COOMEVA GROUP Coomeva, a Financial and Health Insurance Conglomerate in Colombia, is the largest cooperative organization in the country, and parent to a group of 13 companies in different sectors of the economy.
COOMEVA HEALTH DIVISION Coomeva´s health sector is the largest in Colombia and is composed of five companies that target different segments of the economy. Together, these companies provide healthcare services that meet the needs for public and private insurance. These services are delivered through a wide healthcare network across the country that represents all medical specialties.
COOMEVA INTERNATIONAL BUSINESS VALUE PROPOSITION FOR INTERNATIONAL CUSTOMERS Our philosophical approach is to provide cost containment and quality assurance management strategies to contribute in slowing the growth of international health care costs of our partners through a network of selected healthcare providers that have gained international recognition, some in the process of international accreditation.
EXPERIENCE With an international experience of more than 12 years, Coomeva has entered into agreements with private and official underwriters in Aruba, Curacao, Bonaire, Saint Marteen, Sabas and St. Eustatius and the United States. Our understanding in this type business accords makes us leaders in Colombia in Medical Tourism and International Healthcare Agreements. Our customer relies on the solidness and the know-how of Coomeva and its Group of Health Care Companies in Colombia. Our customers abroad can count on the assistance, logistical and administrative support that Coomeva provides. The patient receives the best care in a kind and pleasant environment, with the peace of mind that a company with more than 35 years in the Colombian market can provide.
OUR SERVICES I. LOGISTIC SERVICES
Travel arrangements. Airline reservations Transportation in our own basic or fully equipped ambulance. Air Ambulance Services with life support system – ICU. Ground transportation in each city. Hotel accommodation for the patient and companion. Disbursement of daily allowances. Official procedures with port authorities for longer stays. Funeral Services in case that a patient unfortunately passes away. City Tours and other services required and agreed upon.
II. QUALITY ASSURANCE MANAGEMENT
Coomeva’s stronghold is the Quality Assurance Management procedures done on behalf of clients. Our planned and systematic auditing process provides confidence that our services are suitable for their intended purpose. Concurrent Auditing – performed at the clinics and hospitals by 220 medical auditors. Billing Auditing – corroborate the billing according to client’s negotiations and requirements. Quality Auditing – strict control of quality standards at the institutions and case management sentinel surveillance.
III. ADMINISTRATIVE SERVICES
Coomeva designed our own SOFIB -Software for International Business- through a web based platform provides our clients a tool to manage patient referral to Colombia. Our services include services such as monthly reports, answering inquires for situations that might occur under the treatment of a patient, negotiations to obtain the best available rates for the services rendered and payment to providers amongst others – 24/7/365
CLINICAL AND HOSPITAL NETWORK Coomeva has arranged a wide network of institutions and doctors across the country that meets our quality and service standards for medical care according to the treatment or diagnosis requirements of our international patients in Bogota, Barranquilla, Cali, Medellin, and Bucaramanga.
Newsletter
for health professionals of Coomeva Medicina Prepagada ISSN 2011-3579
Vol. 7
No. 1
February - April 2014
Our commitment today, till the next 50 years
CONTENIDO 3
INTERVIEW Health and home, hand in hand for the patient’s recovery
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HEALT UP TO DAY An halo after alcohol drinking in the DNA of young people
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ebm Polyuria: a diagnostic challenge
promotiOn AND prevention
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Rhinosinusitis in children Acting in time to prevent infections
FROM COOMEVA
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Day Health Provider CELEBrATION
MEDICAL WORLD Books reviews and events
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Thanks to the commitment, excellence, and ethics of more than 10,000 affiliated health care professionals to Coomeva Medicina Prepagada, we have served more than 328,000 people. Making us the most remembered organization in the health care system in Colombia. Fulfilling, by far, our dreams. So we are proud members of the Grupo Empresarial Cooperativo Coomeva (GECC), a leading enterprise in our country, with 50 years of existence, and achievements reflected on the welfare of the whole community. Moreover, this organization is a pioneer in voluntary health insurance. It was born in 1973, and today it is an example of good quality services, generating value day after day, with appropriate responses and accurate solutions to all our affiliate families, with constant innovation and the human warmth that we have always had. None of this would have been possible without the commitment and hard work of a wide network of health care professionals –with all the specialties authorized in Colombia-, whom have built their clinical practices with the unrestricted support of GECC. Solidarity is the philosophical essence of cooperativism, a guide that lead our organization towards becoming one of the most prominent in our country, undoubtedly supported by the hard work and integration of all our partners. And the result could not be different: a better quality of life for all. And we can also offer our affiliates an excellent infrastructure with the best technical, technological and human resources in the country, making it the ideal place to put in practice our purpose of offering only quality health services to our users. However, in spite of all the reasons that we have for celebrations today, in the 50th anniversary of our Organization and the 14th of Coomeva Medicina Prepagada, we have chosen not to yield to the festive climate, neither to the celebrations, nor the public recognitions. We much rather direct our energy on the new challenges we will be facing, and on what’s coming up net, so that we can ensure a more promising future, with more comprehensiveness solutions, and the aim of contributing even more to the well-being of Colombian families. We have done our best to turn that marvelous future for all into an existing reality. And we are not satisfied only with the prestige that our fulfilled goals have brought to us, we also intend to carry on and overcome the new challenges that will make us transcend even more. Infinite thanks to you, our invaluable group of health care professionals.
