Acute, subacute and chronic mountain sickness

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Las imágenes muestran algunos de los estigmas físicos propios de esta patología, como rubicundez facial, cianosis labial y de lechos ungueales, uñas en cristal de reloj e hiperpigmentación distal, eritema palmar, y trayectos varicosos en piernas. Imágenes cedidas por el Dr. Francisco C. Villafuerte." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "E. Garrido, J. Botella de Maglia, O. Castillo" "autores" => array:3 [ 0 => array:2 [ "nombre" => "E." "apellidos" => "Garrido" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Botella de Maglia" ] 2 => array:2 [ "nombre" => "O." 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Garrido, J. Botella de Maglia, O. Castillo" "autores" => array:3 [ 0 => array:4 [ "nombre" => "E." "apellidos" => "Garrido" "email" => array:1 [ 0 => "eduardogarrido@movistar.es" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J." "apellidos" => "Botella de Maglia" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 2 => array:3 [ "nombre" => "O." "apellidos" => "Castillo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Hipobaria y Fisiología Biomédica, Universidad de Barcelona, L’Hospitalet de Llobregat, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario y Politécnico La Fe, Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Instituto Nacional de Biología Andina, Universidad Nacional Mayor de San Marcos, Lima, Peru" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Instituto de Estudios de Medicina de Montaña (IEMM), Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Mal de montaña de tipo agudo, subagudo y crónico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1681 "Ancho" => 1505 "Tamanyo" => 439396 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Chronic mountain sickness or Monge’s disease. The images show some of the physical stigma of this disease, such as facial congestion, labial and nail bed cyanosis, watch-glass nails and distal hyperpigmentation, palmar erythema, and varicose veins in the legs. Images provided by Dr. Francisco C. Villafuerte." ] ] ] "textoCompleto" => "BackgroundIt is estimated that 5% of the worldwide population permanently live in mountainous areas, and approximately 140 million of them live at high altitude (>2500m). Every year, more than 100 million people visit or travel to high mountain areas for professional, touristic, sports or religious reasons, reaching high geographical heights through various means of transportation or by performing intense physical activity.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>Barometric pressure falls dramatically as the altitude increases, resulting in a reduced partial pressure of oxygen and the ensuing drop in arterial oxygen pressure (PaO2) and oxygen saturation (SaO2). Health disorders caused by this hypoxemia depend on the height reached, the speed of ascent, the time spent at that height and the individual’s physiological response (known as acclimatization).<a class="elsevierStyleCrossRef" href="#bib0010">2</a> This biological process launches adaptive phenomena in various organs and systems<a class="elsevierStyleCrossRef" href="#bib0015">3</a> by stimulating complex oxygen-sensing mechanisms<a class="elsevierStyleCrossRef" href="#bib0020">4</a> that activate the hypoxia-inducible factor, transcription factor for the expression of numerous genes that regulate oxygen deprivation and tissue homeostasis.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> Nevertheless, humans can only adapt to extreme altitudes (>5500m) for brief periods.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> Considering that the mean PaO2 and SaO2 values above 8000m are below 35mm Hg and 70%, respectively,<a class="elsevierStyleCrossRefs" href="#bib0035">7,8</a> a state of coma would occur within 3min in the absence of acclimatization.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> When the degree of acclimatization to hypoxia is inadequate for a certain altitude, a varied spectrum of dysfunctions and health disorders occur,<a class="elsevierStyleCrossRefs" href="#bib0015">3,10</a> with mountain sickness the most common condition experienced. Depending on the symptom onset, characteristics and progression, the disease can be classified into 3 well-differentiated forms or types, which do not correspond to different pathochronic stages of the same clinical entity. These types are called acute mountain sickness (AMS), subacute mountain sickness (SMS) and chronic mountain sickness (CMS). <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the main differences between the types.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Acute mountain sicknessAlthough there are old symptomology descriptions, this disease was clinically classified in 1913 by the British doctor Thomas Ravenhill.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> The exact pathogenic mechanism is still not well understood; however, encephalic vasodilation, vasogenic edema, increased intracranial pressure and meningeal distension appear to be the most feasible mechanisms.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> High-altitude cerebral edema (HACE) corresponds to a progressed stage of AMS, and although the form by which it progresses from one stage to another is controversial, it appears to be due to a failure in the blood-brain barrier due to a mechanical or cytotoxic aggression or difficulty draining the cerebral venous flow.<a class="elsevierStyleCrossRef" href="#bib0065">13</a>Clinical presentationAMS typically occurs at altitudes higher than 2500m but can occur around 2000m. The higher the altitude, the higher the incidence and intensity of AMS symptoms, affecting 10–25% of nonacclimated individuals who ascend to heights of approximately 2500m and 50–85% of those who ascend to altitudes of 4500–5500m.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> The mean incidence rate of AMS increases by approximately 13% for each 1000m above 2500m.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> The clinical manifestation is typically nonspecific: isolated headache or accompanied by asthenia, anorexia, nausea, vomiting, lightheadedness and dizziness. Occasionally, there is concomitant facial and peripheral edema, especially in women, although it is not considered pathognomonic of AMS. The symptoms usually start in the first 6–12h and worsen as the individual gains altitude. The diagnosis is performed exclusively by the symptoms. There are several scoring systems for assessing the symptoms,<a class="elsevierStyleCrossRef" href="#bib0080">16</a> although the most recommended for use by medical personnel is the Lake Louise scale,<a class="elsevierStyleCrossRefs" href="#bib0075">15,17</a> which correctly types the patient through the presence and degree of impairment of 4 essential symptoms (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). A total score ≥3, in the presence of headache, is considered diagnostic for AMS; however, a score of 3 in the headache intensity, even without other accompanying symptoms, is also diagnostic for this clinical entity. Headache is therefore an essential symptom in the manifestation of AMS, but the absence of headache does not rule out the diagnosis, which is confirmed in this case with a total score ≥5. Severe cases are usually completely incapacitating for most activities.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> In children, especially in preverbal stages, AMS should always be suspected in the presence of irritability and behavioral changes. Headaches are usually pulsatile, worsen with physical exercise and the Valsalva maneuver, frequently start during the first night and are quickly relieved by inhaling supplemental oxygen. Any headache that starts after the third day while staying at the same altitude of >2500m should not be attributed to AMS. Sleep disorders, very common at high or extreme altitudes due to the onset of periodic breathing, do not have a strict correlation with AMS.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> Nevertheless, there does appear to be an association between this disease and the presence of subclinical high-altitude pulmonary edema.<a class="elsevierStyleCrossRef" href="#bib0095">19</a><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The differential diagnosis should be performed with migraine, exhaustion, dehydration, sunstroke, viral syndrome and alcohol or carbon monoxide poisoning.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> The prognosis is good because the condition is typically self-limiting during the first 4 days of staying at a same altitude. Below 5000m, less than 1% of cases of AMS progress to HACE, an entity that should be suspected in the minimal presence of cognitive disorder and the onset of ataxia 24–72h after the start of AMS.<a class="elsevierStyleCrossRef" href="#bib0100">20</a> HACE is a medical emergency because the onset of coma can occur within a few hours and can be fatal due to brain herniation.<a class="elsevierStyleCrossRef" href="#bib0070">14</a>TreatmentIn general, it is advisable to employ conservative measures, stopping the ascent until the symptoms have spontaneously remitted, although oral ibuprofen (600mg/8–24h) is indicated to treat the headache, as well as oral or parenteral ondansetron (4mg/4–6h) to treat the nausea and vomiting. If, during the first 4 days, there is no improvement, the individual must descend to an altitude 300–1000m lower or reach the previous height where the patient was asymptomatic. The most incapacitating cases should be treated with oral acetazolamide (250mg/12h) or oral or parenteral dexamethasone (4mg/6h). The treatment regimen for children for these drugs is 2.5mg/kg/12h (maximum 250mg per dose) and 0.15mg/kg/6h, respectively. Acetazolamide is most effective for treating mild-moderate AMS, while dexamethasone is most effective for moderate-severe AMS. Either of both drugs should be stopped as soon as the symptoms disappear. Recompression using a hyperbaric chamber, as well as night-time oxygen therapy (0.5−1L/min) are highly effective for moderate AMS. When faced with severe cases and minimal clinical suspicion of progression to HACE, the treatment should consist of urgently descending the patient, administering oral or parenteral dexamethasone at a rate of 4mg/6h (after an initial dose of 8mg) until symptom remission. Oral acetazolamide (250mg/12h) can be added, although corticotherapy is the main drug indication in these cases. If evacuation is delayed, oxygen may also be administered (2–4L/min) or recompression therapy may be started in a portable hyperbaric chamber, attempting to keep SaO2 at levels >90%.<a class="elsevierStyleCrossRefs" href="#bib0015">3,13,14,21</a>PreventionThe best strategy consists of acclimatizing to the altitude progressively, ascending a daily slope of <500m if overnight stays at altitudes >2500–3000m are planned, and devoting a day to rest for every 3–4 days of new altitude gain.<a class="elsevierStyleCrossRefs" href="#bib0065">13,21</a> Caution is recommended for those individuals with a history of migraine or deficient altitude adaptation, given that they are more susceptible to high altitude headache and AMS.