Thrombosis as a complication of extended stay at high altitude.

BACKGROUND: There is limited knowledge about the medical problems of long term stay at high (> 3000 m) and extreme (> 5000 m) altitudes, as these areas are generally considered uninhabitable. METHODS: Prospectively collected clinical records of all patients hospitalized at Command Hospital, Western Command between November 1998 and February 2000 were reviewed to identify thrombotic complications among patients from high and extreme altitude areas as well as those from non-high altitude areas who were < 45 years of age. RESULTS: Of 20,257 hospital admissions during the study period, 1692 were from high and extreme altitude areas. Forty-six patients from these areas had thrombosis-related diseases compared to 17 from non-high altitude areas (odds ratio: 30.49; 95% CI: 17.06-51.67; p < 0.001). The mean (SD) age of all patients with thrombotic complications was 32 (8) years and all were men. The mean duration of stay at high and extreme altitudes of such patients was 10.2 (5.6) months. Only 25 were smokers (mean 5.2 pack-years) and 39 consumed alcohol (mean 54 ml/day). Apart from frostbite in 5, no other medical condition was noted in these patients. The vascular events were deep vein thrombosis (20), pulmonary thromboembolism (6), stroke (15), thrombosis of the abdominal veins (8), and retinal artery and peripheral arterial thrombosis (1 each). The presenting complaint in all patients with thrombosis of the abdominal veins was poorly localized pain in the upper abdomen followed by ascites (6/8). Five of these patients also had a large spontaneous splenic haematoma. None of the patients investigated was found to have a procoagulant disorder. CONCLUSION: Long term stay at high and extreme altitudes is associated with a 30 times higher risk of spontaneous vascular thrombosis. Veins are common sites of such thrombotic events. We also encountered thrombosis of the portal, splenic and superior mesenteric veins in our patients who had stayed at high and extreme altitudes.

Portal system thrombosis: a complication of long-term residence at extreme altitude.

BACKGROUND: With induction of the Indian Army to heights over 5,000 meters above sea level, complications of long-term stay at extreme altitude have come to light. We describe our experience with patients developing portal system thrombosis. METHODS: Clinical data were collected over 2 years on patients hospitalized for thrombotic complications from high-altitude (HAA) and non-high altitude (non-HAA) areas. Site of thrombosis was confirmed by imaging or at surgery. Patients were investigated for conditions that predispose to venous thrombosis. RESULTS: Ten cases of portal system thrombosis were seen during the period; of these, 9 (mean age 28 [SD 3.9] years; all men) were from HAA. Mean duration of residence in HAA was 12.4 (4.9) months; two were smokers and six drank 7-22 g alcohol/day at least 5 times a week. The first symptom was abdominal pain; this was later complicated by gastrointestinal bleeding (n=5), fever (7), vomiting (7), and weight loss (5). Average time between onset of first symptom and reaching a tertiary-care hospital was 9.5 (4.7) days. Clinical examination showed ascites (8 cases), splenomegaly (7), and hepatomegaly (6). Mean hemoglobin level at admission was 15.8 (3.4) g/dL. Ascites was hemorrhagic; five cases also had large splenic hematoma. The site of thrombosis was splenic vein (7 cases), portal vein (6), and superior (4) and inferior (1) mesenteric vein. None of 5 patients investigated had any prothrombotic condition. Endoscopic/ sonographic evidence of development of collaterals appeared as early as 12-20 days after onset of symptoms. CONCLUSION: Residence in HAA for extended periods is a risk factor for development of portal system thrombosis. Persistent pain in abdomen in such individuals should raise the possibility of portal system thrombosis.

PAIN ABDOMEN AT EXTREME ALTITUDES: SINISTER IMPLICATIONS.

2 cases of portal, splenic and superior mesenteric vein thromboses related to prolonged stay at high altitude are presented. Both presented initially with innocuous appearing vague pain in abdomen with no physical signs. Later hepatosplenomegaly, and pleural effusion (left) was also detected. Diagnosis was based on CT scan and colour Doppler study showing thrombosed veins and porto-systemic collateral. 1 patient developed a large splenic haematoma requiring splenectomy. Both were managed with early anticoagulation and have done well in the short follow up.

Cytokines and inflammatory bowel disease.

Cytokines are the key mediators of inflammation in the IBD and are focus of renewed interest to plan therapeutic strategies against this disease. However, there are gaps in our knowledge at present and a lot of questions need clear answers. Even with a therapy as specific as anti-TNF antibody, it is not clear if the benefit is attributable to simple binding and clearance of TNF-alpha or to binding on the cell surface and subsequent deletion of the activated macrophage. When a drug appears to be less effective than pre-clinical models suggest, can failures in effectiveness from delivery or dosing the differentiated? The disappointing results of clinical trials with IL-10 is at odds with the prediction of benefit from animal models. It even brings into question the validity of those models as well as the soundness of design of the clinical trials on which efficacy of IL-10 is assessed. Other exciting new methods to treat IBD could be use of monoclonal antibodies to effector T cell molecules (such as CD4 or CD44v7) removal of such cytokine secreting cells (apheresis), antibodies to proinflammatory cytokines (such as TNF-alpha, IFN-alpha, IFN-gamma, and IL-12) or administration of anti-inflammatory cytokines (such as IL-10, IL-11). Challenges in developing new therapeutic strategies include not only identifying novel agents, but also improving the definitions of clinical endpoints and defining efficacy at the biologic level. There is also need to further refine our knowledge about genetic elements and environment initiators to comprehensively manage IBD.

SONOGRAPHY : A VALUABLE MODALITY IN EVALUATION OF CHRONIC NON-TRAUMATIC DISORDERS OF THE SHOULDER JOINT.

