A Forensic and Medical Evaluation of Dog Bites in a Province of Western Turkey

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1 TECHNICAL NOTE JForensicSci, March 2014, Vol. 59, No. 2 doi: / Available online at: onlinelibrary.wiley.com GENERAL; PATHOLOGY/BIOLOGY Kenan Karbeyaz, 1 M.D. and Unal Ayranci, 2 M.D. A Forensic and Medical Evaluation of Dog Bites in a Province of Western Turkey ABSTRACT: The aim was to evaluate the demographic data of dog-bite cases organized from criminal and forensic reports. This study evaluated 328 cases admitted to the Director of Forensic Medicine, Eskisehir, as a result of dog bites between January 1, 2006 and December 31, It was found that those in the age-group of 0 18 were most frequently exposed to dog bites (48.5%). Injuries to the lower extremity, upper extremity, and chest/abdomen/back were more frequent in men (72.6%, 76.4%, and 66.1%, respectively), while injuries to the head/neck/ face were more frequent in women (52.3%) (p < 0.01). While most of those wounded in the upper extremity, the head/neck/face, and the chest/abdomen/back were in the child age-group, most of those wounded in the lower extremity were in the adult age-group (p < 0.001). Teaching children, in particular, how to behave around dogs would be useful in reducing the incidence of bite. KEYWORDS: forensic science, dog bites, injury, forensic reports, Turkey, gender Dog bites are a major public health problem that cause fatal injuries all over the world, particularly affecting children (1,2). It has been reported that about 2% of the population in America is exposed to dog bites each year and 0.3% seek attention due to dog bites (3). In addition, it has been reported that around 15 people in America and 1 2 people in Canada die annually as a result of injuries sustained from dog bites (4 6). However, in our country, there has, as of yet, been no study concerning deaths due to dog bites. When injuries due to dog bites were evaluated at the outset of this study, 116 patients with dog-bite injuries were identified as having been brought to the university hospital in the province of Eskisehir, Turkey, the study area, during a period of 5 years (7). Eskisehir is not exclusive in presenting dog-bite cases. In a nearby province, Afyon, a dog-bite case had led to neurological deficits and ischemia in the upper extremity (8). A case of penis injury had occurred due to a dog bite in Istanbul (9). Dogs were responsible for 79.1% of a total of animal bites occurring between the periods 2005 and 2009 in Ankara (10). Dog bites are considered to be a significant problem because they can also lead to a lot of infectious disease, particularly rabies as well as causing direct injuries (11 13). Injuries associated with dog bites usually occur in the extremities, followed by head, neck, chest, and abdominal regions (7,14,15). However, head and neck injuries due to dog bites are more frequently encountered in children (16,17). According to Article 177 in the Turkish Penal Code, if an animal under the supervision of a person harms another person, the owner of that animal shall be punished with an imprisonment of 1 Forensic Medicine, Eskisehir Courthouse, Alanonu Mahallesi, Cifteler Cad. No: 87/A, Eskisehir, Turkey. 2 Eskisehir Osmangazi University, Medico Social Center, Meselik- Eskisehir, Turkey. Received 10 Oct. 2012; accepted 3 Feb up to 6 months (18). Therefore, injuries due to dog bites are within the scope of judicial cases. Physicians should edit forensic reports according to both the severity of injury and medical attention, such as treatment and vaccination in injuries due to dog bites. In this study, the aim was to evaluate the demographic data of dog-bite cases from organized criminal and forensic reports. In addition, the forensic size of the event and legal processes were also examined. Methods General Knowledge of the Environment Regarding Dogs in Western Turkey, Eskisehir where the Study was Conducted In the central city, especially until 5 years ago, stray dogs were allowed to roam