Early diagnosis saves life in flesh-eating disease

Coconino National Forest in Arizona. (Dr. Noorali Bharwani)
Coconino National Forest in Arizona. (Dr. Noorali Bharwani)

Recently, an Edmonton lady was diagnosed with flesh-eating disease while on a holiday in Mexico. Media reports say the lady underwent three surgeries to remove the dead tissues secondary to the infection. The good news is she survived and is now back in Canada.

Medically speaking, this condition is known as necrotizing fasciitis. It is not a new disease. It is often called flesh-eating disease because it kills muscle and skin as it spreads through the tissue.

In Canada, in 1954, the famous case of flesh-eating disease was Loucien Bouchard, the former premier of Quebec. He luckily survived and had to have one leg amputated.

It is an uncommon, rapidly progressive and life-threatening infection that requires urgent diagnosis and medical and surgical treatment. Fortunately, the disease is not that common. In Canada, it is estimated 90 to 200 cases of necrotizing fasciitis occur each year. And, unfortunately, approximately 20 to 30 per cent of these cases lead to death. From time to time the disease hits the headlines. Then there is a long silence before another case is reported. This leaves people wondering what is this all about.

The term flesh-eating refers to the toxins produced by a bacterial infection that can destroy muscles, skin and fatty tissues. The infection spreads rapidly. It progressively destroys fat, fascia and muscles. Shock and multi-organ failure are common.

The flesh-eating infections have been described as early as the fifth century B.C. during the time of Hippocrates. More than 2,000 cases of this condition were reported among soldiers during the Civil War.

In 1871, the same disease was recorded by Dr. Joseph Jones, who was an army surgeon for the Confederate Army (in the American Civil War). He called it ‘hospital gangrene’, and 46 per cent of his patients who suffered the condition died.

Who is susceptible to the infection?

Certain illnesses can make people prone to this infection: diabetes mellitus, intravenous drug users and those who are immunocompromised. However, these infections can arise in people who are healthy.

What kind of organisms are involved?

Streptococci (invasive group A hemolytic streptococci) may act alone or in combination with other bacteria.

The most common sites of infection are perineal and groin areas and post-surgical wounds. Infection around the umbilicus in a new born can be life-threatening. Infection can occur in the trunk and the limbs.

What are the signs and symptoms?

Pain, warmth, skin redness, or swelling at a wound, especially if the redness is spreading rapidly. Skin blisters, sometimes with a “crackling” sensation under the skin. Pain from a skin wound that also has signs of a more severe infection, such as chills and fever. Grayish, smelly liquid draining from the wound would suggest the diagnosis.


For diagnosis, it is important to be clinically alert to the condition. Early expert advice when necrotizing fasciitis is suspected should be considered. But early diagnosis of this condition is not always easy. If the diagnosis is in doubt, then surgical exploration is the best way to go.

Here are four key points from the Canadian Medical Association Journal (CMAJ May 23, 2017):

  1. Necrotizing fasciitis can occur in otherwise healthy individuals.
  2. Treatment involves emergency debridement in the operating theatre, broad spectrum antimicrobial drugs, local wound care and eventual free flap reconstruction.
  3. If the diagnosis is not clear, it is important to reassess the patient frequently and seek early expert advice in suspected cases.
  4. Imaging examination is ancillary and should never delay surgical treatment of necrotizing fasciitis.

(Ref: Necrotizing fasciitis after scalpel injury sustained during postmortem examination. Michal Brichacek, Robert Strazar, Kenneth A Murray and Avinash Islur CMAJ May 23, 2017 189 (20))

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My New Year’s wish – better mental and physical health for all.

Canmore, Alberta. (Dr. Noorali Bharwani)
Canmore, Alberta. (Dr. Noorali Bharwani)

“Many years ago, I made a New Year’s resolution to never make New Year’s resolutions. Hell, it’s been the only resolution I’ve ever kept!”
― D.S. Mixell, writer

I hope you had a good holiday season and New Year. Now back to the real world!

Do you believe in making New Year’s resolutions?

In all honesty, I cannot say I have never made any New Year’s resolutions. But after failing to keep any or some of my wishes I quit making them.

One of the common resolutions is to be healthy by eating the right stuff and exercising regularly. But how many people can stick to this? A 2007 study by Richard Wiseman from the University of Bristol involving 3,000 people showed failure rate to be 88 per cent. This is because the goals are too ambitious. Secret to success is to apply the KISS principle (Keep It Simple Stupid). (REF: richardwiseman.com/quirkology/new/USA/Experiment_resolution.shtml).

