ISSN 2011-3579
VOL. 10 # 1 • MARCH 2017
HEALTH UPDATE Clinics, the medical act, returns to its rightful place | PAG. 8
HUMANIZED MEDICINE
Above all, a physician is an ethical communicator | PAG. 18
P&P
Psychoactive use Should prevention campaings be discontinuous? | PAG. 20
MBE
Increased hope and life quality ’Quo Vadis‘ pharmacology? | PAG. 24
Professor Ruedas’s hip transplant
Colombia’s number ‘10’ for excellence in orthopedics and trauma | PAG. 12 Unload the QR application reader in order to see
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Contenido 24 EBM Increased hope and life quality ‘Quo Vadis’ pharmacology? In order to produce useful and cost effective new medicines, research and development are required.
8 5 EDITORIAL Coomeva Medicina Prepagada Rises to the challenge of facing Colombia as a new world powerhouse in the area of healthcare tourism 6 MEDICAL ADVANCES
Brief notes on current events and medical innovation.
8 HEALTH UPDATE Essentials for an effective practice Clinics, the medical act, returns to its rightful place Doctors face decisions after the initial evaluation of the patient, and from the interpretation of these clinical findings stems health, disease and even death.
12 COVER Professor Ruedas’s hip transplant Colombia’s number ‘10’ for excellence in orthopedics and trauma The hip arthrosis the best soccer coach in the American continent had is common, despite what we might think. And also, his replacement surgery suggests that our country is at the vanguard in this field, with excellent professionals, such as doctor León Alberto Sardi, the leader of the specialist team that operated on the manager of Atlético Nacional soccer team.
28 MERITS
Jorge Zapata Builes
General Manager Coomeva Medicina Prepagada
CEM has been an innovative model for the past 15 years Some of the midterm goals are to strengthen the home health care model, while implementing new technologies and working also in other countries
31 COOMEVA
BY THE NUMBERS
32 RESEARCH REPORT
Clínica de Marly, the only Colombian institution within the American Donor Registry Colombia can now offer all alternatives for bone marrow transplants Finding compatibility in a direct identical family member, one with a 50% concordance or with a nonerelated donor within the American Donor Registry, has exponentially increased the probabilities of offering a second life chance to those whom are suffering from a lethal disease, such as acute leukemia, some types of lymphoma and even some benign blood illnesses; while, in the past, patients used to have only a 30% chance for getting these types of treatments. And this has been the goal of Unidad de Trasplantes de la Marly.
35 MEDICAL WORLD Specialties congresses, academic and profesional meetings, books and movies.
18 HUMANIZED MEDICINE The clue to the doctor patient relationship Above all, a physician is an ethical communicator In this world full of technology, doctors
Editorial board Pascual Estrada Garcés, MD National Health Director Martha Liliana Cifuentes National Coordinator of Relationships with Providers Bertha Lucía Varela, MD National Head of Medical Audits Julián Adolfo Villegas National Head of Health Risk Management Ana María Correa National Quality Auditor Marco Emilio Ocampo National Medical Auditor Juan Fernando Saavedra Natinal Head of Publicity and Marketing David Montes National Communications Coordinator
Editorial production and printing Legis S.A.
www.comunicaciongraficalegis.com
Av. El dorado No. 82-70 Tel.: (1) 416 1947 Facebook: impresoslegis Sales: María Cristina Arévalo Durán Cel.: 3112862724 maria.cristina.arevalo@gmail.com
should be capable of maintaining a good communication with the patient, trying to make everything as clear as possible.
March • 2017
20 PROMOTION & PREVENTION Psychoactive use Should prevention campaigns be discontinuous? It is urgent to implement definitive, sustained and effective prevention campaigns for alcohol and drug uses. Prevention starts at home, and should also involve the physician, one of the most credible professionals in our society, so he is considered an opinion leader.
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24 COVER PHOTOS: Jorge Mejía & Abel Cárdenas
Editorial
Coomeva Medicina Prepagada
Rises to the challenge of facing Colombia as a new world powerhouse in the area of healthcare tourism
O
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March • 2017
ur network of excellent in Colombia are among the 44 best hospitals, human rein Latin America (América Economía sources, hospitality, lomagazine), and 4 of them are within gistics, technology and the top 10 in the region. 2) The warmth quality attention has of the personnel involve in medical been working for the past five years, services. 3) The high quality hospitain an almost perfect synergy, so that lity. 4) And also, the affordable prizes. International Business Area of CooSo the cost-benefit ratio for users is meva Medicina Prepagada can now competitive: while a hip replacement show us positive numbers. More than in the United Sates used to cost in 10.000 people have received health2015 around 40.000 dollar, in Colomcare in our country, and they came bia only about 8.000. And dentistry, mainly from the Caribbean, Panama just to mention another example, and the United States. is also one of the cheapest, with a It’s not just us. Colombia has been acworld class quality, in some cases it knowledged by the media as a world is 75% lower, according to findings by powerhouse of the so-called healthCOOMTACTO magazine. So a Huffincare tourism. As a matter of fact, in gton Post article, humorously, publithe last Medical Tourism Index (MTI) shed that Americans can now receive based on data collected in 2016, healthcare services in countries like our country is second in the ranking Colombia without having to mortgage Jorge Alberto Zapata Builes of nations with the most developed General Manager Coomeva Medicina Prepagada the house again in order to pay for the healthcare tourism industry, making it treatments. the nation that receives the most foreigners in Latin AmeAnd we are proud to participate in the development of rica for these purposes. It is noteworthy that most of these the healthcare tourism industry in Colombia, while, at the patients arrive at Bogotá, Cali, Medellín, Barranquilla and same time, we acknowledge and appreciate the effort and Bucaramanga. And they have increased yearly, steadily, commitment of our allies, as well as the professionals we with a spike between 2012 and 2013, when it grew by a can lean on, together with the clinics and hospitals that 60%, generating a cool 216 million dollars. have invested heavily in special spaces in order to take There are four outstanding characteristics about Cocare of foreigners, with bilingual personnel, adequate lombia that for several publications make our country a transport and healthcare teams. worldwide powerhouse on healthcare tourism. 1) Good Coomeva will carry on. We are achieving the goals and quality services, with high level physicians and specialists objectives of our healthcare provider company, with our and researchers, as well as excellent hospitals. Consialready well-known commitment to high quality services, der, for instance, that 21 of the high complexity clinics giving the patient a most memorable experience.
MEDICAL ADVANCES RESEARCHERS CAN INHIBIT GLIOBLASTOMA CELL GROWTH
MUSIC COULD BE USEFUL IN EPILEPSY TEATMENTS
No doubt, glioblastoma is a challenging tumor. It is hard to treat for doctors because of its cellular heterogeneity. Despite that, a recent study by researchers at Peter O’Donnell Jr. Brain Institute and the Harold C. Simmons Comprehensive Cancer Center, in the United States, seem to have found a way to stop glioblastoma cellular growth. Mithramycine, a molecule frequently employed in chemotherapy infusions, acts on proteins that promote tumoral growth. It seems to inhibit three transcription factors linked to the glioblastoma proliferation, Sox2, Olig2 y Zeb1, and opens up the possibility of developing new therapies that could increases life expectancy of these patients.
For several years music has been considered useful in several treatments. Specialists at Ohio State University, in the United States, suggest it can be useful treating nervous system diseases like epilepsy. Research with electroencephalograms on 21 patients with seizures treated with music, compared with healthy people, suggest brain waves change while listening to music, as well as in silence. These patient’s brains react in different manners to musical stimuli, waves tend to synchronize with the melody they are hearing.
S O U R C E : A R T I C L E “ O N C O G E N E S A C T I VAT E A N A U T O N O M O U S TRANSCRIPTIONAL REGULATORY CIRCUIT THAT DRIVES GLIOBLASTOMA”, PUBLISHED IN CELL REPORTS. UNITED STATES. JANUARY 2017.
S O U R C E : ARTICLE “CAN MUSIC HELP PEOPLE WITH EPILEPSY? ”, PUBLISHED IN THE WEB PAGE OF THE AMERICAN PSYCHOLOGICAL ASSOCIATION. UNITED STATES. JANUARY 2017.
March • 2017
In the ongoing fight to develop new treatment strategies for tuberculosis, researchers at California University, in the United States, found a new pharmacological regime that could shorten time by up to 75%, reducing the risk of toxicity and resistance against these antimicrobials. This was achieved using data analysis that showed that certain drug combinations could be more potent than individual treatments. This new approach might offer advantages over the traditional strategies, lasting up to 6 or 8 months.
SOURCE: ARTICLE “DRUG REGIMENS IDENTIFIED AND OPTIMIZED BY OUTPUT-DRIVEN PLATFORM MARKEDLY REDUCE TUBERCULOSIS TREATMENT TIME?”, PUBLISHED IN NATURE. UNITED KINGDOM. JANUARY 2017.
