Coomtacto 11 v1 - A magazine for Coomeva Medicina Prepagada healthcare professionals

ISSN 2011-3579

A MAGAZINE FOR COOMEVA MEDICINA PREPAGADA HEALTHCARE PROFESSIONALS VOL. 11 • # 1 • MAY 2018

ON THE WORLD CUP AND PHYSICAL PAIN

SCIENCE, experts and fans gather around one goal: their stars’ well-being

THE SPECIALITY Endocrinology Thyroid disease, increasingly diagnosed

Edgard Nessin Dayan, MD

EDITORIAL

The new Coomeva Medicina Prepagada

IS ALREADY A REALITY

S

elf-care is self-love! It’s not a slogan, it’s our essence. A value proposition that has enabled us to move towards a challenging direction. This includes not only technological tools, but also the permanent care of our users.

To visualize the modernization of our Coomeva Medicina Prepagada has generated a rewarding connection with your work, the providers, because, besides listening to the expectations you have with us, you have also facilitated ideas for creating new kinds of relationships.

This is how we initiated a project that today is a reality and that will allow us to generate great changes towards the future, such as the transformation of the technological platform, which will file information in a smart way, so that it provides with absolute precision and opportunity the data necessary for decision-making in health management and the administrative structure.

TOP TECHNOLOGY IN FAVOR OF SERVICE

Since our establishment we have worked on the continuous improvement of concepts and how we deliver our services, and today we are preparing for the new stage that the innovation of the technological platform will bring: to provide specialized high-impact portals to our allies, modernize the channel of access to the service and expedite the hiring process with the health institutions and professionals that provide the healthcare to our affiliates, seeking to keep them up to date with secured data, in addition to the implementation of a robust platform that allows us to consolidate the specialized data in all the organizational processes: from affiliation to our services to health risk management, passing through the consolidation of specialized payments and the follow-up to our users’ processes.

A tool that provides connectivity to other platforms in order to share specialized information for the exclusive use of health services, with benefits such as easy access, intuitive navigation and computer security.

This is a transformation thought within the frame of digital connections as a powerful means to generate memorable experiences.

These changes, like any transformation, demand efforts that are worth facing, because this is how we hope that Coomeva Medicina Prepagada becomes lighter in its

Jorge Alberto Zapata Builes General Manager Coomeva Medicina Prepagada

processes, from the contact with the user to the relationship with you, the providers.

We focus on our users and their experience in order to generate a memorable service in every contact with us; that they remind us for being the ones who care for creating a life experience from through comprehensive health care. Likewise, through our relationship with the users we strengthen our bonds of confidence.

The inspiration for this change that we are nurturing is based on the need to strengthen the connectivity with our users and allies. Attributes that allow us to remain at the forefront and move towards excellence.

When we think about health care, we think about those who connect with our brand; therefore, we evolve and modernize our processes permanently to provide the best care.

The new Coomeva Medicina Prepagada is already a reality, with innovation and modernization that allows us to offer our allies and users with cutting-edge health care.

Because ‘Self-care is self-love!’, Coomeva Medicina Prepagada always challenges the future.

MAY 2018

3

CON

Jorge Zapata Builes

General manager Coomeva Medicina Prepagada

Editorial committee Pascual Estrada Garcés, MD Health National Head Martha Liliana Cifuentes National Coordinator of Relationships and Healthcare Providers Bertha Lucía Varela, MD National Medical Audit Chief Julián Adolfo Villegas Health Risk Management National Head Ana María Correa Quality National Auditor Marco Emilio Ocampo Medical National Auditor Juan Fernando Saavedra Publicity and Marketing National Head David Montes Communications National Coordinator

Producción editorial Legis S.A.

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mercadeorelacional@legis.com.co Tels.: (1) 4255255, exts.: 1314, 1393, 1552, 1516 Sales: María Cristina Arévalo Durán Cel.: 3112862724 maria.cristina.arevalo@gmail.com ISSN 2011-3579

A MAGAZINE FOR COOMEVA MEDICINA PREPAGADA HEALTHCARE PROFESSIONALS

10 3 | EDITORIAL 0 The new Coomeva Medicina Prepagada is already a reality

22 | RISK MANAGEMENT Self-care among healthcare teams: a 24/7 need

06 | MEDICAL ADVANCES

26 | RISK MANAGEMENT Thoughts on the close relationship between cancer and stress

Photo: © 2018 SHUTTERSTOCK PHOTOS

VOL. 11 • # 1 • MAY 2018

ON THE WORLD CUP AND PHYSICAL PAIN

SCIENCE, experts and fans gather around one goal: their stars’ well-being

10 | HEALTH UP TO DATE On the world cup and physical pain Science, experts and fans gather around one goal: their stars’ well-being THE SPECIALITY Endocrinology Thyroid disease, increasingly diagnosed

Edgard Nessin Dayan, MD

Editor’s Note Legal texts: The advertorials published in this edition and in all the editions of the Revista COOMTACTO, of intellectual and patrimonial property of Coomeva Medicina Prepagada, correspond to paid spreads by advertisers and are not in any way related to the editorial content of the publication or the opinion, concept or point of view of the companies of the Grupo Coomeva.

4 MAY 2018

14 | THE MEDICAL SPECIALTY

Endocrinology Thyroid, diseases, increasingly diagnosed 18 | THE MEDICAL SPECIALTY

Endocrinology Edgard Nessin Dayan, MD, passionate about the depths of endocrinology

30 | EBM Antidepressants work: a meta-analysis on their efficacy and acceptability 34 | RESEARCH REPORT Ivan Dario Escobar: life-changing lessons for chronic patients 37 | COOMEVA IN DATA

TENTS May 2018

14

FACT PILLS TINNITUS: INCREASING LEVELS AMONG YOUNG PEOPLE The global prevalence of tinnitus is between 10 and 25 per cent among those older than 18, according to the American Tinnitus Association. In only a small percentage of people, the feeling is severely disturbing (1-7%). The number of cases of tinnitus increase with age and reach a peak during the seventh decade of life. However, over the past 10 years it has been diagnosed in groups of younger people, presumably because of an increased exposure to recreational noise.

19% of the adolescent school population develop acoustic trauma. The location of the tinnitus is variable: 50% of the patients report it in both inner ears, approximately 35% suffer from it in only one side and 15% say that it’s in their heads.

CHAGAS DISEASE UNDER THE RADAR

30

34

In Colombia, 34 cases of Chagas disease were reported annually during a period of six years (2012-2017). The percentage decreased to less than 65% by the end of 2017. Data from the Pan American Health Organization (PAHO) show that the departments with the most confirmed acute cases are Casanare (58) and Santander (40). In the country, outbreaks of oral transmission have occurred in Casanare, Santander, Antioquia, Cesar, Bolívar and Meta. The average lethality of Chagas disease, over the past six years, was 13 for every hundred cases. So far, in 2018 it’s 0%. Until now, Sivigila has been notified of 17 patients with acute Chagas disease, of which two were confirmed: one due to vectorial transmission in Guainía, from Venezuela, and another from congenital Chagas in Bogotá.

MEASLES REACTIVATES IN THE AMERICAS

38 | FROM COOMEVA Coomeva Medicina Prepagada: ready for the future

46 | MERITS Emilio José Yunis (RIP) The legacy of a brilliant mind

39 | COOMEVA PROMOTES Advances in the relationship with our healthcare providers An enriching experience!

50 | LAW AND HEALTH Death with dignity for minors: What does the law say?

40 | HUMANIZED MEDICINE Integrative medicine, a new and better approach to patients 44 | MERITS Rewards excelence Red carpet for healthcare providers

54 | EVENTS Highlighted events Músic Books Shows

Since the last epidemiological update issued by the Pan American Health Organization (PAHO/WHO), on March 16, 2018, two countries on the Americas have confirmed cases of measles: Argentina (1) and Ecuador (1). Thus, the number of countries affected by the disease rose to 11: Antigua and Barbuda (1), Argentina (1), Brazil (46), Canada (4), Ecuador (1), United States (41), Guatemala (1), México (4), Perú (2) and Venezuela (279). In Colombia, after being declared free from the disease in 2004, five cases have been reported so far this year in minors coming from Venezuela (closure of the edition in May 2018).

WORLD ALERT DUE TO INCREASED LEISHMANIASIS Leishmaniasis has become a global public health problem. In Colombia, the increased number of cases is worrisome, especially in rural areas. Among the three clinical presentations of the disease, cutaneous leishmaniasis is the most widely distributed through the territory, according to the information of Instituto Nacional de Salud (INS). The document “Comportamiento de la notificación de la leishmaniasis Colombia 2016 a período epidemiológico III - 2018” from the INS reports 955 cases of the disease, of which 945 cases were cutaneous, 7 mucocutaneous and 3 visceral.

MAY 2018 5

MEDICAL ADVANCES

Photos: © 2018 SHUTTERSTOCK PHOTOS

NEW ORGAN CAN EXPLAIN HOW CANCER SPREADS A network of fluid-filled channels, unknown before, could transport cancer cells throughout the body. The discovery happened by chance from routine endoscopies from which a team of researchers expected to find the bile duct surrounded by a wall of hard and dense tissue.

Instead, they found strange patterns that were analyzed by the pathologist from the New York University School of Medicine, Neil Theise, who found that these channels form an organ which contains roughly one fifth of the total fluid volume of the body and acts as a buffer. Besides protecting organs, the network can also aid the spread of cancer since cells could travel to the lymphatic system and disseminate it. A discovery that could be key in the detection of the disease.

SOURCE: ARTICLE “NEWLY-DISCOVERED HUMAN ORGAN MAY HELP EXPLAIN HOW CANCER SPREADS.” PUBLISHED IN THE MAGAZINE NEW SCIENTIST.

A DEVICE “READS” THE MIND If you like science fiction, you probably heard of subvocalization, a practice of saying words silently in one’s head. It has been used recently as a way to interact with mobile devices and computers and, precisely for that purpose, researchers from the Massachusetts Institute of Technology (MIT) created a device that, when used on the face, detects the neuromuscular signals that fire when doing subvocalization. It has electrodes that capture this signals as well as headphones of bone conduction that use the vibrations sent to the bones of the inner ear, without blocking the ear canal. The signals go to a computer that uses neural networks to distinguish the words. So far, the system has been used to do fun things, like asking for the time and inform the chess moves of one’s opponent to obtain optimal counter movements, but it’s believed that this will be a key link between man and machine.

SOURCE: ARTICLE “MIT’S WEARABLE DEVICE CAN ‘HEAR’ THE WORDS YOU SAY IN YOUR HEAD”, PUBLISHED ON THE WEBSITE ENGADGET. UNITED STATES EDITION. 2018.

MOLECULAR TESTS IDENTIFIES TUMORS BY NAME AND SURNAME This diagnostic tool, which is already being used in Colombia, allows obtaining the molecular profile of each type of tumor, so that the most accurate treatments can be selected to treat lung cancer, kidney cancer, melanoma, colon and rectum tumors, considering that all patients are different.

The test can be done using a biopsy sample or a blood sample (liquid biopsies). Although this procedure has been implemented for 10 years around the world, the advantage is that it now helps improve treatments, since the tumors subtypes are already known and the test is faster, more accurate, and less expensive than other diagnostic alternatives. The results can be obtained within 7 or 14 days. In the country not all health insurers (EPS) are familiar with this type of tests, because they are not included in the Mandatory Health Plan (POS), but can be approved through a non-POS request.

SOURCE: LEONARDO ROJAS, MD, ONCOLOGIST AND SPOKESMAN OF BOEHRINGER INGELHEIM.

6 MAY 2018

ADENOMYOSIS AND FERTILITY Adenomyosis is diagnosed more frequently in women with infertility since the average age of motherhood has been delayed towards the late 30s and early 40s, although the mechanisms responsible for this negative effect are unknown. This is a benign disorder of the uterus characterized by the presence of heterotopic endometrial glands and stroma in the myometrium, accompanied by reactive fibrosis of the surrounding smooth muscle cells. The most recently accepted hypothesis suggests that it originates from the invagination of the basal layer of endometrium into the myometrium. The truth is that the thickening of the junctional zone is the best negative predictive factor for failure of implantation during in-vitro fertilization. The studies evaluated by the team of Tasuku Harada, MD, PhD, DMSci, head of the Department of Obstetrics and Gynecology, School of Medicine, Tottori University in Japan, have shown a significant increase in pregnancy rates in women with endometriosis without adenomyosis, compared to those with concurrent endometriosis and adenomyosis, after laparoscopic excision of deep infiltrated endometriosis. Pregnancy rate in patients with colorectal endometriosis and associated adenomyosis was 19%, while that seen in patients with endometriosis alone was 82%.

SOURCE: ARTICLE “THE IMPACT OF ADENOMYOSIS ON WOMEN’S FERTILITY” PUBLISHED BY THE MAGAZINE OBSTETRICAL AND GYNECOLOGICAL SURVEY. 2016.

FIRST EFFECTIVE TREATMENT FOR PANCREATIC CANCER

MORE POLLUTION EQUALS MORE ASTHMA

A study led by the Hospital del Mar in Barcelona found that inhibiting a protein, the galectin-1 (Gal-1), in mice with pancreatic cancer resulted in increased survival, tumors with slower growth rate, less aggressiveness and decreased metastasis, given that the immune system surveillance is restored and able to recognize and reject tumor cells. The study, recently published in the journal PNAS (Proceedings of the National Academy of Sciences of the United States), states that inhibiting this protein could be the first effective treatment to slow down the progression of the most common type of pancreatic cancer, the pancreatic ductal adenocarcinoma (known as PDA).

The galectin-1 (Gal-1) could slow down the development of this type of cancer (diagnosed in 85% of cases), which is very aggressive and has no curative treatment. This study is the entry point to further research which could validate this alternative in humans.

It’s estimated that up to 38% of childhood asthma is attributed to air pollution.

A research team at the Institute of Global Health of Barcelona (ISGlobal) and the Institute for Transport Studies at the University of Leeds have analyzed the impact of exposure to nitrogen oxides (NOx) gases, which are among the air pollutants, in the development of childhood asthma. The study published in Environment International gathered data from four other different models related to traffic emissions, atmospheric dispersion, and studied their impact on health status in Bradford (UK). This allowed researchers to trace the entire chain of impact, from the sources of air pollution to the pathways by which it affects the children’s health. The model estimates showed that 12% of annual cases of childhood asthma could be attributed to air pollution related to traffic. The conclusion is that policies should be designed to reduce the impact of air pollution derived from traffic focusing on volume, type of traffic, and exhaust gas and emissions.

SOURCE: ARTICLE “DISCOVERY OF THE FIRST EFFECTIVE TREATMENT FOR PANCREATIC CANCER.” PUBLISHED ON THE WEBSITE ANTENA 3. APRIL 2018.

SOURCE: ARTICLE “UP TO 38% OF CHILDHOOD ASTHMA IS ATTRIBUTED TO AIR POLLUTION.” PUBLISHED ON THE WEBSITE OF SINC AGENCY. MARCH 2018.

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MEDICAL ADVANCES

WEARABLE TECHNOLOGY TO MONITOR HEALTH

CONSUMPTION OF ANTIBIOTICS MAY INCREASE UP TO 200% IN 2030 A new study led by the Center for Disease Dynamics, Economics and Policy (CDDEP) with headquarters in Washington, examined the trends in antibiotics use in 76 countries, between 2000 and 2015. For this, scientists from institutions such as the School of Medicine at the Johns Hopkins University, the University of Baltimore and the University of Antwerp in Belgium used data from pharmaceutical sales in order to study the consumption of antibiotics in 76 countries during those 15 years.

The results revealed that the daily doses increased by 65%, going from 21,100 to 34,800 million defined daily doses (DDD, a standard measure for the consumption of antibiotics). Likewise, the antibiotic consumption rate increased by 39%, going from 11.3 to 15.7 DDD per 1,000 inhabitants/day especially in low- and middle-income countries. Thus, experts estimate that the use of antibiotics may grow up to 200% in 2030. Antibiotic resistance is a major threat to global public health, since it’s rapidly extending throughout the planet. The report stresses the need for a global monitoring program on antibiotic resistance and policies to reduce their unnecessary use.

