Improve memory tips

JUL 9, 2008

Improve Memory with Sleep, Practice, and Testing

By: Dr. Bill Klemm

There are whole mar­kets (think cross­words, herbal sup­ple­ments, drugs, brain fit­ness soft­ware) aimed at help­ing us improve our memory.

Now, what is “mem­ory”? how does the process of mem­ory work?

Dr. Bill Klemm, Pro­fes­sor of Neu­ro­science at Texas A&M Uni­ver­sity, explains a very impor­tant con­cept below.

- Alvaro

——-

Get­ting from Here to There:
Mak­ing Mem­ory Con­sol­i­da­tion Work

By Bill Klemm,  Ph. D.

Until con­sol­i­da­tion has occurred, a short-term mem­ory is very vul­ner­a­ble, as all of us have expe­ri­enced from look­ing up a phone num­ber only to have some dis­trac­tion cause us to lose the num­ber before we can get it dialed.

What is “consolidation”?

Brain researchers use the term “con­sol­i­da­tion” for the process whereby short-term mem­ory gets made more permanent.

Here, I would like to dis­cuss some aspects of con­sol­i­da­tion that many peo­ple may not know about: why sleep is so impor­tant, why mem­ory must be prac­ticed, and how test­ing pro­motes consolidation.

1. Over-training: You Can Learn Too Much

Exper­i­ments have shown that human mem­ory per­for­mance unex­pect­edly dete­ri­o­rated if learn­ing ses­sions were increased to four 60-minute ses­sions at reg­u­lar inter­vals on the same day. In other words, the more the sub­jects were trained, the poorer they per­formed. How­ever, this inter­fer­ence did not occur if sub­jects were allowed to nap for 30–60 min­utes between the sec­ond and third sessions.

It is hard to explain why over-training dis­rupts per­for­mance, but I sus­pect that as train­ing tri­als are repeated the infor­ma­tion starts to inter­fere with mem­ory con­sol­i­da­tion, per­haps because of bore­dom or fatigue in the neural cir­cuits that medi­ate the learn­ing. Nap­ping must have a restora­tive func­tion that com­pen­sates for the neg­a­tive effects of over-training. What all this sug­gests is that mem­ory con­sol­i­da­tion would be opti­mized if learn­ing occurred in short ses­sions that are repeated but only with inter­ven­ing naps and on dif­fer­ent days with reg­u­lar night-time sleep. In other words, repeat­ing long study peri­ods in the same day on the same task can be counter-productive. This is yet another rea­son why stu­dents should not cram-study for exams. Learn­ing should be opti­mized by rehears­ing the same learn­ing mate­r­ial on sep­a­rate days where nor­mal sleep occurred each night.

Sources:

- Maquet, P. et al. 2002. Be caught nap­ping: you’re doing more than rest­ing your eyes.Nature Neu­ro­science. 5 (7); 618–619.

- Med­nick, Sara, et al. 2002. The restora­tive effect of naps on per­cep­tual deterioration.Nature Neu­ro­science. 5 (7): 677–681.

2. Los­ing Your Past

Do you remem­ber the names of your elementary-school teach­ers? How about the name of the bully in mid­dle school? Or names of your friends when you were a kid? These are all things you remem­bered well at one time and remem­bered for a long time. But you may well have for­got­ten by now.

A recent study on rats sug­gests what it takes to sus­tain longer term mem­o­ries. Rats in the study learned a “bait shy­ness” task. Rats were given a drink of saccharin-flavored water, and then shortly after­wards injected with lithium, which made them nau­se­ated. This was a typ­i­cal con­di­tioned learn­ing sit­u­a­tion, as with Pavlov’s dogs. In this case, rats typ­i­cally remem­bered to avoid such water for many weeks. This is the basis for “bait shy­ness.” If rats sur­vive a poi­son­ing episode, they will avoid that bait in the future. In this exper­i­ment, one group of rats received an injec­tion directly into the part of the brain that holds taste mem­o­ries. This injec­tion con­tained a drug that blocks a cer­tain enzyme, a pro­tein kinase. These rats lost their learned taste aver­sion. The bad mem­ory was lost irre­spec­tive of when the injec­tion was made dur­ing the 25 days after learn­ing occurred. Giv­ing the enzyme blocker before learn­ing had no effect on learn­ing to avoid the fla­vored water. The pro­tein kinase thus seems to be nec­es­sary for sus­tain­ing a long-term mem­ory. It is pos­si­ble that other long-term mem­o­ries the rats may have had were also wiped out by the enzyme-blocking drug.

