Talk:Meningitis

Template:V0.5 Some text in this article was originally taken from http://www.ninds.nih.gov/disorders/encephalitis_meningitis/detail_encephalitis_meningitis.htm (public domain)

Ethics

While lookin' at this article, it occurred to me that people may be using this and an emergency source of information (e.g. a worried mother who supects her child has contracted the disease). So I suggest that the inportant information in diagnosis be included first - in bullet point veiw - and the the infected brain be moved towards the end of the artcle, or replaced by a picture of visual symptoms in a live patient. Just thinking of morality, that's all.

Wikipedia does not profess to be an emergency medical manual, and we have a medical disclaimer. The intro should clearly mention the most important telltale signs (fever, neck stiffness, photo- and phonophobia and petechiae), as should be the case in all medical articles. The remainder should remain unchanged.

I agree the infected brain should be lower down in the article.

I dispute that Wikipedia has a moral duty beyond its stated objective to provide unbiased, sourced and verifiable information. JFW | T@lk 22:34, 29 October 2005 (UTC)

I agree that the tell tale signs should be listed at the top of the page - it would be useful for one (and yes I did just come here looking for them, not a true emergency but it'd be nice if that information was on wikipedia) 137.222.10.58 00:45, 8 February 2006 (UTC)

I added the most common signs/symptoms and (imho) the most relevant and important things about meningitis in the heading. Hopefully it will be more helpful. --Andrewr47 04:16, 26 June 2006 (UTC)

"and Listeria monocytogenes is associated with poor nutritional state and alcoholism" referance for that? looking at the Listeria monocytogenes page there is no mention of poor nutritional state or alcoholism as being related, and it actually says that it is more commonly assocated with food borne illness 71.231.122.233 (talk) 09:37, 30 May 2008 (UTC)Kris

Listeria is more common in extremes of age (ie, infants, elderly). Homelessness is a risk factor, but I agree there should be a reference, as it can occur without poor nutrition. rhetoric (talk) 21:25, 13 September 2008 (UTC)

I agree with this suggestion. This is a pragmatic matter; you may not like it, but people will come here looking for this specific information; I think it is appropriate to make this information more immediately accessible. Electrosaurus (talk) 08:33, 6 October 2008 (UTC)

Suggestions

I'm completely out of my league with this article, and thus I'm not going to edit it. But I am aware of a few things that seem to be missing from this article:

1. What is meningococemia?

2. How long is the vacination effective? (i.e. is it once per lifetime, or yearly boost, or...?)

--Sdfisher 14:58, 26 Jan 2005 (UTC)

• Just got a meningitis shot. The nurse said it was effective for 10 years. 72.230.61.217 23:52, 16 June 2006 (UTC)

Answers:

1. Meningococcemia is also known as meningococcal septicemia ie blood-borne infection with considerably higher mortality rate than the meningitis disease.
2. Duration of effect depends on what vaccine you had - i.e. for which bacteria, and in the case of meningococcus, which strain of the bacteria. Also depends upon one's age (young children mount less of a response and so often need multiple courses to provoke a full protection. See Vaccination schedule for full details
   • Haemophilus influenzae vaccination (HiB) is routinely given as 3 shots to infants in UK, adults needing protection (eg asplenia following splenectomy) need just one dose for lifetime cover
   • Meningococcus - the Men A&C strain mix used for travel vaccinations lasts just 3 years.
   • Conjugated Meningococcus C (conj Men C) - given thrice to infants in UK, but for adults (again for asplenia but also in the catch up program to cover all school leavers), just a single dose is thought to give perminant protection ("perminant" is as yet somewhat ill defined)
   • There are other vaccines for other strains of Meningococcus - but I can't advise as to their duration of effects. David Ruben ^Talk 01:35, 17 June 2006 (UTC)

CT before lumbar puncture

Removed the advise to make a CT scan before all lumbar punctures. Evidence for this: PMID 10597758 PMID 11742046 PMID 8448711 PMID 16010480 --WS 01:23, 1 August 2005 (UTC) dfkgerlkj is known for its brjrhjvlrg inside. —Preceding unsigned comment added by 12.168.59.85 (talk) 03:15, 8 November 2007 (UTC)

Treatment of Viral meningitis

I'm not going to edit this article, as medicine is way out of my league, but the article seems to suggest the treatment for meningitis is always the use of broad spectrum antibiotics. Clearly, that can't be the case with viral meningitis.

