Boletin Coomtacto Vol.7 by PROSPERTECH SA

Newsletter

for health professionals of Coomeva Medicina Prepagada ISSN 2011-3579

Vol. 7

No. 4

October December 2014

CONTENT HEALT UP TO DAte

Be the ‘prince charming’ of your patient’s shoes

ebm

A cetyl salicylic Acid Prevents Deep Venous Thrombosis

promotiOn AND prevention

DOCTORS ALERT BE PREPARED FOR THE CHIKUNGUNYA VIRUS

INTERVIEW

Colciencias in health care, an open door to research

FROM COOMEVA

The Dentist Day Celebration

MEDICAL WORLD Books reviews and events

MORE POSITIVE NEWS IN COOMEVA SALUD PREPAGADA DURING 2014 It has been a very successful year for Coomeva Salud Prepagada, and its more than 340,000 affiliates. During this period we have improved quality, timeliness and ease of access, trying to deliver the most comfortable experience possible in health care services, both for our network of providers and our users. We are very pleased to announce the positive results of these efforts of the organization, health care professionals and institutions. First of all, regarding technological innovations, especially in the southwestern regional, based in Cali, increasing the efficiency of the processes and attention of prepaid health care services with the implementation of a new biometric identification system, that will verify and validate the rights of the users through their fingerprints. Gradually they will be installed in other cities. These tools will most certainly improve the overall quality of our services through a more efficient identification process. On the other hand, thinking about the welfare of our users, our network of health care professionals, and institutions, we implemented authorization models for medical orders via email. This new service is complementary to the one that we are already using, and it will facilitates processes even more, while avoiding unnecessary displacements. Also, we cannot overemphasize the importance of the renewal of the car fleet of Coomeva, better known as CEM Medical Emergency. This year we included the latest models for home medical and dental care services, as well as cars, ambulances, and medical basic level treatment, in order to improve and expand our network nationwide. And we opened a phone line that offers counseling on nutrition and psychology, which can be used by the members of integrative medicine programs, and CEM. The national line, 018000 918082, will solve doubts about the use of medicines, medical treatments, and dietary counseling among other services. Finally, we want to highlight Fonosalud, a phone line operating 24/7. With its highly qualified medical team, it has solved questions relating health issued of our affiliates.

Thus, the General Management of Coomeva Salud Prepagada proudly shares with you this great news, and invites all its customers, both members and professionals within the network of health care providers, to use these new alternatives to improve your health and the quality of your life. We wish you a Merry Christmas and Happy New Year 2015!

HEALTH UP TO DATE

e the ‘prince charming’ of your patient’s shoes

Footwear misuse is a common health problem. Assuming “the shoe fits the foot is wrong, as a matter of fact it is quite the opposite, it is the foot that fits the shoe”, according to specialists. The result is deformations and overlays of the fingers. So teach the patient to wear the right shoe. With the assistance of: Luis Eduardo Moreno Burgos Specialist in orthopedics and traumatology. Foot and ankle surgeon. Universidad Nacional de Colombia.

Forefoot alterations cause retractions of the lesser toes, including claw toes, hammer and mass deformities, overlaps with hyperkeratosis on the dorsal side of the foot, as well as deviations of the great toe, with prominent metatarsophalangeal joint, or bunion, are some of the most common anomalies. And the main cause of them is the improper use of footwear. According to Asociación Española de Medicina y Cirugía del Pie y Tobillo, 85% of women are affected by these maladies, and they are mainly due to “the widespread tendency of buying footwear considering the looks first and foremost, and secondly the way they feel, neglecting comfort”.

“The problems are multiple, ranging from blisters and calluses to foot deformities, especially of the fingers and the metatarsophalangeal joints. High heel users also suffer from disorders of the Achilles tendon and have frequent cramps, “said Luis Eduardo Moreno Burgos, orthopedic, trauma, foot, and ankle surgeon. The specialist also emphasizes that pain is a warning sign, and should always be taken seriously, explore it, make an early diagnosis so that an appropriate treatment can avoid future complications.

For many people it is the first impression that counts when it comes to choosing footwear: shoes, boots, sandals, and slippers displayed in showcases arouse a kind of love at first sight. But experts warn: a shoe that is not well adapted to the characteristics of the foot can lead to multiple aches, and health problems, such as hallux valgus, commonly known as a bunion, a frequent cause of disability especially in women.

SIZE RECOMMENDATION

Also, in men’s footwear, the pointed Italian shoe, as well as cowboy boots, and loafers, tend to tend to deform the feet, they are associated with hammer toes, and hyperkeratosis. Shoe lace models are always preferable. There are also particular disorders associated with inappropriate footwear in children and adolescents. “Usually they are related to inadequate toenail growth, abrasions, and when the shoe is small, fingers are deformed and hallux valgus begins to form”, said the specialist.

