- Emergency Medicine
- Wilderness Medicine
- Altitude Sickness
- Ultramarathon Medicine
Clinical Associate Professor, Emergency Medicine
Medical Education: Tufts University School of Medicine (2012) MA
Board Certification: American Board of Emergency Medicine, Emergency Medicine (2017)
Residency: University of Washington (2016) WA
Blister Eradication Looking at Impact of Experimental Versus Established Regimens
The specific aim of this study is to evaluate whether RockTape has similar efficacy to Elastikon in the treatment of foot blisters in ultramarathon runners. Elastikon with paper tape and spray adhesive is a well-accepted means of blister treatment and has been used by medical staff at over 50 multi-stage ultramarathons around the world. RockTape is another commercially available product that has also been used by runners successfully to treat foot blisters. RockTape's adhesive qualities have a potential advantage over Elastikon, in that it does not require an additional adhesive substituting a level of complexity, weight, and cost for foot care. There have been no studies examining the efficacy of either agent for blister treatment. This randomized controlled trial will compare the traditional method of treating blisters with a multi-step approach of percutaneous drainage, paper tape, spray adhesive and then Elastikon to percutaneous drainage, paper tape and RockTape.
- The Reply. The American journal of medicine 2021; 134 (3): e231–e232
Prospective Observational Study of Weight-based Assessment of Sodium Supplements on Ultramarathon Performance (WASSUP).
Sports medicine - open
2021; 7 (1): 13
BACKGROUND: Sodium supplements are ubiquitous in endurance running, but their impact on performance has been subjected to much debate. The objective of the study was to assess the effect of sodium supplementation as a weight-based predictor of race performance in ultramarathon runners.METHODS: Prospective observational study during an 80 km (50 mi) stage of a 6-stage 250 km (155 mi) ultramarathon in Chile, Patagonia, Namibia, and Mongolia. Finish line hydration status as measured by weight change, point-of-care serum sodium, and questionnaire provided sodium ingestion categories at 33rd percentile and 66th percentile both for weight-adjusted rate and total sodium consumption, then analyzed for significant relationships to race performance, dysnatremia, and hydration.RESULTS: Two hundred sixty-six participants were enrolled, with 217 (82%) with complete sodium supplement rate data, 174 (80%) with finish line sodium, and 161 (74%) with both pre-race weights and total sodium ingestion allowing weight-based analysis. Sodium intake ranged from 131-533 mg/h/kg (2-7.2 gm), with no statistically significant impact on pace, race time, or quintile rank. These outcomes did not change when sodium intake was analyzed as a continuous variable or by sub-group analysis of the 109 (68%) normonatremic runners. When controlled for weight-adjusted sodium intake, performance was poorly correlated with hydration (r = - 0.152, 95% CI - 0.348-0.057). Dehydrated runners outperformed those overhydrated, with 11% of top 25th percentile finishers dehydrated (versus 2.8% overhydrated), with 3.6 min/km faster pace and time 4.6 h faster finishing time.CONCLUSIONS: No association was found between sodium supplement intake and ultramarathon performance. Dehydrated runners were found to have the best performance. This reinforces the message to avoid overhydration.
View details for DOI 10.1186/s40798-021-00302-0
View details for PubMedID 33594588
Predictive Capacity of Pulmonary Function Tests for Acute Mountain Sickness.
High altitude medicine & biology
Small, Elan, Nicholas Juul, David Pomeranz, Patrick Burns, Caleb Phillips, Mary Cheffers, and Grant S. Lipman. Predictive capacity of pulmonary function tests for acute mountain sickness. High Alt Med Biol. 00:000-000, 2021. Background: Pulmonary function as measured by spirometry has been investigated at altitude with heterogenous results, though data focused on spirometry and acute mountain sickness (AMS) are limited. The objective of this study was to investigate the capacity of pulmonary function tests (PFTs) to predict the development of AMS. Materials and Methods: This study was a blinded prospective observational study run during a randomized controlled trial comparing acetazolamide, budesonide, and placebo for AMS prevention on White Mountain, CA. Spirometry measurements of forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and peak expiratory flow were taken at a baseline altitude of 1,250 m, and the evening of and morning after ascent to 3,810 m. Measurements were assessed for correlation with AMS. Results: One hundred three participants were analyzed with well-matched baseline demographics and AMS incidence of 75 (73%) and severe AMS of 48 (47%). There were no statistically significant associations between changes in mean spirometry values on ascent to high altitude with incidence of AMS or severe AMS. Lake Louise Questionnaire scores were negatively correlated with FVC (r = -0.31) and FEV1 (r = -0.29) the night of ascent. Baseline PFT had a predictive accuracy of 65%-73% for AMS, with a receiver operating characteristic of 0.51-0.65. Conclusions: Spirometry did not demonstrate statistically significant changes on ascent to high altitude, nor were there significant associations with incidence of AMS or severe AMS. Low-altitude spirometry did not accurately predict development of AMS, and it should not be recommended for risk stratification.