SOURCE: ARTICLE “CONSUMPTION OF ANTIBIOTICS MAY INCREASE UP TO 200% IN 2030” PUBLISHED ON THE WEBSITE OF SINC AGENCY. APRIL 2018.

Wearable devices are the biggest innovation in technology since the creation of the smartphone. Watches and smart glasses, bracelets and shoes with activity trackers and wifi are some examples of the segment that will sell 34 billion USD by 2020, according to a forecast made by CCS Insight; this opens up a universe of possibilities for the health sector by its capacity to record temperature, muscle activity, percentage of body fat, and heart rate. This technology’s design allows it to be used as a clothing or accessories, and is becoming more popular to record and monitor users’ health through sensors operating in contact with the skin. For example, patients using these devices to monitor their body and sending information to their doctor facilitate the implementation of continuous monitoring to provide preventive care, this can also reduce the costs of healthcare, as indicated in a chapter of the book Wearables: Fundamentals, Advancements and a Roadmap for the Future, from researchers Park, Chung and Jayaraman.

Currently, Pfizer Pharmaceuticals Inc. has developed wrist monitors for patients with diseases such as fibromyalgia and hemophilia that facilitate the input of daily pain levels and monitor physical activity.

SOURCES: DR. DIEGO FORERO, GENERAL MANAGER OF PFIZER’S BRANCH IN COLOMBIA AND VENEZUELA. APRIL 2018.

SUNGMEE PARK, KYUNGHEE CHUNG AND SUNDARESAN JAYARAMAN, CHAPTER 1.1 - WEARABLES: FUNDAMENTALS, ADVANCEMENTS, AND A ROADMAP FOR THE FUTURE, IN WEARABLE SENSORS, ACADEMIC PRESS, OXFORD, 2014, PAGES 1-23, ISBN 9780124186620, HTTPS://DOI. ORG/10.1016/B978-0-12-418662-0.000015. (HTTPS://WWW.SCIENCEDIRECT. COM/SCIENCE/ARTICLE/PII/ B9780124186620000015)

MAGNESIUM USE AGAINST DEPRESSION A nutritional analysis from a research team from the Center for Clinical and Translational Science at the Larner College of Medicine, University of Vermont, published in the scientific journal Plos One revealed that 248 mg of magnesium per day produced a surprising decrease in symptoms of depression. This feature is an addition to its other nutritional benefits, such as helping to prevent mineral deficiencies and chronic diseases, and benefits for cardiovascular, brain and kidney health.

The research consisted in open-label, blocked, randomized cross-over trial involving adults with symptoms of mild to moderate depression, with scores of 5-19 in the Patient Health Questionnaire -9 (PHQ-9). The supplementation during six weeks with magnesium chloride decreased the PHQ-9 scores by a statistically significant value of 6.0 points.

The anxiety disorders measured with the scale for Generalized Anxiety Disorder (GAD-7) also fell by 4.5 points, regardless of age, sex, or baseline depression score or use of pharmaceutical antidepressants.

The subjects taking antidepressants simultaneously tended to experience greater reduction of symptoms. The improvement was evident after two weeks of starting the supplementation.

SOURCE: ARTICLE “STUDY: MAGNESIUM FOUND TO TREAT DEPRESSION BETTER THAN ANTIDEPRESSANT DRUGS.” PUBLISHED ON THE WEBSITE REALFARMACY.COM. JUNE 2017.

TECHNOLOGY AND MEDICINE FOR THE FUTURE OF AN INSTITUTE

SOURCE: JOHNSON & JOHNSON MEDICAL. 2018.

8 MAY 2018

To continue with its work in education, the organization Johnson & Johnson has introduced the Institute for Continuing Medical Education in Latin America, the Johnson & Johnson Institute (JJI), in São Paulo (Brazil), which will be focused in delivering training in new technologies to physicians, surgeons, nurses and other healthcare professionals of the region.

The JJI offers more than 250 programs in 20 medical and surgical specialties, as well as the entire infrastructure needed for professional practice in procedures such bariatric and metabolic surgery, colorectal cancer, osteoporosis and osteoarthritis, electrophysiology and endometriosis. It has seven conference rooms that can be subdivided, a surgical simulation lab, four laboratories with seven surgical stations and an auditorium for 126 people.

“Besides being a center of reference with all physical and technological infrastructure for the practical training of surgical and ambulatory procedures of last generation, the JJI also offers access to continuing education for those who are far from the Institute, through the program “Care for the box”, which offers modular courses delivered through surgical stations and a simulator that are transported to other cities” says Elisabete Murata, the director. This program is already running in Colombia and aims to promote the adoption and practice of laparoscopic surgery.

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HEALTH UP TO DATE

ON THE WORLD CUP AND PHYSICAL PAIN

SCIENCE, experts and fans gather around one goal: their stars’ well-being The World Cup begins and 32 teams with over 700 players will fight for the beloved trophy, and while nobody wants an injury, this is an inherent risk to the profession. Fortunately, current sport sciences offer important alternatives to prevent and treat injuries.

10 MAY 2018

O

n June 14th, at the Luzhniki Olympic stadium in Moscow, the World Cup FIFA Russia 2018 will begin with the match between Russia as the host and Saudi Arabia. With the referee’s first whistle starts the excitement that paralyzes planet Earth, but it also immediately activates alarms and protocols in order to provide medical care with the highest quality.

This includes, as FIFA remarks, “first aid and emergency assistance available for participating teams, players, delegations and spectators”. The preparation for these issues began in 2016 with workshops for the medical officers of each site and the doping control officers (DCO), a programme that was tested during the Confederations Cup 2017.

In soccer, these protocols play an important role since competition increases the risk of injuries during the game. While “most injuries are minor, with sprains and contusions as the most frequent ones”, there are also serious injuries “and it’s important to know how to recognize them in order to provide immediate assistance”.

from Cameroon who played in the match against Colombia during the 2003 Confederations Cup, a very sad and famous case, especially for Colombians for its implication.

In such cases, sudden death can occur due to different reasons, like unsuspected conditions since it’s believed that athletes are healthy people without cardiovascular risks, which isn’t necessarily the case.

“The existence of previous clinical conditions plus the efforts during competition force the body to huge exertions that can lead to death. One can suspect that some athletes may have structural or electrical cardiac abnormalities, either congenital or acquired (hypertrophic cardiomyopathy, arrhythmogenic right ventricular dysplasia, abnormal implantation of coronary arteries, aortic stenosis, Brugada syndrome, Marfan syndrome, myocarditis, asthma, heat stroke, long QT syndrome, among others) or prohibited substances abuse. Often, no pathological cause can be determined in the autopsy”, explains doctor Gonzalez.

MUSCULOSKELETAL INJURIES EXTREME ALERT

Photos: © 2018 SHUTTERSTOCK PHOTOS

The most serious risk that soccer players face is sudden death, as the sports physician Hernando Jaime Gonzalez explains, just like it happened to Marc-Vivien Foé, the player

The anterior cruciate ligament injuries are also common. This topic also brings us painful memories because it was the kind of injury that Radamel Falcao Garcia, forward and captain of the Colombian National team, plus goal scorer and idol, suffered and drew him away from the World Cup in Brazil 2014.

In January 22nd of that year his team, Monaco, was

MAY 2018 11

HEALTH UP TO DATE

Regenerative medicine is currently gaining popularity among sport physicians, physiatrists and orthopedists, since it facilitates and speeds up tissue recovery thanks to the application, among other therapies, of growth factors.

facing the MDA Chasselay and in a fortuitous move he was hit by the defender Soner Ertek who caused him the traumatic event.

It is very clear that since soccer is a sport of physical contact, playing it exponentially increases the risk of contusions, muscle injuries and tears, especially of the hamstrings, and sprains of the knee or ankle; sometimes there is head trauma, or it can also happen that players use different kinds of cleats according to the characteristics of the field to get a better grip and these can get stuck in the ground so that when the player turns, causes the rupture of the anterior cruciate ligament or of the meniscus in the knees.

Dehydration is another risk. Those who do not hydrate well enough can suffer an episode of abrupt low electrolytes levels, which can lead to death if severe.

PREVENTION AND INNOVATION TO ACT FAST Nowadays, sports medicine presents remarkable advances in clinical practice, diagnosis and practical application of strategies for prevention, treatments

12 MAY 2018

A DEFIBRILLATOR AT HAND Enrique Melgarejo, cardiologist and president of the Colombian Society of Cardiology, explains that the causes of sudden death can be many but the “most frequent is hypertrophic cardiomyopathy, common under age 35.

In this condition, the heart develops in a disorganized way; ventricles are enlarged causing an obstruction that blocks the outflow of blood. When the myocardial oxygen demand increases and there is a long-term depressed systolic function, a huge physical exertion is established with an increased heart rate, catecholamines secretion and oxygen consumption, predisposing to arrhythmias.”

Its origin is genetic, “it can be due to a mutation with autosomal dominant inheritance pattern.”

What is important, state doctors Melgarejo and González, is that athletes get complete assessments and rigorous follow-ups by multidisciplinary teams.

Additional good news is an approach that can be effective in some cases, this is to always have defibrillators at hand which is routine in many countries. In Colombia, the 1831 Act of May 2nd, 2017, states the “mandatory use, allocation, arrangement and access to automated external defibrillators (AED) in basic and advanced ambulances, as well as in spaces with high influx of public, such as sports arenas, both public and private: stadiums, coliseums, sports halls, gyms, clubs, synthetic courts, parks, lanes and high-performance training centres.”

“If a person shows signs of sudden death and defibrillation takes place within the first two minutes (according to the AHA guidelines for the prevention of sudden death, the defibrillator should be used in the first two minutes from the onset of symptoms. After 4-5 minutes the probability of survival is less than 25% and after 10 minutes is 0%) the person can be saved without sequelae; shocks can be delivered up to seven minutes maximum, but after that time a cardiac arrest develops and the person may be permanently injured or die” explains Dr. Melgarejo.

and rehabilitation. For example, programs have been designed for injury prevention and physical preparation that without doubt help to reduce risks.

However, a reckless move from an opposing player or a bad fall that causes an injury, among other possibilities, is inevitable; even more fortuitous would be the case of a player who dies due to a strong chest trauma.

“The treatment varies greatly depending on the nature of the injury”, says Dr. Gonzalez.

Among the most recent developments, is the contribution of regenerative medicine, which allows applying platelet rich plasma, growth factors and hypertonic dextrose (prolotherapy) to injured sites, preferably guided by ultrasound.

Regenerative medicine, which is greatly based on the injection of growth factors or substances that stimulate their production to facilitate and speed up the recovery of tissue, is currently gaining popularity among sports physicians, physiatrists, orthopedists and other specialists related to the musculoskeletal system, according to the records of the American Association of Orthopaedic Medicine (AAOM), an institution that pioneered on this issue.

Dr. Gonzalez adds that the AAOM has already developed guidelines about this and it recommends that in many cases the meniscus should not be removed when injured, instead, a regenerative treatment should be applied in the medial collateral ligaments and the ligaments surrounding the meniscus to strengthen and recover them, or rehabilitate them, in order to avoid surgery. However, surgery is imminent is certain cases.

Obviously, there is a situation that cannot be altered and is worth remembering what was attempted with Falcao. “It was said the recovery period was going to be of eight months or a year, then that it could be of six months and some even talked about only four months, which was what the whole country hoped for, but very little can be done against nature’s own healing process and timing. One can help a little with the regenerative aspect to reduce the time it takes, but nothing more” says the sports physician.

FIFA TIPS When facing an injury, FIFA recommends: 1. Ensure that there is a full recovery. Returning to play too soon is risky because the body is not yet able to cope with the stress.

2. Use appropriate protective equipment such as shin guards to protect the legs of possible bone fractures during training and matches. Goalkeepers should wear padded clothing to protect hips, elbows and shoulders (knees during training), as well as proper gloves.

3. Fair play: respect the laws of the game. Dangerous actions that may cause serious injuries are prohibited, such as thrusting your elbow outwards in head duels.

4. Do protective exercises regularly. The body has natural defense mechanisms against injuries that can be trained and strengthened. FIFA has the programme “11+ - a complete warm-up to prevent injuries” which includes “10 evidence based or best practice exercises”.

SUGGESTED READINGS 1. Maron BJ, Epstein SE, Roberts WC. Causes of sudden death in competitive athletes. J Am Coll Cardiol. 1986;7:204-14.

2. Spirito P, Seidman CE, McKenna WJ, Maron BJ. Management of hypertrophic cardiomyopathy. N Engl J Med. 1997;30:775-85.

3. Marfan syndrome. Available at: https://www.mayoclinic.org/ es-es/diseases-conditions/marfansyndrome/symptoms-causes/ syc-20350782 4. Colombia. Congreso de la República. Ley 1831. Available at: http://es.presidencia.gov.co/ normativa/normativa/LEY%20 1831%20DEL%2002%20DE%20 MAYO%20DE%202017.pdf 5. Fundación Española del Corazón.

Síndrome de Brugada. Available at: http://www.fundaciondelcorazon. com/informacion-para-pacientes/ enfermedades-cardiovasculares/ sindrome-de-brugada.html 6. FIFA. Sports injuries. Available at: http://es.fifa.com/development/ medical/players-health/footballinjuries/how-to-prevent-injuries. html 7. FIFA. The 11: injury prevention programme Available at: http:// es.fifa.com/development/news/ y=2007/m=5/news=programaprevencion-lesiones-528200.html 8. American Association of Orthopaedic Medicine. Tear of the medial meniscus. Available at: http://www.aaomed.org/MedialMeniscus-Tear 9. Al-Khatib SM, Stevenson WG, Ackerman MJ, Bryant WJ, Callans DJ, Curtis AB, Deal BJ, Dickfeld T, Field ME, Fonarow GC, Gillis AM, Hlatky MA, Granger CB, Hammill SC, Joglar JA, Kay GN, Matlock DD, Myerburg RJ, Page RL, 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death,Heart Rhythm (2017), doi: 10.1016/j.hrthm.2017.10.036

MAY 2018 13

THE MEDICAL SPECIALTY Endocrinology

THYROID, diseases, increasingly diagnosed

T

he most recent report from Agencia Internacional para la Investigación del Cáncer (IARC), an entity of the World Health Organization and a member of the United Nations, reports a high incidence of thyroid cancer in countries such as Colombia (10,7 cases per 100.000 inhabitants), Costa Rica (12,6), Ecuador (16) and Brazil (14,4).

The reality is that “30 years ago, 5 new cases of thyroid cancer were diagnosed for every 100.000 people, but since 2010 the figures are about 10 new cases for every 100.000 people, in other words, the cases have doubled”, says Dr. Luis Felipe Fierro Maya, endocrinologist, member of the Asociación Colombiana de Endocrinología, Diabetes y Metabolismo (ACE)

14 MAY 2018

Photos: © 2018 SHUTTERSTOCK PHOTOS

The diagnosis of diseases such as hyper and hypothyroidism, thyroid nodules and thyroid cancer is increasing, according to global and national statistics.

Fortunately, progress has been made in their diagnosis and treatment, allowing for a timely monitoring of these pathologies, as stated by the Asociación Colombiana de Endocrinología.

Thyroid dysfunction is among the most common disorders of the endocrine system, with high prevalence worldwide and also associated with increased morbidity and mortality rates. and coordinator of the Oncology-Endocrinology Unit of Instituto Nacional de Cancerología.

The reasons are diverse and they are related not only to the existence of new cases, but also to the great developments in diagnosis, and therefore, with treatments options. It’s the same case with other thyroid-related diseases, which, according to ACE records, have high levels of prevalence and the tendency is to increase; such is the case of hypo and hyperthyroidism.

