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[Dysphagia] Dysphagia Digest, Vol 42, Issue 10
Hi Irene,
Thanks for your input into these discussions, they are very
educational. Can you give more details about the Marek article you
referred to (NEJM 2000)? I can't find it.
Trudy
Trudy Lynch
Speech Pathologist
Royal North Shore Hospital
St Leonards NSW 2065
Phone: (02) 9926 7741
Fax: (02) 9926 6568
>>> <dysphagia-request at dysphagia.com> 10/05/2007 23:37:14 >>>
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Today's Topics:
1. logemann study (Wilma Clancy)
2. Logemann results (Irene Campbell-Taylor)
3. Re: Logemann Robbins results (Jai Gupta)
4. Logemann results and MBS (Irene Campbell-Taylor)
5. Re: Logemann results and MBS (Jai Gupta)
6. Results, research and opinion (Irene Campbell-Taylor)
7. Re: Results, research and opinion (Bill Connors)
8. Re: Logemann results and MBS (Shadd Lagrandeur)
9. Re: Logemann results and MBS (Irene Campbell-Taylor)
----------------------------------------------------------------------
Message: 1
Date: Wed, 09 May 2007 16:38:38 -0300
From: "Wilma Clancy" <Wilma.Clancy at cdha.nshealth.ca>
Subject: [Dysphagia] logemann study
To: <dysphagia at dysphagia.com>
Message-ID: <s641f920.077 at ngate01.cdha.nshealth.ca>
Content-Type: text/plain; charset=US-ASCII
I'd like to respond to the discussion regarding the Logemann study
about
aspiration of thick liquids. We must keep in mind that the
participants
in this study all had dementia, Parkinson's disease or Parkinson's
disease with dementia. Therefore broad statements for all dysphagia
patients are inappropriate.
Furthermore, when you look at the definition of honey consistency in
this trial of 3000 cP, we are in fact talking about what the National
Dysphagia Diet would call puree, not what most of us consider to be
honey consistency as in the Novartis thickened liquids. When you read
the information with this in mind, we are talking about profoundly
dysphagic patients not those that only aspirate thick liquids.
Therefore, of course there is going to be more trouble with pneumonia
if
the patient is aspirating puree rather than nectar consistency. I am
looking forward to reading this study. To my knowledge it has not yet
been published, (I recently did a search) but I have seen the
presentation slides used by Dr. Logemann.
Sincerely,
Wilma Clancy
Neurology Dietitian
------------------------------
Message: 2
Date: Wed, 9 May 2007 15:45:05 -0700 (PDT)
From: Irene Campbell-Taylor <eripley at yahoo.com>
Subject: [Dysphagia] Logemann results
To: Wilma.Clancy at cdha.nshealth.ca, dysphagia at b9.com
Message-ID: <312708.71195.qm at web30212.mail.mud.yahoo.com>
Content-Type: text/plain; charset=iso-8859-1
These are the patients most often found in LTC ? and the Parkinson?s
with dementia is actually the parkinsonian stage of dementing illness. I
don?t believe anyone has made general statements about all dysphagic
patients ? simply that, contrary to popular belief, thickened fluids are
aspirated, the thicker more than the thinner (as Perlman proved years
ago), and, as the authors say, it is probable that the lungs? ciliary
motion cannot clear the gum-based thickener used. If so, this would
apply to all since lung function is not affected by dementing illness.
The importance of the findings is mainly to point out that the almost
universl belief that thickening prevents aspiration is false and that
dehydration is a constant danger.
Dr I Campbell-Taylor
Clinical Neuroscientist
Exclusive Distributor:
www.interactivetherapy.com
------------------------------
Message: 3
Date: Thu, 10 May 2007 09:11:52 +1000
From: "Jai Gupta" <Jai.Gupta at SESIAHS.HEALTH.NSW.GOV.AU>
Subject: Re: [Dysphagia] Logemann Robbins results
To: <dysphagia at b9.com>
Message-ID: <88EEDD02C11B6A4182DD21E42394DCFE15556A at sesahs.nsw.gov.au>
Content-Type: text/plain; charset=iso-8859-1
Hi Everyone,
Can anyone let me know if they observe pt aspirating on thickened
fluid, will they prescribe thickened fluid? I think it common clinical
sense.. you won't....I really wonder if these patients can even handle
water or pureed food if they are aspirating on thickened consistency eg
pudding consistency aspiration ..that is very severe dysphagia ..this
person cannot live on water alone ..atleast I would keep the pt NBM,
water sips for QOL if managed as per FWP and think of alternative
feeding method. I think we tend to look for complex answers for time
tested and simple clinical issue. We know that thickened fluid is not
good for all esp.. the randomised study by Dr Logemann etal last
discussed showing clearly difference in PD, DAT etc...clearly
demonstrated that. I really cannot understand why some people are so
obsessed about not giving thickened fluid when there is clinical
evidence on MBS's that it has some advantages in some cases..this is
clinical fact..yes I agree we have !
