COOMTACTO VOL.9-4 (Versión en Inglés)

ISSN 2011-357 9

A MAGAZINE FOR COOMEVA MEDICINA PREPAGADA HEALTH CARE PROFESSIONAL VOL. 9 # 4 • DECEMBER 2016

HEALTH UPDATE

Nanotechnology: the medical revolution | PAG. 8

P P

Oral care prevents systemic diseases | PAG. 20

EBM

Alzheimer’s disease: some memories are lost but not the feelings | PAG. 26

Hernán Alfonso Urbina Joiro:

MEDICINE AND ART | PÁG. 14

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A MAGAZINE FOR THE HEALTH CARE PROFESSIONALS WORKING WITH COOMEVA MEDICINA PREPAGADA

TENEMOS LA FÓRMULA

QUE ASEGURA TU TRANQUILIDAD

RC MÉDICA COOMEVA En Coomeva conocemos y entendemos los riesgos a los que estás expuesto, por eso te protegemos con nuestra Póliza RC Médica.

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Contents 30 MERITS His priorities are children and research His contribution to the wellbeing of women, particularly to adolescent mothers and their children, as well as several acknowledgements, are part of Doctor Julio César Reina’s world in pediatrics and the prevention of cervical uterine cancer caused by human papiloma virus.

Pascual Estrada Garcés, MD National Health Director

Changing views on menopause

5

EDITORIAL

6 MEDICAL ADVANCES Alzheimer’s disease: some memories are lost but not the feelings.

8 HEALTH UPDATE Nanotechnology: the medical revolution Biosensors, nanorobots and nanomedicines, is a new and promising era, still to be researched.

14 COVER

Hernán Alfonso Urbina Jorio: Medicine and art “To grow in a small town at La Guajira, where people’s ingenuity stimulated my curiosity while listening to roosters at dawn and seeing cayenne flowers all over the place helped me solve questions about life itself.” That’s how Doctor Urbina says it, and he is a poet and a rheumatologist.

General Manager Coomeva Medicina Prepagada

Editorial board

32 RESEARCH INTERVIEW

8

Jorge Zapata Builes

Gynecologist Martha Marrugo Flórez, awarded by Federeción Latinoamericana de Sociedades de Climaterio y Menopausia, is a research advocate and a teacher that benefits women. She headed the elaboration and publication of the Colombian consensus on menopause, a key guideline for doctors.

Martha Liliana Cifuentes National Coordinator of Relationships with the Health Care Professionals Bertha Lucía Varela, MD National Head of Medical Audit Julián Adolfo Villegas National Head of Medical Audit Ana María Correa National Quality Auditor

38 FROM COOMEVA

Virtual provider office: discover our new online services!

Marco Emilio Ocampo National Medical Auditor

We intended to keep on improving our communication with our health care provider network, so Coomeva Medicina Prepagada has developed strategies to strengthen our interactions with health care professionals working with us, looking for benefits for all, that will also improve services with higher standards in technological and human quality for the users.

Juan Fernando Saavedra National Head of Publicity and Marketing David Montes National Communications Coordinator

Editorial production and printing Legis S.A.

39 MEDICAL WORLD Specialty meetings, academic and professional events, books, music and movies.

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

20 PROMOTION & PREVENTION

Oral care prevents systemic diseases

The Massachusetts Medical Society reported it is important to consider oral health as an essential part of general health in order to offer an integral attention to the patients, preventing and improving systemic diseases.

December • 2016

26 EBM Alzheimer’s disease: some memories are lost but not the feelings More than 46 million people worldwide will have Alzheimer’s disease, while initial signals are subtle, usually attributed to normal aging. It is important to consult and adequately treat these patients, because their emotions are still intact.

26

Front page picture: Gerardo Gómez

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Editorial

2016 HAS BEEN A YEAR of outstanding moments for Coomeva Medicina Prepagada

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Diciembre • 2016

A

s the year’s end is clo3. Service model. We consoliser we want to reflect dated our service model duon the positive and ring 2016. The associate is the s at i s f a c t o r y t h i n gs protagonist, and health risk that have happened management is perhaps one to us, and, therefore, benefit our of our main value offers. To affiliates. Important achievements achieve this, we lean on comwithin our innovative philosophy petitive and competent collaof a continuous search of exceborators whose goal is to offer llence, as well as our commitment experienced services that can to improve the services we offer, be positively remembered afthat’s why we have formed a famiterwards. Still, we are committed ly, an excellent team. But also, this to working so that our affiliates implies higher goals for next year, can always smile, because they 2017. So, let’s ponder on some of know they can count on the best these aspects: possible services in one place, 1. Christus Health, 1 of the 10 with excellence, leading to the most relevant heath care syshighest life quality. tems in the United States has 4. Organization updating. We chosen us as its strategic ally Jorge Alberto Zapata Builes started a technological upwithin its growth program in General manager Coomeva Medicina Prepagada dating program with the Latin America. It makes us implementation of CORE proud they have recognized us as being “highly project. The point is to update the operative platcommitted with offering the best health care serform as well as the information flow, optimizing vices” for our affiliates and our associates, as Ernie processes with a new software that improves Sadau, Christus Health CEO said, referring to this access channels to our services through the Interimportant alliance. A joint venture that benefits net and monitor, using follow up tools, the search Grupo Empresarial Cooperativo Coomeva as well of information that will make us more competitive, as the national health care system and also the solving the needs of our interest groups. whole country for that matter.

5. Iberoamerican quality price. Coomeva was awar2. Providers activities model. Our value proded gold by Premio Iberoamericano de la Caliposal offering our users the highest quality dad 2016 in Empresa Privada category, because health care solutions are a standard, making of our “excellence in organizational performance”. our service providers of utmost importanAn award we received officially on October 28th ce to us. And that’s why we started an ambiwithin the XI Encuentro Empresarial, part of the tious actualization and strengthening project XXV Cumbre Iberoamericana de Jefes de Estado y of our relationship model. We intend to imde Gobierno, at Cartagena. And we would like to prove our relationship models with our provishare it with the whole Coomeva family. ders, acknowledging their perceptions about Our achievements would have been impossible Coomeva Medicina Prepagada, finding out about without the excellence and committed performance their perceptions on our processes, while also of our health care professionals and institutions; and allowing us to share with them the language of we wish to make a note of our joy for that collaboraexcellence, satisfaction, and loyalty to our health tion and rejoice for being able to celebrate yet another care professional values and principles.

Christmas with you all.

MEDICAL

DEVELOPMENTS

PEOPLE WITH ACNE MIGHT BE LESS PRONE TO RAPID SKIN AGING

Photos: ®2016 SHUTTERSTOCK PHOTOS

For many, acne represents major skin damage. However, a recent paper from King’s College in London suggests that dermal cells of people whom have had acne tend to be less prone to rapid aging. According to Simone Ribero, a dermatologist and the lead researcher, this finding could be linked to the telomere length in these cells, perhaps making them more durable before they die and are replaced, and this might explain why tend to wrinkle less.

SOURCE: ARTICLE “ACNE AND TELOMERE LENGTH. A NEW SPECTRUM BETWEEN SENESCENCE AND APOPTOSIS PATHWAYS”, PUBLISHED IN THE JOURNAL OF INVESTIGATIVE DERMATOLOGY. HOLAND. SEPTEMBER 2016.

A NEW APPLICATION TRACKS PATIENT HEMOGLOBIN LEVELS

PARENTS WITH MENTAL DESORDERS TEND TO HAVE SUICIDAL CHILDREN

In order to diagnose many diseases, doctors measure hemoglobin levels extracting blood samples. A group of electronic engineers at Washington University, in the United States, have recently developed HemaApp: an application that uses the cell phone camera to calculate the hemoglobin levels in order to estimate if the patient has an anemia. Initial tests in 31 people showed it works as well as Masimo Pronto, the most expensive medical device of this sort approved by the FDA, even though it also measures non invasively hemoglobin levels by placing a sensor on the tip of the finger. HemaApp sheds the light from the cell phone flash on to the finger while it analyses the chromatic characteristics in order to establish the hemoglobin level.

December • 2016

A recent publication by Manchester University, in the UK, links parents with mental diagnosis and adolescents, over 15 years, with aggressive conducts and suicidal behavior. Researchers analyzed data belonging to 1,743,525 people whose parents had had a psychiatric disorder. And they found 2.6% of them had suicidal attempts at a mean age of 21.6 years, and 3.2% had committed their first violent act by 20.6 years. Also, the association with the parent’s disorder was firmer when the diagnosis was antisocial personality disorder, Cannabis use and parental suicidal attempts.

SOURCE: ARTICLE “PARENTAL PSYCHIATRIC DISEASE AND RISKS OF ATTEMPTED SUICIDE AND VIOLENT CRIMINAL OFFENDING IN OFFSPRING: A POPULATION BASED COHORT STUDY”, PUBLISHED IN THE JOURNAL OF THE AMERICA MEDICAL ASSOCIATION. UNITED STATES. OCTUBER 2016.

SOURCE: ARTICLE “HEMAAPP SCREENS FOR ANEMIA, BLOOD CONDITIONS WITHOUT NEEDLE STICKS”, PUBLISHED AT WASHINGTON UNIVERSITY WEB PAGE. UNITED STATES. SEPTEMBER 2016.

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BLOOD VESSELS CAN BE GROWN IN THE LABORATORY

Blood vessel formation within the body has been one of the greatest challenges for bioengineering. However, biomedical engineers at Minnesota University, in the United States, harvested blood vessels that were obtained in the laboratory and then grafted to lambs. These vessels were obtained from postnatal skin donors, and they were extracted soon afterwards, in order to avoid a rejection immunological reaction to the grafted tissue. If this technique works in humans it could drastically reduce the number of surgeries, like in the case of children with congenital heart defects.

