Wilderness Preparticipation Evaluation and Considerations for Special Populations.

Children, older adults, disabled and special needs athletes, and female athletes who participate in outdoor and wilderness sports and activities each face unique risks. For children and adolescents traveling to high altitude, the preparticipation physical evaluation should focus on risk assessment, prevention strategies, early recognition of altitude-related symptoms, management plans, and appropriate follow-up. As the risk and prevalence of chronic disease increases with age, both older patients and providers need to be aware of disease and medication-specific risks relative to wilderness sport and activity participation. Disabled and special needs athletes benefit from careful pre-event planning for the potential medical issues and equipment modifications that may affect their health in wilderness environments. Issues that demand special consideration for female adventurers include pregnancy, contraceptive use, menses, and ferritin levels at altitude. A careful preparticipation evaluation that factors in unique, population- specific risks will help special populations stay healthy and safe on wilderness adventures. The PubMed and SportDiscus databases were searched in 2014 using both MeSH terms and text words and include peer-reviewed English language articles from 1977 to 2014. Additional information was accessed from Web-based sources to produce this narrative review on preparticipation evaluation for special populations undertaking wilderness adventures. Key words include children, adolescent, pediatric, seniors, elderly, disabled, special needs, female, athlete, preparticipiation examination, wilderness medicine, and sports.

Wilderness Preparticipation Evaluation and Considerations for Special Populations.

Children, older adults, disabled and special needs athletes, and female athletes who participate in outdoor and wilderness sports and activities each face unique risks. For children and adolescents traveling to high altitude, the preparticipation physical evaluation should focus on risk assessment, prevention strategies, early recognition of altitude-related symptoms, management plans, and appropriate follow-up. As the risk and prevalence of chronic disease increases with age, both older patients and providers need to be aware of disease and medication-specific risks relative to wilderness sport and activity participation. Disabled and special needs athletes benefit from careful pre-event planning for the potential medical issues and equipment modifications that may affect their health in wilderness environments. Issues that demand special consideration for female adventurers include pregnancy, contraceptive use, menses, and ferritin levels at altitude. A careful preparticipation evaluation that factors in unique, population-specific risks will help special populations stay healthy and safe on wilderness adventures. The PubMed and SportDiscus databases were searched in 2014 using both MeSH terms and text words and include peer-reviewed English language articles from 1977 to 2014. Additional information was accessed from Web-based sources to produce this narrative review on preparticipation evaluation for special populations undertaking wilderness adventures. Key words include children, adolescent, pediatric, seniors, elderly, disabled, special needs, female, athlete, preparticipiation examination, wilderness medicine, and sports.

Prescription history of emergency department patients prescribed opioids.

INTRODUCTION: To use Colorado's prescription drug monitoring program (PDMP) to describe the recent opioid prescription history of patients discharged from our emergency department (ED) with a prescription for opioid pain medications. METHODS: Retrospective cohort study of 300 adult ED patients who received an opioid prescription. We abstracted prescription histories for the six months prior to the ED visit from the PDMP, and abstracted clinical and demographic variables from the chart. RESULTS: There were 5,379 ED visits during the study month, 3,732 of which were discharged. Providers wrote 1,165 prescriptions for opioid analgesics to 1,124/3,732 (30%) of the patients. Median age was 36 years. Thirty-nine percent were male. Patients were 46% Caucasian, 26% African American, 22% Hispanic, 2% Asian and 4% other. These were similar to our overall ED population. There was substantial variability in the number of prescriptions, prescribers and total number of pills. A majority (205/296) of patients had zero or one prescription. The 90th percentile for number of prescriptions was seven, while the 10th percentile was zero. Patients in the highest decile tended to be older, with a higher proportion of Caucasians and females. Patients in the lowest decile resembled the general ED population. The most common diagnoses associated with opioid prescriptions were abdominal pain (11.5%), cold/flu symptoms (9.5%), back pain (5.4%), flank pain (5.0%) and motor vehicle crash (4.7%). CONCLUSION: Substantial variability exists in the opioid prescription histories of ED patients, but a majority received zero or one prescription in the preceding six months. The top decile of patients averaged more than two prescriptions per month over the six months prior to ED visit, written by more than 6 different prescribers. There was a trend toward these patients being older, Caucasian and female.