to be vigilant and see that we are choosing the right pts and weaning
them out as quickly as possible back to normal fluid. ta
Jai Gupta. M.Sc.(S.H.) CPSP MSPA
Manager, Speech Pathology Department
The Sutherland Hospital
* Locked Bag 21, Taren Point NSW 2229 Australia
* +612 9540 7111 page 594 or Direct +612 9540 7558
*+612 9540 7717 *+61 0401 373 324
<mailto:Jai.Gupta@ sesiahs.health.nsw.gov.au>
A Thought
You see things; and you say, "Why?" But I dream things that never were;
and I say, "Why not?" ...... George Bernard Shaw
-----Original Message-----
From: dysphagia-bounces at dysphagia.com
[mailto:dysphagia-bounces at dysphagia.com]On Behalf Of Irene
Campbell-Taylor
Sent: Thursday, 10 May 2007 1:23 AM
To: Cameron, Sharon (R3); dysphagia at b9.com
Subject: Re: [Dysphagia] Logemann Robbins results
The already existing literature seems to argue that not enough water is
supplied and that even when patients drink all of the thickened fluids
given, they still do not ingest/absorb enough water.
Among other articles see:
Inadequate fluid intakes in dysphagic acute stroke
K.WHELAN
Department of Nutrition and Dietetics, Kings College London, UK.
(Correspondence to: KW, Research Dietitian, Department of
Nutrition and Dietetics, Kings College London,150 Stamford Street,
London, SE19NN, UK)
Clinical Nutrition (2001) 20(5): 423?428
"Cameron, Sharon (R3)" <Sharon.Cameron at rvh.nb.ca> wrote: As a
Dietitian on the list, unfortunately I have not been privy to the
ASHA information.
My question for those familiar with the research is a question about
the
dehydration associated with thickened fluids.
Is it a question that the fluid is bound by and therefore not
available
to the body once thickened (more of a concern with gel thickeners) or
is
it a question that once recommended, patients do not drink adequate
quantities of thickened fluids ?
Any info greatly appreciated
Sharon Cameron
Registered Dietitian
Stan Cassidy Centre for Rehabilitation
800 Priestman Street
Fredericton, NB E3B 0C7
506-452-5652
-----Original Message-----
From: dysphagia-bounces at dysphagia.com
[mailto:dysphagia-bounces at dysphagia.com] On Behalf Of Irene
Campbell-Taylor
Sent: Wednesday, May 09, 2007 11:57 AM
To: dysphagia at b9.com
Subject: [Dysphagia] Logemann Robbins results
For those who have difficulty with the links, the following is taken
from the original presentation at ASHA 2006:
Major Findings
Long term results show that despite differential effect of
interventions on immediate elimination of aspiration in
videofluoroscopic suite (Part I findings)......the 3-month incidence
of
pneumonia was similar for chin down posture compared to thickened
liquids
( This, of course, emphasises again that what is seen on VFSS is not
necessarily what happens in real life.)
Adverse Events Hospitalization
Dehydration
(Presumably hospitalization for pneumonia and/or effects of
dehydration.)
Dehydration No difference in measured parameters Subset: n=16
Serum osmolality
Sodium
BUN (mg/dL)
Serum creatine (mg/dL)
Defined by primary physician
Was more frequent in thickened liquid arms (6% vs. 2%, p<0.05)
Current Clinical Notion
"The thicker the liquid, the safer the swallow"
*Not true in patients who aspirate thick liquids - worse health
outcomes
Dr I Campbell-Taylor
Clinical Neuroscientist
Exclusive Distributor:
www.interactivetherapy.com
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Message: 4
Date: Wed, 9 May 2007 17:27:24 -0700 (PDT)
From: Irene Campbell-Taylor <eripley at yahoo.com>
Subject: [Dysphagia] Logemann results and MBS
To: Jai.Gupta at SESIAHS.HEALTH.NSW.GOV.AU, dysphagia at b9.com
Message-ID: <427506.97784.qm at web30205.mail.mud.yahoo.com>
Content-Type: text/plain; charset=iso-8859-1
"I really cannot understand why some people are so obsessed about
not giving
thickened fluid when there is clinical evidence on MBS's that it has
some
advantages in some cases"
The Logemann study showed clearly that what happened on VFSS was not
replicated in real life. That is the point. Whether or not the VFSS
shows aspiration of thickened fluids or not, the end result is the same.
