Special article
Recommendations of the Spanish-Portuguese Internal Medicine services in the fight against climate change and environmental degradation
Recomendaciones de los servicios de Medicina Interna hispano-lusos en la lucha contra el cambio climático y la degradación ambiental
L. Camposa,
, M.M. Chimeno-Viñasb, J. Carretero-Gómezc, L. Santosd, A. Cabrera-Rayoe, P.R. Valdezf, R. Gómez-Huelgasg, en nombre de las sociedades, colegios, y asociaciones de Medicina Interna de los países de habla hispana y lusa
Corresponding author
a Portuguese Council for Health and Environment, Hospital CUF Tejo, Lisbon, Portugal
b Spanish Society of Internal Medicine, Complejo Asistencial de Zamora, Zamora, Spain
c Spanish Society of Internal Medicine, Hospital Universitario de Badajoz, Universidad de Extremadura, Badajoz, Spain
d Portuguese Society of Internal Medicine, Centro Hospitalar Universitário de Coimbra, Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
e Global Summit of Internal Medicine, Instituto Mexicano del Seguro Social, México, Ciudad de México, México
f International Forum of Internal Medicine, Hospital Vélez Sarsfield, Univesidad de Buenos Aires, Buenos Aires, Argentina
g European Federation of Internal Medicine, Hospital Regional Universitario de Málaga, Universidad de Málaga, Málaga, Spain
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"apellidos" => "Gómez-Huelgas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">g</span>" "identificador" => "aff0035" ] ] ] 7 => array:1 [ "colaborador" => "en nombre de las sociedades, colegios, y asociaciones de Medicina Interna de los países de habla hispana y lusa" ] ] "afiliaciones" => array:7 [ 0 => array:3 [ "entidad" => "Portuguese Council for Health and Environment, Hospital CUF Tejo, Lisbon, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Spanish Society of Internal Medicine, Complejo Asistencial de Zamora, Zamora, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Spanish Society of Internal Medicine, Hospital Universitario de Badajoz, Universidad de Extremadura, Badajoz, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Portuguese Society of Internal Medicine, Centro Hospitalar Universitário de Coimbra, Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Global Summit of Internal Medicine, Instituto Mexicano del Seguro Social, México, Ciudad de México, México" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "International Forum of Internal Medicine, Hospital Vélez Sarsfield, Univesidad de Buenos Aires, Buenos Aires, Argentina" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "European Federation of Internal Medicine, Hospital Regional Universitario de Málaga, Universidad de Málaga, Málaga, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Recomendaciones de los servicios de Medicina Interna hispano-lusos en la lucha contra el cambio climático y la degradación ambiental" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In 2021, the Food and Agriculture Organization of the United Nations, the World Organization for Animal Health, the United Nations Environment Program, and the World Health Organization defined the concept of <span class="elsevierStyleItalic">One Health</span> as an integrated and unifying approach that recognizes the close interconnection and interdependence of human, animal, plant and environmental health in general.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> On 28 July 2022, the United Nations General Assembly recognized a new human right: the right to a clean, healthy, and sustainable environment.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The main environmental determinants of human health include superpopulation, climate change, ecosystem degradation, loss of biodiversity, and the depletion of natural resources. On 15 November 2022, the world population reached 8 billion people. Since 1970, our ecological footprint has exceeded the rate of regeneration of the planet Earth.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The effects of climate change include global warming, extreme temperatures, food shortages, increased allergens, loss of biodiversity, more severe storms, floods, fires, and droughts, more poverty, displacement, and health risks. It is estimated that climate change could take over 100 million people into extreme poverty by 2030. The <span class="elsevierStyleItalic">World Meteorological Organization</span> and the Copernicus program have confirmed that July 2023 was the hottest month ever recorded.