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PubMed2002

Development and validation of a language learning model for behavioral and functional-imaging studies.

To obtain a more precise understanding of the mechanisms involved in language acquisition in healthy subjects and the re-acquisition of language following brain damage, we developed a word learning model which can be used in behavioral and functional-imaging studies. We generated a set of spoken pseudowords, which were normalized with respect to duration and loudness, and (based on a rating study with 40 students) selected 50 pseudowords, which yielded few associations with existing words and were of neutral emotional valence. The selected pseudowords were paired with object drawings in a pseudo-randomized manner and each subject received a different combination of pairings. These auditory-visual pairs were used to train ten subjects solely on the basis of different frequencies of 'correct' and 'incorrect' pairings. This procedure resembles the acquisition of the first words during childhood. During a five-session training protocol, with one session per day, there was a linear increase of the learning curves, which then reached a plateau. Learning remained stable at 1 and 4 weeks retest intervals. Furthermore, subjects correctly translated the pseudowords into their native language, demonstrating the acquisition of word meanings. These findings indicate that the described associative learning program meets the requirements for a robust and ecologically meaningful model to study the neural mechanisms of language learning and plasticity.

Adult↗

PubMed2004

Comparison of learning-related neuronal activity in the dorsal premotor cortex and striatum.

Previous studies have reported learning-related changes in neuronal activity during conditional visuomotor learning, also known as arbitrary sensorimotor mapping, conditional visual discrimination, and symbolic or endogenous mapping. Qualitatively similar observations have been reported for the dorsal premotor cortex, the supplementary eye field, the prefrontal cortex, the hippocampus, the striatum and the globus pallidus. The fact that cells in both the dorsal premotor cortex (PMd) and the basal ganglia show changes in activity during associative learning enables a test of the hypothesis that cortex and basal ganglia function in distributed architectures known as cortical-basal ganglionic modules or 'loops'. We reasoned that if these loops represent functional entities, as proposed, then learning-related changes in activity should occur simultaneously in both the cortical and striatal nodes of a loop. The present results confirmed this prediction; as monkeys learned conditional visuomotor associations, neurons in the premotor cortex and associated parts of the putamen changed their rates at approximately the same time. For the largest number of neurons, the evolution in neural activity occurred in close correspondence to the monkeys' learning curves. As a population, however, learning-related changes in activity continued after the monkeys reached an asymptote in performance.

Action Potentials↗

PubMed2006

Treating recurrence after a totally extraperitoneal approach.

BACKGROUND: One of today's most highly regarded procedures for treating inguinal hernia is the totally extraperitoneal approach (TEP), but it can on occasion lead to recurrence. This is commonly managed with an open repair, a transabdominal preperitoneal procedure (TAPP), or another TEP. We report here on our years of experience with the latter. METHODS: The endeavor to a secondary TEP is much the same as to a primary one, but certain differences are encountered as the operation proceeds. For example, many anatomical landmarks found in a first TEP cannot be seen in a second. There can also be a diminished amount of working space, and this occasionally leads to an open conversion. RESULTS: From September 1991 to September 2005, we repaired 1,526 hernias in 1,156 male patients, using the TEP in every case. Of these, 21 were TEPs after a previous TEP. In 3 cases, the space could not be opened, and they were converted to the open Lichtenstein. One patient had peritoneal tears that led to conversion and another had conversion because of excessive bleeding. There were no complications, no bladder or bowel injuries, no transfusions, no preperitoneal hematomas, and no fatalities. All patients were discharged the same day. CONCLUSIONS: A secondary TEP, open repair, and TAPP are alternative solutions to the problem of recurrence after TEP. However, any TEP involves a very prolonged learning curve for general surgeons, since they must learn the anatomy as well as the procedure, both at the same time. This is doubly true for the TEP after a previous TEP.

Hernia, Inguinal↗

PubMed1993

Age-related changes in correlation between behavioral and biochemical parameters in Lewis rats.

This study evaluated aging by using a correlational analysis of behavior and biochemistry in young (4 months old) and old (24 months old) Lewis rats. The rats were subjected to different learning tasks (spatial discrimination learning in the Morris task and cone-field task, temporal discrimination learning, one-trial inhibitory avoidance task) and noncognitive tests (emotional reactivity, motor coordination, and food motivation) and the relation between the various parameters was assessed. In the learning tasks, except for the inhibitory avoidance task, the first part of the learning curve was taken as an index of learning. Blood glucose (baseline and blood glucose regulation) and hippocampal choline acetyltransferase (ChAT) activity were also measured. There was no correlation between the different parameters of learning in young and old rats. This indicates that there are individual differences in performance in different learning and memory tasks. Measures of noncognitive behavior (food motivation, emotional reactivity, and motor performance) did not predict performance in the learning tasks. Hippocampal ChAT activity did not correlate with learning performance in old rats, whereas blood glucose level was found to correlate with spatial learning in old rats. These results suggest that an impaired regulation of blood glucose may be related to cognitive performance in aging.

