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A systematic review" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "435" "paginaFinal" => "444" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Valoración del dolor en personas con demencia y problemas de comunicación en España. Revisión sistemática" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2685 "Ancho" => 2492 "Tamanyo" => 301388 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Flow diagram following the PRISM recommendations.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.Á. de Juan Pardo, M. Saracibar-Razquin, I. Crespo, P. Fuster Linares" "autores" => array:4 [ 0 => array:2 [ "nombre" => "M.Á." "apellidos" => "de Juan Pardo" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Saracibar-Razquin" ] 2 => array:2 [ "nombre" => "I." 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Ramos-Sesma, M. Górgolas-Hernández Mora, J.M. Ramos-Rincón" "autores" => array:3 [ 0 => array:3 [ "nombre" => "V." "apellidos" => "Ramos-Sesma" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Górgolas-Hernández Mora" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:4 [ "nombre" => "J.M." "apellidos" => "Ramos-Rincón" "email" => array:1 [ 0 => "jramosrincon@yahoo.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Marina Alta, Denia, Alicante, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "División de Enfermedades Infecciosas, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital General Universitario de Alicante; Departamento de Medicina Clínica, Universidad Miguel Hernández de Elche; ISABIAL – FISABIO, Alicante, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "El viajero mayor" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Despite the economic crisis in recent years, the number of trips has not fallen. According to the United Nations World Tourism Organization (UNWTO), 1235 million trips were recorded in 2016. It is estimated that this figure will increase in the coming years.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">1,2</span></a> The improved quality of life, the greater control of chronic disease and financial stability after retirement have resulted in an increase in the number of trips among the elderly population.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3,4</span></a> Generally, the elderly population who travel have been traveling since their youth, and age is not a restriction for traveling. We should therefore distinguish between cognitive and chronological age.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">4</span></a> The age at which we considered a population “elderly” is not well-defined.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">5</span></a> For the purposes of this review, we will set the threshold at 65 years. Elderly travelers currently have greater ease of traveling, a certain financial solvency and free time offered by retirement.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3,6,7</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In terms of health during travel, we need to differentiate between problems resulting from chronic disease (such as diabetes mellitus and cardiopulmonary disease) and the limitations resulting from age (such as memory loss, loss of understanding, hearing loss and vision loss).<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3,5</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Pathophysiology of the elderly</span><p id="par0015" class="elsevierStylePara elsevierViewall">Time changes many biologic processes. Aging is not a homogeneous process and depends on genetic and lifestyle factors and environmental exposures. Aging is characterized by progressive changes that are associated with increased susceptibility to numerous diseases. Age-related hearing loss and vision loss can create problems for elderly travelers, preventing them from seeing signs and posters and hearing airport warnings and explanations in crowded locations.<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">5,6,8,9</span></a> This loss of ability to adapt to new situations can lead to a confusional state or anxiety in the traveler.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6,10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">From the respiratory standpoint, the total lung capacity is reduced due to the decrease in the number of alveoli that enable gas exchange. This reduction also increases the respiratory effort by decreasing lung distensibility.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3,4</span></a> The adaptation capacity is therefore lower in conditions of hypoxia, such as at high altitude or after cabin depressurization in airplanes. Elderly travelers are therefore more susceptible to cardiopulmonary diseases such as respiratory failure and pulmonary edema and to exacerbations of these diseases. If appropriate measures are taken, however, even individuals with some type of cardiopulmonary disease barely develop symptoms.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3,4,6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Acclimatization to extreme temperatures triggers problems that can be avoided with common sense (e.g., drinking water abundantly, avoiding the hottest time of the day and staying in rooms with air conditioning). Age reduces renal filtration capacity and produces a loss of homeostasis by reducing the feeling of thirst and the peripheral vascularization's ability to adapt. These travelers are more susceptible to dehydration and acute renal failure, especially if aggravated with diarrhea.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3,4,6–9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Immunosenescence is a common pathophysiological change in elderly individuals.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">11</span></a> The aging of the immune system promotes the loss of mature T-cells and antibodies that protect against diseases the patients had experienced or for which they were vaccinated.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">11</span></a> Moreover, this deregulated immunity can cause administered vaccines to lose their effectiveness (i.e., not generate the same quantity of protective antibodies<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3,9,11</span></a>). The efficacy of vaccines in young adults is 70–90%, while the efficacy in the elderly is 17–35%.