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Posts Tagged ‘cartagena’

As most of my long-time readers know, encounters with two surgeons in particular, during the writing of my first book had a profound impact on me – and ultimately led to significant changes in my career..  (It’s funny how unintended efforts / small encounters can have such effects.  I am sure that Dr. Gutierrez never anticipated that spending a day in the operating room, and visiting patients with a gringa nurse would lead to all this – I certainly never did.)

But this week was the first time I had the opportunity to see one of those surgeons, Dr. Edgard Gutierrez in quite a long time.  It was wonderful to see him – he remains as friendly and enthusiastic as always.  Even better – he tells me that he was recently joined in Cartagena by a second thoracic surgeon, so he finally has some relief from the 24/7 frantic pace of caring for a million-person plus city all on his own.  (The addition of a second surgeon also gives him more time to work on some of his academic projects, like writing up case reports on some of his more interesting surgeries. )

He also reports that he has done several more dual-port diaphragmatic repair cases since we last communicated, along with several other interesting cases.  (I could have talked to Dr. Gutierrez all day, but alas! we had a conference to attend.)  It was wonderful to see him – and to hear about all the work he has been doing.. I volunteered to be his gringa nurse, but ….

(Too bad- I am sure it would be an enlightening/ informative and valuable experience!)

(We were too busy catching up to remember to get any photos.)

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with Dr. Pulido (left) and Dr. Barbosa in Cartagena (2010).

I wanted to post an update on a fantastic surgeon (who has since become a good friend).  In fact, Dr. Cristian Barbosa was one of the first surgeons I ever interviewed back in 2010 – and without his encouragement, the first book would have never gotten off the ground.  Maybe not the second book (Bogotá!) either – since once I said the magic words, “Oh – I interviewed Dr. Barbosa in Cartagena last year,” plenty of other surgeons who might not have talked to me – started to take me seriously.

with Dr. Barbosa back in 2010

Ever since then – I try to keep in contact with Dr. Barbosa – he’s a great person and an absolutely phenomenal surgeon, so I email him every so often..

Since my last visit, back in August – Dr. Barbosa has left Hospital Neuvo Bocagrande – and is now operating in Clinica Santa Maria in Sincelejo, Colombia.

Sincelejo is the capital of the state of Sucre, which is part of the Caribbean region of Colombia.  Like most of this part of Colombia – it has a rich history, and was founded back in 1535 in the name of St. Francis de Assis, though it was long inhabited prior to that by native Colombian tribes such as the Zenu.  Unlike nearby Cartagena (125km north), Sincelejo is a more mountainous landscape, and is known for their agriculture, particularly cattle.  (wow – my stomach just rumbled  – must be missing those gourmet Corral burgers, which are my one Colombian indulgence.. Argentina has nothing on Colombian beef.)

Dr. Barbosa is still living in Cartagena and making a three-hour commute to perform life-saving surgery, while he works on creating a new cardiac surgery program back in our favorite seaside city.  (Hopefully, when he does – we’ll be invited back to take a look!)

gate at the entrance to the historic el centro district

sunset in Cartagena, Colombia

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cobblestone streets in the historic district of Cartagena, Colombia

Summit of the Americas – Cartagena, Colombia

As anticipated, President Obama is receiving some harsh criticisms for the Cuban embargo begun by fellow democrat, President John F. Kennedy in October of 1960.  (Despite the long-standing embargo, the United States remains the fifth largest exporter to the island nation.)

This embargo, which was initiated in response to the Cuban nationalization of private properties as part of the institution of a communist regime, reached full strength in February of 1962, and has continued unabated since then.  In fact, the American embargo was re-affirmed in 1992 with passage of the Cuban Democracy Act, and again in 1996 with Helms – Burton Act which further prevents private American citizens from having business relationships or trade with Cuba.

At the summit, the host of the event, President Juan Manual Santos (Calderon) has been one of the more outspoken critics of this on-going trade policy and public relations nightmare.  President Santos argues, fairly successfully in my opinion, that not only is the embargo an outmoded method of diplomatic negotiation, but that is has been an ineffective one (in inspiring governmental and philosophical change in Cuba.)

