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Non-invasive diagnostic tools in the field of head and neck oncology : A liquid biopsy for head and neck cancers

The development of a liquid biopsy for head and neck cancers via  ScienceDirect Publication: Oral Oncology Publication ...

Δευτέρα, 26 Σεπτεμβρίου 2016

Botulism after Cosmetic Injection of Botulinum Type A Toxin

Delayed Antitoxin Treatment of Two Adult Patients with Botulism after Cosmetic Injection of Botulinum Type A Toxin: Injection of botulinum toxin type A for cosmetic purposes is common. It is believed to be safe, but adverse reactions have been reported, including dysphagia, generalized paralysis, respiratory depression, and death caused by focal injection of the toxin. Early administration of antitoxin in patients with adverse reactions is the mainstay of management, but the time window for its clinical efficacy is not well defined.






Botulism


Key facts

  • Clostridium botulinum is a bacterium that produces dangerous toxins (botulinum toxins) under low-oxygen conditions.
  • Botulinum toxins are one of the most lethal substances known.
  • Botulinum toxins block nerve functions and can lead to respiratory and muscular paralysis.
  • Human botulism, caused by ingestion of contaminated food, is a rare but potentially fatal disease if not diagnosed rapidly and treated with antitoxin.
  • Foodborne botulism is often caused by eating improperly processed food. Homemade canned, preserved or fermented foodstuffs require extra caution.

Overview

Human botulism is a serious, potentially fatal disease. However, it is relatively rare. It is an intoxication usually caused by ingestion of potent neurotoxins in contaminated foods. Person to person transmission of botulism does not occur.
Clostridium botulinum produces spores that are heat-resistant and exist widely in the environment, and in the absence of oxygen they germinate, grow and then excrete toxins. There are seven distinct forms of botulinum toxin, types A–G. Four of these (types A, B, E and rarely F) cause human botulism. Types C, D and E cause illness in other mammals, birds and fish.
Botulinum toxins are ingested through improperly processed food in which the bacteria or the spores survive and produce the toxins. Though mainly a foodborne intoxication, botulism can also be caused by intestinal infection in infants, wound infections, and by inhalation.

Symptoms

Early symptoms are marked fatigue, weakness and vertigo, usually followed by blurred vision, dry mouth and difficulty in swallowing and speaking. Vomiting, diarrhoea, constipation and abdominal swelling may also occur. The disease can progress to weakness in the neck and arms, after which the respiratory muscles and muscles of the lower body are affected. The paralysis may make breathing difficult. There is no fever and no loss of consciousness.
The symptoms are not caused by the bacterium itself, but by the toxin produced by the bacterium. Symptoms usually appear within 12 to 36 hours (within a minimum and maximum range of four hours to eight days) after exposure. Incidence of botulism is low, but the mortality rate is high if prompt diagnosis and appropriate, immediate treatment (early administration of antitoxin and intensive respiratory care) are not given. The disease can be fatal in 5 to 10% of cases.