Most of the resolutions are usually about eating healthy, losing weight and to be happy.

Canadians are suffering from significant mental and physical health. Combine this with overworked, stressed-out doctors, nurses and other health care professionals, the situation is grim.

Canadians agree this is an unacceptable situation.

According Statistics Canada, percentage of Canadians who perceived their health as very good or excellent from 2003 to 2021 was 60 per cent. That means 40 per cent of Canadians are not in good health. A 2022 survey found 63 per cent of Canadians said lack of staff was the biggest problem facing the national healthcare system. Access to treatment and/or long waiting times were also considered to be pressing issues. By the time Canadians reach 40 years of age, one in two have – or have had – a mental illness.

More Canadians are feeling lonely and anxious. In the last one-year, greater proportion of Canadians were suffering from major depressive disorder.

Depression and anxiety disorders are among the most common types of mental disorders in Canada and have been shown to have a major impact on the daily lives of those affected. Access to mental healthcare across Canada is poor. Only one in five people with depression get appropriate treatment.

Can we fix our health care problems?

There are two issues: funding and human resources. If we have the money then we can train and recruit more doctors, nurses and other health care professionals. Before that happens, the provincial and federal governments have to stop arguing. We don’t know when that is going to happen. In the meantime, Canadians will have to suffer unless we take care of our health ourselves.

You can make three New Year’s resolutions: eat healthy, avoid loneliness and enjoy life.

Positive affective well-being (i.e., feelings of happiness and enjoyment) has been associated with longer survival and reduced incidence of serious illness. A study published in the Canadian Medical Association Journal (2014) shows the degree of enjoyment of life remained an important predictor of future functionality, indicating the power of positive outlook on life. (REF: Enjoyment of life and declining physical function at older ages: a longitudinal cohort study – CMAJ 2014. DOI:10.1503).

There is enough evidence to show enjoyment of life is relevant to the future disability and mobility of older people. Efforts to enhance wellbeing at older ages may have benefits to society and health care systems.

Happy New Year and have a wonderful healthy 2023. We hope, 2023 will bring better mental and physical health for all.

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Is weight-loss surgery the best way to manage obesity?

Rosedale Suspension Bridge in Rosedale, AB. (Dr. Noorali Bharwani)
Rosedale Suspension Bridge in Rosedale, AB. (Dr. Noorali Bharwani)

Much has been written and discussed about obesity but we are nowhere close to solving the problem. In fact, the problem is getting worse.

Many factors can contribute to excess weight gain including genetics, a person’s eating pattern, physical inactivity, and sleep routines.

A person whose BMI (body mass index) is greater than or equal to 25 is considered overweight.

A person whose BMI is greater than or equal to 30 is considered obese.

Why non-surgical methods of managing obesity have failed?

As we know to lose weight one has to eat less, eat healthy and exercise regularly. But due to various reasons most people are unable to follow this rule. Those who religiously follow the rules do succeed in losing weight. But the success doesn’t last for too long. Old habits die hard.

In 2003, a study published in the Journal of the American Medical Association found that if you can get people to reduce how much food they eat by about 25 per cent, and you get them to do at least 30 to 40 minutes of exercise five days a week, you can achieve a weight loss of nine per cent. This means a 200-pound person could lose about 20 pounds and successfully maintain it for at least a year. We don’t know how many people maintain this after one year.

Is weight-loss surgery the answer?

Surgery for obesity is called bariatric surgery (from the Greek words “baros,” meaning weight, and “iatrikos,” meaning medicine).

The first weight-loss surgery performed was a gastric bypass surgery in 1954 by Dr. A.J. Kremen. Over the past 65-years, many medical advances in bariatric surgery have occurred. In the last 25-years, the procedure has gained popularity with patients.

Following bariatric surgery, patients lose about 62 to 70 per cent of excess weight and maintain this loss for more than five years. However, this can also result in nutritional and vitamin deficiencies.

Bariatric surgery can have significant health benefits in addition to weight loss, including improvement in cardiovascular risk factors, fatty liver disease, diabetes management, and reduction in mortality.

