Lyme Disease Update 2014

2014, September/October Adirondac Adirondoc

This has been a busy year for Lyme disease in New York State, with the illness beginning to make inroads into the southern foothills of the Adirondacks. Although I covered prevention in this space in July-August 2011, we have had a lot of requests for more information on the disease. I will try to summarize cur – rent information.

What is Lyme disease? Lyme disease is a fascinating condition, caused by Borrelia burgdoeferi, a type of bacterium called a spirochete. Spirochetes cause a variety of other diseases, such as syphilis and leptospirosis. The condition is referred to as a zoonosis, meaning that it is maintained in a reservoir of other animals, in this case mammals such as the white-footed mouse. Unlike some zoonoses, in which infection spreads directly from animal to human, in Lyme disease the spirochete is shuttled back and forth between hosts by ticks, referred to as the vector of infection. Although deer play a role in the tick life cycle (one species is commonly called the  “deer tick”), deer are actually not important in the chain of human infection.

If a tick injects spirochete into the human, the bacterium has an incubation period during which it reproduces and establishes itself. This can range from a day to a month, but is typically about a week and a half. Things may be confusing because ticks occasionally transmit another condition (such as anaplasmosis) coincident with Lyme disease. Lyme disease was first described in Connecticut, and the Mid-Atlantic states are the major region in which it occurs. Other areas in the U.S. with Lyme disease include the Midwest and the northern West Coast.

How does Lyme disease appear? Lyme disease is typically described as occurring in three stages, with different body parts affected in each stage. The early localized stage is marked by a distinctive rash, sometimes described as a “bull’s eye”, and called erythema migrans. This develops after the incubation period, often around the area of the tick bite. It is rarely painful or itchy, but patients may have symptoms such as headache or muscle aches.

 

The early disseminated stage occurs when the spirochete has spread, usually several weeks after the initial infection. This is much more debilitating, with joint or muscle pain, occasional disturbances in the heart rhythm, inflammation of the eye, focal paralysis of parts of the face, and a variety of other manifestations. The rash may recur at this stage, although it may be different in appearance.

Late disease is primarily arthritis, an inflammation of joints such as the knee. In fact, the original description of Lyme disease was as a form of arthritis. Other manifestations such as nerve damage may occur at this stage.

Most patients do not display all these stages. Some may have disease limited to erythema migrans. Alternatively, as many as 20 percent of patients with late disease never had erythema migrans.

How is Lyme disease diagnosed? In the early local stage, the diagnosis is clinical, based upon history and the rash. No other testing is needed, or helpful.

In later stages, the disease is diagnosed by the presence of antibodies to the organism. This is initially determined with a test called EIA, which if positive is confirmed by a Western blot. Once one has had Lyme disease, these tests are generally positive for years. Thus, tests are not useful in gauging success of treatment. The CDC has warned against the use of other, unvalidated testing.

How is Lyme disease treated? Lyme disease is treated with an oral course of a common antibiotic for two to three weeks. Infection of the nervous system requires intravenous therapy.

A final word. For the vast bulk of patients, the above description of Lyme disease applies. There are rare patients who have prolonged symptoms, including profound fatigue. These folks, who clearly have a serious condition, are sometimes said to have “chronic Lyme disease.” Despite commentary to the contrary, there is no consensus on exactly what these individuals have. They clearly do not have persistent infection with spirochete, and there is no place for prolonged courses of oral or intravenous antibiotics.

~ Tom Welch, MD, is professor and chair of pediatrics at Upstate Medical University in Syracuse and an active member of the Wilderness Medical Society. He is a licensed professional guide and a certifying instructor for the Wilderness Education Association, and has guided groups in the Adirondacks, Montana, and Alaska. More information is available at his website and blog: www.adirondoc.com. Leonard Weiner, MD, chief of infectious diseases at Upstate Medical University/Golisano Children’s Hospital, reviewed the article and provided helpful advice.

