Abstract

---

The trade of mollusks and other shellfish play a significant role in the economy of Grenada. The objective of this study was to gather information on the presence of potential human pathogens in clams, oysters, queen conchs, and whelks (West Indian top shell), and to determine the antimicrobial susceptibility patterns of the bacterial isolates. A total of 110 shellfish consisting of 40 clams, 30 oysters, 20 queen conchs, and 20 whelks, was obtained from three different bays along Grenada’s coast and examined for bacterial pathogens by culture of whole soft tissue, intestines, feces, and/or meat.  Selective media, including thiosulfate-citrate-bile-sucrose agar, were used with the aim to isolate various bacteria, particularly the members of the Vibrionaceae family. The isolates obtained were identified based on phenotypic properties, including reactions obtained with the API bacterial identification strips. Of 59 isolates, 35 were identified with >80% probability, with the most prevalent being Vibrio alginolyticus (8), followed by Shewenella putrefaciens (6), and Enterobacter sakazakii (3). Other potential human pathogens included Vibrio fluvialis (2), Stenotrophomonas maltophilia (2), and Vibrio parahaemolyticus (1). All types of shellfish yielded potential human pathogens, including known diarrheal pathogens, Vibrio fluvialis from conch and oysters, and V. parahaemolyticus from clams. On the antimicrobial drug susceptibility tests for the 35 isolates, using a standard disk diffusion method against 10 antimicrobial drugs, none of the isolates demonstrated resistance to the fluoroquinolone drug enrofloxacin. Rate of resistance among other drugs was highest to ampicillin (60%), and lowest to ciprofloxacin and trimethoprim-sulfa (2.9%). In conclusion, this study revealed the presence of potential human pathogens, as well as antimicrobial drug resistance among bacterial isolates from shellfish in Grenada.
SHORT RUNNING TITLE: Bacterial pathogens from shellfish in Grenada, and their drug resistance
KEY WORDS: Shellfish, bacterial pathogens, drug resistance, Grenada

Introduction

---

The term “shellfish” encompasses a variety of animals including bivalves – oysters, clams, quahogs, scallops, mussels, and others including crustaceans – lobsters, crabs, and shrimps. Mollusks and other shellfish make up a significant part of natural marine products, and economy of Grenada. 
The United States alone imported an average of $3.5 million worth of fish and shellfish between the years 2005 to 2009 (US Census Bureau 2010). Shellfish naturally found in Grenada include: clams (Mercenaria mercenaria), oysters (Isognomon isognomon), Queen conchs/lambi (Strombus gigas), whelks (West Indian top shell) (Cittarium pica), and shrimp.
Queen conchs, whelks, and lobster are among the most popular and most consumed shellfish in Grenada. True conchs are marine gastropod mollusks in the family Strombidae and the genus Strombus, and the locally consumed conch in Grenada is referred to as lambi. Queen conch (Strombus gigas) is found throughout the Caribbean (NOAA, 2010), and it is used both for its meat and for its shell. Whelk, known commonly asWest Indian top shell, is a sea snail (Shimek 2005) and it is consumed by many Grenadians. Lobster fisheries are an economically important undertaking in Grenada (McConney et al. 2007) while there have been no efforts to open a hatchery.
Bacteria are ubiquitous in the marine environment. Shellfish can be a source of commensal bacteria that can be pathogenic to shellfish, as well as those pathogenic to humans. There are many bacteria which are pathogenic, but there are some which are more commonly reported. Some of these bacteria include Salmonella, E. coli, Campylobacter, and Vibrio, and these have been isolated from shellfish and/or the water where the shellfish is found.
Several Vibrio species, native to both marine and estuarine environments, have been identified as the causative agents of shellfish-vectored illnesses in humans.  These include Vibrio parahaemolyticus, V. vulnificus, V. cholerae, and V. alginolyticus (Rippey 1994, Hariharan et al. 1995).  Severe Vibrio infections are commonly treated with antibiotics, and therefore, antibiotic resistance is a concern.  Antibiotics recommended for treatment include tetracycline, ampicillin, and ciprofloxacin (Minnesota Department of Helath 2010). Many bacteria are building resistance through different mechanisms, and antibiotics that were once effective, have had to be replaced.  Many foods originating from animals are pretreated with antibiotics, for example, meat from farms, fish and shellfish from hatcheries, etc.  Because antibiotics are widely used in the food industry, many of the bacteria are genetically changing and becoming resistant to different antibiotics.
There have been no publications on the microbial hazards posed by shellfish in Grenada.  This study was aimed to gather information about the potential bacterial pathogens in shellfish Grenada, and to determine the antimicrobial susceptibility patterns of the bacterial isolates.