TIPS THAT FIT WELL* Shoes should be comfortable. It is desirable that they hold the foot firmly, avoiding movement of the heel; also as far as the midfoot is concerned, it should exercise the necessary pressure to give a sense of

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Footwear should also be adjusted according to age and gender. For women high heels are deleterious. As a matter of fact, the higher the shoe, the greater the overload on the forefoot, frequently a very painful situation. So the recommendation is to wear heels not higher than 4 inches, and with a good base, in other words, the opposite of the needle heel.

security without friction; and the forefoot must be sufficiently wide high, allowing fingers to fit comfortably and move freely; also the distance between the heel and the metatarsophalangeal joint of the greater toe should match the distance between the heel and the widest part of the show, and the distance between the tip of the longest toe and the tip of the shoe should not be less than 8 mm.

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HEALTH UP TO DATE The shape of the tip of the shoe can be square, round, or pointy, provided the patient considers the following aspects: • Ensure that the space between the tips of the fingers and the shoe or slipper is not less than half a centimeter. • The heel should be strong and give support. • Choose flexible soles. • Avoid plastic shoes, they do not allow the feet to breathe. • Avoid shoes with internal seams, to prevent chafing. • Do not allow fads to be the only guide for footwear. • The best time to try on shoes is late in the day, when your feet are tired and swollen. • For children the best shoes are those with strong buttress, rubber soles, and flexible enough to bend where ever feet requires. • Limit the time you use high heels to alleviate their effect, also alternate them with good quality sneakers or flat shoes. • For sports use shoes that fit properly, and keep the feet in a natural position. It is also advisable to choose the type of shoe depending on the sport you play. • Use a wide, deep, smooth, and unseamed shoe.

• Use natural leather footwear, shock absorbing soles, shoes of an adequate size, allowing the person to walking and exercise comfortably, without areas of pressure, sliding, or friction.

IN THE CONSULTATION ROOM Asociación Española de Medicina y Cirugía de Pie y Tobillo published figures on podiatric health in women, regarding the effects inadequate footwear, information that can also be extrapolated to the Colombian population (85%). “Although everyday men are paying close attention to feet health, the fact that women are more exposed to improperly fitting shoes, and are more careful with their own health issues and aesthetic appearance, explains why ladies usually consult the phsysician more often than men”, adds Dr. Moreno. Before the deformities are established, the initial therapeutic action is to adapt the shoe to prevent the progress of the deformities, becoming irreversible. It is desirable to wear a comfortable shoe, that allows the fingers to sit properly within the tip, while maintaining their free mobility with reasonable heel height (less than two inches). “Patients can use moisturizers to soften calluses. When fixed, and irreversible deformities occur necessary surgical treatments intended to reverse bone deformities and restore musculoskeletal balance should be performed. Calluses disappear once the bone deformity is corrected, after all they are skin manifestation of abnormal pressures zones on the foot”, says the specialist.

PREVENTION AND CURE

The first preventive action is a proper clinical evaluation, followed by the adjustment of the shoe. Exercise and physical therapy should be designed to maintain the

proper mechanical balance of the foot muscles and tendons. Therapies such as relaxation, adequate care of the nails and calluses, together with massage techniques, muscle toning, lymphatic drainage, hydrotherapy, and ultraviolet rays, may all be therapeutic options. For those who already have irreversible deformities medical management is associated with surgical corrections. “Surgical treatments, contrary to popular belief, are much less painful and debilitating than expected, because new techniques have been developed together with new anesthetics that allow patients to start their functional recovery earlier without using plasters nor eliminating the toe nails, even from the very same day of the surgery”, said the doctor. The science of footwear has advanced a great deal, so large manufacturers have biomechanics laboratories, and create new materials and designs capable of generating durable shoes, with soles that protect the feet, also with adequate size systems that take in to account both the length and width of the foot. So when in the consultation room do not hesitate to promote the culture of proper footwear within the patients, and become the “prince charming” of their shoes.

REFERENCES * Source: Colegio de Podólogos de Madrid Efecto del uso prolongado de zapatos de tacón alto sobre la alineación sagital de la pelvis. Miguel Angel Ruiz-Iban, Maria Elena Elijah Martin Lizán Fausto González, Jorge Díaz Heredia, Jesus Alfredo Ruiz Fernandez. Mexican Journal of Physical Medicine and Rehabilitation. 2007; 19: 69-74. http://www.medigraphic.com/pdfs/fisica/mf-2007/mf074d.pdf Study recommended heel height. Ruiz1 Sonia Hidalgo, Francisco Alonso Tajes2 Carolina Bautista2 Rosen, Francisco M. Garcia Blázquez1, Alfonso Martinez Nova1, Raquel Sanchez Rodriguez1 1

Profesores de Podología Universidad de Extremadura

Profesores de Podología Universidad de A Coruña

Centro Universitario de Plasencia. Av Virgen del Puerto, Plasencia 2. 10600. Caceres E-mail: kirosony@unex.es file: /// C: /Users/redaccion/Downloads/0046353726 437109b1000000.pdf

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cetyl salicylic Acid Prevents Deep Venous Thrombosis

Long-term anticoagulants can be a problem for patients whom have had deep venous thrombosis in the lower limbs, but acetylsalicylic could offer an alternative for them. An Australian group of researches share their results in these cases. The relevance of the Australian paper lies in the fact that it suggests acetylsalicylic acid is effective preventing deep venous thrombosis, while reducing the overall risk of recurrence by more than a third, without significantly increasing the risk of bleeding. And this research was done in a wide population of patients.

