Keyes, Linda E., Thomas Douglas Sallade, Charles Duke, Jennifer Starling, Alison Sheets, Sushil Pant, David S. Young, David Twillman, Nirajan Regmi, Benoit Phelan, Purshotam Paudel, Matthew McElwee, Luke Mather, Devlin Cole, Theodore McConnell, and Buddha Basnyat. Blood pressure and altitude: an observational cohort study of hypertensive and nonhypertensive Himalayan trekkers in Nepal. High Alt Med Biol. 18: 267- 277, 2017.Objectives: To determine how blood pressure (BP) changes with altitude in normotensive versus hypertensive trekkers. Secondary aims were to evaluate the prevalence of severe hypertension (BP 180/100mmHg) and efficacy of different antihypertensive agents at high altitude.Methods: This was an observational cohort study of resting and 24- hour ambulatory BP in normotensive and hypertensive trekkers at 2860, 3400, and 4300m in Nepal. Results: We enrolled 672 trekkers age 18 years and older, 60 with a prior diagnosis of hypertension. Mean systolic and diastolic BP did not change between altitudes in normotensive or hypertensive trekkers, but was higher in those with hypertension. However, there was large interindividual variability. At 3400 m, the majority (60%, n = 284) of normotensive participants had a BP within 10mmHg of their BP at 2860 m, while 21% (n = 102) increased and 19% (n = 91) decreased. The pattern was similar between 3400 and 4300m (64% [n = 202] no change, 21% [n = 65] increased, 15% [n = 46] decreased). BP decreased in a greater proportion of hypertensive trekkers versus normotensives (36% [n = 15] vs. 21% at 3400 m, p = 0.01 and 30% [n = 7] vs. 15% at 4300 m, p = 0.05). Severe hypertension occurred in both groups, but was asymptomatic. In a small subset of participants, 24- hour ambulatory BP monitoring showed that nocturnal BP decreased in normotensive (n = 4) and increased in hypertensive trekkers (n = 4).Conclusions: Most travelers, including those with well-controlled hypertension, can be reassured that their BP will remain relatively stable at high altitude. Although extremely elevated BP may be observed at high altitude in normotensive and hypertensive people, it is unlikely to be symptomatic. The ideal antihypertensive regimen at high altitude remains unclear.

P 4 .05)but was higher in HTN vs NTN subjects at each altitude (P o .05).However, we observed large interindividual variability.Between 2860 m and 3400 m, the majority (60%, n ¼ 284) of NTN SBPs did not change, while 21% (n ¼ 102) increased 410 mm Hg and 19% (n ¼ 91) decreased 410 mm Hg.The pattern was similar in NTNs between 3400 m and 4300 m: (65% [n ¼ 202] no change, 21% [n ¼ 65] increased, 15% [n ¼ 46] decreased).A greater proportion of HTN trekkers had SBP decreases between 2860 m and 3400 m (45% [n ¼ 19] no change, 19% [n ¼ 8] increased, 36% [n ¼ 15] decreased) and between 3400 m and 4300 m (44% [n ¼ 10], 26% [n ¼ 6], 30% [n ¼ 7]), respectively.Conclusions.-Inmost individuals, with and without HTN, BP is likely to change less than 10 mm Hg at altitudes up to 4300 m.In general, travelers, including those with well-controlled HTN, may be reassured that their blood pressure will remain relatively stable at high altitude.

For those traveling to high altitude, it has been postulated that blood pressure (BP) changes when compared to sea level. Also at altitude, periodic breathing has been well described and is correlated to decreased sleep quality.

BACKGROUND The number of tourists in Nepal doubled between 2003 and 2013 is nearly 800 000. With the increased popularity of trekking, the number of those with pre-existing medical conditions requiring access to healthcare is likely to increase. We therefore sought to characterize the demographics and health status of trekkers on the Everest Base Camp route in the Solukhumbu Valley. In addition, we report cases that illustrate the potential complications of an ageing and medicated population of trekkers with underlying diseases. METHODS Trekkers over 18 years were enrolled in a larger observational cohort study on blood pressure at high altitude at 2860 m. They answered a questionnaire regarding demographics, medical history and current medications. Acute medical problems relating to medication use that were brought to the attention of investigators were documented and are presented as case reports. RESULTS We enrolled 670 trekkers, 394 (59%) male, with a mean age of 48 years (range 18-76). Pre-existing medical conditions were reported by 223 participants (33%). The most frequent conditions included hypertension, hypercholesterolemia, migraines and thyroid dysfunction. A total of 276 participants (41%) reported taking one or more medications. The most common medications were acetazolamide (79, 12%), antihypertensives (50, 8%) and NSAIDs (47, 7%), with 30 classes of drugs represented. Excluding acetazolamide, older trekkers (age >50 years) were more likely than younger ones to take medications (OR = 2.17; 95% CI 1.57-3.00; P <0.05). Acetazolamide use was not related to age. CONCLUSIONS Our findings illustrate a wide variety of medical conditions present in trekkers in Nepal with wide-ranging potential complications that could pose difficulties in areas where medical care is scarce and evacuation difficult. Our cases illustrate the potential problems polypharmacy poses in trekkers, and the need for local and expedition healthcare workers to be aware of, and prepared for the common medical conditions present.