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Topics: Insects & Spiders

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Abraham Colles and his fracture

2015, January/February Adirondac Adirondoc

Eighteenth- and nineteenth-century physicians were notorious for attaching their names to various diseases, injuries, and body parts. The Irish surgeon Abraham Colles was prolific in this regard, his name immortalized by at least two separate tissues in the abdomen. Colles is most famous, however, as the namesake of a very common fracture of the arm.

Colles fracture is sometimes referred to as a fracture of the wrist, although that is not technically correct. The wrist is a joint, and joints cannot be fractured. Colles fracture occurs just above the wrist, and involves the two bones of the forearm. The larger of these, the radius, is on the thumb side, while the ulna is the smaller bone on the little-finger side. The radius and ulna are separate bones, but they are very tightly connected to each other. Thus, a fracture of one typically affects the other.

Colles fracture is the most common fracture of adults. The vast majority occur following a fall onto the outstretched hand. Hiking on uneven terrain, especially when fatigued and carrying a pack, is a prime set-up for a Colles fracture. (Children, whose bones are much less brittle than ours, typically get a 11 greenstick” fracture from the same type of fall.)

This fracture is usually easy to diagnose. In fact, Mr. Colles (British surgeons still refer to themselves as “Mr.” rather than “Dr.”) described the fracture beautifully nearly a century before x-rays were available. There is tenderness and bruising, usually about an inch above the wrist joint. Most often, the bones are separated by the break and cause a characteristic deformity, sometimes likened to a dinner fork. Fortunately, this fracture rarely causes disruption of blood supply or nerves, so complications in the field are rare. Field first aid consists of splinting the wrist. If a malleable aluminum splint (“Sam splint”) is in the first aid kit, it is ideal for this type of fracture.

Otherwise, there are many improvised ways of splinting a Colles fracture. Most important for any of these is ensuring that the fingers and thumb are in the “position of function” before wrapping the lower arm. Having the victim hold an Ace bandage in the hand is an effective way to do this. Once the hand is positioned, the hand and lower arm can be wrapped by strips of a cut-up closed foam sleeping pad, for example. Leave the finger tips exposed to check for warmth and circulation. A simple sling completes the first aid.

Definitive treatment of this fracture requires manipulation under anesthesia. Thus, victims need to get out for care. Unless there are associated injuries, Colles fractures are appropriate for “walkout” evacuation. Remember, though, that the patient will have trouble balancing with one arm out of commission, so assistance with walking is mandatory. You don’t want another injury!

~ Tom Welch, MD, is professor and chair of pediatrics at Upstate Medical University in Syracuse. He is a licensed professional guide, an active member of the Wilderness Medical Society, a certifying instructor for the Wilderness Education Association, and has guided groups in the Adirondacks, Montana, and Alaska. More information is available on his website, www.adirondoc.com. William Lavelle, MD, associate professor of orthopaedic surgery at Upstate, reviewed this column and provided helpful comments.

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Topics: Foot, Orthopedics

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Skin Infection: from trivial to fatal

2015, March/April Adirondac Adirondoc

Today’s topic is a reminder of a couple of important facts. First, we all live in a veritable cesspool of bacteria, covering every inch of our body and most surfaces we touch. Fortunately, healthy folks seem to have no difficulty with this. Second, some seemingly minor health issues can simply be “watched” in civilization, but in the backcountry must be taken very seriously. Skin infections go by a variety of names, but for simplicity we will classify them as abscesses and cellulitis. Abscesses are more localized. They can be thought of as walled-off collections of pus, which sometimes drain spontaneously. Often, drainage is all that is required to treat an abscess.

Cellulitis is a bit more complicated, and potentially much more serious. These are infections under the skin tha spread throughout tissues, sometimes with dramatic speed. They are not localized like abscesses, and therefore there is nothing to drain.

Cellulitis generally begins with a small break in the skin, which allows bacteria to enter. Rarely, the infection may be blood-borne and not associated with any obvious breach in the skin. The first sign of the infection is an area of redness that is often quite tender, warm, and hard to the touch. Most often, our body’s intricate defense mechanisms fight off the infection, and it gradually recedes on its own.

