Letters to the Editor - October 1, 1999 - American Academy of Family Physicians

Letters to the Editor

Clinical Criteria as a Preliminary Screen for Cervical Spine Injury

TO THE EDITOR: I enjoyed Drs. Graber and Kathol's recent article¹on the significance of radiographs of the cervical spine in trauma victims, which I thought was a thorough review. However, I would like to address one important point: the fear of failure to identify cervical spine injuries has led doctors to an extremely liberal policy for ordering neck radiographs in trauma patients.

In childhood, adults repeatedly admonished us that if we were not careful we would either "put our eye out" or "break our neck." Everyone knows what happens when a person hangs from the neck or when a secret agent in a movie grabs someone from behind and gives the victim's neck a twist. The fear of neck injury leads a steady stream of trauma patients into physicians' offices and emergency departments.

The authors of the review note that "low-risk criteria have been defined that can be used to exclude cervical spine fractures, based on the patient's history and physical examination." However, these criteria have never been prospectively validated, and five of the six references that the authors cite are small, uncontrolled retrospective studies without explicit criteria that evaluated patients with traumatic cervical spine injuries. One referenced study² was prospective and well researched, but the study group was too small to have the power to validate the low-risk criteria.

In the setting of a litigious society and numerous reports of cervical spine injuries and the common desire of patients to have neck radiographs taken, many physicians order neck radiographs for most patients, regardless of the mechanism of injury or the patient's signs and symptoms. Despite the low-risk criteria described in the review article, Neifeld and colleagues³ have shown that, based on the best estimates of the incidence of occult cervical spine injury in order for the low-risk criteria to be validated, a prospective study of over 30,000 asymptomatic or minimally symptomatic trauma patients would be needed to demonstrate with 99 percent confidence that no significant fracture or dislocation would be missed by failing to obtain a radiograph of the neck in such patients.

The solution to this problem may be at hand. The National Emergency X-Radiography Utilization Study (NEXUS)⁴ is a very large, federally funded, multicenter, prospective study designed to define the sensitivity for detecting significant cervical spine injury using the described low-risk criteria that was previously shown to have a high negative predictive value. The NEXUS study is being conducted at 23 hospital emergency departments in the United States, and 20,000 to 30,000 trauma patients who are at risk for cervical spine injury are expected to be enrolled.

When the results of NEXUS⁴ are reported, we should know definitively about the validity and reliability of clinical criteria used as preliminary screening for cervical spine injury. Hopefully, the estimated 800,000 patients who undergo cervical spine radiography annually in the United States will be reduced to a lower number, saving on costs that are currently in excess of $180 million.⁴ Still, the reported clinical experience to date supports the recommendation that radiographs of the cervical spine be obtained for patients in whom spinal injury is suspected based on clinical assessment.⁵

EDWARD L. FIEG, MAJ, USAF, MC
51 Medical Group/SGOME
PSC #3, Box 2724
APO AP 96266

REFERENCES

Graber MA, Kathol M. Cervical spine radiographs in the trauma patient. Am Fam Physician 1999;59:331-42.

Hoffman JR, Schriger DL, Mower W, Luo JS, Zucker M. Low-risk criteria for cervical-spine radiography in blunt trauma: a prospective study. Ann Emerg Med 1992;21:1454-60.

Neifeld GL, Keene JG, Hevesy G, Leikin J, Proust A, Thisted RA. Cervical injury in head trauma. J Emerg Med 1988;6:203-7.

Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med 1998;32:461-9.

Hockberger RS, et al. Spinal injuries. In: Rosen P, et al., eds. Emergency medicine: concepts and clinical practice. 4th ed. St. Louis: Mosby, 1998:462-505.

IN REPLY: We agree wholeheartedly with the comments of Major Fieg. We, too, await results of the NEXUS trial,¹ which will be the largest prospective trial of neck injuries to date. We also agree with his conclusion that "the reported clinical experience to date supports the recommendation that radiographs of the cervical spine be obtained for patients in whom spinal injury is suspected based on clinical assessment." This is what we suggest in our article.