Impact of computerized physician order entry on ED patient length of stay.

OBJECTIVES: We evaluated whether implementation of computerized physician order entry (CPOE) reduces length of stay (LOS) for discharged emergency department (ED) patients. METHODS: Emergency department LOS for discharged and admitted patients were analyzed in a university-affiliated ED before and after introduction of CPOE. Patient demographics and covariates that may affect LOS (mode of arrival, provider staffing, daily census, and admission rate) were measured. RESULTS: The study included 71,188 patients; 49,175 (69%) were discharged from the ED (28, 687 before and 20,488 after CPOE). Length of stay for discharged patients decreased from 198 to 168 minutes (difference of -30; 95% confidence interval [CI], -28 to -33), whereas LOS for admitted patients increased from 405 to 441 minutes (difference of +36; 95% CI, 26-46). After controlling for covariates, CPOE implementation was associated with a 23-minute decrease in LOS for discharged patients (ß = -23 [95% CI, -26 to -19]). CONCLUSION: Implementation of CPOE was associated with a clinically significant (23-minute) decrease in LOS among patients who were discharged from the ED.

Estimation of the prevalence of rheumatic diseases in Israel.

OBJECTIVES: To study the prevalence of rheumatic diseases in Israel by applying the Community Oriented Program for the Control of Rheumatic Diseases core questionnaire (CCQ). METHODS: Representative samples (total of 2520 people) of the Israeli Jewish population aged ≥20 were surveyed for rheumatic complaints on 4 separate occasions by the CCQ telephone interview. The findings of the telephone interview were compared with a face-to-face interview and to rheumatologist examination, in 2 separate stages. RESULTS: The telephone applied CCQ had a sensitivity level of 88.6% and specificity of 70.0% when compared with the rheumatologist evaluation (κ = 0.576) (P < 0.001). A lower prevalence of rheumatic complaints was found in the summer months (17.7%) than in winter months (26.2%, P < 0.01). Prevalence was related to country of origin (0.008 < P < 0.03) (P range in separate surveys) and increasing age (P < 0.001) and was higher in women than in men (0.003 < P < 0.043). Body sites most affected were the lower back (63%) and the knees (47%). Medically related unemployment was more common in those with rheumatic complaints (7.9%) than in those without such complaints (2.9%, P < 0.01). Among those with rheumatic ailments, 12.7% had a related discapacity recognized by the Israeli National Insurance Institute. CONCLUSIONS: The telephone applied CCQ was reliable in screening for rheumatic complaints. Rates for rheumatic complaints in Israel were similar to those in some other countries. Rheumatic complaints were common, age- and gender-related, associated with work discapacity, and with country of origin. This is the first longitudinal prevalence survey of rheumatic complaints in Israel.

Impact on length of stay after introduction of emergency department information system.