Here is where the approach to possible cellulitis in the backcountry differs from home. When care by one’s physician or urgent care center is a few moments away, watchful waiting may be appropriate. The last time I visited, however, there was no urgent care center in the Five Ponds Wilderness! Waiting too long in the wilderness could be a prescription for disaster.

Some findings with cellulitis demand immediate exit from the backcountry. Anyone who has fever, chills, or other “systemic” symptoms associated with a skin infection needs to get to definitive care rapidly. What seems like a trivial skin infection at one point can progress to overwhelming disease and organ failure within hours.

Another warning sign is the presence of streaks of redness extending from the local infection upward toward the center of the body. This is evidence that the infection is entering the body’s lymph system.

Does this mean that anyone with a little skin redness needs to hike out immediately? Of course not. It means that the individual merits close watching. One very useful technique is to use a pen to outline the margins of redness. Cellulitis that is moving beyond its inked boundary every few hours probably merits an end to the trek If the individual is otherwise feeling well, and the lesion is not spreading, continued careful watching is appropriate.

As with many wilderness problems, hygiene is an important preventive measure for cellulitis. Breaks in the skin should be washed with soap and water, and protected with an over-the-counter antibiotic ointment. Once an infection is established, however, such ointments have no value.

There is little first aid for cellulitis. Warm compresses increase the flow of infection-fighting blood cells, but this is rarely practical in a campsite. Definitive treatment requires oral or intravenous antibiotics. I am not a proponent of non-professionals bringing prescription medications into the wilderness. However, folks entering areas from which medical care is a day or two away may wish to consult with their personal physician about bringing an appropriate drug with them. If this is done, remember that the antibiotic is only to be used during evacuation, not to replace it.

~Tom Welch, MD, is professor and chair of pediatrics at Upstate Medical University in Syracuse and an active member of the Wilderness Medical Society. He is a licensed professional guide and certifying instructor for the Wilderness Education Association, and has guided groups in the Adirondacks, Montana, 4nd Alaska. More information is available at his website and blog: www.adirondoc.com. Infectious disease specialist Jana Shaw, MD, MPH, reviewed this column and provided helpful comments.

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Topics: Skin

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Blisters

2015, May/June Adirondac Adirondoc

Regular readers are familiar with my mantra that wilderness medical emergencies are rarely the “big stuff.” Backcountry disasters often begin with problems which, at home, would hardly merit even a trip to urgent care: mild dehydration, sprained ankles, and sunburn, for example. There have been plenty of incidents in which such seemingly trivial matters started a cascade ending in catastrophe. The “first aid” for such episodes is pretty straightforward; it is their occurrence in a remote location that can spell trouble.

Blisters are a terrific example of such a problem. Most of the time, they are no more than a pesky discomfort. However, if they lead to a fall, exhaustion, pushing beyond one’s limits, or even infection, they are a much bigger deal.

Blisters begin with friction between skin and overlying sock or shoe, generally in a prominent location such as the heel or big toe. The friction eventually leads to a separation between the two layers of skin. Ultimately, the space created by this separation becomes filled with clear fluid. If the upper layer of skin is disturbed, it exposes lower layers and becomes exquisitely painful.

Prevention of blisters begins well before one’s trek. Skin that has been toughened by exposure to air, walking barefoot, and occasional alcohol massage will be more resistant to the effects of friction. Wearing one’s usual hiking footwear for a few hours a day before the actual trip will prepare skin for the upcoming stress of long hiking.

I used to be a proponent of a two-sock system for blister prevention on the trail. No longer. Technology has brought us some amazing moisture-wicking socks; of which I have now become a big promoter.

One rarely goes from normal skin directly to blister. There typically is a period of time when the affected area becomes sore and red, a “hot spot.” Recognizing a hot spot early in a trek permits some interventions to prevent evolution into a blister. Covering the area with an adherent such as tincture of benzoin and then applying a generous moleskin over it may help.

Moleskin also is used when a blister actually develops, although the technique is different. Slather benzoin on the intact skin around the blister, cut a hole in a large piece of moleskin just a bit bigger than the dimensions of the blister, and place this “donut” around the blister. Reinforce the entire dressing with strips of cloth adhesive tape. Avoid folds in tape; they could lead to further skin injury.