A recent study published in the Canadian Journal of Surgery (Five-year outcomes after surgery for class 1 obesity: a retrospective analysis of a Canadian bariatric centre’s experience, by Studer et al, November 16, 2022) concludes bariatric surgery for class 1 obesity was safe and had long-term efficacy, with remission or reduction of related comorbidities. Class 1 obesity is a person with BMI of 30 to <35.

“Our results show that bariatric/metabolic surgery has long-term efficacy, with reduction or remission of related comorbidities, and is an effective treatment modality for patients with class 1 obesity,” says the article. This was a retrospective chart review of patients with class 1 obesity who underwent different types of gastric bypass surgeries.

The authors conclude that bariatric surgery is safe treatment modality for class 1 obesity, with an acceptably low postoperative morbidity rate of 2.7 per cent and no deaths.

Weight-loss success after surgery depends on individual’s commitment to making lifelong changes in eating and exercise habits. This requirement is same if one decides not to have surgery. Post-op complications are rare but can be serious like pulmonary embolism, anastomotic leaks or respiratory failure. A person may experience dumping syndrome, low blood sugar, malnutrition, vomiting and bowel obstruction.

All surgical procedures have advantages and likely complications. A person with obesity with medical issues has a choice and decision to make. Long-term success depends on one’s ability to follow guidelines for diet, exercise and lifestyle changes.

Is bariatric surgery the best way to manage obesity? Bariatric surgery is not a cure for obesity but rather a tool to help one lose weight.

The other option is to reduce daily diet by 25 per cent and do 30 minutes of exercise five days a week. Worth trying!

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Is it possible to control sugar consumption?

Ice cream and fried bananas. (Dr. Noorali Bharwani)
Ice cream and fried bananas. (Dr. Noorali Bharwani)

I call sugar a sweet slow poison, a weapon of mass destruction. We use the poison on ourselves, our families and our friends, but not on our enemies.

It is reported the North American diet contains about 20 per cent sugar. This is equivalent to 30 teaspoons a day! Most of it is hidden in different kinds of juices and food. The major sources of added sugars are in beverages, desserts, sweet snacks, sweetened coffee, sweetened tea and candy.

Like alcohol, sugar has no nutritional value. It has no vitamins, minerals or fiber.

North American children’s consumption of sugar per day is reported to be between 25 to 35 per cent of total calories. The World Health Organization recommends daily dietary sugar intake of no more than 10 per cent of total calories.

Consumption of excess sugar raises blood pressure and makes us overweight. Our risk of becoming diabetic increases and it damages our liver by causing fatty liver. There is increased risk for heart attack and stroke.

Several provinces in Canada have imposed extra tax on sweetened beverages. A new tax on sugary drinks sold in Newfoundland and Labrador has come into effect since September. This is Canada’s first per litre sugar sweetened beverage tax.

In Ontario, anyone who buys sugar-sweetened beverages including energy drinks, iced teas and pop will pay an extra 20 cents per litre in sales tax. Quebec has some laws as well. Around the world about 40 nations have imposed beverage tax.

Should Canada have nationwide beverage tax?

A new University of Alberta study suggests Canada could save $2.5 billion a year if everyone followed international guidelines for sugar intake. That would mean eating the equivalent of 2.2 Kit-Kats of sugar a day instead of our current three (The economic burden of excessive sugar consumption in Canada: should the scope of preventive action be broadened? By Liu et al Canadian Journal of Public Health volume 113, pages 331–340, 2022).

The article suggests increasing tax on sweetened beverages is not going to solve the problem. It says, “Public health interventions to reduce sugar consumption should therefore consider going beyond taxation of sugar-sweetened beverages to target a broader set of products, in order to more effectively reduce the public health and economic burden of chronic diseases.”

Is this possible? Sugar is hidden (for taste and preservation) in so many products that it makes the task of controlling sugar consumption almost humanly impossible. Just like controlling smoking, alcohol consumption, drug abuse, over-eating and obesity.

What’s the solution? Self-control is the only way. Here is a collection of some ideas. There is nothing new in the list. These are the things we all think about and talk about but forget to implement.

  1. Eat a healthy balanced diet with lots of fruits, vegetables, whole grains and proteins.
  2. Replace juice and sweetened drinks with sugar free options.
  3. Do not give kids pop or juice outside of meal times (stick with water).
  4. Check nutrition labels.
  5. Government should tax all sugar-containing foods and use the funds to promote healthy eating and good health.

Sugar is one temptation we should do without! Do you think taxing sugar containing drinks and foods will change much?

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