Sunday, January 27, 2008
DR. ARTHUR LAVIN
Today we interview Dr. Arthur Lavin, Associate Clinical Professor of Pediatrics at Case Western School of Medicine, pediatrician in private practice, and one of the first providers of Cogmed Working Memory Training in the US (the program whose research we discussed with Dr. Torkel Klingberg and Dr. Bradley Gibson). Dr. Lavin has a long standing interest in technology-as evidenced by Microsoft’s recognition of his paperless office- and in brain research and applications-he trained with esteemed Mel Levine from All Kinds of Minds.
• Schools today are not yet in a position to effectively help kids with cognitive issues deal with increasing cognitive demands.
• Working Memory is a cognitive skill fundamental to planning, sequencing, and executing school-related work.
• Working Memory can be trained, as evidenced by Dr. Lavin’s work, based on Cogmed Working Memory Training, with kids who have attention deficits.
Context on cognitive fitness and schools
AF (Alvaro Fernandez): Dr. Lavin, thanks for being with us. It is not very common for a pediatrician to have such an active interest in brain research and cognitive fitness. Can you explain the source of your interest?
AL (Arthur Lavin): Throughout my life I have been fascinated by how the mind works. Both from the research point of view and the practical one: how can scientists’ increasing knowledge improve kids’ lives? We now live in an truly exciting era in which solid scientific progress in neuroscience is at last creating opportunities to improve people’s actual cognitive function. The progress Cogmed has achieved in creating a program that can make great differences in the lives of children with attention deficits is one of the most exciting recent developments. My colleague Ms. Susan Glaser and I recently published two books: Who’s Boss: Moving Families from Conflict to Collaboration (Collaboration Press, 2006) and Baby & Toddler Sleep Solutions for Dummies (Wiley, 2007), so I not only see myself as a pediatrician but also an educator. I see parents in real need of guidance and support. They usually are both very skeptical, since they have been promised too many things too many times by “experts”, yet open-minded to ideas with good foundations. Many professionals have only the skeptical frame, since they were educated when scientists still believed the brain was pretty rigid and “untrainable”. We need much more brain science-based professional development, and appreciate the great work SharpBrains is doing.
AF: Let’s talk about that “trainability” and schools. Most people still think of “intelligence” as fixed. Now, I recently read a report on how KIPP schools emphasize the training on some basic skills, such as shared attention, as a needed foundation for good academic performance. So, even if limited in scope, it seems some schools are starting to understand their role in cognitive development. In your experience, are schools fulfilling their roles as “brain gyms”, places where young minds get shaped and ready for life?
AL: Good question. I have been a pediatrician working with schools in the Cleveland area since 1985, seen all kinds of diseases. For example, I have witnessed the growing incidence of autism spectrum disorders, such as autism and Asperger’s. I have also observed how school work has increasingly become more cognitively demanding, starting from kindergarden. There is too much pressure today, and a growing number of problems, yet I don’t see that schools are applying the best knowledge of how minds work. Just as doctors offices are centers of applied medical science, taking the latest advances in medical research and applying them to the medical care of people, schools should be the best place for applied neuroscience, taking the latest advances in cognitive research and applying it to the job of educating minds. Yet, they aren’t, and I can’t blame them , given the wide variety of pressures they work under, and the large change in perspective becoming institutes of applied neuroscience would take.
A cognitive gap?
AF: Some readers may be skeptical of the claim that school work is more demanding today than, say, 20 years ago. They may say kids are simply becoming “lazy”. What do you say to that?
AL: I have never met a lazy kid. All people want to succeed, in life if not in school. Most children who struggle at school struggle mightily to get adequate grades. It is true that some are more resilient that others-if they fail, they will try 10 times harder. The ones that are labeled as “lazy” are typically ashamed of their lack of capacity to deal with demands, and resort to an evasive strategy, they try to avoid the whole situation, run away.
AF: You mention a “lack of capacity to deal with demands”. Is that gap growing? The equation has 2 components: capacity and demands. In terms of capacity, let me mention that recently, the French Education Ministry just introduced mental arithmetic as part of the curriculum. I remember, as a kid, spending many hours in the math class where the teacher would require us to perform a progressively complex sequence of mental calculations-which is good training for skills such as working memory. Memory traininIn terms of demands, I can see how complex homework assignments are these days even in 3-4rd grade. Kids need to plan and prepare a whole matrix of tasks that require good organizational work to complete. They need to sequence what they do today, tomorrow, the day after. The major difficulty, for which such young brains may not be fully ready, is to deal with an overwhelming amount of information and demands, and execute.
