COOMTACTO - Volumen 11 - #2 by PROSPERTECH SA

ISSN 2011-3579

A MAGAZINE FOR COOMEVA MEDICINA PREPAGADA HEALTHCARE PROFESSIONALS

VOL. 11 • # 2 • NOVEMBER 2018

The specialty

OPHTHALMOLOGY Myopia: the fault is of the environment

XEN: solution to mild open-angle glaucoma

Drops that give quality of life to patients with presbyopia

EDITORIAL

In 2019 we will be delighted with the achievements of technological modernization

THANK YOU FOR YOUR SUPPORT AND TRUST!

oomeva Medicina Prepagada is living, for the benefit of all our users, allied providers and collaborators, a great technological transformation, whose implementation has been taking place with high expectation and great enthusiasm. As expected, the great milestones in any scenario involve overcoming obstacles, overcoming adversities and taking on challenges, derived from the high complexity of these processes, in order to fulfill the mission of responding to our community in a timely manner and with the best possible quality . Obeying the projected, all these difficulties have been solved in favor of our target group. It is time, then, to tell everyone, users, families, allies and collaborators, THANK YOU, THANK YOU! Thank you for your patience, for your support, for understanding that great changes necessarily entail discomforts; and for continuing to place their trust in us. All the members of the great team of Coomeva Medicina Prepagada, each one from its field of action or know-how, we have contributed our bit and we have been willing to 100%, supported by previously established contingency plans, to resolve the intermittent, failures, requirements and incidents of the system; and we will continue doing it indefinitely, as long as our allies, providers and users demand it. In the same sense, we have deployed an additional workforce in the most critical points and service areas. In this way, at the end of the process, we will be able to overcome obstacles, provide an accurate solution to inconsistencies, and optimize service provision so that their benefits reach our population on time, without misunderstandings and without interruption. We will continue forward, with determination and dedication, developing a health model that promotes accompaniment and support for our users and, of course, you, our allied providers, to whom we thank you infinitely for your commitment and dedication.

Jorge Alberto Zapata Builes Gerente General Coomeva Medicina Prepagada

****** I also want to take advantage of this space of the last edition of the year of the Magazine COOMTACTO to send all health professionals, allies of our corporate purpose, a warm and sincere message of congratulations for the celebration on December 3 of the Day of the Doctor, date in which the immeasurable, committed and self-sacrificing work that day after day, working day after working hours , our Colombian physicians practice is recognized, especially those linked to the care of Coomeva Medicina Prepagada. Without their dedication, professionalism and dedication, this simply would not be possible. At the same time, I welcome you to a 2019 hopeful and totally open to the fulfillment of good purposes. 2019 will be the year to reap the fruits of this supreme effort for a structural transformation supported by the most advanced technology at the service of people. NOVEMBER 2018

CON

Jorge Zapata Builes

General Manager Coomeva Medicina Prepagada

Editorial committee Pascual Estrada Garcés, MD Health National Head Martha Liliana Cifuentes National Coordinator of Relationships and Healthcare Providers Julián Adolfo Villegas Health Risk Management National Head

Ana María Correa Quality National Auditor Sandra Viviana Muñoz National Epidemiologist Jessica Montes National Analyst Relations with Providers Juan Fernando Saavedra Advertising and Marketing National Head

Editorial production Legis S.A.

www.comunicaciongraficalegis.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

14 3 | EDITORIAL In 2019 we will be delighted with the achievements of technological modernization. THANK YOU FOR YOUR SUPPORT AND TRUST! 6 | MEDICAL ADVANCES

ISSN 2011-3579

A MAGAZINE FOR COOMEVA MEDICINA PREPAGADA HEALTHCARE PROFESSIONALS

VOL. 11 • No. 2 • NOVEMBER 2018

The specialty

OPHTHALMOLOGY Myopia: the fault is of the environment

XEN: solution to mild open-angle glaucoma

Drops that give quality of life to patients with presbyopia

4 NOVEMBER 2018

10 | HEALTH UP TO DATE Cali, focus of the world fight against cancer

18 22 | THE SPECIALTY Ophthalmology / The interview María Ximena Núñez, MD With an eye on visual health 26 | RISK MANAGEMENT Alert in the Americas Measles returned!

14 | THE SPECIALTY Ophthalmology Myopia: the fault is of the environment

30 | REPORT TO THE INVESTIGATION MD. Luis Felipe Vejarano Restrepo, Drops that give quality of life to patients with presbyopia

18 | THE SPECIALTY Ophthalmology XEN: solution to mild open-angle glaucoma

33 | FROM COOMEVA ‘Sara’, the new virtual assistant of Coomeva Medicina Prepagada

TENTS November 2018

DATA IN DOSES COLOMBIA, EXAMPLE IN COVERAGE One of the conclusions in version 25 of the Pharmaceutical Forum is that Colombia has become a model for the world in access to health. According to the representative of the Comisión Económica para América Latina y el Caribe (Cepal) , Olga Lucia Acosta, we rarely look inward to recognize that since 1993 we have gained equity advantages, and that the health system allows us to be competitive. The senior specialist in health and social protection of the Interamerican Development Bank (IDB), Jaime Cardona, added that today Colombia has an assurance that reaches 97%. And between 2012 and 2016 the coverage in procedures increased by 73% and the number of drugs delivered increased by 119% in the same period.

A FRACTURE BY OSTEOPOROSIS EVERY THREE SECONDS It is estimated that about 200 million people around the planet suffer from osteoporosis, and this disease is already considered a global epidemic in postmenopausal women. According to official data from the Asociación Colombiana de Osteoporosis y Metabolismo Mineral (ACOMM), osteoporosis causes more than 8.9 million fractures a year, equivalent to one every three seconds. The worst thing is that 20% of patients die after a hip fracture, most of them during the first year. A study published in the British Medical Journal found that the disease has a great psychological impact: 80% of women over 75 years of age prefer to die rather than experience the loss of independence that is living in a geriatric home after a hip fracture.

INFECTION BY ‘CHLAMYDIA TRACHOMATIS ‘AND CERVICAL CANCER

42 34 | EBM What’s new in sepsis management One hour to save life 38 | EBM Advances in breast cancer Genetic testing would prevent chemotherapy 42 | HUMANIZED MEDICINE Emergencies: approach beyond the patient 46 | GOOD PRACTICES Oral protocol for cancer patients

49 | COOMEVA PROMOTES ‘Taking care of you is to love you’, a promise of value of our model of care 50 | LEGISLATION AND HEALTH New law of the resident An impulse to the training of more specialists 54 | MEDICAL WORLD Academic events Books Movie theater Music Shows

In the world, cervical cancer is the third most frequent and the fourth cause of cancer death in women. Human papilloma virus (HPV) is considered the main etiological agent. But there are other factors involved in the increase of susceptibility that in turn facilitate its persistence. These are behavioral, lifestyle and sexually transmitted infections, such as bacterial vaginosis or Chlamydia trachomatis. This is one of the most common sexually transmitted pathogens in women, and epidemiological studies have shown a higher rate of infection in patients with cervical cancer.

MENTAL DISEASES BEGIN BEFORE 14 YEARS Between 10% and 20% of adolescents around the world have mental health problems, however, few ask for help. Emotional disorders, such as anxiety; those of eating behavior, such as anorexia or bulimia; those of child behavior, such as hyperactivity; or psychosis, with hallucinations or delusions, are some of the common mental problems in young people. Depression is one of the main causes of illness, while suicide has been positioned as the third cause of death in young people between 15 and 19 years; According to the WHO, in 2016 about 62,000 died as a result of self-harm.

NOVEMBER 2018 5

MEDICAL ADVANCES

CELLULAR THERAPIES FOR ORTHOPEDIC TRAUMAS

Colombian specialists are applying orthobiology in the orthopedic medicine. It is a new technique that uses stem cells and growth factors in the lesions of tendons, ligaments and muscles of athletes, which essentially facilitates the process of repair and regeneration of the joints. The technique, compatible with traumatology and orthopedic surgery, represents a new therapeutic approach less invasive and radical with the use of biological substances that significantly improve the forecasts. The advance is framed in the context of regenerative medicine, when applying knowledge biomechanical and biotechnological approaches to the development of treatments for injuries of the locomotor system. The treatment stimulates natural defense mechanisms of the human organism when applied with precision in the focus of each injury, in the same way as they infiltrate. SOURCE: COLOMBIAN ASSOCIATION OF ARTHROSCOPIC SURGERY (ACCART). APRIL 2018.

THE ERA OF DIGITAL HOSPITALS IS ALREADY HERE A novel solution in digitalisation for the health care sector called Tasy became known recently in Colombia. The new technology take advantage of the benefits of big data in time real to improve administrative processes, the attention to the patient’s opportunity and precision in medical diagnoses. The Royal company Philips launched the solution recently in the market Colombian as an innovative tool that allows interoperability of data within the clinics and hospitals that handle gigantic volumes of information, makes it easier for staff hospitable work in a more collaborative way and efficient by centralizing the management of all processes administrative and clinical services in a single platform, and optimizes patient safety thanks to protocols scientifically established and advanced algorithms for the rapid detection of infections and other risk conditions. SOURCE: ROYAL PHILIPS (NYSE: PHG, AEX: PHIA). BOGOTÁ, JULY 2018.

BIOMETRY FETAL WITH HIGHER PRECISION

Improve the early diagnosis of abnormalities fetal diseases and determine more accurately the gestational age are fundamental parameters in obstetric practice. The continuous advances in this field have increased forcefully the precision of the results. Now it is possible measure the transverse cerebellar diameter (TCD), the Binocular distance (BD) and fetal foot length (FFL). In addition to these parameters, a review published in the research platform ScienceDirect establishes what are the measurements to perform a biometrics more precise, how to determine them and their usefulness medical Among the indications and recommendations that establishes the new guide is the measurement of the Cephalo-caudal length (CCL), the biparietal diameter (BPD) and cranial circumference (CC); the length of the femur (FL), the abdominal circumference (AC), and the determination of growth retardation intrauterine, as well as fetal weight, all with an accuracy close to 100%. SOURCE: ARTICLE “FETAL BIOMETRY: RELEVANCE IN OBSTETRICAL PRACTICE”. PUBLISHED IN THE JOURNAL SCIENCEDIRECT 9. FEBRUARY 2018.

6 NOVEMBER 2018

MONITORING OF THE FASTEST AND SUCCESSFUL GESTATION A new monitoring station will allow 15 mothers in pregnancy and simultaneously be monitored through the internet by the health personnel. The monitoring center called FTS-6 is a revolutionary technology that is responsible for controlling the heart rate and uterine pressure of the fetus by means of transducers with submersible configuration and wifi connection for data transmission. The device allows to analyze, save, print and review the patient and fetus data, as it has an all-in-one computer that shows simultaneously Up to 12 monitoring windows, an optional touch screen, a comprehensive system of alarms for sudden events and a printer Optional external, all in real time. The pregnant mothers You can also download an application so that, from your house and subsequent to the acquisition of the transducers, may be monitored by your obstetrician gynecologist through the data that is They will transmit from the app to the specialist’s teams. SOURCE: EDAN INSTRUMENTS. BOGOTÁ, JULY 2018.

SOLUBREATH’, ASTHMA UNDER CONTROL Asthma crises generate cost overruns to the system of health and affect the quality of life of the patient, but today can be detected through Solubreath, a device biomedical that allows daily monitoring of obstructive status of patients with conditions respiratory, predict episodes of crisis, send timely alerts to health professionals and inform them about their evolution and if the symptoms are controlled. Also, this tool reproduces the protocols of respiratory therapy based on principles of PPE and PPEO (pressure positive expiratory and pressure positive expiratory oscillating). It is about imposing resistance to patient’s respiratory flow, to through exercises, to strengthen the muscles involved in the breath The device is connected to an application mobile phone and, through a tablet or smartphone, with audiovisual indications, guides the patient on what what you should do in a certain case. The invention was developed by the Colombian engineer Andrés Guerra, asthma patient and athlete, who was awarded by the Chamber of Medical Devices and Supplies for Health of the ANDI (Asociación Nacional de Industriales), in first edition of this contest. SOURCE: JOHNSON & JOHNSON. AUGUST 2018.

BUSINESS ERGONOMICALLY SAFE From the year 2019 the Colombian labor legislation will require companies to implement Decree 1072 of 2015 of the Safety and Health Management System in Labor, for employers to provide all the security elements necessary for the equipment of work in order for it to carry out its work without any risk in the spaces of the company; measure includes the adaptation of ergonomic furniture, such as desks, tables and supports for computers, rests-feet, pad mouse and supports-wrists. The regulations seek to prevent occupational diseases, Disabilities and low productivity in employees that stay a long time in the same position in front of the computer and can present musculoskeletal and circulatory damage due to bad postures and repetitive activities. SOURCE: INTERNATIONAL SECURITY FAIR, CORFERIAS, COLOMBIA, 22 TO 24 OF AUGUST 2018.

‘SHIP’ OF RESONANCE FOR CHILDREN The first specialized resonance room in the country for children ends be inaugurated at the Roosevelt Children’s Orthopedic Institute with the purpose of making a complex exam a whole space adventure (especially because of its galactic ship shape). The implementation of this innovation allows them children do not have to move from the facilities of the Institute so that practice resonance, just like that can be sedated in this same space, if it is necessary. With a short design, light coils, sequences silent and a pleasant habitat, it seeks to improve attention and diagnostic experience more of 45 thousand Colombian children. The resonance device magnetic used in this room is the Magnetom Essenza, whose hypersensitivity mechanism the movement provides sharp images of any part of the organism of children, even the most restless. Additionally, throws images in 50% less time spent by teams conventional, thanks to sequences like Caipirinha or a turbo Spin Echo gradient, which avoids long waits. SOURCE: ROOSEVELT INSTITUTE AND SIEMENS HEALTHINEERS. AUGUST 2018.

NOVEMBER 2018 7

MEDICAL ADVANCES

OROFACIAL PAIN CONFUSED WITH RINOSINUSITIS In a review of MEDITECH scientists from the University of Edinburgh of 973 patients with pain Orofacial and presumed rhinosinusitis, only in 1 out of 10 was confirmed breast disease paranasal through endoscopy and computed tomography (CT), according to the British Medical Journal. Therefore, the diagnosis correct can be lost or delay and result inadequate treatment and prolonged symptoms. Orofacial pain lasts more than 12 weeks and by then I could have received treatment in primary care, giving place to the reconsideration of diagnosis before persistence of the symptoms. While there is no solid evidence, this has been related to migraine and pain of the middle facial segment. However, it is diagnosed wrongly as rhinosinusitis due to nasal symptoms who accompany him. The European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) define rhinosinusitis due to the presence of four fundamental symptoms: nasal blockage, congestion, obstruction and secretion nasal. Therefore, it recommends a full examination of the cranial nerves in all patients with orofacial pain chronic, in order to rule out possible intracranial tumors; and rinoscopy and palpation of the temporomandibular joint, to confirm the diagnosis. SOURCE: ARTICLE “OROFACIAL PAIN, HOW ADDRESS IT? “ PUBLISHED ON THE WEB PAGE OF INTRAMED. JULY 2018.

8 NOVEMBER 2018

ALLIANCE FOR THE GLOBALIZATION OF MEDITECH The signing of an alliance between the Asociación Colombiana de Hospitales y Clínicas (ACHC), the Centro Internacional de Negocios y Exposiciones de Bogotá (Corferias) and the logistics operator Messe Düsseldorf seeks to consolidate Meditech as one of the most important fairs in the sector of health in Latin America, for this they manage participation, in the next version of the event, of international companies in the health sector, the presence of more innovations and technologies of the medical industry, and the expansion of the opening of the international market. Director of International Business of Corferias added that the increase in participation of exhibitors and international suppliers in 2020 will attract more health professionals in the same way, as directors of clinics and hospitals, Central American, Caribbean and other countries Andean area. “Health professionals will choose Colombia and Meditech over others Fair events that take place in Europe“. The 6th edition of the fair, which ran from 3 to 6 of July 2018 in the Grand Hall of Corferias, had the participation of 300 exhibitors national and foreign, professional visitors of the sector, managers of health institutions, governmental entities, scientific societies, academia, service providers and specialized products, among others. SOURCE: COLOMBIAN ASSOCIATION OF HOSPITALS AND CLINICS. JULY 2018.