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">12,13</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The yellow fever vaccine is formed by attenuated living viruses, and although it is considered a safe vaccine, caution and even contraindication is advised for immunosuppressed individuals. The vaccine is not contraindicated for individuals older than 65 years,<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">8</span></a> but a delay in the immune response and greater viremia have been observed in these patients,<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3,4,14,15</span></a> and the vaccine should therefore be indicated individually in each case.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Precautions before starting the trip</span><p id="par0040" class="elsevierStylePara elsevierViewall">Elderly travelers should plan their trip well in advance. They should not only consider the places they wish to visit, the hotels to reserve and the monuments they want to enter but also visit a general practitioner for a physical check-up. The elderly traveler can thereby bring with them on the trip a medical report that summarizes their history and medication.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">4,16,17</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Elderly travelers with heart disease should bring a copy of the electrocardiogram. If they have an implanted pacemaker or defibrillator, they should attach a report that explains the type of device. The traveler should have sufficient medication for the entire trip and extra in case the trip is unexpectedly extended. Doctors should advise these travelers about prophylactic medication and assess the potential interactions. Some of the basic issues to consider are information on the health education standards for the prevention of insect bites and how to procure travel insurance.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3,4,9,17</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Recommended vaccines by geographical area</span><p id="par0050" class="elsevierStylePara elsevierViewall">The traveler's consultation can be an important opportunity to update their vaccine calendar.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">9</span></a> The following vaccines are recommended for those older than 65 years: seasonal influenza vaccine, if planning to travel to a country in winter; the pneumococcal vaccine; a dose of the diphtheria/tetanus toxoid vaccine if they have not received it at 60 years; and, eventually, the herpes zoster vaccine.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">8</span></a> Generally, vaccines in those older than 65 years have lower antibody seroconversion rates and are therefore less immunogenic, compared with the response of younger individuals. The elderly also have more adverse effects. Nevertheless, there are no studies sufficiently focused on elderly populations that examine the effectiveness of the vaccines.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">18</span></a><a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a> summarizes the recommended vaccines depending on the trip's destination. <a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a> shows the considerations for the vaccines in elderly travelers. It is advisable to administer vaccines more than 15 days prior to the trip, avoiding the simultaneous administration of attenuated vaccines.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">3</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Traveling with medication</span><p id="par0055" class="elsevierStylePara elsevierViewall">Studies<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3,19</span></a> have indicated that the long-term use of medication influences the trip duration but only among younger populations. These differences are not observed in older travelers. However, in the population older than 60 years, it is estimated that 11–59% of travelers who visit the doctor before a trip take at least one type of long-term medication.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">20</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">As a rule, individuals should travel with the original packaging of the medication and an updated medical report as mentioned above. It is advisable to translate the report into the destination country's language. It is advisable to carry sufficient medication for the entire trip and carry it in the hand luggage, to prevent its loss if the checked baggage is lost. Travelers should not rely on finding the same active ingredient at the destination, especially if traveling to developing countries or remote areas.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3,9,17,20</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Some drugs can create problems, such as those that can be confused with illegal drugs and those with some type of special control, e.g., anxiolytics, antiepileptics and opioid analgesics.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3,9,20,21</span></a> The International Narcotics Control Board provides a guide on their website about the regulation of drugs and countries in which carrying narcotics could present a problem.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">22</span></a> The Spanish Air Navigation Agency (AENA)<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">23</span></a> provides information on the current regulations for any airport in the European Union and allows passengers to travel with medication provided they are accompanied by its medical prescription.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Medication should not be shipped by mail and should not be bought at the destination because, in certain countries, the medication does not have the same safety controls, and fake drugs or drugs with nonequivalent doses are sold instead.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3,4,9</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Drug interactions among long-term drugs</span><p id="par0075" class="elsevierStylePara elsevierViewall">Up to 45% of travelers who take some type of long-term medication can experience some interaction with traveler's diarrhea medication, malaria prophylaxis or altitude sickness drugs.<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">19,20</span></a> The interactions can vary the drug concentrations, producing hyperglycemia, seizures, QT prolongation or arrhythmias. The interactions with dicoumarin agents are important, and their levels depend not only on the drug but also on the ingested food.