AL: Great point. For example, years ago we had to memorize long texts, which, no matter what the content was, was a great way to train and build our attention span, working memory, and to devise strategies to learn. Today, there are less opportunities for such training.
Working Memory and Attention Deficits
AF: That seems to imply a higher need for good executive functions than years ago. A kid needs to have good working memory to retain, prioritize and sequence much information into actionable plans, and then execute them, as I had the fortune to discuss with Mark Katz some months ago. From my previous interviews with Dr. Klingberg and Dr. Gibson, we know that a common problem with many kids with diagnosed attention deficits is, indeed, working memory (the ability to hold in mind and manipulate several units of information). Can you explain what you see in your work with schools?
AL: I am afraid that many schools are too quick to diagnose ADD/ ADHD and consider drugs as the only potential intervention. The label itself can be misleading and counterproductive. School psychologists have wonderful expertise in evaluating subject-related problems and describing attentional deficit symptomatology, but are not trained or asked to complete neuropsychological profiles of a child’s cognitive functions. Up to a point, many kids with attention problems would benefit from educational, not medical, interventions to improve cognitive functions such as working memory. I am seeing it first hand, having used Cogmed Working Memory Training (also called RoboMemo) with 15 pre-screened kids: 80% of them presented a substantive improvement. With 50%, the results we have seen have been dramatic.
AF: Please give us some examples, so our readers can better understand what working memory is and its role in academic performance and daily life.
AL: Let me give you 3 vignettes, all 3 with diagnosed attention deficits, who showed clear benefit not only on cognitive functioning but also on AD/HD rating scales.
Patient 1: 11-year-old boy, very impulsive, even on medication. Doesn’t do homework, constantly forgets chores. After the 5-week program, he is able to sit down and listen instructions, engaging in fewer arguments with his parents. He can do better mental math- for the first time in his life able to do so without using his fingers. He finds that following school and doing homework is easier, grades have improved dramatically.
Patient 2: 16-year-old girl with ADD. She has trouble executing homework, often telling parents she had done it when she really hadn’t. Her parents thought she liked to lie. Yet, when I talk to her, she is clearly more ashamed than dishonest. The working memory training program helps her develop a much improved perception of time. For example, she starts to manage her shower time better, being aware of when 5 minutes have passed-instead of spending 30 minutes in the shower, as before. Much improved school work, lying at home has dropped dramatically.
Patient 3: 19-year-old boy in college, who often became paralyzed when he was faced with complex challenges. He had a tough time with the cognitive training program, but after a while he started learning new strategies and developing self-confidence, and showing marked improvement. Now, he can break complex tasks into manageable pieces . His attentional deficits appeared to threaten his opportunities in his family business. Unable to keep track of change at the cash register, lines at the business would grow and customers get angry, leaving him out of consideration for key start-up employment in the business. Now he can manage day-to-day challenges such as these, and the door to being part of the family business is now open. He can sequence tasks and execute then with a clear plan in mind, without being distracted and losing sight of that plan.
AF: Dr. Lavin, this is all very exciting news, that open the way for new interventions, new policies, a new understanding of what “education” and “learning” is and how to “educate” millions of young minds and equip them for life success. Thank you very much for your time.
AL: Thank you. I really appreciate all the work you are doing to bring the latest neuroscience research and applications to professionals like me and to parents at large.
Monday, January 14, 2008
CDC Issues 2008 Childhood Vaccination Schedules
The 2008 recommended immunization schedules for children 18 years and younger have been published in MMWR.
Among the changes from 2007:
- The live attenuated influenza vaccine (FluMist) is now recommended for children as young as age 2.
- The meningococcal conjugate vaccine (MCV4) is recommended for high-risk children aged 2 to 10 years and all children 13 to 18 who haven't been previously immunized. (Routine MCV4 vaccination continues to be recommended for normal-risk children aged 11 to 12, as well as children through age 18 at increased risk for meningococcal disease.)
- A new catch-up schedule advises that children aged 7 to 18 who received their first dose of the tetanus and diphtheria toxoids/tetanus and diphtheria toxoids and acelluar pertussis vaccine (Td/Tdap) before age 1 should be given four doses, with 4 or more weeks between the second and third doses.