<a class="elsevierStyleCrossRefs" href="#bib0105">21,22</a>Chemoprophylaxis is only indicated for especially susceptible individuals or when faced with scheduled overnight stays at high altitude without possible acclimatization and consists of oral acetazolamide (125mg/12h) or, in rare cases, oral dexamethasone (2mg/6h or 4mg/12h). Dexamethasone is reserved for when acetazolamide is contraindicated or is poorly tolerated. The combination of the 2 drugs or even higher dosages of dexamethasone (4mg/6h) may be considered exclusively in highly justified cases for rapid ascents by air to altitudes >3500m and with planned physical activity, such as is the case for military missions and rescue teams.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> Typically, chemoprophylaxis is started 8–24h prior to the ascent, extending it by at least 2 days if the individual remains at the same high altitude but not exceeding 7–10 days of continuous regimen if the individual keeps gaining altitude. Within these time intervals, the chemoprophylaxis should not be discontinued. Chemoprophylaxis should only be stopped once the descent has started or during the descent.<a class="elsevierStyleCrossRefs" href="#bib0065">13,14,21</a> In children, prophylaxis with dexamethasone is not indicated, and the acetazolamide dosage is identical to the therapeutic dosage, although it is only considered in justified cases and never for infants. Chemoprophylaxis is absolutely not recommended for extremely high altitudes, given that it can entail fatal consequences.<a class="elsevierStyleCrossRef" href="#bib0065">13</a>Other preventive strategies, such as sessions for inhaling mixtures of hypoxic gases prior to an ascent to high altitudes, have shown their effectiveness, although there is no well-established preacclimatization protocol. Regarding the chewing or infusion of leaves from the coca bush (a widespread custom among visitors to some Andean regions), there are no substantial studies that support this practice as prophylaxis. Ginkgo biloba extracts have also failed to show consistent effectiveness in the randomized studies. An abundant intake of liquids does not have a preventive effect, although proper hydration is important because dehydration can simulate AMS.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> Isolated SaO2 monitoring by pulse oximetry during stays at high altitude can indicate if we are within the normal range of this parameter at different altitudes<a class="elsevierStyleCrossRef" href="#bib0115">23</a>; however, the use of this monitoring as a predictor of AMS is controversial.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> Certain sophisticated tests that assess cardiopulmonary function through normobaric hypoxia or in hypobaric chambers do help detect patients at risk.<a class="elsevierStyleCrossRefs" href="#bib0125">25,26</a> Physical training has not been shown to have a protective effect against AMS,<a class="elsevierStyleCrossRef" href="#bib0135">27</a> and vigorous physical exercise performed at high altitude can promote the onset of AMS.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> Women, younger people, smokers, or overweight individuals appear to have a higher susceptibility to AMS.<a class="elsevierStyleCrossRef" href="#bib0145">29</a>In general, the risk of presenting AMS is very high when exceeding the altitude of 3500m in a single day, as occurs in locations highly frequented by tourists and rapidly reached by car, air, cable car or train. The concomitance of diseases, especially cardiopulmonary, can also represent a contraindication for reaching altitudes >2500m. Each case should be assessed according to the altitude goal, type of ascent, length of stay at altitude, activity envisaged, geographical region and possibility of health care.<a class="elsevierStyleCrossRef" href="#bib0150">30</a>Subacute mountain sickness (high-altitude pulmonary hypertension)The presence of pulmonary hypertension in high-altitude residents was noted in 1932 by the Peruvian doctor Alberto Hurtado.<a class="elsevierStyleCrossRef" href="#bib0155">31</a> In 1962, other compatriots detected the presence of right ventricular hypertrophy in native Andean children.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> Chinese physicians had already known of this disease in Asian children, known as high-altitude heart disease; cases were subsequently reported in adults in Tibet.<a class="elsevierStyleCrossRefs" href="#bib0165">33,34</a> More recently, Soviet scientists studied patients with cor pulmonale in the Pamir mountains.<a class="elsevierStyleCrossRef" href="#bib0175">35</a> Despite these pioneers, the pediatric form of this disease was not clinically described until 1988 when a study was conducted on Chinese children younger than 16 months who had been transferred to Tibet and who, after 2months of living in Lhasa (altitude of 3656m), developed severe pulmonary hypertension and congestive heart failure and subsequently died. Their autopsies revealed right ventricular hypertrophy and thickening of the tunica media of the pulmonary arterioles. The clinical condition was called SMS.<a class="elsevierStyleCrossRef" href="#bib0180">36</a> In 1990, the condition was clinically described in adults, specifically in Indian soldiers who lived for weeks or months at 5800–6700m in the Himalayas. The individuals presented heart failure, right ventricular growth, increased pulmonary vascular resistance and tricuspid regurgitation, abnormalities that disappeared over the course of days or weeks after the soldiers descended from the mountains.<a class="elsevierStyleCrossRef" href="#bib0185">37</a>Clinical presentationSMS is compatible with rapidly progressing congestive heart failure because it manifests after weeks or a few months of continuous exposure to high altitude. Its pathogenesis is through alveolar hypoxia, which causes immediate and reversible pulmonary vasoconstriction, mediated by endothelin-1 and other substances. If the hypoxia persists, the pulmonary hypertension is maintained because over time the tunica media of the pulmonary vessels thickens due to the increase in its muscle component.<a class="elsevierStyleCrossRef" href="#bib0190">38</a> The right ventricle dilates and hypertrophies, and if the pulmonary hypertension is very intense, the right ventricle claudicates. The symptoms manifest as dyspnea, cough, cyanosis, jugular venous distention, facial and lower limb edema, hepatomegaly, ascites, pericardial effusion and effort angina. In young children, symptoms can start nonspecifically as irritability, lethargy, anorexia and insomnia. The incidence rate for SMS is higher in children than in adults and higher in male individuals, with cases reported in children and adults at altitudes somewhat below 3000m. As with the Quechua and Aymara of the Andes, virtually all other humans present pulmonary hypertension secondary to hypoxia as the mechanism for optimizing the ventilation/perfusion ratio and are therefore potentially at risk of SMS during long exposures to high altitude. Only Tibetans have a very low incidence of SMS,<a class="elsevierStyleCrossRef" href="#bib0195">39</a> given that they present no or minimal pulmonary hypertension in hypoxia<a class="elsevierStyleCrossRef" href="#bib0200">40</a> and therefore do not develop cor pulmonale. This low incidence is believed to be due to a natural selection process from exposure to a hypoxic atmosphere, a process that has lasted millennia and has remained relatively unchanged by miscegenation. Special phenotypic, physiological and genetic adaptations explain why ethnicities of Tibetan lineage are the best human model for long-term adaptation to environmental hypoxia, given that they provide the longest evolutionary anthropological scale for permanent living at high altitude.<a class="elsevierStyleCrossRef" href="#bib0205">41</a> Nevertheless, permanent human life is not possible above 5500m,<a class="elsevierStyleCrossRef" href="#bib0030">6</a> mainly because of SMS and muscle atrophy at high altitude.<a class="elsevierStyleCrossRef" href="#bib0210">42</a> At the Chilean mine of Aucanquilcha (5800m), adjacent barracks were constructed to avoid having miners ascend daily from a nearby town; however, within a few months, all of the miners became sick and unable to work.<a class="elsevierStyleCrossRef" href="#bib0215">43</a>The fact that SMS occurs in adults at altitudes typically above 5500m and in infants at altitudes above 2500–3000m is due to the fact that children develop greater hypoxic pulmonary hypertension, given that the pulmonary vasoconstrictor response to hypoxia tends to decrease with age.<a class="elsevierStyleCrossRef" href="#bib0220">44</a> The current criterion for considering high-altitude pulmonary hypertension excessive is a systolic pulmonary arterial pressure >50mm Hg or a mean pressure >30mm Hg for adults and a systolic pressure >65mm Hg for children younger than 6 months.<a class="elsevierStyleCrossRef" href="#bib0225">45</a> Nevertheless, SMS can typically be diagnosed in adults noninvasively by the symptoms, through electrocardiography, chest radiology and echocardiography.<a class="elsevierStyleCrossRefs" href="#bib0225">45,46</a> Pediatric cases diagnosed by echocardiography have recently been reported.<a class="elsevierStyleCrossRef" href="#bib0235">47</a>Treatment and preventionAdults should avoid long stays at altitudes higher than 5500m, and non-Tibetan children younger than 12 months should not be transferred to areas above 3000m for extended periods, given that sudden death can occur after only presenting nonspecific pediatric symptoms for a few weeks. Some adults improve temporarily with supplemental oxygen,<a class="elsevierStyleCrossRef" href="#bib0230">46</a> as well as with nifedipine or sildenafil,<a class="elsevierStyleCrossRef" href="#bib0015">3</a> although full remission of SMS (in children and adults) is only achieved by descending to low altitude.<a class="elsevierStyleCrossRef" href="#bib0190">38</a>Chronic mountain sickness (Monge’s disease)In 1925, the Peruvian doctor Carlos Monge first described polyglobulia in a native Andean, subsequently confirming this finding in other Andeans.<a class="elsevierStyleCrossRef" href="#bib0240">48</a> CMS is currently defined as a clinical syndrome that occurs in long-term residents of high-altitude areas (>2500m) and is characterized by excessive erythrocytosis and hypoxemia.<a class="elsevierStyleCrossRef" href="#bib0225">45</a> The concept of loss of high-altitude adaptation secondary to idiopathic central hypoventilation (primary CMS) has been accepted as the etiopathogenic mechanism; however, the presence of concomitant diseases can promote CMS (secondary CMS),<a class="elsevierStyleCrossRef" href="#bib0245">49</a> and a phenomenon of adaptation to disease in a hypoxic environment can also be a valid concept.<a class="elsevierStyleCrossRef" href="#bib0250">50</a> In both contexts, CMS does not correspond to a single entity, given that it can coexist with lung disease, heart disease, nephropathy, hemoglobinopathy and with metabolic disorders, hormonal disorders, carotid body disorders, cobalt in blood and pulmonary thromboembolism.<a class="elsevierStyleCrossRefs" href="#bib0015">3,49,51</a> In recent years, a possible genetic predisposition to CMS in Andean ethnic groups has been reported.<a class="elsevierStyleCrossRef" href="#bib0260">52</a>The mean prevalence rate for CMS is 5–10% among the global population who reside at altitudes higher than 2500m.