When working with animals can hurt your mental health

When working with animals can hurt your mental health

Summary: Veterinarians and those who work in animal shelters report depression, anxiety, and suicidal thoughts as a result of their stressors associated with their jobs.

Source: APA

Veterinarians and those who work in animal shelters report depression, anxiety, and suicidal thoughts as a result of their stressors associated with their jobs.

“People who work or volunteer with animals are often drawn to it because they see it as a personal calling,” said Angela K. Fournier, PhD, of Bemidji State University, who presented at the meeting. “However, they are faced with animal suffering and death on a routine basis, which can lead to burnout, compassion fatigue and mental health issues.”

Veterinarians in particular are at high risk for death by suicide, according to a study from the Journal of the American Veterinary Medical Association, which found that from 1979 to 2015, veterinarians died by suicide between two to 3.5 times more often than the general U.S. population.

“Talking about veterinarian suicide certainly gets people to pay attention, but it does not tell the whole, nuanced story about what may be contributing to poor well-being in this population,” said Katherine Goldberg, DVM, LMSW, community consultation and intervention specialist at Cornell Health and Founder of Whole Animal Veterinary Geriatrics and Palliative Care Services, who also presented at the meeting. “More research is under way to help better understand why veterinarians might be at an increased risk, but a combination of personality traits, professional demands and the veterinary learning environment all likely contribute.”

Goldberg noted that vets also face economic challenges, as the average veterinary school graduate reported having more than $143,000 of school loan debt while earning a starting salary of just over an average of $73,000 annually in 2016.

“Personal finance concerns are stressful for many veterinarians, especially recent graduates, and at the same time, many clients regularly question the cost of care for their animals and may be suspicious that their vet is trying to ‘push’ services that their pet doesn’t need,” said Goldberg.

Goldberg described a multi-center study that looked at rates of adverse childhood experiences (a term used to describe all types of abuse, neglect and other traumatic experiences) in veterinary students, in an effort to understand what may be causing poor mental health among vets. However, veterinarians were not, on entry to the profession, more predisposed to poor mental health than the general population as a result of adverse childhood experiences, she said.

“This indicates that something is happening over the course of veterinary student training or once veterinarians are working to cause poor well-being outcomes,” said Goldberg.

“Well-being education should be integrated into the veterinary curriculum, emphasizing resiliency behaviors and cultivating professional partnerships between veterinary medicine and mental health care.”

Substance use among veterinarians is also an understudied area. Veterinary medicine is the only medical profession in the U.S. that does not have a national monitoring program for substance use and mental health issues, she said.

While veterinarians who are dealing with mental health issues may exhibit symptoms common to all populations, such as sadness that interferes with daily activities or changes in appetite, there are a few specific warning signs to watch for in a clinical veterinary setting, according to Goldberg.

“Increased medical errors, absenteeism, client complaints and spending too little or too much time at work,” are factors to watch for, she said. “For potential substance use issues, warning signs could include missing drugs or missing prescription pads.”

Goldberg believes there needs to be a paradigm shift in veterinary training to better prepare veterinarians not only for the animal-related aspects of their jobs, but the human elements as well.

“We need core curricular material that focuses on coping with the emotional demands of the profession. Mindfulness, moral stress, ethics literacy, grief and bereavement, mental health first aid and suicide awareness all have a role in veterinary education” she said. “Colleges of veterinary medicine that have embedded mental health professionals are a step ahead of those that do not, and I would like to see this become a requirement for all schools accredited by the Association of American Veterinary Medical Colleges.”

Fournier’s presentation looked at employees and volunteers in animal shelters or rescues, and animal welfare and animal rights activists, who are at risk for compassion fatigue and psychological distress.

“Animal welfare agents, as these people are often called, are exposed to animal abuse, neglect and oppression on a regular basis, as well as routine euthanasia that is common in these settings,” said Fournier.

Over 2.4 million healthy cats and dogs are euthanized each year in the U.S., most often homeless animals in shelters, according to the Humane Society of the United States.

“Shelter workers are then caught in a dilemma because they are charged with caring for an animal and they may ultimately end that animal’s life,” she said. “Research suggests that this causes significant guilt, which can lead to depression, anxiety and insomnia, as well as greater family-work conflict and low job satisfaction.”