IS OBESITY CONTAGED?

SOURCE: ARTICLE “AN ‘OBESITY VIRUS’ COULD BE TO BLAME FOR MANY PEOPLE BEING OVERWEIGHT “. PUBLISHED ON THE WEB PAGE OF THE NEW SCIENTIST MAGAZINE. JULY 2018.

Obesity can spread from person to person like a virus. When an individual increases Weight, close friends too. This was revealed by the research recently published in the New England Journal of Medicine, which included an analysis detailed of a social network of 12,067 people who received follow-up for 32 years, from 1971 to 2003. The researchers knew who was friend of whom, they knew their spouse, brother, neighbor, and how much each person weighed. The conclusion was that the odds of being obese increase by 57% when a friend becomes obese. The proximity does not seem to matter, as the influence of friend or relative remains even hundreds of kilometers of distance. Nicholas Christakis, doctor and professor of medical sociology at the Faculty of Medicine of Harvard and principal investigator of the study, says that one explanation is that friends affect the perception of the fatness of others. When a close friend becomes obese, obesity does not look so bad.

Gracias por dedicar tu vida a la salud y bienestar de todos.

¡FELIZ DÍA DEL MÉDICO!

Cuidarte es quererte.

HEALTH UP TO DATE

WORLDWIDE FIGHT AGAINST CANCER The incredible C/Can 2025 intends to reduce the rate of cancer in the capital of the Valle del Cauca by 25% for the year 2025. The design of the political project, considered a multisectorial and global challenge, will be in charge of all the cities concerned. Cali among the three cities chosen in the world. 10 NOVEMBER 2018

he International Union against Cancer (IUAC) chose Cali C / Can 2025 intends to reduce the rate of cancer in the vallecaucana capital as one of the cities where focus will be focused and pilot tests will be implemented for the intensification of the fight against the disease. The project called “Challenge against cities against cancer” aims to reduce the preventable mortality due to high-cost chronic diseases such as cancer by 25% for the year 2025, and thus improve the quality and opportunity in the approach of this. To achieve this goal, it is projected to work on four fronts of action: • Evaluation of basic oncology services. • Effective and efficient management. • Quality in patient care and follow-up. • Access to services as a right that the entire population has. The initiative initiated by the IUAC (an entity that groups about 160 international organizations between government and NGOs, including health secretaries of the main municipalities of Colombia) seeks that cities be organized to fight against one of the sufferings with more high mortality rates

Cali, focus of the

REVELADORS OF THE VALUE OF THE VALLE DEL CAUCA In Cali, each year, approximately 9 thousand people are attended by multiple causes associated with cancer, although a little more than 4,500 are from the city; 250 patients of the total figure are minors, 100 of them also arriving from surrounding municipalities, according to records of the Health Department of the Valle del Cauca. If it is about cancer mortality according to gender, in the region, the first cause in women is breast cancer and the second, cervical cancer. For the case of men, the first cause is cancer of the digestive paths and the second, the prostate. In men, prostate cancer generates an average of 22 deaths per 100 thousand inhabitants; that of stomach, 18 deaths per 100 thousand inhabitants; and lung cancer, 14 deaths per 100 thousand inhabitants. On the other hand, for breast cancer there are 16 deaths of women per 100 thousand inhabitants; and for stomach cancer, 13 deaths per 100 thousand inhabitants. In 2017, the department of Valle del Cauca reported 1,340 women with cancer, the average age was 57 years and the mortality was 50% because the diagnosis was late; In addition, 420 women with cervical cancer were treated, with an average

Photo: IMBANACO

in the world, and that all the actors involved, patients, doctors, private sector and health systems, work in a articulated way to achieve better results. The “Challenge against cities against cancer” is part of the Access Accelerated Organization, which brings together several projects that work in order to avoid premature deaths through treatable and preventable diseases, such as chronic respiratory, diabetes, cardiovascular diseases, mental health conditions and the same cancer. Cali was the first chosen city to advance this initiative, whose stages, according to Olga Isabel Arboleda, project manager, will take place in three years. “Of its success will depend on the achievement of greater resources to fight against this disease; also that the model is replicated throughout the world”, says the spokeswoman. For now there are three cities chosen by the International Anti-Cancer Union for the execution of the project. Cali, Asunción (Paraguay) and Rangún (Birmania), selected from more than 330 options. The cities have in common that they have more than one million inhabitants, they are capital with average income at low and expressed their desire to participate in the first phase C / Can 2025.

Cancer is the second cause of death in Latin America. It is estimated that cases will increase by 106% by the year 2030.

age of 49 years. 25% die because the disease is diagnosed late. In the children of the department, 5% have leukemia and 22% of them have less than one year of life. These statistics, which are managed by the Cali Population Registry of Cancer administered by the Universidad del Valle, and which have been referenced for more than 55 years, played a preponderant role in the choice of the city as the first in implementing the project. In addition, how many cases have been attended to in the city and its characteristics, which has made it possible to have a record of progress in the treatments. The information system is responsible for actively monitoring and reporting the types of cancer reported in the city. For the director of the Population Registry of Cancer of Cali, Luis Eduardo Bravo, the quality of the information, the continuity of the personnel that advances the regis-

NOVEMBER 2018 11

HEALTH UP TO DATE

Fundación Valle del Lili

Hospital Universitario del Valle

Centro Médico Imbanaco

tration process and the use of the obtained data have been of vital importance so that these figures have been consolidated.

EVERYTHING FOR EARLY DETECTION The intense prevention campaigns and the early detection that, from the municipal administration, headed by the Ministry of Health, have allowed, in addition, to reduce the statistical figures, especially in what has to do with the lung and cavity cancer, both mainly associated with lung cancer. For Dr. Bravo, all of the above articulated with the information system that the city has makes it possible for these patterns to be 100% visible to the medical community, the health authorities of the country and the population in general. Survival of cancer has also improved in the city of Cali, although records are still well below the figures of highly developed countries: “Of 100 women diagnosed with breast cancer survive after five years 60%, is say, 20 percentage points less than in Europe or the United States. In some tumors such as lymphomas, the gap is a little higher, which means that, in those cases where there is a treatment based mainly on drugs, the chances of survival are reduced due to the difficult access to medications. high cost”, says Bravo.

WITH INFRASTRUCTURE FOR HIGH COMPLEXITY Another important aspect that defined the election of the capital of Valle as the pioneer in applying this project is the installed capacity of the region,

12 NOVEMBER 2018

“The benefits you will receive the city by the international community, based on this project, go through investment in equipment and the qualification of human talent“: Alexander Durán, Secretary of Health of Cali.

concentrated basically in three level IV hospitals: the Valle del Lili Foundation, the University Hospital of the Valle and the Imbanaco Medical Center, the latter with two sophisticated rooms specialized in bone marrow transplantation, one for children and one for adults. For the specialist in Pediatrics, Hematology and Pediatric Oncology Óscar Ramírez, Coordinator of the Pediatrics Section of the Bone Marrow Transplant Unit of the Imbanaco Medical Center, the advances and technology available in these three medical cities have allowed the community international is set in Cali as the epicenter for the design of strategies aimed at combating the disease worldwide. Technological advances also include the full molecular biology laboratories and the expertise of treating physicians in the application of different bone marrow transplant methodologies, which opens the possibility that practically all cancer patients who require a procedure of this kind may have timely access to a donor. The public policies designed and implemented in Cali to cope with this pathology also constitute a significant advance. The city’s Health Secretary, Alexander Durán, believes that Cali has the political will to increase actions to reduce the figures: “We have been working intensively on the mission of early detection, especially. Since last year, an instrument has been applied to identify the priorities to be solved”, said the official, who also described as a great advance the fact that Cali is one of the pilot cities to implement the challenge. “It is an extraordinary initiative that has made us talk about cancer in the city and allowed us to sit at the table with 182 representatives of private and public entities to review the situation of the city and jointly plan the development in the short term”, he said. The International Union against Cancer will accompany the project until the end of 2019, when it is expected that there will already be a defined action plan that will operate autonomously, although it will continue to be linked to issues of counseling and training, mainly to personnel linked to laboratories. of pathology. The great expectation is that by 2025 more than 200 cities will be linked to the challenge. At present, conversations are being held with the American Society of Clinical Oncology, a partner interested in supporting the process, who would be visiting Cali later this year to define the investment in the project as of 2019.

UNA ALIANZA QUE SE CONSOLIDA CADA VEZ MĂ S. !Transcender en la experiencia del servicio solo es posible cuando juntos generamos experiencias memorables! Gracias por tu confianza

MYOPIA: the fault is of the environment

For the first time in Colombia, real statistics on visual health are consolidated in all demographic groups. The Miopur study reveals a high prevalence of myopia in the population.

Miopía

Hipermetropía

14 NOVEMBER 2018

Astigmatismo

THE SPECIALTY Ophthalmology

etween 2013 and 2017, Miopur, a research, development and innovation project, determined the prevalence of myopia and refractive errors in Colombia and its association with demographic variables and environmental factors (social and economic development). In the Colombian urban, rural, school and adult population. The cross-sectional investigation was carried out in 10 Colombian municipalities with a school-age population between 8 and 17 years old (n = 1,933) and adults between 35 and 55 years old (n = 1,675) living in urban areas (n = 2,067) and rural (n = 1,541). The excluded participants were those with a history of refractive surgeries, intraocular surgeries or corneal ectasias. We included those individuals in whom an appropriate refraction could be performed and their visual acuity with correction was greater than 20/40.

The study could associate living at a medium-high socioeconomic level with the appearance of myopia at a different age.

A questionnaire was applied to each participant (n=4,500 people) in order to know their demographic and socioeconomic characteristics, the visual acuity, the refractive state, and biometrics were assessed. In addition, biological samples were taken to evaluate the glycemic and lipid profile. The probabilistic sample of the Miopur study was developed in the departments of Santander, Caldas, Nariño, Cesar, Casanare, Tolima, Atlántico, Cauca and Quindío. The study, led by researchers attached to the Ophthalmological Foundation of Santander (Foscal) and Colciencias, started from the premise that characterizes myopia as a refractive defect of high prevalence in the world, which considerably affects the quality of life of those who suffer it. The summary of the research presented to Colciencias for funding suggests that the identification of environmental factors in the increase of this visual defect will allow modulate them in order to reduce their prevalence. At the time of its execution, no data existed in Colombia and no analysis with these characteristics had been carried out.

Table 1. PREVALENCE OF REFRACTIVE ERRORS SOURCE: STUDIO MIOPUR, COLOMBIA 2015-2017.

ERROR

Emetropia

1.810

50,2

48,5

IC 95%

51,8

Hyperopia

1.164

32,2

30,7

33,8

Myopia

466

12,9

11,8

14,0

Astigmatism

100

2,8

2,2

3,3

Anisometropia

1,9

1,4

2,3

“Recent research suggests the influence of environmental factors in the increase of this visual impairment in populations of economic and sociodemographic characteristics similar to ours. The identification of these factors would make it possible to modulate them in order to reduce the prevalence of myopia, “explains the ophthalmologist and researcher of the Luz María Gómez Peña project. Miopur established the prevalence of refractive errors and their distribution by department, area of residence, age, ethnicity, antecedent of myopia

EMETROPIA HYPEROPIA MYOPIA MIXED ASTIGMATISM ANISOMETROPIA DEPARTMENT N % IC 95% % IC 95% % IC 95% % IC 95% % IC 95%

Santander

475 32,6 28,4 36,9 50,5 46,0 55,0 10,3 7,6 13,1 4,0 2,2 5,8 2,5 1,1 3,9

Nariño

453 39,3 34,8 43,8 30,0 25,8 34,2 22,1 18,3 25,9 5,3 3,2 7,4 3,3 1,7 5,0

Caldas

223 43,5 37,0 50,0 28,3 22,3 34,2 20,2 14,9 25,5 5,4 2,4 8,4 2,7 0,6 4,8

Cesar

478 54,2 49,7 58,7 34,3 30,0 38,6 8,8 6,2 11,3 1,5 0,4 2,5 1,3 0,3 2,3

Casanare

232 47,4 41,0 53,9 34,1 27,9 40,2 12,9 8,6 17,3 4,3 1,7 6,9 1,3 -0,2 2,8

Table

DISTRIBUTION

OF REFRACTIVE

ERRORS BY

DEPARTMENT

SOURCE: STUDIO MIOPUR, COLOMBIA 2015-2017.

Tolima

327 56,0 50,6 61,4 30,3 25,3 35,3 9,2 6,0 12,3 3,7 1,6

Atlántico

366 58,7 53,7 63,8 29,0 24,3 33,6 9,0 6,1 12,0 1,1 0,0 2,2 2,2 0,7 3,7

5,7 0,9 -0,1 2,0

Cauca

403 60,8 56,0 65,6 25,3 21,1 29,6 10,9 7,9 14,0 1,5 0,3

Quindío

347 54,2 48,9 59,4 30,0 25,1 34,8 12,7 9,2 16,2 1,4 0,2 2,7 1,7 0,4 3,1

Meta

304 59,2 53,7 64,7 23,4 18,6 28,1 16,1 12,0 20,3 0,3 -0,3 1,0 1,0 -0,1 2,1

2,7 1,5 0,3 2,7

NOVEMBER 2018 15

THE SPECIALTY Ophthalmology

in parents or siblings, educational level, anthropometry at birth and estimated time of near vision, and specified: • The prevalence of refractive errors in different age groups by urban and rural area. • The cases of myopia and the relative influence of the refractive component (corneal power) and the axial component (axial length). • Differences in the prevalence of refractive defects among populations of the same ethnic group in rural and urban areas. • The relationship between paternal antecedents of myopia and the presence of myopia in the schoolchildren of the study. • The presence of myopia among siblings of school age, the relationship between the educational level of parents and the presence of myopia in the urban and rural school population studied. • The relationship between weight and height at birth, and the presence of myopia in the population studied. • The association of near and far vision activities in the presence of refractive defects in the urban and rural population. • The association between the performance of outdoor and physical activities with the presence of refractive alterations in the urban and rural area evaluated.

The prevalence of myopia and hyperopia in Colombia is at an intermediate point in comparison with the global data. In adults, their frequency was lower than in European and Asian studies, and increased in age groups of children and adolescents.

Table

3. EMETROPIA HYPEROPIA MYOPIA MIXED ASTIGMATISM ANISOMETROPIA ÁREA N DISTRIBUTION % IC 95% % IC 95% % IC 95% % IC 95% % IC 95%

OF ERRORS REFRACTIVE BY AREA OF RESIDENCE

Urban

2.067 49,6 47,4 51,7 29,4 27,4 31,4 15,7 14,1 17,2 3,1 2,3

3,8 2,2 1,6 2,9

Rural

1.541 50,9 48,4 53,4 36,1 33,7 38,5 9,2 7,8 10,7 2,3 1,6

3,1 1,4 0,8 2,0

SOURCE: STUDIO MIOPUR, COLOMBIA 2015-2017.

