The "speed bump" sign to detect appendicitis

This group in the UAE did a small prospective study suggesting that, among patients presenting with suspected appendicitis, the "speed bump sign" of increased pain over speed bumps is over 90% sensitive for appy.

Again, it's small. And the pretest probability in this group of patients was very high, while the specificity was low (40%). But, as with rebound tenderness, it's another reminder that peritonitis doesn't like to be jostled.

Oh, and hi--Low-Resource Medicine is back after an extended hiatus. We'll be posting relevant tidbits at intermittent intervals and always welcome readers' thoughts. Who knows; we might even update our look.

Visual inspection with acetic acid for cervical cancer screening

In an ideal world, women would get all the Pap smears they need to prevent eminently preventable death by cervical cancer. In reality, many don't. Cervical cancer kills over a quarter-million women each year, most of them in developing nations.

It turns out, though, that painting a woman's cervix with white table vinegar is a cheap means of visually highlighting abnormal areas of the cervix and detecting possible cervical cancer. That's no small thing. Here's the BBC's take.

The vinegar method, a.k.a. visual inspection with acetic acid (VIA), has been around for some time. In one recent study, the test's sensitivity compared favorably to that of the Pap test.

Turmeric and Tumor Metastasis

From MedPage Today, a good tidbit for those of us who like yellow food.

 Curry Component Fights Cancer Spread, by Crystal Phend

'The active ingredient in the curry spice turmeric may help block tumor metastasis, German and Italian researchers found. That compound, curcumin, reduced inflammatory markers, which correlated with a lower incidence of prostate cancer metastasis in their mouse model study reported in Carcinogenesis. Curcumin has also been shown to suppress breast cancer metastasis to the lungs in prior animal studies from the group. "This does not mean that the compound should be seen as a replacement for conventional therapies," lead author Beatrice Bachmeier, PhD, of Ludwig Maximilians University in Munich, cautioned in a press release. "However, it could play a positive role in primary prevention – before a full-blown tumor arises – or help to avert formation of metastases. In this context the fact that the substance is well tolerated is very important, because one can safely recommend it to individuals who have an increased tumor risk.'

A field block for abdominal surgery

Field blocks are ways of delivering anesthesia to a region of the body via a strategically-placed injection. Say you're looking to numb up a fingertip laceration in order to suture it. Injecting lidocaine at the wound itself is not only excruciating, but can also distort the anatomy, since the lidocaine solution in itself takes up space. There's also the chance that you'll miss a spot. But you can numb the entire finger with a field block at its base (alas, not a painless injection). There are a number of field-block techniques out there--whether you're numbing up an ear, an ankle, an abscess, these techniques offer analgesia in a localized region of the body without requiring either wound injection or general anesthesia.

 An anesthesiologist recently told me about a field block for the abdominal wall. It's called a transversus abdominis plane block, or TAP block. Author Karim Mukhtar writes that the TAP block is "indicated for any lower abdominal surgery including appendectomy, hernia repair, caesarean section, abdominal hysterectomy and prostatectomy. Efficacy in laparoscopic surgery has also been demonstrated. Bilateral blocks can be given for midline incisions or laparoscopic surgery."

The TAP block would seem to be an awfully nice option for low-resource surgical practitioners. One can imagine the safety benefits in a setting where general anesthesia is impossible or risky. Mukhtar also describes an ultrasound-guided technique at the hyperlink above.

Developing World's Doctor Brain Drain

From the New York Times, an article by Matt McAllester about the United States' propensity for attracting young physicians from abroad and adding them to the American work force when they're far more needed at home.

The migration of doctors and nurses from poor countries to rich ones elicits some highly emotional responses, not to mention a great deal of ethical debate. Writing in the British medical journal The Lancet in 2008, a group of doctors, several of them from Africa, titled their paper “Should Active Recruitment of Health Workers From Sub-Saharan Africa Be Viewed as a Crime?” They concluded that it should. Other critics have used terms like “looting” and “theft.”