<a class="elsevierStyleCrossRef" href="#bib0225">45</a> Consequently, up to 14 million individuals worldwide might have CMS. Nevertheless, this rate varies according to the altitude of the place of residence and among populations of various mountain regions. Cases have been reported at only 2000m of altitude<a class="elsevierStyleCrossRef" href="#bib0265">53</a>; however, the highest incidence occurs above 3000m, affecting 5–18% of the residents of the Andes,<a class="elsevierStyleCrossRef" href="#bib0270">54</a> 14–29% of the residents of certain areas of the Indian Himalayas<a class="elsevierStyleCrossRefs" href="#bib0275">55,56</a> but only 1% of native Tibetan residents.<a class="elsevierStyleCrossRef" href="#bib0285">57</a> This lower prevalence can be explained by the special adaptation to hypoxia that the Tibetans possess,<a class="elsevierStyleCrossRefs" href="#bib0030">6,41</a> which was discussed earlier in the previous subsection. In general, the higher the altitude and the longer the time residing at that altitude, the greater the risk of CMS, which, starting in the sixth decade of life, can affect a third of the population of certain Andean communities.<a class="elsevierStyleCrossRef" href="#bib0290">58</a>Clinical presentationDepending on the stage or progression of the disease, patients can present dyspnea, palpitations, insomnia, loss of appetite, joint pain, cyanosis, varicose veins in the legs, acropachy, palmar erythema, epistaxis, conjunctival injection and facial flushing (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In addition to the congestive aspect that many patients usually show, there are associated neuropsychological symptoms, such as headaches, dizziness, tinnitus, peripheral neuropathy, depression, confusion and amnesia.<a class="elsevierStyleCrossRefs" href="#bib0015">3,45,49,59–61</a> There have been reported cases that even develop cerebral edema and encephalopathy.<a class="elsevierStyleCrossRef" href="#bib0310">62</a> Nevertheless, it is not uncommon to detect asymptomatic patients who present excessive polyglobulia in routine blood tests and SaO2 values <85%, even at altitudes higher than 4000m.<a class="elsevierStyleCrossRef" href="#bib0245">49</a> CMS is more common in men, especially of Andean ethnicity; however, a significant incidence has been reported in non-Tibetan women who reside in the Himalayas.<a class="elsevierStyleCrossRef" href="#bib0280">56</a> The Qinghai scale classifies patients according to the degree of severity, thereby establishing an overall score by scoring for the presence and intensity of 8 essential symptoms and clinical signs, as well as a hemoglobin concentration threshold of 21g/dL for men and 19g/dL for women (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<a class="elsevierStyleCrossRefs" href="#bib0225">45,49,63</a> Patients with CMS frequently have pulmonary arterial hypertension, whose intensity and clinical manifestation can vary dramatically from one individual to another.<a class="elsevierStyleCrossRefs" href="#bib0015">3,59</a> In advanced stages, there is remodeling of the pulmonary arterioles and right ventricular hypertrophy/dilation.<a class="elsevierStyleCrossRef" href="#bib0320">64</a> Ventricular failure is not typically produced, although its actual incidence rate is unknown.<a class="elsevierStyleCrossRef" href="#bib0325">65</a> There have also been reports of the presence of systemic vascular dysfunction, which can predispose patients to early cardiovascular disease.<a class="elsevierStyleCrossRef" href="#bib0330">66</a> Despite the hypoxemia, increases in hematocrit and subsequent blood hyperviscosity, it has been observed that erythroblast apoptosis is reduced in these patients.<a class="elsevierStyleCrossRef" href="#bib0335">67</a><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Residents of high-altitude areas who present excessive hematocrit levels should initially undergo examinations with spirometry, chest radiology, electrocardiography and echocardiography to assess pulmonary function and detect signs of pulmonary hypertension and right ventricular growth.<a class="elsevierStyleCrossRef" href="#bib0250">50</a> Stress testing has demonstrated that the aerobic function during physical exercise appears to be preserved despite these patients’ pulmonary hypertension and relative hypoventilation.<a class="elsevierStyleCrossRef" href="#bib0340">68</a> Nevertheless, physical activity can induce severe pulmonary hypertension in these patients, with the rapid onset of interstitial pulmonary edema and subsequently increased hypoxemia and exercise intolerance.<a class="elsevierStyleCrossRef" href="#bib0345">69</a> Pronounced pulmonary hypertension, even during moderate physical exercise as part of daily activities, can be the origin of these patients’ greater morbidity and mortality,<a class="elsevierStyleCrossRef" href="#bib0350">70</a> whose death could be caused by congestive heart failure or stroke.<a class="elsevierStyleCrossRef" href="#bib0245">49</a> A number of vasoactive peptides, such as B-type natriuretic peptide and endothelin-1, can have an important role in the clinical expression of Monge’s disease.<a class="elsevierStyleCrossRef" href="#bib0355">71</a> Increased androgenic hormonal activity (given the erythropoietic function of testosterone) can be related to an excessive polyglobulic reaction in these patients.<a class="elsevierStyleCrossRef" href="#bib0360">72</a> The hypoventilation presented by these patients at rest could be a defense mechanism given that it involves a lower energy expenditure.<a class="elsevierStyleCrossRef" href="#bib0365">73</a> Their hypoxemia during sleep is even more pronounced than during their waking hours and has been related to existing pulmonary and systemic vascular dysfunction; the presence of patent foramen ovale can promote this hypoxemia.<a class="elsevierStyleCrossRef" href="#bib0370">74</a> The increased formation of free radicals and the reduced viability of nitric oxide are associated with rapid cognitive impairment and the onset of depressive symptoms in these patients.<a class="elsevierStyleCrossRef" href="#bib0375">75</a> Given that CMS symptoms and clinical signs are aggravated with increases in altitude, attempts have been made to quantify the normal polyglobulic reaction for certain altitudes. For very high hematocrit levels (approximately 80%), a multifactorial mechanism known as triple hypoxia syndrome was proposed (hypobaric hypoxia+chronic hypoxia due to concomitant hypoxemic diseases+acute hypoxia due to superadded inflammatory processes).<a class="elsevierStyleCrossRef" href="#bib0380">76</a> In those cases of CMS where there is diagnostic uncertainty, other causes of polyglobulia should be considered (e.g., polycythemia vera, excessive erythropoietin production secondary to renal or testicular tumors, testosterone treatments).Treatment and preventionEffective strategies include transferring the patient to a location at lower altitude, permanently administering supplemental oxygen and attempting to keep the polyglobulia at an optimal compensation level.<a class="elsevierStyleCrossRef" href="#bib0250">50</a> The first option achieves a decrease in polyglobulia in approximately 3 weeks<a class="elsevierStyleCrossRef" href="#bib0385">77</a>; however, if the patient is transferred to a tropical environment, their risk of pneumonia and asthma-like syndromes increases, especially in cases of secondary CMS. Many patients from the Andes and Himalayas would be forced to leave their jobs and their family’s financial support, with the subsequent severe social problem that this migration entails. The second option reverses many of the symptoms but handicaps the patient by making them oxygen-dependent and is counterproductive in CMS secondary to undiagnosed diseases. Oxygen therapy is only effective in cases of severe CMS.<a class="elsevierStyleCrossRef" href="#bib0390">78</a> The third option focuses on treating the underlying causes of the hypoxemia and, consequently, the polyglobulia. With good control of the underlying diseases, these patients’ life expectancy increases, avoiding the accelerated psychophysical impairment and abandonment of the patients’ residence. Although they immediately reduce blood viscosity, palliative therapies through bloodletting and isovolemic hemodilutions induce metabolic disorders, exertional dyspnea and asthenia, if frequently applied, and are not recommended as long-term therapy for these patients. Oral drug therapy with medroxyprogesterone (60mg/24h), acetazolamide (250mg/24h) or enalapril (5–10mg/24h) also constitute effective therapeutic options,<a class="elsevierStyleCrossRefs" href="#bib0225">45,49,54,79</a> although there is no scientific evidence on their safety in very long-term therapy for CMS. Nevertheless, the most severe cases should leave high altitudes or live at sea level,<a class="elsevierStyleCrossRef" href="#bib0245">49</a> despite the fact that resting pulmonary hypertension in Andean natives can take more than 2 years to normalize, and the pulmonary hypertensive response to exercise can last indefinitely.<a class="elsevierStyleCrossRef" href="#bib0400">80</a> Other stigma such as varicose veins and acropachy also persist.With a minimum clinical suspicion of CMS or patients who might be at risk of CMS (sleep apnea, postmenopause, family predisposition), smoking cessation is essential, as well as preventing diseases of the respiratory system, excess body weight, malnutrition and iron deficiencies. Regular physical exercise at moderate intensity substantially improves these patients’ general condition, but strenuous physical activity should be avoided. These patients should be evaluated annually.<a class="elsevierStyleCrossRef" href="#bib0245">49</a>Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1580909" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1423203" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1580910" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1423202" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Acute mountain sickness" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Clinical presentation" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Treatment" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Prevention" ] ] ] 6 => array:3 [ "identificador" => "sec0030" "titulo" => "Subacute mountain sickness (high-altitude pulmonary hypertension)" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Clinical presentation" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Treatment and prevention" ] ] ] 7 => array:3 [ "identificador" => "sec0045" "titulo" => "Chronic mountain sickness (Monge’s disease)" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Clinical presentation" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Treatment and prevention" ] ] ] 8 => array:2 [ "identificador" => "sec0060" "titulo" => "Conflicts of interest" ] 9 => array:2 [ "identificador" => "xack558384" "titulo" => "Acknowledgements" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-10-16" "fechaAceptado" => "2019-12-16" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1423203" "palabras" => array:6 [ 0 => "Altitude" 1 => "Monge’s disease" 2 => "Pulmonary hypertension" 3 => "Hypoxia" 4 => "Mountain sickness" 5 => "Mountaineering." ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1423202" "palabras" => array:6 [ 0 => "Altitud" 1 => "Enfermedad de monge" 2 => "Hipertensión pulmonar" 3 => "Hipoxia" 4 => "Mal de montaña" 5 => "Montañismo." ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "More than 100 million people ascend to high mountainous areas worldwide every year. At nonextreme altitudes (<5500m), 10–85% of these individuals are affected by acute mountain sickness, the most common disease induced by mild-moderate hypobaric hypoxia. Approximately 140 million individuals live permanently at heights of 2500–5500m, and up to 10% of them are affected by the subacute form of mountain sickness (high-altitude pulmonary hypertension) or the chronic form (Monge’s disease), the latter of which is especially common in Andean ethnicities. This review presents the most relevant general concepts of these 3 clinical variants, which can be incapacitating and can result in complications and become life-threatening. Proper prevention, diagnosis, treatment and management of these conditions in a hostile environment such as high mountains are therefore essential." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Más de 100 millones de personas ascienden cada año a áreas montañosas elevadas en todo el planeta, y en altitudes no extremas (<5.500m) entre el 10-85% se ven afectados por el denominado mal agudo de montaña, la patología más frecuentemente inducida por una hipoxia hipobárica ligera-moderada. Asimismo, unos 140 millones de seres humanos viven de forma permanente en cotas comprendidas entre 2.500–5.500m, y hasta un 10% de ellos padecen la forma subaguda del mal de montaña (hipertensión pulmonar de la gran altitud) o la forma crónica (enfermedad de Monge), esta última especialmente frecuente en etnias andinas. La presente revisión expone los conceptos generales más relevantes en torno a estas tres variantes clínicas, las cuales pueden ser incapacitantes, llegar a complicarse y ser potencialmente mortales, siendo esencial el realizar una correcta prevención, diagnóstico, terapéutica y manejo de las mismas en un entorno hostil como es la alta montaña." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Garrido E, Botella de Maglia J, Castillo O. Mal de montaña de tipo agudo, subagudo y crónico. Rev Clin Esp. 2021;221:481–490." ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1681 "Ancho" => 1505 "Tamanyo" => 439396 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Chronic mountain sickness or Monge’s disease. The images show some of the physical stigma of this disease, such as facial congestion, labial and nail bed cyanosis, watch-glass nails and distal hyperpigmentation, palmar erythema, and varicose veins in the legs. Images provided by Dr. Francisco C. Villafuerte." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "Abbreviations: CHF, congestive heart failure; HACE, high-altitude cerebral edema; PaCO2, partial pressure of carbon dioxide; SaO2, arterial oxygen saturation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Types of mountain sickness \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Acute \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Subacute \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Chronic \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Minimum altitude required \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">2000–2500 m \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">2500–5500 m \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">2500–3000 m \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Risk population \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Children/adults \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Children/adults \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Adults \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Time to symptom onset \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Hours \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Weeks/months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Years \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Predominant symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">CephalicGastrointestinal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">RespiratoryCardiac \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">NeuropsychologicalCardiopulmonaryVascular \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Clinical assessmentHematocrit \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Lake Louise scaleNormal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Clinical presentation↑/↑↑ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Qinghai scale↑↑↑ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">SaO2PaCO2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">↓/↓↓↓/↓↓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">↓/↓↓↓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">↓↓↓↑↑↑ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Pulmonary arterial pressure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Normal/↑ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">↑↑↑ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">↑↑/↑↑↑<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Clinical course \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Self-limitingHACE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">CHF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">CHF \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Effective drugs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">IbuprofenAcetazolamideDexamethasone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">NifedipineSildenafil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">EnalaprilAcetazolamideMedroxyprogesterone \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Therapeutic alternatives \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">OxygenHyperbaric chamberAltitude loss \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">OxygenAltitude loss \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Phlebotomy bleedingHemodilutionOxygenAltitude loss \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2708185.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Occasionally normal or slightly increased." ] ] ] "descripcion" => array:1 [ "en" => "General aspects and main differential characteristics of the 3 types of mountain sickness (the subacute type is also called high-altitude pulmonary hypertension, while the chronic type is called Monge’s disease)." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "No diagnosis or doubtful AMS, score 1–2; mild AMS, score 3–5 (in the presence of headaches); moderate AMS, score 6–9; severe AMS, score 10–12.Based on Roach et al. and the Lake Louise AMS Score Consensus Committee.<a class="elsevierStyleCrossRef" href="#bib0085">17</a>." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Headache \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0: absence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1: mild \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2: moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3: intense (incapacitating) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gastrointestinal symptoms \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0: absence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1: anorexia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2: nausea or vomiting \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3: nausea and vomiting (incapacitating) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fatigue/asthenia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0: absence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1: mild \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2: moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3: intense (incapacitating) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dizziness \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0: absence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1: mild \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2: moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3: intense (incapacitating) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2708186.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Lake Louise scale for diagnosing and qualifying the symptoms of acute mountain sickness." ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "No diagnosis or doubtful CMS, score 1–5; mild CMS, score 6–10; moderate CMS, score 11–14; severe CMS, score >15.Based on León-Velarde et al.<a class="elsevierStyleCrossRef" href="#bib0225">45</a>, Villafuerte and Corante<a class="elsevierStyleCrossRef" href="#bib0245">49</a> and Wu et al.<a class="elsevierStyleCrossRef" href="#bib0315">63</a>." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Dyspnea/palpitations \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0: absence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1: mild \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2: moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3: intense \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Insomnia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0: absence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1: mild \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2: frequent wakings \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3: absolute \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cyanosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0: absence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1: mild \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2: moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3: intense \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Varicose veins \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0: absence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1: mild \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2: moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3: intense \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Paresthesia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0: absence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1: mild \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2: moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3: intense \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Headaches \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0: absence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1: mild \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2: moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3: intense (incapacitating) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tinnitus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0: absence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1: mild \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2: moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3: intense \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hemoglobin (concentration) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0: <21g/dL (♂) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3: ≥21g/dL (♂) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0: <19g/dL (♀) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3: ≥19g/dL (♀) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2708184.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Qinghai scale for diagnosing and qualifying the symptoms of chronic mountain sickness." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:80 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Efectos nocivos de la altitud" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E. 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Acute, subacute and chronic mountain sickness