Exposure and transmission

Foodborne botulism
Clostridium botulinum is an anaerobic bacterium, meaning it can only grow in the absence of oxygen. Foodborne botulism occurs when Clostridium botulinum grows and produces toxins in food prior to consumption. Clostridium botulinum produces spores and they exist widely in the environment including soil, river and sea water.
The growth of the bacteria and the formation of toxin occur in products with low oxygen content and certain combinations of storage temperature and preservative parameters. This happens most often in lightly preserved foods and in inadequately processed, home-canned or home-bottled foods.
Clostridium botulinum will not grow in acidic conditions (pH less than 4.6), and therefore the toxin will not be formed in acidic foods (however, a low pH will not degrade any pre-formed toxin). Combinations of low storage temperature and salt contents and/or pH are also used to prevent the growth of the bacteria or the formation of the toxin.
The botulinum toxin has been found in a variety of foods, including low-acid preserved vegetables, such as green beans, spinach, mushrooms, and beets; fish, including canned tuna, fermented, salted and smoked fish; and meat products, such as ham and sausage. The food implicated differs between countries and reflects local eating habits and food preservation procedures. Occasionally, commercially prepared foods are involved.
Though spores of Clostridium botulinum are heat-resistant, the toxin produced by bacteria growing out of the spores under anaerobic conditions is destroyed by boiling (for example, at internal temperature >85°C for five minutes or longer). Therefore, ready-to-eat foods in low oxygen-packaging are more frequently involved in botulism.
Food samples associated with suspect cases must be obtained immediately, stored in properly sealed containers, and sent to laboratories in order to identify the cause and to prevent further cases.
Infant botulism
Infant botulism occurs mostly in infants under six months of age. Different from foodborne botulism caused by ingestion of pre-formed toxins in food, it occurs when infants ingest Clostridium botulinum spores, which germinate into bacteria that colonize in the gut and release toxins. In most adults and children older than about six months, this would not happen because natural defences that develop over time prevent germination and growth of the bacterium.
Clostridium botulinum in infants include constipation, loss of appetite, weakness, an altered cry and a striking loss of head control. Although there are several possible sources of infection for infant botulism, spore-contaminated honey has been associated with a number of cases. Parents and caregivers are therefore warned not to feed honey to the infants before the age of one year1.
Wound botulism
Wound botulism is rare and occurs when the spores get into an open wound and are able to reproduce in an anaerobic environment. The symptoms are similar to the foodborne botulism, but may take up to two weeks to appear. This form of the disease has been associated with substance abuse, particularly when injecting black tar heroin.
Inhalation botulism
Inhalation botulism is rare and does not occur naturally, i.e. it is associated with accidental or intentional (e.g. bioterrorism) events which result in release of the toxins in aerosols. Inhalation botulism exhibits a similar clinical footprint to foodborne botulism. The median lethal dose for humans has been estimated at two nanograms of botulinum toxin per kilogram of bodyweight, which is approximately three times greater than in foodborne cases.
Following inhalation, symptoms become visible between 1–3 days, with longer onset times for lower levels of intoxication. Symptoms proceed in a similar manner to ingestion of botulinum toxin and culminate in muscular paralysis and respiratory failure.
If exposure to the toxin via aerosol inhalation is suspected, additional exposure to the patient and others must be prevented. The patient's clothing must be removed and stored in plastic bags until it can be washed thoroughly with soap and water. The patient should shower and be decontaminated immediately.
Other types of intoxication
Waterborne botulism could theoretically result from the ingestion of the pre-formed toxin. However, as common water treatment processes (e.g. boiling, disinfection with 0.1% hypochlorite bleach solution) destroy the toxin, the risk is considered low.
Botulism of undetermined origin usually involves adult cases where no food or wound source can be identified. These cases are comparable to infant botulism and may occur when the normal gut flora has been altered as a result of surgical procedures or antibiotic therapy.
Adverse effects of the pure toxin have been reported as a result of its medical and/or cosmetic use in patients, see more on 'Botox' below.

Diagnosis and treatment

Diagnosis is usually based on clinical history and clinical examination followed by laboratory confirmation including demonstrating the presence of botulinum toxin in serum, stool or food, or a culture of Clostridium botulinum from stool, wound or food. Misdiagnosis of botulism sometimes occurs as it is often confused with stroke, Guillain-Barré syndrome or myasthenia gravis.
Antitoxin should be administered as soon as possible after a clinical diagnosis. Early administration is effective in reducing mortality rates. Severe botulism cases require supportive treatment, especially mechanical ventilation, which may be required for weeks or even months. Antibiotics are not required (except in the case of wound botulism). A vaccine against botulism exists but it is rarely used as its effectiveness has not been fully evaluated and it has demonstrated negative side effects.

Prevention

Prevention of foodborne botulism is based on good practice in food preparation particularly preservation and hygiene. Botulism may be prevented by the inactivation of the bacterial spores in heat-sterilized (e.g. retorted) or canned products or by inhibiting bacterial growth in other products. Commercial heat pasteurization (vacuum packed pasteurized products, hot smoked products) may not be sufficient to kill all spores and therefore the safety of these products must be based on preventing bacterial growth and toxin production. Refrigeration temperatures combined with salt content and/or acidic conditions will prevent the growth of the bacteria and formation of toxin.
The WHO Five Keys to Safer Food serve as the basis for educational programmes to train food handlers and educate the consumers. They are especially important in preventing food poisoning. The Five Keys are:
  • keep clean
  • separate raw and cooked
  • cook thoroughly
  • keep food at safe temperatures
  • use safe water and raw materials.