On the Meningitis Foundation of America website, they state:

Unfortunately, there is no specific treatment for viral meningitis at this time. Medical Doctors recommend plenty of rest, relaxation, fluids, and medicine to relieve a fever or headache.

[1]

This seems to be a pretty important point for an article for the general public. Mmmbeer 14:06, 25 September 2005 (UTC)

• I disagree, although fully agreeing with your logical reading of the artice that such information is currently missing :-) - I would point out that the "general public" never themselves make a decision, or should even have suggested to them, on how to self-treat viral meningitis. All cases exibiting signs of meningism need to be urgently admitted to hospital, on the basis that there may be a progressive bacterial cause. UK guidelines are that any General Practitioner seeing a suspected case of menigitis should give an antibiotic injection even before the ambulance transports the patient to the hospital - such is the rapid risk of fatality from bacterial cases and the importance of early treatment being started. Of course, if subsequent lumbar puncture tests suggest a viral cause then further antibiotics need not be given and suitable advice can be given, but it should be remembered that whilst usually not fatal, viral meningitis very occassionally may be.
• Like all internet/book articles on medical topics, it is legally (and ethically) not possible to make diagnosis or give precise advice on an individual's treatment. Readers do and will erroneously interpret advice given, whatever disclaimers & cautions might be given. Therefore WP needs to take great care with this article (in particular) not to suggest that "Mild" symptoms might correlate with less serious causes of meningitis and thereby in anyway delay people from taking the necessary action, namely that all suspected cases, however mild, need emergency medical attention.
• I would suggest that the article, whilst mentioning that antibiotics must be promptly given for bacterial causes, does not explicity suggest that no treatment (ie no antibiotic) is needed for viral cases ("treatment" in the public's mind means seeing a doctor for all the things they do, so "no treatment" would be interpreted as "no need to see a doctor")
• If you can think of a round-about method of mentioning the points you raised, have a go (eg "Following treatment of meningitis cases, people often feel tired for some time for which rest is important and pain-killers for any continuing mild headadache may be advised.") But I think most doctors would be fairly concerned about the wording chosen, most of us will have seen cases that started with a "mild viral-like illness" that soon became something quite different :-) - David Ruben^talk 01:10, 26 September 2005 (UTC)
  • Your points are well taken. However, it seems that there are at the very least two things that can be distilled from what you said: 1) clarify that the treatment is for bacterial (you don't have to say that it excludes viral) 2) state in the first sentence all suspected cases, however mild, need emergency medical attention. Just a thought. Mmmbeer 01:40, 26 September 2005 (UTC)
    • Ok - so incorporated - David Ruben^talk 03:00, 26 September 2005 (UTC)

Um, I know that generally steroids are given, lost of pain medication and waiting. I can't really find a source though. I just know cause I had Meningitus...--Coffeegirlyme (talk) 07:32, 22 December 2007 (UTC)

extreme cold and meningitis

I've read somewhere that extreme cold (like going around without a hat, at -30 C) increases the risk of meningitis? And in the article it says that meningitis is purely viral. Which of the statements is true? --rydel 15:38, 24 January 2006 (UTC)

Well, not purely viral. There are bacterial, viral and parasitic forms of meningitis. Apart from a very rare hereditary condition (CINCA/Muckle-Wells) there is no association between cold exposure and meningitis to my knowledge. JFW | T@lk 16:56, 24 January 2006 (UTC)

Removal of reference

I've removed: Hill, A. Edward. "Benign Lymphocytic Meningitis." "Caribbean Medical Journal", Vol. XI, No. 1, pp. 34-37. for several reasons. Mostly what has this to do with the current contents of the article ('Benign Lymphocytic Meningitis' is not mentioned) ? I could not find the reference in PubMed - the year of publication would have been helpful, is there on online copy of the article anywhere?