</p><p id="par0080" class="elsevierStylePara elsevierViewall">As a rule, malaria prophylaxis is always indicated for elderly individuals traveling to at-risk areas.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3,9,16</span></a> The dose does not need to be adjusted for age and should only be adjusted if there is some comorbidity or insufficiency. <a class="elsevierStyleCrossRef" href="#tbl0020">Table 3</a> summarizes the potential interactions between the drugs that are used in antimalarial prophylaxis and drugs most commonly used by the elderly.</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Time zone and jet lag</span><p id="par0085" class="elsevierStylePara elsevierViewall">Jet lag not only causes abnormal sleep cycles but can also create confusion on when to take medication. The time change can lead to skipping or duplicating doses. Based on the concept of drug forgiveness whereby missing a dose does not mean achieving infratherapeutic levels of the drug in blood, travelers have the option of skipping a dose and adapting the dosing to the new time zone.<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">20,21</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Elderly travelers and flights</span><p id="par0090" class="elsevierStylePara elsevierViewall">The elderly are more likely to have restricted physical mobility or diseases that limit movements.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">23</span></a> Certain airlines have developed recommendations and advice aimed at helping elderly travelers, allowing them to reserve a seat and board before other travelers, offering comprehensive assistance to the elderly at airports, offering special menus aboard the flight, providing a “doctor on board” program with supplemental oxygen and responding to health-related questions regarding travel.<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">24,25</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Travel insurance for elderly travelers</span><p id="par0095" class="elsevierStylePara elsevierViewall">It has been estimated that 30–50% of travelers incur some injury or need to consult with a doctor during the trip.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">24</span></a> Due to the high cost of healthcare coverage abroad, it is advisable to request insurance with good coverage before any trip.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3,8,17</span></a> Procuring good insurance with broad coverage is not usually excessively expensive, compared with the overall price of the trip.<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">5,26</span></a><a class="elsevierStyleCrossRef" href="#tbl0025">Table 4</a> summarizes the basic coverage provided by an insurance plan.</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Other risks and recommendations</span><p id="par0100" class="elsevierStylePara elsevierViewall">Criminals often see elderly individuals as more vulnerable. They usually assume that the elderly wear more objects of value, carry money and have reduced reaction capacity. In tourism zones, people need to be more alert. Elderly individuals should therefore avoid placing themselves at risk and generally be more prudent. Having an unlocked mobile phone and always having it at hand is a good safety measure in case of something unexpected.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">27</span></a> Physical, hearing and visual limitations should also be considered, arriving on time at locations and avoiding long lines and the hottest part of the day.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Elderly travelers with chronic disease</span><p id="par0105" class="elsevierStylePara elsevierViewall">Travelers with pre-existing diseases should be warned that they can only travel when their diseases are stable. Travelers should wait 2–3 weeks before starting a trip in case of a recent infarction. Cabin depressurization and changes in the pressure partial of oxygen can trigger respiratory disease decompensations.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3,17</span></a> Individuals who take diuretic drugs should be advised to reduce their dosage during the flight and to perform the necessary exercises to prevent deep vein thrombosis if taking a trip longer than 5<span class="elsevierStyleHsp" style=""></span>h. <a class="elsevierStyleCrossRef" href="#tbl0030">Table 5</a> lists the needs and characteristics of chronic diseases in elderly travelers and their recommendations.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3,16,17,27</span></a></p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">In general, elderly travelers with stable immunosuppression can travel; however, these travelers should receive individual counseling and obtain travel insurance with good health coverage.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">27</span></a> Examples of immunosuppression include the long-term administration of steroids, human immunodeficiency virus infection with CD4 values greater than 350<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">3</span> and having undergone cancer treatment more than 12 weeks ago.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Elderly travelers who have recently undergone surgery</span><p id="par0115" class="elsevierStylePara elsevierViewall">It is generally advisable to avoid travel up to 2 weeks following any type of operation, due to the potential complications of the surgery. Similarly, patients who have undergone spinal anesthesia should wait at least 10 days before traveling, due to the possibility of severe headaches.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">27</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Getting sick during the trip. Differences between elderly and young travelers</span><p id="par0120" class="elsevierStylePara elsevierViewall">There are few studies that have compared the various comorbidities among travelers according to age. The clinical cohort of GeoSentinel travelers, with a broad worldwide distribution, included 2992 travelers from 1999 to 2009 and analyzed the various ways travelers get sick, classifying them by age group.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">28</span></a> The diseases that most often affect older travelers are respiratory tract and genitourinary infections, high-altitude pulmonary edema, pulmonary thromboembolism, heart disease, severe malaria, gastritis and peptic ulcers. Older travelers are also more susceptible to insect bites and accidents and have higher mortality. In contrast, younger travelers were more likely to experience acute diarrhea, upper respiratory tract infections, influenza, nonsevere malaria, dengue, genital infections, sexually transmitted diseases and schistosomiasis.