EMETROPIA HYPEROPIA MYOPIA MIXED ASTIGMATISM ANISOMETROPIA POPULATION N GROUPS % IC 95% % IC 95% % IC 95% % IC 95% % IC 95%

Children and teenagers

1.933 60,3 58,1 62,5 23,7 21,8 25,6 11,6 10,1 13,0 2,6 1,9

3,3 1,7

Adults

1.675 38,4 36,1 40,8 42,0 39,7 44,4 14,4 12,8 16,1 2,9 2,1

3,7 2,0 1,4 2,8

1,1 2,2

EMETROPIA HYPEROPIA MYOPIA MIXED ASTIGMATISM ANISOMETROPIA AGE GROUPS N % IC 95% % IC 95% % IC 95% % IC 95% % IC 95%

Table

DISTRIBUTION

OF REFRACTIVE

8 to 10 years

614

5,7

5,3

6,0

3,0

2,7

3,4

8,3

6,1

10,5

2,4

1,2

3,6

1,9

0,8

11 to 13 years

678

6,0

5,7

6,4

2,4

2,0

2,7

10,6

8,3

12,9

2,9

1,6

4,2

1,6

0,6

3,0 2,6

14 to 15 years

365

6,2

5,7

6,7

1,9

1,4

2,3

15,0

11,4

18,7

2,7

1,7

4,2

1,6

0,3

2,9

16 to 17 years

276

6,5

5,9

7,0

1,5

1,0

1,9

16,7

12,2

21,0

2,1

0,4

3,9

1,4

0,3

2,9

ERRORS BY AGE

EMETROPIA HYPEROPIA MYOPIA MIXED ASTIGMATISM ANISOMETROPIA AGE IN YEARS N % IC 95% % IC 95% % IC 95% % IC 95% % IC 95%

35 to 39 years

383

4,6

4,0

5,0

2,7

2,3

3,1

19,8

15,8

23,8

4,4

2,4

6,5

2,9

1,1

4,5

40 to 49 years

828

4,3

3,9

4,6

3,9

3,6

4,2

13,5

11,1

15,8

2,6

1,5

3,7

1,7

0,8

2,6

50 to 55 years

464

2,4

2,0

2,8

5,9

5,5

6,4

11,6

8,7

14,5

2,1

0,8

3,5

2,1

0,8

3,5

SOURCE: STUDIO MIOPUR,

COLOMBIA 2015-2017.

16 NOVEMBER 2018

Table 5. DISTRIBUTION OF REFRACTIVE ERRORS BY DEMOGRAPHIC AND SOCIOECONOMIC CHARACTERISTICS

EMETROPIA HYPEROPIA

CARACTERÍSTICAS N

IC 95%

MYOPIA MIXED ASTIGMATISM ANISOMETROPIA IC 95%

IC 95%

Sex Women

2.311 46,5 44,5 48,6 35,0 33,1 37,0 13,3 11,9 14,7 2,9 2,2 3,6 2,1 1,5 2,7

Men

1.297 56,6 53,9 59,3 27,2 24,8 29,6 12,2 10,4 14,0 2,5 1,7 3,4 1,5 0,8 2,1

Housing stratum Low Medium-high

2.569 50,2 48,2 52,1 32,8 31,0 34,7 12,4 11,1 13,6 2,7 2,0 3,3 1,9 1,3 2,4 351 36,5 31,4 41,5 33,9 28,9 38,9 21,0 16,8 25,3 2,7 3,3 8,1 2,8 1,1 4,6

Population group Children and teenagers

1.933 60,3 58,1 62,5 23,7 21,8 25,6 11,6 10,2 13,0 2,6 1,9 3,3 1,7 1,1 2,3

Adults

1.675 38,4 36,1 40,8 42,0 39,7 44,4 14,4 12,8 16,1 2,9 2,1 3,7 2,0 1,4 2,8

Average household income Less than or equal to a minimum wage 1.605 50,5 48,0 52,9 33,0 30,8 35,4 11,7 10,2 13,3 2,7 1,9 3,5 1,9 1,2 2,6

More than a minimum wage

1.315

46,1

43,5 48,8

32,8

30,3 35,4 15,4

13,5

17,4

3,5

2,5

4,5

2,0

1,3

2,8

Ethnicity

Half Blood

White

Afro-Colombian

Indigenous Others

2.189

49,0

46,9 51,0

33,2

31,2

35,1 12,3

10,9

13,7

3,4

2,7

4,2

2,1

1,5

2,7

644 46,3 42,4 50,1 33,2 29,6 36,9 17,0 14,2 20,0 1,9 0,8 2,9 1,5 0,5 2,5 53

45,3

31,7 58,8

34,0

21,0 46,8 15,0

5,4

24,8

3,8

0,8

2,9

1,9

-1,0

5,5

33 66,7 50,3 83,0 15,1 2,7 27,6 15,0 2,7 27,6 3,0 2,9 9,0 -- -- -1 -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

Education level None/ primary children

1.427

58,2

55,7 60,8

26,5

24,2 28,8 10,7

None/ primary adults

702

34,3

30,8 37,8

47,7

44,0 51,4 12,5

Baccalaureate children

135 63,7 55,5 71,8 12,6 44,0 51,4 20,7 13,9 27,6 2,2 -0,2 4,7 0,7 -0,7 2,1

Baccalaureate adult

656 39,5 35,7 43,2 33,5 31,8 29,2 18,7 15,7 21,7 3,6 2,2 5,0 2,6 1,4 3,8

9,1

12,3

2,8

1,9

3,7

1,7

1,0

2,4

10,0 15,0

3,3

1,9

4,6

2,1

1,0

3,2

Health affiliation SOURCE: STUDIO MIOPUR, COLOMBIA 2015-2017.

Subsidized not affiliated

2.054

• The correlation of nutritional patterns and dietary habits of the population with the presence of refractive defects in the urban and rural areas. • The association between the level of socio-economic development and demographic characteristics with the presence of refractive defects of the studied population.

50,4

48,2 52,5

33,0

31,0 35,0 11,6

10,2

13,0

3,0

the rates were 29.4% in urban areas and 36.1% in rural areas. In the multivariate analysis, living in an urban area significantly increased the risk of myopia -OR: 1.45 (1.12 to 1.89); p <0.01-. There were significant regional differences between different areas of the country.

MAIN CONCLUSIONS RESULTS ON DATA The research included 3,608 individuals (100% of whom agreed to participate). The prevalence estimates of refractive errors were: hypermetropia 32.3% (95% CI 30.7 to 33.8), myopia 12.9% (95% CI 11.8 to 14.0), mixed astigmatism 2 , 8% (95% CI 2.2 to 3.3) and anisometropia 1.9% (95% CI 1.4 to 2.3). The prevalence of myopia in 15-year-old adolescents was 14.7%. In children and adolescents, the prevalence of hyperopia decreased, while that of myopia increased with age. In the group of adults, the trend was the reverse. The prevalence of myopia reached 15.7% in urban areas and 9.2% in rural areas; and for the hyperopia,

It was found that the estimates of prevalence of myopia and hyperopia in Colombia are at an intermediate point in comparison with the global data. In adults, the frequency of myopia was lower than in European and Asian studies. The prevalence of myopia increased during infancy and adolescence, and was higher in middle-aged adults (35-39 years) than in older adults. On the other hand, hyperopia rates increased with age, findings that suggest a cohort effect. In the multivariate analysis, residence in urban areas and living in a medium-high socioeconomic level was related to myopia. Some of the main results are recorded in tables 1-5.

2,3

3,8

1,8

1,3

2,4

RECOMMENDED READINGS 1. http://investigacionesfoscal.com.co/wp-content/ uploads/2018/03/Alcance-MIOPUR.pdf 2. http://scienti.colciencias.gov. co:8081/cvlac/visualizador/ generarCurriculoCv.do?cod_ rh=0000153500 3. https://www.ncbi.nlm.nih.gov/ pubmed/29945895 4. https://bjo.bmj.com/content/ early/2018/06/26/bjophthalmol-2018-312149

NOVEMBER 2018 17

THE SPECIALTY Ophthalmology

XEN:

solution to glaucomas slight open angle A small collagen tube of 6 mm in length and 140 microns in internal diameter, introduced in the anterior chamber of the eye is revolutionizing drainage treatment to reduce intraocular pressure in patients with glaucoma. The device facilitates the extraction of aqueous humor.

EN’ occupies one third of the space in the eye compared to traditional valves and its design allows it to be implanted safely, painlessly and quickly. It is a novel therapeutic alternative for primary open angle glaucoma, particularly indicated for patients who do not tolerate medication well in drops (eye drops) or who have an insufficient hypotensive response after the minimally invasive surgical approach. This technique reduces the time of the intervention up to six times, even being less than eight minutes, and is applied by a microincision in the cornea of just 2 mm, which does not require opening the conjunctiva or suturing. XEN achieves an intraocular pressure (IOP) of between 12 and 15 mmHg in a sustained manner and has for it a flexible device that simplifies current surgical

18 NOVEMBER 2018

interventions and decreases the time of postoperative control, as well as the adverse effects and associated complications. The researchers who gave birth to the device in Europe claim that it has been possible to check the control of glaucoma effectively and safely in more than 80% of the patients intervened. Likewise, the technique is much safer and less aggressive than traditional surgeries, and, therefore, allows patients a more comfortable and faster recovery, with little or no impact on their quality of life. “In addition, the implant shortens the time of the procedure, is performed with topical anesthesia and has a high level of safety in the postoperative period because there is practically no hypotonia”, explain doctors Jorge Vila and Aitor Fernández, medical director of

GLAUCOMA Drainage channel blocked. When there is obstruction in the exit of the aqueous humor, the ocular pressure increases. High pressure damages the optic nerve.

The XEN device is implanted with a very fine gauge injector.

Innova Ocular Clínica Vila (Valencia) and head of the Glaucoma Unit of Innova Ocular IOA Madrid, respectively, experts in the application of the treatment, which requires a very fine injector to be implanted. For the ophthalmologist José Antonio Paczka, director of the Glaucoma Institute of Mexico and who has participated in the development, application and

NOVEMBER 2018 19

THE SPECIALTY Ophthalmology

Sclera Retina Choroidal Suspensory ligament Taint

Cornea

Retinin artery and vein

Aqueous humor

Pupil Lens

ANATOMY OF THE EYE HUMAN

Optic nerve Iris Ciliary body

evaluation of XEN, in surgery it is essential to maintain the quality of life of the patient and, therefore, a shorter intervention and With a very small percentage of complications, it is a gigantic jump compared to trabeculectomy. “We want procedures that have greater predictability; with XEN we have very good results, mainly in the primary cases. We can handle very well those more challenging incisions and postoperative management. While it is

20 NOVEMBER 2018

Hyaloid channel

Ora serrata Back cavity

Glaucoma is the main cause of irreversible blindness in the world.

true that we must deal with filtering blebs, with hypotonia and its associated conditions, XEN does not require a goniolent more than to locate the needle well“, specifies the Mexican doctor.

CHARACTERISTICS OF THE IMPLANT The configuration of the implant consists of a hollow microcylinder, manufactured in a totally biocompatible material that avoids inflammatory reactions or erosions in the tissues. The procedure can also be applied to patients who are going to be operated on by cataracts, since it facilitates the operation and only entails a few additional minutes in the operating room. According to spokespersons for Allergan, the pharmaceutical company that created the implant, the device provides a new way to evacuate subconjunctival fluid based on the same principle of trabeculectomy, but with a diffuse, little elevated ampule. In addition, in practice, XEN maintains space for other possible interventions (such as valve surgery) if necessary, given the scarce nullity induced by surgery. Specialists from the Centro Oftalmológico Barraquer in Spain have already begun the surgical approach of glaucoma using the XEN technique, with excellent results; and have highlighted that, “in contact with the ocular structures, the device adopts a

soft consistency that favors the filtration of aqueous humor to get the equilibrium of its flow restored and thus regularize the intraocular pressure”. XEN is part of a new surgical era associated with so-called MIGS or microinvasive techniques, whose common feature is to make less manipulation of ocular tissues with maximum safety, efficacy and with a minimum period of recovery. In Colombia, the XEN system has a sanitary registry by Invima since August 14, 2017, indicated to reduce intraocular pressure (IOP) in patients with primary open-angle glaucoma in whom previous medical treatments have failed.

GOODBYE TO DROPS Studies such as Broadway (1996) or the most recent, PESO (2013), confirm that the inflammatory substrate that arises as a result of the abuse of eye drops with preservatives is responsible not only for the severe anatomical changes, but also for important changes in the response surgical, thus worsening the outcome of glaucoma surgery. “The use of eye drops indiscriminately is causing alterations of the surface that we should take into account in the consultation to prevent and, in any case, treat properly, before the consequences on the conjunctiva and the cornea are irreversible“, says Susana Duch, director of the Glaucoma Unit of Innova Ocular ICO. XEN allows, then, eliminate or significantly decrease the dependence of the drops. Appropriate protection of the ocular surface is the responsibility of the glaucomatologist, who must be alert to the changes that occur in each of your patients with the complementary treatments available to control glaucoma. Therefore, the glaucoma unit of the Instituto Catalán reminded the specialists who treat this disease that “the continued use of these drugs causes inflammatory changes in the ocular surface depending on the amount of preservative administered and the amount of time of use”.

UNDERSTANDING THE DISEASE Glaucoma is defined as a disease that affects the optic nerve and is caused by an increase in the internal pressure of the eye, caused in turn by an obstruction in the outlet of the aqueous humor. It is the main cause of irreversible blindness worldwide. There are several causes and the most important risk factor is high intraocular pressure, which is determined by the balance between the speed of production of the aqueous humor, the resistance and the degree of difficulty in its drainage.

“Being able to expand the range of surgical possibilities and new techniques make us offer a more personalized medicine. The microinvasive technique with the XEN implant is very promising for the surgical control of glaucoma. The control of glaucomatous disease, accompanied by a better quality of life for our patients, is our main objective”, confirms the ophthalmologist María Isabel Canut, coordinator of the Glaucoma Department of the Centro Oftalmológico Barraquer. XEN is an important option for the management of glaucoma. The challenge now for doctors, after handling the technique, is that patients have how to finance it, because it is an expensive device. The implant is in furor in Europe and the United States, and in Latin America, Mexico is the precursor country.

RECOMMENDED READINGS 1. 2016_06_03_innova_ocular_ referencia_nacional_en_ el_tratamiento_eficaz_del_ glaucoma_con_el_nuevo_ implante_inyectable_xen.doc 2. https://clinicavila.es/ innova-ocular-clinica-vilareferencia-nacional-enel-tratamiento-eficaz-delglaucoma-con-el-nuevol.

NOVEMBER 2018 21

THE SPECIALTY Ophthalmology / The interview MARÍA XIMENA NÚÑEZ, MD

With an eye on the

VISUAL HEALTH

oncerned about knowing in depth the visual diseases, but above all about sharing her knowledge with colleagues and future ophthalmologists in the country, Dr. María Ximena Núñez is passionate about the investigation of one of the pathologies that most affects the people in the world, the refractive cataract. For this reason, it carries out research projects with which it intends to provide solutions to the disease considered as the main cause of preventable blindness in the world. Not in vain is she today one of the most influential ophthalmologists in Latin America. His research highlights the contribution to the creation of software for specialized equipment in cornea and refractive surgery, and the design of an algorithm for the early detection of keratoconus (a condition in which the cornea is abnormally thin and protrudes forward), which both affect the quality of life of patients who suffer it.

22 NOVEMBER 2018

Photos: PARTICULAR ARCHIVE

The investigation of visual diseases and sharing knowledge with its students at the Universidad Javeriana of Cali are its greatest passions. Finding solutions to the eye conditions afflicting millions of people is their great challenge. In the future, it is projected as an international consultancy of its specialty.

For seven years, Dr. Núñez investigated the risks for patients undergoing cataract surgery at an early age using intraocular lenses, as well as participating in several investigations on eye infections. Among his most lauded achievements is having directed the multifocal lens research project in which the 21 best opinion leaders in cataract and astigmatism management in Latin America participated. “The idea is to make a Latin American consensus on the management of cataracts using multifocal lenses, with the aim of treating the disease using the appropriate technology so that patients can leave behind cumbersome glasses”, says Dr. Núñez. Catholic and believer, the specialist spends 10 hours a day on patient care at the Clínica de Oftalmología de Cali, where she has been working for 14 years and of which she is a board member. How is the visual health of colombians? I think it is very bad, because although the Ministry of Health and Social Protection established some fundamental pathologies-diabetic retinopathy, glaucoma, cataract and infantile stress, there is no plan to prevent these diseases, there is no execution, there is no a guideline of who and how should be executed to face them; you have some statistics, but they are not well-done incidence studies. That is, how many patients are there in the country? It is known that they are the main affections in the world, but nothing is done for their prevention. The most serious of all is that these are pathologies that, if allowed to advance, cause people blindness or irreversible damage. What are the most frequent causes for the development of these diseases? Visual diseases are very prone in all people, but there is no specific cause that generates them, it could not be said that by ingesting a food or not; that by certain weather or by facing the sun, everything goes through the prevention of the disease. If you do not take care with your eyes, you could very likely have some condition at an early age. Prevention is everything in this. How guilty are people for not taking the necessary precautions to prevent the deterioration of their visual health? What I believe is that there is no education on the subject. Just as campaigns are made with other diseases such as cancer, there should also be that level of promotion of the prevention of ocular pathologies.