As best as I can tell from a quick search of PubMed [2] for 'Benign Lymphocytic Meningitis', the presence of lymphocytes may be associated with a number of different viruses. In the case of a meningitis outbreak, the quick identification of lymphocytes highlights viral cases from bacterial, given that full viral studies may take some time to undertake. However only a minority of cases with lymphocytes identified seem to be proved to be of any viral cause - "of 208 cases of aseptic lymphocytic meningitis seen over a nine-year period, 24 were diagnosed as viral infections" Becq-Giraudon B, Cremault A, Marechaud R, Abadie JC, Castets M, Sudre Y (1982). "[Viral etiology of aseptic lymphocytic meningitis. Twenty-four cases seen over a nine-year period (author's transl)]". Sem Hop. 58 (12): 739–45. PMID 6283647.{{cite journal}}: CS1 maint: multiple names: authors list (link). David Ruben ^Talk 01:43, 7 May 2006 (UTC)

Re-adding the "See also" links

I've re-added the list of "See also" links. Andrewr47 and other editors/contributors, please leave this list on the page. Thank you. -- 201.78.233.162 16:50, 5 July 2006 (UTC)

What about amoebic meningitis?

There's no mention at all of this form of meningitis. Anyone able to provide some info on it?

It is excessively rare, and has a 100% mortality. Nice, innit? JFW | T@lk 15:54, 2 September 2007 (UTC)

Diffrences B/w types of meningitis !

Hello...

well although the topic is very good... but i could't find the differences b/w different types of meningitis like Viral,acute bacterial and tuberculous meningitis.... will u plz help me out :) thanx. Jinn

This has probably been answered for you, but basically the CSF results help you differentiate. The types you listed should clue you in to what the cause is.  ;) Bacterial is usually much more serious. rhetoric (talk) 19:57, 12 September 2008 (UTC)

What is Graham sign?

Article refers to "Graham sign" which is not defined or linked. I can't Google anything about it. Probably should be removed. Gypsydoctor 22:51, 9 November 2006 (UTC)

Think this was just some nonsense applied by an anon editor in these edits - I have now fully reverted back (I had previously only reverted 1 out of their 2 edits).David Ruben ^Talk 01:27, 10 November 2006 (UTC)

So...

I've had viral meningitis, the doctor said if I did not come in that day i would have died. I am wondering if there are any long term effects viral meningiis could have had on my brain? SwiftGeneration 22:40, 17 November 2006 (UTC)

Also, I don't see any mention of a symptom I had, dark red splothes under my skin, as if the vessels were filled with dye and you could see them easily and quite clearly

---

That surprises me. Usually bacterial is much more serious (ie, leading to death). That said, I suppose a bad viral infection can lead to increased intracranial ("in the skull") pressure, causing neurologic (nerve) problems such as seizures. Generally viral meningitis shouldn't have any long term sequelae (effects). rhetoric (talk) 20:00, 12 September 2008 (UTC)

PCR for clinical or research only?

I have seen 2 cases of meningitis in the last 3 years which had cloudy fluid from the lumbar puncture but which never cultured anything, so antibiotics for a wide variety of bacteria were administer IV: gram positive, gram negative, Legionaire's disease, etc. The infectious disease doctor refused to do PCR, saying it was never used for clinical applications, only for research. This was at a teaching hospital affiliated with a medical school. My question is, could a reference be added showing that PCR is an appropriate technique when the csf does not show any bacteria in culture, to identify the infectious agent and reduce the risk of harm from unneeded antibiotics. Edison 01:14, 22 December 2006 (UTC)

Actually, I've studied cases where PCR was done to confirm a viral etiology; however, to be honest, I am not sure as to why exactly it is done... Probably to rule out a tuberculous or fungal cause —Preceding unsigned comment added by Wnb0518 (talk • contribs) 19:59, 20 February 2008 (UTC)

MCOTW

Ahh, this is now the MCOTW - for the last 2 weeks! There is a lot to be done here, and I cannot begin to see the things that need improving. There are no references, especially those very specific claims with regards to steroids (see PMID 17253505 for some developments). A useful recent review (community-acquired meningitis in adults, PMID 16394301) may be used as a backbone.

Some ideas:

