Naja samarensis, a World Health Organization Category 1 venomous snake endemic to the Philippines, causes neurotoxic envenomation, but cardiac complications are rarely documented. Case 1 is a 71-y-old hypertensive male who presented with altered consciousness, ptosis, and dysarthria. Following antivenom administration, he developed supraventricular tachycardia (180 beats/min) requiring adenosine. He recovered after 16 ampules of purified cobra antivenom and was discharged on Day 5. Case 2 is a 66-y-old hypertensive male who presented with neurotoxic symptoms and atrial fibrillation (180 beats/min). Following administration of Taradoc, he acutely deteriorated with hypotension and recurrent atrial fibrillation (200 beats/min), requiring another cardioversion. He subsequently developed progressive pulmonary edema and respiratory failure, leading to death. Case 3 is a 50-y-old female who presented with neurotoxic symptoms, chest heaviness, and elevated troponin (2 ng·mL-1). Electrocardiogram revealed ST elevation, suggesting myocardial injury. Following neostigmine administration, neurotoxic symptoms improved, although dyspnea on exertion persisted. Species identification was based on the reported snake appearance (black and yellow coloration), geographic distribution of venomous snakes in Eastern Visayas, and clinical presentation consistent with neurotoxic cobra envenomation. No snake specimens were physically available for species verification in any of the 3 cases. N samarensis envenomation may be associated with life-threatening cardiac complications, including tachyarrhythmia and myocardial injury. Management priorities include the use of antivenoms with established efficacy, differentiation of venom-induced myocardial injury from acute coronary syndrome, and continuous electrocardiographic monitoring with cardiac biomarker assessment.
Kerosene chemical burns are uncommon but can result in serious injury, particularly among high-altitude porters who carry fuel through difficult terrain and endure prolonged exposure or contact. We describe 2 cases of high-altitude porters who developed chemical burns to the lower back and gluteal region following leakage of kerosene while traversing the Khumbu Icefall in the Everest region. Such injuries highlight the need for awareness among expedition doctors and high-altitude medical personnel, as early recognition, along with appropriate wound care, is critical in resource-limited mountain settings.
IntroductionWhen trapped in a climbing route during a thunderstorm, it is generally recommended that climbers should maintain a maximum distance from rock formations and water accumulations. It is common practice for climbers to untie themselves from the rope and deposit metal equipment a few meters away.MethodsIn an experimental study, the formation of upward leaders from metal gear attached to a climbing harness and the number of lightning strikes to rope, metal gear, and subject were evaluated. A lightning impulse generator was used to simulate high-voltage discharges of up to 2500 kV.ResultsWhen the subject was suspended from a conducting rope, no upward leaders were observed, and no lightning strikes hit the subject. Ungrounded metal gear kept on the climbing harness did not increase the risk of a direct impact, even in the presence of upward leaders. When the metal gear was in contact with the ground, upward leaders were seen to occur and downward discharges to even hit the head of the subject.ConclusionsThe findings of this experimental study indicate that unless grounded, metal gear on a climbing harness does not increase the risk of a direct lightning impact. The authors recommend that when caught in a thunderstorm, climbers should refrain from unnecessary touching of the rope. Furthermore, climbers should ensure that they do not untie from the rope.
Wild felids are apex predators that play a crucial role in tropical ecosystems. In South America, interactions between humans and large felids-particularly jaguars (Panthera onca) and pumas (Puma concolor)-are increasingly reported, raising public concern. However, attacks on humans remain poorly documented, and their frequency is likely overestimated. This study assessed the scale of wild felid attacks in French Guiana and South America through a case series and literature review. We conducted a retrospective observational study of all wild felid attacks managed in healthcare facilities in French Guiana between January 2014 and December 2025. Cases were identified through hospital emergency departments, the regional rabies treatment center, and remote clinics. Medical records were reviewed for sociodemographic data, circumstances, clinical outcomes, and management. A systematic literature review (ie, PubMed, ScienceDirect, SciELO, and LILACS) identified documented attacks involving South American wild felids from 1990 to 2025. Reports involving captive animals or lacking methodologic detail were excluded. Four attacks were recorded in French Guiana, with no fatalities, although 1 case led to significant sequelae. The literature review identified 11 events, mainly attributed to jaguars and occasionally pumas. Attacks were rare and often linked to contextual factors such as forest proximity, domestic animals, or impaired animal condition. Severe injuries were reported, including 3 fatal cases. Wild felid attacks on humans remain exceptionally rare in South America and are usually associated with identifiable environmental or anthropogenic factors rather than inherent aggressiveness. Habitat preservation and reduced human-wildlife overlap are key preventive strategies.