For the people it is not clear and many do not know that, for example, every child should go to the doctor at 4 years to have their eyes checked, it is not clear that one should go to the minimum ophthalmologist once a year, then If there is no education, I can not blame people for that.

“Walking with glasses is not a tragedy, but it is a disability that nobody wants to have”.

How do you rate the progress made in the treatments? In that aspect I see a great gap between everything we have achieved and what people have access to. For example, here at the Clínica de Oftalmología de Cali we have all the equipment that can detect and treat most diseases of the eye, there are robotic equipment and lasers, but what I do not see is the access of the general population to all that technology, there are very few who have access to the latest generation treatment, as the case may be. Because technology is there, but for the common of patients it is very difficult to benefit from it. The health system sees in most of these diseases an aesthetic problem. How are we in prevention of visual diseases? I think we are far from what prevention campaigns should be, there is a lack of education on the subject. For example, the workers in the companies are forced to wear protective glasses and very few do, and in my practice they have arrived with the eye bleeding, with splinters, with infections, with the total loss of the organ, anyway... I see the Latin

NOVEMBER 2018 23

THE SPECIALTY Ophthalmology / The interview

PROFILE

“For people it is not clear and many do not know that every child should go to the doctor at age 4 to have their eyes checked ...”

American culture as a little preventive, but it is fundamentally due to the lack of a well-structured education plan to sow the culture of prevention. What to tell Colombians about the care of their visual health? That they visit the ophthalmologist, because the most important thing that they should know, and that the doctors are obliged to transmit to them, is that the eyes constitute a changing structure, therefore, all human beings will end up being affected by some condition of sight at some point in life. No one will ‘save’ from visiting the ophthalmologist. The eye is born one way and dies another, then you will always need glasses at any time of life. Visit the ophthalmologist at least once a year. You are a professor at the Pontificia Universidad Javeriana of Cali, where you train future ophthalmologists in the country. What do you teach your students the most? The most important thing is that you always have to try to be better, to excel; I hate mediocrity, because when we do not look for the best for everything, we settle for the world as it is and we do not generate changes of anything. All this can be extrapolated to medical practice. You have to have a critical attitude, it seems to me that they should give their best during their entire learning process, as well as in professional practice; question whether what they do is right or not. They must also be challengers and seek the best possible knowledge without staying in mediocrity, because if students are like this, they will stay like this always.

24 NOVEMBER 2018

VISIONARY AS PROFESSIONAL, TEACHER, WIFE AND MOTHER Although she was born in Cali, Dr. María Ximena grew up in El Cerrito, in the same landscapes of Cauca, Valle. yes. He attended his undergraduate studies at Universidad del Valle. She is an ophthalmologist and subspecialist in cornea, cataract and refractive surgery, with certified training by the same university. Currently, she is a member of the board of directors of the Clínica de Oftalmología de Cali, as well as being the coordinator of the Refractive Unit. He is president of the Colombian Society of Cataract and Refractive Surgeons, and researcher and director of the Visión Sana research group. His interest in the search for the best way to solve the ocular problems of the cornea, the lens and the ocular surface is reflected in the 17 publications in national and international journals. Married, with an 11-year-old son, Dr. Núñez boldly distributes her time between the care of her patients, her family and her students from the Faculty of Medicine of the Pontificia Universidad Javeriana, in Cali.

You have obtained many international awards; In fact, he recently assumed the presidency of the Colombian Society of Cataract and Refractive Surgeons. How is the exercise of the profession on the issue of gender equity? The change is taking place basically in statistics. Today we can say that there is 1 ophthalmologist woman for every 3 men, although where the great difference is observed is in the directive positions; there the presence of women is very short. I am the first female ophthalmologist who has integrated the board of directors of this clinic (Clinica de Oftalmología de Cali) and now, as president of the Colombian Society of Cataract and Refractive Surgeons, I am the first to hold this position. All this I have earned it to pulse and with respect for my profession and for my colleagues.

Prepárate para el

Continuaremos reconociendo la eficiencia, calidad y fidelidad con la que ejerces tu labor

Reconocer la entrega de un servicio integral y cercano a nuestros usuarios generador de experiencias memorables.

Incentivar las mejores prácticas a fin de fortalecer la oferta de valor y el vínculo con nuestros aliados prestadores.

Promover el compromiso de los aliados prestadores con el modelo solidario de Coomeva.

“La calidad en el servicio, merece ser reconocida”

Cuidarte es quererte

RISK MANAGEMENT

ALERT IN THE AMERICAS

The measles came back! Although it was thought to be a disease eradicated from the country, the arrival of the population of Venezuela and the lack of controls at the border has triggered the reappearance of the virus. Colombia is, according to the PAHO, the third country in the Americas with the most cases of measles in 2018, after Venezuela and Brazil. 26 NOVEMBER 2018

Adults who have never been vaccinated should be immunized; also children who do not have the triple viral scheme. Any suspicious case must be examined and reported to Sivigila.

n September 2016, the World Health Organization (WHO) declared the region of the Americas as ‘measles-free’, becoming the first in the world to achieve this result, after more than 22 years of effort and sustained strategies to ‘immunize’ the child population. Today, as a consequence of global social processes and trends, as well as very specific health crises, especially in border areas, reality seems to take an unexpected turn, and this is how some cases have been presented in places where it was already controlled or where in recent years there was no record, let alone autochthonous, as happened recently in Brazil, with two outbreaks that managed to be controlled.

For José Antonio Vargas, infectious pediatrician of the Cardiovascular Foundation of Colombia and the International Hospital, “measles has unfortunately re-emerged in recent years as a result of anti-vaccine movements, mainly in Europe and North America, leading to many parents do not vaccinate your children. Likewise, it is due to the health crisis in neighboring countries, such as Venezuela, which is negative for us”. The figures confirm that reality. For example, the cases reported in Antigua and Barbuda and in Guatemala “correspond to cases imported from the United Kingdom and Germany, respectively”, says WHO. “The confirmed cases of measles in Canada and the United States are imported or associated with imports, where 70% were not vaccinated”. In Colombia, until epidemiological week 27 of 2018 (July 1 to July 7), according to the report of the National Institute of Health (INS), a total of 3,443 suspected cases had “entered the National Public Health Surveillance System (Sivigila). of measles, of which 3,143 have been ruled out and a total of 38 cases have been confirmed, 24 imported from Venezuela,

NOVEMBER 2018 27

RISK MANAGEMENT

HIGHLY CONTAGIOUS Adults, caregivers and health personnel should be alert to the presence of clinical symptoms with “fever, general malaise, lack of appetite, congestion in the respiratory tract. Raptors, conjunctivitis, cough, Koplik spots inside the mouth and, later, an outbreak or rash that starts on the face and then extends to the entire body, and lasts approximately between 4 and 7 days, “explains the WHO. If the case is confirmed, a symptomatic management is made and it is also recommended that the patient does not leave home while the period of infection passes, which can range from a few days before sprouting to about two weeks after having acquired the infection. This is because the measles virus, of the respiratory syncytial virus family, is a Paramyxovirus, genus Morbillivirus, highly contagious; “Of the most contagious viruses by the form of transmission through respiratory particles (aerosol) to have contact with a person who coughs or sneezes. This is how they move on to the other“, says José Alejandro Mojica, pediatric infectious disease specialist, consultant of the Ministry of Health, Subdirectorate for Communicable Diseases. Therefore, those who have the disease should avoid contact with others, stay at home and receive a good amount of fluids to maintain adequate hydration. Given the importance of vitamin A or retinol, the WHO has evaluated the possibility of supplementation of this vitamin in patients with measles “as a possible intervention to accelerate the recovery, reduce the severity and prevent the recurrence of acute infections of the lower respiratory tract “ The challenge is to prevent a major outbreak, but also complications in those who develop the disease, “pneumonia being the main one of them. Other less frequent are diarrhea, otitis, and in a minority of affecting the eyes and producing blindness, or, more rarely, some type of brain problem, “says the expert from the International Hospital. For its part, the Ministry of Health has called attention to people who are at higher risk of complications, including “children under 5 years and adults over 30 years; minors with malnutrition and vitamin A deficiency; immunosuppressed persons, including HIV; and pregnant women, in whom the disease can cause abortion or premature birth“. It is worth remembering that those who received the two doses of the triple viral are protected and those who suffered the disease and recovered without any problem will also be immune for life.

SEPTIEMBRE2018 2018 28 NOVEMBER

THE MEASLES

Headache

Infectious disease caused by the virus paraximovirus that occurs in the cells of the throat and lung.

Red spots

Fever

Conjunctivitis

Dry cough Lack of appetite Sore throat Muscle pain

4 days - 12of

incubation

It’s fundamental prepare the workers from the area of health and to society in general for face the needs of the population higher growing.

4 days before and 4 days after the rash is present it can also be contagious.

9 from secondary transmission in people coming from the neighboring country, and they remain under study 262”. Of the confirmed cases, there are “1 in Arauca and 1 in Santa Marta (in Venezuelan residents), 2 in Bogotá, 3 in Norte de Santander (2 cases in Venezuelan residents and 1 Colombian), 5 in Sucre (4 in Venezuelan residents and 1 Colombian) and 26 from abroad. “ According to the most recent update on measles, issued by the WHO, Colombia is the third country in Latin America with the most cases (38, of which 37 are imported and 1 is of unknown origin), surpassed by Venezuela (1,427, with more than 80% of the total) and Brazil (114 cases), mostly of imported origin, a situation that is aggravated by the migration of people from the neighboring country, tired of the tense economic, social and political situation they live in, many of them with children with arms that present malnutrition problems. In this regard, the world’s highest health agency called on governments, ministries and health personnel, as well as parents, not to lower the guard and increase the processes of vaccination.

A COMMON FRONT Although, as Dr. Martha Lucia affirms Ospina, director of the INS: “Colombia has high immunization rates, which gives us a population immunity and allows us to have a margin of tranquility, we

maintain. We are alert”. It means to the strategic plan of response that has already activated the INS, along with the Ministry of Health and Social protection and health secretariats, not just to do peripheral scans, confirm the percentages Vaccination costs and absence of symptomatic patients or if there are any, but to ensure that the dana receive attention and guidance timely, reporting the cases immediately to Sivigila. Dr. Vargas agrees, noting that “fortunately in Colombia vaccination coverage against measles is very good, it’s above 95%, that is, from the point of public health it is adequate. “ What corresponds now that we are facing a great threat, adds the expert is to invite all seniors

to “check if they were vaccinated as children; if they are, they find protected forever; if not, they should be vaccinated“. Similarly, parents should not take care of your children’s immunization schedule, which includes the triple viral, vaccine that immunizes against pion, rubella and mumps, “a very effective vaccine that should be placed to all children when they reach the age of life and with a booster at 5 years”. Those who work in the health area, which are the who are receiving the imported cases, should be vaccinated, and doctors have the ability to recognize the clinical picture of a possible patient with measles, report it to Sivigila and take it samples that confirm the diagnosis.

RECOMMENDED READINGS 1. https://www.minsalud.gov.co/ salud/publica/Paginas/sarampion.aspx 2. https://www.paho.org/ hq/index.php?option=com_content&view=article&id=730%3A2009-measlesrubella-weekly-bulletin&catid=1637%3Ameasles&Itemid=39426&lang=es 3. https://www.minsalud.gov.co/ sites/rid/Lists/BibliotecaDigital/ RIDE/VS/PP/PAI/ficha-vacunas-cara-a-b.pdf 4. https://www.paho.org/ hq/index.php?option=com_content&view=article&id=12528%3Aregion-americas-declared-free-measles&catid=740%3Apress-releases&Itemid=1926&lang=es 5. https://www.paho.org/hq/ index.php?option=com_docman&task=doc_view&Itemid=270&gid=44800&lang=es 6. https://www.ins.gov.co/ buscador-eventos/BoletinEpidemiologico/2018%20 Bolet%C3%ADn%20epidemiol%C3%B3gico%20semana%2027. pdf#search=sarampi%C3%B3n

THE CALL OF WHO Given the current situation and the presence of the virus in the region of the Americas, the Pan American Organization of Health and Organization World Health Organization (PAHO / WHO) have presented guidelines: • Maintain homogeneous immunization coverage above 95% with the first and second dose of the vaccine against measles, rubella and the mumps, in all municipalities. • That the population at risk go be vaccinated. This is, health personnel, who works in tourism and transport (hotels, airports) to, taxis and others), and travelers international. • Maintain a reservation of measles-rubella (SR) vaccine and syringes for control actions of impor-

tion of the groups of rapid response between for this purpose and implementing protocols.

ted cases in each country region of. • Strengthen surveillance Epidemiological study of measles to achieve timely assessment of all suspicious cases in the public health services and private, and ensure that the

samples are received in the laboratory in the term five days after have been taken. • Provide a quick response ask in front of the cases imported from measles to avoid transmission endemic, through the activa-

Also, he recalled WHO that vaccination is essential to prevent measles, so much that “between 2000 and 2016 the vaccine prevented 20.4 million deaths. In the world, deaths for measles have descended 84% “, and asked to reinforce what was done in 2016 when “Approximately 119 million children were vaccinated Measles against measles in vaccination campaigns massive that were carried out in 31 countries. “ The goal to 2020 is to eliminate this immune disease venible and, given the current imported cases, should be reinforce strategies for achieve also that “no child die of measles”.

NOVEMBER 2018 29

RESEARCH REPORT

LUIS FELIPE BEJARANO, MD

Drops that give quality of life to

PATIENTS WITH PRESBYOPIA For eight years he proved in himself the effectiveness of its formula. Your innovation should contain specific concentrations that optimize vision in emmetropic patients and be minimally invasive to improve the quality of life of people with presbyopia. 30 NOVEMBER 2018

PERFECT MIX I wanted to find a drop or a formula with some specific concentrations in which far vision remained in consideration to improve the vision of near. And he bet on a minimally invasive alternative. For about six months he practiced, rehearsed applying the drops in his eyes; took action; reformulated until he achieved the ‘perfect mix’ in which the vision of far away it was maintained and physiologically the eye managed to focus close up. The mixture contains two alphagonists, one parasympathetic mimetic, an anticholinergic, a non-steroidal anti-inflammatory and two lubricants. “What was achieved was to react to the genius muscle of the eye, which fulfills the focus function, with the same intensity as when it was young. It means that when I look away, I look from afar; when I see closer, my eye focuses; and, if I see nearby objects, I can focus them, because my eye is the one that physiologically it is focusing again. The drops cause an impulse is greater than the accommodative normal reflex, what one does to see nearby “, explains the expert. The development patent has already been granted in Colombia, Mexico and Russia. In the United States, it is supplying evaluation supported by two pilot clinical studies that evaluated 20 patients, to whom, applying only one drop, their effect was measured at half an hour, one hour, two, three, four, five hours, a week and a month, and it was possible check that there was an accommodative change in the

Photo: PARTICULAR ARCHIVE

hinking about patients older than 40 years old who They roll presbyopia and want to continue with their lives without the use of glasses, the ophthalmologist Luis Felipe Vejarano Restrepo He engineered a form that, without being monovision (melting an eye so that you see far and the other closely), and not lose the stereopsis (depth vision), allow these patients leave this habit of removing any text they read to be able to focus the words. With his creation he aimed to find the replacement of Traditional medical device, technology and treatment surgical laser (intraocular surgery with a multifocal lens), which carves the cornea to focus the image on the retina and It is functional for young patients. But nevertheless, his interest was focused on those who spend the fourth decade of the life and they develop this refractive problem that occurs when the crystalline lens loses part of its ability to focus that due to the passage of time. Under the premise that presbyopia was associated with aging of the organs and could not be prevented, began to try on it, as an emmetrope patient, different mixtures of drops. “I applied them in my eyes to see how it felt when focusing from far and near, because I always thought of a binocular drop, eliminating the option of returning a myopic eye or that did pharmacological monovision”, explains the director of the Vejarano Ophthalmological Foundation.

