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| <div class="noeditbox">Welcome to [[Pathophysiology of Complex Patient Problems|PT 635 Pathophysiology of Complex Patient Problems]] This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div><div class="editorbox"> | |
| '''Original Editors '''- Natalie Gutmann [[Pathophysiology of Complex Patient Problems|from Bellarmine University's Pathophysiology of Complex Patient Problems project.]] | | '''Original Editors '''- Natalie Gutmann [[Pathophysiology of Complex Patient Problems|from Bellarmine University's Pathophysiology of Complex Patient Problems project.]] |
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| '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} | | '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} |
| </div> | | </div> |
| == Definition/Description == | | == Introduction == |
| | [[File:Tetanus-death-rate.png|alt=|right|frameless|499x499px]] |
| | Tetanus is an infection causing generalised [[Hypertonia Assessment Tool|hypertonia]] presenting with painful muscle spasms of the jaw and neck. Tetanus commonly occurs in the unvaccinated or in the [[Older People Introduction|elderly]] with reduced immunity. |
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| Tetanus derived from the greek word "to stretch"<ref name="Parker" /> is an acute disease caused by the anaerobic (without oxygen)[[Image:Untitled1.jpg|frame|right|Clostridium tetani bacteria]], gram positive, non-capsulated spore forming bacteria ''Clostridium tetani ''("C. tetani"). C. tetani can resist very high temperatures and is not spread from person to person. Tetanus is a rare and often fatal neurological disease that causes increased tone and muscle spasms due to the bacteria.<sup><ref name="Wakim">Wakim N, Henderson S. Tetanus. Topics in Emergency Medicine. July 2003;25(3):256-261.</ref>,<ref name="Linnenbrink">Linnenbrink T, McMichael M. Tetanus: pathophysiology, clinical signs, diagnosis, and update on new treatment modalities. Journal of Veterinary Emergency & Critical Care. September 2006;16(3):199-207.</ref> </sup>The most common way the bacterium enters the body is through wounds which are susceptible to infection if they are: “contaminated with soil, feces, or saliva, puncture wounds including unsterile injection sites, devitalized tissue including burns, avulsions and degloving injuries”.<sup><ref name="Ewcombe">Ewcombe P. Treating and preventing tetanus in A&E. Emergency Nurse. October 2004;12(6):23-29.</ref> </sup><br>The disease tetanus extends all the way back to the fifth century BC. However, it was not until the late 1800s that Arthur Nicolaier discovered the toxins that caused tetanus which have the ability to infect several species and that protection could be provided by passive transfer of an antitoxin. A few years after the discovery of the tetanus toxins Robert Koch was able to obtain a culture of the bacteria.<sup><ref name="Linnenbrink" /><ref name="Parker" /></sup> In 1924, the immunization to protect people against tetanus was developed by Pierre Descombey and by 1940 the tetanus immunization became routine in children’s vaccinations.<sup><ref name="Parker" /><ref name="Wakim" /></sup><br><br>
| | * Vaccination campaigns have decreased the incidence and prevalence of tetanus worldwide. |
| | * Symptoms are caused by toxins produced by the [[Bacterial Infections|bacterium]], Clostridium tetani.<ref name=":0">Bae C, Bourget D. [https://www.statpearls.com/articlelibrary/viewarticle/29997/ Tetanus].[Updated 2020 May 28]. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. 2021.Available:https://www.statpearls.com/articlelibrary/viewarticle/29997/ (accessed 17.12.2022)</ref> |
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| == Prevalence == | | == Etiology == |
| | The most common way the bacterium enters the body is through [[Wound Assessment|wounds]] which are susceptible to infection if they are: contaminated with soil, feces, or saliva; puncture wounds including unsterile injection sites; devitalized tissue including [[Burns Overview|burns]], avulsions and degloving injuries. |