Other conditions, like endemic goiter, which, according to scientific reports, was the first health concern related to the thyroid gland, have been controlled in the country since the end of the last century, thanks, among other approaches, to salt iodization programs implemented by Ministerio de Salud y Protección Social as a strategy for the control of this issue.

Meanwhile, great progress has been made for the management of congenital hypothyroidism, a metabolic-endocrine alteration of this origin that is most frequently diagnosed in the newborn (1 for every 3 thousand-4 thousand live births) and a major cause of preventable mental retardation. This is done through the Programa de Tamizaje Neonatal del Hipotiroidismo Congénito (Resolución 412-Decreto 1544 and Resolución 3384 de 2000). Data from Instituto Nacional de Salud report that 400 children were detected with congenital hypothyroidism in the country in 2017 and in 2014, 600 children, most of which entered treatment programs.

HYPO- AND HYPERTHYROIDISM Thyroid dysfunction is among the most common disorders of the endocrine system, with high prevalence worldwide and also associated with increased morbidity and mortality rates, says John

MAY 2018 15

THE MEDICAL SPECIALTY Endocrinology

Jairo Duque Ossman, an endocrinologist member of the ACE. These disorders are categorized into two major groups: those related to the production of thyroid hormones, such as hypothyroidism and hyperthyroidism, and those derived from a structural problem, such as goiter and neoplasms, the former group being the most statistically representative.

It’s common to encounter poor production of thyroid hormones or a defect in the activity of their receptors, for example, “cases of hypothyroidism that may have various causes, such as iodine deficiency in some countries or the Hashimoto thyroiditis like in Colombia”, explains Dr. Hernán Yupanqui, scientific director of Fundación Colombiana de Obesidad (Funcobes). Other causes are “neonatal, due to a thyroid-extraction surgery and to some drugs”.

On average, up to 4% of the population has some degree of hypothyroidism, including the subclinical type, but only 0,4% has clinical hypothyroidism, states the ACE. As it happens with all thyroid diseases, hypothyroidism is more prevalent among women at a ratio of 4-10 per man, and it increases with age, as reported

16 MAY 2018

THYROID GLAND

by studies that indicate that 15-20 per cent of women over the age of 60 have hypothyroidism.

Regarding hyperthyroidism, states the ACE, it’s important to understand the actual problem, originated from an excess of thyroid hormone synthesis and secretion by the gland itself, as it’s the case in Graves disease, which is associated with physiopathological changes due to an excess of thyroid hormone, independently of its etiology. The main cause is Graves-Basedow disease, which affects 0,5% of the population and it’s associated with 50%-80% of all cases of hyperthyroidism.

THYROID NODULE AND CANCER

CANCER

Instituto Nacional de Cancerología (INC), in the third edition of the publication Incidencia, mortalidad y prevalencia por cáncer en Colombia, 2017, states that “41.366 prevalent cases of cancer were estimated for one year in Colombia; 18.458 in men and 22.908 in women. Among men, the most prevalent locations were prostate, colon-rectum and anus, and stomach. In women, breasts, cervix and the thyroid gland”.

Regarding the new cases, 29.734 were diagnosed in men and 33.084 in women, and the highest

INC (2017) records indicate that the highest incidence of thyroid cancer cases in Colombia were reported in women from Bogotá, Antioquia and Valle del Cauca.

incidence occurred in Bogotá, Antioquia and Valle del Cauca.

This does not necessarily mean that there are many more cases today, but factors such as, for example, “enhanced thyroid nodule detection capability thanks to the use of ultrasound as diagnostic test, allowing for more accurate detection of 20% to 65% of these cases. Before, it all depended on the physical examination, which allowed the detection of 4% to 7% of the cases of thyroid nodules or bumps”, says Dr. Duque.

These nodules are usually asymptomatic, but it’s important to detect and analyze them to determine whether they are malignant (between 5% and 15%) or benign (most of them), since they may cause thyroid dysfunction.

Precisely, “these new diagnostic methods have also allowed us to discover tumors that are around one centimeter in size, which could not be noticed before through the physical exam”, says Dr. Fierro.

Their frequency is higher in women. “In Colombia, there are about 8 cases in women with this type of cancer for every 100.000 people, compared to 1 or 2 cases in men for every 100.000 people”.

There is a great deal of influence of exogenous factors, “from obesity, for example, to radiation exposure and nuclear accidents; all this has somehow made an impact because the frequency of nodules larger than two centimeters has also increased, also being increasingly diagnosed than before”, adds the specialist.

Once the diagnosis has been confirmed, surgery is the curative treatment of choice. “A small group of patients will need additional radioactive iodine therapy to decrease the likelihood of relapse, and it’s estimated that more or less 10% of the cases could have metastatic compromise,” he continues.

Since not all metastatic diseases have the ability to capture iodine, for about 10 years now, a drug has

been available that must be administered with strict medical supervision and that halts the growth rate of cancer.

TREATMENT ADVANCES • Eharmacological sciences already synthesize and produce the tetraiodothyronine or T4 that patients with hypothyroidism need. Those who have hyperthyroidism take other kind of drugs.

• Thyroid hormones do not act directly through the T4 that patients ingest; the cell has a T3 receptor, which means that the T4 needs to be transformed, through deiodinases, into T3 which then enters the cell to perform its function in energy production and metabolic processes.

• In Colombia, the general physician, the family doctor, the psychiatrist or any other specialist may order a TSH or free T4 test. “Lately, we are suggesting to better measure TSH and free T4 because T4 in the blood binds to multiple proteins; this option allows you to study more effectively thyroid diseases”, says Dr. Yupanqui. And if what’s wanted is to rule out Hashimoto thyroiditis, “the thyroid peroxidase antibody (TPOAb) should be requested”, he concludes.

SUGGESTED READINGS 1. Asociación Colombiana de Endocrinología. Fascículos de endocrinología. Nº 2: tiroides. 2017.

2. Vargas H, editor.

Recomendaciones de la Asociación Colombiana de Endocrinología, Diabetes y Metabolismo para el diagnóstico y manejo de las enfermedades tiroideas. 2015.

3. American Thyroid Association.

Available at: https://www. thyroid.org/thyroid-information/ 4. Pregnancy and Thyroid Disease.

Available at: www.thyroid.org/ thyroid-disease-pregnancy/ 5. WHO. Fuentes y criterios de inclusión de los datos en la base de datos sobre la carencia de yodo. Available at: http://www. who.int/vmnis/database/iodine/ iodine_data_sources/en/ 6. Fernández C, et al. Conozca su cuerpo. Intermedio Editores.

7. Jácome Roca A. Aportes colombianos a la tiroidología.

Revista Colombiana de Endocrinología, Diabetes y Metabolismo. 2014;1(1).

8. Consenso colombiano para el diagnóstico y manejo de las enfermedades tiroideas.

Available at: http://www. actamedicolombiana.com/ annex/articles/04-99-06.pdf 9. http://www.cancer.gov.co/files/ fileros/incidence1.pdf 10. Pardo C, Cendales R. Incidencia, mortalidad y prevalencia de cáncer en Colombia, 2007-2011.

1ª ed. Bogotá, D.C.: Instituto Nacional de Cancerología; 2015.

11. https://www.endocrino.org.co/ wp-content/uploads/2015/12/ Perlas_en_Enfermedades_ Tiroideas.pdf

MAY 2018 17

Photos: PERSONAL FILE

THE MEDICAL SPECIALTY Endocrinology

18 MAY 2018

EDGARD NESSIM DAYAN, MD

Passionate about the depths of

ENDOCRINOLOGY Contact with patients and with future endocrinologists is also part of his job, always thinking about contributing to the solution of problems within this specialty that affect Colombians. Diabetes, thyroid cancer and thyroid nodule, are some topics he has studied.

D

r. Edgard Nessim Dayan found a way to contribute to the development of the culture of health and prevention through research, university teaching, talks for patients and colleagues, and through the design of an educational program on diabetes for patients and their family which was founded 20 years ago in the Centro Médico Imbanaco.

It’s not in vain that he’s one of the most prominent physicians in southwestern Colombia and throughout the country; a passionate man and concerned for his profession and everything that has to do with endocrinology, because, although he specialized in cancer and thyroid surgery, there are many issues he cares about.

The list includes the most common endocrine diseases, like those related to the thyroid glands and the pancreas: hypothyroidism, hyperthyroidism, thyroid cancer and diabetes. “I’m concerned about the current management of thyroid nodules, because of the excesses, and the poor prevention on de development of diabetes and the management of its chronic complications”, affirms Dr. Edgard Nessim Dayan, physician from the Universidad del Valle, internist from the same institution and endocrinologist from Universidad Nacional de Colombia.

It is estimated that thyroid diseases are increasingly diagnosed. Why is this?

As knowledge reaches more doctors, diseases are increasingly diagnosed; it’s the case of hypothyroidism and thyroid cancer, we might say that it is a global phenomenon. Now we have the commitment of regulating this.

The increased registration of hypothyroidism is due in part to the increased number of TSH tests and the

refinement of its interpretation. With regard to thyroid cancer, the great aid in its detection has been the increased use of thyroid ultrasound and, likewise, in its interpretation.

Thyroid cancer is increasing, mainly among the female population, what is the actual situation?

As I mentioned, thyroid ultrasounds have allowed for more observation of thyroid nodules; thyroid cancer increased thanks to the possibility we had in performing biopsies to analyze and study nodules under 1 centimeter (micrometers).

In addition, women have always had the highest prevalence of thyroid conditions, in comparison with men.

Furthermore, we must note that, in addition to the ability of making a timely diagnosis of the disease, there is currently a trend to be more conservative with these thyroid nodules and experts’ protocols are being implemented for its management in order to reduce the unnecessary surgeries.

Fortunately, there are also advances in medicines and surgeries?

Yes, of course. Much progress has been made in the development of new drugs for the control of diabetes and of hormone-secreting pituitary tumors, which, along with new techniques in neurosurgery, regulate its production.

Type 2 diabetes remains as the main challenge, which is related to a universal problem: obesity. And this is of great concern to specialists because of the difficulty to prevent it and the lack of medicines for its

MAY 2018 19

THE MEDICAL SPECIALTY Endocrinology

A MASTER IN EVERY WAY Dr. Edgard Nessim Dayan was born in Cali, he studied medicine at Universidad del Valle (UV), internal medicine also at the UV and endocrinology at Universidad Nacional de Colombia.

He combines on a daily basis his passion for this discipline with education, as professor of internal medicine and endocrinology at the Universidad del Valle, and he is also head of the Diabetes Program at the Centro Médico Imbanaco, institution which he joined in 1998.

Doing research is essential to his life and, for that, he never misses a chance to participate in projects within the different thematic related to endocrinology, some of them like the one conducted on the “Study of usefulness of fine needle aspiration cytology for the diagnosis of thyroid diseases in 400 patients” that earned him a research prize awarded by the Colombian physicians living in the United States.

Currently, he is working in the study “Discovering treatment reality of type 2 diabetes in real world”.

He’s also a happy husband and father of two daughters, both professionals, and when time allows for it, he doesn’t hesitate to enjoy his favorite sport, tennis, and delicious seafood or Arabic meals.

control. Bariatric surgery became the solution, a very expensive practice for health systems.

As a researcher you have made several contributions in areas such as cancer and thyroid surgery. Which are these contributions? What motivated you to pursue this field?

The topics of thyroid nodules and cancer interested me since the training in internal medicine and then in endocrinology. In Hospital Universitario del Valle and the Universidad del Valle, teachers of pathology and the area of endocrinology developed several projects of global interest about the prevalence of thyroid cancer in autopsies and the supplementation of iodine in the diet. Another research project demonstrated the poor value of the thyroid scintigraphy with iodine or technetium to help detect thyroid cancer and now we work with a multidisciplinary team in Centro Médico Imbanaco to implement a management protocol that is appropriate for thyroid nodules and cancer.

Are you researching also on diabetes?

Yes. It’s a global work on the “results of diabetes control with the current use of medications in

20 MAY 2018

“At the moment we are conducting a global study on the ‘Resultados del control de la diabetes con el uso actual de medicamentos en la vida real’”.

actual life”; an investigation lasting several years that aims at establishing and knowing the impact of our practice, educational programs, the patient’s compliance and the medications (without the intervention of protocols) in the results of the control of the disease.

How do you evaluate the specialty of endocrinology in the country? We have made great strides in some areas, it’s even said that we are leaders.

In recent years, the area of endocrinology has had a major expansion as a subspecialty.

It’s exercised by pediatricians, internists and gynecologists, and each has its scientific associations carrying out academic activities related to updates for their colleagues.

We, the internists, have the Asociación Colombiana de Hospitales de Endocrinología, Diabetes y Metabolismo (ACE), which carries out an essential work for patients.

The success of the association is due precisely to how active it is through educational programs, conferences, scientific publications, and national and international congresses.

Moreover, getting personally involved with teaching in the university and engaging with the community through information and prevention programs (diabetes) is an important complement to everything that has been done.

The challenge?

The challenges are to maintain good practices, train new high-quality endocrinologists and distribute their activities throughout the country, in order to avoid creating unsatisfied or saturated areas.

What advice can we give (to doctors and the general population) to reduce the impact of these diseases, especially those in which lifestyles or environmental factors have such a big impact?

Without a doubt, all the endocrine and non-endocrine diseases are associated with our lifestyle: diet, physical activity, harmful habits, etc... There are two current trends, first, there is the use of organic products without preserving agents or spraying; and second, the decreased use of unnecessary antibiotics. The former case is due to a manifestation of “disruptive agents” or substances that change vital cellular information; in the latter, the composition of our intestinal microbiological environment is transformed, predisposing us to diseases.

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RISK MANAGEMENT

SELF-CARE among healthcare teams: a 24/7 need

Being a healthcare professional does not generate immunity against the risk of suffering a preventable chronic disease, thus, they must address this issue and take care of themselves, which means a call to save “not only others’ lives” but their own as well. This is the message that Coomeva Medicina Prepagada wants to transmit to their providers through the programme “Self-care is self-love”.

22 MAY 2018

V

arious studies and surveys have revealed that physicians and, in general, healthcare staff do not care– excuse the redundancy–for their own health as it should be and some of them are exposed to even greater risks of stress, anxiety and burnout.

For example, in January of this year, the website Medscape from the United States published the results of a survey with data from 15 thousand physicians from 29 specialties. They found that 42% of physicians (6.300) reported burnout syndrome o work-related exhaustion, with higher levels among women and specialties like intensive care, neurology and family medicine.

To counteract this situation, considering the evident concern for the well-being of those who are responsible for caring and saving others’ lives, and based on very well-structured risk management policies, there are current strategies and programmes aimed at promoting self-care among health workers like the one form Coomeva Prepaid Medicine, which uses the campaign “Self-care y self-love” to motivate healthcare staff to protect their own health and minimize risks.

“We are aware that, as said in a popular phrase, “words convince, but example draws” (lead by example), we need to work on leading our members towards a healthier life, then they will draw patients in the same path. We do this in two ways: with coverage plans and special rates for providers, so that they themselves are beneficiaries of the health risk management model. And, secondly, our best professionals carrying out the “Self-care is self-love” within their lifestyles are the mentors, lecturers or leaders of workshops, talks and calls-to-action addressed to our affiliates to deliver current information on these topics,” explains Dr. Julian Adolfo Villegas Gómez, national chief of Health Risk Management of Coomeva Medicina Prepagada.

Photos: © 2018 SHUTTERSTOCK PHOTOS

FAVOUR YOUR MENTAL AND PHYSICAL HEALTH In addition to the health risks that people in general are exposed to, according to their life cycle, healthcare professionals are exposed in their daily practice to an environment that make them more susceptible to the most harmful agents: “On one hand, there is the biological risk of acquiring infectious diseases through contact with pathogens from the worksite; and, on the other hand, there’s the stress associated with intense, exhausting, long working hours. This situation, combined with physical inactivity, creates a favorable environment for

MAY 2018 23

RISK MANAGEMENT

Regarding physical and mental health, physician’s duties clearly do not generate immunity against diseases and, the worst thing is, doctors are known to be ‘spoiled patients’.

the development of chronic diseases, particularly cardiovascular diseases and those related to mental health, such as depression”, adds Dr. Villegas.

