Newsletter
for health professionals of Coomeva Medicina Prepagada ISSN 2011-3579
Vol. 7
No. 3
August - october 2014
Coomeva, a dream born
CONTENT
out of 27 altruistic doctors 4
HEALT UP TO DAte An overview on organ donation and transplantation in Colombia: the country doesn’t quite make it!
ebm
8
Current recommendations for the treatment of hypertension
promotiOn AND prevention
12
Exercise will change human epidemiology
FROM COOMEVA
16
Celebration: The Secretary Day
MEDICAL WORLD Books reviews and events
18
Cooperativism, the world’s largest socioeconomic organization, is the model for Coomeva, the biggest professional’s venture in the country. We were born 50 years ago as a cooperative in Valle del Cauca, and today we are one of the 20 largest organizations in Colombia, with 17 companies operating in 1,081 townships throughout 25 departments. In our 50th anniversary it is important to remember how in the early 1960s, led by pediatrician Uriel Estrada Calderon, 27 physicians facing adverse working conditions, without coverage nor social security, and shocked by the lack of protection endured by the family after the death of a colleague, they saw the need of insurance for the whole medical community. In this search they found something much bigger, an enterprise that represented a milestone not only for their lives, but also for the socioeconomic development of the country: it was cooperativism. Thus began Coomeva. A feat that started a half a century ago, on March 4th 1964, with a capital of $6,600. And now this organization is part of the history of Colombia, while consolidating the dream of its founding fathers. Today it is a community of more than 250,000 associated professional around the country, and an organization with a capital of $543,305 million pesos, that generates about 13,000 direct jobs, and 25,000 indirect labor oportunities. But Coomeva has also been involved in the general health system in Colombia. In 1974 we created the first prepaid medical service in the country, and 10 years later, with that experience, we supported the Government to develop its health policies, participating in health system by creating Coomeva EPS. Today it has more than three million users, and annually it performs 25 million medical activities. Now, a half a century later, our most immediate priorities are to continue with the sustainable development of our organization. Its businesses are directed towards achieving a greater impact on the quality of its services, generating concrete benefits and more opportunities for its partners and users. Similarly, our activities are aimed at a healthy and significant growth in key sectors of our enterprise, ensuring a stronger future through productivity and efficiency, based on the commitment and talent of our employees. Therefore, our three main goals are to create value, improve our services and to develop Coomeva further in a user oriented manner, accompanied by policies aimed at creating a better environment for our younger associates, as well as gender equity. First, to promote the programs we intend to prepare the new generations, encouraging their participation in management, and decision making within our organization, in order to ensure its sustainability, and of cooperativism in general within the whole country. And secondly, equility, the idea of promoting universal development of all the people that make up Coomeva. We can proudly say that we have endured because of our commitment to the welfare of people, and the development of our country. Alfredo Arana Velasco Executive Chairman Cooperative Business Group Coomeva
©2014 Shutterstock Photos
HEALTH UP TO DATE
A
n overview on organ donation and transplantation in Colombia: the country doesn’t quite make it!
Recent reports by Red de Donación y Trasplantes de Órganos y Tejidos of the Instituto Nacional de Salud (INS) alert not only the scientific community, but also to the general public: in Colombia the donation culture is yet to be developed. Therefore, people are dying while waiting for an organ transplant, and worse, there has been a significant decline of the organ donors. Situation overview. With the participation of Angélica María Salinas National Network Coordinator Red de Donación y Trasplantes
In 2004, Red de Donación y Trasplantes de Órganos y Tejidos was created, and the practice of donation and transplantation was legalized in the country. And only until 2010 donors and transplants peaked. But unfortunately in the last three years organ donations have decrease while the waiting lists have increased, prolonging the periods before they can be transplanted.
45
What is happening to our country? Aren’t we as supportive of the community, nor as sensitive to other people sufferings? Are we afraid to donate organs, or of the myth of the organ black market? These are some questions raised in a study conducted by Instituto Nacional de Salud (INS), the government organism that coordinates health care in the country.
A MESSAGE OF AWARENESS Maria Angelica Salinas, National Network Coordinator, underlines the importance of informing people about organ donation, and transplants, as an act of solidarity for the whole community.
The identification card showing the person is an organ doner is easily processed simply by filling the form at Instituto Nacional de Salud www.ins.gov.co. “Transplants, even though the technology exists in our country, cannot be done without donors, so it is critical that those whom decide to do so, tell their families about their decision, that way the process can be more efficient once they die, saving many more lives”, said the specialist.
Donation and transplantation in Colombia is an urgent need. Between 2007 and 2013 donated organs and tissues increased from 394 to 449, peeking in 2010, when 569 people voluntarily offered their anatomical components. **
Moreover, a joint effort of the health care personnel is required, with a more active role to foster and promote the culture of tissue donation among patients in their practices.
Meanwhile, the most needed organs during 2013 were: kidneys, 1,604; corneas, 697; livers, 103; hearts, 31; and lungs, 4. And the number of death’s while waiting for an organ transplant was 72 in 2012, and 61 in 2013.