In patients with low-risk criteria and normal findings on physical examination, current experience suggests and the accepted standard of care indicates that cervical radiographs are unnecessary. As noted in our article, not all of the so-called missed fractures actually met low-risk criteria. We hope that the NEXUS trial will provide additional evidence to support the current best practice.

MARK A. GRABER, M.D.
Department of Family Medicine
PFP, University of Iowa Hospitals and Clinics
Iowa City, IA 52242

REFERENCE

Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med 1998;32:461-9.

Speech and Language Problems in International Adoptees

TO THE EDITOR: The recent article by Drs. Quarles and Brodie¹ provides an excellent overview of the issues that the families of internationally adopted children must face. Dr. Johnson's editorial,² appearing in the same issue, sheds further light on the trends in international adoption. He notes that 13,000 children were adopted from overseas in 1997. This year, the United States has become home to nearly 16,000 additional international adoptees.³ Family physicians will be called on to contend with some of the significant issues presented by these children.

We recently concluded a study that examined the behavior and emotional issues of 105 children who were adopted from the former Soviet Union. Our community-based study recruited subjects from adoption agency placements, as opposed to a clinic population, to depict the integration of these children into their adoptive families at least two years after placement.

A major issue encountered by the majority of families is that of speech and language problems. Drs. Quarles and Brodie propose that the children be referred to English as second language (ESL) services at subsequent visits. ESL is based on the assumption that first language ability is intact. In our study, 56 percent of the children had speech and language difficulties; other studies support similar findings.⁴ Our research suggests that, rather than ESL services, these children need speech evaluation in their native language, if possible. The availability of such evaluation is variable and seems to depend on the number of internationally adopted children in a given area.

Many factors contribute to the high incidence of speech and language problems in these children. Although a genetic predisposition to speech and language problems may exist, family histories of adopted children are typically unknown. Poor prenatal care and substandard perinatal conditions are common in the countries of the former Soviet Union and contribute to speech and language difficulties. Indeed, the most frequently cited reason for children to be placed in an Eastern European orphanage is abandonment by a single parent who is unable to provide for herself or an infant. Another contributing factor to speech and language disorders is fetal alcohol exposure.⁵ In our sample group of internationally adopted children, the adoptive parents reported (based on information from orphanage records) that 41 percent of the children had birth mothers with histories of alcohol abuse.

Normal language development also requires environmental input to flourish. The orphanages of Eastern Europe have been described as colorless and quiet, with little visual or auditory stimulation.⁶ With child-to-caregiver ratios as high as 30 to 1, the orphanage represents an environment of auditory deprivation, further increasing the risk of speech and language disorders.

Internationally adopted children are often unskilled in their native languages. A child arriving in the United States from Russia is typically monolingual, speaking only in Russian. After several months, the child is monolingual again, this time speaking in English. A child between four and eight years of age will lose the majority of expressive Russian speaking skills within the first few months of living in the United States. Eventually, receptive language will disappear. Thus, the primary language is rapidly extinguished and replaced by English. This initial success in the acquisition of a new language may lead to a false sense of security. Unfortunately, a seemingly smooth mastery of conversational English does not automatically guarantee proficiency in the cognitive and academic aspects of language; these aspects of language become increasingly important as the child enters school. In short, family physicians should not hesitate to refer internationally adopted children for speech and language evaluation.

Multiple resources are available on the Internet to assist adoptive parents in facing the challenges they may encounter. A good place to start would be our Web site, which is devoted to research in international adoption (http://www.adoption-research.org).

TEENA MCGUINNESS, PH.D., R.N.
JOHN MCGUINNESS, M.D.
University of South Alabama
Springhill Area Campus
Mobile, AL 36604

REFERENCES

Quarles CS, Brodie JH. Primary care of international adoptees. Am Fam Physician 1998;58:2025-32.

Johnson DE. The family physician and international adoption [Editorial]. Am Fam Physician 1998;58: 1958-63.

U.S. Department of State Web site. Significant source countries of orphans. Available at: http://travel.state.gov/orphan_numbers.html. Accessed December 26, 1998.

