Systematic review of measurement tools to assess surgeons' intraoperative cognitive workload.

BACKGROUND: Surgeons in the operating theatre deal constantly with high-demand tasks that require simultaneous processing of a large amount of information. In certain situations, high cognitive load occurs, which may impact negatively on a surgeon's performance. This systematic review aims to provide a comprehensive understanding of the different methods used to assess surgeons' cognitive load, and a critique of the reliability and validity of current assessment metrics. METHODS: A search strategy encompassing MEDLINE, Embase, Web of Science, PsycINFO, ACM Digital Library, IEEE Xplore, PROSPERO and the Cochrane database was developed to identify peer-reviewed articles published from inception to November 2016. Quality was assessed by using the Medical Education Research Study Quality Instrument (MERSQI). A summary table was created to describe study design, setting, specialty, participants, cognitive load measures and MERSQI score. RESULTS: Of 391 articles retrieved, 84 met the inclusion criteria, totalling 2053 unique participants. Most studies were carried out in a simulated setting (59 studies, 70 per cent). Sixty studies (71 per cent) used self-reporting methods, of which the NASA Task Load Index (NASA-TLX) was the most commonly applied tool (44 studies, 52 per cent). Heart rate variability analysis was the most used real-time method (11 studies, 13 per cent). CONCLUSION: Self-report instruments are valuable when the aim is to assess the overall cognitive load in different surgical procedures and assess learning curves within competence-based surgical education. When the aim is to assess cognitive load related to specific operative stages, real-time tools should be used, as they allow capture of cognitive load fluctuation. A combination of both subjective and objective methods might provide optimal measurement of surgeons' cognition.

Influence of spray volume on the control of Conyza spp. in soybean pre-sowing with burndown.

The herbicide mixture diclosulam + halauxifen appears to be an alternative for the control of Conyza spp.; however, the spray volume may result in different spray deposition effects on the target and, therefore, on the control. Therefore, the objective of this study was to evaluate the impact of different spray volumes of diclosulam + halauxifen on the control of and damage to the leaf surface of Conyza spp. The experiment was conducted in the field in a randomized block design with four replications. Diclosulam + halauxifen (23.52 g ai ha-1 + 6.32 g ae ha-1) was applied to Conyza spp. at average heights greater than 10 cm, followed by sequential application of glufosinate ammonium (500 g ai ha-1) after 14 days. Different spray volumes (200, 150, 100, 80 and 50 L ha-1) were used. The percentage of droplet coverage was evaluated using hydrosensitive paper and analyzed using DropScan software. After 24 hours of initial application, the leaves were collected for scanning electron microscopy (SEM). Although the different spray volumes did not affect the control, faster necrosis effects were observed at 150 and 200 L ha-1. Moreover, the trichome and stomatal density decreased at a spray volume of 200 L ha-1, indicating greater initial damage at this spray volume. Thus, increased spray spray volumes result in increased spray spray deposition, damage to leaf structures and consequently increased control speed.

Using extended reality (XR) for medical training and real-time clinical support during deep space missions.

Medical events can affect space crew health and compromise the success of deep space missions. To successfully manage such events, crew members must be sufficiently prepared to manage certain medical conditions for which they are not technically trained. Extended Reality (XR) can provide an immersive, realistic user experience that, when integrated with augmented clinical tools (ACT), can improve training outcomes and provide real-time guidance during non-routine tasks, diagnostic, and therapeutic procedures. The goal of this study was to develop a framework to guide XR platform development using astronaut medical training and guidance as the domain for illustration. We conducted a mixed-methods study-using video conference meetings (45 subject-matter experts), Delphi panel surveys, and a web-based card sorting application-to develop a standard taxonomy of essential XR capabilities. We augmented this by identifying additional models and taxonomies from related fields. Together, this "taxonomy of taxonomies," and the essential XR capabilities identified, serve as an initial framework to structure the development of XR-based medical training and guidance for use during deep space exploration missions. We provide a schematic approach, illustrated with a use case, for how this framework and materials generated through this study might be employed.

Selectivity of herbicides used in corn on Crotalaria ochroleuca G. Don.

