Person attending: Patient's wife
Patient's info
Name : Mel Voight
Age : 55
Gender : Male
Diag & Rx : Adenocarcinoma of lung, underwent resection of lung mass followed by chemotherapy and radiation.
Comments : Recurrence of cancer after vacation and metastasize to lymph nodes, brain and lung
History of Presenting Illness
Time : One week ago
Last activity : Gardening
Comments : Patient tachycardic and hypotensive. During transport to ED, patient became pulseless and CPR initiated. Arrival to ED, PEA was reported. Epinephrine and atropine was given, CPR discontinued and intubation started. After 25 mins of ACLS protocol, patient regain spontaneous circulation and was transferred to MRICU on respiratory and BP support.
Patient condition: Stabilized, remain ventilator dependent and failed all trials to wean him from ventilator. Remained unresponsive to voice, touch, painful stimuli.
CT of head : Negative for hemorrhagic or ischemic stroke
Enlarging metastatic lesions spotted.
Comments : Patient diagnosed with severe anoxic brain injury due to prolonged resusucitation effort
CT of chest : Recurrent rapidly progressing adenocarcinoma
Comments : Bad prognosis
Your task as an attendant of MRICU, talk to Mrs Voight as she wishes to talk to you about the events that have occurred since last week and inform her about what his chances are for survival after the event. She has been told briefly about the code blue by the covering intern.
My own personal experience
It's really bad to make patient's relative or spouse to be left in a blank or confused state. I need to be confident in delivering the news and don't be afraid to mention the word "death", but mention them in a correct manner. The phrase here as quoted in my OSCE book: Assure the iwfe of the certainty of her husband's diagnosis and prognosis. [2]I give an example of how to start the conversation, (you can actually ask anything you want since you are the creator):
Physician: Good morning. How are you feeling today?
Patient: Better than I did a week ago.
Physician: I'm glad of that. We have some very serious matters to discuss regarding your health. Do you feel ready for this discussion?
The aforementioned dialog [1] is a nice approach to prepare patient, as in to prepare the patient of the information he or she is going to hear. One can also try to offer a conclusion or the details first. "Do you want the big picture first?" is a nice phrase to be used.
A good handshake (you can use both of your hands to hold their hands) can mean a difference. Even a tap on shoulder or if you want to offer a patient a hug can help the patient, at least to let them feel that death of the loved ones is inevitable and that they need to overcome them. "We really try our best" should be mentioned. Mind you that everyone deep down wants the truth no matter how bad a situation is.
Talking about overcoming them, it's nice. Ask them what else can be done to help, e.g. access to phone to contact family members or access to clergy[2] and always offer support or help. Words like "My doors are opened to you. If you have any questions, you can consult me." If patient's relative still can't make any decision, it's fine mainly because they are shocked about the bad news.
There are a few points mentioned in the handbook. Just act according to situation, and as Dr. Majdan said, "Treat your patient not by your brain, but by your heart."
Correct me if I am wrong in any part of my article
Reference:
1. P Gordon, J Marsh. Crash Course: History and Examination. Philadelphia: Elsevier| Mosby; 2005, p.14.
2. Katrina F Hurley. OSCE and Clinical Skills Handbook. Toronto: Elsevier | Saunders; 2005, p.362.
Thursday, May 13, 2010
Wednesday, May 12, 2010
Lesson I Learnt from Jefferson
It's about two weeks since I have come to Jefferson Medical College, Philadelphia, PA, USA. Everything is new to me here and I have had really good time, as well as bad time here. Lots of mistakes and just tons of things I need to bear in mind when in clinical examination.
I will just point out the serious mistakes I made, some ideas of thoughts and comments I would like to make.
1) History taking.
I need to be more focus on what I should be doing. Do not shoot like a shotgun, and hoping u hit something, instead ask specific and more case related questions. DO NOT SAY TOO OFFENSIVE THINGS. Say it in a rather indirect and polite way. Do not ask a patient some judgmental questions. "Are you obese?" (Duh, bad question. Whether you are overweight or underweight rely mostly on BMI. In other words, just don't ask this question) "Do you have sex with men?" (You are being judgmental about the patient being gay)
Try to speak in a layman level, besides not speaking medical jargon, as it's not just them altogether. If you suddenly utter some too medical jargons, explanation should be made to make them understand.
Review system. Try to do as appropriate. As told earlier, try to generate some questions pin-pointing yourself to the right track. Housing and working environment can be asked at social history (?). If you have the high likely suspicion that patient is not telling the truth, try to prompt them to saying them, ex. smoking. Patient may just say I quit smoking last year, then they tell you that he/she smoke a few cigarettes yesterday. Same goes for drinking. (I forgot how Dr. Majdan phrase it, but it's something like asking you how many you drink, instead of asking do you drink) ALWAYS DEFINE THE PATIENT'S DEFINITION OF BEING NORMAL. Always ask what is normal to patient, ex. bowel movements (no need to say a lot, you know what I mean. :-p)
ALWAYS REMEMBER TO SIT DOWN. Don't bring into your mind any idea of person seeing at eye-level is respect. They WANT you to really sit down and really care for them, and REALLY listen to what they say. Just imagine if you are standing up and taking history, you can just walk out of the room. But if you are sitting, you are showing to patient that you really a caring doctor. Thus, never stand up. Remember to sit down. Screw the eye-level looking respect thingy.
Obstructive Sleep Apnea (OSA), questions like snoring, sleeping well should be asked. "Does your wife tell you that you snores at night?" "Do you feel breathless during the night?" etc.
SEXUAL HISTORY
Just be sensitive. Maintain confidentiality, that's utmost important. Questions like "Do you have regular sexual partner?" "How do you avoid pregnancy?" "What do you mean by protection" In cases of underage sex, ask "Do you have boyfriend or girlfriend?" "Can you talk about sex?" (I remembered that sexually abused kids normally have a really "adult" knowledge on sex)"Have you been abused?" can be replaced by "Do you feel safe at home?"
RELIGION
"Are you raised in any particular faith?" "Do you still practice them?"
2) Clinical skills
In GI, always make a point of auscultate before you palpate the abdomen. IT'S A MUST! Don't be shocked in front of a lady patient or be stunned. Quote from Dr. Majdan: "Do not let the situation controls you. YOU CONTROL THE SITUATION." Just be yourself, be authoritarian somehow but not too obvious and too exaggerating.