View details for DOI 10.1089/ham.2020.0150
View details for PubMedID 33601996
Pain Is Inevitable But Suffering Is Optional: Relationship of Pain Coping Strategies to Performance in Multistage Ultramarathon Runners.
Wilderness & environmental medicine
INTRODUCTION: Ultramarathon runners commonly endure musculoskeletal pain during endurance events. However, the effect of pain coping skills on performance has not been examined.METHODS: A prospective observational study during three 250 km (155 mi), 6 stage ultramarathons was conducted. Finish line surveys were completed after each of the four 40 km (25 mi) and one 80 km (50 mi) stages of racing. Variables gathered included pain intensity, pain coping strategy use, pain interference, finishing position (quintile), and successful race completion.RESULTS: A total of 204 participants (age 41.4±10.3 y; 73% male) reported average pain intensity of 3.9 (±2.0) and worst pain intensity of 5.3 (±2.3) on a 0 to 10 scale. They used greater adaptive pain coping strategies (3.0±1.3) relative to maladaptive strategies (1.3±1.1). Worst pain and pain interference increased over each stage of the race for all runners (P<0.001), with worst pain being significantly different by finishing status (P=0.02). Although all runners endured increased pain and interference, the nonfinishers (28 [14%]) had significantly greater differences in changes in pain intensity (P<0.01) and pain interference (P<0.001). Maladaptive pain coping strategies were more common in nonfinishers; with each 1-point increase (0-6 scale), there was a 3 times increase in odds of not finishing the race.CONCLUSIONS: Although increased pain intensity and pain interference was found in all multistage ultramarathon runners, successful event completion was significantly associated with less maladaptive pain coping. Training in coping with pain may be a beneficial part of ultramarathon preparation.
View details for DOI 10.1016/j.wem.2019.10.007
View details for PubMedID 32044211
Effect of Sodium Supplements and Climate on Dysnatremia During Ultramarathon Running.
Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine
Analyze the effect of sodium supplementation, hydration, and climate on dysnatremia in ultramarathon runners.Prospective observational study.The 2017 80 km (50 mile) stage of the 250 km (150 mile) 6-stage RacingThePlanet ultramarathon in 2017 Chilean, Patagonian, and 2018 Namibian, Mongolian, and Chilean deserts.All race entrants who could understand English were invited to participate, with 266 runners enrolled, mean age of 43 years (± 9), 61 (36%) females, average weight 74 kg (± 12.5), and average race time 14.5 (± 4.1) hours. Post-race sodium collected on 174 (74%) and 164 (62%) participants with both the blood sample and post-race questionnaire.Weight change and finish line serum sodium levels were gathered.Incidence of exercise-associated hyponatremia (EAH; <135 mmol·L) and hypernatremia (>145 mmol·L) by sodium ingestion and climate.Eleven (6.3%) runners developed EAH, and 30 (17.2%) developed hypernatremia. Those with EAH were 14 kg heavier at baseline, had significantly less training distances, and averaged 5 to 6 hours longer to cover 50 miles (80 km) than the other participants. Neither rate nor total ingested supplemental sodium was correlated with dysnatremia, without significant differences in drinking behaviors or type of supplement compared with normonatremic runners. Hypernatremic runners were more often dehydrated [8 (28%), -4.7 kg (± 9.8)] than EAH [4 (14%), -1.1 kg (± 3.8)] (P < 0.01), and EAH runners were more frequently overhydrated (6, 67%) than hypernatremia (1, 11%) (P < 0.01). In the 98 (56%) runners from hot races, there was EAH OR = 3.5 [95% confidence interval (CI), 0.9-25.9] and hypernatremia OR = 8.8 (95% CI, 2.9-39.5) compared with cold races.This was the first study to show that hot race climates are an independent risk factor for EAH and hypernatremia. Sodium supplementation did not prevent EAH nor cause hypernatremia. Longer training distances, lower body mass, and avoidance of overhydration were shown to be the most important factors to prevent EAH and avoidance of dehydration to prevent hypernatremia.