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Fotos: ®2017 SHUTTERSTOCK PHOTOS
RESEARCHERS HAVE DEVELOPED A NEW TREATMENT FOR TUBERCULOSIS
THE IMPORTANCE OF PROPER DECISIONS BEFORE BREAST RECONSTRUCTION After the impact of the diagnosis, 30% to 50% of the breast cancer patients undergo a mastectomy, adding the anxiety of a surgical treatment. Even though, initially, reconstruction has psychological benefits for the patient, this is not always the case. So researchers at Departamento de Medicina y Cirugía from Facultad de Enfermería in Universidad Rovira i Virgili, in Spain, did a qualitative study on such aspects as the impact of the diagnosis, the information quality and the levels of satisfaction with the decision. They found that after completing the recovery from the surgery, new complaints emerged related to complications, such as pain. Also, the authors found the patients needed accurate and realistic information in order to decide. together with the treating physician. With free access to Internet, they are now able to learn more about the implications of the reconstructions, and are better equipped to make an informed decision.
SOURCE: ARTICLE “RECONSTRUCCIÓN INMEDIATA EN CÁNCER DE MAMA. ¿LAS MUJERES ESTÁN SATISFECHAS CON SU DECISIÓN?”, PUBLISHED IN PSICOONCOLOGÍA. SPAIN. JANUARY 2017.
Cardiac electrical activity is continually studied, because of its complexities. Researchers at Universidad Complutense, at Madrid, Spain, found that Tbx20 protein is not only active during the embryonic period of development, while it is involved in cardiogenesis, it also regulates cardiac electrical postnatal activity. This finding is also linked to the discovery of genes involved in the long QT syndrome in two generations of a Spanish family. Among these genes, Tbx20 mutations were linked to the anomaly, and cardiac arrhythmia development. This finding opens the possibility of developing new treatments. SOURCE: ARTICLE “TBX20 CONTROLS THE EXPRESSION OF THE KCNH2 GENE AND OF HERG CHANNELS”, PUBLISHED IN NATURE. UNITED KINGDOM. JANUARY 2017. AND IN PNAS. UNITED STATES. JANUARY 2017.
Doctors at Oregon State University, in the United States, arrived at this conclusion, and also found it might be a public health issue because the syndrome is usually linked to obesity. These results suggest that usual tests measuring vitamin E blood concentration could be of limited precision when compared with those employed in research facilities. By the same token, researchers also found that metabolic syndrome patients could need a 30% to 50% increase in their vitamin E intake more than healthy people. SOURCE: ARTICLE “ METABOLIC SYNDROME I N C R E A S E S D I E TA R Y A -T O C O P H E R O L REQUIREMENTS AS ASSESSED USING URINARY A N D P L A S M A V I TA M I N E C ATA B O L I T E S : A DOUBLE-BLIND, CROSSOVER CLINICAL TRIAL”, PUBLISHED IN THE AMERICAN JOURNAL O F C LI N I C A L N U T R ITI O N . U N IT ED S TAT ES . JANUARY 2017.
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NEW ELECTRICAL HEART SYSTEM STUDY
METABOLIC SYNDROME PATIENTS MIGHT HAVE A VITAMIN E DEFICIENCY
HEALTH
UPDATE
Essentials for an effective
March • 2017
Clinics, the medical act, returns to its rig
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practice
Doctors face decisions after the initial evaluation of the patient, and from the interpretation of these clinical findings stems health, disease and even death.
ghtful place
“There is no art as difficult as observation.” William Osler
TECHNOLOGY VS CLINICAL HABILITIES?
“There is no excuse for not practicing a good medicine”.
Fotos: ®2017 SHUTTERSTOCK PHOTOS
Today the best decisions in medical practice are based on clinical findings, technology, processes and management. But also, some pressing questions remain. Such as, how much
can people participate in the decision process? And, should there be equilibrium between their points of view, or should one of them prevail? These and other related issues were discussed at Clinical Decision Support Systems (CDSS). A dialogue between medicine, technology, processes and management, within a meeting organized by Elsevier Dialogues in November last year at Barcelona. There, European experts discussed the relevance of help systems in the clinical decision making process. While in Brazil, on the other hand, research is taking place on the implications of over diagnosis on clinical engineering. That country’s Medical Federal Council has issued warnings on the negative outcomes that indiscriminate use of biomedical technologies might have. The review of the literature showed that trying to make a precise diagnosis or to prematurely
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ince Hippocrates doctors have devoted their best efforts to benefit the patient’s life and wellbeing. And with the XXI century technology misdiagnosis, as well as treatment and procedures errors, seem impossible. But on occasions doctors and medicine are fallible. Despite the advances in all areas there are still diagnostic problems, insufficient treatments and interventions. Also, in our health care environment, processes and administrative tasks are unavoidable requirements in order to gain access to these services.
HEALTH
UPDATE
IN SEARCH OF THE MOMENTARILY LOST CLINICAL ABILITIES
March • 2017
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find the cause of a disease, tends to use more technological resources, increasing health care expenditure and, ultimately, affecting national health care policies. And now they are developing guidelines that favor both patients and insurers. Clinical engineering is aimed, among other things, at offering high quality and efficient services, with safety and low costs. None the less, globally, there has been an increase in health care services, while financial resources are limited, and, at the same time, medical technology is continuously developing. So, bioethics plays an ever more important role in determining what patients should receive. Which health care services are they entitled to, including desperate diagnostic tests and innocuous treatments. All these are very welcome ethical dilemmas. Also, besides this sort of debates, there is a discussion centered on the paradoxical lack of application of clinical skills during the medical act. An 10
issue that is sometimes justified by limited time, interfering with the possibility to establish an adequate doctor patient relationship, and ultimately the use of a medically sound clinical judgment. As a matter of fact, some people even argue that insurers and management are wholly responsible for limited time. But, be it long or short, doctors must be aware that well used clinical abilities are indispensable for an adequate diagnostic process, avoiding useless paraclinical tests, and providing an opportune treatment for the patient. A skilled clinician is efficient and accurate in his reasoning. A thought process that is acquired through years of training and experience in skills like diagnosis and treatment of patients. Experienced physicians tend to deduce in a non-analytical manner, mainly through a deductive hypothetical method. While at the same time the inexperienced doctor diagnoses predominantly using an analytic reasoning. So, experience does count.
edical education used to be based on memory, mainly on the accumulation of facts. But things have changed. Today it is oriented towards developing clinical abilities to solve ambiguous and indefinite problems. On building uncertainty tolerance and on decision making capabilities, even when information is incomplete. Peter Eldestein (Clinical Solutions Chief Medical Officer at Elsevier); Michael von Wagner (Medical Head of Centralized Patient Management, Frankfurt), John Rayner (Regional Director Europe and Latin America, HIMSS Analytics) and Patricia GĂłmez (Consellera de Salut del Govern de les Illes Balears), through the Elsevier dialogue, explained that every participant in the health care system could evaluate and build towards a future of a more balanced interaction between medicine, technology, processes and management. And they summed up their conclusions in these seven key points on the decision-making process in the clinical settings: 1. Variability is quality and service improvement worst enemy. 2. Clinical decision systems should be measured. 3. Clinical decision systems benefit and support clinical innovation. 4. Medical knowledge and technology transformed medical practice into a sort of digital medicine.
5. We should always be looking for new health care needs, both public and of the professionals that work within the system, as well as in other related areas. 6. New opportunities for innovation and improvement of the clinical decision making systems should be acknowledged, to lead changes, naturally, considering bioethical issues. 7. Investment should be wise and add on to previous efforts, while still changing old models. Finally, meeting these challenges requires synergies between health care professionals and other participants of the system. Also, physicians should be more knowledgeable, and, through their devotion to service, increase their adaptability to these changes: “so, there are no excuses not to practice good medicine”.
Medical students are taught while studying semiology to: • Find meaning to multiple clinical cases and examples. • Search and identify key elements within them. • Build conceptual maps the give “mental representations of clinical problems”. So, in the end, students will have at their disposal a basic set of references that allows them to acquire new knowledge. The challenge for the working doctor is to be more comfortable with his clinical expertise, the same clinical abilities taught laboriously by classical professors, together with the latest technology. The system, and particularly the patients, will be grateful.