“Today transplantation is a very successful process, but without the support of health care professionals, and the institutions, the procedures are impossible. So doctors and other health care professionals should be aware, and active with this cause”, urges Dr. Salinas.
Registro Nacional de Donación y Trasplantes confirmed that in 2013 there was a 32% increase, compared to 2012, in the number of patients waiting for transplants. Of them, 66% were under 18 year olds, and they waited for kidneys, livers, or hearts.
Review of the situation
THE MOST NEEDED ORGANS
INS statistics show a poor situation of organ donation in the country. In 2013, 1,742 patients were waiting for organ or tissue donations in order to save them, or improve their quality of life, a figure that in 2008 did not exceed 826 patients.
The longest list was that of patients waiting for kidney transplants, due to the increase in the country of chronic kidney failure secondary to diabetes mellitus, and hypertension.
In 2013, 961 organ transplants were performed, a 13.3% decrease compared to 2012, 1,108, so the number of transplants performed during 2013 was 20.4 per million inhabitants; while in 2012 it was 23.8 per million inhabitants. (these estimates took into account DANE’s projected population for 2013: 47’121 .089) *. Similarly, in 2013 there was an 18.2% decrease in the number of heart transplants compared to 2012, and 14.5% less liver transplants. However, researchers also found a 75% increase in combined kidney and liver transplants. **
Also, according to Salinas Dr., the problem with pediatric renal transplantation is still more complicated: “when we talk about children’s chances of finding a match, it is even smaller because in this population weights and sizes have to be taken into account, the donor has to have similar characteristics”, said Salinas. Meanwhile, as far as tissues are concerned, corneas are the most needed, there are about 900 patients / month waiting for them. INS also reported that in 2013 1.913 ocular tissues were obtained, while 1.748 alerts for potential musculoskeletal tissue donors were detected,
HEALTH UP TO DATE
WHO CAN BE AN ORGAN AND TISSUE DONOR? Anyone, regardless of sex, age, or race, can be an organ donor. At the time of death diagnostic tests select suitable organs. Consider trauma leading to brain death is the most common source of donors in Colombia
HOW TO BECOME AN ORGAN AND TISSUE DONOR? You only need to have the will to do so, and inform the family of your desire to become a donor, so that they will respect your decision. Adults who wish to become an organ donors can sign up and get an identification card at www.ins.gov.co , or through a national 24 hours toll-free at INS. 018 000 113 400. In 2013 17.396 people got donor cards of anatomical components.
as well as 72 skin donors (which represented a 15% decrease compared to 2012, 85 donors).
Decree 2493 in 2004, which legalizes the whole process. ***
As far as heart valves and cardiovascular tissues 509 potential alerts were detected. And a 57% decrease in amniotic membranes was observed, in 2012 141 were obtained, and in 2013 only 60.
Also during in 2013 the rescue activity of anatomical components obtained 908 apt organs for transplantation.
FAMILY INFORMATION The most common difficulty in the donation process is the negative attitude of the family of the donor, denying access to the organs, and the possibility of saving lives, 37% of the surveyed households in 2013 refused to grant the authorization. Lack of information on the destinations of the organs of the dead family member is the greatest fear, along with the myths about underground organ trafficking network. But INS denies the existence of organ trafficking in Colombia. Organ and tissue donation and transplantation was regulated by
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SOURCES * INS - Sistema Nacional de Información en Donación y Trasplantes. ** Dirección redes en salud pública. Subdirección red nacional de trasplantes y bancos de sangre. Coordinación nacional red donación y trasplantes. Anual network report on donation and transplants 2013. Volumen 3, Bogotá 2013. http://ins.gov.co/lineas-de-accion/Red-Nacional-Laboratorios/Estadsticas/INFORME%20ANUAL%20 2013%20RED%20DE%20DONACION%20Y%20 TRASPLANTES.%20Vol%2003.pdf?Mobile=1&Source=%2Flineas-de-accion%2FRed-Nacional-Laboratorios%2F_layouts%2Fmobile%2Fview. aspx%3FList%3Daa64c04f-f000-4a29-884b 834618c33990%26View%3D94ffb35f-279a-4abe89f3-5bec8487288b%26CurrentPage%3D1 *** Decreto número 2493 de 2004 (agosto 4). That rules on the 9th Law of 1979 y 73 of 1988, in relationship to anatomical components. http://www.transplant-observatory.org/SiteCollectionDocuments/amrlegethcolsp3.pdf
EBM Synthesis of the new JNC 8 (July, 2014)
C
urrent recommendations for the treatment of hypertension
The National Committee on Prevention, Detection, Evaluation and Treatment of Hypertension recently published its updated report (No. 8) on the management of hypertension based on evidence. Since it is important for the medical community, we reproduce it as it was published www.intramed.com , and later it appeared in JAMA. Update based on new evidence from randomized controlled clinical trials for the treatment of hypertension. This is a guide with practical worldwide impact.
