Animal Bites

“When your best friend bites…” is title of an article in the Canadian Journal of Infectious Diseases (CJID). It’s not about human friends who bite but it is about animal friends – dogs and cats.

Dogs and cats are very important to millions of Canadians. It is estimated that there are more than 100 million cats and dogs owned as pets in Canada and the United States. Do these domesticated animals bite? Of course, they do! I know it and many of you have been victims of these domesticated animals. In fact, one to two million dog bites are reported in both countries every year.

The CJID article says that up to 85 percent of dog and cat bites are caused by the victims’ family pet or by a neighbour’s pet. About half of these bites are considered to have been provoked. And 5 to 9 year old males sustain dog bites most frequently. So, let us not blame our animal friends for all the injuries.

And injuries are many. According to the Canadian Injury Reporting and Prevention Program, injuries related to dog bites account for one percent of all visits to hospital emergency departments.

These injuries are more serious in children than in adults. Children are more likely to be bitten on the face, neck and head in upto 70 percent of cases. Children account for the majority of the 10 to 20 deaths from animal bites that occur annually in the United States, says the CJID article.

Is this acceptable? Can we reduce the injury rate? After all, dogs are our best friends!

We should encourage dog owners to take responsibilities with regard to training their pets. This should include discouraging aggressive behaviour when animals are young, says the article. We should teach our children and adults about the risks involved in provoking dogs and other animals. Should we certify certain breeds as being dangerous and not fit to be pets? This is debatable.

What is the appropriate treatment for dog and cat bites?

Your physician will enquire about the status of tetanus immunization and give you a booster dose. He will assess the risk of rabies and arrange appropriate prophylaxis. The wound will require cleaning with removal of dead and dirty tissue. You may require prophylactic antibiotics.

The immunization status of the animal in question should be checked. The local animal control agency should be notified so that they can quarantine the animal and keep it under observation for up to 10 days to see whether clinical symptoms develop, says the author of the CJ ID article.

Dogs and cats can be dangerous. They can be lot of fun as well. Especially for children. But we have to be careful. We do not want fun to turn into fatality.

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Washing Hands

How many times have we seen people walk out of public washrooms without washing hands?

How many times have we seen restaurant servers wipe tables with wet cloth and then take orders without washing hands? Do we know what is going on in the kitchen? How clean are those counters at fast food restaurants where they make and dispense sandwiches? What are the hand washing habits of these servers?

What about the health care workers? Do they wash their hands after examining each patient?

In 1996, the American Society of Microbiology (ASM), did a telephone survey of 7000 Americans, 94 percent said they always washed their hands after using the toilet. But researchers, observing actual behaviour in public washrooms in five cities, found that wasn’t the case. Only 68 percent washed their hands!

A study conducted this year by ASM showed similar results. So ASM’s campaign to improve hand washing habits of Americans has not changed much among men or women, although more women tend to wash their hands than men. It is a question of instilling permanent behavioural change. And that is not always easy. So, this year’s ASM campaign slogan (DON’T GET CAUGHT DIRTY HANDED!) is to keep reinforcing this behaviour (

What about the health professionals? Are they any better? An editorial in the British Medical Journal says, “Many studies have confirmed that doctors decontaminating their hands between seeing patients can reduce hospital infection rates. Nevertheless, healthcare workers still fail to wash their hands and fail to appreciate the importance of doing so.”

In one study, 50 to 95 percent of physicians reported washing their hands before patient contact. But this contrasted sharply with the observed frequency of just 9 percent! The editorial says that role models are important in hospital practice. Junior doctors washed their hands more often when senior doctors set an example. Poor practice habits are also picked up at patient bedside. Junior staff stop washing hands when they see senior staff do not bother to keep their hands clean!

About 150 years ago, it was found that if doctors performing autopsies washed their hands before delivering babies, then they could reduce mortality due to post delivery infection of the uterus from 22 to 3 per cent.

What about the people working in cattle industry? Health Canada says that failure to carefully wash hands after working around and with cattle can lead to infection with a type of E. coli bacteria. The resulting illness occasionally causes kidney failure and in rare cases, death.

These bacteria cause “hamburger disease” with symptoms of stomach cramps and bloody diarrhoea appearing two to eight days later. These symptoms last 7 to 10 days. In Canada, five cases of hamburger disease per 100,000 people were reported in 1995. In some cases, especially among people with immature or weakened immune systems, such as children or the elderly, infection with this bacteria leads to kidney failure.

So, if your mother tells you to wash your hands before meals then she is right. Hand washing is one of the most important means of preventing the spread of infection. Hand washing should be regarded as part of the normal duty of care. DON’T GET CAUGHT DIRTY HANDED!

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Stomach Bugs 2

Mr. Bugged is still worried about the bugs that have been bugging his stomach. As you may remember, the last column was bugged with H. pylori bacterium in response to a question from Mr. Bugged. But Mr. Bugged feels that the column did not completely answer his question. He is not sure if the debugging process was medically indicated in his case and whether it has worked.