Age Factors↗

PubMedDate not supplied

Effect of life-long hypocaloric diet on age-related changes in motor and cognitive behavior in a rat population.

Aged (24 months), adult (12 months), and young (4 months) rats kept on standard or hypocaloric diets from the age of three weeks old were tested in a range of behavioral tests to determine the effects of aging on sensory-motor and cognitive behavior and to assess whether such effects were prevented by life-long calorie restriction. An age-related deterioration of sensory-motor functions, motility and exploratory activity was observed in all the senescent animals independent of diet. Swimming ability did not deteriorate with age. Spatial memory, evaluated by the Morris water maze test, showed some deterioration in normally fed adult rats as indicated by the deceleration in the learning curve. In aged rats, not only was learning slowed down, but memory utilization was also impaired. These cognitive deficiencies were absent in rats fed the hypocaloric diet.

Aging↗

PubMed2006

Tracking pattern learning with single-trial event-related potentials.

OBJECTIVE: The main aim was to track the dynamics of pattern-learning using single-trial event-related potentials (ERPs). A new 'learning-oddball' paradigm was employed presenting eight random targets (the 'no-pattern') followed by eight regular targets (the 'pattern'). In total, six repetitions of the 'no-pattern' followed by the 'pattern' were presented. METHODS: We traced the dynamics of learning by measuring responses to 16 (eight random-eight regular) targets. Since this alternation of the 'no-pattern' followed by the 'pattern' was repeated six times, we extracted single-trial responses to all 96 targets to determine if learning occurred more rapidly with each repetition of the 'pattern.' RESULTS: Following random targets, ERPs contained a marked P3-N2 component that decreased to regular targets, whereas a contingent negative variation (CNV) appeared. ERP changes could be best described by sigmoid 'learning' curves. Single-trial analyses showed that learning occurred more rapidly over repetitions and suggested that the CNV developed prior to the decay of the N2-P3 component. CONCLUSIONS: We show a new paradigm-analysis methodology to track learning processes directly from brain signals. SIGNIFICANCE: Single-trial ERPs analyses open a wide range of applications. Tracking the dynamic structure of cognitive functions may prove crucial in the understanding of learning and in the study of different pathologies.

Acoustic Stimulation↗

PubMed1985

Early experience in extracapsular cataract surgery by residents.

We studied retrospectively the problems encountered by residents learning extracapsular cataract surgery and the variables influencing visual outcomes and complications in 130 patients. Although visual results were comparable to reported series by experienced surgeons, rates of complications were higher with 9% vitreous loss and 17% posterior capsule rupture in the first 25 cases of the average resident's experience. A learning curve depicting when complications occur shows that learning to avoid vitreous loss is a much faster process than learning to avoid posterior capsule rupture. Inter-resident variability in prevalence of complications was large. The axis of postoperative astigmatism was not consistent in residents at this stage of experience. Residents are not accurate judges of the effect faculty attendings have on visual outcomes and complication rates.

Adult↗

PubMed2004

Bowel obstruction after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Bowel obstruction has been frequently reported after laparoscopic Roux-en-Y gastric bypass (LRYGBP). The aim of this study was to review our experience with bowel obstruction following LRYGBP, specifically examining its etiology and management and to strategize maneuvers to minimize this complication. METHODS: We retrospectively reviewed the charts of 9 patients who developed postoperative bowel obstruction after LRYGBP. Each chart was reviewed for demographics, timing of bowel obstruction from the primary operation, etiology of obstruction, and management. RESULTS: 9 of our initial 225 patients (4%) who underwent LRYGBP developed postoperative bowel obstruction. The mean age was 46 +/- 12 years, with mean BMI 47 +/- 9 kg/m(2). 6 patients developed early bowel obstruction, and 3 patients developed late bowel obstruction. The mean time interval for development of early bowel obstruction was 16 +/-16 days. The causes for early bowel obstruction included narrowing of the jejunojenunostomy anastomosis (n=3), angulation of the Roux limb (n=2), and obstruction of the Roux limb at the level of the transverse mesocolon (n=1). The mean time interval for development of late bowel obstruction was 7.4 +/- 0.5 months. The causes for late bowel obstruction included internal herniation (n=2) and adhesions (n=1). 6 of 9 bowel obstructions (66%) were considered technically related to the learning curve of the laparoscopic approach. Eight of the 9 patients required operative intervention, and 6 of the 8 reoperations were managed laparoscopically. Management included laparoscopic bypass of the jejunojejunostomy obstruction site (n=5), open reduction of internal hernia (n=2), and laparoscopic lysis of adhesion (n=1). CONCLUSIONS: Bowel obstruction is a frequent complication after LRYGBP, particularly during the learn ing curve of the laparoscopic approach. Specific measures should be instituted to minimize bowel obstruction after LRYGBP as most of these complications are considered technically preventable.

