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!
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
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.
Peruvian Health System
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.
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.
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.
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
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/
Foto Friday 13 – “Church of la Compañía”
PS… We’re actually in the states today! We’re here in WV to photograph Stephanie and Dave’s Wedding on 11.11.11 as well as visit family – it’s the first time back since moving and we’re excited to be here for a little while.
3 Nuevos Soles
The currency here in Peru is the sole. The exchange rate from U.S. dollars to Peruvian soles is roughly $1.00 = s/ 2.60. With that said, 3 soles here in Peru, is roughly about a dollar. To give you an idea of what all you can buy here with roughly a dollar (s/ 3.00), we made a list of common things that we purchase and that you can find on the streets of Cuzco.
Food:
– Set menu for lunch that includes soup and a drink (s/ 3.00)
– Various sorts of ice cream (s/ 1.00 – 3.00)
– Soft-serve ice cream on a cone (s/ 0.50 – 1.50)
– Various sorts of pastries or baked goods (s/ 1.50 – 3.00)
– Various sorts of local candy bars (s/ 1.00 – 3.00)
– Glass of fresh squeezed juice in the street or market (s/ 1.00 – 2.00)
Groceries:
– Large pack of cookies/oreos (s/ 2.50 – 3.00)
– 1.5 L of coca cola in glass returnable bottle (s/ 1.50)
– 2 L bottle of water (s/ 2.50 – 3.00)
– 1 kg of assorted fruits and vegetables such as tomatoes, peppers, mandarins (s/ 1.00 – 3.00)
– Avocados (2 for s/ 3.00)
– Eggs (s/ 1.00 for 3)
Services:
– Taxi cab ride to anywhere in Cusco (s/ 3.00)
– Bus ride (s/ 0.60)
– Hair cut, includes a shave of your neck with a straight blade (s/ 3.00)
– Shoe shine (s/ 1.00)
– Use of an oven to bake goods (s/ 1.00)
– Internet service (s/1.00 per hour)
– Printing/Photocopying (s/ 0.20 per page)
– Laundry (s/ 3.00 per kilogram)
– Cellular telephone minutes (s/ 0.50 per minute)
Entertainment:
– DVD movies, all pirated, there is no such thing as “originals” here (s/ 2.00 – 3.00)
– 25 Balloons (s/ 3.00)
– Video games (s/ 1.00 per 1 hour)
Personal:
– Bar of soap (s/ 1.50)
– Tube of toothpaste (s/ 2.50)
– Roll of toilet paper (s/ 0.60 – 1.00)
– Notebook (s/ 3.00)
– Extension cord (s/ 3.00)
– Ball-point pen (s/ 1.00)
Other Random Stuff:
– Box of matches (s/ 0.20)
– Newspapers (s/ 0.50 – 1.50)
– School lottery ticket for random goods such as balls, blenders, games, appliances (s/ 3.00)
Sacred Valley 3: Las Salineras
From Maras it was about an hour hike through the beautiful Sacred Valley to Las Salineras (or the Salt Ponds). We could not have asked for better weather!
Kenzo, ready to get started!
Some fellow travelers…the only other people we saw during our hike.
Look at the deep valley in the middle of the photo. It almost has an ominous look to it.
After getting lost for about 30 minutes (we took the wrong turn) we finally saw Las Salineras below!
So…the scoop about the Salt Ponds, they have been in use since Incan times. There is a salty, naturally flowing, hot spring at the top of the mountains that brings tons and tons of salt down to the ponds (which I assume were man-made). It was quite a site to see…and although not on the Tourist Ticket, it is DEFINITELY worth going to. It was one of our favorites.
PS… It looks like it’d be extremely cold, but that is not snow, it is salt. It was actually very comfortable!
The stream of hot water.
A taste test. Yep – salty. Where are the margaritas when you need them?
A local salt-pond worker.
Impressive, right? They just keep going.
Another stream. I included this to show you the clay-like color of the mountain underneath the salt.
Our last view of the Salt Ponds as we headed down to Urubamba for the night, en route to the impressive Ollantaytambo Ruins.
Urubamba – here we come!
To be continued . . .