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We present a method for identifying dominant surface type and estimating high spectral resolution surface albedo at the Atmospheric Radiation Measurement (ARM) facility at the Southern Great Plains (SGP) site in Oklahoma for use in radiative transfer calculations. Given a set of 6-channel narrowband visible and near-infrared irradiance measurements from upward and downward looking multi-filter radiometers (MFRs), four different surface types (snow-covered, green vegetation, partial vegetation, non-vegetated) can be identified. A normalized difference vegetation index (NDVI) is used to distinguish between vegetated and non-vegetated surfaces, and a scaled NDVI index is used to estimate the percentage of green vegetation in partially vegetated surfaces. Based on libraries of spectral albedo measurements, a piecewise continuous function is developed to estimate the high spectral resolution surface albedo for each surface type given the MFR albedo values as input. For partially vegetated surfaces, the albedo is estimated as a linear combination of the green vegetation and non-vegetated surface albedo values. The estimated albedo values are evaluated through comparison to high spectral resolution albedo measurements taken during several Intensive Observational Periods (IOPs) and through comparison of the integrated spectral albedo values to observed broadband albedo measurements. The estimated spectral albedo values agree well with observations for the visible wavelengths constrained by the MFR measurements, but have larger biases and variability at longer wavelengths. Additional MFR channels at 1100 nm and/or 1600 nm would help constrain the high resolution spectral albedo in the near infrared region.

Objective: Altitude-related and exercise-related elevations in blood pressure (BP) increase the likelihood of developing pulmonary hypertension and high-altitude illness during high-altitude sojourn. This study examined the antihypertensive effect and potential exercise benefit of the angiotensin II receptor antagonist losartan when taken at altitude., Methods: Twenty participants, paired for age and ACE genotype status, completed a double-blinded, randomised study, where participants took either losartan (100 mg/day) or placebo for 21 days prior to arrival at 5035 m (Whymper Hut, Mt Chimborazo, Ecuador). Participants completed a maximal exercise test on a supine cycle ergometer at sea level (4 weeks prior) and within 48 hours of arrival to 5035 m (10-day ascent). Power output, beat-to-beat BP, oxygen saturation (SpO 2 ) and heart rate (HR) were recorded during exercise, with resting BP collected from daily medicals during ascent. Before and immediately following exercise at 5035 m, extravascular lung water prevalence was assessed with ultrasound (quantified via B-line count)., Results: At altitude, peak power was reduced relative to sea level (p<0.01) in both groups (losartan vs placebo: down 100±29 vs 91±28 W, p=0.55), while SpO 2 (70±6 vs 70±5%, p=0.96) and HR (146±21 vs 149±24 bpm, p=0.78) were similar between groups at peak power, as was the increase in systolic BP from rest to peak power (up 80±37 vs 69±33 mm Hg, p=0.56). Exercise increased B-line count (p<0.05), but not differently between groups (up 5±5 vs 8±10, p=0.44)., Conclusion: Losartan had no observable effect on resting or exercising BP, exercise-induced symptomology of pulmonary hypertension or performance at 5035 m., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Proteinuria increases at altitude and with exercise, potentially as a result of hypoxia. Using urinary alpha-1 acid glycoprotein (α1-AGP) levels as a sensitive marker of proteinuria, we examined the impact of relative hypoxia due to high altitude and blood pressure-lowering medication on post-exercise proteinuria., Methods: Twenty individuals were pair-matched for sex, age and ACE genotype. They completed maximal exercise tests once at sea level and twice at altitude (5035 m). Losartan (100 mg/day; angiotensin-receptor blocker) and placebo were randomly assigned within each pair 21 days before ascent. The first altitude exercise test was completed within 24-48 hours of arrival (each pair within ~1 hour). Acetazolamide (125 mg two times per day) was administrated immediately after this test for 48 hours until the second altitude exercise test., Results: With placebo, post-exercise α1-AGP levels were similar at sea level and altitude. Odds ratio (OR) for increased resting α1-AGP at altitude versus sea level was greater without losartan (2.16 times greater). At altitude, OR for reduced post-exercise α1-AGP (58% lower) was higher with losartan than placebo (2.25 times greater, p=0.059) despite similar pulse oximetry (SpO 2 ) (p=0.95) between groups. Acetazolamide reduced post-exercise proteinuria by approximately threefold (9.3±9.7 vs 3.6±6.0 μg/min; p=0.025) although changes were not correlated (r=-0.10) with significant improvements in SpO 2 (69.1%±4.5% vs 75.8%±3.8%; p=0.001)., Discussion: Profound systemic hypoxia imposed by altitude does not result in greater post-exercise proteinuria than sea level. Losartan and acetazolamide may attenuate post-exercise proteinuria, however further research is warranted., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Talks, Ben J., Susie B. Bradwell, John Delamere, Will Rayner, Alex Clarke, Chris T. Lewis, Owen D. Thomas, and Arthur R. Bradwell. Urinary alpha-1-acid glycoprotein is a sensitive marker of glomerular protein leakage at altitude. High Alt Med Biol. 19:295-298, 2018.-Proteinuria is an established feature of ascent to altitude and may be caused by a loss of negative charges on glomerular capillary walls (GCWs). To test this hypothesis, we measured two similar sized but oppositely charged proteins in urine: negatively charged alpha-1-acid glycoprotein (α1-AGP, 41-43 kDa) and positively charged dimeric lambda free light chains (λ-FLCs, 50 kDa). Twenty-four-hour urinary leakage was compared with albumin, a 66 kDa negatively charged protein. We studied 23 individuals (ages 23-78 years, male = 17) at baseline (140 m) and daily during an expedition to 5035 m. The results showed a significant increase in median urinary leakage of α1-AGP (p < 0.0001; 6.85-fold) and albumin (p = 0.0006; 1.65-fold) with ascent to altitude, but no significant increase in leakage of λ-FLCs (p = 0.39; 1.14-fold). α1-AGP correlated with the daily ascent profile (p = 0.0026) and partial pressure of oxygen (p = 0.01), whereas albumin showed no correlation (p = 0.19). Urinary α1-AGP was a more sensitive marker of altitude proteinuria than urinary albumin and λ-FLCs, and supported the possibility of loss of GCW negative charges at altitude.