With the assistance of: Alberto Muñoz Hoyos Cardiovascular surgeon Specialist in Vascular Surgery and Angiology Director and founder of Clínica Vascular de Bogotá Cecilia Becattini Specialist in internal and cardiovascular medicine Unit of internal and cardiovascular medicine, and Cerebrovascular accident. University of Perugia

Usually after suffering an episode of deep venous thrombosis, patients take an anticoagulant as a prophylactic measure. However, the extensive use of medications, such as coumadin, may increase the bleeding risk. “Taking acetyl salicylic acid after a regular course of an anticoagulant could reduce the chance of a deep venous thrombosis recurrence, without increasing complications”, was the main conclusion of a recent Australian paper. These findings were already described by doctor Cecilia Becattini in a 2012 study, published in the March 24th edition of the journal New England Journal of Medicine (http://www.nejm.org/doi/full/10.1056/ NEJMoa1114238).

The authors analyzed the results of two clinical trials involving 1,224 patients in all, whom took 100 milligrams of acetyl salicylic acid daily for at least two years, they were compared with two groups, one used warfarin, and the other, coumadin. The study found it was useful instead of coumadin for the treatment of deep venous thrombosis of the lower limbs, in patients who couldn’t the anticoagulant it for any reason, especially for a long period, even though this is a potentially lethal condition, because it could cause embolisms in lungs, for instance. “For the majority of patients whom have had a deep venous thrombosis in the lower limbs or an embolism, the drug of choice is coumadin for at least six months. First, to dissolve the clot, and secondly, to prevent recurrences. But the long-term use of this drug is not always convenient, it requires blood testing and frequent dose adjustments,” says the leader of the research group, Dr. John Simes, Professor of medicine at the University of Sydney.

BACKGROUND Patients with deep venous thrombosis remain at risk of recurrence after the treatment with vitamin K antagonists –the relative risk is nearly 10% in the first year and 5% three years later-. Extended treatment with vitamin K antagonists reduces the risk of recurrence, but it is associated with an increase of the bleeding risk, and also of discomfort because of the need of laboratory monitoring for proper dose adjustments. Several groups have studied the effectiveness of the new oral anticoagulants for the prevention of deep venous thrombosis. And they have found that ©2014 Shutterstock Photos

Meanwhile treatment with acetyl salicylic acid is low cost, and can also prevent new vascular events with fewer side effects. This is the issue that is being evaluated in this Australian combined to paper. It was called INSPIRE, and it intended to measure the effectiveness in the prevention of the recurrence of deep venous thrombosis (WARFASA), as well as its effectiveness in the treatment of these conditions (ASPIRE). The purpose of INSPIRE was to estimate accurately the effects of the treatment with acetyl salicylic acid in general, taking into account individual outcomes, pre-defined patient subgroups, and examine the side effects of the treatment over a period of time. In the end, the paper showed large absolute effects in the treatment, when there is a greater increased risk of recurrence, especially for men and the elderly. Even though there was no clear evidence of the effects of the treatment in time. The recurrence risk of deep venous thrombosis is high during in the first year, and benefits were identified with the use acetyl salicylic acid. This information may be important for patients with high risk of recurrence of these events, and for whom anticoagulants are not an option. Even among the low-risk patients, acetyl salicylic acid therapy is still a very useful treatment because of its favorable risk-benefit profile.

MAIN RESULTS The data analysis of individual patients in these trials was planned a head, before knowing the results, trying to evaluate the effects of acetyl salicylic acid, and comparing it with placebo in cases of recurrent deep venous thrombosis, as well as other vascular events, such as recurrences, pulmonary thromboembolism, myocardial infarction, stroke, and death from cardiovascular disease. And also bleeding risk was evaluated, in general, and in predefined subgroups. The primary analysis was based on the time-to-event data. 1,224 patients, of whom 193 had had previous recurrent events, showed 30.4 months of a median follow-up.

ÂŠ2014 Shutterstock Photos

they are alternatives to Coumadin. Dabigatran and rivaroxaban, for example, are effective drugs that do not require frequent blood tests. But they are expensive, and some patients do not tolerate them. On the other hand, they increase the bleeding risk in some patients. So many patients decide not continue with these drugs after a whileâ&#x20AC;?, said Simes.

Treatment reduces recurrent deep venous thrombosis (7.5% / year, compared to 5.1% /year; hazard risk [RRHR] ratio rate, 0.68; 95% confidence interval [CI]:0.51 to 0.90, p = 0.008), including both deep vein thrombosis (HRR, 0.66 CI 95%, 0, 47-0, 92, p = 0.01), and pulmonary embolism (HRRR, 0.66, CI 95%, 0, 41-1, 06, p = 0.08). On the other hand, acetyl salicylic acid reduced major vascular events (8.7% / year compared to 5.7per cent / year; HRRR, 0.66; 95% CI, 0.50 to 0.86, p = 0.002). The rate of serious bleeding was low (0,4% / year for placebo and 0.5%/ year for acetyl salicylic acid). And after the adjustment of the adherence to the treatment, recurrent deep venous thrombosis, and pulmonary thromboembolism declined 42% (HRRR, 0.58, 95% CI0.40 to 0.85, p = 0.005). Specific subgroup analysis indicated large absolute reductions of the risk in men and in the elderly.