A note about american way of doing clinical examination. First and foremost, is standing on patient's RIGHT side, not only it's for the exam, but all the equipments are on patient's right. So, why not? Why not take this as a note, always go for the equipments side to do your examination. The bed or couch (I not sure of myself) is a fantastic bed/couch which can be extended on the leg side (it won't be taken out, if you don't open them, patient's legs will be left dangling, which is bad. The bed can be tilted 45 degrees too, to do your CVS and Respi examination. Better to use the antiseptic solution than using the soap. Seriously. If vitals are not given, DO ALL THE VITALS, ex. BP, pulse etc. Basically just do everything.
Respi and CVS examination can overlap, especially the apex beat.
3) Conclusion
If you don't know, say you don't know. Do not push your responsibility to other people, ex. the doctor who will be doing the imaging will tell you what's wrong with you (something like that). You are solely responsible of the well-being of the patient upon coming to you. Just tell him/her what you want to do, let him understand the procedures, and to be considerate of patient's possibility of phobia of your words like surgery (maybe the guy have had surgery before and will be traumatized that you tell him/her that she need another surgery).
Oh yeah, most Americans will know the generic name of the drugs. Therefore, be familiarize with the terms so that you will know what drugs they are. They may or may not be as well knowledgeable as you do.
There are lots more to learn. I need time to compile them and put it on my blogspot. I hope that these are all the deterrents that will help me and anyone who is reading this blog. AMITABHA!!!
I will just point out the serious mistakes I made, some ideas of thoughts and comments I would like to make.
1) History taking.
I need to be more focus on what I should be doing. Do not shoot like a shotgun, and hoping u hit something, instead ask specific and more case related questions. DO NOT SAY TOO OFFENSIVE THINGS. Say it in a rather indirect and polite way. Do not ask a patient some judgmental questions. "Are you obese?" (Duh, bad question. Whether you are overweight or underweight rely mostly on BMI. In other words, just don't ask this question) "Do you have sex with men?" (You are being judgmental about the patient being gay)
Try to speak in a layman level, besides not speaking medical jargon, as it's not just them altogether. If you suddenly utter some too medical jargons, explanation should be made to make them understand.
Review system. Try to do as appropriate. As told earlier, try to generate some questions pin-pointing yourself to the right track. Housing and working environment can be asked at social history (?). If you have the high likely suspicion that patient is not telling the truth, try to prompt them to saying them, ex. smoking. Patient may just say I quit smoking last year, then they tell you that he/she smoke a few cigarettes yesterday. Same goes for drinking. (I forgot how Dr. Majdan phrase it, but it's something like asking you how many you drink, instead of asking do you drink) ALWAYS DEFINE THE PATIENT'S DEFINITION OF BEING NORMAL. Always ask what is normal to patient, ex. bowel movements (no need to say a lot, you know what I mean. :-p)
ALWAYS REMEMBER TO SIT DOWN. Don't bring into your mind any idea of person seeing at eye-level is respect. They WANT you to really sit down and really care for them, and REALLY listen to what they say. Just imagine if you are standing up and taking history, you can just walk out of the room. But if you are sitting, you are showing to patient that you really a caring doctor. Thus, never stand up. Remember to sit down. Screw the eye-level looking respect thingy.
Obstructive Sleep Apnea (OSA), questions like snoring, sleeping well should be asked. "Does your wife tell you that you snores at night?" "Do you feel breathless during the night?" etc.
SEXUAL HISTORY
Just be sensitive. Maintain confidentiality, that's utmost important. Questions like "Do you have regular sexual partner?" "How do you avoid pregnancy?" "What do you mean by protection" In cases of underage sex, ask "Do you have boyfriend or girlfriend?" "Can you talk about sex?" (I remembered that sexually abused kids normally have a really "adult" knowledge on sex)"Have you been abused?" can be replaced by "Do you feel safe at home?"
RELIGION
"Are you raised in any particular faith?" "Do you still practice them?"
2) Clinical skills
In GI, always make a point of auscultate before you palpate the abdomen. IT'S A MUST! Don't be shocked in front of a lady patient or be stunned. Quote from Dr. Majdan: "Do not let the situation controls you. YOU CONTROL THE SITUATION." Just be yourself, be authoritarian somehow but not too obvious and too exaggerating.
A note about american way of doing clinical examination. First and foremost, is standing on patient's RIGHT side, not only it's for the exam, but all the equipments are on patient's right. So, why not? Why not take this as a note, always go for the equipments side to do your examination. The bed or couch (I not sure of myself) is a fantastic bed/couch which can be extended on the leg side (it won't be taken out, if you don't open them, patient's legs will be left dangling, which is bad. The bed can be tilted 45 degrees too, to do your CVS and Respi examination. Better to use the antiseptic solution than using the soap. Seriously. If vitals are not given, DO ALL THE VITALS, ex. BP, pulse etc. Basically just do everything.
Respi and CVS examination can overlap, especially the apex beat.
3) Conclusion
If you don't know, say you don't know. Do not push your responsibility to other people, ex. the doctor who will be doing the imaging will tell you what's wrong with you (something like that). You are solely responsible of the well-being of the patient upon coming to you. Just tell him/her what you want to do, let him understand the procedures, and to be considerate of patient's possibility of phobia of your words like surgery (maybe the guy have had surgery before and will be traumatized that you tell him/her that she need another surgery).
Oh yeah, most Americans will know the generic name of the drugs. Therefore, be familiarize with the terms so that you will know what drugs they are. They may or may not be as well knowledgeable as you do.
There are lots more to learn. I need time to compile them and put it on my blogspot. I hope that these are all the deterrents that will help me and anyone who is reading this blog. AMITABHA!!!
Thursday, April 1, 2010
Urine Alkalinization
I kind of forgotten the physiology of the alkalinization and acidition thingy which physiology lecturers like to talk about. Sounds confusing and lots of chemistry inside them. I found out some good sources and why not check'em out?
http://www.fpnotebook.com/Renal/Pharm/UrnAlklnztn.htm
http://www.clintox.org/documents/positionpapers/UrineAlkalinization.pdf
http://www.cystinuria.com/articles/urinary-alkalization/
Urinary Alkalization
By David S Goldfarb, M.D.
