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Introduction: Cambridgeshire is a challenged health economy with a significant current overspend and consistent suboptimal performance against national targets for A&E waiting times. Community care in Cambridgeshire has undergone enormous change in the last 3 years in an attempt to address these problems. An example of this is the instigation of a county wide joint emergency team JET. Practice change: Previously there were small local schemes aimed at avoiding unnecessary admissions to acute care by providing a community response. Other parts of the county had no such provision. As part of a complete re-provision of community care following system wide consultation, a county wide service was commissioned, the JET team. This team initially comprised 6 experienced nurses or paramedics across the county who responded within four hours to a restricted number of presentations. The service has evolved to include a triage service, nursing, paramedics, therapy, care workers and access to community pharmacy. Medical input is currently provided by primary care but adding dedicated medical time is planned. Aim: The aim of JET is to prevent unnecessary hospital admission for the over 65’s or those with long term conditions by treating them rapidly and holistically at home. Targeted population and stakeholders: There are 165,000 people over the age of 65 in Cambridgeshire. We consulted widely with stakeholders including service users, primary care, commissioners, 111 service, ambulance service, acute trusts and local mental health services. Highlights: The service is in its third year. In the last nine months we received 6207 referrals. 87.9% of those have resulted in the patient being treated at home. We have engaged in repeated audits by independent GP’s to look at what is genuine admission avoidance. The latest audit suggests that 42% of patients seen by JET would have been admitted to acute care without JET. Based on the current local tariff for an acute geriatric admission the costs of admission to acute care would have been £4,431,798. The cost of the JET service over that period was less than £1,500,000. Checks ensure patients are not admitted within 30 days of being seen to be sure admission has been genuinely avoided, not delayed. Patient satisfaction is also high with 90.2% of patients willing to recommend the service to their friends/family. Sustainability: Despite some initial scepticism there is now a consensus that JET provides clinically appropriate care at home. This is popular with patients and is cheaper than admitting to acute hospitals. JET has received extra investment and will expand in size and professional heterogeneity as well as providing increased input to new areas, for example psychiatric wards for dementia and diverted calls from the ambulance service. Conclusion and lessons learned: Emergency response teams for the deteriorating frail elderly are feasible and can occur at scale. They can provide quality care in a preferred setting at lower cost. Essential to success has been whole system engagement, a willingness to adapt and change as the service developed and robust data collection to demonstrate the worth of the service.

Introduction: Aldosterone decreases at high altitude (HA) but the effect of hypoxia on angiotensin-converting enzyme (ACE), a key step in the renin-angiotensin-aldosterone system, is unclear. Methods: We investigated the effects of exercise and acute normobaric hypoxia (NH, ~11.0% FiO2) on nine participants and six controls undertaking the same exercise at sea level (SL). NH exposure lasted 5 hours with 90 minutes of submaximal treadmill walking. Blood samples for aldosterone, ACE and cortisol were taken throughout exposure and at rest during a trek to HA (5140 m) in eight separate participants. Results: There was no difference in cortisol or aldosterone between groups pre-exercise. Aldosterone rose with exercise to a greater extent at SL than in NH (post-exercise: 700 ± 325 versus 335 ± 238 pmol/L, mean ± SD, p = 0.044). Conversely, cortisol rose to a greater extent in NH (post-exercise: 734 ± 165 versus 344 ± 159 nmol/L, mean ± SD, p = 0.001). There were no differences in ACE activity. During the trek to HA, resting aldosterone and cortisol reduced with no change in ACE. Conclusions: Acute NH subdues the exercise-associated rise in aldosteroe but stimulates cortisol, whereas prolonged exposure at HA reduces both resting aldosterone and cortisol. As ACE activity was unchanged in both environments, this is not the mechanism underlying the fall in aldosterone.

Introduction High-altitude environments lead to a significant physiological challenge and disease processes which can be life threatening; operational effectiveness at high altitude can be severely compromised. The UK military research is investigating ways of mitigating the physiological effects of high altitude.\ud \ud Methods The British Service Dhaulagiri Research Expedition took place from March to May 2016, and the military personnel were invited to consent to a variety of study protocols investigating adaptation to high altitudes and diagnosis of high-altitude illness. The studies took place in remote and austere environments at altitudes of up to 7500 m.\ud \ud Results This paper gives an overview of the individual research protocols investigated, the execution of the expedition and the challenges involved. 129 servicemen and women were involved at altitudes of up to 7500 m; 8 research protocols were investigated.\ud \ud Conclusions The outputs from these studies will help to individualise the acclimatisation process and inform strategies for pre-acclimatisation should troops ever need to deploy at high altitude at short notice.