INTERVIEW
H
ealth and home, hand in hand for the patient’s recovery
It has been demonstrated scientifically that home care is associated with rapid improvement and better quality of life for the patient, and the providers of this invaluable service are committed increasingly with a more humane attention, as well as better productivity for industry. Example: Hospital en Casa. Technology, highly trained personnel, innovation, and professionalism are some of the corporate values that make up our company Hospital en Casa, part of Grupo Coomeva. An example of excellence in the field of home health care. About 4,000 patients monthly recover quickly, benefiting their families, and the health care system in general, via savings in hospital costs. To learn more about this new methodology, born nearly 17 years ago, and now present in 12 cities in Colombia, Coomtacto spoke to doctor Fabián Osorio Flórez, CEO of Hospital en Casa. And he gave us a detailed account of their progresses, with more efficient, warm, effective, and timely implementation of the policies of home health care. Likewise, he spoke to us about the changes in the perspectives of the insurers, clinics, patients, and physicians, regarding this successful and innovative model.
Photos: Hugo Giraldo
Learn about the advantages of recovering at home.
What are the benefits for the patient if he is sent home to continue his recovery? As it is widely known, and is demonstrated in several scientific papers, the patient’s recovery is better and faster when it takes place at home. Easily they can prevent complications related to hospital settings, such as infections which tend to be very aggressive, and usually deteriorate further more the patient’s health. Also the family’s environment helps, because people are surrounded by the care of the loved ones, and also friends can easily participate in the recovery process. So it turns out that there are also many benefits when the patient is surrounded by his familiar objects, such as his own bed, for example. In sum, this methodology is an opportunity to accompany the sick, improving psychologically while the recovery is shorter. Is it profitable? There are many savings. The patient does not have to pay for transportation of his family to and from the clinic, nor their meals, parkings, or any other additional expense. And also for the health care system it is advantageous, because the costs of the services in the hospital are much more expensive.
INTERVIEW But what happens with the complex cases? If necessary we can take all the required equipment to give comfort, and quality care to that patient. And if from the medical point of view he needs more equipment, and other medical supplies, they will be provided. What are the requirements to move a clinic into the patient’s home? We rely on an interdisciplinary team coordinated by a general practitioner with the support of all sorts of specialists, as well as nurses, both professional and students, some proficient in wound and ostomies care; also experts in rehabilitation participate, as well as therapists, psychologists, nutritionists, and social workers, among others professionals, a team that is able to take care integrally of the patient at home with all his needs. How have patients and doctors responded to the services Hospital en Casa can offer? Very satisfactorily! We have been able to show that we can provide excellent health care services to patients with various levels of complexity. So we have earned the trust of doctors, patients, and families. This success has given the health care sector a clear and reliable knowledge of what we can do. And now, on a daily basis, we can handle 400 patients while they rehabilitate and recover simultaneous in their homes. Would you say there has been a cultural change? Yes, definitely, we brought profound changes in the way people think about taking care of the sick and their families. It has been 17 years since we first started with this program, continuously improving, earning the trust of patients, their loved ones, and the health care professionals. Now we profit from a greater understanding and acceptance by all, specially the physicians, whom at some point, in the beginning, were the most distrustful of these changes. On the other hand, technological advances, computer miniaturization, developments in information
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and communication technologies, as well as progress in distant medical support have allowed us to take home all our services, in a safe, and effective manner. The promise of higher value contributes to the good perception that patients, doctors and insurance companies have today? There is, undoubtedly, much more confidence. We have a policy of high quality consolidated attention. Based on that we provide a certified health care model under ISO 9001:2008, which ensures that we comply with excellent clinical practices, with quality, timeliness, reliability, and above all, a human attention. Plus, our 1,200 directly hired employees, with their formal and committed labor, guarantee their excellence in collaboration with the administrative and operative teams.