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In 2023, in Canada, a forest area equivalent to 17 million football fields was consumed by fire. With the current policies, the planet will exceed the 1.5 °C limit set by the Paris Agreement, and it is estimated that this increase could reach 2.7 °C by 2100 - though the complexity of the ongoing phenomena and the existence of tipping points may make this prediction uncertain. These changes are attributable to the past and future greenhouse gas emissions.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Human activities have contributed to the growing destruction of forests, grasslands and wetlands, threatening people’s lives and well-being.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Food production is not only affected by climate change, but is also responsible for 20% to 30% of greenhouse gases.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> At present, 55 million people are suffering from drought, and it is estimated that 75% of the world population could be affected by 2050.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> On average, 150 species become extinct each day, and one million species are at risk of extinction. (2)</p><p id="par0020" class="elsevierStylePara elsevierViewall">These changes, to which the health sector also contributes, are having a devastating impact on population health. This document expresses the consensus of 32 societies, colleges and associations of Internal Medicine in 29 Spanish- and Portuguese-speaking countries on the priorities in the participation of internists and health professionals, in general, in actions to adapt and mitigate this impact.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">Given the importance of the effects of climate change on the environment and, above all, on human health, and the essential and fundamental role played by Internal Medicine in this emerging problem, a working group was set up in July 2023 with representatives of the 32 scientific societies, colleges and associations of Internal Medicine from 29 Spanish- and Portuguese-speaking countries. The main objective was to develop a consensus document to make this situation visible and to outline strategies to combat this urgent problem.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The secondary objectives were to promote the prevention of the possible consequences of climate change; to encourage specific training and research in this area, and to take measures to combat threats to our health systems and their sustainability resulting from climate change.</p><p id="par0035" class="elsevierStylePara elsevierViewall">For the development of this document, a non-systematic literature review was performed by the members of the working group, selecting recent articles (published in the last two years) and some of special relevance from previous years. The search period ended in August 2023. The document was prepared through virtual meetings held in the last week of August. A two-round DELPHI method was used to build consensus, involving all collaborators from the different countries.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Experts, collaborators, and representatives of the scientific societies, colleges, and associations involved in the preparation of this international consensus document are listed in Appendix 1.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">The recommendations for healthcare professionals resulting from this consensus are presented below:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Ethical obligations:</span> It is our ethical duty to participate in the global fight against climate change and environmental degradation.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Cooperation of health organizations:</span> Health organizations must work together to reduce the health impact of environmental change on the human population.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3</span><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Environmental sustainability practices:</span> We must develop and implement good environmental sustainability practices at all levels to reduce the ecological footprint of the health system.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4</span><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Clinical guidelines:</span> Clinical guidelines for the prevention and management of the health consequences of environmental change should be published.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5</span><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Public awareness:</span> We have to commit ourselves to raising public awareness of these issues.