Late Abstracts

156. ITALIAN COMMISSION FOR CAVE EMERGENCY MEDICINE (COMED SPELEO)

Roberto Buccelli
CoMed Speleo - CNSAS

From its origin the “Corpo Nazionale di Soccorso Alpino e Speleologico” (CNSAS), (Italian mountain and cave rescue) offers both tecnical and medical support. The last one becomes much more important as you need a lot of time (days) to save a patient inside a cave. Co-ordinator of the sanitary aspects is the “Commissione Medica Speleologica” (CoMed Speleo) formed by all the trained nurses and doctors from the different regional. Since 1984 the Comed Speleo hold a threefold role:
- Operative: supporting the rescue team in finding the ideal staff and the equipments it needs and taking care of their renewal.
- Technical: studying new devices and protocols to optimise the treatment and standardizing them in the different regions.
- Didactic: training and evaluating its members and all the speleo rescuers of CNSAS.
Actually all the 15 Italian speleological rescue stations are equipped with backpack first aid kits containing diagnostic and therapeutic material for medical, surgical, orthopaedic and resuscitation interventions. A “National medical kit” containing some sophisticate devices is available to be sent in case of necessity. Regular courses and meetings are organized every year inside the CoMed or with the other boards of the Cave Rescue: technical, canyoning, cave diving, demolition.

157. PATHOLOGICAL AND ULTRASTRUCTURRAL FINDING ON THE BONE MARROW IN PATIENTS WITH HIGH ALTITUDE POLYCYTHEMIA

Feng Jianming
Qinghai Provincial Hospital, Xining, Qinghai, P.R.China

To understand more about the pathogenesis of high altitude polycythemia (HAPC), we have conducted the bone marrow biopsy in 12 excessive polycythemia at high altitude in Qinghai Province. The samples of the bone marrow, which was taken by biopsy, were observed with the optical microscope and H-600 transmission electroscope. The result showed that the bone marrow pathology exhibits an obvious proliferation in hematopoietic cells (58.3%), an extreme proliferation (5cases, 41.7%), nuclear cells occupying 60%-100%, normal bone marrow hematopoietic tissues being 40%±9%, dominated by polycythemia, normoblasts at different developing stages gathering in groups, the proportion of middle-and -late normoblasts being higher than normal. The changes of ultrastructure reveal an active proliferation dominated by polycythemia, mainly gathering in red cell groups, with easily noticeable splitting, an unbalanced development of caryoplasm, vacuolar mitochondrion, vacuolar degeneration, obscure or disappearing spines, some cells exhibiting a megaloblastoid change. Meanwhile, we notice a decrease of fat cells in stroma (the average being 6%, and the normal value being 28%±8%), an increase of vessels, an expansion of venous sinus, a diffusing distribution of granulocytes and no abnormal lymph cells and megalocaryocytes.
Conclusion: HAPC has a complicated pathogenesis, which is caused by comprehensive factors. The initial factor for HAPC is hypoxia, the response of bone marrow to hypoxia is an important link leading to polycythemia, and the subsequent changes of bone marrow pathology and ultrastructure in hypoxia-induced polycythemia are of great significance in the study of pathogenesis of HAPC.

158. THE ACTIONS OF GABA AROUND THE AREA OF THE FOURTH VENTRICLE ON CIRCULATORY RESPONSE TO ACUTE HYPOXIA IN RABBITS

Xu Cunhe, Wang Jianxin, Meng Xianfa, He Jiaqiang
Department of Physiology, Qinghai Medical College, Xining, Qinghai 810001, P.R.China

This paper reports the effects of injection of picrotoxin at the fourth ventricle on the circulatory response to acute hypoxia. The rabbits were anesthetized with urethane and chloralose, immobilized with gallamine triethiodide and ventilated artificially. The animals were divided into two groups: the control group with the injection of physiological saline (100µl) and the experiment group with the injection of picrotoxin (10µg/100µl) at the fourth ventricle. The results indicated that the heart rate (HR) and the mean arterial pressure (MAP) in the control group presented significant decrease during acute hypoxia, then reached to the control level at 5-10min after normoxia; HR in the experiment group presented significantly decrease during acute hypoxia and recovered after normoxia. The decrease of HR in experiment group was more obvious than that in the control group during acute hypoxia. MAP in the experiment group did not presented significant change during acute hypoxia. These results suggest that the decrease of MAP during hypoxia could be mediated through the depressor effect of GABA around the area of the fourth ventricle.

159. HEART RATE CORRELATED WITH OXYGEN CONSUMPTION AND ENERGY METABOLISM AT ALTITUDE OF 3,450m

Zhang Shijie
Research Center for Diseases Control of Qinghai Province, Xining, Qinghai, P.R.China

This article discusses the test for the influence of the heart rate change over the oxygen consumption and also over the energy metabolism rate when people develop physical activities at an altitude of 3,450m. The result indicated that the heart rate changes do have influence over the oxygen consumption: r = -2.2754+0.04117X+0.0001117X2, (RR = 0.9960) and the energy metabolism rate: r = -5.5812+0.091577X+0.0002024X2, (RR = 0.9971). Heart rate increased with altitude. For the above-mentioned reasons, it is necessary to differentiate the exercise intensity according to the different altitude areas, and establish hygienic limits of physical activities at the altitude of 3,450m: heart rate at 150 beats·min-1; oxygen consumption on 1,37 L·min-1 and energy metabolism rate at 3.66 Kcal·min-1·m2.

160. VOLUNTARY BREATHHOLDING TIME (VBHT) AND ALTITUDE

Michiro Nakashima*, Masayoshi Nishimura**, Akio Yanagisawa†
*Takaori Hospital, Kyoto; **Rakuto High School, Kyoto; †Japanese National Training Center for Mountaineering, Toyama, Japan

Voluntary breath holding time (VBHT) decreases with increasing altitude. We have been studying this subject since 1970. We summarize Japanese data on VBHT obtained at altitude between 1,000 and 7,000 meters.
The VBHT data were collected from mountaineers participating Himalayan expeditions and mountaineering in the Japanese Alps. To standardize individual variation, the ratio (VBHT%), that is, 100_VBHT at altitude divided by VBHT at sea level, was used.
All data fell into within a range of a nearly straight line in the VBHT% /Altitude graph. The equation for this line is; VBHT% = 90-0.01h(m) ± 10. There was no effect related to age, sex, staying period at altitude, rate or means of ascent.
On the VBHT% / Altitude graph, the dots of average VBHT% at certain altitude of each expedition stood on a straight line, then at some altitude, the line was interrupted abruptly and shifted to rightward within the range of that equation. These phenomena may offer a clue for solving the mechanism of high altitude acclimatization.

161. MITOCHONDRIAL DNA HAPLOGROUP B PREDOMINANCE IN THE AYMARA POPULATION LIVING IN THE ANDES

Enma Ruiz*, Mercedes Villena*, Dominique Rochet**, Catherine Godinot**
* Instituto Boliviano de Biologia de Altura, La Paz, Bolivia; **CGMC CNRS University Claude Bernard of Lyon I, 69622 Villeurbanne France.

The objective of this study was to know whether there are genetic markers in the amerindian Aymara population living in the Andes that would predispose this population to a better adaptation to the high altitude prevailing in this area. The mitochondrial DNA (mtDNA) was analyzed in populations that were born and are still living around 3,800 m of altitude, either in La Paz (45 subjects) or in rural areas of the altiplano (90 subjects). Four mtDNA haplogroups, A, B, C and D have been defined to characterize the amerindian populations. In the Aymara population, the prevalence of the B haplogroup was impressing: about 85% in the urban area and more than 95% in the rural area. This predominance could be related either to a founder effect or to a selection over the years, due to a better adaptation of this haplogroup to altitude. Sequencing the D-loop hypervariable mtDNA region revealed several differences among the analyzed subjects. This favors the hypothesis of a better adaption that might have induced a selection over the generations. Whether or not and if so, how, the differences in mtDNA sequence might interfere in this adaptation remains to be determined.

164. ACTIVIDAD ATPasa EN ANIMALES DE ALTURA Y DE NIVEL DEL MAR

Luz Oyola*, Delia Whu*, Edgar Florentini, Elizabeth Carranza*, Haydeé Zúñiga*, Elizabeth Gonzáles*
Instituto Nacional de Biología Andina Fac. Medicina, U.N.M.S.M. Lima (Perú); *Facultad de Farmacia y Bioquímica U.N.M.S.M.

Objetivos: Comparar la actividad de ATPasa, y la relación ADP:O (P:O), Control respiratorio (RCR) en cobayos de altura Morococha (4,540 m.s.n.m.) y de nivel del mar (150m.s.n.m.) y observar si existe alguna diferencia por efecto de la altura. Metodología: El estudio se realizó en 60 cobayos machos con un peso promedio de 400 a 450 gramos. Las mitocondrias de corazón fueron obtenidas por centrifugación diferencial a 4° C de un homogeneizado de tejido; la relación P:O y Control Respiratorio (RCR) fueron medidos polarográficamente por el método de Tyler, la concentración de ATPasa se midió por el método de Holton et al. Resultados: Los valores promedios obtenidos para los 60 cobayos fueron:

Conclusiones: Los resultados sugieren que los cobayos de altura han desarrollado la habilidad de realizar la fosforilación oxidativa en forma mas eficiente y el ligero incremento observado en la actividad ATPasa nos indica que tal vez se realizan pequeños ajustes para mantener el equilibrio dentro del medio ambiente mitocondrial.