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| In the United States, from 2000-2007 there has been an “average of 31 reported cases per year with the majority of them being over the age of 40.”<sup><ref name="CDC">CDC. Tetanus: Questions and Answers. November 2010.www.immunize.org.</ref></sup> In recent years the percent of people who contract the bacteria, to those that die from it, has decreased from 30% to 10%. Since 1989 there has only been 2 reported cases of tetanus in the neonatal population.<sup><ref name="CDC" /></sup> It is estimated that about 800,000 to one million people die of tetanus every year worldwide.<ref name="Wakim" /> The majority of the cases are found in underdeveloped countries with children and neonates representing most of the cases due to inadequate immunizations and unhealthy medical procedures especially during childbirth.<ref name="Ewcombe" /> The prevalence of tetanus in the United States has been identified in males over the age of 50, women without formal education, and African Americans in the southern states. Recently, immigrants and intravenous drug users have had a higher prevalence for contracting tetanus. Anyone over the age of 60 are at an increased risk for contracting tetanus due to the fact that they may not have received the protective immunity. <ref name="Wakim" /><br>
| | When in the body the bacterium secretes toxin,<ref name="Ewcombe">Ewcombe P. Treating and preventing tetanus in A&E. Emergency Nurse. October 2004;12(6):23-29.</ref>Tetanus toxin causes the typical clinical manifestations of tetanus by interfering with the release of neurotransmitters and blocking inhibitor impulses. This leads to unopposed muscle contraction and spasm. Seizures may occur, and the autonomic nervous system may also be affected.<ref>NSN search How does tetanus affect muscle contraction? Available: https://nsnsearch.com/how-to/how-does-tetanus-affect-muscle-contraction/ (accessed 18.12.20220</ref> |
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| == Characteristics/Clinical Presentation ==
| | The two toxins secreted into the bloodstream are: |
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| There are four different forms of tetanus: generalized tetanus, local tetanus, cehalic tetanus, and neonatal tetanus.
| | # Tetanospasmin affects the [[Neurone|nerve]] and muscle motor endplate interaction, causing the clinical syndrome of rigidity, muscle spasms, and autonomic instability. |
| | # Tetanolysin damages the tissues.<ref name=":0" /> |
| | == Epidemiology == |
| | [[File:The-number-of-deaths-from-tetanus-by-world-region.png|right|frameless|555x555px|Number of-deaths-from-tetanus]] |
| | The highest prevalence is seen in newborns and young persons. |
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| '''Generalized tetanus'''<br>Generalized tetanus attacks muscles throughout the entire body and is the most common form of te[[Image:Generalized tetanus.jpg|thumb|right|Muscular rigidity and spasms]]tanus occuring in about 80% of the cases.<ref name="CDC" /><ref name="Grunau">Grunau B, Olson J. An interesting presentation of pediatric tetanus. CJEM: Canadian Journal Of Emergency Medical Care = JCMU: Journal Canadien De Soins Médicaux D'urgence. January 2010;12(1):69-72. Available from: MEDLINE, Ipswich, MA. Accessed March 16, 2011.</ref> In generalized tetanus, the tetanospamin attacks and inhibits mostly the motor neurons of the CNS and later the neurons of the ANS as well. As a result a person experiences uncontrollable intense muscle contractions.<sup><ref name="Ewcombe" /></sup> The first muscles affected are the facial and jaw muscles because of their short nerve pathways. This condition is commonly referred to as lock jaw or trismus. As the disease progresses the person will experience stiffness of the neck, difficulty swallowing, and stiffness of the abdominal muscles.<sup><ref name="Ewcombe" /><ref name="CDC" /></sup> Spasms can be produced by a stimulus such as light, noise, touch, or happen unexpectedly with no specific cause.<ref name="Ewcombe" /> Spasms are extremely painful and can occur frequently and can last for several minutes.<ref name="Ewcombe" /><ref name="CDC" /> In generalized tetanus “spasms continue for 3-4 weeks and complete recovery may take months.”<sup><ref name="CDC" /> </sup>After several days the ANS will be affected showing others signs such as fever, sweating, elevated blood pressure, and increased or rapid heart rate.<sup><ref name="Ewcombe" /><ref name="CDC" /></sup>
| | * The World Health Organization (WHO) reports improvement in mortality rates from tetanus, due to vaccination campaigns in recent years. |
| | * The WHO estimates worldwide tetanus deaths in 1997 at around 275,000 with improved rates in 2011 at 14,132 cases.<ref name=":0" /> |
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| | == Presentation == |
| | The incubation period of tetanus varies between 3 and 21 days after infection, with most cases occur within 14 days. |
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| <br>'''Local tetanus'''<br>[[Image:PHIL 2857 thumb.jpg|thumb|right|Lock jaw (also referred to as trismus)]]
| | Symptoms can include: |
