Boletín Coomtacto v.8 - ingles by PROSPERTECH SA

Newsletter

for health professionals of Coomeva Medicina Prepagada ISSN 2011-3579

Vol. 8

CONTENT 4

Juan Mendoza Vega, MD ‘Dignified death is much more than euthanasia’

HEALTH UPDATE Genetic compatibility tests A key preventive tool

Ambulatory thyroidectomy Savings and benefits for the patient

PROMOTION AND PREVENTION

We all have the obligation to feed the world better

EBM

New therapeutic alternatives suggest patients could eventually be free of hepatitis C

ACKNOWLEDGEMENTS 16  A standing ovation to the literary work of Dr. Emilio Restrepo  Let’s give a round of applause to the 35 years of Radiólogos Asociados

FROM COOMEVA

 Well prescribed medicines  Seniors are a priority for Coomeva Salud Prepagada  Unemployed, or temporarily disabled? Do not get left out of Coomeva Medicina Prepagada

MEDICAL WORLD BOOKS, REVIEWS AND EVENTS

July 2015

Coomeva Medicina Prepagada

INTERVIEW

RESEARCH REPORT

No. 2

IS AT THE FOREFRONT OF TECHNOLOGY FOR AN EXCELLENT SERVICE Our main goal is to exceed the expectations of the community, the users, health care professionals, and institutions, as well as the suppliers that work with us fulfilling our mission, so we are undertaking a technological renewal. The Core project, which is being implemented right now, is intended to cover the whole structure of Coomeva Medicina Prepagada. It is focused on achieving the modernization of the whole operating platform and the information flow, which definitely will place us at the forefront among other organizations of the kind. We intend to introduce changes in our culture, a new vision of service, care, and compliance concepts, which will result in welfare for our users. This project has four key features: 1. To optimize the processes, implementing new software that will allow a strategic automation of our operations, with the reduction and control of organizational risk, while increasing the commercial flexibility of our company. 2. More, and better, channels to access virtual services in order to avoid unnecessary, and uncomfortable, displacements of our users, with higher levels of satisfaction. Automated services and transactions benefit not only the affiliates, but also the community at large, they are intended to reduce the consumption of stationery, while minimizing response times. 3. The application of these new technical and administrative tools within a new Internet architecture, supported by an essentially service-oriented advanced technology, and the implementation of real time monitoring tools will simulate and optimize each function. 4. Expanded monitoring, traceability, and accurate information management will enable us to serve a greater number of loyal customers, optimizing resources, and attracting new market opportunities. These transformations come in time to support the strategies of the organization, making it more competitive and contributing to the improvement of the quality of life of our family members.

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Medicina Prepagada

INTERVIEW

uan Mendoza Vega, MD

‘DIGNIFIED DEATH IS MUCH MORE THAN EUTHANASIA’

The voluntary decision to end life by a terminal patient was legalizad 17 years ago in Colombia, and only until now it is about to be regulated. This issue continues to be very controversial in our country. Dr. Juan Mendoza Vega, president of Academia Nacional de Medicina, and Fundación Pro Derecho a Morir Dignamente, gave Coomtacto newsletter an interview on this complex issue in health care, the decision life and death. In resolution 1216, april 2015, Ministerio de Salud y Protección Social sets the legal grounds allowing every colombian to decide how he wants to die when there is no hope of a prolonged life. An initiative that also includes euthanasia. While the General Solicitor is against it, and opposed the law before the State Council, Juan Mendoza Vega, a physician and a neurosurgeon, expects the best decision will be taken for the sake of all Colombians.

How did you receive this decision? What do you think about it? I believe the resolution was well done. It has no formal faults. Even though it is incomplete. It lacks some elements because the Ministry could not regulate what the Court did not ask for. In essence, it refers to people’s right to a dignified life, which ends with a dignified death. Death is the end of life. 17 years ago that was accepted by the Court. Noting that one of the ways to die with dignity, when terminally

Photos: Gerardo Gómez

He is an expert on the topic, and an activist of the right to die with dignity movement, Dr. Mendoza is our guest for this edition.

ill and suffering terribly, without the slightest possibility of improvement, is the alternative of asking the doctor: “relieve me of this suffering, give me euthanasia.” This court decision has been applied through sentence C-239, 1997. But some doctors, many I would say, and people whom are not doctors, were afraid because it was not a law only a sentence by the court. Now, with the case of a lady whom at first was not taken seriously, in response to her request the Court urged the Ministry to define the situation. Does this mean every doctor is required to give the procedure when a patient requests it? No. The doctor is not required to do so if he has a conscience objection. But this cannot be an obstacle for the patient’s decision. The physician must notify the patient’s EPS to convene an ‘interdisciplinary scientific committee for the right to die with dignity’, consisting of three people (a physician specializing in the patient’s disease, not the patient’s doctor, a lawyer, and a psychiatrist or a clinical psychologist), as it is required by the resolution, and they are expected to acknowledge if the application meets the criteria the Court requires for those authorizations. If the physician has conscience objection, he should express it, and the committee will designate another doctor with no such objection to meet the patient’s wish of euthanasia. His creed may be Catholic, Christian, Buddhist, that is not under discusion, it must be respected. But that doesn’t preclude the patient’s rights.

“If the physician has conscience objection, he should express it, and the committee will designate another doctor with no such objection to meet the patient’s wish of euthanasia”.