There are few things as painful to a hiker as a large blister that has become unroofed. The exposed raw skin may make walking nearly impossible. There are several types of dressings for these wounds. Most involve a moist gel dressing which provides pain relief and promotes healing. These come in multiple brands, such as Band Aid ®Advanced Healing Blister.

Here is a very up-to-date and accurate website on blister prevention: www.blisterprevention.com. au/the-advanced-guide-to-blisterprevention#. VOs9jSzYUdU

~Tom Welch, MD, is professor and chair of pediatrics at Upstate Medical University in Syracuse and an active member of the Wilderness Medical Society. He is a licensed professional guide and a certifying instructor for the Wilderness Education Association, and has guided groups in the Adirondacks, Montana, and Alaska. More information is available at his website and blog: www.adirondoc.com.

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Topics: Skin

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Do Spiders “Bite”?

2015, July/August Adirondac Adirondoc

It is not often that my “day job” as an academic physician intersects with my “real job” as an outdoor educator, but it happened the other day. On rounds with our residents, I was presented a four-month-old admitted because of a presumed “spider bite.” The junior doctors could tell that something was up when I started quizzing them (“pimping” is the non-p.c. term) on how one makes the diagnosis of a spider bite.

Not very well, apparently. According to a study published in the Journal of Emergency Medicine, more than 95 percent of patients being seen for a suspected spider bite actually had something else. Most of the time, it was a soft tissue infection such as cellulitis, which was the diagnosis in the child who inspired this column.

With a couple of exceptions that I will mention later, the major problem associated with spiders in North America is arachnophobia, not bites. The former is one of the reasons I gave up on Adirondack lean-tos many decades ago!

If one stops to consider the biology, it should be no surprise that most spiders can’t bite humans. There certainly are some insects and arachnids that are quite capable of piercing our skin. These critters have apparatuses that are exquisitely designed to puncture mammalian tissues deeply. They have evolved these for either protection (bees and wasps) or food (mosquitoes, ticks, and lice).

 

Spiders have no such needs. The puncturing and poisoning mechanisms in spiders are designed to immobilize prey that becomes trapped in webs. While these mechanisms work very well on flies, they would find human skin a veritable brick wall. For spiders to be able to inflict significant injury on humans would be overkill-something evolution usually avoids.

There are a couple of exceptions to this in North America (and a few more that I won’t mention in some other parts of the world).

The Latrodectus species include the notorious black widow and related spiders. Field guides teach us to recognize them by the “hourglass” pattern on their undersurface. I never understood how one could pick off a biting spider and turn it over to examine its underside! These bites are not pa11icularly painful, but occasionally individuals will have a generalized reaction starting about an hour or so after the bite. This is much rarer than lore would suggest, and mainly affects small children and the elderly. The symptoms are mainly muscle cramps and twitching, with anxiety and vomiting. Although it’s usually self-limited in a few hours, anyone experiencing such a reaction should receive prompt medical attention.

The Loxosceles species include the recluse spiders. Their bites rarely cause generalized symptoms, but can be quite painful at first. Occasionally, after a few hours, the bitten area evolves into a very sore, red area which can remain painful and nasty looking. Rarely, these lesions can ulcerate and cause lasting skin damage. Again, these lesions require medical attention. There is little first aid beyond pain medication.

Neither of these species is common to the Adirondacks; readers would more commonly encounter them while traveling south. So, despite those spiders sharing the lean-to with you, sleep tight realizing that they are harmless. Hey, they may even help keep the mosquitoes at bay!

~ Tom Welch, MD, is professor and chair of pediatrics at Upstate Medical University in Syracuse and an active member of the Wilderness Medical Society. He is a licensed professional guide and a certifying instructor for the Wilderness Education Association, and has guided groups in the Adirondacks, Montana, and Alaska. More information is available at his website and blog: www.adirondoc.com.

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Topics: Insects & Spiders

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Bloody Noses and What To Do About Them

2015, September/October Adirondac Adirondoc

Several factors seem to predispose individuals to nosebleeds, many of which may occur in the backcountry.