Director, Kidney Stone Prevention Program, St. Vincents Hospital
Professor of Medicine and Physiology, NYU School of Medicine
Alkalization of the urine is important in cystinuria because it increases the solubility of cystine, meaning that more cystine can be dissolved in a given amount of urine. Alkalization means neutralizing the acid in the urine by adding base. When acid is neutralized there are fewer H+ molecules (also called protons) and the pH rises. pH is a measure of the amount of acid in the urine. Human urine can have pH ranging from about 4 (acid) to about 8 (alkaline). When urine pH rises above 7, cystine becomes much more soluble, so achieving a urine pH of 7.5-8 for a good part of the day is desirable. Measuring and recording your urine pH at various times of the day is very helpful to you and your doctor to show whether you are getting to the desired range.
You can alkalinize your urine by decreasing the amount of acid you take in. You can lower the amount of acid you eat (and therefore the amount of acid your kidneys have to get rid of) by eating less animal protein. Protein is what muscle is made of, and includes fish, beef, chicken and pork. These products also contain some cystine, so limiting your intake of these has 2 benefits.
You can also take in more base to alkalinize your urine. If you eat more fruits and vegetables when you reduce your protein intake, you will take in more base. Base comes in the form of molecules called “organic anions”, such as citrate and malate. They are converted to bicarbonate by the liver. Bicarbonate is the blood’s form of base. One citrate is converted to 3 bicarbonates. So taking citrate and bicarbonate are equivalent. Some of the citrate also is found in the urine where it helps prevent calcium stone formation in non-cystinuric people with the more commonly found calcium oxalate stones. Citrus fruits like oranges and lemons and all fruits and vegetables contain these organic anions.
For most people adequate alkalization does not occur without taking in extra base. It comes in many preparations. Potassium (K) citrate is preferable to sodium citrate preparations because sodium may increase cystine excretion. This is also why I don't usually prescribe baking soda, which is sodium bicarbonate. But the alkalinizing effect, if it works, could override the increase in cystine excretion. If you are doing well with sodium preparations I would not change your prescription.
The major reason why I sometimes prescribe sodium citrate instead of potassium citrate is if there's too much potassium in the blood, which is rarely a problem in young people with normal overall levels of kidney function. Another reason to use sodium citrate is taste. Some people prefer it. A third reason is gastrointestinal tolerance. Some people find that potassium citrate causes heartburn, or diarrhea, or abdominal cramps. These are not usually serious side effects but can be avoided by changing preparations.
Sodium bicarbonate comes as baking soda and in pill form. Sodium citrate can be taken as Bicitra, Shoal’s solution. Polycitra (NOT the same thing as Polycitra-K!) has both sodium citrate and potassium citrate in it. All three contain sodium citrate and citric acid. Why is it OK to take citric acid if you are trying to avoid acid? Because the citric acid provides both base (citrate) AND acid, which neutralize each other. It has no net effect on urine pH, unlike the citrate in food which has only the base part, not the proton (H+) part. Why is it there then? To help dissolve the sodium citrate.
Potassium citrate comes in various preparations. Polycitra-K comes as a liquid and in crystals (packets) that you mix in water. It comes in several flavors which are worth trying. In either case they can be sufficiently diluted or mixed into other juices to minimize the taste. Another option is K-Lyte which comes as an effervescent tablet that dissolves in water, like an Alka-Seltzer. It also comes in different flavors worth trying on your kids. It's a combination of potassium citrate and potassium bicarbonate; that's OK because citrate and bicarbonate are equivalent. It also comes as "DS" or double strength. (You DON'T want K-Lyte/Cl which is potassium chloride and has no alkalinizing property). Another popular form of potassium citrate is Urocit-K, a pill form. They are actually in a wax matrix from which the drug dissolves. People often see the unabsorbed, undissolved wax in their bowel movements; this does not mean the mineral is not being absorbed.
Compare doses of these preparations in milliequivalents (mEq) of bicarbonate equivalents; ignore the number of milligrams. Most people need anywhere from 20 to 120 mEq per day, but measuring the urine pH is the way to determine how much you need. Bicitra and Shohl’s solution are 15 mEq per tablespoon (1 tbsp=15 cc, cubic centimeters), or 1 mEq per cc. Polycitra liquid has 2 mEq per cc (half as sodium, half as potassium). Polycitra-K liquid is 2 mEq per cc, all potassium. Polycitra-K crystals come as 30 mEq per packet. Urocit-K comes in 5 and 10 mEq tablets. K-Lyte comes as 25 mEq per tab, and 50 mEq for the “double-strength” DS. The standard generic sodium bicarbonate tab (325 milligrams, like an adult aspirin) is about 4 mEq.
I know that people often hesitate when a doctor reaches for a prescription pad. I tell my patients that potassium citrate is more like a vitamin, not a drug. Potassium and citrate are in all of your cells, and all the fruits and vegetables you eat. Both are normally found in urine in significant amounts because we take in more than we need. You can't be allergic to these minerals, though rarely people are allergic to dyes in the preparations. If your blood potassium is in the normal range you should not have a problem: the extra potassium is excreted by the kidneys. The occasional heartburn or other GI symptoms can usually be overcome by taking them with meals, which doesn't diminish their absorption or effect on the urine. Sodium citrate or bicarbonate may be a problem for people with decreased heart function, kidney function, or high blood pressure, and can increase urinary cystine levels, but like eating salty pretzels should not cause problems for most otherwise healthy people. I wouldn't be concerned about taking these “supplements” or about giving them to children. I view these medications as safe and effective, though inexplicably expensive.
http://www.fpnotebook.com/Renal/Pharm/UrnAlklnztn.htm
http://www.clintox.org/documents/positionpapers/UrineAlkalinization.pdf
http://www.cystinuria.com/articles/urinary-alkalization/
Urinary Alkalization
By David S Goldfarb, M.D.
Director, Kidney Stone Prevention Program, St. Vincents Hospital
Professor of Medicine and Physiology, NYU School of Medicine
Alkalization of the urine is important in cystinuria because it increases the solubility of cystine, meaning that more cystine can be dissolved in a given amount of urine. Alkalization means neutralizing the acid in the urine by adding base. When acid is neutralized there are fewer H+ molecules (also called protons) and the pH rises. pH is a measure of the amount of acid in the urine. Human urine can have pH ranging from about 4 (acid) to about 8 (alkaline). When urine pH rises above 7, cystine becomes much more soluble, so achieving a urine pH of 7.5-8 for a good part of the day is desirable. Measuring and recording your urine pH at various times of the day is very helpful to you and your doctor to show whether you are getting to the desired range.
You can alkalinize your urine by decreasing the amount of acid you take in. You can lower the amount of acid you eat (and therefore the amount of acid your kidneys have to get rid of) by eating less animal protein. Protein is what muscle is made of, and includes fish, beef, chicken and pork. These products also contain some cystine, so limiting your intake of these has 2 benefits.