MMWR article (Free)
CDC press release (Free)
CDC vaccine site (Free)
Saturday, January 12, 2008
Prophylaxis Not Associated with Lower Recurrence of UTIs in ChildrenPhysician's First Watch for July 11, 2007
The use of antimicrobial prophylaxis after a first childhood urinary tract infection is not associated with lower rates of recurrence — and in fact is associated with an increased risk for resistant infections, according to a JAMA study. Researchers followed some 600 children under age 6 with first episodes of UTI for over a year to examine the characteristics that would predict recurrent infections. They found that white race, age 3 to 5 years, and grade 4 to 5 vesicoureteral reflux were all factors associated with increased risk for recurrence. Antimicrobial prophylaxis had no effect on recurrence risk, but among children in whom infection recurred, prophylaxis was associated with an increased risk for resistant infections. The authors suggest that clinicians "discuss the risks and unclear benefits of prophylaxis with families ... after a first UTI."
The use of antimicrobial prophylaxis after a first childhood urinary tract infection is not associated with lower rates of recurrence — and in fact is associated with an increased risk for resistant infections, according to a JAMA study.
Researchers followed some 600 children under age 6 with first episodes of UTI for over a year to examine the characteristics that would predict recurrent infections. They found that white race, age 3 to 5 years, and grade 4 to 5 vesicoureteral reflux were all factors associated with increased risk for recurrence. Antimicrobial prophylaxis had no effect on recurrence risk, but among children in whom infection recurred, prophylaxis was associated with an increased risk for resistant infections.
The authors suggest that clinicians "discuss the risks and unclear benefits of prophylaxis with families ... after a first UTI."
JAMA article (Free)
Tuesday, January 8, 2008
Revised Guidelines on Early Dietary Intervention for Atopy Prevention
Breast-feeding helps some infants avoid atopy, but limited evidence exists that other nutritional interventions affect the development of atopic disease in children, according to the American Academy of Pediatrics.
The new guidelines, appearing in Pediatrics, replace a policy statement issued in 2000. The academy's committee concludes that:
- infants at high risk for atopy (i.e., those having first-degree relatives with atopic disease) show benefit from exclusive breast-feeding for at least 4 months;
- infants exclusively breast-fed for at least 3 months are at lower risk for asthma;
- maternal dietary restrictions (e.g., avoiding peanuts, cow's milk) during pregnancy and breast-feeding aren't supported by evidence;
- any protection against asthma afforded by early exclusive breast-feeding cannot be shown beyond age 6;
- "modest evidence" exists that if high-risk infants are not exclusively breast-fed, they will have a lower risk for atopic dermatitis if given extensively or partially hydrolyzed formula. <>
Pediatrics article (Free)
Physician's First Watch for January 8, 2008
Sunday, January 6, 2008
National Asthma Education and Prevention Program Updates Guidelines for Asthma Management
August 30, 2007 — The National Asthma Education and Prevention Program (NAEPP) has issued comprehensive updates to their clinical guidelines for the diagnosis and management of asthma. The revised guidelines, which update the complete asthma guidelines published in 1991 and 1997, as well as the update of selected topics issued in 2002, highlight the importance of asthma control and introduce novel strategies to monitor asthma symptoms. They also feature an expanded section on childhood asthma, including an additional age group,
The US Centers for Disease Control and Prevention (CDC) estimate that US prevalence of asthma is 22 million, including 6.5 million children younger than 18 years, and mortality from asthma exacerbations is estimated at 4000 per year.
"Asthma is one of the most common health problems in the United States — and it can significantly affect patients' lives — at school, at work, at play, and at home," NHLBI Director Elizabeth G. Nabel, MD, said in a news release. "It is essential that asthma patients benefit from the best available scientific evidence, and these guidelines bring such evidence to clinical practice."
Under the aegis of NHLBI, an expert panel of 18 unpaid experts convened by NAEPP conducted a rigorous, systematic review of the published medical literature to incorporate the best available evidence into the updated asthma guidelines.
The new recommendations offer treatment options based on a patient's specific needs and level of asthma control. Because the degree of control can change with time and varies among individuals and by age groups, regular monitoring is essential to optimize treatment.
"The goal of asthma therapy is to control asthma so that patients can live active, full lives while minimizing their risk of asthma exacerbations and other problems," said Expert Panel Chair William W. Busse, MD, from the University of Wisconsin in Madison.
The new guidelines for asthma management focus on 4 main areas: measures to evaluate and monitor asthma control, patient education outside the healthcare provider's office, control of environmental exposures known to trigger or exacerbate asthma symptoms, and pharmacotherapy.
"Overall, these components have stood the test of time, and many of the earlier recommendations have been solidly confirmed by additional research throughout the years," said Busse. "For instance, inhaled corticosteroids are still the best long-term control treatment for asthma patients of all ages because we have even stronger evidence that they are generally safe and are the most effective medication at reducing inflammation, a key component of asthma. Our review of the recent scientific evidence helps us incorporate these four components even more effectively to provide quality asthma care."