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6</span><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Education on <span class="elsevierStyleItalic">One Health:</span></span> Education on <span class="elsevierStyleItalic">One Health</span> must be mandatory in the pre- and post-graduate training of healthcare professionals, and should be incorporated into scientific meetings. Research in this field should be encouraged and supported.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7</span><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Climatic resilience:</span> Health systems should be resilient to climate change and develop capabilities to respond to the current epidemiological transition and the increased risk of unexpected events.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8</span><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Prevention of inequalities:</span> We must actively prevent inequalities referred to the health consequences of environmental change and protect the most vulnerable populations.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9</span><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Exemplary behavior:</span> We must be an example of environmentally friendly behaviors.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">10</span><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Role of Internal Medicine:</span> Internal Medicine must be defended as a core specialty for responding to the health consequences of environmental change.</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">Each year, environmental factors cause about 13 million deaths or 20% of overall mortality.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Globally, 9 out of 10 people breathe air with high levels of pollutants exceeding the limits set by the WHO.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Air pollution and increased allergen levels are driving the growth in the incidence of cardio- and cerebrovascular diseases, lung cancer, chronic obstructive pulmonary disease, asthma, and allergies. With the changes in vector ecology, vector-borne diseases are on the rise, causing more than 700,000 deaths a year.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Zoonoses are growing, and account for almost 100% of all pandemics. Water-related diseases cause more than 3.4 million deaths annually, and food-borne diseases cause 420,000 deaths a year, overall.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Climate, weather, and water hazards have accounted for 50% of all disasters and 45% of all reported deaths since 1970.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> More than 10 million people died because of the severe droughts of the last century and, each year, >5 million additional deaths can be attributed to extreme temperatures.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a> Climate change is having stronger and more lasting impacts on people, with direct and indirect damage to their mental health and psychosocial well-being. These consequences particularly affect the most vulnerable populations.</p><p id="par0110" class="elsevierStylePara elsevierViewall">On the other hand, health systems must increase climate resilience and their environmental sustainability.</p><p id="par0115" class="elsevierStylePara elsevierViewall">In 2020, the WHO published a framework for implementing climate resilience and environmental sustainability in health facilities.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> This document highlights four key requirements: the existence of an adequate number of qualified human resources with decent working conditions, and those who are ready to respond to these environmental challenges; sustainable and safe management of water, sanitation and waste services; sustainable energy services; and efficient infrastructure, technologies, products and processes.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Beyond human resources, to address this epidemiological transition and the increased risk of climate catastrophes, health systems must have emergency plans at all levels of care; hospitals must be flexible, scalable, and with matrix-based organization; different levels of care must be integrated; there must be a sufficient number of hospital beds and intensive care beds; information and communication systems must be robust; telemedicine must be facilitated to reduce patient travel; health care disparities must be prevented; and political decisions must be accompanied by science.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Internists were at the forefront of the response to the COVID-19 pandemic, due to their broad training, polyvalence, efficiency, and coordination capacity. General internal medicine is undoubtedly a crucial medical specialty for addressing the uncertainty that threatens our health systems, particularly in hospitals.