Materials and Methods

---

Geographic areas of sampling, sample collection and processing:

Grenada is a small island measuring 23 x 10 miles, and is located in the West Indies, in the Caribbean.  It is the second to the last southernmost island of the Antillean Windward Islands.  The specimens chosen for this project were collected from three different bays in Grenada.  These included La Sagesse (clams, collected during high tide), Woburn (oysters and whelks), and Calliste (Queen conch/lambi).  These three bays are located in the southeast part of Grenada, and they are common places where fishermen collect these shellfish for food. 

Forty clams, 30 oysters, 20 queen conchs, and 20 whelks were collected. For processing, each type of shellfish sampled was divided into two equal batches, except for whelks, which were processed as one batch. They were collected in plastic zip-lock bags or in clean plastic bins pretreated with alcohol. The containers were placed in a cooler box with ice packs and transported to the laboratory.

 Clams and oysters were checked to ensure there were no abnormalities, and that the shells were closed. They were cleaned externally with tap water and a brush (Whitman and McNair 2004). Oysters were dipped in 70% alcohol. Shells were opened aseptically, and soft tissues were collected with sterile precautions. Pooled tissues were homogenized in a sterile pestle and mortar with 100 grams of sterile sand and 15 ml of peptone water. The homogenate was used as the inoculum for culture.

Queen conchs were collected from Calliste, and brought to St. George’s University Marine Station, where they were checked to ensure they were alive and fresh. A hole was made on each between the 3^rd and 4^th horn ring, and the abductor muscle was severed with a knife. The soft tissue was pulled out and placed in a sterile tray. Fecal material was collected from the gastrointestinal tract, and 2 grams of pooled sample was homogenized with 18 ml of peptone water for inoculum. Samples in duplicate were also collected by swabbing the external surface of the soft tissue, and swabbing a deep incision of the meat, made with a sterile blade.

All twenty whelks were processed immediately in one batch, and were later divided into two batches as non-enriched and enriched samples.

Each whelk was placed on a cutting board.  The shell was crushed manually with a pestle making sure that the soft tissue of the whelk did not touch any of the surfaces. Sterile forceps were used to pull the soft tissue off of the shell, and the soft tissue was placed in a sterile pestle, and the pooled sample of 20 whelks was ground with sterile sand and10 ml of peptone water for 5 minutes until one homogeneous mixture was produced, and this was used for culture.

Bacterial Pathogen Isolation and identification:

The process of bacterial pathogen isolation was the same for all samples, which were cultured in duplicate, with and without enrichment. For enrichment, 1 gram of tissue homogenate was added to 9 ml of alkaline peptone water, and incubated at 37˚C for 24 hours. Initial inoculations from all samples were made on one plate of each of the following: thiosulfate citrate bile salt sucrose agar (TCBS), blood agar, MacConkey agar, brilliant green sulfa agar (Dico/Becton, Dickinson & Co, Sparks, MD (BD), Campylobacter blood-free agar (CBF) (Oxoid Ltd., Basingstoke, Hants, England), and Rappaport broth (Dico/BD).  All inoculated media, except for CBF were incubated aerobically at 37°C.  Inoculated plates of CBF were placed in jars with ‘Campy-Pak’ (BD) to create a microaerophilic atmosphere (85% N, 10% CO2, 5% O2). 

After 24 hours (48 hours for CBF plates), plates were examined for colonies and their characteristics. Rappaport broth cultures were inoculated onto Modified Semi-Solid Rappaport Vassiliadis (MSRV) (Dico/BD) media.  A Gram stain was performed on each isolated colony from the first inoculation.

If gram-negative curved rods resembling Vibrio spp. were observed on TCBS, as described by Farmer et al. (2003), additional tests were performed using gelatin agar, triple sugar iron (TSI) slant, and 0129 vibriostat disc (Oxoid) to help characterize them.