In 1972, a chartered plane carrying rugby players crashed in a remote region of the Andes, leaving 32 survivors exposed to extreme cold, high altitude, and near-total deprivation of food and water. After 72 days, only 16 survived. Two secured rescue after crossing a 16,000-foot peak and a 10-day trek despite severe malnutrition. Although widely known, the medical aspects of this event remain underexamined. We conducted a retrospective descriptive study of the 16 survivors. Data were obtained through interviews with survivors conducted by Roberto Canessa, MD-both a cardiologist and a survivor-along with nurse Willma Kock, who provided immediate postrescue care, and through available medical records. Conditions were classified into 4 domains: trauma triage and multiple trauma; pathologies related to high-altitude exposure; malnutrition and dehydration; and mental health sequelae. Survivors applied effective rudimentary strategies including field triage, conservative trauma management, fracture immobilization, and improvised measures to combat hypothermia and dehydration. High-altitude illness and severe malnutrition were widespread; one case of refeeding syndrome and one traumatic brain injury were documented. None met the DSM-5 criteria for PTSD. This case highlights human resilience, physiological adaptation, and survival under extreme conditions, providing insights into trauma management, environmental medicine, and adaptive behavior in unprecedented scenarios.
IntroductionThe aim of this investigation is to gain insight into how humans interact with the avalanche forecast and better understand the role that the avalanche forecast plays in prevention of human-triggered avalanche incidents.MethodsUsing a 5-y cross-sectional study of self-reported survey data of participants involved in avalanches, we performed a secondary analysis to identify trends and patterns in avalanche forecast reading habits. The study assessed avalanche forecast reading habits, perceptions, and retention of information as well as demographic information on participants.ResultsA total of 489 participants were included in the final analysis. Of all the respondents, 12% of people who report normally reading the avalanche forecast report not reading the forecast on the day of their avalanche involvement. The plurality of expert and authority users and people between the ages of 41 and 60 y skipped reading the avalanche forecast the day of their reported avalanche incident. Females were more likely than males to have not read the avalanche forecast the day of their avalanche involvement.ConclusionsAlthough avalanche forecasts are widely used as a component of avalanche risk management, a meaningful proportion of individuals involved in avalanches reported not reading the forecast on the day of their incident. By understanding the forecast reading behavior of the people involved in avalanches, we can begin to design targeted efforts within the forecast aimed to decrease avalanche involvement, injury, and death.
Severe asthma exacerbations may rapidly become fatal when bronchodilator therapy is unavailable. In wilderness and disaster environments, inhaled β2-agonists-the standard treatment-may be lost, depleted, or otherwise inaccessible. Epinephrine has been used for more than a century as a bronchodilator and was historically administered subcutaneously or intramuscularly for acute asthma before selective β2-agonists became widely available. In emergency medicine, parenteral epinephrine remains an accepted rescue therapy for severe asthma exacerbations, particularly when inhaled bronchodilators cannot be administered-for example, because the patient is apneic or no functioning inhaler is available. Epinephrine autoinjectors (eg, EpiPen, Adrenaclick, Auvi-Q, authorized generics, or prefilled syringes such as Symjepi) are commonly carried for anaphylaxis and therefore may represent a practical field improvisation for severe asthma in austere settings. Although reported cardiovascular adverse events have predominantly involved intravenous administration, dosing errors, or patients with preexisting cardiac disease, intramuscular epinephrine at standard autoinjector doses has a well-documented safety profile. This article reviews the physiologic rationale, historical precedent, potential field use, and austere-environment techniques-including retrieval of additional medication from autoinjectors-supporting this approach when standard therapies are unavailable.