So what is the prac­ti­cal impor­tance? I sug­gest that even “long-term” mem­o­ries have to get rehearsed or they may even­tu­ally for­got­ten. Or if you do remem­ber, there is a good chance that the mem­ory is cor­rupted, that is, not totally cor­rect. The con­se­quence is that things that hap­pened long ago may be either for­got­ten, or misremembered.

What sus­tains the enzyme nec­es­sary for long-term mem­ory? I sus­pect it is rehearsal and peri­odic reac­ti­va­tion of the mem­ory. Some sci­en­tists are excited about the pos­si­bil­ity of devel­op­ing a drug to manip­u­late lev­els of the enzyme. The prob­lem with that, how­ever, is that the drug could abol­ish old mem­o­ries that you might not want to for­get (like your name) or may cause you to remem­ber too much that is now irrelevant.

Source: Shema, R., Sack­tor, T. C., and Dudai, Y. 2007. Rapid era­sure of long-term mem­ory asso­ci­a­tions in the cor­tex by an inhibitor of PKM. Sci­ence. 317:951–953.

3. Test­ing Pro­motes Consolidation

Tests do more than just mea­sure learn­ing. Tests are learn­ing events. That is, test­ing forces retrieval of incom­pletely learned mate­r­ial and that very act of retrieval is a rehearsal process that helps to make the learn­ing more per­ma­nent. Test­ing, and not actual study­ing, is the key fac­tor on whether or not learn­ing is con­sol­i­dated into longer term memory.

A recent report from Wash­ing­ton Uni­ver­sity in St. Louis, exam­ined the role that retrieval had on the abil­ity to recall that same mate­r­ial after a delay of a week. In the exper­i­ment, col­lege stu­dents were to learn a list of 40 for­eign lan­guage vocab­u­lary word pairs that were manip­u­lated so that the pairs either remained in the list (were repeat­edly stud­ied) or were dropped from the list once they were recalled. It was like study­ing flash cards: one way is to keep study­ing all the cards over and over again; the other way is to drop out a card from the stack every time you cor­rectly recalled what was on the other side of the card. After a fixed study period, stu­dents were tested over either the entire list or a par­tial list of only the pairs that had not been dropped dur­ing study. Four study and test peri­ods alter­nated back-to-back. Stu­dents were also asked to pre­dict how many pairs they would be able to remem­ber a week later, and their pre­dic­tions were com­pared with actual results on a final test a week later.

The ini­tial learn­ing took about 3–4 tri­als to mas­ter the list, and was not sig­nif­i­cantly affected by the strat­egy used (rehears­ing the entire list or drop­ping items out as they were recalled). On aver­age, the stu­dents pre­dicted that they would be able to remem­ber about half of the list on a test that was to be given a week later. How­ever, actual recall a week later var­ied con­sid­er­ably depend­ing on learn­ing con­di­tions. On the final test, stu­dents remem­bered about 80% of the word pairs if they had been tested on all the word pairs, no mat­ter whether they had been stud­ied mul­ti­ple times with all of them in the list or if they dropped cor­rectly recalled words from the list in later study tri­als. How­ever, recall was only about 30% cor­rect when cor­rectly iden­ti­fied words were dropped from sub­se­quent tests, even though all words were stud­ied repeat­edly. In other words, it was the repeated test­ing, not the study­ing, that was the key fac­tor in suc­cess­ful longer-term memory.

So, what is the prac­ti­cal appli­ca­tion? When using flash cards, for exam­ple, you need to fol­low each study ses­sion (whether or not you drop cards from the stack because you know them), with a for­mal test over all the cards. Then, repeat the process sev­eral times, with study and test epochs back-to-back. Can we extend this prin­ci­ple of fre­quent test­ing to other kinds of learn­ing strate­gies? I would guess so.