The isolates were then inoculated on to the API 20E strip or other appropriate API system such as API NE, API Staph, and identified as per the manufacturer’s (bioMerieux  2010) instructions. The biochemical tests investigated with API 20E were: beta-galactosidase (ONPG), arginine dihydrolase (ADH), lysine decarboxylase (LDC), ornithine decarboxylase (ODC), citrate utilization (CIT), H₂S production (H2S), urease (URE), tryptophane deaminose (TDA), indole production (IND),  Voges-Proskauer (VP), gelatinase (GEL), utilization of glucose (GLU), mannitol (MAN), inositol (INO), sorbitol (SOR), rhamnose (RHA), saccharose (SAC), melibiose (MEL), amygdalin (AMY), and arabinose (ARA). Cytochrome oxidase test was done separately, and taken into account for reference number completion.  API system numbers and percent probabilities in all identification tables were provided by the API system manual (bioMerieux 2010).

Antimicrobial Susceptibility Testing:

A standard disc diffusion method (Jorgensen and Turnidge, 2003) was used. The antibiotics chosen included: ampicillin (AM) (10μg), amoxicillin-clavulanic acid (AMC) (10μg), cephalothin (CF) (30μg), chloramphenicol (C) (30 µg), enrofloxacin (ENO) (5μg), ciprofloxacin (CIP) (5μg), gentamicin (GM) (10μg), streptomycin (S) (10μg), tetracycline (TE) (30μg), and trimethoprim-sulfamethoxazole (SXT) (25μg ) (all from BD). The results were interpreted as per Clinical Laboratory Standards Institute (formerly, NCCLS) standards as recommended by Jorgensen and Turnidge (2003), and Becton Dickinson (BD) (2007). For vibrios the interpretive standards for Enterobacteriaceae were used, as recommended by Farmer et al. (2003).

Interpretative standards for Enterobacteriaceae were used for gram-negative organisms for which no interpretative standards have been described.  An E. coli strain ATCC 25922 (American Type Culture Collection, Manassas, VA) with known sensitivity patterns was used as a control to test the integrity and activity of the antibiotic discs prior to testing.

Results

---

None of the samples were positive for Campylobacter or Salmonella. A total of 59 isolates were recovered from TCBS agar, BG agar, MacConkey agar, or blood agar plates. Of these, 35 isolates were identified with >80% probability (Table 1). Of these, clams yielded 6, oysters and Queen Conch, 8 each, and whelks, 13. The most common species was Vibrio alginolyticus, followed by Shewenella putrefaciens. Details of isolates from each type of shellfish are given below:

Clams:

Three morphologically different colony types of Vibrio alginolyticus were obtained. These were identified with 99.5 %, 99.7%, and 98.5% probabilities. The other isolates were: Aeromonas salmonicida (99% probability), Pantoea spp. (99.2%), and Chrysobacterium meningosepticum (70.4%).

Oysters:

The isolates obtained were, one each of Escherichia coli (99.7% probability) and Vibrio alginolyticus (99.6%), two isolates of Shewenella putrefaciens (99% and 89%), one isolate each of Moraxella lacunata (85.7%), Pantoea spp (85.7%), Vibrio fluvialis (83.9%), and Stenotrophomonas maltophilia (80%).

Queen Conchs:

The isolates obtained from Queen conch feces were, one each of Photobacterium damselae (99.9%), Vibrio fluvialis (98.5%), Stenotrophomonas maltophilia (92.4%), and Klebsiella pneumoniae ssp. rhinoscleromatis (98.6%).

From Queen Conch meat incision swabs, there were 3 isolates of Enterobacter sakazakii (98.4%-99.9%). Other isolates were Vibrio fluvialis, Vibrio alginolyticus, and Pantoea spp. with poor or doubtful profiles (43%-64%).

From Queen conch external meat swab, there was one isolate of Klebsiella pneumoniae ssp. rhinoscleromatis (98.6% probability), and the remaining were of poor probability (≤ 64%), and included Shigella spp., Pasteurella spp., Vibrio alginolyticus, and Leifsonia aquatica.

Whelks:

The bacteria recovered included 4 isolates of Shewenella putrefaciens (all 99.9%), one isolate of Escherichia coli (92.1%), 4 isolates of Vibrio alginolyticus (86%-97.8%), 2 isolates of Pseudomonas fluorescens (both 94.1%), one isolate each of Chrysobacterium meningosepticum (87.5%), and Aeromonas hydrophila (85%). Other isolates had profiles ≤ 76%, and included Staphylococcus epidermidis, Chrysobacterium indologenes, and Shigella spp.

