A case for treating high hepatitis B DNA levels before starting HIV therapy.
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Adult↗
Biomedical subjects
David R Boulware
Publications and source records attributed to David R Boulware.
Travel medicine for the extreme traveler.
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Animals↗
Strongyloides hyperinfection presenting as acute respiratory failure and gram-negative sepsis.
STUDY OBJECTIVES: Disseminated strongyloides is a rarely reported phenomenon and occurs in immunosuppressed patients with chronic Strongyloides stercoralis infection. Typically, patients present with pulmonary symptoms but subsequently acquire Gram-negative sepsis. Several cases have been noted in Minnesota, and their presentation, diagnostic evaluation, and clinical outcomes were reviewed. DESIGN: A retrospective chart review was conducted of complicated strongyloides infections from 1993 to 2002 in Minneapolis and St. Paul, MN. Cases were identified by reviewing hospital microbiology databases. SETTING: Metropolitan hospitals with large immigrant populations. RESULTS: Nine patients, all of Southeast Asian heritage, were identified. Eight patients immigrated to the United States > or = 3 years prior to acute presentation. All patients were receiving antecedent corticosteroids; in five patients, therapy was for presumed asthma. Absolute eosinophil counts > 500/microL occurred in only two patients prior to steroid initiation. Eight patients presented with respiratory distress, and Gram-negative sepsis developed in four patients. Four patients had evidence of right-heart strain on ECG or echocardiography at the time of presentation. Three patients died; all had eosinophil counts of < 400/microL. CONCLUSIONS: Serious complications, including death, may occur in patients with chronic strongyloides infection treated with corticosteroids. Strongyloides hyperinfection usually presents as acute respiratory failure and may initially mimic an asthma exacerbation or pulmonary embolism. Southeast Asian patients presenting with new-onset "asthma," acute respiratory distress, and/or Gram-negative sepsis should undergo evaluation to exclude strongyloides infection.
Acute Disease↗
Passive prophylaxis with permethrin-treated tents reduces mosquito bites among North American summer campers.
OBJECTIVE: Over 2 million adolescents participate in summer-camp experiences, placing themselves at risk for mosquito-borne illness. Insect repellent is recommended but often not used. It is unknown whether permethrin treatment of a location, such as a campsite, provides passive prophylaxis reducing mosquito bites among all persons in the immediate vicinity. METHODS: This randomized, double-blind controlled trial used 0.4% permethrin (2.5% permethrin diluted by 7 parts water) sprayed once onto the external surface of canvas tents at a Boy Scout summer camp. During a 9-week period, subjects (n = 545) completed nightly mosquito-bite and -landing counts for 5 minutes at dusk and recorded insect-repellent use within 2 hours of counting. Weekly mosquito sampling with CO2-baited Centers for Disease Control and Prevention traps occurred at study campsites. The primary outcome measure was the number of mosquito bites per 5 minutes. RESULTS: A total of 1614 person nights averaged 5.1 +/- 7.2 (+/- SD) mosquito bites per 5 minutes. The permethrin-treated campsites had decreased mosquito landings and bites (relative risk reduction [RRR] 44%; 95% CI 34% to 55%; P < .001) compared with controls. Insect repellent was used only 32% of nights, decreasing bites by 36% (RRR 36%; 95% CI 25% to 47%; P < .001). Permethrin was superior to insect repellent alone (RRR 20%; 95% CI 4% to 37%; P = .01). CONCLUSIONS: Permethrin treatment of tents is an effective, inexpensive public health measure to reduce mosquito bites. Permethrin is effective among all individuals in a camping setting and was more effective than topical insect repellent alone, which, although recommended, was inconsistently used.
Adolescent↗
Travel medicine considerations for North American immigrants visiting friends and relatives.
CONTEXT: In the United States, 10% of the population was born outside of its borders. Immigrants and their children frequently return to visit their homeland, referred to as visiting friends and relatives (VFRs). They account for a disproportionately high volume of international travel. EVIDENCE ACQUISITION: Searches of MEDLINE, World Health Organization, Centers for Disease Control and Prevention, International Society of Travel Medicine, and American Society of Tropical Medicine computerized databases, conference proceedings and abstracts, US Census Bureau, bibliographies of pertinent articles, and travel medicine texts. Priority was given to recent (1996-2003) evidence, addressing VFR travelers. General sources including travel medicine and immigrant health were also used. EVIDENCE SYNTHESIS: Immigrants visiting friends and relatives experience excessive rates of travel-related morbidity and mortality. Lack of pretravel care is common due to patient and clinician barriers to care, preexisting health beliefs, and incomplete childhood vaccinations. Travel patterns increase risk with VFRs traveling to high-risk destinations. Susceptibility to infectious and noninfectious illnesses is often increased because of multiple preexisting medical problems and extremes of age. Infectious diseases differ in etiology and magnitude from those of traditional travelers. For example with malaria, VFRs are frequently prescribed inappropriate prophylaxis or take none at all, have longer stays, spend time in high-risk areas, and do not appropriately adhere to chemoprophylaxis regimens. Effective pretravel health advice, guidelines, and services for this high-risk population are essential. There are already a number of useful and readily available databases that may aid clinicians in providing optimal travel-related preventive and therapeutic care. CONCLUSIONS: Immigrants who are visitors of friends and relatives in other countries account for a high volume of international travelers and are at markedly increased risk of travel-related illness. New strategies are needed to properly address the needs of VFR travelers. Pretravel services should be convenient, accessible, affordable, culturally competent, and if possible, located within clinics serving immigrant populations. Clinicians caring for VFRs should be knowledgeable about their travel-related risks and have access to regularly updated, detailed pretravel health information.