CONCLUSIONS This prospective combined analysis in INSPIRE offers evidence that acetyl salicylic acid reduces the risk of recurrent venous thrombosis by 40%, while it remains a very safe treatment. Even though it does not reduce the rate of deep venous thrombosis nor pulmonary thromboembolism, as do antagonists of vitamin K and the new oral anticoagulants (like the direct thrombin inhibitors and inhibitors of factor Xa), among patients in which this type of therapies is considered critical, and it is not appropriate to stop using them, the treatment should be taken very seriously.

EBM

This study shows that acetyl salicylic acid taken daily reduces the risk of new thrombosis episodes, without the bleeding complications, when compared with placebo or any other treatment. Specifically, acetyl salicylic acid taken daily reduces the risk of developing a deep venous thrombosis by 42%, compared to patients taking a placebo. “This has a great importance for patients whom cannot take anticoagulants during long periods for any reason, either because of their personal preferences, the adverse effects of the anticoagulants, or the cost”, concludes Simes.

VENOUS THROMBOEMBOLISM Deep venous thrombosis is a disease that occurs within the veins and arteries when a clot obstructs blood flow. When bleeding, the haemostatic system starts the process of coagulation and healing, there after allowing blood follow again in the vessels. So bleeding stops through because of the thrombus. Deep venous thrombosis is a disease. The main alteration occurs within the veins and arteries when the formation of the blood clot prevents blood flow. Then, as time goes by, the region of the thrombosis dilates

causing blood flow stagnation, later on edema appears as well as skin ulcers, accompanied by paleness and dark discoloration, a stage in the disease known as posthrombotic syndrome. “When the disease ensues without any treatment, fragments of the thrombus can circulate in the blood flow, and obstruct vessels in the lungs originating a pulmonary thromboembolism. While, when this happens within the arteries they can cause myocardial infarction and cerebrovascular accidents”, explained the doctor.

REFERENCES M.D., Maria Rita Vandelli, M.D., Elvira Grandone, M.D., and Paolo Prandoni, M.D., Ph.D. for the WARFASA Investigators N Engl J Med 2012; 366:1959-1967May 24, 2012DOI: 10.1056/NEJMoa1114238 http://www.nejm.org/doi/ full/10.1056/NEJMoa1114238

1. Aspirin for the Prevention of Recurrent Venous Thromboembolism John Simes, MD; Cecilia Becattini, MD; Giancarlo Agnelli, MD; John W. Eikelboom, MB, BS; Adrienne C. Kirby, MSc; Rebecca Mister, MSc; Paolo Prandoni, MD; Timothy A. Brighton, MB, BS; for the INSPIRE Study Investigators* (International Collaboration of Aspirin Trials for Recurrent Venous Thromboembolism) Circulation. 2014; 130: 1062-1071Published online before print August 25, 2014, doi: 10.1161/ CIRCULATIONAHA.114.008828 http://circ.ahajournals.org/content/130/13/1062.full

3. Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: pulmonary embolism prevention (PEP) trial. Pulmonary embolism prevention (PEP) trial collaborative group. The Lancet 2000, 355: 1295-1302 - See more at: http://www.evidencia.org/hitalba-pagina-Articulo. php?cod_producto=376#sthash.baE5qMmU.dpuf

2. Aspirin for Preventing the Recurrence of Venous Thromboembolism. Cecilia Becattini, M.D., Ph.D., Giancarlo Agnelli, M.D., Alessandro Schenone, M.D., Sabine Eichinger, M.D., Eugenio Bucherini, M.D., Mauro Silingardi, M.D., Marina Bianchi, M.D., Marco Moia, M.D., Walter Ageno,

4. Bajas dosis de aspirina previenen el tromboembolismo venoso en pacientes de alto riego quirúrgico. Evidencia Actualización en la Práctica Ambulatoria - Vol. 3 Número 4: Julio-Agosto 2000 http://www.evidencia.org/hitalba-paginaarticulo.php?cod_producto=376#sthash.baE5qMmU.dpuf

Related links: 1.

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http://www.medicalpress.es/la-aspirina-puede-prevenir-la-recurrencia-de-coagulos-sanguineosen-las-venas-profundas 2. http://www.nhlbi.nih.gov/health-spanish/health-topics/temas/dvt/livingwith.html 3. http://www.medicina21.com/doc.php?op=especialidad3&id=1620 4. http://www.rodriguezpalacios.com.ar/flebologia/trombosis-venosa-profunda.html

PROMOTION AND PREVENTION

OCTORS ALERT

BE PREPARED FOR THE CHIKUNGUNYA VIRUS

The Chikungunya virus has been listed by health authorities all over the world as a public health hazard in the American continent, as well as in Colombia. What are doctors facing? How to prevent it? How to treat it? Read all about it. With the participation of: Fernando de la Hoz Physician and epidemiologist Director of the National Institute of health. Joas Benitez Duque National Epidemiology Chief Strategies’ Coordinator for the Health Care Personnel in Coomeva.