• What signs and symptoms predict the presence of meningitis; is there such a thing as asymptomatic/atypical meningitis? How do children differ in their presentation from adults?
• How is meningitis diagnosed. Is a CT scan necessary pre-lumbar puncture?
• What are the forms (e.g. bacterial, viral, tuberculous/mycobacterial, parasitic, aseptic, autoimmune, traumatic). Can they be distinguished clinically (e.g. Listeria causing early cranial nerve pathology) and epidemiologically (again Listeria in alcoholics).
  • What are the commonest causative agents for each form?
  • How are these forms distinguished?
  • How is it related to meningoencephalitis?
• What are the complications (e.g. hydrocephalus)
• Pathogenesis: how does meningitis arise, is it different from infection of other organs and why (discuss blood-brain-CSF barrier). Discuss the peculiar phenomenon re. worsening of inflammation by bacterial breakdown products after commencement of antibiotics and benefit from glucocorticoids in particular forms.
• Treatment: discuss need for broad-spectrum empirical antibiotics, interference with lumbar puncture results, need to add viral or parasitic cover when suspected, the corticosteroid controversy (adults and Western world children only etc), the treatments for complications (neuromonitoring, pressure bolts/Ommaya reservoirs, ventriculosystemic shunts) etc etc.
• Prognosis: discuss natural history and prognosis with treatment (mention poor prognosis tuberculous and Listeria)
• Epidemiology: which populations are at risk (mention children, immunocompromised, pilgrims e.g. for the Hajj). What determines the Meningitis Belt?
• Vaccination: what strains are amenable to vaccination
• History: discovery, major historical developments. Perhaps also mention here any famous patients, significant mentions in world literature (e.g. Phillip in My Cousin Rachel, including mention of therapeutic LP) etc.

Whew. JFW | T@lk 22:23, 29 January 2007 (UTC)

JAMA - how to interpret CSF results! PMID 17062865. JFW | T@lk 22:27, 29 January 2007 (UTC)

Viral Meningitis is very cool to study. I am studying it right now.

Vaccine question

(moved from article page by MarcoTolo 22:24, 24 March 2007 (UTC))

It is a mistake made in this pages under vaccination. Pneumovax and Prevnar / Prevenar are two very different vaccines. Pneumovax- made by Merck is a polisacharid 23 valent vaccine (also Pneumo23 Pasteur). Prevnar / Prevenar - made by Wyeth is a conjugated 7 valent vaccine.— Preceding unsigned comment added by 219.89.184.36 (talk • contribs)

needs indolent meningitis

cryptococcus neoformans causes meningitis in immunosuppressed host and can indolent meningitis in immuno-competent hosts. Could someone please write a section on indolent meningitis?

Other complications: limb loss?

I recently saw a news story about a man who apparently "lost both legs" to meningitis. Is this a common complication of the disease, and if so, what is the mechanism for it? It is not mentioned at all in the article. 217.155.20.163 14:52, 8 April 2007 (UTC)

A person who graduated two years ahead of me from my high school conracted meningitis as a freshman in college, and lost all his limbs as a result. I'm not sure of the specifics but I do know that the case you saw is not an isolated one. PaladinWhite 23:45, 26 April 2007 (UTC)

That would have been from meningococcal septicemia, a blood infection that accompanies meningococcal meningitis. That's also what causes the rash. cyclosarin (talk) 02:43, 16 March 2008 (UTC)

Page Merge

The Bacterial meningitis article is too small to sustain its own and should instead be merged into this one and elaborated upon within its own section. --I Are Scientists 01:15, 12 April 2007 (UTC)

After looking at the content of the page I would agree. It's just a pile of signs, symptoms, and treatment (OH THE BANALITY!). For now it deserves a little home on the Meningitis page. -- Serephine ♠ talk - 01:27, 12 April 2007 (UTC)

This merge has since been actioned. LeeVJ (talk) 23:19, 29 September 2008 (UTC)

Image a bit too graphic?

Am I the only one that thinks the infobox image may be a bit too graphic for the very top of the page? It is of course very informational, but I don't have what I would call a "weak stomach," and I did get some creepy-crawlies when I hit this page. PaladinWhite 23:44, 26 April 2007 (UTC)

I must admit to agreeing, my first thought was "Oh god, tell me that's not a brain, it can't be!" I think it a good and valuable image, but perhaps a bit further down, not right in ones face so to speak? --Brideshead 18:47, 1 May 2007 (UTC)

Yup, that's all I'm saying - don't remove the great image, just give people a chance to decide whether they really want to learn about meningitis before hitting them with the graphics! PaladinWhite 03:27, 2 May 2007 (UTC)

Agreed... I have a strong stomach, but seeing that makes me feel sick. Whstchy 22:54, 11 May 2007 (UTC)

I think the picture is informative, and even if you take it from the top of the page then keep it in another section. --Gak 11:34, 20 May 2007 (UTC)