Blood always looks copious whenever it gets outside the body and on clothes. That is surely the case with bloody noses. Most bloody noses are self-limited and involve only trivial amounts of blood loss. Yet, they may seem massive and often result in drama. Being familiar with the treatment of simple bloody noses can make one a hero in many settings.

There are two distinct types of nosebleeds. Each results from disruption to the many tiny blood vessels of the nasal cavity and nasal septum, which separates the nostrils. Anterior nosebleeds come from the front of the nose, typically from the part that is made up of “soft bone” or cartilage. By far, these are the commoner, less serious, and usually easiest to treat. Posterior bleeds come from farther back in the nose, in the area more protected by the bones of the face. These are unusual, often occur in individuals with other health problems, and may be very serious. Unfortunately, there is little field first aid for these types of nosebleeds, beyond immediate evacuation to a hospital.

Several factors seem to predispose individuals to nosebleeds, many of which may occur in the backcountry. The breathing of dry air, for example, may make the mucous membranes of the nasal septum more susceptible to injury. Picking the nose is another risk factor, perhaps accounting for most nosebleeds. Frequent sneezing or nose-blowing associated with nasal allergies or colds may also be a predisposing factor. Medications that interfere with blood clotting such as aspirin are also risk factors.

When coming across someone with a nosebleed, the first step should be to size up the situation and ensure that the individual has no other problems and has stable breathing and heart rate. Assuring the individual and others present that the problem is not likely to be serious, and that you know what to do, will go a long way toward deescalating the excitement that is likely to be present. Encourage the individual to sit upright, lean forward so blood does not drip down the throat, and spit any blood that has gone down the throat.

As with any bleeding, the next step is applying direct pressure. In this case, pressure is applied by pinching the end of the nose (soft, fleshy part) tightly between thumb and forefinger. I tell my first aid students that the most important piece of equipment in treating a bloody nose is a watch. At least ten to fifteen minutes of pressure, with no peeking allowed, is mandatory.

If it is easily available in one’s pack, a nasal decongestant such as oxymetazoline (Afrin®) can help by causing the- nasal blood vessels to constrict. I always carry this medication in my backcountry first aid kit.

When the bleeding has stopped, the individual should be encouraged to rest for a while and to avoid bending, straining, or blowing the nose. This will minimize the chance of re-bleeding, a common occurrence. If bleeding begins again, or if simple maneuvers do not stop it, then evacuation from the trek is called for. While planning this, some relief may be obtained by packing a small piece of gauze or tissue into the front of the nose; if it’s available, soaking the packing with the decongestant is also helpful. If packing is used, I recommend leaving it in place until definitive care is available.

~Tom Welch, MD, is professor and chair of pediatrics at Upstate Medical University in Syracuse and an active member of the Wilderness Medical Society. He is a licensed professional guide and certifying instructor for the Wilderness Education Association, and has guided groups in the Adirondacks, Montana, and Alaska. More information is available at his website and blog: www.adirondoc.com. Michael Parker, MD, whom he calls “my favorite otolaryngologist-backpacking partner” reviewed this manuscript and provided helpful suggestions.

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Topics: General First Aid

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Too Much of a Good Thing

2016, January/February Adirondac Adirondoc

Most of us probably remember being told to drink at least eight glasses of water per day for better health. It turns out that there is absolutely no supporting evidence for this advice; it is difficult to determine exactly where it came from. Now, we learn that unfounded advice about the importance of drinking water can actually kill you.

First, a bit of background. The element present in our body fluids, such as blood, in the highest concentration is sodium. Proper functioning of body systems requires that the concentration of sodium be maintained in a very narrow range. Outside that range, some very serious consequences can develop.

Maintaining the right concentration of sodium depends on the way we handle water. If our blood concentration of sodium starts getting too high, it triggers our thirst mechanism and we drink more. It also results in messages to our kidneys to concentrate the urine and hold on to the water we drink On the other hand, if our blood concentration of sodium is too low, our thirst shuts off and our kidneys start excreting the extra water until the sodium concentration rises to normal.