Firefighting requires high levels of aerobic fitness, muscular strength and endurance to perform demanding tasks under extreme conditions. Although previous research has focused mainly on general physical fitness, fewer studies have examined the impact of physical training interventions on task-specific performance. This systematic review aims to evaluate the effectiveness of structured physical training programs in improving firefighters' occupational task performance. Following PRISMA guidelines, a systematic literature search was conducted in October 2024 across PubMed, Cochrane, Web of Science and Scopus with no language or year restrictions. Searches used title/abstract fields (and keywords where applicable) with the phrase: ("Fireman" OR "Firefighter") AND ("Training" OR "Physical preparation" OR "Exercise program" OR "Physical fitness" OR "Task performance"). Eligibility criteria followed the PICOS framework: firefighters of any sex or experience, structured physical training interventions, outcomes measuring job-specific task performance and experimental study designs. Methodologic quality was assessed using the TESTEX scale. Five studies met the inclusion criteria. Interventions included high-intensity functional training, circuit training, nonlinear periodization and complex training. Across studies, these programs were associated with improvements in task performance, including reduced completion times in simulated fireground tests and enhanced proficiency in victim rescue, hose advancement and ladder operations. Structured, occupation-specific physical training programs appear to be associated with improvements in firefighters' task performance. Future research should compare protocols, refine training duration and progression and consider contextual factors such as baseline fitness and concurrent job demands.
IntroductionRates of sudden cardiac death (SCD) on ski slopes have been increasing since the 1980's and is the most common cause of nontraumatic death in male skiers. The treatment for SCD is early cardiopulmonary resuscitation (CPR) and difbrillation. Quality CPR, defined as adequate rate, depth, location, and with minimal interruptions, has been shown to improve outcomes. SCD on ski slopes often requires transport down the ski hill on a toboggan, for which manual compression trials have demonstrated inferior CPR quality.MethodsThis was conducted as a prospective, crossover study from November 2024-May 2025. CPR metrics were recorded with a Bluetooth-capable CPR mannikin. Each trial consisted of 2 runs down a specified route with manual compression-only CPR versus mechanical compressions.Results10 trials were conducted, and 9 trials were completed. 3 patrollers were ejected from toboggans while performing manual compressions in three separate trials. Mechanical CPR demonstrated significantly superior compression fraction, compression rate, and correct compression position. There was no significant difference in total scenario time, compression depth, or pause time.ConclusionsThis study demonstrates potential benefits of mechanical CPR in ski patrol toboggans, including rescuer safety, and improved CPR metrics while moving in sustained, complex terrain.
IntroductionHuman rabies exposure occurs at the interface between urban areas, peri-urban environments, and health surveillance systems. This study analyzed territorial and programmatic dimensions of human rabies exposure and postexposure management in a Brazilian municipality.MethodsA population-based ecological study used secondary surveillance data from the Brazilian Notifiable Diseases Information System from 2007 to 2025. All notified human rabies exposure events were included. Variables included age, animal species involved, type of exposure, and postexposure prophylaxis management. Incidence rates per 100,000 inhabitants were calculated.ResultsA total of 14,343 notifications were identified. Dogs accounted for most of the exposures, although cat-related incidents increased over time. Children <15 y of age represented a substantial proportion of notifications. Incidence increased over time, particularly after 2010. Most exposures were classified as preventable events requiring postexposure prophylaxis.ConclusionsHuman rabies exposure in this setting reflects persistent vulnerabilities at the urban-wildlife interface and challenges in postexposure management. Strengthening surveillance, responsible animal ownership, and One Health strategies are essential to reduce preventable exposures.
IntroductionSpaceflight may accelerate degradation of active pharmaceutical ingredients, raising concerns about medication stability during long-duration missions. This study assessed the potency of active pharmaceutical ingredients in a convenience sample of medications flown to the International Space Station alongside lot-matched terrestrial control samples.MethodsSpaceflight-exposed samples and terrestrial control samples were analyzed using ultra-high-performance liquid chromatography with tandem mass spectrometry. At the time of analysis, all medications were beyond their labeled expiration dates following prolonged storage and delayed laboratory testing. Medications included caffeine, diazepam, diphenhydramine, epinephrine, ketamine, lidocaine, naloxone, and promethazine in solid and liquid formulations. Percent difference between exposed and control samples was calculated, and absolute potency was evaluated relative to 95 to 105% and 80 to 120% ranges. Regression analyses examined associations of changes in the potency of active pharmaceutical ingredients with days in space and days expired.ResultsMost samples from both groups fell outside the 95 to 105% range. However, >90% remained within the broader 80 to 120% range. Average percent differences between spaceflight-exposed and ground control samples were generally within ±5% for most medications, suggesting limited relative potency differences despite prolonged spaceflight exposure. Epinephrine exhibited the most consistent reductions, averaging 10% lower potency than control samples. Regression analyses identified medication-specific associations with days expired and days in space but did not show a consistent pattern of spaceflight-associated potency loss.ConclusionWithin the limitations of this lot-matched, post-storage comparison, International Space Station exposure was not associated with large relative potency changes for most medications studied. Epinephrine represented the clearest exception and may require medication-specific stabilization strategies for long-duration space exploration missions.
