Aims Cold stress has been shown to produce dramatic increases in 2-fluoro-2-deoxy-D-Glucose (18FDG) accumulation by brown adipose tissue (BAT) in rodents. However, neither the effects of other types of stress on 18FDG accumulation nor the effects of stressors on the accumulation of tracers of other aspects of energy metabolism have been evaluated. In this report we studied the effects of cold stress, burn injury, and cutaneous wounds on murine BAT at the macroscopic, microscopic, and metabolic level. Main Methods Glucose metabolism was studied with 18FDG, fatty acid accumulation was evaluated with trans-9(RS)-18F-fluoro-3,4(RS,RS)- methyleneheptadecanoic acid (FCPHA) and tricarboxcylic acid cycle (TCA) activity was evaluated with 3H acetate. Key Findings All three stressors produced dramatic changes in BAT at the macroscopic and microscopic level. Macroscopically, BAT from the stressed animals appeared to be a much darker brown in color. Microscopically BAT of stressed animals demonstrated significantly fewer lipid droplets and an overall decrease in lipid content. Accumulation of 18FDG by BAT was significantly (P <0.01) increased by all 3 treatments (Cold: ∼16 fold, burn ∼7 Fold and cutaneous wound ∼14 fold) whereas uptake of FDG by white fat was unchanged. This effect was also demonstrated non- invasively by μPET imaging. Although less prominent than with 18FDG, BAT uptake of FCPHA and acetate were also significantly increased by all three treatments. These findings suggest that in addition to cold stress, burn injury and cutaneous wounds produce BAT activation in mice. Significance This study demonstrates brown fat activated by several stressors leads to increased uptake of various substrates.

Ultrasonography is a useful tool in the assessment of intravascular volume at altitude. In this sample, we found ultrasonographic evidence that subjects with AMS have a higher intravascular volume than asymptomatic individuals. These data support the hypothesis that individuals with AMS have decreased altitude-related diuresis compared with asymptomatic individuals.

Background: Tularemia is a devastating disease that affects multiple organ systems and can have several different presentations. In its most frequent form—that of ulceroglandular tularemia—a detailed history and physical examination can enable a physician to make the diagnosis clinically, leading to the prompt initiation of the appropriate antibiotic treatment. Detailed Case Description: A 63-year-old man was brought by ambulance to the emergency department for an evaluation of an altered mental status noted by his psychiatrist at a telehealth appointment. A physical examination revealed a fever and two ulcerative lesions with a central eschar on his left leg (of which the patient was unaware) with ipsilateral tender inguinal lymphadenopathy. When asked, the patient recalled visiting Martha’s Vineyard and having removed ticks from his legs. Gentamicin was administered on the clinical suspicion of ulceroglandular tularemia. Blood and skin lesion cultures grew Gram-negative rods, which were confirmed to be Francisella tularensis on hospital day eight, and the patient fully recovered. Conclusion: This case highlights the importance of clinician perception of altered mental status as a key alarm sign, the necessity of a thorough physical exam independent of the chief compliant in the emergency department, and the essential role of pattern recognition by front-line providers for the appropriate management of uncommon but serious infections such as tularemia.

There is a broad differential for dizziness in any environment. Assessing a thorough history, concurrent medical problems, and careful physical examination can often narrow the possible causes significantly. In the setting of ear pain and recent altitude or pressure change, barotrauma should be suspected. Although most care is supportive, including the use of nonsteroidal anti-inflammatory drugs, the Frenzel maneuver and decongestants can help equilibrate inner ear and atmospheric pressures. This chapter examines the case of a woman who presents to the emergency room with ear pain following a recent airplane trip and addresses the patient history, details of the physical exam, diagnosis, and treatment plan.