If these mechanisms fail, and the concentration of sodium falls because of an overload of water, a dangerous condition called hyponatremia ensues. Hyponatremia can result in rapid neurologic deterioration and death. Because the major symptoms relate to the nervous system, the possibility of a disturbance in body water may be unrecognized until it is too late.

Over the past decade or so, there have been some worrisome reports of fatal hyponatremia developing in athletes, especially during marathons and similar endurance activities. There are a couple reasons for this. First, the mantra for such athletes has been to avoid dehydration and to drink even if one does not seem thirsty. (I mentioned this in a recent column on “sports drinks.”) Second, the stress of exertion may impair the kidney’s ability to excrete excess water. The combination of drinking too much and peeing too little becomes a set-up for dangerous hyponatremia.

Could this possibly happen to someone hiking? Until a few weeks ago, my answer would have been “possibly, but no one has ever seen it.” Sadly, we now have seen it. The current issue of the medical journal Wilderness and Environmental Medicine includes a case report of a previously healthy 47-year-old woman who was hiking in the Grand Canyon on a warm, sunny day. She was observed by her husband to be drinking copious amounts of water. At the end of the hike, she had some vague neurologic complaints, which rapidly evolved into stupor and unresponsiveness. She was urgently evacuated to a hospital, where she was found to have hyponatremia. Imaging of the brain showed severe swelling, the classic complication of hyponatremia. She died within less than a day of her hike. Although the differential diagnosis at first had included such problems as head injury, the ultimate determination was that she had fatal water overload.

This report has stimulated a lot of interest and discussion among wilderness physicians and educators. For many of us, the comment has been ” … saw this one coming …. ” Concerns about dehydration during exercise have been overblown for years. In particular, advice to “keep drinking even if you’re not thirsty” has never made physiologic sense. We now realize that it is dangerous. The best advice for the hiker, or any athlete: If you’re thirsty, drink If you’re not, don’t. That’s what thousands of years of evolution has prepared us for!

~Tom Welch, MD, is professor and chair of pediatrics at Upstate Medical University in Syracuse and an active member of the Wilderness Medical Society. He is a licensed professional guide and certifying instructor for the Wilderness Education Association, and has guided groups in the Adirondacks, Montana, and Alaska. More information is available at his website and blog: www.adirondoc.com.

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Topics: Diet & Nutrition

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Cruisin’ Down the River

2016, March/April Adirondac Adirondoc

No doubt you have read about one of the outbreaks of intestinal illness that seem to strike cruise lines occasionally. I cannot imagine too many things worse than paying in the five figures for a luxury vacation, and spending much of it confined to a small room, vomiting. In fact, this is one of the excuses I use with my wife to avoid these sorts of vacations!

These unfortunate events have been pretty well explained. Actually, the cruise industry has been putting a lot of procedures in place to minimize them, and they may not be occurring as often as once was the case. Most are caused by a viral infection called norovirus. Like most such illnesses, norovirus infection is spread when someone’s personal hygiene is less than optimal and after leaving the bathroom he or she leaves traces of the virus on surfaces such as doorknobs, faucets, railings, etc. Someone else touches the surface, then picks up a piece of cheese for a snack, and voila! Another infection strikes.

The virus is widespread, and occurs in many settings. Having hundreds of people confined on a ship, sharing many spaces for several days, is a prime setting for the virus to take hold and spread. That is why hand sanitizer stations have become ubiquitous on cruise ships, and why gloved crew members, not the guests themselves, serve the items in the buffet line. If any passenger has but a hint of a gastrointestinal problem, he or she is generally “confined to quarters.” Let’s hope the TVs work.

What does this have to do with the backcountry? A recent report in a medical journal describes another type of cruise which has been spoiled by norovirus: A group of physicians from Colorado have published a study of several outbreaks of this infection in rafters on the Colorado River. These are guided expeditions, in which participants travel in multi-passenger rafts, camping along the river. Groups share equipment, and chemical toilets are provided. Meals are usually prepared by staff and taken as a group.