IntroductionThe impact of lower limb joint replacement on those wishing to return to climbing has not yet been studied. This study aims to assess self-reported return to climbing and any themes or commonalities leading to any reduction in their return to the sport.MethodsAn online questionnaire was widely disseminated to climbers and mountaineers across the United Kingdom. Responses were collected from those who had undergone either hip, knee, or hip and knee replacement. The participants' age range, gender, site and number of joint replacements were recorded together with their current joint-specific and activity scores. Participants also were asked to score their climbing ability in the 3 months prior to surgery and then 3, 6, and 12 months after surgery.ResultsAmong participants, the median Oxford Hip Score (OHS) and Oxford Knee Score (OKS) after surgery ranged from 45.5 to 48 (OHS) and 36 to 48 (OKS). Median measurements of physical performance ranged from 4 to 8 (Tegner) and 7 to 10 (UCLA). The median climbing score fell from 9 (best prior to surgery) to 8 (3 months prior to surgery) (P<0.05). In the 3 months following surgery, the median climbing score fell further to 5 (P<0.05). Although this improved in subsequent months, it did not exceed that found before surgery.ConclusionOur research reveals that it is possible to climb again after lower limb joint replacement. Although some climbers return to their previous level of performance, many do not. Further research is needed to determine why this occurs and what interventions are available for those who wish to do so.
IntroductionThe purpose of this study was to investigate coagulatory changes across multiple wildfire seasons among wildland firefighters.MethodsWe evaluated data on 127 federal wildland firefighters. Pre- and post-season and pre- and post-shift wildland fire response measurements were obtained, including venous blood samples analyzed for platelet closure time; prothrombin time, partial thromboplastin time, and activated partial thromboplastin time; lipids (cholesterol, low-density lipoprotein, high-density lipoprotein, and triglycerides); high-sensitivity C-reactive protein; and complete blood cell counts with differential (hemoglobin, hematocrit, red blood cells, white blood cells, lymphocytes, monocytes, neutrophils, basophils, and eosinophils).ResultsPre- to post-season, there were decreases in high-sensitivity C-reactive protein and prothrombin time; no change in partial thromboplastin time, platelet count, and platelet closure times; and increases in white blood cells, hemoglobin, and hematocrit. Changes over a shift showed that white blood cells, lymphocytes, monocytes, neutrophils, and high-sensitivity C-reactive protein increased and eosinophils and partial thromboplastin time decreased. Platelet number was unchanged, but platelet closure time was prolonged.ConclusionWe found no evidence of increased coagulatory potential following a season of firefighting activity and only modest changes in white blood cells, suggesting that there may not be long-term increased thrombotic potential (formation of blood clots) with wildland firefighting. We found conflicting evidence of increased and decreased coagulatory potential following a single shift of wildland firefighting, although neither the procoagulatory nor anticoagulatory shifts were of great magnitude.
ObjectiveThis study aims to compare serum albumin levels among healthy adults residing in the plateau and plains of Sichuan Province, China.MethodsIn this study, data from 464 adults who underwent annual health check-ups at the same center were analyzed. Participants were categorized into a plains group (n=244; ∼500 m) and a plateau group (n=220; ∼3500 m). Group comparisons were made using χ2 and t tests. Linear regression and logistic regression models were employed to assess risk factors.ResultsThe mean serum albumin level was significantly lower in the plateau group (42.9±2.6 g·L-1) compared with the plains group (45.6±3.0 g·L-1; P<0.001). Hypoalbuminemia (<40 g·L-1) prevalence was higher in plateau residents than in plains residents (P<0.001). In linear regression adjusting for covariates, the plateau group had a mean albumin level 2.41 g·L-1 lower than the plains group (95% CI -2.89 to -1.93; P<0.001). Logistic regression results were consistent (plateau: adjusted odds ratio [aOR]=2.90, 95% CI 1.37-6.16, P=0.005; hemoglobin: aOR=0.957 per g·L-1, 95% CI 0.929-0.986, P=0.004; age: aOR=1.03 per year, 95% CI 1.01-1.05, P=0.011).ConclusionHealthy high altitude residents have lower serum albumin levels than plains residents. These findings suggest that the conventional albumin reference range may need reevaluation for high altitude populations.
