Revista Medica Herediana

Algunos aspectos del Programa de residentes en el Departamento de Medicina del Hospital Nacional Cayetano Heredia

Resistencia bacteriana

**Resistencia de Streptococcus pneumoniae a penicilina en portadores nasofaringeos menores de 2 años**

El neumococo es un agente etiológico importante de infecciones comunes que afectan a todas las edades. En las últimas décadas han aparecido a nivel mundial cepas de neumococo resistentes a la penicilina. A nivel local no se conoce la magnitud de este problema. Objetivo: El objetivo fue determinar el porcentaje de resistencia del neumococo a la penicilina en portadores nasofaríngeos menores de 2 años en el Consultorio de Crecimiento y Desarrollo del Hospital Nacional Cayetano Heredia en Lima. Material y métodos: Se tomaron muestras de hisopeado nasofaríngeo en 170 niños (Setiembre 1996-Marzo 1997), para cultivo de neumococo y determinación de su sensibilidad a la penicilina con el E-test y a otros antibióticos con la sensibilidad en disco. Resultados: Se encontró 44% (75/170) de portadores nasofaríngeos de neumococo en niños de 6 meses a 2 años. La presencia de tres o más niños en la familia estuvo asociado a un mayor porcentaje de portadores. De las 75 cepas aisladas, 4 (5.3%) fueron resistentes a la penicilina, incluyendo 3 (4%) con resistencia intermedia y 1 (1.3%) con alta resistencia (MIC=1.5my g/mL). La resistencia a otros antibióticos fue: trimethoprim/ sulfamethoxazole 39 cepas (52%), cefaclor 18 (24%), cloranfenicol 17 (22.7%), eritromicina 14 (18.6%), clindamicina 9 (12%) y rifampicina 8 (10.7%). Conclusión: La resistencia del neumococo a la penicilina continúa baja en el Hospital Cayetano Heredia; sin embargo, es urgente establecer estrategias de prevención y control de la emergencia y diseminación de microorganismos resistentes. ( Rev Med Hered 1998; 9:56-62).

Pneumococcus is an important etiologic agent of common diseases in all ages. In the recent decades pneumococcus strains resistant to penicillin began to appear worldwide. Locally the problem is not well known. Objective: The purpose of this study was to determine the percentage of penicillin resistant pneumococcus among nasopharyngeal carrier-children less than 2 years of age in the pediatric outpatient clinic (Crecimiento y Desarrollo) at the Hospital Nacional Cayetano Heredia in Lima. Material and methods: Nasopharyngeal cultures for S. pneumoniae were obtained from 170 children (September 1996-March 1997). The E-test was used to determinate penicillin resistance and disk diffusion for other antibiotics. Results: In a group of children aged 6 months to 2 years 44% (75/170) were nasopharyngeal carriers of pneumococcus. The presence of three or more children in the family was associated with a higher percentage of carriers. Among 75 strains isolated, 4 (5.3%) were resistant to penicillin: of these, 3 strains (4%) were intermediately resistant and 1 (1.3%) was highly resistant (MIC=1.5mu g/mL). Resistance to other antibiotics was: trimethoprim/sulfamethoxazole 39 strains (52%), cefaclor 18 (24%), chloramphenicol 17 (22.7%), erythromycin 14 (18.6%), clindamycin 9 (12%) and rifampin 8 (10.7%). Conclusion: The percentage of penicillin-resistant pneumococcus remains low at Cayetano Heredia Hospital. Nevertheless it is urgent to establish strategies to prevent and control the emergence and spread of antimicrobial-resistant microorganism. (Rev Med Hered 1998; 9: 56-62).

Modos de afrontamiento al estrés en residentes de medicina

Objetivo: Conocer las estrategias empleadas por los residentes de medicina para afrontar el estrés así como algunos factores que influyen en ellas. Material y Métodos: Se aplicó el Inventario de modos de afrontamiento al estrés de Carver, a todos los 49 residentes del Departamento de Medicina del Hospital Nacional Cayetano Heredia, registrándose además: la edad, año de estudios, sexo, estado civil, especialidad, y lugar de nacimiento. Los resultados se analizaron estadísticamente. Resultados: Los afrontamientos al estrés inadecuados de mayor uso por los residentes, fueron aquellos enfocados en la emoción, empleando el 67.3% la aceptación - resignación. Algunas de las características de los residentes influyeron en el empleo de la búsqueda de apoyo social por razones instrumentales y en el recurrir a la religión. El 32.7% de los residentes usaron con regular frecuencia los afrontamientos inadecuados enfocados en el problema y el 42.9% los enfocados en la emoción. Los residentes más inadecuados en el afronte de la emoción eran más jóvenes que el resto o cursaban en su mayoría el 1º año. Conclusiones: Casi la mitad de los residentes tienen dificultades en el aspecto emocional del estrés, hecho que afecta negativamente la relación médico - paciente y su rendimiento, razones por las que debe disminuirse el estrés hospitalario o brindarle al residente estrategias que fortalezcan su capacidad para afrontarlo. (Rev Med Hered 1998; 9:63-68).

Objective: To know the strategies that were used for medical residences to affront the stress and some factors that influence in it. Material and Methods: The Carvers inventory for mode of affronting he stress were applies to all of the 49 residents of the medical department at the National Hospital Cayetano Heredia, and we registered too: the age, year of residence, gender, marital status, specialty and place of born. The results were processed statistically. Results: The inadequate affronts of the stress that were more for the residents were those focus in the emotions, employing 67.3% the acceptation - resignation. Some of the characteristics of the residents had some influence in the use of the looking for social support for instrumental reasons and in the use of the religion. 32.7% of the residents used with regular frequency the inadequate affronts that were focused in the problem and 2.9% the focussed in the emotions. The residents more inadequate in the affront of the emotion were younger than the rest or were studying the first year most of them. Conclusion: Near the half of the residents reveal difficulties in the emotional side of the stress, and this fact affects the medical - patient relationship and their productivity, for that reason its necessary to decrease the hospital stress or teach them strategies that strength their capacity for affront it. (Rev Med Hered 1998; 9: 63-68).

