Infant Cataracts: Screening in Primary Care

From CHOP Expert Commentary Monte D. Mills, MD Posted: 09/26/2011 Director of the Division of Ophthalmology at Children's Hospital of Philadelphia. Infant cataracts are rare. About 1 in 2000 to 1 in 5000 children will have unilateral or bilateral cataracts during infancy. Early detection and treatment are crucial to getting the best visual outcomes for our infants with cataracts. The primary care provider is in the perfect situation to detect and refer these infants for treatment early on during early infant examinations in the hospital and office. The critical and best instrument to detect cataract is the direct ophthalmoscope that you have in your office and in the hospital. You would use it by setting it to the large white spot setting and shining it in a darkened room into the infant's eyes. As you look through the peephole, look at the quality of the red reflex in both eyes simultaneously, examining for symmetry, redness, and brightness of the red reflex. Cataracts would be seen as a dull red reflex or as an asymmetrical red reflex, bright in one side and dull in the other side. It can also be visible as a white pupillary reflex. Children with asymmetry, a dull red reflex, or a white reflex should be referred for evaluation to an ophthalmologist. Infant cataracts should be treated during the first 6 weeks of life to get the best visual outcome. With prompt detection and an early referral and treatment, we can get the best possible outcomes for our patients with infant cataracts. Later in life, infant cataracts might be seen with symptoms including nystagmus, poor visual fixation and following, poor social smile, or strabismus. These children, of course, should also be referred for a full evaluation to an ophthalmologist and potentially for treatment. With early detection using the red reflex test with the direct ophthalmoscope, you'll be able to detect early cataracts. Refer them promptly to achieve the best possible visual outcomes.

New Method of Scoliosis Assessment

From Spine Preliminary Results Using Computerized Photogrammetry Rozilene Maria Cota Aroeira, MSc; Jefferson Soares Leal, MD; Antônio Eustáquio de Melo Pertence, PhD Posted: 09/26/2011; Spine. 2011;36(19):1584-1591. © 2011 Lippincott Williams & Wilkins Study Design. A new method for nonradiographic evaluation of scoliosis was independently compared with the Cobb radiographic method, for the quantification of scoliotic curvature. Objective. To develop a protocol for computerized photogrammetry, as a nonradiographic method, for the quantification of scoliosis, and to mathematically relate this proposed method with the Cobb radiographic method. Summary of Background Data. Repeated exposure to radiation of children can be harmful to their health. Nevertheless, no nonradiographic method until now proposed has gained popularity as a routine method for evaluation, mainly due to a low correspondence to the Cobb radiographic method. Methods. Patients undergoing standing posteroanterior full-length spine radiographs, who were willing to participate in this study, were submitted to dorsal digital photography in the orthostatic position with special surface markers over the spinous process, specifically the vertebrae C7 to L5. The radiographic and photographic images were sent separately for independent analysis to two examiners, trained in quantification of scoliosis for the types of images received. The scoliosis curvature angles obtained through computerized photogrammetry (the new method) were compared to those obtained through the Cobb radiographic method. Results. Sixteen individuals were evaluated (14 female and 2 male). All presented idiopathic scoliosis, and were between 21.4 ± 6.1 years of age; 52.9 ± 5.8 kg in weight; 1.63 ± 0.05 m in height, with a body mass index of 19.8 ± 0.2. There was no statistically significant difference between the scoliosis angle measurements obtained in the comparative analysis of both methods, and a mathematical relationship was formulated between both methods. Conclusion. The preliminary results presented demonstrate equivalence between the two methods. More studies are needed to firmly assess the potential of this new method as a coadjuvant tool in the routine following of scoliosis treatment. Introduction Scoliosis has been defined as a lateral curvature of the spinal column superior to 10° Cobb, generally associated to vertebral rotation. Monitoring of this angle has been one of the principal parameters used in defining the type of treatment to be instituted in young patients who are still growing. The most trustworthy method to accompany the evolution of the curvature has been the standing posteroanterior full length spine radiograph, with curvature measurement using the Cobb method.[3] However, over the course of follow-up, this can result in taking more than 25 radiographs. Nearly 15% of patients in one study had undergone 50 or more radiographic examinations, and approximately 17% had received an estimated cumulative radiation dose of 20 cGy or greater. This high number of radiographs can expose patients to relatively high doses of ionizing radiation. Various studies have shown that repeated exposure to radiation in children could be harmful to their health. Many nonradiographic methods of scoliosis accompaniment have been proposed as an alternative to radiographic evaluation.Nevertheless, the majority has not demonstrated a good correlation with the Cobb method. Photogrammetry can be regarded as the science and technology of obtaining spatial measurements, and other geometrically reliable information, derived from photographs.The computerized photogrammetry method proposed in this study can be considered one of many uses of photogrammetry. It has been used in different fields, such as: cartography, architecture, engineering, quality control, and three-dimensional modeling. However, its use in the evaluation of scoliosis has not been well studied. To the authors' knowledge, no data are presently available in the literature that proposes a protocol for photogrammetric measurement of scoliosis, which is applicable to clinical practice. The goals of this investigation were to develop a protocol for computerized photogrammetry method for the quantification of scoliosis curvature as well as to compare the results with those from the Cobb radiographic method in the group of volunteers. Our hypothesis is that both methods yield similar results in obtaining the scoliosis curvature angle. http://www.medscape.com/viewarticle/749301?src=mp&spon=9