Objective: To assess whether acetazolamide (Az), used prophylactically for acute mountain sickness (AMS), alters exercise capacity at high altitude., Methods: Az (500 mg daily) or placebo was administered to 20 healthy adults (aged 36±20 years, range 21-77), who were paired for age, sex, AMS susceptibility and weight, in a double-blind, randomised manner. Participants ascended over 5 days to 4559 m, then exercised to exhaustion on a bicycle ergometer, while recording breath-by-breath gas measurements. Comparisons between groups and matched pairs were done via Mann-Whitney U and Pearson's χ 2 tests, respectively., Results: Comparing paired individuals at altitude, those on Az had greater reductions in maximum power output (P max ) as a percentage of sea-level values (65±14.1 vs 76.6±7.4 (placebo); P=0.007), lower VO 2max (20.7±5.2 vs 24.6±5.1 mL/kg/min; P<0.01), smaller changes from rest to P max for VO 2 (9.8±6.2 vs 13.8±4.9 mL/kg/min; P=0.04) and lower heart rate at P max (154±25 vs 167±16, P<0.01) compared with their placebo-treated partners. Correlational analysis (Pearson's) indicated that with increasing age P max ( r =-0.83: P<0.005) and heart rate at P max ( r =-0.71, P=0.01) reduced more in those taking Az., Conclusion: Maximum exercise performance at altitude was reduced more in subjects taking Az compared with placebo, particularly in older individuals. The age-related effect may reflect higher tissue concentrations of Az due to reduced renal excretion. Future studies should explore the effectiveness of smaller Az doses (eg, 250 mg daily or less) in older individuals to optimise the altitude-Az-exercise relationships., Competing Interests: Competing interests: None declared.

Objective: Following discussions on peer review by the British Society for Rheumatology, the West Midlands Rheumatology Service and Training Committee established a peer review scheme for the West Midlands in 1998. We report our initial 6 yr of experience, during which all 14 units have been visited., Methods: A rotating programme of visits was organized. Following this first cycle of peer review, questionnaires were sent to all consultants and senior allied health professionals in each visited unit and to all members of each visiting team to evaluate the process., Results: There was clear consensus amongst staff from both visited units and visiting teams that a peer review visit is worthwhile and constructive. It is a good opportunity for education and exchange of ideas between staff and to promote the multidisciplinary team in rheumatology. Most recommendations from the reports were considered necessary. The most frequent recommendations were for an increase in consultants and therapy staff. Appointing further consultants has been successful. Opinion was only divided on whether the reports were viewed seriously by Trusts, whether peer review should be regional or national, and how to accurately assess the quality, as well as the quantity, of care provided. Staff would support further cycles of peer review visits., Conclusions: This has been a successful initiative and a positive learning experience for all staff involved. Specifically, it helped to obtain more staff and secure facilities. We recommend developing this scheme and promoting it to other regions.

We have reported an increased frequency of the rare B3 allotype of the fourth component of complement (C4B3) in insulin-dependent diabetics, especially in those with microangiopathy. This study has now been expanded--20 of 106 subjects with microangiopathy and 9 of 116 without possessed the C4B3 allotype (p less than 0.02). C4B3 is said to be in linkage disequilibrium with HLA-DR4. HLA typing was performed on 94 of these patients, 52 with and 42 without microangiopathy. There was no significant difference in the frequency of DR4 (62 vs 50%), DR3 (65 vs 52%), B8 (40 vs 40%) or B15 (32 vs 19%) respectively between these 2 groups. These results confirm an HLA-linked predisposition to microangiopathy, but do not determine whether the primary association is with C4B3, DR4 or another gene with which they are in linkage disequilibrium.