With regard to physical and mental health, their job clearly does not convey immunity to diseases and, worst of all, physicians are famous for being “bad patients.”

The literature is full of cases. An exploratory study, published in 2007 in Revista Med (15-2 edition)–official journal for scientific matters from the School of Medicine, Universidad Militar Nueva Granada–, developed by specialists and professors from the school, found shortcomings in the lifestyles of the professionals evaluated, mainly in a sensitive issue like engaging in physical activity, which in some cases is completely absent, more in nurses than doctors.

Spokespersons of the research team that did the follow-up manifest that this situation is disturbing since, as declared by the World Health Organization (WHO),

MORE AWARENESS ON BIOSECURITY Regarding exposure to pathogens, there’s arguably more awareness about it and the approach to these issues has evolved rapidly, as Adriana Alvarez Martinez says, president of the Association of Xaverian Bacteriologists (ABJ), who declares: “We have come far. In the ‘90s, just the fact of taking samples from a patient was a cause for concern. No one wanted to do it. Nowadays, with the guidelines and manuals on basic biosafety procedures and with better understanding of the physiology of diseases like HIV, as professionals working in these areas we are aware that, if done correctly and following the guidelines, we have no reason to get infected” Technological developments have pioneered in every process, from taking the sample with the syringe and pouring it in a test tube. The industry developed a closed system of vacuum storage which prevents

24 MAY 2018

even the smallest contact with blood.

It’s worth remembering that the Ministry of Health and Social Protection defines “biosafety” as the “preventive measures that aim to control the risks factors at the workplace derived from biological agents, physical or chemical, to achieve prevention of harmful impacts and ensure that the processes or products of the job will not attempt against the health and safety of health workers, patients, visitors and the environment.”

The different kinds of health insurers (EPS, IPS, ARL & EMP) have not only designed biosafety programmes, but they also have development manuals for their health professionals, providers

and collaborators o associated staff, within the different areas of medicine.

The WHO has also established guidelines on this topic and to reiterate the importance of the use of “methods to reduce exposure and prevent the transmission of infections, such as hand hygiene, protection barriers (high caliber gloves), minimal usage of sharp instruments (such as injection material), and the appropriate separation and elimination of sharp objects after being used.

The idea, stresses Dr. Villegas, is to mitigate the biological risk of communicable infectious diseases, “to adhere to security policies of clinical practice defined for each worksite”.

sedentary lifestyles are 1 of the top 10 causes of mortality and morbidity in the world, and in the study on the global burden of disease, physical inactivity represents “the fourth risk factor associated with overall global mortality.” Physical inactivity is responsible for 3.2 million deaths every year, according to the WHO. Another exploratory study developed by Universidad del Rosario, which surveyed 134 physicians, reports that 20.6% of the doctors claimed to have emotional exhaustion; an additional study published in the medical journal The Lancet concludes that, in general, healthcare staff have higher risks of stress due to their daily practice. The study states that facts like this predispose health professionals to depression, fatigue, extreme exhaustion, and having family problems in greater proportion than other members of their community.

This issue sets off alarms on the need to raise awareness about this matter in order to avoid other harmful habits as well, some deeply rooted in this community, such as the practice of self-medication or informal consultations among colleagues.

START AT HOME “The main challenge here is adherence to the actual medical recommendations. As said by popular slang, “example starts at home”. Public health and primary care policies emphasize the need of a GP or family doctor, but health professionals do not appear to have that role clear, thus, they tend to fall for self-diagnosis, self-medication or the informality among colleagues,” says Dr. Villegas.

In his concept, it is essential that health professionals get routine medical check-ups, according to their life cycle; hence, they’re invited to adhere to healthy lifestyles, following the recommendations on healthy diet, with a high consumption of fruit and vegetables; the need for adopting regular physical activity; avoid tobacco and alcohol; and lead a safe sex life. If a check-up is needed, “the right thing to do is to seek a qualified colleague, but not those who are close friends or with whom one shares sentimental or familial relationships, to avoid informality and subjectivity.”

With regard to stress and the risk of mental health disorders, it is imperative to try to achieve

a balance between working hours and family and personal time, and why not, even get an appointment with a psychiatrist, as explained by Dr. Juan Angel Isaac Llanos, specialist in psychiatry and president of Asociación Colombiana de Psiquiatría (ACP), which just launched the campaign “I also go to the psychiatrist” to eradicate the stigma ingrained in the community about the consultation with these professionals.

“To become a psychiatrist, I had to see one for almost two years, in order to resolve my internal conflicts and doubts, therefore, today I’m able to help patients properly and efficiently. Additionally, psychiatrists need to retake now and then consultations as patients, whether we’re in the psychoanalytic, the behavioral or the transactional school,” says the expert.

Even more so, the SCP spokesperson continues saying, any member of a health team with symptoms of stress, anxiety or depression “should make an appointment so that the psychiatrist can evaluate the signs and symptoms, make a good diagnosis and start an appropriate treatment”.

BIBLIOGRAPHICAL REFERENCES 1. https://www.medscape.com/ slideshow/2018-lifestyleburnout-depression-6009235#2 2. Sanabria-Ferrand P, González Q. L A., Urrego D. Estilos de vida saludable en profesionales de la salud colombianos. Estudio exploratorio. Revista Med. Facultad de Medicina Universidad Militar Nueva Granada. Bogotá.

2007. 15 (2): 207-217.

3. http://www.cgcom.es/ noticias/2015/10/15_10_09_ fpsomc_paime 4. Sansó N, Galiana L et al. Palliative Care Professionals’ Inner Life: Exploring the Relationships Among Awareness, Self-Care, and Compassion Satisfaction and Fatigue, Burnout, and Coping With Death. J Pain Symptom Manage. 2015 Aug;50(2):200-7.

Source: https://ww.ncbi.nlm.nih. gov/pubmed/25701688 5. http://apps.who.int/iris/ bitstream/handle/10665/75247/9 789243599250_spa. pdf?sequence=1 6. https://www.minsalud.gov.co/ salud/Documents/observatorio_ vih/documentos/prevencion/ promocion_prevencion/ riesgo_biol%C3%B3gicobioseguridad/b_bioseguridad/ BIOSEGURIDAD.pdf 7. https://encolombia.com/ medicina/guiasmed/ guia-hospitalaria/ medidas debioseguridadytecnicas1/

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RISK MANAGEMENT

D

r. Pere Gascón, a Basque tumoral immunologist, has once again put his finger on the sore and warned the world about how the current stress levels can become a costly bill for the population’s health.

The reason? The work of this specialist, a senior consultant at the Servicio de Oncología Médica del Hospital Clinic de Barcelona (Spain) and responsible for the Laboratorio de Oncología Molecular y Traslacional from the school of medicine of the Universidad de Barcelona, has confirmed the close link between inflammation, nervous system and cancer, a relationship that he has been studying since he suspected it 20 years ago.

The macrophages, which are responsible for phagocytosing foreign bodies and defending the body, when faced with the adverse effects of this inflammation-brain-cancer link, “they take the side of cancer” and “fibroblasts support them”.

This is the researcher’s claims after his thorough analysis.

A DANGEROUS REALATIONSHIP Cancer is basically a multifactorial disease, which means that “it needs the simultaneous occurrence of genetic, environmental and personal factors plus a cancerous agent, which has been identified for many types of cancers, for example, the hepatitis B and C viruses for liver cancer, cigarette smoking for lung cancer, asbestos for pleural mesothelioma, helicobacter Pylori for gastric cancer, etc.”, explains Dr. William Otero, professor of medicine, coordinator of Gastroenterology at the Universidad Nacional de Colombia, researcher and co-author of books about ‘mind and digestive diseases’.

Some important personal factors include eating habits such as not eating vegetables and fruits, or consuming products processed with nitrites and other preservatives. “Additionally, in recent years it has been found that stress, anxiety and depression may cause biological and immunological alterations that basically decrease anti-tumoral cell depression and also of immunological substances (cytokines) that usually eliminate permanently multiple cancer cells that emerge daily in the body”, adds the Colombian specialist.

Furthermore, “the production of certain hormones such as steroids, ACTH etc. is [also] modified. The interaction between the central nervous system and the immune and endocrine systems with the mental sphere has led to a new scientific discipline: psychoneuroimmunoendocrinology. The everyday

26 MAY 2018

Photos: © 2018 SHUTTERSTOCK PHOTOS

life expression is that people who have depression, anxiety or stress (distress, that is, chronic stress which is the harmful one) have higher risks for cancer. In the book La mente y las enfermedades digestivas we describe it in greater depth”, says the specialist.

This complex matter also involves epigenetics, as Dr. José Guillermo Ortega explains, a specialist in medical sciences and epigenetics, to whom “the way of how and where we live can determine, taking into account our daily ‘biological experience’, which epigenetic changes can take place in our genetic

Thoughts on the close relationship between

CANCER AND STRESS Being alert and knowing how to react to daily life situations is very important, but when this is not achieved properly and instead one lives in extreme distress, inflammatory processes and negative reactions can occur in our system leading to the development of tumoral lesions.

material, and these changes also act as a switch to determine how to activate or not our genes”. In the case of a stressful life, tumoral cells may get activated and generate cancer, which is “an instantaneous alteration in the smallest cellular universe; a mutant cell that multiplies into thousands of malignant cells that result in a tumor. In most cancer cases there are traces of stress”, Ortega explains.

Thus, the call is to strengthen policies to manage mental health disorders, especially stress, a strategy

championed by the World Health Organization (WHO), which not only has a Mental Health Action Plan 2013-2020, but has ratified that “mental disorders often influence other diseases such as cancer, cardiovascular and digestive diseases”. Moreover, the WHO led a mental health survey with 53 thousand people in 19 countries, including Colombia, concluding that “there is a relationship between mental disorders, such as post-traumatic stress disorder and depression, with cancer development”.

SUGGESTED READINGS 1. http://www.cancer.gov.co/files/ libros/archivos/,Manual 2. http://www.iets.org.co/ gpc2016/Documents/ Priorizaci%C3%B3n%20de%20 preguntas%20GPC%20Ca%20 de%20mama%2026102016.pdf 3. https://www.cancer.gov/espanol/ cancer/sobrellevar/sentimientos/ hoja-informativa-estres 4. http://apps.who.int/iris/ bitstream/handle/10665/ 178879/9789241565011_eng. pdf;jsessionid=9EA931C18A7E 26A64A 9C0B71E441BD9 F?sequence=1

MAY 2018 27

RISK MANAGEMENT

Macrophage

Granulocyte

Lymphocyte

CYTOKINE

Mast cell

Fibroblast Endothelial Cells

THE IMPACT OF CANCER Every year about 71 thousand new cancer cases occur in Colombia and it’s estimated that by 2035 around 150 thousand will occur, according to the data from Instituto Nacional de Cancerología; it’s a serious public health issue that leads to “the daily death of 95 people due to this cause”, according to the information in the Abecé del cáncer, from Ministerio de Salud y Protección Social.

Within the many factors that increase the risk of cancer, explains Dr. Jorge Téllez, the scientific director of Asociación Colombiana contra la Depresión y el Pánico, there is stress, but not the acute one, the “day-today stress”, when one has to wake up, work, assume some commitments, etc. That stress keeps the balance, one seeks to adapt and this provides wellness. The problem is chronic stress, meaning that the body is living to a level of maximum hormonal excitement, a situation closely related to the operation of the hypothalamus, which presents a state of maximum demand to generate a response for a prolonged period of time”, says the specialist.

Today we know that the hypothalamus is the coordinator of the hormonal response, adaptation processes, emotional state disorders and immune status; if it works at its maximum capacity, it will result in alterations.

28 MAY 2018

As a result, a person with high levels of stress cannot concentrate, has an accelerated heart rate, disturbed metabolic processes, “all this leads to a situation of insulin resistance, that is, the pancreas will be blocked, but it will definitely ask for food, will withdraw all the cholesterol that is stored in the liver and the person will be predisposed to an inflammatory condition, where interleukins, inflamatory factors, will be altered resulting in a metabolic problem: hyper-excitement; add to all of this the decreased concentration capacity. In summary, the person is maladapted, irritable and with a higher risk of cancer”, says the specialist.

In the opposite case, within the factors that influence the improvement of patients, the mind is also included.

“There is evidence that tranquility, joyfulness, enthusiasm and optimism can decrease the progression and growth of malignant tumors. The mechanisms of the beneficial effects of the ‘positive moods’ on the damage caused by cancer are still unknown; however, there is evidence that they operate by improving immune and anti-tumoral endocrine activity. Another indirect evidence is that antidepressants, for example, decrease the production of inflammatory substances by blood cells that protect against infections and biological aggressors, such as lympho-

cytes and neutrophils, and also eosinophils”, says Dr. William Otero.

In conclusion, because the body has no coping and solution-oriented strategies, it maintains defensive mechanisms against those negative situations, thus affecting the rest of the biological systems such as the circulatory, nervous, digestive and immune systems, which makes human beings more vulnerable to different diseases coming from the environment, says Beatriz Basabe Cruz, specialist in medical psychology and health, with a master degree in Psychology and emphasis on public health.

The solution is to promote among patients and communities, says the specialist Basabe, adequate healthy habits, that is, “maintaining a balanced diet that provides enough energy to respond to the different needs of the environment; eat at the right time, at least three times the day; sleep at least eight hours a day, since this process is one of the most important for the human being, because during the sleeping time the body manages to stabilize all the biological and cognitive mechanisms, and this prepares you for the activities of the next day; engaging in physical activity helps people activate different physiological functions, it detoxifies the body and allows the psychic structure to relax to then start other activities”.

EBM

ANTIDEPRESSANTS WORK: a meta-analysis on their efficacy and acceptability

Psychiatric disorders account for 22,8 % of the global burden of diseases and it’s estimated that currently more than 350 million people are affected by depression, which in turn leads to the use of antidepressants.

Their effectiveness in disease management has recently been reconfirmed, thanks to this metaanalysis developed in partnership with some of the most important universities in the world.

30 MAY 2018

W

orldwide health systems face a great challenge. It’s about how to contribute not only to the assessment, diagnosis, and care of those with mental disorders such as depression, but also how to improve their compliance to treatment; the challenge becomes even bigger when taking into account the stigma on a mental illness and the lack of confidence on antidepressants, occasionally blamed for causing addiction or not being as effective as expected.

These and other facts motivated an international research team, including experts from the Department of Psychiatry at the University of Oxford, in the United Kingdom; the University of Bern, in Switzerland; the University of Health and Science of Oregon, in the United States; and the University of Kyoto, in Japan,

Photos and illustrations: © 2018 SHUTTERSTOCK PHOTOS

All antidepressants were more effective than placebo in adults with major depressive disorder, according to the meta-analysis report published in The Lancet.

THE ABC’S OF THE STUDY

to analyze the use of antidepressants by more 116 thousand patients, hence, the biggest and most complete study until now was developed, it included 522 double-blind, randomized clinical trials comparing antidepressants with placebo or another active ingredient.

The main outcome, which has just been published in the British journal The Lancet, silences the dissonant voices that questioned the efficacy of these medications to treat depression: “All antidepressants were more efficacious than placebo in adults with major depressive disorder. Smaller differences between active drugs were found when placebo-controlled trials were included in the analysis, whereas there was more variability in efficacy and acceptability in head-to-head trials. These results should serve evidence-based practice and inform patients, physicians, guideline developers, and

The research about the efficacy and acceptability of antidepressants was based on a systematic review and network meta-analysis of randomized double-blind controlled trials with placebo and 21 antidepressants. “We searched Cochrane Central Register of Controlled Trials, Embase, LILACS database, MEDLINE, MEDLINE In-Process, PsycINFO, the websites of regulatory agencies, and international registers for published and unpublished, double-blind, randomised controlled trials from their inception to Jan 8, 2016.” “...antidepressants used for the acute treatment of adults (≥18 years old and of both sexes) with major depressive disorder diagnosed according to standard operationalised criteria.” researchers explained.