Animal welfare agents may also hear gruesome stories of animal abuse or witness the consequences firsthand when they are rehabilitating the animals, which can cause a lot of distress and lead to compassion fatigue, said Fournier.

“Experts suggest that animal welfare agents carry an even heavier burden than those in other helping professions who are susceptible to compassion fatigue because of the issues unique to working with animals, such as euthanasia and caring for living beings who have experienced pain and suffering but cannot articulate their needs and experiences,” said Fournier.

This shows a vet with a puppy

Fournier suggested that psychotherapists who work with animal welfare agents offer patients strategies to reframe negative experiences, identify ways in which they get fulfillment and gratification from the work they do, and establish healthy boundaries between their work and personal lives.

“There are certainly positive and negative aspects of the job and over time or during times of acute stress, it can be difficult to see the positive,” she said. “It may be necessary to help someone focus on the big picture that overall they are making a difference and animals have been saved, rather than ruminating on individual stories of crisis and loss. Self-care is also critical to ensuring the best mental health outcomes for those who work and volunteer with animals.”

ABOUT THIS NEUROSCIENCE RESEARCH ARTICLE

Source:
APA
Media Contacts: 
Jim Sliwa – APA
Image Source:
The image is in the public domain.

Original Research: Open access
“Suicide among veterinarians in the United States from 1979 through 2015”. Suzanne E. Tomasi DVM, MPH; Ethan D. Fechter-Leggett DVM, MPVM; Nicole T. Edwards MS; Anna D. Reddish DVM; Alex E. Crosby MD, MPH; Randall J. Nett MD, MPH.
Journal of the American Veterinary Medical Association. doi:10.2460/javma.254.1.104

The study will be presented at 2019 American Psychological Association Convention in Chicago.

Abstract

Suicide among veterinarians in the United States from 1979 through 2015

OBJECTIVE To assess proportionate mortality ratios (PMRs) for suicide among male and female US veterinarians from 1979 through 2015.

DESIGN PMR study.

SAMPLE Death records for 11,620 veterinarians.

PROCEDURES Information for veterinarians who died during 1979 through 2015 was obtained from AVMA obituary and life insurance databases and submitted to a centralized database of US death records to obtain underlying causes of death. Decedent data that met records-matching criteria were imported into a software program for calculation of PMRs for suicide stratified by sex and indirectly standardized for age, race, and 5-year calendar period with 95% confidence intervals.

RESULTS 398 deaths resulted from suicide; 326 (82%) decedents were male, 72 (18%) were female, and most (298 [75%]) were ≤ 65 years of age. The PMRs for suicide for all veterinarian decedents (2.1 and 3.5 for males and females, respectively), those in clinical positions (2.2 and 3.4 for males and females, respectively), and those in nonclinical positions (1.8 and 5.0 for males and females, respectively) were significantly higher than for the general US population. Among female veterinarians, the percentage of deaths by suicide was stable from 2000 until the end of the study, but the number of such deaths subjectively increased with each 5-year period.

CONCLUSIONS AND CLINICAL RELEVANCE Results of the study indicated that PMRs for suicide of female as well as male veterinarians were higher than for the general population. These data may help to inform stakeholders in the creation and implementation of suicide prevention strategies designed for veterinarians.

Inflammatory bowel disease in pets

Inflammatory bowel disease in pets can give us  health cues as humans have similar body functions. Pets do not eat sugar, dairies, trans fat, smoke or stress out like we do.
We can start with cleansing and then nourishment. Do drink raw carrots juice with garlic and ginger. Limit refined foods, sugar, alcohol, smoking and unhealthy fats/trans fat. Email motherhealth@gmail.com for personal health coaching.
Connie
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Listen as Dr. Karen Becker discusses the very common problem of IBD in companion animals – how it starts, what to look for, treatment options and how to prevent this miserable disorder in your furry family member.

Dr. Becker’s Comments:

Inflammatory bowel disease (IBD) is a condition of inflammation of the intestines.

There are four common types of IBD, classified by what kind of white blood cells infiltrate the intestine: lymphocytes, plasmacytes, eosinophils and neutrophils. Without a doubt, the most common cause of IBD in pets is lymphocytic-plasmacytic enteritis, gastritis and colitis.

If your pet’s intestines are inflamed long enough, the situation can create a host of other debilitating health conditions.