HEALTH UP TO DATE
A
n halo after alcohol drinking in the DNA of young people
For the first time ever a study explores the levels of cellular oxidative trauma associated with alcohol intake in students between 18 and 23 years, a condition also known as social alcoholism. Tests found damage in 44% of the cells in the study group, exceeding the expectations of the researchers. Drowsiness, tiredness, lack of attention and general malaise in students attending the clinical biochemistry class of researcher Adela Rendón, at Instituto Politécnico Nacional in Mexico, on Monday mornings, led her to inquire about the consequences of drinking alcohol during weekends, and to raise attention in the community on these issues.
©2014 Shutterstock Photos
She invited the students to participate in a study designed to evaluate the preliminary effects on the oxidative metabolic paths related to weekend drinking, considered ‘social alcoholism’, a habit thought to be harmless by most people.
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“When we talk about social alcoholism in young people, we refer to youngsters who drink without becoming addicted. Addiction involves more complex social and psychological issues. We face a different situation. But anyway social alcoholism can cause extensive damage on the long run, and we should be aware.” Enthusiasm about being part of an unprecedented research that originated within the group led the students to accept to participate in the protocol, as well as to submit to medical tests, surveys, and administrative requirements. “The object of the study on oxidative damage related to alcohol
intake in young people really interested them.” And this research was supported by grants of the Universidad Autónoma in Nayarit (Mexico) and the University of the Basque Country (Spain).
TWO STUDY GROUPS The students were divided into two groups: the control, consisting of those who did not use alcohol at all, and the study group, including students who drank regularly on weekends, the average consumption was a liter and a half of beer.
THE BACKGROUND The study of DNA packaging in the nucleus in early stages of alcoholism was the first step to find out about what was happening with the nucleotides of young people who began drinking at an early age. A perspective that contrasted with other investigations mainly directed towards the effects of long term abuse of alcohol, usually with consequences such liver disease, various cancers, depression and effects on the central nervous system. Alcohol intake is a worldwide phenomenon, and represents a major health problem with social and economic consequences. World Health Organization confirms that liquor is associated with 2.5 million deaths yearly, and of them 320,000 are young people between 19 and 25 years. But it also causes problems way beyond the physical and mental health of the drinker, it affects the economy and the health systems. A recent study in Colombia, on patterns of consumption of alcohol and its harmful use, was carried out in 2012 by the Facultad Latinoamericana de Ciencias Sociales (Flacso), an institution whose headquarters are in Costa Rica. This investigation revealed that young people, between 18 and 24 years, are responsible for 80% of overall alcohol intake. And nearly 20% of respondents had tried alcohol before they were 18. “Our country (Mexico) has a consumption of alcohol well above the average in Latin America. This means more people use it and also that they have greater intake by person. Therefore this investigation should turn on the alarms on these
two issues. We can find indexes of risky occasional intake in young people, as well as of excessive occasional intake”, said Carlos Sojo, at that time director of research (< http://www.flacso. or.cr/images/documentos/epca_mexico_2012. pdf >).
HOW DID THEY DO THE STUDY As we mentioned earlier, the first thing the researcher and her collaborators sought was to determine if alcohol intake was associated with oxidative damage to the DNA in young drinkers, and if so, in a second stage, they would measure that effect. For the first objective, they tested the activity of the enzyme alcohol dehydrogenase, responsible of metabolizing ethanol into acetaldehyde, then to acetoacetate, and finally in acetone. The measurement of oxidative trauma was carried out with a biochemical assay called TBAR, determining the chemical species that reacted. These tests revealed lipoperoxidation of cell membrane in relation to the presence of ethanol and acetaldehyde in the blood flow. Then, to assess the effect of free radicals on DNA, they extracted the nucleotides from the nucleus of lymphocytes obtained from blood samples
HEALTH UP TO DATE
The results of this preliminary study revealed damage in 8% of the cells in the control group, and in 44% in the group exposed to regular alcohol intake, therefore they had 5.3 times more damaged cells.
belonging to the control and the study groups. The material was studied with electrophoresis. The tests showed that at least two metabolic pathways were activated, thus ethanol generated free radicals that can potentially affect the integrity of cell membranes.
THE RESULTS LED TO OTHER FINDINGS The researcher suspected that they would find oxidative damage, but their findings surpassed her expectations: “we observed that the group that consumed alcohol had, on average, two times more oxidative trauma than the control group”, said the biochemist. In terms of these findings on DNA, “the interesting thing about these results is that if chromatin is not well compacted, damage in the DNA is possible, an effect that leaves a halo called ‘comet tail’ on electrophoresis tests. And, indeed, the chromatin of the exposed group frequently showed a small halo, greater than the control group,” said the doctor. So the results showed damage in 8% of the cells in the control group, while it reached a 44% of the cells in the study group. Therefore, the exposed group was 5.3 times more prone to cell damage. To establish that there is a relevant DNA damage, the length of the comet tail must exceed 20 nm, but that was not the case in this study
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group. “Fortunately it was not so. But they should not have damage at all. They have been drinking for a relatively short time, so they have not been exposed chronically”, said the researcher.