'Botox'

The bacterium Clostridium botulinum is the same bacterium that is used to produce Botox, a pharmaceutical product predominantly injected for clinical and cosmetic use. Botox treatments employ the purified and heavily diluted botulinum neurotoxin type A. Treatment is administered in the medical setting, tailored according to the needs of the patient and is usually well tolerated although occasional side effects are observed.

WHO's response

Botulism outbreaks are rare but are public health emergencies that require rapid recognition to identify the disease source, distinguish outbreak types (between natural, accidental or potentially deliberate), prevent additional cases and effectively administer treatment to affected patients2.
Successful treatment depends significantly on early diagnosis and the rapid administration of the botulinum antitoxin.
WHO's role in responding to outbreaks of botulism that may be of international concern is as follows.
  • Surveillance and detection: WHO supports the strengthening of national surveillance and international alert systems to ensure rapid local outbreak detection and an efficient international response. WHO’s main tool for these activities of surveillance, coordination and response is the use of the International Network of Food Safety Authorities (INFOSAN) which links national authorities in Member States in charge of managing food safety events. This network is managed jointly by FAO and WHO.
  • Risk assessment: WHO response is based on a risk assessment methodology that includes consideration of whether the outbreak is natural, accidental, or, possibly, intentional.
  • Containment at the disease source: WHO coordinates with national and local authorities in order to contain outbreaks at their source.
  • Delivery of assistance: WHO coordinates between international agencies, experts, national laboratories, airlines and commercial organizations to mobilize response equipment, materials and supplies, including the provision and administration of botulinum antitoxin.



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Tinnitus

1. Chadha NK, Gordon KA, James AL, Papsin BC. Tinnitus is prevalent in children with cochlear implants. International Journal of Pediatric Otorhinolaryngology. 2009;73:671-675. [abstract]

2. Akdogan O, Ozcan I, Ozbek C, Dere H. Tinnitus after cochlear implantation. Auris Nasus Larynx. 2009;36:210-212. [abstract]

3. Pan T, Tyler RS, Ji H, Coelho C, Gehringer AK, Gogel SA. Changes in the tinnitus handicap questionnaire after cochlear implantation. American Journal of Audiology. 2009;18:144-151. [abstract]

4. Andersson G, Freijd A, Baguley DM, Idrizbegovic E. Tinnitus distress, anxiety, depression, and hearing problems among cochlear implant patients with tinnitus. Journal of the American Academy of Audiology. 2009;20:315-319. [abstract]

5. Rothholtz VS, Tang Q, Wu EC, Fine EL, Djalilian H, Zeng F-G. Exploring the parametric space of tinnitus suppression in a patient with a cochlear implant. Laryngoscope. 2009;119.

6. Di NW, Cianfrone F, Scorpecci A, Cantore I, Giannantonio S, Paludetti G. Transtympanic electrical stimulation for immediate and long-term tinnitus suppression. International Tinnitus Journal. 2009;15:100-106.[abstract]

7. Litre CF, Theret E, Tran H et al. Surgical treatment by electrical stimulation of the auditory cortex for intractable tinnitus. Brain Stimulation. 2009;2:132-137. [abstract]

8. Evans RW, Ishiyama G. Migraine with transient unilateral hearing loss and tinnitus. Headache: The Journal of Head & Face Pain. 2009;49:756-759. [abstract]

9. Pirodda A, Brandolini C, Raimondi MC, Ferri GG, Borghi C. Tinnitus as a warning for preventing vasovagal syncope. Medical Hypotheses. 2009;73:370-371. [abstract]

10. Anderson JE, Teitel D, Wu YW. Venous hum causing tinnitus: case report and review of the literature. Clinical Pediatrics. 2009;48:87-89. [abstract]

11. Liess BD, Lollar KW, Christiansen SG, Vaslow D. Pulsatile tinnitus: a harbinger of a greater ill? Head & Neck. 2009;31:269-273. [abstract]

12. Singh DP, Forte AJ, Brewer MB, Nowygrod R. Bilateral carotid endarterectomy as treatment of vascular pulsatile tinnitus. Journal of Vascular Surgery. 2009;50:183-185. [abstract]

13. Delgado F, Munoz F, Bravo-Rodriguez F, Jurado-Ramos A, Oteros R. Treatment of dural arteriovenous fistulas presenting as pulsatile tinnitus. Otology and Neurotology. 2009;30:897-902. [abstract]