You can also take in more base to alkalinize your urine. If you eat more fruits and vegetables when you reduce your protein intake, you will take in more base. Base comes in the form of molecules called “organic anions”, such as citrate and malate. They are converted to bicarbonate by the liver. Bicarbonate is the blood’s form of base. One citrate is converted to 3 bicarbonates. So taking citrate and bicarbonate are equivalent. Some of the citrate also is found in the urine where it helps prevent calcium stone formation in non-cystinuric people with the more commonly found calcium oxalate stones. Citrus fruits like oranges and lemons and all fruits and vegetables contain these organic anions.
For most people adequate alkalization does not occur without taking in extra base. It comes in many preparations. Potassium (K) citrate is preferable to sodium citrate preparations because sodium may increase cystine excretion. This is also why I don't usually prescribe baking soda, which is sodium bicarbonate. But the alkalinizing effect, if it works, could override the increase in cystine excretion. If you are doing well with sodium preparations I would not change your prescription.
The major reason why I sometimes prescribe sodium citrate instead of potassium citrate is if there's too much potassium in the blood, which is rarely a problem in young people with normal overall levels of kidney function. Another reason to use sodium citrate is taste. Some people prefer it. A third reason is gastrointestinal tolerance. Some people find that potassium citrate causes heartburn, or diarrhea, or abdominal cramps. These are not usually serious side effects but can be avoided by changing preparations.
Sodium bicarbonate comes as baking soda and in pill form. Sodium citrate can be taken as Bicitra, Shoal’s solution. Polycitra (NOT the same thing as Polycitra-K!) has both sodium citrate and potassium citrate in it. All three contain sodium citrate and citric acid. Why is it OK to take citric acid if you are trying to avoid acid? Because the citric acid provides both base (citrate) AND acid, which neutralize each other. It has no net effect on urine pH, unlike the citrate in food which has only the base part, not the proton (H+) part. Why is it there then? To help dissolve the sodium citrate.
Potassium citrate comes in various preparations. Polycitra-K comes as a liquid and in crystals (packets) that you mix in water. It comes in several flavors which are worth trying. In either case they can be sufficiently diluted or mixed into other juices to minimize the taste. Another option is K-Lyte which comes as an effervescent tablet that dissolves in water, like an Alka-Seltzer. It also comes in different flavors worth trying on your kids. It's a combination of potassium citrate and potassium bicarbonate; that's OK because citrate and bicarbonate are equivalent. It also comes as "DS" or double strength. (You DON'T want K-Lyte/Cl which is potassium chloride and has no alkalinizing property). Another popular form of potassium citrate is Urocit-K, a pill form. They are actually in a wax matrix from which the drug dissolves. People often see the unabsorbed, undissolved wax in their bowel movements; this does not mean the mineral is not being absorbed.
Compare doses of these preparations in milliequivalents (mEq) of bicarbonate equivalents; ignore the number of milligrams. Most people need anywhere from 20 to 120 mEq per day, but measuring the urine pH is the way to determine how much you need. Bicitra and Shohl’s solution are 15 mEq per tablespoon (1 tbsp=15 cc, cubic centimeters), or 1 mEq per cc. Polycitra liquid has 2 mEq per cc (half as sodium, half as potassium). Polycitra-K liquid is 2 mEq per cc, all potassium. Polycitra-K crystals come as 30 mEq per packet. Urocit-K comes in 5 and 10 mEq tablets. K-Lyte comes as 25 mEq per tab, and 50 mEq for the “double-strength” DS. The standard generic sodium bicarbonate tab (325 milligrams, like an adult aspirin) is about 4 mEq.
I know that people often hesitate when a doctor reaches for a prescription pad. I tell my patients that potassium citrate is more like a vitamin, not a drug. Potassium and citrate are in all of your cells, and all the fruits and vegetables you eat. Both are normally found in urine in significant amounts because we take in more than we need. You can't be allergic to these minerals, though rarely people are allergic to dyes in the preparations. If your blood potassium is in the normal range you should not have a problem: the extra potassium is excreted by the kidneys. The occasional heartburn or other GI symptoms can usually be overcome by taking them with meals, which doesn't diminish their absorption or effect on the urine. Sodium citrate or bicarbonate may be a problem for people with decreased heart function, kidney function, or high blood pressure, and can increase urinary cystine levels, but like eating salty pretzels should not cause problems for most otherwise healthy people. I wouldn't be concerned about taking these “supplements” or about giving them to children. I view these medications as safe and effective, though inexplicably expensive.
Monday, March 15, 2010
Soft Drink Consumption Linked to Pancreatic Cancer
http://cme.medscape.com/viewarticle/717006?src=cmemp&uac=104510MK
Warning to all people who loves soft drink very much. Your habits may lead to a rather nasty disease, it's a "may". Main problem as mentioned in the article is that excessive consumption of sweet drinks can lead to serious problem.
Below is from the link:
February 16, 2010 — The regular consumption of sugar-laden soft drinks could boost a person's risk of developing pancreatic cancer. The results of a new study found that individuals who consumed 2 or more soft drinks per week had an 87% increased risk for pancreatic cancer, compared with those who did not.
Even after taking factors such as smoking, caloric intake, and type 2 diabetes mellitus into account, the authors found that consuming soft drinks might play an independent role in the development of pancreatic cancer.
The finding is reported in the February issue of Cancer Epidemiology, Biomarkers & Prevention.
Both soft drinks and fruit juices have a high glycemic load relative to other foods and drinks, and it has been hypothesized that both are risk factors for pancreatic cancer. The high levels of sugar can increase levels of insulin in the body, and this can contribute to pancreatic cancer cell growth, the researchers explain.
Association Not Seen With Fruit Juice
However, this study did not find an association between consumption of juice and an increased risk for pancreatic cancer.
"There are several plausible explanations why fruit juice was not significantly associated with pancreatic cancer," said first author Noel Mueller, MPH, a research associate at Georgetown University Medical Center in Washington, DC.
One reason is that the finding was based on a relatively small number of cases, so there might have been too few cases to detect an effect with fruit juice, he explained. Another is that there are differences between soft drinks and fruit juice — fruit juice is lower in sugar, includes many nutrients, and is typically served in smaller portion sizes.
A third explanation is that fruit juice intake is associated with healthier lifestyle characteristics than soft drink intake, he said.