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| Local tetanus can occur before generalized tetanus but this is a much milder form with a decreased amount of associated toxin release.<sup><ref name="Ewcombe" /></sup> Local tetanus, for the most part, just attacks muscles in a specific (local) area of the body<sup><ref name="Grunau" /></sup> Localized tetanus is rare, but there is a better prognosis with only about 1% of the cases resulting in death.<ref name="CDC" /> The presentation of local tetanus is muscle rigidity and continuous contractions close to the injury site.<sup><ref name="Ewcombe" /><ref name="CDC" /></sup>
| | * Jaw cramping/inability to open the mouth |
| | * Muscle spasms commonly in torso, abdomen and extremities |
| | * Painful muscle spasms triggered by eg sudden noises |
| | * Dysphagia |
| | * Seizures |
| | * Headache |
| | * Fever |
| | * Unstable [[Blood Pressure|blood pressure]] or [[tachycardia]].<ref name=":1">World Health Organisation [https://www.who.int/news-room/fact-sheets/detail/tetanus Tetanus] Available:https://www.who.int/news-room/fact-sheets/detail/tetanus (accessed 17.12.2022)</ref> |
| | [[Image:Neonatal tetanus.jpg|thumb|right|Neonatal muscluar rigidity and spasms]]Neonatal tetanus causes more than 50% of deaths from tetanus worldwide but is very rare in developed countries. Neonates present within a week of birth with a short history of failure to feed, vomiting, and ‘convulsions’. Spasms are generalized and mortality is high. Poor umbilical hygiene is the cause of the disease which is preventable by maternal [[Vaccines|vaccination]], even during pregnancy.<ref>Cook TM, Protheroe RT, Handel JM. Tetanus: a review of the literature. British Journal of Anaesthesia. 2001 Sep 1;87(3):477-87. Available: https://academic.oup.com/bja/article/87/3/477/333174?login=false<nowiki/>(accessed 18.12.2022)</ref> |
| | == Treatment == |
| | Tetanus, a medical emergency, requires |
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| <sup></sup><br> | | * Hospitalisation |
| | * Early intramuscular or intravenous administration of the human tetanus immunoglobulin (HTIG). |
| | * Combative wound care |
| | * Antispasmodics eg benzodiazepines, baclofen, vecuronium, pancuronium, and propofol |
| | * Antibiotic therapy (metronidazole, slows progression of disease)<ref name=":0" /> |
| | * Tetanus vaccination. |
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| | Patients with severe symptoms need to be admitted to the ICU for close monitoring and mechanical ventilation. Healthcare providers need to provide supportive care, especially for patients with autonomic instability. |
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| [[Image:1657 thumb.jpg|thumb|left]]'''Cehalic tetanus'''<br>Cehalic tetanus is also rare and shows a combination of both generalized and local tetanus.<ref name="Ewcombe" /> The characteristics of this type of tetanus are facial spasms and paralysis as a result of involvement of the cranial nerves. Head wounds are the main cause with occasional occurrence found with ear infections (otitis media) associated with a head wound.<ref name="Linnenbrink" /><ref name="Ewcombe" /><ref name="CDC" /><ref name="Grunau" /> Cehalic tetanus can progress to generalized tetanus and can be associated with a high fatality rate.<sup><ref name="Ewcombe" /></sup>
| | Rehabilitation may take weeks or months.<ref name=":1" /> |
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| <br> | | == Diagnosis == |
| | There are no specific laboratory or diagnostic tests used to diagnosis tetanus. The diagnosis is made based on clinical signs and symptoms and not on the confirmation of the bacteria C. tetani in the body. <ref name="CDC">CDC. Tetanus: Questions and Answers. November 2010.www.immunize.org.</ref><ref name="Grunau">Grunau BE, Olson J. [https://pubmed.ncbi.nlm.nih.gov/20078924/ An interesting presentation of pediatric tetanus.] Canadian Journal of Emergency Medicine. 2010 Jan;12(1):69-72. Available:https://pubmed.ncbi.nlm.nih.gov/20078924/ (accessed 23.12.2022)</ref>“C. tetani is recovered from the wound in only 30% of cases and can be isolated from patients who do not have tetanus.”<sup><ref name="CDC" /></sup> |
| | == Physical Therapy Management == |
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| <sup></sup><br> | | Currently research is limited on the Physical therapy management of individuals with tetanus. Cardiopulmonary physical therapy can be used to help in the prevention of respiratory complications.<ref name="Cook">Cook T, Protheroe R, Handel J. Tetanus: a review of the literature. British Journal Of Anaesthesia. September 2001;87(3):477-487. Available from: MEDLINE, Ipswich, MA. Accessed April 2, 2011.</ref> Physical therapy can also be used to help with muscle rigidity and spasms. |
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| <sup></sup><sup></sup>'''Neonatal tetanus'''[[Image:Neonatal tetanus.jpg|thumb|right|Neonatal muscluar rigidity and spasms]]