They did not include quasi-randomised trials nor incomplete trials or those that included 20% or more of participants with bipolar disorder, psychotic depression or depression resistant to treatment; or patients with a serious concurrent medical illness.

“Primary outcomes were efficacy (response rate) and acceptability (treatment discontinuations due to any cause). We estimated summary odds ratios (ORs) using pairwise and network meta-analysis with random effects. This study is registered with PROSPERO, number CRD42012002291”.

MAY 2018 31

EBM

policy makers on the relative merits of the different antidepressants”, states the report.

BEAR IN MIND...

• According to the researchers, psychiatric disorders account for 22,8% of the global burden of diseases. The main illness is depression, which affects people of all ages and social conditions and from every country. It causes mental anguish and impairs the ability to carry out simple daily tasks, and it affects relationships with family and friends, and overall work capacity.

• According the World Health Organization (WHO) estimates, more than 300 million people live with depression, an increase of over 18% between 2005 and 2015. In the Americas, about 50 million people were living with depression in 2015, around 5% of the population.

• In Colombia, the Mental Health Bulletin (March 2017) cites data from the National Survey of Mental Health 2015 (ENSM) and from the SABE Survey 2014-2015: “The ENSM 2015, showed that, among those who were 45 or older, 10.6% of women and 6,2% of men reported seven or more symptoms of depression.”

• The SABE Survey found that “the overall prevalence of symptoms of depression in older adults was 41,0%, in both sexes, and highlighted that from 60 years onward its prevalence decreases as age increases.”

• While even the most serious depression can be overcome with the right treatment, in the Americas, nearly 7 out of every 10 people with depression don’t get the treatment they need.

• Grouped in a number of classes of medications with slightly different action mechanisms, antidepressants are widely used for the treatment of major depressive disorders.

• Depression is also a major risk factor for suicide. “The WHO reported 800 thousand suicides in 2017 around the world; many could be prevented if we eliminate the stigma associated with mental illness, if we comprehend issues like depression and if patients have access to treatment”, stresses Dr. Juan Angel Isaac Llanos.

32 MAY 2018

The study compares the effectiveness and acceptability between drugs and placebo, as well as between the different drugs; the top five molecules with the highest criteria were ranked as a result of this analysis.

BETWEEN EFFICACY AND ACCEPTANCE LEVEL When considering which is the most effective, it can’t be said that either is, by far, the worst or the best, just that they’re better than placebos, and that other elements should be assessed like their tolerance, side effects and acceptability, with the latter now having major support from the published study.

The study compares efficacy and acceptability between medications and placebo, as well as between the different active ingredients. Taking this into consideration, the first five medications within the ranking is as follows: top 5 in efficacy: agomelatine, amitriptyline, escitalopram, mirtazapine and paroxetine. Top 5 in acceptability: agomelatine, citalopram, escitalopram, fluoxetine and sertraline.

Dr. Jorge Tellez, scientific director, of Asociación Colombiana contra la Depresión y el Pánico, emphasizes about the meta-analysis: “The most remarkable result is that all antidepressants showed to be effective, although not all work in the same way; some work on serotonin, others on dopamine, and even others work on 2 or 3 neurotransmitters; moreover, it is remarkable that an

EFFICACY OF ANTIDEPRESSANTS

ACCEPTABILITY OF ANTIDEPRESSANTS

(Response rate)

(Dropout rate)

Significantly in favour of active drug

Non-significant result

Significantly in favour of placebo

OR (95% Crl)

antidepressant such as fluoxetine, available and prescribed for over 30 years, remains acceptable and better tolerated, and that a new one, agomelatine which has been around for about 10 years, is so too”.

“If they are all effective, we need to ask ourselves which are better tolerated, which have fewer side effects, because people will likely want to take more of them, or will use them for a longer time without thinking how to discontinue them”, he adds.

Efficacy (responde rate)

OR (95% Crl) Acceptability (dropout rate)

Amitriptyline

2•13 (1•89-2•41)

Agomelatine

0•84 (0•72-0•97)

Mirtazapine

1•89 (1•64-2•20)

Fluoxetine

0•88 (0•80-0•96)

Duloxetine

1•85 (1•66-2•07)

Escitalopram

0•90 (0•80-1•02)

Venlafaxine

1•78 (1•61-1•96)

Nefazodone

0•93 (0•72-1•19)

Paroxetine

1•75 (1•61-1•90)

Citalopram

0•94 (0•80-1•09)

Milnacipran

1•74 (1•37-2•23)

Amitriptyline

0•95 (0•83-1•08)

Fluvoxamine

1•69 (1•41-2•02)

Paroxetine

0•95 (0•87-1•03)

Escitalopram

1•68 (1•50-1•87)

Milnacipran

0•95 (0•73-1•26)

FIRM FOUNDATIONS FOR MORE COMPLIANCE

Nefazodone

1•67 (1•32-2•12)

Sertraline

0•96 (0•85-1•08)

Sertraline

1•67 (1•49-1•87)

Bupropion

0•96 (0•81-1•14)

Juan Angel Isaac, president of Asociación Colombiana de Psiquiatría (ACP), highlights the fact that these studies and their results are favorable because they contribute to demystify and eradicate the stigma associated with mental health conditions, they also feature the importance of the appropriate treatment for those with any mental disorder like depression, whether it’s mild, moderate or severe.

Regarding chronic depression, the condition addressed by the study, the ACP specialist considers that having 21 medications with proven efficacy and acceptability will provide assurance to those patients who need to be treated, thus increasing treatment compliance. Even so, he insists, the diagnosis is key, as well as educating the patient and evaluating other concurrent conditions. “If patients have sleeping disorders, for example, we need to help them improve their sleeping habits, otherwise they won’t get better; they also need to understand that improvement is not achieved overnight, because antidepressants start working by the end of the second or third week of treatment, although they have effects form the beginning”.

Likewise, there is a need to go further and the goal of psychiatrists is not only that their patients stop being sad, feel cheered up and are able to sleep, “but that they can concentrate again, make decisions, have the same speed of performance they had before. It is a challenge that is raised from the management of depression”, says Dr. Tellez.

To achieve this, we must implement “every strategy available, like being clear about expectations regarding the medication, considering psychotherapy,

Votioxetine

1•66 (1•45-1•92)

Mirtazapine

0•99 (0•85-1•15)

Agomelatine

1V65 (1•44-1•88)

Vortioxetine

1•01 (0•86-1•19)

Vilazodone

1•60 (1•28-2•00)

Venlafaxine

1•04 (0•93-1•15)

Levomilnacipran

1•59 (1•24-2•05)

Desvenlafaxine

1•08 (0•88-1•33)

Bupropion

1•58 (1•35-1•86)

Duloxetine

1•09 (0•96-1•23)

Fluoxetine

1•52 (1•40-1•66)

Fluvoxamine

1•10 (0•91-1•33)

Citalopram

1•52 (1•33-1•74)

Vilazodone

1•14 (0•88-1•47)

Trazodone

1•51 (1•25-1•83)

Trazodone

1•15 (0•93-1•42)

Clomipramine

1•49 (1•21-1•85)

Reboxetine

1•16 (0•96-1•40)

Desvenlafaxine

1•49 (1•24-1•79)

Levomilnacipran

1•19 (0•93-1•53)

Reboxetine

1•37 (1•16-1•63)

Clomipramine

1•30 (1•01-1•68)

0•5

1•0 Favours placebo

2•5

2•5

Favours active drug

1•0 Favours placebo

0•5 Favours active drug

SOURCE: THELANCET.COM/JOURNALS/ARTICLE/PIISO140-6736(17)32802-7/FULLTEXT

lifestyle changes, cognitive strategies, and advising patients against thinking that the solution depends only on them, their self-control or willpower, as is often said. Depression is a disease that requires specialized treatment, sometimes with mood stabilizers (which were not included in the study) or antidepressants, or some combination of the two, and that may present again (remission). This is something that we need to assess and should work on”.

Fortunately it’s currently possible to measure whether the medications are having the desired effect. “The first assessment is subjective, obviously, but there are also scales and one can measure cortisol, prolactin, and vitamin D now plays a very important role because we started to identify very low levels among patients with depression and anxiety; C-reactive protein can also be measured, among others“, adds the expert.

SUGGESTED READINGS 1. http://www.thelancet.com/ journals/lancet/article/PIIS01406736(17)32802-7/fultext 2. http://www.paho.org/hq/index. php?option=com_content&v iew=article&id=13102%3Adep ression-lets-talk-says-who-asdepression-tops-list-of-causesof-ill-health&catid=740%3Apressreleases&Itemid=1926&lang=es 3. http://www.who.int/mental_ health/advocacy/investment_ paper_lancet_psychiatry_final. pdf?ua=1&ua=1&ua=1 4. https://www.minsalud.gov.co/ sites/rid/Lists/BibliotecaDigital/ RIDE/VS/ED/GCFI/ResumenEjecutivo-Encuesta-SABE.pdf 5. https://www.javerianacali.edu. co/sites/ujc/files/node/fielddocuments/field_document_file/ saludmental_final_tomoi_color. pdf

MAY 2018 33

RESEARCH REPORT

ENDOCRINOLOGY AS A VOCATION

IVAN DARIO ESCOBAR: life-changing lessons for chronic patients

IvĂĄn DarĂ­o Escobar, endocrinologist

Photos: PERSONAL FILE

Being a leading participant in the development of the clinical practice guidelines for the assessment of overweight and obesity has been one of his greatest achievements within the fields of research and education on this topic, aiming at improving the quality of life of people diagnosed with metabolic syndrome. He credits mass media with a primary role in disease prevention.

34 MAY 2018

H

aving a sister with type 1 diabetes, without a doubt, boosted Dr. Iván Dario Escobar’s interest for researching this disease. The outcomes from his work, based on clinical evidence from his studies, have allowed him to exemplify that despite the fact that a person is facing a chronic disease on a daily basis, the condition can be kept under control.

“My sister developed type 1 diabetes about 50 years ago but, due to permanent care, she has not suffered from any complications until today,” says the doctor, trying to spread a message to the entire population: “yes, it can be done.”

The how-to achieve this goes hand in hand with education. Hence, he considers that working with the communities is key, and in this sense he highlights the key role that mass media plays.

Dr. Escobar, what are your most recent research projects and contributions to the control of diseases such as diabetes and overweight?

In recent years, my biggest contribution has been to participate as a thematic leader in the development of clinical practice guidelines (GPC) for the prevention, diagnosis and treatment of overweight and obesity in adults (Sistema General de Seguridad Social en Salud, Guía para profesionales de la salud Nº 52, octubre de 2016). These GPC were developed based on the available scientific evidence until that date and with the contribution health professionals and methodology experts with the highest scientific qualities.

We need to encourage health professionals, health managers and different health decision makers in the country to implement these guidelines in order to reduce the burden of disease caused by obesity and its consequences, including diabetes.

How did you get interested in these issues?

As endocrinologists, besides studying subjects related to endocrine glands and hormones, part of our job is to address the most critical public health problems, such as obesity, diabetes and other metabolic diseases.

Just as I finished the fellow in endocrinology I got involved with the Asociación Colombiana de Diabetes (ACD), the institution where I worked for 18 years.

There, in addition to seeing people with this disease, I was able to carry out various research projects on new medications (now available) and studies related to prevention, education and health complications.

While the ACD was (and still is) an important center for education of patients and their family, something I carried out with great dedication and that has left me

The experience of having a sister with type 1 diabetes inspired him to dedicate his life to the thorough study of this complex disease and its origins; likewise, it inspired him to undertake thoughtful social work for his patients. great satisfaction were the courses for “diabetes educators” and physicians. More than 50 courses were delivered and this allowed that the ACD was promoted by the International Diabetes Federation as an international center for the training of diabetes educators.

I could also say that I have great interest in this issue because I have a sister with type 1 diabetes. A consequence of this interest is to study obesity, arguably its main cause.

In numbers: 90-95% of people with diabetes have the type 2, and 80% of these are overweight or obese.

What additional contributions have you made to medicine?

In addition to what I have mentioned, I consider that my greatest contribution to medicine, and to society in general, has been my participation and the activities I developed within different scientific societies, especially when I was president of the Asociación Colombiana de Endocrinología (ACE), then of the Federación Colombiana de Diabetes (FDC) and finally of the Fundación Colombiana de Obesidad (Funcobes).

MAY 2018 35

RESEARCH REPORT

During my presidency of the ACE, I consider that my main achievement was the development of the “Colombian consensus for the diagnosis and management of thyroid diseases,” published in the journal Acta Médica Colombiana.

Regarding the FDC, I consider myself one of their founders and I led the drafting of the foundation’s regulations. I was its second president (1999 and 2001) and its executive secretary until the year 2007. Something worth highlighting is that I organized, as president of the FDC, the 1st Colombian Conference on Diabetes and I started the “National Updating Course on Diabetes ACMI-FCD” which is still done (87 courses have been completed).

Finally, during my time as an executive in this institution, we worked with the Ministry of Health and Social Protection on the possibility that the EPS (healthcare companies) implemented diabetes teams, units or centers, along with education programs; we also oversaw that patients could be provided with the supplies required for their daily follow-up (basically glucose meters and test strips).

This was achieved several years later thanks to the ongoing work of the following presidents.

In Funcobes, I was president from 2011 to 2015, and then vice president in 2016. In addition to the Colombian conferences on obesity, we were able to deliver regional updating courses about

obesity and healthy lifestyles habits in association with Coldeportes and educational entities and local government.

“We were able to increase awareness about the seriousness and impact of diabetes and obesity on public health”.

Are there new diagnosis and treatment approaches for these diseases?

It is important to emphasize that there is higher awareness about both obesity and diabetes as serious public health issues. Governments, health systems, health programs directors, health professionals and the media are very oriented onto promoting healthy lifestyles.

There aren’t major changes in the diagnosis of diabetes. The body mass index (BMI) remains as the main parameter for diagnosing obesity, but it is also important to assess waist circumference: abdominal obesity is present if the it is greater than 90 cm in men or 80 cm in women, this being a very important risk factor for coronary disease.

Regarding the treatment of diabetes, of course there has been much pharmacological progress in recent years, with new analogue insulins and new oral or injectable medications, but the key and basis of the treatment still relies heavily on the adoption of proper diets and regular physical activity. These are essential habits for the entire population, for the healthy ones and for patients diagnosed with chronic illnesses.

BIKING TO THE OFFICE Dr. Iván Dario Escobar was born in Medellín, 62 years ago, along with another brother (twin). “I was born last, so I’m the youngest of 10 siblings (typical paisa family!)”, he says.

He studied general medicine and internal medicine at the Universidad Pontificia Bolivariana, and did his fellow in endocrinology at the Universidad del Rosario. After working for 18 years in the Colombian Association of Diabetes, 10 years ago he created the Institute of Diabetes and Endocrinology in Bogota. “The team includes a nutritionist, a psychologist, a licensed physical activity professional, a podiatrist and a diabetes educator. We assess and treat our different patients with an interdisciplinary approach.”

He had three children in his first marriage (Luis Carlos, Juan Sebastian and Ivan David), excellent roller in-line hockey players and members of the Colombian national team of the same sport. Currently, “I have a happy and harmonious relationship with Angelica Pinzon, and we’re close to getting married.”

36 MAY 2018

In addition to being a member of the Colombian scientific associations, he has belonged to the executive boards of international scientific associations, such as the Latin American Diabetes Association, the Latin American Thyroid Association and the Latin American Federation of Societies of Obesity; he has several publications about thyroid issues, diabetes, obesity and dyslipidemia, and has been guest speaker at multiple national and international conferences.

“I don’t have many hobbies or pastimes, but I must say I like biking and I try to bike to my office, at least twice a week. Patients love to see me arriving at the office in my bike! It also works as an example for my colleagues, since I’ve long promoted a program called “Médicos Caminantes”.

