DISERTACIÓN DEL DR. JOSÉ PABLO SALA EN EL HOSPITAL “MEIR MEDICAL CENTER”

ISRAEL. OCTOBER 12, 2014

Good morning. It is a pleasure for me, to be here with you to share our 40 years of experience in health care

in Cordoba, Argentina.

INSTITUTO MODELO DE CARDIOLOGÍA PRIVADO S.R.L CORDOBA, ARGENTINA

JOSE PABLO C. SALA M.D. F.A.C.C.info@imcnet.com.ar - www.imcnet.com.ar

First, let me show you a little bit of my home city. Cordoba city is located at Cordoba State in the middle of the country. It is

the second city in Argentina with a population of 1.4 millions. We have a lot of history, for example we have a university that

is more than 400 years old. Here you have some pictures of this beautiful city and its landscapes.

Córdoba

ARGENTINA

As previously mentioned, we have had 40 years in health care now.

It all began in 1974, when with two other Cadiologists, Dr Serra and Dr Balestrini, we started CERECA, the first Cardiac

Rehabilitation center outside Buenos Aires, and with the full support from Professors Henry Denolin and Rene Favaloro.

September 11th 1974

CE . RE . CA CENTRO DE REHABILITACIÓN CARDIOVASCULAR

1st cardiac rehab center (outside Buenos Aires)

40 YEARS!!!

Dr. Henry Denolin was a world expert from Belgium, a pioneer of Cardiac Rehabilitation. Dr Rene Favaloro, a cardiovascular

surgeon from Argentina who was a pioneer of coronary Bypass surgery.

Prof. Dr. Henri Denolin (Bruselas- Bélgica)1st president of the Rehabilitacion counsil, International Society of Cardiology

Prof. Dr. René Favaloro (Argentina)CV surgery pioneer

CERECA started with 6 severe coronary disease patients who could not undergo surgical treatment, so we enrolled them in our

program where they performed exercise under careful monitorization. This practice was only supported by us. Many

physicians all over Argentina questioned us and stated that this was not correct.

As we expected, these high CV risk patients sometimes had exercise induced angina that required we stopped the exercise and performed a 12 leads ECG, and waited for full recovery. We now know that these patients have ischemic preconditioning, that in the case of an acute MI it reduces the level of myocardial damage, so we were preconditioning our patients’ hearts without knowing it!

In 1975, I was asked to lecture about our first year of experience at the Deborah Heart and Lung Center, in New Jersey USA, and right after it I was invited to stay to create their CV Rehab Program, but I had to go back to Cordoba.

CE.RE.CA - 1974

We currently have 280 patients in the program. In 40 years our mortality is zero and only 5 patients have been hospitalized due to

hypertension or arrhythmias. I am one of those 5 patients!!! 2 years ago, I was being checked

before performing exercise and an asymptomatic atrial flutter was diagnosed. This ended with my hospitalization, a transesophageal

ultrasound and cardioversion under anesthesia.

CE.RE.CA - 1982

CE.RE.CA - 1994

CE.RE.CA - 1995

CE.RE.CA – 2013 /2014

CURRENT CERECA STAFF

In 1976 I presented at the Cordoba's Cardiology Society the first study in Argentina that looked at CV risk factors in a supposedly

"normal population". I performed it while working at a public national petroleum Company "YPF" and I included DATA from 150 patients. Here you can see some of the charts that I filled

out for the study.

1976 - CV RISK FACTORS STUDY

On January 29th, 1977 with my partners, in the middle of riots that were taking place in Cordoba, we opened the Instituto Modelo de Cardiologia, a private cardiovascular institution that would provide “state of the art cardiovascular treatment” to our patients. It was not an easy decision but we had no choice, as in the public hospitals we were working at, the cardiovascular surgeries results were suboptimal and the burocracy was in crescendo. We either created our own institution, or we left Cordoba for good. I remember very well several conversations we had at that time with my father.