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Although the health system is essential to respond to epidemiological change and the increased risk of unexpected events, it is also responsible for 4.4% of greenhouse gas emissions.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Reducing the ecological footprint of the health sector requires a strategy at the national level and has to be seen as a political priority. Everyone, at every level of decision, is urged to contribute. Many of these measures may imply short-term investments, but they generate important medium- and long-term savings.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Health systems, through demands placed on their providers, can also have an indirect influence in many other sectors. In the United Kingdom, the NHS (National Health Service) has set itself a target of zero emissions by 2040, in everything directly dependent upon it, and by 2045, in everything indirectly dependent on it.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Several scientific societies have already taken positions calling for greater involvement of healthcare professionals in this effort. The European Federation of Internal Medicine also published a position paper, calling for the same.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Health professionals have an unavoidable responsibility for this emerging problem.</p><p id="par0145" class="elsevierStylePara elsevierViewall">The sense of the duty of intergenerational solidarity and the notion that doctors, in addition to carer providers, should also be advocates for our patients, must be our motivation to be involved in the fight against climate change, environmental degradation, and its consequences for the health of the population. We as physicians, and health professionals, have an ethical obligation to participate in this global movement. We do not have the right to ensure our well-being at the expense of the next generations, which are the generations of our children and our grandchildren.</p><p id="par0150" class="elsevierStylePara elsevierViewall">It is not the survival of the planet or even life that is threatened, but that of many species, including us humans. Robert Swan, the first man to reach both poles, said: “The biggest threat to our planet is the belief that someone else will save it.” Changing the announced fate for humanity requires everyone’s commitment, and health professionals have an additional responsibility in this fight.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of interest</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres2103844" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1792952" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2103845" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1792953" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-10-25" "fechaAceptado" => "2024-01-10" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1792952" "palabras" => array:5 [ 0 => "Environment" 1 => "Climate change" 2 => "One Health" 3 => "Internal Medicine" 4 => "Physicians" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1792953" "palabras" => array:5 [ 0 => "Ambiente" 1 => "Cambio climático" 2 => "<span class="elsevierStyleItalic">One Health</span>" 3 => "Medicina Interna" 4 => "Médicos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Facing the severity of the impact of climate change and environmental degradation on human health, 32 Internal Medicine societies, colleges, and associations of 29 Spanish and Portuguese-speaking countries issue a consensus document in which they call for the implication of doctors and all health professionals in the global fight against the causes of these changes. This commitment requires the cooperation of health-related organizations, elaboration and implementation of good environmental sustainability practices, greater awareness of professionals and population, promotion of education and research in this area, increasing climate resilience and environmental sustainability of health systems, combating inequalities and protecting the most vulnerable populations, adopting behaviors that protect the environment, and claiming Internal Medicine as a core specialty for empowerment of the health system to respond to these challenges.