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| Neonatal tetanus (which is found in newborn babies) is a form of generalized tetanus which also has a high fatality rate.<ref name="Ewcombe" /> The diagnosis is determined from the symptoms that present. When the baby is born they are able to suck and swallow normally for 2-3 days and then they lose that ability. The symptoms of neonatal tetanus are muscle rigidity and spasms which appear around "4-14 days after birth”.<ref name="CDC" /><ref name="Tetanus vaccine">Tetanus vaccine. Relevé Épidémiologique Hebdomadaire / Section D'hygiène Du Secrétariat De La Société Des Nations = Weekly Epidemiological Record / Health Section Of The Secretariat Of The League Of Nations. May 19, 2006;81(20):198-208. Available from: MEDLINE, Ipswich, MA. Accessed March 16, 2011.</ref> The most common way neonatal tetanus occurs is due to non- immune mothers and poor hygiene during the delivery process.<ref name="Ewcombe" /> Most of the cases of infected infants is a result of infection of the unhealed stump of the umbilical cord especially if the cord has been cut with unsterile instruments. Neonatal tetanus is very common in third world countries.<sup><ref name="CDC" /></sup>
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| Images: http://phil.cdc.gov/phil/quicksearch.asp<br>
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| == Associated Co-morbidities ==
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| *Laryngospasm: Spasms in the muscles of respiration which can interfere with breathing<sup><ref name="CDC" /></sup>
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| *Fractures: As a result of spasms, most frequently affect the spine and long bones<ref name="CDC" />
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| *Hypertension or abnormal heart rhythm: Due to hyperactivity of the ANS<ref name="CDC" />
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| *Nosocomial infections: Due to prolonged hospitalization<ref name="CDC" />
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| *Pulmonary Embolism: Mostly seen in the elderly and drug users<ref name="CDC" />
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| *Aspiration pneumonia: Found in the elderly and late stages of tetanus<ref name="CDC" />
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| == Medications ==
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| If an individual has contracted tetanus the drugs of choice and most commonly used to help remove the infection are Penicillin and Metronidazole. Other alternatives are Erthromycin, Tetracycline, Chloramphenicol, and Clindamycin.<ref name="Grunau" /><ref name="Cook">Cook T, Protheroe R, Handel J. Tetanus: a review of the literature. British Journal Of Anaesthesia. September 2001;87(3):477-487. Available from: MEDLINE, Ipswich, MA. Accessed April 2, 2011.</ref><ref name="Ahmadsyah">Ahmadsyah I, Salim A. Research from the South: Treatment of tetanus: an open study to compare the efficacy to procaine penicillin and metronidazole. British Medical Journal (Clin Res Ed). September 7, 1985;291(6496):648. Available from: Academic Search Premier, Ipswich, MA. Accessed April 2, 2011.</ref>
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| *Penicillin: Has been used for many years but it is a GABA antagonist and is associated with convulsions.<sup><ref name="Ahmadsyah" /></sup>
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| *Metronidazole: Has recently been discovered and is the best option for treating and preventing anaerobic bacterial diseases.<ref name="Ahmadsyah" />
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| '''Vaccinations''':<br>Tetanus can be prevented through vaccinations. The vaccination consists of being injected with the tetanus toxoid. The toxoid is available in two different forms: absorbed toxoid and fluid toxoid. The toxoids work by producing specific antitoxins that will neutralize the bacteria. The toxoid is inactivated and does not contain any live organisms. Therefore, the toxoids can not replicate themselves once injected which is why it requires several doses to prevent immunity.<sup><ref name="Grunau" /><ref name="Ahmadsyah" /><ref name="Parker">Parker J. Managing tetanus. (Cover story). Emergency Nurse. July 2006;14(4):14-17. Available from: Academic Search Premier, Ipswich, MA. Accessed March 16, 2011</ref></sup> The tetanus vaccine has been combined with pertussis and diptheria to make the DTP vaccine for infants.<sup><ref name="Tetanus vaccine" /></sup> The vaccination is started in infants 2 months of age in a series of four injections on monthly intervals. The next injections are given at 4, 6, and 15-18 months of age. A booster shot is given to the child between ages 4-6. For adolescents and adults the Tdap vaccine is used which is a combination of tetanus and diphtheria toxin with acellular pertussis.<sup><ref name="Ewcombe" /><ref name="CDC" /><ref name="Parker" /></sup> It is recommended to get a booster shot every 10 years.<ref name="Fraser">. Fraser D. Preventing Tetanus in Patients with Wounds. Annals of Internal Medicine. January 1976:95. Available from: Academic Search Premier, Ipswich, MA. Accessed April 2, 2011.</ref>