My dad is a surgeon and we have a real human skull in the house, I wasn't very impressed. Most people see worse things on shows like CSI or ER, but it's the fact that the pic is REAL that makes people sick. So leave the pic alone, if the infobox said that it was a fake no one would complain that much... XXX

Haha.. oh... sorry. I put the image there, didn't think it would freak out the general traffic to Meningitis (I assumed it would be mainly medical students). Personally it doesn't look gross to me at all, it's mainly just blood, neural tissue and some connective tissue? I've seen worse at the local deli! In any case, it's still in a good position so its all good -- Serephine ♠ talk - 00:42,

I don't consider myself to be sensitive regarding the details of the human anatomy, but I don't think the image should be shown without a warning of some kind. Somebody else investigating meningitis, could be far less "relaxed" about this image. I guess this could be said about many other images on wikipedia, so maybe there should be a general rule for explicit images like these. Anyway, I would suggest that a warning label, a link or some other method could be used to remove this image to a less exposed place. 24 September 2008 (UTC)

23 May 2007 (UTC) could there be a warning added above where the picture is stating that the image may be considered too graphic?

Yeah, even just perusing the page, I really wasn't expecting that image. Spirit Stiff 23:12, 3 July 2007 (UTC)

Agreed, I wasn't expecting this image. I'm not that squeamish but this image is particularly disturbing, especially when not expecting it. Is there some way we could link to it or have it expand upon warning? I came looking for general info on Meningitis, not knowing what it was, and I suspect most traffic here will not be from medical students who are accustomed to looking at things like the said image.

It's probably a very nice, and informative picture, but I think that most users would be disturbed enough, and not expecting it enough, to warrant moving it. James Lednik (talk) 02:40, 19 November 2007 (UTC)

Just because it has educational value does not mean the image isn't also just plain gruesome. This is the sort of thing you'd expect to find on rotten.com, not wikipedia. Maybe the article could just link to the picture, with a brief warning, giving the reader a choice about whether they really want to see it? 216.161.145.199 (talk) 07:40, 14 January 2008 (UTC)

Anthrax

I was reading this book about Amerithrax recently, and one of the symptoms of anthrax inhilation was Meningitis. Could someone add this?

Completement deficiency

Complement deficiency is not presently mentioned as a cause for recurrent meningitis. PMID 16026838 seems to deal with this, but does it mention meningitis specifically? JFW | T@lk 11:05, 2 September 2007 (UTC)

Recurrent meningitis is not mentioned at all in the article yet. It may be caused by cranial defects or immunodeficiencies. Of the immunodeficiencies, deficiencies of complement factors C7, C8 and C9 are associated with N. meningitidis meningitis. --WS 17:46, 2 September 2007 (UTC)

My question was whether that review (PMID 16026838) on complement deficiencies made any specific mention of meningitis. If that is the case, it could be included as a source. Obviously, any form of immunocompromise, as well as fistulae between the nasal cavity and the neurocranium, can predispose to meningitis. I just remember reading that complement deficiencies were particularly likely to cause recurrent bacterial meningitis because the membrane attack complex (MAC) is needed to destroy capsulated organisms. JFW | T@lk 09:01, 4 September 2007 (UTC)

We're not doing very well, are we?

Goodness, not many edits for MCOTW. Seems we're all too busy doing other things... Some articles that we can integrate: Does this adult patient have acute meningitis? (JAMA Rational Clinical Examination series) and How Do I Perform a Lumbar Puncture and Analyze the Results to Diagnose Bacterial Meningitis? (ditto) JFW | T@lk 21:02, 5 September 2007 (UTC)

Clinical prediction rule

doi:10.1016/j.jinf.2006.06.009 - distinguishes between viral and bacterial meningitis. JFW | T@lk 03:08, 29 November 2007 (UTC)

interesting

Meningitis is very interesting. This will help my firends and I with our projects. :) —Preceding unsigned comment added by Kkhoneybee (talk • contribs) 02:27, 23 January 2008 (UTC)

Remember to reference appropriately ;) —CycloneNimrod^Talk? 11:05, 18 July 2008 (UTC)

treatment regimens

I think the section saying Listeria coverage goes until age 3 is questionable. I've read that ampicillin (for Listeria) can be discontinued somewhere between 1 and 6 months of age...