A MEDICINE COULD TREAT ALZHEIMER’S DISEASE In a research paper, scientists from Zurich University, Switzerland, found data suggesting it is possible to reduce type β amyloid protein plaques linked to Alzheimer’s disease, perhaps reducing the patient’s cognitive deterioration.

These proteins are found in the brain, but with the use of this medicine, made up of human antibodies, the accumulation could be reduced. Even though this was a lab research in rats, these findings suggest this could be a therapeutic alternative with great potential on the long term.

SOURCE: ARTICLE “ALZHEIMER’S DISEASE: ATTACK ON AMYLOID-B PROTEIN”, PUBLISHED IN NATURE. UNITED STATES. AUGUST 2016.

PREGNANCY NAUSEA MIGHT PROTECT AGAINST ABORTIONS

S O U R C E : ARTICLE “TISSUE ENGINEERING OF ACELLULAR VASCULAR GRAFTS CAPABLE OF SOMATIC GROWTH IN YOUNG LAMBS”, PUBLISHED IN NATURE .

UNITED STATES. SEPTEMBER 2016.

SOURCE : ARTICLE “ASSOCIATION OF NAUSEA AND VOMITING DURING PREGNANCY WITH PREGNANCY LOSS: A SECONDARY ANALYSIS OF A RANDOMIZED CLINICAL TRIAL”, PUBLISHED IN JAMA . UNITED STATES. SEPTEMBER 2016.

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Diciembre • 2016

In spite pregnant women consider nausea probably the worst symptom they have to withstand; it might be good news, suggest the findings of researchers at the Children Health and Human Development Eunice Kennedy Shriver, in the United States. As a matter of fact this condition could be linked to a decrease in the abortion risk. 797 women were included in this investigation. The patients wrote down their daily symptoms associated with the ongoing pregnancy, including nausea and vomit. By the eighth week 57.3% had nausea, while only 26.6% vomited; also among those who had these symptoms 50% to 75% had lesser abortion risk and only 188 ended in an involuntary abortion. This research included all signs from the time of conception, and suggests th protective effect against fetal loss.

HEALTH UPDATE

December • 2016

NANOTECHNOLO THE MEDICAL REVOLUT 8 A MAGAZINE FOR THE HEALTH CARE PROFESSIONALS WORKING WITH COOMEVA MEDICINA PREPAGADA

BIOSENSORS, NANOROBOTS AND NANOMEDICINES IS A NEW AND PROMISING ERA, STILL TO BE RESEARCHED.

ION

Photos: ®2016 SHUTTERSTOCK PHOTOS

GY:

60 years”, says the fully informed and elated expert.

Coincidently, the 2016 chemistry Nobel Price was awarded to 3 researchers “for molecular machine design and synthesis” at a nano scale, so this machines are even smaller than a human’s hair, and have very promising uses.

French chemist Jean-Pierre Sauvage, at Straburgh University, in France, the Scottish Sir James Fraser Stoddart, at Evanston Northwestern University, in the United States, and the dutch Bernard Lucas Feringa, from Groninga University, in Holland, whom, according to the Science Academy from Sweden, have participated in the development of molecules with controllable movements “so the technology of miniaturization can be quite revolutionary”.

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Diciembre • 2016

S

ince 1958, when Colombian researcher Jorge Reynolds and his team created the first external artificial pacemaker with internal electrodes, a machine that weighed around 50 kilograms, it was made up with tubes and a car battery, things are very different up to today scientific and technological revolution.

So much so that doctor Reynolds has in his hands right now the new pacemaker that is going to be implanted soon in a person. He has been working on it at his laboratory at Fundación Clínica Shaio, in Bogotá. “I weighs around 8 tenths of a gram and its size is about a fourth a rice grain, also it will be controlled by the doctor from his cell phone. This shows us how electronics and miniaturization have evolved over the past

HEALTH UPDATE A WIDE RANGE OF APPLICATIONS Nanotechnology is the development of devices of a nanometer size, that is a billionth of a meter, that have a wide range of applications for industry, environment, military and health care.

Doctor Marcos López, PhD, head of Grupo de Investigación Biomédica Traslacional at Fundación Cardiovascular de Colombia, in Floridablanca (Santander), explains: “since the nanotechnology boom started, many Latin-American countries, including Colombia, started applied research on the topic. All it applications can be used in medicine, as a matter of fact it has been already used in oncology. Probably, during this decade, the benefits of years of research can be used for to help patients in diagnosis, treatment, monitoring and the cure of diseases”, he acknowledges.

Radiology and invasive radiology are the two areas closest to benefiting from nanoparticle design like

diagnostic images and multifunctional nanoparticles that contribute to the detection, intelligent treatment and directed to tumors.

In the clinical laboratory new nanotechnologies can improve molecular diagnostic. “Biotechnology use of nanopores to sequence DNA is going

LET’S TALK ABOUT MEDICINES

December • 2016

H

igh hopes are set on the possibility of affecting the very sensitive field of medicines with the development of therapeutic agents (pharmacological and biopharmacological, with capsules or absorbed, such as nanodrugs, intended have a controlled liberation or in a specific part of the body.

“These ‘nanotaxies’ improve encapsulated drug solubility, prevent their chemical and biological degradation, decreases secondary effects, it makes the nanoparticle’s surface functional in order to impact directly on affected areas and the compatibility with biodegradables and non-toxics”, says doctor Marcos López.

At a research level, Fundación Cardiovascular pioneers the synthesis of nanofibers made out of biocompatible polymers. “A decade ago we created a patch out of nanofibers that liberated nitric oxide used in the treatment of diabetic ulcers and cutaneous leishmaniosis. Today we can find new surgical adhesives and hemostatics made up of biocompatible nanofibers thanks to a project totally supported by Colciencias 700-2014 grant for ColombiaBio, with

which we created Centro de Producción de Nanofibras y Nanomateriales”.

“With Colciencias grant 745-2016 doctor Víctor Castillo Mantilla FCV president, and a senior researcher and director of Grupo de Bioingeniería, preapproved a project to build elements that liberate chlorine dioxide from nanofibers to sterilize in health institution. We hope this nanotechnologies will be implemented very soon in our institution”, adds doctor López.

On the other hand, researchers Abraham Faustino Vega and Carlos Tomás Quirino Barreda in an article titled “Nanomedicina y biomimetismo”, published in Mundo Nano, a journal belonging to Universidad Nacional Autónoma de México, underscores nanodrug’s benefits, even though “there are many obstacles that nanoparticles must overcome before being able to liberate the drug in the target size”.

They must ensure characteristics like biocompatibility, the capability to liberate the medicine in a controlled manner in the right place, while avoiding the action of the immune system, all these are subjects of intense research.

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HEALTH UPDATE to be an innovation”, doctor López adds.

With autoimmune diseases, such as multiple sclerosis, “modulatory biodegradable nanoparticles design to affect the immune system so that it doesn’t attack the myelin cover of the nervous system, and, in order to treat lupus, a nanogel has been developed that can alter the celular shape within the immune system”, complements the specialist from Fundación Cardiovascular de Colombia, in the east of the country.

The advent of nanotechnology has an unlimited future, according to experts. In the field of oral health “resins have been manufactured at a nano scale that can be used in dental esthetical restoration; nanocompounds for inorganic fillings to the creation of artificial teeth that are more longing than acrylic and Microfill, also with more resistance to abrasion, and dental creams have been created with carbonate nanoparticles favoring mineralization of early defects in the enamel”.

We are in a revolutionary field, even though, and specialists agree, we are lacking research and to establish what happens with relatively toxic nanoparticles.

So it is worthwhile to remember Doctor Martha Elena Londoño’s words, she is a researcher at Escuela de Ingeniería de Antioquia, at Medellín, that in an editorial in the journal Biomédica, of the Instituto Nacional de Salud, se says: “even though a great deal is still to be sorted out, issues like safety for the patient and toxicological aspects, as well as ethical and regulatory elements, the fascinating world of nanomedicine is developing rapidly. Many and varied clinical phase researches are success stories and a good many of them have already been patented, so, as we anticipated, the XXI century will be dominated by nanotechnology and nanomedicine, promising benefits for humanity in the near future”.

ADVANCES IN ONCOLOGY

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or Doctor Jorge Reynolds, “with nanorobotics and elements around one hundredth the size of a red blood cell it is possible, for instance, to locate a tumoral cell, absorb it and neutralize it in such a way that they can be eliminated via the kidneys. So, probably, this is going to be one of the therapeutic alternatives to be used soon”.

Most advances are found in oncology. At Fundación Cardiovascular de Colombia liposomal oncological formulations have been employed in patient treatment. “For instance, certain cancer drugs, like liposomal doxorubicine or Doxil, are nanodrugs with more than 30 years of approval by the Food and Drug Administration, FDA, in the United States, and it is used regularly around the world, even in our country”, explains doctor López.

This nanodrugs works much the same as normal drugs, while reducing secondary side effects like cardiotoxicity.

Using the same concept, other antitumoral drugs have been functionalized as nanodrugs based on liposomes. Such as liposomal daunomicine for several blood neoplasias and liposomal vincristine sulphates for acute lymphoblastic leukemia.

For HIV there are researches on more efficient nanosuspensions and nanodrugs that diliver antivirals. Nanodrugs and nanoparticles are being developed, in order to make them safer and more effective.

REFERENCES AND RECOMMENDED READINGS 1. FOLADORI G, INVERNIZZI N. IMPLICACIONES SOCIALES Y AMBIENTALES DEL DESARROLLO DE LAS NANOTECNOLOGÍAS EN AMÉRICA LATINA Y EL CARIBE. ZACATECAS, CURITIBA: RELANS-IPEN; 2012.

