Update: Outbreak of acute febrile illness among athletes participating in Eco-Challenge-Sabah 2000--Borneo, Malaysia, 2000

Common Injuries in Whitewater Rafting, Kayaking, Canoeing, and Stand-Up Paddle Boarding

Paddle sports continue to be popular forms of outdoor recreation in the United States and around the world. This includes not only the more traditional sports of rafting, kayaking, and canoeing but also the newer and growing sport of stand-up paddle boarding. Because these sports are based in an aquatic environment, and frequently whitewater, there are unique, significant risks of injury. Overall, injuries in paddling sports are mostly musculoskeletal and are both acute and chronic in nature. Some injuries, such as environmental and head injuries, are especially problematic because they can lead to serious morbidity and mortality, most importantly drowning. This review describes the epidemiology, type, and location of injuries across paddle sports. It not only focuses on whitewater injuries but also includes information on injuries sustained in other aquatic paddling environments.

Other Potentially Life-Threatening Conditions with Mucocutaneous Findings (Leptospirosis, Typhoid Fever, Dengue, Diphtheria, Murine Typhus)

There are several conditions with mucocutaneous findings that are potentially life-threatening, particularly in certain vulnerable populations. In this chapter, leptospirosis, typhoid fever, dengue, diphtheria, and murine typhus are reviewed. The disease time course of classic and atypical presentations is detailed to assist making the diagnosis in subtle cases. Associated symptoms are discussed as well as a comparison with disease mimics and differential diagnoses. Key diagnostic features are emphasized, and evidence-based management of each condition is detailed in this chapter.

6-year review of +Redivi: a prospective registry of imported infectious diseases in Spain

BACKGROUND

Understanding and detecting imported diseases is a priority in the prevention and management of prevalent and emergent infectious diseases acquired abroad. The +Redivi network measures the burden of imported infections in Spain and is essential for closing the gap in travel medicine.

METHODS

Demographic characteristics, travel information, syndromes and confirmed travel-related diagnoses were registered in a standardised online database.

RESULTS

A total of 10 767 cases of imported infectious diseases were registered between October 2009 and December 2015. Of these, 60.8% of cases were immigrants seen for the first time after arrival, 20.6% were travellers, and 18.4% were individuals visiting friends and relatives (VFR [immigrants and travellers]). The median time between arrival and medical consultation was 5.5 years for immigrants, 2.0 weeks for travellers, 3.1 weeks for VFR-travellers and 11.4 for VFR-immigrants. The most prevalent diagnoses were Chagas disease in immigrants and nonspecific acute diarrhoea in travellers. Malaria by P. falciparum was one of the most prevalent diagnoses among VFR. More than half the travellers saw a physician before travelling, although one-third of those for whom antimalarial medication was indicated did not take their medication correctly. As for VFR, only 10.4% of VFR-immigrants and 32.5% of VFR-travellers sought pre-travel advice. Only 23 and 21%, respectively, of those for whom antimalarial prophylaxis was indicated took the medication properly.

CONCLUSIONS

+Redivi provides a clear picture of the prevalence of imported infectious diseases among travellers and immigrants in Spain. The data collected could be used to improve everyday health care provided to travellers and immigrants after travel, to guide pre-travel consultations and to monitor the potential occurrence of tropical or exotic infectious diseases.

Extreme event medicine: considerations for the organisation of out-of-hospital care during obstacle, adventure and endurance competitions

Obstacle, adventure and endurance competitions in challenging or remote settings are increasing in popularity. A literature search indicates a dearth of evidence-based research on the organisation of medical care for wilderness competitions. The organisation of medical care for each event is best tailored to specific race components, participant characteristics, geography, risk assessments, legal requirements, and the availability of both local and outside resources. Considering the health risks and logistical complexities inherent in these events, there is a compelling need for guiding principles that bridge the fields of wilderness medicine and sports medicine in providing a framework for the organisation of medical care delivery during wilderness and remote obstacle, adventure and endurance competitions. This narrative review, authored by experts in wilderness and operational medicine, provides such a framework. The primary goal is to assist organisers and medical providers in planning for sporting events in which participants are in situations or locations that exceed the capacity of local emergency medical services resources.

Risk factors of leptospirosis among febrile hospital admissions in northeastern Malaysia

BACKGROUND

Leptospirosis is a worldwide zoonotic disease. Risk factors for the disease may vary among countries.

OBJECTIVE

This study was conducted to determine the risk factors of leptospirosis among febrile cases.