Mal de montaña de tipo agudo, subagudo y crónico

E. Garridoa,d,

Corresponding author

eduardogarrido@movistar.es

Corresponding author.

, J. Botella de Magliab,d, O. Castilloc

a Servicio de Hipobaria y Fisiología Biomédica, Universidad de Barcelona, L’Hospitalet de Llobregat, Barcelona, Spain

b Servicio de Medicina Intensiva, Hospital Universitario y Politécnico La Fe, Valencia, Spain

c Instituto Nacional de Biología Andina, Universidad Nacional Mayor de San Marcos, Lima, Peru

d Instituto de Estudios de Medicina de Montaña (IEMM), Barcelona, Spain

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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chronic mountain sickness or Monge&#8217;s disease&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The images show some of the physical stigma of this disease&#44; such as facial congestion&#44; labial and nail bed cyanosis&#44; watch-glass nails and distal hyperpigmentation&#44; palmar erythema&#44; and varicose veins in the legs&#46;</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Images provided by Dr&#46; Francisco C&#46; Villafuerte&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">It is estimated that 5&#37; of the worldwide population permanently live in mountainous areas&#44; and approximately 140 million of them live at high altitude &#40;&#62;2500m&#41;&#46; Every year&#44; more than 100 million people visit or travel to high mountain areas for professional&#44; touristic&#44; sports or religious reasons&#44; reaching high geographical heights through various means of transportation or by performing intense physical activity&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Barometric pressure falls dramatically as the altitude increases&#44; resulting in a reduced partial pressure of oxygen and the ensuing drop in arterial oxygen pressure &#40;PaO<span class="elsevierStyleInf">2</span>&#41; and oxygen saturation &#40;SaO<span class="elsevierStyleInf">2</span>&#41;&#46; Health disorders caused by this hypoxemia depend on the height reached&#44; the speed of ascent&#44; the time spent at that height and the individual&#8217;s physiological response &#40;known as <span class="elsevierStyleItalic">acclimatization</span>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> This biological process launches adaptive phenomena in various organs and systems<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> by stimulating complex oxygen-sensing mechanisms<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> that activate the hypoxia-inducible factor&#44; transcription factor for the expression of numerous genes that regulate oxygen deprivation and tissue homeostasis&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Nevertheless&#44; humans can only adapt to extreme altitudes &#40;&#62;5500m&#41; for brief periods&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Considering that the mean PaO<span class="elsevierStyleInf">2</span> and SaO<span class="elsevierStyleInf">2</span> values above 8000<span class="elsevierStyleHsp" style=""></span>m are below 35<span class="elsevierStyleHsp" style=""></span>mm Hg and 70&#37;&#44; respectively&#44;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> a state of coma would occur within 3<span class="elsevierStyleHsp" style=""></span>min in the absence of acclimatization&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> When the degree of acclimatization to hypoxia is inadequate for a certain altitude&#44; a varied spectrum of dysfunctions and health disorders occur&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;10</span></a> with mountain sickness the most common condition experienced&#46; Depending on the symptom onset&#44; characteristics and progression&#44; the disease can be classified into 3 well-differentiated forms or types&#44; which do not correspond to different pathochronic stages of the same clinical entity&#46; These types are called acute mountain sickness &#40;AMS&#41;&#44; subacute mountain sickness &#40;SMS&#41; and chronic mountain sickness &#40;CMS&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the main differences between the types&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Acute mountain sickness</span><p id="par0015" class="elsevierStylePara elsevierViewall">Although there are old symptomology descriptions&#44; this disease was clinically classified in 1913 by the British doctor Thomas Ravenhill&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The exact pathogenic mechanism is still not well understood&#59; however&#44; encephalic vasodilation&#44; vasogenic edema&#44; increased intracranial pressure and meningeal distension appear to be the most feasible mechanisms&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> High-altitude cerebral edema &#40;HACE&#41; corresponds to a progressed stage of AMS&#44; and although the form by which it progresses from one stage to another is controversial&#44; it appears to be due to a failure in the blood-brain barrier due to a mechanical or cytotoxic aggression or difficulty draining the cerebral venous flow&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Clinical presentation</span><p id="par0020" class="elsevierStylePara elsevierViewall">AMS typically occurs at altitudes higher than 2500<span class="elsevierStyleHsp" style=""></span>m but can occur around 2000<span class="elsevierStyleHsp" style=""></span>m&#46; The higher the altitude&#44; the higher the incidence and intensity of AMS symptoms&#44; affecting 10&#8211;25&#37; of nonacclimated individuals who ascend to heights of approximately 2500<span class="elsevierStyleHsp" style=""></span>m and 50&#8211;85&#37; of those who ascend to altitudes of 4500&#8211;5500<span class="elsevierStyleHsp" style=""></span>m&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The mean incidence rate of AMS increases by approximately 13&#37; for each 1000<span class="elsevierStyleHsp" style=""></span>m above 2500<span class="elsevierStyleHsp" style=""></span>m&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> The clinical manifestation is typically nonspecific&#58; isolated headache or accompanied by asthenia&#44; anorexia&#44; nausea&#44; vomiting&#44; lightheadedness and dizziness&#46; Occasionally&#44; there is concomitant facial and peripheral edema&#44; especially in women&#44; although it is not considered pathognomonic of AMS&#46; The symptoms usually start in the first 6&#8211;12<span class="elsevierStyleHsp" style=""></span>h and worsen as the individual gains altitude&#46; The diagnosis is performed exclusively by the symptoms&#46; There are several scoring systems for assessing the symptoms&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> although the most recommended for use by medical personnel is the Lake Louise scale&#44;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;17</span></a> which correctly types the patient through the presence and degree of impairment of 4 essential symptoms &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; A total score &#8805;3&#44; in the presence of headache&#44; is considered diagnostic for AMS&#59; however&#44; a score of 3 in the headache intensity&#44; even without other accompanying symptoms&#44; is also diagnostic for this clinical entity&#46; Headache is therefore an essential symptom in the manifestation of AMS&#44; but the absence of headache does not rule out the diagnosis&#44; which is confirmed in this case with a total score &#8805;5&#46; Severe cases are usually completely incapacitating for most activities&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> In children&#44; especially in preverbal stages&#44; AMS should always be suspected in the presence of irritability and behavioral changes&#46; Headaches are usually pulsatile&#44; worsen with physical exercise and the Valsalva maneuver&#44; frequently start during the first night and are quickly relieved by inhaling supplemental oxygen&#46; Any headache that starts after the third day while staying at the same altitude of &#62;2500<span class="elsevierStyleHsp" style=""></span>m should not be attributed to AMS&#46; Sleep disorders&#44; very common at high or extreme altitudes due to the onset of periodic breathing&#44; do not have a strict correlation with AMS&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Nevertheless&#44; there does appear to be an association between this disease and the presence of subclinical high-altitude pulmonary edema&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The differential diagnosis should be performed with migraine&#44; exhaustion&#44; dehydration&#44; sunstroke&#44; viral syndrome and alcohol or carbon monoxide poisoning&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The prognosis is good because the condition is typically self-limiting during the first 4 days of staying at a same altitude&#46; Below 5000<span class="elsevierStyleHsp" style=""></span>m&#44; less than 1&#37; of cases of AMS progress to HACE&#44; an entity that should be suspected in the minimal presence of cognitive disorder and the onset of ataxia 24&#8211;72<span class="elsevierStyleHsp" style=""></span>h after the start of AMS&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> HACE is a medical emergency because the onset of coma can occur within a few hours and can be fatal due to brain herniation&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Treatment</span><p id="par0030" class="elsevierStylePara elsevierViewall">In general&#44; it is advisable to employ conservative measures&#44; stopping the ascent until the symptoms have spontaneously remitted&#44; although oral ibuprofen &#40;600<span class="elsevierStyleHsp" style=""></span>mg&#47;8&#8211;24<span class="elsevierStyleHsp" style=""></span>h&#41; is indicated to treat the headache&#44; as well as oral or parenteral ondansetron &#40;4<span class="elsevierStyleHsp" style=""></span>mg&#47;4&#8211;6<span class="elsevierStyleHsp" style=""></span>h&#41; to treat the nausea and vomiting&#46; If&#44; during the first 4 days&#44; there is no improvement&#44; the individual must descend to an altitude 300&#8211;1000<span class="elsevierStyleHsp" style=""></span>m lower or reach the previous height where the patient was asymptomatic&#46; The most incapacitating cases should be treated with oral acetazolamide &#40;250<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h&#41; or oral or parenteral dexamethasone &#40;4<span class="elsevierStyleHsp" style=""></span>mg&#47;6<span class="elsevierStyleHsp" style=""></span>h&#41;&#46; The treatment regimen for children for these drugs is 2&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;12<span class="elsevierStyleHsp" style=""></span>h &#40;maximum 250<span class="elsevierStyleHsp" style=""></span>mg per dose&#41; and 0&#46;15<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;6<span class="elsevierStyleHsp" style=""></span>h&#44; respectively&#46; Acetazolamide is most effective for treating mild-moderate AMS&#44; while dexamethasone is most effective for moderate-severe AMS&#46; Either of both drugs should be stopped as soon as the symptoms disappear&#46; Recompression using a hyperbaric chamber&#44; as well as night-time oxygen therapy &#40;0&#46;5&#8722;1<span class="elsevierStyleHsp" style=""></span>L&#47;min&#41; are highly effective for moderate AMS&#46; When faced with severe cases and minimal clinical suspicion of progression to HACE&#44; the treatment should consist of urgently descending the patient&#44; administering oral or parenteral dexamethasone at a rate of 4<span class="elsevierStyleHsp" style=""></span>mg&#47;6<span class="elsevierStyleHsp" style=""></span>h &#40;after an initial dose of 8<span class="elsevierStyleHsp" style=""></span>mg&#41; until symptom remission&#46; Oral acetazolamide &#40;250<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h&#41; can be added&#44; although corticotherapy is the main drug indication in these cases&#46; If evacuation is delayed&#44; oxygen may also be administered &#40;2&#8211;4<span class="elsevierStyleHsp" style=""></span>L&#47;min&#41; or recompression therapy may be started in a portable hyperbaric chamber&#44; attempting to keep SaO<span class="elsevierStyleInf">2</span> at levels &#62;90&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;13&#44;14&#44;21</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Prevention</span><p id="par0035" class="elsevierStylePara elsevierViewall">The best strategy consists of acclimatizing to the altitude progressively&#44; ascending a daily slope of &#60;500<span class="elsevierStyleHsp" style=""></span>m if overnight stays at altitudes &#62;2500&#8211;3000<span class="elsevierStyleHsp" style=""></span>m are planned&#44; and devoting a day to rest for every 3&#8211;4 days of new altitude gain&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;21</span></a> Caution is recommended for those individuals with a history of migraine or deficient altitude adaptation&#44; given that they are more susceptible to high altitude headache and AMS&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Chemoprophylaxis is only indicated for especially susceptible individuals or when faced with scheduled overnight stays at high altitude without possible acclimatization and consists of oral