Objective.—The duration of tick attachment is related to the likelihood of disease transmission. To be able to locate and remove an attached tick is important.

Methods.—Sixty-seven patients presenting with tick bites to the Karadeniz Technical University emergency department and 3 different first-stage health institutions between April and July 2006 were investigated to determine the distribution of the bites.

Results.—Tick attachment site distribution was determined as follows: 9% head-neck, 5% arm, 24% stomach-groin, 7% back, 18% chest-shoulder, 25% leg-foot, and 12% hip.

Conclusions.—According to the results of our study, 20% of ticks attach to regions of the body that patients cannot themselves see. After travel in endemic areas, a complete inspection of the entire body surface is required to achive early tick removal

Category 1 Continuing Medical Education credit for WMS member physicians is available for this article. Go to  http://wms.org/cme/cme.asp?whatarticle=1911 to access the test questions.

Objective.—There is not a single data source for information on the extent of nonfatal injuries inflicted by animals. Although individuals bitten or stung by animals may not visit a health care provider, they may call poison control centers (PCCs) for information. These centers are one source of information on the frequency of occurrence of injuries from animals.

Methods.—The American Association of Poison Control Centers compiles an annual report of exposure calls to various agents, including chemicals, medications, animal bites and stings, plants, and use of antivenoms from their network of PCCs. An estimate of the severity of exposure for each call is also determined. This review examines summary data on different species of animal bites and stings reported by PCCs from 2001 to 2005.

Results.—From 2001 to 2005 there were 472 760 reports of animal bites and stings, an average of 94 552 per year. There was a trend noted for increasing use of antivenom over this period. Twenty-seven deaths were recorded, most from snakebites.

Conclusions.—Poison control centers are a source of information for health care workers on management of animal bites and stings. The database maintained by the American Association of Poison Control Centers is another source of information on the magnitude and public health impact of injuries from animals.

Objective.—This study assessed a potential relationship between elevated carboxyhemoglobin (COHb) levels and the presence of acute mountain sickness (AMS) at 4300 m on Denali and evaluated the relationship between COHb levels, AMS, and climber characteristics and behaviors. Building on our research done in 2004, in this article we report further data gathered during the 2005 climbing season and evaluate the combined results.

Methods.—Participants were screened for AMS using the Lake Louise Self-Report Questionnaire and answered questions focusing on AMS symptoms, AMS prevention, and previous history of altitude illness. Carboxyhemoglobin levels were measured by serum co-oximetry. Additional questions assessed stove practices, climbing practices, and climber behaviors. Nonparametric statistical analyses were performed to examine potential relationships between COHb levels, AMS symptoms, and climber behaviors across the 2 years and with years combined.

Results.—Overall, 317 climbers participated in the 2-year study. As in 2004, the combined data demonstrated no relationship between positive carbon monoxide (CO) exposure and positive criteria for AMS (P = .276). Climbers in 2005 were 1.92 times more likely to meet positive criteria for AMS, compared to climbers in 2004 (P = .028). On the contrary, climbers in 2004 were 3.93 times more likely to be CO exposed than climbers in 2005 (P = .003). Overall, climbers descending the mountain were more likely to be positive for CO exposure (5.56 times more likely than ascending climbers, P = .002) and to have higher overall mean COHb levels (2.26% descending vs 0.93% ascending, P = .006). The previous association between increased stove use and climbers who met positive criteria for AMS was not observed in the 2005 or in the combined data (P = .715). A relationship was observed between increased hours of operating stoves and increased COHb levels (P = .002). Female climbers were 2.041 times more likely to meet criteria for AMS (P = .043).

Conclusions.—No relationship between AMS symptoms and CO exposure was observed. As found in our initial study, descending climbers had higher overall COHb levels and an increased risk of CO exposure (COHb of >3% in nonsmokers and >10% in smokers). Also, increased hours of stove operation was linked to climbers who had elevated COHb levels.

Objective.—Sherpas are well-known for their physical strength at high altitudes. They adapt to high altitude so well that little acute or chronic mountain sickness has been documented in them. The possible genetic basis for this adaptation is, however, unclear. The objective of this study was to elucidate the genetic background underlying this characteristic among Sherpas with respect to the angiotension-converting enzyme (ACE) gene.

Methods.—We enrolled 105 Sherpa volunteers in Namche Bazaar (3440 meters) and 111 non-Sherpa Nepalese volunteers in Kathmandu Valley (1330 meters) in Nepal. Information about high-altitude exposure and physiological phenotypes was obtained via fieldwork investigation. The genotype of the insertion/deletion (I/D) polymorphism in the ACE gene was identified by polymerase chain reaction. Serum ACE activity was also measured.

Results.—The distribution of the I dominant genotype (II & ID) and the I allelic frequency were significantly more prevalent in Sherpas (II & ID: 94.3%, I allele: 73.3%) than in non-Sherpas (II & ID: 85.6%, P = .035; I allele: 64.0%, P = .036). Moreover, despite residing at high altitude, the circulating ACE levels of Sherpas were statistically similar to those of non-Sherpas at low altitudes (Sherpas: 14.5 ± 0.4 IU/L/37°C; non-Sherpas: 14.7 ± 0.4 IU/L/37°C; P = .755).

