Rubella Immunization

corpus luteum. Cystic degeneration of the ovarian remnant is common since the blood supply to the remnant is compromised. However, ovulation occasionally occurs, and the bleeding that ensues causes tissue reaction around it, which would render future dissection most difficult. If the bleeding occurred into a cyst (corpus luteum or follicular), there would be an increase, possibly dramatic, in the size of the ovarian remnant. In these two cases the bleeding was probably into a corpus luteum cyst.


Rubella immunization
Stimulated by our group's interest in the report of the Canadian Task Force on the Periodic Health Examination' and the response of the section on general and family prac-tice of the Ontario Medical Associa-tion2 we wanted to assess our effectiveness with a procedure that was well accepted for its benefits to patients and could readily be monitored. Because of an earlier study by Mills and colleagues3 we selected rubella immunization. We looked at our documented immunization rates for children 4 to 6 years old (born between 1976 and 1978) and for girls 10 to 12 years old (born between 1970 and 1972). We also looked at the relation between immunization status in girls 10 to 12 years old and their attendance in the family practice unit in the preceding 2 years.
We found that 70% of the children 4 to 6 years old but only 48% of the girls 10 to 12 years olda significant difference (p < 0.05)had documented evidence of immunization against rubella. Compared with the findings of Mills and col-leagues3 our rate was comparable for the group aged 5 to 9 years (62%) but somewhat better for the group aged 10 to 14 years (25%). Whether the girls 10 to 12 years old were seen in our unit in the past 2 years had no influence on the rate of documented immunization.
Our findings certainly support the 1982 decision of the Ontario Ministry of Health to require immunization for all school-aged children. The lower rate of documented immunization for older children raises questions about the immunization practices in Manitoba and Alberta, where rubella vaccine is recommended for prepubertal girls but not for infants. 4 We also question our effectiveness in providing initiatives considered beneficial to patients. We suggest that family practices need a system of monitoring and recalling patients for specified inves-tigations5 and preventive measures.  Dermatitis herpetiformis is an uncommon but not rare disease. It is an intensely itchy, chronic papulovesicular eruption that is usually symmetrically distributed on extensor surfaces of the body. The commonest age of onset is from the late teens to the 30s. Without treatment the symptoms persist indefinitely. Direct immunofluorescence study of normal or perilesional skin demonstrates IgA deposits at the dermalepidermal junction. This is quite a specific and sensitive diagnostic test. There is a marked increase in the prevalence of the major histocompatibility antigens HLA-B8 and HLA-Dw3. Most patients have an associated symptomatic gluten-sensitive enteropathy that mimics celiac disease.' Recent investigations have demonstrated that patients with dermatitis herpetiformis have high serum levels of gluten. 2 Dermatitis herpetiformis usually responds dramatically to dapsone, but patients must continue taking this medication indefinitely, and its side effects may be fatal; they include hemolysis (especially marked in patients with a deficiency of glucose-6phosphate dehydrogenase), methemoglobinemia, erythema multiforme, erythema nodosum, toxic effects in the kidneys and liver, psychosis, the diaminodiphenylsulfone syndrome, neuropathy and agranulocytosis. Many of these side effects are dose-related.3 Fortunately, a gluten-free diet is effective in the treatment of dermatitis herpetiformis."4'5 Strict adherence to it will cause a reversal of the intestinal villous atrophy seen in this disease after a few months. It is often possible to decrease the dose of dapsone in patients who have adhered to a gluten-free diet for several months. Complete remission is much more frequent when such a diet is followed. Unfortunately, strict adherence to the 4iet does not appear to protect against intestinal lymphoma.6 The printed nutritional advice about a gluten-free diet available to these patients makes no mention of their disease and its response to a gluten-free diet. Such information should be available in pamphlets to encourage the patients to continue with their diet.

Research in family medicine
A letter from Dr. Michael C.P. Livingston in the Nov. 15, 1982 issue of CMAJ, "A firmer foundation for family medicine?" (127: 953-954), has prompted me to comment on current research in family medicine.
Certainly family medicine has yet to be justified on a research basis, but have any of the more established disciplines justified their existence on this basis? As Dr. Livingston correctly points out, the number of Canadian textbooks on the subject is limited.
The College of Family Physicians of Canada (CFPC) has recognized the lack of good research into family medicine and has set up a national library of family medicine, an index of articles on family medicine (FAMLI) and a research newsletter. Several departments of family medicine in Canada now have faculty with postgraduate training in epidemiology and actively pursue the teaching of critical evaluation skills and research methods. Indeed, i\n a majority of Canadian family medicine departments, research by faculty and residents is either obligatory or strongly encouraged. The journal published by the CFPC, Canadian Family Physician, now peer-reviews its-research-based articles, and the gathering strength of the North American Primary Care Research Society, which will hold its next meeting in April 1983 in Banff, adds considerably to the research base for family medicine. It is also significant that approximately $7 million in research monies goes to funding primary care research in Canada.
Finally, in the 1 960s and early '70s many of the concepts of family medicine were indeed "soft" to the conservative discipline of medicine because they brought new data from primary care sources and new concepts that challenged the traditional hospital-based studies. In addition, medical journals did not encourage articles on family practice. Fortu-