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  September, 2002

Deep Vein Thrombosis at High Altitude

 
 


Acute mountain sickness high altitude pulmonary oedema (HAPE) and high altitude cerebral oedema (HACE) are common at high altitude but just a few cases of coronary and cerebral thrombosis and phlebitis of limbs have been reported1.
A young man who was performing his duties at 17000 ft in northern areas of Pakistan developed progressive painless swelling of his right leg. He was a chronic smoker and did not have any trauma, fever and chest pain. Examination revealed signs of deep vein thrombosis in his right leg. Rest of systemic examination was unremarkable.
He was descended within next forty-eight hours of incident to Rawalpindi at 2000 ft. above sea level. The investigations revealed following:
Haemoglobin- 14.8g/dl, platelets - 190x 109 per liter while total leukocytes count, ECG, X-rays chest, bleeding time, clotting time, PT, PTTK were with in normal limits. Lung scan was also normal. Doppler duplex ultrasound and radioisotope scanning of right leg revealed a large thrombus in popleteal artery extending up to femoral artery. Blood lupus anticoagulant was positive while anticardiolipin antibody, factor V Leiden and protein C levels were within normal limits. Inj. heparin 1000 unit per hour was given by continuous infusion for 4 days. Concurrently oral warfarin 10 mg per day was started before stopping heparin. Within one week swelling of the leg resolved and he became hilly mobile. He was advised to continue warfarin for next four months.
The patient was healthy but developed deep vein thrombosis when he went to high altitude. Various factors attribute to the hypercoagulability at high altitude, In this case smoking, decreased physical activity, coagulation disparities and probably dehydration are important. Decreased physical activity and dehydration lead to stasis of blood and hence cause tendency to coagulate. Coagulation enhancement may also result from abnormal platelets with increased adhesiveness2, red cell anisocytosis3 and polythermia4 leading to microthrombi which initiate progressive coagulation cascade. Thromboembolism manifests itself in various ways like crebrovascular accident5 pulmonary embolism6 and deep vein thrombosis. The role of microthrombi in acute mountain sickness has also been theoretically suggested. The successful medical treatment results from the fact that all disorders of coagulation return to normal on decent to lower heights i.e. less than 10000 ft (ideally sea levels) and early anticoagulant therapy with adequate mobilization.
This is to highlight the role of high altitude as a factor leading to tendency towards hypercoagulability. Management of cases of thrombosis occurring at high altitude depends on rapid evacuation to lower heights and early anticoagulant therapy.

1. Hussain, A. Niaz
Department of Medicine, Medical Unit II, Military Hospital, Rawalpindi.


References

1.Funimaki T, Matsutani M, Asai A, et al. Cerebral venous thrombosis due to high altitude polycythemia. Case report. J. Neurosurg., I 986;64: 148-50.
2.Sharma SC. Platelet count and adhesiveness on induction to high altitude by air and road. lnt.J. Biometeorol, 1982;26:219-24.
3.Rowel PM, William ES. Abnormal red cell morphology in venous blood of men climbing at high altitude. Br. Med. J., 1983;286:1396-97.
4.Whittaker S, Winton FR. The apparent viscosity of blood flowing in the isolated hind limb of the dog and its variation with corpuscular concatenation. J. Physical, 1983;78:339-69.
5.Asajin T, Sakoral E, Tanizaki V. et al. Report of medical aspects of Mt. Lhotse and Everest expedition in 1983: with special reference to a case of cerebral venous thrombosis in the altitude. Jpn. J. Mount. Med., 1984;4:98.
6.Winslow RM, Monge CC. Hypoxia, polycythemia and chronic mountain sickness. John Hopkins University Press, Baltimore, 1987, p. 37.


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WHO/GOARN Request for technical assistance for Cholera Control in Northern Iraq

Request for assistance

WHO is requesting assistance from GOARN partners to identify the following cholera and diarrhoeal diseases expertise to support the Ministry of Health of Iraq in cholera risk assessment and immediate preparedness activities to improve the health outcomes of the Syrian refugees current living in camps in the Kurdistan region of Iraq.

  • two (2) epidemiologists
  • two (2) clinical management experts
  • one (1) environmental health expert (WATSAN)
  • one (1)laboratory expert

Duration

6 day mission starting 13 June 2014 (this excludes travel time).

Location

Northern Iraq (Kurdistan region).

Language requirements

All candidates must be fluent in English- written, spoken and comprehension. Fluency in Arabic is an asset. Knowledge, abilities and skills All candidates are expected to demonstrate the following

  • Ability to conceptualize and promote innovative strategies and policies.
  • Ability to communicate and write in a clear concise manner, and to develop effective guidelines.
  • Excellent negotiation and interpersonal skills complemented by ability to motivate and lead others and to promote consensus. Tact, discretion and diplomacy
  • Demonstrated ability for project appraisal, project management, monitoring and evaluation and project impact assessment.
  • Ability to work with host governments and their agents, INGOs and national NGOs an advantage.
  • Proven experience of managing a large workload and multiple priorities.
  • Ability to work in difficult conditions.

Support to the mission

WHO/GOARN will cover the travel and per diem (to cover daily expense in the field) expenses for the duration of their mission. GOARN missions do NOT offer salary, consultancy fees or any other form of remuneration.

WHO will provide appropriate logistics support for the field mission. Pre-deployment orientation/training may be required at WHO.

Partners offers of assistance

Partners are requested to reply with offers of assistance, together with CVs and details of the availability of staff for this mission by email to goarn@who.int latest by 30 May 2014. Details of all offers from partners and eventual deployments will be maintained on the GOARN SharePoint.

Operational Contacts

Mamunur Malik WHO EMRO malikm@who.int

William Perea WHO HQ pereaw@who.int

Patrick Drury GOARN druryp@who.int



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