165. EVALUACION DE LOS VALORES DE HEMOGLOBINA, GLICEMIA, COLESTEROL, TRIGLICERIDOS Y ACIDO URICO EN TRABAJADORES DE BHP BILLITON TINTAYA S.A. 4000 msnm. AÑO 2000

Manuel Muro, Jaime Silva, Carolina Casaverde, María Chavez, Eliana Carpio
Hospital BHP Billiton Tintaya S.A., Cuzco (Perú)

El presente trabajo pretende hacer una descripción de los resultados de laboratorio: hemoglobina, glicemia, colesterol, triglicéridos y ácido úrico, los cuales fueron tomados como parte del examen prevacacional a los trabajadores de BHP Tintaya durante el año 2000. La población estudiada correspondió a 472 trabajadores (95% varones y 5% mujeres). Se formaron grupos etáreos, siendo el más prevalente de 40 a 49 años (53.6%) y el menos prevalente de 20 a 29 años (1.5%). En la Hemoglobina (Hb), su media fue de 17.6 gr%, correspondiendo al percentil 5 (p5) 15.4 gr% y al p95 20.15 gr%, así mismo los valores de Hb se incrementan conforme se incrementa la edad del trabajador; no se encontró correlación significativa de la Hb con el tiempo de trabajo en Tintaya. La glicemia: su media fue de 80 mg%, siendo su distribución entre 62 y 100 mg% (p5 y p95). El promedio del colesterol fue de 193 mg% y su distribución entre 147 y 246 mg%, según los percentiles antes señalados. En los triglicéridos su promedio fue de 175 mg% y su distribución entre 70 y 322 mg%. El promedio del ácido úrico fue de 49.2 mg%. Los valores de colesterol, triglicéridos y ácido úrico, se incrementan progresivamente con la edad. Es de resaltar los valores mas bajos en las cifras de glucosa, así mismo valores mas elevados en las cifras de triglicéridos, que podrían explicarse por las características metabólicas del hombre que vive en altura.

166. EVALUACION DE LOS VALORES DE SATURACION DE OXIGENO, FRECUENCIA DE PULSO Y PRESION ARTERIAL, EN POBLADORES DE COMUNIDADES CAMPESINAS QUE VIVEN A 4100 msnm DE LA PROVINCIA DE ESPINAR –CUSCO

Jaime Silva, Manuel Muro, Manuel Chacon, Carolina Casaverde, Karina Cornejo
Hospital BHP Tintaya S.A., Cuzco – Perú

Se realizó la medición de los valores de presión arterial (PA), saturación de oxígeno arterial (Sat. O2) y frecuencia de pulso (P), en los pobladores nativos de las comunidades aledañas a la mina Tintaya a 4100 msnm. Se incluyó en el estudio a todos los pobladores sin patología cardiorrespiratoria, que acudieron a solicitar atención médica por otras causas. Se tomó la presión arterial bajo estándares establecidos, al igual que la saturación de oxígeno y frecuencia de pulso mediante un oxímetro de pulso.
Se estudió un total de 121 personas, 78 mujeres (65%) y 43 varones (35%), entre niños, adultos y ancianos, encontrándose valores promedios de saturación de oxígeno de 90%, presión arterial de 100/70 mmHg y frecuencia de pulso de 75 lat/min.
Se encontró cierta tendencia de disminución de la saturación de oxígeno con el transcurso de los años. No se encontró diferencias significativas de PA, Sat. O2 y P, en relación al sexo. Se concluye, que el nativo de altura regula adecuadamente estas constantes vitales en relación con su ambiente.

167. PREVALENCIA DE PARASITOSIS EN NIÑOS DE LA COMUNIDAD DE ALTO HUANCANÉ a 4100 msnm. Octubre 2001

Manuel Muro, Jaime Silva, Carolina Casaverde, Alberto Chacon, Karina Cornejo, María Chavez, Eliana Carpio, Judith Castilla
Hospital BHP Billiton Tintaya S. A., Cuzco (Perú)

La parasitosis es una patología altamente prevalente en el Perú, con características propias según la región geográfica, afectando principalmente a la población escolar. Se realizó un estudio de tipo descriptivo, transversal. Se tomaron tres muestras por defecación espontánea a 64 niños, así como el test de Graham, todos ellos provenientes de la comunidad de Alto Huancané (4100 msnm), entre los 0 a 15 años. Las muestras fueron llevadas al laboratorio para estudio parasitológico, analizadas mediante el método de examen directo y de concentración. Encontramos una prevalencia de parasitosis del 39,1%; predominando el sexo masculino con un 56%. El método de concentrado tiene mayor sensibilidad para el diagnóstico de parasitosis (excepto oxiuriasis). El Test de Graham demostró ser el mejor para el diagnóstico de oxiuriasis. Los parásitos predominantes fueron: Oxiuros (23%), Giardias (17%) y Ascaris (8%). La poliparasitosis fue similar a la monoparasitosis (19%). La parasitosis predominó en el grupo de 6 a 10 años (56%). Las condiciones de higiene fue inadecuada en el 93.8% de la población, así mismo en el 78.9% de la población no tiene buenos hábitos higiénicos.

168. CONOCIMIENTOS, ACTITUDES Y PRACTICAS EN PLANIFICACION FAMILIAR Y SEXUALIDAD EN ESCOLARES DE TERCERO, CUARTO Y QUINTO DE SECUNDARIA, EN COLEGIOS DE TINTAYA MARQUIRI Y CAMPAMENTO MINERO BHP BILLITON TINTAYA 4000 msnm. Cusco – Perú. 2001

María Chavez, Jaime Silva, Carolina Casaverde, Manuel Muro, Manuel Chacon
Hospital BHP Billiton Tintaya, Cusco – Perú

Es preocupante la elevada incidencia de embarazos en adolescentes, por lo que es necesario identificar los conocimientos, actitudes y prácticas de la población escolar en riesgo, a fin de implementar programas preventivos con metas a buscar una actitud saludable frente a la sexualidad en el adolescente. Se realizó un estudio descriptivo transversal, mediante aplicación y análisis de encuesta prediseñada. Se estudiaron 208 alumnos (51% varones y 49% mujeres) entre 13 y 20 años de edad (media de 15 años). El 91% de los adolescentes reconoció uno o varios métodos anticonceptivos, siendo los más reconocidos los preservativos (84%) y las píldoras (62%), no existiendo diferencias por sexo. El 42% obtuvo información a través de charlas educativas en el colegio, el resto a través de amigos, familiares y televisión. El 7.2% inició sus actividades sexuales (varones 87%), promedio de edad de 15.7 años, 60% utilizó algún método anticonceptivo. El 35% de todos los adolescentes conocen sobre sexualidad y métodos anticonceptivos, el 65% restante no conoce o tiene una idea equivocada sobre éstos.

169. EVALUACIÓN DEL SOBREPESO Y LA OBESIDAD EN TRABAJADORES DE BHP BILLITON TINTAYA. 4000 msnm. AÑO 2000

Jaime Silva*, Manuel Muro*, Laura Luna**, Alex Retamozo†
*Hospital BHP Billiton Tintaya S.A., Cusco-Perú. **HNGAI-Essalud. †Bienestar Social

El sobrepeso y la obesidad, constituyen un importante factor de riesgo de salud pública, su origen es multifactorial y se desarrolla a partir de una interacción del genotipo y el ambiente. El estándar más reciente para evaluar el sobrepeso y la obesidad es el Índice de Masa Corporal (IMC). El propósito de nuestro estudio fue determinar la prevalencia del sobrepeso y la obesidad en los trabajadores del campamento minero de BHP Billiton Tintaya, ubicado en la provincia de Espinar-Cusco-Perú a 4000 msnm. El IMC se determinó por la fórmula peso/ talla2, se consideró normal 19–24.9, sobrepeso 25-29.9, y obesidad Ž 30. Se evaluaron 416 trabajadores (mujeres 10% y varones 90%), el 50% presentaron sobrepeso y el 12% obesidad; la prevalencia de sobrepeso y obesidad se incrementa progresivamente con la edad (36.5% en el grupo 20-29 años y 91.7% en el grupo 50-59 años). En los varones se encontró 52.3% de sobrepeso y 12.8% de obesidad, en las mujeres 31.7% de sobrepeso y 4.9% de obesidad. No existe diferencia si se compara personal de área operativa con personal de área de soporte. El personal estable presentó una mayor prevalencia de sobrepeso (60.8%) y obesidad (15.8%) en relación al personal contratado (42.9% y 9.4%). La prevalencia de sobrepeso en el personal estable (60.8%) es mayor a los reportados en EEUU por las encuestas NHANES III (40 %); influye las características de la dieta y falta de actividad física adecuada.