Table 1. Recommendation level Grade
Relationship quality
Author: Drs. James BP; OBPril S, Carter BL, et al. JAMA 2014, 311:507-520.
A
Solid recommendation. There is high probability based on evidence of substantial benefit.
Introduction
B
Moderate recommendation. Benefit fluctuates between moderate and substantial.
The evidence on the efficacy of antihypertensives for these guidelines was obtained from randomized controlled clinical trials. The quality of the evidence and the recommendations was classified according to endpoints. Rigorous evidence based methods were used after a systematic review of the literature in order to address the needs and concerns of primary care physicians.
C
Weak recommendation. There is little benefit.
D
There is no benefit, or the risk supersedes the benefit
E
Not enough evidence to determine harm or benefit, but the committee considers the possibility of using the treatment.
N
No recommended because of a lack of adequate information
The work group of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure, in its report No. 8 (JNC 8), evaluated the evidence in adults, ≥ 18 years, with hypertension, and also included subgroups such diabetes, coronary disease, peripheral artery disease, heart failure, stroke, chronic renal failure, proteinuria, elderlies, and smokers.
Inclusion criteria Included publications studied the effects of interventions on overall mortality, as well as on morbidity from cardiovascular and cerebrovascular diseases, and chronic kidney failure. Also studies with samples < 100 patients and less than 1 year follow up were discarded. Trails had clear assessment criteria, they were randomized, and controlled. The evidence quality is described in Table 1.
Questions addressed by the expert panel These evidence based recommendations on the treatment of hypertension mainly address three questions: 1 – Does outcome improve if specific blood pressure (BP) thresholds are considered before starting the treatment? 2 – Does outcome improve if antihypertensive treatment in adults is directed towards a specific BP objective? 3 – Are there any differences between antihypertensive drugs regarding their benefits and adverse effects?
Recommendation 1 In the general population >= 60 years drug treatment will be initiated to reduce systolic blood pressure (SBP) ≥ 150 mm Hg, or diastolic BP (DBP) ≥ 90 mm Hg.
89
Based on the content of the article JAMA 2014; 311:507-520
Grade A Recommendation This recommendation is based on controlled clinical trails showing that in this age group the reduction in BP <150/90 mm Hg will decrease stroke, coronary disease and heart failure incidence. The reduction in SBP <140 mm Hg in this age group, showed no further benefit.
Recommendation 2 In the general population <60 years, treatment should start when DBP is ≥ 90 mm Hg. Recommendation Grade A for ages 30 and 59. Recommendation Grade E for ages 18 and 29. Recommendation 2 is based on high quality evidence coming from five trails focused on DBP (HDFP, Hypertension-Stroke Cooperative, MRC, and VA Cooperative ANBP), they showed improvement in hypertension and health in general for patients between 30 and 69 years. Initiation of antihypertensive treatment at ≥ 90 mm Hg DBP reduces the risk of cerebrovascular events, heart failure, and overall mortality. On the other hand, the HOT study showed no benefits if DBP ≤ 80 mm Hg. Since their is lack of quality evidence for adults <30 years, expert panel suggests that this age group be treated like other adults between 30 and 59 years.
Recommendation 3 In the general population <60 drug treatment was initiated to reduce SBP ≥ 140 mm Hg.
Expert Opinion grade E This recommendation is based on expert opinions. While there is high evidence to support a specific threshold of SBP for people ≥ 60 years, the expert panel found insufficient evidence for a specific threshold of SBP in persons <60 years. Therefore, they recommended a treatment threshold of SBP <140 mm Hg. The recommended target to reduce SBP <140 mm Hg in people with diabetes or chronic kidney disease (Recommendations 4 and 5), also applies to persons <60 years.
Recommendation 4 In the age group ≥ 18 years with chronic kidney disease, drug treatment was initiated to reduce SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg.
Expert Opinion grade E. This recommendation applies to persons <70 years with glomerular filtration rate <60 ml/min/1, 73 m2 and at any age with albuminuria> 30 mg albumin / g creatinine regardless of the value of glomerular filtration. In adults <70 years with chronic kidney failure the evidence is insufficient to determine whether the BP reduction <130/80 mm Hg with antihypertensives diminish the overall mortality risk of cardiovascular disease or cerebrovascular events. The reduction in BP below these valuesdoes not improve when reducing BP <140/90 mm Hg. Risks and benefits of reducing BP in patients ≥ 70 years with glomerular filtration rate <60 ml/min/1, 73m2 must be evaluated, so the use of antihypertensives depends on the characteristics of each case, taking into account factors like the clinical condition, associated diseases, and the presence of albuminuria.
Recommendation 5 In diabetic adults drug treatment should start when SBP > 140 mm Hg or DBP ≥ 90 mm Hg.