Chronic non-traumatic shoulder pain may be due to arthralgia, shoulder myalgia, glenohumeral synovitis, adhesive capsulitis, or degenerative joint disease. Clinical skills and routine radiography may not be adequate to establish the diagnosis. This study was designed to assess the role of sonography in such a setting. Twenty-six consecutive patients attending the clinical immunology outpatient department for chronic shoulder pain were evaluated. Based on our findings, we have described 4 distinct sonographic patterns. Pattern 1 consisted of the normal sonographic appearance with semicircular smooth humeral head profile parallel to which was an echo-free synovial space measuring 1-2 mm. This pattern indicated shoulder arthralgia or myalgia without intrinsic shoulder joint disease. Pattern 2 consisted of reduction in the echo-free space indicative of adhesive capsulitis. Pattern 3 consisted of uniform increase in this space, thus indicating active synovial inflammation with effusion. Pattern 4 showed irregularity of the humeral head with reduction in the gleno-humeral joint space and loss of parallelism between the humeral head and the surrounding gleno-humeral synovial space. This last pattern indicated advanced deformed inflammatory or degenerative arthritis. It is concluded that these 4 sonographic patterns will be of considerable help in pinpointing the diagnosis in cases of chronic non-trumatic shoulder pain.

Adult onset Still's disease in northern India: comparison with juvenile onset Still's disease.

The present study compared the clinical and laboratory picture, the disease course and outcome in 31 patients having adult onset Still's disease (AOSD) with 23 patients having juvenile onset Still's disease (JOSD). The median age at disease onset was 20 and 7 yr for AOSD and JOSD patients, respectively. On analysing and comparing our data on these two groups, no significant differences emerged except that adults had a significantly lower time interval from disease onset to remission as compared to juveniles. Upon comparison of data on our AOSD patients with that published from abroad, rash, adenopathy and sore throat were less frequent. No clinical or laboratory variables were found to predict the subsequent disease course and outcome in either group. The functional outcome was good in about 70% of both groups and mortality was low. It is concluded that the clinical picture and outcome in AOSD is similar to that of JOSD.

Intravenous dexamethasone pulse therapy in diffuse systemic sclerosis. A randomized placebo-controlled study.

Thirty-five patients with diffuse systemic sclerosis were studied in a randomized, placebo-controlled, double-blind study. Seventeen patients received intravenous dexamethasone "pulse" therapy, while 18 patients received placebo. Each "pulse" consisted of 100 mg dexamethasone in 250 ml 5% dextrose infused intravenously over 1 h. Pulse therapy was repeated every month for 6 months. Assessment of disease status with various parameters was done at entry and at completion of trial, i.e. after 6 months. Significant improvement in skin involvement was seen in the study group, with the total skin score (TSS) decreasing from 28.5 +/- 12.2 to 25.8 +/- 12.8, while in the control group, TSS increased from 30.6 +/- 13.2 to 34.7 +/- 10. Similarly, significant improvement was noted in the flexion index. Other parametres that included extension index, maximum oral opening, range of movement of joints, functional disability score, Raynaud's phenomenon (frequency and duration), ESR, proteinuria, chest X-ray, ECG, lung function tests, barium swallow and antinuclear antibody were unchanged. Adverse effects of therapy were limited to an increased incidence of minor chest infections. It is concluded that intravenous pulse dexamethasone may be useful in the treatment of diffuse systemic sclerosis.

EFFICACY OF SUCRALFATE IN PREVENTING GASTROINTESTINAL SIDE EFFECTS OF NSAIDs.

To find out the efficacy of sucralfate in preventing gastrointestinal side effects of non-steroidal anti-inflammatory drugs (NSAIDs) a prospective, randomised single blind study was conducted from 1989 to 1992. Patients with osteoarthritis, rheumatoid arthritis and other long standing painful conditions, who were expected to receive NSAIDs for over three months, were recruited into the study. All medicines were discontinued for a period of 10-15 days prior to initial endoscopic assessment. NSAID therapy was started and the patients were randomised to receive either placebo (group A) or sucralfate (group B) in addition. Patient were reassessed clinically every week and an endoscopic examination was repeated after 6-8 weeks of follow-up. A total of 176 patients were studied in group A (n=91) and group B (n=85). At the end of 8 weeks gastrointestinal symptoms were present in 30.6% and 26.4% patients of group A and B respectively. Endoscopic assessment showed superficial lesions in 36.5% and 18.7% while endoscopic ulcer in 2.4% and 1.1% patients of groups A and B respectively. Thus in patients receiving chronic NSAID therapy, simultaneous administration of sucralfate reduces the incidence of superficial gastric lesions but has no significant effect on symptoms or ulcer formation.

Dapsone in cutaneous lesions of SLE: an open study.

This short report describes a possible beneficial effect of dapsone in the treatment of chronic unresponsive muco-cutaneous lesions of systemic lupus erythematosus (SLE) without any serious side effects.

Adult-onset Still's disease in India.

Adult onset Still's disease was provisionally diagnosed in 31 patients from northern India over a period of five years, in 27 of whom the diagnosis was subsequently felt to have been confirmed. This report describes the clinical characteristics of these patients along with the different therapeutic measures used and their response. Adult onset Still's disease should be considered in the differential diagnosis of 'pyrexia of unknown origin'.

Survival in patients with systemic lupus erythematosus in India.

Survival in patients with systemic lupus erythematosus (SLE) in developed countries has improved considerably over the last 2 decades. In India, however, survival in patients with SLE reported 5 years ago from this tertiary referral centre was very poor. The present study was conducted to examine trends, if any, towards improvement in the survival of patients with SLE attending the same centre during the period 1981-1990. No statistically significant change in survival was noted. It appears that improvement in the survival of SLE patients would require an overall improvement in the standard of medical care in India.