Daily wound probing reduces surgical-site infections

An article in the Archives of Surgery reports that a daily routine of poking between the staples of a healing surgical wound with a Q-tip (a wound-probing protocol or WPP) greatly reduced surgical-site infections in patients recovering from open appendectomies after perforated appendicitis.

"...SSI in contaminated wounds can be dramatically reduced by a simple daily WPP," the study authors write. "This technique is not painful and can shorten the hospital stay. Its positive effect is independent of age, diabetes, body mass index, abdominal girth, and wound length. We recommend wound probing for management of contaminated abdominal wounds."

The investigators note that the mechanism by which wound probing reduces SSIs is not clearly understood but that it may allow for drainage of contaminated fluid within the soft tissue.

Good nursing care prevents an awful lot of complications. It probably costs almost nothing to add this bit of wound care to the routine, especially if performed by trained family members, and may keep many recovering patients in low-resource settings out of trouble. A news article about the study can be found here.

More beans, less rice

Eating more beans and less rice lowered the risk of metabolic syndrome (thickened waistline, low good cholesterol, high blood pressure, and some other factors that are often precursors to diabetes and cardiovascular disease) in this study of 1,879 Costa Rican people, published recently in the American Journal of Clinical Nutrition.

Recommending less white rice in favor of a protein probably makes good nutritional sense, but many people will be unable to afford the substitution. White rice is cheap and filling, and in some places, whatever's eaten with it is viewed more or less as a condiment.

Why do people eat polished rice when unpolished rice (containing the husk, bran, and germ) is nutritionally superior? I believe the answer is that it's easier to store polished rice, as rice germ contains fats that spoil easily. The price people pay is worse nutrition--not only a higher risk of metabolic syndrome, but also thiamine deficiency.

Easing hyperglycemia with H2O

French researchers reported some interesting preliminary results of a study of people with diabetes. Those who drank more water had a lesser risk of developing high blood sugar than those who didn't drink as much water. It's not clear if there's a cause-and-effect relationship yet (it may be that a third, unknown factor leads to both a lower blood sugar and a tendency to drink more water), and these results haven't yet been reviewed by other scientists. But it would be awfully convenient if diabetics in a low-resource setting could take better care of themselves by doing something as simple as drinking more water.

(Of course, that's assuming they have access to clean drinking water--not a safe assumption in many parts of the world.)

WHO's List of Essential Medicines

The World Health Organization publishes a frequently-updated list of essential medicines, organized by type of drug and whether it's a "core" drug to treat high-priority conditions, or a complementary drug for settings with more resources and specialists. It flags drugs for which any equivalent drug in the same class is just as good, as well as those that are only for children or other subgroups. It's worth browsing if you're looking to put together an essential toolkit for a low-resource setting.

I get a little misty looking at this list. Every one of these drugs is a technological achievement, the result of years of work and centuries of scientific investigation into chemistry and physiology. We've gradually learned how the human machine works, and now we have this--a toolkit, a concise record of human smarts directed toward relief of disease and suffering. Creationists, the evolutionists you abhor use the same methods that the inventors of your blood-pressure pills did. And Luddites, take note: technology can serve the good. This list is proof.

Quitting smoking can be a warning sign of lung cancer

A fascinating study in the March Journal of Thoracic Oncology lends weight to something many of us physicians have long suspected: people who quit smoking after many years may be doing so in response to an early lung cancer, often long before they have symptoms. Here in our low-resource clinic, we already worry more about lung cancer in symptomatic patients who have a history of having randomly quit smoking in the last few years. That little point of history doesn't replace diagnostics, but it does raise our suspicions. This study suggests we have good reason.

Pain relief and opiates--or the lack thereof

Opiates like morphine or fentanyl are in short supply here in rural Indonesia. Our clinic treats patients who suffer from acute or chronic pain with a mixture of ibuprofen, acetaminophen (paracetamol), and occasionally codeine. Friends who have worked in Uganda and other developing countries tell me the situation is similar there. The lack of opiates condemns many end-stage cancer patients to a nightmare existence.

The International Narcotics Control Board, a United Nations drug organization, recently issued a report decrying the lack of availability of narcotic pain medications in many parts of the world, and argued correctly that such drugs should be considered indispensable in medical practice. Inadequate policies and regulatory constraints are among the reasons why many countries have made pain relief a low priority. One of my American colleagues once opined that that's because some cultures believe in the sanctity of suffering. I don't know enough about Islam to know if that's the case here, but Mother Theresa seems to have believed that, at least when it came to other people's.

But  the relief of suffering is at the heart of medicine. If prevention and cure fail, or when there's a delay before a treatment takes effect, there is palliation. At the very least, a health care worker ought to make a patient comfortable. I've never been as glad to have morphine in my toolbox as I was when I took care of a little kid in my ER in the US who had been severely burned and needed to be transferred to a burn center. He was fully conscious, suffering pain few of us can imagine, but we pulled him out of the depths of hell with large and repeated doses of morphine. His agony subsided even as he remained awake, and watching his transformation from tortured to calm made me feel a near-religious sense of gratitude to have been able to do that for him. I think about him from time to time and hope he enjoyed his helicopter ride, at least a little.

Who needs doctors, anyway?! Lessons from rural India.

I'll let these two important New York Times articles by Tina Rosenberg about community health workers speak for themselves: "Villages Without Doctors" and a follow-up article incorporating important comments on the factors that make or break such programs.

Curative medicine, the kind physicians are trained in, has a tendency to reach the few and the rich rather than the many and the poor. And it treats so many conditions that could have been prevented. What a poor use of resources. The world needs more simple public health initiatives and basic health care, and the vulnerable poor have a perfect right to implement them. Prevention! Prevention! Prevention! Education! Education! Education!

That health care belongs to "the people" is also the core belief of the wonderful Hesperian Foundation, of Where There Is No Doctor fame--a topic for another day.