Luis Felipe Vejarano Restrepo

near vision. In Colombia, the Evolution Laboratory, specialized in ophthalmology and in master products, he welcomed the idea and, along with Dr. Vejarano, he began to execute her.

THE CANDIDATES For the prescription of the drops, which are sold under medical formula, you need to have the accreditation of Vejarano doctor in Popayán. Currently, Colombia has six ophthalmologists located in Medellín, Bucaramanga, Cúcuta, Villavicencio, Montería and Bogotá authorized for its formulation. Patients older than 40 years who receive the drops must be submitted to a medical protocol that includes an evaluation to establish if it is a candidate for use them to improve the quality of your vision. When the candidate is accepted, an opinion is made personalized presbyopia that includes exams tomography, topography, aberrometry, endothelial counting, visual quality and quality of the tear film. In medical consultation, the drops are applied and the measurements are taken before and after then for the patient to describe his visual change; the retina is checked and, if the eye is healthy, we proceed to give it the prescription and indications for the correct instillation of the drops. This therapeutic method, in the opinion of the Vejarano ophthalmologist, has made it possible to demonstrate to the ophthalmological scientific guild the safety of the product, which works by showing the results of

NOVEMBER 2018 31

RESEARCH REPORT

PROFILE

WITH ‘EYES’ FOR AUTOMOBILISM AND KARTISM

Photo: PARTICULAR ARCHIVE

Dr. Luis Felipe Vejarano Restrepo He was born in Popayán 51 years ago. He is a surgeon at the Universidad del Cauca, ophthalmologist from the Fundación Oftalmológica de Santander, and has two supra-specialties: one in the anterior segment, cornea and refractive surgery; and another in the anterior segment and external diseases. He is currently the head of surgery of the Vejarano Ophthalmological Foundation, a family institution created 20 years ago by the father of this ophthalmologist, Alberto Vejarano, who sowed in his son the love for the profession and the specialty. Its exercise complements it with its work as a professor of ophthalmology at the Universidad del Cauca. In addition to the drops for presbyopia, this curious ophthalmologist is the creator of the phaco-chop technique designed to prevent Take any damage to the anterior capsule of the lens, and that can be used in all kinds of cataracts, even the most advanced. He also designed no-

far vision and near vision, and that, over time, does not cause effects side effects, other than the normal aging process eye.

THEY ARE NOT MAGICAL The drops do not cure presbyopia, a bottle can last between a month and a half and two months. Your mode of use, after giving the patient the consent informed and reading guides, is to apply a drop at least twice a day, once in the morning (before starting the daily tasks) and another in the afternoon, with the aim of activating the genial muscle”. The drops they do not heal by magic, nor are they medicated, therefore, it is not mandatory to determine a time for its use or the number of times. The drops are totally personalized and the patient is the one who determines its use according to your need“, specifies the Vejarano ophthalmologist. The registration of use in Colombia to the year 2016, date in which droplets went on the market, includes near 730 patients. In 2017, 53 people in Popayán, who They take between 6 and 7 months of use, they participate in a study controlled led by Dr. Vejarano. For the researcher, his development has an important recognition in the world-wide scope, it verifies it with certifications in symposiums and conferences where, even, a significant number of colleagues have submitted to test the drops.

32 NOVEMBER 2018

velty ophthalmological instruments that applies among your patients for your wellbeing in the query. Lecturer and author of several specialized publications, when his You are allowed, Dr. Vejarano focuses his eyes on a hobby that does vibrate at ‘maximum speed’. It’s about the practice of karting and motorsport. “I started driving cars more than 10 years, with them I release all the adrenaline possible and any manifestation of stress, “says the doctor. The doctor’s coat usually changes it the car racer suit, which I used to participate in several valid and national and world competitions. Even He has won several times. He usually shares this hobby with his family and especially with his son Felipe, 17 years old. Empathetic, kind, generous, gratefulwith life and given service to the co- munity, Luis Felipe Vejarano Restrepo is one of the most recognized ophthalmologists in the department of Cauca and a reference for research in the country.

RECOMMENDED READINGS 1. Vejarano LF. Topical drops show promise as treatment for presbyopia. Agent allowed a ‘dynamic’ pupil and was without significant adverse effects. Ophthalmology Times [internet]. 2016. Disponible en: http://ophthalmologytimes.modernmedicine.com/ophthalmologytimes/news/topical-drops-show-promise-treatment-presbyopia 2. Vejarano LF. A closer look at presbyopia correction better corrective lenses and a multitude of surgical approaches give your presbyopic patients more options than ever before. Review of Optometry [internet]. 2016. Disponible en: https://www.reviewofoptometry.com/ article/a-closer-look-at-presbyopia-correction 3. Vejarano LF. Presbyopia eye drop targets miosis and accommodation. Refractive Surgery Outlook [internet]. 2016. Disponible en: http://isrs.aao.org/resources/february-2016 4. Berdahl J, Vejarano LF. Future of non invasive presbyopia treatment; new generation of nonsurgical presbyopia options show promise, but will they make it to market? Eyeworld [internet]. 2016. Disponible en: http://educationhub.eyeworld.org/sites/default/files/pdf-articles/EW%20APR%202016_Future%20of%20noninvasive%20presbyopia%20treatment.pdf 5. Vejarano LF, Renna A, De la Cruz E, Alio JL. Pharmacological treatment of presbyopia by novel eye drops binocularly-instilled: a pilot study. Ophthalmology and Therapy [internet]. 2016;5(1):63-73. Disponible en: http://link.springer.com/article/10.1007/s40123-0160050-x 6. Vejarano LF, Alio JL. To the pharmacy and beyond. Patients may soon gain access to a noninvasive option of compensation for accommodative loss. Cataract and Refractive Surgery Today - Europe [internet]. 2016. Disponible en: http://crstodayeurope.com/articles/2016-sep/to-the-pharmacy-and-beyond/ 7. Vejarano LF, Alio JL, Renna A. Pharmacological treatments of presbyopia: a review of modern perspectives. Eye and Vision [internet]. 2017. Disponible en: https://eandv.biomedcentral.com/articles/10.1186/s40662-017-0068-8 http://rdcu.be/Gq49 8. Vejarano LF, Alio JL. Pharmacological treatment of presbyopia FOV tears. EC Ophthalmology [internet]. 2017;5(2):65-8. Disponible en: https://www.ecronicon.com/ecop/pdf/ ECOP-05-0000124.pdf y https://www.ecronicon.com/ecop/volume5-issue2.php 9. Vejarano LF, Renna A, De la Cruz E, Alio JL. Symptomatic control of presbyopia through pharmacological ciliary body stimulation. EC Ophthalmology [internet]. 2017;5(3):106-20. Disponible en: https://www.ecronicon.com/ecop/pdf/ECOP-05-00131.pdf y https://www. ecronicon.com/ecop/volume5-issue3.php 10. Vejarano LF, Alio JL. Gouttes oculaires pour la presbytie? Revue L’Optométriste [internet]. 2017;39(3):6-9. Disponible en: https://www.aoqnet.qc.ca/wp-content/uploads/2017/05/ Gouttes-oculaires-presbytie-art1-MaiJuin2017.pdf 11. Vejarano LF. Can an eye drop eliminate presbyopia? New therapies under investigation have the potential to radically alter your approach to this age-old problem. Review of Optometry [internet]. 2017. Disponible en: https://www.reviewofoptometry.com/article/ ro0617-can-an-eye-drop-eliminate-presbyopia 12. Vejarano LF. Presentation spotlight: topical accommodating eye drops. New study demonstrates better near vision and high patient satisfaction in presbyopic patients using topical drops, with unchanged distance vision. Eyeworld [internet]. 2018. Disponible en: https://www.eyeworld.org/topical-accommodating-eye-drops 13. Chou B, Vejarano LF. Presbyopia eye drops are in sight: the future looks bright for topical presbyopia treatment. Review of Optometry, Review of Cornea & Contact Lenses [internet]. 2018. Disponible en: https://www.reviewofoptometry.com/ce/presbyopia-eye-dropsare-in

FROM COOMEVA

‘SARA’

The new virtual assistant Coomeva Medicina Prepagada

n order to update models and processes according to the demands of the digital environment in which contemporary societies are developing, Coomeva Medicina Prepagada has defined a digital strategy project to strengthen the relationship with our users through of the promotion of technological tools and functionalities. The engineer Hugo Alberto Pava Carvajal, national director of Projects and Engineering of Prepaid Medicine Coomeva, explains that within the framework of this strategy was born Sara, a model of chatbot designed to provide virtual assistance to users in the network. What exactly is Sara? A chatbot has the task of simulating a sufficiently fluid conversation with a real person: based on an artificial intelligence computer program. This being the case, Sara arrives to address the need to provide advice and complete information to our current and potential users regarding the coverage of our products and services, as well as related administrative issues, all through the website www. medicinaprepagada.coomeva.com.co and Messenger on Facebook Sara - virtual assistant Coomeva Medicina Prepagada. Sara has been programmed by our experts to respond to any type of concern, questioning or consulting about our plans, services, programs, coverage

or procedures, all from the comfort of a device with access to the web. This tool takes advantage of the opportunities that arise from the wide coverage of the Internet that we currently evidence to offer virtual assistance 24 hours a day, seven days a week, from the most practical mobile communication channels, such as smartphones, tablets. and laptops. “With the availability of our virtual assistant, we are contributing to the strengthening of various added values for our users, as the continuous assistance on aspects related to our product portfolio and services, greater speed and ease in the processing

and resolution of concerns, updated and affordable information about our offer frameworks, a comfortable, pleasant and efficient service experience with our entity, among other advantages that primarily favor our users“, according to the engineer Pava, about the benefits that are perceived from the implementation of this innovative tool. As of today, shortly after having started the project implementation process, there are already more than 100 thousand concerns that have been effectively posed. by the users and successfully resolved by Sara. Pava points out that “this is a figure that allows us to foresee that Sara has the capacity to be the channel of attention preferred for our users”, taking into account the facilities that characterize its use and its permanent state of updating and refinement. Therefore, as an artificial intelligence, Sara learns at every moment that she interacts with the user to offer, eventually, answers that are more and more in line with the questions that users ask.

NOVEMBER 2018 33

Sara is the name assigned to the ‘chatbot’ that we have designed from Coomeva Medicina Prepagada to offer our users closer answers and more accurate solutions.

EBM

WHAT IS NEW IN SEPSIS HANDLING

One hour for

SAVE THE LIFE

34 NOVEMBER 2018

SEPSIS

2. Bacteria enter the blood

1. Sources of infection

In order to avoid a septic shock, the protocol recommends treating sepsis as a medical emergency and not losing valuable minutes for resuscitation of the patient.

3. Blood vessel leakage

4. Organ dysfunction

ith a new ‘hour 1 package’, the health authorities are working to prevent sepsis. One of the most promoted concepts is that the management of sepsis is a ‘medical emergency’ and should be treated as such. This is reiterated by the researchers from the National Quality Forum, the New York Department of Health, and the United States Medical and Health Care Centers, who have just presented the update of the Sepsis Survival Campaign. (SSC, by the acronym in English of Surviving Sepsis Campaign), by reviewing clinical evidence and existing protocols, and focusing on five treatment steps and in the first key time as the major strategies. WHO itself, in its most recent World Health Assembly, also focused on the need to “improve the prevention, diagnosis and treatment of sepsis”, which registers more than 30 million new cases each year; of

them, 1.2 million children and 3 million newborns, and that can kill 6 million people, 500 thousand newborns, and causes 1 of every 10 maternal deaths.

TIME AND VALUABLE STRATEGIES Luis Guillermo Uribe Rodríguez, internist, epidemiologist and infectious disease specialist, head of the Infectious Disease Service of the Cardiovascular Foundation of Colombia, emphasizes the importance of unifying concepts for the prevention of deaths, based on studies and clinical evidences, and on the criteria that must be met. Before, a period of 3 to 6 hours had been established “to carry the patient’s goals, and much emphasis was placed on resuscitation and reaching some physiological parameters. When sepsis returns an emergency status, such as a heart attack

NOVEMBER 2018 35

EBM

THE FIVE KEY STEPS The update of the SSC packages, based on the 2016 SSC guidelines, highlights the first hour as vital, during which time these steps must be carried out. “It may take more than an hour to complete resuscitation, but start resuscitation and treatment, as well as obtain blood to measure lactate and blood cultures, administer fluids and antibiotics, and, in the case of potentially fatal hypotension, starting the vasopressor makes the difference between surviving or not, “said Dr. Mitchell M. Levy, MCCM, of the Brown University School of Medicine, lead author of the latest SSC update.

Measure lactate levels. If the initial lactate level is high (> 2 mmol / l), it should be re-measured within 2-4 hours to guide the reactivation in order to normalize lactate in patients with high levels of lactate as a marker of tissue hypoperfusion.

Obtain priority blood cultures for the administration of antibiotics. Alteration of cultures of microorganisms may occur minutes after the first dose of an appropriate antimicrobial, so cultures must be obtained before. But, if it is not possible to get them soon, the use of the antibiotic should not be delayed.

Administer broad-spectrum antibiotics, ieven before confirming the type of infection, and then reduce when the results are available or the causative agents and sensitivities have been identified of the pathogen.

Quickly administer 30 ml / kg of crystalloids by hypotension or lactate greater than or equal to 4 mmol / l. Effective and early fluid resuscitation is crucial for the stabilization of tissue hypoperfusion induced by sepsis or septic shock.

Apply vasopressors within the first hour if the patient is hypotensive during or after the resuscitation fluid to obtain MP> or equal to 65 mmHG. The goal is to maintain an average blood pressure, and keep in mind that most complications of sepsis are originate from an uncontrolled elevation of blood pressure.

36 NOVEMBER 2018

or cerebrovascular event, as is now done and as detailed in the research, that first hour has a fundamental impact on the prevention of mortality”, adds the specialist. For his part, Dr. Mitchell M. Levy, of the Faculty of Medicine of Brown University, principal author of the latest update of SSC, has insisted that “there is no reason to delay the treatment of patients with sepsis and septic shock. This must start immediately, because they are critically ill patients”. Quick fluid administration is recommended, use of vasopressor immediately when lowering blood pressure, taking blood cultures, measuring lactate, and using broad-spectrum antibiotics. The latter is fundamental given the bacterial resistance, which makes it difficult to treat infections and increases the risk of sepsis. “The longer the administration of broad spectrum antibiotics is delayed, the mortality increases by 8% every hour”, concluded a study conducted in the hospitals of the Kaiser Foundation (California), within the framework of the Cost and Use of Care Project. Health - National Sample of Inpatients (NIS), whose results were published in the journal JAMA. Another study, entitled “Effects of the delay and inadequacy of antibiotic treatment in the survival of patients in septic shock”, of the Intensive Medicine Service of the Marqués de Valdecilla

University Hospital, in Santander (Spain), found that there was a delay or delayed administration of the first dose of antibiotic treatment and that this influenced the mortality figures. “The deceased patients received the antibiotic significantly later (1.3 ± 14.5 h versus 5.8 ± 18.02, p = 0.001) than the survivors. The percentage of inadequacy of the antibiotic treatment was 12% “. These and other data originated the update of the management of sepsis and a call to emergency centers and intensive care units, but also to general practitioners, emergency physicians, internists and infectious diseases, to empower themselves and act quickly, in a process that begins with the health personnel, which is the first one that the patient consults. Even a resolution, WHO “urges governments to strengthen policies and processes related to sepsis, especially to prevent infections and the spread of resistance to antimicrobials. It underlines the importance of reinforcing the training of health workers to recognize and effectively treat the disease, improve the follow-up and reporting of cases, and promote research to develop more tools for the diagnosis and treatment of sepsis”. “The objective is not to lose initial hours, which are those of the emergency and in which one must act quickly. This is what will prevent mortality and prevent a septic shock developing“, says Dr. Uribe. Likewise, the last word has not yet been said regarding this medical challenge that has led WHO to lead a global study on maternal sepsis (GLOSS), based on a follow-up carried out in 54 countries, and whose results are being parameterized, with a view to “assess the burden and current management of maternal and neonatal sepsis”. The situation is evidenced by the study “Global epidemiology of severe pediatric sepsis: prevalence of sepsis, results and study of therapies”, carried out by specialists from the Division of Critical Care Medicine of the Children’s Hospital of Philadelphia, according to which “sepsis Severe pediatric remains a costly public health problem, with prevalence, morbidity and mortality rates similar to those reported in populations of critically ill adults.