President Santos respectfully requests that Obama reconsider the decades old policies of trade embargo. Photo by AP press

This comes after President Obama was embarrassed by a prostitution scandal involving several of his private security detail.  At the time of this writing, eleven members of the secret service along with five members of the military has been openly disciplined, and returned home.

Colombian prostitutes – photo found at multiple sites, including another wordpress blog and http://azizonomics.com/tag/colombian-prostitutes/
(If this is your photo – let me know, so I can give proper credit)

Protests against the United States have been small scale and without injury as small explosives were detonated near the American embassy.

President Obama also fielded criticism on America’s ‘War on Drugs’.  While conceding that the efforts have been a multi-billion dollar failure (with the exception of small scale victories such as the capture/ death of Pablo Escobar in 1994), Obama refused to consider efforts to legalize drugs, as are under discussion in several other nations.

In other news – in a surprise move that may predict more future instability for Venezuela, President Hugo Chavez has decided to forgo the summit as he pursues treatment for cancer (in Cuba).  This move leads to intense speculation regarding both the presidential and governmental prognosis in Venezuela.  Previously, President Chavez had been adamant that his cancer was curable and disputed reports of a more serious condition. There are now several media reports that the president has widespread metastasis affecting multiple organs.  (May I suggest that you consider HIPEC, President Chavez?)

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Big news out of Cartagena, Colombia as Hugo Chavez (Venezuela) and Bolivia’s president, Evo Morales come together with President Barack Obama and Secretary of State, Hilary Clinton along with 30 other member nations for the Summit of the Americas.  Most certainly on the agenda – discussions regarding both Mexico’s and Colombia’s decisions to decriminalize drugs, as well as the continued drug violence affecting both countries.  President Evo Morales’, a former coca grower, position on drugs and the so-called ‘Drug war’ are already well-known.

While Colombia’s crime has decreased dramatically, the reverse is true in certain parts of Mexico* – where the nightly news seems more like Vietnam footage, as reporters discuss caches of guns toted by young teenagers, and Cuidad de Juarez claims the title of ‘Murder capitol of the world.”   Much of this criminal activity has been attributed to illegal drug commerce to the United States leading several countries to blame the USA for creating havoc in their home countries as suppliers attempt to feed the hoards of American drug users.

Tensions between Venezuela, Bolivia, and Cuba against the United States are unlikely to change as a result of this Summit, but hopes remain.  The summit is also expected to put pressure on the United States regarding the 50-year-old Cuban embargo.

It’s an interesting turn of the tide – as these issues along with the economic problems plaguing the United States (and causing problems globally) put the US at a significant disadvantage.

In related news – here at Cartagena Surgery, readers are asking:

— So how dangerous is Mexico? —

Since I am currently living in a Mexican border city, you’ve picked the right time to ask.

* There are still plenty of safe and beautiful places in Mexico – but it remains a tragedy that the Sinoloa gang / drug activity have resulted in over 47,000 murders in the last five years.  ([To put this into context, let’s do some simply math.. Simple math since I’m a nurse not a statistician, so keep that in mind as you consider the limited variables here.]

1.  Mexico has over a hundred million people (or 1/3 the people of the USA)

with  47,000 murders over five years (or that’s the number that has been widely quoted.)  Divide 47,000 by five = 9,400 people murdered per year.

2.  The US has over 300 million people, and had 18,361 murders in 2007 (last year available by the US census.) So three times the people.  Hmmm.  I can already see that 18,361 divided by three is 6,120. 

3. But to be fair – let’s also look at cummulative average for the US – and compare apples to apples.. (or five years of data to five years of data.)  It’s still not entirely comparable since our latest available data is from 2007.

2007:  18,361

2006: 18,573

2005: 18,124

2004: 17,357

2003: 17,732

for a total of 90,147 murders over five years.  If we divide that by three, we get 30,039 which is only 69% of the murders in Mexico in the same number of years.  Now you can argue it either way – since the USA numbers aren’t current, etc. etc.. but Mexico’s rate IS significantly higher..