What are the provisions established by the Court? In the case of euthanasia, the committee decides whether the request meets the Court’s requirements, and the patient’s initiative should be respected. If not, when it doesn’t comply, it is rejected. We are refering to terminally ill patients. Article 2 of Law 1733, 2014, defined terminally ill as “anyone with a grave disease or condition that has been accurately diagnosed by an expert physician; a progressive and irreversible ailment with a fatal outcome in a relatively short time, which is not susceptible to a proven curative treatment, modifying the imminent death prognosis; or when the therapeutic medical resources used are no longer effective. “ And isn’t palliative care enough? Palliative care is fundamental. Anyone who suffers should receive care, and treatment. If their is no cure, palliative care is used, for example, with pain management. The resolution from the Ministry established that palliative care is required before deciding on euthanasia, it should not be a desperate request. For instance, if the patient does not recieve adequate pain treatment, he could says, “I want to die, I’d rather die, I cannot take it anymore.” But it is not that simple. First, the pain has to be treated in the best possible way, and if it is not enough, then the case has entered into the authorized field by Corte Constitucional.

INTERVIEW

How is euthanasia defined? Euthanasia is the medical act requested by a patient suffering intolerably, and the doctor agrees to comply with that request, providing him with what is needed to die as painlessly as possible, after exhausting, and having offered all existing therapeutic alternatives. Also the patient may decide not to receive a treatment, and he is entitled to do so. Euthanasia is not offered, not imposed, and not required. The patients asks for it, for himself, not for anyone else. Therefore, according to the Ministryâ&#x20AC;&#x2122;s decision, when a person is unconscious and cannot express his will, it authorizes euthanasia only if there is a previous demonstration, a document. If not, it cannot be done. No one owns the life of another person. What is the difference between euthanasia and a dignified death? Dignified death is more than euthanasia. Euthanasia is a

form of dignified death, not all dignified death. A death with dignity is to die as a person choses to do so. Pope John Paul II, for instance, died while suffering terribly, and he had a dignified death, by his religious beliefs suffering was necessary. Another case is when a person does not want to go to the hospital, because he prefers to die at home. But that doesnâ&#x20AC;&#x2122;t mean he is abandoned, a dignified death includes that the patient will recieve all that he needs to relieve this part of his life. Does it apply only to adults? Yes. Because we are all owner of our own lives, and it is not possible if we donâ&#x20AC;&#x2122;t have enough judgment to decide for ourselves. Neither is it aceptable for an adult to give such a sensitive authorization. In Holland, for instance, they consider that children are also entitled to freedom, so they authorize it in certain very special situations.

HEALTH UP TO DAY

A key preventive tool

With these tests it is possible to make preconception diagnosis allowing parents to take early actions to delay the onset of certain inherited diseases, and even prevent them; some of these illnesses could be fatal or very disabling.

Up until a few decades ago it was very difficult to anticipate the risk of inheriting certain diseases and abnormalities. But today, with medical and scientific advances, it is possible to identify them, and decide what to do. For instance, the use of assisted reproduction techniques can minimize the possibility of inherited diseases like cystic fibrosis, and entering preventive protocols can delay the onset, and even avoid them. “According to the way characteristics are inherited, or encoded by the genes, diseases can be classified as defects in a single gene, a chromosome, or multifactorial disorders,” says Dr. Paula Margarita Hurtado V., a specialist in Medical Genetics (Pontificia Universidad Javeriana in Bogota), currently working at Centro Médico Imbanaco in Cali.

TYPES OF INHERITANCE There are several ways to inheriting these illnesses, we will only mention three of them. The most common is the autosomal dominant gene, which, according to Dr. José Ignacio Madero Cervera, director at Clínica Eugin Colombia, a reproductive medical center, “it occurs when a single altered allele dominates over the normal one, and that abnormality by itself

is enough for the disease to express itself. The gene is autosomal, so it can be found in any of the 22 pairs of non sexual chromosomes, making it is equally likely in boys and girls, also it can be inherited from the father or the mother, and it usually occurs in all generations of the family. “ Other cases of inheritance are linked to the X chromosome. Remember women have two X chromosomes, while men have one X and one Y. “They usually occur in men, and the mutant allele is inherited from the mother. The affected male will transmit the mutant allele, so the daughters will be carriers, while

ENETIC COMPATIBILITY TESTS

RARE CASES ARE SCIENTIFIC CHALLENGES Currently a large number of genes are known to be involved in many diseases, and for some of them there are several genes. Also many times specific pathogenic genes cannot be identified beforehand, because they are unknown. In these cases a genetic exome analysis is indicated. It studies genes that encode for proteins and regulate cell functions. After a thorough evaluation of each case by a specialist in human genetics through genetic counseling, two types of exome analysis are available: • Directed clinical exome: it is used to confirm a defined clinical diagnosis when there is a high genetic heterogeneity. These are situations where the differential diagnosis is very complex, many genes could be involved, or it is impossible to select a set of genes. It is used for cases like mitochondrial myopathy, imperfect osteogenesis, and Charcot-Marie-Tooth. • Full clinical exome: it is used with patients having nonspecific syndromes with high genetic heterogeneity, also when conditions mentioned above are satisfied but there is no particular gene set to be selected. This strategy is suitable for cases of autism, epilepsy, mental retardation, and some types of deafness.

the sons will manifest the disease, because they have a Y chromosome instead of another X”, says the specialist. Finally, there is mitochondrial inheritance. These abnormalities come from the genes in the mitochondria, which can only be inherited from the mother. “Sons and daughters of affected woman will equally inherit the mitochondrias containing the mutation, and will eventually manifest the disease. But, on the other hand, if the man is affected, there is no risk for his children,” he notes.