WHAT COMES NEXT So far, the study from the University of the Basque Country and Universidad Autónoma de Nayarit has shown connections between alcohol consumption and oxidative alterations in DNA in young healthy people. So, indeed, there is a possibility of deterioration in the genes of the drinker. Further studies should determine the precise routes by which alcohol alters DNA. The next step for scientists will be to design studies on the packaging of chromatin and on the behavior of complex mechanisms of histones, which, as it is known now for several years, they are related with the stability of the double helix of DNA. This study was originally published in the Journal Alcohol, with the title, “Oxidative damage in young alcohol drinkers: a preliminary study”.
BIBLIOGRAPHY Rendón-Ramírez A, Cortés-Couto M, Martínez-Rizo AB, Muñiz-Hernández S, Velázquez-Fernández JB. Oxidative damage in young alcohol drinkers: a preliminary study. Alcohol 2013;47(7):501-4. <http://www.ncbi.nlm.nih.gov/ pubmed/24080163>. Rendón-Ramírez A, Gelover Reyes E, Couto M, Königsberg M, Castro P. ¿Genera cometas el alcoholismo? Bioquimia 2004;29 Suplemento:84. <http://www.medigraphic. com/pdfs/bioquimia/bq2004/bqs041d.pdf>.
EBM
P
olyuria: a diagnostic challenge
In December 2013 two United Kingdom nephrologists, Adam D Jakes and Sunil Bhandari, published in the British Medical Journal a review of the medical literature that surprised readers because of its novelty, and its usefulness as therapeutic guidelines for polyuria. It was directed to the general practitioner, helping him classify and treat the patient in primary care setting, or referring him to the specialist as needed. Polyuria is a diagnostic challenge that requires a careful evaluation to determine the seriousness of the underlying condition. Especially, to establish if it requires referral for specialized attention, or not.
medicines, not even over-the-counter nor herbal. Neither did he have a family history of diabetes, nor kidney disease. Finally, the physical examination was normal, and he had 138/84 mm Hg blood pressure.
ORIGINS OF THE STUDY
ESSENTIAL RECOMMENDATIONS
The idea of this research paper emerged after facing the case of a 43 years old patient. He was a male professor who went to the doctor after six weeks of increased urinary frequency and polydipsia. His urinary volume had increased notoriously day and night, and he had no dysuria, nor urinary urgency. On the other hand, his daily fluid intake was as usual: approximately two liters per day. And he had no medical history regarding polyuria. Plus he did not lose weight, experience sight changes, nor experience any gastrointestinal disturbances. He wasn’t taking
The experience of these British researchers from the Leeds Teaching Hospitals NHS Trust Renal unit Hull and East Yorkshire Hospitals NHS Trust unit Hull York Medical School, suggests several initial procedures can be done by the primary care health professional in the emergency room or the office when facing a patient with polyuria. After all the procedures applied to this 43 yearold patient while studying his polyuria derived in
Š2014 Shutterstock Photos
EBM the diagnosis of an idiopathic central diabetes insipidus. In the end, his symptoms improved after the treatment was initiated, and he gradually returned to his homeostasis.
Polyuria can also occur after paroxysmal tachycardia, atrial flutter, and fibrillation. So that the clinical history guides the investigation of the patient.
These are the activities these doctors suggest be carried out, and their general recommendations: Take a careful medical history, an essential element to differentiate between polyuria and plain increased urinary frequency.
OTHER MEDICAL PROCEDURES USEFUL IN THE DIAGNOSTIC PROCESS
The diagnostic use of the urinary volume can be difficult to estimate by the patients. So they used fluid balance sheets, carefully registering input and output of liquids. And it turned out to be a very useful tool under these circumstances. Symptom identification: take into account the presence of urinary symptoms, along with its chronology, and other characteristics, like if it occurs at night, all day, or both. This information helps the differential diagnosis of several diseases, including tubular disorders, anatomical abnormalities, an overactive bladder, and prostate disease. The physical examination: record it thoroughly, including blood pressure, the general appearance and signs of dehydration (turgor, capillary filling, as well as other skin characteristics and of the mucous membranes). Also, weight shifts can indicate diabetes mellitus or thyroid disease, while muscle weakness may be a manifestation of a metabolic disorder. “Clinical examination rarely leads to positive results, however, it is important to exclude bitemporal hemianopsia, a sign of a tumor that increases intracranial pressure and leads to central diabetes insipidus. And if it is suspected, referral to secondary care is warranted to continue the study of the patent with an MRI of the brain, and the measurement of pituitary hormones”, the British doctors wrote in their article. Anyway the physical examination has to be complete. Including the palpation of the abdomen to detect masses, especially an enlarged kidney that would justify an ultrasound to rule out hydronephrosis and other abnomalities of the urinary tract.