Antimicrobial drug resistance:

There was resistance to nine of the ten antibiotics used (Table 2).  Resistance was highest to ampicillin  (60%), followed by cephalothin (40%), streptomycin (28.6%), amoxicillin-clavulanic acid (20%), tetracycline (17.1%), chloramphenicol, gentamicin, ciprofloxacin, and trimethprim sulfa (all <10%).  All isolates were susceptible to enrofloxacin. Bacterial isolates which were susceptible to every antibiotic included, one isolate each of V. parahaemolyticus, Escherichia coli, and Chryseobacterium meningosepticum Many isolates were resistant to more than on antibiotic used for susceptibility testing. One isolate of Stenotrophomonas maltophilia showed simultaneous resistance to ampicillin, amoxicillin-clavulanic acid, chloramphenicol, cephalothin, streptomycin, tetracycline, and trimethoprim-sulfamethoxazole. It was susceptible only to fluoroquinolones and gentamicin (Table 3).

Discussion

---

Oysters, mussels, and other shellfish have a long history of being vectors of infectious agents, especially when they are consumed raw or partially cooked.  Many of these infectious agents are native to the marine environment.  As filter-feeding organisms, shellfish magnify public health problems associated with environmental contamination because they accumulate microbial pathogens many fold over the densities found in overlying waters (Lee et al. 2003).  In terms of the severity of human illness and death, the Vibrio genus, specifically V. vulnificus, presents a serious problem (Rippey 1994).  In a study in the United States (Hood et al.1984), it was observed that certain types of shellfish are more likely to harbor vibrios than others.  For example, clams may be far less likely a source of vibrio-related gastrointestinal illness than oysters.

No published information is available regarding the occurrence of bacterial pathogens in various shellfish in Grenada. The present study on shellfish in Grenada, specifically clams, oysters, Queen conch, and whelks, revealed the presence of potential human pathogens, as well as bacteria that may cause morbidity and mortality in shellfish or other marine animals. The organisms isolated in the present study, which are known to have a worldwide distribution in marine animals or their environment, include Vibrio alginolyticus, V. fluvialis, V. parahaemolyticus, Aeromonas hydrophila, Shewenella putrefaciens, Stenotrophomonas maltophilia, Klebsiella pneumoniae, Pseudomonas fluorescens, and Pantoea spp. (Twedt 1989, Dignani et al. 2003, Buller 2004, Furushita et al. 2005, Pagniez and Berche 2005).

Thirty-five bacterial isolates were identified with >80% acceptable probability, using the API bacterial identification system. The API 20E system, is suitable for identification of Enterobacteriaceae and Vibrionaceae (Koneman 1992). O’hara et al. (2003) did a study comparing the accuracy of six commercially available systems for identification of members of the family Vibrionaceae, and found that 92% of V. alginolyticus, 97% of V. parahaemolyticus, and 100% of V. damselae are correctly identified by API 20E.  No system identifies all vibrios correctly by 100%.  Boinapali et al. (2007) also used API 20E for identification of vibrios in a study about antibiotic resistance in shrimp in South Carolina.  The use of API 20E is recommended for identification of Vibrio spp. for practical identification of bacteria from fish and other aquatic animals (Buller 2004). In a recent article published by Okoh and Igbinosa (2010), API 20E was exclusively used to identify marine vibrio strains, consisting of V. vulnificus, V. metschnikovii, V. fluvialis, and V. parahaemolyticus.   