Severe and uncontrolled hypertension have been reported in high altitude sojourners but have not been studied systematically. Additionally, few studies have evaluated the efficacy of antihypertensive medications at high altitude. We documented the prevalence of severe hypertension and efficacy of antihypertensive medications in high-altitude trekkers in Nepal. Observational cohort study in Nepal's Solukhumbu Valley. We recruited trekkers 18 years of age and older. Subjects reported demographics, medical history, and medications. Resting blood pressure (BP) was recorded at 2860 m, 3400 m, and 4300 m on ascent and descent. Severe hypertension was defined as systolic BP ≥180 and/or diastolic BP ≥100. We enrolled 60 self-reported hypertensive (HTN) trekkers and 606 normotensive (NTN) trekkers. Out of 2158 BP measurements at all altitudes, 109 (5%) were severe. Of these, 39 occurred in 22 (37%) HTN trekkers and 70 were distributed among 51 (8%) NTN trekkers. Occurrence of severe hypertension was similar across altitudes (P < .05). No subject was symptomatic. Among HTN trekkers, 10 took no antihypertensives and 5 of those had one or more severe BP measurements, accounting for 21% of all severe BPs in HTN trekkers. Seven out of 14 subjects on angiotensin converting enzyme inhibitors (ACEI) accounted for another one-third of all severe BPs. No subject taking a beta-blocker (BB), thiazide, ACEI + calcium channel blocker (CCB), ACEI + BB, or angiotensin receptor blocker (ARB) + alpha-1 antagonist had severe hypertension. Severe hypertension occurred in a smaller proportion of trekkers on combinations of CCB plus either ACEIs (0/3) or ARBs (1/3), and those taking more than 3 antihypertensives (1/3). Asymptomatic severe hypertension occurred at high altitude in normotensive and hypertensive subjects, but was more common in those with underlying hypertension. The clinical importance of these episodes is unclear. Our preliminary results suggest some antihypertensives may be more effective at high altitude than others.

OBJECTIVE: To determine if the prescription of lacosamide was associated with significant changes in depression and/or anxiety. BACKGROUND: Depression and anxiety are common comorbid conditions in people with epilepsy. Certain antiepileptic drugs (AEDs) are known to have mood stabilizing and anxiolytic effects, while others have been found to potentially worsen psychiatric symptoms. Lacosamide is a third generation AED approved for the treatment of focal onset seizures. However, its effects on mood have not been vigorously explored. We evaluated changes in depression and anxiety following the initiation of lacosamide. DESIGN/METHODS: We compared patients' scores on the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E, n=91) and Generalized Anxiety Disorder 7-item (GAD-7, n=20) scale prior to and following the prescription of lacosamide. Paired t-test and Wilcoxon singed rank tests were used to compare the changes in NDDI and GAD-7 scores. The treatment effect was examined in subgroups with histories of mood disorders, concomitant psychiatric medications, and mood stabilizing concomitant AEDs using unpaired t-test/Wilcoxon signed rank tests. RESULTS: Following the initiation of lacosamide, there were no significant changes in mood. The mean baseline NDDI-E score was 12.14+/-4.64; this was similar to the mean NDDI-E after treatment of 11.91+/-4.14 (p=0.5136). The mean GAD-7 scores at baseline (4.10+/-4.52) and after treatment (4.75+/-5.51) were not significantly different (p=0.226). NDDI-E and GAD-7 scores pre and post lacosamide initiation were not significantly affected by a history of mood disorders, concomitant psychiatric medications, or mood stabilizing concomitant AEDs. CONCLUSIONS: Our study suggests that lacosamide does not have a clinically significant impact on mood or anxiety symptoms as measured by the NDDI-E and GAD-7 scales. This suggests that lacosamide can be prescribed to patients with comorbid depression and/or generalized anxiety without fear of the treatment significantly worsening those disorders. Study Supported by: No outside funding was utilized.

Depression and anxiety are common in patients with epilepsy. Moreover, some antiepileptic drugs (AEDs) have mood stabilizing and anxiolytic effects, while others may worsen psychiatric symptoms. The effects of lacosamide, a third generation AED approved for the treatment of focal onset seizures, on depressive and anxiety symptoms are unknown. We evaluated changes in depression and anxiety following the initiation of lacosamide. We compared patients' scores on the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E, n = 91) and Generalized Anxiety Disorder 7-item (GAD-7, n = 20) scales prior to and following lacosamide treatment. Following the initiation of lacosamide, there were no significant changes in NDDI-E scores when all patients were analyzed aggregately (baseline: 12.14 ± 4.64 vs post-treatment: 11.91 ± 4.14, p = 0.51). Similarly, the mean GAD-7 scores at baseline (4.10 ± 4.52) and after treatment (4.75 ± 5.51) did not differ (p = 0.23). In the 25 patients with initial NDDI-E scores of >15, lacosamide was associated with a significant decrease in depressive symptoms (baseline: 17.60 ± 1.63 vs post-treatment: 14.64 ± 2.78, p < 0.001). NDDI-E and GAD-7 scores pre- and post-lacosamide initiation were not significantly affected by a history of mood disorders, concomitant psychiatric medications, or concomitant AEDs with mood-stabilizing effects.