Coomtacto

ISSN 2011-357 9

A MAGAZINE FOR THE HEALTH CARE PROFESSIONALS WORKING WITH COOMEVA MEDICINA PREPAGADA VOL. 8 No. 4 • DECEMBER 2015

HEALTH UPDATE 2016 is ‘loaded’ with new vaccines | PAG. 8

P P

Be prepared for the holiday peak of seasonal poisonings | PAG. 18

Javier Gutiérrez Jaramillo, MD

A VIRTUOUS HEART During the last six decades he has been dedicated to taking care of the heart, and sharing his knowledge with internal medicine, and cardiology students. | PAG. 14

Content

8

Jorge Zapata Builes General Manager Coomeva Medicina Prepagada

Editorial Board Pascual Estrada Garcés, MD National Health Director Martha Liliana Cifuentes Castaño National Coordination of Relationships with Providers

5 EDITORIAL 6 MEDICAL ADVANCES

Brief notes on actual and innovative medicine

8 HEALTH UPDATE 2016 is ‘loaded’ with new vaccines Biologicals against dengue, and Ebola are some of the new immunizations that will be available next year. AIDS must still wait for a while.

14 COVER Javier Gutiérrez, MD A virtuous heart During the last six decades he has been dedicated to taking care of the heart, and sharing his knowledge with internal medicine, and cardiology students.

18 PROMOTION AND PREVENTION Be prepared for the holiday peak of seasonal poisonings Colombian guidelines, called ‘Guías colombianas para el manejo de intoxicaciones’, together with the hotline Cisproquim, and other emergency sites at hospitals, and clinics make it easier to work, and take care of this cases in a timely manner.

24 MERITS A very well deserved award for ophthalmology in the Colombian Caribbean region

32 RESEARCH NEWS Colombia investigates breast cancer Colombian researchers have taken on the task of analyzing the characteristics of the local population, and their relationship to breast cancer, as well as the available diagnostic methods, and other issues, such as the incidence of BRCA1 and BRCA2 mutations.

36 FROM COOMEVA And now, very easy authorizations!

Bertha Lucía Varela, MD National Chief of Medical Audits Julián Adolfo Villegas National Chief of Health Risk Management Ana María Correa National Quality Auditor Marco Emilio Ocampo National Medical Auditor Editorial production

LISA, is a dedicated telephone line for health care professionals working with Coomeva Medicina Prepagada

38 OUR PLUSES Special coverage for our members, and their families 39

COOMEVA BY THE NUMBERS

40 HEALTH WORLD

www.segmente.com mercadeorelacional@legis.com.co Tels.: (1) 4255255, Exts.: 1314, 1393, 1552, 1516 Sales María Cristina Arévalo Durán Cel.: 3112862724 maria.cristina.arevalo@gmail.com

December • 2015

26 MBE

A new era in the treatment of nonHodgkin lymphomas (NH) Better understanding of these diseases has emerged from the development of new technologies, with more accurate diagnostic tests, and better drugs, improving the overall prognosis.

26 Cover Photo: Jorge Mejía

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Editorial

We overhauled

Jorge Alberto Zapata Builes General Manager

I

ndeed we are proud, and happy, for us it is a great pleasure to introduce you to the new format, our main communication means.

You are reading it right now. It is the beginning of a new era for all of us. Starting with this issue our newsletter has become a complete magazine, it has more pages, and better graphics, in order to reach many more readers, and meet their information needs about the vast and dynamic health care universe.

This has been an excellent project. In order to satisfy, and even to exceed the expectations of our invaluable health care professional community, the newsletter was born more than nine years ago, and it has had such a very favorable development since then, that the magazine started taking its actual shape, meanwhile it was very welcome by increasingly many readers, becoming a firsthand resource for those interested in being up to date in health care issues. But our commitment to excellence lead us to improve it even more, making it

competitive, offering better quality, in order to become a leader informing the public about science, but also opening up a space to acknowledge our commitment to the hundreds of anonymous heroes, who, with devotion, ethics, and professionalism, fight daily battles against disease, while helping patients improve their health, and lifestyle.

And our new magazine format reflects all these goals.

From now on, its name is going to be ,MAGAZINE. It has been designed especially for you; after all it is the answer to your information needs.

And we would very much appreciate your comments; they will guide us while continuing on the right path with this developing project, making it increasingly interesting for healthcare professionals. We are very grateful to all of you, and we wish to acknowledge your commitment to the fulfillment of our mission, and our vision.

Finally, this enthusiastic message is also an opportunity to send you our best wishes for the holydays. We hope you also feel the pride of your dreams turned into achievements, with the hope of good health, and happiness for all of you, and your families. Let peace, love, solidarity, and harmony always be with you.

We wish you a merry Christmas, and a happy 2016, full of new challenges, and hopes!

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for you

MEDICAL ADVANCES THE FIRST 3D PRINTED RIBCAGE IMPLANT WAS PERFORMED IN SPAIN

After several tests, for the first time ever a person received a prosthesis made with a 3D printer. The procedure was performed on a 54 year old Spaniard, whom, because of a metastasic cancer, had lost the sternum and parts of the rib cage. Surgeons at Hospital Universitario de Salamanca used a 3D high-resolution scanner on the patient’s chest to upload the precise anatomy of the stuctures that were going to be replaced. Data was sent to an Australian company, Anatomics, where a prototype was designed and finally a definite piece was built with a 3D printer that used an electron beam.

SOURCE: ARTICLE “CANCER PATIENT RECEIVES 3D PRINTED RIBS IN WORLD FIRST SURGERY” POSTED ON THE WEBSITE OF ANATOMICS. AUSTRALIA SEPTEMBER 2015.

FDA APPROVES A NEW DRUG THAT ALLEVIATES POSTCHEMOTHERAPY SYMPTOMS Varubi™ (rolapitant) is a drug already tested in nearly 3,000 cancer patients on phase III chemotherapy. This molecule turned out to be more effective than other treatments used for its side effects, such as dizziness, nausea, and vomiting, as well as other signs and symptoms that seriously affect life quality. The new medicine blocks brain receptors involved in the vomit reflex pathways. However it also has adverse effects, such as low white blood cell counts, anorexia and hiccup. FDA recommends this treatment to be used only on selected patients, according to their needs, and to acknowledge the possibility of other drugs that can compete pharmacocinetically with rolapitant.

SOURCE: ARTICLE “FDA APPROVES NEW DRUG TREATMENT FOR NAUSEA AND VOMITING FROM CHEMOTHERAPY” POSTED ON THE FDA WEBSITE. UNITED STATES, SEPTEMBER 2015.

December • 2015

A recent research conducted by experts at Escuela Nacional de Sanidad at Instituto Carlos III showed that noise pollution caused by traffic could harm the baby in pregnant women. A statistically significant association was found between traffic noise in cities like Madrid, and premature birth, low birth weight, and fetal mortality.

Researchers showed that a mean decrease of 1 decibel in daytime noise levels could reduce the frequency of low birth weight by 6.4%, preterm births by 3.2%, and fetal mortality by 6%.

SOURCE: ARTICLE “TRAFFIC NOISE AND ADVERSE BIRTH OUTCOMES IN MADRID: A TIME-SERIES ANALYSIS”, PUBLISHED IN THE SCIENTIFIC JOURNAL EPIDEMIOLOGY. UNITED STATES. OCTOBER 2015.

Photos: ®2015 SHUTTERSTOCK PHOTOS

TRAFFIC NOISE COULD AFFECT PREGNANCY

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STERILIZATION OF MEDICAL INSTRUMENTS WITH WATER AND ULTRASOUND Researchers at Southampton University, in the UK, showed that a pioneering ultrasonic device, the Starstream, can significantly improve the cleaning process of medical instruments, reducing the risk of contamination, and infection. It provides a gentle stream of water through a nozzle that generates ultrasonic waves, creating tiny bubbles that powerfully scrub the surfaces. And it also reduces significantly the use of additives and heat. To demonstrate its effectiveness several tests were carried out with cold water. It turns out it suppressed biological contamination in the medical instrument’s surgical steal, including those used i n n e u ros u rg e r y.

Fur thermore, the device successfully eliminated bacterial biofilms that can cause dental disease.

It was also effective eliminating soft tissue from bone, a procedure required before performing a transplant in order to avoid rejections.

CHILDHOOD TRAUMA IS RELATED TO ADULT PSYCHOSIS A study conducted at Universidad de Granada in Spain showed that traumatic experiences during childhood and adolescence increase seven fold the risk of developing a psychosis later on during adulthood. In this research, 50 psychotic patients were compared to their asymptomatic siblings.

As emotional instability rises, the psychosis risk increases by 30%.

Working with brothers, this research controls the genetic causes, and underlines the importance for health care professionals to inquire about the patient’s history about this type experiences.

Through MRI scans on 3,000 men, and women between 54, and 94 years, without any previous heart disease, significant differences were identified in the aging hearts in both sexes.

For instance, left ventricular muscle tended to enlarge in men progressively as age increased; also the capacity of the left ventricle decreased in both sexes, specially in women, by 13 mm, and in men, 10 mm.

According to these researchers, the changes are unrelated to other risk factors that affect the size and ventricular performance, such as weight, blood pressure, cholesterol levels, exercise, and tobacco..

SOURCE: ARTICLE “ADVERSE LEFT VENTRICUL AR REMODELING AND AGE ASSESSED WITH CARDIAC M R I I M A G I N G : T H E M U LT I - E T H N I C S T U D Y O F ATHEROSCLEROSIS”, PUBLISHED IN THE SCIENTIFIC JOURNAL RADIOLOGY. UNITED STATES. OCTOBER 2015.

SOURCE: ARTICLE “CHILDHOOD TRAUMA AS A RISK FACTOR FOR PSYCHOSIS: A SIB-PAIR STUDY “PUBLISHED IN THE JOURNAL PSYCHIATRIC RESEARCH . UNITED STATES. OCTOBER 2015.