“I consider myself a happy person, a good father and lover of my career, which I represent with love and dedication. I’m also a good doctor, and I generally have good doctor-patient relationships. I like to study and keep myself updated.”

COOMEVA IN DATA

GENERAL MEDICINE CONSULTATION

183.722

TRIMESTER 2017-2018

TOTAL

SPECIALIST CONSULTATION TRIMESTER 2017-2018

40.613

35.812

34.959

APR./ JUN. 2017

JUL./ SEP. 2017

OCT./ DEC. 2017

JAN./ MAR. 2018

1.100.321

JAN./ MAR. 2017

TOTAL 200.510

223.798

229.727

229.537

JAN./ MAR. 2017

APR./ JUN. 2017

JUL./ SEP. 2017

OCT./ DEC. 2017

216.749

JAN./ MAR. 2018

SAO POPULATION

TOTAL

Medicina Prepagada

39.619

MARCH 2018

35000

100000

30000

91.306

80000

20000

60000

13.376 8.931

20000

29.648 12.101

13.453

TOTAL

215.784

INTEGRAL MEDICINE POPULATION

200000

SOUTH-WEST

0

COFFEE REGION

6

TOTAL

SOUTH-WEST

COFFEE REGION

CENTER-EAST

CARIBBEAN

1.859

CENTER-EAST

2.919

5000

36.098

40000

NORTH-EAST

7.520

NORTH-WEST

5.014

NORTH-WEST

15000

0

CEM POPULATION MARCH 2018

25000

10000

TOTAL

COOMEVA

CARIBBEAN

40000

42.497 29.841

MARCH 2018

150000 100000 50000

78.504 64.768 27.462

29.413 9.653

0

CARIBBEAN

CENTER-EAST

COFFEE REGION

5.967

17 INTERNATIONAL

NORTH-WEST

NORTH-EAST

SOUTH-WEST

TOTAL

MAY 2018 37

FROM COOMEVA CONNECTIVITY AND VANGUARD

Coomeva Medicina Prepagada:

READY FOR THE FUTURE New winds have arrived to the company, important changes that allow us to offer an optimal level of service, previewing the needs of our affiliates and providers communities, and to continue the path that leads to excellence.

C

oomeva Medicina Prepagada has ignited a new history for the organization, its allies and users.

This mission is supported by an innovative technological platform that is currently being implemented with the purpose of consolidating and making the organizational processes safer and more efficient; from the affiliation Photo: © 2018 SHUTTERSTOCK PHOTOS to our different programs to the rigorous monitoring of services in order to ensure maximum service satisfaction and risk QUICK AND FRIENDLY management, including the recruitment of VIRTUAL OFFICE allies, the configuration of the providers netOne of the most remarkable aspects of work and the easy processing of payments. this modernization is that the virtual office “Updating and modernizing the tech- offers greater benefits and possibilities to nological platform allow us to have reliable the provider: “It can be accessed with a sinand timely information on a permanent ba- gle password to update data, consult and sis”, argues Xiomara Iveth Campo, National download documents, such as account exDirector of Culture and Change Manage- tracts, file invoices, check or monitor their ment of Coomeva Medicina Prepagada. traceability and generate retention certiThanks to the launch of this transcen- ficates”, adds the director of Culture and dental strategy, all the company processes Change Management. are being automated and it’s intended that it can minimize errors in the flow of activ- BIOMETRIC DEVICE ities and access or availability of informaThe connectivity between users, altion, moving towards excellence in each lies and providers is a priority. Nowadays, service, regardless of how simple or com- Coomeva Medicina Prepagada keeps inplex it is. “We have developed a software novating within the health sector, thanks that allows us, besides the automation of to the application of a biometric mobile operations and the control of organizational device that facilitates the authorizations risk, to have commercial flexibility”, adds the and, in general, the whole management of spokeperson. both users and providers. The fingerprint

38 MAY 2018

allows for validation and verification of the identity and affiliation rights of the user.

“We pioneered in the health sector by working in collaboration with Registraduría Nacional del Estado Civil in the implementation of the new model of biometric authorization (fingerprint) for health care, which allows us to move forward in simplifying the operation with our providers and speed up the delivering of care to our users”.

GOODBYE TO VOUCHERS The changes will also reach the physical structures and components of the corporate visual branding. As a sample, the identification cards will have a new presentation and will enable the provider to have the necessary information from the user during the process of delivering a service.

Likewise, the service orders will also have a new design, as well as the forms for invoice annotations which are also renewed to enable a much better and rigorous debit and credit notes required for the billing.

“Acknowledging the voice of the providers, we deliver new and powerful tools, more flexibility in the processes and new channels of communication with our providers”, says Campo.

COOMEVA PROMOTES

ADVANCES IN THE RELATIONSHIP WITH OUR HEALTHCARE PROVIDERS

An enriching

EXPERIENCE! Photos: © 2018 SHUTTERSTOCK PHOTOS

The first results balance from the Healthcare Providers Management Model exceeded expectations with its achievements.

T

he relationship with healthcare providers in Coomeva Medicina Prepagada makes a difference due to characteristics such as trust and contribution to the development of a comprehensive care model.

It’s precisely for this reason that the results from the dialogue meetings with the healthcare providers from the various regions, which took place throughout 2016, proved to be much more positive and successful than expected. “These dialogues were key for the development of the new management model with the healthcare providers, as it itself was born from that initiative.” These are Martha Liliana Cifuentes claims, leader of Coomeva Medicina Prepagada Healthcare Providers Affairs Office. This office aims for the continuing improvement of the organizational model of Coomeva Medicina Prepagada and the optimization of its competitive

processes and corporate image. Likewise, it seeks to generate a higher sense of belonging with the institution among the almost 8,000 healthcare providers and professionals.

Among the first achievements made through this democratic exercise is the revision of policy rates to improve the agreements: the outpatient consultation rates were settled at 42% and surgical procedures and interventions at 64%, well above than the rates authorized for 2017. Additionally, this model has improved the response time and the process of searching for effective solutions during the delivery of services to users, through the strategy of “Shared Vision”, which promotes actions such as increased agility at the user experience points, effective management of complementary orders with Coomeva EPS, identification of users from the “premium” communities within the different applications to improve the value

proposition and definition of an alternative, sufficient network. The creation of the Vocation Plan is also worth mentioning, as it’s an exclusive benefit for linked professionals, also affiliated to the prepaid medicine from Coomeva through the Gold and Gold Plus programs, which aims to offer preferential rates and privileges to our healthcare providers and their family group.

We also awarded the Quality Prize for the Prepaid Medicine Healthcare Provider 2017 for the quality, efficiency and fidelity of 30 of our professionals and health institutions, linked to the national network of medical services. We will continue to transform the relationship with our network of Healthcare Providers to strengthen the bonds of trust and fidelity, which will enable us to continue to work towards the delivery of a comprehensive and familiar service for our users, full of memorable experiences.

MAY 2018 39

HUMANIZED MEDICINE

INTEGRATIVE MEDICINE,

a new and better approach to patients

The proposal to treat the individual needs of patients, including their genetics, lifestyle, the environment they live in and even their spirituality, is a concept that has already been the subject of public health policies in many countries worldwide. It’s the medicine of the future, some people say. In Guainía, Ministerio de Salud y Protección Social is running a pilot program.

T

he concept of integrative medicine seems to have reached its adulthood in the United States, Switzerland and the United Kingdom, to cite only three scenarios. Universities such as Arizona, Cleveland and Duke have designed integrative medicine programs that are aimed at healing, taking into account the complexity of the human being and relying on clinical evidence and tools of popular and ancestral wisdom.

Precisely, “the common ground is a reaffirmation of the importance of the therapeutic relationship; it’s also a perspective that accounts for the person and his lifestyle, and not only for their physical body; it’s

40 MAY 2018

about a renewed focus on healing and the willingness to use all appropriate, conventional and alternative therapeutic approaches”, explains Dr. Paola A. Medina Muñoz, anesthetist at the San Ignacio University Hospital (Bogotá) and specialist in Integrative Medicine from the University of Arizona.

This means breaking big paradigms in medicine while including all healing methods “such as acupuncture, massages, yoga, psychotherapy, meditation, herbal medicine, among others, that help to maintain the well-being of patients; also adding lifestyle changes, controlled sleeping hours and other factors,” explain specialists from Duke

Photos: © 2018 SHUTTERSTOCK PHOTOS

University’s Integrative Medicine Program in Durham, North Carolina.

These strategies aim to halt or lower the impact of chronic diseases, which, according to the Centers for Disease Control and Prevention, are “the cause of 70 per cent of all deaths in the United States and represent over $1.5 trillion in costs per year (75 per cent of all annual medical expenses)”.

ON BEING UNIQUE One of the principles of integrative medicine is to see the patient as a unique person who is immersed in a specific environment, with particular needs,

problems and expectations. Dr. Medina cites the importance of understanding that, for example, a woman with breast cancer, who is separated, eats bread and coffee every day, who is responsible for her children and takes care of her sick mother, does not have the same breast cancer as a woman who has no children, is happily married, comes from a wealthy family that supports her and who eats salmon and salad daily; “it’s also different if one has a dedicated spiritual practice and the other does not”.

It’s not that one woman is better than the other, rather, that each has different needs and hence the importance of providing them with what is known as

MAY 2018 41

HUMANIZED MEDICINE

Patient-centered care (PCC) is the vertebral column of integrative medicine and it’s based on the fact that human beings are a composed of spirituality, emotions and corporal systems operating in permanent synchronization with the former two components.

COLOMBIA IS ON THE RIGHT PATH “Integrative or holistic medicine is a reality and it’s redefining the notion of health and disease, which for us, stops being just a biological concept to become one that is social, cultural and historical, where the biological aspect is subsumed. In other words, health and disease cannot be seen as a purely biological problems, but rather, as integrated issues within the whole socio-cultural context that surrounds these conditions, which in turn have a definite influence on health and illness.” With these words, Dr. Gustavo Quintero, Dean of the School of Medicine of the Universidad del Rosario, highlights the importance of this new approach and how Colombia is going towards it.

Regarding the Universidad del Rosario, specifically its School of Medicine, he states: “This new concept and what it means is understood and practiced here, and, consequently, our programs have this clear tendency to unify the biomedical sciences with the clinics and the social and humanistic perspectives, within the context of public health. This school assumed that definition about 10 years ago and made it the basis for its curricula in a way no other medical school in our community has. We have led this fundamental trend for the transformation of health education,” says Quintero.

Another case is the Fundación Universitaria de Ciencias de la Salud (FUCS), which has a department of integrative medicine and alternative therapies, where therapeutic disciplines such as colon therapy, floral therapy, neural therapy and acupuncture have been introduced. Every day a more holistic approach is promoted and even an individual’s religion, faith and belief are topics of classroom deliberations.

Jorge Ernesto Cantini, associate professor of Plastic Surgery at the FUCS Medical School, explains that they also participate “in a program that will be the future for the Ministerio de Salud y Protección Social in terms of comprehensive care”.

It’s about the Comprehensive Model of Health Care (MIAS, in Spanish), which is currently being developed in the department of Guainía, and will be key to all the regions of the country. It integrates the knowledge of the allopathic medicine with the knowledge of the complementary medicines of indigenous communities channeled through the wisdom of their shamans.

This project is part of the Ministry’s Scattered Population Programme, it’s developed in collaboration with the Government of the Department of Guainía and it’s supported by the Inter-American Development Bank (IDB).

“It focuses on the individual, the family and the community; it responds to the needs of the department and its population to guarantee effective access to health services, in order to reduce the existing inequality gaps,” the specialist concludes.

42 MAY 2018

patient-centered care (PCC), a key approach used in integrative medicine, involving “patients in medical decision-making and self-management, coordinating and integrating medical care, providing physical comfort and emotional support, understanding the concept of disease and cultural beliefs of patients, and understanding and applying the principles of disease prevention that are appropriate for various populations”.

In Dr. Medina’s opinion, this aspect was missing from Western medicine, and it could be the answer to why some patients do not improve. “It might be because we are not assessing their emotions, environment, and exposure to toxins”.

THE PROCESS STEP BY STEP Integrative medicine and CPP have shown effective results in oncology, pediatrics and pain management, as reported by studies published by the National Center for Complementary and Integrative Health of the United States National Institutes of Health, a country that is betting on what they call ‘the medicine of the future’.

The World Health Organization (WHO) itself refers to the integration of traditional and complementary medicines (T&CM) with western medicine. Moreover, they launched the ‘WHO Traditional Medicine Strategy: 2014-2023’ to leverage the potential contribution of the T&CM to health, well-being, patient-centered health care and universal health coverage. The guide also aims to promote the safe and effective use of T&CM through legislation, research and integration of their products, practices and professionals in health systems, as appropriate; and to assist countries in identifying the best way to promote health and protect users who wish to use these products, practices and professionals.”

In Switzerland, for example, the Government established the Complementary Medicine Evaluation Programme (PEK, in German) and in 2009, “over 67% of the country’s voters supported the introduction of a new constitutional article on complementary and alternative medicine, resulting in some complementary therapies being reintroduced into the basic health insurance program available to all Swiss citizens”, as read in the WHO strategy.

In Sweden and Denmark, integrative medicine is growing every day, promoting complementary and traditional medicines, official ones, avoiding charlatans, in search of that comprehensive approach.

The United States, in addition to the work of universities such as the University of Arizona whose center for integrative medicine is championing the

transformation of health care, is undergoing changes in major areas through a unified and sustainable evidence-based approach. In 1991 the United States government founded the Alternative Medicine Agency, which became the National Center for Alternative and Complementary Medicines in 1998, and which changed its name again in 2014 to finally become the National Center for Complementary and Integrative Health. Additionally, the Society of Integrative Oncology, which develops protocols using evidence-based medicine, was created with the purpose of providing the best therapies to patients, and they have published guidelines for patients in general (2009) and for patients with lung cancer (2013), which include recommendations that “are not aimed to aid the treatment, instead, they are an integral part of it”.

All this means breaking paradigms and it’s not easy.

In Spain, according to the media, defamation campaigns against alternative medicine have been taking place, but gradually there has been improvements towards a greater understanding of the issue, there is even a policy project that aims to include alternative medicine as part of the comprehensive management of patients, supported by the WHO guidelines.

SUGGESTED READINGS 1. https://www.minsalud.gov.co/ sites/rid/Lists/BibliotecaDigital/ RIDE/DE/05-rias-presentacion. pdf 2. http://apps.who.int/iris/ bitstream/handle/10665/ 95008/9789243506098_spa. pdf;jsessionid=B3AAF119D8DAF3CEDA771A9F2A4C08AC?sequence=1 3. https://integrativemedicine. arizona.edu/about/definition. html 4. https://my.clevelandclinic.org/ departments/wellness/integrative/staff/integrative 5. https://www.dukeintegrativemedicine.org/ 6. https://www.mskcc.org/cancer-care/diagnosis-treatment/ symptom-management/integrative-medicine 7. https://integrativemedicine. arizona.edu/about/definition. html 8. https://my.clevelandclinic.org/ departments/wellness/integrative/staff/integrativehttps://www. dukeintegrativemedicine.org/ 9. https://www.mskcc.org/cancer-care/diagnosis-treatment/ symptom-management/integrative-medicine 10. https://www.minsalud.gov.co/ sites/rid/Lists/BibliotecaDigital/ RIDE/VS/PSA/anexo-4-documento-mias.pdf

MAY 2018 43

MERITS COOMEVA MEDICINA PREPAGADA REWARDS EXCELENCE

RED CARPET

for healthcare providers During the annual celebration of the Healthcare Provider Day, Coomeva Medicina Prepagada carried out the first version of the Quality Prize for the Prepaid Medicine Healthcare Provider (2017) which recognized and exalted the efficiency, quality and fidelity of 30 health professionals and institutions that excelled with their work.

A

key criteria: efficiency, quality and fidelity. In the end, 90 professionals managed to enter the list of nominees and 30 of them, those with the best scores, were awarded with the prize.