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• Urine test strip: it detects glucosuria in cases of diabetes. Also the measurement of the blood level of glucose can help identify these patients, so that further investigations and treatment can be initiated promptly. On the other hand, leukocytes and nitrites in conjunction with urinary symptoms suggest urinary tract infections. Whereas most studies have arrived to the conclusion that negative urine strips, without specific urinary symptoms, is more than enough to rule out an infection of this sort.
COMMON CAUSES Several chronic diseases can cause polyuria, these are some examples: Diabetes mellitus, both types 1 and 2, can be suspected if the patient has also lost weight. Patients with heart failure may experience nocturia due to the accumulation of fluids, such as pedal edema, that re-enters the blood stream at night in horizontal position. Elderlies with high blood pressure may also have nocturnal polyuria as a result of the effects of hypertension on cardiovascular and renal physiology. Renal insufficiency, such as moderate to severe chronic kidney disease, has a prevalence of 0.2% in the general population. And it may also lead to polyuria and nocturia. It is therefore necessary to check for hematuria, mycrospopic or macroscopic, and to rule out other systemic causes of kidney disease. Also arthralgia, rash, and constitutional symptoms are frequent in patients with vasculitis due to lupus erythematosus, and occasionally they may also have polyuria.
• Measurement of plasma antidiuretic hormone • Hormones of the anterior pituitary • MNR of the brain and the pituitary
CONCLUSIONS
• Serum urea, electrolytes and calcium: these simple tests further inform about the renal function. Hypernatremia is a good marker of water depletion, while hypokalemia, a common electrolyte disorder, is a rare cause of the polyuria. And abnormalities of calcium levels justify measurements of parathyroid hormone, phosphate, and alkaline phosphatase. • Fasting glucose and glycocilated haemoglobin (HbA 1 c): capillary blood glucose, plasma glucose, and HbA 1 c are quick and easy screening tests that can help determine if the patient requires complementary tests. Diagnosis of diabetes mellitus is made if the patient has a history of polyuria, polydipsia, and weight loss, along with at least two glucose tolerance tests above 11.1 mmol/L, or a fasting glucose over 7.0 mmol/L. • Osmolality in plasma and urine: osmolality is controlled by osmoreceptors in the hypothalamus that detect homeostatic changes, and the release antidiuretic hormone is the result of these stimulus. If the production of antidiuretic hormone is low or the kidney is insensitive to it, like in diabetes insipidus, urine osmolality will be low, while plasma osmolality high.
In secondary care endocrinology: • Water deprivation test • Administration of desmopressin, an antidiuetic hormone
Evidence-based medicine suggests that: • The evaluation of patients with increased urinary flow must start with a complete medical history. To determine whether it is plain increase of the urinary frequency or polyuria. Also a graph of the daily fluid balance can help make that distinction. • The use of drugs (e.g., caffeine, alcohol, diuretics and lithium) and diabetes mellitus should be ruled out. • Urine test sticks are useful while studying these patients, and in the future urinary specific gravity is going to be very useful. • The urine/plasma osmolality ratio can help the differential diagnosis. • Vitamin D supplement excesses can lead to hypercalcemia, which can in turn cause polyuria and polydipsia. • Hyperthyroidism is a common endocrine condition, found in 1,3% of the general population. The symptoms of thyrotoxicosis (sweating, heat intolerance), also stimulate the thirst increasing circulating natriuretic peptides, and augmenting the excretion of sodium and water, and therefore polyuria. • Primary polydipsia is due to an excessive intake of fluids without a physiological stimulus to drink. It is attributed to mental disorders. So primary polydipsia is difficult to treat in the community, because of the risk of hyponatremia hypotonic, it requires hospitalizations frequently. BIBLIOGRAPHY h t t p : / / w w w. i n t r a m e d . n e t / c o n t e n i d o v e r. asp?contenidoID=82348 BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj. f6772 (Publicado 02 de diciembre 2013). Citar este artículo como: BMJ 2013; 347: f6772. Adam D Jakes, académico médico de base. Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds LS9 7TF, Reino Unido. Sunil Bhandari, nefrólogo consultor/profesor clínico honorario. Unidad Renal, Hull y East Yorkshire Hospitals NHS Trust y Hull York Medical School, Kingston upon Hull HU3 2JZ, Reino Unido.