acetazolamide &#40;125<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h&#41; or&#44; in rare cases&#44; oral dexamethasone &#40;2<span class="elsevierStyleHsp" style=""></span>mg&#47;6<span class="elsevierStyleHsp" style=""></span>h or 4<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h&#41;&#46; Dexamethasone is reserved for when acetazolamide is contraindicated or is poorly tolerated&#46; The combination of the 2 drugs or even higher dosages of dexamethasone &#40;4<span class="elsevierStyleHsp" style=""></span>mg&#47;6<span class="elsevierStyleHsp" style=""></span>h&#41; may be considered exclusively in highly justified cases for rapid ascents by air to altitudes &#62;3500<span class="elsevierStyleHsp" style=""></span>m and with planned physical activity&#44; such as is the case for military missions and rescue teams&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Typically&#44; chemoprophylaxis is started 8&#8211;24<span class="elsevierStyleHsp" style=""></span>h prior to the ascent&#44; extending it by at least 2 days if the individual remains at the same high altitude but not exceeding 7&#8211;10 days of continuous regimen if the individual keeps gaining altitude&#46; Within these time intervals&#44; the chemoprophylaxis should not be discontinued&#46; Chemoprophylaxis should only be stopped once the descent has started or during the descent&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14&#44;21</span></a> In children&#44; prophylaxis with dexamethasone is not indicated&#44; and the acetazolamide dosage is identical to the therapeutic dosage&#44; although it is only considered in justified cases and never for infants&#46; Chemoprophylaxis is absolutely not recommended for extremely high altitudes&#44; given that it can entail fatal consequences&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Other preventive strategies&#44; such as sessions for inhaling mixtures of hypoxic gases prior to an ascent to high altitudes&#44; have shown their effectiveness&#44; although there is no well-established preacclimatization protocol&#46; Regarding the chewing or infusion of leaves from the coca bush &#40;a widespread custom among visitors to some Andean regions&#41;&#44; there are no substantial studies that support this practice as prophylaxis&#46; <span class="elsevierStyleItalic">Ginkgo biloba</span> extracts have also failed to show consistent effectiveness in the randomized studies&#46; An abundant intake of liquids does not have a preventive effect&#44; although proper hydration is important because dehydration can simulate AMS&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Isolated SaO<span class="elsevierStyleInf">2</span> monitoring by pulse oximetry during stays at high altitude can indicate if we are within the normal range of this parameter at different altitudes<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&#59; however&#44; the use of this monitoring as a predictor of AMS is controversial&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> Certain sophisticated tests that assess cardiopulmonary function through normobaric hypoxia or in hypobaric chambers do help detect patients at risk&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a> Physical training has not been shown to have a protective effect against AMS&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> and vigorous physical exercise performed at high altitude can promote the onset of AMS&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Women&#44; younger people&#44; smokers&#44; or overweight individuals appear to have a higher susceptibility to AMS&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In general&#44; the risk of presenting AMS is very high when exceeding the altitude of 3500<span class="elsevierStyleHsp" style=""></span>m in a single day&#44; as occurs in locations highly frequented by tourists and rapidly reached by car&#44; air&#44; cable car or train&#46; The concomitance of diseases&#44; especially cardiopulmonary&#44; can also represent a contraindication for reaching altitudes &#62;2500<span class="elsevierStyleHsp" style=""></span>m&#46; Each case should be assessed according to the altitude goal&#44; type of ascent&#44; length of stay at altitude&#44; activity envisaged&#44; geographical region and possibility of health care&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Subacute mountain sickness &#40;high-altitude pulmonary hypertension&#41;</span><p id="par0055" class="elsevierStylePara elsevierViewall">The presence of pulmonary hypertension in high-altitude residents was noted in 1932 by the Peruvian doctor Alberto Hurtado&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> In 1962&#44; other compatriots detected the presence of right ventricular hypertrophy in native Andean children&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> Chinese physicians had already known of this disease in Asian children&#44; known as <span class="elsevierStyleItalic">high-altitude heart disease</span>&#59; cases were subsequently reported in adults in Tibet&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">33&#44;34</span></a> More recently&#44; Soviet scientists studied patients with <span class="elsevierStyleItalic">cor pulmonale</span> in the Pamir mountains&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> Despite these pioneers&#44; the pediatric form of this disease was not clinically described until 1988 when a study was conducted on Chinese children younger than 16 months who had been transferred to Tibet and who&#44; after 2<span class="elsevierStyleHsp" style=""></span>months of living in Lhasa &#40;altitude of 3656<span class="elsevierStyleHsp" style=""></span>m&#41;&#44; developed severe pulmonary hypertension and congestive heart failure and subsequently died&#46; Their autopsies revealed right ventricular hypertrophy and thickening of the tunica media of the pulmonary arterioles&#46; The clinical condition was called SMS&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> In 1990&#44; the condition was clinically described in adults&#44; specifically in Indian soldiers who lived for weeks or months at 5800&#8211;6700<span class="elsevierStyleHsp" style=""></span>m in the Himalayas&#46; The individuals presented heart failure&#44; right ventricular growth&#44; increased pulmonary vascular resistance and tricuspid regurgitation&#44; abnormalities that disappeared over the course of days or weeks after the soldiers descended from the mountains&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Clinical presentation</span><p id="par0060" class="elsevierStylePara elsevierViewall">SMS is compatible with rapidly progressing congestive heart failure because it manifests after weeks or a few months of continuous exposure to high altitude&#46; Its pathogenesis is through alveolar hypoxia&#44; which causes immediate and reversible pulmonary vasoconstriction&#44; mediated by endothelin-1 and other substances&#46; If the hypoxia persists&#44; the pulmonary hypertension is maintained because over time the tunica media of the pulmonary vessels thickens due to the increase in its muscle component&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> The right ventricle dilates and hypertrophies&#44; and if the pulmonary hypertension is very intense&#44; the right ventricle claudicates&#46; The symptoms manifest as dyspnea&#44; cough&#44; cyanosis&#44; jugular venous distention&#44; facial and lower limb edema&#44; hepatomegaly&#44; ascites&#44; pericardial effusion and effort angina&#46; In young children&#44; symptoms can start nonspecifically as irritability&#44; lethargy&#44; anorexia and insomnia&#46; The incidence rate for SMS is higher in children than in adults and higher in male individuals&#44; with cases reported in children and adults at altitudes somewhat below 3000<span class="elsevierStyleHsp" style=""></span>m&#46; As with the Quechua and Aymara of the Andes&#44; virtually all other humans present pulmonary hypertension secondary to hypoxia as the mechanism for optimizing the ventilation&#47;perfusion ratio and are therefore potentially at risk of SMS during long exposures to high altitude&#46; Only Tibetans have a very low incidence of SMS&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> given that they present no or minimal pulmonary hypertension in hypoxia<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> and therefore do not develop <span class="elsevierStyleItalic">cor pulmonale</span>&#46; This low incidence is believed to be due to a natural selection process from exposure to a hypoxic atmosphere&#44; a process that has lasted millennia and has remained relatively unchanged by miscegenation&#46; Special phenotypic&#44; physiological and genetic adaptations explain why ethnicities of Tibetan lineage are the best human model for long-term adaptation to environmental hypoxia&#44; given that they provide the longest evolutionary anthropological scale for permanent living at high altitude&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> Nevertheless&#44; permanent human life is not possible above 5500<span class="elsevierStyleHsp" style=""></span>m&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> mainly because of SMS and muscle atrophy at high altitude&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> At the Chilean mine of Aucanquilcha &#40;5800<span class="elsevierStyleHsp" style=""></span>m&#41;&#44; adjacent barracks were constructed to avoid having miners ascend daily from a nearby town&#59; however&#44; within a few months&#44; all of the miners became sick and unable to work&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The fact that SMS occurs in adults at altitudes typically above 5500<span class="elsevierStyleHsp" style=""></span>m and in infants at altitudes above 2500&#8211;3000<span class="elsevierStyleHsp" style=""></span>m is due to the fact that children develop greater hypoxic pulmonary hypertension&#44; given that the pulmonary vasoconstrictor response to hypoxia tends to decrease with age&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> The current criterion for considering high-altitude pulmonary hypertension excessive is a systolic pulmonary arterial pressure &#62;50<span class="elsevierStyleHsp" style=""></span>mm Hg or a mean pressure &#62;30<span class="elsevierStyleHsp" style=""></span>mm Hg for adults and a systolic pressure &#62;65<span class="elsevierStyleHsp" style=""></span>mm Hg for children younger than 6 months&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> Nevertheless&#44; SMS can typically be diagnosed in adults noninvasively by the symptoms&#44; through electrocardiography&#44; chest radiology and echocardiography&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">45&#44;46</span></a> Pediatric cases diagnosed by echocardiography have recently been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Treatment and prevention</span><p id="par0070" class="elsevierStylePara elsevierViewall">Adults should avoid long stays at altitudes higher than 5500<span class="elsevierStyleHsp" style=""></span>m&#44; and non-Tibetan children younger than 12 months should not be transferred to areas above 3000<span class="elsevierStyleHsp" style=""></span>m for extended periods&#44; given that sudden death can occur after only presenting nonspecific pediatric symptoms for a few weeks&#46; Some adults improve temporarily with supplemental oxygen&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> as well as with nifedipine or sildenafil&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> although full remission of SMS &#40;in children and adults&#41; is only achieved by descending to low altitude&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Chronic mountain sickness &#40;Monge&#8217;s disease&#41;</span><p id="par0075" class="elsevierStylePara elsevierViewall">In 1925&#44; the Peruvian doctor Carlos Monge first described polyglobulia in a native Andean&#44; subsequently confirming this finding in other Andeans&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> CMS is currently defined as a clinical syndrome that occurs in long-term residents of high-altitude areas &#40;&#62;2500<span class="elsevierStyleHsp" style=""></span>m&#41; and is characterized by excessive erythrocytosis and hypoxemia&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> The concept of <span class="elsevierStyleItalic">loss of high-altitude adaptation</span> secondary to idiopathic central hypoventilation &#40;primary CMS&#41; has been accepted as the etiopathogenic mechanism&#59; however&#44; the presence of concomitant diseases can promote CMS &#40;secondary CMS&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> and a phenomenon of <span class="elsevierStyleItalic">adaptation to disease in a hypoxic environment</span> can also be a valid concept&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> In both contexts&#44; CMS does not correspond to a single entity&#44; given that it can coexist with lung disease&#44; heart disease&#44; nephropathy&#44; hemoglobinopathy and with metabolic disorders&#44; hormonal disorders&#44; carotid body disorders&#44; cobalt in blood and pulmonary thromboembolism&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;49&#44;51</span></a> In recent