Early

Sarah DiGregorio

I found this book to be all that the book jacket promises. Since I cannot improve on that description, the following is directly from the cover of this book.

“The Neonatal Intensive Care Unit (NICU) is a place where humanity, ethics, and science collide in dramatic and deeply personal ways, as parents, physicians, and nurses grapple with sometimes unanswerable questions. When does life begin? When and how should life end? And what does it mean to be human?

The NICU is a place made of stories – the stories of parents and babies who spend days, weeks, and even months waiting to go home, and of the dedicated clinicians who care for these tiny, developing humans. Early explores the fascinating evolution of neonatology and its significant breakthroughs – modern medicine can now save infants at five and a half months gestation who weigh less than a pound, when only fifty years ago there were a few effective treatments for premature babies. Each year, nearly four hundred thousand babies are born prematurely in the United States. When the scope is widened to include the entire world, that number climbs to fifteen million.

For the first time, journalist Sarah DiGregorio tells the rich and complex story of one of the most boundary-pushing medical disciplines – and the many people it has touched. Weaving her own story and those of other parents and NICU clinicians with in-depth reporting, DiGregorio examines the history and future of neonatology: how the first American NICU was set up as a sideshow on the Coney Island boardwalk; how modern advancements have allowed viability to be pushed to a mere twenty-two weeks; the political, cultural, and ethical issues that continue to arise in the face of dramatic scientific developments; and the clinicians at the front lines who are moving to new frontiers. Eye-opening and vital, Early uses premature birth as a window into our own humanity.”

For More:

Developmental Variation and Learning Disorders

Vision: It’s Development in Infant and Child

The Role of Accommodations in the Management of Visual Problems

Accommodations are modifications in the visual demands of a task with the intent of making the task easier. When visual problems are more severe, accommodations will be less effective or totally ineffective. The accommodations that I am going to address here are those that relate to the difficulties that students with healthy eyes have learning and while taking examinations.

The children who would receive that most benefit from accommodations are many children who have undiagnosed visual problems. These children have been able to cope with tracking, crowding, eye-hand coordination, focusing, and eye teaming problems, but school work could be easier for them and they could perform better if the print was bigger, the pages less crowded, they had frequent breaks, and they had more time to complete their work.

Children with diagnosed visual problems typically have more severe visual difficulties. While the above accommodations may still be appropriate, their effects will be limited.

This became personal for me lately due to the need for hip replacement surgery. Prior to the surgery and during the recovery, there were things that I just could not do regardless of accommodations. When I was able to “walk” with a walker and then for short distances with a walking stick, this was still far from walking automatically. I had to attend to walking. I was slow. There was little that I could think of other than walking due to the attention required and the associated discomfort. I fatigued quickly. Other parts of my body hurt from compensating. Student’s visual problems are no less incapacitating. I can look forward to putting this in my past. Without effective treatment, this will not happen for the children with significant visual problems.

A common example is a child who can keep their place much better when they point to each word with their finger. They cannot read without the finger and this can seem like a miracle, but it should not be equated with normal reading. It is similar to walking with a walker. It cannot be smooth. It takes longer. It is more tiresome. Attention is distracted from the reading material (comprehension) to the mechanics of reading. It is clumsy.

We will continue to recommend accommodations as appropriate. We don’t take crutches away from people who need them, but everyone who works with these children cannot forget that the effects of their problems have not been eliminated, even in the short-term.

Ironically, visual problems are less visible than many other problems. When I am walking with my walking stick, everyone knows that I have a problem and they do not expect me to function as if I did not have the problem. That can only happen when my problem is resolved. The same is also true for visual problems.

For More:

Crowding

Tracking

Eye-Hand Coordination

Visual Factors in Reading

Vision Therapy is Messy

In his book Messy: How to be Creative and Resilient in a Tidy-Minded World, Tim Harford provides examples of how extreme organization and structure, reduced diversity, and oversimplification makes things easier but constrain and compromise outcomes.

Vision is complex and each person’s combinations of problems and circumstances is unique. Vision doesn’t function in isolation. It is represented in more areas of the brain than any other sense. It is involved in almost everything we do. How we see the world is an integral part of who we are. It follows that enhancing essential visual functions;

-eye alignment and movement,

-focusing,

-object perception, spatial perception, and guidance of movement

is messy and complex and that it is naïve to think that therapy is not influenced by the patient’s mindset, age, conflicts, and prior experiences.