Why does forced recall, as dur­ing test­ing, pro­mote con­sol­i­da­tion? It prob­a­bly relates to other recent dis­cov­er­ies show­ing that each time some­thing is recalled the mem­ory is re-consolidated. If the same infor­ma­tion is con­sol­i­dated again and again, the mem­ory is pre­sum­ably reinforced.

This study also showed that the sub­jects could not pre­dict how well they would remem­ber, which is con­sis­tent with my 45 years expe­ri­ence as a pro­fes­sor. Stu­dents are fre­quently sur­prised to dis­cover after an exam­i­na­tion that they did not know the mate­r­ial as well as they thought they did. Tests not only reveal what they know and don’t know, but serve to increase how much they even­tu­ally learn. If I were still teach­ing, I would give more tests. And I would encour­age stu­dents to use self-testing as a rou­tine learn­ing strat­egy, some­thing that one study revealed to be a seldom-used strat­egy. The repeated self-tests should include all the study mate­r­ial and not drop out the mate­r­ial that the stu­dent thinks is already mastered.

Source: Karpicke, Jef­frey D., and Roedinger, Henry L. III. 2008. The crit­i­cal impor­tance of retrieval for learn­ing. Sci­ence. 319: 966–968.

— W. R. (Bill) Klemm, D.V.M., Ph.D. Sci­en­tist, pro­fes­sor, author, speaker As a pro­fes­sor of Neu­ro­science at Texas A&M Uni­ver­sity, Bill has taught about the brain and behav­ior at all lev­els, from fresh­men, to seniors, to grad­u­ate stu­dents to post-docs. His recent books include Thank You Brain For All You Remem­ber and Core Ideas in Neu­ro­science.

Teens & Cosmetic Surgery

From Medscape Pediatrics

Teens and Elective Cosmetic Surgery

An Expert Commentary on Real-World Scenarios

Sherrell J. Aston, MD; Robert L. Findling, MD, MBA; Laurie Scudder, DNP, PNP

Authors and Disclosures

Posted: 02/23/2012

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Editor's Note:
The topic of plastic surgery in teens has been in the news lately and raises many clinical and ethical questions. Medscape asked experts in psychiatry, cosmetic surgery, and bioethics to help us explore this issue.

Robert L. Findling, MD, MBA, Professor of Psychiatry and Pediatrics at Case Western Reserve University and Director of Child & Adolescent Psychiatry at Rainbow Babies & Children's Hospital, presented the mental health perspective. Sherrell J. Aston, MD, Professor of Surgery in the Department of Plastic Surgery at New York University School of Medicine and Chairman, Department of Plastic Surgery, Manhattan Eye, Ear and Throat Institute of Lenox Hill Hospital provided input from the surgeon's perspective. The participants also discussed some cases that, although hypothetical, represent real-world scenarios.

Medscape: Appearance is important to all of us -- none more so than teens, who are often uncomfortable with their evolving bodies. Perceived flaws do not only diminish a teen's self-image but can affect his or her social interactions, leading to difficulties in school, withdrawal, or aggression. Teens sometimes have valid cosmetic conditions that may benefit from plastic surgery.

Child and adolescent cosmetic surgery is not new, but the topic has come to the forefront as a result of recent media attention. A major factor in consideration is the fact that the patient is still growing, both physically and emotionally. The decision requires input and agreement from both the child and the parent. What are the very first factors that a clinician should consider when approached about cosmetic concerns by either a patient or a family member?

Dr. Findling: It's important to understand the psychological effects of the cosmetic concern. Certainly, there are issues where cosmetic issues could clearly affect a youngster's emotional well-being. However, there are cases where the degree of the effect of a more modest cosmetic concern on the psychological state of the patient may be less clear. Along the same line, there are times when a patient may express negative emotional sequelae about a perceived flaw, and that cosmetic concern is not even readily apparent.

Simply put, discrepancies can exist between the magnitude of the visible cosmetic concern and the expressed emotional distress associated with it. Appreciating this disconnect can be quite important. This is because such disconnects can lead to unrealistic expectations about the degree to which a surgical procedure might improve a youngster's well-being. Certainly, when the discrepancy between the emotional concern and the physical manifestations are apparent, an understanding of such disconnects can be pivotal.