14. Cowley PO, Jones R, Tuch P, McAuliffe W. Pulsatile tinnitus from reversal of flow in an aberrant occipital artery: Resolved after carotid artery stenting. American Journal of Neuroradiology. 2009;30:995-997. [abstract]

15. Stimmer H, Borrmann A, Loer C, Arnold W, Rummeny EJ. Monaural tinnitus from a contralateral inferior colliculus hemorrhage. Audiology & Neurotology. 2009;14:35-38. [abstract]

16. Latifpour DH, Grenner J, Sjodahl C. The effect of a new treatment based on somatosensory stimulation in a group of patients with somatically related tinnitus. International Tinnitus Journal. 2009;15:94-99. [abstract]

17. Department of Health. Provision of services for adults with tinnitus: a good practice guide. 2009. [full text]

18. DH. Tinnitus Map of Medicine care pathway. 2010. [Full text]

19. BTA. Tinnitus: guidelines for primary care. 2010. [Full text]

20. Schneider P, Andermann M, Wengenroth M et al. Reduced volume of Heschl's gyrus in tinnitus. NeuroImage. 2009;45:927-939. [abstract]

21. Landgrebe M, Langguth B, Rosengarth K et al. Structural brain changes in tinnitus: grey matter decrease in auditory and non-auditory brain areas. NeuroImage. 2009;46:213-218. [abstract]

22. Melcher JR, Levine RA, Bergevin C, Norris B. The auditory midbrain of people with tinnitus: Abnormal sound-evoked activity revisited. Hearing Research. 2009;257:63-74. [abstract]

23. Lanting CP, de KE, van DP. Neural activity underlying tinnitus generation: Results from PET and fMRI. Hearing Research. 2009;255:1-13. [abstract]

24. Kaltenbach JA. Insights on the origins of tinnitus: an overview of recent research. Hearing Journal. 2009;62:26-31. [Full text]

25. Shulman A, Goldstein B, Strashun AM. Final common pathway for tinnitus: theoretical and clinical implications of neuroanatomical substrates. International Tinnitus Journal. 2009;15:5-50. [abstract]

26. Schutte NS, Noble W, Malouff JM, Bhullar N. Evaluation of a model of distress related to tinnitus. International Journal of Audiology. 2009;48:428-432. [abstract]

27. Hesser H, Pereswetoff-Morath CE, Andersson G. Consequences of controlling background sounds: the effect of experiential avoidance on tinnitus interference. Rehabilitation Psychology. 2009;54:381-390.[abstract]

28. Argstatter H, Krick C, Bolay HV. Music therapy for chronic tinnitus. Heidelberg treatment model. Psychotherapeut. 2009;54:17-26. [abstract]

29. Lugli M, Romani R, Ponzi S, Bacciu S, Parmigiani S. The windowed sound therapy: A new empirical approach for an effective personalized treatment of tinnitus. International Tinnitus Journal. 2009;15:51-61.[abstract]

30. Langguth B, Salvi R, Elgoyhen AB. Emerging pharmacotherapy of tinnitus. Expert Opinion on Emerging Drugs. 2009;14:687-702. [abstract]

31. Campbell KCM. Emerging pharmacologic treatments for hearing loss and tinnitus. ASHA Leader. 2009;14:14-18. [Full text]

32. Hesser H, Westin V, Hayes SC, Andersson G. Clients' in-session acceptance and cognitive defusion behaviors in acceptance-based treatment of tinnitus distress. Behaviour Research & Therapy. 2009;47:523-528. [abstract]

33. Hesser H, Andersson G. The role of anxiety sensitivity and behavioral avoidance in tinnitus disability. International Journal of Audiology. 2009;48:295-299. [abstract]

34. Shulman A, Goldstein B. Subjective idiopathic tinnitus and palliative care: a plan for diagnosis and treatment. Otolaryngologic Clinics of North America. 2009;42:15-38. [abstract]

35. Forti S, Costanzo S, Crocetti A, Pignataro L, Del BL, Ambrosetti U. Are results of tinnitus retraining therapy maintained over time? 18-month follow-up after completion of therapy. Audiology & Neuro-Otology. 2009;14:286-289. [abstract]