years&#44; a possible genetic predisposition to CMS in Andean ethnic groups has been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The mean prevalence rate for CMS is 5&#8211;10&#37; among the global population who reside at altitudes higher than 2500<span class="elsevierStyleHsp" style=""></span>m&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> Consequently&#44; up to 14 million individuals worldwide might have CMS&#46; Nevertheless&#44; this rate varies according to the altitude of the place of residence and among populations of various mountain regions&#46; Cases have been reported at only 2000<span class="elsevierStyleHsp" style=""></span>m of altitude<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a>&#59; however&#44; the highest incidence occurs above 3000<span class="elsevierStyleHsp" style=""></span>m&#44; affecting 5&#8211;18&#37; of the residents of the Andes&#44;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a> 14&#8211;29&#37; of the residents of certain areas of the Indian Himalayas<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">55&#44;56</span></a> but only 1&#37; of native Tibetan residents&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> This lower prevalence can be explained by the special adaptation to hypoxia that the Tibetans possess&#44;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;41</span></a> which was discussed earlier in the previous subsection&#46; In general&#44; the higher the altitude and the longer the time residing at that altitude&#44; the greater the risk of CMS&#44; which&#44; starting in the sixth decade of life&#44; can affect a third of the population of certain Andean communities&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a></p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Clinical presentation</span><p id="par0085" class="elsevierStylePara elsevierViewall">Depending on the stage or progression of the disease&#44; patients can present dyspnea&#44; palpitations&#44; insomnia&#44; loss of appetite&#44; joint pain&#44; cyanosis&#44; varicose veins in the legs&#44; acropachy&#44; palmar erythema&#44; epistaxis&#44; conjunctival injection and facial flushing &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; In addition to the congestive aspect that many patients usually show&#44; there are associated neuropsychological symptoms&#44; such as headaches&#44; dizziness&#44; tinnitus&#44; peripheral neuropathy&#44; depression&#44; confusion and amnesia&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;45&#44;49&#44;59&#8211;61</span></a> There have been reported cases that even develop cerebral edema and encephalopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a> Nevertheless&#44; it is not uncommon to detect asymptomatic patients who present excessive polyglobulia in routine blood tests and SaO<span class="elsevierStyleInf">2</span> values &#60;85&#37;&#44; even at altitudes higher than 4000<span class="elsevierStyleHsp" style=""></span>m&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> CMS is more common in men&#44; especially of Andean ethnicity&#59; however&#44; a significant incidence has been reported in non-Tibetan women who reside in the Himalayas&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a> The Qinghai scale classifies patients according to the degree of severity&#44; thereby establishing an overall score by scoring for the presence and intensity of 8 essential symptoms and clinical signs&#44; as well as a hemoglobin concentration threshold of 21<span class="elsevierStyleHsp" style=""></span>g&#47;dL for men and 19<span class="elsevierStyleHsp" style=""></span>g&#47;dL for women &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">45&#44;49&#44;63</span></a> Patients with CMS frequently have pulmonary arterial hypertension&#44; whose intensity and clinical manifestation can vary dramatically from one individual to another&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;59</span></a> In advanced stages&#44; there is remodeling of the pulmonary arterioles and right ventricular hypertrophy&#47;dilation&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">64</span></a> Ventricular failure is not typically produced&#44; although its actual incidence rate is unknown&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a> There have also been reports of the presence of systemic vascular dysfunction&#44; which can predispose patients to early cardiovascular disease&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a> Despite the hypoxemia&#44; increases in hematocrit and subsequent blood hyperviscosity&#44; it has been observed that erythroblast apoptosis is reduced in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Residents of high-altitude areas who present excessive hematocrit levels should initially undergo examinations with spirometry&#44; chest radiology&#44; electrocardiography and echocardiography to assess pulmonary function and detect signs of pulmonary hypertension and right ventricular growth&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> Stress testing has demonstrated that the aerobic function during physical exercise appears to be preserved despite these patients&#8217; pulmonary hypertension and relative hypoventilation&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">68</span></a> Nevertheless&#44; physical activity can induce severe pulmonary hypertension in these patients&#44; with the rapid onset of interstitial pulmonary edema and subsequently increased hypoxemia and exercise intolerance&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">69</span></a> Pronounced pulmonary hypertension&#44; even during moderate physical exercise as part of daily activities&#44; can be the origin of these patients&#8217; greater morbidity and mortality&#44;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a> whose death could be caused by congestive heart failure or stroke&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> A number of vasoactive peptides&#44; such as B-type natriuretic peptide and endothelin-1&#44; can have an important role in the clinical expression of Monge&#8217;s disease&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">71</span></a> Increased androgenic hormonal activity &#40;given the erythropoietic function of testosterone&#41; can be related to an excessive polyglobulic reaction in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">72</span></a> The hypoventilation presented by these patients at rest could be a defense mechanism given that it involves a lower energy expenditure&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">73</span></a> Their hypoxemia during sleep is even more pronounced than during their waking hours and has been related to existing pulmonary and systemic vascular dysfunction&#59; the presence of patent foramen ovale can promote this hypoxemia&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">74</span></a> The increased formation of free radicals and the reduced viability of nitric oxide are associated with rapid cognitive impairment and the onset of depressive symptoms in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">75</span></a> Given that CMS symptoms and clinical signs are aggravated with increases in altitude&#44; attempts have been made to quantify the normal polyglobulic reaction for certain altitudes&#46; For very high hematocrit levels &#40;approximately 80&#37;&#41;&#44; a multifactorial mechanism known as <span class="elsevierStyleItalic">triple hypoxia syndrome</span> was proposed &#40;hypobaric hypoxia<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>chronic hypoxia due to concomitant hypoxemic diseases<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>acute hypoxia due to superadded inflammatory processes&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">76</span></a> In those cases of CMS where there is diagnostic uncertainty&#44; other causes of polyglobulia should be considered &#40;e&#46;g&#46;&#44; polycythemia vera&#44; excessive erythropoietin production secondary to renal or testicular tumors&#44; testosterone treatments&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Treatment and prevention</span><p id="par0095" class="elsevierStylePara elsevierViewall">Effective strategies include transferring the patient to a location at lower altitude&#44; permanently administering supplemental oxygen and attempting to keep the polyglobulia at an optimal compensation level&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> The first option achieves a decrease in polyglobulia in approximately 3 weeks<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">77</span></a>&#59; however&#44; if the patient is transferred to a tropical environment&#44; their risk of pneumonia and asthma-like syndromes increases&#44; especially in cases of secondary CMS&#46; Many patients from the Andes and Himalayas would be forced to leave their jobs and their family&#8217;s financial support&#44; with the subsequent severe social problem that this migration entails&#46; The second option reverses many of the symptoms but handicaps the patient by making them oxygen-dependent and is counterproductive in CMS secondary to undiagnosed diseases&#46; Oxygen therapy is only effective in cases of severe CMS&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">78</span></a> The third option focuses on treating the underlying causes of the hypoxemia and&#44; consequently&#44; the polyglobulia&#46; With good control of the underlying diseases&#44; these patients&#8217; life expectancy increases&#44; avoiding the accelerated psychophysical impairment and abandonment of the patients&#8217; residence&#46; Although they immediately reduce blood viscosity&#44; palliative therapies through bloodletting and isovolemic hemodilutions induce metabolic disorders&#44; exertional dyspnea and asthenia&#44; if frequently applied&#44; and are not recommended as long-term therapy for these patients&#46; Oral drug therapy with medroxyprogesterone &#40;60<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&#41;&#44; acetazolamide &#40;250<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&#41; or enalapril &#40;5&#8211;10<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&#41; also constitute effective therapeutic options&#44;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">45&#44;49&#44;54&#44;79</span></a> although there is no scientific evidence on their safety in very long-term therapy for CMS&#46; Nevertheless&#44; the most severe cases should leave high altitudes or live at sea level&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> despite the fact that resting pulmonary hypertension in Andean natives can take more than 2 years to normalize&#44; and the pulmonary hypertensive response to exercise can last indefinitely&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">80</span></a> Other stigma such as varicose veins and acropachy also persist&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">With a minimum clinical suspicion of CMS or patients who might be at risk of CMS &#40;sleep apnea&#44; postmenopause&#44; family predisposition&#41;&#44; smoking cessation is essential&#44; as well as preventing diseases of the respiratory system&#44; excess body weight&#44; malnutrition and iron deficiencies&#46; Regular physical exercise at moderate intensity substantially improves these patients&#8217; general condition&#44; but strenuous physical activity should be avoided&#46; These patients should be evaluated annually&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a></p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflicts of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "identificador" => "sec0005"
          "titulo" => "Background"
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        5 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Acute mountain sickness"
          "secciones" => array:3 [
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              "titulo" => "Clinical presentation"
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              "titulo" => "Treatment"
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              "titulo" => "Prevention"
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          "identificador" => "sec0030"
          "titulo" => "Subacute mountain sickness &#40;high-altitude pulmonary hypertension&#41;"
          "secciones" => array:2 [
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              "identificador" => "sec0035"
              "titulo" => "Clinical presentation"
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              "titulo" => "Treatment and prevention"
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          "identificador" => "sec0045"
          "titulo" => "Chronic mountain sickness &#40;Monge&#8217;s disease&#41;"
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              "identificador" => "sec0050"
              "titulo" => "Clinical presentation"
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              "titulo" => "Treatment and prevention"
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          "titulo" => "Conflicts of interest"
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          "identificador" => "xack558384"
