Profile of Patients Attending SKIMS Srinagar during 2011

altitude of 3880 meters above sea level. Yatri's(pilgrims) have to trek a distance of 14000 feet, as no vehicular transport is available right up to a cave except a helicopter service during yatra period for ferrying emergency patients and VIPs. The Yatra usually lasts for 45 days, mid summer, every year. During the yatra period, Lakhs of devotees visit the cave, posing a great challenge to the authorities for providing adequate civic amenities like space, sanitation, medical care facilities, food hygiene. As a consequence and because of close contact of yatris in camps and other temporary makeshift accommodations, Yatris are prone to many illnesses including respiratory and gastrointestinal infections, food poisoning, road traffic accidents, and high altitude pulmonary edema (HAPE).

CONCLUSION: Yatris attending Amrnath ji yatra face many health related challenges.A pre-yatra checkup of all yatris planning for Amarnathji yatra should be made mandatory for all.Elderly pilgrims (>65 years) and those with any morbidity who are undertaking for yatra by foot/surface transport should be well-informed about the potential health hazards of the yatra.JMS 2012;15(2):170-73 Key words: Amarnathji yatra, Amarnathji cave, high altitude pulmonary edema, acute myocardial infarction, death, health hazard

Methods
This prospective study was conducted at SKIMS; a 630-bed multispecialty hospital in the Valley of Kashmir.All pilgrims of Amarnathji yatra referred to SKIMS between July and August 2011 were recruited for the study.Baseline demographic data was collected from the Accident & Emergency Department (A&E) whereas the followup data was collected from progressive patient care areas.However patients who were directly referred to the Department of Endocrinology for Diabetic ketoacidosis or hyperglycemic state are not included in the study.The patients were followed up till they were discharged from the hospital.The data was entered in a specially designed 15 point Performa, and then keyed into Microsoft Excel 2007.The data was analyzed by SPSS version 19.0, using standard analytical techniques.

Results
Of the 185 patients received in SKIMS during the mentioned yatra period, 100 were discharged on emergency-OPD card on the same day (Table 1).The remaining 85 patients were admitted, which included 48 men (56.5%) and 37 women (43.5%).Age of the study subjects ranged from 15 to 85 years with a mean of 51.5 ±15.5 (median, 53 years).Age and gender distribution of these patients is shown in Table 2

Discussion
This pilot study was of short duration, limited to patients referred to our hospital during one yatra period.However, it gives a good reflection of pattern of illnesses during Amarnathji yatra season.It displays the demographic characteristics of the pilgrims and shows that elderly yatris have higher morbidity and mortality particularly those aged 65 years or higher.Two most common co-morbidities encountered at arrival to the hospital were coronary heart disease and diabetes.However, this study does not include data of patients who were directly referred to the Department of Endocrinology of this institute for Diabetic ketoacidosis or hyperglycemic state.
Amarnath cave is a famous shrine in Hinduism located in the Indian state of Jammu and Kashmir.It is dedicated to Shiva.The cave is situated at an altitude of 3,888 m (12,756 ft), about 141 km (88 mi) from Srinagar, the capital of 1 Jammu and Kashmir and reached through Pahalgam town.The shrine forms an important part of Hinduism, and is considered to be one of the holiest shrines in Hinduism.The cave is surrounded by snowy mountains.The cave itself is covered with snow most time of the year except for a short period of time in summer when it is open for pilgrims.An annual pilgrimage is made to the Amarnath cave by lakhs (hundreds of thousands) of Hindu devotees on challenging mountainous terrain to see an ice stalagmite formed inside 1 the cave.The history of Amaranth dates back to the times of Arayaraja (34BC to 17&CE) who used to spend his summer here worshipping an, ice lingam, that was then located in the region that was beyond the forest.The city also finds its reference in the Rajataringini, where the city was mentioned as Amareshwara.The city has also been mentioned by Kalhana and its sequel, Rajataringini that talks about the records of Kashmir.
As the cave is situated at a high altitude, the terrain is difficult and the weather conditions are often harsh, the yatra poses a significant challenge to the physical fitness and endurance of the devotees.It is no surprising that majority (27%) of the patients referred to our hospitals were related to trauma and accidents, i.e., head injury and poly-trauma occurring in 23 of our 85 admitted patients.Trauma during pilgrimage is a real surgical problem which deserves more attention.In one study in Saudi Arabia, orthopedic and neurosurgical cases were the most common surgical cases 2 during the Hajj period.Understandably, the yatra is not suitable for elderly patients and those with co-morbidities, especially those with higher cardiovascular risk.Similar health problems have been reported in other pilgrimages like Hajj.In one such study on Hajj pilgrims, it was found that 54% elderly more often develop serious illnesses with higher 3 death rates.Therefore, it is not surprising to find that most common cause for referral to our hospital in the yatra patients was acute myocardial infarction.For that reason, every potential Yatri should be particularly screened for cardiovascular disease during pre-yatra health check.
Apart from trauma and AMI, another common reason for referral in our patients was high altitude pulmonary edema (HAPE) which is again self explanatory.Of course Individual susceptibility to HAPE is the most important 4 determinant for its occurrence.Symptoms associated with HAPE can be incapacitating fatigue, chest tightness, dyspnoea at the slightest effort, orthopnoea, and cough with due to haemoptysis in an advanced stage of the disease pink frothy sputum.The hallmark of HAPE is an excessively elevated pulmonary artery pressure (mean pressures of 35 and 55 mm Hg), which precedes the development of pulmonary oedema.Elevated pulmonary capillary pressure and protein-as well as red blood cell-rich oedema fluid without signs of inflammation in its early stage are characteristic findings.Furthermore, decreased fluid clearance from the alveoli may contribute to this non-cardiogenic pulmo-4 nary oedema.
Other common illness observed in our patients included diabetes, stroke, COPD, gastroenteritis and poisoning.The cases of food poisoning, which we received About the implications of this study, we would like to suggest that, i) Pre-yatra checkup should be done before registering yatris for Amaranth pilgrimage; ii) those with co morbidity should allowed to visit the Holy cave only after special travel arrangements are made for them, taking due cognizance of the medical illness; iii) there should be upgradation of health infrastructure on way to cave, and iv) to avoid overcrowding and mass movement, the number of yatris should be limited as per facilities available, particularly those related to sanitation and other civic amenities en route to cave.
. As shown in the table, majority of patients were in the age group of 45 to 65 years.There was no statistically significant difference in the age between men and women (48.65 ±15.87 vs. 55.19 ±14.35, p =0.053).Acute myocardial

TABLE 3 . Showing diagnosis on arrival and mortality rate of admitted patients
3%) were the most common disease reported among these pilgrims.Respiratory, cardiovascular and metabolic diseases affected 74%, 57% and 23 % of pilgrims.There were 57 deaths with a mortality rate of 7.4%.Myocardial infarction infarction was the most common cause of death; old age, poor physical fitness, multiple diseases, neglect in continuous treatment of known chronic diseases and failure to seek early medical advice were the major factors responsible for morbidity and mortality.Our results are not very different from those reported in these studies except the high frequency of HAPE which quite understandable.