Expert Opinion grade E. There is moderate quality evidence from three studies (SHEP, Syst-Eur and UKPDS) on the treatment to reduce SBP <150 mm Hg, improving cardiovascular and cerebrovascular prognosis in adults with diabetes and hypertension. No randomized controlled study indicated that treatment to reduce SBP <140 mm Hg in comparison with a higher threshold (eg <150 mm Hg) improves health in adults with diabetes and hypertension. In the absence of this evidence the panel recommends a threshold of SBP <140 mm Hg and DBP <90 mm Hg, in the opinion of these experts based on the ACCORD-BP this threshold was applied to a similar control group.
The panel recognizes the ADVANCE study where the effects of antihypertensives on microvascular and macrovascular events were evaluated, but this trail did not meet the inclusion criteria because participants were considered suitable regardless of their baseline BP and there was no random classification of the therapeutic targets, nor the thresholds. The panel also recognizes that the goal of a SBP <130 mm Hg is usually recommended for adults with diabetes and hypertension. However, it is not backed by a randomized controlled study that has distributed the participants into 2 or more groups, in which treatment was initiated at a threshold of SBP <140 mm Hg, and evaluated the effects on different endpoints. The only randomized trail that evaluated reducing SBP <140 mm Hg and analyzed the results on various health parameters was the ACCORD-BP. No difference was found in the primary endpoint, cardiovascular death, nonfatal myocardial infarction, and stroke. No difference was found on the secondary endpoints. The Panel concluded that the results of ACCORD-BP did not show enough evidence to recommend reducing BP <120 mm Hg in adults with diabetes and hypertension. Likewise, the panel recommended the same antihypertensive approach as for the general population (<90 mm Hg). While the panel did not find enough evidence to support the recommendation that adults with diabetes and hypertension should achieve values of DBP <80 mm Hg, there are no randomized trails evaluating morbidity and mortality as primary or secondary endpoints, to determine whether a reduction in DBP <80 mm Hg is better. UKPDS is frequently cited, it had a target BP <150/85 mm Hg in the intensive treatment group compared with a group of moderate antihypertensive treatment <180/105, and it showed that treatment in this second group was linked with lower rates of stroke, heart failure, diabetes and diabetes-related death. However, the comparison in the UKPDS was a DBP <85 mm Hg vs <105 mm Hg; therefore, it is not possible to determine whether treatment with DBP <85 mm Hg improves outcomes compared with a target DBP <90 mm Hg. In addition, the UKPDS was a mixture of DBP and SBP goals so it cannot be determined if the benefits were due to the reduction in SBP, DBP, or both.
EBM Recommendation 6 In the population, including diabetics, the ideal antihypertensive treatment includes thiazide diuretics, blockers of the calcium channels (BCC), inhibitors of the angiotensin converting enzyme (ACI), or blocker of the angiotensin receptors (BARs).
Moderate Recommendation grade B. For this recommendation only randomized controlled studies that evaluated antihypertensive with placebo controls studies were included. Reviewers took into consideration only three (VA Cooperative Trial, HDFP and SHEP), which demonstrated that the treatment of hypertension with antihypertensives reduces cardiovascular and cerebrovascular events and mortality. And in all three studies thiazide diuretics were compared to placebo.
Table 2. Evidence-based antihypertensive dosages Initial dally dose (mg)
Ideal dose (mg)
Number of daily doses
50
150 - 200
2
Enalapril
5
20
1-2
Lisinopril
10
40
1
Eprosartan
400
600-800
1-2
Candesartan
400
12-32
1
Drug ACEI Captopril
ARB
Losartan
50
100
1-2
Valsartan
40-80
160-320
1
More evidence that antihypertensive treatment reduces risks comes from studies comparing beta-blockers or BCC versus placebo. They showed comparable hypotensive effects and improvement on overall mortality and cardiovascular, cerebrovascular and renal parrameters, with one exception, heart failure. Thiazide diuretics were more effective than ACI, or BCC and ACI, and more effective than BCC alone improving heart failure. This does not mean antihypertensives should be excluded from heart failure treatment.
Irbesartan
75
300
1
The panel does not recommend beta-blockers for the initial treatment of hypertension because some studies did not show favorable results.
BB Atenolol
25-50
100
1
50
100-200
1-2
Amlodipine
2.5
10
1
Diltiazem AP
120-180
360
1
Nitrendipine
10
20
1-2
5
10
1
Metoprolol CCB
Tiazide Diuretics Bendoflumetiazide
These medicines are not recommended as first choice antihypertensives:
Clortalidone
• Alpha blockers; • Dual agents + beta blockers alpha blockers (eg, carvedilol); • Vasodilating beta-blockers (eg, nebivolol); • Central alpha agonists 2 adrenergic (eg, clonidine); • Direct vasodilators (eg, hydralazine); • Aldosterone receptor antagonists (eg, spironolactone); • Adrenergic neuronal depressants (eg, reserpine); • Loop diuretics (eg, furosemide).
Indapamide
These indications also apply for patients with diabetes because several studies showed similar results in the general population.
Highlights
Hidroclorotiazide
12.