TIMELY AND SPECIALIZED CONSULTATION If there is a family history of a genetic disease, the parents have a certain degree of consanguinity

(for instance, they are cousins), and if one of the parents is affected by a known genetic condition, among other strategies, the recommendation is, says doctor Hurtado, to go to a preconception appointment with a gynecologist and a geneticist. Together they take into account the characteristics of each case, in order to advice parents on the possibilities for the children with genetic diseases. “Fortunately, today several diseases can be diagnosed with specialized consultations, family studies, and laboratory test. It is also possible to determine in some cases the risk of having a second child with the same disease”, says the specialist. “One of the latest services available for these couples are genetic compatibility tests”, said Dr. Madero, “in order to make a preventive preconception diagnosis, these tests can search a 1,000 mutations related to some 200 genetic disorders. Information that is useful for couples whom want to anticipate risks.” “Other studies that can be conducted are basic cytogenetics, such as a karyotype, which gives a general idea of the conditions of the chromosomes, both numerically and structurally,” said Dr. Madero. It is also possible, as Dr. Yeni Patricia Rodríguez Sanabria, a trained in cancer genetics physician whom works at Clínica del Country explained us, through a genetic inheritance panel 25 genes associated with hereditary cancers (for instance, breast cancer) can be evaluated. But prevention and early cancer detection programs are recommended only

HEALTH UP TO DAY for very selected patients, meeting certain criteria, people with alterations, or whom are known to be mutation carriers. And when the child turns into an adult, he can also test these diseases.

In other cases, like when patients who do not have children are known to be mutation carriers, they can use assisted reproductive techniques to implant in the uterus previously studied healthy embryos.

FREQUENT INHERITED GENETIC DISORDERS These are some of the inherited abnormalities which are highly prevalent in our population: • Achondroplasia: it is an alteration that belongs to the family of the osteochondrodysplasias, causing 70% of cases of dwarfism. Mutations in the FGFR3 gene cause it. This gene carries the information for the receptor of the fibroblast growth factor type 3, a protein related to the control of the growth processes of the cartilage. The mutation causes a decrease in the proliferation of these cells, leading to less longitudinal bone growth, and the symptoms of the anomaly. • Cystic Fibrosis: it is an alteration of the secretion of mucus, so it affects many systems of the body. It is a highly lethal condition. Disruption of the CFTR gene (cystic fibrosis transmembrane conductance regulator) is responsible for this syndrome. • Amyotrophic Lateral Sclerosis (ALS or Lou Gehrg’s disease): it is the progressive loss of motor neurons (nerve cells that regulate muscle movement). It is a progressive, debilitating, and ultimately fatal alteration, because eventually the person will lose the ability to breath, swallow, speak, and walk. Only one in 10 cases has a recognizable genetic origin, the rest are unknown. • Fragile X syndrome: it mainly causes developmental problems, including learning problems and mental retardation. It can appear in men and women with equal frequency. Anxiety, hyperactivity, uncontrollable physical movements, and attention deficit, are common manifestations of the condition. In the early 90s, scientist discovered its cause was a mutation in FMR-1 gene located on the X chromosome. It encodes protein FMRP that participates in the transmission of nerve impulses. Because the X chromosome is altered, it is more frequent and severe in males. • Thalassemias: a group of blood diseases caused by an abnormal hemoglobin, it is a deficiency in alpha globin and beta globin, hemoglobin subuints. In severe cases, newborns have anemia

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and heart failure, usually they are stillborns or die within hours after birth. Alpha thalassemia affects HBA1 and HBA2 genes, related to alpha globin production. While beta thalassemia is associates with mutations in HBB gene, that encodes for the beta-subunit. • Marfan syndrome: is a connective tissue alteration that affects the whole body. These patients are very tall, elongated if you will, with long limbs, and excessive joint flexibility. Also they have deformities in the chest, frequently accompanied by respiratory problems, and sleep apnea. It is caused by mutations in the FBN1 gene, which encodes fibrillin-1, a protein essential for normal connective tissue synthesis. It can be found in bones, lungs, the ligaments of the lens, and large arteries, like the aorta. • Hemophilia: is a disease that interferes with blood clotting because of a lack of coagulation factors. Hemophilia A is caused by mutations in the F8 gene that encodes for coagulation factor VIII, while hemophilia B is due to mutations in the F9 gene, which affects factor IX. • Huntington’s disease: is a neuronal degeneration causing involuntary movements, loss of cognitive abilities, and emotional conflicts. It affects main basal ganglia cells, a structure in the brain related to some types of memory and movements. But it can also affect the brain cortex, the outer surface, which is associated with thought, and perception. This disorder is due to a mutation in the HTT gene, which encodes for the Huntington protein, and its alteration leads to neuronal death in the brain. • Phenylketonuria: it is a decrease or absence of the phenylalanine hydroxylase enzyme, or PAH, necessary convert phenylalanine into other substances the body needs. The resulting accumulation of phenylalanine is toxic to the nervous system, causing severe damage, and mental retardation. Other less frequent inherited syndromes are Duchenne muscular dystrophy, sickle cell anemia, celiac disease, and Noonan syndrome.

