Photo credit: Sura Nualpradid

It may seem counterproductive to inject disease into the body to protect yourself from contracting that disease. However, routine immunizations are an important step in remaining healthy for both children and adults. Vaccines produce antibodies within the body, and these “agents of immunity” attack and kill the specific virus or bacteria from which the vaccine was prepared. Unfortunately, not all diseases can be fought with a vaccine. For example, there are immunizations for hepatitis A and hepatitis B, but not hepatitis C. Polio can be prevented with a vaccine, but no vaccine exists to prevent malaria or HIV infection.

Generally speaking, vaccines we receive as children protect us in adulthood. However, not all adults received the required vaccinations as children. Many received partial immunizations, and many received no vaccinations at all. Also, the development of vaccines has progressed since most of us were children. Newer vaccines, such as herpes zoster, which prevents chicken pox or shingles, and human papilloma virus, which prevents genital warts and related cervical cancer, were not available until recently. Some vaccinations given during childhood, such as pertussis, which prevents whooping cough, and tetanus, which prevents lockjaw, may lose their effectiveness over time and no longer protect us. In many cases booster shots are recommended

Reasons for Not Getting Vaccinated
So why hasn’t everyone been vaccinated? For a variety of reasons, not everyone receives the recommended vaccinations. Some may be recent immigrants, and vaccination programs were not available in their home countries; some have cultural or religious objections to vaccinations. Recently there has been some controversy about a link between vaccinations and diseases such as autism. While these studies have been thoroughly discredited, they have caused a lot of fear of confusion for parents, many of whom have chosen not to have their children vaccinated. The result is a resurgence of childhood illnesses that we have not seen in such numbers since the introduction of vaccination programs.

Common Vaccinations
The vaccine most commonly given in our offices is a combination of Tetanus, Diphtheria and Pertussis, called the TDaP vaccine. We’ll provide a brief review of these illnesses and the recommendations for vaccinations against these diseases.

Tetanus is an illness caused by the toxin released by the bacteria Clostridium tetani, the spores of which are widely found in contaminated dirt. They enter the body through a cut or open wound on the skin, and the bacteria multiply and produce the toxin, which causes stiffness and spasms of muscles, most commonly of the facial muscles, which causes “lockjaw” and prevents patients from being able to open their mouths and swallow. Although rare in the United States, tetanus can be fatal in 10 to 20 percent of cases. Treatment includes alleviating the symptoms and supportive treatment and tetanus immune globulin, which works by providing antibodies against the toxin that produces the symptoms. However, prevention is the best medicine. If you think you have an infected would, it should be evaluated by your doctor.

Diphtheria is caused by the toxin-producing bacteria Corynebacterium diphtherium. Symptoms of respiratory diphtheria include a sore throat with a low-grade fever and a grayish film on the tonsils, pharynx or nose. Swelling of the neck is common in patients with a severe form of the disease. Skin-based or cutaneous diphtheria appears as infected skin lesions that don’t have a particularly remarkable appearance. Diphtheria is transmitted through cough secretions or direct contact with lesions. The disease is still extremely rare in the United States. Even with treatment, respiratory cases can be fatal in 5 to 10 percent of cases. Treatment includes antibiotics and diphtheria anti-toxin.

Pertussis is caused by the bacteria Bordetella pertussis. The bacteria cause respiratory illness by releasing toxins which paralyze the fine hairs of the respiratory tract, called cilia, causing inflammation and difficulty breathing. Since the 1980s, there has been an increase, especially in 10 to 19 year olds and infants younger than 6 months old. In 2010, 27,550 cases were reported to the Centers for Disease Control and Prevention. The illness develops in three stages. The first stage usually lasts 7 to 10 days, and includes runny nose, low-grade fever and mild cough. The second stage usually lasts 1 to 6 weeks, includes bursts of rapid coughs, especially at night, followed by a high-pitched “whoop.” Other symptoms include vomiting and thick mucus which is difficult to bring up. The last stage usually lasts 7 to 10 days, with the cough gradually disappearing in 2 to 3 weeks. Pertussis is transmitted through coughing. The disease can be very serious and life-threatening, especially for young children or patients with other medical problems. Treatment includes antibiotics and alleviating the symptoms. Because the disease is becoming more common and is life-threatening, it is recommended that pertussis be included in the vaccines given in the majority of teens and adults requiring a booster.