Some of the anger is directed toward the doctors who leave. The managing director of University Teaching Hospital in Lusaka, Lackson Kasonka, suggested to me that doctors who received government financing for their educations and then left exhibited “a show of dishonesty and betrayal.” ...Peter Mwaba, the most senior civil servant in Zambia’s ministry of health, said that doctors overseas should not “hold their country to ransom” by staying away until things, in their minds, sufficiently improve.

The public health challenges in Zambia are intimidating: life expectancy is 46, more than one million of Zambia’s 14 million people are living with H.I.V. or AIDS and more than 1 in 10 children will die before they reach 5. To cope with this, there are slightly more than 600 doctors working in the public sector, which is where most Zambians get their health care. That is 1 doctor for every 23,000 people, compared with about 1 for every 416 in the United States. If Desai decides to stay here, the world’s richest country will have gained a bright young doctor. The loss to Zambia will be much greater.

The author visits an understaffed Zambian hospital with plenty of donated equipment from Japan, making it clear that more doctors are needed there to put it to use. Yes, it's clear that with those new ventilators just sitting around, more doctors would make it a much better hospital. But not all hospitals in these doctors' home countries are even minimally equipped. In my opinion, he doesn't adequately examine the difficulties a doctor faces in running a facility with extremely severe equipment shortages, of which there are all too many in developing countries.

Low-resource medicine is a noble practice, but has its limits. Too few resources and a hospital becomes a hospice--with no IVs, sterile equipment, meds, or adequate staff, it becomes essentially impossible for caregivers to do their jobs. Patients either get better or they lie around and die. Hard to blame a doctor for not wanting to walk around, much less try to work, in a place like that. If you bring doctors back to such hospitals, will even the simplest of the tools they need somehow follow them there?

Candida susceptible to coconut oil

Interesting abstract:

J Med Food. 2007 Jun;10(2):384-7.
In vitro antimicrobial properties of coconut oil on Candida species in Ibadan, Nigeria.
Ogbolu DO, Oni AA, Daini OA, Oloko AP.

Department of Medical Microbiology & Parasitology, University College Hospital, Ibadan, Nigeria.

The emergence of antimicrobial resistance, coupled with the availability of fewer antifungal agents with fungicidal actions, prompted this present study to characterize Candida species in our environment and determine the effectiveness of virgin coconut oil as an antifungal agent on these species. In 2004, 52 recent isolates of Candida species were obtained from clinical specimens sent to the Medical Microbiology Laboratory, University College Hospital, Ibadan, Nigeria. Their susceptibilities to virgin coconut oil and fluconazole were studied by using the agar-well diffusion technique. Candida albicans was the most common isolate from clinical specimens (17); others were Candida glabrata (nine), Candida tropicalis (seven), Candida parapsilosis (seven), Candida stellatoidea (six), and Candida krusei (six). C. albicans had the highest susceptibility to coconut oil (100%), with a minimum inhibitory concentration (MIC) of 25% (1:4 dilution), while fluconazole had 100% susceptibility at an MIC of 64 microg/mL (1:2 dilution). C. krusei showed the highest resistance to coconut oil with an MIC of 100% (undiluted), while fluconazole had an MIC of > 128 microg/mL. It is noteworthy that coconut oil was active against species of Candida at 100% concentration compared to fluconazole. Coconut oil should be used in the treatment of fungal infections in view of emerging drug-resistant Candida species.

PMID: 17651080 [PubMed - indexed for MEDLINE]

Squatting to Poop

Low-resource medicine is all about prevention. There may be substantial health benefits to squatting to poop rather than using a sit toilet: by removing the need to force stool out, hemorrhoids, diverticuli, and other nasty disorders may be averted. In Indonesia, I grew to greatly prefer the squatting position to the throne-sit I'd grown up with, and I'm not the only converted Westerner; a number of companies offer products (like this one) to hack your sit toilet and replicate the experience. But that's a lot costlier than just building a squat toilet in the first place. The lesson for practitioners: Don't assume you have to include sit toilets in your low-resource clinic. You and your patients may be better off in a squat.