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December • 2015

Photos: ®2015 SHUTTERSTOCK PHOTOS

THE HEARTS OF MEN AND WOMEN AGE DIFFERENTLY

SOURCE: ARTICLE “COLD WATER CLEANING OF BRAIN PROTEINS, BIOFILM AND BONE - HARNESSING AN ULTRASONICALLY ACTIVATED STREAM”, PUBLISHED IN THE SCIENTIFIC JOURNAL PHYSICAL CHEMISTRY CHEMICAL PHYSICS. UK, SEPTEMBER 2015.

HEALTH UPDATE

2016 IS ‘LOADED’ WITH NEW VACCINES BIOLOGICALS AGAINST DENGUE, AND EBOLA ARE SOME OF THE NEW IMMUNIZATION THAT WILL BE AVAILABLE NEXT YEAR. AIDS MUST STILL WAIT FOR A WHILE.

December • 2015

E

radicating smallpox, and polio, in most continents (there are still some African countries where you can find these diseases), and reducing the morbidity, and mortality figures for whooping cough, diphtheria, tetanus, measles, mumps, and congenital rubella (a complication that used to be a serious public health concern) are some examples of what vaccines are capable of doing. After access to clean water, it is the most cost-effective strategy.

Vaccines are important. Researchers continue to look for vaccines against other diseases, especially those with a high incidence, and new infectious diseases that are starting to cause public health problems.

And 2016 seems to be full of good news. Vaccines against dengue and Ebola are available, and shortly others will complete the clinical phase

research, and will be available to the community.

LET’S TALK ABOUT DENGUE “Dengue is about to become a vaccine-preventable disease”, notes Sandra Bessada Lombana, medical director of Dengue-América Latina at Sanofi Pasteur.

“During the last 20 years we have been involved in research in order to develop this vaccine, and we finally found one with a 67% efficacy, so it can prevent 2 out of 3 cases of the disease in communities where it is indicated -that is, in patients over nine years old-.

It also has a 90% efficacy preventing severe dengue, and 80% avoiding hospitalizations because of dengue, two important issues. And also it is a vaccine

with a good safety profile”.

‘Bone breaker fever’, as they call dengue, is a viral disease transmitted by infected Aedes female mosquitoes, Aedes aegipty is the most important species, followed by Aedes albopictus, according to World Health Organization (WHO )1.

It is a common disease in tropical and subtropical climates, and its incidence has multiplied by 30 over the last 50 years. Between 50 and 100 million new infections are diagnosed

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100,000 inhabitants, while in 2010 to 2013 it rose to 400 cases per 100,000 inhabitants. Canada, Uruguay, and mainland Chile are the only places in the continent where it has not been detected. In the United States, cases have been reported in southern Florida and Texas”.

Countries have made great efforts to control the vector,

including Colombia3, “the vaccine (that comes in three doses) is going to be an important tool for the control of the disease. But it is clear that vaccines are strategies that work in addition to what it is already being done”.

According to Juan Manuel Gomez, a specialist in infectious diseases, member of Asociación Colombiana de Infectología 9

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December • 2015

Fotos: ®2015 ShutterStock Photos

each year in over a hundred countries where dengue is endemic. Nearly half of the world’s population is at risk of acquiring the infection2.

“Even though the mosquito does not fly more than 1,800 meters”, adds Dr. Bessada Lombana, “cases have been reported at heights above sea level of up to 2,200 meters. So mosquitoes are adapting to new niches. In Latin America it became endemic in the 80s, with an outbreak in Cuba. In those days, incidence was 16 cases per

SALUD AL DÍA “IT IS PROMISING NEWS. AN EFFECTIVE VACCINE AGAINST EBOLA WILL BE CRUCIAL IN CASE OF FUTURE OUTBREAKS”:

MARGARET CHAN.

(ACIN), and the main author of the vaccination guidelines in Colombia, “the dengue vaccine has already gone through the late stages of research involving human subjects, and most of them have been carried out by Sanofi in our country and in Asia, where the incidence is high, and causes high morbidity and mortality, particularly in South Asia “.

“Currently, the company works closely with governments to promote the vaccine so that it can be used in better ways, and have a greater impact”, says doctor Bessada Lombana. “To do this we need the sanitary registration, cost-effectiveness studies, the support of WHO, and an evaluation at Comité Nacional de Prácticas de Inmunizaciones”4.

December • 2015

AGAINST EBOLA WHO announced clinical trials in humans with the vaccine against Ebola are complete, with 4,000 patients in Guinea. Researchers reported a 100% efficiency.

Investigators from WHO, and Doctors Without Borders, as well as doctors from Guinea, Norway, Canada, United States, France, Switzerland and the UK, conducted further tests, including in children.

“It is promising news. An effective vaccine against Ebola will be crucial in case of future outbreaks”, said a statement published by WHO General Manager, Margaret Chan.

And in Colombia, doctor Gómez acknowledges “this is one of the most anticipated vaccines, it works against this highly fatal, and contagious disease. For now, only maneuvers for infection control, and contact isolation are effective”.

From late 2013 to the first quarter of 2015, WHO has records of more than 28,000 cases, and 11,000 deaths in West Africa, although underreporting is suspected.

According to experts, vaccination tests used the ‘circle’ or ‘guard ring’ strategy, in other words, they used the vaccine on infected patients, and in

those who have been in close contact with him, or her.

The vaccine is called VSV-EBOV. It was developed by the Public Health Agency of Canada (PHAC); although the license belongs to Merck and NewLink Genetics Corp. And there is another vaccine under development

by GlaxoSmithKline (GSK) and the American Institute of Allergy and Infectious Diseases (NIAID). Also, the GSK vaccine is about to start testing “in healthy volunteers in Liberia”, said doctor Gomez.

MORE PROTECTION AGAINST HPV Another novelty is the updated presentation of the papilloma virus vaccine, against the agent that causes many cervical cancers, and anogenital cancers in men and women. Available vaccines are effective against 2 (16 and 18,

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SALUD AL DÍA CervarixTM) and 4 (6, 11, 16 and 18, GardasilTM) important strains that cause these diseases, while the new vaccine will act against 9 serotypes (6, 11, 16, 18, 31, 33, 45, 52 and 58); and it is already being used in the United States for immunization in children, and young adults at risk”, explains doctor Gómez.

The Ministry of Health in Colombia informed COOMTACTO it has not been yet confirmed exactly when these vaccines will be available in the country.

REFERENCES 1. H T T P : / / W W W . W H O . I N T / T O P I C S / D E N GUE/9789995479213_SPA.PDF?UA=1 2. HTTP://WWW.WHO.INT/TOPICS/DENGUE/ES/ 3. HTTP://WWW.INS.GOV.CO/TEMAS-DE-INTERES/PAGINAS/DENGUE.ASPX 4. HTTPS://WWW.MINSALUD.GOV.CO/LINEAMIENTOS/ LINEAMIENTOS%20PARA%20LA%20INTRODUCCI%C3%B3N%20DE%20NUEVAS%20VACUNAS.PDF

HIV: HOPE IS NOT LOST

December • 2015

S

everal research groups are looking for a vaccine against HIV. Recently the executive director of UNAIDS, Michel Sidibé announced the first injectable treatment will be available next year. But it is not a vaccine.

This breakthrough is a positive development in antiretroviral therapy. Patients use to take more than 20 pills a day, and now treatments are simpler, with higher adherence. “In the future it is possible that it will be enough with one injection every six months”, said doctor Sidibé.

Human trials should start in 2016, after completing tests in monkeys, and mice, of a vaccine developed jointly by Departamento de Salud of Generalitat de Cataluña, and Instituto de Investigación Contra el Sida of Obra Social ‘La Caixa’, although it probably wouldn’t be available for use on humans for the next three years.

Researchers at Johnson & Johnson are also developing a vaccine against HIV, it has already been tested in small groups of monkeys.

“In 6 out of 12 monkeys, there was

antibody production against simian immunodeficiency virus, analogous to human HIV. The major difficulty with this particular vaccine is that human antibodies that target the disease destroy the immune system that also produce them. Research groups

are conducting phase I studies in humans”, said UNAIDS spokesman.

So today, “there is no vaccine that offers sufficient coverage protection”, says Luis Angel Moreno, Country Manager Colombia of the Joint Program of the United Nations on HIV/AIDS.

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COVER

JAVIER GUTIÉRREZ JARAMILLO, MD

A VIRTUOUS HEART DURING THE LAST SIX DECADES HE HAS BEEN DEDICATED TO TAKING CARE OF THE HEART, AND SHARING HIS KNOWLEDGE WITH INTERNAL MEDICINE, AND CARDIOLOGY STUDENTS. HE IS THE CREATOR OF THE ‘CARDIAC WINDOW’, AN INSPIRATION FOR A MEDICAL EXCELLENCE AWARD, AND AN ORTHOTHANASIA ADVOCATE. DOCTOR GUTIÉRREZ JARAMILLO, AN INTERNIST AND A CARDIOLOGIST, IS DEVOTED TO MEDICAL RESEARCH, AND TO SERVE HUMANITY. THIS IS A TRIBUTE TO HIM.

December • 2015

H

e dresses impeccably, with a suit, a tie, and a white medical coat. He walks from his office to the reception where he meets the patient; then he introduces himself with a hand shake, and starts a friendly conversation. He does that every day with every patient.

During the last six decades Javier Gutiérrez Jaramillo has been a doctor.

Last May he turned 80 years old. “Since 1953, during my internship, I have been working. I chose cardiology because of the available diagnostic aids of the specialty, the methods it uses, and

because my father was a general practitioner, and his colleagues used to tell me stories about cardiology, and how to help other people”, said the specialist, who also works with Coomeva Medicina Prepagada.

He lives in Cali. Universidad del Valle, his alma mater, offers a medical award of excellence with his name.

And currently he is a professor of internal medicine and cardiology at Universidad ICESI. Over the past 20 years he has dedicated his professional life, and his heart, to the patients at Fundación Valle del Lili. He receives them

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PROFILE

A TEACHER OF LIFE

J

Photo: Jorge Mejía

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December • 2015

avier Gutiérrez Jaramillo is an exceptional human being, no doubt about that.