Adult↗

PubMed1999

A neural network model with dopamine-like reinforcement signal that learns a spatial delayed response task.

This study investigated how the simulated response of dopamine neurons to reward-related stimuli could be used as reinforcement signal for learning a spatial delayed response task. Spatial delayed response tasks assess the functions of frontal cortex and basal ganglia in short-term memory, movement preparation and expectation of environmental events. In these tasks, a stimulus appears for a short period at a particular location, and after a delay the subject moves to the location indicated. Dopamine neurons are activated by unpredicted rewards and reward-predicting stimuli, are not influenced by fully predicted rewards, and are depressed by omitted rewards. Thus, they appear to report an error in the prediction of reward, which is the crucial reinforcement term in formal learning theories. Theoretical studies on reinforcement learning have shown that signals similar to dopamine responses can be used as effective teaching signals for learning. A neural network model implementing the temporal difference algorithm was trained to perform a simulated spatial delayed response task. The reinforcement signal was modeled according to the basic characteristics of dopamine responses to novel stimuli, primary rewards and reward-predicting stimuli. A Critic component analogous to dopamine neurons computed a temporal error in the prediction of reinforcement and emitted this signal to an Actor component which mediated the behavioral output. The spatial delayed response task was learned via two subtasks introducing spatial choices and temporal delays, in the same manner as monkeys in the laboratory. In all three tasks, the reinforcement signal of the Critic developed in a similar manner to the responses of natural dopamine neurons in comparable learning situations, and the learning curves of the Actor replicated the progress of learning observed in the animals. Several manipulations demonstrated further the efficacy of the particular characteristics of the dopamine-like reinforcement signal. Omission of reward induced a phasic reduction of the reinforcement signal at the time of the reward and led to extinction of learned actions. A reinforcement signal without prediction error resulted in impaired learning because of perseverative errors. Loss of learned behavior was seen with sustained reductions of the reinforcement signal, a situation in general comparable to the loss of dopamine innervation in Parkinsonian patients and experimentally lesioned animals. The striking similarities in teaching signals and learning behavior between the computational and biological results suggest that dopamine-like reward responses may serve as effective teaching signals for learning behavioral tasks that are typical for primate cognitive behavior, such as spatial delayed responding.

Animals↗

PubMed2002

Minimally invasive surgery.

During the last 10 years, minimally invasive surgery has influenced the techniques used in every specialty of surgical medicine. This development has not only led to the replacement of conventional procedures with minimally invasive ones, but has also stimulated surgeons to reevaluate conventional approaches with regard to perioperative parameters such as pain medication. However, two major drawbacks have emerged with the introduction of this new technique: firstly, the prolonged learning curve for most surgeons, in comparison with the learning process in open surgery; and secondly, increased costs due to investment in the equipment required and the use of disposable instruments, as well as longer operating times. In the various health-care systems around the world, these increased costs are not always compensated for by shorter hospital stays. This review focuses on major areas of indication for minimally invasive surgery in the gastrointestinal tract. These include functional disorders of the upper and lower gastrointestinal tract, obesity surgery, minimally invasive techniques in gastric and hepatobiliary surgery and in other solid organs, and laparoscopic colorectal surgery. The shortening of the hospitalization period has led to increasing use of outpatient laparoscopic surgery, and many centers specializing in day-care surgery are using these techniques. The frontiers are being pushed even further, as the size of the instruments is reduced to achieve better cosmetic results. Clinical research has also focused on the topic of expanding the indications for minimally invasive approaches in the elderly and in high-risk patients, to take advantage of the shorter hospital stays and reduced surgical trauma that are possible. A considerable amount of basic research has been carried out on the stress response during and after minimally invasive procedures, and an improved immune response with the minimally invasive approach has been observed, leading to better results after extensive oncological procedures. Robotic surgery and telesurgery involve new computer-aided methods that allow greater precision in surgical technique, as well as offering an opportunity to supply surgical skill and expertise remotely, over long distances. Minimally invasive surgical techniques are thus now fully established in routine use, and the indications are continuing to expand.