Allergic to Antihistamines---really!

Gary Stadtmauer, MD, Allergy & Clinical Immunology, 08:22AM Oct 17, 2011 How many times have we heard patients say they are "allergic" to drugs like antihistamines and corticosteroids? Hypersenstivities to medications used to treat allergic diseases are fortunately uncommon. Both the allergy literature and the dermatology literature describe delayed (and even immediate) hypersensitivity reactions to corticosteroids. Patch testing is the preferred method of detecting Type IV hypersensitivity to corticosteroids since intradermal testing may cause dermal atrophy. Corticosteroids with C16 methylation (such as betamethasone) are less allergenic than other steroids. I have seen a couple of cases of drug exanthema from antihistamines but never immediate hypersensitivity...until now. I recently saw a young woman who has had recurrent urticaria/angioedema of immediate onset due to Benadryl. She had no associated symptoms. Scratch testing to Benadryl 5mg/ml was negative but ID was positive at 0.5 mg/ml (W/F of 4/10) and 5 mg/ml (W/F o 5/10). See image below. One could question whether this is an IgE-mediated event. Perhaps it is or perhaps in the occasional patient the antihistamine acts as an agonist, binding to the receptor instead of blocking it thereby triggering histamine release. Anaphylactic shock caused by a challenge with 12.5 mg oral diphenhydramine has been reported and the authors of this case suggest the mechanism was IgE-mediated.