© 2017 American College of Sports Medicine There is evidence to suggest that high altitude (HA) exposure leads to a fall in heart rate variability (HRV) that is linked to the development of acute mountain sickness (AMS). The effects of sex on changes in HRV at HA and its relationship to AMS are unknown. METHODS: HRV (5-minute single lead ECG) was measured in 63 healthy adults (41 men and 22 women) aged 18-56 years at sea level (SL) and during a HA trek at 3619m, 4600m and 5140m respectively. The main effects of altitude (SL, 3619, 4600 and 5140m) and sex (men vs women) and their potential interaction were assessed using a Factorial Repeated Measures ANOVA. Logistic regression analyses were performed to assess the ability of HRV to predict AMS. RESULTS: Men and women were of similar age (31.2 ±9.3 vs 31.7±7.5 years), ethnicity, body and mass index. There was main effect for altitude on heart rate, SDNN (standard deviation [SD] of normal-to-normal [NN] intervals), RMSSD (Root mean square of successive differences), NN50 (number of pairs of successive NNs differing by > 50 ms), pNN50 (NN50/total number of NNs), very low frequency (VLF), low frequency (LF), high frequency (HF) and total power (TP). The most consistent effect on post hoc analysis was reduction in these HRV measures between 3619 and 5140m at HA. Heart rate was significantly lower and SDNN, RMSSD, LF, HF and TP were higher in men compared with women at HA. There was no interaction between sex and altitude for any of the HRV indices measured. HRV was not predictive of AMS development. CONCLUSIONS: Increasing HA leads to a reduction in HRV. Significant differences between men and women emerge at HA. HRV was not predictive of AMS.

Central arterial systolic blood pressure (SBP) and arterial stiffness are known to be better predictors of adverse cardiovascular outcomes than brachial SBP. The effect of progressive high altitude (HA) on these parameters has not been examined. Ninety healthy adults were included. Central BP and the augmentation index (AI) were measured at the level of the brachial artery (Uscom BP + device) at < 200 m and at 3619, 4600 and 5140 m. The average age of the subjects (70% men) were 32.2±8.7 years. Compared with central arterial pressures, brachial SBP (+8.1±6.4 mm Hg; P < 0.0001) and pulse pressure (+10.9±6.6 mm Hg; P < 0.0001) were significantly higher and brachial diastolic BP was lower (-2.8±1.6 mm Hg; P < 0.0001). Compared with < 200 m, HA led to a significant increase in brachial and central SBP. Central SBP correlated with AI (r=0.50; 95% confidence interval (CI): 0.41-0.58; P < 0.0001) and age (r=0.32; 95% CI: 21-0.41; P < 0.001). AI positively correlated with age (r=0.39; P < 0.001) and inversely with subject height (r=-0.22; P < 0.0001), weight (r=-0.19; P=0.006) and heart rate (r=-0.49; P < 0.0001). There was no relationship between acute mountain sickness scores (Lake Louis Scoring System (LLS)) and AI or central BP. The independent predictors of central SBP were male sex (coefficient, t=4.7; P < 0.0001), age (t=3.6; P=0.004) and AI (t=7.5; P < 0.0001; overall r 2 =0.40; P < 0.0001). Subject height (t=2.4; P=0.02), age (7.4; P < 0.0001) and heart rate (t=11.4; P < 0.0001) were the only independent predictors of AI (overall r 2 =0.43; P < 0.0001). Central BP and AI significantly increase at HA. This rise was influenced by subject-related factors and heart rate but not independently by altitude, LLS or SpO 2.

