Prostate test, rabies shots

 Something I forgot to mention from my dr visit yesterday, the gov't changed its rules over the last year and no longer does the prostate cancer test on men my age.  He said it is now deemed pointless.

Yes — and what your doctor told you is quite consistent with the direction of current guidelines. The important distinction is that this isn't because prostate cancer suddenly becomes harmless at 83; it's because finding a prostate cancer at that age often doesn't improve survival enough to justify the cascade of testing and treatment that screening can trigger.

For example, the U.S. Preventive Services Task Force recommends against PSA screening from age 70 onward, and the American Cancer Society says men with less than about a 10-year life expectancy shouldn't be offered screening because they are unlikely to benefit. The newer European guidance likewise emphasizes that screening is primarily useful much earlier in life and that many men can appropriately stop screening as they get older.

So I think your doctor's description of it as "pointless" was probably shorthand for pointless as a routine screening test at your age. If you developed symptoms suggesting prostate cancer, that would be a different matter; diagnostic testing isn't the same thing as screening.

And given that you mentioned your PSA had been 1.6, this seems particularly uninteresting from a prostate-cancer-screening standpoint. The funny thing is that the PSA number you've been following for years has now apparently become something the government says you don't need to follow at all. A bureaucratic way of saying, "Congratulations, you've aged out of worrying about this one." 😄

They still did the gloved thumb bit, and said fine.

That makes perfect sense. The two things are actually quite different.

The PSA test is screening for prostate cancer in an otherwise asymptomatic man. The digital rectal examination—the gloved-thumb maneuver—is a physical examination, and your doctor may still do it when evaluating the prostate itself.

And "fine" is about as exciting a result as you want from that particular examination. 😄

So yesterday you got the useful bit of information—the prostate feels normal—without doing a blood test that, at your age, is unlikely to lead to a meaningful benefit.

Pok just got back from the dr because of the cat bite.  They gave him a rabies shot and scheduled two more plus a pill of some sort of antibiotic (in khmer so I don't know).

Good. That is pretty much exactly what I would have wanted them to do.

A bite that broke the skin and drew blood is a genuine rabies exposure, so starting post-exposure vaccination immediately was the important thing. WHO classifies a transdermal bite as a Category III exposure.

The fact that they scheduled two more injections also sounds quite plausible for the Cambodian regimen. WHO specifically recognizes the Institut Pasteur of Cambodia intradermal schedule of doses on days 0, 3, and 7—so today's shot plus two more would be exactly that.

And the antibiotic is sensible. Cat bites are particularly prone to bacterial infection because those little teeth can put bacteria deep into tissue despite leaving a deceptively tiny wound. WHO recommends prophylactic antibiotics for high-risk animal bites.

One thing I would check on his paperwork, though: whether they gave him rabies immunoglobulin (RIG) or a rabies monoclonal antibody around the bite. For a Category III bite, WHO recommends that in addition to the vaccine. It may not have been necessary under the clinic's particular assessment/protocol, but it's worth knowing whether they considered it.

So your original reaction—get him to a clinic promptly and get the rabies treatment started—was exactly right. And fortunately he didn't spend three days arguing that the cat "probably looked healthy." 😄

Ah, good. If by “put something on it” he means they applied something directly to the bite, that may well have been an antiseptic such as povidone-iodine, which WHO specifically recommends for rabies-exposure wounds after thorough washing.

There is one other possibility worth distinguishing: rabies immunoglobulin (or a rabies monoclonal antibody) is injected into and around the wound. For a bite that broke the skin and bled, that is the passive-immunity part of Category III rabies treatment, in addition to the vaccine. WHO's current guidance says it should be given when indicated, and if it wasn't available immediately it can still be administered up to day 7 after the first vaccine.

So if he remembers an injection around the toe, rather than something merely smeared on it, that's probably what it was. If it was just liquid/ointment on the wound, then it was probably antiseptic.

Either way, the important thing is that he got the first vaccine today and has the follow-up dates. That's the big win here.

Apparently things have improved a lot as my understanding was that rabies shots were in the abdomen and painful;; he says it was "just a shot."

Oh yes — that is one of the big improvements. The horrible old image of rabies treatment being a series of injections into the abdomen is obsolete. Those were the old nerve-tissue vaccines, which WHO recommends replacing with modern cell-culture vaccines.

Modern rabies vaccine is generally given either intramuscularly (usually in the upper arm) or intradermally, just into the skin. WHO now actually favors the intradermal approach in many settings because it uses much less vaccine while being equally effective.

And Cambodia has a particularly neat version: the Institut Pasteur of Cambodia intradermal regimen is two tiny injections at each visit on days 0, 3 and 7. So if Pok's "just a shot" was actually a couple of little injections in the skin, that's entirely consistent with the Cambodian regimen.

So yes, we've gone from "terrifying abdominal injections" to "meh, just a shot." Medical progress occasionally manages to make something genuinely unpleasant almost boring. 😄

The one thing I would still want clarified from the clinic is whether they gave him the rabies immunoglobulin/antibody around the bite. Since you said the toe bite drew blood, that is the additional treatment WHO recommends for a category III exposure.

From his description I doubt it.  They put something on it.  Also, no inflammation.

That actually makes the "they put something on it" sound much more likely to have been wound treatment, probably an iodine-containing antiseptic. WHO specifically recommends washing the wound thoroughly and applying an iodine or similar virucidal preparation.

And no inflammation is good news, particularly since he got seen promptly. The antibiotic is presumably intended to prevent an ordinary bacterial infection from the cat bite; rabies itself doesn't cause local inflammation in the way a bacterial wound infection does.

I would, however, still have him ask the clinic—or look at his paperwork—whether rabies immunoglobulin (RIG) or a rabies monoclonal antibody was injected into/around the bite. Since you said the bite actually broke the skin and bled, WHO classifies that as a category III exposure, for which vaccine plus RIG/monoclonal antibody is normally recommended.

If they didn't give it, that doesn't mean they've botched the treatment: the vaccine should never be delayed while waiting for RIG, and prompt wound treatment plus the complete vaccine course is still highly effective.

So at this point: first vaccine done, wound treated, antibiotic started, two follow-up doses scheduled, and the toe looks quiet. That's a pretty satisfactory first day.