According to current psychiatric nosology, there is a condition known as body dysmorphic disorder. Patients with this condition may be inordinately distressed by or preoccupied with a minor or even nonexistent cosmetic concern. I should point out that body dysmorphic disorder should be differentiated from developmentally expected body image concerns.

Dr. Aston: First, it is important for the plastic surgeon to determine that the teenager, not the parents or boyfriend or girlfriend, is initiating the request for the cosmetic procedure. The surgeon must determine that the patient has reached a level of physical maturity and that further growth is unlikely to occur. The surgeon must also decide whether the patient's anticipated surgical result is appropriate and consistent with their anatomy, and whether the patients anticipated change in their life is realistic. The surgeon needs to determine that the teenager has realistic requests and goals, as well as sufficient emotional maturity to understand the nature of their requested surgical procedure, the potential problems, the recovery process, and the anticipated long-term results.

Medscape: You both referred to the importance of determining whether the teen's desire for a cosmetic change is realistic. Dr. Findling voiced concern that the magnitude of the perceived flaw may be less significant than the teen believes it to be; Dr. Aston noted the importance of determining whether the desired change is achievable. Recognizing that there is a degree of subjectivity to these assessments, what are the metrics that can be used to evaluate both the degree of distress and the desired change on the part of the teen? Are there strategies that should be implemented in the primary care arena -- where many teens and families will begin this process -- that can assist providers in making a determination as to which child and family can and should be referred for follow-up, whether by a cosmetic practitioner or a mental health provider?

Dr. Findling: From the emotional and psychological perspective, several strategies should be considered.

1. Identify the cosmetic concern and try to gauge the subjective degree to which the cosmetic concern is "atypical." This assessment applies to both the youngster and the guardian. Compare this concern with that of the "typical" child and family -- recognizing, of course, that there is a wide range of "normal" and that a cosmetic issue that may cause great concern for one teen may be acceptable to another. That same range of perspectives applies to parents.
2. Try to assess the magnitude of distress due to the physical concern.
3. Try to assess the sequelae associated with the distress due to the cosmetic concern.
4. Attempt to identify how the youngster's life might change due to the cosmetic surgery. Is the expectation reasonable or rational?

Although there certainly is a subjective quality to this, physicians, particularly those who are familiar with working with teens, can help identify thoughts, beliefs, and ideas that would raise red flags.

Dr. Aston: Dr. Findling and I are saying the same thing, just in different words. It boils down to the individual cases. I've operated on several thousand teenagers and can't remember a case where there was a postoperative psychological problem. In general, teenagers just want to correct their area of concern and get on with life. Teens, or adults, who are emotionally immature or have unrealistic expectations should not have surgery.

Putting It Into Practice: Case Discussions

Medscape: Perhaps we could briefly discuss some individual cases to illuminate key clinical considerations.

First case: A 15-year-old moderately obese boy presents with concerns about gynecomastia. Both of his parents, who are also obese, accompany him to the visit. All report that they have engaged in multiple unsuccessful attempts at weight loss. The young man voices concern about his "embarrassing" breast development and, upon questioning, notes that he is frequently teased by other kids in school. What are the specific issues that should be addressed in this young man? For situations with alternative treatment options-- in this case, more intensive weight-loss programs -- should surgery be considered? If so, are there any guidelines to determine at what point other options can be deemed unsuccessful and a decision made to move to a surgical option?

Dr. Findling: As you noted, the question for the surgeon is, "When should surgery be done"? It is not an either/or answer of surgery or other therapies. Surgery does not preclude other strategies.

Dr. Aston: A 15-year-old moderately obese young man with concerns about gynecomastia needs a more strict dietary control regimen and exercise plan for weight loss. At 15 years of age, it is possible that hormonal influences are causing his breasts to be larger than they may be in 4 or 5 years. I would defer surgery on this young man until he is 19 or 20 years old, and then consider it only after significant dieting, exercise, and weight loss.