One cannot extrapolate from a VFSS as to what will happen during a meal
with real food and liquid.
Dr I Campbell-Taylor
Clinical Neuroscientist
Exclusive Distributor:
www.interactivetherapy.com
------------------------------
Message: 5
Date: Thu, 10 May 2007 11:10:47 +1000
From: "Jai Gupta" <Jai.Gupta at SESIAHS.HEALTH.NSW.GOV.AU>
Subject: Re: [Dysphagia] Logemann results and MBS
To: <dysphagia at b9.com>
Message-ID: <88EEDD02C11B6A4182DD21E42394DCFE15556B at sesahs.nsw.gov.au>
Content-Type: text/plain; charset="iso-8859-1"
Hi
I agree everyone has a right to opinion, and I still think the issue if
thickened fluid goes over board at times. I don't think there is enough
evidence to support that in real practice use of thickened fluid should
be obsolete, we know FWP is not for all clients. With our current
practice I think we are doing well. Unless we know (large scale
multicentre studies or data) what is documented level on Asp Pneumonia
in pt seen with thickened fluid and those without thickened fluid, we
cannot ascertain if thickened fluid bad. It is a complex issue. We have
started collecting data on Performance Indicator on how many pts develop
Asp Pneumonia(AP) after Speech Pathology interventions and preliminary
data on multicenter study shows on 618 pt only 18 developed and some of
these already had AP and some were end stage QOL and not compliant and
some had PEG so Pneumonitis rather then AP. We are hoping in future we
will get more accurate data. I still take the stand thickened fluid is
a!
useful intervention strategy if used cautiously and skilfully and as
a mean to reach the goal of restoring normal/ adequate swallow.
Ta
Jai Gupta. M.Sc.(S.H.) CPSP MSPA
Manager, Speech Pathology Department
The Sutherland Hospital
* Locked Bag 21, Taren Point NSW 2229 Australia
* +612 9540 7111 page 594 or Direct +612 9540 7558
*+612 9540 7717 *+61 0401 373 324
mailto:Jai.Gupta @ <mailto:Jai.Gupta@ sesiahs.health.nsw.gov.au>
sesiahs.health.nsw.gov.au
A Thought
You see things; and you say, "Why?" But I dream things that never were;
and I say, "Why not?" ...... George Bernard Shaw
-----Original Message-----
From: Irene Campbell-Taylor [mailto:eripley at yahoo.com]
Sent: Thursday, 10 May 2007 10:27 AM
To: Jai Gupta; dysphagia at b9.com
Subject: Logemann results and MBS
"I really cannot understand why some people are so obsessed about
not giving
thickened fluid when there is clinical evidence on MBS's that it has
some
advantages in some cases"
The Logemann study showed clearly that what happened on VFSS was not
replicated in real life. That is the point. Whether or not the VFSS
shows aspiration of thickened fluids or not, the end result is the same.
One cannot extrapolate from a VFSS as to what will happen during a meal
with real food and liquid.
Dr I Campbell-Taylor
Clinical Neuroscientist
Exclusive Distributor:
www.interactivetherapy.com
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contacts list with the details of the email addresses contained within.
This email, and the files transmitted with it, are confidential and
intended solely for the use of the individual or entity to whom they are
addressed. If you are not the intended recipient, you are not permitted
to distribute or use this email or any of its attachments in any way. We
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This email message has been virus-scanned. Although no computer viruses
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containing any computer viruses.