170. GROWTH VELOCITY AND DEVELOPMENTAL CHARACTERISTICS OF HIGH ALTITUDE PERUVIAN POPULATIONS WITH VARYING SOCIOECONOMIC BACKGROUNDS

Ivan G. Pawson*, Manuel Muro**, Jaime Silva**, Alberto Pacheco**, Luis Huicho†
*Center for Biostatistics and Data Management, Genentech, Inc., South San Francisco, CA 94080. **BHP Billiton Tintaya SA, Tintaya, Perú. †Instituto del Salud del Niño

Recent studies have shown a clear pattern of socioeconomic effects on growth among high altitude populations (4000m) of predominantly Quechua ancestry with close proximity to a major copper mine in southern Peru. This research has focused on three specific groups: (1) Children attending a school operated by BHP Billiton Corp. in Tintaya, (2) Students attending a nearby school in a community not directly associated with mining operations, and (3) Children in the community of Nunoa, approximately 80km distant, which has been extensively studied since the 1960s. This paper reports additional information collected from these populations which throws light on growth velocity around the time of adolescence among populations of varying socioeconomic background. Over the 4 year span of this study, significant catch-up growth has occurred among children in the community situated close to the BHP mine, while children in the community of Nunoa have shown little improvement. Children attending the BHP Billiton school exhibit growth velocities similar to US standards up to the age of 12. After this age, growth velocity rapidly declines, suggesting an early cessation of growth. This study is among the first to present detailed longitudinal data on the growth of high altitude populations of varying socioeconomic levels.

171. EVALUACION DEL CRECIMIENTO Y ESTADO NUTRICIONAL EN NIÑOS DE 0 a 5 AÑOS EN EL CAMPAMENTO MINERO BHP TINTAYA ( 4000 msnm) 1999

Jaime Silva, Manuel Muro
Hospital BHP Tintaya S.A., Cuzco (Perú)

El propósito del presente estudio, es determinar el crecimiento y estado nutricional de los niños de 0 a 5 años que viven en el campamento minero de BHP Billiton Tintaya, localizado en la sierra sur del Perú a 4000 msnm. Se utilizó una ficha de recolección de datos en cada paciente; para la talla se utilizó tallímetro de pie en niños > 2 años y camilla con tallímetro en niños < 2 años, para el peso se utilizó balanza electrónica autocalibrante. Las mediciones fue realizada por una sola persona, según los protocolos internacionales. Los indicadores de peso, talla y edad se compararon entre sí usando las tablas NCHS de los EEUU. Se consideró anormal o desnutrición toda comparación < p10. Se estudiaron 112 niños (43% varones y 57% mujeres). En el 82% su crecimiento y estado nutricional fue normal; en 20 de ellos (18%) se encontró alteración de los percentiles T/E, P/T o ambos. La desnutrición fue mayor en los niños (25%) que en las niñas (12.5%). Usando la escala de waterloo predomina la desnutrición crónica (11.6%) sobre la desnutrición aguda (1.8%). Mayor prevalencia de desnutrición se encontró en niños de 1-2 años (35%). En los niños de 0-6 meses no se encontró ningún tipo de desnutrición (lactancia materna 100%). Estos porcentajes de desnutrición son bajos, si se compara con otros estudios nacionales o internacionales.

172. USO EN MEDIO EXTRAHOSPITALARIO DEL SISTEMA DE INFUSIÓN ELASTOMÉRICO PORTÁTIL BAXTER®: APLICACIÓN EN RESCATE Y EVACUACIÓN MEDICALIZADA EN MEDIOS COMPLICADOS

Manuel Vázquez Martínez
Enfermero SEMAM-SEMAC

Se partió del desarrollo de un sistema de infusión elastomérico perteneciente a la empresa Baxter® diseñado para la administración de medicamentos en perfusión continua para que determinados pacientes puedan seguir tratamientos de una forma ambulatoria. Su aplicación en los rescates de accidentados en medios complicados y hostiles, como nos encontramos en la medicalización del espeleosocorro, aporta una serie de avances a tener en cuenta a la hora de administrar algunos fármacos en estas situaciones durante las maniobras de evacuación de los accidentados. METODO.- Observación durante la situaciones en simulacros y de rescate real. Recopilación de datos técnicos, sugerencias y opiniones. Evaluación de las necesidades y problemas existentes durante las maniobras del rescate medicalizado. Análisis de las características técnicas del elastomero. Experimentación sobre la utilidad y versatilidad de los productos existentes. RESULTADOS.- Ventajas para el accidentado y para el personal sanitario durante el rescate medicalizado en la utilización de perfusiones intravenosas continuas. CONCLUSIONES.- Aporta una serie de ventajas sobre los sistemas convencionales de perfusión intravenosa por gravedad.

173. TIBETAN WOMEN AT HIGH ALTITUDE

Wu T.Y.; Wang X.Q.; Liu H.P.; Cheng H.W.; Zhao H.L.; Gen-Den; Ji J.; P. Sliwinski*, R. Plywaczewski*
High Alt.Med.Res. Inst.Xining Qinghai 810012,P.R.China. *Institute of Tuberculosis and Lung Disease, Warsaw, Poland

To test the hypothesis that the altitude adaptation been influenced by the gender differences, we studied Tibetan and Han high-altitude residents in Tibet. Physical examinations, including hematological parameters (Hb, Hct and RBC), SaO2, VE, HVR, and AaDO2.60 healthy native Tibetans and 60 Han long-term sojourners were studied. Men and women were half and half in each group, ranging in age from 20 to 50. Subjects living at altitude ranging from 3720 to 4520m. Compared to Tibetan males, Tibetan females had higher VE when corrected for body size and higher SaO2, females had very slightly but not significantly higher HVR, AaDO2 was similar in both genders. As compared with Han females, Tibetan females had higher VE, higher HVR and higher SaO2. AaDO2 was similar, but had significantly lower Hb values at any altitude. Thus a part of the better adaptation to altitude in Tibetan females is that of a better sustained hyperventilation, maintain higher levels of oxygenation, and less erythrocytosis.

174. HAN CHINESE CHILDREN ON THE TIBETAN PLATEAU

Wu T.Y.; Wang X.Q.; Miao C.Y.; Wang X.Z.; Xu F.D., Wie C.Y.
High Alt. Med. Res. Inst. Xining, Qinghai 810012 P.R.China

Approximately 2 million Han children whether they were taken to high altitude with their families or having been born and raised at high altitude in the last fifty years. The scope of this paper is focussed on the altitude healthy problems among Han pediatric populations. First, lower birth weight (< 2500g occur in 12-28% of the newborns at 3000-4000m) and a higher neonatal mortality force the parents taken their babies brought to low altitude until the child beyond age 5, re-ascend to their mountain home. Paradoxically, this child lost an opportunity for early adaptation of life. Second, Han children are not like the adults, they acclimatized to high altitude without erythrocytosis whereas presented a marked pulmonary hypertension. Thus, a high incidence of high altitude heart disease, i.e, SIMS in the Han infants to be 1% at 3050-5188M.For The severe case descent is mandatory but sometimes the progress of the illness is so rapid that even this does not prevent a fatal outcome. Finally, Han children are also susceptible to congenital heart disease, the incidence was 1.15% in Tibet. Therefore, the healthy problems in migrated lowlander children at high altitude should be regarded a more attentive.

175. EPIDEMIOLOGY OF HYPERTENSION IN TIBETAN HIGH-LANDERS

Wang X.Q., Wu T.Y., Ji J., Liu P.F., Wang X.Z., Lu Y.Z.
High Alt. Med. Res. Inst. Xining Qinghai 810012,China

The prevalence of hypertension in Tibetan highlanders is still controversial. The present study was undertaken to clarify matters of prevalence of hypertension and assess possible involved epidemiological factors in Tibetan highlanders. During the period 1979-2000 we surveyed a total of 18,678 Tibetan natives and 16,178 Han immigrants, all above the age 15. The surveying places are located at elevations between 2261 and 5188m above sea level. The diagnostic criteria of hypertension was based on the WHO/ISH (1999). In the Tibetans 536 cases of hypertension were observed, yielding a prevalence of 2.87% with an age-adjusted rate of 3.12%, compared with a prevalence of 4.98% and an age-adjusted rate of 5.21% in the Han immigrants( P<0.01). Actual quantities of salt intake in the various Tibetan groups were quite different, from 14.6g/day to 2.2g/day, but the majority have lower intake of salt at an average of 4.5g daily. The 24-h urinary excretion of sodium intake in the Tibetan nomads was lower than in the farmers. The present 22 year survey among Tibetan highlanders living on the high Tibetan plateau, revealed a relatively lower prevalence of hypertension when compared to that observed in low altitude areas of China.