Medscape: Now, a second hypothetical case: A 17-year-old girl, Tanner stage 5, with mild cerebral palsy and developmental delay is referred to a local cosmetic dermatology practice. She and her parents report that she has long been teased about the size and shape of her nose. Her parents delayed seeking surgical correction until they thought she was "old enough to decide." She attends her local high school but is in special education classes and has limited interaction with students outside of her self-contained classroom. Most of the history is provided by her parents, but the teen confirms that other students are "mean" to her. Is her developmental delay a relative contraindication to surgery? Does she require assessment beyond that provided to teens whose intellectual status is age-appropriate?

Dr. Findling: There are several issues that should be explored in a situation like this:

• The emotional magnitude of the concern for the patient;
• The degree of objective substantiveness of the physical defect;
• The severity of the developmental delay, which can clearly influence the decision-making capacity of this teen, and
• The probable postoperative outcome with regard to the amount of teasing/emotional distress this youngster is likely to continue to experience.

Dr. Aston: This young lady's developmental delay is probably cause to decline surgery at this time. Most of the information is provided by her parents, making a determination of her intellectual status difficult. Although the patient will soon be of legal age to give consent for her own surgery, it is not clear from this information whether she understands the nature of the surgical procedure and its potential risks and complications, and whether she has a perspective on the anticipated result. If she undergoes surgery with an excellent cosmetic change, it is still possible that other students may continue to be "mean" to her.

Medscape: Thank you. Now, on to our third and final case: An 18-year-old woman who has just graduated from high school is preparing to enter a performing arts program at a very prestigious university. She is unaccompanied by her parents but reports that they are aware of her request for breast augmentation surgery. She described their feelings as ambivalent but states that they are "leaving the decision" in the young woman's hands. She notes that her appearance will be a strong factor in her ability to be successful in musical theater and does not believe that she will be cast for roles requiring a more robust physique. What are the issues to be considered in an older teen who makes a request for surgery to enhance her appearance that is not motivated by social concerns, such as teasing? Would you suggest that parents be involved in this decision in a teen who has reached the age of consent but is still financially dependent on parents?

Dr. Findling: Ideally, parents would be involved. Even though the child in this case is 18 years old, family support can be helpful. An important question is, How realistic is the chance of success in the performing arts with this operation? The concern about looks and performing arts is a realistic one. This was noted poignantly in the 1975 musical A Chorus Line, in the song "Dance: Ten; Looks: Three..."

Dr. Aston: This is the kind of patient whom plastic surgeons see frequently. It is important for the surgeon to determine that the patient has a realistic expectation of the benefits of the surgical procedure. Plastic surgeons understand that patients may not be cast for roles in musical theater regardless of the robustness of their physique. Such decisions are probably made on overall appearance, ability, talent, personality, and other factors. The patient needs to understand these points.

The fact that the patient's request for surgery is not motivated by social concerns, such as teasing, is not particularly important. What is most important is that the patient has a realistic expectation and understanding that breast augmentation will give her more of her desired body shape but will not guarantee success in musical theater.

The extent to which parents are involved in the decision-making process for a young adult varies from family to family. I think it is important for parents to give their opinions to their children. It is stated that they are leaving the decision in the young woman's hands, which suggests that they are not against her having the procedure. Who pays, and other financial considerations, should be left to the patient and her family.

Resources

As these experts have made clear, decisions about elective cosmetic surgery are complex and individual. Arguments, pro and con, are found on parenting Websites, and the lay press reports that the number of procedures is on the rise. The American Society of Plastic Surgeons (ASPS) reports that cosmetic procedures in persons aged 13-19 years accounted for 2% of the over 13 million procedures performed in 2010, although the number of procedures in this age group increased 4% between 2009 and 2010.^[1] It is likely that if a primary care provider has not had yet had the experience of dealing with a family requesting information or a referral for a cosmetic procedure, it will happen sooner or later.

Initial screening can and should occur in the primary care environment. Medscape's Aesthetic Medicine resource center provides stories on the latest news, links to full-text articles from leading journals, and in-depth discussion.

The ASPS provides several helpful online resources for professionals and parents. For clinicians, Plastic Surgery For Teenagers Briefing Paper provides information about specific procedures, accreditation, and informed consent issues. For parents, Cosmetic Surgery and Your Teen -- Talking to Young Adults about Cosmetic Surgery includes discussion about specific procedures, questions for interviewing a potential surgeon, and information about insurance and payment.