In 2012, norovirus was reported in ten rafting groups. The number of participants affected in these groups ranged from 6 to 88 percent. The investigators were able to isolate the virus itself from some of the equipment in the boats.

Those who like to blame wilderness water for intestinal infection may jump to blaming the Colorado River for the infections, but they would be wrong. Although many individuals in these groups were affected, it is very important to note that these groups comprised only a tiny fraction of the hundreds of parties using the river during the rafting season. There is no reasonable explanation for these infections beyond infected persons spreading them to others by the hand-to-mouth route.

Many of us have, for years, pointed to poor personal sanitation as the most likely cause of intestinal distress in the backcountry. In an earlier column, I discussed another study that I published in which we identified fecal contamination on the hands of Adirondack hikers. This new report, however, is the first that definitively demonstrates transmission of actual intestinal infection within a wilderness group.

The evidence is incontrovertible. Intestinal infections occur within groups of backcountry campers. There is no good evidence that these are caused by drinking water. There is excellent evidence that they are spread among individuals within the group. Hand-washing or the use of sanitizing gels is one of the most important health measures for backcountry campers.

~ Tom Welch, MD, is professor and chair of pediatrics at Upstate Medical University in Syracuse and an active member of the Wilderness Medical Society. He is a licensed professional guide and certifying instructor for the Wilderness Education Association, and has guided groups in the Adirondacks, Montana, and Alaska. More information is available at his website and blog: www.adirondoc.com.

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Topics: Hygiene

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The Dark Side of Mosquitoes

2016, May/June Adirondac Adirondoc

All who hike or camp in the Adirondacks have a particularly bad mosquito story. Many of us return from a few days in the woods with arms and necks covered with mementos of our visits. We do not, however, view mosquito bites as serious health threats. Should we?

On its surface, the answer would seem to be “yes.” Sharing syringes and needles is a very efficient way to spread blood-borne infections. Most mosquitoes are promiscuous, taking blood from several individuals of many species, with no mechanism for sterilizing themselves. So, mosquitoes might be considered very dangerous disease vectors.

There certainly are diseases that depend upon mosquito transmission. In fact, it is fair to say that more humans are killed by mosquitoes than by any other animal. Viruses transmitted by mosquitoes generally are not passed “passively” from bug to person, but must infect the insect before transmission. Thus, transmission is limited to the specific species of mosquito that are susceptible to specific infections. New York has about seventy species of mosquitoes, only a few of which transmit disease.

Mosquito-borne viruses are called “arboviruses,” and there are several that cause infection in New York State. Most result in fairly minor illness (fever, rash, headache, and “achiness”), although some cause severe infection of the nervous system and death.

Although extremely rare, eastern equine encephalitis (EEE) is the best example of the latter. There have been only a few known cases of EEE in New York State over the past forty-five years, and most have been fatal. West Nile virus infection is more common (hundreds of cases), and although potentially fatal it is much less likely to result in death than EEE.

Two arboviruses have recently begun to cause trouble in the U.S. Dengue fever had previously been thought to be limited to tropics. Although cases were increasingly common in Florida and Hawaii, there now are documented cases in New York. Chikungunya, an obscure tropical disease for years, recently made its way into the U.S. via travelers. It now appears to have spread within our country. There have been sixty-nine New York cases of this painful (rarely fatal) infection, all in travelers. (Lindsay Lohan is a 11 celebrity” chikungunya patient.)

Most recently, we have been hearing about a South American arbovirus infection, Zika. Although Zika has received a lot of hype, largely as a possible cause of birth defects, it is generally a mild illness.

None of these diseases has any specific therapy, so prevention of bites is the only real strategy. (I have discussed this subject in earlier columns.)

In the early days of the HN/ AIDS epidemic, there was consideration of a role for insect transmission. That notion has been discarded. The reasons are complicated, but boil down to the fact that HN survives and replicates by infecting specific cells in hosts. Mosquitoes lack these cells. Any HN that might get into a mosquito would likely be digested. Similarly, there is no evidence that hepatitis B or Chas been transmitted by this route.