Most of the bacterial isolates identified in this study have been known to cause pathogenicity in humans. None of the isolates were identified as Vibrio vulnificus, a major human pathogen.  Vibrio alginolyticus, which can cause wound infections as well as gastroenteritis, was found in whelks, clams, and oysters, with maximum numbers in whelks.  In a study on oysters and mussels in the Netherlands (Schets et al. 2010), 80% of Vibrio isolates belonged to V. alginolyticus species, and 10% were V. parahaemolyticus.  Vibrio alginolyticus was the most common organism isolated from mussels in Prince Edward Island, Canada (Hariharan et al. 1995). Ripabelli et al. (1999), who studied mussels from Adriatic sea, Italy also observed that vibrios were the most common group isolated, with V. alginolyticus as the most common species. No Salmonella, or Campylobacter was isolated in their study on mussels, as was the case in the present study of shellfish in Grenada.  Similarly, Miller et al. (2006) could not detect Campylobacter or Salmonella in mussels from coastal California.  However, oysters sold in Trinidad have been found to be positive for Salmonella and E. coli, including O157 strains (Rampersad et al. 1999).  The single isolate of V. parahaemolyticus in the present study originated from clams.  V. parahemolyticus is known to cause gastrointestinal illness and has also been isolated from infected wounds (Buller 2004).  V. parahemolyticus was isolated by Hood et al. (1983) from oysters as well as V. cholera, and by Deepanjali et al. (2005) in India.  Marine halophilic vibrios related to V. parahemoliticus and V. natrigenes have been isolated from the coastal waters of Prickly Bay, Grenada in a study by Caputo et al. (2008). Vibrio fluvialis, another gastrointestinal pathogen, was isolated from oysters and conch in the present study.  V. fluvialis has been documented to cause acute gastroenteritis following ingestion of oysters carrying these bacteria (Levine, et al. 1993).  V. fluvialis, V. alginolyticus, and V. parahemolyticus were all isolated by Maugeri et al. (2000) from brackish waters and mussels in Sicily and Italy.

Among members of the genus Aeromonas, A. hydrophila is well known for its involvement in gastroenteritis. A. hydrophila was isolated from whelks in the present study.  Hood et al. (1983) also found A. hydrophila, but in oysters, as did Ristori et al. (2007) in a study which identified pathogenic bacteria associated with oysters and estuarine waters in Brazil.  In the aforementioned study, V. vulnificus, and V. parahemolyticus were also identified.  Aeromonas salmonicida was isolated from clams. This bacterium is mostly a fish pathogen.

Stenotrophomonas maltophilia, formerly known as Pseudomonas maltophilia or Xanthomonas maltophilia, was isolated from oysters and conches in the present study.  It has been known to cause bacteremia and has been involved in wound and soft tissue infections in humans (Gilligan et al. 2003).  S. maltophilia has also been isolated from water sources and fish (Rodrigues et al. 2003).  Nevertheless, little is known about its involvement and its pathogenicity regarding shellfish. 

Escherichia coli was isolated from oysters and whelks in the present study.  E. coli is a well-known human pathogen, and among other systems, pathogenic strains affect the gastrointestinal system most (Edgeworth, 2005).  Being a human pathogenic bacterium, E. coli is found in water, and has been isolated from shellfish such as clams (Levesque et al. 2006). Previous research in Grenada has shown that E. coli is commonly found in the waters of Grenada (Davis et al. 2004, Patel et al. 2010), and this present study demonstrates that shellfish from Grenada can harbor this potential human pathogen.

Enterobacter sakazakii was isolated from conchs.  This bacterium has been implicated in causing gastrointestinal disease as well as sepsis. Kim et al. (2008) found this organism commonly in dried shrimp in Korea. Its presence in shellfish of Grenada could be of concern.  E. sakazakii usually causes symptoms in immunocompromised humans, commonly infants (Anon. 2010).

Pantoea spp. was isolated from clams and oysters.  This bacterium has been known to cause wound infections, and gastrointestinal disease (Buller, 2004).  Shellfish are not a usual host.  Nevertheless, it was isolated from oysters and clams in the present study. Vieira et al. (2004) reported its presence in crabs marketed in Brazil.

Shewanella putrefaciens was isolated from oysters and whelks and Pseudomonas fluorescens was isolated only from whelks.  Both bacteria are cause for public health concern, since many Pseudomonas spp. are becoming more resistant to antibiotics.  S. putrefaciens has been isolated from human specimens and has been the cause of bacteremia, septicemia, skin and soft tissue infections, and peritonitis (Chen et al. 1997).  Although a rare pathogen in humans, bacteremic infections are very severe in nature and cause high morbidity (Brink et al., 1995).  P. fluorescens has also been known to cause bacteremia in immunocompromised individuals (Hsueh et al., 1998).

Klebsiella pneumonia ssp. rhinoscleromatis was isolated from queen conch. This bacterium is a pathogen of public health concern.  As the name suggests, it affects the respiratory system by causing a granulomatous infection termed rhinoscleroma, and may spread to the trachea and larynx (Abbott 2003). A study conducted by Paille et al. (1987), revealed the presence of K. pneumoniae in oysters of Louisiana in their survey for fecal coliforms.  