IntroductionNumerous foreign tourists climb Mount Fuji, but the factors influencing falls and the symptoms of acute mountain sickness (AMS) in Japanese and foreign climbers remain unclear.MethodsA questionnaire survey assessed fall occurrence, AMS symptoms, sex, age, climbing experience, use of a tour guide, awareness of fall risks, trekking-pole use, shoe type and sole condition, fatigue, height, body mass, and a single day or overnight climbing. Multiple logistic regression with Akaike information criterion-based model selection was used to identify predictors, including interaction effects of nationality.ResultsValid responses were obtained from 693 Japanese and 244 foreign climbers. The fall rate was 27% in both groups. Female sex and greater fatigue were associated with a higher fall risk regardless of ethnicity. Advancing age was associated with a lower fall risk among foreign climbers but a higher fall risk among Japanese climbers. The prevalence of AMS was 47% among Japanese climbers and 32% among foreign climbers. Younger age and higher fatigue increased AMS risk. Foreign climbers without guides had a lower risk of AMS, whereas guide status was not associated with AMS risk among Japanese climbers.ConclusionsThese findings highlight the importance of targeted preventive guidance to reduce fall risk among female climbers, those experiencing greater fatigue regardless of ethnicity, and older Japanese climbers as well as to reduce AMS risk among foreign climbers participating in guided tours on Mount Fuji.
IntroductionTrauma patients often require intravenous (IV) access for analgesia. Alternatively, analgesia can be administered intranasally (IN). This open-label crossover randomized, controlled trial aimed to determine the time required for IV and IN analgesia administration by military nurses in simulated prehospital trauma scenarios.MethodsMilitary nurses completed 2 simulated prehospital trauma scenarios using a high-fidelity mannequin. Each scenario included patient assessment and administration of a simulated analgesic (water for injection). Military nurses administered the simulated analgesic intravenously in the first scenario and intranasally in the second scenario (sequence IV/IN) or vice versa (sequence IN/IV). Primary outcome was the time required for administration of the simulated analgesic. Secondary outcomes included on-scene time and user satisfaction with the route of administration employed.ResultsOf the 16 participants, 8 were allocated to sequence IV/IN and 8 to sequence IN/IV. Median age was 29 y, and 69% were female. IV administration required significantly more time than IN administration: mean difference 2.9 min (95% CI 2.4-3.4, p<0.0001). On-scene time also was significantly longer for IV administration: mean difference 3.3 min (95% CI 2.5-4.1, p < 0.0001). Median satisfaction scores were 6 (interquartile range 5-7) for IV administration and 9 (interquartile range 8-9) for IN administration. Satisfaction scores were lower for IV administration (p<0.0001).ConclusionsAdministration of a simulated analgesic required 2.9 min longer for IV compared with IN administration when performed by military nurses in simulated prehospital trauma care scenarios.
Introduction: Tick-borne-disease (TBD) risk is high along the Appalachian Trail (AT), yet little is known about how long-distance hikers practice recommended prevention behaviors. Because their prolonged outdoor exposure limits the feasibility of standard guidelines, understanding their behaviors and the beliefs shaping them is essential. This study examines TBD prevalence and prevention behaviors using the health belief model (HBM). Methods: A self-administered Qualtrics survey, pilot-tested for clarity, assessed demographics, AT hiking experience, diagnosis of TBD, prevention behaviors, and HBM constructs. Participants were ≥18 years old with AT experience. Recruitment occurred through in-person sampling, online forums, and snowball sampling. Prevention behaviors and HBM variables were analyzed using descriptive statistics and multiple regression models. Results: A total of 202 responses were analyzed. Over one-fifth of participants reported a previous TBD, most commonly Lyme disease. Prevention behaviors varied, with carrying tick removal devices, conducting daily tick checks, and using permethrin being the most frequently practiced. Regression models indicated that perceived barriers consistently predicted all prevention behaviors, while perceived benefits, susceptibility, and cues to action were significant in select models. Conclusions: Long-distance hikers demonstrated high TBD prevalence and inconsistent prevention practices. Tick checks, removal tools, and permethrin use were common prevention behaviors. Perceived barriers and perceived benefits were the strongest behavioral predictors, underscoring the need for interventions that reduce barriers and strengthen perceptions of effectiveness. Findings highlight opportunities to improve prevention strategies for hikers in high-risk environments.