REFERENCES:
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1) HTTPS://WWW.ELSEVIER.ES/CORP/CONECTA/DIALOGOS-ELSEVIER-7-CLAVES-LOS-SISTEMAS-AYUDA-LA-TOMA-DECISIONES-CLINICAS/ 2) SOBREDIAGNÓSTICO E SUAS IMPLICAÇÕES NA ENGENHARIA CLÍNICA / OVERDIAGNOSIS AND ITS IMPLICATIONS IN CLINICAL ENGINEERING / EL SOBREDIAGNÓSTICO Y SUS IMPLICACIONES EN LA INGENIERÍA CLÍNICA BY: FOTINI SANTOS, TOSCAS; FERNANDA, TOSCAS. IN: REVISTA BIOÉTICA. DEC 2015 23(3):535-541; BRASÍLIA: CONSELHO FEDERAL DE MEDICINA. 3) DESARROLLO DEL RAZONAMIENTO CLÍNICO EN MEDICINA.CLINICAL REASONING DEVELOPMENT IN MEDICINE. BY: GORMAZ BARDAVID, CLAUDIA; BRAILOVSKY, CARLOS. REVISTA DE DOCENCIA UNIVERSITARIA. SEP/OCT 2012 ESPECIAL, VOL. 10, P177-199. 23P 4) LA PROFESIÓN MÉDICA HOY: NUEVA LLAMADA DE LA TRADICIÓN HIPOCRÁTICA / MEDICAL PROFFESIONALISM TODAY: A NEW CALL FROM THE HIPPOCRATIC TRADITION BY: J. A., GIMÉNEZ MAS. IN: MEDIFAM. NOV 2002 12(9):49-58; MADRID: ARÁN EDICIONES, S. L. 5) (GMIE) GRUPO MÉDICO DE INVESTIGACIÓN Y EDICIÓN: EDUARDO GÓMEZ GUTIÉRREZ, MD/JAIRO HERNÁN ORTEGA ORTEGA, MD EGOMEZ1962@YAHOO.COM
COVER PAGE
Professor Ruedas’s hip transplant
Colombia’s number ‘10’ for excellence in
orthopedics and trauma The hip arthrosis the best soccer coach in the American continent had is common, despite what we might think. And also, his replacement surgery suggests that our country is at the vanguard in this field, with excellent professionals, such as doctor León Alberto Sardi, the leader of the specialist team that operated on the coach of Atlético Nacional soccer team.
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surgery, they now feel calm and grateful, with more reason to see who very soon could travel to Montevideo to receive the award as the ‘Best coach of America ‘. “He is in excellent condition”, says doctor Sardi, the orthopedist and traumatologist specialized in joint replacements, who lead the high complexity surgery that took place at Intelligent Operating Theater System from Centro Médico Imbanaco, in Cali, and to whom we spoke in order to learn more about this topic.
¿Doctor Sardi, what did it mean to you to operate on the best coach in the American continent, and to have half the world’s attention on your group and on the outcome of the procedure? No doubt, it was an additional pressure. Those situations are always stressing, because the media can blame you or make you a hero just as easily. It is a double edge sword. Fortunately we had a healthy patient to start with, and he was also disciplined
Photo: ABEL CÁRDENAS
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or an hour and forty minutes surgeons León Alberto Sardi and Mario Figueroa, as well as anesthesiologist Soledad Cartagena and their work group, were observed by everybody, not only in the sports world, but also at a national, continental and even worldwide level. Why? In their capable hands, relying on their precision and ability, lied the destiny of one of the most renown and loved Colombians: professor Reinaldo Rueda, Atlético Nacional’s head coach. It is the soccer team that was champion of Copa Libertadores de América in 2016 and also he was chosen the best coach in America in the same year. That was the estimated time that the surgery to replace the totality of the left hip was estimated to last for the coach from Valle del Cauca, whom has worked with several worldcup teams. Today, the medical part is not only very positive, but there is tranquility in those who have been on a daily basis the teacher from the day of the
PERFIL
HIS PASION? ORTHOPEDICS octor León Alberto Sardi is a physician with many human qualities: he is passionate about medicine, research and culture; and he is the proud father of an 18 year old woman. Despite his work requires a great deal of time, he is always able to enjoy his favorite hobbies: sailing and gastronomy, and seafood is his favorite. He graduated from the medical school at Universidad del Valle (Cali) and has been studying it ever since. Also he graduated from a Masters degree in public Health at Alabama University in Birmingham (United States). He was an orthopedics and traumatology resident at Universidad del Valle and at Alabama University, as well as a subspecialist in joint replacement and reconstructive surgery also from Alabama University. He has been a national and international lecturer, and was awarded Diploma de Honor de la Sociedad Colombiana de Ortopedia, for his outstanding orthopedics career and belongs to Coomeva’s Consejo de Administración Nacional, as well as to the editorial board of the journal of Sociedad Colombiana de Cirugía Ortopédica y Traumatología, and president of the hip and knee chapter of Sociedad Colombiana de Cirugía Ortopédica y Traumatología, among other activities. Also he has published several scientific papers in specialized journals, such as “Fracturas toracolumbares en Cali (Colombia)” in Revista Panamericana de Trauma and “Rehabilitación en el reemplazo total de cadera” in Revista Colombiana de Ortopedia y Traumatología, among others. He has also participated in several research projects, like “Diseño de un fijador interno transpedecular de columna toracolumbar” and “Diseño de un fijador externo para extremidades”, that were presented at Congreso de la Sociedad Colombiana de Ortopedia.
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Photos: JORGE MEJÍA
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Photo: CENTRO MÉDICO IMBANACO
COVER PAGE
At which time the team of specialists in orthopedics and trauma, Centro Médico Imbanaco, practices surgery to the soccer coach Reinaldo Rueda.
and careful. These characteristics improved the odds of success, in spite of the risks the surgery implies.
Was he your most famous patient? We have had politicians and other celebrities, but none of them of the magnitude of professor Rueda, and all that he represents.
March • 2017
What was professor Rueda’s precise diagnosis? He had a severe hip osteoartrosis of unknown origin. Perhaps years ago he had an acetabular clipping that evolved into an arthrosis. Generally speaking, these types of problems have primary and secondary causes. It is more common that what one would expect, maybe because of the increase in the population’s life expectancy, or the history of a previous 14
trauma or a congenital defect that evolved into an arthrosis or perhaps even a particular type autoimmune arthritis. Also overweight and obesity are factors that have influence within the population, because they increase the workload. And it is frequently seen it in elder patients, but it can also be found in young people, such as professor Rueda.
regain its mobility and normal function. Finally we repaired the muscles and tendons around the joint. This surgery is complex because it involves an area that carries a load and moves, so, biomechanically, prosthesis must be very well put in place.
How is the surgery done?
Professor Rueda left the hospital on January 15th, the rehabilitation started quickly. In the beginning, patients use a wheel chair, and a few weeks later they are able to even drive a car. Usually the recuperation takes around three months, that’s why I think he will soon be back in his sports life in good conditions.
The professor had a deteriorated hip joint, so we had to replace it completely. We removed the femoral head, it had no cartilage, and dissected that part together with the acetabulum. After that we installed the prosthesis (the implant) in the acetabulum and on the femur, in order that the hip would
How long does the rehabilitation take, when will we see professor Rueda again at the helm of his team, Atlético Nacional?
COVER PAGE
From the beginning the prognosis has been excellent. He is healthy, so probably he won’t have any troubles and, he also exercises, overall he is a disciplined man, he is also careful and follows instructions.
So Colombian medicine is advanced and has a unique human element? No doubt. In any city in Colombia there are professional groups capable of these types of surgeries. We also have many high level clinics that enable us to perform these types of operations on a regular basis. These procedures require high complexity institutions.
What is the success rate with these transplants? It is high, over 95%. And it depends on several factors, such as the patient’s age, if he is healthy, like professor Rueda, and his cooperation. The person must be aware that the replacement of a complete joint is a big and complex surgery.
For how long will he be limited or can he behave normally?
March • 2017
He can behave normally by now. He can drive, for instance, but there are some limitations. Impact exercises are inadequate. We recommend sports like golf, swimming and bicycling, for example. On the other hand, soccer and basketball are not recommended.
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A MULTIDISCIPLINARY TEAM
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multidisciplinary team is required for a high complexity surgery such as a total hip replacement. A working team that includes an orthopedist, an anesthesiologist, a surgeon, a trained physiotherapists, in order to quickly rehabilitate the patient. And in this case, the group is headed by doctor León Alberto Sardi, a physician graduated from Universidad del Valle (Cali, Colombia), magister in public health from Alabama University in Birmingham (United States). Also, these types of surgeries require a high complexity institution, such as Centro Médico Imbanaco, the institution where professor Reinaldo Rueda was operated in. It has smart operating rooms that allow the transmition of diagnostic images that can be integrated with prior studies and with those taken in the operating room. They even offer the possibility of transmitting live teleconferences with the auditoriums within the clinic or elsewhere in the world.
®2017 SHUTTERSTOCK PHOTOS
HUMANIZED MEDICINE
The clue to the doctor patient relationship
Above all, a physician is an ethical communicator In this world full of technology, doctors should be capable of maintaining a good communication with the patient, trying to make everything as clear as possible.