“Invaluable”, say those who know him closely. He loves classical music, as well as boleros, bambucos, and pasillos; and he doesn’t miss a nap, a black coffee, and, occasionally, a spirit.

He is the father of Javier Fernando, an oncologist surgeon, Pamela, a speech therapist, and Luz Stella, an industrial engineer.

He is also the grandfather of five children with whom he shares his days, when he is not busy at the office, or in class.

“Maturity allows me to enjoy teaching, but also to learn from students, as well as each person I come in contact with; it is people I love”, he says.

Two years ago a bowel obstruction made him very ill. With his family’s affection, as well as his colleagues, and students, he got better, and he reflects on that situation: “I was very close to death, but I deleted that episode, it is as if nothing ever happened”.

He adds that for him one of the most satisfying things is to meet with doctors whom studied with him 30 or 40 years ago, and to hear them say, “doctor Gutiérrez, I remember you as a teacher, I like your style”.

That is wonderful for him.

Finally, He doesn’t think about retiring. He strongly believes that while he is mentally capable, “there is going to be a doctor around for a long time”. He says it, even though he is aware that age demands choices that affect the rest of the life.

“I am an absolute nap supporter, even though sometimes I have a difficult time to take it, because of my hectic schedule. But, if you are able to combine exercise, rest, a healthy diet, and a peaceful life, you have the perfect balance that will maintain your heart strong”, says the teacher, not only in medicine but also in life.

COVER

December • 2015

with enthusiasm, offering hope, he completely committed his life to the patients. No wonder many tease him, they calling him ‘Cardiology’s Patch Adams’. “I’m always in a good mood, I’m friendly, I think that when the patient laughs, it helps him, that is part of the cure”, he explains.

“There’s nobody like him”, says Elizabeth, his secretary for the last 16 years. And dermatologist Fabian Sandoval agrees, adding, “he is an example to be followed, he inspires all of us; he was my teacher and, although today we have different specialties, I always remember what he taught me, those things he gave me as a person, and as a physician”.

H e i s o n e of t h e m o s t l o v e d and admired doctors, especially for his devotion to medicine, and cardiology, but also because of his temperament. “Every day I great the guards and the cleaning ladies with a hand shake, I stop to ask them how they are doing, how is the family. And the same happens with my patients, and everybody else,” adds professor Gutiérrez Jaramillo.

And this illustrious cardiologist spoke with COOMTACTO about medicine, his passion, and also about education, as well as his outlook on the future of the profession, his experience as a doctor working with Coomeva Medicina Prepagada, and as a user of its services.

How have these six decades of cardialogy been for you?

They have been wonderful years.

I helped people, and learned a lot.

I’ve also had the opportunity to write books, and articles for several journals, that can be useful for present, and future doctors. During these years, I have worked daily on the basis that the patient is the most important person in clinical practice, and he should be heard, guided, and assisted.

You are a doctor, and a teacher, and you use PBL methodology, what is that?

PBL is Problem Based Learning. A

scientific. There is no such thing as a diagnostic plan. I always stress the new generations that the patient must leave the doctor’s office knowing what he thinks. He must know the next step.

Although diagnoses are weird words, we must teach them so that they will know what to expect, what to do.

What do you recommend young doctors for a good clinical practice?

We, doctors, must learn to listen to the patient, and must always tell him the truth, however hard it may be. My father, who was also a doctor, taught me the most important thing is honesty. If you cannot handle a patient, you should consider referring him. You should always be honest, and that generates trust.

El doctor Gutiérrez Jaramillo acaba de cumplir 80 años, pero para él la palabra jubilación no existe.

didactic tool that invites students, and residents to participate, commenting, to think and take a stance. And also to order lab tests with a clinical reasoning.

What was the experience that marked you career during your teaching years?

We have been doing the “cardiac window” for at least 50 years. Weekly, fourth year medical students, together with interns, and residents, participate in this exercise in a room, in all with 30 to 40 people, studying cardiology. For each meeting one of them prepares a clinical case, and all of them participate, debate, argue, and finally, together, we all look for solutions.

When you open the window, you are able to see different aspects of the case, an electrocardiogram, the medical charts, the results of a catheterization, and that’s why we call this meeting, the window.

How has medicine changed during these past six decades?

The doctor patient relationship has cooled down. Today it is mainly

TODAY’S MEDICINE The clock stops when doctor Javier Gutiérrez Jaramillo is working with a patient. Doctor’s warmth originates connection, and trust, elements the patient requires desperately.

“They come with hope and confidence, but if the doctor has a bad relationship with them, patients will leaves the office thinking doctors are bad”, adds the cardiologist.

He believes that a short time for the patient is part of an awkward medical practice, “today volume is the important thing, not quality, but five minutes is not enough to talk to the patient, you cannot interact in that time, doctor patient relationship fades away”.

For several years now, you have been in favor of orthonasia, do you still think the same now that euthanasia has been approved in Colombia?

I’m not in favor of euthanasia, direct death. I believe in orthothanasia.

It is another way to support terminally ill patients, treating pain, allowing the disease to run its natural course, using palliative management, soothing them, also with psychological support. After all, you have to treat depression, and insomnia, there are methods to do that.

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FELIZ DÍA DEL MÉDICO

PROMOTION

PREVENTION

BE PREPARED FOR THE HOLIDAY PEAK OF SEASONAL POISONINGS COLOMBIAN GUIDELINES, CALLED ‘GUÍAS COLOMBIANAS PARA EL MANEJO DE INTOXICACIONES’, TOGETHER WITH THE HOTLINE CISPROQUIM, AND OTHER EMERGENCY SITES AT HOSPITALS, AND CLINICS MAKE IT EASIER TO WORK, AND TAKE CARE OF THIS CASES IN A TIMELY MANNER.

December • 2015

U

p until the epidemiological week number 42 (18 to 24 October 2015), data published by Instituto Nacional de Salud (INS) had showed a 34,7% decrease in cases of food borne diseases (ETA), compared to last year’s same week.

This year’s weekly average has been 159 cases, 6.67911 in all1.

During the holiday season there is usually an increase in the number of emergency visits related to poisonings, food borne illness, and alcohol

Photo: ®2015 ShutterStock Photos

intoxication. So hospital personnel are on high alert, and educational campaigns are being issued in order to reduce the risks for the community.

In general, legislation –tells us doctor Myriam Gutiérrez Salazar, MD, master in toxicology- states that “emergency services should be prepared to receive patients with confirmed or suspected clinical symptoms of poisoning, trauma, drug intoxications, and criminal or suicidal events associated with substances. The approach to these patients requires

special care, in order to adequately diagnose, and treat them with successful medical and paramedical interventions and also with the highest respect, and responsibility”.

Precisely, in order to accomplish this directive, Ministerio de Salud y Protección Social, in partnership with the medical faculty at Universidad Nacional de Colombia, developed the guidelines for these emergencies, including specific recommendations for each of the possible toxicological accidents, according to the substance

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TABLE 1

INTOXICATIONS DUE TO FOOD MICROORGANISMS Microorganism

Incubation period

Bacillus cereus

1-6 h (emesis) 8-16 h (diarrhea)

Campylobacter jejuni

Symptoms, and action mechanism

Foodstuff

Vomit and diarrhea Toxins: intestinal and/or food

Cooked food, fried rice, vegetables and meat

1-8 d

Diarrhea with blood, Fever. Direct intestinal mucose invasionl

Water, milk, poultry or shellfish

Clostridium perfringens

6-16 h

Cramps and abundant diarrhea. Toxins produced in the intestine stimulate adenil cyclase

Beef, turkey or chicken sauces, poorly handled meat, fecal contamination

Listeria monocytogenes

9-32 h

Diarrhea and systemic symptoms. Direct bacterial invasion

Milk and cheese

Salmonella spp.

12-36 h

Diarrhea and cramps Bacterial invasion

Raw meat, eggs, sausages

Shigella spp.

1-7 d

Diarrhea, fever, mycroabscesses in the ileal wall. Intestinal endotoxins

Water, milk, ice cream, shrimp, eggs, flower

Escherichia coli enterotoxic

12-72 h

Diarrhea and vomit Intestinal toxin. Traveler’s diarrhea

Cream, cakes, mashed potatoes, lettuce, fish

Escherichia coli enteroinvasive

24-72 h

Diarrhea Direct invasion of the colonic mucose

Water, meat preparations, raw vegetables

Escherichia coli enterohemorragic

1-8 d

Diarrhea and systemic symptoms, SHU Ingestion of the preformed toxin

Raw meat, salami, pasteurized milk

Staphylococcus aureus

1-6 h

Vomit and diarrhea Preformed food toxin

People, cows, birds, sauces, potatoes, etc.

Yersinia enterocolitic

3-7 d

Fever, abdominal pain, and diarrhea Direct bacterial invasion

Water, milk, pork

Vibrio parahaemolyticus

8-30 h

Vomit and diarrhea Direct invasion and/or intestinal formation of the toxin

Seafood

Clostridium botulinum

12-36 h

Fatigue, diplopia, odynophagia, flacid paralysis, respiratory failure Preformed Toxin in the food

Vegetables, beef, and canned fish

Source: modified from Olson KR. Poisoning & drug overdose. 4th ed. United States of America: McGraw-Hill; 2004.

Consejo Colombiano de Seguridad (Cisproquim), where professionals can answer all sorts of questions about this topic, including what to do in case of toxicity3.

“Since 2005, with the help of Ministerio de Salud, we have been working in order to advice on toxicity issues, and even though a large percentage of the questions solved by the specialists working with us come from doctors at hospitals, and clinics, we also advise people with no medical training”, explains doctor Diana Marcela Gil, manager at CISPROQUIM. Also, at an international level, a campaign called “Choosing Wisely”,

created in the United States, includes lists of recommendations for doctors, and patients, on treatments, and procedures required to protect the patient’s health, based on the best quality scientific evidence, case studies, and other methodologies.

The American College of Medical Toxicology and the American Academy of Clinical Toxicology have issued these recommendations4.