Awards were given to the following categories:

iming at promoting the best practices among our providers, as well as encouraging their commitment to deliver a comprehensive service to users, we created the Quality Prize for the Prepaid Medicine Healthcare Provider and held the first version last year.

The 7,811 health professionals linked nationally to Coomeva Medicina Prepagada are categorized by natural and legal figure (institution) within the services of comprehensive healthcare and oral health. This network of providers underwent a rigorous evaluation that accounted for three

Natural figure or person: • Surgical category • Clinical category • Oral Health Category Legal Figure or person: • Hospital category • Oral Health Category

The award ceremonies took place in Cali, Bogotá, Medellín, Pereira, Barranquilla and Bucaramanga; more than 1.200 providers attended to the event which was loaded with emotional moments from the entire medical community. This award will be granted every two years. With its creation, Coomeva Medicina Prepagada not only steps towards improving the service to his members, but also aims to strengthen the management model with healthcare providers, highlighting excellence through comprehensive and familiar care, creating memorable experiences.

CATEGORIES NATURAL FIGURE OR PERSON

CITY

SURGICAL

COMPANY

CLINICAL

ORAL HEALTH

HOSPITAL

ORAL HEALTH

NAME

SPECIALITY

NAME

SPECIALITY

NAME

SPECIALITY

Juan Carlos Erazo Vila

Urology

Olga Marcela Urrego Meléndez

Hematology/ Oncology

Julián Córdoba Mejía

General Odontology

Centro Médico Imbanaco

IPS Felipe Gutiérrez Zuluaga

Carlos Enrique Restrepo López

Obstetrics and Gynecology

Luis Alfonso Medina Ochoa

Internal Medicine

Amalia Castro Vélez

General Odontology

Clínica Las Américas

Centro Odontológico de Especialistas Brasilia SAS

Bogotá

María Cristina López Assmus

Oncologic Plastic Surgery

William Ricardo Cabra Cruz

Pediatrics

Luisa Estella Vergara Díaz

Periodontology

Clínica del Country

Clínica Protección Oral SAS

Bucaramanga

Edel Mary Afanador Quiñónez

Otorhinolaryngology

Heberth García Rincón

Biological Medicine and Alternative

Mónica García Gutiérrez

Oral Rehabilitation

Barranquilla

Juan Carlos Daza Hinojosa

General Surgery

Juan Luis Consuegra Asmar

Pediatrics

Nadima Chams Saad

Odontopediatrics

Clínica Norte

Soluciones Orales Blanco SAS

Pereira

Paola Andrea Orrego Zapata

Obstetrics and Gynecology

Luis Guillermo Rojas González

Gastroenterology

Édgar Hugo Moya Suárez

Orthodontics

Clínica Comfamiliar

Orthodiagnosticar

Cali

Medellín

44 MAY 2018

Gatech Importaciones EU

Congratulations to the winners!

SOUTHWEST REGIONAL. From left to right, Dr. Pascual Estrada, National Director of Health Coomeva Medicina Prepagada; Andrea Atehortúa, Executive of Management with Providers Southwest Regional-Coomeva Medicina Prepagada; Drs. Juan Fernando Rojas, Manager of Southwest Regional-Coomeva Medicina Prepagada; William Duarte, Medical Manager of Centro Médico Imbanaco; Olga Marcela Urrego, Hemato-oncologist; Felipe Gutiérrez, Specialist in General dentistry and Agent of IPS Felipe Gutiérrez Zuluaga; Julián Córdoba, Specialist in General dentistry.

CARIBBEAN REGIONAL. From left to right, doctors Carlos Alberto Barraza, Manager of Caribbean Regional-Coomeva Medicina Prepagada; Martha Blanco, Manager and Owner of Soluciones Orales Blanco; Juan Carlos Daza, Specialist in General Surgery; Juan Luis Consuegra, Pediatrician; Nadima Chams, Pediatric Dentist; Mrs. Kelly Patricia Caballero, Executive of Management with Providers Caribbean Regional-Coomeva Medicina Prepagada; Dr. Emma Ruth Corredor, Oral Health Chief of Caribbean Regional-Coomeva Medicina Prepagada.

NORTHEAST REGIONAL. From left to right, Drs. Paula Arévalo, Orthodontist and Manager of Gatech; Luisa Fernanda Quintana, Chief of Northeast Regional-Coomeva Medicina Prepagada; Hermes Jaimes, Gynecologist and Obstetrician-Endocrinologist; Mónica García, Specialist in Oral Rehabilitation; Edel Mary Afanador, Otolaryngologist; Leonardo Rangel, Agent of Clínica Norte de Cúcuta; Pascual Estrada Garcés, National Director of Health-Coomeva Medicina Prepagada; Lina Rueda, Chief of Oral Health Eje Cafetero RegionalCoomeva Medicina Prepagada.

EJE CAFETERO REGIONAL. From left to right, Valentina Flórez, Executive of Management with Providers Eje Cafetero Regional-Coomeva Medicina Prepagada; Drs. Adriana del Pilar Ospina, Chief of Oral Health Eje Cafetero Regional-Coomeva Medicina Prepagada; Paola Andrea Orrego, Obstetrician; Olga Lucía Caldas; Luis Guillermo Rojas, Gastroenterologist; María Mercedes Ramírez, Medical Director of Clínica Comfamiliar; María Eugenia López, Manager of Eje Cafetero Regional-Coomeva Medicina Prepagada; Luz Stella Quintero, Agent of Orthodiagnosticar Centro de Radiología Oral; Pascual Estrada, National Director of Health-Coomeva Medicina Prepagada; Édgar Hugo Moya, Orthodontist.

EAST CENTER REGIONAL. From left to right, Drs. Humberto Ortiz, Health Director of East Center Regional-Coomeva Medicina Prepagada; Mauricio Camacho, Agent of Clínica Protección Oral SAS; Luisa Estella Vergara, Periodontist; Andrea Enríquez Erazo, Chief of Oral Health East Center Regional-Coomeva Medicina Prepagada; Carlos Mario González, Manager of East Center Regional-Coomeva Medicina Prepagada; Ana Julia Velásquez, Commercial and Marketing Manager of Clínica del Country; William Ricardo Cabra, Pediatrician; Pascual Estrada Garcés, National Director of Health Coomeva Medicina Prepagada; María Cristina López Assmus, Specialist in Oncological Plastic Surgery.

NORTHWEST REGIONAL. From left to right, Drs. Jorge Alberto Zapata Builes, General Manager of Coomeva Medicina Prepagada; Juan Gabriel Cendales Rey, Manager of Clínica Las Américas; Carlos Enrique Restrepo, GynecologyObstetrician; Amalia Castro Vélez, Specialist in General Dentistry; Luis Alfonso Medina, Specialist in Internal Medicine; Rodrigo Moreno, Manager of Centro Odontológico Brasilia; Sandra Marcela Mora, Chief of Oral Health Northwest Regional-Coomeva Medicina Prepagada; Mrs. Carolina Londoño Ramírez, Executive of Management with Providers Northwest Regional-Coomeva Medicina Prepagada; Dr. Santiago Adolfo Restrepo, Manager of Northwest RegionalCoomeva Medicina Prepagada.

MAY 2018 45

MERITS EMILIO JOSÉ YUNIS (RIP)

The legacy of a

BRILLIANT MIND A scientist, researcher, writer, humanist, but above all a devotee of his work as a geneticist. In few words, this is who Emilio Yunis was: a thinker who spoke clear and who left a sea of knowledge of legacy; it’s not in vain that he is recognized as the father of genetics in Colombia and Latin America.

46 MAY 2018

Photo: CLAUDIA RUBIO EL TIEMPO

“A

brilliant mind left us, my idol, my father, my friend and my professor. I will always have you with me, my father.” With this soulful message, his son Juan José, also a geneticist, announced the death of Emilio José Yunis, 81 at the time, on March 23rd.

Undoubtedly, Dr. Emilio José Yunis was an eminence who inherited his work on genetics to the medical and scientific world, a specialty to which he devoted his life.

He was born in Sincelejo in 1937, in the house of José Yunis and Victoria Turbay, of Lebanese origin, who had eight children in total. The geneticist was the youngest of five brothers, all of them doctors.

TALENT EXPOSED The school of Simón Araújo, located in Sincelejo, became the first place where they recognized his talent and intelligence, which also earned him the nickname of “Andrés Bello”, because he learned to read and write very quickly: “He read the newspaper to my grandparents, and he knew all the capitals of the world,” said his son Juan José.

Emilio Yunis studied medicine at Universidad de Antioquia, in Medellín. After some time he settled in Bogotá to work at the Universidad Nacional de Colombia, with a contract that he signed on September 20th, 1961. At that time, he lectured on Biology at the School of Medicine and earned 1,500 pesos for this work.

Subsequently, in 1964 he received his appointment as professor. During that decade, he was devoted to cytogenetic research or the study of chromosomes. He created the unit of genetics at the School of Medicine, as part of the Department of Morphology.

During the 70s, he published a substantial amount of scientific articles in different journals, such as the Journal of Clinical Genetics and the Journal of Medical Genetics. “In fact, he wrote the first article in 1971, about Down syndrome and it was published in the journal of the School of Medicine of the Universidad Nacional. He also addressed cytogenetics, genetic disorders and chromosome alterations. In 1973, he received the National Prize in Medicine Federico LLeras Acosta, for a study on sexual ambiguity conducted with Dr. Emilia Federici de la Cruz.

NEW DISEASES In 1975, the researcher faced one of his greatest challenges: he assessed a patient with manifestations that were not described in the literature and a couple of years later, he assessed two other families with members undergoing similar conditions. Together with Dr. Humberto Varón, a radiologist, they published an article in 1980 describing

MAY 2018 47

MERITS

Photo: ANDREA MORENO EL TIEMPO

The honors and awards chased him along his professional life although these were not a priority interest. One of his greatest achievements: founding the Institute of Genetics of the Universidad Nacional.

IN SHORT Juan José Yunis describes his father as an innovative, visionary, very demanding and strict person at work, someone who didn’t like the shades of gray nor the warm waters, and a man who defended his convictions bravely, with arguments.

He always saw Dr. Emilio as a tireless worker who hated improvisation. He couldn’t bear the lack of professionalism, training and study.

“I think that’s why he liked to see Cantinflas so much, because he embodied everything that this country is, the “everything-is-allowed” mindset” says his son.

Although some would say that he served in the military due to his discipline, he simply wanted everything to be done well, without cheating, without shortcuts. “Those were the lessons he gave us: always work well and the everything else comes by itself. Worry about getting your training, your studies, the rest will come along the way.”

Emilio Yunis had four sons. Juan José is the only one who followed his steps in medicine as a geneticist. The others took the business administration path. From them, he left nine grand-daughters.

He was passionate about reading, he could devour 3 or 4 books simultaneously without losing the thread. He was also a great writer; he published nine books, including two novels and one about the role of DNA in human identification, with his son Juan José. The other books address topics that were exciting to him, such as science, politics and sociobiology. At the same time, he supervised more than 30 thesis research projects of postgraduate students from the Universidad Nacional.

Yet, the father of genetics also lived in love with plants and flowers.

At his house in Chía, roses were a must, and so were bromelias and orchids. And as a true costeño he never missed a match of the big leagues.

It can be said that Emilio José Yunis was a pioneer in every way: clinical genetics, cytogenetics, forensic genetics, immunogenetics and in testing for organ transplants in the country. He introduced the latest genetic analysis technologies in his laboratory, equipped with the technology that no other lab in Latin America had.

48 MAY 2018

a new genetic syndrome which they named the Yunis Varón syndrome (a rare autosomal recessive condition that is characterized by the widespread dysplasia of bones and teeth; in addition, it usually affects the cardiovascular system and tissues derived from the ectoderm). This work was presented in 1979 to the Alejandro Angel Escobar Foundation, along with two other new diseases, and it won the award of Alejandro Angel Escobar in 1980.

Two years later, in 1977, another key event for the future of genetics took place: the Universidad Nacional named Dr. Emilio José Yunis as coordinator of a unit that would later become the office for the vice presidency for research. The resources to build the Institute of Genetics of the institution, which began to operate in 1993, also became available at that time.

The awards kept coming throughout his career, as he won once again the award of Alejandro Angel Escobar for a work done, along with Dr. Josefina Cano, on a tumor of the eye called retinoblastoma. Later, other medical honors would come his way. In 1986, the students at the Universidad Nacional gave him the Recognition to Excellence in Medicine.

Emilio Yunis also became the first to introduce DNA tests in the country to be used not only in paternity tests but in forensic genetics as well, he did it even earlier than the Instituto de Ciencias Forenses.

Likewise, he is known as the creator of the Colombian Institute for Family Welfare (he directed it from 1972 to 1992).

After 37 years of service at the Universidad Nacional, he decided to retire in 1997 and he focused his entire attention on his private genetics laboratory, which he managed parallel to his practice as a specialist physician in genetics, thus, he gradually became a national reference. Unfortunately, this year he will not be present when the new headquarters of the Institute of Genetics Yunis Turbay is inaugurated, after a great investment in modernization, infrastructure and equipment.

LAW AND HEALTH

Death with dignity for minors:

WHAT DOES THE LAW SAY?

I

n compliance with the Constitutional Court’s Sentence T-544 of 2017, Ministerio de Salud y Protección Social (MinSalud) regulated everything regarding the right to die with dignity for minors through the Resolution 825 of March 2018; a kind of policy that is current only in Belgium and the Netherlands… and now in Colombia.

This measure has awakened all kinds of opinions, both in favor and against, and it has caused controversy precisely because there are doubts about some aspects of it, specifically regarding euthanasia. Moreover, scientific meetings have been held to assess the issue, like the Conference on Euthanasia in Girls, Boys and Adolescents, which was organized by the Doctorate program of Public Health at the School of Medicine, Universidad Nacional, Bogotá headquarters, during last March;

50 MAY 2018

Photos: © 2018 SHUTTERSTOCK PHOTOS

The concepts of palliative care and euthanasia are part of the right of children and teenagers to die with dignity. Such is reflected in the Resolution 825 of 2018 of Ministerio de Salud y Protección Social that has just been issued and has already generated controversy and debates in the country.

WHAT DOCTORS NEED TO KNOW Among the most frequent questions that physicians make to the lawyer Ricardo Barona Betancourt, an expert in the topic consulted exclusively for this article by the COOMTACTO Magazine, are:

The Resolution explains that euthanasia does not apply for newborns, neonates, nor for children in early childhood (up to six years).

or the forum Advances and Challenges of the Right to Die With Dignity in Colombia, organized by the Academia Nacional de Medicina, Universidad del Rosario and Fundación Pro Derecho a Morir Dignamente, on April 25th, among other events.

Dr. Ricardo Luque Núñez, adviser to the Directorate for Promotion and Prevention of the MinSalud, explains that the resolution basically expands the concept of death with dignity, which does not only equals euthanasia. “We all have the right to a death with dignity without the need to access euthanasia, primarily through palliative care. Thus, the second chapter of the resolution addresses palliative care, which is mandatory prior to any other consideration”.

In its 4th article, the resolution states: “Pediatric palliative care. Palliative care for girls, boys and adolescents is the approach to an active a comprehensive care, from the diagnosis or recognition of their needs, through life and the process of death. It includes the attention for the physical, psychological, emotional, social and spiritual elements. It is mainly focused on improving the quality of life of the boy, girl or adolescent and on supporting his family during the process of illness and after the death of the boy, girl or adolescent”.

ON EUTHANASIA It isn’t until chapter III that the document details the “protocol to make effective the right to die with dignity through the euthanasia of adolescents and exceptionally of boys and girls between the ages of

1. About the concurrence to request the implementation of euthanasia with whom exercises the parental authority over the boy, girl or adolescent. This will be governed by the superior interest of the minor, as follows: from the age of 6 to 14 it is mandatory to have the approval of the person exercising the parental authority over the minor; from the age of 14 to 17 it is not mandatory to have the approval of the person exercising the parental authority over the adolescent. The parental authority will always be informed about the decision made by the patient.