In the cropping systems that integrate the corn crop, the insertion of Crotalaria ochroleuca G. Don is predominantly intercropped. In this context, there is a need to observe herbicides that present selectivity for this sunn hemp species. The objective of this study was to evaluate the selectivity of pre and post-emergent herbicides on C. ochroleuca. Two field experiments were conducted in randomized blocks with four replications, involving the pre-emergence and post-emergence application of different herbicide treatments. For the pre-emergent ones, amicarbazone, atrazine and flumioxazin provided phytotoxicity higher than 90% and, consequently, low plant biomass. On the other hand, acetochlor and s-metolachlor did not cause phytotoxicity and did not affect the dry mass of crotalaria. In post-emergence, atrazine + mesotrione showed phytotoxicity >95%, followed by nicosulfuron and 2.4-D with phytotoxicity between 50-60%, whereas tembotrione did not cause injury to the plants. Thus, it was found that among the pre-emergent, acetochlor and s-metolachlor were selective, and for the emerging powders, only tembotrione was the most selective for all parameters analyzed.

Using machine learning to predict perfusionists' critical decision-making during cardiac surgery.

The cardiac surgery operating room is a high-risk and complex environment in which multiple experts work as a team to provide safe and excellent care to patients. During the cardiopulmonary bypass phase of cardiac surgery, critical decisions need to be made and the perfusionists play a crucial role in assessing available information and taking a certain course of action. In this paper, we report the findings of a simulation-based study using machine learning to build predictive models of perfusionists' decision-making during critical situations in the operating room (OR). Performing 30-fold cross-validation across 30 random seeds, our machine learning approach was able to achieve an accuracy of 78.2% (95% confidence interval: 77.8% to 78.6%) in predicting perfusionists' actions, having access to only 148 simulations. The findings from this study may inform future development of computerised clinical decision support tools to be embedded into the OR, improving patient safety and surgical outcomes.

Studies on the anchorage of ATP diphosphohydrolase in synaptic plasma membranes from rat brain.

ATP diphosphohydrolases are described as ecto-enzymes in several tissues. In the present study, synaptic plasma membrane (SPM) was exposed to a series of agents used to distinguish between peripheral (hydrophilic), G-PI-anchored and transmembrane-polypeptide-anchored membrane proteins. These procedures included: (a) nondetergent extraction, (b) Triton X-114 phase partitioning, (c) phosphatidylinositol-specific phospholipase C (PI-PLC) extraction and (d) protease incubation. In cases (a), (c) and (d) the SPM was incubated with different agents and the ATPase-ADPase activities and the protein concentration was determined in the original sample, in the pellet and in the supernatant obtained after 100,000 g centrifugation. In procedure (b), the SPM was solubilized in 1% triton X-114 and submitted to phase separation onto a sucrose cushion. The aqueous and detergent rich phases obtained by this treatment were assayed for ATPase-ADPase activities and protein determination. The results obtained suggest an intrinsic behaviour for ATP diphosphohydrolase since none of the nondetergent treatments was efficient in removing the enzyme from SPM. Moreover, ATPase and ADPase activities were recovered predominantly (> 50%) in the detergent-rich phase obtained by Triton X-114 partitioning. The enzyme was not released by PI-PLC or proteases. These results indicate that the enzyme is not a GPI-anchored protein, but is probably deeply anchored on the plasma membrane in agreement with the amino acid sequence of the enzyme recently published.

Characterisation of an ATP diphosphohydrolase (Apyrase, EC 3.6.1.5) activity in Trichomonas vaginalis.

In the present report the enzymatic properties of an ATP diphosphohydrolase (apyrase, EC 3.6.1.5) in Trichomonas vaginalis were determined. The enzyme hydrolyses purine and pyrimidine nucleoside 5'-di- and 5'-triphosphates in an optimum pH range of 6.0--8.0. It is Ca(2+)-dependent and is insensitive to classical ATPase inhibitors, such as ouabain (1 mM), N-ethylmaleimide (0.1 mM), orthovanadate (0.1 mM) and sodium azide (5 mM). A significant inhibition of ADP hydrolysis (37%) was observed in the presence of 20 mM sodium azide, an inhibitor of ATP diphosphohydrolase. Levamisole, a specific inhibitor of alkaline phosphatase, and P(1), P(5)-di (adenosine 5'-) pentaphosphate, a specific inhibitor of adenylate kinase, did not inhibit the enzyme activity. The enzyme has apparent K(m) (Michaelis Constant) values of 49.2+/-2.8 and 49.9+/-10.4 microM and V(max) (maximum velocity) values of 49.4+/-7.1 and 48.3+/-6.9 nmol of inorganic phosphate x min(-1) x mg of protein(-1) for ATP and ADP, respectively. The parallel behaviour of ATPase and ADPase activities and the competition plot suggest that ATP and ADP hydrolysis occur at the same active site. The presence of an ATP diphosphohydrolase activity in T. vaginalis may be important for the modulation of nucleotide concentration in the extracellular space, protecting the parasite from the cytolytic effects of the nucleotides, mainly ATP.