RESEARCH

REPORT

Ambulatory thyroidectomy

SAVINGS AND BENEFITS FOR THE PATIENT

Thyroidectomy is perhaps one of the most frequent surgical procedures of endocrinological nature that takes place in the neck. It is indicated in patients with pathologies whose symptoms include malignant nodules, diseases that are resistant to conventional treatments, and compretions of the airway, the digestive tract, and masses on the thyroid region. It is performed in the hospital, the patient stays overnight so he can be monitored during the first 24 hours. However, a recent study by the surgeon Álvaro Sanabria, and three coauthors, suggest that this operation can be done safely and cost effectively in an outpatient basis. This research on 44 patients, 23 outpatients, and 21 hospitalized, took into account variables like age, sex, type and indication of the surgery, surgical time, hospital stay, complications and costs. “We monitored the patients during the six hours following the procedure, and if no complications appeared, we sent them house. They usually present themselves initially, while the other 18 hours do not contribute significantly to safety. Instead they increase health care costs, because they involve bed occupation, medications, and personnel,” explains Dr. Sanabria.

PROFILE

ÁLVARO SANABRIA, MD (Professional assigned to Coomeva Medicina Prepagada)

Dr. Sanabria is a doctor from Universidad Nacional de Colombia, with a specialization in General Surgery at Universidad de Antioquia. In 2005 he earned his Master Degree on Clinical Epidemiology at Universidad Javeriana, and in 2011 he graduated from his Master Degree on Health and Medicine Economics at the University Pompeu Fabra. His long experience in head and neck surgery is his subspecialty, he graduated from Fundação Antonio Prudente, do AC Camargo Cancer Hospital in Sao Paulo (Brazil). This professional has many awards for his research, and is a member of distinguished institutions, such as Asociación Colombiana de Cirugía, the Brazilian Society of Head and Neck Surgery, the American Thyroid Association and Asociación Colombiana de Cirujanos de Cabeza y Cuello.

BENEFITS OF OUTPATIENT SURGERY This research showes this procedure is safe without hospitalization, as it has also been shown in other countries, like the United States. No statistically significant differences were found in relation to age, type of thyroidectomy, surgical time, nor indication for the surgery. However, according to this study, there are certain criteria for a candidate for an ambulatory thyroidectomy. “These are healthy patients under 65, without other diseases, like diabetes, hypertension, nor heart disease, whom are living relatively close to the hospital, so that if there are any late complication, the patient can quickly go to emergency, and he does not live alone, he has company at home,” says the professional. Further more the benefits to the patient are notorious. First, the exposure to nosocomial infections is minimized. It is also comfortable for the patient, since he

will be at home, and he can rest more, and better in his privacy. The calculations showed the cost reduction of the outpatients was approximately 400,000 pesos per patient. This study will help evaluate the possibility of implementing and popularizing this type of surgery on an outpatient basis, taking into account the patient’s safety, while providing maximum benefit. “The idea is to show colleagues that an outpatient thyroid surgery can be done safely following specific criteria. We want to show that it is as adequate as for the inpatient, but with the advantages that the hospital bed can be used by another patient who probably needs it more,” says the specialist.

We encourage our health proffesionals to share with us their experiences research topics, academic activity or community programs. In this way we can enrich this section providing its achievements and developments in their professional work. Write to prestadores_coomeva@coomeva.com.co

PROMOTION AND PREVENTION

E ALL HAVE THE OBLIGATION TO FEED THE WORLD BETTER

Farmers, manufacturers, and consumers are just three links in a chain that should be perfect, to prevent food contamination, and thereby threatening global health. WHO is promoting an initiative to implement immediate preventive strategies. According to the World Health Organization (WHO), unsafe food is related to the deaths of some two million people every year, most of them children, elderly, and sick patients. It happens when some part of the process of the food chain is contaminated, infected with bacteria such as Salmonella, Campylobacter and Escherichia coli, as well as viruses, parasites, and fungi. But it can also be due to harmful chemicals, such as heavy metals like lead, mercury, and cadmium. And many cases are related to air, water and soil pollution. Globally, these factors can cause more than 200 diseases, ranging from diarrhea to severe gastrointestinal disorders, malnutrition, poisoning, and even some cancers. WHO says it is a growing problem despite continuous campaigns and programs constantly and globally put into motion. So much so that to mark World Health Day 2015 the theme was “Food safety”, a conference that took place in

April, and extended the rest of the year in order to remain vigilant strengthening these initiatives in several countries, always taking into account their characteristics and needs, eventually leading to the reduction of high rates of malnutrition and mortality. WHICH ARE THE HEALTHY FOODS? “Food safety is defined as the conditions and actions during production, storage, distribution, and preparation that can ensure that once ingested they do not pose a significant health risk. We cannot do without food safety as a part of the quality criteria, because it is a fundamental aspect, “says a publication of Ministerio de Salud y Protección Social. The aim, as stated by WHO, is to have “safe foods from the farm, and the sea, to the table”. This goal involves governments, farmers, fishermen, manufacturers, retailers, wholesalers, health care professionals, food engineers, salespeople, universities, and the general population. The plan is to develop a comprehensive approach towards “ensuring that food is free of risks and contaminants. The objective is to strengthen each link in the complex process of the food production chain, so that products reach the consumer safely, because a faulty link, especially if it is at the beginning, can ruin the whole food chain, “says Adriana Coral Durango, a member of the board of Asociación Colombiana de Ciencia y Tecnología de Alimentos (ACTA, for its acronym in Spanish). Thus the mission is to strengthen food safety, as defined by the United Nations for Food and Agriculture Organization (FAO), “when all

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people, at all times, have physical and economical access to sufficient safe and nutritious food required to meet their dietary needs and preferences, in order to lead active and healthy lives”1.