Recent media fixation on these rare and often minor illnesses is a sort of national narcissism. The real infection risk from mosquitoes is malaria, a disease that kills millions, including two children every minute. Since it is not transmitted in the U.S., we rarely give it a moment’s thought. We are blessed to live in an area where the “misery” of mosquito bites is short-lived!

~Tom Welch, MD, is professor and chair of pediatrics at Upstate Medical University in Syracuse and an active member of the Wilderness Medical Society. He is a licensed professional guide and certifying instructor for the Wilderness Education Association, and has guided groups in the Adirondacks, Montana, and Alaska. More information is available at his website and blog: www.adirondoc.com. Infectious disease experts Leonard Weiner, MD, and Jana Shaw, MD, MPH, provided helpful comments and review of this column.

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Topics: Insects & Spiders

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Healing the Heel

2016, July/August Adirondac Adirondoc

A reader recently inquired about the problem of heel pain in hikers.

Although heel pain rarely causes early termination of treks (as opposed to sprained ankles, which are the number one cause of this), it is a frequent complaint and can be very bothersome.

There is a host of possible causes of pain in the heel, so a full review would be outside the scope of this column. Thus, I will limit the discussion to the most common: plantar fasciitis.

The foot is a very complicated structure, comprised of twenty-six bones. The arch of the foot is secured by a ve1y thick connective tissue called the plantar fascia. The plantar fascia is on the sole, extending from the front of the heel bone (the calcaneus) to the bones of each of the toes. If it were not for the plantar fascia, there would be no arch to the foot. Indeed, the plantar fascia is critical to the proper working of the foot. As one can imagine, prolonged standing or walking, especially if one has a generous body weight, puts enormous strain on this mechanism.

Although stress can damage the plantar fascia in any place, it most commonly affects the spot where the fascia attaches to the heel bone. Inflammation of the fascia in that location is plantar fasciitis.

The major symptom of plantar fasciitis is heel pain. It is often localized to the bottom of the foot, in front of the calcaneus. This is about where the “ball” of the foot is located. There is no real laboratory or x-ray testing for plantar fasciitis; the diagnosis is usually made by history and physical examination.

Typical patients with plantar fasciitis report that their symptoms began after an increase in their usual activity- often running, hiking, or dancing. They may wear shoes without firm support. Interestingly, their pain is often most severe upon awakening and putting weight on the feet for the first time in the morning.

On examination, it may be possible to elicit pain by pressing over the spot on the sole where the plantar fascia attaches to the calcaneus while stretching the fascia by lifting the toes upward.

The good news is that plantar fasciitis typically gets better within a year or so, no matter what one does. Sturdy shoes with a gel insert (available in many drug or running stores) may help the problem. Rest and ice are useful during severe flares. Nonsteroidal anti-inflammatory drugs such as ibuprofen (Advil® or Motrin®) also are helpful.

Exercises, generally involving foot stretches, help to prevent plantar fasciitis in those prone to it. A physical therapist can help with these. Physical therapists can also demonstrate a technique of taping the foot that also stabilizes the plantar fascia.

Severe cases of plantar fasciitis sometimes lead to health care providers suggesting steroid or other medication injections, shock wave therapy, or even surgery. I would seek a second opinion before entertaining any of these.

While most pain that follows the pattern I describe here can safely be considered plantar fasciitis, there are a large number of rare causes of heel pain, some of which can be very serious. If the pain follows a fall or other injury, for example, another cause is much more likely. If there is any numbness of the foot, a more detailed investigation is needed. Redness, swelling, or fever are also worrisome, and should prompt physician evaluation. Finally, pain in any other joints should lead to consideration of some form of arthritis.

If a flare of plantar fasciitis occurs during a trip, it is generally possible to “walk through it” with ibuprofen and occasional rest.

~ Tom Welch, MD, is professor and chair of pediatrics at Upstate Medical University in Syracuse and an active member of the Wilderness Medical Society. He is a licensed professional guide and certifying instructor for the Wilderness Education Association, and has guided groups in the Adirondacks, Montana and Alaska. More information is available at his website and blog: www.adirondoc.com.

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