The alert has been turned on. It is estimated that nearly 26 million Colombians are vulnerable to this viral infection, so there is an urgent need for appropriate measures to limit the spread of the Chikungunya virus in the country. “At the moment, we have reported nearly 1,500 cases, most of them in Bolivar, but we have also identified some in Guajira, Atlántico, Valle, and Boyacá, as well”, according to the most recent epidemiological survey of the Colombian National Institute of Health (link:http://www.ins.gov.co/Noticias/ Paginas/Lo-que-debes-saber-sobre-la-fiebre-Chikungunya. aspx#. VCBjkhaZe_E). The authorities of the Health Ministry announced that the virus has had an explosive behavior, probably due to the fact that Colombia has extensive borders with Panama and Venezuela, two countries where the epidemic is growing strong. So, for us, the most useful tool is prevention, and education of the public. But also it is necessary to have the medical facilities ready to handle this situation, that requires an immediate response of the global health care system.

throughout the American continent. It is characterized by intense fever, headaches, and multiple arthralgias, which tend to improve within a few. “We intend that health care workers learn more about the natural history of the disease, keeping in mind the susceptibility of the patients and identifying key signs and symptoms that can help the differential diagnosis between dengue and chikunguya. “The general suggestion for physicians is: first think it is a case of dengue, because it can be deadly and can be treated, then consider the possibility of a chikungunya”, ensures Fernando de la Hoz, an epidemiologist and the director of the Colombian National Institute of Health. Also chikungunya, unlike dengue, does not repeat, while its natural history is longer and more disabling. Between 5% and 10% of the patients who suffer from it could also develop arthritis. So we must pay attention to the patients at risk, and focus our efforts on them (such as pregnant women, patients with hypertension, diabetes, tuberculosis, HIV, cancer, anemia, cardiovascular, and renal diseases, including children, and people over 60 years). “Unlike dengue, chikungunya is accompanied by severe pain in the muscles (myalgia) and joints (arthralgia), symptoms that tend to worsen in the mornings. Ankles, wrists, and small joints of the hands are usually the most affected. While hemorrhages or dyscrasias are most frequent in patients with dengue”, ensures doctor de la Hoz.

What is the Chikungunya virus, and how does it differ from the dengue virus, despite having the same carrier, the Aedes Aegypti?

Skin rashes, accompanied by leukopenia, lymphopenia, and neutropenia may also appear, and the last three elements are related with immune system alterations. In addition, it may also cause thrombocytopenia, a decrease in the circulating platelets in the bloodstream.

‘Chikungunya’ is a noun that comes from the African language makonde, it means “a terrible pain”. This arbovirus is causing a widespread disease

Chikungunya fever is an emerging disease which, for now, has not received sufficient attention in current research, it has no specific treatment, nor an effective vaccine. So health care services give symptomatic treatment, and timely identification

DENGUE IS THE DIFFERENTIAL DIAGNOSIS

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of atypical and severe forms. On the other hand, the main recommendation for primary prevention are actions that tend to modify risk factors, specially eliminating mosquitoes by reducing their reproduction environment.

THE NATIONAL PLAN The Ministry of Health and the National Institute of Health in Colombia, implemented the plan in response to the emergence of the Chikungunya Virus in the country. Its purpose is to prepare the monitoring system and the response activities to the risk posed by the introduction of the virus in the country, with emphasis on regions infested by the vector Aedes aegypti and Aedes albopictus. Likewise, they implemented the necessary guidelines for interventions in the clinical setting, including handling of the cases under standardized criteria, which allow rational and efficient use of available resources, while ensuring timely, and optimal treatment outcomes. The director of the Colombian National Institute of Health ensures: “the Institute works to strengthen the surveillance of the cases nationwide, by supporting regional or local authorities in early and timely diagnosis of outbreaks, and with the support to the Ministry of Health we can tackle control and prevention issues of the virus”. Other governmental strategies include the design of procedures that will slow down the increasing demand for health care services before the arrival of the virus. For example, they created communication tools that facilitate the access of the user to friendly information lines. Likewise, the Colombian Ministry of Health assigned major resources to reduce the mosquito reproduction rate in different regions of the country, especially in the most vulnerable regions.

RECOMMENDATIONS The main recommendation for prevention primary is according to actions to modifying risk factors as measures of individual protection for the entire population and the elimination of mosquitoes by reducing their breeding steadily.

COOMEVA IN ACTION In accordance with the government guidelines, Coomeva health care providers already reviewed, together with the Ministry of Health, risk areas and insured the presence of its members in these regions. “One of the key features is that the vector can easily be found below 1,800 meters above sea level; and the other established criteria is the historical presence of cases of classical dengue or of dengue reports in the past five years”, explained Joas Benitez Duque, national head of epidemiology and coordinator of these strategies in Coomeva. The EPS is already working on an action plan that allows, in accordance with the activities of the national plan, it has also implemented strategies to estimate the burden of the disease within the population, where it can be found, and then transfer that knowledge to lenders. “We suspect the emergency is going to grow, and hospital admissions will also surely climb, but unlike dengue, the burden of this crippling disease will probably be related to complications such as arthritis that can also impact costs in terms of pensions, health, and treatments,” says the doctor Benítez.