The consumption of soft drinks coincided with a number of other unhealthy lifestyle characteristics, making it somewhat difficult to separate smoking, caloric intake, body weight, and type 2 diabetes mellitus from soft drink consumption. "But the findings from our study suggest that soft drinks may play an independent role in the development of pancreatic cancer," Mr. Mueller told Medscape Oncology.
"The influence of soft drink intake on the risk of pancreatic cancer remained virtually unchanged after adjustment for smoking status, energy intake, body weight, and type 2 diabetes mellitus," he added.
Results Statistically Significant for Soft Drinks
The current study examined the association between the consumption of soft drinks and juice and the risk for pancreatic cancer among Chinese people residing in Singapore. The data came from the Singapore Chinese Health Study (n = 60,524), and information regarding the consumption of soft drinks, juice, and other dietary items, along with lifestyle factors and environmental exposures, was collected at recruitment to the study. The participants were followed for up to 14 years.
At the start of the study, 9.7% of the participants consumed at least 2 soft drinks per week and 10.2% consumed at least 2 servings of juice per week. The authors note that, compared with those who did not consume soft drinks, those who consumed 2 or more soft drinks per week were younger, were more likely to be men, and were more likely to smoke cigarettes. They also had higher levels of education, alcohol consumption, and total energy intake; lower levels of physical activity; and consumed more total carbohydrates, fat, added sugar, and red meat.
Individuals who reported consuming 2 or more juice drinks a week had lifestyle and dietary habits that were similar to those who consumed soft drinks. However, there was no association between juice intake and cigarette smoking, and body mass index (BMI) was comparable across different categories of soft drink and juice consumption.
At 14 years and a cumulative 648,387 person-years of follow-up, 140 incident pancreatic cancers developed in people who were cancer free at baseline. After adjustment for confounders such as BMI, type 2 diabetes mellitus, and fruit juice intake, the authors found that those consuming 2 or more soft drinks per week experienced a statistically significant increased risk for pancreatic cancer (hazard ratio [HR], 1.87; 95% confidence interval [CI], 1.10 - 3.15).
Although people who consumed 2 or more juice drinks a week had an increased risk for pancreatic cancer of approximately 30%, elevated HR was not statistically significant after adjustment for variables.
However, in an age-adjusted analysis, smoking was also a risk factor. After excluding former smokers, the authors found that current smokers had a 49% increased risk for pancreatic cancer, compared with never smokers (HR, 1.49; 95% CI, 0.98 - 2.27). This risk factor remained unaffected after adjustment for diabetes and BMI.
Can Be Extrapolated to United States and Europe
Singapore is a highly industrialized nation with lifestyle and nutritional patterns reminiscent of many westernized countries. In that sense, these findings could be extrapolated to the United States and Europe, explained Mr. Mueller. Soft drinks are the leading source of added sugar in the American diet, the authors note.
"However, there are inherent differences between Singaporean Chinese and Caucasians, which is why one must be cautious when generalizing these results to the United States and Europe," he said. "But it is important to note that other studies in Caucasian populations have suggested that soft drink intake may increase risk for pancreatic cancer."
Because pancreatic cancer is a relatively rare disease, the number of cases in this study was relatively small, the authors point out. This limited the statistical power of the study. Another limitation was the inability to collect repeated dietary measurements during the course of the study; therefore, they could not account for changes in consumption of soft drinks and juices.
However, this study adds to the evidence that soft drink consumption plays a role in the development of pancreatic cancer, they conclude, and that "clinical studies examining biomarkers for glycemia and insulinemia and taking a mechanistic approach to the question of soft drink consumption and pancreatic cancer are warranted."
There is "still much to understand on the link between sugar-sweetened beverages and pancreatic cancer," the authors write.
The study was supported by a grant from the National Cancer Institute. The researchers have disclosed no relevant financial relationships.
Cancer Epidemiol Biomarkers Prev. 2010;19;447-455. Abstract
---Clinical Context
Carcinoma of the pancreas has high metastatic potential and poor prognosis because of lack of good treatment options and late presentation, with a 5-year survival time of less than 5% and no specific primary preventive strategies available. Smoking, obesity, and diabetes mellitus have been reported as risk factors for pancreatic cancer. Also, high glycemic foods that may predispose to diabetes may predispose to pancreatic cancer.
This is a prospective, 14-year cohort study of Chinese people living in Singapore to examine the association between consumption of soft drinks and fruit juice and the risk for the development of pancreatic cancer.
Study Highlights
The Singapore Chinese Health Study is a population-based, prospective cohort study of diet and cancer risk conducted in permanent residents from government-built housing estates where 86% of the population resided.
This study involved 2 dialect groups: the Hokkien and Cantonese originating from the southern part of China.
Participants were men and women aged 45 to 74 years without preexisting pancreatic cancer.
Recruitment was by letter, and staff went from door to door inviting participation with each subject.
A trained interviewer then interviewed the participants face-to-face using a structured scanner-readable questionnaire.
The interviewer asked subjects about demographics, lifestyle, diet, and medical history.
Diet was elicited with a semiquantitative 165-item food frequency questionnaire.
The questionnaire included commonly eaten food from Singapore, with 3 portion sizes and frequency in 8 categories ranging from never or hardly ever to 6 or more times daily.
Photographs of foods were presented to identify the food groups.
The questionnaire was validated against 24-hour recall in at least 1000 participants.
Soft drink portions were defined as 1 glass.
1 glass was designated as 237 mL and was equivalent to 1 cup.
Juices were categorized into specific drinks that included sugarcane, honeydew melon, apple, watermelon, carrot, pineapple, star fruit, and lemon juices.
The Singapore Food Composition Table was developed to analyze the nutritional content of food types.
Other risk factors for pancreatic cancer were assessed, including BMI, smoking, and physical activity.
Pancreatic cancer cases were ascertained by linkage to the population-based cancer registry and registry of births and deaths.
142 incident cases were identified, of which 56.4% were histologically confirmed, 38.8% were by clinical and radiologic findings, and 4.8% were identified by death certificates.
Rate of loss to follow-up was only 0.03%.
Mean age was 56 years, 55% were women, mean BMI was 23 kg/m2, 30% were ever-smokers, and 10% had type 2 diabetes.
At baseline, 9.7% of participants consumed at least 2 soft drinks per week and 10.2% consumed at least 2 servings of juice per week.
Those who consumed 2 or more soft drinks or juices weekly were likely to be younger, men, smoke, have higher levels of education, consume alcohol, and have higher energy intake and lower physical activity vs those who consumed no soft drinks or juices.