January 29th 1977INSTITUTO MODELO DE CARDIOLOGIA

My father was considered by my partners and others,a brillant interpreneur and a very well respected businessman. It was with his blessing that we decided to go ahead; Dr Serra at the age of 44 and Balestrini and myself at the age of 33. Dr Serra made it clear from the beginning that our institution could not only cover health care, but it had to have 2 more pillars, Teaching and Research. It was because of him that in March that same year we started our 3 year cardiology residence program.

“my father, our advisor”

Our residents need to have at least one year of internal medicine in order to apply. By now, we havetrained more than 200 cardiologist distributed all over the world, in the USA, Canada, Italy, Spain, France, Chile, Brazil, Costa Rica, Peru, for example. In addition, we have had foreign residents from Spain, Brazil, Peru, Paraguay, Honduras, Bolivia, Venezuela, who came to do their residence with us and return to their native countries.

CARDIOLOGY RESIDENTS

1977-1980 GRADUATION

DR. MOISES RAUL SUED LICHTENSTEIN

1979 - 1982BEFPORE HE WAS A RESIDENT OF RAMBAMIN HAIFA

The Institute, has been a pioneer in Cordoba since its creation in 1977. We had the first 2 coronary care ambulances and that same

year we were the first to measure bedside cardiac output in patients suffering from an acute MI in the CCU.

We have also been pioneers in Argentina. In 1988 following a group from Kansas USA, we were the first institution in the country to perform an angioplasty during an acute MI. We were severely

criticized for this in many national meetings as we were interfering with the drugs companies that provided thrombolytic therapeutic

options, supposedly the only choice of treatment at that time.

5 years later, the first publication that supported this practice came out in the NEJM and nowadays there is no doubt at all, that

primary PTCA is the best practice all over the world for treating Acute Myocardial Infarction.

1st PRIMARY PTCA IN ARGENTINA

JANUARY 1988

5 YEARS LATER, 1ST PUBLICATION ABOUT PRMARY PTCA

Our institution kept growing and growing, we had started in 1977 renting one property downtown Cordoba, and by 1987 we had 13 properties rented out to cover all our needs. It was not until 1989 when we moved to our own building where we are located nowadays. We had bought the land back in 1978 but had to wait due to Argentina's economic turn downs for 11 years, to be able to fulfill our dream of our own building. We were able to do so not only to our continuous effort but also thanks to full support from several patients and friends who donated more than 500.000US$ by now. Let me tell you how difficult it is to create a “state of the art” institution in a developing country such as Argentina. In 1981 the institution almost disappeared, as we had to go to the banks and mortgage our own houses in warranty to get loans to make payments and we had to go through a huge reengineering process. It is important to mention that our wives have always given us full support, and this is true, as the three of us, we are still married. In 1996 with my partners, we decided to open our doors to other specialties. It was because our patients demanded that we had to expand our horizons as they wanted to be taken care of in all specialties at our institution. Nowadays, we can perform from a simple ECG to a heart transplant and we have almost every specialty but OBGYN and neonatology.

IMC 2014 – CE.RE.CA

We have a 10.000 square meter institution; with 72 beds; with 450 monthly hospitalization; more than 14.000 monthly outpatients and more than 12.000 diagnostic studies. We are a third level institution fully equipped that receives patients from all over Argentina. Let me tell you some details of our daily work that makes a difference in regards to health care, teaching and research. When providing health care one of our main accomplishments is to have performed these 37 years two daily rounds, one at 8am and another at 5pm, Monday through Friday. The first without patients and the second at the bedside of the patients. In addition, every weekend and holidays we perform rounds one time. Our residents and staff from the ICU, CCU, etc, have to know about each hospitalized patient’s pathology. Thus, they need to be alert about 60 patients conditions average, which is an interesting challenge as we have a bed turnover time of 2.3 days.