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| *DTaP(dipteria and tetnus toxoid and acellular pertussis): Given to infants 6 weeks to 6 years of age.<sup><ref name="CDC" /><ref name="Parker" /></sup>
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| *DT(diptheria and tetanus toxoid) : Given to infants 6 weeks to 6 years who have a contraindication for perussis.<ref name="CDC" /><ref name="Parker" />
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| *Tdap (tetanus and diptheria toxoid and acellular perrussis): Given as a one time does to adolescents and adults.<sup><ref name="CDC" /><ref name="Parker" /></sup>
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| *Td(tetanus and diphtheria toxoid): Given to children and adults 7 years and older. Contains smaller dosages of diptheria.<ref name="CDC" /><ref name="Parker" /><br><br>
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| == Diagnostic Tests/Lab Tests/Lab Values ==
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| There are no specific laboratory or diagnostic tests used to diagnosis tetanus. The diagnosis is made based on clinical signs and symptoms and not on the confirmation of the bacteria C. tetani in the body. <ref name="CDC" /><ref name="Grunau" />“C. tetani is recovered from the wound in only 30% of cases and can be isolated from patients who do not have tetanus.”<sup><ref name="CDC" /></sup><br>
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| == Etiology/Causes ==
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| Once the bacteria C. tetani enters the body the spores multiply and germinate due to the anaerobic environment. In the body, two toxins are released: tetanospamin and tetenolysin.<sup><ref name="Wakim" /><ref name="Grunau" /> </sup>It is not certain the exact role of tetanolysin but it is believed that it works together with the toxin tetanospamin.<sup><ref name="Wakim" /><ref name="CDC" /></sup> Tetanospamin reaches the peripheral nerves by retrograde neuronal transport through the blood or lymphatic system.<ref name="Wakim" /><ref name="Grunau" /> “The length of the peripheral nerves determines how long it takes for the neurotoxins to reach the CNS and cause symtoms. The toxin tetanospamin disrupts the release of the inhibitory neurotransmitters glycine and GABA throughout the CNS but most commonly at the motor end plates, spinal cord, brain, and sympathetic nervous system”.<sup><ref name="Wakim" /></sup> “The disinhibition allows for unopposed muscular contraction followed by muscular rigidity and spasms”.<ref name="Wakim" /> Once the bacteria has entered the body the incubation period may range from days to months. The average incubation period is around 4-14 days. The incubation period is shorter the closer the injury site is to the CNS.<sup><ref name="Wakim" /><ref name="Linnenbrink" /><ref name="CDC" /></sup> A shorter incubation period usually correlates with poor prognosis due to a more severe disease.<sup><ref name="Linnenbrink" /></sup>
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| == Systemic Involvement ==
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| '''Cardiovascular''':<ref name="Linnenbrink" />
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| *Hyperkinetic circulation is a result of elevated basal sympathetic and muscle activity.<ref name="Cook" />
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| *Tachycardia with hypertension
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| *Increased stroke volume
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| *Thromboembolus<br>
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| '''Respiratory:<sup><ref name="Cook" /></sup>'''
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| *Muscular spasms: chest wall, diaphragm, abdomen, pharyngeal, and laryngeal tract (can lead to an obstructed airway which can be life threatening)
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| *Atelectasis, pneumonia, and aspiration: inability to cough secondary to muscular rigidity, spasms, and being sedated.
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| *Hyperventilation: common because of fear and autonomic disturbances.
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| <br>'''Renal''':<ref name="Cook" /> <br>Renal involvement is only found in severe cases of tetanus.