Pediatric Pneumonia n antibiotics use

From Archives of Disease in Childhood

Why Do Children Hospitalised With Pneumonia Not Receive Antibiotics in Primary Care?

CC Grant; A Harnden; D Mant; D Emery; G Coster

Authors and Disclosures

Posted: 02/17/2012; Arch Dis Child. 2012;97(1):21-27. © 2012 BMJ Publishing Group Ltd & Royal College of Paediatrics and Child Health

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• Abstract and Introduction
• Methods
• Results
• Discussion

• References
• Sidebar

Abstract and Introduction

Abstract

Background Although antibiotics are recommended for the primary care management of community-acquired pneumonia, a recent UK study reported that most children admitted to hospital had not received antibiotics.
Objective To describe primary care antibiotic use for children subsequently hospitalised with community-acquired pneumonia.
Design/methods A case series of 280 children <5 years old hospitalised with pneumonia in Auckland, New Zealand. Pneumonia was defined as an acute illness with cough or respiratory distress, the presence of tachypnoea or indrawing and an abnormal chest radiograph. Receipt of antibiotics was determined by parental report and medical record review.
Results Fewer than half (108, 39%) of the children had received an antibiotic before hospital admission. For 60 children (21%) there had been no opportunity to prescribe because the illness evolved rapidly, resulting in early hospital admission. For the remaining 112 children (40%) an opportunity to receive antibiotics was missed. The parent failed to obtain the antibiotic prescribed for 23 children (21% of 112), but in 24 children (21%) pneumonia was diagnosed but no antibiotic prescribed and in a further 28 children (25%) the diagnosis was not made despite parental report of symptoms suggesting pneumonia. Missed opportunities to prescribe were not associated with increased overall severity of symptoms at hospital presentation but were associated with an increased risk of: focal chest radiological abnormalities (rate ratio (RR)=2.14; 95% CI 1.49 to 2.83), peripheral leucocytosis >15×10⁹/l (RR=2.29; 95% CI 1.61 to 2.98) and bacteraemia (RR=6.68, 95% CI 1.08 to 58.44).
Conclusions Young children with community-acquired pneumonia may not receive an antibiotic before hospital admission because the illness evolves rapidly or the prescribed medicine is not given by parents. However, missed opportunities for appropriate antibiotic prescribing by health professionals in primary care appear to be common.

Introduction

Antibiotics are recommended as first-line treatment for community-acquired pneumonia and are almost always prescribed to preschool aged children on hospital admission with pneumonia. For example, the British Thoracic Society recommends amoxicillin as first-line treatment for children <5 years old with community-acquired pneumonia. However, the same guideline also says that children with 'mild' symptoms of lower respiratory tract infection (LRTI) do not require antibiotics. This creates a diagnostic challenge for primary care doctors. Not treating serious disease can result in death. Antibiotic overprescribing for lower respiratory infections increases the risk of antimicrobial resistance.

A case series of children hospitalised with community-acquired pneumonia in England called into doubt whether primary care doctors are meeting the diagnostic challenge effectively. It reported that only 22% of infants and 31% of children 1–15 years old had received antibiotics before admission.^[1] Moreover, the children not prescribed antibiotics had more severe disease on hospital admission.^[1] However, the report was not based on a consecutive series of cases from a defined population and no information was reported about the primary care given or the reasons for non-prescribing.

We therefore analysed a consecutive series of admissions of children from a defined catchment population in New Zealand (NZ) to confirm, in a country with a similar health system to the UK, the low rate of preadmission antibiotic prescribing for community-acquired pneumonia. We also sought to go further by consulting parents and reviewing primary care records to explore why this might happen.

