Our findings illustrate a wide variety of medical conditions present in trekkers in Nepal with wide-ranging potential complications that could pose difficulties in areas where medical care is scarce and evacuation difficult. Our cases illustrate the potential problems polypharmacy poses in trekkers, and the need for local and expedition healthcare workers to be aware of, and prepared for the common medical conditions present.

Most travelers, including those with well-controlled hypertension, can be reassured that their BP will remain relatively stable at high altitude. Although extremely elevated BP may be observed at high altitude in normotensive and hypertensive people, it is unlikely to be symptomatic. The ideal antihypertensive regimen at high altitude remains unclear.

Funding and support: By JACEP Open policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.

Bear attacks, although rare, can inflict life-threatening injuries. We present the case of a 50-y-old woman from rural Pennsylvania who was attacked by a North American black bear, Ursus americanus. She sustained multiple complex injuries including near-complete scalp avulsion, bilateral ear avulsions, and fractures of the face, ribs, and pelvis. These injuries are similar to those sustained in other bear maulings reported in the literature and required both acute intervention and a multidisciplinary approach to recovery.

IntroductiondA history of preexisting hypertension is common in people participating in mountain activities; however, the relationship between blood pressure (BP), preexisting hypertension, and acute mountain sickness (AMS) is not well studied. We sought to determine these relationships among trekkers in the Everest region of Nepal. MethodsdThis was a prospective observational cohort study of a convenience sample of adult, nonpregnant volunteers trekking in the Everest Base Camp region in Nepal. We recorded Lake Louise Scores for AMS and measured BP at 2860 m, 3400 m, and 4300 m. The primary outcome was AMS. ResultsdA total of 672 trekkers (including 60 with history of preexisting hypertension) were enrolled at 2860 m. We retained 529 at 3400 m and 363 at 4300 m. At 3400 m, 11% of participants had AMS, and 13% had AMS at 4300 m. We found no relationship between AMS and measured BP values (P>0.05), nor was there any relation of BP to AMS severity as measured by higher Lake Louise Scores (P>0.05). Preexisting hypertension (odds ratio [OR] 0.16; 95% CI 0.025e0.57), male sex (OR 0.59; 95% CI 0.37e0.96), and increased SpO 2 (OR 0.93; 95% CI 0.87e0.98) were associated with reduced rates of AMS in multivariate analyses adjusting for known risk factors for AMS. ConclusionsdAMS is common in trekkers in Nepal, even at 3400 m. There is no relationship between measured BP and AMS. However, a medical history of hypertension may be associated with a lower risk of AMS. More work is needed to confirm this novel finding.

Pericardial cysts were first described in 1837 as diverticula extending from the pericardium. They are rare and frequently asymptomatic. Symptomatic presentations may be similar to more common causes of chest pain or dyspnea such as acute coronary syndrome or pulmonary embolism. Emergency physicians should consider mediastinal mass, and in this case pericardial cyst, in the differential diagnosis of chest pain because of the risk for tamponade, sudden cardiac death, or other life-threatening complications. Here, we describe a novel presentation of a pericardial cyst presenting as atypical chest pain.

unclear. Our preliminary results suggest some antihypertensives may be more effective at high altitude than others.

The dataset was queried for all cases under product code 1275: "Scuba diving (activity, apparel or equipment)" between January 1, 2012 and December 31, 2014. These data then were analyzed to provide a descriptive analysis of the epidemiology of scuba diving-related injuries.Results.-The NEISS representative dataset produced 122 unique cases that resulted in an estimated total national injury burden over this 3-year period of 4151 cases. The most common injury diagnosis (2188, 52.7%) was coded as "other." Musculoskeletal-related injuries were noted in 1072 (26%) cases, 2439 (58.7%) patients were discharged, and 861 (20.7%) were treated and transferred to another facility. Similar numbers of patients presented to small, medium, and very large facilities.Conclusions.-Scuba diving injuries present to emergency departments of all sizes, and providers at small-and medium-sized facilities need to be prepared to treat these patients. The injuries identified included many musculoskeletal injuries that commonly occur with moving heavy equipment in a wet environment. Future safety initiatives aimed at the diving community should provide additional focus on the safe movement of equipment and increase awareness of the risks posed by the wet environment. Rescue Association, Kathmandu, Nepal Background.-Hypertension is the most common cardiovascular disease among those recreating at high altitude. Previous studies with smaller, more homogenous participant pools have demonstrated increases, decreases, and no change in blood pressure (BP). We sought to characterize how BP changes with altitude on both a population-wide and individual level in normotensive (NTN) and hypertensive (HTN) trekkers in Nepal. Methods.-Trekkers in the Solukhumbu Valley of Nepal, aged 18 years and older, were recruited at 2860 m. They reported demographic information, medical history, and medications. Resting BP was recorded at 2860 m, 3400 m, and 4300 m on ascent and descent. Responses were compared between NTN and HTN subjects and across altitudes. Results.-We enrolled 604 NTN and 60 self-reported HTN trekkers. At 2860 m, mean systolic BPs (SBP) in NTN and HTN trekkers were elevated relative to self-reported home measurements (n ¼ 303, mean difference ¼ 9 mm Hg [95% CI 5-13], P o .05). Mean SBP did not differ between altitudes on ascent or descent Introduction.-Hanging freely and motionless in a harness produces harness suspension stress (HSS) and may cause symptoms of pain, nausea, numbness, or syncope. The etiology of symptoms has not been well defined or understood, leaving medical providers without a good rationale for possible treatment. Objective.-To evaluate biomarker shift while inducing HSS. Methods.-Eighteen healthy volunteers were recruited (men ¼ 9, women ¼ 9). Each subject was prescreened with a questionnaire and tilt table test. A treadmill maximum oxygen consumption test then was performed, and skin fold measurements were obtained. Subjects were randomized to front point or dorsal point of attachment for HSS testing and subsequently cross...