OBJECTIVE: An electronic emergency department information system (EDIS) can monitor the progress of a patient visit, facilitate computerized physician order entry, display test results and generate an electronic medical record. Ideally, use of an EDIS will increase overall emergency department (ED) efficiency. However, in academic settings where new interns rotate through the ED monthly, the "learning curve" experienced by the new EDIS user may slow down patient care. In this study, we measured the impact of the "intern learning curve" on patient length of stay (LOS). METHODS: We retrospectively analyzed one year of patient care data, generated by a comprehensive EDIS in a single, urban, university-affiliated ED. Intern rotations began on the 23rd of each month and ended on the 22nd of the next month. Interns received a 1.5-hour orientation to the EDIS prior to starting their rotation; none had prior experience using the electronic system. Mean LOS (± standard error of the mean) for all patients treated by an intern were calculated for each day of the month. Values for similar numerical days from each month were combined and averaged over the year resulting in 31 discrete mean LOS values. The mean LOS on the first day of the intern rotation was compared with the mean LOS on the last day, using Student's t-test. RESULTS: During the study period 9,780 patients were cared for by interns; of these, 7,616 (78%) were discharged from the ED and 2,164 (22%) were admitted to the hospital. The mean LOS for all patients on all days was 267 ± 1.8 minutes. There was no difference between the LOS on the first day of the rotation (263±9 minutes) and the last day of the rotation (276 ± 11 minutes, p > 0.9). In a multiple linear regression model, the day of the intern rotation was not associated with patient LOS, even after adjusting for the number of patients treated by interns and total ED census (ß = -0.34, p = 0.11). CONCLUSION: In this academic ED, where there is complete intern "turnover" every month, there was no discernible impact of the EDIS "learning curve" on patient LOS.

The effect of removal of point-of-care fecal occult blood testing on performance of digital rectal examinations in the emergency department.

STUDY OBJECTIVE: We determine whether removing point-of-care fecal occult blood testing from the emergency department (ED) is associated with a decrease in documented digital rectal examinations. METHODS: We performed a retrospective observational chart review study examining documented digital rectal examinations, before and after removal of a point-of-care fecal occult blood test, on all adult patients who presented to our ED with chief complaints that were likely to warrant a fecal occult blood test (intervention-sensitive). We studied the 6 months immediately before and after switching from bedside fecal occult blood testing to immunohistochemical laboratory fecal occult blood testing. We compared the results with those from a similar cohort of patients who presented during the same period, with chief complaints that would warrant a digital rectal examination for reasons other than fecal occult blood test (intervention-insensitive). RESULTS: A total of 4,981 and 5,557 patients met our inclusion criteria during the before and after intervention periods, respectively. We observed an overall reduction of 10% (95% confidence interval [CI] 8% to 12%) in digital rectal examinations in patients with intervention-sensitive chief complaints. The largest relative decreases in digital rectal examinations were observed in patients with chief complaints of abdominal pain, nausea/vomiting, and diarrhea. Smaller decreases were observed in gastrointestinal bleeding, constipation, and rectal problem. There was an overall reduction of 3% (95% CI 0% to 5%) in documented digital rectal examinations in intervention-insensitive chief complaints. After controlling for all covariates, digital rectal examinations decreased in the postintervention period for intervention-sensitive (odds ratio 0.44 [95% CI 0.39 to 0.50]) and, to a lesser extent, for intervention-insensitive (odds ratio 0.67 [95% CI 0.52 to 0.86]) conditions. CONCLUSION: Removal of point-of-care fecal occult blood test from our ED was associated with a reduction in digital rectal examinations, particularly among chief complaints that may require fecal occult blood testing.

Simvastatin induces apoptosis of fibroblast-like synoviocytes.

BACKGROUND: Statins (3-Hydroxy-3-methylglutaryl-CoA reductase inhibitors) exert favorable effects on lipoprotein metabolism, but appeared to possess anti-inflammatory properties among others, as suggested by their ability to inhibit collagen-induced arthritis in mice. Their activity in fibroblast-like synovial cells (FLS) has not yet been studied. OBJECTIVES: To evaluate the effect of varying doses of simvastatin on apoptosis of FLS. METHODS: Synovial tissue, obtained during total knee replacement due to osteoarthritis, was cut into small pieces and cultured in Petri dishes with test materials, as previously described. FLS were incubated for 48 hours with 1 mumol/ml, 5 mumol/ ml, 15 mumol/ml and 50 mumol/ml of simvastatin. Following incubation, apoptosis was analyzed by two-dimensional flow cytometry (FACS) using annexin V/PI staining according to the manufacturer's instructions. RESULTS: Different concentrations of simvastatin induced apoptosis of FLS. The level proportion of apoptotic cells of resting or activated with lipopolysaccharide (LPS; 3 mug/ml) FLS, not treated with simvastatin, was 21%. At 48 hours, the rate of apoptosis of activated fibroblasts, incubated with 1 mumol/ml, 5 mumol/ml, 15 and 50 mumol/ml was 22%, 32%, 48% and 41% respectively. Synovial cell viability evaluated by tetrazolium salt XXT was unaffected by the simvastatin concentration used. CONCLUSION: Varying concentrations of simvastatin induce apoptosis of activated fibroblast-like synoviocytes, suggesting another possible mechanism of anti-inflammatory effects of statins in inflammatory conditions.