36. Bessman P, Heider T, Watten VP, Watten RG. The tinnitus intensive therapy habituation program: a 2-year follow-up pilot study on subjective tinnitus. Rehabilitation Psychology. 2009;54:133-138. [abstract]

37. Gudex C, Skellgaard PH, West T, Sorensen J. Effectiveness of a tinnitus management programme: A 2-year follow-up study. BMC Ear, Nose and Throat Disorders. 2009;9. [Full text]

38. Henry J, Zaugg T, Myers P, Kendall C, Turbin M. Principles and application of educational counseling used in progressive audiologic tinnitus management. Noise and Health. 2009;11:33-48. [abstract]

1. Hazell JW, Jastreboff PJ. Tinnitus. I: Auditory mechanisms: a model for tinnitus and hearing impairment. J Otolaryngol. 1990;19:1-5. [Abstract]

2. Jastreboff PJ, Jastreboff MM. Tinnitus Retraining Therapy (TRT) as a method for treatment of tinnitus and hyperacusis patients. J Am Acad Audiol. 2000 Mar;11(3):162-77. [Abstract]

3. Marcondes RA, Sanchez TG, Kii MA, Langguth et al. Repetitive transcranial magnetic stimulation improve tinnitus in normal hearing patients: a double-blind controlled, clinical and neuroimaging outcome study. Eur J Neurol. 2009. [Epub ahead of print] ) [Abstract]

4. Cannon SC Pathomechanisms in channelopathies of skeletal muscle and brain. Annu Rev Neurosci. 2006;29:387-415. [Abstract]

5. Davies E, Knox E, Donaldson I. The usefulness of nimodipine, an L-calcium channel antagonist, in the treatment of tinnitus. Br J Audiol. 1994;28:125-129. [Abstract]

6. Baguley DM, Jones S, Wilkins I, Axon PR, Moffat DA. The inhibitory effect of intravenous lidocaine infusion on tinnitus after translabyrinthine removal of vestibular schwannoma: a double-blind, placebo-controlled, crossover study. Otol Neurotol. 2005;26:169-176. [Abstract]

Eggermont JJ. Cortical tonotopic map reorganization and its implications for treatment of tinnitus. Acta Otolaryngol Suppl. 2006;9-12. [Abstract]

Hoke ES, Muhlnickel W, Ross B, Hoke M. Tinnitus and event-related activity of the auditory cortex. Audiol Neurootol. 1998;3:300-331. [Abstract]

Mirz F, Pedersen B, Ishizu K et al. Positron emission tomography of cortical centers of tinnitus. Hear Res. 1999;134:133-144. [Abstract]

Muhlnickel W, Elbert T, Taub E, Flor H. Reorganization of auditory cortex in tinnitus. Proc Natl Acad Sci U S A. 1998;95:10340-10343. [Abstract]

Norena AJ, Eggermont JJ. Enriched acoustic environment after noise trauma abolishes neural signs of tinnitus. Neuroreport. 2006;17:559-563. [Abstract]

Schlee W, Hartmann T, Langguth B, Weisz N. Abnormal resting-state cortical coupling in chronic tinnitus. BMC Neurosci. 2009;10:11. [Full text]

Schlee W, Mueller N, Hartmann T, Keil J, Lorenz I, Weisz N. Mapping cortical hubs in tinnitus. BMC Biol. 2009;7:80. [Full text]

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HIPPOCRATE'S OATH

"I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement:

To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art.

I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.

I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessaryto cause an abortion.

But I will preserve the purity of my life and my arts.

I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.

In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves.

All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.

If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot."

MAIMONIDE'S PRAYER

"Almighty God, Thou has created the human body with infinite wisdom. Ten thousand times ten thousand organs hast Thou combined in it that act unceasingly and harmoniously to preserve the whole in all its beauty the body which is the envelope of the immortal soul. They are ever acting in perfect order, agreement and accord. Yet, when the frailty of matter or the unbridling of passions deranges this order or interrupts this accord, then forces clash and the body crumbles into the primal dust from which it came. Thou sendest to man diseases as beneficent messengers to foretell approaching danger and to urge him to avert it.