All of this must be taken into consideration to treat patients. Computerized programs cannot do this but they can be useful to stimulate attention and motivation. It also requires more than a list of techniques. Doctors and therapists need to be ready and able to modify plans to match the patient’s current visual abilities. Optometric vision therapy is provided by doctors and therapists with specialty qualifications. Certified doctors are Fellows in the College of Optometrists in Vision Development (FCOVD). Certified therapists earn the title, Certified Optometric Vision Therapists (COVT). The College of Optometrists in Vision Development is the certifying body for this specialty.

Relationships between providers, patients, and their families are integral to the success of all healthcare, especially incremental care. Atul Gawande wrote about one of thirteen centers for treating patients with cystic fibrosis in the US in his book Better. One center had much better outcomes than all of the others even though the centers all followed the same protocol. The difference was that the director in one center got to know his patients personally. The better understanding and communication that resulted from these personal relationships fostered improved compliance. Atul Gawande also addresses this in his article on The Heroism of Incremental Care.

Therapy is an interplay between treatment and assessment as the patient progresses. The doctor and therapist continue to learn about patients from the way each patient responds. Dwight D. Eisenhower stated in reference to war that “Plans are useless, but planning is indispensable.” This also applies to other complex, messy situations.

Vision therapy is not easy and can be frustrating. Plasticity in Sensory Systems makes therapy possible. While neuroplasticity declines with age, it continues throughout life. Motivation can recruit surprising amounts of plasticity.  The Power of Habit balances our ability to change. Habit enables us to function without consciously thinking through everything we do, which is not possible, but it can also cause us to err when conditions change. Therapy develops new visual habits.  Focused rehearsal under a variety of circumstances facilitates supplanting existing habits with new skills and makes them more automatic than the dysfunctional patterns that they are replacing.

Optometric vision therapy takes advantage of neuroplasticity and the messiness in our visual system to make change possible. Therapy creates new visual patterns to be more efficient, more comfortable, and less taxing. Patients must achieve this for themselves, but appropriate feedback at the right time can be powerful, which is why doctors and therapists are indispensable in this process. Daniel Coyne provides example which demonstrate this in The Talent Code as does Norman Doidge in The Brain that Changes Itself. Humans are endowed with amazing abilities to learn and to adapt.

Automation and Technology

In the book Messy, Tim Harford reveals some of the dangers of overconfidence in the increasing competency of technology. The most dramatic example is the unnecessary crash of Flight 447 with the loss of the lives of everyone on board. The plane was an Airbus 330, one of the world’s safest airplanes. The three pilots’ experiences made them overconfident. Instead of using technology to assist them, they abdicated their judgment and responsibility. It is a paradox that the likelihood of having serious outcomes increases from problems with technology as technology becomes more proficient.

This problem also exists in healthcare as doctors become more reliant on tests than on observation and patient interviews. We can also fall into the trap of expecting everything to be better with enhanced technology. The use of computer screens does not make everything better. Due to their efficiency, they are likely to increase vision-related problems. Most visual problems develop incrementally. It is fortunate that we do not notice every little change and it is usually an advantage that we are able to adapt. But adapting for this many hours a week can cause people to be unaware of or ignore problems which should be treated sooner.

This also applies to vision and driving. People who have not needed glasses to drive are often reluctant to accept when glasses will enhance their comfort and safety while driving. Seeing better can provide more time to make decisions, speed up reactions to sudden changes which need to be interpreted, and ameliorate the problems associated with night driving. Driving requires sustained attention and working memory. If seeing requires more effort and attention, the result can be similar to when people are talking on their phones; their useable visual field constricts.

This attitude about glasses and driving is not new. What is new is the response: “I don’t need glasses to drive. I have GPS.” Driving in unfamiliar places is stressful. Most of us do at least 95% of our driving where we know the roads and traffic patterns and know how we will get to our destination. Satellite navigation does help but it does not eliminate the importance of vision for judging distance and speed, and for seeing everything around us which an efficient visual system processes simultaneously. Vision enables us to see into the future and predict what will happen. It enables us to catch a ball. It also enables us to predict the movement of our car and those around us to avoid collisions.

We all have GPS stories. Problems occur when we are not using technology to assist us but to replace planning and judgment. Our GPS world is narrowed to what is on the screen and what we are being told. Tim Harford shares these examples.

Our learned helplessness in the hands of technology is sometimes more amusing than horrifying. In March 2012, three Japanese students visiting Australia decided to drive to North Stradbroke, guided by their GPS system. For some reason the GPS was not aware that their route was blocked by nine miles of the Pacific Ocean. These things happen, of course, but the reaction of the three tourists was extraordinary: in thrall to their technology, they drove their car on to the beach and across the mud flats towards the ocean. As the water lapped around their Hyundai, they realized, to their embarrassment, that they were stuck. With astonished ferry passengers looking on, the students abandoned their car and waded to shore. It’s fun to laugh at incompetent tourists. But it is also worth asking how on earth three sentient beings can drive into the Pacific Ocean on the instructions of GPS gone haywire.

