To the Editor:
While reading "Animal-Assisted Therapy" in Dimensions of Critical Care Nursing (September/October 2010), I became extremely intrigued with the idea of animal-assisted therapy (AAT). It's really interesting to think that bringing a specially trained animal to help stimulate the patient can actually "reorient patients to reality, improve body image, reduce stress, stimulate comatose patients, provide emotional support, increase social interaction, decrease depression, and provide comfort to both patients and families."1(p211)
As a health studies major, I've recently been researching the benefits of stress reduction due to household pets; however, I hadn't had the idea of actually bringing the animal into a hospital, clinic, or nursing home setting. This article inspired me to research other benefits and reflect back on personal experiences of how animals can help an individual with relieving stress and creating companionship. After reflecting on the pets that I have owned during my lifetime, I believe that it is logical to deduce that reducing stress can actually help affect the other positive outcomes listed in this article, making this holistic treatment quite beneficial for those who are neither afraid of nor allergic to the animal.
I agree that each patient and animal should have to undergo screening tests to guarantee the best situation for not only the patient but the animal and animal caretaker as well. I believe that the article could have been extended to include what the training specifications and criteria are not only for the animal but for the animal's caretaker as well. Moreover, mentioned was that pet visitation could be done, but only to improve the patient's sense of well-being and loneliness. This left me wondering if the patient's own animal would be more beneficial to him/her if given the proper training such as the designated "therapy animal." In addition, during my research, I came across a study that concluded that "pet ownership at a baseline, and cat ownership in particular, is associated with increased cardiac morbidity and mortality in the year following an admission for an acute coronary syndrome, a finding contrary to precious reports."2(p30) I understand that AAT is used for a wide variety of conditions, but the conclusion to this study pushes me to inquire if, possibly, pet therapy, only in the place of care, is beneficial instead of owning a personal pet or if the outcome is affected more by the personalities and companionship of the human and animal rather than the mere presence of the animal? Either way, I found this article to be refreshing and very intriguing, causing me to further research the topic of AAT.
Jamie Bloom238
Leonard Street
Sherrill, NY 13461
[email protected]
The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article.
To the Editor:
I have just come across your article "Black Widow Spider Bite: A Case Study" (March/April 2011), and the abstract intrigued me because death from latrodectism is a very rare event. Both the abstract and the article seem to state that your patient died of envenoming by a black widow spider. This is based on the history of a bite, the finding of Latrodectus in the patient's home environment, and the information on clinical effects of latrodectism sourced from a Web site.
As a clinical toxinologist, I am naturally very interested in major envenoming, including fatal cases, particularly if it is a fatality ascribed to a spider that is rarely fatal. However, my reading of your case indicates some rather different conclusions, and I very much doubt that your patient's death can be blamed on envenoming by a widow spider. Having made such an assertion, perhaps I should provide some reasoning for my conclusion.
Firstly, your information source on widow spider bites is, in my view, partly inaccurate. The relevant section from that source is included below.
Damage: The female black widow possesses a venom 15 times more potent than rattlesnake venom. The bite is like a pin prick but causes pain within a few minutes of the attack. The pain spreads rapidly to arms, legs, chest, back, and abdomen. Chills, vomiting, difficult respiration, profuse perspiration, delirium, partial paralysis, violent abdominal cramps, and spasms may occur within a few hours of the bite. The victim usually recovers in 2 to 5 days; about 5% of all black widow attacks are fatal. The black widow, however, usually bites people only when its web is disturbed. Male black widows do not bite.
Measuring venom toxicity, let alone as it relates to humans, is a difficult and often unsatisfactory process. The common measure, the LD50 in mice, can have little relationship to humans. The description of the bite as minor, followed by extending pain, is accurate, except the pain is initially local then can become regional (such as the bitten limb). Then in severe cases, the pain may become generalized. There may be associated sweating, hypertension, nausea, and malaise. Vomiting is less common. Secondary infection of the bite site is a rare sequela but in any case would take at a minimum many hours to develop, more likely a day or more. Paralysis is occasionally mentioned in the literature, but generally unreliably so and makes little sense given the neuroexcitatory nature of the [alpha]-latrotoxins. They are quite different to the presynaptic and postsynaptic paralytic neurotoxins found in some snake venoms. Recovery over days is the rule and death is rare; a figure of 5% is wildly overestimating the lethal potential of latrodectism. Indeed, a clear method for the toxins to cause a fatal outcome in humans is not apparent. Yes, the spider generally only bites when disturbed in its web. Male widow spiders, being smaller and more delicate than females, are unlikely to successfully bite a human, although rare cases of bites causing minor envenoming are now known. Please see more substantial information sources such as http://www.toxinology.com (link to nonsubscriber page on widow spiders), http://www.toxinology.com/fusebos.cfm?fuseaction=main.spiders.display&id=SP00061 (subscriber level information attached), eMedicineHealth (http://www.emedicinehealth.com/black_widow_spiker_bite/page2_em.htm), Medscape Reference (http://emedicine.medscape.com/article/772196-overview#showall), and the leading textbook on clinical toxinology, The CRC Handbook of Clinical Toxicology of Animal Venoms and Poisons, 1995 (spider bite chapter attached).
There was a clear history of a bite in your case, but no organism was identified at that time. The later finding of organisms, such as widow spiders, does not prove cause, especially if these spiders are a common part of the environment.
More importantly, the local findings suggestive of infection clinically, a view apparently substantiated at autopsy, are the diagnostic indicator, and subsequent events, consistent with severe sepsis, strongly suggest that your patient had overwhelming infection leading to multiple organ failure and, ultimately, death. Did a bite introduce the infection? Spider bite can introduce infection, although it is rare, except for recluse spiders. Widow spiders generally cause little to see locally but may cause local erythema, sometimes with central blanching and there may be associated profuse local sweating. They do not tend to cause the "bulls-eye" lesion you describe, with blueish skin; that is more suggestive of loxoscelism. Was this, in fact, a case of loxoscelism? Certainly, your hospital is within the known range for Loxosceles recluse, but I hesitate to blame this case on a recluse spider.
I do not think anyone can be exactly sure what bit your patient, nor how many of the subsequent symptoms and signs were due to envenoming as the cause of death. I think it far more tenable that your patient developed a fulminate infection which was, through secondary multiple organ failure, the cause of death. The bite may have been the origin of the infection.
Thank you for publishing your case. It is both interesting and instructive, albeit tragic, and although I do not agree with your conclusions regarding cause of death, that does not diminish the value of learning from your case.
Yours sincerely,
Professor Julian White, MB, BS, MD, FACTM
Consultant Clinical Toxinologist Head of Toxinology Women and Children's Hospital
North Adelaide SA 5006, Australia
[email protected]
http://www.toxinology.com&net
The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article.
AUTHOR'S RESPONSE
Dr White, thank you for your response to our article. We are honored that you have provided evidence for an alternative diagnosis. I also sincerely appreciate your work in ensuring that the best information about black widow spider bites is available to practitioners all over the world.
Obviously, nurses are not diagnosticians-and your e-mail illustrates the importance of team work in providing the best care possible for patients. I believe you should submit a manuscript to our editor, Dr Vickie Miracle, for possible publication in Dimensions of Critical Care Nursing, as we all want nurses and physicians to provide the best care possible. Thanks again.
Submitted by:
Kristine Gaisford, MSN, RN, CCRN
Clinical Supervisor
Marion HealthCare Services
Salisbury, NC
Donald D. Kautz, PhD, RN, CRRN, CNE
Associate Professor of Nursing
The University of North Carolina at Greensboro
[email protected]
The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article
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