PROMOTION AND PREVENTION
R
hinosinusitis in children Acting in time to prevent infections
The differential diagnosis between viral and bacterial upper respiratory tract infection is a thin line that makes the difference avoiding complications like rhinosinusitis, a disabling problem that can lead to prolonged and difficult treatments. The key to avoid them is the use of preventive measures as well as specialized control of the patients. This article was researched with the assistance of doctors: Carlos Arturo Moreno Montoya Pediatrician; Master’s degree in alternative medicine of Universidad Nacional of Colombia, and a member of Sociedad Colombiana de Pediatría. Frida Scharf Sanabria Pediatrician; specialist in pediatric otolaryngology. President of the Asociación Colombiana de Otorrinolaringología Pediátrica (ACOP).
Climatic changes have contributed to epidemiological transformations, especially in children. Upper respiratory tract infection is a high incidence disease, and a problem than can become very serious when it develops complications such as rhinosinusitis.
There are four pairs of sinuses, and they develop at different ages: the ethmoid (located between the eyes) are present at birth; where as the maxillary (on the sides of the nose) appear at four years of age; then the sphenoid and frontal (above the eyebrows) start maturing at eight, although they do not develop completely until adolescence. Eventually any sinus could become inflamed, but in young children only the maxillary and the ethmoidal are vulnerable because they have developed by seven years.
BETWEEN ACUTE AND CHRONIC The difference between acute and chronic sinusitis is the time of evolution. “The acute form is present at least in 7% of the children as a complication arising from an acute respiratory infection or allergic rhinitis, which has similar symptoms to upper respiratory tract infections, such as nasal obstruction, serous, mucous or purulent rhinorrhea, and headache. And in older children, cough during the day that gets worse at night can be accompanied with bad breath, fatigue
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The physiopathology of rhinosinusitis is the result of inflammatory changes involving the upper respiratory tract, especially the linings of the sinuses. Usually a complication of allergic reactions or viral infections (catarrhal rhinopharyngitis).
and anorexia for more than 10 days. It occurs when there is a recurrence or worsening of symptoms after an apparent recovery during the 5th or 6th day, with rhinorrhea, fever and other symptoms. Symptoms of sinusitis can also start with a 39 degree fever, on average, and purulent discharge for at least three consecutive days, and it is likely to become chronic,” explains doctor Scharf. In cases of acute rhinosinusitis, symptoms are mainly runny nose, mucous discharge, serous or purulent, and erythematous turbinates, often associated with viral or bacterial infections of the upper airways. “Chronic rhinosinusitis is a long, and almost painless condition. But it is also a very annoying process that could last three months, or more. These children
usually also have asthenia, persistent coughing, halitosis, nasal congestion, voice changes,” explains doctor Carlos Arturo Moreno Montoya.
BACTERIAL OR VIRAL INFECTION? The differential diagnosis allows an effective treatment. To do so, doctors must classify what kind of upper respiratory infection they are facing: In case of viral infections, symptoms include nasal congestion, with anterior and posterior drainage, and they become more severe around the third day. If there is significant improvement by 7 to10 days later, it can be inferred that it was a common cold, usually by riniovirus. Even if the infection is associated with bronchitis, and pharyngitis, it could still be consider rhinoviral. On the other hand, severe bacterial rinisinusitis are characterized by thick, opaque colored purulent rhinorrhea, with nasal congestion, facial pain and irritability. While less severe forms can also present with otalgia, fever, and periorbital edema.
THE CURRENT SCENE Epidemiological tendencies show that 15% of the allergic rhinitis are complicated with sinus infections. Data of the Ministerio de Salud y Protección Social de Colombia estimate that between 5% and 10% of all the acute upper respiratory tract infections in children are complicated by a sinus infections. Considering it is normal that a child can have around 6 to 8 colds a year, mostly of the viral type. “In the pediatric population respiratory diseases are on the rise. The most predominant are chronic and recurrent forms, a frequent reason for consultation, both at the office and in emergency wards”, says doctor Carlos Arturo Moreno Montoya. These diagnoses are confirmed with a physical examination that reveals on the nasal exploration swelling, redness, pus, and in the mouth, a rear discharge.
THEY COME TO THE CLINIC Children with these complications arrive at the clinic with a purulent discharge, nasal obstruction, malaise that last at least 7 or 8 days, when it is an acute process of a rhinopharyngitis. “There is swelling of the turbinates usually with secretion on the floor of the nose. The pharynx has a grained surface with a subsequent discharge. Then doctor can
Children come to consultation with purulent secretion, obstruction nasal, malaise, of at least 7 days and antecedent rinofaringitis infection. make a presumptive diagnosis based on clinical findings, not the x-rays”, indicated doctor Scharf.