SAFE FOOD During the holidays, emergencies related to gastrointestinal infections, such as gastroenteritis, and other food transmitted diseases, including 19

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December • 2015

involved in each one of them. They include methyl alcohol, as well as criminal and abuse drugs, chemicals and food stuffs, in addition to topics related to the stabilization of poisoned patients, the diagnostic approach, decontamination, and methods that decrease the circulating toxic agent. Its recommendations are still valid even though they were published in 2008, and are being updated as we speak2.

Also, health care professionals are available 24 hours a day on a hotline (018000 916 012 for nationwide calls, and 2886012 in Bogotá) at Centro de Información de Seguridad de Productos Químicos del

PROMOCIÓN

PREVENCIÓN

food poisoning, also usually increase.

Given the customary changes in the routines during this season, explains Ana María Quijano Barriga, head of Departamento de Urgencias at Clínica del Country: “people tend to be more sociable, changing eating and drinking habits, on these days they tend to eat out more frequently”.

The problem is that “some of those places handle food without adequate hygiene precautions, so they are unable to prepare, and maintain these products properly, keeping them safe for the consumers.”

According to World Health O r g a n i z a t i o n , W H O, t h e m o s t common causes of these events

are bacteria, viruses, marine toxins, chemicals, parasites, and plant toxins, which are easily found in seafood, beef, water, milk, poultry, eggs, cream, and mayonnaise (see tables 1 and 2).

Patients can have local and / or systemic clinical manifestations.

“Gastrointestinal signs and symptoms, such as enteriform or disenteriform diarrhea, according to the pathogen involved in the disease, and also vomit, fever, abdominal pain, and cramps; but also, in severe cases, patients can even become dehydrated and have electrolyte imbalances that could eventually even cause death”, says the document.

And don’t forget, emphasizes

TABLE 2

December • 2015

FISH AND SHELLFISH TOXINS Tipo

Incubación

Especies

Síntomas

Ciguatere

1-6 h

Barracuda

Gastroenteritis, paresthesias, myalgia, muscular weakness

Scombrid toxin

Minutes to hours

Tuna, bonito, makrell

Gastroenteritis, skin rash, urticaria, dyspnea

Shellfish neurotoxins

Minutes to 3 h

Bivalves, shellfish

Gastroenteritis, ataxia, paresthesias, convulsions

Shellfish paralysis toxin

Within 30 min

Bivalves, cat fish

Gastroenteritis, paresthesias, ataxia, respiratory paralysis

Tetroadontidae toxin

Within 30 to 40 min

Puffer fish, porcupine

Vomit, paresthesias, clonus, diaphoresis, muscular weakness, respiratory paralysis

Source: taken from Olson KR. Poisoning & drug overdose. 4th ed. United States of America: McGraw-Hill; 2004.

Edgar Velandia, a medical toxicologist working at CISPROQUIM, children, elderly patients, and pregnant women, are more prone to these complications, so they require extra care and attention. Also the elderly could have other conditions that would make them even more vulnerable.

Some recommendations according to these guidelines are related to laboratory tests searching for pathogens in the presence of disenteriform diarrhea, a prolonged presentation lasting more than 2 days, with persistent vomit, sustained fever over 39°C, and neurological symptoms, like muscular weakness, numbness, convulsions, and alterations of the consciousness. Stool samples are recommended to rule out, or to confirm, the inflammatory nature of the diarrhea, and serial stool cultures are indicated to establish the presence of Salmonella, Shigella, and Yersinia”.

BEWARE OF LIQUOR During this season tampered liquor is a major concern. “Physical properties, and its components, are nefariously altered replacing ethanol with methanol, a very different alcohol, that causes severe complications, and even death, when ingested”, says Dr. Velandia.

“While ethanol affects almost all organs and systems of the body, acetaldehyde, its metabolite, produces the most toxicity. It causes structural and functional abnormalities of the mitochondria and the hepatocytes, with a broad range of liver abnormalities, that go from fatty liver to cirrhosis with all its consequences and complications, such as digestive tract bleeding due to esophageal varices, ascites, hepatic encephalopathy, and hepatorenal syndrome; also dilated cardiomyopathy of alcoholic origin can occur, as well as malnutrition, hypogonadism, erectile dysfunction, infertility, pancreatitis, and alcoholic hallucinosis, among other manifestations of its abuse”, says “Guías colombianas para el manejo de las intoxicaciones”.

20 MAGAZINE FOR PROFESSIONALS IN THE HEALTH OF COOMEVA MEDICINE PREPAID

IMPORTANTE

SUBSTANCE GROUPS

I

n o r d e r to m o n i to r c h e m i c a l poisoning more efficiently, eight groups of substances have been devised:

• Pesticides • Medicines • Methanol • Metals • Solvents • Other chemicals • Gases • Psychoactive substances

“The diagnosis of ethanol intoxication should be established, like in any other acute intoxication, with the clinical history with an anamnesis (if possible), and a careful physical examination; so clinicians or forensic examiners will determine if additional laboratory tests are required, such as measurements of circulating alcohol levels in the blood stream.”

On the other hand, health care personnel should be aware of patients arriving with early intoxication with methanol symptoms, as well as pathological intoxication, with clinical manifestations such as increasing global severe or throbbing headache, sudden impaired vision (distortions or brilliant images, with sparkling colors, and a halo around the objects).

With these clinical findings, “no food or drink should be allowed for these patients. Many believe bread, tomato, oil, milk could help. But this conduct has been scientifically disproven. This is an urban myth. This conduct increases the risk of aspiration into the airways.

The safest conduct is simply to take the patient to an emergency facility”, complements doctor Quijano.

SCOPOLAMINE POISONING Scopolamine cases also increase during the holyday season. It is an alkaloid used by criminals; usually they mix it with benzodiazepines, phenothiazines, or ethyl alcohol. “The minimum toxic dose is estimated at 10 mg for children, and 100 mg for adults.

It is an antagonist that competes with acetylcholine at peripheral and central muscarinic receptors, affecting mainly the heart and smooth muscles, exocrine glands, and the central nervous system.”

Patient under the influence of scopolamine have clinical manifestations such as “dry mouth,

mydriasis, blurred vision, photophobia, dry erythematous skin, hyperthermia, hypertension, tachycardia, decreased peristalsis, urinary retention, a g g re s s i v e n e s s , h a l l u c i n a t i o n s , passivity, extreme obedience, anterograde amnesia, drowsiness, coma, and convulsions”.

Scopolamine intoxication is treated symptomatically. Guidelines suggest: “use the ABCD; do not induce vomit, it increases the risk of central nervous system depression, and seizures; also use thorough gastric wash with water (200 cm3 for adults, and 10 cm3 / kg for children) until the stomach’s contents comes out clear; and then administer activated carbon at a dose of 1 g/kg of body weight in a 20-25% solution with a nasogastric catheter, among other procedures”.

It is also recommended, if the patient is agitated, to sedate him, or her, using benzodiazepines. And always avoid antipsychotics, such as haloperidol, because they tend to increase cardiac toxicity, and lower the seizure threshold.

REFERENCES, AND RECOMMENDED READINGS 1. http://www.ins.gov.co/boletin-epidemiologico/Boletn%20Epidemiolgico/2015%20Boletin%20epidemiologico%20semana%2042.pdf 2. https://www.minsalud.gov.co/Documentos%20y%20Publicaciones/Gu%C3%ADa%20de%20Manejo%20 de%20Urgencias%20Toxicol%C3%B3gicaas.pdf 3. http://ccs.org.co/interna_cispro.php?idnoticia=63&opcacordeon=1 4. http://www.choosingwisely.org/ 5. http://www.ins.gov.co/lineas-de-accion/Subdireccion-Vigilancia/Lineamientos%20y%20Documentos/01%20LINEAMIENTOS%202015.pdf?Mobile=1&Source=%2Flineas-de-accion%2FSubdireccion-Vigilancia%2F_layouts%2Fmobile%2Fview. aspx%3FList%3D6426a2e5-0c1f-43b9-b17d-cd3871df3514%26View%3D46d93405-083f-4e62-9ff7-2b316 23422e1%26CurrentPage%3D1

21 MAGAZINE FOR PROFESSIONALS IN THE HEALTH OF COOMEVA MEDICINE PREPAID

December • 2015

Up until 2014 poisoning reports were done through a code that identified the substance causing the intoxication, but as of this year the notification code (365) was unified retaining the eight groups of chemicals. “Lineamientos 2015 p a ra l a p r eve n ci ó n , v i g i l a n ci a y control en salud pública” established it is mandatory to report these cases to the depar tmental units (U N D) and Instituto Nacional de Salud (INS) through a phone call (mobile 350 553 1390 or land line 2207700, extensions 1432 through 1433) o r v i a E m a i l ( i n t oxq u i m i c a s @ g m a i l . co m ; e r i @ i n s .g ov. co ; equipoderespuestains@gmail.com).5

ADVERTORIAL

Photo: ®2015 SHUTTERSTOCK PHOTOS

THE COMPLEXITIES OF A SAFE MEDICAL PRACTICE By: Harold Aristizábal Marín Managing Director Consortium Aristizábal Velásquez Abogados LTD.

December • 2015

M

edicine is one of the most complex and demanding activities. This level of performance requires considerable resources in academic training, not only economically, but also represented in time, labor, and effort. All this, in order to consolidate a promising career.

Therefore, it is crucial to keep in mind that we are no strangers to current issues of ‘responsibility’ related to decision making in medical settings.

Specially, considering the growth of the population, the emergence of new pathologies, eventual technological shortcomings, and many other variables that could involve legal, professional, and financial risks for the medical practice.

M e d i c a l l i a b i l i t y i s re g u l a t e d by the Colombian Civil Code. Its development has been the result of decisions based on jurisprudences of the highest courts, to the extent patient’s relationships with physicians, institutions, organizations, and the general health care system itself has evolved, becoming increasingly complex. To the point that they involve a significant occupational hazard that led the specialized market to design insurance policies intended to handle and care these situations, as well

as mutual funds. Useful products developed to protect doctors in case of contingencies. But what are they?