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Ante la gravedad del impacto sobre la salud del cambio climático y la degradación ambiental 32 sociedades, colegios, y asociaciones de Medicina Interna de 29 países de habla hispana y lusa divulgan un documento de consenso en que llaman a la implicación de los médicos y todos los profesionales de salud en la lucha global contra las causas de estos cambios. Este compromiso requiere la cooperación de las organizaciones relacionadas con la salud, elaboración e implementación de buenas prácticas de sostenibilidad ambiental, sensibilización de los profesionales de la salud y de la población, promoción de la educación e investigación en esta área, refuerzo de la resiliencia climática y la sostenibilidad ambiental de los sistemas de salud, combatir las desigualdades y proteger a las poblaciones más vulnerables, adopción de comportamientos que protegen el medio ambiente, y defensa de la Medicina Interna como una especialidad central para habilitar al sistema de salud para responder a estos desafíos.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">This paper was edited by Revista Clínica Española and Revista Medicina Interna, and co-published by Elsevier Spain and the Sociedade Portuguesa de Medicina Interna (SPMI). The articles are identical except for stylistic and spelling variations reflecting each journal's style guide. Either citation format is acceptable when referencing this article.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:2 [ 0 => array:4 [ "apendice" => "<p id="par0175" class="elsevierStylePara elsevierViewall">Andrea Fiabane-Salas (Sociedad Chilena de Medicina Interna)</p> <p id="par0180" class="elsevierStylePara elsevierViewall">António Carlos Lopes (Sociedade Brasileira de Clínica Médica)</p> <p id="par0185" class="elsevierStylePara elsevierViewall">Bismarck Perez (Asociación Nicaragüense de Medicina Interna)</p> <p id="par0190" class="elsevierStylePara elsevierViewall">Carlos Araya-Fonseca (Sociedad de Medicina Interna de Costa Rica)</p> <p id="par0195" class="elsevierStylePara elsevierViewall">Carlos W. Contreras-Camarena (Sociedad Peruana de Medicina Interna)</p> <p id="par0200" class="elsevierStylePara elsevierViewall">Claudia Arias (Asociación de Medicina Interna de Centroamérica y El Caribe)</p> <p id="par0205" class="elsevierStylePara elsevierViewall">Diego Alberto Brosio (Sociedad Argentina de Medicina)</p> <p id="par0210" class="elsevierStylePara elsevierViewall">Diego Graña-Cruz (Sociedad de Medicina Interna de Uruguay)</p> <p id="par0215" class="elsevierStylePara elsevierViewall">Emilio F. Buchaca-Faxas (Sociedad Cubana de Medicina Interna)</p> <p id="par0220" class="elsevierStylePara elsevierViewall">Evelyn Murillo (Sociedad Cruceña de Medicina Interna - Bolivia)</p> <p id="par0225" class="elsevierStylePara elsevierViewall">Fortuna Peralta (Sociedad de Medicina Interna de Republica Dominicana)</p> <p id="par0230" class="elsevierStylePara elsevierViewall">Helga Codina (Sociedad Hondureña de Medicina Interna)</p> <p id="par0235" class="elsevierStylePara elsevierViewall">João Francisco Pascoal (Colégio de Especialidade de Medicina Interna da Ordem dos Médicos de Angola)</p> <p id="par0240" class="elsevierStylePara elsevierViewall">José Javier Arango-Alvarez (Asociación Colombiana de Medicina Interna)</p> <p id="par0245" class="elsevierStylePara elsevierViewall">Jesús Falcón (Sociedad Paraguaya de Medicina Interna)</p> <p id="par0250" class="elsevierStylePara elsevierViewall">Jorge Rafael Soto-Castillo (Sociedad de Medicina Interna de la República Dominicana)</p> <p id="par0255" class="elsevierStylePara elsevierViewall">Juan L. Salgado-Loza (Colegio de Medicina Interna de México)</p> <p id="par0260" class="elsevierStylePara elsevierViewall">Karen Elizabeth Cárcamo de Villatoro (Asociación de Medicina Interna de El Salvador)</p> <p id="par0265" class="elsevierStylePara elsevierViewall">Ligia Maria M. D. Almeida (Colégio de Especialidade de Medicina Interna da Ordem dos Médicos Caboverdianos)</p> <p id="par0270" class="elsevierStylePara elsevierViewall">Liza Matlombe (Colégio de Medicina Interna da Ordem dos Médicos de Moçambique)</p> <p id="par0275" class="elsevierStylePara elsevierViewall">Maria Lucía Fortuna de Galarza (Asociación Dominicana de Médicos Internistas)</p> <p id="par0280" class="elsevierStylePara elsevierViewall">Mariflor Vera (Sociedad Venezolana de Medicina Interna)</p> <p id="par0285" class="elsevierStylePara elsevierViewall">Mário Évora (Associação de Médicos de Língua Portuguesa de Macau)</p> <p id="par0290" class="elsevierStylePara elsevierViewall">Mayra Cifuentes (Asociación de Medicina Interna de Guatemala)</p> <p id="par0295" class="elsevierStylePara elsevierViewall">Meno Nabicassa (Ordem dos Médicos da Guiné-Bissau)</p> <p id="par0300" class="elsevierStylePara elsevierViewall">Natalie Maynard Gamboa (Asociación Costarricense de Medicina Interna)</p> <p id="par0305" class="elsevierStylePara elsevierViewall">Omar Castillo-Fernandez (Sociedad Panameña de Medicina Interna)</p> <p