WHAT YOU SHOULD NOT FORGET Alicia Cleves Huergo, a nutritionist at Centro Integral de Medicina y Nutrición (Cinumed), stresses the importance of “controlling the products that will be consumed, to establish if the food chain has been compromised, if it has had an adequate sanitary control. This includes buying in safe and trustworthy places, but also looking at expiration dates on the packages, and following instructions on the proper handling, storage, and preparation.” Also, WHO and FAO have defined five keys strategies for food safety3: 1. Cleaning. Wash your hands thoroughly after using the bathroom, and before preparing the food, and often during the process. Also, wash and disinfect all surfaces and tools used in the kitchen. 2. Separation. Red meat, poultry, and seafood should be separated from other foods, and, to manipulate them, you must use different utensils, such as knives and cutting boards. 3. Cooking. Red meat, poultry, eggs, and fish should be well done, avoid raw foods, this procedure kills almost all dangerous microorganisms. 4. Temperature. Keep food at safe temperatures when chilling, freezing, or eating. 5. Pure water. Wash fruits, and vegetables with clean water, especially if you are going to eat them raw.

ACTIONS THAT MULTIPLY THEMSELVES Today the food industry in Colombia invests heavily on safety, as well as in controls of raw materials, and on educational campaigns for people that participate in every link of the food chain. ACTA, for instance, has developed a strategy called “Towards a well-fed society, an all out effort”, it works in favor of changes in the diet of the population towards organic products, free of pesticides and other contaminants, as well as the correct handling and storage, which not only involves doctors, nutritionists, and patients, it also includes food engineers, retailers, distributors, restaurateurs, even small food stall owners. Ministerio de Salud y Protección Social has issued guidelines on sanitary and phytosanitary strategies (SPS), after all it is the governing body for the policies on food safety2. Also other entities, such as Instituto Nacional para la Vigilancia de Medicamentos y Alimentos (Invima), Instituto Nacional de Salud (INS), and regional authorities, are involved in this project. It is a matter of education, states Jorge A. Cabrera, a member of the ACTA board. “You have to educate people who harvest in order to handle food properly at all levels, also industry, to work in compliance with control, health and distribution food standards, as well as retailers, consumers, and professionals, in short the whole society. Better regulations will pay off shortly.“

REFERENCES 1. http://www.fao.org/americas/perspectivas/inocuidad/es/ 2. http://www.minsalud.gov.co/salud/Documents/general-temp-jd/SISTEMA%20DE%20MEDIDAS%20SANITARIAS%20Y%20FITOSANITARIAS%20-%20MSF.pdf 3. http://www.who.int/foodsafety/publications/consumer/ manual_keys_es.pdf

EBM

New therapeutic alternatives

UGGEST PATIENTS COULD EVENTUALLY BE FREE OF HEPATITIS C

The side effects of conventional treatments, and their severe impact on the liver, motivated the research for new treatments. And the future seems promising to offer an excellent outlook.

due to the inability of the liver to remove toxins from the blood,” says Dr. María Luisa Yataco, a specialist in the Transplant Department of the Division of Gastroenterology and Hepatology at the Mayo Clinic at Jacksonville (Florida, USA).

Medical research shows encouraging results in the fight against hepatitis C, controling it, and treatment it, improving life expectancy, and its quality, for those who have already had irreversible damage to the liver, and have undergone a liver transplant.

Although there are effective treatments for this condition, drugs do not always work, and they have adverse effects (anemia, depression, flu symptoms, insomnia, etc.), wich are sometime severe, leading the patient to abandon the therapy (non-adherence to the treatment).

This is important news considering hepatitis C virus (HCV), according to the World Hepatitis Association, which brings together more than 200 patient groups, and in agreement with the World Health Organization (WHO), affects over 170 million people in the world1.

But new combinations allow faster and less toxic treatments of hepatitis C, including for those patients with liver transplant, whom are at risk of infecting the new liver. A few weeks ago, at the American Association for the Study of Liver Diseases, in Boston, researchers at the Mayo Clinic reported that the use of two new oral medicines after transplantation are

In general, in hepatitis the liver is inflamed, an ailment frequently due to an infectious disease (viral or bacterial), many of them blood transmited, but it can also be caused by immune defects (low defenses and antibodies), and toxicity (alcohol and certain medications), among other causes.

Several viruses cause hepatits, and hepatitis C accounts for up to two thirds of the newly diagnosed cases of chronic hepatic disease, and 40% of all organ transplants. It is also a frequent cause of acute liver failure, “the progressive deterioration of liver function, with a sudden and intense onset, which can trigger hepatic encephalopathy, an alteration of the brain

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Hepatitis is a silent enemy, explains internist and hepatologist Jaime Holguín, it usually doesn’t appear until it is late, that is, “initially, there are no symptoms when the virus is just starting to cause liver damage, patients eat normally, they have no jaundice, they feel healthy, and strong. “

