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Wednesday, September 20, 2006

Something is wrong in some peruvian medical schools.

Left. Infography. La Republica/Peru. Courtesy. Click to enlarge.


With stupor, astonishment and pity, I assimilate the death of a productive 41 year-old male, (C.CH.R.C) to consequence of a Fever Syndrome of 45 days of duration that at the end turn out to be a case of Bartonellosis or Carrion's Disease (Fever + anemia / abdominal pain/ in 98,5% - 69,1% and 45,5% of the cases, respectively, detectable among 500-3 200 meter above sea level), caused by the bacteria Bartonella bacilliformis and vectorized for the sting of Lutzomyia verrucarum (titira, manta blanca). The patient's clinical record estimates that the 02/July/2006, being of holliday for the town of Barba Blanca/Santa Eulalia (interandine western valley : 800 masl), suffered the sting of a female Lutzomyia. Several doctors consulted -some from the Social Security, noticed in the affected a Fever Syndrome (he received 20 pills of Paracetamol), headache and abdominal pain. At some moment he was tentatively diagnosed of Hepatitis, and for this reason maintained in domiciliary observation, with the days happening and without an adequate diagnosis he got complications dying finally for hepatic, renal complications and an hemorrhagic syndrome (intravascular disseminated clotting).

Most of experts in Bartonellosis, said that if it is diagnosed early (clinical sign/symptoms + blood film), all the patients can be cured by means of the administration of common antibiotics. Nowadays for the TV we find out the possible existence of another similar case (male, 17 years, Fever for 30 days). If this new patient died for omission the fact would question our superior education system, especially to certain human medicine schools. Leaving aside some few cases of bacterial easy dissemination (immunosupresed), the case of C.CH.R.C., seems to go but well for the side of an inadequate diagnosis, because : I) Bartonellosis, is an endemic, broadly well-known illness. There are hundred of articles published to this respect expliciting the form to recognize and to treat it. It is our illness flag. It is inconceivable that we cannot diagnose (unless inadequate methodologies are used) it. Here - like in other professions - it is commendable to outline a lack of professionalism - for deficiencies in the teaching of the medicine or, by lack of control and supervision of the medical act.

II) In a country lacking of a scientific politic of vast reach, it is logical that in many medicine schools, the universal scientific method (dialectical or hypothesis-test-hypothesis) shine for its absence, with which they should not be diagnosed alone illnesses, but also any natural, social, physical problem, etc. In this case, to the murdered was not carried out (or, was observed improperly), a blood film, they didn't take him, hemocultures and were left aside the statistics and the knowledge of geographical Peruvians endemic diseases. Santa Eulalia is an endemic area of Bartonellosis. The Fever Syndrome has established and well-known algorithms. The irresolute fevers, suggest located processes (abscesses: ear, rectum, intraabdominal, etc), all easily located. Not being this the case, one has to think then of an General Infectious Process (GIP), of systemic localization whose process diagnosis demands blood count, blood film in search of Bartonella, urine exams, urine cultivations, blood cultures, processes that when not having been completed, conditioned partly the patient's erratic course. It could also have been studied this patient by means of algorithms associated to the Anemic Syndrome, evaluable for clinical history and constant corpuscular index. This Syndrome demands coombs test, reticulocites counts, blood films, etc. Here it has lacked scientific rigor, there are problems with the methodology of the teaching of the medicine in several Peruvian medicine schools. The present case suggests this way it.
Today the former Dean of the UNMSM : Manuel Burga, has published an article in La Republica, affirming that the UNMSM, has few Doctors and that their professors are being mostly dedicated to Undergraduates and that the robustness and quality exhibited by the Brazilian universities, are due to a bigger emphasis in Postgraduates activities and to count with more Doctors. In the year 2004, an online warning of UNMSM, said. ..."Doctors are needed"...As such and being Dr. Burga, the Dean of the UNMSM, I ran for Main Professor's category, without success. I stay the impression that to ascend, more important than academic degrees was to be kindred to the Dean. I had then all academic degrees, included the grade of Doctor in Medicine. The problem, Dr Burga is that being in the power (you were), it is necessary to prioritize the academic and not the political thing, to achieve a real change in our universities.

Algo falla en algunas facultades de medicina peruanas.