176. THE RELATION BETWEEN HEMOGLOBIN CONCENTRATION AND MENOPAUSE AMONG TIBETAN WOMEN

Wu T.Y., Li W.S., Liu H.P., Wei C.Y., Zhao H.L., Zi G., Wang X.
High Alt. Med. Res. Inst. Xining Qinghai P.R.China

Studies in the Andes suggest that women protected from CMS during their pre-menopausal span. How is the situation among Tibetan females? To address this issue, a total of 784 Tibetan premenopausal and 275 postmenopausal women living at three different altitudes (2664m, 3813m, and 4520m), 576 Han premenopausal and 236 postmenopausal women residing at the same altitudes were studied. Among Han females, the postmenopausal women have a higher Hb concentration than those of the premenopausal women with a high significant difference (P<0.01) for the all three altitudes. Surprisingly, in Tibetans an age-related increase in Hb concentration occurred in older postmenopausal women was only in higher residents of 4520m,indicates that the threshold altitude for erythrocytosis is much higher for Tibetan women than Han women. This difference is due in part to the Tibetan older women seems to ventilate more than Han, at 4520m, the menopausal Tibetan women have higher resting ventilation per unit of body surface area (8.2±0.4 vs.7.4±0.6 L·min-1·m2 SE, P<0.01) and higher oxygen saturation (88.3±0.05 vs. 84.2±0.06% SE, P<0.01 when compared to menopausal Han women.

177. CHARACTERISTICS OF CARDIOVASCULAR X-RAY AT VARIOUS ALTITUDES

*Quanhui Li; *Li Len; **Qingyu Meng, **Liwen Qu
*The First Affiliated Hospital Of Xi’an Medical University and **Medical College of Da Lian University

An X-ray examination is an important way to evaluate the changes of function of heart and lung in a high altitude population. Many documents have been acquired recently. The report about the changes in cardiovascular x-rays in residents who frequently lived at various altitudes came from 918 male physical workers, 18-50 years old (mean 31), independent of lung/heart cardiopulmonary diseases. All originated from five altitude gradients, altitude 1,400m (meters) control group (n=60), high altitude group 2,500m, (n=262), 3,500m, (n=313), 4,500m, (n=223), 5,200m, (n=60). TDripa, Ppas, DB/TDt, TDh and heart/chest were increased with ascending altitude (P<0.01)(tale 1). The changes of TDripa, however, is more suceple than that of Ppas in altitude exposure early. Ppas is more remarkable than TDripa until the exposure is prolonged, especially at the altitudes of 4,500m and 5,200m. The four indices, TDripa, Ppas, DB/TDt and TDh associated closely with high altitude hypoxia in subjects who had taken stress to depend on their capacity of adaptation to high altitude conditions. We showed study results: The Ph is more significant and quicker to occur when the altitude exposure is higher and ascending rate is quicker while the active function of heart-lung lower. The reaction to high altitude hypoxia more serous; The high altitude lung edema and peumonectasis present generally over altitude of 3,000m, and there are changes of pulmonary interstitial edema, pulmonary infection and pulmonary congestion at lower altitudes.

Acknowledgment: I would like to thank Professor Xianfa Meng for all his help.

178. EXAMINATION OF THE HUMORAL IMMUME SYSTEM ON HUMAN AFTER BEING ELEVATED TO A HIGH ALTITUDE (4,850METERS)

*Quanhui Li, **ZhongQi Xu, **Qingyu Meng, **Liwe Qu, *Li Len
*The first Affiliated Hospital of the Xi’an Medical University, Xi’an, China and **Medical School, Dalian, China

There were some earlier studies on people living at high altitudes. According to these studies: Due to the elevated high altitude, the immune system gradually got weaker and the content of serum immune globulin gradually increased. Therefore, the immunity of people living in high altitudes changed enormously. The regular immune function didn’t balance. Recently, researcher observed: High altitude pulmonary edema is related to unusual reaction of body fluid immunity. At above 4,000meters(m) alexin CH50 and C3 levels significantly decreased. But some other research showed there is no big difference between the immunity of the people living in high altitude and the people who have moved to high altitude from other places. In our study <<The rate of anoxia compensation (Z value) was compared by the cardiovascular indices>>, we guessed the group’s level index of serum immunity before and after 15 days then moved to an elevated high altitude to trace the changes of early body fluid immunity of people in high altitude. 33 people male, average age 30.0 ± 7.5 non-organic disease, -liver function is normal HbsAg negative. They were moved by bus from 2,269 m to 4,850m altitude.
At 8 AM before and after 15 days of entering the mountains. We took blood from test group with empty stomachs, 5 ml each. By using turbidity method test the content of IgG, IgA, IgM, serums. By using tube immune haemolysis serums activity of compliment C3. We also tested serum Activity of total complement (ERFC). The result showed that after 15 days, the average serum of the group Ig, C3, CH50 and ERFC didn’t change much (P>0.05). According to the rate of amoremia compensation (Z) in the three different level groups, the result showed no significant change (P>0.05). Our article presents that when people initially elevated to high altitudes, the serum Ig, C3, CH50 and ERFC doesn’t change significantly. The fourth day, we tested 10 indices of systemic circulation (blood pressure, heart rate, output a minute, ventricular energy, myocardial strength, external resistance) by explanation of rate of amoremia compensation (Z), we computed Z value of the group, and divided in three different groups (Good; Average; Poor). We compared each immune index and there was no significant change. There was no direct connection between acute hypoxia reaction and body serum immunity.

Acknowledgment: I would like to thank Professor Xianfa Meng for all his help.

179. THE INDUCED EFFECTS OF ACTH AND TESTOSTERONE ON INCREASE OF ERYTHROCYTES

*Quanhui Li, **Qingyu Meng, **Liven Qu, *Li Lei
*The first Affiliated Hospital of the Xi’an Medical University, Xi’an, China **Department of the Neurology of Dalian Medical College, Dalian, China

Production of erythrocytes is mostly controlled by erythropoietin (EPO). But there is debate on its controlling function. We gradually discovered some problems during the research of functions of high altitude polycythemia (HAPC). Although human beings can react by increasing EPO in high altitude hypoxia, why did the EPO level of HAPC patients not change? Males have a higher number of red blood cells than females. But the level of EPO for both male and female are almost the same .Why? According to epidemology, in high altitude hypoxia, incidence of HAPC among males is much higher than females. Also, children easily get high altitude heart disease. Why? From now on, there is not much understanding about the association between EPO of human body and pathological physiology. The prevention and treatment of blood disease is a very active research field. We describe the association between exciting hormone and sex hormone on the production of red blood cells in hypoxic mice. Test of HCT and EPO in hypoxic mice-Concentration of EPO quickly increased in hypoxic mice. EPO levels peaked on the third day and subsequently decreased. The EPO levels were statistically different from the control during the entire hypoxic period. The Hct continued to increase during this same hypoxic period (P<0.01). In contrast to mice experiencing 3 days of hypoxia, mice experiencing 6 days of hypoxia did not show significant changes in marrow sensitivity to EPO. In summary, early hypoxia increased the sensitivity of the marrow to EPO induced effects. Continued hypoxia reduced the sensitivity of the marrow to EPO. ACTH injections (2.5u daily) increased the Hct of hypoxic mice (at 3 or 6 days) when compared to hypoxic mice not receiving ACTH injections (P<0.05). The concentration of EPO decreased (p>0.05). The induced effects of ACTH and hypoxia worked in coordination. The Hct increased but concentration of EPO had no obvious change. Testosterone had similar effects as ACTH, but streng senses in hypoxia, didn’t present the same result. We found in the lab that the production and release of red cells showed an uncoordinated effect on reaction of EPO. In early hypoxia, production of red cell from marrow has high sensitivity to EPO, but as hypoxia continues this kind sensitivity obviously decreases. In conclusion, we think that testosterone can maintain high sensitivity of the blood making organ in the marrow to EPO. ACTH can increase this sensitivity and evoke increased production red blood cells. There will be significant effects with continued physiological research on EPO receptors in the blood making organ of the marrow.

Acknowledgment: I would like to thank Prof. Xianfa Meng’s help and Neal Davis and University of Utah School of Medicine

180. MOUNTAINS OF THE WORLD. CHALLENGES FOR THE 21ST CENTURY

Bruno Messerli

From Rio 1992 to the International Year of Mountains 2002 we notice an unbelievable change in the perception of mountains and in the appreciation of mountain resources for the surrounding lowlands. New data show that around 25% of the land surface is covered by mountains and approximately 26% of the world population is living in or very close to mountains as part of a highland-lowland interactive system. As an example, Mexico City with its metropolitan area at an altitude of about 2300m and surrounded by mountains and high volcanoes, has approximately the same number of inhabitants as the whole of Canada.
Natural resources: in the arid and semi-arid regions of the developing world, where most probably more than half of the world population is living, water scarcity will become a very serious problem during our century. In these regions, 80-100% of the water is coming from mountains and highlands and will serve not only for domestic use and basic need, but also for irrigation and food security. Moreover the different altitudinal vegetation belts represent a compression of different climatic zones along vertical gradients, thus producing hotspots of biodiversity with a still unknown treasure for future generations.
Human impacts on mountain ecosystems have a long and informative history with periods of sustainable use and periods of deforestation and land degradation. To disentangle natural variability and human impacts is not only fundamental for the interpretation of global change indicators on one hand and for the understanding of future sustainable land and resource use on the other hand, but also for the well-being of mountain communities and for the ensuing benefit for the population in the surrounding lowlands.