Emigration and Immigration↗
Gender differences among long-distance backpackers: A prospective study of women Appalachian Trail backpackers.
OBJECTIVE: Backpacking is a popular recreational activity, yet the differential experiences of women are unknown. The objective was to compare women with men backpackers to determine the extent to which injuries and illnesses limit endurance outdoor recreational activities. METHODS: This was a prospective cohort surveillance survey of 334 persons who hiked the Appalachian Trail for > or =7 days. At the end of their hike, 280 subjects completed a questionnaire. Male hikers served as controls for injury and illness. RESULTS: Women comprised 26% (72 of 280) of the sample. The mean (+/-SD) duration of hiking was 144 +/- 66 days covering 1570 +/- 680 miles. Fifty-seven percent (41 of 72) of women and 72% (150 of 208) of men attained their goal (P = .02). The occurrence of individual musculoskeletal problems, such as strains, sprains, arthralgias, tendonitis, and fractures, were similar (P = .9) between sexes. The occurrence of diarrhea (56%) was also similar (relative risk [RR] 1.0; P = .9) between sexes. Of regularly menstruating women, 87% (43 of 49) had menstrual changes while hiking, such as change in frequency (45%) or character (43%) (RR 3.1; 95% CI, 2.0-4.8; P < .001). Shortened duration of menses was most common (41%). Amenorrhea occurred in 22% (11 of 49) of women, including 5 of 25 taking oral contraceptive pills (OCPs). Breakthrough, midcycle bleeding occurred in 20% (10 of 49) of women. CONCLUSIONS: Women had similar experiences as compared with men when backpacking. Menstrual changes were very common including amenorrhea. Prolonged amenorrhea raises concern for potential bone mineral density loss, and OCPs should be considered to prevent such loss.
Adult↗
Medical risks of wilderness hiking.
PURPOSE: We sought to determine the extent to which injuries and illnesses limit long-distance or endurance outdoor recreational activities. METHODS: In a prospective surveillance study, 334 persons who hiked the Appalachian Trail for at least 7 days (mean [+/- SD] length of hike, 140 +/- 60 days) in 1997 were interviewed. At the end of their hike, subjects completed a questionnaire on injuries, illnesses, water purification methods, and hygiene practices. RESULTS: Of the 280 backpackers who responded (a combined 38,940 days of wilderness exposure), 69% (n = 192) achieved their goal. The most important reasons for ending a hike prematurely were injury, time limitation, and psychosocial reasons. The most common medical complaints were feet blisters (64%; n = 180), diarrhea (56%, n = 156), skin irritation (51%, n = 143), and acute joint pain (36%, n = 102). The incidence of vector-borne disease was 4% (n = 11); physician-diagnosed Lyme disease was the most common, and 24% of hikers (n = 68) reported tick bites. The risk of diarrhea was greater among those who frequently drank untreated water from streams or ponds (odds ratio [OR] = 7.7; 95% confidence interval [CI]: 2.7 to 23; P <0.0001), whereas practicing "good hygiene" (defined as routine cleaning of cooking utensils and cleaning hands after bowel movements) was associated with a decreased risk (OR = 0.46; 95% CI: 0.22 to 0.97; P =0.04). CONCLUSION: Diarrhea is the most common illness limiting long-distance hikers. Hikers should purify water routinely, avoiding using untreated surface water. The risk of gastrointestinal illness can also be reduced by maintaining personal hygiene practices and cleaning cookware.
Adult↗
Backpacking-induced paresthesias.