March • 2017
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aw 23 of 1981, dictates norms for medical ethics issues, not only does it establish that “doctor patient relationship is a primordial aspect of clinical practice”, but also says it is a successful activity if it is “based on a responsible, loyal and authentic commitment”. Juan Mendoza Vega, a neurosurgeon, as well as a member of Academia Nacional de Medicina and president of Fundación Pro Derecho a Morir Dignamente, explains it is a relationship based on “lex artis ad hoc, in other words, the good doctor has the patient as the main goal of his actions, it is about a person that puts his life, health and confidence in the physician´s hands in ways unlike any other professional”. 18
So communication is a fundamental aspect of the doctor patient relationship. It is an essential tool not only to transmit messages in search of a concrete response, says researcher David K. Berlo, it is also intended to change attitudes, and the patient will follow indications and treatments. That’s why doctor Anneliese Dörr, a psychologist at the medical faculty in Universidad de Chile, underlines the importance of “observing the gaze, verbal expression, physical contact and the instrumental relationship, as key elements of the doctor patient relationship”, in order for the physician and the patient to communicate “among them, one is the ‘ill person’ and the other ‘the person capable of technical services’; and both of them,
are ‘people’. But, unfortunately, that type of relationship has been compromised by several factors, explains doctor Carlos Alberto Calderón Ribero, president of Federación Diabetológica Colombiana and Fundación Colombiana de Diabetes, specially by excessive technology and administrative chores. On occasions, modern society advances, like informatics and social networks, become barriers instead of communication allies: “they require doctor to spend the patient’s time asking for documents and feeding them into the system, so he is incapable of listening properly, while the patient ends up feeling disgruntled, because, after all, he needs attention and help”, adds doctor Calderón.
EFFECTIVE COMMUNICATION STRATEGIES Let’s overview some key elements for a quality doctor patient communication, remember them and turn every moment in the consultation room into a success! 1. Confidence is key in the doctor patient relationship, starting with good bedside manners and the humanization principle, without regard of gender, race nor occupation. 2. Understand and apply communication principles like listening and receiving, listening and being listened to. 3. Devote enough time to the patient as per his needs. 4. Explain clearly the medical condition in a plain language, together with what he can expect from the
physician, the treatment and the future of the disease, recommends doctor Enrique Jiménez Hakim. The goal is to be as clear and honest as possible. Physicians should also forget about what doctor Mendoza Vega calls ‘mediqués’: the inadequate use of specialized language with technical terms. Otherwise it be a lost effort. 5. Understand verbal and non-verbal language, trying to figure out whether the patient is confused or embarrassed, and says nothing or does not ask questions. So ask if he understand the instructions, what did he understand and how is he going to do it. Try to clear all the doubts. 6. If it is a severe, chronic, degenerative or high cost disease, such as cancer, physicians are obliged to tell the truth to the patient, prudently and gently. Lying only makes the patient lose confidence, in the doctor and in medicine general. 7. Don’t forget, as Ortega y Gasset used to say, each person is “with his circumstances” and “life cannot be
HAY QUE ACTUAR DE WEINMEDIATO SHOULD ACT IMMEDIATELY
P I
ara evitar que la deavoid comun falta order to the nicación afecte el acto effects of commumédico, surgen difenication problems on rentes propuestas. El the medical act, there doctor Carlos Alberto are several alternatives. Calderón considera que Doctor Carlos Alberto son las sociedades Calderón considers méthat dicas científicas que scientific medicallas socie“deberían parar la mala práctica se da en el abordaje y manejo ties “should stoptoda all malpractice within que the doctor patient relationship”. del For paciente”. doctor Juan Mendoza Vega it is essential to work from the start, in Por sufaculties, parte, para el doctor Juan Mendoza tramedical but sadly not all of them do so,Vega, of thees60fundamental there are in our bajar desde dethese medicina, lastimosamente no todas, country, notlas all facultades are aware of needs.pero He insists on the usefulness of de las más de 60 que hay en el país, son conscientes de ello. Insiste en la informing. urgencia de informar. Meanwhile, neurosurgeon Enrique Jiménez Hakim underscores the Mientrasof tanto, el neurocirujano Enriquethe Jiménez Hakim resalta importance the environment. “Even though consultation room is notla importancia “Aunque el consultorio no lothat decoré concon ese decorated todel thatambiente. purpose, over the years I have learned patients fin, losataños he dado cuenta de losbeing pacientes muy feelcon more ease,me happy and thankful justque from there”,sehesienten says about tranquilos, contentos agradados estarand ahíperhaps sentados”, dice refiriéndohis own office. It is fully of presents,por details useless things for se a supeople, consultorio, regalos, detalles y cosastoque para otros son some but helleno feels de those objects give warmth his working space inservibles, pero parahis él le dan un toque with de calidez a su espacio de and allow him to que improve communication the patients. trabajo y le permiten romper el hielo con sus pacientes.
understood without taking these circumstances into account”. Consider the patient is not alone, he has a family and other surroundings; so, a dialogue should also be established with them. And, if they want, for instance, that their loved one doesn’t find out about the disease, explain to them that he has a right to know. 8. New laws and bioethics (20th century) imply that patients have the right to decide over themselves, and physicians are obliged to give them all the necessary information for them to do so properly. 9. Saint Augustin used to say humans always commit mistakes. If the doctor is wrong, he must be sufficiently professional to acknowledge the situation and communicate it. Errors are not bad, what’s wrong is to try to hide truths, blame somebody else or lie. 10. It is crucial to understand and adequately use the power and impact of social networks. But they do not substitute the medical act, the diagnostic procedures nor the prescription protocols. They could strengthen the doctor patient relationship, using them as communication strategies that promote health and prevent disease. It is necessary to be informed on the tendencies and ways of learning about the patients. Doctors should always be ready to solve questions, because on the Internet patients can find equally accurate and inaccurate facts, and need a trustworthy ally that will solve with them all sorts of doubts.
LECTURAS RECOMENDADAS 1. HTTP://WWW.ACTAMEDICACOLOMBIANA.COM/ANEXO/ ARTICULOS/03-1994-05-EL_ACTO_MEDICO.PDF 2. HTTP://WWW.ARCHIVOGENERAL.GOV.CO/SITES/ALL/ THEMES/NEVIA/PDF/TRANSPARENCIA/LEY_23_DE_1981. PDF 3. HTTP://PERSONAYBIOETICA.UNISABANA.EDU.CO/INDEX. PHP/PERSONAYBIOETICA/ARTICLE/VIEW/1687/2263 4. DÖRR A. ACERCA DE LA COMUNICACIÓN MÉDICO-PACIENTE DESDE UNA PERSPECTIVA HISTÓRICA Y ANTROPOLÓGICA. REVISTA MÉDICA DE CHILE 2004;132(11):1431-6. DISPONIBLE EN: HT TP:// W W W. SCIELO. CL /SCIELO. PHP?SCRIPT=SCI_ARTTEXT&PID=S0034-98872004001100 014&LNG=ES. [FECHA DE CONSULTA: 21 DE FEBRERO DE 2017]. 5. HTTPS://ES.SCRIBD.COM/DOC/30705951/DAVID-BERLO 6. HTTP://WWW.BIOETICAUNBOSQUE.EDU.CO/PUBLICACIONES/REVISTA/REVISTA14/ARTICULONELSONMOLINA.PDF 7. HTTP://PERSONAYBIOETICA.UNISABANA.EDU.CO/INDEX. PHP/PERSONAYBIOETICA/ARTICLE/VIEW/1687/2263
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March • 2017
And because of the loss of these communicational abilities, not only do diagnostic problems arise, but also unsatisfied patients increase and even medical malpractice risks augment.