Experts see this treatment as a great source of hope for patients, given that in the clinical phases of the study not only was there a notorious improvement on the patients, but also a ginormous decrease of the side effects. safe, beneficial, and require only 12 weeks of treatment. “This is the first study on the use of these two new medicines (simeprevir and sofosbuvir) for liver transplant recipients. A better option than the current treatment, both before and after transplant. It is a major clinical advance,” said the lead researcher, Dr. Surakit Pungpapong, transplant hepatologist and associate medical professor at the Mayo Clinic. Dr. Pungpapong also states it is a very strict protocol, and as it advances within the clinical trail stages, it is becoming a fundamental tool in the fight against hepatitis C, considering the current standard treatment before and after transplant is based on the use of interferon in combination with ribavirin, and, although this combination has been useful, because it benefits the immune system fighting hepatitis C virus, the immune response can also lead to the organ rejection. “Interferon can cause a variety of side effects, including anemia, irritability, and even hair loss, among others.” The new guidelines seek to combine it with other medicines in lower doses, and even use only the new molecules without interferon. For now, large-scale clinical trials are on the way, and they are yielding favorable results. For this particular study, Mayo Clinic researchers made extensive monitoring of post-transplant patients in Rochester (Minnesota), Scottsdale (Arizona), and the Transplant Center at the Mayo Clinic at Jacksonville (Florida), one of the five most active liver transplant program in the States2.

NEW FINDINGS Additionally, in late April 2015, at the 50th Annual Meeting of the European Association for the Study of the Liver, held in Vienna (Austria), hepatitis C was again a central issue, and results were announced of several phase 2 trials supporting the use of Harvoni (ledipasvir 90 mg/ sofosbuvir 400 mg) and Sovaldi (sofosbuvir 400 mg) to treat hepatitis C patients with advanced liver disease. Some of these projects were led by Gilead Sciences, Inc., an american biotechnology company. “Patients whom participated in these studies had serious complications, and were considered difficult to treat and cure,” said Dr. Michael P. Manns, professor and chair of the Department of Gastroenterology, and Hepatology at Hannover Medical School in Germany, for whom there is new hope with these results, not only were they favorable, but also side effects were significantly low, with good tolerance, and adherence to the treatment. In the future, when the clinical trails are completed, and it is approved for the use in patients with hepatitis C, they will definitely change the course of this cripling infection.

BIBLIOGRAPHY 1. http://www.journal-of-hepatology.eu/article/ S0168-8278(14)00621-7/fulltext 2. http://www.mayoclinic.org/

ACKNOWLEDGEMENTS

standing ovation to the literary work of Dr. Emilio Restrepo

Although many have not noticed, medicine and literature have gone hand in hand throughout history, and they continue to do so. Colombian obstetrician and laparoscopic surgeon Emilio Restrepo has over 25 years of experience in his medical practice, alternating it with his literary talent. From an early age the doctor felt the desire of storytelling, and now he has combined his two passions taking medicine as a source of inspiration for the creation of successful works, like El pabellón de la mandrágora. A novel based on the stories he heard during his hospital practice. It was awarded with “Beca a la creación” of the municipality of Medellín. Similarly, his book “Crónica de un proceso”, is an outstanding novel that revolves around the stresses of a gynecologist. “Real life, what one knows and lives, in this case my work, my relationships, my family, and my neighbors allow me to capture elements, change them, and create fictions. Now 10 works have been published, and 15 are still unpublished,” says Dr. Restrepo. Among his writings, thriller stands out. A variant of detective prose, which explores the underworld of cities, and the

motivations of the criminal world. Its characters include Joaquín Tornado, a detective whom becomes the main character of his stories. The writings of this health care provider of Coomeva Medicina Prepagada in Antioquia for the last 20 years, are also recognized in academic literature. He has published in renown scientific journals more than 20 medical articles in his field, many of them arising from within the medical faculty at Universidad de Antioquia. Furthermore, doctor Restrepo is a general editor, and a medical editor of gynecology textbooks. Through his work, he has earned important ackowledgements, local, national, and internationally, including poetry prizes, and a first place in the Envigado novel contest, as well as in several scripts contests. He was also a finalist in the Mario Vargas Llosa Short Story Award, organized by FIL in Arequipa, in 2011, and also in the script competition “Novelas de Películas”, organized by Buenos Aires Negra in 2014.

et’s give a round of applause to the 35 years of Radiólogos Asociados

Last May 8 Coomeva Medicina Prepagada gave a due recognition to the company Radiólogos Asociados for lifetime achievements, after 35 years serving patients with conventional radiology, ultrasound, first, second and third level, CT scans, mammograms and interventionism. In a private ceremony a commemorative plaque was given in the management office of Coomeva Health Sector. In that ocasion it was recognized that the work begun by Dr. Blas Cárdenas Martínez and Jorge Iván Ospina Alzate, standouts with its legacy, managing to meet the needs of hundreds of users who have had accessed their specialized services. “The relationship Radiólogos Asociados has had with Coomeva has been excellent, and we received this award with great joy,” said Dr. Francisco Javier Sánchez, manager and director of the organization. Currently, Radiólogos Asociados has offices in Pereira, north of Valle del Cauca, Villavicencio, and other areas. The organization has 220 employees committed to providing the best services possible with warmth and respect.

“We have achieved a level of over 98% satisfaction, and it has been two years since we started working for a new accreditation. We have an ISO 9000: 2008, and that allows us to be attentive to continuous improvement. We are constantly training our staff to achieve these goals,” said the manager. Coomeva Medicina Prepagada is proud to have this valuable provider in Risaralda, and wishes them many more years of success, and good experiences with their patients.