Travel to high altitude with young children: an approach for clinicians.

As more families travel to mountainous destinations, clinicians are frequently asked for advice regarding children at altitude. We briefly review the principles of altitude illness in children, offer a management plan for the clinician, and highlight the gaps in current evidence. Planning for ascent, altitude illness management, and diagnostic follow-up are discussed.

Language used in Lake Louise Scoring System underestimates symptoms of acute mountain sickness in 4- to 11-year-old children.

The Lake Louise Scoring System (LLSS) was designed to evaluate adults for symptoms of acute mountain sickness (AMS). The language used in the LLSS may be too complex for young children to comprehend. This study evaluates if age-appropriate language alters the results of AMS diagnostic scores in 4- to 11-yr-old children. With parental help, subjects completed the LLSS and an equivalent Lake Louise Age-Adjusted Symptom Score (LLAASS) daily for 3 days. Measurements were made at 1605 m, in the subjects' homes, without any altitude change. Equivalent questions between the two surveys were assessed for agreement on the day when the most symptoms were recorded for each question. Thirty-seven children (19 girls), ages 4 to 11 yr (mean age 7.4 +/- 2.3 yr) completed the study. Kappa values: headache (kappa = 0.22), gastrointestinal (kappa = 0.34), fatigue (kappa = 0.88), dizziness (kappa = 0.65), and sleep (kappa = 0.88) ranged from fair to very good. The LLAASS resulted in higher mean symptom scores (1.14 +/- 0.98) compared to LLSS questions (0.61 +/- 0.82) (p < 0.01). The AMS diagnostic threshold was reached in 9% (95% CI, 4-16) of measurements using the LLAASS and 4.5% (95% CI, 1.5-10) with the LLSS. The LLSS results in reporting of fewer AMS symptoms in this population when compared with a diagnostic tool using age-appropriate language and/or visual representations. Age-appropriate communication must be used to assess AMS, particularly for headache (the key symptom of AMS) and gastrointestinal symptoms. Young children report symptoms of AMS at baseline without altitude gain; therefore, the AMS diagnostic threshold in this population may require modification.

Distribution of HLA-B27 subtypes in ankylosing spondylitis in an Israeli population.

BACKGROUND: The aim of this study was to investigate the contribution of the B27 subtypes to ankylosing spondylitis (AS) expression in a group of Jewish patients from Israel and to compare their distribution with that found in Mexican Mestizo patients. Several HLA-B27 alleles have been clearly associated with AS. Among them, B( *)2705 and B( *)2702 are involved in susceptibility in different populations worldwide. The aim of this study was to investigate the associated subtypes in Israel and to compare the results with Mexican Mestizos, who have Semitic genes as part of their ancestry. METHODS: This is a case/control study that included a group of 24 HLA-B27+ Israeli patients with AS and 51 B27+ healthy subjects, most of them Ashkenazi Jews. The B27 subtypes were characterized using a PCR-SSP method. RESULTS: Only B( *)2702 and B( *)2705 alleles were present in AS patients. However, their allele frequency was not significantly different from that found in the control group, probably because of the small sample size: B( *)2702 (patients 62.5% vs. controls 41.2%, OR = 2.31) and B( *)2705 (patients 37.5% vs. controls 50.9%). Two additional alleles were present only in the controls in low frequency: B( *)2707(5.9%) and B( *)2701(1.9%). It is clear that the major susceptibility allele in Ashkenazi Jews from Israel is B( *)2702. CONCLUSIONS: The only allele conferring risk to AS expression in Israeli Jews was B( *)2702, as was previously described in Mexican Mestizos. Populations of Mediterranean ancestry, such as Latin Americans, should be further explored to understand the contribution of ethnicity to the etiopathogenesis of AS.