the streets freely, and there was a significant problem with wild and feral dogs in the community. However, for the last 5 years, a large number of stray dogs have been placed under control and have been vaccinated by the municipalities. Nevertheless, there are still many dogs roaming the streets in the city center that are not under control. On the other hand, the vast majority of towns and villages are full of unvaccinated dogs that are not under control. In the entire city boundary, which includes towns and villages, there are about 600 dogs. As a result, in recent years, a modern healthcare system related to dogs in western Turkey has been thriving, and it is already more advanced than most of its Middle Eastern neighbors with regard to care and enjoyment of dogs. At the moment, there are at least three or five dogs in each street of the city, most of which are vaccinated and under the control of the municipalities. This study evaluated cases admitted to the Director of Forensic Medicine, Eskisehir, as a result of dog bites within a 5-year period between January 1, 2006 and December 31, The 2013 American Academy of Forensic Sciences 505

2 506 JOURNAL OF FORENSIC SCIENCES hospital file of each case was examined by the researchers themselves. The cases were evaluated in terms of their ages, gender, injury regions, severity of injury, and the contents of forensic reports, treatment, and length of hospital stay. In this study, injuries due to exclusively dog bites, not any other type of animal injuries, were included in the study. All the dogs involved were stray dogs, and all cases were nonlethal. The injuries were classified from simple to severe as ecchymosis/abrasions/bruising/ break such as scratch or puncture in the skin, laceration, flapstyle injury, and vascular injury, respectively, by the researchers. The data were evaluated using the SPSS 15.0 package (SPSS Inc., Chicago, IL, USA) program. Chi-square analysis and frequency analysis were performed, and a p value of below 0.05 was considered significant. Results The forensic reports for three hundred and 28 cases injured due to dog bites had been written up within a 5-year period. Most of the cases (71.6%) were men, and only 28.4% of them were female. The average age of the cases was , ranging from 18 months to 75 years old. Table 1 shows the comparison of the cases age-groups, regions of injury, types of injury, form of treatment, and information on the treatment received, according to gender. It was found that the cases exposed the most frequently to dog bites were in the age-group of 0 18, the youngest age-group (n = 159, 48.5%). More female cases were in the age-group 0 18 when compared with male cases (68.8% and 40.4%, respectively); whereas in the other age-groups, male cases were more predominant than females (p < 0.001). Lower extremity, upper extremity, and chest/abdomen/back injuries were more frequent in men (72.6%, 76.4%, and 66.1%, respectively), while injuries to the head/neck/face were more frequent in women (52.3%) (p < 0.01). Most of the cases (73.2%) had simple injuries such as ecchymosis/abrasion, while the least number (1.8%) had vascular injury, which was categorized as very severe. All types of wound were more frequent in men than women except for vascular injury, which was equal for both types. It was found that most of the cases had been treated as outpatients or had been kept under observation (78.0%), and had received treatment at a public health institution (76.5%). Most had not been hospitalized, and the number of days of hospitalization was seven and less (52.5%). Many cases had been treated medically (79.3%), and primary repair was the most common reason for surgical treatment (44.4%). Although the vaccination status of most patients was unknown (82.3%), many cases had been vaccinated against rabies (12.8%), and 4.9% cases did not receive any vaccination. Most of those receiving inpatient treatment were women (60.0%), whereas most of those being treated as an outpatient or under observation were men (77.7%) (p < 0.001). Most of those receiving treatment at all the health institutions were men when compared with women (p > 0.05). While the number of hospitalized days amounting to <8 and more than 7 days was more in women, the number of those unknown was more in men (p < 0.05). Most of those treated medically were men; whereas, most of those treated with a surgery method were women (66.7%) (p < 0.001). A large majority of those receiving primary repair, wound care plus debridement, and skin graft as surgical treatment methods were women; whereas, vascular repair was performed equally between men and women (p > 0.05). Most of TABLE 1 Comparison of age-groups, regions of injury, types of injury, forms of treatment, and information on treatment by gender. Men 235 (71.6) Gender Women 93 (28.4) n (100%) 328 (100) Age-groups v 2 = 23.9; p = age 95 (40.4) 64 (68.8) 159 (48.5) age 84 (35.7) 12 (12.9) 96 (29.3) (23.9) 17 (18.3) 73 (22.2) Region of injury v 2 = 13.3; p = 0.01 Lower extremity 117 (72.6) 44 (27.4) 161 (49.1) Upper extremity 78 (76.4) 24 (23.6) 102 (31.1) Head/Neck/Face 21 (47.7) 23 (52.3) 44 (13.4) Chest/abdomen/back 35 (66.1) 18 (33.9) 53 (16.1) Type of Wound Fisher s exact test; p = Ecchymosis/abrasions/bruising/ 187 (77.9) 53 (22.1) 240 (73.2) break such as scratch or puncture in the skin Laceration 32 (54.2) 27 (45.8) 59 (18.0) Flap-style injury 13 (56.5) 10 (43.5) 23 (7.0) Vascular Injury 3 (50.0) 3 (50.0) 6 (1.8) Information on the cases treatment Type of treatment v 2 = 25.71; p = Outpatient/observation 199 (77.7) 57 (22.3) 256 (78.0) Inpatient 16 (40.0) 24 (60.0) 40 (12.2) Health institution from which the v 2 = 6.62; p = case received treatment Primary health center 17 (89.5) 2 (10.5) 19 (5.8) University hospital 16 (61.5) 10 (38.5) 26 (7.9) Public hospital 182 (72.5) 61 (27.5) 251 (76.5) Number of days of hospitalization v 2 = 10.19; p = (33.3) 14 (66.7) 21 (52.5) >7 1 (11.1) 8 (88.9) 9 (22.5) Unknown 8 (80.0) 2 (20.0) 10 (25.0) Treatment method v 2 = 32.62; p = Medical 203 (78.1) 57 (21.9) 260 (79.3) Surgical 12 (33.3) 24 (66.7) 36 (10.9) Surgical treatment method v 2 = 1.35; p = Primary repair 4 (25.0) 12 (75.0) 16 (44.4) Wound care + debridement 3 (33.3) 6 (66.7) 9 (25.0) Skin graft 2 (40.0) 3 (60.0) 5 (13.9) Vascular repair 3 (50.0) 3 (50.0) 6 (16.7) Vaccination status v 2 = 41.76; p = Vaccinated against rabies 18 (75.0) 24 (25.0) 42 (12.8) Vaccinated against tetanus 16 (42.1) 22 (57.9) 38 (11.6) No vaccination 6 (37.5) 10 (62.5) 16 (4.9) Unknown 209 (77.4) 61 (22.6) 270 (82.3) those vaccinated against rabies were men; however, most of those vaccinated against tetanus were women (57.9%) (p < 0.001). Table 2 shows a comparison of the regions of injury by agegroups. The most frequently wounded region was the lower extremity (49.1%), followed by upper extremity (31.1%). When injury regions of the cases were evaluated according to agegroups, while most of those wounded in the upper extremity, head/neck/face, and chest/abdomen/back were in the child agegroup, most of those wounded in the lower extremity were in the adult age-group (p < 0.001). In addition, it was determined that there were injuries in multiple regions in 32 cases (18 male, 14 female), 26 of which were in the child age-group (unshown data). Table 3 shows a comparison of the contents of the forensic report by injury. Upon forensic evaluation of the report contents, it was determined that 26.5% of the cases had a lesion which