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FROM COOMEVA

ELL PRESCRIBED MEDICINES

For proper medical prescriptions by professionals working with Coomeva Medicina Prepagada, we highlight some of the key recommendations included in the operational annex of the contract of Coomeva Medicina Prepagada.

• Prescription do not contain corrections, deletions, acronyms, codes, secret signs, abbreviations, nor chemical symbols. • The identification and user name must be clearly recorded. • It contains the attending physician’s name, professional registration number, and the institution where the patient is being treated, if available. • Active ingredient, concentration, dosage, pharmacological presentation, quantity, in letters and numbers, frequency, and administration route.

1. Verification of the medical prescription Verify that the prescription is done by a duly authorized health care professional, with clear, readable and concise writing, and all the necessary information for administration, complying with provisions in Article 17 of the Decree 2200 of 2005, partially modified by Decree 2330 of 2006, as well as resolutions 1438 of 2007, 2330 of 2006, 1478 of 2006, 1403 of 2007, and those forthcoming that add or replace:

• The prescription should allow the confrontation between the prescribed medication and dispensed medicine in the case of an outpatient, as well as the diagnosis. • The dose of the medicine is expressed in metric system and, in special cases, in international units. • The prescription is less than 30 working days after issued. 2. Prepared prescriptions, not available vitals, nutritional formulas, and other products. These products regularly involve a special process by the logistics operator. The prescription requires the following information:  Signature of the attending physician, and professional registration  Information about the patient  Health care facility where issued  Generic name of the product  Dosage  Pharmaceutical form and concentration  Administration route, if required  Date of issue 3. Controled medicines The prescription should be issued on paper by Servicio Seccional de Salud, in original and two copies. The original is destined to the drugstore for Oficina de Salud Pública, a copy is for the distributor, whom must include the bill as a support, and the second copy is for the patient.

FROM COOMEVA

ENIORS ARE A PRIORITY

for Coomeva Medicina Prepagada

In strict compliance with the provisions in External Notice 000004 (about preferential treatment to the population over 60 years) issued by Superintendencia Nacional de Salud on March 20th of this year, Coomeva Medicina Prepagada is inviting all its health care providers to ensure that their service processes ensure special protection for the elderly. The notice states: “Special attention. People over 60 years are subject to constitutionally reinforced protection, demanding from the state and health care providers, priority and special health care services, without limiting their access to the health care services because of neither administrative formalities nor economic issues”. For this reason, since last March, we are providing all the necessary arrangements to enforce rigorously the following instructions:

• Full and timely delivery of medicines: when POS medicines are not delivered immediately, the sale must be guaranteed within the next 48 hours following the request, in the established place, unless the condition of the elderly is urgent; in this case, Coomeva Medicina Prepagada must ensure the prompt delivery of the medicine to the home of the patient or to the agreed place for that purpose, otherwise there will be administrative sanctions. It is mandatory to report delayed medicine applications by shortages of the product, as well as the proof of delivery. • Continuity in treatment: must be guaranteed for the elderly, with no interruption because of neither administrative nor economic reasons. • Service promotion and prevention: it is required to implement promotion and prevention programs which foster integral development, both physically and mentally for the elderly, in order to encourage healthy lifestyles, control chronic non communicable diseases, and reduce risks for these patients. • Customer service offices: must have sufficient and suitable accommodations to take care of the needs of elderly. Architectural barriers must be removed to ensure

• Timely care. General medicine, dentistry, medical specialties, and diagnostic support appointments: these areas shall be capable of scheduling appointments for each working day of the year in general medicine, dentistry, specialized medicine and diagnostic support for all 60 year old patients and older, within the next 48 hours. For reception of these requirements and scheduling the appointments, reliable and

secure remote channels will be implemented ensuring adequate services.

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• Dignified treatment: it is required to calculate the average users served during rush hours each month, and the minimum number of seats in each service office should be at least that average. And of all seats located in the offices for the users, those for the exclusive use of the elderly should be signaled in accordance with the percentage that this population represents in that particular site, without affecting the rights and prerogatives of other people with special protection, such as pregnant women and the handicapped.

easy access to the facilities, for instance, several story buildings must implement lifts or ramps, with optimal safety conditions, according to legal standards for such adjustments.

• Preferential attention: The offices must have adequate personal and infrastructure to serve the needs of the elderly, including logistical and technological tools allowing personal, agile, efficient, and effective services. Those who work in those offices should guide, accompany, manage, and respond in a clear, accurate, and timely manner to the user’s requirements. To meet them, they should have preferential booths with proper signals according to the following guidelines: of all the windows, those marked for priority attention must correspond at least to the same percentage of elderly population in the region covered by that particular office. This percentage should be established in accordance with the guidelines of Superintendencia Nacional de Salud. The work we all do together in order to socialize and enforce this special protection program will result in benefits for all, while abiding the law.

Contamos con tecnología de vanguardia para ofrecer los servicios diagnósticos visuales más precisos y confiables. Biometría Ocular Campos Visuales Paquimetría Tomografía Corneal Fotografía Ocular Topografía Corneal Angiografía Fluoresceínica Electrofisiología Ocular Sensibilidad al Contraste Ecografía Ocular RetCam 3 (para uso pediátrico) Microscopía Especular

Carrera 47 Sur No 8C-94 PBX: (2) 511 0200 opción 1 www.clinicaofta.com citas@clinicaofta.com Cali - Colombia

Te ayudamos a ver lo que siempre has querido!