"Thou has blest Thine earth, Thy rivers and Thy mountains with healing substances; they enable Thy creatures to alleviate their sufferings and to heal their illnesses. Thou hast endowed man with the wisdom to relieve the suffering of his brother, to recognize his disorders, to extract the healing substances, to discover their powers and to prepare and to apply them to suit every ill. In Thine Eternal Providence Thou hast chosen me to watch over the life and health of Thy creatures. I am now about to apply myself to the duties of my profession. Support me, Almighty God, in these great labors that they may benefit mankind, for without Thy help not even the least thing will succeed.

"Inspire me with love for my art and for Thy creatures. Do not allow thirst for profit, ambition for renown and admiration, to interfere with my profession, for these are the enemies of truth and of love for mankind and they can lead astray in the great task of attending to the welfare of Thy creatures. Preserve the strength of my body and of my soul that they ever be ready to cheerfully help and support rich and poor, good and bad, enemy as well as friend. In the sufferer let me see only the human being. Illumine my mind that it recognize what presents itself and that it may comprehend what is absent or hidden. Let it not fail to see what is visible, but do not permit it to arrogate to itself the power to see what cannot be seen, for delicate and indefinite are the bounds of the great art of caring for the lives and health of Thy creatures. Let me never be absent- minded. May no strange thoughts divert my attention at the bedside of the sick, or disturb my mind in its silent labors, for great and sacred are the thoughtful deliberations required to preserve the lives and health of Thy creatures.

"Grant that my patients have confidence in me and my art and follow my directions and my counsel. Remove from their midst all charlatans and the whole host of officious relatives and know-all nurses, cruel people who arrogantly frustrate the wisest purposes of our art and often lead Thy creatures to their death.

"Should those who are wiser than I wish to improve and instruct me, let my soul gratefully follow their guidance; for vast is the extent of our art. Should conceited fools, however, censure me, then let love for my profession steel me against them, so that I remain steadfast without regard for age, for reputation, or for honor, because surrender would bring to Thy creatures sickness and death.

"Imbue my soul with gentleness and calmness when older colleagues, proud of their age, wish to displace me or to scorn me or disdainfully to teach me. May even this be of advantage to me, for they know many things of which I am ignorant, but let not their arrogance give me pain. For they are old and old age is not master of the passions. I also hope to attain old age upon this earth, before Thee, Almighty God!

"Let me be contented in everything except in the great science of my profession. Never allow the thought to arise in me that I have attained to sufficient knowledge, but vouchsafe to me the strength, the leisure and the ambition ever to extend my knowledge. For art is great, but the mind of man is ever expanding.

"Almighty God! Thou hast chosen me in Thy mercy to watch over the life and death of Thy creatures. I now apply myself to my profession. Support me in this great task so that it may benefit mankind, for without Thy help not even the least thing will succeed."

Information for Health Professionals

Information for Patients

Modern challenged parts of the oath:

  1. To teach medicine to the sons of my teacher. In the past, medical schools gave preferential consideration to the children of physicians.
  2. To practice and prescribe to the best of my ability for the good of my patients, and to try to avoid harming them. This beneficial intention is the purpose of the physician. However, this item is still invoked in the modern discussions of euthanasia.
  3. I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan. Physician organizations in most countries have strongly denounced physician participation in legal executions. However, in a small number of cases, most notably the U.S. states of Oregon,[10] Washington,[11]Montana,[12] and in the Kingdom of the Netherlands,[13] a doctor can prescribe euthanasia with the patient's consent.
  4. Similarly, I will not give a woman a pessary to cause an abortion. Since the legalization of abortion in many countries, the inclusion of the anti-abortion sentence of the Hippocratic oath has been a source of contention.
  5. To avoid violating the morals of my community. Many licensing agencies will revoke a physician's license for offending the morals of the community ("moral turpitude").
  6. I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art. The "stones" referred to are kidney stones or bladder stones, removal of which was judged too menial for physicians, and therefore was left for barbers (the forerunners of modern surgeons). Surgery was not recognized as a specialty at that time. This sentence is now interpreted as acknowledging that it is impossible for any single physician to maintain expertise in all areas. It also highlights the different historical origins of the surgeon and the physician.
  7. To keep the good of the patient as the highest priority. There may be other conflicting 'good purposes,' such as community welfare, conserving economic resources, supporting the criminal justice system, or simply making money for the physician or his employer that provide recurring challenges to physicians
http://www.worldallergy.org/educational_programs/world_allergy_forum/barcelona2008/rabe/

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