181. ORIGIN OF LIFE AND EVOLUTION

Joan Oró, PH. D.
Department of Biology and Biochemistry. University of Houston , Houston, Texas, USA

Four of the main questions in the Science are: the Universe birth; the origin of life; the evolution of mankind and the possible existence of life in other planets. The conference briefly describes the following evolution states of Earth and Cosmos:
1. “Big-Bang” and the evolution of the Universe.
2. The nuclear synthesis of carbon and other biogenic elements in the stars.
3. The molecular organic composition of interstellar medium.
4. The formation of the Solar System and the Earth-Moon System.
5. The comets and its supply of water and organic material to the early Earth.
6. The evolution of Life in the Earth from 4.000.000.000 years ago.
7. The collision of a meteor in the K-T limit and the extinction of dinosaurs.
8. The evolution of hominids until Homo sapiens.
9. The possible presence of life forms on Mars and extra solar planets recently discovered.

182. UPDATE: ACUTE MOUNTAIN SICKNESS AND HIGH ALTITUDE CEREBRAL EDEMA

Peter H. Hackett
University of Colorado School of Health Sciences, Division of Emergency Medicine (hackett@ismmed.org)

Hypoxia affects all organ systems, but primarily the brain. On ascent to high altitude, hypoxemia triggers time-dependent processes causing acute mountain sickness (AMS), a common and generally benign illness characterized by headache and other neurological symptoms. AMS, however, sometimes progresses to life-threatening high altitude cerebral edema (HACE). HACE appears to be vasogenic edema, due to leaky blood-brain barrier. Exactly what causes the leak is not clear, but hypoxia-induced mediators such as vascular endothelial growth factor, reactive oxygen species and iNOS are being investigated. Moderate to severe AMS is milder vasogenic edema than HACE; the two conditions overlap. Whether mild AMS is mild cerebral edema is unknown. Risk factors for AMS/HACE include a past history, altitude reached, fast rate of ascent, and exercise. Oxygen and descent are the mainstays of treatment. Steroids are very effective for AMS and early HACE, but as HACE becomes advanced steroids are less valuable. Acetazolamide helps AMS when used early. Acetazolamide, steroids, and NSAIDs help prevent AMS and therefore HACE. New approaches for prevention include anti-oxidants, theophylline and ginkgo. AMS is common in high altitude areas and should be considered a public health problem. Preventive education is key to reducing morbidity.

183. UPDATE ON HIGH ALTITUDE PULMONARY EDEMA

P. Bärtsch
Division of Sports Medicine, Department of Internal Medicine, University of Heidelberg, Germany

Altitude, speed and mode of ascent and, above all, individual susceptibility are the most important determinants for the occurrence of high altitude pulmonary edema (HAPE). Usually, this illness develops only within the first 2-5 days after acute exposure to altitudes above 2,500-3,000. Excessive rise of pulmonary artery pressure, which precedes edema formation, is the crucial pathophysiologic factor. Recent investigations by right heart catheter and bronchoalveolar lavage (BAL) in beginning edema demonstrated that HAPE is a hydrostatic edema in the presence of normal left atrial pressure with a non-inflammatory high permeability leak of the alveolo-capillary barrier and mild alvoeolar hemorrhage. An inflammatory response may develop later in more advanced cases as has been documented by BAL. Furthermore, a decreased fluid clearance from the alveoli may contribute to this non-cardiogenic pulmonary edema. Supplemental oxygen is the primary treatment in areas with medical facilities while the treatment of choice in remote mountain areas is immediate descent. When this is impossible and supplemental oxygen is not available, treatment with nifedipine is recommended until descent is possible. Even susceptible individuals can avoid HAPE when they ascend slowly with an average gain of altitude not exceeding 300 - 350 m/ day above an altitude of 2500 m.

184. ERYTHROPIETIN AND RESPIRATION IN CMS

L. Bernardi
Medicina Interna Malattie Vascolari e Metaboliche IRCCS S.Matteo - Universita di Pavia, Italy

Polycythemia is one of the key factors involved in the chronic mountain sickness syndrome, a condition frequent in Andean natives but whose causes still remain unclear. Polycythemia may be secondary to abnormalities in ventilation, in turn stimulating excessive erythropoietin (Epo) production. Alternatively, polycythemia and excessive Epo secretion may result from either autogenous production, or be dependent on sustained stimulation by co-factors (eg cobalt) which can induce erytropoiesis independently from ventilatory abnormalities. To answer these questions we studied 31 subjects with or without polycythemia, all born and living in Cerro de Pasco (Peru, 4330m asl, CP) and evaluated the relationship between Epo and respiratory variables (resting ventilation, hypoxic and hypercapnic ventilatory responses, resting oxygen saturation, end-tidal CO2, and an index of ventilation efficiency (Vd/Vt)) in CP, before and after 45 min. of normoxia (CP+O2), and in Lima, at sea-level, after one night of sleeping in normoxia (SL), and after 45 min (SL+hypoxia) of breathing 12% O2. Also, resting cobalt levels (mass spectrometer) were measured in CP. Compared to controls, polycythemic subjects tended to have higher Epo in all conditions, had lower SaO2 and HVR, higher Vd/Vt and higher CO2 (p<0.05 or better), suggesting ventilatory inefficiency. CP+O2 and SL reduced Epo, in both groups, and SL+hypoxia slightly increased Epo. All Epo changes were related to similar directional changes in SaO2, particularly in EE. Cobalt levels were normal in all subjects and correlated poorly with haematologic variables. Our data indicate that the increased Epo production is mainly related to a greater ventilatory inefficiency, and not to altered sensitivity to hypoxia or to cobalt. The excessive Epo production could be relieved by improved oxygenation, thus suggesting a possible therapeutic option to this syndrome.

185. RESPIRATORY PATHOLOGIES AND MOUNTAIN

R. Fischer
Medizinische Klinik Innenstadt, Ludwig-Maximilians Universität, Munchen, Germany

The ability of patients with pulmonary disease for travel at high altitudes is mainly determined by the oxygen partial pressure in the inhaled air. Among the factors leading to decreased alveolar oxygen partial pressure are the decreased oxygen pressure in the air (at an altitude of 5500m oxygen pressure is approximately halved), decreased air humidity and changes of blood flow in pulmonary vessels. At extreme altitudes alterations of diffusing capacity increasingly limit arterial oxygenation. During air travel patients may be exposed to an altitude not exceeding 2400m. Some patients with pulmonary disease may require oxygen supplementation. To determine the degree of hypoxaemia which can be expected in an individual during stay at high altitude, lung function testing should be carried out (blood gas analysis with and without exercise, flow-volume loop, body plethysmography, diffusing capacity). Exposure to high altitude may be simulated by the high altitude simulation test (inhalation of of air with reduced oxagen concentration) in patients with severe impairment of lung function. Continuous oxygen supplementation is recommended for Pa02 values below 50 mmHg, in some young, well adapted patients (e.g. patients with cystic fibrosis) this may not be necessary.
Another problem may be trapped air in patients with emphysema or cystic fibrosis, which may lead to decompression pneumothorax.
Patients with pulmonary disease should be in a stable clinical condition, they should be informed about possible complications, emergency treatment and self-monitoring (e.g. via peak flow) may be useful.

186. CHRONIC EXPOSURE TO INTERMITTENT HYPOXIA: THE CHILEAN MINER MODEL

Jean-Paul Richalet*, Manuel Vargas Donoso**, Daniel Jiménez†, Ana-María Antezana*, Cristián Hudson**, Guillermo Cortés**, Jorge Osorio**, Angélica León**
*A.R.P.E. Laboratoire "Réponses cellulaires et fonctionnelles à l'hypoxie", EA2363, Faculté de Médecine, Bobigny, Université Paris 13, France. **Centro de Investigación en Medicina de Altura, Mutual de Seguridad, Iquique, Chile. †Compañía Minera Doña Inés de Collahuasi, Iquique, Chile.

Mining activities in North Chile exposes a great number of workers to chronic intermittent hypoxia (CIH). This model of exposure to CIH was studied in a prospective study in order to know whether this condition may progressively lead to a chronic pattern or to a specific condition. Twenty nine miners, aged 25 ± 5 yr., working 7 days at HA (3800 - 4600 m) and resting 7 days at sea level (SL) were studied. Subjects underwent a physical examination, EKG, hematological status, maximal exercise test, ventilatory and cardiac response to hypoxia (FiO2=0.114) at rest and exercise, pulmonary vascular response to hypoxia by echocardiography, 24-h monitoring of EKG and arterial pressure. HA measurements were daily AMS score, sleep status, 24-h monitoring of EKG and arterial pressure. All these measurements were repeated after a mean period of 12, 19 and 31 months. Hematocrit increased but reached values lower than those observed in chronic permanent exposure. Systemic and pulmonary arterial pressure measured at SL did not change, but were higher in hypoxia. Right ventricle showed a slight dilatation. Exercise performance decreased by 12.3% and maximal heart rate by 6.8% after 31 months of CIH. Ventilatory acclimatization developed after 12 months. Symptoms of AMS and sleep disturbances were still seen on the first 2 days at HA, whatever the time of exposure to CIH. In conclusion, CIH led to a status of acclimatization different from chronic hypoxia. However, subjects are still at risk of acute altitude-induced illnesses.