They also had a higher consumption of total carbohydrates, sugar, and red meat.
After 14 years and 648,387 person-years of follow-up, invasive exocrine pancreatic cancer developed in 140 persons .
Smokers had a 49% increased risk for pancreatic cancer.
BMI and a history of diabetes were not associated with an increased risk for pancreatic cancer.
Results for all risks were similar for men and women, and analysis was combined for the 2 sexes.
Drinking 2 or more soft drinks per week was associated with more than 80% increase in risk for pancreatic cancer after adjustment for other risks (HR, 1.87).
This risk was independent of diabetes and smoking and persisted after excluding those who had pancreatic cancer within 5 years of baseline.
After adjustment, juice intake of 2 or more drinks per week overall was not associated with increased risk, but when smokers were excluded, there was an association between juice intake and pancreatic cancer risk (HR, 1.60).
The authors concluded that soft drink consumption was positively associated with pancreatic cancer risk but that juice consumption was associated with risk among nonsmokers only.
---Clinical Implications
--Consumption of 2 or more soft drinks weekly is associated with an increased risk for pancreatic cancer in the Chinese population.
--Consumption of 2 or more fruit drinks weekly is not associated with an increased risk for pancreatic cancer overall, but the risk is increased in nonsmokers.
Warning to all people who loves soft drink very much. Your habits may lead to a rather nasty disease, it's a "may". Main problem as mentioned in the article is that excessive consumption of sweet drinks can lead to serious problem.
Below is from the link:
February 16, 2010 — The regular consumption of sugar-laden soft drinks could boost a person's risk of developing pancreatic cancer. The results of a new study found that individuals who consumed 2 or more soft drinks per week had an 87% increased risk for pancreatic cancer, compared with those who did not.
Even after taking factors such as smoking, caloric intake, and type 2 diabetes mellitus into account, the authors found that consuming soft drinks might play an independent role in the development of pancreatic cancer.
The finding is reported in the February issue of Cancer Epidemiology, Biomarkers & Prevention.
Both soft drinks and fruit juices have a high glycemic load relative to other foods and drinks, and it has been hypothesized that both are risk factors for pancreatic cancer. The high levels of sugar can increase levels of insulin in the body, and this can contribute to pancreatic cancer cell growth, the researchers explain.
Association Not Seen With Fruit Juice
However, this study did not find an association between consumption of juice and an increased risk for pancreatic cancer.
"There are several plausible explanations why fruit juice was not significantly associated with pancreatic cancer," said first author Noel Mueller, MPH, a research associate at Georgetown University Medical Center in Washington, DC.
One reason is that the finding was based on a relatively small number of cases, so there might have been too few cases to detect an effect with fruit juice, he explained. Another is that there are differences between soft drinks and fruit juice — fruit juice is lower in sugar, includes many nutrients, and is typically served in smaller portion sizes.
A third explanation is that fruit juice intake is associated with healthier lifestyle characteristics than soft drink intake, he said.
The consumption of soft drinks coincided with a number of other unhealthy lifestyle characteristics, making it somewhat difficult to separate smoking, caloric intake, body weight, and type 2 diabetes mellitus from soft drink consumption. "But the findings from our study suggest that soft drinks may play an independent role in the development of pancreatic cancer," Mr. Mueller told Medscape Oncology.
"The influence of soft drink intake on the risk of pancreatic cancer remained virtually unchanged after adjustment for smoking status, energy intake, body weight, and type 2 diabetes mellitus," he added.
Results Statistically Significant for Soft Drinks
The current study examined the association between the consumption of soft drinks and juice and the risk for pancreatic cancer among Chinese people residing in Singapore. The data came from the Singapore Chinese Health Study (n = 60,524), and information regarding the consumption of soft drinks, juice, and other dietary items, along with lifestyle factors and environmental exposures, was collected at recruitment to the study. The participants were followed for up to 14 years.
At the start of the study, 9.7% of the participants consumed at least 2 soft drinks per week and 10.2% consumed at least 2 servings of juice per week. The authors note that, compared with those who did not consume soft drinks, those who consumed 2 or more soft drinks per week were younger, were more likely to be men, and were more likely to smoke cigarettes. They also had higher levels of education, alcohol consumption, and total energy intake; lower levels of physical activity; and consumed more total carbohydrates, fat, added sugar, and red meat.
Individuals who reported consuming 2 or more juice drinks a week had lifestyle and dietary habits that were similar to those who consumed soft drinks. However, there was no association between juice intake and cigarette smoking, and body mass index (BMI) was comparable across different categories of soft drink and juice consumption.
At 14 years and a cumulative 648,387 person-years of follow-up, 140 incident pancreatic cancers developed in people who were cancer free at baseline. After adjustment for confounders such as BMI, type 2 diabetes mellitus, and fruit juice intake, the authors found that those consuming 2 or more soft drinks per week experienced a statistically significant increased risk for pancreatic cancer (hazard ratio [HR], 1.87; 95% confidence interval [CI], 1.10 - 3.15).
Although people who consumed 2 or more juice drinks a week had an increased risk for pancreatic cancer of approximately 30%, elevated HR was not statistically significant after adjustment for variables.
However, in an age-adjusted analysis, smoking was also a risk factor. After excluding former smokers, the authors found that current smokers had a 49% increased risk for pancreatic cancer, compared with never smokers (HR, 1.49; 95% CI, 0.98 - 2.27). This risk factor remained unaffected after adjustment for diabetes and BMI.
Can Be Extrapolated to United States and Europe
Singapore is a highly industrialized nation with lifestyle and nutritional patterns reminiscent of many westernized countries. In that sense, these findings could be extrapolated to the United States and Europe, explained Mr. Mueller. Soft drinks are the leading source of added sugar in the American diet, the authors note.
"However, there are inherent differences between Singaporean Chinese and Caucasians, which is why one must be cautious when generalizing these results to the United States and Europe," he said. "But it is important to note that other studies in Caucasian populations have suggested that soft drink intake may increase risk for pancreatic cancer."
Because pancreatic cancer is a relatively rare disease, the number of cases in this study was relatively small, the authors point out. This limited the statistical power of the study. Another limitation was the inability to collect repeated dietary measurements during the course of the study; therefore, they could not account for changes in consumption of soft drinks and juices.