View details for DOI 10.1097/JSM.0000000000000832
View details for PubMedID 32097177
- Interstitial Pulmonary Edema Assessed by Lung Ultrasound on Ascent to High Altitude and Slight Association with Acute Mountain Sickness: A Prospective Observational Study HIGH ALTITUDE MEDICINE & BIOLOGY 2019
- Altitude Sickness Prevention with Ibuprofen Relative to Acetazolamide AMERICAN JOURNAL OF MEDICINE 2019; 132 (2): 247–51
Interstitial Pulmonary Edema Assessed by Lung Ultrasound on Ascent to High Altitude and Slight Association with Acute Mountain Sickness: A Prospective Observational Study.
High altitude medicine & biology
Alsup, Carl, Grant S. Lipman, David Pomeranz, Rwo-Wen Huang, Patrick Burns, Nicholas Juul, Caleb Phillips, Carrie Jurkiewicz, Mary Cheffers, Christina Evans, Anirudh Saraswathula, Peter Baumeister, Lucinda Lai, Jessica Rainey, and Viveta Lobo. Interstitial pulmonary edema assessed by lung ultrasound on ascent to high altitude and slight association with acute mountain sickness: A prospective observational study. High Alt Med Biol. 00:000-000, 2019. Background: Acute mountain sickness (AMS) is a common disease that may have a pulmonary component, as suggested by interstitial pulmonary edema quantified by the B-line score (BLS) on ultrasound (US). This subclinical pulmonary edema has been shown to increase with ascent to high altitude and AMS severity, but has not been prospectively associated with AMS incidence in a large prospective study. Materials and Methods: This prospective observational study was part of a randomized controlled trial enrolling healthy adults over four weekends ascending White Mountain, California. Subjects were assessed by lung US and the Lake Louise Questionnaire at 4110 ft (1240 m), upon ascent to 12,500 ft (3810 m), and the next morning at 12,500 ft (3810 m). Results: Three hundred five USs in total were completed on 103 participants, with 73% total incidence of AMS. The mean (±standard deviation) BLS increased from baseline (1.15 ± 1.80) to high altitude (2.56 ± 2.86), a difference of 1.37 (±2.48) (p = 0.04). Overall BLS was found, on average, to be higher among those diagnosed with AMS than without (2.97 vs. 2.0, p = 0.04, 95% confidence interval [CI] -∞ to -0.04). The change in BLS (ΔBLS) from low altitude baseline was significantly associated with AMS (0.88 vs. 1.72, r2 = 0.023, 95% CI -∞ to -0.01, p = 0.048). Conclusions: Interstitial subclinical pulmonary edema by lung US was found to have a small but significant association with AMS.
View details for PubMedID 31045443
- Re: "Ultrasound in Austere Environments" by Canepa and Harris (High Alt Med Biol 2019;20:103-111). High altitude medicine & biology 2019; 20 (4): 440
How variability in pain and pain coping relate to pain interference during multistage ultramarathons.
2019; 160 (1): 257–62
An important and substantial body of literature has established that maladaptive and adaptive coping strategies significantly impact pain-related outcomes. This literature, however, is based primarily on populations with painful injuries and illnesses. Little is known about coping in individuals who experience pain in other contexts and whether coping impacts outcomes in the same way. In an effort to better understand pain coping in such contexts, this study evaluated pain coping in ultramarathon runners, a population known to experience moderate levels of pain with minimal perceived negative effects. This study reports on pain coping in 204 entrants in 2016 RacingThePlanet multistage ultramarathon events. Participants provided data over 5 consecutive days on pain severity, pain interference, exertion, and coping. Results demonstrated that the study participants were more likely to use adaptive than maladaptive coping responses. However, maladaptive coping, but not adaptive coping, was positively associated with percent time spent thinking about pain and pain-related interference. Taken together, the study supports the idea that this high functioning group of individuals experiencing pain emphasizes the use of adaptive coping strategies over maladaptive strategies, reinforcing the perspective that such a pattern may be the most effective way to cope with pain. Within the group, however, results supported traditional patterns, such that greater use of maladaptive strategies was associated with greater pain-related interference, suggesting that optimizing pain coping may be critical to reducing factors that may interfere with ultramarathon performance.