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">28</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Elderly travelers upon return</span><p id="par0125" class="elsevierStylePara elsevierViewall">Health problems when returning from trips should be dealt with in the same manner as with younger travelers. The case history should include the destination visit, the activities conducted and the degree of previous immunization. Travelers with pre-existing diseases are more susceptible to developing trip-related diseases, which deteriorates their physical condition and decompensates the pre-existing disease. When a patient has returned from a trip, it is important to conduct an overall approach of the disease<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3,16,17,27</span></a> and not just focus on the syndrome acquired during the vacation. For example, comorbidity can include fever due to malaria in a patient with underlying heart disease such as chronic heart failure and chronic obstructive pulmonary disease.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">16</span></a> All medical problems during and after a trip can trigger an acute confusional syndrome in elderly travelers, which will interfere with the correct management of the underlying disease.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Final considerations and conclusions</span><p id="par0130" class="elsevierStylePara elsevierViewall">Elderly travelers require special care. <a class="elsevierStyleCrossRef" href="#tbl0025">Table 4</a> summarizes the main advice for elderly travelers,<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3,16,17,27</span></a> and there are various websites that offer additional information on the recommendations for this type of traveler. Most are in English; however, very few of them focus exclusively on elderly travelers (<a class="elsevierStyleCrossRef" href="#sec0085">Appendix A</a>).</p><p id="par0135" class="elsevierStylePara elsevierViewall">Age is not a restriction or impediment for traveling. Prevention, planning and common sense are the basis of a good trip. However, elderly travelers should follow a number of recommendations before the trip, take special precautions during the trip and receive proper care upon their return. A proper understanding of the problems that might arise during the trip will enable better care for these adventurous patients.</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:21 [ 0 => array:3 [ "identificador" => "xres1100568" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1041563" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1100567" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1041564" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Pathophysiology of the elderly" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Precautions before starting the trip" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Recommended vaccines by geographical area" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Traveling with medication" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Drug interactions among long-term drugs" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Time zone and jet lag" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Elderly travelers and flights" ] 12 => array:2 [ "identificador" => "sec0045" "titulo" => "Travel insurance for elderly travelers" ] 13 => array:2 [ "identificador" => "sec0050" "titulo" => "Other risks and recommendations" ] 14 => array:2 [ "identificador" => "sec0055" "titulo" => "Elderly travelers with chronic disease" ] 15 => array:2 [ "identificador" => "sec0060" "titulo" => "Elderly travelers who have recently undergone surgery" ] 16 => array:2 [ "identificador" => "sec0065" "titulo" => "Getting sick during the trip. Differences between elderly and young travelers" ] 17 => array:2 [ "identificador" => "sec0070" "titulo" => "Elderly travelers upon return" ] 18 => array:2 [ "identificador" => "sec0075" "titulo" => "Final considerations and conclusions" ] 19 => array:2 [ "identificador" => "sec0080" "titulo" => "Conflict of interest" ] 20 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-01-07" "fechaAceptado" => "2018-03-20" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1041563" "palabras" => array:4 [ 0 => "Travelers" 1 => "Elderly" 2 => "Immunosenescence" 3 => "Chronic diseases" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1041564" "palabras" => array:4 [ 0 => "Viajero" 1 => "Anciano" 2 => "Inmunosenescencia" 3 => "Enfermedades crónicas" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Improved living conditions and advances in medicine have extended life expectancy and quality of life, resulting in an increasing number of elderly travelers. Pathophysiological changes and treatments can reduce the efficacy of vaccines and facilitate drug interactions. Elderly travelers have various characteristics that should be considered when offering pre-trip counseling, which should include proper management of chronic diseases that are susceptible to worsening during the trip, as well as an appropriate study and follow-up after the trip. We performed a narrative review of the main problems of elderly travelers.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La mejora de las condiciones de vida y los avances de la medicina han prolongado la esperanza y la calidad de vida, de tal forma que cada vez es mayor el número de viajeros de avanzada edad. Los cambios fisiopatológicos o los tratamientos pueden reducir la eficacia de las vacunas o facilitar interacciones medicamentosas. El viajero mayor presenta una serie de particularidades que se deben tener en cuenta a la hora de ofrecer un buen consejo pre-viaje. Esto debe incluir un correcto manejo de sus enfermedades crónicas susceptibles de agravarse durante el viaje, así como un adecuado estudio y seguimiento después del mismo. Se ha realizado una revisión narrativa de los principales problemas del viajero mayor.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Please cite this article as: Ramos-Sesma V, Górgolas-Hernández Mora M, Ramos-Rincón JM. El viajero mayor. Rev Clin Esp. 2018;218:426–434.