OBJECTIVE: To evaluate the presence of numbness and paresthesias among long-distance backpackers on the Appalachian Trail. METHODS: Backpackers who hiked a minimum of 7 days were interviewed while hiking. Following their hike, a written questionnaire was mailed to the participants that explored the incidence of injuries and illnesses among hikers. Paresthesias were defined as either numbness or "phantom, burning, or shooting pains." A case-control analysis of risk factors for paresthesias was performed. RESULTS: Paresthesias were reported by 34% (96 of 280) of the backpackers completing the study. They included ulnar paresthesias (n = 4), meralgia paresthetica (n = 10), tarsal tunnel syndrome (n = 6), digitalgia paresthetica (n = 21), and nonspecific paresthesias (n = 61). The most common symptom was numbness: 81% (78 of 96). Significant risk factors included a distance of >2000 miles (relative risk [RR] = 1.3; 95% CI, 1.1-1.6; P = .01) and the duration of hiking (RR = 2.0; 95% CI, 1.2-3.2; P = .004) for the longest quartile. Nonsignificant factors included backpack weight, initial body weight, percentage of weight loss, running shoe usage, and multivitamin usage. Ninety-eight percent of the paresthesias (94 of 96) had resolved by the time of follow-up (median = 30 days). CONCLUSIONS: Paresthesias were a surprisingly common complaint among long-distance backpackers. Although they were distressing during backpacking, these neuropathies were self-limited and resolved after completion of hiking.
Adult↗
A randomized, controlled field trial for the prevention of jellyfish stings with a topical sting inhibitor.
BACKGROUND: Jellyfish stings are a common occurrence among ocean goers worldwide with an estimated 150 million envenomations annually. Fatalities and hospitalizations occur annually, particularly in the Indo-Pacific regions. A new topical jellyfish sting inhibitor based on the mucous coating of the clown fish prevents 85% of jellyfish stings in laboratory settings. The field effectiveness is unknown. The objective is to evaluate the field efficacy of the jellyfish sting inhibitor, Safe Sea. METHODS: A double-blind, randomized, placebo-controlled trial occurred at the Dry Tortugas National Park, FL, USA and Sapodilla Cayes, Belize. Participants were healthy volunteers planning to snorkel for 30 to 45 minutes. Ten minutes prior to swimming, each participant was directly observed applying a blinded sample of Safe Sea (Nidaria Technology Ltd, Jordan Valley, Israel) to one side of their body and a blinded sample of Coppertone (Schering-Plough, Kenilworth, NJ, USA) to the contralateral side as placebo control. Masked 26 g samples of both Safe Sea SPF15 and Coppertone SPF15 were provided in identical containers to achieve 2 mg/cm(2) coverage. Sides were randomly chosen by participants. The incidence of jellyfish stings was the main outcome measure. This was assessed by participant interview and examination as subjects exited the water. RESULTS: A total of 82 observed water exposures occurred. Thirteen jellyfish stings occurred during the study period for a 16% incidence. Eleven jellyfish stings occurred with placebo, two with the sting inhibitor, resulting in a relative risk reduction of 82% (95% confidence interval: 21%-96%; p= 0.02). No seabather's eruption or side effects occurred. CONCLUSIONS: Safe Sea is a topical barrier cream effective at preventing >80% jellyfish stings under real-world conditions.
Administration, Cutaneous↗
Influence of hygiene on gastrointestinal illness among wilderness backpackers.
BACKGROUND: Gastrointestinal illness is a common risk for wilderness travelers, even among those who consistently disinfect their water, yet the importance of hygiene has not been characterized. METHODS: In a prospective surveillance study, 334 Appalachian Trail backpackers who hiked for at least 7 days in 1997 were interviewed. Upon completion of their hike, a written questionnaire was sent, addressing illnesses, water disinfection methods, and hygiene. Hygiene inquiries focused on the frequency of behaviors concerning handwashing and cleaning cookware. RESULTS: Two hundred and eighty backpackers compiled 38,940 wilderness exposure days, with 56% (n=56) experiencing diarrhea. Diarrhea correlated with the frequency of drinking untreated surface water (relative risk (RR) 2.4, 95% confidence interval (CI) 1.0-4.7%, p5.03). Of those who consistently treated water, 45% suffered from diarrhea, whereas 69% of those who inconsistently treated water experienced diarrhea (RR 0.65, 95% CI 0.53-0.81%, p5.001). Hikers practicing "good hygiene", defined as handwashing post-defecation and cleaning cookware routinely, were less likely to ever experience diarrhea (RR 0.47, 95% CI 0.22-0.99, p5.04). Routine handwashing with soap and water after both urination and defecation reduced the risk of diarrhea (RR 0.11, 95% CI 0.04-0.31%, p,.001). In a case-control analysis of those experiencing diarrhea, decreased diarrhea was associated with routine consumption of multivitamins (RR 0.50, 95% CI 0.37-0.66%, p,.001), routine cleaning of utensils with warm, soapy water (RR 0.38, 95% CI 0.20-0.74%, p,.01), and post-defecation handwashing with soap and water (RR 0.61, 95% CI 0.39-0.93%, p5.006). CONCLUSIONS: Lack of hygiene, specifically handwashing and cleaning of cookware, should be recognized as a significant contributor to wilderness gastrointestinal illness. Hikers should routinely disinfect water and avoid untreated surface water.
Adult↗