Vision loss in Children

From Archives of Disease in Childhood

Visual Impairment in Children in Middle- and Lower-income Countries

Paul Courtright; Amy K Hutchinson; Susan Lewallen

Posted: 02/03/2012; Arch Dis Child. 2011;96(12):1129-1134. © 2011 BMJ Publishing Group Ltd & Royal College of Paediatrics and Child Health

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• Abstract and Introduction
• Retinopathy of Prematurity
• Paediatric Glaucoma
• Amblyopia
• Vitamin A Deficiency
• Cataract
• Refractive Error
• Other Causes
• The Need for Special Programmes for Children's Vision Health
• Summary Box

• References

Abstract and Introduction

Abstract

Reducing visual impairment and blindness in children in resource-poor countries is one of the key components of the major global prevention of blindness initiative, VISION 2020 the Right to Sight. Although visual impairment and blindness among children is much less common than among adults, the potential lifespan of a child means that the lifelong impact of such impairment is very large. Over 10 years ago, it was estimated that, globally, 1.4 million children were blind. Much has changed in the past 10–20 years and there is a need to reassess both the magnitude and causes of global childhood blindness and visual impairment. While the widespread implementation of vitamin A supplementation and measles immunisation programmes have led to a reduction in vitamin A deficiency-related blindness in many poor countries, retinopathy of prematurity is now undergoing a third wave of endemicity, particularly in newly industrialising countries in Latin America and Asia. Childhood cataract is better recognised as an important potentially avoidable problem, as is paediatric glaucoma and refractive error in some populations. Trained paediatric ophthalmologists, although still too few, are growing in number in poor countries. A programmatic approach with a multidisciplinary team is essential to reducing childhood blindness. The elements of such programmes and the need for planning are discussed.

Introduction

Reducing vision loss in children in resource-poor settings has been the focus of considerable efforts by governments, non-governmental organisations, donors, public health professionals and eye care providers for the past 30 years. Research on vitamin A deficiency in Indonesia and elsewhere provided the link between specific ocular conditions and childhood morbidity and mortality.^[1] This body of work was instrumental in including childhood blindness in VISION 2020 Right to Sight, a broad initiative by the WHO and non-governmental organisations to eliminate avoidable blindness by the year 2020.^{[2 3]} At the launch of VISION 2020, over 10 years ago, it was estimated that 1.4 million children were blind with about half of these cases being avoidable. There are no reliable estimates of disability-adjusted life years (DALYs) lost owing to childhood blindness in low- and middle-income countries. Because of the devastating immune effects of vitamin A deficiency, it was further estimated that 60% of children die within 1 year of becoming blind.^[4]

At the launch of VISION 2020, based on the known strong link between childhood mortality and vitamin A deficiency blindness, an estimate of overall childhood blindness and visual impairment was made using country-and region-specific under-5 deaths.^[5] WHO defines blindness as presenting visual acuity (better eye) of <3/60, severe visual impairment as presenting visual acuity (better eye) of <6/60 (but ≥3/60) and visual impairment as presenting visual acuity (better eye) of <6/18 (but ≥6/60 or better). Additional information on causes of blindness was provided by many systematic surveys in blind schools in developing countries, although it was always acknowledged that the children attending these schools did not necessarily represent all blind children.^[6] Much has changed in the past couple of decades and there has been a recent call to reassess both the magnitude and causes of childhood blindness.^[6]

Childhood blindness is uncommon, relative to blindness in adults and thus poses a great challenge to obtaining true population-based data. However, surveys using key informants and other approaches to identify children with blindness provide some information on the likely magnitude of blindness in some settings. These surveys,^[7,–,12]summarised in Table 1 uggest that in many resource-poor settings, the prevalence of blindness is lower than the previously suggested figures of >1/1000 children in most of sub-Saharan Africa or 0.5–0.9/1000 children in most of Asia. In addition, more recent studies in schools for the blind,^[13,–,16] while not providing data on blindness prevalence, have shown changing patterns in the causes of blindness, with fewer children with corneal conditions secondary to measles and vitamin A deficiency and more congenital conditions (disorders of the whole globe or retina) and inadequately treated cataract ( Table 2 ). The population-based surveys shown in Table 1 also present a mixed picture, with lens-related causes and posterior segment causes being the most frequent. Causes of blindness in childhood are different in the industrialised countries and it is difficult to make direct comparisons; most surveys in resource-poor settings use a WHO form for classifying causes,^[17] reporting one major anatomical site responsible for blindness. On the other hand, reports from industrialised countries rely on more specialised testing and extensive history and recognise that multiple anatomical sites are often involved. An extensive study in the UK^[18] reported 'lens' as a site of abnormality in only 5% of incident cases, found that 77% of cases had additional non-ophthalmic disorders and that 75% of cases were neither preventable nor treatable.