View details for PubMedID 30204649
Day of Ascent Dosing of Acetazolamide for Prevention of Acute Mountain Sickness.
High altitude medicine & biology
Lipman, Grant S., Carrie Jurkiewicz, Christopher Winstead-Derlega, Andrew Navlyt, Patrick Burns, Anne Walker, Caleb Phillips, Aaron Reilly, Andre Burnier, Joseph Romero, Keiran Warner, and Peter Hackett. Day of ascent dosing of acetazolamide for prevention of acute mountain sickness. High Alt Med Biol 00:000-000, 2019. Background: Acetazolamide is the most common medication used for prevention of acute mountain sickness (AMS), usually administered the day or night before ascent. The objective of this study was to evaluate the efficacy of day of ascent dosing of acetazolamide for AMS prevention. Methods: Double-blind, randomized, controlled noninferiority trial of acetazolamide 125 mg twice daily beginning either the night before or the morning of ascent. Healthy low altitude adults ascended from 1240 m (4100 ft) to 3810 m (12,570 ft) during summer 2018 on White Mountain, California. Primary outcome was incidence of AMS with the two different dosing patterns, assessed by the 1993 Lake Louise Questionnaire (LLQ) of ≥3 with headache and a minimum of 1 for other symptom. Results: One hundred four participants completed the study, with 54 (52%) randomized to night before acetazolamide and 50 (48%) to day of ascent dosing, without differences in baseline characteristics. There was 9% greater incidence of AMS in the day of ascent acetazolamide group (48.0% vs. 39%, 95% confidence interval [CI] -11.8 to 30, p = 0.46, number needed to treat [NNT] = 5.6 vs. 3.7), with the CI just surpassing the predetermined 26% noninferiority margin. There was a lower incidence of severe AMS (1993 LLQ >5) in the day of ascent group (n = 5, 10%, NNT = 2.3) compared with night before dosing (n = 12, 22%, NNT = 3.1) (95% CI -28 to 3.6), and lower average symptom severity in the day of ascent group (3 vs. 3.5, 95% CI -0.5 to 1.4). Conclusions: Day of ascent acetazolamide demonstrated higher rates of AMS compared with traditional dosing by a small margin. With similar rates of severe AMS and overall symptom severity, the potential for improved convenience and compliance may support day of ascent use.
View details for DOI 10.1089/ham.2019.0007
View details for PubMedID 31259608
- How variability in pain and pain coping relate to pain interference during multistage ultramarathons PAIN 2019; 160 (1): 257–62
Altitude Sickness Prevention with Ibuprofen Relative to Acetazolamide.
The American journal of medicine
BACKGROUND: Acute mountain sickness is a common occurrence with travel to high altitude. Although previous studies of ibuprofen have shown efficacy for acute mountain sickness prevention, recommendations have been limited, as it has not been compared directly with acetazolamide, until this study.METHODS: Adult volunteers were randomized to ibuprofen 600 mg, three times daily, 4 hours before ascent or acetazolamide 125 mg, twice daily, started the night before ascent to 3810m in the White Mountains of California. The main outcome measure was acute mountain sickness incidence, using the Lake Louise Questionnaire (LLQ), with a score of >3 with headache. Sleep quality and headache severity were measured with the Groningen Sleep Quality Survey (GSQS) and a modified visual analogue scale (mVAS).RESULTS: Ninety-two participants completed the study: 45 (49%) ibuprofen and 47 (51%) acetazolamide. The incidence of acute mountain sickness was 56.5%, with ibuprofen 11% greater than acetazolamide, surpassing the predetermined 26% noninferiority margin (62.2% vs. 51.1%, 95% CI: - 11.1% to 33.5%). No difference was found in the total LLQ scores or subgroup symptoms between drugs (p=0.8). The GSQS correlated with LLQ sleep (r=0.77, 95% CI: 0.67 to 0.84) as was the mVAS with total LLQ severity (r = 0.57, 95% CI: 0.42 to 0.7). The acetazolamide group had higher SpO2 than ibuprofen (88.5% vs. 85.6%, p=0.001).CONCLUSION: Ibuprofen was slightly inferior to acetazolamide for acute mountain sickness prevention and should not be recommended over acetazolamide for rapid ascent. Average symptoms and severity were similar between drugs, suggesting prevention of disease.