In regards to teaching, we currently have 27 residents in Cardiology. Our residents are required to rotate many months in the ICU and CCU. As they are the only residents we have, they end up being trained not only in cardiology but also in Emergency medicine, etc. We consider it the best training they can achieve because they are able to perform invasive practices as locating central lines, transitory pacemakers, swan-ganz, upper airway intubation, etc.The residency training program covers 1 year rotation through internal medicine and 3 years through cardiology.The Residence qualifies as practical training in order to achieve the Cardiologist certificate. The residents are also able to complete Academic requirements by attending a Cardiology postgrade, at a private University which was started by Dr. Serra in 1985.

CARDIOLOGY RESIDENCE 1977 - 2014

• 35 GRADUATIONS • 205 Cardiologists • 27 in Training

Let me share with you something really nice that we have been doing for the past 10 years. For each graduation, we invite former residents that left the institute 25 years before, to share their life experience after graduation. One very important thing for us is to see that our institution’s philosophy remains intact! Later on, I will

come back to this and insist on our philosophy.

CARDIOLOGY RESIDENTS

1977-1980 GRADUATION

CARDIOLOGY RESIDENTS

2010-2013 GRADUATION

2013 Residents Graduations’ Speaches

“THE” same philosophy continues!!!

Resident that is about to start a new life!

25 YEARS AFTER, shares his experience!!!

In regards to research, our institution has participated in several international studies and has published several Cardiology books

for peers and for patients.

One major book we published had an editorial written by Professor Valentin Fuster who stated that "this is the reference book on

myocardial infarction in Spanish speaking countries”

“…in my opinion, this is the reference book on myocardial infarction in Spanish speaking countries…”

Professor Valentin Fuster MD PhDMount Sinai, NY, USA

We have also published many articles in national and international magazines as shown in the slide. Lately our staff has published in the American Journal Physiology, Heart Circulation; American Journal of Physiology, Regulatory and integrative Physiology; Molecular Cell Biochemistry; Physiological Measurements; British Medical Journal Open; etc.

This last publication was performed in conjunction with HARVARD University, University of MASSACHUSETTS and WAYNE STATE University from the US.

RECENT PUBLICATIONS BY OUR STAFF• Role of cardiac output versus peripheral vasoconstriction in mediating

muscle metaboreflex pressor responses: dynamic ecercise versus postexercise muscle ischemia. Am J Physiol Regul Integr Comp Physiol. 2013 Apr 15;304(8):R657-63.

• Muscle metaboreflex induced coronary vasoconstriction limits ventricular contractility uring dynamic exercise in heart failure. Am J Physiol Heart Circ Physiol. 2013 Apr 1;304(7):H1029-37.

• Altered calsequestrin glycan processing in common to diverse models of canine heart failure. Mol Cell Biochem 377(1-2):11-21;2013.

• Cardiac output is not a significant source of low frequency mean arterial pressure ariability. Physiological Measurements 34: 1207-1216; 2013.

RECENT PUBLICATIONS BY OUR STAFF• Attenuated muscule metaboreflex induced increases in cardiac

function in hypertension. Am J Physiol Heart Circ. Physiol. 2013 304 H1029-1037.

• Cardiac output in not a significant source of low frequency mean arterial pressure variability. Physiol Meas. 2013 Sep;34(9):1207-16.

• Point of care assessment of platelet reactivity in the emergency departament may facilitate rapid rule-out of acute coronary syndromes: a prospective cohort pilot feasibility study. BMJ Open; 4 (1) January, 2014.

• Stimulation of the cardiopulmonary baroreflex enhances ventricular contractility in awake dogs: a mathematical analysis study. Am J Physiol Regul Integr Comp Physiol. 2014 Aug 15;307(4):R455-64.

As we all know, medicine is constantly evolving. Thus, in 1978 we started organizing scientific courses and since 1989 international symposiums. We have been distinguished by the visit of many outstanding professors and scientists.

To mention a few Professors: Valentin Fuster; S. Rahimtoola; L. Gould; A. Iskandrian; W. Boommer; W. Parmley; B. Katsen; E. Beven; P. O'Gara; W. O'Neill; Barry Franklin; G. Stone; Lawrence Sinoway; Marc Kaufman; Phillip Levy; etc. This past year we had 8 simultaneous sessions going on and more than 1000 attendees.