ABC OF THE SEPSIS Sepsis, which originates from an infection with bacteria, viruses, fungi or parasites, can develop in any environment, and this is another topic on which specialists want to draw attention. The authors of the study at the Kaiser Foundation analyzed data from 1,051 hospitals, whose results contradict the belief of some health authorities that sepsis is mainly due to an infection acquired in the hospital. Although at the hospital level it evolves faster, because sometimes the patient is already weak, has a condition of inequality, debilitating, suffers from cancer or is hospitalized recently operated on something, it is not exclusive of the institutions. “A person in the house may develop sepsis, because he fell, cut himself, the wound became infected, let him progress, or a patient with a urinary infection who does not receive or does not follow the treatment may end up with a stronger pain when urinating , chills, fever, malaise, and develop sepsis; pneumonia also begins with cough and malaise, then progresses a little more and gives the person a choke, fever, chills, there the person is already becoming septic, and if he does not go to the emergency room quickly, he can also develop sepsis. Thus, it is not necessarily in the hospital that is triggered. The progression of infection in any organ or system can occur in the out-of-hospital setting”, explains Dr. Luis Guillermo Uribe Rodríguez. Therefore, the recommendation is to go to the doctor when you have or suspect that it is an infection, in order to identify those variables of septic state. Physicians must be up to date in the parameters of sepsis, resuscitation, for the prevention of morbidity and mortality related to sepsis and septic shock.

RECOMMENDED READINGS 1. https://www.ncbi.nlm.nih.gov/pubmed/29675566 2. https://link.springer.com/article/10.1007%2Fs00134-018-5085-0 3. https://www.paho.org/hq/index.php?option=com_content&view=article&id=13377%3A70ams-adopto-decisiones-reglamento-sanitario-internacional-sepsis&catid=1443%3Aweb-bulletins&Itemid=135&lang=es 4. https://www.paho.org/hq/index.php?option=com_content&view=article&id=13377%3A70ams-adopto-decisiones-reglamento-sanitario-internacional-sepsis&catid=1443%3Aweb-bulletins&Itemid=135&lang=es 5. https://www.ncbi.nlm.nih.gov/pubmed/25734408 6. http://www.survivingsepsis.org/SiteCollectionDocuments/SurvivingSepsisCampaignInternational_Spanish_2018.pdf 7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4968574/) 8. http://www.medintensiva.org/es/efectos-del-retraso-inadecuacion-del/ articulo/S0210569114002836/).

NOVEMBER 2018 37

EBM

ADVANCES IN BREAST CANCER

Genetic testing would prevent

CHEMOTHERAPY If practiced in the initial stages, the Oncogene DX test makes it possible to differentiate which women benefit or not from the treatment of chemotherapy. 38 NOVEMBER 2018

he approach to the treatment of breast cancer has undergone a radical change due to a new genetic test. This is Oncogene DX, which in a study of 7,000 women allowed identifying who required chemotherapy infusions and who did not. The women had a specific type of breast tumor known as a positive hormone receptor, HER2-negative and negative axillary lymph nodes, that is, in the early stages. The good news is that, according to the study’s author, Dr. Joseph Sparano, one of the directors of clinical research at the Albert Einstein Cancer Center in New York, half of breast cancers are hormone receptor positive , HER2-negative and negative axillary lymph nodes. The study showed that chemotherapy could be avoided in about 70% of these women when the decision to practice it is taken from the test. Thus, this treatment is limited to 30% of cases, which would actually benefit from its application, explained Sparano in a press release from the American Society of Clinical Oncology (ASCO). The study’s finding was also published in the New England Journal of Medicine. In this regard, oncologist Erna Busch-Devereaux, breast surgeon at Huntington Hospital of Northwell Health in New York, said that many women with breast cancer can avoid undergoing chemotherapy thanks to the results of the study, which constitute a effective and effective guide when deciding a line of treatment for breast cancer early detection.

THE PROOF Oncogene DX examines 21 different genes in tumor cells of the breast and offers a score that allows predicting how cancer will behave in the next 10 years, which facilitates the choice of the step that will be followed after surgery. In women whose tumors had a low score on Oncogene DX, from 1 to 10; or a high one, from 26 to 100, decisions about postoperative chemotherapy are already clear. In the first case they receive hormonal therapy to prevent the cancer from spreading, while in the latter they must undergo hormone therapy and chemotherapy. The doubt then pointed to what was the best treatment for women with a score in the middle range, from 11 to 25, and to know this new research was done. The patients received after the surgery a hormonal therapy or combination with chemotherapy. But after seven and a half years of follow-up, the researchers found no benefits with the latter, neither with respect to survival nor possible metastases. It was only beneficial for a very small group, with a score of 16 to 25, under 50 years old.

In contrast, hormone therapy was effective alone in stopping the progression of cancer in women with an Oncogene score of 10 or less. And of those who got 26 or more, 13% developed a metastatic cancer despite receiving hormone therapy and chemotherapy. The conclusion was that chemotherapy is not justified for women over 50 with this type of breast cancer who score on the Oncogene less than 26. That includes approximately 85% of women with breast cancer of this age group, according to the researchers. For women up to 50 years of age, chemotherapy is not recommended if the score on the Oncogene is less than 16, this is equivalent to 40% of breast cancers in this age group. The new finding represents a great advance, since it will avoid side effects in patients, such as nausea, hair loss, fatigue, infection and numbness in the hands and feet, as well as emotional disorders, infertility and heart failure in the long term. According to Dr. Sebastián Quintero, surgeon, oncologist, mastologist and scientific director of Integrative IPS, “in Colombia this test is requested regularly in patients who require it, in cases of early carcinomas with negative nodes that have certain molecular characteristics. and when it is believed that the patient will benefit from the results of the study. We send (to a research center in San Francisco) part of the tumor to be subjected to

NOVEMBER 2018 39

EBM

IN COLOMBIA, DETECTION IS KEY According to the World Health Organization, breast cancer is the most common disease among women. In Colombia, 7,626 diagnoses are made every year and 2,600 people die from this cause, according to the report of the Ministry of Health and Social Protection. In the country the BRCA test + 16 genes are applied for its detection. It is a genetic test that, through a blood or saliva sample, analyzes 18 genes related to breast, ovarian and endometrial hereditary cancer, providing highly reliable information about the risk of suffering from them. BRCA + 16 genes is a test that is defined under a strict view on the clinical usefulness of the test. It is indicated for women with a family history of breast cancer (female or male) and / or ovary in order to determine its hereditary character. Also for women from 30 years without antecedents, with the purpose of analyzing their hereditary genetic risk and being able to evaluate the preventive options. For example, a person with a mutation in the BRCA1 gene has a risk of breast cancer up to 87%.

an analysis where the recurrence score is measured at 10 years, and if it is low and the chances of relapse are reduced, then it will not benefit from chemotherapy. When the score is high, it requires it and it is an intermediate level, we analyze the characteristics of the tumor, age and if chemotherapy favors it”. In his opinion, the test is an excellent option to not condemn the patient to go through a toxic therapy with side effects.

THE STUDY RECOMMENDED READINGS 1. https://consumer.healthday. com/espanol/cancer-information-5/breast-cancer-news-94/ una-prueba-gen-eacute-ticapodr-iacute-a-permitir-a-muchas-mujeres-con-c-aacutencer-de-mama-en-etapa-inicialevitar-la-quimioterapia-734543. html 2. https://www.cancer.gov/espanol/tipos/seno/investigacion/ tailorx-riesgo-bajo 3. http://anmdecolombia. net/index.php/48-home/ noticias1/539-prueba-genetica-que-detecta-la-predisposicion-al-cancer-de-mama 4. https://www.cancer.org/es/ noticias-recientes/pruebas-geneticas-para-riesgo-del-cancer. html 5. https://www.cancer.org/es/ noticias-recientes/pruebas-geneticas-para-riesgo-del-cancer. html

40 NOVEMBER 2018

The research in which the test called ‘Study of assignment of individualized options for treatment’ was used (trial assigning individualized options for treatment or Tailor) shows that for women with hormone-receptor breast cancer who have a low risk of recurrence, according to an expression test of 21 genes, the five-year recurrence rates are very low, when the postoperative treatment is hormone therapy. Five years after starting the study, in the subset of low risk that was the subject of the initial analysis, 93.8% of the women were free of invasive breast cancer, 99.3% did not suffer distant relapse and 98 % were still living. These results provide further support for the use of 21 gene tests at the time of identifying a subset of

low risk for women who can abstain from chemotherapy after surgery. However, it should be clarified that the study has its limitations, because although it identifies patients who do not benefit from chemotherapy, only 16% had a recurrence score of 10 or less. Nearly 70% were in the range of 11 to 25 and the results to date do not provide information about whether this subset of women can avoid chemotherapy. The truth is that all women with this type of breast cancer, 75 years of age down, should be tested and discuss the results with their treating doctor to be guided on whether chemotherapy after surgery is the best option to prevent the recurrence. It is believed that studies like this are part of a large movement of doctors and researchers seeking to reduce the costs of treatments, since, according to the newspaper The Wall Street Journal, the prices of medicines have doubled from 7,300 on average in 2006 to $ 15,000 in 2015. For Dr. Quintero, with the new study many doubts are clarified for the treatment and his conclusion is that in any case what has to be looked for is everything that benefits the patient before thinking about the economic cost.

EN COOMEVA EMERGENCIA MÉDICA

TE ACOMPAÑAMOS SIEMPRE

Afíliate y cuenta con un servicio de atención médica domiciliaria disponible permanentemente.

24 Atención médica domiciliaria.

Atención de urgencias y emergencias.

Urgencias odontológicas domiciliarias.

Disponible las 24 horas, 7 días de la semana.

Orientación médica telefónica.

#586 Número de fácil recordación para solicitar el servicio desde celulares (Claro, Movistar y Tigo).

Médicos y paramédicos con entrenamiento continuo.

Asesoría telefónica con nutricionista y psicólogo (lunes a sábado en horarios definidos).

Disponible en Cali, Bogotá, Medellín, Barranquilla y Cartagena.

Línea asesoría con nutricionista 018000 918 082, opción 1.

Beneficios adicionales

Toma de exámenes básicos de laboratorio (4 en el año)

Terapias básicas a domicilio (4 en el año)

Asistencia telefónica pediátrica (Ilimitada)

Descuento con especialistas (ilimitado)

Más información en: Barranquilla (5)386 1126 - Bogotá (1) 390 4713 - Cali (2) 489 9624 - Cartagena (5) 694 3370 - Medellín (4) 607 1236.

teacompañamossiempre.co

Aplican condiciones. Aplica área de cobertura definida por Coomeva Emergencia Médica.

HUMANIZED MEDICINE

EMERGENCIES: boarding beyond the patient

Remain calm and follow the protocols are part of the training that every health professional should have when dealing with an emergency. His words have the power to mitigate pain or increase chaos.

42 NOVEMBER 2018

lthough on more than one occasion health personnel would like someone else to take their place when communicating unfortunate news or dealing with an emergency or an emergency, this is something that can not be avoided and that, on the contrary, entails a exhaustive preparation with a view to learning how to handle the situation, first as a human being and then as a professional, to bring peace or quiet at times when it is conspicuous by its absence. â&#x20AC;&#x153;Although bad news is always bad news, the main value that a patient recognizes is trust and, for that reason, the information provided must

be true, but it must be given to people in such a way that mitigate the pain and facilitate its acceptance“, explains the doctor María Clara Mendoza Arango, Emergency Head of the Hospital Universitario San Vicente Fundación, in Medellín. It also emphasizes that, definitively, the emergency service or an unforeseen emergency situation are not in the least the quietest environments. Hence “the challenge of communicating” painful diagnoses of chronic diseases or the impossibility of offering treatment with the intention of curing or other tragic news, among other situations. What to do? It is necessary to prepare, although that does not guarantee that sometimes they are so difficult subjects to handle that not all at that moment can assume the situation. Dr. Mendoza specifies that “the ability of health personnel to remain calm in emergency situations depends on the characteristics of the personality of those who decide by vocation to do this job, vocation of service also associated with training and experience”

Where there is humanization, complaints diminish.

In the Guide to Mental Health in Emergencies and Disasters, of the Ministry of Health and Social Protection, it is stated that “to be an effective professional in mental health in emergencies and disasters, one must be flexible, have facility for establish relationships, be respectful of differences and tolerant in situations of ambiguity and confusion “.

CERTIFICATION IN HUMANIZATION This work in emergencies, emergencies and disasters, inevitably stressful, requires training in mental health and emotional management; organization

TEAMWORK The human approach in the management of an emergency demands a true work in team. Undoubtedly, “an assertive communication within the healthcare group and the awareness that we are a team where one’s work alone can not achieve the expected results is required, but becomes effective only if we recognize that the work of all the members is necessary”, says Dr. Mendoza. The majority of companies, including health institutions, have a welfare, health office and safety at

work, and from here and with the support of human management, activities are carried out to accompany the care personnel in order to ensure that personal conditions do not interfere with their work, as well as promoting activities to remain in welfare. However, sometimes the pressure or anguish is such that courses and protocols can be forgotten. In the Ministry of Health guidelines, the concept of ‘universal vulnerability’, proposed by Jeffrey Mitchell, is repeated, according to which “there is no type of

training or previous preparation that completely eliminates the possibility of a person treating primary victims being affected by post-traumatic stress disorder (what has been called the ‘compassion syndrome’)”. The National Center for Posttraumatic Stress Disorder of the United States has stated that “1 out of every 3 lifeguards arrives to present symptoms of this disorder”. Therefore, in addition to preparing health personnel to handle an emergency and be able to give bad news,

help to keep calm and avoid chaos, the protocols insist on the need to think about their emotional stability, their rest and their recovery. “The stress of the team is not something that can be postponed”, is specified in the guides of the Ministry of Health. There is also talk that over time they may present “burnout syndrome”, which generates irritability and fatigue, progresses slowly without prior warning and can markedly decrease the effectiveness and capacity of the individual “.

NOVEMBER 2018 43

HUMANIZED MEDICINE

From the District Department of Health and Minsalud it has been established that the doctors who attend emergencies have an approved course to learn how to give bad news.

and distribution of work and factors that for any other person may be impossible to control. From the District Department of Health and Ministries of Health, it has been established that physicians attending emergencies and “have approved a course to learn how to tell bad news”, says Dr. Miguel Ángel Saavedra Ortiz, vascular surgeon. Head of the Emergency Service of the Hospital San José Centro and San José Infantil. It is divided into two parts: one is special only for the subject of HIV, which involves how and why to request an HIV test, and then give the result of the test; and another is general, on how to speak and address the patient and his / her companions on specific issues and situations. More and more attention is paid to this disjunctive, and within hospitals accredited by the ISO standard, one of the parameters of high quality accreditation is humanization. “We have to have a humanization center, which in our case has psychiatrists, psycho logists and chief nurses dedicated exclusively to the

44 NOVEMBER 2018

topic of humanization and specialized in information management and duels. All of this corresponds to a trend in most hospitals, not only to be accredited, but to better support the medical team and all the staff”, explains Dr. Saavedra. The patient also benefits when there is a staff totally aligned with the concept of humanization. “We look for the satisfaction of having felt well cared for, well informed, despite the fatal outcome; that gives

The patient also benefits when they have a staff aligned with the concept of humanization and feel well cared for and informed.

them security to be in a professional and academic environment; this reverts to confidence for the doctor. In addition, there is another very important value, which is to minimize demands or complaints. It has been seen that where there are humanization centers and trained personnel, these complaints fall radically”, adds the specialist. For the experts from Ministry of Health and Icontec, “it is of great importance that the institutions that provide health services, the universities and organizations that train health professionals, implement training in humanization, and that these issues are fundamental in the care and staff training, because this is how people and users of health are considered as human beings in a global sense”. It is essential, then, that hospital institutions or emergency care centers develop an education

SIX STAGES PROTOCOL The Buckman-Dance protocol, designed by Drs Robert Buckman and Walter F. Baile, highlights six stages to communicate bad news:

Prepare the physical space (place, moment and person). It is important to try to retire to a quieter space, give the information at the appropriate time and recognize the right interlocutor.

program continued that allows the health professional to keep up-to-date on the approach of patients, relatives and close persons when the tragic event or the emergency situation is involved. In order to improve the quality of customer service, the medical community must always apply humanistic values and principles, all aimed at transforming the doctor-patient relationship.