Low-Dose Intradermal Flu Vaccine Effective as Intramuscular

From Medscape Medical News Daniel M. Keller, PhD October 24, 2011 (Boston, Massachusetts) — Injecting a lower dose of 2010/11 trivalent influenza vaccine (TIV) intradermally was more immunogenic than a traditional full-dose intramuscular injection for chronically adults, Ivan Hung, MD, clinical assistant professor in the Department of Medicine at the University of Hong Kong, China, reported here at the Infectious Diseases Society of America (IDSA) 49th Annual Meeting. Dr. Hung and colleagues used 1 of 2 devices to administer intradermal injections using 20% or 60% of the standard dose, and compared the immunogenicity with standard doses delivered intramuscularly in an open-label, prospective, randomized trial. From December 2010 to March 2011, 282 chronically ill adults were randomly assigned to 1 of 4 treatments: TIV containing 3 μg of hemagglutinin antigen per strain, administered with a MicronJet600 device; the same treatment but with 9 μg of hemagglutinin antigen per strain; 9 μg of Intanza9 vaccine, administered with the Soluvia device (Sanofi-Aventis); and 15 μg of TIV administered intramuscularly (control group). Immunogenicity was determined through a hemagglutination inhibition assay at baseline and 21 days after vaccination. Of the 282 subjects enrolled, 262 completed the study — approximately evenly divided among the 4 groups (63 to 68 per group.) Demographically, the groups were similar, with a median age of 73.5 years (range, 68.0 to 78.5 years). At day 21, the seroconversion rates for influenza A/H1N1 for all the intradermal lower-dose groups were higher (approximately 50%) than for the intramuscular full-dose group (approximately 13%; P = .017). Similarly, seroprotection, determined by hemagglutination inhibition assay, was greater for all the intradermal groups than for the intramuscular group (P = .024). In all cases, seroconversion, seroprotection, and geometric mean titer fold increases were at least as good or better for the intradermal groups than for the intramuscular group in terms of response to the A/H1N1, H3N2, and influenza B components of the vaccines. "The reason for that is perhaps [because] the intradermal vaccination attracted dendritic cells, and that actually mounted a much better immune response," Dr. Hung said, also noting that no serious adverse effects were detected. He recommends that all elderly and immunocompromised individuals receive intradermal influenza immunizations to compensate for their reduced reactivity to vaccines. "Intradermal vaccination actually mounted a much better immune response, and that would offer better protection against influenza and the complications of influenza (for example, pneumonia) in the elderly population and also for those immunocompromised hosts," Dr. Hung told Medscape Medical News. "For the lower dose, you have slightly fewer side effects in terms of swelling, in terms of redness, which is important for elderly people and perhaps has less systemic effects." He explained that intradermal injection is quite easy to give, and suggested that intradermal dose reduction might be an effective way to make vaccine go further in situations of high demand during future pandemics, once the efficacy of dose-sparing vaccination in healthy individuals has been demonstrated. Andrew Pavia, MD, chief of pediatric infectious disease at the University of Utah, Salt Lake City, and chair of the Pandemic Influenza Task Force of the IDSA, who was not involved in the study, told Medscape Medical News that it is worthwhile investigating better ways for influenza immunization. "The weakness of flu vaccine is that it doesn't cause as good an antibody response in the elderly. One of the things that we'd like to do is to get a flu vaccine or a way of delivering the old flu vaccine that works just as well in the frail elderly as it does in healthy young and middle-aged adults." Besides the equivalent or better efficacy that Dr. Hung showed, Dr. Pavia sees other advantages of intradermal injections. "There have been reports that with intradermal devices, it hurts much less going in because the needle is a microneedle, which people barely feel, but there may be increased itching or redness at the site, compared to getting a deeper injection with an intramuscular vaccine. Some people may prefer itching to injection pain," he said. "The efficacy studies really haven't been done to show that they're truly equivalent. Cost would be the only other barrier. I think as an alternative, this is very interesting and potentially very useful." He also sees intradermal injection as an advantage for people who are "relatively needle-phobic." "It may be useful when you've got a less-skilled population because this is pretty much an automatic device — you don't have to be skilled in giving an intramuscular injection, and of course, there's less risk of needle sticks," he explained. The study received no commercial funding. Dr. Hung reports a collaboration with and receiving research support from NanoPass Technologies. Dr. Pavia has disclosed no relevant financial relationships. Infectious Diseases Society of America (IDSA) 49th Annual Meeting: Abstract 533. Presented October 21, 2011.