Neeraj M Shah,1 Sidra Hussain,2 Mark Cooke,3 John P O’Hara,3 Adrian Mellor3,4 1Division of Asthma, Allergy and Lung Biology, King’s College London, UK; 2School of Medicine, University College London, London, UK; 3Research Institute for Sport, Physical Activity and Leisure, Leeds Beckett University, Leeds, UK; 4Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK Abstract: Travel to high altitude is increasingly popular. With this comes an increased incidence of high-altitude illness and therefore an increased need to improve our strategies to prevent and accurately diagnose these. In this review, we provide a summary of recent advances of relevance to practitioners who may be advising travelers to altitude. Although the Lake Louise Score is now widely used as a diagnostic tool for acute mountain sickness (AMS), increasing evidence questions the validity of doing so, and of considering AMS as a single condition. Biomarkers, such as brain natriuretic peptide, are likely correlating with pulmonary artery systolic pressure, thus potential markers of the development of altitude illness. Established drug treatments include acetazolamide, nifedipine, and dexamethasone. Drugs with a potential to reduce the risk of developing AMS include nitrate supplements, propagators of nitric oxide, and supplemental iron. The role of exercise in the development of altitude illness remains hotly debated, and it appears that the intensity of exercise is more important than the exercise itself. Finally, despite copious studies demonstrating the value of preacclimatization in reducing the risk of altitude illness and improving performance, an optimal protocol to preacclimatize an individual remains elusive. Keywords: hypoxia, acute mountain sickness, acclimatization, biomarkers, preacclimatization

Purpose To investigate whether there is a differential response at rest and following exercise to conditions of genuine high altitude (GHA), normobaric hypoxia (NH), hypobaric hypoxia (HH) and normobaric normoxia (NN). Method Markers of sympathoadrenal and adrenocortical function (plasma normetanephrine [PNORMET], metanephrine [PMET], cortisol), myocardial injury (highly sensitive cardiac troponin T [hscTnT]) and function (N-terminal brain natriuretic peptide [NT-proBNP]) were evaluated at rest and with exercise under NN, at 3375 m in the Alps (GHA) and at equivalent simulated altitude under NH and HH. Participants cycled for 2 hours {15 minute warm-up, 105 minutes at 55% Wmax (maximal workload)} with venous blood samples taken prior (T0), immediately following (T120) and 2 hours post-exercise (T240). Results Exercise in the three hypoxic environments produced a similar pattern of response with the only difference between environments being in relation to PNORMET. Exercise in NN only induced a rise in PNORMET and PMET. Conclusion Biochemical markers that reflect sympathoadrenal, adrenocortical and myocardial responses to physiological stress demonstrate significant differences in the response to exercise under conditions of normoxia versus hypoxia while NH and HH appear to induce broadly similar responses to GHA and may therefore be reasonable surrogates.

© 2018 Boos et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Introduction Whilst the link between physical factors and risk of high altitude (HA)-related illness and acute mountain sickness (AMS) have been extensively explored, the influence of psychological factors has been less well examined. In this study we aimed to investigate the relationship between ‘anxiety and AMS risk during a progressive ascent to very HA. Methods Eighty health adults were assessed at baseline (848m) and over 9 consecutive altitudes during a progressive trek to 5140m. HA-related symptoms (Lake Louise [LLS] and AMS-C Scores) and state anxiety (State-Trait-Anxiety-Score [STAI Y-1]) were examined at each altitude with trait anxiety (STAI Y-2) at baseline. Results The average age was 32.1 ± 8.3 years (67.5% men). STAI Y-1 scores fell from 848m to 3619m, before increasing to above baseline scores (848m) at 4072m (p = 0.01). STAI Y-1 scores correlated with LLS (r = 0.31; 0.24–0.3; P

a Wales College of Medicine, Cardiff University, Cardiff CF14 4XN, UK b St George’s Hospital, Blackshaw Road, London SW17 0QT, UK c Newcastle General Hospital, Westgate Road, Newcastle upon Tyne NE4 6BE, UK d Ambulance Services Association, Friars House, 157—168 Blackfriars Road, London SE1 8EZ, UK e Royal Berkshire Ambulance NHS Trust, 44 Finchampstead Road, Wokingham, Berkshire RG40 2NN, UK f Freeman Hospital, High Heaton, Newcastle upon Tyne NE7 7DN, UK

the 3rd CRD, 24 h after the last WAS (day 5). The VMR to CRD after WAS was expressed as percentage of the respective baseline values at different pressures of CRD. Data were analyzed using two-way ANOVA followed by a multiple comparison Bonferroni post-hoc test. Results: Immediately after the 1h exposure to WAS, on day 4, non-injected male and female rats exhibited visceral analgesia at 40 mmHg (p