The Advisory Committee on Immunization Practices (ACIP) recommends the TDaP vaccine for adolescents aged 11 to 18, boosters for those aged 18 to 64, and any adults in contact with infants 12 months of age or younger. Additionally, ACIP recently recommended that women’s health care providers begin a TDaP vaccination program for women who have not previously received the vaccine. For pregnant women, health care providers should administer TDaP during the third trimester or late second trimester (after 20 weeks gestation). If not administered during pregnancy, TDaP should be administered immediately postpartum.

eMedical Offices provides routine vaccination, including those discussed above. Call our office for more information, or stop in.

John V. Morlino, D.O., has been with eMedical Offices since 1984.  He received his medical degree from Philadelphia College of Osteopathic Medicine. He holds a bachelor’s degree in physics from Georgian Court University and a paralegal diploma from Monmouth University.

Oscar A. Marcilla, M.D., has been with eMedical Offices since 2010. He is board-certified in emergency medicine. Prior to joining eMedical Offices, Dr. Marcilla was an emergency physician with Emergency Medical Associates. He earned his medical degree from Mount Sinai School of Medicine, New York City, and completed his emergency medicine residency at Jacobi Hospital, Bronx, N.Y. Dr. Marcilla is a fellow of the American Academy of Emergency Medicine and Fellow American College Emergency Physicians.

Whether you slip on the ice and suffer an abrasion or are injured while gathering wood for the fireplace, how do you decide if a wound needs stitches? There are several issues that have to be taken into account when answering to that question. You’ll also need to determine if the wound should be treated with antibiotics, if it requires a specialist’s care, such as a plastic surgeon, or if a tetanus shot is needed. In this post I’ll discuss some of the factors doctors use to decide how to treat wounds.

What to do First
The first thing to do if you or your child is wounded is to put direct pressure on the wound to try to stop the bleeding. If the wound is in an area that can’t be compressed or it’s too painful to apply pressure directly to the wound, try applying pressure above the wound or elevating the area. Ice can also be helpful in stopping the bleeding and can decrease swelling as well. If the would is dirty, it should be washed with soap and warm water and rinsed with warm water to help remove any large particles of dirt and debris.

A Physician Evaluation
When examining a wound, your doctor will evaluate:

The age of the wound: In general, the longer it takes to heal, the higher the risk of infection. The best approach is to repair the wound within 2 to 4 hours. Bacteria can grow in a dirty wound within 3 to 4 hours. However, wounds in vascular areas (such as the face) can be safely closed within 24 hours as long as the wound is thoroughly cleaned. Because there is no definitive rule, it’s important for each injury to be evaluated by a physician, who can determine the best course of care.

Any underlying medical conditions: Certain factors put the wound at higher risk for infection, such as the patient’s age or other medical conditions. Very young and very old patients are at higher risk of infection due to lowered ability to fight infection. Certain medical conditions – diabetes, congestive heart failure, kidney disease, liver disease, blood disorders, immune disorders, cancers and malnutrition – can weaken the immune system and increase risk of infection. Also, treatments such as chronic steroid use, chemotherapy or radiation therapy can put patients at higher risk. Being able to provide your or your child’s immunization history is important. This should include date of last tetanus shot and if the full series of tetanus immunization has been completed.

Type of wound:

• Abrasions are caused by friction of the skin on a hard surface, resulting in injury to outer layer(s) of skin
• Lacerations are caused by a tear in tissues, which can be produced by shear forces, such as a knife, or compressive forces, such as hitting your forehead on a car dashboard.
• Crush wounds are caused by the impact of an object against tissue, particularly over a bony surface, which compresses the tissue.
• Puncture wounds are those with a small opening whose depth can’t be entirely viewed.
• Avulsions are wounds in which a portion of tissue is completely separated from its base and is either lost or left with a narrow base of attachment (a flap).
• Combination wounds are the result of a combination of the above types of wounds.

Possible contamination of the wound: All traumatic wounds are contaminated to some extent with bacteria. Any wound that has been exposed to biological fluids (saliva, blood or feces) or those exposed to vegetation, soil or water will be at high risk for infection. Abrasions, crush wounds and avulsion injuries are at higher risk of infection due to injury to tissues. Puncture wounds are at higher risk because it’s more difficult to fully explore, clean and rinse the wound.