2. PASTRANA HF, ÁVILA A, MORENO G. NANOTECNOLOGÍA, PATENTES Y LA SITUACIÓN EN AMÉRICA LATINA. MUNDO NANO 2012;5(9).

3. HTTP://WWW.REVISTABIOMEDICA.ORG/INDEX.PHP/BIOMEDICA/ARTICLE/VIEW/3143/2958 4. HTTP://WWW.NATIONALGEOGRAPHIC.COM.ES/CIENCIA/ACTUALIDAD/PREMIO-NOBEL-QUIMI -CA-2016-DESARROLLO-MAQUINAS-MOLECULARES_10757 5. HTTP://WWW.REVISTAS.UNAM.MX/INDEX.PHP/NANO/ARTICLE/VIEWFILE/49708/44712 6. HTTP://WWW.NIH.GOV/SCIENCE/NANOTECHNOLOGY/ 7. HTTP://WWW.ESF.ORG/HOME.HTML 8. BOISSEAU P, LOUBATON B. NANOMEDICINE, NANOTECHNOLOGY IN MEDICINE. 2011.

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COVER

HERNÁN ALFONSO URBINA JOIRO:

MEDICINE AND ART

“TO GROW IN A SMALL TOWN AT LA GUAJIRA, WHERE PEOPLE’S INGENUITY STIMULATED MY CURIOSITY WHILE LISTENING TO ROOSTERS AT DAWN AND SEEING CAYENNE FLOWERS ALL OVER THE PLACE HELPED ME SOLVE QUESTIONS ABOUT LIFE ITSELF”. THAT’S HOW DOCTOR URBINA SAYS IT, HE A IS POET AND A RHEUMATOLOGIST.

December • 2016

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octor Hernán Alfonso Urbina Joiro is a combination of composer, researcher, journalist and doctor, he is a well respected internist and a rheumatologist. His social, artistic and humanist interests enrich his life.

Thinking that we all –even though we might not accomplish it- tend to work in areas that help us solve our own existential questions, for instance, “who am I?”, “why am I here?”, “what is happiness?”, in his case it was “to grow in a small town at La Guajira, where people’s ingenuity stimulated my curiosity while listening to the roosters at dawn and seeing cayenne flower all over the place”. One morning a teacher showed us a hen, she wanted to teach us about domestic birds, and I asked her why they raised their heads in order to drink water; she answered me, with a smile that increased even more my desire to learn, “perhaps to thank god”.

When he was 10, he continued his personal search in vallenatos’ lyrics, like “he who cries now, if he suffers

patiently, may sing tomorrow”, this is a verse from a very popular song by Máximo Movil. Doctor Urbina wrote lyrics and melodies, and recited them towards heaven and birds… “As a matter of fact, once the primary school principle caught me reciting to flowers, I was already sick of Gabriel Mistral’s teachings, and that was my school’s name, ‘the good planter, plants singing’ (Pensamientos, 1925). I do still sing silently to flowers!”.

WHEN DID YOU DECIDE TO BECOME A DOCTOR? It occurred to me at high school.

Even though I was a distinguished poet (1977), because of a poem I composed to the Virgin Mary, and in December of that same year I won at Festival Nacional de Compositores Vallenatos, I think my medical inclination is related to my close friendship with the biology teacher, Gabriel Estrada, and especially with Moisés Fontalvo, because they got me interested in human biology. One day I got a little red book in a drug store, and over the months, I learned all the names and other details

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PERFIL

AN ARTIST ALL AROUND

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Diciembre • 2016

Photos: GERARDO GÓMEZ

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ernán Alfonso Urbina was born in Valledupar, Colombia. Ever since he was a kid his passions have been journalism, vallenato and composing, as well as research. And for the past 16 years he has lived in Cartagena with his daughter, “it is the town that has blessed me, and I hope to bless it with all I do”. He graduated from the medical school of Colegio Mayor de Nuestra Señora del Rosario, in Bogotá, and specialized in internal medicine at Hospital Militar de Bogotá and in rheumatology at Instituto Nacional Salvador Zuburán, at UNAM in Mexico.

He has received several medical awards and has also published fictions and articles in news papers, as well as in national and international journals. In 2006, for instance, he was awarded ‘Homenaje Nacional’ at Festival Nacional de Compositores Vallenatos for his humanitarian trajectory over the past 30 years. Some of the titles of his short stories are, Ocurrirá, Vuelo y Novum Gestum; among his essays outstand, Lirica Vallenata and En la Era de Caduceo de Mercurio. Also, his most notorious musical compostions are Mis Tristezas, La Última Palabra, Nuestro Amor, Locamente Enamorado, Muñeca de Piel Canela and Canción de la Despedida. Not to mention Tú Eres la Reina and Hija, songs that were recorded by Diomedes Díaz.

COVER of the medicines by hard. So for me it was just a matter of time to get into medical school.

Later on, during the second semester at Universidad del Rosario, perhaps because of my closeness with the head of Immunology, doctor Jorge León, I became fascinated with antibodies and immune cells. They were even capable of turning against the body from one moment to the next. Then I met a systemic lupus erythematosus patient three semesters later, and since then I have been studying rheumtology.

AND HOW ABOUT RESEARCH? Yes, I started in 1991 formal medical research, when I was studying internal medicine. I chose the topic in part because I had hypertense relatives, and also a friend, Doctor Eduardo Arredondo, had told me about a paper that suggested a relationship between insulin and hypertension. So I read Doctor Gerald Reaven’s articles on X syndrome and got his bibliography. And also circumstances helped me, at Hospital Militar there was a well organized hypertension program and

the head of the medical department was knowledgeable on the topic, Doctor Hernán Torres, he helped me get the necessary elements to measure blood insulin in the patients.

AND WHAT’S THE SIGNIFICANCE OF THAT COMBINATION OF MEDICINE AND ART

December • 2016

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started understanding in 1983. At that time, the Rosario medical faculty was still at Hospital de San José, and in those cloudy days, not only because of Bogotá’s climate, but because of the internal shadows of my doubts of whether to quit poetry and music, I found light. I went to a medical history class with doctor Juan Mendoza Vega. Only seeing him and listening to him showed me I was with someone like nobody else. He told us, how great authors and other artist had been crucial for medical development. He also taught us medicine is an art, so I concluded there was no need for me to forget about art, I could integrate it with medicine.

If I hadn’t been introduced to that that I call ‘the inclination to the human aspect of life’ (book Humanidad Ahora), probably, I would have never have become the doctor I am right now, nor the writer I am or the satisfied man I am. Still, as a medical student, in 1989, I was elected as the best vallenato composer in a press and critics vote. But I insist, one of the best indicators of having done things the right way as a poet and a musician is that patients thank me, and sometimes recite my verses, ocasionally with tears in their eyes.

And so it was the first and biggest case control research in Latin-American that showed a strong correlation between insulin levels and blood pressure, as well as an increase in the incidence of cardiovascular complications. This paper was awarded with Mejor Trabajo Científico del XII Congreso de Medicina Interna (1992).

I had worked in this project for two years with Raúl Villanueva, my partner at the internal medicine residence.

In 1991 I had also named this ailment caused by insulin resistance, dismetabolia, and today it is called metabolic syndrome.

Additionally by 1991 I wanted to explore the possibility of developing monoclonal antibodies and synthetic peptides designed to block several aspects of different phases of rheumatoid arthritis. With those plans in mind, in 1993 I was admitted at Instituto de Inmunología, headed by Doctor Manuel Elkin Patarroyo, where I then published the paper “Monoclonal antibodies and synthetic peptides: a new strategy for rheumatoid arthritis”. And that same year I was awarded Premio de la Asociación Colombiana de

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COVER

December • 2016

Medicina Interna y Laboratorios Synthesis for the best Colombian scientific project. But this project withered away because of lacking funds.

Later, in February 1994, I traveled to Mexico to specialize in rheumatology, and also with the hope to carry it on over there. Anyway, years later, biological therapy with monoclonal antibodies directed against several elements in different rheumatoid arthritis phases would emerge, even though a vaccine with synthetic peptides has not yet been developed, as I proposed in 1993.

In Mexico I published several papers in the best journals in the rheumatologic world, with the help of doctors Mario Cardiel and Julio Granados, my teachers at Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubarán. Then I returned full of projects back to Colombia in 1996. Almost as I got off the plane they said to me: “it can’t be done, there is no budget”. While, on the other hand, I never understood why there was so much money available for symposiums, a Greek word that originally means parties with company and drinks.

ONE MORNING A TEACHER SHOWED US A HEN, SHE WANTED TO TEACH US ABOUT DOMESTIC BIRDS, AND I ASKED HER WHY THEY RAISED THEIR HEADS IN ORDER TO DRINK WATER; SHE ANSWERED ME, WITH A SMILE THAT INCREASED EVEN MORE MY DESIRE TO LEARN, “PERHAPS TO THANK GOD”.

REFLECTIONS ON RHEUMATIC DISEASES

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here are around 150 rheumatologists in Colombia. According to several investigations, profound changes are taking place in our immunity after eradicating, fortunately, parasites like helminthes. This is a relationship described by Luis Caballero, a doctor from Cartagena.

Perhaps this is due to the fact that these parasites induce ‘a needed immune suppression’ due to lymphocytes T in order to live with humans, and as they disappear lymphocyte activity increases against our own bodies, causing in the genetically predisposed several allergies and autoimmune diseases. Of course, the solution is not to load ourselves all over again with helminths and other parasites, but to develop that million-year-old ‘natural immune suppression’, possibly through selected helminth antigens.

Other factors, such as overweight, are also related to increasing rheumatoid disease incidence, like knee arthrosis. There are more than 150 different ailments, all very uncomfortable, but they can be modified profoundly and rapidly.

But that was also an opportunity. While tending to my patients in Bogotá, I started publishing in news papers, like El Tiempo , El Heraldo , Vanguardia Liberal, El Universal. I also founded two magazines, Romanceros and Reumatismo , and started a research in history that ended taking me

to Archivo General de Indias in Seville, Spain: I wanted to examine XVI century papers in order to publish the first India Catalina biography.

