UIAA Medical Commission Recommendations for Mountaineers, Hillwalkers, Trekkers, and Rock and Ice Climbers with Diabetes

Hillebrandt, David, Anil Gurtoo, Thomas Kupper, Paul Richards, Volker Schöffl, Pankaj Shah, Rianne van der Spek, Nikki Wallis, and Jim Milledge. UIAA Medical Commission recommendations for mountaineers, hillwalkers, trekkers, and rock and ice climbers with diabetes. High Alt Med Biol. 24: 110-126.-The object of this advice article is not only to give the diabetic mountaineer general guidance but also to inform his or her medical team of practical aspects of care that may not be standard for nonmountaineers. The guidelines are produced in seven sections. The first is an introduction to the guidelines, and the second is an introduction to this medical problem and is designed to be read and understood by diabetic patients and their companions. The third section is for use in an emergency in mountains. The fourth is for rock, ice, and competition climbers operating in a less remote environment. These initial sections are deliberately written in simple language. The fifth and sixth sections are written for clinicians and those with skills to read more technical information, and the seventh looks at modern technology and its pros and cons in diabetes management in a remote area. Sections One and Two could be laminated and carried when in the mountains, giving practical advice.

Leptospiral myocarditis and pancreatitis

While Leptospira are known to cause multi-system dysfunction, cardiac involvement is uncommon. We present a case febrile myocarditis diagnosed to have leptospirosis. The patient also had pancreatitis, jaundice and renal failure but recovered well with timely management.

Factors associated with mortality among moderate and severe patients with COVID-19 in India: a secondary analysis of a randomised controlled trial

OBJECTIVE

Large data on the clinical characteristics and outcome of COVID-19 in the Indian population are scarce. We analysed the factors associated with mortality in a cohort of moderately and severely ill patients with COVID-19 enrolled in a randomised trial on convalescent plasma.

DESIGN

Secondary analysis of data from a Phase II, Open Label, Randomized Controlled Trial to Assess the Safety and Efficacy of Convalescent Plasma to Limit COVID-19 Associated Complications in Moderate Disease.

SETTING

39 public and private hospitals across India during the study period from 22 April to 14 July 2020.

PARTICIPANTS

Of the 464 patients recruited, two were lost to follow-up, nine withdrew consent and two patients did not receive the intervention after randomisation. The cohort of 451 participants with known outcome at 28 days was analysed.

PRIMARY OUTCOME MEASURE

Factors associated with all-cause mortality at 28 days after enrolment.

RESULTS

The mean (SD) age was 51±12.4 years; 76.7% were males. Admission Sequential Organ Failure Assessment score was 2.4±1.1. Non-invasive ventilation, invasive ventilation and vasopressor therapy were required in 98.9%, 8.4% and 4.0%, respectively. The 28-day mortality was 14.4%. Median time from symptom onset to hospital admission was similar in survivors (4 days; IQR 3-7) and non-survivors (4 days; IQR 3-6). Patients with two or more comorbidities had 2.25 (95% CI 1.18 to 4.29, p=0.014) times risk of death. When compared with survivors, admission interleukin-6 levels were higher (p<0.001) in non-survivors and increased further on day 3. On multivariable Fine and Gray model, severity of illness (subdistribution HR 1.22, 95% CI 1.11 to 1.35, p<0.001), PaO₂/FiO₂ ratio <100 (3.47, 1.64-7.37, p=0.001), neutrophil lymphocyte ratio >10 (9.97, 3.65-27.13, p<0.001), D-dimer >1.0 mg/L (2.50, 1.14-5.48, p=0.022), ferritin ≥500 ng/mL (2.67, 1.44-4.96, p=0.002) and lactate dehydrogenase ≥450 IU/L (2.96, 1.60-5.45, p=0.001) were significantly associated with death.

CONCLUSION

In this cohort of moderately and severely ill patients with COVID-19, severity of illness, underlying comorbidities and elevated levels of inflammatory markers were significantly associated with death.

TRIAL REGISTRATION NUMBER

CTRI/2020/04/024775.

The Syndromic Spectrum of COVID-19 and Correlates of Admission Parameters with Severity-outcome Gradients: A Retrospective Study

BACKGROUND

Clinical and laboratory features of COVID-19 may have regional variations. This study aimed to discern their association with severity of illness and mortality in tertiary setup of Delhi, India.

METHODS

Retrospective data of hospitalised COVID-19 patients over 3 months (end March to June 2020) were evaluated for symptom profile, blood investigations and chest radiograph data and classified according to COVID-19 severity and as survivors and non-survivors.

RESULTS

Average age (n=182) was 46.1 years, male to female ratio 1.4:1. Fever (51.1%), cough (49.4%) and breathlessness (48.3%) were the commonest symptoms, and frequency of all the three increased with severity of COVID-19. Fever duration, leucocytosis, neutrophilia, elevated blood urea, transaminitis and higher Brixia score on chest X-ray were also more in severe COVID-19 compared to mild and moderate categories. Higher age, more comorbidities, fever, breathlessness and chest pain; longer duration of fever, leucocytosis, neutrophilia, lymphopenia, high neutrophil to lymphocyte ratio, elevated serum urea, creatinine, transaminases and hyperglycemia, and higher radiographic Brixia score were observed in non-survivors compared to survivors.