Mr. Bugged is having sleepless nights worrying about these bugs. He thinks that the bugs, in the middle of the night, crawl up his oesophagus and have a late night party in his mouth. Well, Mr Bugged, let me assure you that nothing like that has been reported in the scientific literature.

Mr. Bugged says that his stomach rumbles every time he has a meal. He wonders if the bugs are eating away his food. Starving him of essential nutrients. Again, this is not true.

The last column said that H. pylori should be treated if only a person is proven to have an ulcer in the stomach or duodenum. But Mr. Bugged did not have an ulcer. Mr. Bugged is upset with his doctor. The doctor had given him two antibiotics and an acid suppressing expensive drug. Mr. Bugged’s diagnosis? Non-ulcer dyspepsia with H. pylori infection.

Was Mr. Bugged’s doctor wrong? Not really. Mr. Bugged, your doctor must have carefully assessed your symptoms and findings before prescribing the medications. Let me explain the term non-ulcer dyspepsia and the controversy surrounding the treatment of this condition when associated with H. pylori infection.

The term “dyspepsia” is derived from the Greek word dys (bad) and pepsis (digestion). Symptoms of dyspepsia include upper abdominal pain, discomfort, early satiety, bloating, nausea and vomiting. About 30 percent of the population suffers from this but only 20 percent of them seek medical help.

The question is – is H. pylori the cause of dyspepsia? No, the jury is still out on that. Then why treat H. pylori in patients who have no ulcer? This is controversial.

A review article, published in the New England Journal of Medicine, November 1988, says that in 8 of 16 studies, the eradication of H. pylori significantly improved symptoms in patients with non-ulcer dyspepsia. And a recent review article (September 16) in the British Medical Journal says that H. pylori eradication treatment was significantly superior to placebo in treating non-ulcer dyspepsia, one case of dyspepsia being cured for every 15 people treated. Is this a good reason to prescribe medications to get rid of H. pylori in patients with no ulcer? Depends on individual cases.

So, Mr. Bugged, if your symptoms have disappeared after the treatment then your doctor was right. If not, then atleast he tried as long as he explained to you his reasons.
So have a good sleep and enjoy your meals. One day, hopefully, we will have an answer for you.

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Stomach Bugs

Dear Dr. B: My doctor says I have bugs in my stomach. He gave me antibiotics to kill the bugs. Can you please tell me more about these bugs? Where do they come from? How did I get them? Will I pass them to my family? What are my chances of getting them again? Yours, Mr. Bugged!

Dear Mr. Bugged: The bug (bacterium) is called Helicobacter Pylori (H. pylori). The discovery of this bacterium in 1982 has changed how we think about ulcers and non-ulcer symptoms of the stomach and duodenum. Despite significant research and advances in understanding this organism, its cause remains poorly understood.

Let us start with a short history. Once upon a time, most ulcers in the stomach and duodenum were thought to be due to acid produced by the stomach. For more than hundred years, thousands (could be millions) of people all over the world underwent surgery to reduce acid in the stomach, to get rid of the ulcers and prevent their recurrence.

The results of these surgeries (there were variety of them) were not always satisfactory. There were numerous complications and side effects. There were many unhappy patients and surgeons. Then, we saw some newer drugs come in the market to reduce the acid in the stomach. This was 25 years ago. It started with tagamet and now we have a variety of them, better and stronger like losec, pantaloc, prevacid etc.

These drugs did considerably cut down the number of surgical procedures for peptic ulcer disease. But the recurrence rate of ulcers continued to be high unless the patient stayed on the pills for a long time. This made patients unhappy, as the pills are expensive. Thus the compliance rate was poor.

So, what about H. pylori?

Peptic ulcer disease affects about 10 percent of the population at some time in their lives. There are approximately 2500 new cases each year in Alberta. Over 90 percent of duodenal ulcers and 70 percent of gastric ulcers are associated with H. pylori infection. But only about 15 percent of patients with H. pylori infection will develop peptic ulcer disease or cancer of the stomach as a consequence of their infection. Some ulcers are caused by aspirin or NSAID (non-steroidal anti-inflammatory drugs).

Where do the bugs come from?

Only proven reservoir for H. pylori is the human host. Major modes of transmission are still unclear. Oral-oral and fecal-oral routes are possibilities. There is also considerable evidence that H. pylori is transmitted between spouses. In Canada, the majority of H. pylori infections are acquired before the age of five years and that infection after that age is uncommon, less than one percent per year.

Who should be treated?

“Eradication therapy for patients with H. pylori infection who do not have underlying peptic ulcer disease has generally not been advocated,” says Alberta Clinical Practice Guidelines administered by the Alberta Medical Association. Two types of antibiotics and an acid suppressing drug like losec should be given for seven days to patients who have a proven peptic ulcer. Eradication rates are approximately 90 percent. Side effects of medications occur in less than five percent of patients.

Would I get it again?

True reinfection within one year is generally uncommon unless the initial management or compliance was poor. Late reoccurrence is caused by repeated exposure through contact with an infected partner.

So, Mr. Bugged, I hope this information helps to debug your stomach!

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