A FIRST STEP TOWARDS TREATMENT GUIDELINES The INS welcomed the guidance of the Pan American Health Organization and the World Health Organization (WHO/ PAHO), which gave the main recommendations for health care personnel providing services to the population affected by chikungunya, so that they can make an early diagnosis of the disease and start the appropriate treatment. Information for health care providers in the WHO/PAHO guidelines include other possible and common associated symptoms, such as: artralgiaartralgias, poliartritispoliartritis, back pain, headache, rashes, estomatitis, oral ulcers, discolorations, mialgias, exfoliative dermatitis, otofobia, retrobital pain, vomit, diarrhea, meningeal irritation (adapted from Guidelines on Clinical Managementof Chikungunya fever, 2008.) WHO/SEARO).

PROMOTION AND PREVENTION Clinical manifestations

Clinical presentation of the acute forms of chikungunya fever affect all age groups and both genders. After an incubation period of 3 to 7 days, ranging from 1 to 12 days, after the mosquitoes inoculates de virus, high fever appears associated with other symptoms such as arthralgia and arthritis (87%), back pain (67%), and headache (62%). It is important to take into account that joint pain tends worsen in the mornings, and it can be relieved with mild exercise, while it will exacerbate with sudden movements. Ankles, wrists and small joints of the hand tend to be the most affected. But it may also affect large joints, knee, shoulder and spine joints. Also migratory arthritis with effusions have been found in about 70% of the cases.

Clinical outcome In most patients symptoms subside between 1 to 3 weeks later. However, some may relapse, and other might remerge with rheumatologic symptoms, such as polyarthralgia, polyarthritis, and tenosynovitis. Neurological, dermatological and emotional complications have also been described. Mortality is rare, and it occurs mainly in vulnerable population, such as the elderly.

Referring the patient • To diagnose a case that can be treated specifically. • Persistent fever during more than five days. • Incessant pain. • Postural dizziness, cold extremities. • Urinary flow reduction. • Any type of bleeding. • Intractable vomiting. • Pregnancy. • People over 60 year, and newborns.

DIFFERENTIAL DIAGNOSIS Chikungunya fever may not have the characteristic manifestations, or it may coexist with other infections. The differential diagnosis should take into account the epidemiological characteristics of the region, the person’s travel history, and the exposure antecedents. Laboratory findings that confirm Chikungunya fever: • Viral culture. • PCR. • IgM antibodies. • IgG or positive neutralizing antibodies. Normally the disease is accompanied with leucopenia, and a predominance of lymphopenia, while thrombocytopenia is rare. Also the erythrocyte sedimentation rate rises, while PCR increases during the acute phase, and may stays high for a few weeks thereafter.

Treatment guidelines • There is no specific antiviral against chikungunya virus. • The treatment is symptomatic.

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• Analgesics and antipyretics are the drug of choice until other etiologies, such as dengue, are discarded. • Other analgesics such as nonsteroidal anti-inflammatory drugs, and narcotics, can be used if the pain does not subside. • During the acute stage of the disease steroids are usually not recommended due to the adverse effects. • Avoid aspirin because of the hemorrhage, and Reye’s syndrome risks. • Mild forms of exercise and physical therapy are recommended in the recovery phase. • Treatment in all suspected cases should be instituted without waiting for viral serological confirmation. • During an epidemic it is not necessary to carry out virological and serological tests in all cases. • All suspected cases must be kept under mosquito nets during the febrile period. • Communities in the affected areas should be educated on the control measures for mosquitoes in the hospitals and at home.

PUBLIC HEALTH MEASURES Patients with chikungunya virus are the reservoir for the infection at home and in the community at large. Accordingly, public health measures are conceived to minimize the exposure to mosquito bites preventing the spreading of the outbreak. Education of the patients, and other family members, about the risks and forms of transmission, reduce the possibility of infection, and help the authorities, diminishing vectors populations, and the possibility of contact. So: • Increase the efforts to eradicate larval habitats within, and in the vicinity, of households, eliminating standing water in the trash or elsewhere. • Tell the patient to sleep under mosquito nets, preferably impregnated with permethrin. • Wear long sleeves, and long pants, cover extremities. • Use wire nets in windows and doors. • Prevent possible breeding sites for the vector, especially standing water.

• Be aware of the maintenance of tanks and swimming pools. • Discard objects that can accumulate water, such as bottles, tires, pots, and garbage.

NOTIFICATION Any case of chikungunya in the community should be reported immediately to the public health authorities, allowing control measures within the community.

Case definition Clinical criteria: acute onset of fever > 38.5°C with severe arthralgia or arthritis, unexplained by other medical conditions. Epidemiological criteria: living in or having visited areas where the virus has been reported within 15 days prior to the onset of symptoms. On this basis, the cases are to be classified as: Suspects: a patient who meets the clinical and epidemiological criteria. Confirmed: a suspected patient who meets the lab criteria. Blood borne transmission of chikungunya virus is possible. Therefore it is necessary to ask donors to notify the disease before donating blood, and maintaining the blood products on standby for 2 to 5 days before releasing it for use.