Do Not Give Flu Vaccine by Jet Injection, FDA Says

From Medscape Medical News > Alerts, Approvals and Safety Changes > Medscape Alerts Robert Lowes October 24, 2011 — Clinicians should not administer influenza vaccines with needleless "jet injectors" because the vaccines have not been approved for such devices, the US Food and Drug Administration (FDA) has warned. The announcement, issued October 21, follows recent advertisements by major retailers such as Kroger stating that customers can receive such a needleless seasonal flu vaccine instead of the standard injection at their in-store pharmacies. Kroger announced October 21 that it had discontinued the use of this administration technique. A jet injector shoots a high-pressure stream of liquid medication that can penetrate the skin and deliver a dose to tissues underneath. Two manufacturers of jet injectors, PharmaJet and Bioject Medical Technologies, have contested the FDA warning, noting that their products already have received FDA clearance for delivering drugs and vaccines. FDA spokesperson Shelly Burgess told Medscape Medical News that the manufacturers are entirely correct on that point. However, influenza vaccines themselves need to be approved for specific administration methods, regardless of whether the device is approved, Burgess said. So far, the FDA has not cleared any influenza vaccine for jet injection. The agency is advising clinicians to abide by label instructions for administration, whether it is by needle injection or nasal spray. The only vaccine cleared for use with approved jet injectors is for measles, mumps, and rubella (MMR). "Jet injectors represent a different method of delivery that has the potential to change the characteristics of an approved vaccine," the FDA stated in its announcement. "Therefore, each vaccine preparation must be individually evaluated for administration by jet injector, and safety and effectiveness data for that vaccine must be submitted to [the FDA's Center for Biologics Evaluation & Research] for review and approval." The FDA has not received any reports of adverse events associated with jet-injected influenza vaccine, nor is it voicing specific safety concerns, Burgess told Medscape Medical News. "We just haven't studied it yet." When asked whether customers who received influenza vaccine by jet injection should get immunized again during the current influenza season, Burgess referred the matter to a spokesperson for the US Centers for Disease Control and Prevention (CDC). CDC spokesperson Thomas Skinner told Medscape Medical News that "based on current, though limited, information from publications, CDC and FDA believe that it is not necessary for people who got their flu vaccine via jet injector to be re-vaccinated." More information about the FDA announcement is available on the agency's Web site. To report adverse events related to jet injection of an influenza vaccine, contact MedWatch, the FDA's safety information and adverse event reporting program, by telephone at 1-800-FDA-1088, by fax at 1-800-FDA-0178, online at http://www.fda.gov/medwatch, or by mail to MedWatch, FDA, 5600 Fishers Lane, Rockville, Maryland 20852-9787.

BABIES AND TODDLERS SHOULD LEARN FROM PLAY, NOT SCREENS

News Release from the American Academy of Pediatrics. BABIES AND TODDLERS SHOULD LEARN FROM PLAY, NOT SCREENS October 18 BOSTON - The temptation to rely on media screens to entertain babies and toddlers is more appealing than ever, with screens surrounding families at home, in the car, and even at the grocery store. And there is no shortage of media products and programming targeted to little ones. But a new policy statement from the American Academy of Pediatrics (AAP) says there are better ways to help children learn at this critical age. In a recent survey, 90 percent of parents said their children under age 2 watch some form of electronic media. On average, children this age watch televised programs one to two hours per day. By age 3, almost one third of children have a television in their bedroom. Parents who believe that educational television is "very important for healthy development" are twice as likely to keep the television on all or most of the time. The policy statement, "Media Use by Children Younger Than Two Years," will be released Tuesday, Oct. 18, at the AAP National Conference & Exhibition in Boston and will be published in the November 2011 issue of Pediatrics (published online Oct. 18). Ari Brown, MD, FAAP, lead author of the policy, will discuss the recommendations in an embargoed news briefing for reporters at 10 a.m. ET Monday, Oct. 17, at the Boston Convention & Exhibition Center. The AAP first provided guidance on media use for children under age 2 in 1999. This consisted of a recommendation in the Academy's policy statement, "Media Education," which discouraged TV viewing for children in this age group. At the time, there was limited data on the subject, but the AAP believed there were more potential negative effects than positive effects of media exposure for the younger set. Newer data bears this out, and the AAP stands by its recommendation to keep children under age 2 as "screen-free" as possible. More is known today about children's early brain development, the best ways to help them learn, and the effects that various types of stimulation and activities have on this process. "The concerns raised in the original policy statement are even more relevant now, which led us to develop a more comprehensive piece of guidance around this age group," said Dr. Brown, a member of the AAP Council on Communications and Media. The report set out to answer two questions: Do video and televised programs have any educational value for children under 2? Is there any harm in children this age watching these programs? The key findings include: Many video programs for infants and toddlers are marketed as "educational," yet evidence does not support this. Quality programs are educational for children only if they understand the content and context of the video. Studies consistently find that children over 2 typically have this understanding. Unstructured play time is more valuable for the developing brain than electronic media. Children learn to think creatively, problem solve, and develop reasoning and motor skills at early ages through unstructured, unplugged play. Free play also teaches them how to entertain themselves. Young children learn best from-and need-interaction with humans, not screens. Parents who watch TV or videos with their child may add to the child's understanding, but children learn more from live presentations than from televised ones. When parents are watching their own programs, this is "background media" for their children. It distracts the parent and decreases parent-child interaction. Its presence may also interfere with a young child's learning from play and activities. Television viewing around bedtime can cause poor sleep habits and irregular sleep schedules, which can adversely affect mood, behavior and learning. Young children with heavy media use are at risk for delays in language development once they start school, but more research is needed as to the reasons. The report recommends that parents and caregivers: Set media limits for their children before age 2, bearing in mind that the AAP discourages media use for this age group. Have a strategy for managing electronic media if they choose to engage their children with it; Instead of screens, opt for supervised independent play for infants and young children during times that a parent cannot sit down and actively engage in play with the child. For example, have the child play with nesting cups on the floor nearby while a parent prepares dinner; Avoid placing a television set in the child's bedroom; and Recognize that their own media use can have a negative effect on children. The report also recommends further research into the long-term effects of early media exposure on children's future physical, mental and social health. According to Dr. Brown, "In today's ‘achievement culture,' the best thing you can do for your young child is to give her a chance to have unstructured play-both with you and independently. Children need this in order to figure out how the world works."