IBD and Leaky Gut

Both cats and dogs get IBD. Both are susceptible to dysbiosis or ‘leaky gut,’ which means the balance of bad to good intestinal bacteria gets out of whack.

Leaky or permeable gut is a condition in which inflammation weakens the tight junctions of the cells of the GI tract, allowing partially digested proteins and potential allergens to escape into your pet’s bloodstream.

Allergens in the bloodstream trigger a systemic immune reaction – your pet’s body senses foreign invading substances and mounts a powerful defense. The result is allergies or worse – autoimmune or immune-mediated disease. A simple explanation for this condition is that your pet’s body is attacking itself.

IBD Leads to Secondary Infections, Organ Degeneration, Nutritional Deficiencies and Even Cancer

Secondary infections are very common in dogs and cats with inflammatory bowel disease. This is the result of not having a balanced, healthy digestive system.

Over half your pet’s immune function is located in his GI tract, so if the intestines are inflamed and compromised, the immune system is compromised right along with it.

Secondary organ degeneration is common with IBD, especially in the kidneys and liver.

Nutritional deficiencies are also typical in IBD pets because inflammation disrupts the normal absorption and processing of nutrients from food.

With kitties, there’s a correlation between GI cancer (lymphoma of the GI tract) and chronic IBD.

A Common Cause of IBD – GI Parasites

There are a few common causes of inflammatory bowel disease in dogs and cats.

One that is often overlooked is the presence of parasites.

My estimate is the vast majority of puppy mill pets and abandoned/rescued animals left at shelters are positive for parasites – roundworms, hookworms, tapeworms, coccidia, and Giardia. Parasites cause GI inflammation.

Another source for parasite infestation is in litters whose mothers were not tested or treated prior to being bred. Responsible breeders arrange for testing and deworming of females before they are bred, which insures litters will be parasite free.

Less responsible or unknowledgeable breeders don’t take the same precautions and end up selling litter after litter of puppies and kittens that have GI parasites.

The next problem arises at the veterinary clinic, where broad spectrum dewormers are given to infected animals at regular intervals until 16 weeks. At the end of the 16 weeks, the pets are re-checked to see if the parasites are gone.

But here’s the issue: if the specific parasite isn’t identified, it may not be killed by a broad spectrum dewormer. So pets wind up with several weeks of unnecessary medication that doesn’t even solve the problem.

Many dogs I see at my Natural Pet hospital have been dewormed three or four times but are still having problems. When I check fecal samples for these pups, I often find they are coccidia or Giardia-positive. Broad spectrum dewormers don’t take care of these particular parasites. Giardia, for example, causes intermittent diarrhea and chronic low-grade inflammation of the GI tract. It is not responsive to the dewormers most vets prescribe.

A saner, safer approach is for your vet to do at least three fecal analyses one month apart to determine the type of parasite and to confirm your pet is rid of them. Selecting the appropriate dewormer for the type of parasite, and treating the pet until the parasites are completely resolved is a crucial part of decreasing GI inflammation and preventing full-blown IBD.

By the time these unfortunate pups are seen at my practice, they are over 16 weeks old, with intermittent soft stools indicating GI inflammation, and they typically still have a parasite problem which requires treatment before any other symptoms can be resolved.

Another Root Cause – Antibiotics and Steroids

Another of my frustrations is that animals with low-grade GI inflammation are treated with antibiotics by the traditional veterinary community.

Antibiotics are a second common trigger for inflammatory bowel disease.

GI antibiotics kill the healthy bacteria right along with the bad guys. When all bacteria is obliterated from your pet’s gut, the regrowth often results in an imbalance featuring too many gram-negative, unhealthy bacteria or opportunistic yeast and not enough of the friendly variety. This is the definition of dysbiosis.

Now we have a 16+ week old puppy or kitten that has had several weeks of GI inflammation, ineffective deworming treatments, one or two rounds of antibiotics which have obliterated all the bacteria in his GI tract, and no re-seeding of bacteria with an appropriate probiotic to insure a healthy balance.

This little guy is well on his way to low-grade GI inflammation and IBD.

I’ve also seen dogs and cats that at six months of age are already on Prednisone therapy for GI inflammation. Prednisone is an immunosuppressive steroid, which turns the immune system down or completely off, wiping out troublesome symptoms and giving the appearance of a ‘cure.’ Unfortunately, this treatment doesn’t do a thing to uncover the root cause of the GI inflammation and ultimately postpones true healing.