EMOTIONAL INTELLIGENCE IN PRACTICE

RECOMMENDED READINGS

The postulates of emotional intelligence are also perfectly applicable in this type of practice, which essentially is the integrality of the human being (mind-body-emotions). The principles of this discipline manage to strengthen the personal capacity to know oneself, regulate feelings and emotions, exercise empathy and be motivated by what is done. It is also key to put into practice assertiveness, defined as the social ability to express what is thought, felt or believed in adequately, which provides confidence and security, an imminent need at the time of giving unfortunate news or tragic.

Find out what the recipient of the information knows to recognize their expectations and fears, and thus manage the information in a clear but delicate way, with an appropriate language for each person and situation.

Do not lose yourself technically in the situation, illness or treatment, but in what is relevant to the patient or family member.

Share accurate information, in the appropriate language for the cultural or educational level.

1. https://www.minsalud.gov.co/ Documentos%20y%20Publicaciones/Gu%C3%ADas%20 para%20manejo%20de%20 urgencias%20-Tomo%20III.pdf 2. https://www.minsalud.gov.co/ sites/rid/Lists/BibliotecaDigital/ RIDE/VS/PP/Calidad-y-humanizacion.pdf 3. https://www.paho.org/disasters/ index.php?option=com_docman&view=download&category_slug=publications&alias=2510-proteccion-salud-mental-situaciones-desastres-emergencias-0&Itemid=1179&lang=es 4. https://www.minsalud.gov.co/ salud/publica/PI/Paginas/calidad-humanizacion-atencion. aspx 5. https://www.minsalud.gov.co/ sites/rid/1/Guia_comunicacion_interna_al_paciente.pdf

Respond to the patient’s feelings. The most important thing in this stage is the form of verbal and non-verbal communication; it can be represented in silences to allow digesting information.

Planning and explanation of the therapeutic plan to follow, and follow-up of the process. It is important to close the information delivery event, making it clear that there will be availability to continue discussing the situation in accordance with the evolution of the disease or care.

NOVEMBER 2018 45

GOOD PRACTICES

ORAL PROTOCOL

Photo: ÂŠ 2018 SHUTTERSTOCK PHOTOS

for the cancer patient

n patients diagnosed with cancer, regardless of their origin, three very specific considerations must be taken into account:

Systemic condition

Oral conditions

The origin of the cancer, histological type, stage, functional status, general state of the patient (chronic noncommunicable diseases, CND) is taken into account in broad terms.

It refers to the general state of the stomatognathic system, where bone, joint, muscle, glandular, soft tissue, dental, vascular and nervous structures are articulated in such a way that they allow the development of vital functions such as chewing, swallowing, phonation, impacting the general health of individuals in terms of

46 NOVEMBER 2018

Regardless of age, patients diagnosed with cancer must undergo oral health control before, during and after oncological therapies to prevent possible systemic complications of oral origin. By: LUZ DARY QUINTERO MORALES Oncology dentistry, specialist in Health Management ludquim123@hotmail.com

well-being, absence of pain and suffering, and, therefore, their quality of life.

Considerations related to oncological therapies

The purpose of different oncological therapies is to allow healing, optimize survival rates, control relapse, reduce mortality rates and improve the quality of life of cancer patients. However, although they are aimed at controlling the proliferation of tumor cells, there are indirect side effects (myelosuppression, immunosuppression) and direct side effects that can affect healthy tissues and structures; Specifically in oral structures, the direct side effects can be expressed as xerostomia, mucositis, muscle fibrosis, dental neuropathies, osteonecrosis, which require a multidisciplinary team that also integrates an oral health team experienced in oncology, which allows this complementary multidisciplinarity a comprehensive care of the patient with cancer.

Once these considerations are understood, it is required that patients diagnosed with cancer, adults or children, perform an oral health protocol that allows a control before, during and after oncological therapies, in order to prevent and control systemic complications of oral origin In a hemato-oncological unit in the city of Cali, a transversal descriptive study was carried out: the review of clinical histories between 2004-2012. The population and sample were 192 clinical histories of cancer patients who attended the dentistry service in the period described, and 182 clinical histories that met the inclusion criteria were taken into account for this analysis. To characterize the oral profile in these patients, the COP index, the prevalence of periodontal disease and edentulism were determined. According to the origin of the cancer in the study population, the following classification was established: a) Patients with cancer of hematopoietic origin b) Patients with cancer of lymphatic origin c) Patients with solid tumors

In a study done in Cali it was shown that the 58.2% of the cancer population suffer from periodontal disease.

In the total study population, 98% of the patients evaluated already have a history of caries and 80% of patients continue with active cavitational caries without treatment. We will explain in a simple way that the COP index represents the sum of decayed teeth (C), filled (O) and lost (P) in an individual. Its use is international, which allows us to make comparable assessments in different populations. The ideal index is COP equal to zero. To the extent that the index moves away from zero, we observe how the burden of caries disease begins to manifest itself in a population. The COP index acceptable to the WHO in children under 12 years of age is 2.3. The cancer population is 16, which means that the burden of caries disease is very high; remember that it is an infectious disease caused by Streptococcus mutans and Lactobacillus spp., whose progress can affect periodontal and systemic structures. Periodontal disease was determined by the presence of three periodontal markers: calculus,

ESPECIALIZADA

EN:

GOOD PRACTICES FIGURE 1 FREQUENCIES ACCORDING TO THE ORIGIN OF CANCER IN PATIENTS TREATED BY DENTISTRY 2004-2012

Solid tumors

OTHERS

ANO

BREAST

Lymphatic

ORGANS PLAYERS

GASTRIC

OTHERS LYMPHOMAS

LYMPHOMA NO HODGKIN

LEUCEMIAS

3 DISEASE OPF HODGKIN

MYELOMA MULTIPLE

STRAIGHT

COLON

FIGURE 2 CARIES HISTORY VERSUS CARIES PREVALENCE IN CANCER POPULATION

35-44

45-54

55-64

75-82

80%

100%

75%

25-34

72,4%

15-24

65-74

63,2%

85,7%

100%

89,2%

100%

82,3%

67%

Prevalence of caries

56%

100%

Caries history

TOTAL

FIGURE 3 CLASSIFICATION OF THE SEVERITY MEASURED THROUGH THE TRADITIONAL COP SCALE BY DIAGNOSTIC GROUP

16,9

16,6

16,2

19,0

15,9

16,0

TOTAL DIAGNOSIS FROM CA.

OTHERS CA.

SLUNG

ORGANS PLAYERS

COLORRECTAL

GASTRIC

12,3

BREAST

NEOPLASIAS HEMATOLOGICAL

14,3

FIGURE 4 PREVALENCE OF PERIODONTAL DISEASE

85,0%

77,7% 61,3%

60,8%

58,2%

50,0%

47,6%

FIGURE 5 DENTAL LOSS OR EDENTULISM

TOTAL DIAGNOSIS FROM CA.

87,0%

55,0%

62,5%

52,0%

TOTAL DIAGNOSIS FROM CA.

OTHERS CA.

SLUNG

ORGANS PLAYERS

33,3%

COLORRECTAL

BREAST

30,1%

47,8%

GASTRIC

45,5%

OTHERS CA.

SLUNG

ORGANS PLAYERS

COLORRECTAL

GASTRIC

BREAST

NEOPLASIAS HEMATOLOGICAL

33,3%

NEOPLASIAS HEMATOLOGICAL

bleeding on probing and periodontal pockets> 4 mm. Ensab III reports that 50.2% of the people assessed (without systemic commitment) presented loss of insertion. In the study it was evidenced that 58.2% of the oncological population manifested periodontal disease. 85% of patients with cancer in reproductive organs (prostate, cervix) had periodontal disease. Periodontitis, previously considered a disease limited to the gums, causes a systemic inflammatory response with the elevation of several acute phase reactants, such as C-reactive protein, fibrinogen, and platelet aggregation. The microbiota found in patients with periodontitis is very diverse, comprising about 150 species that vary between patients and between different bags in the same patient. Usually, they are strict anaerobic gram negative bacteria. The bacteria that are most frequently isolated from the periodontal pocket are Porphyromonas gingivalis, Prevotella intermedia, Tannerella forsythensis, Fusobacterium nucleatum, Aggregatibacter actinomycetemcomitans, Capnocytophaga gingivalis, Micromonas micros, Treponema denticola and Campylobacter rectus. Chronic infections, such as periodontal disease, have been reported as risk factors for the development of atherosclerosis, cardiovascular diseases, cerebrovascular accidents and total risk of cancer. 52% of patients with cancer had less than 20 teeth in the mouth, lost due to caries disease and considered as partial edentulism. Only 11.5% of the patients presented 28 teeth, which means pain, suffering and loss in the quality of life of these individuals.

Hematopoietic

LUNG

N=182

SOURCE: LUZ DARY QUINTERO MORALES, OD.

48 NOVEMBER 2018

We r e c o g n i z e t h e e n o r m o u s efforts of the Ministry of Health and Social Protection, which has issued a series of technical documents in which it records that oral health is an integral part of general health and includes oral health as objective 3 in the Ten-Year Plan of Public Health 2012-2021 (PDSP), committing the actors of the health system to execute actions in accordance with the lines of policies to advance in the improvement of oral health conditions, among whose goals the decrease of the average COP index is established. less than 2.3 in children of 12 years and achieve maintain permanent teeth in 60% of those over 18 years; In addition, within the framework of the Comprehensive Health Care Policy (PAIS-MIAS-RIAS) resolutions 429/2016 and 3202/2016, the protection ministry establishes the Comprehensive Care Route for the promotion and maintenance of oral health for the population without systemic commitment. In laws 1384/2010 and 1388/2010, the provision of oncological services is established in an integral manner, attention that was regulated by Resolution 1477 of 2016 on the issue of qualification of cancer care units for pediatrics (UACAI) and adult (UFCA), but oral health has no integration to the comprehensive care of cancer patients.

Conclusions The high indexes of oral health indicators indicate that it is essential to include oral health in the integral treatment of cancer patients. Oral health should be recognized as an essential element of general health in terms of reducing suffering, pain and improving the quality of life of cancer patients.

COOMEVA PROMOTES

‘CARING FOR YOU IS LOVING YOU’,

a promise of value of our model of care

Generating tools that allow patients to stay healthy is the goal of this program, which promotes good habits of life.

ith the aim of creating strategies to prevent illnesses and avoid complications when they are affected, Coomeva Medicina Prepagada created its risk management model two and a half years ago, with global strategies for health promotion, early detection, management of diseases and individual case management. From this we seek to segment the population by diseases, demographic groups, age and risk conditions, according to the consultations with our professionals. The program has evolved, in agreement with Dr. Julián Villegas, national head of Risk Management at Coomeva Medicina Prepagada, to the point that it has been using an application for two months.

‘My story’, in which, from a test about their lifestyle and health conditions, the patient identifies their own risks and receives individual recommendations of healthy habits, recipes, tips about emotional behavior and activity physical, to prevent or mitigate diseases. “If we identify that there is an imbalance, after the consultation we send the person a nutritionist to the house, as part of an individual strategy. We also invite you to workshops, especially when there are risks of nutritional imbalance, diabetes or hypertension, in coordination with your treating specialist doctor“. The information of ‘My history’ is key, because it allows to identify if there is high, medium or low risk, and, according to this, according to Dr. Villegas, the care activity

is prioritized or encouraged. Thanks to ‘Cuidarte es quererte’, the characterization of 98% of the population affiliated by diseases and by demographic group has already been achieved. “So far, we have found that the population between 20 and 30 years has less risk of disease. As regards the most frequent problems, overweight, obesity, smoking and, in general, unbalanced life habits are found, “says the specialist. Precisely, patients at risk will be tested individually, in partnership with Christus Synergy, to develop a multidisciplinary consultation and treatment with your attending physician, as well as nutritionist, sportsman, psychologist and nurse, in order to agree on a plan for personalized health that can be carried out in a single site with the agreement of the professionals. But, obviously, the result depends on the patient, their self-care and their awareness when modifying habits, such as eating well, stopping smoking, exercising and controlling stress. “Among our goals in the medium term are that at least 30% of the members have an individual plan and, later, 60%, to reduce the incidence of diseases by about 10% and mitigate the complications. associated at least between 20% and 40% of people who are already sick, “he adds. And Dr. Villegas concludes that Coomeva Medicina Prepagada will go beyond this model of personalized and preventive care, with an incentive program for patients, with the goal of reducing the prepaid medical premium; Likewise, we will be giving out bonuses for healthy food markets to members of our institution and linked to ‘Cuidarte es quererte’.

NOVEMBER 2018 49

LAW AND HEALTH

NEW RESIDENT LAW

AN IMPULSE to the training of more specialists

50 NOVEMBER 2018

For the first time in Colombia, doctors will be economically compensated while studying a specialization. The regulation seeks to train a greater number of residents, reduce barriers to access university programs, expand the graduate places and reduce tuition fees.

t is no secret to anyone that the medical career is the most expensive in the country, and education during its exercise does not stop. It is practically of all the life. Precisely, with the aim of guaranteeing the adequate conditions for the academic and practical training of the students who attend specialized medical-surgical programs, Law 1917 of July 12, 2018, which came into force as of its presidential sanction, creates the National System of Medical Residences in Colombia, defines its financing mechanism and establishes strengthening measures for practices in the area of health. The regulation involves all health care institutions (HCI) that serve as scenarios of training practice, to higher education institutions that have duly authorized medical-surgical specialization academic programs, to health professionals who study specializations and the authorities of national, departmental, district and municipal character that act within the Social Security Health System. The medical residencies system covers a set of institutions, resources, norms and procedures that intervene in the training process of professionals who attend a medical-surgical specialization program and require training practice within the framework of the relationship teaching-service, existing between the

institution of higher education and the institution providing health services. On the other hand, the resident is a doctor with current authorization to practice his profession in Colombia, who studies a medical-surgical specialization in legally approved academic programs and, in addition, he / she requires to do his training practices. In general, they are young professionals between 28 and 35 years of age, with an established family, who have practiced their profession, advanced the compulsory social service and dedicate themselves full-time, and exclusively in an HCI, to training as specialists. in programs of between 3 and 5 years, an activity that, despite not being remunerated in the country, will begin to be once the Residentâ&#x20AC;&#x2122;s Law is regulated.

DOCTORS WILL HAVE A CONTRACT The law establishes that every doctor who carries out a specialization has a training contract and the Social Security Health System guarantees him at least three basic salaries ($ 2,343,726) per month, an appropriate rest period, vacations and adequate conditions for their training process, in technological terms, of human talent, assistance and locative. The contract determines that the doctor provides his

NOVEMBER 2018 51

LAW AND HEALTH

THE LAW IN THREE POINTS

The resources financing

The law will cost the Colombian State about 110 billion pesos a year. The sources of financing may be up to 0.5% of contributions from the contributory scheme, resources from the general budget of the nation, monies from the family compensation funds and from the scholarship fund itself, which has the Ministry of Health for residents.

Benefits for hospitals

Thanks to this new regulation, public hospitals in Colombia will have resident physicians in their personnel plant, since they will be turned over to national resources for payment to these residents, and, in addition, they will have professionals who will support the resolution capacity of the institution in question.