The effects of leflunomide on clinical parameters and serum levels of IL-6, IL-10, MMP-1 and MMP-3 in patients with resistant rheumatoid arthritis.

OBJECTIVE: The purpose of this open pilot study was to assess possible mechanisms of the effects of leflunomide by studying the influence of the drug on the serum levels of MMP-1, MMP-3, IL-10, IL-6 and their possible correlation with clinical disease parameters. PATIENTS AND METHODS: Thirty patients with long standing active rheumatoid arthritis were enrolled in this study. All patients failed at least 5 DMARDs in the past and were on stable treatment for at least 3 months before starting the protocol. The patients received a loading dose of 100 mg for 3 days followed by 20 mg/day thereafter and followed up monthly for 6 months. Disease activity was assessed at baseline, 2 weeks, and every month of therapy thereafter using the following variables: tender joint count, swollen joint count, morning stiffness duration, pain, tiredness, physician's and patient's global assessment, using VAS, ESR and CRP. Clinical effects of the treatment regimen were calculated using the American College of Rheumatology (ACR) criteria for clinical response. Adverse events were recorded. Serum levels of MMP-1, MMP-3, IL-10 and IL-6 were measured before and 3 months after starting the protocol. RESULTS: Except for tiredness, a statistically significant improvement in all clinical and laboratory parameters of disease activity was reached after 3 months. At this time point the ACR-20 response rate was 46.2%. The levels of MMP-1, MMP-3, IL-6 and IL-10 decreased significantly after 3 months. A statistically significant correlation between serum levels of MMP-1, IL-10 and IL-6 and clinical and laboratory parameters was also shown. After 6 months, 16 out of 30 patients withdrew from the study [adverse events (35.4%), lack of efficacy (9.7%), and low compliance (6.4%)]. CONCLUSIONS: Leflunomide was clinically efficacious in this group of long standing resistant RA in an open study "real life" design. These results comply with those reported in previous clinical trials. Serum MMP-1, MMP-3, IL-10 and IL-6 levels decreased significantly. Despite high withdrawal rate, no serious adverse effects were recorded.

The effect of infliximab on extraintestinal manifestations of Crohn's disease.

OBJECTIVE: The purpose of this open pilot study was to assess prospectively the effect of infliximab on extraintestinal manifestations in patients with active Crohn's disease refractory to conventional treatment. PATIENTS AND METHODS: Twenty-two consecutive patients with Crohn's disease and one with ulcerative colitis presenting at least one of the known extraintestinal manifestations of Crohn's disease participated in the study. All the patients had Crohn's disease activity index (CAI) scores above 2. Each patient received an intravenous infusion of infliximab at a dosage of 5 mg/kg. A thorough questionnaire was used reviewing the extraintestinal manifestations of Crohn's disease such as erythema nodosum, pyoderma gangrenosum, eye lesions, arthritis or arthralgia, sacroiliitis or inflammatory back pain, hepatic disease, hematologic manifestations (megaloblastic, iron deficiency or hemolytic anemia, thrombocytosis), thrombosis, and nephrolithiasis. Musculoskeletal complaints were evaluated using the parameters intensity of pain, duration of morning stiffness (in minutes), presence of inflammatory back pain, Schober's test of the lumbar region, chest expansion, and distance from occiput to wall. The clinical assessment was performed on the day of the infusion and 2 weeks later. RESULTS: Eleven out of 23 patients had arthralgia of inflammatory nature, three others had evidence of active synovitis on physical examination, and 11 reported inflammatory back pain. Four patients suffered from protracted pyoderma gangrenosum; three had resistant aphthous stomatitis. Eleven patients had more than one extraintestinal manifestation. All four with pyoderma gangrenosum demonstrated significant improvement of their ulcers after one course of infliximab, with complete resolution of the skin lesions in three of them after repeated infusions of infliximab. Aphthous stomatitis completely responded in all patients after a single infusion. Seven out of 11 patients with arthralgia and seven out of 11 with inflammatory back pain/sacroiliitis experienced benefit after treatment with infliximab and reported at least partial clinical improvement in duration of morning stiffness, tender joint count, and visual analogue scale for pain. Only one of three patients with frank arthritis demonstrated clear improvement, and two others failed to respond to infliximab treatment. CONCLUSION: These preliminary results are encouraging and suggest a promising role of infliximab in the treatment of extraintestinal symptoms of Crohn's disease.