LET’S REVIEW: Insurance policies provide the actual coverage of an insurance contract, while mutual funds are just an aid.

Policies are backed by an insurance company supervised

by Superintendencia Financiera, while mutual funds do not have such support.

Insurance policies include economic, and financial support from reinsurers, while mutual funds don’t.

Insured sums are larger than those of mutual funds.

Insurance policies provide the opportunity to complete the process settling in different stages of the process, while mutual funds provide their assistance only when there is a conviction.

I n s u r a n c e p o l i c i e s p ro v i d e comprehensive legal aid in all scenarios where professional responsibility is an issue, and offer a choice of nationwide legal professionals, with extensive experience in the field of medical defense, or reimbursing,

1.

2.

3.

4.

5.

6.

according to the coverage, and the attorney fees. You choose.

On the other hand, in the case of mutual funds, although legal aid in all scenarios is provided, and they also have a team of lawyers, they designate your lawyer. You cannot choose.

Insurance policies allow you to expand economic coverage at the time of renewal, mutual funds do not.

Every year insurance policies increase of the insured sum, while mutual funds don’t.

Insurance policies are sufficient guarantees for the requirements of medical institutions, such as EPS or IPS, mutual funds are not.

Insurance policies include in their business schemes payment of compensations, while mutual funds offer economic aids only if there is a conviction.

In sum, medical liability is a risk, and should be handled as such. The market offers tools for that purpose, so it is important for health care professionals to inquire about the pros and cons of these tools, and decide how to handle risks related to medical practice.

It is not enough to be insured.

What is really important is to be ‘well insured’.

7.

8.

9.

10.

22 MAGAZINE FOR PROFESSIONALS IN THE HEALTH OF COOMEVA MEDICINE PREPAID

Elige

Coomeva

MIENTRAS TÚ CUIDAS DE NOSOTROS Nosotros cuidamos de ti En Coomeva, la Cooperativa que nació para los profesionales de la salud, conocemos y entendemos los riesgos a los que estás expuesto, por eso te protegemos con nuestra póliza RC Médica.

Algunos beneficios: • Cubre los perjuicios patrimoniales (lucro cesante) y extra patrimoniales (perjuicios morales, fisiológicos y de vida en relación) sin afectar el amparo básico, por errores u omisiones involuntarios.

• Línea de asesoría jurídica gratuita atendida por especialistas en riesgos legales de los profesionales de la salud. Puedes comunicarte desde cualquier lugar del país a la línea 018000 180252 o desde Cali al 893 3231

• Gastos de defensa del proceso civil, penal, tribunal de ética médica, administrativo o laboral.

• Cubre los eventos que se descubren durante la vigencia de la póliza o el periodo de retroactividad contratado.

• Asesoría y acompañamiento de abogados expertos en defensa de los médicos, desde la etapa pre procesal hasta el final del proceso.

• Respaldo de Liberty Seguros, una compañía de seguros AAA, vigilada por la Superintendencia Financiera.

• No aplica deducible para todas las coberturas.

Adquiérela en nuestras oficinas.

Coomeva nos facilita la vida

Corredores de Seguros

Línea Nacional: 018000 950 123, desde Cali 333 0000, Bogotá 748 1515, Barranquilla 361 9800, Pereira 316 9300, Medellín 415 7700, Palmira 273 3302. Opción 4.

MERITS

December • 2015

D

octor Luis José Escaf Jaraba, an ophthalmologist with a specialty on the anterior segment, and subspecialties in cataracts, corneal, and refractive surgery, received a very well deserved award fo r h i s c o m m e n d a b l e a n d h a rd work promoting visual health for residents of the northern part of the country. The Colombian Congress acknowledged his merits with Medalla Simón Bolívar, in the degree of Cruz Oficial, for his achievements as a teacher, researcher, and scientist.

Doctor Escaf Jaraba graduated as a physician from Universidad de Antioquia, and as an ophthalmologist at Hospital Militar Central, in Bogotá, medical faculty of Colegio Mayor de Nuestra Señora del Rosario. And today he is at the helm heading Clínica Oftalmológica del Caribe, in

A VERY WELL DESERVED AWARD FOR OPHTHALMOLOGY IN THE COLOMBIAN CARIBBEAN REGION Barranquilla, founded by him 30 years ago, achieving his lifelong dream. He is its scientific director.

Under his guidance the institution has become an important specialized medical center, where, in addition to meeting patient’s needs, major

research projects are being carried out in his field. And today they are acknowledged worldwide, because several of their researches have resulted in innovative procedures, methods, and techniques that changed ophthalmology. Including

24 MAGAZINE FOR PROFESSIONALS IN THE HEALTH OF COOMEVA MEDICINE PREPAID

Doctor Luis Escaf celebrating with his family: his wife, Fanny Sales (at the center), and their children, Vanessa (left), and Luis Carlos Escaf (right).

feels it belongs to the valuable, and committed team that works with him at the clinic, an organization that has grown with them in an orderly manner, with clear goals. Currently it has 200 direct employees, performing yearly more than 10,000 eye surgeries, and it is also a teaching, and research facility, where future domestic and foreign eye care specialists are being trained.

“So we receive this award with pleasure, and satisfaction, it is an

acknowledgement for more than three decades of dedication to the service of the community, as well as to the Latin American scientific community”, says doctor Escaf.

And with the idea of offering the best of their profession to the community, this physician faces his short, medium, and long term goals with a strategic growth plan for the clinic, that includes the improvement, and the expansion of the services in visual health care for the Caribbean coastal region, strengthening ophthalmology training programs in partnership with local and national universities, with special interests in research and development, while strengthening its social programs, and health brigades for low income patients throughout the country, under the guidance of Fundación Oftalmológica del Caribe (FOCA), and its mission is to achieve the best possible eye care for vulnerable populations.

For Coomeva Medicina Prepagada it is an honor to have been working during these years with such a prestigious specialist, as doctor Luis Escaf, and we want to join in the celebration of this momentous occasion of the award he so deservedly received last August.

25

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December • 2015

some international patents for instruments especially useful in his main field (cornea, cataract, and refractive surgery), such as the first ultrasonic scalpel, called Ultrachopper, that cuts the cataract into smaller fragments so it can easily be removed, decreasing tremendously trauma for the patient.

Beyond his professional work, this remarkable physician has directed his efforts to high quality education, and entrepreneurship. So every two years he organizes, and promotes Congreso Internacional Barranquilla Facorrefractiva, one of the great academic and scientific meetings in the field of ophthalmology in the world.

“Ophthalmology is a very dynamic profession, in recent years several surgical techniques have emerged, together with innovative designs of instruments, as well as new drugs and treatments, of which we have led some. Today, our institution, and the ophthalmologists working with us, are always updating their knowledge in order to offer patients the best of themselves, and the most up to date medical, and surgical treatments in the field”, says the doctor.

For doctor Escaf this award is not only his personal achievement, he

MBE

A NEW ERA IN THE TREATMENT OF

NON HODGKIN

LYMPHOMAS (NH) BETTER UNDERSTANDING OF THESE DISEASES HAS EMERGED FROM THE DEVELOPMENT OF NEW TECHNOLOGIES, WITH MORE ACCURATE DIAGNOSTIC TESTS, AND BETTER DRUGS, IMPROVING THE OVERALL PROGNOSIS.

December • 2015

S

ince Thomas Hodgkin, a British pathologist, discovered in the autopsy of a young patient numerous enlarged lymph nodes, especially in the neck, much has been studied in the field of lymphomas, and yet there is still a long way to go, its etiology is unknown, for instance.

So this group of diseases was named after their discoverer, at the suggestion of his London colleague Samuel Wilks1, “covering a wide variety of malignant tumors, originated in the lymph nodes,” says doctor Juan Manuel Herrera, hematoncologist at Centro Médico Imbanaco, in Cali (Colombia).

In those days, little could be done, the diagnosis was made usually in advanced stages, but today everything is different. Chemotherapy and radiotherapy have developed and advanced a great deal. And we have identified as many as 40 varieties of lymphomas, of which 20 to 22% are

Hodgkin varieties, and 80% are non Hodgkin 2. The difference between the two types of lymphomas is that Hodgkin disease is characterized by the presence of Reed-Sternberg cells (also named after the pathologist who first identified them), while they are absent in non-Hodgkin3 types.

But all lymphomas affect the lymphatic system, particularly the lymphocytes, whose function is to eliminate harmful substances. “The system is made up of a microscopic network of vessels extending all over the body, from head to toe, and they coalesce into lymph nodes in specific areas,” says doctor Carlos Castro, medical director at Liga Colombiana contra el Cáncer.

Also lymphomas can occur both in adults and in children in the bone marrow, lymphoid tissue, and any other organ containing lymph nodes. “Hodgkin and non-Hodgkin lymphomas rank third among all children cancers. And non Hodgkin

Muestra microscópica de linfoma no Hodgkin.

26 MAGAZINE FOR PROFESSIONALS IN THE HEALTH OF COOMEVA MEDICINE PREPAID

THE NON HODGKIN MAJORITY Non-Hodgkin lymphomas arises from B and T lymphocytes, so they are called B cell or T cell non Hodgkin

lymphomas according to their cellular origin, and each group also has a wide variety of malignancies.

“B lymphocytes originate in the bone marrow, and then they enter into the lymphatic system, including the lymphoid organs, where they fulfill their defensive role. And, on the other

hand, T lymphocytes are related to the thymus activity. Anyway, both types of immune cells act together destroying invading agents”, says doctor Maria Nelly Niño de Arboleda, an hematologist at Clínica del Country, and the director of Centro Javeriano de Oncología.

27

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December • 2015

Fotos: ®2015 SHUTTERSTOCK PHOTOS

lymphoma comprises 7 to 10% of all the cancers in children and young people under 20”4.