187. ACCLIMATIZATION AND TOLERANCE TO ALTITUDE IN THE INTERMITTENT HYPOXIA (IH) REGIMEN

Vargas M* and Jiménez D**
*International Centre Altiplanic Studies, Chile University and **Collahuasi

The physiological acclimatization process and tolerance to IH have been determined through a 30-plus month follow-up period of the biomedical variables in lowlander mining workers, exposed to IH, and through comparison to other groups working at different altitude, 2700, 3800, 4300m, and different shift systems 4x4, 7x7, commuting sea level/altitude.
The findings show that tolerance in healthy workers is supported by a series of biomedical indicators, such as hemoglobin, sleep oxygen saturation, quality sleep perception, acute mountain sickness, pulmonary artery pressure, oxygen saturation at maximum exercise, and evolution of VO2max. A 30 month follow-up period shows that the greater part of acclimatization indicators reach stability after 24 months IH exposure. The potential risks could be: sleeping disturbances, intense sleep oxygen desaturation, polyglobulia, HAPE, pulmonary arterial hypertension, right ventricular hypertrophy, aerobic capacity decrease, and hypoxia-associated systemic arterial hypertension. The course of these risks in the long run remains to be determined.
The feasibility of a productive altitude project with IH shift system can be ascertained if it incorporates the biomedical criteria in the overall organization design.

188. CARDIOVASCULAR CHANGES IN CHRONIC INTERMITTENT HYPOXIA

Ana-Maria Antezana* and the FONDEF PROJECT**
*A.R.P.E. Faculté de Médecine, Bobigny, France and **Universidad Arturo Prat, Mina Collahuasi and C.I.M.A. Mutual de Seguridad, Iquique, Chile.

Cardiovascular changes were studied in a 32 months prospective study of exposure to chronic intermittent hypoxia (CIH). The purpose was to know whether this condition may lead to a chronic pattern observed in residents at high altitude (HA) or whether a lack of acclimatization remains, with still the same characteristics in each ascension. Twenty nine miners, aged 25 ± 5 yr., working 7 days at HA (3800 - 4600 m) and resting 7 days at sea level (SL) were studied. Subjects underwent a physical examination, EKG, echocardiography and Doppler in order to measure pulmonary pressure during normoxia and simulated hypoxia, at sea level, 24-h monitoring of EKG and arterial pressure at SL and in HA. Basal evaluations were performed at SL before the first exposure to hypoxia. Measurements were repeated after a mean period of 12, 19 and 31 months. Pulmonary arterial pressure always increased in hypoxia, but further registers did not show any pattern of pulmonary hypertension. Right ventricle showed a slight dilatation, at different moments of the study. Systemic arterial blood pressure (BP) showed a great variability, mostly with acute but transitory increments, with no persistent hypertension at the end of the studied period.
In conclusion, subjects did not show the cardiac status of HA residents and maintain their pulmonary and systemic vascular response, with no exacerbation or attenuation after this period.

189. ALTITUDE DETERIORATION

James S. Milledge MD, FRCP

The term high altitude deterioration was first used by members of early Everest expeditions to denote deterioration in mental and physical condition as a result of prolonged stay at high altitude. It is well known amongst climbers that staying at extreme altitudes for long is deleterious. Altitudes above 8000m have been called “The Death Zone” and climbers wisely plan to spend as short a time as possible in this zone. The symptoms and signs of deterioration may be caused by factors such as dehydration, starvation, physical exhaustion and cold. However, the question is, in the absence of such factors can hypoxia per se cause deterioration if sufficiently severe? The altitude at which deterioration becomes manifest is about 6000m, with considerable individual variation. Highlanders can probably tolerate prolonged periods at a higher altitude better than lowlanders. Altitude deterioration is characterized by weight loss, poor appetite, slow recovery from fatigue, lethargy, irritability, slowing of mental and physical processes and an increasing disinclination to start tasks. The specific mechanisms underlying this deterioration are unknown. Appetite becomes poor at extreme altitude and negative caloric balance is normal. Malabsorption from the small gut may contribute to weight loss; sleep is increasingly disturbed; the rate of resynthesis of glycogen may be reduced. There may well be other mechanisms but there has been very little study of this phenomenon in the last 20 years.

190. PRESENTATION OF MEDCOM UIAA AND MEDCOM ICAR/MEDCOM UIAA UPDATED RECOMMENDATIONS

Bruno Durrer, Lauterbrunnen, Switzerland and Hermann Brugger, Brunneck, Italia. MEDCOM UIAA and MEDCOM CISA/IKAR

RECOMMENDATIONS of MEDCOM UIAA:
1.Emergency treatment of Acute Mountain Sickness (AMS) and High Altitude Pulmonary Edema (HAPE). 2.Model contract for health care on trekking and expeditions. 3.The transfer of blood-to blood infections in climbing competitions. 4.Hiking sticks in mountaineering. 5.The ten health rules for the mountaineers. 6.Nutrition in mountaineering. 7.People with pre-existing conditions going to the mountains. 8.Hyperbaric bag

RECOMMENDATIONS MEDCOM ICAR/MEDCOM UIAA:
1.A modular first aid kit for mountaineers, mountain guides and mountaineering doctors. 2.Reccomendations for the first aid kit of a mountain hut. 3.Curriculum for the Int.Diploma of Mountain Medicine

JOINT PAPER ISMM/ MEDCOM ICAR/MEDCOM UIAA:
Children and Mountains

191. GENES AND MOUNTAINS: AN EVOLUTIONARY PERSPECTIVE

L.G. Moore
University of Colorado at Denver and Health Sciences Center Denver, CO USA

Populations have resided as high altitudes for different lengths of time. While there is widespread belief that “adaptation” of long-resident Tibetans or Andeans has occurred, the genetic factors and physiological processes involved are unclear. Anecdotal reports suggest that high-altitude newcomers, historically as well as today, experience increased complications of pregnancy and fetal life. We hypothesize that an altitude-associated increase in the frequency of intrauterine growth restriction (IUGR) and preeclampsia contribute to the altitude-related rise in infant mortality present in Bolivia today. To address genetic factors are involved, we are comparing birth weights of babies born to parents with Andean (Aymara/Quechua), mestizo, or foreign (largely European) surnames across an altitude range of 300 to 4100 m. We are also studying Andean and foreign women residing at ~3600 m throughout pregnancy and again postpartum for a measurement in the nonpregnant state. Foreign babies are smaller in utero (by ultrasound) with umbilical and middle cerebral artery ratios indicative of exaggerated fetal hypoxia. During pregnancy, Andean women appear to have higher cardiac outputs, as judged by common iliac blood flow, and greater uterine artery diameters and blood flow, suggesting more oxygen and other nutrients are being delivered to the uteroplacental circulation. We speculate that such physiological adaptations during may not only have be adaptive during pregnancy/fetal life but also, via “fetal programming” against later-in-life complications of systemic and perhaps pulmonary hypertension. Further study is required to identify the specific genes involved.

(NIH TW01188, HL60131)

192. NEW ASPECTS ON PATHOPHYSIOLOGY OF FROSTBITE

Bernard Marsigny
Chamonix, France

Now a pathology of leisure activities, in particular in the mountains, frostbite of the extremities remains a frequent outcome, the cause of sometimes very disabling consequences. The mechanism is not univocal. The severity essentially depends on the intensity of the cold, on the ambient humidity, on the length of exposure, the energy reserves of the patient and his individual susceptibility. An understanding of the pathophysiological mechanisms is essential in order to carry out effective treatment. Classically, frostbite evolves in three phases: (1) A phase of freezing of the tissues. The duration of this stage must be kept to a minimum and prevention is the only efficient treatment. (2) A phase of progressive tissue necrosis during which time the action of treatment must be maximal. (3) a late phase of restoration, when surgery and physiotherapy take place. Experimental models are numerous, but, being usually limited to small mammals, these have limited relevance to the phenomena to which the fingers or toes of mountaineers are subjected. Nevertheless, a spectroscopic study of cellular viability by nuclear magnetic resonance has confirmed the existence of the progressive tissue necrosis phase in man. Other studies have confirmed the liberation, during this phase, of mediators of inflammation such as cytokines, free radicals, prostaglandin derivates, etc.. Consequently the present therapeutic options (NSAID, thrombolytics, prostaglandins) lean towards this theory. It is attractive on paper, but its real validity has never been established by a statistically valid study. A multicentric survey needs to be performed.

193. RETROSPECTIVE STUDY OF 70 CASES OF SEVERE FROSTBITE LESIONS: A PROPOSED NEW CLASSIFICATION SCHEME

Emmanuel Cauchy
Chamonix France

OBJECTIVE: Previous frostbite classifications were mainly based on retrospective diagnosis and, most of the time, could not be used to predict the final outcome of the lesions and especially the probability of an amputation and its level. The aim of this study was to suggest a new classification at day 0 based mainly on the topography of the lesions and on early bone scan results, which are more convenient and accurate in predicting the final outcome of frostbites.