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0145" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Travel websites and blogs that provide tips for elderly travelers" "identificador" => "sec0085" ] ] ] ] "multimedia" => array:6 [ 0 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "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="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">North Africa \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sub-Saharan Africa \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Southeast Asia \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">India \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Near East \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Latin America \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Oceania \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Europe \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yellow fever<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Panama toward the south \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Typhoid fever \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Meningococcal meningitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">November–June \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">If epidemic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pilgrimage to Mecca \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">If epidemic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cholera \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hepatitis A and B<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Japanese encephalitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rural, long stay, epidemics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Some islands \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tick-borne encephalitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rabies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Long stay \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Long stay \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Long stay \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Long stay \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Polio \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Malaria<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">c</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">August-October. Rural area \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+++<br>Rural If long stay, treatment. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Certain islands \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1883038.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Not contraindicated for individuals older than 65 years but should be indicated individually in each case. One single dose offers sufficient life-long immunity, memory doses are unnecessary.</p>" ] 1 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">It is recommended that the immune state of the hepatitis B vaccine be assessed.</p>" ] 2 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "c" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Not a vaccine but included to illustrate the indication for prophylaxis.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Recommended vaccines depending on the destination and malaria prophylaxis.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "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="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yellow fever \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The immunosenescence of the elderly favors an increase in viral replication. Severe adverse effects therefore occur more frequently \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diphtheria and tetanus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The vaccine dose should be repeated every 10 years, up to 65 years. Has good effectiveness in individuals older than 65 years \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Influenza \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Seroconversion depends on the type of vaccination, varying between 17% and 58%. Advantages: decreases the number of hospitalizations by 10% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pneumococcus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The sequential use of the pneumococcal vaccine is recommended, starting with the 13-valent pneumococcal conjugate vaccine, followed by the 23-valent pneumococcal polysaccharide vaccine. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hepatitis A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The approximate seroconversion rate of 60% in individuals older than 50 years, compared with 90–100% in younger individuals after the first dose. The rate increases to 97% after the second dose. At least 2 doses are recommended for elderly travelers. The vaccine should be administered to elderly individuals up to 4 weeks before traveling. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hepatitis B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The seroconversion rates are lower for individuals older than 65 years. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rabies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Has an adequate response after completing the full immunization, but the antibody levels reached are lower than those in younger individuals. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Typhoid fever \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">There have been no studies that have shown the efficacy in the elderly traveler; the effectiveness is therefore unknown. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1883039.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Main differences in the effect of vaccines in populations younger and older than 65 years.</p>" ] ] 2 => array:9 [ "identificador" => "tbl0020" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Medscape. <a class="elsevierStyleInterRef" target="_blank" id="intr0005" href="https://reference.medscape.com/drug-interactionchecker">https://reference.medscape.com/drug-interactionchecker</a>)." "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "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="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Drug \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Interactions \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mefloquine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The combination with the following drugs causes no interactions: warfarin, metformin, levofloxacin, acetazolamide, digoxin, analgesics.