3 KARBEYAZ AND AYRANCI. EVALUATION OF DOG BITES 507 TABLE 2 Comparison of regions of injury by age-group. Age-groups Between 0 and (56.4) 19 and over 175 (43.6) 328 (100) Injury regions v 2 = 20.97; p = Lower extremity 34 (21.1) 68 (78.9) 161 (49.1) Upper extremity 89 (88.11) 72 (11.89) 102 (31.1) Head/neck/face 30 (68.2) 14 (31.8) 44 (13.4) Chest/abdomen/back 32 (60.4) 21 (39.6) 53 (16.2) TABLE 3 Comparison of forensic report contents in personal injury. Contents of Forensic Reports Resolved by Simple Medical n = 261 (73.2%) Unresolved by Simple Medical n = 67 (26.5%) n = % Injury regions v 2 = ; p < Extremities 225 (96.6) 8 (3.4) 233 (71.1) Head/neck/face 9 (20.4) 35 (79.6) 44 (13.4) Chest/abdomen/back 27 (52.9) 24 (47.1) 51 (15.5) could not have been resolved with a simple medical intervention. Injuries to the head, neck, and facial area were more serious; whereas injuries to the extremities and chest/abdomen/back were simpler (p < 0.001). Six cases had been in danger of life (1.8%), and all of these had injury in multiple regions. The radial artery and radial nerve had been injured in two cases, the external carotid artery in two cases, the femoral artery and vein in one case, and the popliteal artery in one case. It was found that all of the cases who had been exposed to life-threatening were under age 18 (unshown data). In 19 cases, there was a permanent scarring to the face, of which eleven were women (57.9%) and eight were men (42.1%) (unshown data). Table 4 indicates a comparison of data on the dogs and forensic report consents. Nearly ¼ of the dogs (23.8%) were of unowned status, and the owners of over ¼ (28.0%) were unknown. The proportion of serious injury occurring from dogs whose owners had been identified was only 13.9%; whereas that of serious injury by dogs of an unknown owner was rather high (39.8%) (p < 0.001). Whether most dogs were placed under observation after causing injury was unknown (83.8%). The proportion of dogs placed under observation was only 12.5%. The proportion of serious injury caused by dogs placed under observation was rather high (85.4%), whereas the proportion of those not placed under observation was very low (16.7%) (p < 0.001). The proportion of vaccinated dogs was <50% (47.3%). However, the proportion of dogs in total with an unvaccinated and unknown vaccination status was higher (52.7%). Discussion In this study, most cases (n = 328) were men (71.6%) and only 28.4% were female, compatible with another study conducted in the same province indicating that men were exposed to dog bites more when compared with women (58.7% and 41.3%, respectively) (7). An explanation for this could be that men spend more time wandering outside of the home or are more engaged with jobs such as hunting and livestock (1,4). It was found that the cases which had been exposed the most frequently to dog bites were in the age-group of 0 18, the youngest age-group (n = 159, 48.5%). The reason for this may be that children constantly play outside, and they interact with dogs more than adults and that they may also be less cautious, more curious, have a greater desire to play or interact with the dogs, or may be less able to defend themselves, in line with various studies (1,4,19,20). A study in Belgium indicated that the proportion of those exposed to dog bites under age 15 was higher, and 30.2% of the cases were between 0 and 7 years old (21). This shows that more attention should be paid to children. In parallel, as the age increases, the proportion of injuries shows a decrease; the proportion was 48.5% in the age-group 0 18, whereas it was 22.2% in the age-group 35 and over. It shows that an older age is at decreased risk. Injuries to the lower and upper extremities were rather high (80.2%) compared with the other regions of the body (19.8%), a finding compatible with various studies (7,14,22); studies from Italy and India reported that the proportion of extremity injuries was between 66.5% and 80.2%, respectively (22,23). In comparison with other body regions, the extremities are more peripheral regions, and this status predisposes to dog bites. When compared with adult cases, more children had been exposed to dog bites (56.4% and 43.6%, respectively), a result which is compatible with a study in Canada reporting that 85.7% of 28 cases who had died due to dog bites were those of children (11). In addition, it was determined that there were Status of Dogs TABLE 4 Data on the dogs and forensic report consents. Bites Resolved by Simple Medical n = 261 (73.2%) The Contents of Forensic Report Bites Unresolved by Simple Medical n = 67 (26.5%) Owned or unowned v 2 = 23.55; p = Owned 136 (86.1) 22 (13.9) 158 (48.2) Unowned 47 (60.2) 31 (39.8) 78 (23.8) Unknown 78 (84.8) 14 (15.2) 92 (28.0) Status of observation v 2 = ; p = Placed under observation 6 (14.6) 35 (85.4) 41 (12.5) Not placed under observation 10 (83.3) 2 (16.7) 12 (3.7) Unknown 245 (89.1) 30 (10.9) 275 (83.8) Status of vaccination v 2 = 27.69; p = Vaccinated 110 (70.1) 45 (39.9) 155 (47.3) Unvaccinated (0.00) 3 (100.0) 3 (0.9) Unknown 151 (88.8) 19 (11.2) 170 (51.8)