12.5-25
1
12.5-25
25-100(*)
1-2
1.25
1.25-25
1
ACEI: angiotensin converting enzyme inhibitor; ARB: angiotensin receptor blocker; BB: beta blocker; CCB: calcium channel blocker Ideal dosages or target doses are based on the results of controlled randomized trails. (*): recent evidence suggests that a dose of 20-50 mg/day is efficient and safe. Based on the content of the article, JAMA 2014; 311:507-520.
these patients. Recommendations for patients with chronic kidney disease are provided in recommendation 8.
Recommendation 7
1- Many patients need more than one antihypertensive to achieve adequate BP control. Any of the 4 types of antihypertensives (ACI, BCC, beta-blockers, and BAR), can be used from the beginning or complementarily. 2 - This recommendation is specific for thiazide diuretics (chlorthalidone, indapamide), not for loop diuretics nor potassium savers. 3 - Medications should be used in adequate doses to achieve the results seen in randomized controlled studies (Table 2).
In African Americans, including diabetics, initial antihypertensives should include a thiazide diuretic or a BCC.
4 - Randomized trails limited to nonhypertense population, such as people with coronary artery disease or heart failure, were not considered in these guidelines. Therefore, recommendation 6 should be used with caution in
This recommendation is based on a major study (ALLHAT), it was rated by the panel as good. In this trail thiazide diuretics were more effective than ACI preventing cerebrovascular events, heart failure and their combinations. The sample included a large number of diabetics.
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For African Americans in general: moderate grade B recommendation. For African Americans with diabetes: weak degree C
recommendation
As an alternative to a thiazide diuretic therapy, a BCC may be used. An ACI is not recommended at first because ALLHAT results were no satisfactory.
Recommendation 8
Table 3. Strategies for dosage and combinations of antihypertensives according to patient responses Tipe of strategy A
The blood pressure target was not reached with the first antihypertensive (ACEI, ARB, CCB, tiazide diuretic), then the dose will be adjusted to the maximum recommended. If the target is still out of reach, add a second antihypertensive at the maximum recommended dose. If the target is not yet achieved, initiate a third antihypertensive, at a maximum recommended dosage. And never prescribe ACEI with ARB at the same time.
B
Start with an antihypertensive, and before reaching the maximum recommended dosage, add a second antihypertensive, and then adjust them both until they reach the maximum recommended dosage. If the patient is still not normotense add a third antihypertensive, and adjust it to the maximum recommended dose. And never prescribe ACEI with ARB at the same time.
C
Start the treatment with two simultaneous antihypertensives, in separate tablets or in combined presentations. Two or more antihypertensives are recommended when SBP > 160 mm Hg, or DBP > 100 mm Hg, also when SBP > 20 mm Hg, or DBP > 10 mm HG, above the target BP. If BP is still not normal, a third antihypertensive can be added at a maximum recommended dosage. And never prescribe ACEI with ARB at the same time.
In adults ≥ 18 years with chronic renal failure and hypertension, the initial or complementary treatment should include an ACI or a BAR, in order to improve renal function. This applies to all cases of chronic renal failure with hypertension regardless of race and blood sugar level.
Moderate grade B recommendation This recommendation applies regardless of the presence of proteinuria, because studies with ACIs and BARs showed improvement in renal parameters. No randomized controlled studies comparing ACI and BARs with respect to cardiovascular outcomes were found. However, both showed similar effects on kidney function. The AASK study showed the benefit of using ACI inhibitors on renal function in African Americans with chronic renal failure. In this study direct renin inhibitors were not included because there are no trails that show their benefits on renal function and the prevention of cardiovascular events. Recommendation 8 applies for adults with chronic renal failure, but there is no evidence to support the use of inhibitors of the rennin angiotensin system in people > 75 years. While treatment with an ACI or a BAR may benefit people in this age group, the use of a thiazide or a BCC is suggested. The use of an ACI or a BAR tends to increase serum creatinine and may cause other metabolic effects such as hyperkalemia, especially in patients with impared renal function. While the increase of serum creatinine or potassium does not always require an adjustment of the medication, the use of drugs which act on the rennin angiotensin pathway require electrolytes and plasma creatinine controls, and in some cases, for safety reasons, it may be necessary to reduce the dose or change to another antihypertensive.
Recommendation 9 The goal of the antihypertensive treatment is to reduce BP to an acceptable levels, and keep it stable that way. If this goal is not achieved after a month, the initial dose of the drug should be increased, or a second medication should be added from within the pharmacological classes suggested in recommendation 6 (thiazide diuretic, BCC, ACI or BAR). Doctors must control BP, and make the necessary adjustments to achieve the desired values. If the target is not reached with the second drug, a third antihypertensive is indicated. Even though ACI and BAR should not be used at the same time. And if after that BP is still not normal, the patient should be remitted to a specialist.