Recently, I have begun researching again on medical subjects, this time with Fundación Humanidad Ahora, www.humanidadahora.org.

An organization I head, and it is dedicated to urgent topics like electronic trash and the health impact of mercury intake through seafood in urban areas.

Perhaps it is difficult to impose only one research topic on someone who is always looking, in each of his activities, trying to link man with his thought and feeling. He is devoted patient care, not so much to his personal economical gains nor the pharmaceutical industry’s; he is dedicated to finding the singularity in each case, as a suffering person. It is difficult to demand just one research topic to someone, whom even as a child, learned to speak with flowers and hens!

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PROMOTION

PREVENTION

ORAL CARE PREVENTS

SYSTEMIC DISEASES THE MASSACHUSETTS MEDICAL SOCIETY REPORTED IT IS IMPORTANT TO CONSIDER ORAL HEALTH AS AN ESENTIAL PART OF GENERAL HEALTH IN ORDER TO OFFER AN INTEGRAL ATTENTION TO THE PATIENTS, PREVENTING AND IMPROVING SYSTEMIC DISEASES.

December • 2016

T

he oral cavity is one of the mycrobiomas of the human body. A healthy mouth could contain near to 600 different types of bacteria and other microorganisms.

Also Human Mycrombioma is a scientific project, explained by Joshua Lederber as “the communal, symbiotic and pathologic microorganism ecological community that share our body space, and that have been ignored as important elements of health and disease”. Oral mycrobioma represents 26%, and knowing it is fundamental to the study, prevention and treatment of diseases.

Oral flora can be altered with the presence of opportunistic bacteria that alter essential characteristic and contribute to a complex organization, adhering to dental surfaces and adjacent tissues, promoting the growth of

colonies in the form of biofilm, initiating pathologies, such as dental cavities and periodontal disease, gingivitis and periodontitis.

PERIODONTAL DISEASE Periodontal disease is one of the most common mouth diseases worldwide and one of the main causes of dental loss. Gingivitis is the mild presentation, and it is caused by the accumulation of dental plaque, the biofilm, adjacent to the gums, the gingival tissue. While in the more severe form is periodontitis, considered an infectious and inflammatory disease, caused by various infectious agents, characterized by the destruction of connective tissue and the bone support until teeth are lost. It is also related to environmental and genetic risk factors, such as smoking and stress. Periodontitis increases with

age, it is more prevalent in men and it is more common in underprivileged communities.

Its main cause is the presence of pathogen bacteria that has been researched for the past 40 years in vitro and in vivo . Near 50 bacterial species are linked to periodontal disease. The most common are: Aggregatibacter (Actinobacillus), Porphyromonas

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inflammatory response because of antigen antibody reaction and complement activity. Pathogen lipolysacharid as well as other virulence factors, such as proteases, lipases, toxins, etc., generate molecular cellular changes in the fibroblasts, epithelial cells and alveolar bone, producing proinflammatory mediators, like interleukin 1, tumoral necrosis factor alfa, E2 prostaglandin, RANK-L expression in TCD4 lymphocytes with alterations in the expression of metaloproteinases in the matrix MMP 1, 2 and 3, among others, destroying the dental support tissue.

gingivalis, Tannerella forsythia and Tr e p o n e m a d e n t i c o l a , a m o n g others. Also Pseudomonas and Acinetobacter, β -hemolitic Streptococcus, Staphylococcus y Candida, have been identified in these lesions, as well as virus, like herpes.

Bacteria unleash an inflammatory response that affects epithelial and connective tissue, as well as the periodontal ligament and the alveolar

bone. If the inflammation advances and ulcers can form in the gingival sulcus or periodontal sacs, that increase the immune response and through different mechanisms pathogen bacteria and their products enter the body affecting the general condition of the patient. These mechanisms can be direct access of the pathogen to the blood stream, endotoxin and lipolysacharid liberation, and the increases

The relationship between dentistry and medicine has been debated during for several decades around the concept of al localized infection.

The pathogenesis of periodontal disease has attracted attention to this relationship to the general health of the patient. In the 1996 International Workshop, Steven Offenbacher used for the first time the term ‘periodontal medicine’ as “the discipline that studies associations between periodontal disease and systemic illnesses, as well as its biological plausibility animal models and in humans”.

For several years now researches have been suggesting that periodontal disease is an independent risk factor for ailments such osteoporosis, diabetes mellitus, pulmonary infections, premature birth, low birth weight, cardiovascular diseases, rheumatoid arthritis, pancreas cancer chronic renal failure, neurodegenerative conditions and metabolic syndrome.

Evidence suggests that in periodontitis, an infectious disease caused by gram negatives, anaerobes and facultative anaerobes, could cause other diseases either because bacteria pass into the blood stream or because of an increase of inflammatory mediators in response to lipopolysacharides in the in the bacterial wall. Identified inflammatory mediators include PGE2, TNF-α, IL-1, IL-6, which are 21

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PERIODONTITIS AND SYSTEMIC CONDITIONS

PROMOTION

PREVENTION

common in systemic diseases, such as infectious, immune and chronic.

This new ideas change the traditional conception of oral pathogens and opportunists, in health and in sickness, and also suggest the convenience of handling it with an interdisciplinary group of doctors and dentists, in order to broaden the spectrum of therapeutic alternatives and also to learn more.

Different mechanisms initially proposed by Offenbacher included: • Bacteremia, bacterial pass or of its into the blood stream, and the systemic circulatory system, through periodontal sacks ulcered walls.

• Colonization and infection of the lower respiratory tract in patients with predisposing factors, mainly direct aspiration.

progestins. By pregnancy end progestin levels are multiplied 10 fold and estrogens 20 fold compared to normal menstrual periods. Periodontal sacs act as deposits for the traslocation of gram negatives, such as Porphyromonas gingivalis, Prevotella intermedia y F. nucleatum, and their products can reach the placenta through the blood stream.

Bacterial plaque control with a good dental hygiene is very important during pregnancy. Gestational vascular and hormonal changes increase tissue response to bacterial plaque presence and to periodontal disease. And even though periodontal treatment helps and lowers risks because it is an infectious chronic disease.

December • 2016

PERIODONTITIS AND PREGNANCY It has been suggested that the inflammatory response increases in the presence of periodontal pathology, and that could affect the chorioamnionic membrane and cross the placental barrier, increasing the risk of complications during pregnancy, such as preeclampsia, premature birth and low birth weight. Even though there is significant evidence, there are also many confounding variables that make it difficult to establish a firm and constant association. In spite of that, treating periodontal disease in pregnant women reduces the risk of obstetric complications, and, on the other hand, these complications are more common in pregnant women with periodontal disease.

An inflammatory state is present in preeclampsia with an increase in cytokine production, such as IL-1β, IL-6, TNF-α TNF-a and C reactive protein, elements related to untreated infections.

Inflammatory mediator shared with periodontal disease, and could exacerbate immune responses which could be risk factors for these complications.

Anaerobic biofilm, especially of Prevotella intermedia, is linked to increased serum levels of estrogens and 22 A MAGAZINE FOR THE HEALTH CARE PROFESSIONALS WORKING WITH COOMEVA MEDICINA PREPAGADA

CARDIOVASCULAR DISEASE Because of its chronic condition, periodontitis has also been related to vascular endothelium alterations and to systemic arterial hypertension, acute myocardial infarction and cerebrovascular event, among other ailments.

Patients with periodontitis and artheriosclerosis could have an increased risk because of their increased IL-6 and RCP concentrations found in patients with cerebrovascular events, as well as positive endotoxins from bacteria, mainly P. gingivalis.

After treating the periodontal disease a decrease in these markers has been documented, including a reduced expression of E-selectin. Evidence suggests periodontitis is a risk factor for cerebrovascular events. And worldwide periodontal has been included as a preventive strategy. In the last guidelines by European Society of Cardiology on heart disease prevention in the clinical practice, published in the European Heart Journal, periodontitis is linked to endothelial disfunction, atherosclerosis and an increased risk of myocardial infarction, and it also puts periodontitis together with other know risk factors for cerebrovascular events.

DIABETES The association with periodontitis is bidirectional: diabetes exacerbates periodontal disease, while periodontal disease is linked to diabetes and the glycemic control. This relationship is probably due to increased cytokines

that exacerbate the inflammatory response to pathogens and alter the capacity to resolve inflammation and to repair, increasing periodontal support tissue destruction, through glycosylation on receptors on cellular surface due to hyperglycemia.

It has been established that periodontitis can initiate and increase insulin resistance through a chronic increase in immune response activating cytokines.

International Diabetes Federation (IDF 2009) recommends dental care for diabetic patients, and to teach them about the importance of healthy gums, consulting alterations or bleeding to the dentist, in order to treat

GINGIVITIS IS THE MILD PRESENTATION, AND IT IS CAUSED BY THE ACCUMULATION OF DENTAL PLAQUE, THE BIOFILM, ADJACENT TO THE GUMS, THE GINGIVAL TISSUE. WHILE IN THE MORE SEVERE FORM IS PERIODONTITIS, CONSIDERED AN INFECTIOUS AND INFLAMMATORY DISEASE, CAUSED

BY VARIOUS INFECTIOUS AGENTS, CHARACTERIZED

BY THE DESTRUCTION OF CONNECTIVE TISSUE AND THE BONE SUPPORT UNTIL TEETH ARE LOST.

them adequately and prevent periodontal disease and its implications on diabetes.

ARTHRITIS Rheumatoid arthritis and periodontitis share characteristics: they are chronic inflammatory diseases with genetic and environmental influences, immunoregulatory alterations and in their progression both destroy structures, such as connective tissue and bone.

Their natural history and pathogenesis are similar, they are related to immunegenetic factor, with cellular infiltrate and increased enzyme and cytokine activity.