View details for PubMedID 30419226
Budesonide Versus Acetazolamide for Prevention of Acute Mountain Sickness.
The American journal of medicine
2018; 131 (2)
BACKGROUND: Inhaled budesonide has been suggested as a novel prevention for acute mountain sickness. However, efficacy has not been compared with the standard acute mountain sickness prevention medication acetazolamide.METHODS: This double-blind, randomized, placebo-controlled trial compared inhaled budesonide versus oral acetazolamide versus placebo, starting the morning of ascent from 1240m (4100 ft) to 3810m (12,570 ft) over 4 hours. The primary outcome was acute mountain sickness incidence (headache and Lake Louise Questionnaire≥3 and another symptom).RESULTS: A total of 103 participants were enrolled and completed the study; 33 (32%) received budesonide, 35 (34%) acetazolamide, and 35 (34%) placebo. Demographics were not different between the groups (P>.09). Acute mountain sickness prevalence was 73%, with severe acute mountain sickness of 47%. Fewer participants in the acetazolamide group (n=15, 43%) developed acute mountain sickness compared with both budesonide (n=24, 73%) (odds ratio [OR]3.5, 95% confidence interval [CI] 1.3-10.1) and placebo (n=22, 63%) (OR0.5, 95% CI 0.2-1.2). Severe acute mountain sickness was reduced with acetazolamide (n=11, 31%) compared with both budesonide (n=18, 55%) (OR2.6, 95% CI 1-7.2) and placebo (n=19, 54%) (OR0.4, 95% CI 0.1-1), with a number needed to treat of 4.CONCLUSION: Budesonide was ineffective for the prevention of acute mountain sickness, and acetazolamide was preventive of severe acute mountain sickness taken just before rapid ascent.
View details for PubMedID 28668540
- Budesonide Versus Acetazolamide for Prevention of Acute Mountain Sickness AMERICAN JOURNAL OF MEDICINE 2018; 131 (2)
Ibuprofen versus placebo effect on acute kidney injury in ultramarathons: a randomised controlled trial
EMERGENCY MEDICINE JOURNAL
2017; 34 (10): 637–42
Despite concerns that non-steroidal anti-inflammatory drugs (NSAIDs) contribute to acute kidney injury (AKI), up to 75% of ultramarathon runners ingest these during competition. The effect of NSAID on AKI incidence in ultramarathon runners is unclear.Multisite randomised double-blind placebo-controlled trial in the Gobi, Atacama, Ecuador and Sri Lankan deserts to determine whether ibuprofen (400 mg every 4 hours) would be non-inferior to placebo during a 50-mile (80 km) foot race. The primary outcome was incidence of AKI defined as severity categories of 'risk' of injury of 1.5× baseline creatinine (Cr) or 'injury' as 2× Cr, combined to calculate total incidence at the finish line. Non-inferiority margin for difference in AKI rates was defined as 15%.Eighty-nine participants (47% ibuprofen and 53% placebo) were enrolled with similar demographics between groups. The overall incidence of AKI was 44%. Intent-to-treat analysis found 22 (52%) ibuprofen versus 16 (34%) placebo users developed AKI (18% difference, 95% CI -4% to 41%; OR 2.1, 95% CI 0.9 to 5.1) with a number needed to harm of 5.5. Greater severity of AKI was seen with ibuprofen compared with placebo (risk=38% vs 26%; 95% CI -9% to 34%; injury=14% vs 9%; 95% CI -10% to 21%). Slower finishers were less likely to encounter AKI (OR 0.67, 95% CI 0.47 to 0.98) and greater weight loss (-1.3%) increased AKI (OR 1.24, 95% CI 1.00 to 1.63).There were increased rates of AKI in those who took ibuprofen, and although not statistically inferior to placebo by a small margin, there was a number needed to harm of 5.5 people to cause 1 case of AKI. Consideration should therefore be taken before ingesting NSAID during endurance running as it could exacerbate renal injury.NCT02272725.
View details for PubMedID 28679502