------------------------------
Message: 6
Date: Thu, 10 May 2007 05:17:58 -0700 (PDT)
From: Irene Campbell-Taylor <eripley at yahoo.com>
Subject: [Dysphagia] Results, research and opinion
To: dysphagia at b9.com, Jai.Gupta at SESIAHS.HEALTH.NSW.GOV.AU
Message-ID: <203362.9769.qm at web30202.mail.mud.yahoo.com>
Content-Type: text/plain; charset=iso-8859-1
I find it difficult to express just how infuriating it is to be told
that my "opinion" is interesting or that "everyone is entitled to an
opinion". In life, yes. In science, no. Opinion, by definition, is a
personal belief without proof. I don't believe I have ever expressed
"opnion without proof" unless so stated. When faced with proof, it is
mandatory that one examine it carefully and adjust accordingly if it is
valid. An opinion, in medicine and a dollar (unless it's Starbucks)will
get you a cup of coffee.
Dr I Campbell-Taylor
Clinical Neuroscientist
Exclusive Distributor:
www.interactivetherapy.com
------------------------------
Message: 7
Date: Thu, 10 May 2007 08:26:32 -0400
From: "Bill Connors" <bill at aphasiatoolbox.com>
Subject: Re: [Dysphagia] Results, research and opinion
To: "'Irene Campbell-Taylor'" <eripley at yahoo.com>, <dysphagia at b9.com>,
<Jai.Gupta at SESIAHS.HEALTH.NSW.GOV.AU>
Message-ID: <200705101226.l4ACQNsm023308 at boa.b9.com>
Content-Type: text/plain; charset="windows-1250"
Good Morning Irene.
Good Lord Irene. I remember when I used to say, "That and a DIME will
get
you a cup of coffee." If I didn't feel so young you might make me feel
old
:-)
And by the way, could you ever have imagined years a go that you would
have
been paying 2 bucks for a cup of Joe?
Bill Connors
The Aphasia Center of Innovative Treatment
bill at aphasiatoolbox.com
-----Original Message-----
From: dysphagia-bounces at dysphagia.com
[mailto:dysphagia-bounces at dysphagia.com] On Behalf Of Irene
Campbell-Taylor
Sent: Thursday, May 10, 2007 8:18 AM
To: dysphagia at b9.com; Jai.Gupta at SESIAHS.HEALTH.NSW.GOV.AU
Subject: [Dysphagia] Results, research and opinion
I find it difficult to express just how infuriating it is to be told
that my
"opinion" is interesting or that "everyone is entitled to an opinion".
In
life, yes. In science, no. Opinion, by definition, is a personal
belief
without proof. I don't believe I have ever expressed "opnion without
proof"
unless so stated. When faced with proof, it is mandatory that one
examine it
carefully and adjust accordingly if it is valid. An opinion, in
medicine and
a dollar (unless it's Starbucks)will get you a cup of coffee.
Dr I Campbell-Taylor
Clinical Neuroscientist
Exclusive Distributor:
www.interactivetherapy.com
_______________________________________________
Dysphagia mail list: Normal and disordered swallowing information
Dysphagia at dysphagia.com
Manage subscription: http://lists.b9.com/mailman/listinfo/dysphagia
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------------------------------
Message: 8
Date: Thu, 10 May 2007 08:36:54 -0400
From: "Shadd Lagrandeur" <slagrandeur at lrgh.org>
Subject: Re: [Dysphagia] Logemann results and MBS
To: "'Irene Campbell-Taylor'" <eripley at yahoo.com>,
<Jai.Gupta at SESIAHS.HEALTH.NSW.GOV.AU>, <dysphagia at b9.com>
Message-ID: <000601c792ff$e3e1cb90$7d06a8c0 at practice.lrgh.org>
Content-Type: text/plain; charset="us-ascii"
" Whether or not the VFSS shows aspiration of thickened fluids or not,
the
end result is the same. One cannot extrapolate from a VFSS as to what
will
happen during a meal with real food and liquid."
One cannot help but extrapolate from the evidence provided during an
MBS....that is what we get paid to do. What actions should we take,
otherwise? We know we get plenty of false negatives, however if a
patient
silently aspirates thin barium during the MBS, you can safely
extrapolate
that they aspirate thin fluids. If patients are aspirating thin
liquids
during the exam, and thick liquids at home, then they are obviously
unsafe
for PO. If a patient keeps getting aspiration pneumonias despite our
interventions, then we try more interventions, put in a PEG tube, or
let the
patient eat as they wish and die.
What are the practical implications of these discussions...no one has
talked
about how this should actually change how we view, diagnose, treat, and
make
recommendations for dysphagic patients.