A Third Culprit: Food Intolerance

In my practice I see many pets brought in for intermittent soft-to-watery stools, a situation many pet parents dub ‘sensitive stomach.’

Typically, this ‘sensitive stomach’ means the dog or cat cannot undergo any sort of dietary change without major GI consequences. This isn’t what nature had in mind when it built your favorite furry friend.

Just as you are designed to eat different foods at every meal without GI disturbance, pets with healthy, resilient GI tracts should be able to tolerate changes in the food they eat without negative consequences.

Probably more than half the pet owners I talk to assume it’s normal for their dog or cat to have GI sensitivity to changes in diet. But what’s really going on is the animal’s gut is in some way compromised and therefore cannot withstand dietary variety. It could be a low-grade inflammation that has been present for weeks, months or even years by that time.

Food intolerance or sensitivity can begin with a poor quality, non-species appropriate diet – one that is high in unnecessary carbohydrates. Processed pet food containing a lot of corn, wheat or rice can create inflammation in the gut of your carnivorous dog or cat, designed to digest meat – not grains.

I also have clients that feed a raw, species-appropriate diet without carbohydrates, which is wonderful, except they feed the same protein source for weeks, months or years.

Many animals (including humans) develop hypersensitivity to a food they eat over and over again. Inflammation is the result and can lead to IBD.

So overfeeding too much of even the right foods can lead to problems in the digestive tract.

Testing for IBD

There are two different diagnostic tests that are commonly done to detect IBD.

One test is what is known as a ‘confirming’ test, in which a biopsy is taken to assess morphologic characteristics common in the GI tracts of animals with inflammatory bowel disease. This is not my first choice because it’s expensive, invasive and involves anesthesia and the inherent risks that come with it.

The other test, which I use often in my practice, is a functional gastrointestinal test using a blood sample.

What we’re looking for with this test is two types of B vitamin absorption, the first of which is folate. Folate is a water-soluble B vitamin that is not easily absorbed in the small intestine unless it is deconjugated there.

If your pet’s small intestine can’t deconjugate folate, meaning it can’t break it down into an absorbable form, she can end up folate-deficient, in which case her blood test will show low or suboptimal levels of folate.

A low folate level means either your pet’s assimilation and absorption of nutrients is poor, or her body is challenged by the deconjugation process, indicating a disease or disorder of the small intestine.

If your pet’s folate is high rather than low, it indicates another type of problem. Your pet’s small intestine contains a small amount of bacteria critical for the production and assimilation of certain B vitamins. If this bacteria blooms into an overgrowth, your pet can wind up with high folate levels and a condition known as SIBO – Small Intestinal Bacterial Overgrowth.

The second blood test I use to assess GI function involves another B vitamin called cobalamin, which is bound to protein.

Cobalamin is released from protein through a complex series of events that starts in the stomach and finishes in the small intestine.

If cobalamin levels are low, we can assume this complex process is not occurring optimally. Cobalamin levels are a measure of digestion. This condition of maldigestion can sometimes also involve the pancreas. The disorder is called EPI – Exocrine Pancreatic Insufficiency and can be diagnosed via another GI blood test called a TLI (Trypsin-like Immunoreactivity).

If you suspect your pet has IBD but you’re not interested in doing a biopsy at this point, ask your vet to perform functional GI testing to determine a diagnosis.

In my practice, I also do two additional functional tests, TLI and PLI, which assess pancreatic function. Secondary pancreatitis is a very common condition in IBD patients, so assessing your dog’s or cat’s pancreatic function is also important.

These functional GI tests are available through the gastrointestinal lab at Texas A&M University.

Dietary Recommendations for IBD

Upon diagnosis, your veterinarian will probably tell you to feed a bland diet if your pet is symptomatic with vomiting, diarrhea or soft stool with mucus and/or blood.

My idea of a bland diet is different from a traditional veterinarian’s. I recommend ground cooked turkey and canned pumpkin or cooked sweet potato. I don’t recommend the traditional beef and rice. Beef is high in fat, which can exacerbate GI inflammation and pancreatitis.

Rice is a complex carb which can be fermented in the GI tract, causing gas, which can lead to additional digestive upset.

I recommend a grain-free, bland diet because in my experience it’s more suitable to pets with active symptoms of IBD.

