Prenatal Cannabinoid Exposure Elicits Memory Deficits Associated with Reduced PSA-NCAM Expression, Altered Glutamatergic Signaling, and Adaptations in Hippocampal Synaptic Plasticity.

Cannabis is now one of the most commonly used illicit substances among pregnant women. This is particularly concerning since developmental exposure to cannabinoids can elicit enduring neurofunctional and cognitive alterations. This study investigates the mechanisms of learning and memory deficits resulting from prenatal cannabinoid exposure (PCE) in adolescent offspring. The synthetic cannabinoid agonist WIN55,212-2 was administered to pregnant rats, and a series of behavioral, electrophysiological, and immunochemical studies were performed to identify potential mechanisms of memory deficits in the adolescent offspring. Hippocampal-dependent memory deficits in adolescent PCE animals were associated with decreased long-term potentiation (LTP) and enhanced long-term depression (LTD) at hippocampal Schaffer collateral-CA1 synapses, as well as an imbalance between GluN2A- and GluN2B-mediated signaling. Moreover, PCE reduced gene and protein expression of neural cell adhesion molecule (NCAM) and polysialylated-NCAM (PSA-NCAM), which are critical for GluN2A and GluN2B signaling balance. Administration of exogenous PSA abrogated the LTP deficits observed in PCE animals, suggesting PSA mediated alterations in GluN2A- and GluN2B- signaling pathways may be responsible for the impaired hippocampal synaptic plasticity resulting from PCE. These findings enhance our current understanding of how PCE affects memory and how this process can be manipulated for future therapeutic purposes.

Interdisciplinary speed dating augments diabetes self-management education and support to improve health outcomes.

OBJECTIVE: To determine if a novel interdisciplinary "speed-dating" clinic augments Diabetes Self-Management Education and Support (DSMES). METHODS: Adult patients with diabetes attended a DSMES class. Two weeks later patients attended an interdisciplinary clinic utilizing a "speed-dating" format during which they progressed through 5 stations hosted by different healthcare disciplines at 30-minute increments: physician, pharmacist, nurse/dietitian, case manager, and psychologist. Shared decision-making was utilized to identify mutually agreeable recommendations. Change in clinical outcomes were compared for DSMES-only attenders versus Dual-attendees; utilization of emergency department and hospital services were measured 12 months before and after attending the Speed Dating clinic. This analysis represents patients attending the program during 2016. RESULTS: Sixty-nine attended the DSMES class, 40 of whom followed-up in the "speed-dating" clinic (58% return rate). Attending the Speed Dating clinic improved A1C (p = 0.003) and LDL-C (p = 0.003) compared to the DSMES class alone. Comparatively, after attending the speed-dating clinic, patients had fewer emergency department (p = 0.366) and hospital admissions (p = 0.036), and shorter lengths of hospital stay (p = 0.030). CONCLUSIONS: The interdisciplinary "speed-dating" approach improved diabetes outcomes beyond DSMES alone and reduced utilization of hospital services. PRACTICE IMPLICATIONS: Patients should attend DSMES but also participate in an Interdisciplinary Speed Dating follow-up to further improve outcomes.

Adiponectin Knockout Mice Display Cognitive and Synaptic Deficits.

Adiponectin is an adipokine that has recently been under investigation for potential neuroprotective effects in various brain disorders including Alzheimer's disease, stroke, and depression. Adiponectin receptors (AdipoR1 and AdipoR2) are found throughout various brain regions, including the hippocampus. However, the role of these receptors in synaptic and cognitive function is not clear. Therefore, the goal of the current study was to evaluate synaptic and cognitive function in the absence of adiponectin. The current study utilized 12-month-old adiponectin knockout (APN-KO) mice and age-matched controls to study cognitive and hippocampal synaptic alterations. We determined that AdipoR1 and AdipoR2 are present in the synaptosome, with AdipoR2 displaying increased presynaptic vs. postsynaptic localization, whereas AdipoR1 was enriched in both the presynaptic and postsynaptic fractions. APN-KO mice displayed cognitive deficits in the novel object recognition (NOR) and Y-maze tests. This was mirrored by deficits in long-term potentiation (LTP) of the hippocampal Schaefer collateral pathway in APN-KO mice. APN-KO mice also displayed a reduction in basal synaptic transmission and an increase in presynaptic release probability. Deficits in LTP were rescued through hippocampal slice incubation with the adiponectin receptor agonist, AdipoRon, indicating that acute alterations in adiponectin receptor signaling influence synaptic function. Along with the deficits in LTP, altered levels of key presynaptic and postsynaptic proteins involved in glutamatergic neurotransmission were observed in APN-KO mice. Taken together, these results indicate that adiponectin is an important regulator of cognition and synaptic function in the hippocampus. Future studies should examine the role of specific adiponectin receptors in synaptic processes.