The incident is far from unique. People following GPS guidance have driven their cars into a lake in Washington state, straight on a T-intersection and into a house in New Jersey, down a flight of stairs in Manhattan, along a rocky footpath to the brink of a cliff in Yorkshire and into a large sand pit at a construction site in Hamburg. This is known as automation bias; once a computer has made a recommendation, it is all too easy to accept that recommendation unthinkingly.

This is also an example of perceptual bias. Seeing is not passive. When we look, we usually have an expectation of what we will see. We recognize the object or person faster due to our expectation. Our perception is slower when we are just looking around without an expectation. But when our eyes are looking at something that is very different from what we expected, our perception may not only be slower, we may become temporarily overwhelmed and freeze. When this happens when we are driving, it may be humorous, but it may also be dangerous. Knowing that it is normal human behavior, Tim Harford suggests that a solution may be to require more human input (introduce a degree of messiness) even though it is not required by the technology.

For More:

Look To See

Narrative Medicine

Your Inner Fish

Neil Shubin

            Neil Shubin is a paleontologist whose team discovered fossils in 2004 of an animal which is a transition between a fish and a land-living animal. How we have evolved is fascinating and much more than a curiosity. He uses examples from living animals, fossils, and DNA to show how we are all related and how that information can be used to help understand our health problems and is being used to develop new treatments. The links are fascinating. How can it not be fascinating when we realize that all of our cells have the same genetic code and our cells differentiate and develop into thousands of kinds of cells which link to become our organs through communicating with each other and turning genes on and off. It is, as Neil Shubin states, like a pile of bricks being able to build a house by themselves. Mutations have enabled evolution but are also the cause of cancers. Did you know…

            Our sense of smell allows us to discriminate among five thousand to ten thousand odors. Some people can detect the odor molecules in a green bell pepper at a concentration of less that one part per trillion. That is like picking out one grain of sand from a mile-long beach…. Fully three percent of our entire genome is devoted to genes for detecting different odors…. Our large number of odor genes makes sense – mammals are highly specialized smelling animals….  But when geneticists looked at the structure of human genes in more detail, they found a big surprise: fully three hundred of these three thousand genes are rendered completely functionless by mutations…. Why have so many of our odor genes been knocked out? The answer was found by comparing genes among different primates. Primates that developed color vision tend to have large numbers of knocked-out smell genes. The conclusion is clear. We humans are part of a lineage that has traded smell for sight. We now rely on vision more than smell, and this is reflected in our genome.

            If we look around the animal world, we can assess whether animals are specialized for daylight or night by looking at the percentage of each type of light-sensing cell in their eyes. In humans these cells make up about 70 percent of all the sensory cells in our body. That is a clear statement about how important vision is to us.

            The whole system we use to perceive position and acceleration (our vestibular system) is connected to our eye muscles via connections in our brain. The motion of our eyes is controlled by six small muscles attached to the side walls of the eyeball. The muscles contract to move the eye up, down, left, and right. We can move our eyes voluntarily by contracting these muscles each time we decide to look in a new direction; but some of the most fascinating properties of these muscles is related to their involuntary action. They move our eyes all the time, without our even thinking about it. To appreciate the sensitivity of this eye-muscle link, move your head back and forth while looking at the page. Keep your eye fixed in one place as you move your head. What happened during this experiment? Your eyes stayed fixed on a single point while your head moved. This motion is so commonplace that we take it for granted, but it is incredibly complex. Each of the six muscles in both eyes is responding to the movement of the head. Sensors in your head record the direction and velocity of your head’s movement. These signals are carried to the brain, which then sends out signals telling your eye muscles to fire. This system can misfire, and misfires have much to tell us about our general well-being. This is one of the many things that our ambient visual system does subconsciously. This system can be disrupted from drinking too much alcohol. It can also be disrupted when the connections and timing are disturbed by a head injury and is often the most debilitating problem in post-concussion syndrome. So few things in life are simple.

For More:

Plasticity in Sensory Systems

The Body: A Guide for Occupants

Visual Paradox

It was interesting to find the following information about vision in The Beautiful Cure: The Revolution in Immunology and What it Means for Your Health by Daniel M. Davis. In trying to understand more about the immune system and how it makes an appropriate level of response, the immunologist Ralph Steinman discovered accessory cells by looking at cells from the spleen which stuck to glass, cells with a unique appearance and movement from within a hodgepodge of cells. This was not only an exceptional act of science but also an exceptional act of perception.