          "titulo" => "Acknowledgements"
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          "titulo" => "References"
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    "fechaRecibido" => "2019-10-16"
    "fechaAceptado" => "2019-12-16"
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          "clase" => "keyword"
          "titulo" => "Keywords"
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          "palabras" => array:6 [
            0 => "Altitude"
            1 => "Monge&#8217;s disease"
            2 => "Pulmonary hypertension"
            3 => "Hypoxia"
            4 => "Mountain sickness"
            5 => "Mountaineering&#46;"
          ]
        ]
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            0 => "Altitud"
            1 => "Enfermedad de monge"
            2 => "Hipertensi&#243;n pulmonar"
            3 => "Hipoxia"
            4 => "Mal de monta&#241;a"
            5 => "Monta&#241;ismo&#46;"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">More than 100 million people ascend to high mountainous areas worldwide every year&#46; At nonextreme altitudes &#40;&#60;5500<span class="elsevierStyleHsp" style=""></span>m&#41;&#44; 10&#8211;85&#37; of these individuals are affected by acute mountain sickness&#44; the most common disease induced by mild-moderate hypobaric hypoxia&#46; Approximately 140 million individuals live permanently at heights of 2500&#8211;5500<span class="elsevierStyleHsp" style=""></span>m&#44; and up to 10&#37; of them are affected by the subacute form of mountain sickness &#40;high-altitude pulmonary hypertension&#41; or the chronic form &#40;Monge&#8217;s disease&#41;&#44; the latter of which is especially common in Andean ethnicities&#46; This review presents the most relevant general concepts of these 3 clinical variants&#44; which can be incapacitating and can result in complications and become life-threatening&#46; Proper prevention&#44; diagnosis&#44; treatment and management of these conditions in a hostile environment such as high mountains are therefore essential&#46;</p></span>"
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      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">M&#225;s de 100 millones de personas ascienden cada a&#241;o a &#225;reas monta&#241;osas elevadas en todo el planeta&#44; y en altitudes no extremas &#40;&#60;5&#46;500<span class="elsevierStyleHsp" style=""></span>m&#41; entre el 10-85&#37; se ven afectados por el denominado mal agudo de monta&#241;a&#44; la patolog&#237;a m&#225;s frecuentemente inducida por una hipoxia hipob&#225;rica ligera-moderada&#46; Asimismo&#44; unos 140 millones de seres humanos viven de forma permanente en cotas comprendidas entre 2&#46;500&#8211;5&#46;500<span class="elsevierStyleHsp" style=""></span>m&#44; y hasta un 10&#37; de ellos padecen la forma subaguda del mal de monta&#241;a &#40;hipertensi&#243;n pulmonar de la gran altitud&#41; o la forma cr&#243;nica &#40;enfermedad de Monge&#41;&#44; esta &#250;ltima especialmente frecuente en etnias andinas&#46; La presente revisi&#243;n expone los conceptos generales m&#225;s relevantes en torno a estas tres variantes cl&#237;nicas&#44; las cuales pueden ser incapacitantes&#44; llegar a complicarse y ser potencialmente mortales&#44; siendo esencial el realizar una correcta prevenci&#243;n&#44; diagn&#243;stico&#44; terap&#233;utica y manejo de las mismas en un entorno hostil como es la alta monta&#241;a&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Garrido E&#44; Botella de Maglia J&#44; Castillo O&#46; Mal de monta&#241;a de tipo agudo&#44; subagudo y cr&#243;nico&#46; Rev Clin Esp&#46; 2021&#59;221&#58;481&#8211;490&#46;</p>"
      ]
    ]
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      0 => array:8 [
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        "etiqueta" => "Fig&#46; 1"
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        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chronic mountain sickness or Monge&#8217;s disease&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The images show some of the physical stigma of this disease&#44; such as facial congestion&#44; labial and nail bed cyanosis&#44; watch-glass nails and distal hyperpigmentation&#44; palmar erythema&#44; and varicose veins in the legs&#46;</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Images provided by Dr&#46; Francisco C&#46; Villafuerte&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; CHF&#44; congestive heart failure&#59; HACE&#44; high-altitude cerebral edema&#59; PaCO<span class="elsevierStyleInf">2</span>&#44; partial pressure of carbon dioxide&#59; SaO<span class="elsevierStyleInf">2</span>&#44; arterial oxygen saturation&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Types of mountain sickness&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Acute&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Subacute&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Chronic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Minimum altitude required&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">2000&#8211;2500 m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">2500&#8211;5500 m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">2500&#8211;3000 m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Risk population&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Children&#47;adults&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Children&#47;adults&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Adults&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Time to symptom onset&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Hours&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Weeks&#47;months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Predominant symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">CephalicGastrointestinal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">RespiratoryCardiac&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">NeuropsychologicalCardiopulmonaryVascular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Clinical assessmentHematocrit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Lake Louise scaleNormal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Clinical presentation&#8593;&#47;&#8593;&#8593;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Qinghai scale&#8593;&#8593;&#8593;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">SaO<span class="elsevierStyleInf">2</span>PaCO<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#8595;&#47;&#8595;&#8595;&#8595;&#47;&#8595;&#8595;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#8595;&#47;&#8595;&#8595;&#8595;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#8595;&#8595;&#8595;&#8593;&#8593;&#8593;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Pulmonary arterial pressure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Normal&#47;&#8593;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#8593;&#8593;&#8593;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#8593;&#8593;&#47;&#8593;&#8593;&#8593;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Clinical course&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Self-limitingHACE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">CHF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">CHF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Effective drugs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">IbuprofenAcetazolamideDexamethasone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">NifedipineSildenafil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">EnalaprilAcetazolamideMedroxyprogesterone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Therapeutic alternatives&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">OxygenHyperbaric chamberAltitude loss&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">OxygenAltitude loss&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Phlebotomy bleedingHemodilutionOxygenAltitude loss&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">General aspects and main differential characteristics of the 3 types of mountain sickness &#40;the subacute type is also called <span class="elsevierStyleItalic">high-altitude pulmonary hypertension</span>&#44; while the chronic type is called <span class="elsevierStyleItalic">Monge&#8217;s disease</span>&#41;&#46;</p>"
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          "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">No diagnosis or doubtful AMS&#44; score 1&#8211;2&#59; mild AMS&#44; score 3&#8211;5 &#40;in the presence of headaches&#41;&#59; moderate AMS&#44; score 6&#8211;9&#59; severe AMS&#44; score 10&#8211;12&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Based on Roach et al&#46; and the Lake Louise AMS Score Consensus Committee&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#46;</p>"
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#58; mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#58; moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#58; intense &#40;incapacitating&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Gastrointestinal symptoms</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0&#58; absence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#58; anorexia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#58; nausea or vomiting&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#58; nausea and vomiting &#40;incapacitating&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Fatigue&#47;asthenia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0&#58; absence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#58; mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#58; moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#58; intense &#40;incapacitating&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Dizziness</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0&#58; absence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#58; mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#58; moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#58; intense &#40;incapacitating&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Lake Louise scale for diagnosing and qualifying the symptoms of acute mountain sickness&#46;</p>"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">No diagnosis or doubtful CMS&#44; score 1&#8211;5&#59; mild CMS&#44; score 6&#8211;10&#59; moderate CMS&#44; score 11&#8211;14&#59; severe CMS&#44; score &#62;15&#46;</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Based on Le&#243;n-Velarde et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a>&#44; Villafuerte and Corante<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> and Wu et al&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">63</span></a>&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">Dyspnea&#47;palpitations</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0&#58; absence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#58; mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#58; moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#58; intense&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Insomnia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0&#58; absence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#58; mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#58; frequent wakings&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#58; absolute&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Cyanosis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0&#58; absence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#58; mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#58; moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#58; intense&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Varicose veins</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0&#58; absence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#58; mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#58; moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#58; intense&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Paresthesia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0&#58; absence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#58; mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#58; moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#58; intense&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Headaches</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0&#58; absence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#58; mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#58; moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#58; intense &#40;incapacitating&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Tinnitus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0&#58; absence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#58; mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#58; moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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Article information

ISSN: 22548874
Original language: English

DOI:10.1016/j.rceng.2019.12.009

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