Rationale of family medicine physicians in effectively identifying patients with chronic hyperglycemia through point-of-care hemoglobin A1C screenings.

PURPOSE: Many patients are unknowingly living with chronic hyperglycemia, possibly due to low screening rates. We aimed to correlate detection of unidentified chronic hyperglycemia to practitioner reported rationale for conducting diabetes screening. METHODS: Physicians screened patients via a point-of-care A1C tests and recorded corresponding rationales. Elevated outcomes (A1C ≥ 5.7%) were correlated to recorded rationales, frequency of repeat screenings, documented diagnoses, and therapeutic actions taken as a result of elevated A1C. RESULTS: Nearly one-half (45%) of selected patients were unknowingly living with chronic hyperglycemia, having an average A1C of 7.92% for outcomes ≥6.5%. Most commonly recorded rationales were overweight status (71%), high-risk ethnicity (58%), and age > 45 years (48%); previously recorded A1C result of ≥5.7% (χ2 16.02, p < 0.001) and hypertension diagnosis (χ2 10.37, p = 0.0013) showed statistically significant correlation with elevated A1C outcomes. A1C results ≥6.5% versus 5.7-6.5% more frequently prompted repeat screenings (77% vs 20%), ICD-10 code documentation (91% vs 28%), lifestyle modification recommendations (78% vs 35%), and drug therapy initiation (78% vs 9%). CONCLUSIONS: Reported rationales were largely impacted by visual inspections of age, race, and weight, and prediabetic A1C values garnered less attention compared to higher values. Utilization of POC A1C screening followed by conformational repeat testing is a practical approach to improve diagnostic rates and initiation of care for diabetes.

Prenatal cannabinoid exposure and altered neurotransmission.

Marijuana is one of the most commonly used illicit drugs worldwide. In addition, use of synthetic cannabinoids is increasing, especially among adolescents and young adults. Although human studies have shown that the use of marijuana during pregnancy leads to adverse behavioral effects, such as deficiencies in attention and executive function in affected offspring, the rate of marijuana use among pregnant women is steadily increasing. Various aspects of human behavior including emotion, learning, and memory are dependent on complex interactions between multiple neurotransmitter systems that are especially vulnerable to alterations during the developmental period. Thus, exploration of neurotransmitter changes in response to prenatal cannabinoid exposure is crucial to develop an understanding of how homeostatic imbalance and various long-term neurobehavioral deficits manifest following the abuse of marijuana or other synthetic cannabinoids during pregnancy. Current literature confirms that vast alterations to neurotransmitter systems are present following prenatal cannabinoid exposure, and many of these alterations within the brain are region specific, time-dependent, and sexually dimorphic. In this review, we aim to provide a summary of observed changes to various neurotransmitter systems following cannabinoid exposure during pregnancy and to draw possible correlations to reported behavioral alterations in affected offspring.

Simulator training to automaticity leads to improved skill transfer compared with traditional proficiency-based training: a randomized controlled trial.

OBJECTIVE: We hypothesized that novices will perform better in the operating room after simulator training to automaticity compared with traditional proficiency based training (current standard training paradigm). BACKGROUND: Simulator-acquired skill translates to the operating room, but the skill transfer is incomplete. Secondary task metrics reflect the ability of trainees to multitask (automaticity) and may improve performance assessment on simulators and skill transfer by indicating when learning is complete. METHODS: Novices (N = 30) were enrolled in an IRB-approved, blinded, randomized, controlled trial. Participants were randomized into an intervention (n = 20) and a control (n = 10) group. The intervention group practiced on the FLS suturing task until they achieved expert levels of time and errors (proficiency), were tested on a live porcine fundoplication model, continued simulator training until they achieved expert levels on a visual spatial secondary task (automaticity) and were retested on the operating room (OR) model. The control group participated only during testing sessions. Performance scores were compared within and between groups during testing sessions. RESULTS: : Intervention group participants achieved proficiency after 54 ± 14 and automaticity after additional 109 ± 57 repetitions. Participants achieved better scores in the OR after automaticity training [345 (range, 0-537)] compared with after proficiency-based training [220 (range, 0-452; P < 0.001]. CONCLUSIONS: Simulator training to automaticity takes more time but is superior to proficiency-based training, as it leads to improved skill acquisition and transfer. Secondary task metrics that reflect trainee automaticity should be implemented during simulator training to improve learning and skill transfer.