Tdap Vaccine for Pregnant Women

From Medscape Medical News Updated Recommendations for Tdap Include Pregnant Women Ricki Lewis, PhD October 21, 2011 — The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention is taking measures to fill a gap in the protection of infants from pertussis, by vaccinating pregnant women and people in contact with infants younger than 1 year. The tetanus, diphtheria, and pertussis (Tdap) vaccine consists of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine. Vaccinating pregnant women and those in contact with infants will supplement the current practice of "cocooning," in which unvaccinated postpartum mothers and other family members receive Tdap. Although ACIP has recommended cocooning since 2005, compliance has been poor. ACIP also recommends Tdap for people aged 11 through 18 years after they complete the childhood vaccine regimen of diphtheria and tetanus toxoids and pertussis/diphtheria and tetanus toxoids and acellular pertussis, as well as for adults between the ages of 19 and 64 years who have not received Tdap, in addition to people older than 65 years who may be in contact with infants who have not received the vaccine. The reason for the new recommendations is that infants, especially those younger than 2 months, which is when vaccination begins, are particularly vulnerable to developing severe illness and death from pertussis. Vaccinating pregnant women will pass antibodies to the newborn before and during birth. ACIP advises administration after 20 weeks' gestation to minimize the confounding effects of early pregnancy loss in evaluating safety and to maximize the maternal antibodies transmitted to the fetus and infant, given that the half-life of such antibodies is 6 weeks. This new perinatal exposure should provide protection until the infant's first vaccination at 2 months. In the United States each year since 2004, a mean of 3055 infants contract pertussis, with 19 or more deaths, according to the National Notifiable Diseases Surveillance System of the US Centers for Disease Control and Prevention. The total number of cases reported for 2010 was 27,550. Abundant evidence indicates that tetanus and diphtheria vaccines are safe during pregnancy. Although the possible teratogenicity of the vaccine was not initially studied, data from patient registries maintained by the vaccine manufacturers (Sanofi Pasteur and GlaxoSmithKline Biologicals) indicate that Tdap is safe. Further studies will investigate whether exposure to maternal antibodies is indeed protective, or whether it blunts the infant's vaccine response. MMWR Morb Mortal Wkly Rep. 2011;60:1424-1426. Full text