New Site

We now have a new blog site, http://www.peru-zo.com/.  Besides a slightly different layout, we have added some new galleries that we will be continuing to update throughout the year.  Thanks for stopping by!

Foto Friday 16 – “No to Violence”

Today in Peru we celebrate "The Day Against Violence Against Women" and since I (Janie) work at a center that provides counseling services to families struggling with domestic violence issues - we participated in a parade throughout the city. This is one of my favorite photos of the day. It says "Nothing justifies someone hitting you." (More to come)

Case Study 6 – Bony Disfiguration

Brief case study of a rare disease seen at Hospital Regional in Cuzco, Peru.

HPI:  28 year old male described symptoms of cough and malaise for the past year.  Recently in the past few months, he began having hemoptysis.  Patient went to a regional clinic, where he was diagnosed with pulmonary tuberculosis and started on RIPE therapy.  Patient has been continuing therapy, but was referred to Hospital Regional for further management.

PMHx, PSHx, FHx: Has had short stature and some deformities of his extremities since growing up as a child.

Social Hx: Non-contributory.

Physical Exam:
Gen:  Short stature, pale, with some diaphoresis, using oxygen.
Lungs:  Significant adventitious sounds including wheezing in both lung fields.  Some respiratory distress.
Heart:  Regular rate and rhythm, no murmurs, rubs, gallops.
Abdomen:  Soft, non-tender, bowel sounds present.
Extremities:  Significant hard non-tender lesions located in both arms and legs, causing some deformity of the extremities and shorted stature.

Brief Differential Dx:
-Chondrosarcoma
-Ewing’s sarcoma
-Fibrosarcoma
-Osteosarcomas
-Endochondroma
-Multiple Endochondroma (Ollier, Marfucci)
-Chondrosarcoma

 Lab Tests:
-Extremity X-rays
-Chest X-rays

Chest X-ray showing multiple lesions, patient was diagnosed with pulmonary tuberculosis.

X-ray image of upper extremity showing significant disfiguration of ulna and radius, as well as some intramedullary lesions. Patient was diagnosed with Ollier's disease based on clinical exam and x-ray imaging.

Discussion:
From Silve & Jüppner, 2006:

“Enchondromas are common intraosseous, usually benign asymptomatic cartilaginous tumors, which develop in the metaphyses and may become incorporated into the diaphyses of long tubular bones, in close proximity to growth plate cartilage. When multiple enchondromas are present, the condition is called enchondromatosis also known as Ollier disease (WHO terminology). The estimated prevalence of Ollier disease is 1/100,000. Clinical manifestations often appear in the first decade of life. Ollier disease is characterized by an asymmetric distribution of cartilage lesions and these can be extremely variable (in terms of size, number, location, evolution of enchondromas, age of onset and of diagnosis, requirement for surgery). Clinical problems caused by enchondromas include skeletal deformities, limb-length discrepancy, and the potential risk for malignant change to chondrosarcoma.”

(Continued):
“Roentgenograms typically show multiple, radiolucent, homogenous lesions with an oval or elongated shape and well defined slightly thickened bony margin. The lesions and long bone axis run parallel. The lesions usually calcify with time and become diffusely punctated or stippled, a light trabeculation may be visible.”

(Continued):
“Enchondromas in Ollier disease present a risk of malignant transformation of enchondromas into chondrosarcomas, which usually occurs in young adults, and thus at an earlier age than observed in patients with chondrosarcoma alone. The reported incidence of malignant transformation is variable and estimated to occur in 5–50% of the cases.”

(Continued):
“There is no medical treatment for Ollier disease. Surgery is indicated in case of complications (pathological fractures, growth defect, malignant transformation).”

References:
1.  Silve C, Jüppner H. Ollier disease. Orphanet Journal of Rare Diseases. 2006, 1:37.

Foto Friday 15 (Tuesday Edition) – “Bath Time”

We're a little late on our Foto Friday post - but we still wanted to get you something!! Here C Fabion was taking a bath and loving it!

Peruvian Health System

Brand logo for one of the national insurances, "EsSalud"

The health system in Peru has two sectors, one public and one private.  Within the public sector, there are two types of national insurance.  The first, called Seguro Integral de Salud (SIS) is mandated by the Peruvian Ministry of Health (Ministerio de Salud, or MINSA).  SIS is what I would describe as the equivalent of Medicaid or Medical in the United States, and is further discussed below.

The second type of national insurance is called EsSalud, and is coverage given through employment for working families and individuals.  It is similar to most employment-based plans in the United States, but is on a national coverage scale, and offers full coverage of services within the health plan.  More information about EsSalud is described below.

In addition, MINSA (Ministry of Health) mandates certain public hospitals (e.g. Hospital Regional and Hospital Antonio Lorena, both in Cuzco) that offer healthcare services, regardless of insurance coverage.  At these public hospitals, the government provides health care to the uninsured population in exchange for a fee of variable amounts under the discretion of the individual hospitals/organizations or through the Seguro Integral de Salud (SIS).