INTERNATIONAL SYMPOSIUMS

2013 NTERNATIONAL SYMPOSIUM

2015 SYMPOSIUM, August 7 th

With my 2 partners we decided that the institute needed to participate and reach out to the community. This was the main reason for us to create a non profit organization in 1981 called FU.C.C.A.D.I.M., independent from the Institute but sharing cardiology and medicine as a target. The foundation, with the participation of our residents, has trained more than 22.000 individuals from the community in CPR. The foundation has performed different campaigns, for example in 1994 it launched the program called "Pasos" which means "steps" in four different strategic locations in the city and once we ended up having 800 participants.

FU.C.C.A.D.I.M. 1980

CPR courses22.500 individuals trained

This program would train people to walk and perform controlled exercise to get in shape, loose weight and live a better life.

This program was then taken over by politicians but, as with many things in our country, when the politicians participate, it

disappears...At least people learned that walking is enough to live a better life, it is not running but walking what we recommend.

Many workshops are given every year at FUCCADIM, such as "CV risk factors control"; for example "eating well", "why to perform

exercise"; "stress management"; "stop smoking"; "Dyslipidemia"; "Diabetes"; "HTN" etc.

CV RISK FACTORS WORKSHOPS

Moreover, this foundation has reached many poor remote areas from our state providing food, clothes, medications, and free health consultations, including dental and ophthalmologic. Once we even trained a local nurse for this people as no doctors' offices were available for many miles, note that these people have no motor transportation, they travelled on foot or horses. We contribute to many poor institutions with kids day campaign and religion celebrations. In regards to providing the public with useful information we have weekly participated during 15 years on a highly ranked radio program.

Trips to Provide Health Care to Extremely Poor Areas

For the last 10 years, we have been hosting weekly a 30 minutes TV program which received two excellence awards. The institute is constantly consulted by many journalists on different topics of general interest and also as we usually have celebrities, we are on the news almost every week. We also are asked to write for daily journals.In addition for the past 2.5 years we have been dedicated to review every process medical and non medical at our institution.

TV PROGRAM

We have professionalized every area, we applied different approaches such as LEAN Healthcare techniques into optimizing our processes such as ER and OR patient flow, etc and we also

updated our equipment with “state of the art” technology.

STATE OF THE ART TECHNOLOGY

We have started exercise programs for our personnel and also given workshops for them to learn how to take care of

themselves.

EMPLOYEES AND STAFF SEDENTARISM PREVENTION

We have also started new recreational activities such as the Family day, Santa Claus day, etc. We believe that "With Change comes

opportunity" and although it has been challenging and time consuming we are proud to see the results.

RECREATION, FAMILY DAY!

RECREATION, FAMILY DAY!

RECREATION, NEW YEARS’ PARTY!

RECREATION, NEW YEARS’ PARTY!

NURSES, RETIRING AFTER 30 YEARS!

"First comes the patient, then the patient, then the patient, & then the patient & his family” We provide a personalized type of health care, we do not seek for quantity but for quality. In this regards, this past august our institution received a full accreditation from ITAES, which is a national certificating non profit organization for health care institutions. As just mentioned, the most important thing for us is our patients and their families.

PERSONALIZED HEALTH CARE

THERE IS ONLY ONE INSTITUTION, NOT 200!!!

• COMMITMENT • COMUNICATION • RESPECT & CONSIDERATION• HUMILITY • SENSE OF BELONGING • SOLIDARITY • CAUTION • SELF-CRITICISM • LOYALTY• ACCOUNTABILITY• PRUDENCE

TEAM WORK & RESPONSIBILITY

Last September 16th we were honored to have our Distinguished Lecturer:

Dr. José Boris Wolaj(Research on Basic Neutrophil Function and Patients

Immunocompromised)

SEPTEMBER 16 - 2014

TANK YOU !