However, this study adds to the evidence that soft drink consumption plays a role in the development of pancreatic cancer, they conclude, and that "clinical studies examining biomarkers for glycemia and insulinemia and taking a mechanistic approach to the question of soft drink consumption and pancreatic cancer are warranted."
There is "still much to understand on the link between sugar-sweetened beverages and pancreatic cancer," the authors write.
The study was supported by a grant from the National Cancer Institute. The researchers have disclosed no relevant financial relationships.
Cancer Epidemiol Biomarkers Prev. 2010;19;447-455. Abstract
---Clinical Context
Carcinoma of the pancreas has high metastatic potential and poor prognosis because of lack of good treatment options and late presentation, with a 5-year survival time of less than 5% and no specific primary preventive strategies available. Smoking, obesity, and diabetes mellitus have been reported as risk factors for pancreatic cancer. Also, high glycemic foods that may predispose to diabetes may predispose to pancreatic cancer.
This is a prospective, 14-year cohort study of Chinese people living in Singapore to examine the association between consumption of soft drinks and fruit juice and the risk for the development of pancreatic cancer.
Study Highlights
The Singapore Chinese Health Study is a population-based, prospective cohort study of diet and cancer risk conducted in permanent residents from government-built housing estates where 86% of the population resided.
This study involved 2 dialect groups: the Hokkien and Cantonese originating from the southern part of China.
Participants were men and women aged 45 to 74 years without preexisting pancreatic cancer.
Recruitment was by letter, and staff went from door to door inviting participation with each subject.
A trained interviewer then interviewed the participants face-to-face using a structured scanner-readable questionnaire.
The interviewer asked subjects about demographics, lifestyle, diet, and medical history.
Diet was elicited with a semiquantitative 165-item food frequency questionnaire.
The questionnaire included commonly eaten food from Singapore, with 3 portion sizes and frequency in 8 categories ranging from never or hardly ever to 6 or more times daily.
Photographs of foods were presented to identify the food groups.
The questionnaire was validated against 24-hour recall in at least 1000 participants.
Soft drink portions were defined as 1 glass.
1 glass was designated as 237 mL and was equivalent to 1 cup.
Juices were categorized into specific drinks that included sugarcane, honeydew melon, apple, watermelon, carrot, pineapple, star fruit, and lemon juices.
The Singapore Food Composition Table was developed to analyze the nutritional content of food types.
Other risk factors for pancreatic cancer were assessed, including BMI, smoking, and physical activity.
Pancreatic cancer cases were ascertained by linkage to the population-based cancer registry and registry of births and deaths.
142 incident cases were identified, of which 56.4% were histologically confirmed, 38.8% were by clinical and radiologic findings, and 4.8% were identified by death certificates.
Rate of loss to follow-up was only 0.03%.
Mean age was 56 years, 55% were women, mean BMI was 23 kg/m2, 30% were ever-smokers, and 10% had type 2 diabetes.
At baseline, 9.7% of participants consumed at least 2 soft drinks per week and 10.2% consumed at least 2 servings of juice per week.
Those who consumed 2 or more soft drinks or juices weekly were likely to be younger, men, smoke, have higher levels of education, consume alcohol, and have higher energy intake and lower physical activity vs those who consumed no soft drinks or juices.
They also had a higher consumption of total carbohydrates, sugar, and red meat.
After 14 years and 648,387 person-years of follow-up, invasive exocrine pancreatic cancer developed in 140 persons .
Smokers had a 49% increased risk for pancreatic cancer.
BMI and a history of diabetes were not associated with an increased risk for pancreatic cancer.
Results for all risks were similar for men and women, and analysis was combined for the 2 sexes.
Drinking 2 or more soft drinks per week was associated with more than 80% increase in risk for pancreatic cancer after adjustment for other risks (HR, 1.87).
This risk was independent of diabetes and smoking and persisted after excluding those who had pancreatic cancer within 5 years of baseline.
After adjustment, juice intake of 2 or more drinks per week overall was not associated with increased risk, but when smokers were excluded, there was an association between juice intake and pancreatic cancer risk (HR, 1.60).
The authors concluded that soft drink consumption was positively associated with pancreatic cancer risk but that juice consumption was associated with risk among nonsmokers only.
---Clinical Implications
--Consumption of 2 or more soft drinks weekly is associated with an increased risk for pancreatic cancer in the Chinese population.
--Consumption of 2 or more fruit drinks weekly is not associated with an increased risk for pancreatic cancer overall, but the risk is increased in nonsmokers.
Saturday, March 6, 2010
Capnocytophaga canimorsus and Dog Bites
Capnocytophaga canimorsus is a Gram-negative bacillus (rod-shaped) bacterium, in which it can harbor potentially dangerous complication if an asplenic patient was bitten by a dog[1]. This bacterium actually can be found on not just dog bites, but can also be found on those bitten by cats[2]. Clinical infections by C. canimorsus generally appear as fulminant septicemia, peripheral gangrene or meningitis[2].
Management of dogbite is as follows:
In initial treatment, thorough history should be taken with risk of rabies infection (can lead to serious manifestation), the time of the injury, whether the animal was provoked, and the general health, immunization status and current location of the animal, tetanus immunization status, current medications and allergies must be noted in the record. During the physical examination, the measurement and classification of the wound (laceration, puncture, crushing or avulsion), and the range of motion of the affected and adjacent areas should be documented. Nerve, vascular and motor function, including pertinent negative findings, should be recorded. Diagrams and photographs are useful, especially in cases with irregular wounds or signs of infection, and in cases that may involve litigation, such as a wound inflicted by an unleashed dog.
Interestingly, only 15 to 20 percent of dog bite wounds become infected, with Pasteurella multocida and Staphylococcus aureus are the most common aerobic organisms, occurring in 20 to 30 percent of infected dog bite wounds. C. canimorsus is aerobic organism too itself. Treatment with prophylactic antibiotics for three to seven days is appropriate for dog bite wounds, unless the risk of infection is low or the wound is superficial. Amoxicillin-clavulanate potassium (Augmentin) is the antibiotic of choice for a dog bite. For patients who are allergic to penicillin, doxycycline (Vibramycin) is an acceptable alternative, except for children younger than eight years and pregnant women. Erythromycin can also be used, but the risk of treatment failure is greater because of antimicrobial resistance. Other acceptable combinations include clindamycin (Cleocin) and a fluoroquinolone in adults or clindamycin and trimethoprim-sulfamethoxazole (Bactrim, Septra) in children. When compliance is a concern, daily intramuscular injections of ceftriaxone (Rocephin) are appropriate[3].