Johnson DE, Albers L, Iverson S, Mathers M, Dole K, Georgieff M, et al. Health status of Eastern European (EE) orphans referred for adoption. Pediatric Res 1996;39(4 Pt 2):134A.

Church MW, Abel EL. Fetal alcohol syndrome. Hearing, speech, language, and vestibular disorders. Obstet Gynecol Clin North Am 1998;25:85-97.

Ames EW, Chisholm K, Fisher L, Morison SJ, Thompson S, Mainemer H. The development of Romanian children adopted to Canada. Burnaby, B.C.: Human Resources Development Canada,1997:138.

IN REPLY: We would like to thank Drs. McGuinness and McGuinness for their response to our article¹ regarding the importance of vigilance in the evaluation of international adoptees for speech and language abnormalities. Information collected from adoption clinics evaluating children from Romania, Eastern Europe and the former Soviet Union indicate that up to 85 percent of these children will have some form of developmental abnormality, and this is especially profound in very young children who come from institutions.^2,3 Family physicians are likely to have the opportunity to care for such childern as more immigrate to the United States. We agree that developmental problems, including speech and language difficulties, are frequent challenges for adopting parents, the children and their physicians.

The impact of institutionalization, environmental deprivation and toxic exposures on the development of speech and language cannot be minimized. However, records from orphanages in these countries frequently depict ominous diagnoses and histories that are sometimes inaccurate.³ We agree with the recommendations of Albers and colleagues³ to consider children who come from such environments as children with "special needs" and to aggressively work to help them meet their developmental potential.

We did not mean to imply that training in English as a second language (ESL) is the answer to identification or treatment of speech and language challenges in these children. For most adoptive parents, gaining access to speech evaluation in the child's native language is difficult, but if available, identification and treatment of language challenges may occur earlier. Many adoptive parents want their children to learn English, and for children without suspected or identified speech and language deficits, ESL services can be invaluable. Early intervention programs for very young children and early identification of older children who lack proficiency in "cognitive and academic aspects of language" are key to the future of these children. Clearly, country of origin is a risk factor, and certain countries should mandate rallying whatever resources are available to ensure optimal speech and language development for these children and their families. Thanks to Drs. McGuinness and McGuinness for underscoring these points.

CHRISTOPHER S. QUARLES, LCDR, MC, USNR
Branch Medical Clinic
Lamaddalena, Italy
JEFFREY H. BRODIE, CAPT, MC, USN
Naval Hospital, Bremerton
HPO1 Boone Rd.
Bremerton, WA 98312-1898

REFERENCES

Quarles C, Brodie J. Primary care of international adoptees. Am Fam Physician 1998;58:2025-32.

Johnson DE, Miller LC, Iverson S, Thomas W, Franchino B, Dole K, et al. The health of children adopted from Romania. JAMA 1992;268:3446-51.

Albers LH, Johnson DE, Hostetter MK, Iverson S, Miller LC. Health of children adopted from the former Soviet Union and Eastern Europe. Comparison with preadoptive medical records. JAMA 1997; 278:922-4.

Corrections

Two patient information handouts were transposed in the March 1, 1999 issue. The handout on gastroesophagreal reflux disease should have been on page 1172; the handout on congenital adrenal hyperplasia should have been on page 1199.

The article "Warfarin Therapy: Evolving Strategies in Anticoagulation" (February 1, 1999, page 635) contained an error in Figure 1 (page 638), pertaining to warfarin dosing adjustments. In the Monday column of that figure, the third entry down should read 0.5 tablet.

A "Newsletter" item about the AARP campaign against Medicare fraud (March 15, 1999, page 1375) provided an incorrect Web site address for the AARP (correct address: http://www.aarp.org/medfraud).

In a "Special Medical Report" on tuberculosis screening in patients with human immunodeficiency virus infection (March 15, 1999, page 1682), the address for the Division of TB Elimination was incorrect (correct address: http://www.cdc.gov/nchstp/tb).

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 8880 Ward Pkwy., Kansas City, MO 64114; fax: 816-333-0303; e-mail: afplet@aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors may edit letters to meet style and space requirements.

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