Novel method for quantitative assessment of physical workload of healthcare workers by a tetherless ergonomics workstation.

Healthcare workers are at risk of physical injury. Our laboratory has developed a tetherless ergonomics workstation that is suitable for studying physicians' and nurses' physical workloads in clinical settings. The workstation uses wearable sensors to record multiple channels of body orientation and muscle activity and wirelessly transmits them to a base station laptop computer for display, storage, and analysis. The ergonomics workstation generates long records of multi-channel data, so it is desired that the workstation automatically process these records and provide graphical and quantitative summaries of the physical workloads experienced by the healthcare workers. This paper describes a novel method of automated quantitative assessment of physical workload, termed joint cumulative amplitude-duration (JCAD) analysis, that has advantages over previous methods and illustrates its use in a comparison of the physical workloads of robotically-assisted surgery versus manual video-endoscopic surgery.

Tetherless ergonomics workstation to assess nurses' physical workload in a clinical setting.

Nurses are at risk of physical injury when moving immobile patients. This paper describes the development and testing of a tetherless ergonomics workstation that is suitable for studying nurses' physical workload in a clinical setting. The workstation uses wearable sensors to record multiple channels of body orientation and muscle activity and wirelessly transmits them to a base station laptop computer for display, storage, and analysis. In preparation for use in a clinical setting, the workstation was tested in a laboratory equipped for multi-camera video motion analysis. The testing included a pilot study of the effect of bed height on student nurses' physical workload while they repositioned a volunteer posing as a bedridden patient toward the head of the bed. Each nurse subject chose a preferred bed height, and data were recorded, in randomized order, with the bed at this height, at 0.1 m below this height, and at 0.1 m above this height. The testing showed that the body orientation recordings made by the wearable sensors agreed closely with those obtained from the video motion analysis system. The pilot study showed the following trends: As the bed height was raised, the nurses' trunk flexion at both thoracic and lumbar sites and lumbar muscle effort decreased, whereas trapezius and deltoid muscle effort increased. These trends will be evaluated by further studies of practicing nurses in the clinical setting.

A miniature, wearable activity/fall monitor to assess the efficacy of mobility therapy for children with cerebral palsy during everyday living.

Children with cerebral palsy may have difficulty walking and may fall frequently, resulting in a decrease in their participation in school and community activities. It is desirable to assess the effectiveness of mobility therapies for these children on their functioning during everyday living. Over 50 hours of tri-axial accelerometer and digital video recordings from 35 children with cerebral palsy and 51 typically-developing children were analyzed to develop algorithms for automatic real-time processing of the accelerometer signals to monitor a child's level of activity and to detect falls. The present fall-detection algorithm has 100% specificity and a sensitivity of 100% for falls involving trunk rotation. Sensitivities for drops to the knees and to the bottom are 72% and 78%, respectively. The activity and fall-detection algorithms were implemented in a miniature, battery-powered microcontroller-based activity/fall monitor that the child wears in a small fanny pack during everyday living. The monitor continuously logs 1-min. activity levels and the occurrence and characteristics of each fall for two-week recording sessions. Pre-therapy and post-therapy recordings from these monitors will be used to assess the efficacies of alternative treatments for gait abnormalities.

Monitor height affects surgeons' stress level and performance on minimally invasive surgery tasks.

