Practical guidance on caring for refugees

According to an article on primary care for refugees that appears in AFP's February 15th issue, more than 600,000 refugees from more than 60 countries have resettled in the United States during the past decade. Although all refugees must pass an overseas medical screening examination to be admitted to the U.S., they often present to family physicians with musculoskeletal and pain issues, mental and social health problems, infectious diseases, and undiagnosed chronic conditions. Additional challenges to providing high-quality primary care for refugees include language barriers, cultural medical beliefs, and low health literacy levels.

It is important to be aware that persons who have immigrated into the U.S. illegally, while having much in common with legal immigrants, will be less likely to have received examinations, immunizations, and infectious disease screenings recommended in domestic refugee health guidelines from the Centers for Disease Control and Prevention.

You can find additional information about caring for ethnic minorities in the AFP By Topic collection on Care of Special Populations.

Diphtheria as a cause of sore throat

I read with interest the editorial in AFP's January 1st issue, "Avoiding Sore Throat Morbidity and Mortality: When Is It Not 'Just A Sore Throat'?" It brought back memories. I was surprised that diphtheria was not mentioned as a cause of tonsillitis and sore throat.

I graduated from Minnesota Medical School in 1944 after a 9-month Ob-Gyn residency. I was then sent to Japan to be Chief of Obstetrics and Gynecology at the 118th Station Hospital, 24th Infantry Division, at Fukuoka Kyushu, Japan. On one occasion, as officer of the day, I admitted a newly arrived recruit to the hospital with tonsillitis. A viral culture was taken and a smear swab sent to our lab. He was given sulfanilamide (penicillin was just being tried as a new wonder drug). We had a wake-up call when he died shortly after being admitted. He was a new recruit from a ship docked at Yokohama that was manned mainly by soldiers from the rural South where childhood vaccinations were not always routinely administered. We quickly quarantined the ship's personnel, many of whom were experiencing similar symptoms.

Dr. Cy (Cyrus) Lifshultz, an internist from the northeast U.S., was our medical officer in charge of infectious disease. Dr. Lifshultz stayed up all night with these very sick men, spraying their throats with a hand syringe containing penicillin. He also painstakingly removed the scar tissue that lined the throat and upper lung areas. Dr. Lifschultz never got an award for what he did, but in my opinion, he deserved the Medal of Honor.

Fortunately, routine vaccination has made diphtheria a rare cause of sore throat in the U.S. today. However, when treating unvaccinated populations in other areas of the world, clinicians would be wise to not underestimate diphtheria – it is deadly.

Frederick M. Hass, MD
Minneapolis, Minnesota

Osteochondrosis and joint pain in children

A review article in the February 1st issue of AFP summarizes a group of childhood skeletal disorders known collectively as osteochondrosis:

Osteochondrosis results from abnormal development, injury, or overuse of the growth plate and surrounding ossification centers. Overall, boys are more affected and symptoms generally appear between 10 and 14 years of age. It is thought that boys are more commonly affected because of their greater susceptibility to childhood trauma and overuse injuries. Patients usually present with pain and disability. Areas of the body most often affected include the hip, knee, foot, elbow, and back.

Although the majority of these disorders are self-limited and require only rest and pain control, all patients with possible diagnoses of Legg-Calve-Perthes disease (interruption of vascular supply to the femoral head) or Scheuermann disease (disturbance of the vertebral end plates causing kyphosis, or humpback deformity) should be referred for orthopedic evaluation. In addition, medial eipcondyle apophysitis (better known as "Little League elbow") can be prevented by limiting young athletes' numbers of pitches, curveballs, and sliders.

2011 Immunization Schedules are here

The February 1st issue of AFP contains copies of the new Child and Adolescent and Adult immunization schedules from the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP). Dr. Doug Campos-Outcalt, the AAFP's liasion to the ACIP, summarizes the new and revised recommendations in a Practice Guidelines commentary. The paradox of vaccines, he notes, is that the better they work, the harder it is to persuade patients to accept them:

Many of today's physicians have never seen a patient with measles, rubella, polio, or other diseases that in the past were leading causes of morbidity and mortality. One could say that vaccines are a victim of their own success—the better they work, the less they are appreciated. With the absence of vaccine-preventable diseases, the benefit of vaccines goes unnoticed, while exaggerated and false claims of harm receive increasing attention and concern about safety becomes the most important issue to parents. Family physicians now need to spend more time reassuring patients and families of the safety and effectiveness of vaccines.

Speaking of "exaggerated and false claims," the British Medical Journal recently disclosed that Dr. Andrew Wakefield falsified the data for his subsequently retracted 1998 Lancet article that suggested a link between autism and the measles, mumps, and rubella vaccine. Hopefully, this new revelation, as well as a summary of the evidence in the September 15, 2010 AFP Journal Club, will help family physicians "debunk the myth" that childhood vaccines are more likely to harm than help.