While feeding your dog or cat a bland diet, you should be thinking about what’s next for her in terms of nutritional requirements. Bland is fine for a short time, but balance in the diet is crucial

I recommend you work with an integrative veterinarian to select a novel protein source — one your pet has either never consumed or hasn’t for a long while. This will give the GI tract and your pet’s immune system a good rest.

You’ll also want to select a novel vegetable or fiber source as well, to create an anti-inflammatory menu that will facilitate healing within both the large and small intestine.

An integrative vet can help you build a comprehensive protocol for your pet that addresses not only dietary issues, but also vaccinations, the use of drug therapy, and any potential toxins in your pet’s environment or lifestyle that could be contributing to unaddressed inflammation.


Connie’s notes: We start with cleansing and then nourishment. Do drink raw carrots juice with garlic and ginger. Limit refined foods, sugar, alcohol, smoking and unhealthy fats/trans fat. Email motherhealth@gmail.com for personal health coaching.

https://www.pxscanner.com/content/microsites/pxscanner/en_US/purchase/01103891.html

NANO CARROT

Their pets are their lifeline, giving them hope and will to live

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A young boy who had stunted growth, anorexic teen and army vet fighting depression, all of them survived and lived a happy life with the help of their pets.

Many more stories of pets helping their human friends survive the most difficult part of their lives can be seen every day and every where.

The power of love from animals and humans propels us to live happy lives.

We are uplifted each day we know that someone or some thing care for us.

Let us share more love to other humans and animals. We are all created equally.  With the gift of will to the humans, we should be role models to our animal friends.

Oregano essential oil for ringworm by Case Adams

Ask any veterinarian: Ringworm is one of those infections considered to have no conventional cure. When cats are infected, they may be cleaned and washed and hopefully will repel the infection over time, but there is no known cure for the infection among conventional veterinarians.

In humans, applying antifungals repeatedly over months and months can effect a removal of the infection – but these will often take time. In some cases, powerful prescription antifungals are necessary, and they usually work, but they have been shown to exert considerable toxicity and possible resistance over time, and for these reasons the European Community has banned the use of most ringworm antifungals on sheep and other farm animals.

Over-the-counter antifungal creams advertised as useful for combating the infection also tend to be often ineffective, depending upon the species of infection. Whether this is because the Microsporum canis or Trichophyton mentagrophytes fungi – which produce dermatophytoses that infect the cells – have become resistant remains to be fully understood.

What is known by most veterinarians is that ringworm infections are so difficult to treat that they will often refuse to allow ringworm-infected animals into their clinics or treatment areas.

Does Nature provide Antifungals?

Yet researchers from the University of Pisa have found that certain essential oils can effectively treat and largely cure the ringworm infection. In one study they applied a mixture of essential oils to seven cats infected with ringworm. The mixture cured four of the seven cats completely and the others showed improvement.

The mixture was composed of 5% essential oil of Oregano (O. vulgare), 5% essential oil of Rosemary (R. officinalis) and 2% essential oil of Wild Thyme (Thymus serpyllum) – in a base of sweet almond oil.

The researchers also tested a number of essential oils against no less than eleven different isolated species of ringworm. They found that Wild Thyme and Oregano show the most inhibition of the ringworm fungi. Star anise (Illicium verum), Rosemary and lemon oil (Citrus limon) closely trailed those oils in their ability to stop the infection.

A more recent study at the University of Pisa studied the same essential oils for ringworm infections occurring in sheep – infected by Trichophyton mentagrophytes. The researchers applied the same combination of oils described above onto 13 ringworm-infected sheep. They applied the oil combination twice a day for 15 days. Seven untreated sheep acted as controls.

The mixture was successful in treating all of the infected sheep given the essential oil blend, while the infection among the control animals continued.

Other Studies Confirm These Oils’ Antifungal Actions

Other research has found that Oregano and Wild Thyme have antifungal effects in other areas. A number of studies have found Oregano and Rosemary oils useful in eliminating aflatoxins from harvested fruits and grains.

A species related to Wild Thyme – Thymus broussonetii – was found to inhibit candida in a study from Morroco’s University of Cadi Ayyad.

And In vitro and In vivo tests from Pakistan’s University of Karachi found that Oregano can inhibit urinary tract infections – many of which are fungal in nature.