MBE LINFOMA DE HODGKIN INFANTIL

December • 2015

The cause of non-Hodgkin lymphoma is not entirely clear. But according to the National Cancer Institute, in the United States, “it is related to immunological diseases, like some particular cases of rheumatoid arthritis, as well as hepatitis B and C, and other risk factors, such as viral infections like HIV, Epstein-Barr, and human T-cell lymphotropic virus type 1 (HTLV-1).

Although some lymphomas do not have characteristic symptoms, it is important to take into account that if “you feel a lump, mass or lymph

node in the neck, armpit or groin, go immediately to the physician. Also there are unusual sites for the disease, like in the case of a patient who consulted because he had a mass in the middle of the leg, it turned out to be benign, but there are patients with lymph nodes in unexpected areas, as well as with other suggestive symptoms of these diseases”, says doctor Niño de Arboleda. According to doctor Castro, “80% of the patients consult because of painless enlarged lymph nodes, so laboratory checkups should be performed in those cases.”

THANKS TO THESE ADVANCES IN DETECTION AND TREATMENT, IT IS NOW POSSIBLE TO SAY THAT NON-HODGKIN LYMPHOMAS ARE NO LONGER A DEATH SENTENCE.

But there are other cases where the patient has “fever, weight loss, and night sweats”, adds doctor Herrera, while others can even have headaches and seizures, and on the physical exam a mass suggests a lymphoma or another type tumor.

So the clinical presentation of lymphomas is diverse. This does not mean that every enlarged lymph node is a lymphoma. But it is helpful to pay attention to changes, even though enlarged node can occur normally when the body is defending itself against an infectious disease. They are benign, and suggest other conditions.

Therefore the diagnosis, as noted doctor Niño de Arboleda, requires the expertise of a certified physician, a careful physical examination, and the confirmation of the diagnostic impression with histopathologic studies of the mass, as well as blood tests, and diagnostic images, so as not to treat as a lymphoma an enlarged lymph node secondary to an inflammatory disease; but, on the other hand, if a lymphoma is overlooked, and not treated, it tends to grow and spread into lymph nodes and organs, complicating the treatment modality, and the clinical response, while it deteriorates life quality.

“PET Scan is the most sensitive and specific test available for lymphomas, even though it is an expensive technology, but it evaluates the entire immune system detecting involved organs. Other imaging techniques like CT scan, and MRI may also be required”, said doctor Niño de Arboleda. “Blood tests can also detect bone marrow alterations, anemia, impaired platelet function, and altered gamma globulin concentrations, among other clinical manifestations.

Also liver, and kidney functions, as well as tumor markers, are used to detect specific types off lymphomas, together with lactic dehydrogenase and beta2-microglobulin, which may also be abnormal in these patients, although these changes are not exclusive o f l y m p h o m a s . F i n a l l y, l u m b a r

28 MAGAZINE FOR PROFESSIONALS IN THE HEALTH OF COOMEVA MEDICINE PREPAID

El más completo portafolio de servicios en salud visual: • Consulta de Oftalmología • Servicios Quirúrgicos • Unidad de Optometría y Óptica • Servicio de Contactología • Unidad de Cirugía Refractiva • Unidad de Diabetes y Salud Ocular • Tratamientos con Tecnología Láser • Terapias de Ortóptica y Baja Visión • Farmacia Especializada

Sub-especialidades Oftalmológicas: • Catarata • Glaucoma • Neuro-Oftalmología • Oftalmopediatría • Cirugía Plástica Ocular • Retina y Vítreo • Uveítis • Cirugía Refractiva • Córnea • Oncología Ocular

Ayudas Diagnósticas Aberrometría, Angiografía Fluoresceínica, Biometría Ocular, Campos Visuales, Ecografía Ocular, Electrofisiología Ocular, Fotografía Ocular, Microscopía Especular, Paquimetría, RetCam 3 (para uso pediátrico), Sensibilidad al Contraste, Tomografía Corneal, Tomografía Macular y de Nervio Óptico, Topografía Corneal

Para remisión de pacientes comunicarse con: Gloria Valencia - Móvil: 316 8303340 e-mail: gloria.valencia@clinicaofta.com Carrera 47 Sur No 8C-94 - PBX: (2) 511 0200 www.clinicaofta.com Cali - Colombia

MBE SO THE CLINICAL PRESENTATION OF LYMPHOMAS IS DIVERSE. THIS DOES NOT MEAN THAT EVERY ENLARGED LYMPH NODE IS A LYMPHOMA. BUT IT IS HELPFUL TO PAY ATTENTION TO CHANGES, EVEN THOUGH ENLARGED NODE CAN OCCUR NORMALLY WHEN THE BODY IS DEFENDING ITSELF AGAINST AN INFECTIOUS DISEASE. THEY ARE BENIGN, AND SUGGEST OTHER CONDITIONS.

LINFOMA DE HODGKIN ADULTOS

puncture and bone marrow studies are important, but they require the expertise of a specialist because they involve a risk that non-Hodgkin large cells can affect the brain”.

December • 2015

PROMISING TREATMENT Once the diagnosis is established, treatment is usually surgical in cases when a single early-stage lesions is found, the idea is to remove the existing node. Chemotherapy and radiotherapy are required when the disease involves the several areas of the body, then it is said to be systemic, so it is necessary to act on cells located in several tissues and organs. Lymphomas are usually radiosensitive. And among the most recent therapeutic options, alternatives like immunotherapy, anti-CD20, or anti-CD30 have been able to attack the tumor directly, while creating a kind of a protective shield with specific patient’s antibodies.

So lymphoma requires an interdisciplinary treatment, says doctor Castro, a team that involves “pathologists, whom will determine what kind of disease we are facing; radiologists, that will allow us to interpret the images and establish how widespread the disease is, if it is limited or disseminated; and hematologists as well as hematoncologists that will treat the malignancy, along with other malignant blood diseases”.

After the treatment is completed, much the same way as it happens with other types of cancer, patients enter into a strict control program. “It is important to diagnose promptly if recurrences or secondary tumors appear, so patients are controlled, at first, every three months, then every six months, then yearly, up to a five year follow-up”, says doctor Niño de Arboleda.

With these advances in detection, and treatment, it is safe to say that

non-Hodgkin lymphomas are no longer a death sentence.

Although there are no accurate records, there are between 1,200 and 1,290 affected men, and 920 women, whom have survived the disease, with an appropriate treatment. Globocan statistics (Information System of the International Agency for Research on Cancer) shows that in Colombia there are 7.9 cases per 100,000 inhabitants, and there are more than 400,000 new cases worldwide.

REFERENCIAS 1. http://www.historiadelamedicina.org/hodgkin. html 2. http://www.lymphoma.org/PTCL 3. http://www.cancer.gov/espanol/tipos/linfoma/paciente/tratamiento-lnh-adultos-pdq 4. Clinical Practice Guidelines for early detection, diagnosis, treatment and monitoring of Hodgkin lymphoma and non-Hodgkin acute lymphoma in children and adolescents. Available in: http://gpc.minsalud.gov.co/Documents/ Guias-PDF-Recursos/Linfomas/GPC_Prof_ Sal_Linfoma.pdf_-Guía. And right now they are preparing adult guidelines. http://www. cancer.gov.co/content/gu%C3%ADa-linfomas-en-adultos

30 MAGAZINE FOR PROFESSIONALS IN THE HEALTH OF COOMEVA MEDICINE PREPAID

RESEARCH

NEWS

COLOMBIA INVESTIGATES

December • 2015

BREAST CANCER

32 MAGAZINE FOR PROFESSIONALS IN THE HEALTH OF COOMEVA MEDICINE PREPAID

COLOMBIAN RESEARCHERS HAVE TAKEN ON THE TASK OF ANALYZING THE CHARACTERISTICS OF THE LOCAL POPULATION, AND THEIR RELATIONSHIP TO BREAST CANCER, AS WELL AS THE AVAILABLE DIAGNOSTIC METHODS, AND OTHER ISSUES, SUCH AS THE INCIDENCE OF BRCA1 AND BRCA2 MUTATIONS.

said doctor Carlos Andres Ossa Gómez, a researcher at this group3. He is a physician who studied at Universidad Pontificia Bolivariana, and has a master’s degree on molecular oncology CNIO, in Madrid (Spain).

THE 2.200 PATIENT COHORT The latest publication by this group appeared recently under the title, “Global survival, and disease free period according to the intrinsic molecular subtypes in a 2.200 breast cancer patient cohort, the experience at a Colombian center”. It is the first paper ever on survival rates in Colombia in relation to immunohistochemical molecular subtypes.

Its main goal was to describe the disease-free period, and the overall survival rates according to molecular subtypes, together with the clinical characteristics of the breast cancer patients treated at Instituto de Cancerología Clínica Las Americas, between January 2008 and December 2012.

Researchers obtained the information about the cases from Sistema de Información para el Seguimiento de Pacientes de Oncología, a database that records demographic, clinical, and treatment data of the patients at the institute. Then they reviewed the medical records of the operated patients, classifying the tumors in five histological subtypes, and they also considered the Ki67 33

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December • 2015

B

reast cancer is the second most common cancer in the world for both sexes, and the first in women, with an estimated 1,7 million new cases in 2012 (11,9% of all cancers), according to the World Cancer Report 20141.

So, naturally, breast cancer is a dynamic area of investigation. In Colombia, it accounts for 21,5% of all women’s cancers, it has a high incidence, and it is the leading cause of death among them 2. It has also increased its incidence, during recent decades it went from a rate of 3,5 women per 100.000 in 1981, to 10,3 per 100.000 in 2010.

The cancer research group at Instituto de Cancerología Clínica Las Americas (IDC), in Medellín, according to Colciencias a category B institution, is a leader in this field in Colombia.