RISK FACTORS Rhinosinusitis can drastically alter the patient’s quality of life. It can be chronical, and can also become severe on occasions. So it is important to control and prevent risk factors: • Physical and immune system immaturity of the child. • Adenoid hypertrophy and adenoiditis. • Attendance to preschool for the very young. • Exposure to cigarette smoke. • Environmental pollution. • Family history of allergic diseases, such as asthma, allergic rhinitis, atopic dermatitis, among others. • History of prematurity. Ventilatory assistance during the postpartum and neonatal periods have been associates with developmental defects leading to smaller airways. • Anatomical alterations, nasal septal deviation or history of persistent nasal foreign bodies for several days. • Exposure to strong temperature changes.
ATTENTION TO TRIGGERS Upper respiratory tract infections do not have to become persistent diseases. Specialized advice is key to the prevention of the severe forms of these infections, along with an integral treatment that will allow definitive improvement. Be alert, identify risk factors that can trigger infections and sinus complications. • Badly treated colds • Allergies • Swimming pools • Temperature changes • Anatomical problems • Foreign bodies that inflame the nasal mucosa, and therefore the sinuses • Nasal trauma • Infections caused by the child scratching his nose, and introducing in it his dirty fingers
PROMOTION AND PREVENTION • Contact with other children that are having viral infections. • Diminished defenses • Overcrowded places
MANAGING THE COMPLICATIONS In case of a flu, specialists recommend avoiding sudden temperature changes. Antibiotics are usually not required, instead saline solution at body temperature is very useful, although sometimes antihistamines are necessary in the presence of allergic symptoms. “If the patient already has sinusitis, management can avoid complications based on making the appropriate diagnosis so that a treatment can be started with antibiotics. The physician has to be very alert. Because in children complications are frequent. Since the nose communicates with the ethmoid sinus, which has a very thin wall and few blood vessels, they are very vulnerable to infections. Thus, they can become complicated easily with orbital and brain infections”, complements doctor Scharf.
TREATMENT The conventional treatment protocol is summarized in these four key tips: 1. For the patient it is best to keep a good rhythm of moisturizing. Washing the nostrils with saline, controlling humidity, for example, with a humidifier. Analgesics, mucolytics, and topical corticosteroids, which are powerful anti-inflammatories, may also be useful. It all depends on each patient’s symptoms. 2. In cases with high suspicions that the infection may be due to bacteria, because of the fever and pus, it is appropriate to start treatment with antibiotics. There are different guidelines for these drugs in allergic children to penicillin. Age and risk factors must also be evaluated and monitored. 3 Surgery of the sinuses, adenoidectomy and septoplasty, are used as a last resort in the treatment of cases of poor prognosis and orbital complications. 4 Hospitalization is required in the presence of periorbital edema, ocular displacement, double vision, ophthalmoplegia, changes in visual acuity, intense unilateral or bilateral frontal headache, frontal tumefaction, as well as signs of meningitis or neurological focal lesions.
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RECOMMENDATION FOR THE DOCTORS Once the diagnosis of an acute sinusitis is made, antibiotic therapy should be initiated, preferably for 10 days. Also, the formula may include: a nose wash, to moisturize the area, and to allow the flow of mucus. Vasoconstrictor spray can also be useful, only during three days, to decongest the turbinates and allow the sinuses to drain. Avoid swimming pools and sudden temperature changes. “If the child has serious complications, such as orbital cellulitis or abscesses, and signs of cerebral complications, including convulsions, the doctor must hospitalized and treat the patient with intravenous antibiotics. And if in 24 hours there has been no improvement, surgical treatment should be considered”, concludes doctor Scharf.