CONCLUSION

Greater prevalence of symptoms (alone and in combination) and derangements in blood biochemistry are seen in severe COVID-19 compared to mild or moderate cases, and also in non-survivors compared to survivors.

Pancreatic Injury in COVID-19 Patients

BACKGROUND AND AIM

Coronavirus disease 2019 (COVID 2019) outbreak caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may cause multisystem dysfunction. We studied pancreatic injury (serum amylase and serum lipase levels) in COVID-19 patients.

METHODS

A retrospective study involving 42 COVID-19 patients (diagnosed by real-time PCR) admitted to a tertiary care hospital was conducted. Serum amylase and serum lipase levels were analysed in relation to severity of COVID-19 and mortality.

RESULTS

Mean age of patients was 50 ± 16 years, with male to female ratio of 3.7:1. Serum amylase was elevated in 14 patients (33%). Serum lipase was elevated in 7 out of 29 patients (24.1%). Mortality was seen in 18 patients (42.8%). Serum amylase or lipase did not correlate with severity of COVID-19 or its mortality. However, both patients who had high lipase (>3times) died.

CONCLUSION

The prevalence of hyperamylasemia in patients of COVID-19 was 33%, while that of elevated lipase was 24.1%. Pancreatic injury failed to show any statistically significant relation to severity or outcome of COVID-19.

Level of Health Literacy Among Type 2 Diabetic Persons and its Relation to Glycemic Control

INTRODUCTION

Health literacy is the degree to which an individual can obtain, process, understand and communicate about health related information to make informed health decisions. Our aim was to study the influence of Diabetic health literacy in affecting the glycemic control in Diabetic patients.

METHODOLOGY

This is a Cross sectional Analytical study in 200 diabetic patients. Diabetic Knowledge Test developed by Michigan Diabetic Research and Training Center was modified after appropriate permission and was used to measure health literacy. HbA1C was used as a measure of glycemic control.

RESULTS

In the study population, Median HbA1C was 9 gm% with Interquartile Range (IQR) of 6.10-11.80 in low health literacy group, 7.80 with an IQR of 5.95-9.32 in marginal health literacy group and 6.20 with an IQR of 5.38-7.90 in adequate health literacy group (P Value <0.001). After adjusting for socio demographic characteristics, Linear regression analysis showed that HbA1C decreased by 0.385 for every one point increase in Questionnaire score [Std.error 0.60, 95% C.I. "-0.502 to -0.267, P Value <0.001]. The Odds of achieving adequate glycemic control was 0.309 in marginal health literacy group and 0.205 in low health literacy group. (95% C.I=0.092-0.455). On applying Pearson's correlation between answer score and HbA1C,we got correlation coefficient "r"=-0.417 indicating a strong negative correlation. We also found that patients with low health literacy had higher chances of developing hospitalizations (P=0.027), Neuropathy (P =0.001) and retinopathy (P=0.049).

CONCLUSION

This study shows that inadequate health literacy is an independent predictor of glycemic control and complications. Development of strategies to communicate more effectively with patients who have poor health literacy are needed at the patient clinician level and the patient system level and should be based on a deeper understanding of the needs and competencies of patients with poor health literacy.

Physiology and Medicine at High Altitude: The Exposure and the Stress

<p>Increase in altitude causes decrease in atmospheric barometric pressure that results in decrease of inspired<br />partial pressure of oxygen, a source for stress and pose a challenge to climbers/trekkers or persons posted on<br />high altitude areas. This review discusses about the high altitude sickness, their incidence rates, pathophysiology<br />and the classic model of acclimatisation, which explains about how oxygen requirement in extreme environment<br />is achieved by complex interplay among pulmonary, hematological and cardiovascular processes. The acute<br />high altitude illness (AHAI) is basically composed of two syndromes: cerebral and pulmonary that can afflict<br />un-acclimatised climbers/trekkers. The cerebral syndrome includes acute mountain sickness (AMS) and high<br />altitude cerebral oedema (HACO) and pulmonary syndrome typically refers to high altitude pulmonary oedema<br />(HAPO). The core physiological purpose, according to the classic model is centered upon the optimisation of<br />increased delivery of oxygen to the cells through a coherent response involving increased ventilation, cardiac<br />output and hemoglobin concentration with aim to increase the oxygen flux across the oxygen cascade, which<br />will help in preventing the development of majority of high altitude illness.</p>

Fulminant hepatic failure in a 15 year old boy with borderline lepromatous leprosy and type 2 reaction

The liver is the most frequently affected visceral organ in leprosy, particularly in the multibacillary group. Administration of hepatotoxic drugs may also affect liver function. We report the case of a male patient, diagnosed as borderline lepromatous leprosy with Type 2 reaction, who was managed with multibacillary multidrug therapy and steroids, and who then developed acute hepatitis and succumbed to sudden cardiac death. Although erythema nodosum leprosum has been described as a rare cause of death in the literature, such an occurrence in the present era when leprosy has been eliminated needs a special mention.