METHODS: The retrospective study of the clinical histories of 70 patients hospitalized at Chamonix Hospital (Mont-Blanc Massif) from 1985 to 1999 for severe frostbite injuries of the extremities has allowed us to classify the aspects of the initial lesions on day 0 and to compare them with final outcomes.

RESULTS: A strong correlation was found between the extent of the lesion and the outcome of each finger or toe. When the initial lesion was on the distal phalanx, the probability of bone amputation was around 1% for the digit, 31% for the middle phalanx, 67% for the proximal phalanx, 98% for the metacarpal/metatarsal, and 100% for the carpal/tarsal.

CONCLUSIONS: Based on these clinical results and on the results of bone scans (previously validated), a new classification of frostbite severity at day 0 is proposed. Four degrees of severity are defined: first degree, leading to recovery; second degree, leading to soft tissue amputation; third degree, leading to bone amputation, and fourth degree, leading to large amputation with systemic effects.

194. IMPLICATION OF TREATMENT AND OUTCOME OF SURVIVORS OF ACCIDENTAL DEEP HYPOTHERMIA: THE NEED FOR A HYPOTHERMIA REGISTRY

B. Walpoth
Department of Cardiovascular Surgery, University Hospital, CH-3010 Bern, Switzerland

Transient mild hypothermia (body temperature 35 - 32 °C) is common and usually without consequences for the brain or other organs. However, prolonged deep hypothermia due to accidents is rare and usually associated with premature death. However, a few people survive and can be resuscitated with appropriate means in due time. The degree of hypothermia, the exposure time and type of accident may vary but longterm survival rates without sequellae of 47 % have been reported(1). Previous reports have been based mainly on case reports with successful therapy of survival patients whereas the negative outcomes have not been reported. Larger epidemiologic studies have proposed outcome score models for facilitating triage and decision making(2). In an effort to gain more information on the severity of sequellae and outcome of deep hypothermia victims, we propose to start an international registry. The data of this registry shall be collected worldwide using the internet as a common database for entry and retrival of the accumulated scientific data. The registry should collect important information on body temperature, exposure time, type of accident, environmental factors and concomitant injuries. In addition, rescue modalities, prehospital treatment, hospital rewarming methods and patients’ outcome data should be included. This registry shall be directed by an international working group which will be responsible for data safety and data analysis as well as preparing guidelines for prevention, rescue treatment and follow-up of these patients.

(1) Outcome of Survivors of Accidental Deep Hypothermia and Circulatory Arrest Treated with Extracorporal Blood Warming. B. H. Walpoth, B. N. Walpoth-Aslan, H. P. Mattle, B. P. Radanov, G. Schroth, L. Schaeffler, A. P. Fischer, L. von Segesser and U. Althaus; N Engl J Med 1997; 337: 1500 - 1505.
(2) Akzidentelle Hypothermie in der Schweiz (1980 - 1987) - Kasuistik und prognostische Faktoren. Th. Locher, B. Walpoth, D. Pfluger, U. Althaus. Schweiz Med Wschr 1991; 121: 1020 - 1028.

195. ALUD EN EL DAULAGHIRI?

Joan Casdevall
Barcelona, España

En 1997 un alud sepultó a una parte de una expedición en la zona del Daulaghiri, aproximadamente a 5.200m. mientras nuestra expedición de carácter comercial, se encontraba en el campo base. Inicialmente hubo 12 muertos y 40 heridos de diferente gravedad (15 politraumáticos y 25 con lesiones de miembros periféricos). El grueso de heridos eran porteadores. En la atención inicial se efectuó una RCP que resultó infructuosa, se intubaron a cuatro pacientes con traumatismos craneales y torácicos graves y se realizó un drenaje torácico por neumotórax traumático. Todos los pacientes europeos (12 personas) algunos de ellos de escasa gravedad, fueron evacuados en helicóptero horas más tarde, “abandonando” a los porteadores. El helicóptero nunca regresó y tuvimos que atender a los heridos y evacuarlos a pie hasta Jomoson con medios precarios. En los siguientes días murieron debido a su estado crítico 6 pacientes con hipoxia crónica, hipotermia y shock hemorrágico (TCE graves y dos contusiones pulmonares). Tres días después llegamos a Jomoson con el resto de los heridos, donde pudieron ser transportados en burro hasta Birethanti y de allí a Pokhara y Katmandú. Esta experiencia nos enseñó no solamente la dificultad de una asistencia médica en altitud, sino también el trasfondo de un problema social y humano sin calificativos.

196. RESCUE ON EXPEDITIONS – SOME IDEAS

Urs Wiget
Zurich, Switzerland

Many expeditions have no medical problems. But if a situation occurs which requires a rescue action high up on the mountain it becomes quite often dramatic. In most expedition places quick helicopter rescue is difficult to organise since pilotes normally don’t agree to fly higher than the base camp. Therefore, rescue has to be performed by the expedition team itself. To think about strategies prior to the expedition and to train procedures before may help to avoid disasters. For the expedition doctor, prevention and training includes the following: Choice of the first aid equipment including, for example, a hyperbaric chamber and/or oxygen supply, improvised transportation and splinting devices and ventilation material. Furthermore, he should be aware of the rescue facilities of the region and know how the cooperation between the members and the local organisation should be organised. During the first days of the expedition, the whole team should be trained in recognition and emergency treatment of high altitude illnesses, cold injuries, fractures and dislocations and wounds. The team should be familiar with improvised transportation possibilities and know how to use drugs in emergency situations.

197. PECULIARITIES OF CANYON RESCUES

P.Fernandez, F.Mengelle, P. Roche, Ch. Virenque
Toulouse, France

The practice of the canyons widely developed as activity of open air since about fifteen years. The number of accidents increased regularly during this same period.
The main thing of the met pathology is of order traumatologic moving preferentially the lower limb. Certain accidents are more serious as drowning, spine and head injuries, polytrauma. Hypothermia is often a pejorative factor frequently associated at the victims.
The peculiarities of the natural environment (cold atmosphere, high hygrometry, difficult access) interfere on the various phases of the help (alert, location of the victim, medical balance, preparation and evacuation of the wounded person, coordination of, medical - technical means …) and impose an adaptation of the "traditional" pre-hospital medicine. The doctor should have a double technical competence (to evolve in security) in the aquatic environment) and medical (to establish a diagnosis enough precise and a preparation of the victim by maintaining vital functions, allowing so his evacuation towards the hospitable structure the most adapted to his state) to limit the exhibition of the victim to this hostile environment. Waterproofness, congestion and weight will condition its medical technical equipment.

198. RESCATE SUBTERRÁNEO, UN DESAFÍO PARA EL MÉDICO ESPELEÓLOGO

D. Dulanto*,**; I. Yzaguirre**, P. Miralles**, S. Palacios, J. Mª López de Ipiña†
*Servicio de Anestesiología y Reanimación. Hospital de Basurto. Bilbao. **S.E.M.A.C. (Sociedad Española de Medicina y Auxilio en Cavidades).†Espeleosocorro Vasco

Introducción: La espeleología como deporte-ciencia tiene sus riesgos. El medio subterráneo puede ser muy hostil. La finalidad del rescate espeleológico es evitar muertes o discapacidades ocurridas en este medio. Muchas de estas situaciones, solo pueden ser controladas por médicos espeleólogos expertos y con gran capacitación técnica (conocimientos médicos) que atiendan al accidentado “in situ”. Hay pocos médicos espeleólogos. Se considera al médico espeleólogo especialista en anestesiología, como uno de los médicos con más capacitación técnica para afrontar las diferentes patologías que tienen estos accidentados.
Equipo médico: Lo forman el médico y sus ayudantes (8 a 10 personas). El equipo decide el modo y el momento de la evacuación, que puede demorarse muchos días. Las principales patología en los accidentes espeleológicos son: politraumatismos, agotamiento extremo e hipotermia grave, intoxicación por gases (CO, CO2, etc.), ahogamiento, lesiones por explosión, etc. Conclusión: para llevar a cabo el rescate con éxito es necesario un equipo médico especializado (espeleólogos) y una logística y medios humanos adaptados al medio.

199. NON-ALTITUDE RELATED CONSIDERATIONS WHEN TREKKING WITH CHILDREN

Susi Kriemler, MD
Triemli Hospital, Dept of Pediatrics, Zürich, Switzerland

Trekking as a family can be very rewarding for children and parents alike.
But: Children have to know what they expect. Children are prone to boredom and are physically and mentally more vulnerable to fatigue. They eat and drink what they like, irrespective of hunger and thirst. Especially young children may be or become incontinent. Children are more vulnerable to sun and cold exposure. And finally, they are more prone to severe, life-threatening illness such as gastro-enteritis with dehydration.
In order to have a relaxed holiday, however, a number of factors should be considered:

200. RISKS AND SECURITY IN AVALANCHE RESCUE

Urs Wiget
Zurich, Switzerland

As a professional mountain rescue physician I see two main problems of security during avalanche rescue actions:

Nevertheless, there is one question which is difficult to resolve:
Can a professional rescuer stay near a buried patient without performing an immediate rescue action because there is a constant danger of a second avalanche?