Influence on memory of posttraining or pre-test injections of ACTH, vasopressin, epinephrine, and beta-endorphin, and their interaction with naloxone.

The intraperitoneal (i.p.) injection of ACTH 1-24 (0.2 microgram/kg), lysine--vasopressin (10.0 micrograms/kg) or epinephrine HCl (5.0 micrograms/kg) shortly after training or prior to testing caused memory facilitation of a step-down inhibitory avoidance task in rats, acquired with low intensity training footshocks (0.3 mA, 60 Hz). Naloxone HCl (0.4 mg/kg) potentiated their posttraining effect, but antagonized their pre-test effect. Naloxone on its own caused retrograde memory facilitation but had no effect on the test session. Posttraining human beta-endorphin (1.0 microgram/kg) was amnestic, and its pre-test administration enhanced retention. Both effects were naloxone-reversible. Neither the pre-test facilitation caused by beta-endorphin nor those caused by any of the other drugs (which are possible releasers of endogenous beta-endorphin) were observed in animals in which the influence of endogenous opioids was prevented at the posttraining period by the administration of naloxone. These results are compatible with, and considerably strengthen, the previously advanced hypothesis that learning of this task, and possibly others, depends on a state induced by beta-endorphin after training, and that it would normally be dissociated because this peptide is normally not released during test sessions. In addition, the posttraining facilitation caused by ACTH, vasopressin, and epinephrine stands out as an effect separate from, and in fact normally hindered by, posttraining beta-endorphin release.

Effect of ACTH, epinephrine, beta-endorphin, naloxone, and of the combination of naloxone or beta-endorphin with ACTH or epinephrine on memory consolidation.

The effect on retention of the post-training intraperitoneal administration of ACTH1-24 (0.2 or 2.0 micrograms/kg), epinephrine HCl (5.0 or 50.0 micrograms/kg), human beta-endorphin (0.1 or 1.0 microgram/kg), naloxone (0.4 mg/kg), and of the combination of naloxone or beta-endorphin with ACTH or epinephrine was studied in two different but closely related step-down inhibitory avoidance tasks in rats: task 1 (5 cm high 25 X 25 cm platform; 0.5 mA continuous footshock) and task 2 (7 X 25 cm platform, 0.3 mA discontinuous footshock). In task 1, saline control animals showed good retention in a test session carried out 24 hr later; beta-endorphin, ACTH and epinephrine caused amnesia; beta-endorphin potentiated the amnesic effect of ACTH and epinephrine; and naloxone caused memory facilitation and reversed the amnesic effect of ACTH and epinephrine. In task 2, control animals showed poor retention; beta-endorphin caused amnesia at the dose of 0.1 but not 1.0 microgram/kg; the other three drugs caused memory facilitation; naloxone potentiated the facilitatory effect of ACTH and epinephrine; and beta-endorphin reversed it and transformed it into a deep amnesia. These findings suggest that an opioid-mediated amnesic mechanism modulates the effect of ACTH and epinephrine on memory consolidation, either by dampening that effect when training parameters tend to make it facilitatory, or by enhancing it when training conditions tend to make it amnesic. On the basis of these and previous data it seems likely that the amnesic effect of ACTH and epinephrine could be mediated by endogenous beta-endorphin release.

Involvement of alpha-adrenergic receptors in the amnestic and anti-amnestic action of ACTH, beta-endorphin and epinephrine.