Tumores desmoides: cuadro clínico y sobrevida

Objetivos: Identificar el cuadro clínico, la recurrencia y sobrevida quinquenal por tumor desmoide. Material y métodos: Analizamos 18 pacientes manejados en el Hospital Belén, Trujillo, Perú, desde 1966 a 1994. Resultados: Los antecedentes más frecuentes fueron embarazo reciente (n=8), cirugía previa (n=3) y traumatismo (n=1). La edad promedio fue de 29.5 ± 16.7 años (rango, 5 meses a 75 años). El 50% de los casos se presentó en la tercera década de la vida. Hubo 6 hombres y 12 mujeres (H:M, 1:2).El síntoma y signo más común fue tumor (100%), acompañado por dolor (66.7%), impotencia funcional (22.2%) y parestesias (16.7%). El diámetro tumoral promedio fue 10.9 ± 5.6 cm. Las neoplasias se localizaron en pared abdominal (n=12), cabeza - cuello (n=3) y miembros inferiores (n=3). El tratamiento más utilizado fue el quirúrgico (n=14), y la radioterapia se utilizó en 2 casos irresecables. En los 10 pacientes que tuvo seguimiento completo la tasa de recurrencia quinquenal fue de 33.3%, siendo ésta menor con el tratamiento quirúrgico (25%) que con el radioterápico (50%). Además, hubo menor recurrencia con la cirugía amplia y radical (16.7%) en comparación con la resección local simple (50%). La sobrevida quinquenal en la serie total fue de 87.5%, siendo ésta menor con el tratamiento quirúrgico (83.3%) que con el radioterápico (100%). Conclusiones: La localización más frecuente de estos tumores estuvo en la pared abdominal. El tratamiento quirúrgico con un margen amplio de resección ofrece un mejor control local de los tumores desmoides. (Rev Med Hered 1998; 9:69-76 ).

Objective: To identify the clinical picture and the 5 year recurrence and survival rates. Material and methods: We analized information on 18 patients managed at Belén Hospital, Trujillo, Peru from 1966 through 1994. Results: The most frequent antecedents were recent pregnancy (n=8), previous surgery (n=3) and trauma (n=1). The mean age was 29.5 ± 16.7 years (range, 5 months to 75 years). Fifty percent of the tumours appeared on third decade of life. There were 6 men and 12 women (M:F, 1:2). The most common symptom and sign was tumour (100%) followed by pain (66.7%), functional impotence (22.2%) and paresthesias (16.7%). The mean tumoral diameter was 10.9 ± 5.6 cm. The most common localization of desmoid tumours was abdominal wall (n=12), head and neck (n=3) and inferior limbs (n=3). Fourteen patients underwent surgical treatment, and radiotherapy was administered in 2 non resected cases. Among the 10 patients with complete follow - up, there was a five - year recurrence rate of 33.3% (25% with surgical treatment, 25% and 50% after radiotherapy). The recurrence rate after radical surgery and local resection was of 16.7% and 50%, respectively. The five - year survival rate was 87.3% (83.3% with surgical treatment and 100% with radiotherapy). Conclusions: These type of tumours were more frecuently found in the abdominal wall. The wide - edge surgery is the safest choice of treatment for desmoid tumours. (Rev Med Hered 1998; 9: 69-76 ).

Clínica quirúrgica de los cuerpos extraños en el abdomen: oblito quirúrgico abdominal

Philosophic medical and legal principles are stated introducing the name oblito, explaining its linguistic root. the definition of foreing body accidentally forgotten during an operation and with no therapeutic value, is proposed. The characteristics of the foreing body left in the abdomen during surgery from the nosographic and nosologic point of view, give this process an individuality, that allows to speak about its clinics. The symptomatology is clear and connected to the clinical forms analyzed. diagnosis is reached specially by radiology. In orden to complete the oblito's pathological similitude with other abdominal processes, it is necessary to point out that it has a regulated prophilaxis, in nearly every surgical center. (Rev Med Hered 1998; 9:77-80).

Anatomía patológica en el Perú: un enfoque histórico

Silla turca vacía e hipopituitarismo

We present the case of a multiparous and obese woman of 59 years with partial hypopituitarism having an empty sella syndrome. We describe the clinical, radiological and biochemical findings. The diagnosis of empty sella was confirmed by computarized tomography. The levels of thyroxine, cortisol and growth hormone were decreased, with pituitary hyporresponsiveness to hypoglicemia induced with insulin. The replacement therapy was successful. (Rev Med Hered 1998; 9: 84-88).

Toxoplasmosis y amigdalitis

Acquired toxoplasmosis is a widespread, usually asymptomatic zoonotic infection caused by an intracellular protozoan parasite Toxoplasma gondii. Due to its predilection for parenchymal cells and those of the reticuloendothelial system, involvement of the lymphoid tissue is the most common clinical finding. This patient presented with abdominal pain predominantly in the right lower quadrant, which dissapeared promptly, painful cervical lymph node involvement and a severe case of acute exudative tonsilitis which is exceedingly unusual. Diagnostic levels of IgM Against Toxoplasmosis highly suggests that the patient had acute or a very recent infection with the protozoan. It is difficult to determine whether the parasite was the cause of her illness or that she acquired a concomitant viral infection, like adenovirus. It would had been important and diagnostic to do a biopsy of the cervical lymph node involved, which was not done due to reasons out of our reach. (Rev Med Hered 1998; 9: 89-93).