Ambulatory Surgical Procedures↗

PubMed2004

Effective nonanatomical endoscopy training produces clinical airway endoscopy proficiency.

We studied the effectiveness of two nonanatomical endoscopic dexterity training models: "Choose the Hole" and Dexter. Effectiveness was assessed in terms of time spent training, subjective rating, performance on an anatomical manikin, and clinical performance on fellow participants who acted as awake subjects. Forty-three anesthesia specialists, trainees, and technicians volunteered. Performances were videotaped, timed, and scored with a Global Rating Scale (GRS) from 1 (very poor) to 5 (clearly superior). The Dexter group spent more time training than the Choose the Hole group (median time [range], 152 min [70-510 min] versus 75 min [17-281 min]; P < 0.01). Subjective ratings were better in the Dexter group. In clinical bronchoscopy, the Dexter group was faster (30.7 s [17.1-43.5 s] versus 36.6 s [22.8-105.1 s]; P = 0.02) and had higher GRS scores (mean [sd]: 3.0 [0.4] versus 2.6 [0.6]; P = 0.04), indicating superior performance. Clinical and manikin performance (GRS scores) were significantly correlated (rho = 0.62; P = 0.0001). Benchmark levels of clinical bronchoscopic performance can be anticipated from bench model performance without a clinical learning curve. Dexter is a more effective model for learning endoscopic dexterity than the Choose the Hole model. Airway topicalization with lidocaine in a dose range consistent with published series (490-980 mg or 7.14-14.77 mg/kg) resulted in a frequent incidence of side effects. No major adverse events occurred.

Bronchoscopy↗

PubMed2004

Lessons learned from the first 100 cases in a new minimally invasive bariatric surgery program.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a technically demanding procedure with a steep learning curve. Experienced laparoscopic surgeons and bariatric surgeons can learn from the outcomes and complications of their initial experience in LRYGBP. METHODS: Between August of 2002 and July of 2003, we performed our first 100 LRYGBPs. Our surgical technique involves the ante-colic, ante-gastric placement of the Roux-limb. A 21-mm circular stapler is used to create the gastrojejunostomy. The stapler anvil is placed transgastrically. RESULTS: The mean preoperative BMI was 49.7 kg/m(2) (range 37-70). 12% of patients were male. Early complications (14%) included 3 leaks, 4 bleeding episodes and 2 gastrogastric fistulas. There was 1 peri-operative mortality and 1 conversion to laparotomy. Late complications (17%) included stenosis of the gastrojejunostomy which occurred in 14 patients. Leaks occurred more commonly in males (16% vs 1%, P<0.05). Elevated BMI was also found to be a risk factor for leak (BMI 58.7 leak vs 49.3 no leak, P<0.05). Stenosis was often associated with other complications such as leak or marginal ulcer. Stenosis responded well to endoscopic dilation. Co-morbid medical conditions responded to weight loss in all patients, regardless of initial BMI. Mean excess weight loss was 69% at 1 year, but varied according to preoperative BMI. CONCLUSIONS: Careful recording of patient outcomes and complications is important, particularly in a new minimally invasive bariatric surgery program. Review and analysis of specific complications may help to minimize the occurrence of similar subsequent complications.

Adult↗

PubMed1985

Intact verbal paired-associate learning in alcoholics.

Evidence for impaired verbal learning/memory in alcoholics is inconsistent. In part, this may be due to variations in task parameters such as difficulty level. The latter was varied in a paired-associate paradigm with 60 chronic male alcoholics abstinent 1 month and 60 nonalcoholic matched controls. Each subject was presented four lists with seven pairs of stimulus-response combinations of word meaningfulness of high-high, low-high, high-low and low-low values. The more difficult lists resulted in greater errors for both groups, but the predicted relative impairment of alcoholics with more difficult material did not occur, nor did the groups' learning curves differ. Under our experimental conditions, rote associative learning either remains intact or recovers satisfactorily with 1 month of abstinence in alcoholics. The results emphasize the importance of methodological variables and suggest restrictions on current generalizations about cognitive impairment in alcoholics.

Adult↗

PubMed2004

Beyond curve fitting? Comment on Liu, Mayer-Kress, and Newell (2003).