Specifically for C. canimorsus, you can visit the site: http://hopkins-abxguide.org/pathogens/bacteria/capnocytophaga_canimorsus.html?&contentInstanceId=255804
Prevention is very important to prevent from being bitten by dogs[4].
Before you bring a dog into your household:
-Consult with a professional (e.g., veterinarian, animal behaviorist, or responsible breeder) to learn what breeds of dogs are the best fit for your household.
-Dogs with histories of aggression are not suitable for households with children.
-Be sensitive to cues that a child is fearful or apprehensive about a dog. If a child seems frightened by dogs, wait before bringing a dog into your household.
-Spend time with a dog before buying or adopting it. Use caution when bringing a dog into a household with an infant or toddler.
If you decide to bring a dog into your home:
-Spay/neuter your dog (this often reduces aggressive tendencies).
-Never leave infants or young children alone with a dog.
-Don’t play aggressive games with your dog (e.g., wrestling).
-Properly socialize and train any dog entering your household.
-Teach the dog submissive behaviors (e.g., rolling over to expose the abdomen and giving up food without growling).
-Immediately seek professional advice (e.g., from veterinarians, animal behaviorists, or responsible breeders) if the dog develops aggressive or undesirable behaviors.
P/S: If you want to know more about vertigo, check out: http://www.bcm.edu/oto/studs/vertigo.html
References:
1. Janda JM, Graves MH, Lindquist D, Probert WS. Diagnosing Capnocytophaga canimorsus infections. Emerg Infect Dis [serial on the Internet]. 2006 Feb [date cited]. Available from http://www.cdc.gov/ncidod/EID/vol12no02/05-0783.htm
2. Mally M, Shin H, Paroz C, Landmann R, Cornelis GR (2008) Capnocytophaga canimorsus: A Human Pathogen Feeding at the Surface of Epithelial Cells and Phagocytes. PLoS Pathog 4(9): e1000164. Available from : http://www.plospathogens.org/article/info:doi/10.1371/journal.ppat.1000164
3. R. JOHN PRESUTTI. Prevention and Treatment of Dog Bites. American Academy of Family Physicians. 2001, April 15. Available from: http://www.aafp.org/afp/2001/0415/p1567.html
4. Centers for Disease Control and Prevention. Dog Bite Prevention. Atlanta. May 14, 2009[last reviewed]. Available from: http://www.cdc.gov/homeandrecreationalsafety/dog-bites/biteprevention.html
Management of dogbite is as follows:
In initial treatment, thorough history should be taken with risk of rabies infection (can lead to serious manifestation), the time of the injury, whether the animal was provoked, and the general health, immunization status and current location of the animal, tetanus immunization status, current medications and allergies must be noted in the record. During the physical examination, the measurement and classification of the wound (laceration, puncture, crushing or avulsion), and the range of motion of the affected and adjacent areas should be documented. Nerve, vascular and motor function, including pertinent negative findings, should be recorded. Diagrams and photographs are useful, especially in cases with irregular wounds or signs of infection, and in cases that may involve litigation, such as a wound inflicted by an unleashed dog.
Interestingly, only 15 to 20 percent of dog bite wounds become infected, with Pasteurella multocida and Staphylococcus aureus are the most common aerobic organisms, occurring in 20 to 30 percent of infected dog bite wounds. C. canimorsus is aerobic organism too itself. Treatment with prophylactic antibiotics for three to seven days is appropriate for dog bite wounds, unless the risk of infection is low or the wound is superficial. Amoxicillin-clavulanate potassium (Augmentin) is the antibiotic of choice for a dog bite. For patients who are allergic to penicillin, doxycycline (Vibramycin) is an acceptable alternative, except for children younger than eight years and pregnant women. Erythromycin can also be used, but the risk of treatment failure is greater because of antimicrobial resistance. Other acceptable combinations include clindamycin (Cleocin) and a fluoroquinolone in adults or clindamycin and trimethoprim-sulfamethoxazole (Bactrim, Septra) in children. When compliance is a concern, daily intramuscular injections of ceftriaxone (Rocephin) are appropriate[3].
Specifically for C. canimorsus, you can visit the site: http://hopkins-abxguide.org/pathogens/bacteria/capnocytophaga_canimorsus.html?&contentInstanceId=255804
Prevention is very important to prevent from being bitten by dogs[4].
Before you bring a dog into your household:
-Consult with a professional (e.g., veterinarian, animal behaviorist, or responsible breeder) to learn what breeds of dogs are the best fit for your household.
-Dogs with histories of aggression are not suitable for households with children.
-Be sensitive to cues that a child is fearful or apprehensive about a dog. If a child seems frightened by dogs, wait before bringing a dog into your household.
-Spend time with a dog before buying or adopting it. Use caution when bringing a dog into a household with an infant or toddler.
If you decide to bring a dog into your home:
-Spay/neuter your dog (this often reduces aggressive tendencies).
-Never leave infants or young children alone with a dog.
-Don’t play aggressive games with your dog (e.g., wrestling).
-Properly socialize and train any dog entering your household.
-Teach the dog submissive behaviors (e.g., rolling over to expose the abdomen and giving up food without growling).
-Immediately seek professional advice (e.g., from veterinarians, animal behaviorists, or responsible breeders) if the dog develops aggressive or undesirable behaviors.
P/S: If you want to know more about vertigo, check out: http://www.bcm.edu/oto/studs/vertigo.html
References:
1. Janda JM, Graves MH, Lindquist D, Probert WS. Diagnosing Capnocytophaga canimorsus infections. Emerg Infect Dis [serial on the Internet]. 2006 Feb [date cited]. Available from http://www.cdc.gov/ncidod/EID/vol12no02/05-0783.htm
2. Mally M, Shin H, Paroz C, Landmann R, Cornelis GR (2008) Capnocytophaga canimorsus: A Human Pathogen Feeding at the Surface of Epithelial Cells and Phagocytes. PLoS Pathog 4(9): e1000164. Available from : http://www.plospathogens.org/article/info:doi/10.1371/journal.ppat.1000164
3. R. JOHN PRESUTTI. Prevention and Treatment of Dog Bites. American Academy of Family Physicians. 2001, April 15. Available from: http://www.aafp.org/afp/2001/0415/p1567.html
4. Centers for Disease Control and Prevention. Dog Bite Prevention. Atlanta. May 14, 2009[last reviewed]. Available from: http://www.cdc.gov/homeandrecreationalsafety/dog-bites/biteprevention.html
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