Specific recommendations in these 4 areas of asthma management are as follows:
- Assessment and Monitoring: Multiple measures of the current level of impairment include frequency and intensity of symptoms, markers of lung function, and limitations of daily activities. Determination of future risk should consider risk for exacerbations, progressive loss of lung function, or adverse effects associated with antiasthma medications. Some patients with good daily functioning when evaluated may still be at high risk for frequent exacerbations, according to the EPR-3.
- Patient Education: It is essential to teach patients appropriate skills to self-monitor and manage their asthma. A written asthma action plan is needed for each patient, which should include instructions for daily treatment as well as strategies to detect and manage asthma exacerbations.
Unlike previous guidelines, the EPR-3 emphasizes reaching beyond the medical office for educational opportunities, with new settings for teaching to include pharmacies, schools, community centers, and patients' homes. An additional section of the EPR mandates clinician education programs to improve patient communications and to implement system-wide approaches that will incorporate the guidelines into healthcare practice.
- Control of Environmental Factors and Other Asthma Triggers: Isolated measures to limit exposure to allergens and other triggers are seldom sufficient, so the EPR-3 reviews recent evidence for using a combination of several strategies.
A newly expanded section of the guidelines describes comorbid conditions commonly present in asthma patients. Asthma control is often improved by treating chronic diseases including rhinitis and sinusitis, gastroesophageal reflux, overweight or obesity, obstructive sleep apnea, stress, and/or depression.
- Pharmacotherapy: As in previous asthma guidelines, the EPR-3 advocates a stepwise approach to control asthma, increasing medication dosages and types as needed, and decreasing them whenever possible, based on the level of asthma control. The EPR-3 includes revised stepwise asthma management charts that are expanded to guide treatment for 3 age groups: 0 to 4 years, 5 to 11 years, and 12 years or older.
Although earlier guidelines combined the 5- to 11-year age group with adults, the EPR-3 added this group because of new data concerning pharmacotherapy in this age group, as well as emerging evidence supporting differences in response to anti-asthma drugs between children and adults.
The EPR-3 has updated pharmacotherapy recommendations based on recent efficacy and safety data. As in previous guidelines, the EPR-3 reiterates that patients with persistent asthma, defined as daytime symptoms more than twice weekly or nighttime symptoms more than twice monthly, should have a 2-pronged approach to asthma control. This includes medications to control asthma and prevent exacerbations during the long-term, as well as fast-acting medications to control acute symptoms on an as-needed basis.
For all age groups, the EPR-3 recommends inhaled corticosteroids as the most effective medication for long-term control. New treatment options covered in EPR-3 include leukotriene receptor antagonists and cromolyn for long-term control, long-acting β-agonists as adjunct therapy with inhaled corticosteroids, and omalizumab for severe asthma.
For acute asthma exacerbations, albuterol, levalbuterol, and corticosteroids are recommended. Urgent medical care in the emergency department should include oxygen to relieve hypoxemia; a short-acting β2-agonist (SABA) to relieve airflow obstruction, with inhaled ipratropium bromide added for severe exacerbations; systemic corticosteroids to decrease airway inflammation in moderate or severe exacerbations, or for patients who do not respond promptly and completely to a SABA; and adjunct therapy in some cases, such as intravenous magnesium sulfate or heliox, for patients refractory to the aforementioned measures.
Additional strategies being tested to improve asthma management include new strategies to monitor asthma control by testing sputum and exhaled air and treatment options tailored to patient-specific clinical characteristics and genetic profile makeup.
"Research is beginning to help us identify genes that influence how well certain patients respond to certain asthma medications," said James Kiley, PhD, director of the NHLBI Division of Lung Diseases. "This information is helping us move toward providing personalized treatment for asthma based on a patient's individual characteristics."National Heart, Lung, and Blood Institute. Published online August 29, 2007.
Influenza is transmitted predominantly from person to person through infectious respiratory droplets
Although more than 70 years have passed since influenza A was discovered, debate continues over its mode of transmission; specifically, whether influenza is transmitted via airborne contact, respiratory droplets, or direct contact, or via a combination of these routes.
Possible modes of respiratory virus transmission include the following (Brankston, 2007):
Some basic principles to help prevent the spread of influenza include:
1) avoid close contact with people who are sick;
2) stay home when you are sick;
3) cover mouth and nose when sneezing;
4) wash hands frequently;
5) avoid touching eyes, nose, or mouth while you are sick; and
6) get plenty of sleep, be physically active, manage your stress, drink plenty of fluids, and eat nutritious food.