The post-training administration of ACTH1-24 (0.2 microgram/kg), human beta-endorphin (1.0 microgram/kg) or epinephrine HC1 (5.0 micrograms/kg), intraperitoneally, caused retrograde amnesia for a step-down inhibitory avoidance task in rats, and their pre-testing administration reversed this effect. The concomitant administration of the alpha 2-adrenergic receptor blocker, yohimbine HC1 (2.0 mg/kg), antagonized both the post-training amnestic and the pre-testing anti-amnestic effects of the three substances. The anti-amnestic effect of epinephrine, but not that of ACTH or beta-endorphin, was also antagonized by the alpha 1-adrenergic receptor blocker, prazosin HC1 (2.0 mg/kg). These findings suggest that alpha 2-adrenergic receptors are involved both in the amnestic and in the anti-amnestic effect of ACTH, beta-endorphin and epinephrine at the doses used, and that, in the case of the anti-amnestic effect of epinephrine, alpha 1 receptors also are involved. It seems likely that memory regulation by post-training and pre-testing ACTH and beta-endorphin requires the concomitant activity of alpha 2-adrenergic mechanisms, either central or peripheral.

Differential effect of posttraining naloxone, beta-endorphin, leu-enkephalin and electroconvulsive shock administration upon memory of an open-field habituation and of a water-finding task.

Rats were trained and tested in an open field for habituation of rearing responses, for a water-finding task, or for both tasks simultaneously. Training-test interval was 24 hr. The water-finding task consisted of locating a metal tube in one of the walls of the box, which was attached to a water bottle on the outside; animals were water deprived between training and testing. Retention was estimated by measuring the latency to lick from the tube on the test session. Rats learned this task either with or without water deprivation, also prior to training. Habituation learning (reduction of the number of rearings between the training and test session) occurred either simultaneously with the water-finding task or in animals trained without the water tube, so that they could not learn the water-finding task. As happens with many other tasks, training in the open field was followed by a large decrease of hypothalamic beta-endorphin immunoreactivity, attributable to a release of this substance. Posttraining IP naloxone (1.6 mg/kg) administration facilitated, and posttraining beta-endorphin (2.0 micrograms/kg), leu-enkephalin (5.0 micrograms/kg), or electroconvulsive shock (15 mA, 60 Hz, 2 sec) depressed the retention of habituation; this occurred regardless of whether the animals were trained and/or tested with or without water deprivation, and whether the task was acquired alone or simultaneously with the water-finding task. By contrast, none of these treatments had any effect on retention of the water finding task, acquired either with or without prior water deprivation. Thus, habituation was, and water-finding was not, sensitive to posttraining treatments known to affect endogenous opioids: the opioids themselves, their antagonist, naloxone, and electroconvulsive shock which releases brain opioids and causes naloxone-reversible retrograde amnesia. Learning of the water-finding task was merely incidental to exploration of the open field; it took place even when the animals were trained without the water tube. This suggests that the posttraining treatments that affect endogenous opioid function affect memory only of the task(s) that actually cause the release of brain beta-endorphin (in this case, probably habituation), and not of others that may occur simultaneously but are merely incidental (water-finding). A feature apparently common to the former is that they must directly involve either the recognition of novelty, or the initiation of an interaction with a new environment, or perhaps the habituation of such interaction.

Effect of morphine, ACTH, epinephrine, Met-, Leu- and des-Tyr-Met-enkephalin on beta-endorphin-like immunoreactivity of rat brain.

Morphine (1,0 mg/kg), ACTH1-24 (10.0 micrograms/kg), epinephrine (12.0 micrograms/kg), Met-enkephalin (2.0 and 5.0 micrograms/kg), Leu-enkephalin (2.0 micrograms/kg) and des-Tyr-Met-enkephalin (2.0 micrograms/kg) all produced marked reductions of beta-endorphin-like immunoreactivity in the rat diencephalon. At a dose of 0.4 mg/kg, naloxone had no effect of its own and was unable to reverse the depleting effect of the other substances. The depletion of beta-endorphin-like immunoreactivity caused by the various treatments is attributable to release and subsequent degradation of beta-endorphin and/or of its precursors. The various behavioral effects of morphine, ACTH, epinephrine and the enkephalins may be explained by the release of endogenous beta-endorphin.

Effect of various behavioral training and testing procedures on brain beta-endorphin-like immunoreactivity and the possible role of beta-endorphin in behavioral regulation.