Another bacterium isolated from Queen conch included Photobacterium damsela, which has been involved in causing secondary wound infection in humans, and vibriosis, systemic disease, and death in fish and shellfish.  Chryseobacterium meningosepticum, isolated from whelks in this study, has been the cause of meningitis in infants (Buller 2004).

Finally, the bacterium Moraxella lacunata was isolated from oysters. This organism, although an unusual pathogen, has been reported as a cause of septicemia, as well as meningitis in humans (Ray and Kar 2006, Pavlatou and Athanasiades 1953).           

With regard to the use of antibiotics, non-cholera Vibrio infections (enteric as well as systemic), are generally treated with ciprofloxacin or doxycycline (Beers and Berkow 1999).  The present study shows susceptibility of all vibrio isolates from shellfish to these drugs.  Halophilic vibrios isolated from seafood can be resistant to β-lactam drugs such as ampicillin and older cephalosporins (Ottaviani et al. 2001).  This is also evident from the results of the present study.  Non-Vibrio isolates with resistance to β-lactam drugs included Pseudomonas fluorescens, and Shewanella putrefaciens, both of which were sensitive to ciprofloxacin.

 One of the multi-drug resistant non-Vibrio isolates was Stenotrophomonas maltophilia, isolated from conch, and it demonstrated resistance to several drugs, including trimethoprim-sulfa. Although nearly ninety percent of strains of S. maltophilia are susceptible to trimethoprim-sulfa, resistant strains are emerging (Falagas et al. 2008).  Further studies on this trimethoprim-sulfa resistant strain may be worthwhile.  This bacterium, isolated from cultured yellowtail from fish has been reported to be resistant to several beta-lactams including a 3^rd generation cephalosporin, ceftazidime (Furushita et al. 2005).  This organism is well known for its intrinsic resistance to several drugs that are commonly used against gram-negative infections. The resistance profile of our oyster isolate did not match with that of a typical S. maltophilia, our isolate being susceptible to all drugs. Further studies are required to clarify this discrepancy

Although some results were expected, there is novel data which has been discovered in this study and needs future investigation. 

 In summary, this present study on shellfish in Grenada including clams, oysters, queen conchs, and whelks, revealed the presence of potential human pathogens, and some that could be pathogenic to shellfish themselves. The antimicrobial susceptibility profiles revealed that most of the isolates demonstrated resistance to one or more of the antibiotics chosen for the study.  This is significant since it demonstrates that there may be resistant strains of the isolates that are developing in the marine environments of Grenada.  Even though minimal or no cases have been attributed to these pathogens, it does not mean that shellfish have not been the vectors for gastrointestinal illness of the population of Grenada.  Given that the present study has demonstrated the presence of human pathogens in shellfish, public awareness programs should be implemented to educate the population of Grenada, so far as to report if shellfish has been consumed as part of the clinical history of the patient to better attribute a cause to the diseases, to therefore be able to treat the diseases more efficiently, instead of just blindly treating the patients. 

Given that resistance to antibiotics was seen among most of the isolates to one or more antibiotics, if unchecked, it can become a concern in resulting in inefficacy of treatment. In other words, multi-drug resistant human pathogens might be emerging.

Acknowledgements

---

The authors are thankful to Dr. R. N. Sharma for initiating this project, and for his keen interest. The help of Dr. S. Kotelnikova in providing several publications, and the general laboratory assistance of Erica Brathwaite-Sylvester and Vanessa Matthew are much appreciated.

Source(s) of Funding

---

none

Competing Interests

---

none

Disclaimer

---

This article has been downloaded from WebmedCentral. With our unique author driven post publication peer review, contents posted on this web portal do not undergo any prepublication peer or editorial review. It is completely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscript but also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions before submitting any information that requires obtaining a consent or approval from a third party. Authors should also ensure not to submit any information which they do not have the copyright of or of which they have transferred the copyrights to a third party.
Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater to the needs of an individual patient. The web portal or any content(s) therein is neither designed to support, nor replace, the relationship that exists between a patient/site visitor and his/her physician. Your use of the WebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harm that you may suffer or inflict on a third person by following the contents of this website.