Expert opinion grade E. These recommendations were developed by the panel in response to the needs of professionals to define therapeutic strategies. They are based on randomized controlled trails
Therapeutic plan
AHT: antihypertensive; BP: blood pressure; ACEI: angiotensin converting enzyme inhibitor; ARB: angiotensin receptor blocker; BB: beta blocker; CCB: calcium channel blocker; SBP: Systolic blood pressure; DBP Diastolic blood pressure. Based on the content of the article JAMA 2014; 311:507-520.
that showed improvement in outcomes and the experiences provided by members of the panel. 3 Strategies for antihypertensive treatment were mentioned by the panel based on their own experiences, they are summerized in Table 3, but there are no randomized trails comparing these strategies. Therefore there is no evidence. Therefore, each strategy is an acceptable medical therapy that can be adjusted according to the patient’s case, the preference and experience of the physician, and the presence of adverse effects. With all approaches clinicians should monitor BP regularly, encourage healthy lifestyles and ensure compliance.
Limitations of these recommendations These evidence based recommendations for the treatment of hypertension in adults are not exhaustive because the evidence focused on answering 3 specific questions, which are important to most physicians and patients. Compliance and the costs of medicines were beyond the scope of this review, although the Panel recognizes the importance of both issues. The Panel decided to focus only on randomized controlled trials because they represent the best scientific evidence, and because there were fairly numerous papers involving large numbers of patients thar met our inclusion criteria. Translation and objective summary: Dr. Ricardo Ferreria.
PROMOTION AND PREVENTION
E
xercise will change human epidemiology
The World Health Organization (WHO) is promoting several campaigns designed to make physical activity a daily medicine for all, planning to improve disease statistics on the planet. And maybe even the cheapest choice: 30 minutes of rhythmic movements, five days a week is enough. This is also the responsibility of health professionals. With the assistance of: Enrique Alvarez, MD Specialist in sports medicine John Duperly, MD Specialist in Internal Medicine PhD in Sports Medicine
In the medical interview with patients the answer to the question, “do you exercise?”, is frequently a resounding no. Well, it is important to make it clear, 150 minutes of a weekly routine that consumes energy, tones and lubricates the musculoskeletal structure, reduces overweight, obesity (including morbid forms), brain events and cardiovascular disease, diabetes, hypertension, atherosclerosis, fibromyalgia, some types of cancer (such gastric cancer), thrombosis, paralysis, memory loss, even Alzheimer’s.
“It is a mission that concerns not only the general practitioners, but also all personnel involved in health care, we should all encourage healthy habits among patients, warn them about the risk factors, and monitor whether they exercise, they have physical activity or a sport, and the frequency with which they do it”, said doctor Álvarez. Research suggests that exercise is one of the most powerful strategies to prevent, cure and rehabilitate. On the other hand, Dr. John Duperly, explains that 150 minutes should be considered a minimum, a reference prescribed to the patient. “But people tend to understand it as if it was the perfect recipe, while it is the lowest dose that a human being needs to benefit from physical activity. So it is important to make it clear that moderate or
©2014 Shutterstock Photos
Dr. Enrique Alvarez, sports physician at Universidad del Bosque, argues that, as indicated by WHO, the idea is to recommend the patients to do 30 minutes of a high
intensity physical activity five days a week, or a hour daily three times a week.
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©2014 Shutterstock Photos
vigorous activity should be continuous during that period of time, therefore a brisk walk for 150 minutes, for instance, is a low dose, so the person requires about 300 minutes of to obtain the same benefits”, said doctor Duperly, and then added that people ideally should surpass the 150 minutes mark, in other words everybody should exercise at least one hour a day with a moderate or vigorous activity.
Teaching Doctors How to make exercise a habit for everyone? What recommendations should health professionals give patients in order to achieve an adequate activity? After all, doctors are responsible of leading patients to exercise habits, as much as eating and resting properly. It is important for the doctor to take detailed notes on the activity the patient has engaged, while interrogating him, as well as of the advice given to him. Everybody, taking into account age, gender, and general health, will eventually benefit from the numerous positive effects exercise has on body and mind. There are many aspects that should change in the doctor’s practice: “education and training is essential,” emphasizes Dr. Duperly, and continues, “science has shown that exercise is the greatest contribution we can give to the patient, but in our medical training that is not an issue”. So these are three basic professional skills: 1. Recognize the potential benefits for the individual, whether male, female, pregnant, child, elderly, cancer patient or diabetes, among other diseases. 2. Timely health care should be considered when prescribing physical activity to the patient. “The menu of possibilities depends on the person’s possibilities, and preferences,” says Dr. Duperly. 3. Practice and promote the general principles of exercise prescription. Start with low doses, and then increase them gradually. “It is about progression and recovery with a healthy load, as well as considering resting periods, and identifying the patient’s exercise tolerance”. Other components of an activity prescription include frequency, duration, and intensity of the exercise, how many times a week, and for how long, and how hard each day.