Beta-Endorphin-like immunoreactivity is reduced in the rat diencephalon after the animals are exposed for the first time to any of the following behavioral situations: 50 tones (habituation), 50 tone-footshock shuttle avoidance trials, one step-down inhibitory avoidance trial, simple exposure to the avoidance apparatus with no footshocks, or inescapable shock. The effect is not observed when animals are exposed to any of these situations for a second time. The reduction of brain beta-endorphin-like immunoreactivity is attributable to release and subsequent metabolism of the substance, and correlates with the novelty inherent in the diverse training or test situations. The role of beta-endorphin in behavior is discussed in the light of these and previous results which showed that it causes both retrograde amnesia and a facilitation of retrieval. The substance would appear to serve an adaptive function when animals are exposed to a new experience, by inducing a temporary forgetting of the experience together with (or leading to) a state of alertness or preparedness for what may happen next.

Memory facilitation by posttraining and pretest ACTH, epinephrine, and vasopressin administration: two separate effects.

Rats were trained in a step-down inhibitory avoidance task using a 0.3-mA, 2-s, 60 Hz footshock and tested 24 hr later. The animals received, 1 min after training and/or 5 min before testing, an ip injection of saline, ACTH (0.2 microgram/kg), lysine-vasopressin (10 micrograms/kg), epinephrine (5 micrograms/kg), naloxone (0.4 mg/kg), or a combination of naloxone with one of the hormones. Both the posttraining and the pretest injection of the hormones enhanced retention test performance; the enhancement was larger in animals that received the two treatments. Posttraining, but not pretest, naloxone administration also caused an enhancement. However, posttraining naloxone potentiated, and pretest naloxone antagonized, the effect of the concomitantly injected hormones. These data show that the posttraining and the pretest effect of the hormones are independent, are due to different mechanisms, and can be additive. In addition, it does not seem possible to explain posttraining memory facilitation by the hormones as owing to an addition to the reinforcement.

The influence of adrenergic receptor antagonists on the amnestic and antiamnestic actions of adrenaline and tyramine.

The posttraining IP administration of adrenaline (epinephrine) HCl (5.0 micrograms/kg) or tyramine HCl (1.0 mg/kg) causes retrograde amnesia for a one-way step-down inhibitory avoidance task in rats. The effect is cancelled by the simultaneous injection of the alpha 2-adrenergic receptor antagonist yohimbine HCl (2.0 mg/kg) or of the beta 1 - beta 2 blocker propranolol HCl (2.0 mg/kg). The amnestic effect of posttraining adrenaline or tyramine is counteracted by the administration of adrenaline or tyramine prior to testing: each drug has a greater antiamnestic effect against itself than against the other drug. The antiamnestic effect of tyramine and adrenaline is antagonized by the simultaneous administration of prazosin or yohimbine, but not by that of propranolol. We conclude that the posttraining amnestic effect of adrenaline and tyramine is mediated by alpha 2 receptors (probably postsynaptic) and that it does not reflect a storage deficit, since memory can be restored by an appropriate treatment given before the test session. The antiamnestic effect of adrenaline and tyramine is mediated both by alpha 1 and by alpha 2 receptors, and probably reflects the dependency of mechanisms that make stored information available for retrieval on circulating catecholamines. The present findings provide no clue as to the anatomical distribution of the adrenergic receptors involved in the amnestic or antiamnestic actions of adrenaline and tyramine.

Beta-endorphin causes retrograde amnesia and is released from the rat brain by various forms of training and stimulation.

The endogenous opiate peptide, beta-endorphin (0.4, 1.0, 2.0, and 10.0 microgram/kg) was injected IP into rats immediately after training in a shuttle avoidance task, and its effect on memory retention was evaluated in test sessions carried out 24 h later. The drug was found to cause retrograde amnesia, the ED50 being 1.0 microgram/kg. Beta-endorphin immunoreactivity was measured in the hypothalamus and rest of the brain of rats submitted to training, or test sessions of shuttle avoidance learning, pseudoconditioning in the shuttle-box, tones alone, or foot-shocks alone. After training in any of the four paradigms, there was a marked (46-60%) depletion of beta-endorphin immunoreactivity in the rest of the brain. No changes were detected in the hypothalamus or after test sessions. The loss of beta-endorphin immunoreactivity may be attributed to release of this substance caused by the stimuli used for training. From the present findings, as well as previous observations on the memory-facilitating influence of the opiate receptor antagonist, naloxone, it is concluded that there is a physiological amnesic mechanism mediated by beta-endorphin (and perhaps other opoid peptides as well), which is triggered by the non-associative factors present in the various forms of learning.