Furthermore, though the section listing appropriate antibiotics is nicely detailed, I think it loses the point. Basically here's how to think of it:

1) 3rd generation cephalosporin for everyone, with or without vancomycin (it's easier to just say with) 2) add ampicillin for extremes of age to cover Listeria 3) add dexamethasone (before giving antibiotics) if Pneumococcus or TB meningitis are suspected

I hope this is helpful. rhetoric (talk) 19:55, 12 September 2008 (UTC)

Ideally we should base these sections on national guidelines by professional bodies, or at least the conclusions of recent reviews, rather than relying on our own expertise or experience. JFW | T@lk 20:02, 13 September 2008 (UTC)

Ideally, yes.  ;) If I find the time, I'll reference an article, but I'm just basing what I said on my textbooks/lectures. rhetoric (talk) 21:23, 13 September 2008 (UTC)

MCOTW again

I think most of the points from the last MCOTW are unchanged. There is still quite a lot of ground to cover, but it is possible to get this article to GA status with some dedicated effort. Most of my edits are likely to reflect doi:10.1053/jinf.2002.1110 - which are the guidelines I'm using in practice (or try to). JFW | T@lk 23:42, 25 September 2008 (UTC)

I might try and find a good paper on paediatric meningitis and focus on that. —Cyclonenim (talk · contribs · email) 06:49, 26 September 2008 (UTC)

I've decided to try and write about recurrent bacterial meningitis as caused by aquired and congenital anatomic defects or disorders in immune mechanisms. I've got a textbook on paediatric neurology available but it's information is very likely to be outdated in terms of guidelines for treatment. I'll likely only use it for general information, signs and symptoms and causes etc. —Cyclonenim (talk · contribs · email) 10:24, 27 September 2008 (UTC)

For treatment I would prefer to stick to professional guidelines by the major bodies:

• Infectious diseases society of America
• British Infection Society
• SIGN guideline (children)

Those of other countries could be included, but US and UK sources are the minimum. JFW | T@lk 21:28, 27 September 2008 (UTC)

Sepsis disambiguation and chronic bacterial meningitis

• I think the article should have at the top "This article is about infection of the meninges. For meningococcal septicaemia, see Sepsis. Either that or a disambiguation would be useful, because I only realised that the two things were different when I started my medical education.
• There is a type of meningitis called chronic bacterial meningitis, associated with several organisms, including spirochetes and mycobacteria, and with much less mortality than acute pyogenic. It's in Robbin's 8th ed Basic Pathology. Should the article be changed to reflect this? Electrosaurus (talk) 08:40, 6 October 2008 (UTC)

Meningitis is meningitis. I don't think we need to disambiguate so prominently for meningococcal disease. Bear in mind that other bacteria can cause meningitis.

Please add information about chronic meningitis. This is relevant to the subject. JFW | T@lk 23:20, 6 October 2008 (UTC)

 Question: Isn't 'chronic bacterial meningitis' the same thing as recurrent bacterial meningitis? If so, we have a section on it. —Cyclonenim (talk · contribs · email) 06:49, 7 October 2008 (UTC)

No, they are different things. Recurrent bacterial meningitis is sudden and severe, then responds to treatment but comes back again. There are various causes, such as infections in the head & neck area and immune problems. Chronic meningitis is meningitis with less severe symptoms that is still caused by infection of the meninges. It is caused by different pathogens, and requires a slightly different approach to treatment. JFW | T@lk 17:27, 7 October 2008 (UTC)

Ah fair enough :) I look forward to seeing the content added then. —Cyclonenim (talk · contribs · email) 20:56, 7 October 2008 (UTC)

Before we leave

I have removed the pusbrain picture (Image:Streptococcus pneumoniae meningitis, gross pathology 33 lores.jpg). I really don't find it particularly useful or illustrative, apart from the gross factor that I'm not even particularly worried about. If people disagree we can also try to find a slightly more informative gross pathology picture (with "gross" here meaning non-microscopic pathology images).

I'm not particularly thrilled by the fact that the article now has various references to online FAQ pages rather than peer-reviewed journal articles. Is there no way we can replace the Seattle and King County Public Health Department source with something that has more teeth? JFW | T@lk 12:04, 12 October 2008 (UTC)

When were those references added, and where? I'll try and search for some alternative sources. —Cyclonenim (talk · contribs · email) 13:19, 12 October 2008 (UTC)

PMID 18598630 might be a good candidate. —Cyclonenim (talk · contribs · email) 13:26, 12 October 2008 (UTC)