References 1. PAHO/CDC. The preparedness and response against virus Chikungunya in the Americas. Washington, D.C.: PAHO, 2011. http:/ www.paho.org/ hq/index.php? option = com_docman &amp; task = doc_download &amp; gid = 16984 &amp; Itemid = &amp; lang = in 2. Plan Nacional de Respuesta Frente a la Introducción del Virus del Chikungunya en Colombia. Ministerio de Salud y Protección Social – Instituto Nacional de Salud. Bogotá. Agosto de 2014 http://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/ RIDE/VS/PP/ET/PLAN%20NACIONAL%20DE%20RESPUESTA%20CHIKUNGUNYA%20COLOMBIA%202014.pdf 3. World Organization of health, Regional Office for South-East Asia Regional Office. Guidelines for the clinical management of Chikungunya fever. New Delhi, 2008. http:/ www.searo.who.int/ entity/emerging_diseases/documents/SEA_CD_180/in/index .html 4. CDC. Information for clinicians. www.cdc.gov/ chikungunya/ pdfs/CHIKV_Clinicians.pd http:/ 5. h t t p : / / w e b c a c h e . g o o g l e u s e r c o n t e n t . c o m / search?q=cache:DWFbqfpGJzQJ: www.paho.org/ hq/index. php%3Foption%3Dcom_docman%26task%3Ddoc_download% 26gid%3D23977%26Itemid%3D%26lang%3Des+&cd=2&hl =es-419&ct=clnk&gl=co 6. Guía de manejo clínico para la infección por el virus chikungunya (CHIKV). Ministerio de Salud Pública Santo Domingo, República Dominicana, 2014. ISBN: 978-9945-436-94-5

INTERVIEW

olciencias in health care, an open door to research

Stimulus to scientific research is decisive for personal and academic development of health care professionals. Daily in medical practice doctors build their science while treating patients. Learn how to access government grants. This is an interview with the Director of Colciencias Research Promotion. With the assistance of: Gabriela Delgado Director of Colciencias Research Promotion Bacteriologist, PhD in Pharmaceutical Sciences Professor at Universidad Nacional de Colombia

Coomtacto Newsletter: What is the point of encouraging and promoting scientific research within health care? Gabriela Delgado: In abstract terms, it is common knowledge that we must promote research in all areas, and most developing countries have

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understood that part of the economic progress implies improving the quality of life for the people leaning on products and processes derived from scientific studies. Science is a mechanism through which cultural, economic, educational and social gaps can be closed, particularly in health care.

INTERVIEW CN: What it the support available for scientific research in health care through Colciencias?

And Colciencias considers research protocols on topics that are related with national priorities. Particularly during the last four years priority has been given to those investigations consistent with the national health plan, based on the needs and strengths of the country, as well as on its human resources. Therefore, Colciencias focuses on supporting and leading research groups that have shown that in their daily actions they have consolidated their work with patients and can design research projects that solve prominent health problems in Colombia. CN: How can physicians access grants by Colciencias? GD: The system is universal, and has been well known for a long time. To access Colciencias courses, interested parties should enter the system in the world wide web. Register within Colciencias platform, and fill in the form. A personal resume is required, as well as the research group’s, particularly stating all scientific productions, including publications of any type. And then, when the time comes, annual planning at Colciencias establishes which research lines are adequate for each group according to its strengths and area of expertise.

“The fact that the doctor attend to a patient generates a very important information, as he can provides data that serve as support for projects research“.

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GD: Colciencias has established Programa Nacional de Ciencia, Tecnología e Innovación en Salud. Its funding comes from Fondo para Investigación en Salud, also administered by the Ministerio de Salud y la Protección Social, since part of the taxes coming from gambling are destined to scientific research through this fund.

Unquestionably, not everything in health care is a field of research. At Colciencias we try to finance projects directly related with high impact on epidemiological indicators of diseases prevalent in our country. CN: What is the message for health care workers who want to participate in these programs, and are interested in finding out more about Colciencias grants? GD: Doctors working in hospitals are valuable human resources. Daily procedures with patients, is also investigation. It is important that health care services providing institutions promote scientific dialogue, allowing scientifically inclined medical personnel time within the workday to generate ideas for new research projects. The fact that doctors treat patients generates important information, providing data that is useful to support research projects. But one of the great difficulties is that professionals do not have time for that. So it is important not only to motivate health care professionals, but also administrative personnel, to understand the relevance of scientific research beyond their own private committees. We are trying to develop real commitment within health care providers and insurance companies, opening up spaces for scientific research, because in this sense, health care professionals who work in the clinical setting have all the data, and organizing it as published knowledge is fundamental for the country.

FROM COOMEVA Coomeva Prepaid Medicine was present at the traditional Dentist Day Celebration through the participation of executives for the regional providers, whom shared with all the participants a momentum, a symbol of gratitude for their dedication and commitment.

The Dentist Day Celebration barranquilla

 At Clínica Denticenter: Dr. Claudia Rivera, and Kelly Caballero, Attention executive for the Caribean Regional Providers; with Drs. Hernando Salazar, Esperanza Osorio, and Luisa Fernanda Correa.