What will happen with the universities

The regulation specifies that the national government is obliged to structure and present a public policy for the training of human talent and of medical specialists that seduces universities to expand the number of existing quotas in one term. of six months. Data from the Ministry of Education estimate that in universities such as Antioquia, the Valley and the National, 300 students are presented for three specialization quotas, and in private universities the enrollment can reach 40 million pesos per year. The value of the enrollment of the medical-surgical specialization programs may not exceed the total administrative and operational costs required by the university institutions for their development. “Universities should continue to defend the commitment from their missionary work, which is to ensure education, eliminating that conception that it is a business, and continue with a collective work that allows research and returns to Colombia. image that recognized her as a reference in the world for the training of doctors and human talent in health“, concludes the president of the National Association of Interns and Residents.

52 NOVEMBER 2018

Law 1917 (2018) establishes that residents must have monthly remuneration not less than three minimum basic salaries, affiliation to health systems and occupational risks, vacations and shifts that do not exceed 12 hours a day.

services during the duration of the academic program, and in return, the hospital provides him with a remuneration that constitutes support for monthly educational support. For Jorge Iván Ospina, doctor, senator and speaker coordinator of the Resident Law, “many talented young people will be able to do their specialization and not only, as it happens now, a small elite that has the resources, that accesses the few credit scholarships or that assumes large debts to study”. In addition to the monthly remuneration, not inferior to the three basic minimum wages, the doctor will have: • Guarantee of the conditions, means and resources redear ones for the formative development. • Affiliation to health systems and occupational risks. • Right to vacation for 15 business days per year academic. • Work plan or practice within the hours that the IPS has contemplated. • Sustainability by the IPS if their work requires rotation in different scenarios in order to be able to perform the practice • Shifts that do not exceed 12 hours a day and 66 hours per week.

REDUCE THE DEFICIT One of the most important arguments for the approval of the law was the deficit of medical specialists that Colombia has. The promoters of the regulations in the Congress demonstrated that there is an asymmetry in relation to the location of these professionals

in the country. For example, in remote areas, such as the old national territories, there is practically no presence of basic specialists, such as internists, paediatricians, obstetricians or surgeons; while there is a significant concentration of specialists in the main cities, but with a significant shortage of subspecialists. The law seeks to reduce this deficit, achieving a quantitative and qualitative increase in human talent to meet the needs of specialized consultations of the Colombian population. Data from the Ministry of Health and Social Protection confirm that. In our country there are about 5,300 resident doctors and between 19 thousand and 23 thousand specialists, when we should have about 35 thousand. The regulations require the national government to initiate a sectoral epidemiological differentiation study, which should lead the National Health Institute to identify what type of specialists are needed in the regions and what incentives there are for these professionals to reach the sectors where they are needed. they are required. Actors such as the National Association of Interns and Residents, the Federación Médica Colombiana, the medical colleges, the health faculties of the country and the medical associations are pleased and support what they consider to be a just cause and a proposal that defends the interests of the guild. “It is a victory after 30 years of several injustices in the guild, since there was an economic bias at the time of entering a medical-surgical specialization, one that we intend to eliminate. We managed to improve the quality of the training, given that the specialist is going to invest his time of study in what should be: research or quality and the warmth of the care“, says Luis Carlos Leal, general surgery resident of the Universidad Nacional de Colombia and president of the National Association of Interns and Residents. On July 13, 2018, the Minister of Health, Alejandro Gaviria, made official through his Twitter account the signature of the law by his office: “Congratulations to the promoters and the medical specialists. I celebrate the union of the sector around a just cause”, said the official on the network. The law was also formed by the Ministers of Finance and Education.

BRAKE THE BRAIN LEAK Many of the young Colombian doctors who wished to specialize migrated abroad in order to be educated, several of them did not return to the country, constituting an important brain drain. All this in addition to the loss of opportunities that occurred

One of the most important arguments for the approval of the law was the deficit of medical specialists in Colombia. In our country there are about 5,300 resident doctors and between 19 thousand and 23 thousand specialists, when we should have about 35 thousand.

among doctors, who could not access their specialization because they had no way to defray the expenses of their families. Those who accessed a credit scholarship were a very small number. Many of these professionals even acquired important debts or worked illegally taking turns to obtain income. “Paying a doctor to study for five years and become a specialist is the largest strategic investment a nation can make, because that human talent will return in preventive, curative, rehabilitative and acquired knowledge, that is why the countries they should bear in mind that the medical specialist and the doctor in general is a strategic human resource that should be strengthened and that should be remunerated appropriately”, concludes Dr. Ospina. “The Resident’s Law is an invitation to continue presenting to the medical programs that exist within the country; that doctors continue in the union struggle in favor of health professionals, patients and better quality of care. The regulations will prevent the brain drain and will rationalize tuition costs for doctors who wish to continue their training”, adds Dr. Leal.

RECOMMENDED READINGS 1. https://www.minsalud.gov.co/ Documentos%20y%20Publicaciones/Apoyo%20a%20IPS%20 p%C3%BAblicas%20para%20 formaci%C3%B3n%20de%20residentes%20en%20%C3%A1reas%20 prioritarias%20de%20salud.pdf 2. https://www.facebook.com/photo. php?fbid=10205005982345727&set=pcb.10205005983945767&type=3&theater 3. http://caracol.com.co/descargables/2018/07/13/f2d4280a68341f418e77c0948b207cb8.pdf 4. https://www.minsalud.gov.co/ sites/rid/paginas/freesearchresults. aspx?k=m%C3%A9dicos%20residentes&scope=Todos 5. Pontificia Universidad Javeriana, Cendex. Estudio de disponibilidad y distribución de la oferta de médicos especialistas, en servicios de alta y mediana complejidad en Colombia. [internet]. 2013. Disponible en: https://www.minsalud.gov. co/sites/rid/Lists/BibliotecaDigital/ RIDE/INEC/INV/disponibilidaddistribucionmdespecialistascendex. pdf

NOVEMBER 2018 53

MEDICAL WORLD

HIGHLIGHTED EVENTS Date and location:

‘EUROPEAN COURSE OF DIAGNOSTIC AND INTERVENTIONAL NEURORRADIOLOGY IN LATIN AMERICA’ ‘CARDIOVASCULAR CARDIOLOGY AND HEALTH WORLD CONGRESS 2018’ Date and place: December 5-8, Dubai (United Arab Emirates) Reports: World Heart Federation Phone: +41 (22) 807 0320 Email: info@worldheart.org Website: https://www.world-heart-federation.org/congress

Date and place: November 7 to 10, San Pablo (Brazil) Reports: Paulista Society of Radiology Telephone: +55 (11) 5053-6363 Email: comunicacao@spr.org.br Website:http://spr.org.br/

‘MEDICA 2018’ Date and place: November 12 to 15, Düsseldorf (Germany) Reports: Messe-Düsseldorf GmbH Telephone: +49 (0211) 4560 01 Email: info@medica.de Website: http://https//www.medica-tradefair.com

‘WORKSHOP FOR PATIENTS AND THEIR FAMILIES ON DIABETES’ Date and place: November 14, Bogota Reports: Colombian Association of Endocrinology, Diabetes and Metabolism Phone: (1) 642 0245 E-mail: secretario@endocrino.org.co Website: http://www.endocrino.org.co/

III INTERNATIONAL CONGRESS OF RESEARCH IN HEALTH AND EDUCATION SCIENCES Date and place: November 15 to 18, Bogota Reports: Research Center of the Juan N. Corpas University Foundation Phone: (1) 662 2222 E-mail: centro.investigacion@juanncorpas.edu.co Website: http://www.cinvest.com.co/

54 NOVEMBER 2018

HIGHLIGHTED EVENTS ‘5th CONGRESS OF AESTHETIC MEDICINE AND ANTI-AGING MEDICINE LATIN AMERICA’ Date and place: November 15 to 17, Medellin Reports: EuroMediCom Phone: (4) 448 2810 E-mail: comercial.amwcla@ce.com.co Website: http://amwc-la.com/es/inicio/

‘SYMPOSIUM DIABETES: A SWEET ENEMY’ Date and place: November 17, Cali Reports: Colombian Association of Endocrinology, Diabetes and Metabolism Phone: (1) 642 0245 E-mail: secretario@endocrino.org.co Website: www.endocrino.org.co/

‘VI INTERNATIONAL FORUM OF MEDICAL DEVICES’ Date and place: November 20 and 21, Bogota Reports: National Association of Businessmen of Colombia Phone: (1) 326 8500 E-mail: eventos@andi.com.co Website: http://www.andi.com.co/Home/Evento/22-vi-foro-internacional-de-dispositivos-medi

‘SYMPOSIUM UPDATE IN DISLIPIDEMIA’ Date and place: November 24, Barranquilla Reports: Colombian Association of Endocrinology, Diabetes and Metabolism Telephones: (1) 642 0245 E-mail: secretario@endocrino.org.co Website: http://www.endocrino.org.co/

‘II ECANCER CONGRESS COLOMBIAN LEAGUE AGAINST CANCER’ Date and place: November 29 and 30, Bogota Reports: Colombian League Against Cancer Phone: (1) 744 1780 E-mail: latinamerica@ecancer.org Website: http://ecancercolombia.org/#

NOVEMBER 2018 55

MEDICAL WORLD

BOOKS ‘LIFE WITH A DOG IS MORE HAPPY’ Author: Emilio Ortiz The book aims to be told through the experiential voice of what has long been called ‘the best friend of man ‘, precisely to relate his experiences and the relationship he has had with the human species. Emilio Ortiz is looking for from us, his readers, a greater and better understanding of the way emotions work and feelings of these domestic dogs.

56 NOVEMBER 2018

‘MANAGEMENT CRITICAL AREAS’ Authors: Antonio Gallesio, María del Pilar Arias López, Eduardo Schnitzler y Sebastián Cosenza

‘ENFERPEDIA’ With an approach that goes from the theoretical prescription to the practical description of the themes, the 51 chapters distributed in the eight sections the authors of this work represent a multidisciplinary and multicultural contribution to the clarification of specificities such as cardiology, general surgery, intensive medical care, nursing, internal and general medicine, pharmacy, medication management, transplant medicine, procurement of bodies, computer science applied to management and, even, economy and procedural costs.

Authors: Sergio Galarreta Aperte y Carlos Martín García This text refers to the explanation of the most common procedures of nursing; the 1,168 pages serve as the essential manual for daily clinical practice. Considered a basic instrument for reading and consulting for nursing professionals, Enferpedia summarizes the concepts, precepts and core skills of daily and extraordinary healthcare activities. Most of the explanations are supported by graphs, drawings, cards, tables, infographics and other visual resources that highlight the most relevant points of each procedure.

‘PHYSIOLOGY HUMAN’ Author: Bryan Derrickson Based on the development of fundamental techniques in clinical reasoning, the Biology teacher of the Valencia Community College of Orlando supports its analysis in four principles that it declares paradigmatic for the field of physiology: homeostasis, mechanisms of action, communication and integration. The language of the text is punctual and clear, which contributes to making the ideas at play easy to interpret, even for those who are not completely related to concepts and values of the medical discipline. The content of the book is complemented with access to a web platform that proposes pedagogical and interactive activities.

‘THE ENCÉFALO’ Author: Anne G. Osborn This specialist in radiology takes a thematic tour that takes her from trauma and non-traumatic hemorrhages, to infections, demyelinating and inflammatory diseases. The organization of the book is strategically planned to facilitate the quick consultation of information in boxes that summarize and dose the most important data. The contents printed in the text are the result of the author’s prolific career, his decades of teaching and learning, and of his professional affections towards neuropathology, neurosurgery and clinical neurosciences. The work is particularly characterized by its richness in visual material, which mitigates the complexity of the subjects presented.

‘LOVE LESS THANKS‘ Director: Juan Vera Distribution: Ricardo Darín, Mercedes Morán, Claudia Fontán, Andrea Pietra, Luis Rubio, Jean Pierre Noher, Claudia Lapacó, Chico Novarro

MOVIE THEATER ‘FANTASTIC ANIMALS: THE GRINDELWALD CRIMES’

The story of Ana and Marcos, a married couple of more she is 25 years old and, after the departure of her only son to carry out her university studies abroad, she is involved in an existential crisis that separates them by mutual agreement. The enjoyment of the freedoms and reassurances of the bachelorhood is exhausted rather quickly, and questions about love, desire and fidelity will seize their minds to the point of making a decision that will transform their lives radically. and definitely.

Director: David Yates Distribution: Eddie Redmayne, Katherine Waterston, Dan Fogler, Alison Sudol, Ezra Miller, Claudia Kim Eddie Redmayne, Katherine Waterston, Dan Fogler, Alison Sudol, Ezra Miller, Claudia Kim After collaborating in the capture of the dark magician Gellert Grindelwald, Newt Scamander joins the legendary sorcerer, and old friend, Albus Dumbledore to stand up to the followers of Grindelwald, who manages to escape from his custody and finds himself gathering a army to incite the ‘pureblood’ magicians to rule over all nonmagical creatures. The loyalty of Newt’s group of friends will be tested as they face the dangers of a magical world that is increasingly fragmented.

MUSIC ‘EGYPT STATION’ Paul McCartney After a long five years without studio news, the ex-Beatle launches his new album, described by McCartney himself as a “travel blog, where each song is a page that explores different musical terrains. ”Egypt Station is a kaleidoscopic route through different spatial and temporal stations each time; a trip whose rhythm is marked by the tunes in each theme.

‘FOLLOW THE PARTY’ Faith of Rats The eleventh record release of the Spanish punk rock group includes a total of five new songs that are added to their musical record, started with the founding of the band in 1995. The album was produced by Tutu Estudios, in Corvera de Asturias , and the spirit of his songs retains a breath of rebellion and protest, a historical characteristic of the genre.

NOVEMBER 2018 57

SHOWS

MEDICAL WORLD

‘CONSTELLATIONS’: A WORK INSPIRED IN THE CHANCE As of September 5, the citizens of Bogotá will be able to witness Constellations, a play written by Nick Payne, a young English playwright, and directed by Fabio Rubiano, renowned Colombian playwright, whose plot recreates, once after another, and with different results each time, the meeting between Marianne, quantum physicist, and Roland, beekeeper. The name of the work, inspired by the infinite number of combinations that emerge from the group of stars, alludes to the endless possible outcomes that arise from the encounter between the protagonist couple, interpreted by Marcela Mar, Angélica Blandón and the Mexican Humberto Busto. The piece of art has been presented successfully in London, Madrid, Mexico City, Montevideo, Santiago de Chile, Buenos Aires and, even, Broadway (New York), and will be offered for the first time at the District Planetarium of the World Capital Theater , with an auditorium apt for 340 spectators. Tickets are available in www.tuboleta.com y en www. planetariodebvogota.gov.co.

INTERNATIONAL MOTOR SHOW 2018 From November 7 to the 18 of the same month, the facilities of the Corferias fairground, located in the Colombian capital, will once again host the 2018 edition of the International Motor Show. It is nothing less than the specialized showcase of greater importance for the automotive sector throughout the country; a temple for the affections of automobiles, where visitors will find examples of models belonging to the most recognized brands worldwide, as well as the accessories and accessories of the best quality. The event not only brings together the community of fans of automotive products, also, because of the importance that this fair has claimed as a marketing opportunity, representatives of the main financial institutions of the market meet to spread the news of the sector. For more information, consult the www.salondelautomovil.com.

58 NOVEMBER 2018

‘SALSA AL PARQUE 2018’ Eliades Ochoa and his group Patria, Elito Revé and his Charangón, the Black Market orchestra and Gilberto Santa Rosa are some of the international artists confirmed in the poster of the 21st installment of the Salsa al Parque Festival, which will take place every day November 10 and 11 in the Simón Bolívar Metropolitan Park, Bogotá. This edition represents, as the poster points, “a perfect excuse for the meeting of the family salsera”, Well on stage will be presenting the best exponents of the genre, both on an international scale, with the names already mentioned, and on a national scale (Catorce Son Charanga, La Diferente, Las Guaracheras, Charanga La Nueva, Guapo Orchestra, La Cosmic Charanga, Pico Márquez and La Colombiana, Puerto Colombia Ensamble, Radio Bembé Orchestra and Salsa’s Bakatá). If you want to know more about the Salsa Park Festival, check the website www.salsaalparque.gov.co.