DO NOT FORGET Doctors agree that although there is no new classification for rhinosinusitis, other management protocols should be considered in the presence of allergies, and gastroesophageal reflux. Diagnostic images should also be considered depending on the clinical presentation of the patient. Finally, treatments should also include other alternatives such as immunotherapy and the functional endoscopic surgery. Bibliography 1. American Academy of Pedriatics. Subcommittee on Management of Sinusitis and Committee on Quality Improvement. Clinical practice guideline: management of sinusitis. Pediatrics 2001;108(3):798-808. 2. Desrosiers M, Evans GA, Keith PK, Wright ED, Kaplan A, Bouchard J, et al. Canadian clinical practice guidelines for acute and chronic rhinosinusitis. Allergy Asthma Clin Immunol 2011;7(1):2. 3. International Conference on Sinus Disease held in Princeton, NJ, in July 1993. 4. Clement PA, Bluestone CD, Gordts F, Lusk RP, Otten FW, Goossens H, et al. Management of rhinosinusitis in children: consensus meeting, Brussels, Belgium, September 13, 1996. Arch Otolaryngol Head Neck Surg 1998;124(1):31-4. 5. Guía EPOS European position paper on rhinosinusitis and nasal polyps. 6. Aitken M, Taylor JA. Prevalence of clinical sinusitis in young children followed up by primary care pediatricians. Arch Pediatr Adolesc Med 1998;152(3):244-8. 7. Ueda D, Yoto Y. The ten-day mark as a practical diagnostic approach for acute paranasal sinusitis in children. Pediatr Infect Dis J 1996;15(7):576-9. 8. Wald ER, Guerra N, Byers C. Upper respiratory tract infections in young children: duration of and frequency of complications. Pediatrics 1991;87(2):129-33. 9. Wald et al., 1984, Wald et al., 1981; Wald, Guerra & Byers, 1991. 10. Lusk R. Definition of sinusitis in children. Sinus CME 2012 St Peterburg. 11. Wald et al., 1981; McLean, 1970; Williams & Simel, 1993; Fireman, 1992. 12. Cincinnati Children’s Hospital Medical Center. National Guideline Clearinghouse. 2006. 17 p. 13. Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial. Peds 2013 – 1071 262-280
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MEDICAL WORLD BOOKS REVIEWS ‘Mammary Gland Diseases’
Gustavo Cortese / Jorge Itala / Diego Lange / Sergio Provenzano Ideal as a reference for medical students and residents in oncological specialties, also an invaluable practical guidance for all surgeons, gynecologists, medical oncologists and radiotherapists; this textbook describes the treatment guides for various diseases with an emphasis on integrated multidisciplinary management of patients with breast carcinoma, and their various surgical treatments, as well as radiotherapy, and chemotherapy. Likewise, the authors address special conditions such as breast cancer in pregnant and puerperal women, Paget disease, inflammatory cancer, lymphoma, sarcoma, and man breast cancer.
‘Mechanical Ventilation in Pediatrics’
Sociedad Argentina de Terapia Intensiva (SATI) / Comité Pediátrico de Pneumología Crítica Published by Editorial Médica Panamericana, this textbook details topics such as the various ventilatory modes, and there complications, also ventilation in different obstructive, and restrictive diseases, also other complex modes, such as non-conventional techniques of ventilatory support, home mechanical ventilation, monitoring, interfaces, and patient ventilator interactions. No doubt this is a very useful book for residents in pediatrics during their rotation in the pediatric intensive care unit, but also for pediatric intensivists, as well as other doctors, physical therapist, and nurses that use mechanical ventilation on a daily basis.
‘Advanced Ultrasound in Emergency and Trauma. Advanced USET’
Paula Ferrada, MD In the six chapters of this textbook, the author narrates the practical principles for the use of ultrasound in crisis situations, as well as the suggested protocol to establish when the patients need these tests. Emphasis is placed on how the procedures are performed, in which cases are they necessary, and it also includes recommended readings that can help and guide readers within the health care profession. This textbook was published by the medical publisher Distribuna.
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EVENTS V International Symposium on Patient Safety Date and place: 12 to 14 March, Cali Information: Centro Médico Imbanaco Phone numbers: (2) 682-1000 - 6000-518 Email: simposiodeseguridad@imbanaco.com.co Website: www.imbanaco.com.co
‘14th International Symposium of Pediatric Allergy and Pneumology’ Place and date: 28 to 29 March, Cartagena Information: Clínica Respiratoria y de Alergias Phone numbers: (5) 674-5182 - 662-8620 Email: simposio@clinialergias.com Website: www.clinialergias.com
‘XXV Regional Congress and I International of Internal Medicine. Atlantic Coast Chapter’ Place and date: 25 to 27 April, Cartagena Information: Asociación Colombiana de Medicina Interna. Capítulo Costa Atlántica Phone number: 316-860-5882 Email: congreso@acmicca.org - acmi.cca@gmail.com Website: www.acmicca.org
‘Practical Aspects of Pediatric Anesthesiology and Critical Care’ Place and date: 2 to 4 may, Boston (United States) Information: Harvard Medical School Boston Children’s Hospital Phone number: (+ 1) 617 384 8600 Email: hms-cme@hms.harvard.edu Website: www.hms-cme.net/342645
Gerente General Coomeva Medicina Prepagada Jorge Alberto Zapata Builes
Comité
editorial
Pascual Estrada Garcés, MD Director Nacional Médico Coomeva Medicina Prepagada Martha Liliana Cifuentes Castaño Coordinadora Nacional de Relacionamiento con Prestadores Bertha L. Varela, MD Jefe Nacional de Auditoría Médica Mauricio Castillo Director Nacional de Negocios Internacionales Paula Lilián Henao Analista Nacional de Comunicaciones Directora Editorial: Ana Luz Castillo Barrios Traductor: Santiago Barrios Vásquez, MD Corrección de Estilo: Lina Andrea Morales Diagramación: Eduardo Camargo Moreno Fotografías: Hugo Giraldo, ©2014 Shutterstock Photos y Coomeva Medicina Prepagada