 A scientific discovery such as this, made by just watching cells down a microscope, doesn’t happen as simply as might be imagined. One of the reasons it is so difficult has been strikingly illustrated by two Harvard psychologists, Christopher Chabris and Daniel Simons, who asked volunteers to watch a video of six basketball players – three in white T-shirts and three in black – walking around and passing basketballs between them. Chabris and Simons asked the viewers to count the number of times a basketball is passed between two players both wearing white T-shirts, which takes a bit of concentration. Halfway through the video, which you can watch for yourself online, a woman in a gorilla costume walks onto the scene, stands among the players, beats her chest facing the camera, and walks off. Afterwards, the viewers are asked if they noticed anything unusual. Despite the fact that eye-tracking equipment showed that all the viewers had gazed straight at the gorilla for an equivalent length of time, only half had noticed her. This ‘perceptual blindness’ was even worse when tested on a group of expert radiologists, who were asked to look through computed tomography (CT) scans of lungs in search of nodules, which would appear as bright white circles. While some of the scans also showed pictures of a gorilla that was forty-eight times larger than the nodules the experts were told – and trained – to look for, 83% of the radiologists missed seeing the gorilla despite gazing right at her.

These experiments emphasize an important truth: we see with our brains rather than with our eyes. Our brains filter and interpret everything detected by our body’s sensory organs and because of this, we often see only what we are looking for and fail to notice the unexpected.  

        

When vision is enhanced or re-mediated, most of the changes take place in the brain. The effects of vision therapy cannot be understood without realizing this.

For More:

Reading as a Perceptual Skill

Visual Perception and Who We Are

Stress and Mindset

The Body: A Guide for Occupants

Bill Bryson

Bill Bryson is a talented communicator who has written about travel, language and science and manages to insinuate humor to increase the reader’s pleasure and to inject emphasis which makes facts more meaningful and memorable. The Body is his latest book which would make a wonderful Christmas gift for any curious readers on your list. Instead of attempting a review, I will include two excerpts as examples.

“The great paradox of the brain is that everything you know about the world is provided to you by an organ that has itself never seen that world. The brain exists in silence and darkness, like a dungeoned prisoner. It has no pain receptors, literally no feelings. It has never felt warm sunshine or a soft breeze. To your brain, the world is just a stream of electrical pulses, like taps of Morse code. And out of this bare and neutral information it creates for you – quite literally creates – a vibrant, three-dimensional, sensually engaging universe. Your brain is you. Everything else is just plumbing and scaffolding.”

“Just sitting quietly, doing nothing at all, your brain churns through more information in thirty seconds than the Hubble Space Telescope has processed in thirty years. A morsel of cortex one cubic millimeter in size – about the size of a grain of sand – could hold two thousand terabytes of information, enough to store all the movies ever made, trailers included, or about 1.2 billion copies of this book. Altogether, the human brain is estimated to hold something on the order of two hundred exabytes of information, roughly equal to “the entire digital content of today’s world,” according to Nature Neuroscience. If that is not the most extraordinary think in the universe, then we certainly have some wonders to find yet….”

“There is a huge amount we have left to learn and many things we may never learn. But equally some of the things we do know are at least as amazing as the things we don’t. Consider how we see – or, to put it slightly more accurately, how the brain tells us what we see.”

“Just look around you now. The eyes send a hundred billion signals to the brain every second. But that’s only part of the story. When you “see” something, only about 10 percent of the information comes from the optic nerve. Other parts of the brain have to deconstruct the signals – recognize faces, interpret movement, identify danger. In other words, the biggest part of seeing isn’t receiving images; it’s making sense of them.”

“For each visual input, it takes a tiny but perceptible amount of time – about two hundred milliseconds, one-fifth of a second – for the information to be processed and interpreted. One-fifth of a second is not a trivial span of time when a rapid response is required – to step back from an oncoming car, say, or to avoid a blow to the head. To help us deal better with this fractional lag, the brain does a truly extraordinary thing: it continuously forecasts what the world will be like a fifth of a second from now, and that is what it gives us as the present. That means that we never see the world as it is at this very instant, but rather as it will be a fraction of a moment in the future. We spend our whole lives, in other words, living in a world that doesn’t quite exist yet….”

All the richness of life is created inside your head. What you see is not what it is but what your brain tells you it is, and that’s not the same thing at all.What Bill Bryson does not say is that much of this function is learned though experimentation and experience disguised as play and we all learn a little differently.

For More:

Action in Perception

The River of Consciousness