Con estupor, asombro y pena, asimilé la muerte de un productivo varón de 41 años (C.CH.R.C), a consecuencia de un Sindrome Febril de 45 dias de duracion, que al final resulto ser un caso de Bartonellosis o Enfermedad de Carrion (Fiebre + anemia/cefalea/dolor abdominal, en 98,5% - 69,1% y 45,5% de los casos, respectivamente, detectable entre los 500-3200 msnm), causada por la bacteria Bartonella bacilliformis y vectorizada por la picadura de Lutzomyia verrucarum (titira, manta blanca). El historial del paciente estima que el 02/Julio/2006, estando de paseo por la localidad de Barba Blanca/Santa Eulalia (valle occidental interandino: 800 msnm), sufrio la picadura de una Lutzomyia hembra. Varios medicos consultados dentro de ellos algunos de la Seguridad Social, advirtieron en el afectado, un Sindrome Febril (recibio 20 pastillas de Paracetamol), cefalea (dolor de cabeza) y dolor abdominal. El algun momento le plantearon el diagnostico tentativo de Hepatitis, manteniendolo en observacion domiciliaria, con lo que pasando los dias y sin diagnostico de por medio, se complicaron las cosas, falleciendo finalmente por complicaciones hepaticas, renales y un sindrome hemorrágico (coagulacion intravascular diseminada).

La mayoria de expertos en Bartonellosis, coincide en que diagnosticada tempranamente (cuadro clinico+frotis sanguineo), todos los pacientes se curan mediante la administracion de antibioticos comunes. Hoy dia por la TV nos enteramos de la posible existencia de otro caso similar (varon, 17 años, Fiebre por 30 dias). Si a este ultimo paciente le fuese mal por omision y resultase siendo un caso curable, el hecho pondria en entredicho a nuestro sistema de enseñanza superior, en especial a gran numero de facultades de medicina humana. Porque dejando de lado algunos pocos casos de facil diseminación bacteriana (inmunosuprimidos), el caso de C.CH.R.C., parece ir mas bien por el lado de un enfoque diagnostico inadecuado, porque I) la Bartonellosis, es una enfermedad endemica, ampliamente conocida. Hay cientos de articulos publicados al respecto explicitando la forma de reconocerla y tratarla. Es nuestra enfermedad bandera. Es inconcebible que no se la pueda diagnosticar (a menos que se empleen metodologias inadecuadas). Aquí -al igual que en otras profesiones -es plausible plantear una falta de profesionalismo- por deficiencias en la enseñanza de la medicina o, por falta de control y supervision del acto medico.

II) En un pais carente de una politica cientifica de vasto alcance, es logico que en muchas facultades de medicina, brille por su ausencia el metodo cientifico universal (dialectica o hipotesis-prueba-hipotesis), con que deben diagnosticarse no solo las enfermedades, sino tambien cualquier problema natural, social, fisico,etc. En este caso, al occiso no se le realizo (o, se observo inadecuadamente), un frotis sanguineo, no le tomaron hemocultivos y se dejaron de lado las estadisticas y los conocimientos medico geograficos peruanos. Santa Eulalia es un area endemica de Bartonellosis. El Sindrome Febril tiene algoritmos establecidos y conocidos. Las fiebres irresolutas, sugieren procesos localizados (abscesos: oido, recto, intraabdominales, etc), todos facilmente localizables. No siendo este el caso, se tiene que pensar entonces en un Proceso Infeccioso General (PIG), de localizacion sistemica, cuyo proceso diagnostico exige hemogramas, frotices sanguineos en busca de Bartonella, examenes de orina, cultivos de orina, de heces, de sangre, hemocultivos, procesos que al no haber sido completados, condicionaron en parte el curso erratico del paciente. Tambien podia haberse estudiado a este paciente mediante algoritmos asociados al Sindrome Anemico, evaluable por historia clinica y constantes corpusculares. Este Sindrome exige test de coombs, cuenta de reticulocitos, frotis sanguineo,etc. Aquí ha faltado rigor cientifico, hay problemas con la metodologia de la enseñanza de la medicina en varias facultades de medicina peruanas. El presente caso lo sugiere asi.
Hoy dia el ex-Rector de la UNMSM, Manuel Burga, ha publicado un articulo en La Republica, afirmando que la UNMSM, cuenta con pocos doctores, estando sus docentes mayormente dedicados al Pregrado y que la robustez y calidad exhibida por las universidades brasileñas, se debe a un mayor enfasis en el Postgrado y contar con mas Doctores. El 2004, un aviso online de la UNMSM, decia…”se necesitan doctores”…Como tal y estando el Dr. Burga de Rector, postulé a la categoría de Profesor Principal, sin éxito. Me quedo la impresión de que para ascender –mas que merecimientos academicos- era necesario ser afin al Rector. Tenia, entonces todos los grados academicos, incluido el de Doctor en Medicna. El problema, Dr Burga es que estando en el poder (Usted lo estuvo), hay que priorizar lo académico y no lo politico, para lograr un cambio real en nuestras universidades.

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