So what does that mean for travelers?  It means – stay the heck out of Juarez..  Be extra cautious in Tijuana, and Nuevo Larado – but otherwise,  use caution & commonsense when traveling in other parts of Mexico (like you would any where else!) – and enjoy yourselves.

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Hello magazine says Hello to the beautiful Cartagena de Indias in this new article that highlights the romance and ambience of this charming, coastal city that was founded during the swashbuckling days of pirates and buccaneers..

Cartagena de Indias

In other news (from Colombia Reports) – if you can’t make it to Cartagena right now, don’t worry – the city is taking steps to safeguard and protect its rich history for generations of tourists to come.

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New allegations of gross medicare fraud from overstenting and unnecessary interventional procedures has been filed against surgeons in Pennsylvania, including the prestigious UPMC medical center.  This story, (based on cases dating back to 2001 and onwards), comes just as the dust in settling from an outbreak of unnecessary stent cases in neighboring Maryland.

What is overstenting?

Article by Michael R’iordan from the Heart.com re-posted below:

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Erie, PA – A new whistle-blower lawsuit filed in US District Court in Erie, PA claims that five cardiologists from two medical practices defrauded Medicare by performing unnecessary cardiac and vascular surgeries and interventional procedures between 2001 and 2005.

The suit, filed under the False Claims Act (FCA) and first reported January 22, 2012 in the Erie Times-News [1], states that as a result of the fraud, Medicare overpaid for these procedures, which wasted substantial public money, and patients were placed at significant and unnecessary risk of harm.

According to a copy of the lawsuit obtained by heartwire, the physicians named are Drs Richard Petrella, Robert Ferraro, Charles Furr, Timothy Trageser, and Donald Zone. The two medical practices named in the lawsuit are Medicor Associates Inc—and its affiliate Flagship Cardiac, Vascular, and Thoracic Surgery (CVTS)—and the University of Pittsburgh Medical Center (UPMC) Hamot (formerly known as Hamot Medical Center). The Medicor practice is the full-service cardiology center affiliated with UPMC Hamot.

The lawsuit states that from June 2001 and earlier, the defendants “knowingly, systematically, routinely, and repeatedly submitted false claims to and received reimbursements from Medicare and other federal healthcare programs for medically unnecessary cardiac catheterizations and cardiac and vascular surgical procedures, including but not limited to . . . PCI.”

As result of the false claims, the physicians received money to “which they were not entitled.”

Paid directorships and kickbacks

Dr Tullio Emanuele, who worked at Medicor and Hamot Medical Center from 2001 to 2005, filed the suit and claims that Medicor engaged in illegal “kickbacks” with Hamot Medical Center and referred cardiac patients to the hospital. In the lawsuit, it is alleged that Hamot signed contracts with Medicor and Flagship CVTS, valued at $75 000 per physician and as high as $525 000 per year, and the doctors would refer patients in need of medical procedures to Hamot Medical Center.

“Specifically, Hamot identified physicians who referred a high volume of patients and/or had potential to refer a high volume of patients for special treatment and offered remuneration to them in the guise of sham contracts for medical directorships or other similar personal service arrangements,” according to the lawsuit.

The claim states the physicians and the participating hospitals violated the federal Anti-Kickback Statute and the federal Stark Act, which says that a hospital is not allowed to submit a claim for reimbursement from Medicare if the procedure has been referred by a physician with improper financial ties to the hospital.

The suit also claims that Emanuele began to grow suspicious in 2004 when he noticed higher rates of intervention among certain physicians within the group. Between 2004 and 2005, 4408 catheterizations were performed, and Petrella, Trageser, and Ferraro had a “rate of surgical intervention following catheterization of double the junior members of the group.”

Emanuele, according to the lawsuit, believes that many of the procedures were performed unnecessarily. For example, Trageser is accused of performing a cardiac catheterization in a patient with chest pain, despite the symptomology being inconsistent with angina. Ferraro is accused of implanting a stent in an artery with moderate stenosis, even though Emanuele previously recommended medical therapy. Zone performed a cardiac catheterization and overstated the severity of stenosis, sending the patient on to CABG surgery, where he/she later died.

