The Epidemiology and Medical Morbidity of Long-Distance Backpackers on the John Muir Trail in the Sierra Nevada.

INTRODUCTION: The baseline characteristics and medical morbidity of hikers on the 354 km (220 mi) John Muir Trail (JMT) have not been previously reported. METHODS: Using online and on-site recruitment, hikers completing the JMT in 2014 were directed to an online 83-question survey. Pearson correlations, regression models, and descriptive statistics were applied to data, reported as mean±SD (range). Statistical significance was set at P<0.05. RESULTS: Of 771 respondents, 57% were men aged 43±14 (13-76) y; they hiked 15.2±7.6 (5-34) days and traveled 272±129 (45-1207) km (169±80 [28-750] mi). Backpackers lost 3.5±2.6 (+3.6 to -18.2) kg (7.7±5.8 [+8 to -40] lbs). Over half (57%) of respondents reported illness or injury, with blisters (57%), sleep problems (57%), and pack strap pain (46%) most prevalent. Altitude illness affected 37%. Thirty hikers left the trail; of these, 4 required emergency medical services evacuations (3 by helicopter). Increasing age, base pack weight, and body mass index (BMI) were all associated with a decrease in the distance hiked per day. Higher base pack weight was associated with illness or injury, whereas older age was slightly protective. Increasing BMI was associated with a slight increase in medical illness or injury and a strong association with evacuation from the trail. CONCLUSIONS: JMT hikers experienced medical issues seen on other national trails. Weight loss was prevalent. Most hikers had medical complaints, with few seeking medical attention. Heavy packs and higher BMIs were associated with undesirable outcomes, while older hikers fared better.

Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department.

BACKGROUND: Gastroparesis associated nausea, vomiting & abdominal pain (GP N/V/AP) are common presentations to the emergency department (ED). Treatment is often limited to antiemetic, prokinetic, opioid, & nonopioid agents. Haloperidol (HP) has been shown to have analgesic & antiemetic properties. We sought to evaluate HP in the ED as an alternative treatment of GP N/V/AP. METHODS: Using an electronic medical record, 52 patients who presented to the ED w/GP N/V/AP secondary to diabetes mellitus and were treated w/HP were identified. Patients who received HP were compared to themselves w/the most recent previous encounter in which HP was not administered. ED length of stay (LOS), additional antiemetics/prokinetics administered, hospital LOS, and morphine equivalent doses of analgesia (ME) from each visit were recorded. Descriptive statistics, categorical (Chi Square Test or Z-Test for proportion) and continuous (Wilcoxon Signed Rank Test) comparisons were calculated. Statistical significance was considered for two tail p-values less than 0.05. RESULTS: A statistically significant reduction in ME (Median 6.75 [IQR 7.93] v 10.75 [IQR12]: p=0.001) and reduced admissions for GP (5/52 v 14/52: p=0.02) when HP was administered was observed. There were no statistically significant differences in ED or hospital LOS, and additional antiemetics administered between encounters in which HP was administered and not administered. No complications were identified in patients who received HP. CONCLUSIONS: The rate of admission and ME was found to be significantly reduced in patients with GP secondary to diabetes mellitus who received HP. HP may represent an appropriate, effective, and safe alternative to traditional analgesia and antiemetic therapy in the ED management of GP associated N/V/AP.

A season of snakebite envenomation: presentation patterns, timing of care, anti-venom use, and case fatality rates from a hospital of southcentral Nepal.

Snakebite envenomation affects thousands of people annually in Nepal. Published hospital-based studies of snakebite treatment in Nepal are scarce. Here we present the results of the first prospective, cross-sectional study of hospitalized envenomed snakebite cases in southcentral Nepal, a region characterized by poor pre-hospital care of snakebites, limited supply and excessive use of antivenom, and a high case/fatality ratio. We seek to identify clinical management problems and suggest potential interventions to improve treatment of snakebites. Out of the 342 patients presented with snakebites to an urban emergency department in the Terai region of Nepal between April and September of 2007, 39 patients were enrolled based on development of ptosis or swelling of bitten body parts. We collected patient demographic information and documented circumstances of snakebite, prehospital care, hospital care, and development of complications. Among 39 envenomated patients admitted to Bharatpur Hospital enrolled in the study 34 (92%) exhibited features of clinically significant neurotoxicity and were treated with antivenom. Antivenom use ranged from 4 to 98 vials of Polyspecific Indian Antivenom per patient. Each of victims (n=34) received antivenom an average of 4.3 (median) ±0.73 (standard error of mean) hours after receiving the snakebite. The overall case fatality rate was 21%. Neurotoxicity developed up to 25.8hr after suspected elapid snakebites. This was not observed for viperid snake bites. No enrolled patients received any of the currently recommended first aid for snake bite. The prevalence of nocturnal elapid snake bites, the practice of inappropriate first aid measures and highly variable administration of antivenom were identified as major challenges to appropriate care in this study. To address these issues we suggest development of a comprehensive checklist for identification of snake species, management of envenomation, and an educational program which teaches proper care at all stages of snakebite treatment.