Periodontal pathogens unleash periodontal tissue chronic inflammation that exacerbate or initiate rheumatoid arthritis. Bacterial DNA has been identified in synovial fluid, and rheumatoid factor and anticitrulinic peptide antibodies expression. P. gingivalis has been observed in the citrulation process, and it is considered a link between periodontal disease and rheumatoid arthritis.

In spite of research a connection has not been established where patients with rheumatoid arthritis have an increased risk of having periodontal disease, nor that treating periodontal disease decreases rheumatic activity.

PROMOTION

PREVENTION

IMPACT OF PERIODONTAL DISEASE IN THE POPULATION

December • 2016

The American Academy of Periodontology (AAP) and European Federation of Periodontology (EFP) accept there is a periodontal systemic connection. Reports published in 2012 cover the consensus of several experts as a result of a workshop on the links between periodontitis and some systemic diseases.

They link: 1. Cardiovascular diseases and periodontal disease.

2. Diabetes and periodontal disease.

3. Complications during pregnancy and periodontal disease.

4. New connections are being explored between periodontal disease and several systemic diseases, such as PCOD, pneumonia, chronic renal failure, cognitive impairment, obesity, metabolic syndrome and cancer.

In Colombia IV Estudio Nacional de Salud Bucal (ENSAB 2014) undertaken by Ministerio de Salud y Protección Social, showed periodontal disease incidence increased from 50% to 75%. Troubling figures because of their impact in the oral cavity and the patient’s general health.

Since 2007, medical and dental researchers, Adolfo Contreras and Jorge

Ramírez, have emphasized on the topic. “Even though periodontal disease and relationship with several systemic diseases is highly prevalent, the country lacks a public health policy. (…) Colombia requires cost effective policies in health care designed to decrease inequalities in dental health in the general population. Oral health goals in Colombia can only be achieved with a public health strategy that includes community educational programs, the further development of medical dental cooperation, to increase the availability of dental services to the population and financing of interdisciplinary research projects”.

Periodontal specialist, dentists, physicians and other health care professionals should know and share this consensus, in order to work in an interdisciplinary manner, improving dental for all. The oral cavity should not be isolated or unknown to health care professionals; it should always be considered as part of the patient’s general health.

It is important to encourage dental care among our patients. Evidence suggests that periodontal disease treatment can improve and benefit the patient’s general health. Also medical and dental organizations should publish the following information.

Good quality epidemiological evidence suggests periodontitis increases the risk of future cardiovascular disease, as well as systemic arterial hypertension, obesity and smoking.

Periodontal treatment in patients with a history of cardiovascular disease should always follow the guidelines issued by American Heart Association (AHA).

Furthermore a link has been established between the severity of the periodontal disease and the risk of developing or progressive diabetes.

Periodontal checkups should be part of the usual control program of the diabetic patient.

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impairment, obesity, metabolic syndrome and cancer. However additional studies are required in order to better understand these links.

PERIODONTAL DISEASE TREATMENT To inform the patient on dental hygiene habits and techniques.

• In healthy people, a checkup and prophylaxis twice a year will suffice.

• Periodontal disease diagnosis should be confirmed by a periodontist, in order to initiate an adequate treatment. It includes mechanical treatment, dental scaling, in order to remove the biofilm, dental plaque and calcifications, and to control risk factors. Yearly or semenstral controls with the periodontist are useful.

• Antibiotics and antiseptics are sometimes required.

REFERENCIAS 1. CONTRERAS A, ET AL. PERIODONTAL MICROBIOLOGY IN LATIN AMERICA. PERIODONTOL 2015;67:58-86.

2. TAKAHASHI N. ORAL MICROBIOME METABOLISM: FROM “WHO ARE THEY?” TO “WHAT ARE THEY DOING?”. CRITICAL REVIEWS IN ORAL BIOLOGY & MEDICINE, JOURNAL OF DENTAL RESEARCH 2015;94(12):1628-37.

3. HAJISHENGALLIS G. PERIODONTITIS: FROM MICROBIAL IMMUNE SUBVERSION TO SYSTEMIC INFLAMMATION. NAT REV IMMUNOL 2015;15. WWW.NATURE.COM/REVIEWS/IMMUNOL 4. DONOFF B, ET AL. INTEGRATING ORAL AND GENERAL HEALTH CARE. MASSACHUSETTS MEDICAL SOCIETY. N ENGL J MED 2014;371(24). WWW.NEJM.ORG 5. FRIEDEWALD VE, KORNMAN KS, BECK JD, ET AL. THE AMERICAN JOURNAL OF CARDIOLOGY AND JOURNAL OF PERIODONTOLOGY EDITORS’ CONSENSUS: PERIODONTITIS AND ATHEROSCLEROTIC CARDIOVASCULAR DISEASE. AM J CARDIOL 2009;104:59-68.

6. NANCY L. NEWHOUSE. PRESIDENT OF THE AMERICAN ACADEMY OF PERIODONTOLOGY. NEW EFP/AAP REPORTS CONFIRM PERIO-SYSTEMIC CONNECTION AND OUTLINE CLINICAL RECOMMENDATIONS. MAY 2013. AAP-NEW REPORTS CONFIRM PERIO-SYSTEMIC CONNECTION. AMERICAN ACADEMY OF PERIODONTOLOGY, COMUNICATION; 05/01/2013.

7. HTTP://WWW.PERIO.ORG/PERIO.ORG/CONSUMER/EFP.AAP.WORKSHOPPROCEEDINGS 8. EFP MANIFESTO: PERIO AND GENERAL HEALTH. HTTP://PERIOWORKSHOP.EFP.ORG/ 9. CONTRERAS A, ET AL. ¿SE DEBE CONSIDERAR A LA ENFERMEDAD PERIODONTAL UN PROBLEMA DE SALUD PÚBLICA EN COLOMBIA? COLOMBIA MÉDICA 2007;38(3):181-2.

precisamente transmitir todo aquello que aprendió: “Haber educado a varias generaciones de cirujanos de mama y oncólogos del país y extranjeros,

haberles enseñado las técnicas quirúrgicas y lo que pude aprender, ese ha sido mi mayor logro y es de lo que más orgulloso me siento”, concluye.

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Diciembre • 2016

en mama sin ser radiólogo, luego de Even though some haber impulsado la ‘Ley de radiolostudies suggest a slight gía’ en el Congreso, que buscaba que relationship between otros médicos pudieran hacer uso del maternal periodonultrasonido en sus titis diferentes and especialiadverse dades: cirujanos, anestesiólogos, oftalpregnancy o utmólogos, cirujanoscomes, de mama, siempre periodony cuando mostrarantal untreatments entrenamiento are adecuado. recommended beTambién fue elcause primero el país theyen maintain en utilizar la técnica ganglio thedel patient in centigood nela para el tratamiento shape. del melanoma y el cáncer de mama.

Junto a los docConsidering general tores Jaime obstetric Gómez, Rafael Gutiérrez guidelines, sur-y Emilio Forero se should convirtióbeenavoided promotor geries in en Colombia y Latinoamérica de trilas pregnancies during the first cirugías conservadoras dethreatening la glándula mester, except for life mamaria. Promovió la avoid reconstrucción situations, in order to unnecesmediante colgajos musculocutáneos, sary complications. conEvidence los doctores Orticochea also Miguel suggests a relation-y José between Robledo. periodontitis and other ship A pesardiseases, de todosincluding sus títulos, recosystemic chronic nocimientosobstructive y logros, eldisease, doctor pneuQuinpulmonary tero asegura que suarthritis, mayor aporte es monia, rheumatoid cognitive

Photo: ®2016 SHUTTERSTOCK PHOTOS

EBM

December • 2016

ALZHEIMER’S DISEASE:

SOME MEMORIES ARE LOST BUT NOT THE FEELINGS 26 A MAGAZINE FOR THE HEALTH CARE PROFESSIONALS WORKING WITH COOMEVA MEDICINA PREPAGADA

MORE THAN 46 MILLION PEOPLE WORLDWIDE WILL HAVE ALZHEIMER’S DISEASE, WHILE INITIAL SIGNALS ARE SUTTLE, USUALLY ATTRIBUTED TO NORMAL AGING. IT IS IMPORTANT TO CONSULT AND ADEQUATELY TREAT THESE PATIENTS, BECAUSE THEIR EMOTIONS ARE STILL INTACT. happiness, are still there. Researchers studied how sad and happy scenes of movies affected patients with Alzheimer’s disease, compared to people without it. Alzheimer’s patients remembered less information about the films, but their emotions endured.

Useful findings to understand that these people also need warm and kind handling. While rough and discourteous treatment of these patients affect them grossly.

For doctors Caicedo and Hoyos, “the main characteristic of Alzheimer’s disease is that it affects declarative memory, changes related to hippocampal

atrophy. This is the brain structure related with memory storage and retrieval. But there are also other affected brain areas in this neurodegenerative disease that interfere with other cognitive functions beyond memory, so it can also involve attention, visuospatial processes and verbal fluidity. In contrast to memory, emotional processes are preserved, especially during the first stages, the mild phases”.

Other precisions must be made, they add, “this disorder directly affects autonomy: it is not the same thing a person that can take care of himself, as someone who can’t”.

PROTECTIVE FACTORS

S

everal protection factors have been identified, but there is no vaccine nor a drug that ensures that in the future the person is not going to suffer from Alzheimer’s disease. Some of them are the following, as geriatricians Sandra Milena Caicedo Correa and Saith de Jesús Hoyos Porto explain.

• A high schooling level.

• A healthy lifestyle: daily exercise, with a healthy and balanced diet, rich in antioxidant, cereals, fruits, vegetables, as well as vegetable oils as a source of unsaturated lipid source.

• Cognitive stimulus: reading, and other artistic, recreational and social activities.

• As general advice, we should inform people about the types of diseases that affect neurons, that don’t regenerate, and so their loss is irreparable.

Research, say experts at Alzheimer’s Association, suggests “preventive measures for heart disease also reduce Alzheimer’s disease risk.