First case of mirtazepine-induced Stevens-Johnson syndrome from India

A 28-year-old woman, a known case of systemic lupus erythematosus (SLE), was admitted with mucocutaneous ulceroerosive lesions with blisters and thrombocytopenia after taking antidepressant mirtazepine. Exacerbation of SLE and drug-induced eruption was diagnosed. Clinical and laboratory markers were suggestive of Stevens-Johnson syndrome. This is a rare adverse effect of the newer generation antidepressant mirtazepine.

A study of acceptability & feasibility of integrating humanities based study modules in undergraduate curriculum

BACKGROUND & OBJECTIVES

The field of medical education in our country remains deeply fragmented and polarised between the biomedical technical domains which are overrepresented and the humanitarian domains which are under-represented within the universe of medical pedagogy. To overcome this imbalance, we designed a module that integrates the two domains in a holistic biomedical and socio-cultural framework with the objective of providing unified field of learning experience to the undergraduate medical students attending rotatory clinical postings in a medical college in New Delhi, India.

METHODS

Undergraduate medical students of 6 th and 8 th semesters were enrolled in humanities based study module (HSM) on voluntary basis for a total duration of six months. During their compulsory rotatory medicine ward posting, they were introduced and exposed to learning bedside experience of HSM with various tools of art and literature in the form of poem, short narratives, paintings, sketches and group discussions to express their feelings about patients' sufferings. Students' feed-back was recorded through an anonymized questionnaire.

RESULT

Of the 235 students, 223 (95%) enrolled themselves voluntarily and 94 per cent (210 of 223) of them completed the total six month duration of the study module. Seventy three per cent of the students found HSM effective in improving their affective motivational behavior, 82 per cent found it effective in motivating them to learn more about core medical subjects, and 85 per cent wanted its continuation as part of medical curriculum.

INTERPRETATION & CONCLUSIONS

The positive response of the students towards the HSM was an indicator of the potential for integrating the module within the undergraduate medical curriculum.

Apolipoprotein A1 gene polymorphism (G-75A and C+83T) in patients with myocardial infarction: a pilot study in a north Indian population

The apolipoprotein A1 gene polymorphism (G-75A and C+83T) was studied in 100 subjects (50 patients diagnosed with myocardial infarction and 50 healthy subjects). Serum apolipoprotein (apo) A1 and apo B levels were estimated immunoturbidometrically. Extracted DNA from blood was amplified by polymerase chain reaction, digested with MspI restriction enzyme, run on 8% polyacrylamide gel, and restriction fragment length polymorphism was studied by using a gel documentation system. Serum (mean +/- SD) apo A1 levels were significantly higher in control subjects than the study group (100.80 +/- 7.06 mg/dL [1.0 +/- 0.07 g/L] and 72.56 +/- 9.86 mg/dL [0.73 +/- 0.1 g/L], respectively; P < .0001), whereas apo B levels were significantly lower (72.12 +/- 11.32 mg/dL [0.7 +/- 0.1 g/L] and 97.45 +/- 9.04 mg/dL [1.0 +/- 0.09 g/L], respectively; P < .0001). The G allele frequency at the -75-base-pair (bp) site was higher in the study group (79%) compared with the control group (58%). The T allele frequency at the +83-bp site was higher in the study group (56%) than in the control group (32%). G at -75 bp upstream from the start of transcription and T at +83 bp in the first intron may be susceptibility alleles for myocardial infarction.

Dengue encephalitis: an entity now common in dengue-prone regions

As well as dengue fever (DF) and dengue haemorrhagic fever-dengue shock syndrome (DHF/DSS), other atypical manifestations of dengue virus infection have also been reported. The frequency of CNS involvement in dengue remains unknown, although isolated cases with neurological manifestations have been reported in Southeast Asia, Malaysia, Burma, Puerto Rico and India. We present two cases of encephalitis associated with DF and DHF from New Delhi, India.

Acute intermittent porphyria as a cause of acute respiratory failure

A fatal case of acute intermittent porphyria in a 22 years old Indian male is reported. He presented with abdominal pain and constipation, subsequently developed status epilepticus, acute respiratory failure and quadriparesis. He succumbed to the illness on the twelfth day. Among the neuromuscular causes of acute respiratory failure, requiring ventilatory support, porphyria is a condition potentially treatable, but rarely suspected.

Hypocalcemia-induced reversible hemodynamic dysfunction

A series of three cases of 'hypocalcemic dysfunction' that reflects a range of clinical profiles from a purely calcium responsive peripheral collapse to paroxysmal nocturnal dyspnea and orthopnea is reported. The underlying diversity of clinical presentation is noteworthy, as is its prompt response to calcium therapy.

Worsening heart failure in a case of rheumatic heart disease--the hypocalcaemic link

A case of rheumatic heart disease is reported with hypocalcaemia due to hypoparathyroidism. This rare combination has therapeutic implications which affect the course and outcome of the cardiac symptoms.