Location of the wound: Wounds in areas where capillaries carrying blood are close to the skin surface, such as the scalp or face, are at lower risk of infection; wounds on the extremities such as hands, fingers, feet and toes will be a higher risk. Your doctor should only prescribe antibiotics after careful examination, decontamination and review of risk factors for infection. Any involvement of tendons, ligaments, bones, muscles or nerves may require surgery.

Treating the Wound
Once the wound has been evaluated and the doctor has decided that it needs to be sutured, the area will be prepped with an antiseptic cleaner. A local anesthetic is injected around the edge of the wound to numb the area and decrease the bleeding. This tends to be the most painful aspect of the procedure since the anesthetic can cause burning and stinging. For children, an anesthetic cream may be applied to the wound before local anesthetic is injected to minimize pain.

After the wound has been numbed, it will be thoroughly cleaned and examined for tissue damage, foreign objects and contamination. If you have a deep wound, a layer of dissolvable sutures may be used. The top layer of skin may be closed with nylon sutures strong enough to hold the wound closed. Staples are another option for closing large lacerations on areas such as the scalp.

BioGlue, a sterile surgical adhesive, also can be used to close the wound. It works best for straight cuts that aren’t over areas that are frequently bent, such as joints. The adhesive may be used without anesthesia, but wounds still require careful cleaning, rinsing and examination.

After Treatment
Generally, sutures stay in for five days in areas like the face, and up to 10 days in areas like the scalp. These time frames can vary based on location of wound and how much tension is on the sutures. If the injury was at high risk for infection, antibiotics may be prescribed. If you aren’t prescribed antibiotics, you may be asked to return to your doctor’s office in 24 to 48 hours to check for any signs of infection.

The wound should be kept covered with non-stick gauze and triple antibiotic ointment to help keep the wound moist, prevent infection and decrease scarring. All lacerations will result in a scar, which may not be apparent for 6 to 12 months. Avoiding direct sunlight to further decrease scarring.

Oscar Marcilla, MD, has been with eMedical Offices since 2005. He is board-certified in emergency medicine. He earned his medical degree from Mount Sinai School of Medicine, New York City, and completed his emergency medicine residency at Jacobi Hospital, Bronx, N.Y. Dr. Marcilla is a fellow of the American Academy of Emergency Medicine and Fellow American College Emergency Physicians.

Sore throat, also known as pharyngitis or tonsillitis, is a frequent complaint that brings patients to the urgent care center. I’m going to explain the causes and symptoms of sore throats. To treat them, urgent care centers are a convenient option to get the medical attention you need to get you back to feeling better.

Causes of Sore Throats
Up to 60 percent of sore throats are caused by viruses. The most common of these are adenoviruses, coxsackieviruses, Epstein-Barr virus, cytomegaloviruses and herpes simplex viruses.

The second-most popular type is “strep” throat, which is caused by Streptococcus pyogenes or Group A beta-hemolytic streptococcus (GABHS). Only 5 to 15 percent of adults and 15 to 30 percent of children with sore throats actually have strep throat.
Other less frequent causes of a sore throat are fungal infections (oral thrush or candidiasis), HIV-1 infection in the acute phase and gonorrhea. Non-infectious causes of sore throat include heartburn or gastro-esophageal reflux disease (GERD), allergies, post-nasal drip, chemical injuries and smoking.

Symptoms of Strep Throat
Strep throat most commonly occurs in children aged 5 to 15 years old in the fall and early spring. This usually happens after children come in contract with someone who is infected, like in a classroom or daycare facility, or a family gathering.

Classic symptoms of strep throat include:

• Sudden onset
• White patches and pus on the throat and tonsils
• A fever greater than 101˚
• Difficulty swallowing
• Tender and swollen lymph nodes in neck
• Headache
• Chills and shakes alternating with cold sweats

In children, the above symptoms can be accompanied by nausea, vomiting or abdominal pain.

Symptoms of a Virus
Signs that the sore throat is caused by a virus include:

• Cough
• Runny nose
• Conjunctivitis (pink eye)
• Sneezing

Testing and Treatment of Sore Throats
Doctors use several methods to determine if a sore throat is in fact strep throat. One of the most reliable methods is the rapid strep test. This test is quick and accurate, and allows treatment to start immediately following a positive result.