Their research is aimed at “analyzing, from the view point of public health, the differences in the access barriers for breast cancer patients within our population; also, in relation to adjuvant chemotherapy, how do these patients react to chemotherapy before surgery, and how do they fair on the long term; and the third area is ​​genetics, trying to assess the presence of BRCA1 and BRCA2 mutations in our country in particular, and in Latin America in general. Because genes may protect, or increase breast cancer risk”,

RESEARCH

REPORT

RESEARCHER’S PROFILE

CARLOS ANDRÉS OSSA GÓMEZ, MD (A PROFESSIONAL THAT WORKS WITH COOMEVA MEDICINA PREPAGADA)

December • 2015

H

e is a surgeon, and a gynecologist, graduated from Universidad Pontificia Bolivariana; a fellow at Cirugía Oncológica de Mama (Mastología) at Instituto Nacional de Cancerología (Bogotá, Colombia); also an observer fellow at MD Anderson Cancer Center in Houston (Texas, USA); and has a Master’s degree in Molecular Oncology CNIO, in Madrid (Spain). Currently doctor Gómez is a member of Sociedad Colombiana de Mastología; as well as a member of Grupo de Cirugía de Mama del Instituto Cancerología Clínica Las Américas and Centro de Excelencia en Mama de Antioquia (CEMA); also he is an active member of the American Society of Breast Surgeons. He participated during 2011 in the development of the national guidelines for breast cancer. He has also been a speaker at several national and international meetings on the subject, and he is the author of several peer-reviewed papers. He has also received several awards, such as Mención de Honor de la Asociación Colombiana de Mastología, in the poster category, with the paper “Diagnostic experience in breast pathology with Suros vacuum biopsy technique in two Colombian institutions”, at Cartagena, November 6, 2011. And a second place was awarded to him by Instituto de Cancerología-Clínica Las Américas, for his work entitled, “Breast cancer patient survival rate after treatment at Instituto de Cancerología de Medellín, Colombia 2008-2012”.

KAPLAN-MEIER CURVES WERE PERFORMED, TAKING INTO ACCOUNT VARIABLES, AND SUBTYPES. THE RESULTING AGE MEAN WAS 56,4 YEARS. AND BREAST CANCER WAS DETECTED IN EARLY STAGES (I-IIA) IN 48,1% OF THE PATIENTS, WHILE IN ADVANCED STAGES (IIB-IIIC) IN 38,7% OF THE STUDIED CASES. report, when it was available. Subsequently, patients were interviewed by telephone, enquiring about their current health. It turned out to be the largest sample ever reported in Colombia.

Kaplan-Meier curves were performed, taking into account variables, and subtypes. The resulting age mean was 56,4 years. And breast cancer was detected in early stages (I-IIA) in 48,1% of the patients, while in advanced stages (IIB-IIIC) in 38,7% of the studied cases.

Doctor Gómez says, “the research group found the overall survival and the disease-free survival rates were similar to those reported in the literature, but no differences in biological behavior were identified between the molecular subtypes in pre and postmenopausal women. Interestingly these results disagree with other reports that suggest associations with age, and molecular subtype of the malignancy. We also analyzed breast cancer rates in women under 50. Evidence suggests this group would have a shorter life expectancy than advanced stages. But we found their survival rates were similar to those of patients over 50, implying that younger women with breast cancer are doing better. But this finding should be

further studied with larger prospective research protocols. Another interesting aspect of our results is that rates of advanced tumors are high, this points in the direction that there is work to be done in order to improve early detection of breast cancer in the general population”.

In another paper this group already published, they referred to the use of diagnostic imaging in breast pathology diagnosis and treatment, specifically with modalities like mammography, ultrasound, and nuclear magnetic resonance, the three most used technologies for this purpose4.

REFERENCES 1. International Agency for Research on Cancer (IARC), part of the World Health Organization, available in: http://www.who.int/mediacentre/news/releases/2014/cancer-report-20140203/es/ 2. Piñeros M, Gamboa O, Hernandez-Suarez G, Pardo C, Bray F. Patterns and trends in cancer mortality in Colombia from 1984 to 2008. Cancer Epidemiol 2013; 37 (3): 233-9.

3. Researchers: Carlos Andres Gomez Ossa, is a surgeon, and a breast oncologists, working with Grupo de Investigación en Cáncer IDC, Instituto de Cancerología-Clínica Las Américas (Medellín).

Luis Rodolfo Gómez Wolff, is a clinical oncologist, and the head of Grupo de Investigación en Cáncer IDC, Instituto de Cancerología-Clínica Las Américas. Johana Ascuntar Tello is the manager of Sistemas de Información en Salud del Grupo de Investigación en Cáncer IDC, Instituto de Cancerología-Clínica Las Américas. And, finally, doctor Hector Ivan Garcia Garcia is a MSc in Public Health, as well as in Epidemiology, and he is also part of Grupo de Investigación en Cáncer IDC, Instituto de Cancerología-Clínica Las Américas y Grupo Académico de Epidemiología Clínica (Graepic), Universidad de Antioquia (Medellín, Colombia).

4. file:///C:/Users/panamericana/Downloads/Imagenes%20Diagnosticas%20en%20Patologia%20 Mamaria%20%20Final%20(1).pdf

34 MAGAZINE FOR PROFESSIONALS IN THE HEALTH OF COOMEVA MEDICINE PREPAID

FROM

COOMEVA

MEDICINA PREPAGADA

AND NOW, VERY EASY AUTHORIZATIONS!

C

OOMEVA Medicina Prepagada also thinks about your time, as well as your family’s, so we developed a quick and simple process by which you can process service orders in three simple steps..

Scan the medical order and the clinical history the doctor gave you, and store them in PDF or JPG format *

1.

2.

Send these documents from your email account, with the following information: Name and surname Type and number of identity document Contact phone number, mobile and land line E -mail, where authorization would be received N a m e o f t h e i n s t i t u t i o n o r medical personnel whom would provide the requested service

3.

December • 2015

When the order is approved, you will receive an email with the authorization documents, so that you can print them.

Authorizations will take stipulated time frames depending on the required service. Note that each individual test, or procedure, generates an authorization that will be printed separately.

It is important to remember that to attend to the appointment, the patient should have the separate hard copies of each authorization sent to you, along with the original medical order and the clinical history that the treating physician gave you in the first place.

AT COOMEVA MEDICINA PREPAGADA WE WANT TO CONTRIBUTE TO REDUCE UNNECESSARY DISPLACEMENTS AND DELAYS! Send your authorization requests to the following emails, according to where you are located: Southwestern Regional: Cali - Buga - Popayán - Buenaventura - Palmira - Tuluá - Pasto cmpsuroccidente@coomeva.com.co

Northwestern Regional: Medellín - Apartadó - Montería Quibdó - Rionegro cmpnoroccidente@coomeva.com.co

Regional Coffee Zone: Pereira - Armenia - Manizales Cartago cmpejecafetero@coomeva.com.co

Caribbean Regional: Cartagena - Barranquilla - La Guajira Santa Marta - Valledupar cmpcaribe@coomeva.com.co

Northeastern Regional: Bucaramanga - Cúcuta cmporiente@coomeva.com.co

Centraleastern Regional: Bogotá - Ibagué - Neiva - Villavicencio cmpcentrooriente@coomeva.com.co

*IMPORTANT NOTICE: When imaging diagnostic tests, like X rays, require printed copies, the administrative procedure should be done personally at Coomeva Medicina Prepagada authorization centers.

36 MAGAZINE FOR PROFESSIONALS IN THE HEALTH OF COOMEVA MEDICINE PREPAID

LISA,

IS A DEDICATED TELEPHONE LINE FOR HEALTH CARE PROFESSIONALS WORKING WITH COOMEVA MEDICINA PREPAGADA

R

emember you can now use this dedicated phone line that will meet your concerns as a health care professional, and as a user of Coomeva Medicina Prepagada. .

AS A HEALTH CARE PROFESSIONAL: • You can request tax certificates, such as Retefuente, rete-ICA, and rete-VAT • Consult the payment of your medical fees • Update your personal data • A u t h o r i ze p a y m e n t s t h ro u g h electronic transfers • Consult outstanding checks

Schedule, every day from 7:30 a. m. to 6:00 p. m.

To communicate from a mobile or a land line follow these steps:

1

Dial 018000 961338

2 3

Select option 3, for health care professionals working with Coomeva Medicina Prepagada Introduce your health care ID number, and finish pressing #

El contacto de los Empleadores

Línea Empresarial LISA 37

MAGAZINE FOR PROFESSIONALS IN THE HEALTH OF COOMEVA MEDICINE PREPAID

December • 2015

AS A COOMEVA MEDICINA PREPAGADA USER: • Request authorizations for medical orders for you, and your family • Validate you due balance • C o n s u l t y o u r a s s i s t a n c e o n coverage, benefits, and fees of the health care programs you are entitled to • Consult the list of national network providers • Update da ta about your family • Request certificates of membership, pre-existances, and uses • Validate your due balance up to date

ACCESS LISA LINE

OUR

PLUSES

SPECIAL COVERAGE FOR OUR

MEMBERS, AND THEIR FAMILIES LEARN ABOUT THE SPECIAL HEALTH COVERAGES YOU ARE ENTITLED TO, BECUASE YOU ARE ASSOCIATED WITH COOPERATIVA COOMEVA. Special rates: • Free Oral Health Care Program registration • Special Rate for Coomeva Emergencia Médica, only $ 30,030 • Expansion of the associate’s family group at the same rate

December • 2015

SPECIAL BENEFITS: GOLD PROGRAM • Blood transfusion: unlimited • Osteosynthesis material: up to 20 SMMLV • Psychiatric hospitalization: from the first day of the second month of becoming an associate

• Ground ambulance service: 5 events per year / user • Maternity coverage for one user in the contract, starting on the first day of the second month

PARTNER PROGRAM • Complex diagnostic procedures: unlimited coverage beginning on the first day of the 13th month • High-risk sports injuries: 100% coverage starting on the first day of the 4th month • Psychiatric hospitalization: 20 days per user / year per contract • Osteosynthesis material: up to 15

SMMLV due to illness • Airlift service can be refunded up to 15 SMMLV

TRADITIONAL SPECIAL PROGRAM • Direct access to eight medical specialties, when you are an associate and have access to the program.

You can also consult up to three times per user / year per contract, outside our network, with a refundable modality at Coomeva Medicina Prepagada rates for specialties not included in the program (only consultations).