 Drs. Carlos Acevedo, and Kelly Caballero, Attention executive for the Southwestern Regional Providers.

BOGOTÁ

 Dr. Andrea Enríquez, coordinator of Oral Health at Coomeva Prepaid Medicine; Dr. Layla Kali, and Catalina Sánchez, Attention executive for the Centraleastern Regional Providers.

 Drs. Omaira Herrera, and Andrea Enríquez, regional  Dr. Andrea Ramos, and Oral Health coordinator Catalina Sánchez, Attention executive for the Centraleastern Regional Providers.

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 Drs. Carlos Barbosa Correa, and Luz Edith Forero Sánchez.

 Dr. Javier Serge, Vital Plus.

BUCARAMANGA

 Dr. Tatiana Landínez, dentist at Unidad Integral de Salud (UIS); Dr. Lina Maritza Rueda, Regional Oral Health Coordinator; and Eliana Murillo, Attention executive for the Northeastern Regional Providers.

 Dr. Libia Pérez, Odontosan Centro de Especialistas; also Dr. Lina Maritza Rueda, regional Oral Health coordinator; and Eliana Murillo, executive for the Northeastern Regional Provider.

CALI

 Dr Margarita Rosa Padilla, odontopediatrician; Andrea Atehortúa, Attention executive for the Southwestern Regional Providers.

 Dr. Felipe Gutiérrez Zuluaga, dentist; Andrea Atehortúa, Attention executive for the Southwestern Regional Providers.

MEDELLÍN

PEREIRA

 Centro Odontológico Oral Láser: Drs. Natalia Vanegas, and Ana María Jaramillo, with Carolina Londoño, Attention executive for the Northwestern Regional Providers.

 Dr. Marcela Madrid Duque, dentist; Carolina Londoño, Attention executive for the Southwestern Regional Providers.

 A group of dentists that work at Coomeva Prepaid Medicine Southwestern Regional: Drs. Martha Usma, Sergio Erazo, María Victoria Villada and Adriana Perdomo.

 Dr. Carlos Hernán Manzano López, dentist; Carolina Londoño, Attention executive for the Southwestern Regional Providers.

 Dr. María Claudia González,dentist.

 Dr. Mario Augusto Ruiz, orthodontist; Mauricio Ospina, Attention executive for the Eje Cafetero Regional Providers.

 Dr. Hugo Moya with work collaborators, Orthodontics.

MEDICAL WORLD BOOKS  ‘Prostate Cancer’ Luis Montes de Oca / Carlos Scorticati This is a book is designed for the library of urologists, oncologists and professionals of all specialties whom are interested in prostate cancer. It focuses on problems faced by patients at risk of developing this disease or that already have been diagnosed. Also, it describes the difficulties that might occur during the process, for instance, biochemical relapses after radical surgery and radiation treatments. This is a book published by Editorial Médica Panamericana.

EVENTS  ‘II International Symposium on Heart Failure, Heart Transplantation and Pulmonary Hypertension’ Date and place: 27 to 29 November, Bogotá Information: Sociedad Colombiana de Cardiología y Cirugía Cardiovascular Phones: (1) 523 1640 - 523 0012 Email: asispresidencia@scc.org.co Website: www.scc.org.co

 ‘X Panamerican Congress of Aesthetic Medicine’ Date and place: 4 to 6 December, Cartagena Information: Asociación Científica Colombiana de Medicina Estética Phone: (4) 333 5397 - 332 7528 Email: acicme@gmail.com Website: www.acicme.com.co

FILM  ‘A beautiful Sunday’

Director: Nicole Garcia Starring: Louise Bourgoin, Pierre Rochefort, Dominique Sanda, Deborah François, Eric Ruf, Benjamin Lavernhe

This film tells the story of Baptiste, a lonesome teacher in southern France, that spends only a trimester in a school. However, everything changes one Friday when the father of a student, Mathias, does not show up to pick up the boy. One thing leads to another, and the teacher meets the boy’s mother, Sandra. A gorgeous woman with whom, only in one day, he creates an unusually strong bond. However, the magic is short winded, she is in trouble, and Baptiste decides to help her, confronting him with his painful past.

MUSIC  ‘Songs of Innocence’

U2 The famous Irish band presents its new album, the thirteenth studio album, and the first since the release of ‘No Line On The Horizon’ in 2009. For this new project U2 included electronic elements never heard before in this group. So itt contains 11 long awaited songs by the fans, such as “The miracle”, “Song of someone”, “The troubles” and “Volcano”.

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General

manager

Coomeva Medicina Prepagada

Jorge Alberto Zapata Builes

Editorial Meeting

Pascual Estrada Garcés, MD National Medical Director Coomeva Medicina Prepagada Martha Liliana Cifuentes Castaño National Coordinator Relationship with providers Bertha L. Varela, MD National Chief of Medical Audit Mauricio Castillo National Director of International Business Paula Lilián Henao National Communications Analyst Publishing production

mercadeorelacional@legis.com.co Avda. Calle 26 No. 82-70, Bogotá D.C. Phone: (571) 4255255, Exts.: 1314, 1552, 1142, 1486, 1516