And this link seems sound, the brain needs a rich vascular network, so cardiovascular health is of the utmost relevance. Especially important is to maintain a healthy weight, blood pressure, as well as normal cholesterol and blood sugar levels, to decrease diabetes, heart and cerebrovascular disease incidence”.

There also seems to exist “a strong relationship between severe head injuries and an increased risk of developing Alzheimer’s disease.

It is recommended to protect the head, fastening the seatbelts and wearing a helmet in risky activities, also changing the house to avoid accidents”, they add.

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Diciembre • 2016

A

ccording to DANE, in Colombia 3.6% of the population is over 65 years.

And, among them, 9.4% have some type of dementia, according to the national survey Salud y Bienestar del Adulto Mayor 2015, where Alzheimer’s disease is the most common form, it affects 256 thousand patients in the country.

Alzheimer’s disease doesn’t have a unique presentation, the progression and symptoms vary from case to case.

However, doctors Sandra Milena Caicedo Correa and Saith de Jesús Hoyos Porto, specialists in geriatrics from Pontificia Universidad Javeriana, say “in neurocognitive disorders related to Alzheimer’s disease mild cognitive symptoms appear years before a dementia can be diagnosed, with predominantly resent memory defects, such as an occasional loss of a daily use object, such as the glasses or the keys”.

These “subtle events usually do not interfere with routine activities, people are still capable of taking care of themselves, and, even though with difficulties, they can still work, and take care of social and academic engagements”.

That’s why this cases are usually overlooked, and don’t attend the physician.

As time goes by, amnesia increases, with progressive involvement of recent and work memories. The family may perceive them, and trivialize them as normal aging. But things are not that simple.

It is also incorrect to suppose that because these patients have memory alterations, they don’t feel anything, that they have also lost their emotions and feelings. They most certainly know if they are being illtreated or not.

A recent study by a group at Iowa University published in Cognitive and Behavioral Neurology, showed even though memories vanish, emotions and feelings, such as sadness and

EBM Also, they tend to have affective symptoms, such as depression, with sadness, apathy, lack of motivation and isolation as initial manifestations, and when they consult the doctor “most of them treat the symptom and not the underlying problem”.

WHEN TO CONSULT “If someone in the family becomes repetitive, asks several times the same thing because he forgets what has been said, and also becomes disoriented in time, space or person, together with language changes, such as forgetting the

names of things and people, and they can even become silent, sad, isolated; or are unable to handle money because they get confused by the different note values or they lose things frequently because they can’t remember where they left them, these people should go to the doctor in order to diagnose the disorder in a timely manner”, recommend doctors Caicedo and Hoyos.

And once the diagnosis has been established there is a pharmacological and a non-pharmacological strategy to treat them. Even though there is no cure for the disease, there are alternatives,

STEP BY STEP

December • 2016

D

octor José Fernando Gómez Montes, head of Grupo de Investigaciones en Gerontología y Geriatría, at Universidad de Caldas, insists an accurate diagnosis is required, and it is usually achieved by exclusion, since Alzheimer’s disease is difficult to differentiate from other dementias, such as those of vascular origin, so diagnostic images such a brain CT scan or an MRI are required.

Alzheimer’s disease can also be confused with normal pressure hydrocephalia. Doctor Fernando Hakim, neurosurgery head at Fundación Santa Fe, explains “the major difference between Alzheimer’s and normal pressure hydrocephalia is that this disease has a cure and it tends to present itself with movement alterations. Especially magnetic walking, as if the shoes were made up of metal and the floor of magnets. While patients with Alzheimer’s disease could also have movement difficulties, but they tend to appear late in the progression of the disease”.

Alzheimer’s, in its early stages, “is characterized by a mild anterograde amnesia and anosognosia, with visiospatial alterations as well as in calculations difficulties, that tend to present themselves as problems handling money, with judgement and insight problems, such as being unable to identify their own disease, without motor signs nor symptoms”, explains Doctor Gómez.

Then it becomes difficult for them to recognize faces and forget family relationships; language comprehension difficulties may also appear, as well as early anomia signs, such as problems finding correct words, as well as an inability recognizing similarities and differences between related words.

And in advanced stages “walking, dressing and speech apraxias become common. Patients in terminal stages frequently cannot speak, and have an immobilizing syndrome together with urinary and fecal incontinence”, adds Doctor Gómez.

Neurological signs also emerge “in late stages, they include akinesia, loss of balance, rigidity, myoclonias and seizures due to gradual effects on subcortical structures. In severe cases, death can occur because of malnutrition and infections, usually about 5 to 10 years after symptom unset”.

such as acetylcholinesterase inhibitors, that tend to decrease the progression of the symptoms while maintaining the patient’s functionality. Experts at Alzheimer’s Association say the future is promising in this field, this is a health care volunteer organization that takes cares of Alzheimer’s patients in the United States. Referring to β-amyloid, they say “it is a protein fragment that accumulates forming plaques in certain areas of the brain, that are considered pathognomonic of the disorder, and researchers have developed several methods to eliminate or avoid their accumulation forming these plaques. Several experimental drugs are being tested as of right now for this purpose”.

Available medicines, for now, “allow brain cells to work in a more efficient manner, compensating for the loss of others. They cannot stop progressive neuron death in specific brain areas related to Alzheimer’s disease, but they do slow down the process and the symptom appearance”, say specialists.

On the other hand, within the non-pharmacological alternatives, cognitive rehabilitation therapies are useful, as well as physical therapy, phonoaudiology, psychology, and more recently strategies that include art, music and other recreational activities, together with a warm family environment.

Centro de Memoria y Cognición Intellectus, has benefitted many, with individual cognitive stimulation performed by a group of neuropsychologists, as well as cognitive stimulation based on a personalized attention model, considering their wishes, values, family situation, circumstances and life style.

REFERENCIAS Y LECTURAS RECOMENDADAS 1. HTTP://JOURNALS.LWW.COM/COGBEHAVNEUROL/ FULLTEXT/2014/09000/FEELINGS_WITHOUT_MEMORY_IN_ALZHEIMER_DISEASE.1.ASPX 2. HT TP S: // W W W. M I N SALU D.GOV.CO/SITES/RI D/ LISTS/BIBLIOTECADIGITAL/RIDE/VS/ED/GCFI/RESUMEN-EJECUTIVO-ENCUESTA-SABE.PDF 3. HTTP://WWW.SANITAS.ES/SANITAS/SEGUROS/ES/ PARTICULARES/BIBLIOTECA-DE-SALUD/TERCERA-EDAD/DEMENCIAS/TEST-RELOJ.HTML 4. HTTP://WWW.ALZ.ORG/NATIONAL/DOCUMENTS/ SP_BROCHURE_BASICSOFALZ.PDF 5. HTTP://WWW.ALZ.ORG/NATIONAL/DOCUMENTS/ SP_BROCHURE_BASICSOFALZ.PDF 6. GÓMEZ F, CURCIO CL. VALORACIÓN DE LA SALUD DEL ANCIANO. 3ª ED. EDITORIAL BLANECOLOR; 2014.

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Photos: JORGE MEJÍA

MERITS

HIS PRIORITIES

ARE CHILDREN AND RESEARCH HIS CONTRIBUTION TO THE WELLBEING OF WOMEN, PARTICULARLY TO ADOLESCENT MOTHERS AND THEIR CHILDREN, AS WELL AS SEVERAL ACKNOWLEDGEMENTS, ARE PART OF DOCTOR JULIO CÉSAR REINA’S WORLD IN PEDIATRICS AND THE PREVENTION OF CERVICAL UTERINE CANCER CAUSED BY HUMAN PAPILOMA VIRUS.

I December • 2016

n the beginning of the interview his simple words referring to his work don’t reflect his preparation nor the awards he has received. “Children are my life! –he says laughing- and my greatest satisfaction are my achievements in this field. I thank God for allowing me to get to where I am: a

teacher, a researcher and to be able to work with children”.

Julio César Reina always knew he wanted to be a doctor, even though he tells his patients he wanted to be a fireman. His mother’s family, that includes several doctors, influenced him and his desire to help the community, key factors in his life’s choice.

He graduated and specialized at Universidad del Valle, more than 50 years ago, and as he studied during his undergraduate years his interest developed for this specialty. Then he studied for 4 years pediatric nephrology and endocrinology at Rochester University. And then returned to Universidad del Valle as a professor at the

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pediatrics department, where he worked for 31 years until he retired.

Doctor Reina is a founding member of Centro Médico Imbanaco, in Cali, where he works as a pediatrician. He remembers: “for more than 30 years I have been a researcher at the medical faculty of Universidad del Valle, and I have worked with several professors form several universities in Colombia, as well as from other countries”.

He is sure he was right when he chose to be mainly a researcher. A decision that turning him into a leader, even to other medical specialties, as a matter of fact doctors consult him on their new projects. “Some teachers I used to have when I was becoming a pediatrician motivated me to research, and I’m still doing it 30 years later”, tells us doctor Reina.

That’s why he has been awarded on 3 occasions: 2 of them because of a research titled “Adolescents and pregnancy: health and nutrition”, at XXI Congreso Colombiano de Pediatría, in October 1999, and I Congreso

“I THANK GOD FOR ALLOWING ME TO GET TO WHERE I AM: A TEACHER, A RESEARCHER AND TO BE ABLE TO WORK WITH CHILDREN”.

Boliviano de Obstetricia y Ginecología, in March 2000. And his most recent award was awarded to him in May 2008 for “The newborn of an adolescent mother”, in XXIX Congreso Colombiano de Ginecología y Obstetricia at Cartagena. He also wrote in 1992 the book “Fluids and electrolytes in children. The ABC on fisiopathology and handling. Precise ways”. And he also has over 130 publications, including contributions to scientific journals and abstracts on presentations in national and international meetings.

Today, Julio César Reina, a pediatrician, works as a reseacher and in a program, that helps adolescent mothers.