<br>The combination with the following drugs increases the risk of arrhythmias: calcium antagonists.<br>Fluoxetine/olanzapine. The combination of these drugs increases the QT interval. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chloroquine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The combination with the following drugs causes no interactions: calcium antagonists, metformin, digoxin, levofloxacin, acetazolamide, citalopram.<br>Fluoxetine/olanzapine. The combination of these drugs produces minor interactions such as increased fluoxetine levels. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Atovaquone/proguanil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The combination with the following drugs causes no interactions: calcium antagonists, metformin, digoxin, levofloxacin, acetazolamide, citalopram, fluoxetine. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Doxycycline \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The combination with the following drugs causes no interactions: calcium antagonists, metformin, digoxin, levofloxacin, acetazolamide, citalopram, fluoxetine.<br>Warfarin. The combination of these drugs produces minor interactions such as hypocoagulability. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Quinolones \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The combination with the following drugs causes no interactions: atorvastatin, calcium antagonists, acetazolamide.<br>Warfarin, metformin, digoxin. The combination of these drugs produces minor interactions.<br>Fluoxetine/olanzapine. The combination of these drugs increases the QT interval. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1883037.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Interactions between the main drugs for long-term use and the drugs employed as prophylaxis for malaria or for traveler's diarrhea.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "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="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Main tips for elderly travelers</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Plan the trip in advance (if traveling abroad, go to a specialized center at least 1 month before traveling to assess the vaccine state and schedule the vaccine calendar). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Carry with you an updated report with your personal history and baseline situation, as well as a summary of the medication you are taking. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Carry the necessary medication in your hand luggage for the duration of the trip and some extra in case of loss. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Take in account the time changes when taking your medication. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Be careful of drug interactions among vaccines and prophylactic medication. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Basic coverage of the health insurance</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>The payment of emergency care, either emergency hospitalization or surgery. The diagnostic tests resulting from emergency hospitalization. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>The prescription of medication for a period of time. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Use of ambulances for transfers. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Usually exclude:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Pre-existing medical conditions. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Injuries resulting from risky activities. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Injuries resulting from alcohol consumption or the abuse of illegal drugs. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Psychological problems such as panic attacks, anxiety. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Injuries resulting from exposure to contamination or radiation. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Sexually transmitted diseases acquired during the trip. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cosmetic and dental operations. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1883036.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Summary of the main tips for elderly travelers and the basic coverage that the health insurance should cover.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0030" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "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="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Chronic problems \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Precautions and recommendations \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Extreme temperatures and inadequate hydration can lead to the onset of syncope, dizziness, renal failure and electrolyte disturbances.<br><span class="elsevierStyleItalic">Recommendations</span>: Rehydration and reducing the dosage or stop taking the medication for a while.<br><span class="elsevierStyleItalic">Recommendations</span>: Be careful with antihypertension medication during a trip. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Syncope \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Boosting drug-induced hypotension, dehydration, pulmonary thromboembolism, time changes caused by jet lag. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dehydration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Greater susceptibility due to perspiration from the heat, the taking of diuretics and traveler's diarrhea. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cardiopulmonary disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Should be assessed before starting a trip and should remain stable and free of disease for at least 3 weeks. The blood pressure changes during flight can decompensate the underlying disease.<br><span class="elsevierStyleItalic">Recommendations</span>: request supplemental oxygen.<br><span class="elsevierStyleItalic">Recommendations</span>: hand hygiene or the use of a facemask in crowded locations to avoid respiratory superinfections. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Deep vein thrombosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Greater susceptibility due to an insufficient venous system, dehydration, changes in cabin pressure, the same position for long periods, obesity, congestive heart failure and cancer.