This study investigated the effect of monitor height on surgeons' workload and performance during simulated minimally invasive surgery (MIS). Fourteen volunteer subjects (7 experienced, 7 inexperienced) performed a cutting task in a training box at a standard MIS station with the video monitor positioned in random order at, below (-35 degrees), and above (+15 degrees) the subject's eye level. Task time and error, difficulty and discomfort, head orientation, trapezius and neck muscle activity, and skin conductance were recorded. The experienced subjects performed the task faster, with less error, and with less difficulty than did the inexperienced subjects. For the experienced subjects, error decreased when the monitor was lowered. Difficulty and discomfort increased at the high monitor position. As the monitor was lowered, the head pitched forward, and paraspinal cervical muscle activity increased. Variability in sternocleidomastoid activity increased both at the low and high monitor positions. The results show that monitor height affects both performance and workload. The monitor should be lowered to reduce error and task difficulty but not so low as to produce excessive neck flexion.

A simple virtual instrument to monitor surgeons' workload while they perform minimally invasive surgery tasks.

Monitoring the workload of surgeons while they perform minimally invasive surgery (MIS) tasks can help them learn to reduce effort as they improve performance and can help develop better human-technology interfaces for MIS. To monitor workload, we developed a personal computer based virtual instrument (VI) that uses orientation sensors worn on the surgeon's left and right upper arms to measure upper arm flexion, abduction, and outward rotation angles. From these sensors, we compute indices of effort and integrated effort. One effort index is the upper arm elevation angle. The time integral of this index provides a corresponding integrated effort index. A second effort index is hand velocity. Hand trajectory length is the corresponding integrated effort index. We used the workload monitor VI to study 29 volunteer surgeon subjects while they performed a knot-tying task in a laparoscopic trainer at a standard MIS station. For five of these subjects, we also monitored the workload indices while they performed simulated MIS tasks on a virtual reality Procedicus MIST System. For the subject group, integrated effort, but not level of effort, decreased with increased performance. At each performance level, some subjects worked much harder than others, suggesting that these subjects could benefit by learning to reduce their effort levels. The workload measures from the arm sensors augmented the performance measures provided by the MIST system.

A comparison of the physical effort required for laparoscopic and open surgical techniques.

HYPOTHESIS: Performing complex tasks requires greater muscle effort with laparoscopic instruments than with open surgical instruments. DESIGN: A nonrandomized 2-condition trial. SETTING: A semienclosed ergonomics station in the exhibit hall at the Annual Meeting of the Society of American Gastrointestinal Endoscopic Surgeons. SUBJECTS: Twenty-one surgeons volunteered to participate in the study. INTERVENTIONS: Knot tying during 90 seconds, performed first using a laparoscopic technique (ie, axial instruments in a standard laparoscopic trainer) and then using an open technique (ie, 2 hemostats). MAIN OUTCOME MEASURES: Mean and peak surface electromyographic (EMG) signals collected from the thenar compartment, the flexor digitorum superficialis, and the deltoid muscles of the dominant arm. RESULTS: Compared with open knot-tying, laparoscopic tasks resulted in higher average EMG amplitudes in all 3 muscles (thumb, P =.02; forearm flexor, P =.01; and deltoid, P =.01) and higher peak EMG in the thumb (P =.04) and deltoid (P =.02) muscles. Body part discomfort scores were significantly higher during laparoscopic knot-tying for the forearm flexor and deltoid muscles (P =.02 for both). CONCLUSION: Complex manipulative tasks using laparoscopic techniques require substantially higher upper-extremity muscle effort compared with open surgical techniques.

Wireless virtual instrument measurement of surgeons' physical and mental workloads for robotic versus manual minimally invasive surgery.

The human-technology interface in traditional minimally invasive surgery (MIS) is difficult for the surgeon. Efforts to improve this interface include the use of robotic surgery systems. Ergonomics studies are required to help understand and improve the MIS user interface. We have developed a tetherless virtual instrument (VI) ergonomics workstation for measuring the physical workloads and stress levels of surgeons performing MIS. The workstation records physiological measures of workload and stress and audio and multiple channels of video. The workstation frees up the subject so that studies can be performed in complex and realistic settings, including the operating room. We illustrate the use of the tetherless ergonomics workstation in a study to compare performance and workload for manual and robotically-assisted MIS. The surgeon volunteers were experienced with manual MIS but had no previous experience with the robotic system. The study results showed that the robotic system reduced the workload and stress levels for these subjects but somewhat degraded their performance. Additional studies are needed to determine the relative effects on performance of user inexperience and the robotic interface.