Mother Nature’s Formulary

Thyme and Oregano share potent antifungal constituents, particularly thymol, which has been isolated and utilized as an antifungal in conventional medicines. Oregano oil contains from
40 to 64% thymol.

Natural Oregano oil was found in a 2012 assay to also contain p-cymene, terpinene, bicyclogermacrene, terpinen-4-ol, α-pinene, octenol, α-terpinene, carvacrol, β-caryophyllene, β-myrcene, terpinenol, octanol, β-pinene, cineole, α-cubebene and β-ocimene. How is that for one of Mother Nature’s recipes!

REFERENCES:

Mugnaini L, Nardoni S, Pistelli L, Leonardi M, Giuliotti L, Benvenuti MN, Pisseri F, Mancianti F. A herbal antifungal formulation of Thymus serpillum, Origanum vulgare and Rosmarinus officinalis for treating ovine dermatophytosis due to Trichophyton mentagrophytes. Mycoses. 2013 May;56(3):333-7.

Mugnaini L, Nardoni S, Pinto L, Pistelli L, Leonardi M, Pisseri F, Mancianti F. In vitro and in vivo antifungal activity of some essential oils against feline isolates of Microsporum canis. J Mycol Med. 2012 Jun;22(2):179-84.

de Sousa LL, de Andrade SC, Athayde AJ, de Oliveira CE, de Sales CV, Madruga MS, de Souza EL. Efficacy of Origanum vulgare L. and Rosmarinus officinalis L. essential oils in combination to control postharvest pathogenic Aspergilli and autochthonous mycoflora in Vitis labrusca L. (table grapes). Int J Food Microbiol. 2013 Jun 10;165(3):312-318.

Jamali CA, El Bouzidi L, Bekkouche K, Lahcen H, Markouk M, Wohlmuth H, Leach D, Abbad A. Chemical composition and antioxidant and anticandidal activities of essential oils from different wild Moroccan Thymus species. Chem Biodivers. 2012 Jun;9(6):1188-97.

Khan A, Bashir S, Khan SR, Gilani AH. Antiurolithic activity of Origanum vulgare is mediated through multiple pathways. BMC Complement Altern Med. 2011 Oct 17;11:96.

Portillo-Ruiz MC, Sánchez RA, Ramos SV, Muñoz JV, Nevárez-Moorillón GV. Antifungal effect of Mexican oregano (Lippia berlandieri Schauer) essential oil on a wheat flour-based medium. J Food Sci. 2012 Aug;77(8):M441-5.

Kloucek P, Smid J, Flesar J, Havlik J, Titera D, Rada V, Drabek O, Kokoska L. In vitro inhibitory activity of essential oil vapors against Ascosphaera apis. Nat Prod Commun. 2012 Feb;7(2):253-6.

Avila-Sosa R, Palou E, Jiménez Munguía MT, Nevárez-Moorillón GV, Navarro Cruz AR, López-Malo A. Antifungal activity by vapor contact of essential oils added to amaranth, chitosan, or starch edible films. Int J Food Microbiol. 2012 Feb 1;153(1-2):66-72.

Gómez-Sánchez A, Palou E, López-Malo A. Antifungal activity evaluation of Mexican oregano (Lippia berlandieri Schauer) essential oil on the growth of Aspergillus flavus by gaseous contact. J Food Prot. 2011 Dec;74(12):2192-8.

Verma RS, Padalia RC, Chauhan A. Volatile constituents of Origanum vulgare L., ‘thymol’ chemotype: variability in North India during plant ontogeny. Nat Prod Res. 2012;26(14):1358-62.

Missopolinou D, Tsioptsias C, Lambrou C, Panayiotou C. Selective extraction of oxygenated compounds from oregano with sub-critical water. J Sci Food Agric. 2012 Mar 15;92(4):814-20.

Bisht D, Pal A, Chanotiya CS, Mishra D, Pandey KN. Terpenoid composition and antifungal activity of three commercially important essential oils against Aspergillus flavus and Aspergillus niger. Nat Prod Res. 2011 Dec;25(20):1993-8.

Lazar-Baker EE, Hetherington SD, Ku VV, Newman SM. Evaluation of commercial essential oil samples on the growth of postharvest pathogen Monilinia fructicola (G. Winter) Honey. Lett Appl Microbiol. 2011 Jan 19.