4 508 JOURNAL OF FORENSIC SCIENCES injuries in multiple regions in 32 cases (18 male, 14 female), 26 of whom were in the child age-group. These results highlight the fact that children are more sensitive to dog bites. In addition, injury to the head neck face was more common in children than in adults (68.2% and 31.8%, respectively) (p < 0.001), a finding compatible with many studies (6,11,19,24). As children are shorter and lighter than most adults, dogs can reach the head neck regions directly. Moreover, when children are attacked by dogs, they fall over more easily. Thus, these areas are more susceptible to injury than in adults. Most of the cases (73.2%) had injuries such as bruising and abrasions, while the least percentage (1.8%) had vascular injury. This result is compatible with studies about the incidence of injuries due to dog bites (1,2,19,24). This result gives important clues in terms of the nature of dog bites and indicates that most dog bites result in simple injuries. In this study, it was determined that 26.5% of the cases had a lesion which could have not been resolved with a simple medical intervention, indicating that more than ¼ of dog bites cause serious injuries and can be fatal. Injuries in the head, neck, and facial areas were more serious; whereas injuries in extremities and chest/abdomen/back were simpler (p < 0.001). This shows that injuries to the head/neck/ face are life-threatening and require more comprehensive interventions. In the current study, six cases had been in danger of life (1.8%), and all of them had injury in multiple regions. It was found that all of the cases who had been exposed to life-threatening injuries were under the age of 18. These results show that children are more vulnerable or more unprotected to dog bites. Most cases had been treated as outpatients or had been kept under observation for a short time (78.0%). This indicates that dog bites generally cause minor injuries, but it should be kept in mind that dog bites sometimes may cause very serious and fatal injuries. On the other hand, the high risk of germ transmission of rabies should not be overlooked as 12.2% of dog bites require inpatient hospital treatment, consistent with a study by Brogan et al. (25). The proportion of the vaccinated dogs was <50% (47.3%). Most dogs were unvaccinated, or their vaccination status was unknown (52.7%). This indicates that unclaimed or stray dogs wander the streets freely and that children in particular face great threats or dangers because stray dogs are unvaccinated or unclaimed. Most cases had received treatment at a state hospital (76.5%). A reason for this may be that the Turkish emergency health system is the only authorized entity in terms of urgent admissions because the emergency departments of private hospitals are not very well developed. In this study, the vaccination status of most cases was unknown (82.3%). A reason for this could be that the immunization rate of dogs is low and that the public is not educated enough, compatible with a study in China (26). Most of those who had received inpatient treatment were women (60.0%), whereas most of those who were treated as an outpatient or under observation were men (77.7%) (p < 0.001). In parallel, most of those who were medically treated were men; whereas, most of those surgically treated were women (66.7%) (p < 0.001). These findings offer important information about how emergency departments must be structured in terms of dog bites, with gender being a significant indicator to be considered during planning. Another