UPMC Hamot and the named physicians received copies of the lawsuit last week, according to the Erie Times-News, and have 20 days to respond. If they are found guilty, UPMC Hamot and the Medicor physicians would be required to reimburse Medicare at triple the cost of the original procedure. Emanuele, as the whistle-blower in the case, would be entitled to 30% of the reimbursed money.

More on similar stories here at Cartagena Surgery:

The Ethics of the Syntax Trial

Stent Scandal series:

Cardiology takes another hit

Mark Midei – or the man who started it all..

This is just a sample of the articles available here at Cartagena Surgery.. For more on this topic, look under the cardiology tab..

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As many of my long time readers know, that during the last month or so, I have been reviewing studies, and data on the Syntax trial as part of a presentation at my hospital.  This has been more time-consuming and angst-wrenching than I would have ever expected; the more data I reviewed, the more conflicted I became about the ethical questions involved in a study of this kind.

Granted, I have a sensitive nature, and as a nurse, patient advocacy is one of my primary goals.  But thankfully, I found that I am not alone in questioning the legitimacy of subjecting patients to a ‘non-inferiority’ trial.

“In our opinion, the Syntax study disregarded the safety of the patients, by including death and major complications of a primary end-point of a non-inferiority study.”
— Mantovani et. al (2010).
Mantovani et al. (2010) Non-inferiority randomized trials, an issue between science and ethics: the case of the Syntax study.  Scandinavian Cardiovascular Journal, 2010; 44: 321-324.  Mantovani et al. full text pdf.   They question the benefit of subjecting patients to unproven therapies using a trial design that really fails to prove much at all about the effectiveness of the proposed treatment, (in this case, PCI).  They have an excellent discussion (and definitions for the uninitiated) on trial designs and what they really mean, in real terms.
As they point out – studies with this kind of trial design – really don’t prove anything at all.  It was a methodology designed by pharmaceutical companies in order to get new drugs on the market (whether or not these newer, more expensive versions of existing drugs were an improvement over older, safer, cheaper versions or not.)
But in this case – the real results were the unintended ones! Despite a skewed set of accounting (weighing heavily in cardiology’s favor) the results were determinedly negative, showing worse patient outcomes with stents, more deaths, more serious adverse events with stents.
As I delved even further into the data,  I began to question the concept of patient ‘informed consent’ all together.  Can a patient really comprehend the risks involved and what these outcomes really mean in practical terms for something like this?  Would anyone in the study actually break it down in a honest and straight-forward (no BS) fashion to potential study participants?
And how do patients (lay public) understand all of this anyway?  Their perceptions might radically differ from what we (researchers) think we’ve presented.  And, in fact – there are some HUGE differences, as multiple studies attest.  What patients hear and understand is DRAMATICALLY different from what we might expect.
Somehow, I don’t expect that researchers said to patients (for example):
“Mr. X, you are 50 years old, with HTN, diabetes and severe CAD affecting all three major arteries.  Since your labs, and general health is otherwise unremarkable, according to experience and the STS risk calculator, your risk for death with bypass surgery is Y (pretty darn safe). However, we would like to put you in a study where you may receive anywhere from 3 to 20 stents with extensive exposure to nephrotoxic (kidney-harming) dye,  and radiation.  These stents may close either acutely (stent thrombosis) or over time, causing a potentially fatal heart attack.  Stent occlusion happens much more frequently then bypass graft occlusion.  Oh, and by the way – we aren’t doing this study to see if stents are better than bypass surgery (we already know it isn’t) – we are doing it to see how much worse it is – within acceptable margins, of course [whatever than may be].”
No, somehow – I don’t think it went down like that.
More on the Syntax Trial comparing PCI and CABG:
Syntax, part II: New guidelines for revascularization
More on PCI appropriateness  (we have an entire series on PCI here at Cartagena Surgery)

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