Somatostatin analogue treatment attenuates histological findings of inflammation and increases mRNA expression of interleukin-1 beta in the articular tissues of rats with ongoing adjuvant-induced arthritis.

OBJECTIVE: Somatostatin is a neuropeptide with modulatory effects on the immune system and the function of synovial cells; it has antiangiogenic and antiproliferative properties. This study aimed to evaluate the clinical, histological, and articular tissue cytokine mRNA response to somostatin treatment in rat adjuvant-induced arthritis (AIA). METHODS: Adjuvant-induced arthritis was induced in a total of 68 Lewis rats by immunization with complete Freund's adjuvant. Twenty-four rats were treated with a long-acting somostatin analogue 14 days after disease induction. Twenty-four untreated rats served as controls. The severity of arthritis was scored weekly for 42 days. In a second experiment, 20 rats (ten treated, ten controls) were killed 21 days after treatment for assessment of joint histopathology and articular tissue cytokine mRNA expression. RESULTS: Somatostatin analogue treatment significantly reduced histological scores of early inflammatory changes and increased articular tissue mRNA expression of interleukin-1 beta (IL-1beta). A trend toward improvement in physical scores of joint inflammation was seen in the treated group. Late destructive changes were not significantly different. CONCLUSION: Treatment with a somostatin analogue attenuated early inflammatory changes in AIA joints and increased mRNA expression of IL-1beta in the articular tissues of rats with ongoing arthritis. Improvement in the physical findings of joint inflammation was mild.

Sleep disturbance after rapid ascent to moderate altitude among infants and preverbal young children.

Rapid ascent to high altitude is known to result in sleep disturbances among adults. No data exist regarding the effects of altitude exposure on sleep in children. The objective of this study was to determine the effect of rapid ascent to moderate altitude on sleep in infants and young children. In this prospective study, each child served as his or her own control. Each subject was studied over 7 days and nights. On days 1 and 2, children were studied at home (1601 m), day 3 at a hotel without ascent (travel control), day 4 at home, days 5 and 6 at a hotel after ascent (3109 m), and day 7 at home. Since increased motion is a characteristic of sleep disturbance among infants and young children, continuous measurements of motion were made using an ankle-mounted Actigraph. Thirty children, 17 girls and 13 boys, with a median age of 16.5 months (range = 4 to 33 months) participated in the study. Significant changes in the activity counts, reflecting a sleep disturbance during nocturnal sleep, were noted between the travel control night (20.9 +/- 1.9) and the first night at altitude (29.4 +/- 2.5): p < 0.01. This sleep disturbance is most significant during the first night at altitude and may be similar to sleep disturbance with altitude exposure seen in adults.

Early and late effects of low-dose aspirin on renal function in elderly patients.