<br><span class="elsevierStyleItalic">Recommendations</span>: change positions, appropriate hydration, exercise the legs, walk on the airplane or rest every 2<span class="elsevierStyleHsp" style=""></span>h during car trips or use compression stockings.<br><span class="elsevierStyleItalic">Recommendations</span>: In case of risk factors, use low-molecular-weight heparins before the flight \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diabetes mellitus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Recommendations</span>: Take care with the type of food, physical activity during the trip and the time changes, which especially affect travelers who use insulin. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Osteoarticular disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Falls and blows are very common during trips. Physiological aging and loss of reflexes increases the likelihood of falls.<br><span class="elsevierStyleItalic">Recommendations</span>: Be careful with falls and blows.<br><span class="elsevierStyleItalic">Recommendations</span>: Be careful with excessive physical activity during the trip. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dementia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The stress of a trip, the change in routine, the need to sleep in hotels and jet lag can result in a confusional state for frail elderly travelers.<br><span class="elsevierStyleItalic">Recommendations</span>: Travelers with dementia should travel with a companion. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Constipation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">This is a problem for all ages but increases with age, dehydration and prolonged immobility during the trip.<br><span class="elsevierStyleItalic">Recommendations</span>: dietary and pharmacological measures. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1883041.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Chronic problems in the elderly that can worsen during trips.</p>" ] ] 5 => array:5 [ "identificador" => "tbl0005" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => false "mostrarDisplay" => true "tabla" => array:1 [ "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="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Link \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Websites</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Centers for disease Control and Prevention, Senior Citizens \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><a class="elsevierStyleInterRef" target="_blank" id="intr0015" href="https://wwwnc.cdc.gov/travel/page/senior-citizens">https://wwwnc.cdc.gov/travel/page/senior-citizens</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Government of Canada. Older Traveler \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><a class="elsevierStyleInterRef" target="_blank" id="intr0020" href="https://travel.gc.ca/travelling/health-safety/older-travellers">https://travel.gc.ca/travelling/health-safety/older-travellers</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Travel Health Pro. Older travelers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><a class="elsevierStyleInterRef" target="_blank" id="intr0025" href="https://travelhealthpro.org.uk/factsheet/70/older-travellers">https://travelhealthpro.org.uk/factsheet/70/older-travellers</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>U.S. Passports and International Travel. Considerations for Older Travelers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><a class="elsevierStyleInterRef" target="_blank" id="intr0030" href="https://travel.state.gov/content/passports/en/go/older-traveler.html">https://travel.state.gov/content/passports/en/go/older-traveler.html</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Australia Government. Department of Foreign Affairs and trade. Smarttraveller \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><a class="elsevierStyleInterRef" target="_blank" id="intr0035" href="http://smartraveller.gov.au/Pages/default.aspx">http://smartraveller.gov.au/Pages/default.aspx</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Vaccines and Travel \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><a class="elsevierStyleInterRef" target="_blank" id="intr0040" href="http://www.vacunasyviajes.es/vacunasyviajes/Viajeros_especiales_enfermos.html">http://www.vacunasyviajes.es/vacunasyviajes/Viajeros_especiales_enfermos.html</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Fundacion io. Elderly travelers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><a class="elsevierStyleInterRef" target="_blank" id="intr0045" href="http://fundacionio.org/viajar/otros/viajeros%20mayores.html">http://fundacionio.org/viajar/otros/viajeros%20mayores.html</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Travel blogs for elderly travelers</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>TravelBlog. The Old Age Travelers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><a class="elsevierStyleInterRef" target="_blank" id="intr0050" href="https://www.travelblog.org/Bloggers/The-Old-Age-Travellers">https://www.travelblog.org/Bloggers/The-Old-Age-Travellers</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Lonely planet Thorn Tree forum. Older Traveler \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><a class="elsevierStyleInterRef" target="_blank" id="intr0055" href="https://www.lonelyplanet.com/thorntree/forums/older-travellers">https://www.lonelyplanet.com/thorntree/forums/older-travellers</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1883040.png" ] ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:28 [ 0 => array:3 [ "identificador" => "bib0145" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Available at: <a class="elsevierStyleInterRef" target="_blank" id="intr0060" href="http://www2.unwto.org/es">http://www2.unwto.org/es</a> [accessed 14.12.17]" "contribucion" => array:1 [ 0 => array:1 [ "titulo" => "World Tourism Organization (UNWTO)" ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2017" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0150" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Available at: <a class="elsevierStyleInterRef" target="_blank" id="intr0065" href="http://estadisticas.tourspain.es/es-es/estadisticas/familitur/informesdinamicos/paginas/default.aspx">http://estadisticas.tourspain.es/es-es/estadisticas/familitur/informesdinamicos/paginas/default.aspx</a> [accessed 14.12.17]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Subdelegación General de Conocimiento y Estudios Turísticos. 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