2. The alternative consent. It refers to the one made by the person exercising the parental authority over the boys, girls or adolescents, who may have manifested their will but are unable to reaffirm it. But it can’t replace the will of the boy, girl or adolescent who has legal representations other than the parental authority.

3. Waiving the request. It is the physician’s duty to inform the patient from the beginning about his right to withdraw the request. At any point in the process, either during the filing for the request or during the committee’s assessment and even up to the time of applying the euthanasia, the boy, girl or adolescent may waive from continuing the process and choose other alternatives like palliative care, which will always be offered and ensured. However, the withdrawal is exclusively for the minor.

4. Conscientious objection. In this regard, the Resolution 825 of 2018 states that only the treating physicians have the authority to intervene during the procedure to ensure the fulfillment of the right to die with dignity. If the physician files a conscientious objection, written and duly motivated, the Scientific-Interdisciplinary Committee for the Right to Die with Dignity through the Euthanasia for Boys, Girls and Adolescents will order the IPS (healthcare institution) to assign another doctor to perform the medical act within the 48 hours after the objection was submitted.

6 and 12 years”. On this regard, Dr. Luque clarifies that for this issue the “three basic principles that are defined since the Sentence of Corte Constitucional C-239 of 1997” must be met; the first principle corresponds to the will of the patient, which the patient

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LAW AND HEALTH

The resolution issued by Ministerio de Salud y Protección Social envisions palliative care as a fundamental right for both adults and minors.

SUGGESTED READINGS 1. https://www.minsalud.gov.co/sites/ rid/Lists/BibliotecaDigital/RIDE/DE/ DIJ/resolucion-825-de-2018.pdf 2. http://www.urosario.edu.co/ Home/Principal/Orgullo-Rosarista/ Destacados/Eutanasia-enColombia-y-el-Derecho-a-morirdigname/ 3. https://www.minsalud.gov.co/sites/ rid/Lists/BibliotecaDigital/RIDE/ DE/CA/Protocolo-aplicacionprocedimiento-eutanasiacolombia.pdf

must manifest explicitly and in front of witnesses; second, the case must involve a terminal illness; and, third, there must be serious suffering for the person.

In this case, to talk about willingness –regarding boys, girls and adolescents– some of them will not be able to manifest it or some may not have the capacity to make such decisions, which is why the law provides for de facto exclusions”.

In essence, euthanasia does not apply for newborns, neonates or those in early childhood (up to the age of 6); nor for those who have consciousness alterations, a disability for decision-making or with psychiatric disorders that have been previously diagnosed and that modify the ability for judgement or reasoning”, says Dr. Luque.

It has been accepted in exceptional cases for children between the ages of 6 and 12 “who have a disease or condition at terminal stage and who endure constant and unbearable suffering that cannot be relieved... Once the relevant assessments have been made, the team of health professionals that is treating the patient may exceptionally make the request to the committee if the case fulfills the criteria detailed in the body of the article 3”, adds the expert.

It should also be assessed whether the patient can benefit from a modification to the therapeutic approach or from new symptomatic care and relief goals, and implement those without prejudice for the request, also reviewing that the application was manifested explicitly and never as a result of suggestion, inducement or coercion, so that it can be considered as a willingly and free act.

In the case of adolescents, it is indicated that after the request is received, the treating physician has the obligation to inform the person who exercises the parental authority over the adolescent and to reiterate or bring to their knowledge the patient’s right to receive pediatric palliative care, according to the definition stated in the resolution, and within the framework of the Law 1733 of 2014; the physician also needs to inform about the right of the patient to waive at any time from the request, among other things.

WHAT LIES AHEAD The structure of the Resolution 825 came from the encounter of knowledge and experts representing scientific societies, Procuraduría General de la Nación through its delegated offices for childhood matters; Defensoría del Pueblo; Superintendencia Nacional de Salud; Alta Consejería Presidencial para la Infancia, the universities CES, from Medellín, and Javeriana, El Bosque and El Rosario from Bogotá; Fundación Pro Derecho a Morir Dignamente, Sociedad Colombiana de Pediatría, Sociedad Colombiana para los Cuidados Paliativos, Instituto Nacional de Cancerología; and Ministerio de Salud y Protección Social units related to the subject, among others.

52 MAY 2018

The next step is to raise this issue to the Congress; for this purpose a bill is being prepared, which is expected to be ready for presentation later this November. The bill aims to broaden the scope and weight of the policies regarding the right of all people to be assisted with palliative care during the suffering of a terminal illness, or to die with dignity.

As a matter of fact, the lawyer Ricardo Barona Betancourt thinks these issues should be regulated by the Congress: “I disagree that the regulation for this matter comes from the Corte Constitucional and MinSalud, because this practice is a violation of article

152 of the Colombian Constitution, which states that “through the statutory laws, the Congress will regulate the following matters: (a) fundamental rights and duties of individuals and the procedures and resources for their protection…”. Additionally, the relevant regulations should be based and also protect the following articles of the Colombian Constitution: 4th, 11th and 13th”.

In his concept, it would be very interesting to have “a great national debate on this complex issue; that is, the regulation being the responsibility of Congress, to ensure that all the rights at stake are addressed”.

EVENTS

HIGHLIGHTED EVENTS ‘X INTERNATIONAL EXPERTS CONFERENCE OF MECHANICAL VENTILATION AND INTERMEDIATE ACMI CONFERENCE Date and location: Junio 7th - 9th, Cartagena More information: Asociación Colombiana de Medicina Crítica y Cuidado Intensivo Phone: (4) 448 2810 ext. 217 E-mail:registro@comunicacionesefectivas.zendesk.com Website:www.acmi.org.co/congreso2018

‘XIII INTERNATIONAL CONFERENCE OF HOSPITALS AND CLINICS’ Date and location: July 4th and 5th, Bogota More information: Asociación Colombiana de Hospitales y Clínicas Phone: (1) 312 4411 Website: http://www.achc.org.co

‘1st INTERNATIONAL UPDATE COURSE IN NEUROPSYCHOPHARMACOLOGY’ Date and location: Junio 13th - 16th, Mexico City (Mexico) More information: Asociación Iberolatinoamericana de Neurociencias y Psiquiatría Phone: (52) (55) 5350 7500 E-mail:apaz@anfitriones.com.mx Website:www.ailancyp.com/

Organized by: Asociación Colombiana de Hospitales y Clínicas (ACHC) y Corferias

‘MEDITECH 2018.

INTERNATIONAL HEALTH FAIR’ ate and location: July 3rd - 6th, Corferias, Bogota D More information: Asociación Colombiana de Hospitales y Clínicas Phone: (1) 312 4411 Website: www.feriameditech.com

54 MAY 2018

‘VI INTERNATIONAL SYMPOSIUM OF UPDATES IN PEDIATRICS’ Date and location: July 5th - 7th, Cartagena More information: Sociedad Colombiana de Pediatría Phone: (1) 649 5352 E-mail:eventos@scp.com.co Website: www.scp.com.co

HIGHLIGHTED EVENTS ‘44th NATIONAL CONFERENCE OF ADVANCES IN SURGERY AND 31st PAN AMERICAN TRAUMA CONFERENCE’ Date and location: August 14th - 17th, Cartagena More information: Asociación Colombiana de Cirugía Phone: (1) 257 4560-257 4501 E-mail: info@ascolcirugia.org Website: www.asocolcirugia.org

‘CALI CADERA’ ‘XLIII COLOMBIAN CONFERENCE OF RADIOLOGY’’ Date and location: August 2nd - 4th, Cartagena More information: Asociación Colombiana de Radiología Phone: (4) 262 6978 E-mail: congreso@acronline.org Website: www.ccr2018.org

Date and location: June 7th - 9th, Cali More information: Instituto de Enfermedades Osteoarticulares Phone: 301 271 6280 E-mail: cursoscadera@gmail.com Website: www.osteoarticularimbanaco.com

‘5th INTERNATIONAL CONFERENCE OF PAIN MEDICINE AND PALLIATIVE CARE’ Date and location: August 24th - 25th, Bogota More information: Universidad del Rosario - Méderi Phone: (1) 678 9872 E-mail: info@congresodedolor.com Website: www.congresodedolor.com

‘14th LATIN AMERICAN MEETING OF HIP AND KNEE SURGEONS’ Date and location: August 1st - 4th, Cartagena More information: Sociedad Colombiana de Cirugía Ortopédica y Traumatología Phone: (1) 625 7445 E-mail:secretaria@sccot.org.co, direccion@elccr.org Website: www.elccr.org

MAY 2018 55

EVENTS

BOOKS

‘DESPUÉS DE LA IRA’ Author: Cristian Romero

‘COMO ESTA TARDE PARA SIEMPRE’ Author: Jaime Manrique

To San Isidro, a town in the middle of nowhere, has arrived a multinational corporation that wants to conquer its lands to grow genetically modified corn crops.

Samuel refuses to sell them what is left of his land, rather, he witnesses his crops fade away and his marriage crumble in the midst of heat and despair. Liliana, his wife, only wants to take her daughter away from the plagues and the silent conflict that ravage the town. But as if it were a punishment, it seems that this place is the only hell they deserve to live in.

Lucas and Ignacio are two young seminarians who soon discover they have fallen in love.

This is a novel that reflects the current Colombia, revealing it through the practice exercised by these priests in communities that are ravaged by war and despair. This is a lesson about love, about life always lived against the current and also about death, but, above all, it’s a beautiful tale inspired by facts regarding how spiritual calm is only achieved though communion with others

ESSENTIAL CLINICAL NEUROANATOMY

Author: Thomas H. Champney

‘THE BEAUTIFUL MYSTERY’ Author: Louise Penny

56 MAY 2018

This is the first neuroanatomy book that illustrates and explains in a coordinated and comprehensive way the anatomy of the central nervous system from a clinical perspective. Its illustrations are presented from a medical point of view (using the standard axial nomenclature used in CT scans and MRI), which provides the text and its reading with continuity and consistency. Furthermore, the neuroanatomy of clinical relevance is emphasized through case studies, clinicaloriented review questions and summary boxes.

In a virgin province of Quebec, there is the monastery of Saint-GilbertEntre-les-Loups, where two dozen monks live for the meditation. It’s known that the monks have never opened their doors to any stranger until now, when inspectors Armand Gamache and Jean-Guy Beauvoir are about to become the first outsiders to access the campus. Their ticket inside the place is a dead man, brother Mathieu, who has been killed after a strong blow to the skull. While the fragile harmony of the congregation deteriorates as it reveals the disagreements of a deeply divided group, Gamache will have to conjure his own demons and confront one of the most critical and complex cases of his career.

Escanea este código QR, conoce nuestra página web y todos los beneficios de Vital Procolágeno.

REGISTRO INVIMA: SD2008-0000664

Es importante saber que el PROCOLÁGENO y el colágeno no son lo mismo, ya que uno depende del otro.

Esto significa que sin PROCOLÁGENO nuestro cuerpo no produce colágeno.

Línea Nacional: 01 8000 515433 Pereira: calle 15 #12b-17 325 6000 www.colombianatural.com Este producto es un suplemento dietario, no es un medicamento y no suple una alimentación equilibrada

PUBLIRREPORTAJE

SHOWS

EVENTS

ES UN MITO DECIR QUE TOMAR COLÁGENO NOS REJUVENECE Es importante saber que el procolágeno y el colágeno no son lo mismo, ya que uno depende del otro; esto significa que sin procolágeno nuestro cuerpo no produce colágeno, comentó el doctor Isaac Morhaim, especialista en Medicina Regenerativa y Antienvejecimiento, y creador del producto Vital Procolágeno.

Los avances en la ciencia han demostrado que después de los 20 años el organismo no produce la misma cantidad de colágeno y por esto nuestra piel y cuerpo comienzan a tener cambios, a tal punto que cuando llegamos a los 60 años de edad nuestro cuerpo produce menos del 70% del colágeno que necesita para verse joven y reducir las molestias de la edad.

La deficiencia del procolágeno en nuestro cuerpo produce envejecimiento de la piel con manifestaciones como arrugas, flacidez, debilidad en pelo y uñas, bolsas debajo de los ojos y dolores en las articulaciones, entre otros. Es así, que a partir del procolágeno nuestro cuerpo produce el colágeno, las fibras que estiran nuestra piel y también el cartílago de las articulaciones.

Por eso es un mito decir que el organismo produce colágeno a partir de un suplemento elaborado a base de este componente porque es el procolágeno el que actúa como estimulante de las células que lo producen. Los estudios aclaran que el procolágeno estimula los fibroblastos, osteoblastos y condroblastos, las células del cuerpo para la producción de colágeno, cartílago y elastina.

Por ello, el doctor Morhaim recomienda el procolágeno que juega un papel definitivo cuando se busca:

‘COLOMBIA AL PARQUE’: A FESTIVAL FOR ALL Joropo, cumbia, vallenato, salsa and other typical rhythms of our country will be the stars of this event which turned 17 and is the perfect excuse to gather in Bogota people from all the corners of the country. Therefore, from July 18th to 20th, places such as the Parque de los Novios and the Media Torta will be the ideal scenarios for enjoying this feast that, year after year, brings loads of joy and folklore to assistants, who will be able to enjoy the presentations of recognized groups that play a variety of musical rhythms.

For more information, visit www.colombiaalparque.gov.co

EVERYONE READY FOR THE FIFA WORLD CUP From June 14 to July 15 , the eyes of the world will be placed in Russia, where 32 teams will compete for the trophy. These are some facts to consider during this date with soccer: • The inaugural match will take place on Thursday, June 14th, at 10:00 a.m. (Colombian time). During this match, the teams from Russia and Saudi Arabia will face each other at the Luzhnikí stadium in Moscow.

• The first match of the Colombian team will be on Tuesday, June 19th, against the Japanese team at the Mordovia Arena at 7:00 a.m.

• The match for the third place is scheduled on Saturday, July 14th, at 9:00 a.m. at the St. Petersburg stadium. The final match, will take place the next day at the Luzhnikí stadium in Moscow at 10:00 a.m.

ENJOY ‘JAZZ AL PARQUE’ This party will take place on September 22nd and 23rd in Bogota, where improvisation and freestyle will be protagonists thanks to the performance of groups that will bring classical melodies, but also more modern tones. Likewise, the stars will also be instruments such as the piano, the bass, the harmonic and the saxophone, which will delight the audience’s senses in different stages across the city. For more information, visit the www.jazzalparque.gov.co

58 MAY 2018

1. Reducir las bolsas de los ojos.

2. Reducir la flacidez de la piel.

3. Fortalecer las uñas y el cabello.

4. Disminuir la celulitis.

5. Reducir la resequedad de la piel.

6. Producir el colágeno y las fibras que estiran la piel.

7. Regenerar los cartílagos.

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REGISTRO SANITARIO INVIMA: SD2008-000064

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Como estos son muchos los beneficios que obtenemos del producto VITAL PROCOLÁGENO, que de manera natural logra que nuestro propio organismo comience a producir el colágeno que perdemos con el pasar los años.

En Coomeva Medicina Prepagada evolucionamos nuestros procesos Modernizamos nuestra plataforma tecnológica para brindarte un servicio más ágil y cómodo.

Oficina Virtual Más tiempo para ti • Actualización de datos básicos y cuenta bancaria.

• Consulta y descarga de extractos de cuenta.

• Radicación de facturas.

• Consulta de trazabilidad al estado de tus facturas.

• Certificaciones de retenciones.

• Módulo de negociación.

Autorización por biometría Identifícate como usuario con tu huella dactilar.

IVR Ten acceso a los valores del Copago.

Nuevo diseño Carné

Órdenes de servicio

Formato de glosa

Facturación

ORO Plan Fecha de Nacimiento

Inicia

Para más información escríbenos al correo prestadores_coomeva@coomeva.com.co o comunícate con la ejecutiva de servicio al prestador de tu ciudad.

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