Seguro Integral de Salud (SIS):  Translated as “Comprehensive Health Insurance,” SIS is under the Ministry of Health, and aims to protect the health of Peruvians who do not have health insurance, giving priority to those vulnerable populations who are at poverty and extreme poverty.   The beneficiaries of the SIS, about 18% of the population, are mostly in rural and urban areas, where poverty is greatest.  Additionally, SIS benefits pregnant women and men over the age of 17 who live in poverty and extreme poverty, both in rural and urban provinces, provided they do not have coverage of EsSalud or other social security schemes.  Qualification for coverage of SIS is based on an individual’s or family’s economic level.

SIS is funded almost entirely (94%) with regular resources from the general budget. The remaining 6% of its resources come from donations and contributions, international aid agencies, contributions from individuals, and public and private institutions.

Brand logo for SIS

Poster of SIS benefits

El Seguro Social de Salud del Perú (EsSalud):  EsSalud is a national insruance coverage that provides health services to the working population and their families within national EsSalud facilities and hospitals.

EsSalud benefits are financed by employer contributions, equivalent to 9% of the wages of active workers.  In the case of retirees, the contribution comes from the insured and is 4% of insurable earnings.

EsSalud covers approximately 20% of the population, which includes formal sector workers, retirees and their families.  Again, the health plan provides health services in its own health units that are located mainly in urban areas.

Sign for one of the EsSalud city clinics.

Promotional tent for EsSalud coverage at a local open market.

Example of a typical facility under the coverage of EsSalud.

While the two national plans have been successful in providing more coverage and access to health services in the community, one of the biggest disadvantages that I have heard from local Peruvians is that the waiting time to receive appointments or schedule an operation is generally very long.

Table showing the percentage of the population that has insurance coverage. Basically, in 2008 48% of the population has some kind of social health coverage, compared with 32% in 2000. In 2008 20% and 18% of the population had either EsSalud or SIS insurance coverage, respectively. In 2008 4% of the population had some other type of insurance and 58% of the population was not covered by any type of social insurance.

Other Plans:  Similar to the United States system, the military, police and their families have their own health subsystem composed of the Armed Forces Medical Services (Armed Forces) and the National Police of Peru (PNP).

Private insurance and prepaid services offer coverage to just under 2% of the population.

Between 10 and 20% of the population is totally excluded from the health care system despite the government has tried, through the MINSA and regional governments, to reach the poorest.  To clarify this statement, 20% of the population does not have access to to any health care services or facilities, regardless of their insurance coverage.

References:
1.  Alcalde-Rabanal JE,  Lazo-González O, Nigenda G.  Sistema de salud de Perú.  Salud Publica Mex 2011;53 supl 2:S243-S254.

Hospital Antonio Lorena

View of main entrance to Hospital Antonio Lorena

There are 3 main hospitals within Cuzco, 2 are public and 1 is more private.  One of the two public hospitals, which is older and in a much poorer part of town (Santiago District) is called Hospital Antonio Lorena.  This hospital offers a variety of outpatient clinical services including cardiology, pediatrics, neurology, etc., but also houses several inpatient wards.  Interestingly, many of the inpatient wards are separate buildings that are located in an open area behind the main building (see pictures below).  Each building or ward has about 30 hospital beds.  Hospital Antonio Lorena, as well as the other public hospital, called Hospital Regional, are available to all of the people in Cuzco, regardless if they have any insurance.  Both hospitals provide care free of charges…the only problem is that the facilities are not as modern or technological advanced as the private hospital (Hospital de Salud) and there are longer waiting times.

There are a lot of interesting cases that come to Hospital Antonio Lorena, most of the patients have a low socio-economic status, and minimal or no insurance.  As a foreign medical student, you can come do a month long rotation in whatever service you would like, after providing some documentation as well as a $100 tuition (per month).

For more information, check out the hospital website here:  http://www.hospitalantoniolorena.com/

Entrance to emergency room at Hospital Antonio Lorena

View of the courtyard in the back of the hospital. Notice some of the medical ward buildings shown as you continue walking through the courtyard.

View of the back courtyard behind the hospital that houses several of the inpatient wards.

One of the hospital buildings in the back courtyards that houses inpatient services...this one in particular is a pediatric leukemia ward.

Another one of the hospital wards in the back courtyard, this one is the medicine ward.

Typical view of one of the wards, usually an open space housing several patient beds. Notice the doorway in the back of the ward leads to the "quarantine" area where patients with tuberculosis stay.

Close-up of the "quarantine" area.

Foto Friday 14 – “Rounding”

A typical day of rounding on the infectious disease ward at Hospital Regional in Cusco. The medical team can often consist of several attending physicians, interns, students, and nurses. On this particular day, 20 persons were counted leaving the room.