BACKGROUND: Although low-dose aspirin is used by many elderly patients, monitoring of renal function is currently not recommended. We recently reported transient retention of uric acid and creatinine caused by aspirin in doses of 75 to 325 mg/d. We therefore evaluated the renal effects of aspirin (100 mg/d), including post-treatment effects. METHODS: We studied 83 stable geriatric patients in long-term care (aged 56 to 98 years) who were treated with low-dose aspirin (100 mg/d) for 2 weeks and 40 control patients. Other medications and diet were kept constant. Biochemical monitoring including blood samples and 24-hour urinary collections for creatinine and uric acid at baseline and weekly for a total of 5 weeks. RESULTS: After 2 weeks on aspirin, urinary excretion of creatinine decreased in 60 (72%) and excretion of uric acid decreased in 54 (65%) of the 83 patients, and their mean clearances decreased; during the same period, serum blood urea nitrogen, creatinine, and uric acid levels increased (P <0.05 for all). Deterioration from baseline levels was significantly greater (and more prevalent) in the aspirin-treated group than in the 40 control patients (P = 0.001 to 0.09). After withdrawal of aspirin these parameters improved. However, 3 weeks after stopping aspirin, 48% (35 of the 73 in whom this measurement was available) had a persistent decline in creatinine clearance from baseline, as compared with only 8% (3/36) controls (P <0.001). CONCLUSION: Short-term low-dose aspirin treatment may affect renal function in elderly patients. These effects persist 3 weeks after cessation of the drug in some of these patients.

Physiologic response to moderate altitude exposure among infants and young children.

Substantial numbers of children are exposed to moderate altitude while traveling to mountain resorts with their families. Although there has been extensive study of the adult physiologic response to altitude exposure, few studies of infants and young children exist. This investigation examines the acute physiologic responses to moderate altitude exposure among young children and the relationship of these responses to the development of acute mountain sickness (AMS). Children 3 to 36 months old participated in the prospective observational study, which included baseline measurements at 1610 m and measurements after a 24-h exposure to 3109 m. Measurements included pulse and respiratory rate, end-tidal CO(2), arterial oxygen saturation (pulse oximetry), cerebral tissue oxygenation (St(O2)) by near-infrared spectroscopy, middle cerebral artery resistive index by transcranial Doppler, lateral ventricle volumes (ultrasound), and clinical evaluation for the presence of acute mountain sickness (Children's Lake Louise Score). Twenty-four children (13 girls and 11 boys, age 14.5 +/- 10.2 months) participated. After acute exposure to 3109 m, these children showed an increase in respiratory rate from 45 +/- 13 to 51.9 +/- 15 breaths/min (p < 0.008), accompanied by a decrease of end-tidal CO(2) from 31 +/- 3 to 28 +/- 2 mm Hg (p < 0.001) and a reduction of arterial oxygen saturation from 95 +/- 2 to 91 +/- 2% (p < 0.001). St(O2) also decreased from 78 +/- 8 to 67 +/- 13% (p < 0.001), and this reduction appeared to be related to age (r = 0.58, p < 0.05), with lower saturations found in younger children. No evidence of increased intracranial pressure, as assessed by middle cerebral artery resistive index, was seen during ascent. Seven subjects developed symptoms of AMS; however, no relationship was found between the physiologic changes observed and the presence of symptoms. Ascent from 1610 to 3109 m resulted in tachypnea, relative hypoxia, hypocapnia, and a reduction in cerebral tissue oxygenation (St(O2)). The reduction in St(O2) appeared to be related to age, with infants appearing to be the most susceptible to cerebral tissue oxygen desaturation at high altitude. No relationship appears to exist between the presence of AMS and the physiologic measurements.

Rapid and complete resolution of proteinuria due to renal amyloidosis in a patient with rheumatoid arthritis treated with infliximab.

We describe herein a patient with rheumatoid arthritis who developed proteinuria due to AA amyloidosis, in whom the inflammatory disease was rapidly and completely suppressed by treatment with infliximab. This response was accompanied by resolution of the proteinuria and stabilization of the amyloid deposits as seen on serial (123)I-labeled serum amyloid P scintigraphy.