A trail conducted in 2011 by Universidad Tecnológica de Pereira (UTP), one of the few publications referring specifically to colombian medical exercise prescription, is a guideline for physicians in this regard. Many elements must be taken into account, when making the appropriate exercise prescription, among the most important are intensity, duration, frequency, and stress progression. Also the prescription should be detailed, taking into account factors like heart rate (HR), blood pressure (BP), the scale of perceived exertion (RPE), and the response to exercise. The main objectives of exercise prescriptions are to improve the quality of life, and reduce risk factors. The art of exercise prescription is to successfully integrate science and behavioral, so that the objectives can be achieved harmonizing people with their ability to carry out a long term exercise1 program. It is paradoxical, knowing the benefits of physical activity for all sorts of people, doctors have recommended bed rest for many diseases, and at the same time they defend and promote exercise as part of the treatment of many sicknesses, especially cardiovascular (Grima & Calafat 2004).
Studies Show
CREATE A CULTURE FOR YEARS TO COME
Interestingly medical schools and health care systems have neglected exercise prescription despite the extensive literature about its benefits, a very different situation to what already happens with bad eating habits or smoking. Everything suggests that physical activity is effective and in some cases, more effective than pharmacological treatment, and medical interventions, including surgery2.
We call upon health care professionals to make exercise a habit that is part of the lifestyle, much the same way as they do with food or rest.
Much to the delight of the medical community, and the general population, the British Medical Journal (BMJ), one of the major medical publications in the world, in October
PROMOTION AND PREVENTION
The World Health Organization recommends at least 150 minutes every week of a moderate to intense exercise for a healthy body.
“There is a well studied group of illnesses, such as stroke, coronary disease, type 2 diabetes, breast and colon cancer, Alzheimer’s, Parkinson’s, depression and anxiety, where physical activity has a comparable effect to drugs, while it is less expensive, and has fewer side effects”, notes Dr. Duperly. In sum, BMJ raises the issue that any new drug that hits the marketplace should also have comparative trails with exercise, given its great potential therapeutic effects3.
EXERCISE AS A MEDICAL TREATMENT The following is a brief review of trails that investigated the benefits of physical activity on health, as well as on cognitive, social, and psychological wellbeing. And they lend the conclusion that exercise is the best available medicine of our time.
In Diabetes A trail published in early 2014 in JAMA concluded that increased physical activity can reduce the risk of gestational diabetes turning into diabetes mellitus type 2, or adult onset diabetes. With data from the Nurses’ Health Study II, a team of American researchers reviewed 4,554 cases of women with histories of this disease, and a follow up from 1991 to 2007. It turned out that 635 ladies, whom did not exercise, developed the disease4.
In Breast Cancer Recent research (2012) of the Provincial Board of the Spanish Association Against
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Cancer suggests physical activity and exercise offers many benefits for women with breast cancer. Hence the idea of starting an exercise program in patients who have suffered, and have been operated for such cancer5.
In High Blood Pressure The Mayo Clinic in March 2014 conducted a systematic review of the quantification of the effects of isometric resistance training on systolic blood pressure (SBP), diastolic blood pressure (DBP), and the mean arterial pressure in subclinical populations. They concluded that isometric resistance training improves these parameters. Even more, the magnitude of the effect is greater than previously reported with dynamic resistance and aerobic training. Data suggest that this type of activity has the potential to produce a significant reduction in blood pressure, exercise could be a very useful complement6.
In Chronic Diseases Trails comparing the effectiveness of exercise versus drugs, in patients with chronic illnesses, turned out that physical activity was recommended for coronary disease, stroke, and diabetes. The results of this metanalysis suggest that exercise is as effective as many drugs preventing death in these patients7.
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2013 carried an article that included the most relevant evidence on the benefits of exercise compared to pharmacological treatment. The megatrail joined the London School of Economics, Harvard University and Stanford University the States, gathering the most accurate international evidence on the benefits of physical activity, especially its implications on health care economics comparing it with drug use and traditional interventions.
In Survival According to a study conducted by researchers from the department of epidemiology at the University of North Carolina (USA) published in the journal Cancer, endorsed by the American Cancer Society, that exercise acts as a protective factor in patients diagnosed with breast cancer. Mortality rates declined by 34% in patients whom reported higher levels of physical activity when compared with those who did not8.
A Conclusion Regarding Exercise According to experts and recent data, physical activity has shown to contribute to mental health and, it is an important factor for happiness, even though psychological and philosophical concepts, there are many aspects that have been studied in medicine. Such as improving social relationships, with a positive attitude, self-confidence, improving self esteem, efficacy, all components of modern life worth mentioning, because, ultimately, it is one of the most important points when a person talks about the motivations for exercise.