explanation could be that female children especially generally have less body mass index than males, and thus, it is easier for them to be captured and bitten by their dogs. This opinion may explain why girls seek inpatient treatment more frequently. While most of those who were wounded in the upper extremity, head/neck/face, and chest/abdomen/back were in the child age-group, most of those who were wounded in the lower extremity were in the adult age-group (p < 0.001). This result shows that dogs more frequently bite adults lower extremities, which are very close to the ground, because they are not easily wrestled to the floor by a dog. However, as children fall down much more easily due to fear of being bitten, areas such as the head neck are more vulnerable places (3 5,16,17) and may be fatal (27). Another explanation may be that while children are feeding the dogs, their hands may be wounded easily (2 5). Injuries in the head, neck, and facial area were more serious; whereas injuries in the extremities and chest/abdomen/back were simpler (p < 0.001). Dog bites can result in subcutaneous incisions, lacerations, and tissue loss to facial region skin, and this tissue loss can be particularly difficult to heal. This result indicates that either the children or the dogs must be kept under continuous observation and surveillance. Nearly ¼ of the attacking dogs (23.8%) were unowned, and the owners of 72.0% were unknown, not consistent with a study from Pennsylvania where the owners of only 47.2% were unknown. This difference may be due to the level of development of different countries. The proportion of serious injury caused by dogs whose ownership was known was only 13.9%; whereas that of serious injury involving dogs whose ownership had not been established was rather high (39.8%) (p < 0.001). Because unowned dogs are neither trained nor particularly docile, they can perceive any behavior by people as a threat against themselves (28). Thus, necessary arrangements should be carried out by local governments, such as municipal departments. It is unknown whether most dogs were placed under observation after having caused injury (83.8%). The present study found that the proportion of dogs placed under observation was only 12.5%. This indicates that either dog bites are not given enough importance or record-keeping awareness is not sufficiently developed in Turkey. As nearly all of the cases presented to the emergency department following a dog bite in this study, emergency systems at the least should be restructured, or staff in emergency departments should be trained in these matters. The proportion of vaccinated dogs was <50% (47.3). Most dogs were unvaccinated, or their vaccination status was unknown (52.7%). This indicates that Turkey has serious deficiencies in dog health and care. All dogs kept at house or on the street must be vaccinated without exception, and their records must be kept. We are well aware of the limitations of the present survey. First, it was performed in a single province, and therefore, the sample may not be representative of all Turkish cases of dog bites. Another limitation on the data employed throughout this survey was the use of the retrospectively scanning dog bites. This may have given rise to bias; thus, we did not report on the instances of rabies, tetanus, and infections and their association with vaccination status and treatment due to the nature of its being a retrospective study. In addition, the paper also suffers from a large range of data being supplied with insufficient detail in each area due to the studies retrospective nature. For example, the paper does not comment on paired type injuries often seen from the canine teeth these would have substantially increased the value of the paper.