Conclusions.—These findings suggest that the overrepresented I allele of the ACE gene in Sherpas might be one of the fundamental genetic factors responsible for maintaining physiological low-altitude ACE activity at high altitude, which may have an advantageous physiological role in adapting to a high-altitude environment.

Objective.—Exercise stress, immune status, and mood are interrelated. The stress of adventure racing is unique; exercise is very prolonged and competitive, with severe sleep deprivation and sustained cognitive demands, usually in arduous terrain and environmental conditions. The purpose of this prospective, descriptive study was to identify mood changes along with symptoms of illness and injury during and in the weeks following an international-level adventure race.

Methods.—Mood, sleep, injury, and illness data were collected using questionnaires before, during, and for 2 weeks following New Zealand's Southern Traverse Adventure Race in November 2003.

Results.—Mood was variable between athletes, but peaks of altered mood subscores were evident (P < .05) during the first 24 hours of racing, around race completion, and, as was hypothesized, 3 days after racing. Altered mood subscores resolved within 2 weeks. Symptoms of upper respiratory illness were most common immediately before (25/60, 42%) and after (28/49, 57%) racing, and largely resolved over the 2-week follow-up (5/27, 19%). Skin wounds and infections were common (43/49, 88%) immediately after the race but settled quickly. Pain was universal (100%), and musculoskeletal injury was common (38/48, 79%). Gastrointestinal complaints were common at the finish (8/49, 16%) and during the next 5 days but settled more quickly than upper respiratory symptoms.

Conclusions.—Adventure racing of approximately 100 hours causes significant symptomatic injury and illness and mood state disruption, which generally resolve within a fortnight following racing. Disrupted mood and symptoms of illness and injury indicate athlete susceptibility to overreaching or overtraining without sufficient recovery.

The cardiovascular system participates in both blood pressure (BP) and temperature regulation. As a result, salt ingestion creates conflict between BP and temperature homeostasis, as vasodilatation that would promptly lower the BP would simultaneously increase cutaneous blood flow, thereby accelerating heat loss. If temperature homeostasis has precedence over blood pressure homeostasis, as postulated by the thermoregulatory-vascular remodeling (TVR) hypothesis, then in order to minimize heat loss, BP remains elevated following salt ingestion until the kidneys excrete the excess salt. A case of amlodipine overdose offered an opportunity to test a corollary of the TVR hypothesis: vasodilators should cause a drop in body temperature and/or an increase in the metabolic rate. Following the ingestion of 1000 mg of amlodipine, the temperature and BP of a single patient were monitored during the initial 36 hours and during the 13th day of hospitalization. The BP dropped markedly between the fifth and seventh hours postingestion, but then rose steadily and normalized by 28 hours postingestion. The temperature was normal at 7 hours postingestion, declined gradually between the seventh and 26th hours postingestion, stabilized between the 26th and 31st hours postingestion, then began to rise. During this case of amlodipine overdose, a modest temperature decline lagged behind a marked BP decline. As the BP rose, the temperature also rose, but lagged behind the BP increases. These findings suggest that there is a relationship between BP and temperature and are consistent with the TVR hypothesis.

Category 1 Continuing Medical Education credit for WMS member physicians is available for this article. Go to  http://wms.org/cme/cme.asp?whatarticle=1912 to access the test questions.

Exercise-associated hyponatremia is the most common medical complication of ultradistance exercise and is usually caused by excessive hypotonic fluid intake. We report a case of severe hyponatremia in a healthy male trekking the Kokoda Trail in the remote Southern Highlands of Papua New Guinea. A 43-year-old male collapsed and had a generalized seizure in the afternoon of the third day of a guided trek. He was evacuated the following morning and was found to have a serum sodium level of 107 mmol/L on arrival to hospital. The case highlights that a high index of suspicion is required to identify patients with exercise-associated hyponatremia. Early diagnosis and appropriate management is critical to avoid the potentially fatal consequences of severe hyponatremia. The diagnosis and treatment of exercise-associated hyponatremia is particularly challenging in the remote Papua New Guinea jungle. Education of trek leaders, medics, and trekkers in appropriate preventative measures and the rapid treatment of exercise-associated hyponatremia is essential to avoid recurrences of this life-threatening condition.

Category 1 Continuing Medical Education credit for WMS member physicians is available for this article. Go to  http://wms.org/cme/cme.asp?whatarticle=1913 to access the test questions.

Objective.—Few portable point-of-use (POU) devices are available for treatment of water by recreational enthusiasts who may obtain water from untreated sources (rivers, lakes, etc.). This study evaluated a POU device containing a structure matrix capable of removing viruses from water without the use of a disinfectant.

Methods.—The unit was evaluated for the removal of poliovirus type 1, rotavirus SA-11, human norovirus, and a wide range of different coliphages exhibiting different isoelectric points, sizes, and shapes.

Results.—The removal of all virus types tested exceeded 99.99%.

Conclusion.—The tested unit complied with the criteria guidelines for virus removal under the US Environmental Protection Agency's “Guide Standard and Protocol for Testing of Microbiological Water Purifiers.”

Wilderness, mountain, and expedition medicine training for physicians is now well developed in North America and Europe. This paper describes the development and content of the first such program in Australia. The Special Skills Post in Expedition Medicine is a 6-month post, developed by General Practice Training Tasmania, that is integrated into general practice training and combines clinical placements in travel medicine, general practice, emergency medicine, a self-guided workbook covering core and elective topics, and an 8-day field trip.