MATERIALS AND METHODS

A hospital-based cross-sectional study was conducted among 999 febrile patients admitted to 10 hospitals in northeastern Malaysia, from August 2010 to February 2011. An interviewer-guided proforma sheet on sociodemography, type of occupation and social history data was distributed to all adult patients with fever on admission. Serum sample for leptospirosis was screened by IgM Enzyme-linked Immunosorbent Assay (IgM ELISA) test and confirmed by Microscopic Agglutination Test (MAT). The cut-off point for positive MAT was ≥ 1:400 titer in single acute specimens.

RESULTS

Seroprevalence of leptospirosis was 8.4% (95% CI: 6.8, 10.3) (n=84/999) by MAT. Multiple logistic regression analysis showed that the high risk occupation group (OR: 1.95, 95% CI: 1.22, 3.13) (p=0.005) and history of recent recreational activity (OR: 2.36, 95% CI: 1.46, 3.85) (p<0.001) were significant associated factors for leptospirosis.

CONCLUSION

This study shows a relatively high seroprevalence of leptospirosis in northeastern Malaysia. Identification of high risk occupational group and history of recent recreational activity will help to increase the index of suspicion to diagnose leptospirosis among febrile inpatients due to its mimicking other common febrile illnesses in Malaysia.

Wilderness event medicine: planning for mass gatherings in remote areas

BACKGROUND

An increasing number of large recreational events are taking place in remote environments where medical care is far away. Such events include adventure races and large outdoor trips. Wilderness event medicine (WEM) has been previously defined as the healthcare response at any discrete event with more than 200 persons located more than 1h from hospital treatment. However, there is little literature describing the steps for providing medical care at such events.

METHODS

This article provides a framework for planning and executing WEM. It reviews the published data on wilderness injury and illness rates and describes the nature of injuries as they relate to specific activities. The article then discusses the three stages of WEM: pre-event planning, medical treatment at the event, and post-event tasks.

RESULTS

Wilderness events include myriad activities, including orienteering, mountain biking, mountaineering, and whitewater paddling. The injury and illness rates are in the range of 1-10 per 1000 person-days of exposure, with rates one order of magnitude greater for events which last many days, include extremes of environment (heat, altitude), or are competitive in nature. Professional adventure racers may present for medical evaluation at rates as high as 1000 encounters per 1000 racer-days. Injuries depend largely on activity. Illnesses are mostly gastrointestinal, 'flu-like' malaise, or related to the event environment, such as humidity or altitude. Providing medical care requires the proper staff, equipment, and contingency plans. The remoteness of these events mandates different protocols than would be used at an urban mass gathering.

CONCLUSIONS

WEM will likely continue to grow and evolve as a specialty. Additional reports from wilderness events, perhaps facilitated through a web-based incident reporting system, will allow medical providers to improve the quality of care given at remote events. Research into wilderness activity physiology will also be useful in understanding the prevention and treatment of injuries and illnesses encountered.

Purification and proteomic analysis of outer membrane vesicles from a clinical isolate ofLeptospira interrogans serovar Copenhageni

The severe pulmonary form of leptospirosis (SPFL) is an especially serious and rapid disease process characterized by alveolar hemorrhage and acute respiratory failure. The outer membrane of Leptospira facilitates direct interactions with the environs and likely contains important constituents involved during infection, transmission, survival, and adaptation to environmental conditions, including putative vaccinogen and diagnostic candidates. Outer membrane vesicles (OMVs) were purified by incubation in low-pH citrate buffer, treatment in a French press, and centrifugation over a continuous sucrose gradient. OMVs characterized by two-dimensional gel electrophoresis (2-DE) contained the previously described outer membrane proteins OmpL1, Qlp42, LipL32, LipL41, LipL36 and Loa22. In addition, unknown, hypothetical and putative outer membrane proteins were identified. High-performance liquid chromatography (HPLC) coupled with mass spectrometry and fraction collection (LC-MS+) measured the intact mass profile of the major outer membrane protein, LipL32, and the putative lipoprotein Qlp42. In contrast to a predicted molecularmass of 27,653.5 Da for LipL32 after cleavage of its signal peptide, intact mass proteomics measured the mass as ranging from 28,468 to 28,583 Da, consistent with lipidation of LipL32. In contrast to a predicted molecular mass of 39.8 kDa for Qlp42, the actual mass was measured as 24,811 and 26,461 Da consistent with a 30 kDa doublet observed on sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) gels and processing of the N-terminus of the mature protein. These studies indicate that purified OMVs are highly compatible with proteomics technologies including 2-DE and intact mass proteomics using LC-MS+ that facilitates definition of actual molecular masses of intact outer membrane proteins, and heterogeneity associated with them.