5 KARBEYAZ AND AYRANCI. EVALUATION OF DOG BITES 509 Because a large percentage of dog bite victims are younger than 18 years old, it is appropriate to begin prevention education with children and parents. Teaching children, in particular, how to behave around dogs would be useful in reducing the incidence of bite cases. More attention and research needs to be devoted to the prevention of dog bites (29). Thus, one of the most important steps in attempting to reduce the incidence of dog bites is education of the public. Educational programs need to involve parents as well so that they clearly understand the elements of danger that their children face. References 1. Castrodale L. Hospitalizations resulting from dog bite injuries Alaska, Int J Circumpolar Health 2007;66: Morgan M, Palmer J. Kopek isiriklari. BMJ Turkiye 2007;12: Sacks JJ, Kresnow M, Houston B. Dog bites: how big a problem? Inj Prev 1996;2: Avis SP. Dog pack attack: hunting humans. Am J Forensic Med Pathol 1999;20: Ozanne-Smith J, Ashby K, Stathakis VZ. Dog bite and injury prevention analysis, critical review, and research agenda. Inj Prev 2001;7: Sacks JJ, Sattin RW, Bonzo SE. Dog bite-related fatalities from 1979 through JAMA 1989;262: Gunduz T, Elcioglu O, Balci Y. An evaluation of dog and cat bites over a five-year period: a sample case from Eskisehir. Ulus Travma Acil Cerrahi Derg 2011;17: Eser O, Kocaogullari CU, Cosßar M, Emmiler M, Cekirdekci A. Dog bite causing ischemia and neurological deficit at the upper extremity: a case report. Turk Neurosurg 2008;18: Faydaci G, Tarhan F, Eryõldirim B, Tuncer M, Kuyumcuoglu U. Unexpected penile trauma; dog bite. Turk Uroloji Dergisi 2008;34: Aksoy M, Demirbas B, Maden F. ve ark. Ankara ilinde yõllarõ arasinda gorulen supheli isiriklarin ve kuduz asilamasinin degerlendirilmesi. 3. EKMUD Kongresi, Ankara Mayis 2010, Kongre Ozet Kitabi s: Raghavan M. Fatal dog attacks in Canada, Can Vet J 2008; 49: Jackson AC. Rabies in the critical care unit: diagnostic and therapeutic approaches. Can J Neurol Sci 2011;38: Numazaki K, Chiba S, Ueno H. Infected dog and cat bites. N Engl J Med 1999;10(340): Mitmoonpitak C, Tepsumethanon V, Raksaket S, Nayuthaya AB, Wilde H. Dog-bite injuries at the animal bite clinic of the Thai Red Cross Society in Bangkok. J Med Assoc Thai 2000;83: Sunam GS, Ceran S, Aribas OK, Akyol K, Demirci S, Ural O. A pneumothorax case due to dog bite. Genel Tip Derg 2002;12: Iannelli A, Lupi G. Penetrating brain injuries from a dog bite in an infant. Pediatr Neurosurg 2005;41: Wilberger JE Jr, Pang D. Craniocerebral injuries from dog bites. JAMA 1983;249: Yilmaz Z. TCK anayasa TCK-CMK. Kanunu I, editor. Ankara, Turkey: Seckin Yayinevi, 2009; Patrick GR, O Rourke KM. Dog and cat bites: epidemiologic analyses suggest different prevention strategies. Public Health Rep 1998;113: Gilchrist J, Sacks JJ, White D, Kresnow MJ. Dog bites: still a problem? Inj Prev 2008;14: De Keuster T, Lamoureaux J, Kahn A. Epidemiology of dog bites: a Belgian experience of canine behaviour and public health concerns. Vet J 2006;172: Ostanello F, Gherardi A, Caprioli A, La Placa L, Passini A, Prosperi S. Incidence of injuries caused by dogs and cats treated in emergency departments in a major Italian city. Emerg Med J 2005;22: Shetty RA, Chaturvedi S, Singh Z. Profile of animal bite cases in Pune. J Commun Dis 2005;37: Pinto FG, Tavares WM, Cardeal DD, Bor-Seng-Shu E, Andrade AF, Teixeira MJ. Craniocerebral injuries from dog bites. Arq Neuropsiquiatr 2008;66: Brogan TV, Bratton SL, Dowd MD, Hegenbarth MA. Severe dog bites in children. Pediatrics 1995;96: Song M, Tang Q, Wang DM, Mo ZJ, Guo SH, Li H, et al. Epidemiological investigations of human rabies in China. BMC Infect Dis 2009;9: Oshima T, Mimasaka S, Yonemitsu K, Kita K, Tsunenari S. Vertebral arterial injury due to fatal dog bites. J Forensic Leg Med 2008;15: Bernardo LM, Gardner MJ, Rosenfield RL, Cohen B, Pitetti R. A comparison of dog bite injuries in younger and older children treated in a pediatric emergency department. Pediatr Emerg Care 2002;18: Hunthausen W. Effects of aggressive behavior on canine welfare. J Am Vet Med Assoc 1997;210: Additional information and reprint requests: Unal Ayranci, M.D. Eskisehir Osmangazi University Medico Social Center Meselik-Eskisehir Turkey unalayrancioglu@yahoo.com