PROMOTION
PREVENTION
Psychoactive use
Should prevention campaigns be discontinuous? It is urgent to implement definitive, sustained and effective prevention campaigns for alcohol and drug uses. Prevention starts at home, and should also involve the physician, one of the most credible professionals in our society, so he is considered an opinion leader. “Every addiction is bad, be it to drugs, alcohol, morphine or idealism.” March • 2017
Carl Jung
20
R
eal Academia Española dictionary defines ‘prevention’, in its second sense, as a “Preparation and disposition before hand in order to avoid risks or executing something”.
data by Informe mundial sobre las drogas 2015, by Oficina de las Naciones Unidas contra la Droga y el Delito (ONUDD). So, the problem is how to eradicate, for instance, the 200 thousand hectares that today are thought to be planted with coca in Colombia, a product that will ultimately be processed, distributed and eventually used as cocaine hydrochloride, out in the streets, pubs, discotheques, schools, universities and businesses, as well as at many homes? As an example, in order to make this point even clearer, suppose, just for discussion sake, that the Bogotá surface (1.587 km2 or 158.700 hectares) is completely planted with coca leaves. Now add 50 thousand more hectares, say 10 townships the size of Cajicá, all of them planted also with coca. This brings the point home that it is impossible to eradicate all illicit drugs, not only in Colombia, but all over the world. And in many occasions, the law doesn’t work the way we would like it to. Otherwise, how do we explain the recent and controversial sentence by Corte Constitucional2 that allows people to work under the influence of alcohol and other drugs? The Court says 21
March • 2017
®2017 SHUTTERSTOCK PHOTOS
By: Eduardo Gómez Gutiérrez, MD*
Sadly, there are so many adverse situations everyday in our country that ignore –and do not honor- such an academic definition. Most prevention campaigns focused on alcohol intake as well as psychoactive substances uses, intended to make the community aware of their undesirable effects, do not last. They appear and disappear rapidly; without a chance neither to achieve goals nor to evaluate their usefulness. Suffice to recall that great initiative that started in the end of 2008 by Dirección Nacional de Estupefacientes (DNE): “Do not harvest the plant that kills”. Then we found out to an article in Semana1 announcing it was taken out: “Corte Suprema de Justicia ordered the government to eliminate that publicity campaign against illicit crops based on a massage against all coca plants”. “The high Court made it clear that this message goes against the individual rights of the defendant, who sued in her condition of responsible of Coca Nasa, a small business that makes coca products, such as drinks and cookies”. Today, the situation is alarming in Colombia: 16% of the population are illicit drug users, while 87% are drinkers and 47% are smokers, according to
PROMOTION
PREVENTION
“moderate levels of drug use might not affect a workers capacity of performing certain activities, particularly simple and repetitive ones”.
THE LAWS IRONIES
B
ut how can a physician, be it a general practitioner or a specialist, practice legally with an altered conscience under the influence of alcohol or psychoactive drugs? Any way Corte Constitucional also ruled in favor of not punishing the personal dose. How can the weight be estimated, not only of what can legally be carried in the pocket, but also those drugs that are affecting the user’s brain? What could the ‘minimal brain dose’ be? According to law 1801 of 2016 is Código Nacional de Policía y Convivencia, that has been in place since January 30th 2017, “majors can authorize places for psychoactive drug usage at minimal dosage”. In accordance with this law, and “since the hardening of the prohibition of psychoactive substance intake in the new Código Nacional de Policía”, the major of Tuluá had the idea of building a public space in the township, a place that he named ‘marihuanodrome’. The project was quite controversial. It was considered a sort of state sponsored drug use program, that goes beyond what the law permits on the liberty of the recreational use drugs and the possibility to carrying as much as 20 grams of marihuana (an equivalent of 50 cigarettes!) as a personal dosage.
ACTIONS TOWARDS A MENTALITY CHANGE In Colombia very few campaigns survive for the prevention of alcohol and drug intake. There are very few exceptions that can grow and mature, that are responsible, serious and, above all effective. For instance, ‘La Verdad sobre las Drogas’, is a campaign designed by the american non-profit, Foundation for a Drug Free World. Thinking about cocaine, heroin, hallucinogens, marihuana, among many other psychoactive substances –natural or synthetic-, they are more live than ever in our country. And they make many people ill and even kill them everyday”. High costs involved in caring for thousands of alcohol and psychoactive drug abusers represent for EPS, prepaid medicine companies, IPA, insurers, ARL and for all the medical actors involved in the Colombian health care system, due to accident settlements, work absentees, permits, administrative workload, ambulatory consultations, emergency services, lab tests, diagnostic imaging, prescriptions, paraclinical support, intensive care units, trauma attention and wound care, surgeries, hospitalizations, deaths and repetitive treatment payments in rehabilitation centers. ONUDD presents us with scary world data: •
•
March • 2017
•
22
Two hundred and forty six million people used illicit drugs during 2013 (and the intake keeps increasing yearly). One in ten drug users are problematic, suffering disorders related to drug usage or drug dependence. Half of the problematic consumers (12,19 million people)
•
•
•
•
•
use injectable drugs, and it is estimated that 1,65 million of them were affected by HIV in 2013. A heavy burden on public health care systems in relation to prevention, treatment and attention to disorders related to drug usage and health consequences. The annual death number related to drug consumption (estimated in 187.100 in 2013) remains unchanged. An unacceptable number of drug consumers are still dying prematurely, often because of an overdose, in spite these are deaths that can be prevented. The number of people needing treatment for Cannabis is growing in most regions. The number of people needing treatment for amphemine-like stimulants is growing all over the world. New psychoactive substance proliferation to around 500,
• Non-lethal overdoses are frequent and not always reported. • Advances in Cannabis plant harvesting and the use of genetically selected strands has increased the productivity of the crops and increased the potency. When measuring the concentration of THC (Δ9-tetrahydrocannabinol, the main psychoactive ingredient in Cannabis), it has increased in many markets over the last ten years, increasing the health hazards. • Synthetic drug world market is still dominated by methamphetamine. • The total amphetamine-like stimulants seized by
•
•
authorities has practically doubled, it is wel lover 144 tons yearly (the highest level since ONUDD started keeping these statistics. A growing number of countries has notified the appearance of an increasing variety of psychoactive drugs, with troubling findings, such as an increased injected usage. Most new psychoactive substances are still synthetic cannabinoids (39%), phenethylamines (18%) and synthetic cathinones (15%). The growing number of available new psychoactive substances all over the world suggests that synthetic drugs are ever more varied.
PREVENTION IS THE GOAL!
•
•
• •
I
nforme mundial sobre las drogas concludes: “Everytime there are more studies suggesting that many interventions that intend to prevent the drug usage initiation, they can be effective in they take into account several aspects related with personal vulnerability, as well as children’s and young people’s environment, aspects that are not whole related to the person’s free will. So, the time has come for al physicians to start individually and as a group prevention campaigns against alcohol and psychoactive drugs, that will contribute even more to the peace in Colombia, starting with our patients right now in our offices and medical centers. Trying to maintain Hippocrates and Galen’s maxim: “Prevention is more important than curing”.
REFERENCES 1. SEMANA, 17 DE DICIEMBRE DE 2010. 2. CORTE CONSTITUCIONAL, SENTENCIA C-636 DE 2016, CONDICIONA EL NUMERAL 2 DEL ARTÍCULO 60 DEL CÓDIGO SUSTANTIVO DEL TRABAJO (CST), EL CUAL SE CENTRA EN LA PROHIBICIÓN PARA LOS TRABAJADORES DE PRESENTARSE A SU LUGAR DE TRABAJO EN ESTADO DE ALICORAMIENTO O BAJO LOS EFECTOS DE NARCÓTICOS. 3. CORTE CONSTITUCIONAL, SENTENCIA C-221 DE 1994. 4. LEY 1801 DE 2016, CÓDIGO NACIONAL DE POLICÍA Y CONVIVENCIA. 5. INFORME MUNDIAL SOBRE LAS DROGAS, DE LA OFICINA DE LAS NACIONES UNIDAS CONTRA LA DROGA Y EL DELITO (ONUDD) - (UNODC), 2015. 6. GRUPO MÉDICO DE INVESTIGACIÓN Y EDICIÓN (GMIE): EDUARDO GÓMEZ GUTIÉRREZ, MD - JAIRO HERNÁN ORTEGA ORTEGA, MD. EGOMEZ1962@YAHOO.COM * PHYSICIAN, WRITER, EDITOR AND ADDICTION EXPERT, CONTRIBUTOR TO FOUNDATION FOR A DRUG FREE WORLD.
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March • 2017
•
including mephedrone, is a menace for the health of drug users and has increase the need for the treatment for it. Cocaine is the most troubling in Latin America and the Caribbean, while opiate use it the most worrisome worldwide. T h e p o p u l at i o n ’ s p e rce p tion of drug user’s rehabilitation process tends to oversimplify la magnitude of the dependence. There is no quick or easy way to stop drug dependence. Affected people are vulnerable throughout their lives and require a continuous prolonged treatment. One in three consumers is a woman. The odds of consuming Cannabis, cocaine and amphetamines, is three times higher in men, while it is more probable that women misuse prescribed opiates and tranquilizers.
EBM
March • 2017
Increased hope and life qua
‘Quo Vadis’ pharmac 24
cology?