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| *Dehydration
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| *Urinary stasis and infection
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| *Renal failure
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| *Altered renal blood flow secondary to catecholamine surges<br>
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| '''Gasto-intestinal:'''<ref name="Cook" /><br>
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| *Gastric statis
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| *Illeus
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| *Diarrhea
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| *Hemorrhage
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| *Weight loss: As a result of the inability to swallow
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| '''Neuromuscular:<ref name="Linnenbrink" />'''
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| *Autonomic dysfunction: Leads to excess sympathetic activation and catecholamine levels
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| '''Musculoskeletal:<ref name="Grunau" /><ref name="Cook" />'''<br>
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| *Muscle rigidity and spasms
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| *Lock-jaw (trismus)
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| *Risus sardonicus
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| *Opisthotonos (reactions of the head)
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| *Tendon avulsions: a result of spasms
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| *Fractures: a result of spasms<br>
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| == Medical Management (current best evidence) ==
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| The management of tetanus is categorized into three steps. First the organism in the body needs to be destroyed to prevent further release of the toxin. Next the toxin in the body outside of the CNS needs to be neutralized and finally the effects of the toxin in the CNS need to be minimized.<ref name="Grunau" /><ref name="Cook" /> Wound debridement, if possible, should be done to help remove the toxin from the body.<ref name="Grunau" /> The general medical management consists of controlling the spasms, prevent other infections, control fluid and electrolyte balance, and respiratory support.<ref name="Grunau" /><ref name="Ahmadsyah" /><ref name="Parker" /> The primary way to control muscle spasms is sedation and muscle relaxants.<sup><ref name="Ahmadsyah" /></sup> The prognosis of individuals with tetanus depends on the supportive care and ventilatory access.<sup><ref name="Grunau" /></sup>
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| == Physical Therapy Management (current best evidence) ==
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| Currently research is limited on the Physical therapy management of individuals with tetanus. Cardiopulmonary physical therapy can be used to help in the prevention of respiratory complications.<ref name="Cook" /> Physical therapy can also be used to help with muscle rigidity and spasms.<br>
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| == Differential Diagnosis ==
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| *Orofacial infection<sup><ref name="Grunau" /><ref name="Cook" /></sup>
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| *Dystonic drug reactions<ref name="Grunau" /><ref name="Cook" />
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| *Hypocalcaemia<ref name="Grunau" /><ref name="Cook" />
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| *Strychnine poisoning<sup><ref name="Grunau" /><ref name="Cook" /></sup>
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| *Seizures<sup><ref name="Grunau" /><ref name="Cook" /></sup>
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| *Infections of the head, neck, and central nervous system<ref name="Grunau" /><ref name="Cook" /><br><br>
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| == Case Reports/ Case Studies<br> ==
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| *Katz K, Walmsley S. Postoperative tetanus: a case report. CMAJ 200: 163(5):571-3. http://canadianmedicaljournal.ca/cgi/reprint/163/5/571
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| *Grunau B, Olson J. An interesting presentation of pediatric tetanus. CJEM: Canadian Journal Of Emergency Medical Care = JCMU: Journal Canadien De Soins Médicaux D'urgence. January 2010;12(1):69-72. Available from: MEDLINE, Ipswich, MA. Accessed March 16, 2011. http://www.cjem-online.ca/v12/n1/p69<br>
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| *Quackenbush P, Tuorinsky S, Rabb R. Tetanus Diagnosis Sometimes Elusive. Nurse Practitioner. November 2003;28(11):50-53. http://web.ebscohost.com.libproxy.bellarmine.edu/ehost/pdfviewer/pdfviewer?sid=8b4e7522-592e-4f01-9971-d7d388843320%40sessionmgr14&vid=5&hid=10<br>
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| == Resources <br> ==
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| CDC: http://www.cdc.gov/vaccines/vpd-vac/tetanus/default.htm
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| == Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) ==
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| see tutorial on [[Adding PubMed Feed|Adding PubMed Feed]]
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| <div class="researchbox">
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| <rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=14I4jFUaJ8_ce_WWgfrGngd-zjeMNGPC_0_4XJU1_u1xZLFkNP|charset=UTF-8|short|max=10</rss>
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| </div>
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| == References == | | == References == |
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| <references /> | | <references /> |
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| see [[Adding References|adding references tutorial]]..<br>
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| [[Category:Bellarmine_Student_Project]] | | [[Category:Bellarmine_Student_Project]] |