The American Academy of Pediatrics recommends that doctors perform both a traditional throat culture and a rapid strep test on children. Although it takes 1 to 2 days to get results from a throat culture, because children are more likely to develop strep throat, this dual-testing method provides the most accurate diagnosis.

While only a fraction of adults and children with sore throats nationwide actually have GABHS bacterial infections, more than 75 percent are prescribed antibiotics. This practice leads to resistant bacteria, meaning the infection doesn’t improve because it’s gotten used to antibiotics, as well as side effects from treatment, including allergic reactions, diarrhea and yeast infections. Our doctors use rapid strep testing and throat cultures, and follow guidelines for the diagnosis and treatment of GABHS set by the Infectious Disease Society of America.

Strep throat responds well to penicillin. It can be given as a single dose injection or in pill form. Other prescription options include amoxicillin, cephalexin and azithromycin. To help relieve the pain and swelling of the throat, your doctor also may prescribe a single dose of dexamethasone, a steroid which is an anti-inflammatory, either by injection or by mouth.

Strep Throat Shouldn’t Be Ignored
GABHS pharyngitis will improve in a few days even if not treated with antibiotics, but we treat patients so that they feel better faster and are less contagious to others. If left untreated, strep throat can put you at risk for developing rheumatic fever, which can damage the heart valves. Another rare but serious complication is acute glomerulonephritis, an injury to the kidney, which can occur regardless of treatment.
If you are on antibiotics and aren’t feeling better or if you’ve developed a rash, jaundice or abdominal pain, contact your doctor immediately, as this might indicate Epstein Barr virus or mononucleosis infection.

In most cases, with proper evaluation and treatment, sore throats can be treated quickly and easily, often without antibiotics.

Oscar Marcilla, MD, has been with eMedical Offices since 2005. He is board-certified in emergency medicine. He earned his medical degree from Mount Sinai School of Medicine, New York City, and completed his emergency medicine residency at Jacobi Hospital, Bronx, N.Y. Dr. Marcilla is a fellow of the American Academy of Emergency Medicine and Fellow American College Emergency Physicians.

It is estimated there are 3 million head injuries each year related to contact sports, according to the Centers for Disease Control and Prevention. For teens and young adults aged 15 to 24 years, it is second only to motor vehicle accidents as the cause of traumatic brain injuries.

Concussions can be caused by mild or more severe blows to the head. They may or may not involve loss of consciousness. Recently, more attention has been placed on recognizing and treating concussions earlier to decrease the risk of long-term neurological damage.

The Signs of a Concussion
Early signs of a concussion include:

• Headache
• Dizziness
• Nausea or vomiting
• Confusion
• Disorientation
• Vision changes
• Unequally sized pupils
• Lack of awareness of surroundings
• Slurred or incoherent speech
• Lack of coordination

If your child is injured and shows any of the above signs, he or she should stop participating in the sports activity immediately. The New Jersey State Interscholastic Athletic Association requires that any student athlete who sustains a possible concussion or any loss of consciousness be removed immediately from play. A medical evaluation is required to determine if a concussion was sustained. If it’s determined that your child did have a concussion, he or she must be symptom-free for one week before he or she can return to play.

You should seek immediate medical attention if your child’s symptoms persist for more than 10 minutes. If the symptoms are mild, such as mild headache, dizziness, nausea without vomiting or loss of memory for a few minutes, watch to see if the symptoms worsen. The physicians at eMedical Offices can help determine if further care is needed.

When to Go to the Emergency Department
You should bring your child to the nearest emergency department if the injury involves:

• Large cuts
• Prolonged loss of consciousness
• Severe headaches
• Drowsiness
• Inability to walk
• Slurred speech
• Seizures

What to Expect After a Concussion
A few days to a few weeks after having a concussion your child might experience:

• A persistent, low-grade headache
• Light-headedness
• Poor attention and concentration
• Memory issues
• Fatigue
• Irritability
• Frustration
• Anxiety and/or a depressed mood
• Trouble sleeping

The recovery period for concussions can vary from patient to patient. Some may develop “post-concussion syndrome,” which can last weeks or months and includes chronic headaches, dizziness and nausea.  If your child sustains a more severe concussion, he or she should be seen by a neurologist in addition to your primary physician to manage ongoing care.

- Oscar Marcilla, MD