id="par0310" class="elsevierStylePara elsevierViewall">Ricardo Hidalgo Ottolenghi (Asociación Ecuatoriana de Medicina Interna)</p>" "etiqueta" => "Appendix 1" "titulo" => "Collaborators representing the societies, colleges and national associations of Internal Medicine signing this consensus document" "identificador" => "sec0040" ] 1 => array:4 [ "apendice" => "<p id="par0315" class="elsevierStylePara elsevierViewall">Asociación Colombiana de Medicina Interna – Colombia</p> <p id="par0320" class="elsevierStylePara elsevierViewall">Asociación Costarricense de Medicina Interna – Costa Rica</p> <p id="par0325" class="elsevierStylePara elsevierViewall">Asociación de Medicina Interna de Centroamérica y El Caribe – Centroamérica y el Caribe</p> <p id="par0330" class="elsevierStylePara elsevierViewall">Asociación de Medicina Interna de El Salvador - El Salvador</p> <p id="par0335" class="elsevierStylePara elsevierViewall">Asociación de Medicina Interna de Guatemala - Guatemala</p> <p id="par0340" class="elsevierStylePara elsevierViewall">Asociación Dominicana de Médicos Internistas - República Dominicana</p> <p id="par0345" class="elsevierStylePara elsevierViewall">Asociación Ecuatoriana de Medicina Interna – Ecuador</p> <p id="par0350" class="elsevierStylePara elsevierViewall">Asociación Nicaragüense de Medicina Interna - Nicaragua</p> <p id="par0355" class="elsevierStylePara elsevierViewall">Associação de Médicos de Língua Portuguesa de Macau – Macau</p> <p id="par0360" class="elsevierStylePara elsevierViewall">Colégio de Especialidade de Medicina Interna da Ordem dos Médicos Caboverdianos – Cabo Verde</p> <p id="par0365" class="elsevierStylePara elsevierViewall">Colégio de Especialidade de Medicina Interna da Ordem dos Médicos de Angola – Angola</p> <p id="par0370" class="elsevierStylePara elsevierViewall">Colégio de Medicina Interna da Ordem dos Médicos de Moçambique - Moçambique</p> <p id="par0375" class="elsevierStylePara elsevierViewall">Colegio de Medicina Interna de México - México</p> <p id="par0380" class="elsevierStylePara elsevierViewall">Foro Internacional de Medicina Interna - América Latina y El Caribe</p> <p id="par0385" class="elsevierStylePara elsevierViewall">Ordem dos Médicos da Guiné-Bissau – Guiné-Bissau</p> <p id="par0390" class="elsevierStylePara elsevierViewall">Sociedad Argentina de Medicina – Argentina</p> <p id="par0395" class="elsevierStylePara elsevierViewall">Sociedade Brasileira de Clínica Médica - Brasil</p> <p id="par0400" class="elsevierStylePara elsevierViewall">Sociedad Chilena de Medicina Interna - Chile</p> <p id="par0405" class="elsevierStylePara elsevierViewall">Sociedad Cubana de Medicina Interna - Cuba</p> <p id="par0410" class="elsevierStylePara elsevierViewall">Sociedad Cruceña de Medicina Interna - Bolivia</p> <p id="par0415" class="elsevierStylePara elsevierViewall">Sociedad de Medicina Interna de Costa Rica - Costa Rica</p> <p id="par0420" class="elsevierStylePara elsevierViewall">Sociedad de Medicina Interna de Guatemala - Guatemala</p> <p id="par0425" class="elsevierStylePara elsevierViewall">Sociedad de Medicina Interna de la República Dominicana - República Dominicana</p> <p id="par0430" class="elsevierStylePara elsevierViewall">Sociedad de Medicina Interna de Nicaragua - Nicaragua</p> <p id="par0435" class="elsevierStylePara elsevierViewall">Sociedad de Medicina Interna de Uruguay - Uruguay</p> <p id="par0440" class="elsevierStylePara elsevierViewall">Sociedad Española de Medicina Interna - España</p> <p id="par0445" class="elsevierStylePara elsevierViewall">Sociedad Hondureña de Medicina Interna - Honduras</p> <p id="par0450" class="elsevierStylePara elsevierViewall">Sociedad Panameña de Medicina Interna - Panamá</p> <p id="par0455" class="elsevierStylePara elsevierViewall">Sociedad Paraguaya de Medicina Interna - Paraguay</p> <p id="par0460" class="elsevierStylePara elsevierViewall">Sociedad Peruana de Medicina Interna - Peru</p> <p id="par0465" class="elsevierStylePara elsevierViewall">Sociedade Portuguesa de Medicina Interna - Portugal</p> <p id="par0470" class="elsevierStylePara elsevierViewall">Sociedad Venezolana de Medicina Interna - Venezuela</p>" "etiqueta" => "Appendix 2" "titulo" => "Societies, colleges and national associations of Internal Medicine signing this consensus document" "identificador" => "sec0045" ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Food and Agriculture of the United Nations. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 49 | 17 | 66 |
| 2024 September | 194 | 51 | 245 |
| 2024 August | 92 | 81 | 173 |
| 2024 July | 135 | 51 | 186 |
| 2024 June | 136 | 55 | 191 |
| 2024 May | 770 | 70 | 840 |
| 2024 April | 219 | 53 | 272 |
| 2024 March | 98 | 40 | 138 |