®2017 SHUTTERSTOCK PHOTOS
“There will always be unanswered questions. In general, these are the questions that haven’t been asked”. Linus Pauling
S
earch is an early stage that establishes if the studied molecule is active for the intended purpose. This phase also involves synthesis, the isolation of the molecule from the natural source or the production through biotechnology. Then follows the preclinical phase, it includes toxicological studies before testing it on humans, the product must be safe and effective. And this stage could last up to 6 years, depending on the type of molecule and the technological conditions. Then comes the drug development phase, involving the clinical trails and the pharmaceutical registry, a process that could, again, take up to 6 years and will always
be determined by the technological infrastructure and resources available in the country and within the laboratory working on the project. So, over a hundred million dollars are usually spent before a new medicine reaches the market. It is interesting, and even alarming, to muse on the fact that 1 in every 10,000 tested molecules reaches the development phase. And among them, 1 in 100,000 are clinically tested and registered, so in the end only 3 in 10 new drugs are profitable. Therefore new developments involve strict design rationality guidelines in order to ensure success and economical soundness. Developing medicines requires a huge effort of a high quality multidisciplinary group. 25
March • 2017
ality
In order to produce useful and cost effective new medicines, research and development are required
®2017 SHUTTERSTOCK PHOTOS
EBM
FROM THE MOLECULE TO THE PILL SUCCES IS BASED ON SAFETY AND EFFECTIVENESS
S
March • 2017
everal institutions intend safe, effective and successful medicines. The European Network for Health Technology Assessment (EUnetHTA) is a public collaborative network that forms an organization that evaluates health technologies within the European Union. In order to test new drugs they have developed methodological guidelines and common procedure standards that originated the HTA Core Model®. They also publish the therapeutic positioning report (TPR) on recently approved molecules for the market. As well as “Report on evidence synthesis: medicines” that comparatively evaluates pharmacological efficacy and safety, and then originates a TPR. By the same token, in most countries health care authorities have formed scientific and research ethics committees. All these initiatives are intended to ensure sound scientific criteria are being used, avoiding incidents, such as when in January 2016 media informed that during the clinical trails with the experimental drug BIA 10-2474, in Remmes (France), 5 healthy volunteers were hospitalized in grave health conditions, and 1 of them died. Reporters wondered, unjustifiably, if these adverse events were common.
26
Knowing the molecular basis of the disease or metabolic disorder allows researchers to design medicines using these same mechanisms to treat the pathology. If the molecular basis of the process is known, the involved molecules are identified, and medicines can be designed to intervene in those precise metabolic pathways in order to change, control and even cure the disease. Also to establish the molecular basis for the disease, normal physiology should be known in order to understand the abnormalities. The Human Gene Project is a progress in this field, offering a molecular reference. Despite the complexities, rigor and expense required to produce new medicines, when they are registered a detailed technical record is kept where detailed pharmacodynamical and pharmacokinetical information is
kept and made available to doctors and patients. There are several methods to find new lead or head compounds, and even their structural variations, such as starting with already known active products or the development of
new molecules through chemical synthesis and biotechnology. Both methods require carefully designed trials that allow researchers to establish, in a rapid and certain manner, the pharmacological behavior of these new molecules. When the head of
the series is defined, the whole series, including all the modulations of the chemical structure, are investigated in search of the best possible product, with the most activity and bioavailability, but also with the least toxicity and side effects.
It is interesting, and even alarming, to muse on the fact that 1 in every 10,000 tested molecules reaches the development phase. And among them, 1 in 100,000 get to be clinically tested and registered, so that in the end only 3 in 10 new drugs are profitable. Therefore new developments involve strict design rationality guidelines in order to ensure success and economical soundness.
U
niversities are forming more knowledgeable professionals, experts in pharmacology and basic sciences, in order to improve our understanding of medicines at molecular, cellular and genetical levels. And pharmacogenetics is the field that studies the genetical basis of individual variations in drug response. Several review articles have been published on inherited differences on drug metabolizing enzymes, just to mention one aspect of the importance of inheritance on the efficacy and toxicity of medicines in humans. Even though this is a young discipline, there are molecular diagnostic tests that allow doctors and pharmacologists to choose medicines and the doses for a particular patient. Pharmacogenetics is a way to get to tailor made treatments and future developments.
REFERENCES: 1) LA PÍLDORA DE LOS 800 MILLONES DE DÓLARES LA VERDAD SOBRE EL COSTO DE LAS NUEVAS DROGAS MERRILL GOOZNER ; TRANSLATION: ADRIANA DE HASSAN BY: GOOZNER, MERRILL. BOGOTÁ (COLOMBIA) GRUPO EDITORIAL NORMA 2005 [VOLUME 1] 2) METHODOLOGICAL GUIDELINE FOR THE EFFICACY AND SAFETY ASSESSMENT OF NEW PHARMACEUTICALS: IMPLEMENTATION OF EUNETHTA’S RECOMMENDATIONS BY UBAGO PÉREZ, RUTH; CASTILLO MUÑOZ, MARÍA AUXILIADORA; BANQUERI, MERCEDES GALVÁN; GARCÍA ESTEPA, RAÚL; ALFARO LARA, EVA ROCÍO; VEGA COCA, MARÍA DOLORES; BELTRÁN CALVO, CARMEN; MOLINA LÓPEZ, TERESA. IN GACETA SANITARIA. JUL 2016 3) CLINICAL DEVELOPMENT OF NEW DRUGS. SAFETY OF CLINICAL TRIALS IN HEALTHY VOLUNTEERS BY: DAL-RÉ, R.. MEDICINA CLINICA, 19 AUGUST 2016, 147(4):154-156 4) FARMACOGENÉTICA: MEDICINA PERSONALIZADA / PHARMACOGENETICS: PERSONALIZED MEDICINE BY: REINALDO, GUTIÉRREZ GUTIÉRREZ. IN: REVISTA CUBANA DE FARMACIA. DEC 2004 38(3):1-1; CIUDAD DE LA HABANA: EDITORIAL CIENCIAS MÉDICAS. 5) (GMIE) GRUPO MÉDICO DE INVESTIGACIÓN Y EDICIÓN: EDUARDO GÓMEZ GUTIÉRREZ, MD/JAIRO HERNÁN ORTEGA ORTEGA, MD. EGOMEZ1962@YAHOO.COM
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March • 2017
TOWARDS TAILOR MADE THERAPEUTICS
MERITS
CEM has been an innovative model for the past 15 years Some of the midterm goals are to strengthen the home health care model, while implementing new technologies and working also in other countries.
March • 2017
C
oomeva Emergencia Médica (CEM) has become a highly effective and innovative alternative since it was established 15 years ago, only in Cali in the beginning. And today it operates in Medellín, Bogotá, Barranquilla and Cartagena. Also it is a market reference on risk management in home health care that has been certified for 13 years now with norm ISO 9001. 28
It began with the goal of answering to the urgent needs of the population of accessing specialized health care at home and at the work place, “whether the internal triage of the service considers it an emergency, or not”, says doctor Hernán Darío Rodríguez Ortiz, CEM national head. An essential strategy responding in Colombia, and elsewhere, because it intends that home health care can contribute to reducing congestions at
the emergency networks, as well as in the general practice clinics, while decreasing costs. We have achieved this little by little, through serious and responsible work, as well as with the help of a great professional team. And the program has been so successful; it has become a leader in prehospital and home health care, with innovation, strengthening its network. “We offer services to users without additional costs. Such
A TEAM THAT WORKS A-OK!
T
his enterprise from Coomeva to Colombia outstands in it service model, its valuable human group, the technical quality, the high level of resolution because of its team and equipment, the follow up after attentions and the support for people with chronic pathologies, also the emergency home dental program in every city without an additional cost, and the technological development supporting the operation that makes communication easier with patients and families. The team working with CEM is lead by four heads at Dirección Nacional. In the cities each one has a team that varies according the number of users in the region. So each team is administrative, commercial and includes professionals offering health care services directly. We also have a national head quarter that directs and coordinates personnel and equipment requirements in order to answer to the needs of the patients nationwide.
as home emergency dentistry, telehealth, counseling by physicians, nurses, nutricionists and psychologists”, says doctor Rodríguez. For users affiliated to all the companies within our health care group, integrality makes efficient administrative tasks and patient remissions to hospitals when required. Overall within the CEM model all the population has been characterized, so all affiliates belong to some group with similar characteristics that could induce healthy or unhealthy behaviors. So in some groups of patients demand strategies have been developed through a prevention and education program, in order to contribute to the integral handling of disease and control of health risk. In order to work and achieve the goals within these groups we have physicians, nurses, nutritionists and psychologists that help us improve user’s health.
MERITS
Within our midterm plans we intend to work in other cities in the country, and even in other countries in the region
Groups that have been developed are: obesity, cardiovascular risk, mental health, chronic respiratory diseases, renal protection, diabetes type I and palliative care. Given the high impact mental Health problems have in our country, as shown by Encuesta Nacional de Salud Mental (ENSM 2015), by Pontificia Universidad Javeriana, Colciencias and Ministerio de Salud y Protección Social, presented in 2016. On average 10 out of 100 adults, among ages between 18 and 44 years, while in adolescents 12 in
100, have some sort of situation or problem that could suggest a mental disorder. So Coomeva Emergencia Médica has turned into a reference center for those with mental disorders, who do not know what to do or where to go. Today, “mental health disorders, in all their complexity, are among the most frequent cases in our service. Specifically, dementia, depression, anxiety and neurosis are the most common diagnosis, frequently among the lonely and ill elderly”, says the CEM director.