Postnatal development of ATPase-ADPase activities in synaptosomal fraction from cerebral cortex of rats.

ATPase-ADPase activities in synaptosomes from cerebral cortex was measured in rats of various ages (0-, 7-, 10-, 14- and 21- and 60-90-days). The activities (nmol Pi/min/mg) increased steadily from birth, reaching maximum values at 21 days of age. The increase was primarily due to increases in Vmax; the Km values are the same from birth until adult age. The developmental profile was similar for ATPase-ADPase activities and acetylcholinesterase from the same fraction. Several specific ATPase inhibitors and Ap5A (P1P5-di(adenosine-5)-pentaphosphate) did not interfere with the hydrolysis of ATP and ADP at all ages studied, suggesting that classical ATPases and adenylate kinase were not involved in the degradation of both nucleotides by synaptosomal fraction in the assay conditions. Other phosphatases were also ruled out. It is conceivable that ATPase-ADPase activities play an important role in neurotransmitter metabolism.

Beta-endorphin like immunoreactivity of brain, pituitary gland and plasma of rats submitted to postnatal protein malnutrition: effect of behavioral training.

Wistar-derived rats were raised and maintained either on a normal- (25% casein) or on a low-protein (8% casein) diet until the age of 100 to 114 days. Both diets were isocaloric and contained an adequate supply of salts and vitamins. There were gross differences in body, brain and pituitary weight between the two groups. In addition, the brain and pituitary content of beta-endorphin like immunoreactivity was lower in the protein malnourished rats, and three different forms of training (50 tone-footshock shuttle avoidance trials; 50 tones alone (habituation); 50 footshocks alone) caused a depletion of brain beta-endorphin like immunoreactivity in the normal, but not in the malnourished rats. Footshock stimulation caused, in addition, a pituitary decrease and a plasma increase of beta-endorphin like immunoreactivity, also restricted to the normal diet group. Performance in the habituation and in the shuttle avoidance tasks was similar in the two groups, despite the different responsiveness of their brain and pituitary beta-endorphin systems to training and/or stimulation. In view of the possible involvement of these systems in learning suggested by these and by previous data, it seems likely that the neurohumoral regulation of habituation and avoidance learning may be different in rats submitted to protein malnutrition when compared to controls.

The role of opioid peptides in memory and learning.

Evidence is discussed which points to the existence of a physiologic amnesic mechanism mediated by beta-endorphin and perhaps by other opioid peptides as well. This mechanism is triggered by various forms of training and by either painful or painless stimulation. It may operate through the inhibition of central dopaminergic and beta-adrenergic systems that modulate the memory consolidation process. This amnesic mechanism in unrelated to the regulation of pain perception, and operates at opioid peptide levels several orders of magnitude below those that are needed to cause analgesia or other effects. In addition, shuttle avoidance and habituation learning seem to be dependent on a state induced by the release of beta-endorphin. It is possible that this may be related to the amnesic properties of this substance. Therefore, it appears that the endogenous opioid peptides may exert their primary function in the modulation of memory processes.

Effect of naloxone, haloperidol and propranolol on cyclic 3',5'-adenosine monophosphate content of rat amygdala.

Naloxone (0.4 mg/kg, i.p.) causes an increase of cyclic adenosine monophosphate levels in the amygdala, but not in the hippocampus, caudate, or hypothalamus, of rats. The effect is antagonized by haloperidol (0.5 mg/kg, i.p.) and by propranolol (0.5 mg/kg, i.p.). This is consistent with the hypothesis of a tonic inhibitory influence of endogenous opiates on central dopaminergic and beta-noradrenergic systems. Haloperidol had an effect of its own on amygdala cyclic adenosine monophosphate levels which was blocked by propranolol. This suggests the possibility of an antagonistic interaction between dopaminergic and beta-noradrenergic innervation on this structure.