Influenza virus survives on the hands for < 5 minutes but regular hand washing is a commonsense action that should be widely followed (Inglesby, 2006).
The impact of influenza can vary from year to year and be influenced by the circulating strains and protective antibody levels in the population. However, the efficacy of influenza vaccine among children in preventing laboratory-confirmed influenza is estimated to be 80%
School-age children and young adults who are completely susceptible experience the highest incidence of infection and contribute most of the spread of infection during an epidemic.
source: Medscape's Medpulse CME
Limiting the Spread of Influenza in a Family Setting to Reduce Secondary Infections
Friday, January 4, 2008
Bilukha OO, Rosenstein N; National Center for Infectious Diseases, Centers for Disease Control and Prevention (CDC).
Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, CDC, 1600 Clifton Road NE, MS C-09, Atlanta, GA 30333, USA. OBB0@cdc.gov
In January 2005, a tetravalent meningococcal polysaccharide-protein conjugate vaccine ([MCV4] Menactra, manufactured by Sanofi Pasteur, Inc., Swiftwater, Pennsylvania) was licensed for use among persons aged 11-55 years. CDCns Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination of young adolescents (defined in this report as persons aged 11-12 years) with MCV4 at the preadolescent health-care visit (at age 11-12 years). Introducing a recommendation for MCV4 vaccination among young adolescents might strengthen the role of the preadolescent visit and have a positive effect on vaccine coverage among adolescents. For those persons who have not previously received MCV4, ACIP recommends vaccination before high-school entry (at approximately age 15 years) as an effective strategy to reduce meningococcal disease incidence among adolescents and young adults. By 2008, the goal will be routine vaccination with MCV4 of all adolescents beginning at age 11 years. Routine vaccination with meningococcal vaccine also is recommended for college freshmen living in dormitories and for other populations at increased risk (i.e., military recruits, travelers to areas in which meningococcal disease is hyperendemic or epidemic, microbiologists who are routinely exposed to isolates of Neisseria meningitidis, patients with anatomic or functional asplenia, and patients with terminal complement deficiency). Other adolescents, college students, and persons infected with human immunodeficiency virus who wish to decrease their risk for meningococcal disease may elect to receive vaccine. This report updates previous reports from ACIP concerning prevention and control of meningococcal disease. It also provides updated recommendations regarding use of the tetravalent meningococcal polysaccharide vaccine (MPSV4) and on antimicrobial chemoprophylaxis.
Tuesday, January 1, 2008
Routine Pneumococcal Vaccination Linked to Fewer Medical Visits in Kids Under 2
Healthcare visits and expenditures due to pneumonia in children under age 2 have declined markedly since routine pneumococcal vaccination was implemented in that age group, reports Archives of Pediatric and Adolescent Medicine.
Researchers reviewed health records from a large database of self-insured employers across the U.S. Data on approximately 77,000 children younger than 2 years were available each year from 1997 through 2004. Among the findings:
- From the prevaccination period (1997–1999) to 2004, hospitalization of children for all-cause pneumonia and pneumococcal pneumonia dropped by 52% and 58%, respectively.
- Ambulatory visits for all-cause pneumonia fell by 41%, while visits for pneumococcal pneumonia decreased by 47%.
- Estimated national annual medical expenditures for all-cause pneumonia and pneumococcal pneumonia dropped by 45% and 27%, respectively.
The authors conclude: "The decline in disease ... highlights the further health and economic benefits of [the 7-valent pneumococcal conjugate vaccine] in young children in the United States."
ACIP Recommends Meningococcal Vaccine in Children at Increased Risk
Children between the ages of 2 and 10 and at increased risk for invasive meningococcal disease should receive quadrivalent meningococcal conjugate vaccine (MCV4), the Advisory Committee on Immunization Practices recommends.
Previously, the MCV4 vaccine was only approved for people aged 11 to 55 years.
As detailed in MMWR, children may be considered to be at increased risk if they:
- travel to or live in nations with hyperendemic or epidemic meningococcal disease;
- have terminal complement component deficiencies;
- suffer anatomic or functional asplenia;
- are infected with HIV (MCV4's efficacy among these children is not known);
- received the MPSV4 (polysaccharide) vaccine at least 3 years ago and are still at increased risk.
The vaccine may also be used to control outbreaks of meningococcal disease in children.
Physician's First Watch for December 7, 2007
David G. Fairchild, MD, MPH, Editor-in-Chief