular, to the lungs compared with ground transport. This may exacerbate otherwise subclinical pathology and, eventually, manifest as abnormalities in gas exchange or possibly end-organ function.
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Affiliation(s)
- Anke H Scultetus
- Neuro Trauma Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910.,Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Michelle A Jefferson
- Department of Pathology, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD 20910
| | - Ashraful Haque
- Neuro Trauma Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910.,Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive, Bethesda, MD 20817
| | - Jordan N Hubbell
- Neuro Trauma Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910.,Parsons, 100 West Walnut Street, Pasadena, CA 91124.,Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive, Bethesda, MD 20817
| | - Francoise G Arnaud
- Neuro Trauma Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910.,Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814.,Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive, Bethesda, MD 20817
| | - Paula Moon-Massat
- Neuro Trauma Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910.,Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive, Bethesda, MD 20817
| | - Richard M McCarron
- Neuro Trauma Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910.,Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Debra L Malone
- Neuro Trauma Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910.,Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814.,Department of Surgery, Walter Reed National Military Medical Center, 4494 North Palmer Road, Bethesda, MD 20889
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Chronic lifestyle diseases display seasonal sensitive comorbid trend in human population evidence from Google Trends. PLoS One 2018; 13:e0207359. [PMID: 30540756 PMCID: PMC6291106 DOI: 10.1371/journal.pone.0207359] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 10/30/2018] [Indexed: 02/08/2023] Open
Abstract
Seasonal and human physiological changes are important factors in the development of many diseases. But, the study of genuine seasonal impact on these diseases is difficult to measure due to many other environment and lifestyle factors which directly affect these diseases. However, several clinical studies have been conducted in different parts of the world, and it has clearly indicated that certain groups of population are highly subjected to seasonal changes, and their maladaptation can possibly lead to several disorders/diseases. Thus, it is crucial to study the significant seasonal sensitive diseases spread across the human population. To narrow down these disorders/diseases, the study hypothesized that high altitude (HA) associated diseases and disorders are of the strong variants of seasonal physiologic changes. It is because, HA is the only geographical condition for which humans can develop very efficient physiological adaptation mechanism called acclimatization. To study this hypothesis, PubMed was used to collect the HA associated symptoms and disorders. Disease Ontology based semantic similarity network (DSN) and disease-drug networks were constructed to narrow down the benchmark diseases and disorders of HA. The DSN which was further subjected to different community structure analysis uncovered the highly associated or possible comorbid diseases of HA. The predicted 12 lifestyle diseases were assumed to be “seasonal (sensitive) comorbid lifestyle diseases (SCLD)”. A time series analyses on Google Search data of the world from 2004–2016 was conducted to investigate whether the 12 lifestyle diseases have seasonal patterns. Because, the trends were sensitive to the term used as benchmark; the temporal relationships among the 12 disease search volumes and their temporal sequences similarity by dynamic time warping analyses was used to predict the comorbid diseases. Among the 12 lifestyle diseases, the study provides an indirect evidence in the existence of severe seasonal comorbidity among hypertension, obesity, asthma and fibrosis diseases, which is widespread in the world population. Thus, the present study has successfully addressed this issue by predicting the SCLD, and indirectly verified them among the world population using Google Search Trend. Furthermore, based on the SCLD seasonal trend, the study also classified them as severe, moderate, and mild. Interestingly, seasonal trends of the severe seasonal comorbid diseases displayed an inverse pattern between USA (Northern hemisphere) and New Zealand (Southern hemisphere). Further, knowledge in the so called “seasonal sensitive populations” physiological response to seasonal triggers such as winter, summer, spring, and autumn become crucial to modulate disease incidence, disease course, or clinical prevention.