A POSITIVE BALANCE AT ALL LEVELS The director says the CEM activity balance over the past 15 years can be viewed in several ways:
March • 2017
• “From the point of view of Society, it creates 600 jobs in the country, with direct contracts and optimal working conditions, making it a reference for people working in prehospital care, medicine and safety, as well as work place health. It is also a low cost solution for users (below 40.000 pesos), with high satisfaction levels for most of them. Only in 2016 more than 270.000 attentions were given, with a steady increase in home dentistry services and telehealth.
30
By 2017, celebrating 15 years, there are big projects with improvements in operative centers, investment that strengthens the model, the implementation of new technological tools that will make our operation easier and improve communication channels with the users. Also, we expect to strengthen emergent products, such as home dentistry and telehealth, as well as Escuela de Formación y Entrenamiento CEM. “Within our midterm plans we intend to work in other cities in the country, and even in other countries in the region”.
• Since contributing to Sistema General de Seguridad Social en Salud (SGSSS), more than 240.000 personal attentions yearly have been given, while more than 30.000 by phone. These are major savings for SGSSS, because home health care avoids a considerable amount of attendances to the emergency network, with no cost for the system (user pays for the service). • From the entrepreneurial point of view, it is a profitable business that improves Grupo Empresarial Coomeva’s image, with an excellent future projection, and an ample service portfolio for different clients. CEM attention model is a reference within the market place in the cities it operates”.
COOMEVA
BY THE NUMBERS
PREPAID MEDICINE
Population Integral medicine December 2016 by gender 136.254
106.830
Program Gold Silver Young Gold plus Classical Special Traditional HCM Traditional Associates Silver Total
Integral medicine population December 2016
TOTAL 243.084 80 mil 70 mil COFFEE REGION
INTERNATIONAL
NORTHWESTERN
NORTHEASTERN
SOUTHWESTERN
30 mil 20 mil
CENTRALEASTERN
50 mil 40 mil
CARIBEAN
60 mil
50.272
31.168
9.595
32
68.580
5.766
77.671
10 mil
Specialist attendances January through December 2016 82.599
100 mil 80 mil
74.786
73.175
74.770
74.352
75.223
75.076
Population 163.054 45.216 10.839 5.991 5.479 4.606 4.087 2.195 1.617 243.084
TOTAL 880.850 77.452
73.665 70.532
57.136
72.084
60 mil 40 mil 20 mil JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
General practitioner attendances January through December 2016
NOVEMBER DECEMBER
TOTAL 172.932
25.856
30 mil 25 mil 20 mil
14.036
13.330
14.826
13.495
14.334
12.441
13.176
JULY
AUGUST
13.439
13.016
13.097 11.886
15 mil 10 mil 5 mil JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
SEPTEMBER
OCTOBER
NOVEMBER DECEMBER
TOTAL 1.053.782
Total January through December 2016 120 mil 108.455
100 mil 80 mil 60 mil
88.822
88.001
88.265
88.686
87.664
88.240
90.891
86.681
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
83.624
83.970
70.466
40 mil
JANUARY
FEBRUARY
NOVEMBER DECEMBER
31
March • 2017
20 mil
RESEARCH
REPORT
Clínica de Marly, the only Colombian institution within the American Donor Registry
Photos: GERARDO GÓMEZ
Colombia can now offer all alternatives for bone marrow transplants
March • 2017
Finding compatibility in a direct identical family member, one with a 50% concordance or with a none-related donor within the American Donor Registry, has exponentially increased the probabilities of offering a second life chance to those whom are suffering from a lethal disease, such as acute leukemia, some types of lymphoma and even some benign blood illnesses; while, in the past, patients used to have only a 30% chance for getting these types of treatments. And this has been the goal of Unidad de Trasplantes of Clínica de Marly. 32
So, today, the eligible population for hematopoietic cell allogeneic transplants has all the existing possibilities in the world to access a highly compatible donor. These are: • Identical direct family line donor, 100% compatible. • American Registry Donor, with over 90% compatibility, having similar results to those with total compatibility. • Haploidentical donor, another pioneering alternative offered at Clínica de Marly, involving 50% compatibility for a successful transplant with donors like the father, the mot h e r, t h e children or even a brother.
Doctor Enrique Pedraza Mesa, trained in internal medicine and clinical hematology, as well as the head of Unidad de Trasplantes of Clínica de Marly, says that reaching this level of performance is very difficult: “searching for international compatible donors that are willing to give their cells, and then to get them into our country and finally to the precise patient with leukemia or lymphoma, is a complex task. Around 40 quality requirements must be fulfilled”. So, it is very hard work. In 2016 Clínica de Marly performed 147 transplants: 81 of them were autologous and the rest were from unrelated donors, that is, from the American Donor Registry, haploidentical transplants (father, mother or brother) and from brothers who were 100% HLA identical. And because of this certification, the clinic has now been able to get stem cells from Germany, Poland, Israel, France, the United Kingdom and the United States.
“So we can now say Colombians have more than 25 million potential donors from Hispanic races, worldwide. A huge advance if we consider it is much harder for us to find donors than for Asian, for instance, because of our racial diversity” A COMPLEX PROCEDURE When a patient arrives at doctor Pedraza’s office –or at any of the other 10 specialists at Unidad de Trasplantes of Clínica de Marly-, for him to be considered for a stem cell transplant a detailed clinical history is taken. Then labs and other tests are rigorously performed, establishing the patient’s state and alternatives. 33
March • 2017
C
olombia is proud to have a hospital credited as a transplant center of the American Donor Registry (National Marrow Donor Program). It is a distinction only given to world class high complexity centers, and very few of them are located in Latin America. Five years ago, Clínica de Marly achieved this important goal making it a reference center for the whole country for bone marrow transplants.
RESEARCH
REPORT
Then the case is presented at a medical meeting where the adequate and opportune procedure is elected. The first choice is a direct donor transplant, sharing 10 out of 10 HLA markers with the patient, in other words, from a brother, for example. If this is not possible, a donor from the Registry or a haploidentical graft is selected. “For urgent cases this is a most adequate alternative, since getting a donor from the Registry and then importing the cells takes longer”, explains a clinic’s spokesperson. Such is the case of a 17 year old patient from Barrancabermeja with an acute leukemia –an example given by doctor Pedraza-, who was a single child, so he didn’t have the alternatives of 100% compatible donor, nor from the American Donor Registry. So he was transplanted from a 52 year old family donor with direct consanguinity, in other words, with 50% compatibility. And with this procedure, health was restored in the patient. “Haploidentical transplants have changed radically the life options for people in need of bone marrow transplants”, says doctor Pedraza.
While the patient is hospitalized at Unidad de Trasplantes of Clínica de Marly, and treated with intensive chemotherapy, donor stem cells are stimulated with an infusion of medicines through a subclavian catheter. When the procedure works, and there are no traces of malignant cells -this is called the ‘cero day’- hematopoietic cells are transplanted, also through an infusion using a subclavian catheter. This way the patient receives stem cells that will eventually start producing healthy white cells, red cells and platelets, This treatment usually last for 30 days. And during that time, the patient is under extreme care by a highly specialized team in an area offering all safety precautions, as well as asepsis, sterilization and ventilation. Unidad de Trasplantes of Clínica de Marly has the most advanced technology, and also one of the best blood banks in the country, perhaps in Latin America, together with certified ventilation filters and careful hygiene practices. All these elements led to the certification by the American Donor Registry. After the time has elapsed, and considering the response to the transplant and complementary therapies, the patient can then be declared free of leukemia, “and can return home to his usual life”, says the expert.
ALL THIS IS DONE IN ORDER TO MINIMALIZE THREATS
March • 2017
There are always complications, especially with haploidentical transplants. So we asked doctor Pedraza how is the 50% missing compatibility accounted for? And he answers clearly: “there are always risks involved in transplants; they are neither magical nor miraculous”. The mortality rate of bone marrow transplants is around
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10 to 20%. “The goal is to keep it below 10%. That’s why we are comparable worldwide. The transplant unit is an intensive care unit, offering all possible alternatives to minimize risks. Complications can be immunological, such as a primary failure of the graft or a graft disease, but there are also infections and febrile neutropenia. Doctor Pedraza explains that even though the allogeneic transplant with a direct donor 10 out of 10 has the least risk, the other alternatives, thanks to technological and pharmacological advances, have comparable risks, in other words, they tend to have much less adverse effects. “That’s why we are able to choose among them. Always the cost benefit ratio should be taken into account”, he continues. After almost 25 years as head of the team at Unidad de Trasplantes of Clínica de Marly, doctor Pedraza is keen to say that Colombia is privileged because we can offer treatment alternatives to most people in need of it, without discrimination. “It is time to acknowledge the health care system and the EPS’s missions: they have done everything in order to make this a reality for us. Patients cared for in this unit are sent here by EPSs, not because they are rich enough to pay for the treatment, and, by the way, it is a very expensive treatment”, says the expert. Also, this project would be impossible without the participation and commitment of a highly qualified interdisciplinary team that works together in order to succeed in each treatment. Very especially we would like to consider the psychoncologists: “we are a humanist group that cares for the mental health and spirituality of the patients. Psychologists are fundamental for our good results. It has been proven that a good part depends on the attitude and the mental state of the patient and his family”, concludes doctor Enrique Pedraza.