It seems there is no longer one single leading cause of global blindness in children. We will review the major causes, then discuss programme issues relevant to reducing childhood blindness.

UTI in Children and MCU

From Medscape Pediatrics > Viewpoints

Judicious Urinary Tract Imaging in Pediatric UTI

William T. Basco, Jr., MD, MS

Posted: 02/03/2012

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Impact of a More Restrictive Approach to Urinary Tract Imaging After Febrile Urinary Tract Infection

Schroeder AR, Abidari JM, Kirpekar R, et al
Arch Pediatr Adolesc Med. 2011;165:1027-1032

Study Summary

In 2007, the United Kingdom instituted updated guidelines for the management of urinary tract infection (UTI) in children. The guidelines recommend more limited use of renal ultrasound (RUS) and voiding cystourethrogram (VCUG). The UK guidelines recommend RUS for most children with UTI but limit the use of VCUG to children meeting the following criteria:

• UTI with bacteremia;
• inadequate clinical response in the first 48 hours;
• UTI caused by pathogens other than Escherichia coli;
• any clinical indication of poor urine flow;
• elevated serum creatinine level;
• palpable abdominal mass; or
• abnormal findings on the initial RUS.

The new guidelines do not generally recommend prophylactic antibiotics.

This study by Schroeder and colleagues reports the implementation of the UK guidelines to a medical center in California in September 2008, with periods of data collection corresponding to 1 year before and after implementation of the algorithm, separated by a period of time during which the new guidelines were being implemented. This study was conducted to determine how implementation of these guidelines affected the ordering of urinary tract imaging after UTI and whether the guidelines led to changes in prophylactic antibiotic use. They also compared the frequency of recurrent UTI before and after instituting the restricted guidelines.

The subjects of the analysis were children under 2 years of age. Urine cultures positive for pathogens were identified using clinical databases, the medical records for each child were reviewed, and any second UTI within 6 months of the index UTI was defined as a "recurrent UTI." Children with previous UTIs, genitourinary or neuromuscular abnormalities, or other conditions that might affect the results were excluded. The prealgorithm group included 98 children, and the postalgorithm group included 103. The groups were very similar at baseline.

A comparison of pre- and postimplementation findings includes the following:

• VCUG frequency declined from 99% to 12.6%.
• RUS frequency declined from 99% to 67%.
• Rates of recurrent UTI were almost identical, at 7.1% in the preguideline children compared with 7.8% in the postguideline children (not statistically significant).
• Frequency of grade 4-5 vesiculoureteral reflux was not different preguideline (2.0%) vs postguideline (2.9%)
• No grade 1-3 vesiculoureteral reflux was identified after implementation of the guidelines.
• Almost complete elimination of prophylactic antibiotic use was seen between completion of treatment for UTI and VCUG attainment.
• Indefinite prophylaxis with antibiotics decreased from 26.5% prealgorithm to 2.9% postalgorithm.
• Frequency of obtaining follow-up cultures for any reason between the 2 groups was identical, at 0.3%-0.4%.

The main effect of following the more restricted guidelines for post-UTI imaging was in not identifying low-grade vesiculoureteral reflux. Furthermore, fewer children received prophylactic antibiotics. Schroeder and colleagues support the application of this more restricted approach to the child with UTI.

Viewpoint

Many readers will be familiar with the updated American Academy of Pediatrics (AAP) guidelines for diagnosis and management of UTI in children,^[1] released in the fall of 2011. Those guidelines suggest the basic approach outlined in this article with respect to the first febrile UTI. The change in guidelines was prompted by building evidence that most children with high-grade reflux will have an abnormal RUS during the acute illness, allowing the clinician to avoid obtaining a VCUG in children whose initial RUS is normal. Viewing the results another way, most of the reflux identified through universal VCUG testing will be low grade and clinically inconsequential. I suspect that over the next 5 years we will see additional publications reporting short-term outcomes (1-5 years) in children with UTI after widespread implementation of the AAP guideline in the United States.