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Chhabra V, Anand AS, Baidya AK, Malik SM, Kohli E, Reddy MPK. Hypobaric hypoxia induced renal damage is mediated by altering redox pathway. PLoS One 2018; 13:e0195701. [PMID: 30005088 PMCID: PMC6044529 DOI: 10.1371/journal.pone.0195701] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 03/28/2018] [Indexed: 12/29/2022] Open
Abstract
Systemic hypobaric hypoxia is reported to cause renal damage; nevertheless the exact pathophysiological mechanisms are not completely understood. Therefore, the present study aims to explore renal pathophysiology by using proteomics approach under hypobaric hypoxia. Six to eight week old male Sprague Dawley rats were exposed to hypobaric hypoxia equivalent to altitude of 7628 metres (pO2-282mmhg) at 28°C and 55% humidity in decompression chamber for different time intervals; 1, 3, and7 days. Various physiological, proteomic and bioinformatic studies were carried out to examine the effect of chronic hypobaric hypoxia on kidney. Our data demonstrated mild to moderate degenerative tubular changes, altered renal function, injury biomarkers and systolic blood pressure with increase in duration of hypobaric hypoxia exposure. Renal proteomic analysis showed 38 differential expressed spots, out of which 25 spots were down regulated and 13 were up regulated in 7 dayhypobarichypoxic exposure group of rats as compared to normoxia control. Identified proteins were involved in specific molecular changes pertinent to endogenous redox pathways, cellular integrity and energy metabolism. The study provides an empirical evidence of renal homeostasis under hypobaric hypoxia by investigating both physiological and proteomics changes. The identification of explicit key proteins provides a valuable clue about redox signalling mediated renal damage under hypobaric hypoxia.
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Affiliation(s)
- Varun Chhabra
- Cardio-Respiratory Division, Defence Institute of Physiology and Allied Sciences (DIPAS), Defence Research and Development Organisation (DRDO), Ministry of Defence, Timarpur, Delhi, India
| | - Avnika Singh Anand
- Neurobiology Division, Defence Institute of Physiology and Allied Sciences (DIPAS), Defence Research and Development Organisation (DRDO), Ministry of Defence, Timarpur, Delhi, India
| | - Amit Kumar Baidya
- Cardio-Respiratory Division, Defence Institute of Physiology and Allied Sciences (DIPAS), Defence Research and Development Organisation (DRDO), Ministry of Defence, Timarpur, Delhi, India
| | - Shajer Manzoor Malik
- Cardio-Respiratory Division, Defence Institute of Physiology and Allied Sciences (DIPAS), Defence Research and Development Organisation (DRDO), Ministry of Defence, Timarpur, Delhi, India
| | - Ekta Kohli
- Neurobiology Division, Defence Institute of Physiology and Allied Sciences (DIPAS), Defence Research and Development Organisation (DRDO), Ministry of Defence, Timarpur, Delhi, India
| | - Maramreddy Prasanna Kumar Reddy
- Cardio-Respiratory Division, Defence Institute of Physiology and Allied Sciences (DIPAS), Defence Research and Development Organisation (DRDO), Ministry of Defence, Timarpur, Delhi, India
- * E-mail: ,
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8
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Echoes from Gaea, Poseidon, Hephaestus, and Prometheus: environmental risk factors for high blood pressure. J Hum Hypertens 2018; 32:594-607. [PMID: 29899375 DOI: 10.1038/s41371-018-0078-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 05/01/2018] [Indexed: 12/14/2022]
Abstract
High blood pressure (BP) affects over one billion people and is the leading risk factor for global mortality. While many lifestyle and genetic risk factors are well-accepted to increase BP, the role of the external environment is typically overlooked. Mounting evidence now supports that numerous environmental factors can promote an elevation in BP. Broadly speaking these include aspects of the natural environment (e.g., cold temperatures, higher altitude, and winter season), natural disasters (e.g., earthquakes, volcanic eruptions), and man-made exposures (e.g., noise, air pollutants, and toxins/chemicals). This is important for health care providers to recognize as one (or several) of these environmental factors could be playing a clinically meaningful role in elevating BP or disrupting hypertension control among their patients. At the population level, certain environmental exposures may even be contributing to the growing pandemic of hypertension. Here we provide an updated review of the literature linking environment exposures with high BP and outline practical recommendations for clinicians.