201. AVALANCHE RESCUE IN AUSTRIA

Franz Berghold
University of Salzburg, Department of Sports Sciences, Austrian Society for Mountain and Altitude Medicine

One third of the Alps belongs to Austria, more than any other alpine country. 63 % of Austria are mountains. In our mountains, every year there are about 10 mio of mountaineers / climbers and about 6 - 8 mio of wintersport tourists. About 10 % of the latter are backcountry skiers and 8 % snowboarders. These two groups dominate the annual average of 30 avalanche victims in Austria. The mortality risk of backcountry skiing is as high as 1.8 (deaths per 100.000 skiers).
Avalanche rescue in Austria has a long tradition and is organised on a very high level. It is done by the Austrian Mountain Rescue Association (ÖBRD), who was the first national rescue organization of the world and now consists of 291 local teams with 10.717 permanently trained rescuers, 388 mountain rescue emergency doctors and 224 avalanche dogs. These teams will occasionally be supported by the Austrian helicopter rescue system, by special army forces and by police experts. In 2000, the ÖBRD did 6.676 rescues with altogether 6.869 rescued people (199 fatalities). During the 58 avalanche rescues of 2000 29 victims died. Although avalanche rescues, in relation to the total of mountain rescues, are not very frequent, they are most demanding due to some particular, typical circumstances. Beside the terribly poor survival rate due to an organised avalanche rescue there are usually tremendous tactical requirements especially if a greater number of people has been buried. This will be shown by a big avalanche tragedy happened on March 28, 2000, in Pinzgau/Salzburg. Due to excellent weather conditions 80 rescuers (ÖBRD, army, police), 12 emergency doctors, 20 avalanche dogs and 9 helicopter within less than an hour arrived on site of the avalanche. Nevertheless no one of the 12 buried young ski instructors survived. This sad result is unfortunately not an exception but the usual outcome not only in Austria but everywhere even if the rescue system is on such a high level. On the same mountain and a few months later, 155 skiers died in a burning mountain train. Is this the terrible account we have to pay for having conquered the Alps for tourism so intensively?

202. FIELD MANAGEMENT OF AVALANCHE VICTIMS. THE ICAR GUIDELINES 2000

Herman Brugger
CISA-IKAR

The median annual mortality from snow avalanches registered in the 17 ICAR countries 1981 – 1998 was 146 (range 82 – 226). Swiss data document a mortality rate of 52.4% in completely-buried, versus 4.2% in partially-, or non-buried, persons (n = 1886). Survival probability of completely-buried victims in open areas (n = 638) plummets from 91% 18 min after burial to 34% at 35 min, then remains fairly constant until a second drop after 90 min. Standardised guidelines are introduced for the field management of avalanche victims. Strategy by rescuers confronted with the triad hypoxia, hypercapnia and hypothermia is primarily governed by the length of snow burial and victim’s core temperature, in the absence of obviously fatal injuries. With a burial time < 35 min survival depends on preventing asphyxia by rapid extrication and immediate airway management; cardiopulmonary resuscitation for unconscious victims without spontaneous respiration. With a burial time > 35 min combatting hypothermia becomes of paramount importance. Thus, gentle extrication, ECG and core temperature monitoring and body insulation are mandatory; unresponsive victims should be intubated and pulseless victims with core temperature < 32°C [89.6°F] (prerequisites being an air pocket and free airways) transported under continuous cardiopulmonary resuscitation to a specialist hospital for extracorporeal re-warming.

203. THE IMPACT OF VISITORS IN THE NEPAL HIMALAYAS

B. Basnyat
Katmandu. Nepal

Given the popularity of trekking and mountaineering in the Nepal Himalayas, the impact of this form of tourism in the local population and the environment is potentially an area of concern. However the tremendous economic benefits for the local population derived from these activities is clearly substantial in this poverty stricken country and will be explored in this presentation. The negative impact on the environment including littering, polluting water sources, deforestation due to the demand of firewood by tourism, the construction of new buildings will also be articulated. In addition the controversial impact on the socio cultural aspect in the Himalayas will be addressed. Finally, suggestions to enhance the positive impact and to diminish the negative impact will be brought up.

204. ALTITUDE TRAINING

Josep Lluís Ventura, Ferran A. Rodríguez
Unitat d’Hipobària INEFC-UB, Universitat de Barcelona, Spain

Altitude training has been used for improving athletic performance during the last few decades. In practice, the hypoxic stimulus can be attained by several means: 1) environmental or altitude (hypobaric) hypoxia occurs upon ascent to moderate to high altitude (mountains or flights) as barometric pressure decreases with altitude; 2) simulated altitude generally stands for artificial hypobaric hypoxia in low-pressure, hypobaric chambers; and 3) normobaric hypoxia can also be attained artificially by modifying the oxygen concentration of inspired air using various technologies. Available evidence on the physiological adaptations and effects of athletic training open many possibilities for enhancing athletic performance at sea level in competitive sports, although the issue is also highly controversial. This workshop will focus on the “hot” issues of training at altitude (real and simulated), with special attention to intermittent hypoxic training. Accordingly, an invited lecture on this topic and five selected oral communications will deal with several aspects of altitude training, from physiological mechanisms of adaptation to application to athletic performance.

205. DRUG ABUSE IN THE MOUNTAINS

Franz Berghold
University of Salzburg, Department of Sports Sciences, Austrian Society for Mountain and Altitude Medicine

The most common field of using drugs in the mountains concerns high altitude tourism, trekking and climbing. Drugs are expected to speed acclimatization, to avoid acute mountain sickness or other altitude related health disorders and to maintain the physical performance. The best known of such drugs since quite a long time are acetazolamide, dexamethasone and oxygen. Others are: aspirin, nifedipine, low molecular weight heparines, tocopherol (Vitamin E), pentoxyphylline, benzolamide, stimulants, montelukast, EPO, ginkgo biloba, mate de coca, garlic etc.
Mountain doctors are faced with this critical matter more and more since the instant demand for such drugs increases from year to year. More people want to travel „higher faster“ because „acclimatization is a waste of time“. This tendency raises some serious problems: As a physician one has always to consider carefully the benefits as well as the risks of using drugs; most of the mentioned drugs are for good reasons set on the IOC-doping-list; for non-medicals the use of drugs in remote areas can cause life-threatening situations (using errors, adverse effects); those who recommend or prescribe drugs carry not only the medical but also a legal responsibility (reliability aspects). Finally, the general use of most of these drugs is still controversial even within high altitude medicine (e.g. acetazolamide) except only in particular situations - if there is a very high individual susceptibility or for high altitude rescuers.

206. WATER DISINFECTION IN THE MOUNTAINS

Javier Botella de Maglia & Hisao Onaga Pueyo

Water can transmit a number of micro-organisms which can cause human disease. Several procedures can be use to disinfect it in the mountains. All of them have their advantages and disadvantages.

207. TROPICAL MEDICINE. THE TRAVELLING MOUNTAINEER

Javier Botella de Maglia & Hisao Onaga Pueyo

Mountaineers have to face several specific problems during their travels to tropical countries.

208. HYPOBARIC CHAMBER USE AND APPLICATIONS

H. Casas, M. Casas, G. Viscor
Unitat d’Hipobària INEFC-UB, Universitat de Barcelona, Spain

Practical description of procedures for exposure to simulated altitude in the hypobaric chamber of INEFC-UB Hypobaria Service. The main procedures described and developed will be:
1. Test of tolerance to hypoxia: Measures the sensitivity of the subject to hypoxia, which is related to the risk of AMS (Acute Mountain Sickness). Is recommended to anyone who has to travel or stay in locations at high altitude (over 3,500 m).
2. Programme for pre-acclimation: Shortens the period of acclimation to high altitude, thus reducing the expedition cost and also increasing the chances of success. Directed to climbing expeditions at high altitude.
3. Standard programme of intermittent exposure to hypoxia: Elicits an adaptative response at hematological, respiratory and cardiovascular levels, thus increasing the aerobic work capacity. Focussed to sportsmen or women, patients or anyone needing to improve their aerobic capacity or increase their blood oxygen transport capacity.
4. Technical tests: To check the function of any kind of device or equipment in low environmental pressure conditions. Applied to industrial processes in general, and specially to manufacturers of equipment and high mountain accessories.

209. HANDLING DIABETES MELLITUS IN THE MOUNTAINS – CONSIDERATIONS FOR THE DIABETIC CLIMBER

E. Bladé, Barcelona and D. Panofsky, Madison, WI. USA IDEA 2000, Inc.

Insulin dependent diabetic mountaineers must address the often complex challenge of managing a chronic disease while contending with the array of hazards facing the mountain traveler. While it is true that diabetic climbers have died or become ill in the mountains, having diabetes is not necessarily a contraindication to climbing mountains. Self-management of diabetes can be successfully accomplished by motivated, educated diabetics during both difficult environmental conditions and difficult climbing objectives. The goal of our workshop is to provide insight on handling Type 1 diabetes in the mountains from the perspective of the diabetic mountaineer and medical lay-person. Topics to be covered include the following:

We will use case studies from personal experience in the Karakorum and from the International Diabetic Expedition to Aconcagua to illustrate the concepts presented.