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AGAINST HPV He was selected by the Colombian government in 2011 as a researcher on the follow up of the original human papilloma virus vaccine.

This investigation started over 10 years ago, and has arrived at important conclusions, such as that the vaccine has a protection ratio around 72%, and, as it also happens in other countries, it reduces considerably precancerous alterations related with papilloma.

He is still part of the research team that works with the nonavalent HPV vaccine, in other words, the preparation that includes 9 genotypes: “7 of them are related with cancer and the other 2 with genital warts; and those 7 genotypes protect up to 92% of the cases, so it is a much more effective presentation”, assures doctor Reina.

But that’s not the whole story: with the foundation that carries his name, and with the economical help of some families in Cali, for more than 20 years he has developed a program intended to help adolescent mothers, offering them counseling, with instructions and medical controls, so that their babies will be born normally. While at the same time he speaks in national and international meetings about the impact of pregnancy in adolescence.

And, today he is also finishing the data recollection on children under 1 year in order to describe the incidence of important micronutrient deficiencies that affect the brain development, such as iron, vitamin E and zinc. In the end, when he gets to publish this information, it is going to be very useful for all of us.

RESEARCH

INTERVIEW

CHANGING VIEWS ON

MENOPAUSE GYNECOLOGIST MARTHA MARRUGO FLÓREZ, AWARDED BY FEDERACIÓN LATINOAMERICANA DE SOCIEDADES DE CLIMATERIO Y MENOPAUSIA, IS A RESEARCH ADVOCATE AND A TEACHER THAT BENEFITS WOMEN. SHE HEADED THE ELABORATION AND PUBLICATION OF THE COLOMBIAN CONSENSUS ON MENOPAUSE, A KEY GUIDELINE FOR DOCTORS.

L

December • 2016

ife expectancy has increase worldwide, today it stands at 75 years, and by 2050 it will probably reach 85. Therefore women are living around a third of their lives in the climactic phase.

It is a challenge for researchers and doctors, whom, as Doctor Martha Marrugo Flórez says, “we can feel the aging process, and should be aware of it, always ready to treat the associated pathologies, preventing risk factors that could diminish life quality; so we are working from preconception to childhood and adolescence in order to achieve a healthy and happy mature population”.

She works full time on women’s health present and future. And that’s why Federación Latinoamericana de Sociedades de Climaterio y Menopausia (Flascym), an organization that every 3 years acknowledges achievements in medical practice, research and teaching, for the benefit of women in the region, awarded her as Experta Latinoamericana en Climaterio y Menopausia.

WE INVITE OUR HEALTH CARE PROFESIONALS to share with us your research, academic or community experiences.

This way we can enrich this section, while publishing your professional achievements and developments. Write to us at prestadores_coomeva@coomeva.com.co 32 A MAGAZINE FOR THE HEALTH CARE PROFESSIONALS WORKING WITH COOMEVA MEDICINA PREPAGADA

Diciembre • 2016

Photos: ®2016 SHUTTERSTOCK PHOTOS

33 A MAGAZINE FOR THE HEALTH CARE PROFESSIONALS WORKING WITH COOMEVA MEDICINA PREPAGADA

RESEARCH

INTERVIEW

CLIMACTERY AND MENOPAUSE A BEAUTIFUL PHASE

December • 2016

T

he climacteric phase is the transit from the reproductive stage of life to the non reproductive, and implicitly it includes menopause, when the menstrual flow stops for at least a year. It is a physiological process not caused by age. “But, on average, Latin-American women usually reach menopause by age 49, even though it isn’t a rule. There are situations associated early menopause, such as immunologic factors like lupus, arthritis, thyroiditis, and others; also diseases like endometriosis and ovarian cancer, as well as the toxicity of tobacco and alcohol, even stress and also surgeries like early oophorectomy and hysterectomy, radiotherapy and chemotherapy”, explains Doctor Martha Marrugo Flórez.

In the beginning of the climacteric phase women start to have menstrual irregularities, cycles can shorten and then prolong, and can also be accompanied

by vasomotor symptoms, for instance heat waves and palpitations, but also by insomnia, emotional liability and decreased sexual drive. “But there are also women without any of these symptoms, who feel fulfilled and have a positive attitude”.

Research has modified preventive programs, informing women, helping them to find new ways to enjoy this phase. Doctor Marrugo summarizes it like this: “a positive attitude, a desire to live, spirituality, a loving and active couple, with ample time for pleasure, as well as sharing with friends, also help us to look at the mirror and recognize yourself as a pretty woman”. But also “it is necessary to consider the health realities in order to identify aspects that need improvement, and acknowledgement of the changes, allowing us to age better”, she says.

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RESEARCH

INTERVIEW

“I’m happy with this award. We have worked for the health and wellbeing of women in all age groups, especially during the climacteric phase. It is an incentive to keep on creating prevention and treatment strategies that could help us improve life quality”.

December • 2016

RISK FACTOR CONTROL It’s been more than 12 years since doctor Marrugo started working on new preventive strategies focused on controlling, stopping or reducing risk factors that negatively affect the mature femenine population, including cardiovascular risks, such as infarctions, and also diabetes, metabolic problems, together with breast and colon cancers.

“In 2011 and 2013, when I was the first woman to be elected as president of Asociación Colombiana de Menopausia, we headed the elaboration and publication of Consenso Colombiano de Menopausia, a key guideline for doctor working with mature women on how to handle this period integrally”, she remembers filled with satisfaction and the joy of having helped society through her profession.

Also she has worked in several research lines related to life quality of women in the Colombian Caribbean, using several scales designed around the world to evaluate different aspects of the climacteric phase, such as symptoms like heat waves, insomnia, depression, concentration alterations, muscular and joint pains, changes in sexual activity.

“We compare these symptoms with other population groups and establish the most frequent in mature women, together with their negative impact.

And this information has been very useful to guide prevention strategies”.

She has also developed other research lines with Grupo de Investigación en la Salud de la Mujer at Universidad de Cartagena, headed

by Professor Álvaro Monterrosa. They have worked on topics like quality of life in relation to alcohol and drug intake, smoking, stress, physical inactivity, and also life quality after a

PERFIL

A TRAVELER INLOVE WITH LOVE

D

octor Martha Marrugo just turned 50, and she says “I thank god for all that he has given to me. I’ve been happily married for the last 5 years and 9 months with the radiologist Adalberto Rafael Mejía Barrios.

She is the mother of 2 wonderful kids: Laura Marcela, a 13 year old, and Jorge Mario, a 14 year old, whom arrived at my life after their mother died because of a colon cancer. They are my greatest achievement as a mother and a wife. Being a mother is not only a biological event, it is also to be able to feel the divine inspiration to love and protect, the mission our Lord has given us. I’m so happy with what I do: care for my family and my mother, who has inspired me, as well as for my patients”.

She studied medicine at Universidad del Norte and specialized in gynecology and obstetrics in Pontificia Universidad Católica de Sorocaba y Maternidad de Capinas, in Brazil, and then she did another specialization in reproductive medicine at Perola Byington as well as in gynecologic endoscopy and mastology at Facultad de Medicina ABC Paulista. She a tireless student.

But she also loves to travel, to sightsee and exchange knowledge, as well as to enjoy a glass of wine with nice food, and theater, comedy, jazz, salsa, merengue.

Recently she arrived from Prague after attending to the world meeting on menopause. And right now she is preparing for a new challange: she has been honored when she was elected to preside XII Congreso Nacional de Menopausia. An event that will take place in Barranquilla between March 9th and 11th 2017, together with the first Feria de la Salud de la Mujer, on March 8th 2017.

She has also been awarded on several opportunities.

At Barranquilla, Asociación Internacional de la Mujer acknowledged her as an outstanding Woman in the medical area, while Flascym named her as Experta Lanoamericana en Climaterio y Menopausia.

hysterectomy. They found “this surgery, in women during the reproductive phase and the premenopausal stage, can be linked to early ovarian failure and negative health effects”.

“We have also worked with women in all social conditions, offering them programs based on preventive strategies for risk factors that limit life quality and increase the risks of diseases and death, like obesity, alcoholism, inactivity and stress”, explains Doctor Marrugo.

And this work includes altering myths and preconceived ideas, especially in those women who see maturity as a nuisance. “I’ve always told patients life gives us many years to acquire wisdom, and a positive attitude, and this is our best medicine. It is important learn how to adapt to unavoidable changes.

Mature women can be active, exercise daily, have a healthy diet, cherish their spirituality, and live a dynamic and productive life”, she adds.

36 A MAGAZINE FOR THE HEALTH CARE PROFESSIONALS WORKING WITH COOMEVA MEDICINA PREPAGADA

Te ofrecemos un motivo para celebrar

Paga con anticipación las cuotas del año 2017 de tus programas de Coomeva Medicina Prepagada, CEM y Salud Oral de acuerdo a tu plan, y aprovecha los descuentos que hemos preparado para ti.

Plan Familiar

Plan Asociado

pagando 12 meses Efectivo, tarjetas débito o crédito.

pagando 12 meses Efectivo, tarjetas débito o crédito.

5%DCTO

6%DCTO

Cooperando es posible Nos facilita la vida

Medicina Prepagada

FROM

COOMEVA

MEDICINA PREPAGADA

VIRTUAL PROVIDER OFFICE: DISCOVER OUR NEW ONLINE SERVICES! WE INTEND TO KEEP ON IMPROVING OUR COMUNICATION WITH OUR HEALTH CARE PROVIDER NETWORK, SO COOMEVA MEDICINA PREPAGADA HAS DEVELOPED STRATEGIES TO STRENGTHEN OUR INTERACTIONS WITH HEALTH CARE PROFESSIONALS WORKING WITH US, LOOKING FOR BENEFITS FOR ALL, THAT WILL ALSO IMPROVE SERVICES WITH HIGHER STANDARDS IN TECHNICAL AND HUMAN QUALITY FOR THE USERS.