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Shamloo K, Chen J, Sardar J, Sherpa RT, Pala R, Atkinson KF, Pearce WJ, Zhang L, Nauli SM. Chronic Hypobaric Hypoxia Modulates Primary Cilia Differently in Adult and Fetal Ovine Kidneys. Front Physiol 2017; 8:677. [PMID: 28979210 PMCID: PMC5611369 DOI: 10.3389/fphys.2017.00677] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 08/24/2017] [Indexed: 11/13/2022] Open
Abstract
Hypoxic environments at high altitude have significant effects on kidney injury. Following injury, renal primary cilia display length alterations. Primary cilia are mechanosensory organelles that regulate tubular architecture. The effect of hypoxia on cilia length is still controversial in cultured cells, and no corresponding in vivo study exists. Using fetal and adult sheep, we here study the effect of chronic hypobaric hypoxia on the renal injury, intracellular calcium signaling and the relationship between cilia length and cilia function. Our results show that although long-term hypoxia induces renal fibrosis in both fetal and adult kidneys, fetal kidneys are more susceptible to hypoxia-induced renal injury. Unlike hypoxic adult kidneys, hypoxic fetal kidneys are characterized by interstitial edema, tubular disparition and atrophy. We also noted that there is an increase in the cilia length as well as an increase in the cilia function in the hypoxic fetal proximal and distal collecting epithelia. Hypoxia, however, has no significant effect on primary cilia in the adult kidneys. Increased cilia length is also associated with greater flow-induced intracellular calcium signaling in renal epithelial cells from hypoxic fetuses. Our studies suggest that while hypoxia causes renal fibrosis in both adult and fetal kidneys, hypoxia-induced alteration in cilia length and function are specific to more severe renal injuries in fetal hypoxic kidneys.
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Affiliation(s)
- Kiumars Shamloo
- Department of Biomedical and Pharmaceutical Sciences, Chapman UniversityIrvine, CA, United States
| | - Juan Chen
- Department of Biomedical and Pharmaceutical Sciences, Chapman UniversityIrvine, CA, United States
| | - Jasmine Sardar
- Department of Biomedical and Pharmaceutical Sciences, Chapman UniversityIrvine, CA, United States
| | - Rinzhin T Sherpa
- Department of Biomedical and Pharmaceutical Sciences, Chapman UniversityIrvine, CA, United States
| | - Rajasekharreddy Pala
- Department of Biomedical and Pharmaceutical Sciences, Chapman UniversityIrvine, CA, United States
| | - Kimberly F Atkinson
- Department of Biomedical and Pharmaceutical Sciences, Chapman UniversityIrvine, CA, United States
| | - William J Pearce
- Departments of Basic Sciences, Physiology and Pharmacology, Lawrence D. Longo MD Center for Perinatal Biology, Loma Linda University School of MedicineLoma Linda, CA, United States
| | - Lubo Zhang
- Departments of Basic Sciences, Physiology and Pharmacology, Lawrence D. Longo MD Center for Perinatal Biology, Loma Linda University School of MedicineLoma Linda, CA, United States
| | - Surya M Nauli
- Department of Biomedical and Pharmaceutical Sciences, Chapman UniversityIrvine, CA, United States.,Division of Nephrology and Hypertension, Department of Medicine, University of California, IrvineIrvine, CA, United States
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Keyes LE, Sallade TD, Duke C, Starling J, Sheets A, Pant S, Young DS, Twillman D, Regmi N, Phelan B, Paudel P, McElwee M, Mather L, Cole D, McConnell T, Basnyat B. Blood Pressure and Altitude: An Observational Cohort Study of Hypertensive and Nonhypertensive Himalayan Trekkers in Nepal. High Alt Med Biol 2017; 18:267-277. [DOI: 10.1089/ham.2017.0001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- Linda E. Keyes
- Department of Emergency Medicine, University of Colorado, Aurora, Colorado
- Longmont United Hospital, Longmont, Colorado
| | | | - Charles Duke
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jennifer Starling
- Department of Emergency Medicine, University of Colorado, Aurora, Colorado
- Colorado Permanente Medical Group, Saint Joseph Hospital, Denver, Colorado
| | | | - Sushil Pant
- Mountain Medicine Society of Nepal and Kunde Hospital, Kathmandu, Nepal
| | - David S. Young
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
| | - David Twillman
- Department of Emergency Medicine, University of Colorado, Aurora, Colorado
| | - Nirajan Regmi
- Mountain Medicine Society of Nepal, Kathmandu, Nepal
| | | | - Purshotam Paudel
- Mountain Medical Society of Nepal and District Hospital, Dhading, Nepal
| | - Matthew McElwee
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Luke Mather
- Family Medicine Residency of Idaho, Boise, Idaho
- University of Washington School of Medicine, Seattle, Washington
| | - Devlin Cole
- Kapiolani Women and Children's Hospital, Honolulu, Hawaii
| | | | - Buddha Basnyat
- Oxford University Clinical Research Unit-Nepal, Nepal and Nepal International Clinic, Kathmandu, Nepal
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
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