38 MAGAZINE FOR PROFESSIONALS IN THE HEALTH OF COOMEVA MEDICINE PREPAID

COOMEVA BY THE NUMBERS INTEGRAL MEDICAL POPULATION BY GENDER IN SEPTEMBER 2015

MEDICINA PREPAGADA

NUMBER

103.342 NUMBER

132.912 Program Golden Years Classical Golden Years Other

ACTIVE POPULATION IN SEPTEMBER 2015 74.837 80.000 67.872

70.000 80.000 60.000 80.000 70.000 50.000 70.000 60.000 40.000 60.000 50.000 30.000 50.000 40.000 20.000 40.000 30.000 10.000 30.000 20.000 0 20.000 10.000 10.000 0 0

74.837 74.837 48.210 48.210 48.210

30.386 30.386 30.386

Bogotá Regional Bogotá Regional Bogotá Regional

67.872 67.872

8.840

Cali Regional Cali Regional Cali Regional

49 8.840 49 Coffee Internacional Caribe 8.840 49 Zone Regional Regional Caribe Regional Coffee Internacional Regional Zone Internacional Regional Caribe Coffee Regional Regional Zone Regional Regional

6.060 6.060 Medellín Santander 6.060 Regional Regional Medellín Santander Regional Regional Medellín Santander Regional Regional SUBTOTAL

236.254

REGIONAL POPULATION CEM 35.000

32.738

30.000 35.000 25.000 35.000 30.000 20.000 30.000 25.000

32.738 32.738

27.158

573

Associate Classical HCM Gold Gold Plus Silver Young Traditional Traditional Special Golden Years HCM Silver Total

1.641 4.886 4.549 155.895 9.627 39.789 4.394 4.631 65 1.159 236.254

12.574

10.486 10.486 10.486

12.574 12.574

5 5 Coffee 5 Zone Coffee Regional Zone Coffee Regional Zone Regional

Caribe Regional Caribe Regional Caribe Regional

Medellín Regional Medellín Regional Medellín Regional

5.000 0 0

Golden Years Silver

27.158 27.158

15.000 25.000 20.000 10.000 20.000 15.000 5.000 15.000 10.000 0 10.000 5.000

Number 1.108 7.937

Bogotá Regional Bogotá Regional Bogotá Regional

Cali Regional Cali Regional Cali SUBTOTAL Regional

82.958

11.418

ORAL HEALTH BY REGIONAL POPULATION 12.000

10.000 12.000 12.000 8.000 10.000 10.000 6.000 8.000 8.000 4.000 6.000 6.000 2.000 4.000 4.000 0 2.000 2.000 0 0

11.418 11.418

7.324 5.957

1.181

Medellín Regional Medellín Regional Medellín Regional

7.324 7.324

3.814

5.957 5.957 1.181 1.181 Santander Regional Santander Regional Santander Regional

2.092

3.814 3.814

2.092 2.092 Coffee Zone Coffee Regional Zone Coffee Regional Zone Regional

Caribe Regional Caribe Regional Caribe Regional

Bogotá Regional Bogotá Regional Bogotá Regional

Cali Regional Cali Regional Cali Regional SUBTOTAL

31.779 TOTAL

350.991

GENERAL MEDICINE AND SPECIALIZED CONSULTATIONS JANUARY THROUGH SEPTEMBER 2015

January February March April

0

January February March April

May June July August September Total

666.822

76.893

77.158

74.319

73.176

77.001

75.945

76.724

TOTAL

76.127

800 700 600 500 400 300 200 100 0

59.479

85.390

9.492

9.602

9.520

20

9.378

40

9.071

60

10.090

80

9.072

581.432

67.401

64.799 67.556

63.798

67.930

May June July August September Total

GENERAL MEDICINE CONSULTATIONS

January February March April May June July August September Total

39 MAGAZINE FOR PROFESSIONALS IN THE HEALTH OF COOMEVA MEDICINE PREPAID

December • 2015

0

65.855

100

67.652

200

65.986

300

50.455

400

100

10.141

SPECIALIZED CONSULTATIONS

500

9.024

600

MUNDO MÉDICO

EVENTS ‘‘XXVII NATIONAL CONGRESS OF NEUROSURGERY’ Date and Place: March 31st, April 1st and 2nd, 2016, at Medellín Information: Asociación Colombiana de Neurocirugía Phone: (1) 610 0090 Email: asoneurocirugiaacncx@gmail.com

‘XII COLOMBIAN CONGRESS OF NEUROLOGY’

Web page: http://www.acncx.org/index.php/noticias/eventos-2015/16-xxviicongreso-nacional-de-neurocirugia-medellin-2016

Date and place February 25th through the 28th, 2016, at Cali Information: Asociación Colombiana de Neurología Phone: (1) 611 2474 Email: eventos@acnweb.org Website: http://www.acnweb.org/es/ congreso-2016.html

‘XVI COLOMBIAN CONGRESS OF OCCUPATIONAL THERAPY’ Date and place: March 3rd through the 5th, 2016, at Medellín Information: Colegio Colombiano de Terapia Ocupacional Phone: (4) 448 2810 Ext 207.

Email: academico@ccto2016.com Website: http://www.tocolombia.org/ eventos-y-noticias/

December • 2015

‘XXVI COLOMBIAN CONGRESS OF CARDIOLOGY AND CARDIOVASCULAR SURGERY’ Date and place: March 10th through the 12th, 2016, at Pereira Information: Sociedad Colombiana de Cardiología y Cirugía Cardiovascular Phone: (1) 523 0012 - 523 1640 Website: www.scc.org.co

“XVI INTERNATIONAL SYMPOSIUM OF PEDIATRIC PNEUMOLOGY AND ALLERGY ‘ Date and place April 22nd through the 23rd, 2016, at Cartagena Information: Clínica Respiratoria y de Alergias Phone: (5) 662 8620 Email: simposio@clinialergias.com Website: www.clinialergias.com/simposio/index.html

40 MAGAZINE FOR PROFESSIONALS IN THE HEALTH OF COOMEVA MEDICINE PREPAID

BOOKS ‘ALL EGG’ Authors: Clara Inés Correa and Ana Maria Arango

‘THE LIFE OF THE ELVES’ Author: Muriel Barbery

‘THE KULLERVO STORY’ Author: J. R. R. Tolkien

I

nterestingly this is a novel that the author began writing in 1914, influenced by his reading of Kalevala, a Finn epic poem. Hapless Kullervo was a man who faced a tragic fate because his father was killed, and his mother kidnapped by a dark sorcerer called Untamo, who then raised him with his twin sister, Wanona, and ultimately sold him as young slave.

So he seeks revenge form the sorcerer.

T

his novel tells the story of Mary and Clara, two young women with very different lives, but who, unknowingly, have a connection: they are in touch with the wonderful world of the elves. A place full of art, inventions and mysteries, but it is also threatened by a rogue elf. So the girls share the responsibility of saving the magical land. So this is a story about the power of narratives, dreams, and imagination, indispensable elements to build a better world.

Author: Blue Jeans This Spanish author tells us the story of a group of youngsters in college, falling in love for the first time, in sum, learning to live away from home.

Madrid is their new environment, and each one has a different problem, and ways to cope with it. Demanding situations that put them to the limit. “The guys, going to Benjamin Franklin school, fulfill their dreams and face their insecurities. But things are not always what they seem to be, or as good as they should be. But, anyway, they must live their own lives, there is no alternative”, Blue Jeans.

The egg, one of the most versatile, nutritious, and economic ingredients, is the center of this cookbook presented by Círculo de Lectores. It contains several recipes intended to make the most of the nutritious properties this product can give your body. Readers will find in it breakfasts, main courses, light meals, snacks, and desserts.

41 MAGAZINE FOR PROFESSIONALS IN THE HEALTH OF COOMEVA MEDICINE PREPAID

December • 2015

“SOMETHING AS SIMPLE AS TWEETING I LOVE YOU’

MUNDO MÉDICO

CINEMA

This classic cartoon is back on the big screen, and it promises a great deal ‘SNOOPY & CHARLIE BROWN of fun for the whole PEANUTS, THE FILM’ family. The cartoons, Director: Steve Martino which will start showing in Cast: French Capaldi, Noah Colombia on this coming Schnapp, Bill Melendez, Noah December, include the Johnston popular Charlie Brown and his friends, Lucy, Linus and Snoopy.

Together they will embark on an adventurous journey to participate in a competition. Teaching us that perseverance is the best way to fulfill the most improbable dreams.

MUSIC ‘CONNECTION’ Fonseca his is the fifth studio album by this Bogotá born singer, who is already promoting his first single “Between my life, and yours” in several Latin American countries. This new work is a mixture of Latin, and Colombian rhythms, including salsa, ranchera, and pop. On this project the artist worked with producer, pianist, and composer Julio Reyes Copello, who has already participated in several musical enterprises, with Ricky Martin, Nelly Furtado, Alejandro Fernandez, and Thalia, among others.

T

December • 2015

‘‘UNBREAKABLE’ Janet Jackson he sister of the late ‘King of Pop’, is returning to stages after six years after launching her last album. She announced THE 33 recently this new production Director: Patricia Riggen with Rhythm Nation Seal / BMG, Cast: Antonio Banderas, Rodrigo Santoro, featuring rapper J. Cole in two Kate del Castillo, Juan Pablo Rada, Martin songs, “No sleeep”, and “The Sheen great forever”. And also Missy Elliott participates in the single This is the story of the 33 Chilean miners “Burnitup”. Jackson made this whom survived 69 days, 700 meters new album with producers underground after San José mine collapsed Jimmy Jam and Terry Lewis, in August 2010. This movie narrates the whom have also worked with ordeal these men, and their families, went artists like as Usher and Mariah through while they were rescued. The film is Carey. a tribute to the courage of these people while in that extreme situation that tests faith and hope.

T

42 MAGAZINE FOR PROFESSIONALS IN THE HEALTH OF COOMEVA MEDICINE PREPAID