S

o starting on December 15th new alternatives will be found in our web page that will allow you to contact us permanently. Updated online access on information that will make it easier to communicate with us through the new Oficina Virtual de Prestadores, where you will be able to: 1. Generate consolidated and detailed bills any time you may require them: this allows you see the value of the medical due amount after taxes and you will also be able to see the detailed list of the users during the selected period.

2. Additionally you will be able to change your basic information any time you need to do so: this online service will allow you to modify tax and banking information, as well as the E mail, specialty and new address.

December • 2016

What our new web site will offer soon: Portal de Prestadores de Coomeva Medicina Prepagada is workong in some new developments that will shortly be available to the health care profesional network, and will allow you to: • Generate tax certificates, such as retefuete, reteICA and reteIVA.

• Find out about delivered invoices according to the following stages: delivered, in process, payment approval, returned and/or partial payment approval.

We hope these new communication channels will strengthen even more our relationship.

¡Coomeva Medicina Prepagada makes life easier!

38 A MAGAZINE FOR THE HEALTH CARE PROFESSIONALS WORKING WITH COOMEVA MEDICINA PREPAGADA

MEDICAL

WORLD

EVENTS ICRAN 2016.

INTERNATIONAL CONFERENCE ON RECENT ADVANCES IN NEUROTRAUMATOLOGY Date and place: December 8th through 11th 2016, Bogotá Information: Asociación Colombiana de Neurocirugía Phone number: (1) 6100090 E mail: asoneurocirugiaacncx@gmail.com Web page: www.acncx.org

XVI NATIONAL SCHOOL OF BACTERIOLOGY INTERNATIONAL CONGRESS Date and place: November 4th through 7th 2016, Bogotá Information: Colegio Nacional de Bacteriología Phone number: 3103238275 - 3204338027 E mail: congreso@cnbcolombia.org Web page: www.cnbcolombia.org

XIV INTERNATIONAL OPHTHALMOLOGY CONGRESS, LOOKING AHEAD AT THE VANGUARD Date and place: May 25th through the 27th 2017, Cali Information: Clínica de Oftalmología de Cali S.A. Phone number: (57) (2) 5110237 E mail: 14congresointernacional@clinicaofta.com Web page: www.14congresointernacionaldeoftalmologiacali.com

5TH ACTUALIZATION COURSE ON BASIC SCIENCES AND 11TH NATIONAL ENCOUNTER OF ORTHOPEDICS AND TRAUMATOLOGY RESIDENTS

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Diciembre • 2016

Date and place: November 25th through 26th, Villadeleiva 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.co

MEDICAL

WORLD

EVENTS AUDIOLOGY ACTUALIZATION Date and place: February 16th through the 18th 2017, Cali Information: Asociación Colombiana de Audiología Clínica Phone number: 311 532 9859 (57) (2) 5110237 E mail: asoaudio@asoaudio.org.co Web page: www.asoaudio.org.co

‘INFARMA. BARCELONA 2017’ Date and place: March 21st through 23rd 2017, Barcelona, Spain E mail: cofm@cofm.es, cofb@cofb.net Web page: http://www.infarma.interalia.es/

‘XII INTERNATIONAL SIMPOSIUM ON PEDIATRIC PNEUMOLOGY AND ALLERGY’ Date and place: April 21st through 22nd 2017, Cartagena Information: Clinialergias Phone number: 3156202499 E mail: info@clinialergias.com Web page: http://clinialergias. com/simposio/index.html

‘10TH CONGRESS OF THE VASCULAR ACCESS SOCIETY – VAS 2017’ Date and place: April 5th through 8th 2017, Ljubljana, Slovenia Information: Congress Organizing Committee Phone number: +420 284 001 E mail: vas2017@guarant.cz Web page: www.vas2017.org

December • 2016

‘THE 4 STAGES OF MUSCULO SKELETAL ULTRASONOGRAPHY’ Date and place: February 3rd through 4th 2017, Córdoba, Spain Information: Ecografía Integral Phone number: 34 932212242 E mail: inscripciones@geyseco.es Web page: http://www.geyseco.es/musces2016/

40 A MAGAZINE FOR THE HEALTH CARE PROFESSIONALS WORKING WITH COOMEVA MEDICINA PREPAGADA

BOOKS AND PLEASE, LIE TO ME

Author: Fernando Araújo

FOOD GUIDE

‘REGIONAL ANESTHESIA FUNDAMENTALS‘

Authors: Carlos Tornero, Vicente Roqués, Jorge Hernando Sáez y Luis Aliaga Font

T

his book is a useful guide for healthcare professionals. With vital sections, such as the basic anatomy required for this type of procedures, also detailed indications, complications and adverse effects. It is divided into six thematic blocks: upper limb, lower limb, thoracoabdominal wall, head and neck, central blocks and specific situations. And an additional section, only available in the web page for good image quality, is devoted to sectional and sonographic anatomy.

Authors: Roberto Cano de la Cuerda, Rosa Mª Martínez Piédrola y Juan Carlos Miangolarra Page

T

hanks to the participation of several professionals on motor control and learning, this book has an interdisciplinary perspective with a structured content divided into thematic blocks regarding general and basic concepts, as well as practical perspectives on different therapeutic approaches.

Also, the textbook includes a glossary that will help the reader who wants to deepen his knowledge in this fascinating area.

A

dequate food preparation requires attention to flavor, color, texture, as well as aroma and hygiene. If errors occur while preparing them, bacterial growth increases. So this book offers a wide view of food microbiology, including a practical review of the main agents that can cause foodborne toxicinfections, losses due to foodstuff degradation, and other topics related to these pathogens.

T

his is a polyphonic novel. Several voices tell the lies that surround them. And the Villa family’s great lie might be the reflection of the great lie of a society, our Colombian society.

So lying is also a form of the truth? In this book, his first novel, the author gives us a pleasant impression of a professional narrator, who knows how to capture the reader’s attention, and leaves him thinking after he finishes reading.

TO CREATE. THE CHALLENGE OF ALLWAYS IMPROVING Author: Diego Simeone

T

his is Diego Simeone’s fascinating story. The renowned soccer coach tells us his secrets as a group leader and as a protagonist in world soccer.

Also, he confesses vividly, and without hesitation, how he lives soccer and life. Since his motivation is continuous improvement, he considers difficulties the best school.

Value should be given to the present, because fights start on the first minute.

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A MAGAZINE FOR THE HEALTH CARE PROFESSIONALS WORKING WITH COOMEVA MEDICINA PREPAGADA

Diciembre • 2016

MOTOR LEARNING

Author: Miguel Ángel, Hernández Urzúa

MEDICAL

WORLD

MUSIC

MOVIES

MTV UNPLUGGED Miguel Bosé ecorded live in may 2016 and R transmitted by MTV Latin-America, this is the Spaniard’s 25 album, accompanied th

by 21 musicians playing instruments like violin, marimba, cello, vibraphone, tube bells and a concert hall piano. Among the beautiful songs sung by Bosé we can find Nena, Amante Bandido, Bambú, Nada Particular and Si tú no vuelves.

W ‘JACK REACHER: WITHOUT RETURN Director: Edward Zwick Cast: Tom Cruise, Cobie Smulders, Robert Knepper, Aldis Hodge, Danika Yarosh y Holt McCallany

hile Major Susan Turner commands Reacher’s old army research division, she is arrested for treason, while innocent. Reacher must free her from prison and uncover the truth behind this big government conspiracy, intended to clean their names and save their lives. So Reacher becomes a fugitive, when he discovers a secret in his potential past that could change his life forever.

‘TRAINS, AIRPLANES AND INTERPLANETARY TRIPS Santiago Cruz

T ‘PASSENGERS Director: Morten Tyldum Cast: Jennifer Lawrence, Chris Pratt, Michael Sheen y Laurence Fishburne

W

his is a different project from his other musical productions, the composer born in Ibagué worked with several artists, in order to interpret several songs in the record, among them Sebastián Yepes, Elsa and Elmar, George Noriega, Pedro Capo and Juan Pablo Vega. This album was recorded at Botafogo (Brazil), with local musicians in an old studio, the whole point was to give the songs a retro flavor. Among them me like to mention: Start from scratch, Coffee with a hug, Count to three (or up to ten) and My superhero.

December • 2016

hile in a routine space travel towards their new home, two sleeping passengers in suspended animation wakeup 90 years before they should’ve, because of a malfunction in the craft.

So, Jim and Aurora must face the fact the they will spend the rest of their lives on board, surrounded by all conceivable luxuries. And they start falling in love, while the spacecraft is in grave danger, so suddenly they are in charge of the lives of the other 5.000 sleeping passengers. They are the only ones that can save them.

42 A MAGAZINE FOR THE HEALTH CARE PROFESSIONALS WORKING WITH COOMEVA MEDICINA PREPAGADA

Hospital en Casa es la institución pionera en la prestación de servicios de salud, hospitalización y cuidados integrales domiciliarios, que contribuye a la recuperación del paciente con la calidad y tecnología de una clínica, pero en la comodidad y la seguridad del hogar.

Recomiende a sus pacientes Hospital en Casa.

Conozca nuestros servicios: • Extensión Hospitalaria • Terapias de rehabilitación • Clínica de heridas • Suministro de medicamentos, insumos, dispositivos y equipos biomédicos • Cuidado del paciente crónico • Ventilación mecánica • Cuidado paliativo • Nutrición y dietética Ingrese a nuestra página web www.hospitalencasa.com.co o comuníquese a nuestras líneas de atención:

Cali: 321 12 19 - Resto del país: 01 8000 934 046 Encuentre nuestras sedes en: • Bogotá • Cali • Palmira • Buga • Tuluá • Popayán • Pasto • Medellín • Ríonegro • Montería • Barranquilla • Cartagena • Sabanalarga