In the end this is all evidence that despite our best attempts at
prolonging
some of these people's unfortunate existences, nature still takes its
course!
Shadd LaGrandeur, MA, CCC-SLP
LRGHealthcare Speech Pathology
Program Coordinator
603-527-2888
-----Original Message-----
From: dysphagia-bounces at dysphagia.com
[mailto:dysphagia-bounces at dysphagia.com] On Behalf Of Irene
Campbell-Taylor
Sent: Wednesday, May 09, 2007 08:27 PM
To: Jai.Gupta at SESIAHS.HEALTH.NSW.GOV.AU; dysphagia at b9.com
Subject: [Dysphagia] Logemann results and MBS
"I really cannot understand why some people are so obsessed about
not
giving
thickened fluid when there is clinical evidence on MBS's that it has
some
advantages in some cases"
The Logemann study showed clearly that what happened on VFSS was not
replicated in real life. That is the point. Whether or not the VFSS
shows
aspiration of thickened fluids or not, the end result is the same. One
cannot extrapolate from a VFSS as to what will happen during a meal
with
real food and liquid.
Dr I Campbell-Taylor
Clinical Neuroscientist
Exclusive Distributor:
www.interactivetherapy.com
_______________________________________________
Dysphagia mail list: Normal and disordered swallowing information
Dysphagia at dysphagia.com
Manage subscription: http://lists.b9.com/mailman/listinfo/dysphagia
Visit the new Dysphagia Web Forum: http://dysphagia.com/forum
------------------------------
Message: 9
Date: Thu, 10 May 2007 06:37:08 -0700 (PDT)
From: Irene Campbell-Taylor <eripley at yahoo.com>
Subject: Re: [Dysphagia] Logemann results and MBS
To: Shadd Lagrandeur <slagrandeur at lrgh.org>,
Jai.Gupta at SESIAHS.HEALTH.NSW.GOV.AU, dysphagia at b9.com
Message-ID: <21227.26492.qm at web30214.mail.mud.yahoo.com>
Content-Type: text/plain; charset=iso-8859-1
Shadd Lagrandeur <slagrandeur at lrgh.org> wrote:
One cannot help but extrapolate from the evidence provided during an
MBS....that is what we get paid to do. \
*** On the contrary. What one is paid to do is identify the cause of
the problem - and saying, for example-that the patient had a stroke is
insufficient, and thence formulate goals and management plans for the
individual patient (emphasis on individual) with follow up. It has been
shown over and over that VFSS does NOT duplicate a real meal. Indeed it
cannot duplicate a real meal because of the situation and the materials
provided. The VFSs is was only ever meant to identify the dynamics of
the swallow and has been so demonstrated as far back as the late
1980's.
We know we get plenty of false negatives, however if a patient
silently aspirates thin barium during the MBS, you can safely
extrapolate
that they aspirate thin fluids.
*** Absolutely not. There is no evidence to support such a
conclusion. It depends on so many variables that such a homology is
invalid.
If a patient keeps getting aspiration pneumonias despite our
interventions, then we try more interventions, put in a PEG tube, or
let the
patient eat as they wish and die.
*** Is it really an accepted notion that aspiration leads inevitably
to death? Nothing could be further from the truth. As repeatedly shown
in the medical literature, the hazards of aspiration depend on four main
variables, to be considered together:
What is being aspirated, how much, over how long a period and, most
importantly, what is the patient's resistance/immune response. Please
read Marek on Pneumonia and Pneumonitis, NEJM 2000 I believe. It
explains this very clearly as well as the near drowning literature.
What are the practical implications of these discussions...no one has
talked
about how this should actually change how we view, diagnose, treat, and
make
recommendations for dysphagic patients.
*** I think the practical implications couldn't be clearer. What has
been taken as received wisdom is often if not always wrong. Other means
of gaining hydration are available - drinking water, hypodermoclysis,
drinking in different positions etc. etc. These need to be learned and
used more extensively.
In the end this is all evidence that despite our best attempts at
prolonging
some of these people's unfortunate existences, nature still takes its
course!
*** Nature will always take its course. All we can do with respect to
swallowing impairment is to try to improve or maintain nutrition and
hydration for as long as possible in a manner that is comfortable,
efficient and acceptable to the patient.
Dr I Campbell-Taylor
Clinical Neuroscientist
Exclusive Distributor:
www.interactivetherapy.com
------------------------------
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