MEDICAL
WORLD
EVENTS
‘WORLD CONGRESS ON MATERNAL FETAL NEONATAL MEDICINE’ Date and place: April 24th through 26th, London, England Information: MCA Scientific Events Phone number: (39) 0234934404 E mail: info@worldmfnm.eu Web page: www.mcascientificevents.eu/worldmfnm2017/
3RD INTERNATIONAL CONGRESS OF THE LATIN FEDERATION OF GYNECOLOGIC ENDOCRINOLOGY
XVII INTERNATIONAL SYMPSIUM ON PEDIATRIC PNEUMOLOGY AND ALLERGY Date and place: April 28th through 29th, Cartagena Information: Clínica Respiratoria y de Alergias Phone number: (5) 6628620 - 6745182 E mail: simposio@clinialergias.com Web page: www.clinialergias.com
Date and place: April 6th through 8th, Cartagena Information: Sociedad Colombiana de Cirugía Ortopédica y Traumatología (SCCOT) Phone number: (1) 6257445 E mail: secretaria@sccot.org.co Web page: www.sccot.org
III INTERNATIONAL CONGRESS ON CLINICAL INGENEERING Date and place: May 15th through 18th, Medellín Information: Congreso Internacional de Ingeniería Clínica E mail: info@coniic.com Web page: www.coniic.com
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March • 2017
INTERNATIONAL CONGRESS ON ARTHROSCOPY, SOCCER AND SPORTS MEDICINE
Date and place: May 4th through 6th, Santiago de Chile (Chile) Information: Federación Latina de Endocrinología Ginecológica E mail: fleg@socheg.cl Web page: www.fleg2017.cl
MEDICAL
WORLD
EVENTS 62ND SCCOT NATIONAL CONGRESS Date and place: May 10th through 13th, Cartagena Information: Sociedad Colombiana de Cirugía Ortopédica y Traumatología (SCCOT) Phone number: (1) 625 7445 E mail: secretaria@sccot.org.co Web page: www.sccot.org
37TH COLOMBIAN CONGRESS ON LABOR MEDICINE AND OCCUPATIONAL HEALTH Date and place: May 17th through 19th, Bogotá Information: Sociedad Colombiana de Medicina del Trabajo Phone number: (1) 622 0120 - 622 4916 E mail: scmt14@outlook.com Web page: www.medicinadeltrabajo.org
XXXV ANNUAL MEETING OF LATINAMERICAN DERMATOLOGISTS Date and place: May 26th through 29th, Bogotá Cartagena Information: RADLA Phone number: (34) 913 612 600 E mail: radla2017@kenes.com Web page: www.radla2017.com
11° NATIONAL CONGRESS ON CRITICAL MEDICINE AND INTENSIVE CARE, 8° NATIONAL CONGRESS ON PEDIATRIC CRITICAL MEDICINE AND INTENSIVE CARE, 2° NATIONAL CONGRESS ON CRITICAL NURSING AND 2° NATIONAL CONGRESS ON THERAPY AND REHABILITATION OF THE CRITICAL PATIENT Date and place: May 25th through 27th, Medellín Information: Asociación Colombiana de Medicina Crítica y Cuidado Intensivo Phone number: (1) 215 0990 E mail: registro@comunicacionesefectivas.zendesk.com Web page: www.amci.org.co/congreso2017
March • 2017
VIII INTERNATIONAL SYMPOSIUM ON IMMUNETHERAPY AND BIOLOGICAL MEDICINE Date and place: May 20th through 21th, Mexico City (Mexico) Information: Sonamex E mail: cmatadamas@sonamex.com Web page: www.facebook.com/events/222297954817826/ 36
BOOKS EXPLICIT CONTENTS MEDITATION WITH COLORS Author: Ingrid Kraaz von Rohr
Authors: Luïsa Garcia-Esteve and Manuel Valdés Miyar
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his practical hand book is directed to family doctors, psychologist, psychiatrists and specialists in materno-fetal medicine, based on the importance of integral knowledge of the clinical aspects of neurodevelopmental biology, with a particular emphasis on the need for perinatal mental health units. It also includes the main disorders that could affect the pregnant woman and other issues related to stress and infant development. There is also a section on pharmacological and psychological treatments of anxiety, depression, bipolar and psychotic disorders.
C
Author: T Gregory Walker
T
he demanding clinical and technical skills required to be a interventionist radiologist have been intimidating to residents and other doctors, so this textbook explains specific interventions, including their indications and contraindications, as well as the clinical and image pre-procedure evaluation, including the medication and required equipment. This book is divided into six sections in order to discuss all interventionist vascular and non vascular procedures.
olors offer a simple and powerful body, mind and soul healing tool. To meditate with colors acts directly on energy centers that will connect the physical and the astral body, in order to restore the equilibrium of non harmonic frequencies causing diseases and other alterations. This book describes the effect and significance of the most important colors, while offering meditation guidelines and tools. The reader will immediately recognize which color he needs to start the healing process.
T
his is an interesting book that assembles three novels exploring the North American culture, without reserves it shows us the most complex and ignored details. Shotgun Zen is a desolate portrait set in the southern Texas desert. It narrates Carter Atwood’s violent story, a peasant fleeing law enforcement together with Floyd, his autistic brother. And, on the other hand, Mojave Flowers follows Lester Ramsey’s footsteps. A thug the catholic decency legion entrusts with getting back a scandalous script in the 1930s Hollywood, where censorship and debauchery compete to control the streets.
OVUM BANK
Author: Javier Nadal Pereña
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ecently an increasing need to research assisted reproductive techniques has emerged. And this book is a guide that, among other things, is a state of the art on human reproduction, oocyte banks, their legal and ethical issues, as well as their organization. It also touches other topics, like donor and receptor genetics in order to identify monogenetic diseases, improving their odds.
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March • 2017
PERINATAL PSYCHIATRY MANUAL
IMAGE DIAGNOSIS. INTERVENTIONIST PROCEDURES
Author: Juan Sebastián Gaviria
MEDICAL
WORLD
MUSIC MOVIES
‘FIRE IN THE OCEAN’ Director: Gianfranco Rosi Cast: Samuele Pucillo, Pietro Bartolo and Giuseppe Fragapane
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his Oscar nominated movie is a metaphor of the lives
of thousands of refugees searching peace, freedom and happiness. As they go through the easy town of Lampedusa, the lives of its 6,000 inhabitants changes after witnessing and rescuing them from tragedy. This film is a winner of the Golden Bear award in Berlin, more than a simple movie it is an urgent call to make these voices heard.
‘VOLUME 11’ Andrés Calamaro
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t last the Argentinean singer and composer fans will be able to get his new record, loaded with rock and intense lyrics about life and death, according to the declarations given by Calamaro himself. The 18 song contained in Volume 11 bring a history full of emotions, including singles such as Rock y Juventud, Atunes y Ballenas, El Huevo y la Gallina, Apocalipsis en Malasaña and Almas Agradecidas.
‘THE AFTERLOVE’ James Blunt
A ‘FRANTZ’ Director: François Ozon Cast: Pierre Niney, Paula Beer, Cyrielle Clair, Johann von Bülow, Marie Gruber, Ernst Stötzner and Anton von Lucke
I
March • 2017
n a small German town after the First World War, Anna visits everyday Frantz’s grave. He was her fiancé, but died in combat. Until one day she notices Adrien, an old French solder mysteriously taking flowers to Franz’s grave. This enigmatic presence, while Germany has been defeated, will question her about the past and the true events of war.
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fter Moon Landing, this new production is the fifth album the world known British singer and composer launches, with hit songs such as You’re Beautiful and Goodbye My Lover. For this new record Blunt worked with stars like Ed Sheeran, who wrote several tracks, Ryan Tedder, Amy Wadge and Johnny McDaid. Among the songs included in The Afterlove we can find Love Me Better, Lose My Number, California, Paradise, Heartbeat and Someone Singing Alone.
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