References 1. Giraldo JL, Castaño PA. Conocimientos y actitudes para promoción y prescripción de la actividad física de los médicos generales de la nueva EPS en Pereira. Dosquebradas: Universidad Tecnológica de Pereira, Facultad de Ciencias de la Salud, Programa de Ciencias del Deporte y la Recreación; 2011. 2. http://johnduperly.com/el-ejercicio-a-la-altura-de-tratamientos-medicos-tradicionales-2/?utm_content=buffer8bd2a&utm_medium=social&utm_source=facebook. com&utm_campaign=buffer 3. School of Economics and Political Sciences (London, United Kingdom), Harvard School of Mdicine and Harvard Pilgrim Health Care Institute (Boston, MA, EE. UU.), Stanford University School of Medicine (California, EE. UU.). Naci H, Ioannidis JP. Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study. BMJ 2013;347:f5577. 4. Pan A, Sun Q, Bernstein AM, Manson JE, Willett WC, Hu FB. Changes in red meat consumption and subsequent risk of type 2 diabetes mellitus: three cohorts of US men and women. JAMA Intern Med [internet] 2013;173(14):1328-35. Available in: http:// archinte.jamanetwork.com/article.aspx?articleid=1697785 5. Find the complete annual review 2012 at, https://www.aecc.es/Comunicacion/ Informeanual2012 6. Carlson DJ, Dieberg G, Hess NC, Millar PJ, Smart NA. Isometric exercise training for blood pressure management: a systematic review and meta-analysis. Mayo Clin Proc [internet] 2014;89(3):327-34. Available at: http://dx.doi.org/10.1016/j. mayocp.2013.10.030 7. Overview Mueller PS de Naci H, Ioannidis JP. Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study. BMJ 2013;347:f5577. Available at: http://www.jwatch.org/na32439/2013/11/05/comparative-effectiveness-exercise-vs-drug-interventions#sthash.6UfllreD.dpuf 8. http://www.elhospital.com/temas/La-falta-de-ejercicio-podria-disminuir-la-sobrevidade-las-pacientes-con-cancer-de-seno+98158
FROM COOMEVA
Your secretaries, assistants and administrative staff are also important to us.
S E C R E T A R Y D AY
CELEBRATION OF PROVIDERS ASSIGNED TO COOMEVA MEDICINA PREPAGADA
C
OOMEVA MEDICINA PREPAGADA celebrated the traditional Secretary Day with a massive participation of secretaries of health professionals and billing staff and admissions of main clinics nationwide.
Discoteca Bendito - Bogotá May 7th 2014.
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This year, the cities of Cali, Bogotá, Medellín, Bucaramanga and Barranquilla were filled of colors with the party Pink Happy Secretary's Day.
Disco 40 – Medellín April 23th 2014.
Discoteca Zambomba – Cali April 30th 2014.
The flashes of cameras, the shows and surprises, turned them into the stars of the night.
María Casquitos Parrilla Bar – Bucaramanga May 9th 2014.
Discoteca Simón Dice – Pereira April 30th 2014.
Meanwhile, in the city of Pereira were encouraged with Carnival Mundialista. The euphoria, the World Cup styles and whistles showed the joy of the audience.
Distrito Restaurante Bar - Barranquilla May 8th 2014.
MEDICAL WORLD
EVENTS ‘III International Course of Foot, and Ankle Surgery’
BOOKS ‘Oftalmodatos’ Oscar Jaime Velasquez Gaviria, MD This is a practical pocket book that provides the student, doctor, resident, or even an experienced ophthalmologist, with the necessary tools to understand the anatomy of the eye and the adnexa, it also includes the physiopatholgy, clinical manifestations, diagnostic criteria and the therapeutic alternatives. And it includes the International Classification of Diseases (ICD-10) for the proper registration of patients and pathologies.
Date and place: September 4th through 6th, Medellin Information: Sociedad Colombiana de Cirugía Ortopédica y Traumatología Phone: (1) 625 7445 Email: secretaria@sccot.org.co Website: www.sccot.org
‘V International Symposium on Diagnostic PET-CT Imaging in Oncology’ Date and place: October 24th and 25th, Medellin Information: Centro Avanzado de Diagnóstico Médico Phone: (4) 444 0019, ext. 155, 157, 176 Email: simposio@cedimed.com Website: www.cedimed.com
FILM ‘The Notebook’ Directed by Janos Szasz Starring: Gyemant András László Gyemant, Piroska Molnár The film tells the story of the twins Egyik and Masik, who move to their grandmother’s shortly before the end of World War II, in order to elude the horrors of violence. However, when they reach the village times are rough, full of death and sadness. And every night they write about suffering in the notebook, entries that narrate the way their personalities develop within the hardships of the adult world.
MUSIC
General
Maroon 5 has ‘Maps’
Pascual Estrada Garcés, MD National Medical Director Coomeva Medicina Prepagada
The award-winning Californian pop rock group, presents a new song which suddenly became the first single from the upcoming album entitled V. It features the production of Max Martin, Benny Blanco, Ryan Tedder, Shellback, and Sam Martin. This work is a reunion of the band with the original keyboardist, Jesse Carmichael, after a break during the recording of Overexposed, his most recent album of 2012.
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manager
Coomeva Medicina Prepagada
Jorge Alberto Zapata Builes
Editorial Meeting
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