FROM COOMEVA

Unemployed or temporarily disabled?

O NOT GET LEFT OUT OF COOMEVA MEDICINA PREPAGADA

With this new insurance policy, covering up to six installments of the Coomeva Medicina Prepagada bill, avoid jeopardizing something as important as your access to health care services. From now on, users of Coomeva Medicina Prepagada have the opportunity to purchase a special insurance policy, at preferential rates, which will cover the fees of the health care service if they are out of jobs, even without a just cause, or happen to have a temporary disability in the case of freelancers. Coomeva Medicina Prepagada offers this service for the welfare and safety of its members, through a partnership with Coomeva Corredores de Seguros.

WHAT DOES THIS INSURANCE COVER? In the event of unemployment, this insurance will pay the monthly bills of Coomeva Medicina Prepagada for up to six months. And if there is a surplus, it can be used to pay for public utilities bills, credit cards, cell phone, as well as other recurring bills. Affiliates will also be protected in case of an accident that requires a hospitalization for more than 24 hours. The policy will cover COP $ 200,000 daily for up to 30 days.

INSURANCE PLANS Monthly Cost Plan A: up to COP $ 800,000 monthly for six months, COP $ 35,700 Plan B: up to COP $ 500,000 monthly for 6 months, COP $ 22,800 To have access to health care services is a must for you and your family. Coomeva Medicina Prepagada offers a complete portfolio with a wide coverage and a large network of specialists, clinics and medical centers nationwide. Health is a wonderful gift that should not be put at risk. Ensure health care coverage for you and your family. Purchase your unemployment insurance policy by calling the national hotline (Colombia) 01 8000 960001 or write to our email: seguros@coomeva.com.co

ÂŠ2015 Shutterstock Photos

*Personal accident insurance with unemployment and temporary total disability annex is issued by ACE Seguros.

2021

MEDICAL WORLD BOOKS  ‘Treaty on Sleep Medicine’ Sociedad Española del Sueño (SES) After a comprehensive scientific research, this book is organized in three parts: normal sleep, sleep and wakefulness disorders, and sleep study methodology. Each chapter has been prepared by professionals with broad experience and proficiency.

 ‘Neither attack nor defend, but on the contrary’ Daniel Samper Pizano Football has its own rules, but the author knows that the written standards are less important than the hidden laws of the game. Why do Germans always win? What mystery always makes an urgent commitment coincide with the biggest game of our team? Why no child dreams of being a referee? With the subtle humor that characterizes Samper Pizano, together with his Latin American passion for soccer, this book offers readers a very personal guide to the vicissitudes, and immutable principles governing the inexact science of victory, defeat, and everything in between.

MUSIC  ‘The same’

ChocQuibTown This group from Chocó, Colombia, launches its new album, the fifth one to be precise. In it, Goyo, Tostao and Slow composed all the songs, and it promises to make the whole world dance. The album was produced by Andres Castro, and it includes rhythms like champeta, hip hop, and rap. The most famous song of the album is “When I see”, a single than has been for several weeks in the first places among the hottest songs in the country.

EVENTS  ‘XXXI Pan American Congress of Ophthalmology’ Date and place: August 5th to 8th, Bogotá Information: Sociedad Colombiana de Oftalmología Phone: (1) 635 1592 Email: socoftal@socoftal.com Website: www.paaobogota2015.com

 ‘XV Colombian Congress of Rheumatology’ Date and place: August 13th to 16th, Cali Information: Asociación Colombiana de Reumatología Phone: (1) 635 0840 Email: congresocolombianoreumatologia@gmail.com Website: www.xvcongresoreumatologia.com

 ‘II Latin American Congress of Epidemiology and Public Health’ Date and Place: September 2nd to 4th, Santiago de Compostela (Spain) Information: Sociedad Española de Epidemiología Phone: (+34 93) 932 212 242 Email: inscripciones@geyseco.es Website: www.reunionanualsee.org

 ‘National Cancer Congress’ Date and place: September 3rd to 5th, Bogotá Information: Asociación Pro Congreso de Cancerología Phone: (1) 334 0240 Email: contacto@asoprocancer.com Website: www.asoprocancer.com

General

manager

Coomeva Medicina Prepagada

Jorge Alberto Zapata Builes

Editorial Meeting

Pascual Estrada Garcés, MD National Medical Director Coomeva Medicina Prepagada

MOVIES  ‘PAPER CITIES’ Director: Jack Shreir Starring: Nat Wolff, Cara Delevigne, Cara Buono In his senior year, Quentin is not yet satisfied with his popularity nor his romantic life, but everything changes when his neighbor, the legendary and enigmatic Margo Roth Spiegelman, showed up in the middle of the night asking him to help her with an outrageous revenge plan. After a memorable night remembering their childhood shared history that seems to open up a new and promising future, Margo disappears leaving behind only strange clues.

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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

LABORATORIO CLÍNICO IMBANACO

ACREDITADO INTERNACIONALMENTE* Es reconocido por su equipo humano experto, su alta tecnología y sus estándares de calidad. Cercano y disponible en sus tres sedes: Principal, Ciudad Jardín y Chipichape, para cuidar y preservar la Vida.

Sede Principal: Carrera 38A No. 5A-109 Sede Ciudad Jardín: Calle 15A No. 103-20 Sede Chipichape: Piso 6, Hall Empresarial

Conmutadores: 518 6000 - 682 1000 Cali, Colombia