Y.-T. Liu, G. Mayer-Kress, and K. M. Newell (2003) fit learning curves to movement time data and suggested 2 new methods for analyzing learning. They claimed that the methods go "beyond curve fitting." However, in neither their curve fitting nor their new methods is measurement noise accounted for, and therefore they produce inefficient and biased results. Using the data of Liu et al., in which variance caused by learning is small relative to the level of noise for most participants, the present authors demonstrate those problems and provide better alternatives that are more noise tolerant, more powerful, and go beyond curve fitting without displaying the extreme bias produced by the methods of Liu et al.

Humans↗

PubMed2001

Auditory verbal learning in drug-free Ecstasy polydrug users.

Drug-free Ecstasy polydrug users have shown impairment on tasks of verbal working memory and memory span. Current research aims to investigate how these deficits may affect the learning of verbal material by administration of the Auditory Verbal Learning Task (AVLT) (Rey, 1964). The task provides a learning curve by assessing immediate memory span over multiple trials. Learning strategies are further analysed by tendencies to confabulate as well as demonstrate either proactive or retroactive interference elicited by a novel 'distractor' list. Three groups completed the task: two groups of 14 Ecstasy users (short- and long-term) and one group of 14 polydrug controls. Compared with controls both Ecstasy groups recalled significantly fewer words and made more confabulation errors on the initial three recall trials as well as a delayed recall trial. Long-term users demonstrated increased confabulation on the initial trials and the novel 'distractor7' trial, compared with short-term users. Only following repeated presentations were both short- and long-term users shown to perform at control levels. As such, deficits in verbal learning may be more related to storage and/or retrieval problems than problems associated with capacity per se. No interference errors were demonstrated by either of the Ecstasy groups. However, a high level of intrusion errors may indicate selective working memory problems associated with longer-term use of the drug. Copyright 2001 John Wiley & Sons, Ltd.

Journal Article↗

PubMed1993

Pro: one-lung ventilation is best accomplished with the Univent endotracheal tube.

Over the years, thoracotomy has changed from a procedure that prompted major concern over cross-contamination caused by infection to pulmonary tumors. Assisting the thoracic surgeon by providing OLV is one of the most specialized skills an anesthesiologist can offer. This must be done in a safe, easy, and efficient manner. The Univent tube appears to be a hybrid, combining the best qualities of both the DLT and the single-lumen endotracheal tube with separate Fogarty-like catheter. The Univent tube is a technical improvement over separate endobronchial blocking catheters because its blocker shaft is attached to the main tube and, therefore, displacement is less likely. In addition, the Univent's axial blocker shaft has a lumen that provides for irrigation, suction, oxygen insufflation, CPAP, and HFV. Though equally as effective as the DLT in treatment of intraoperative hypoxemia, the Univent tube presents a unique advantage in the areas of aspiration prevention, prolonged intubation without tube exchange, and selective blockade of lung segments. The Univent tube is also easier to insert and has fewer associated risks compared to the DLT. Is it my purpose to suggest that because the Univent tube is equal to, or better than, the DLT in many areas, we should abandon the use of DLTs? Definitely not. Double-lumen tubes have performed well in the past and will continue to offer specialized functions, such as postoperative independent lung ventilation in single-lung transplant recipients. As with the acquisition of any new medical skill, the use of the Univent tube has a learning curve. It is worth the time and effort to learn to use the Univent tube.(ABSTRACT TRUNCATED AT 250 WORDS)

Catheterization↗

PubMed1999

Laparoscopic ultrasonography versus operative cholangiography during laparoscopic cholecystectomy: review of the literature and a comparison with open intraoperative ultrasonography.

BACKGROUND: Laparoscopic ultrasonography (LUS) has been used increasingly over the last several years as a new imaging modality. To define the role of LUS during laparoscopic cholecystectomy, we evaluated LUS by prospectively comparing it with operative cholangiography (OC), by reviewing the literature on LUS, and by retrospectively comparing it with intraoperative ultrasonography performed during open cholecystectomy. STUDY DESIGN: LUS and OC were compared prospectively in 100 consecutive patients during laparoscopic cholecystectomy. The success rate of examination, the time required, the accuracy in diagnosing bile duct calculi, and the delineation of biliary anatomy were evaluated. RESULTS: The success rate of examination was 95% for LUS and 92% for OC. The main reason for unsatisfactory LUS was incomplete visualization of the distal common bile duct. The time required was 8.2 minutes for LUS and 15.9 minutes for OC (p<0.0001). Nine patients had bile duct calculi. LUS had one false-negative result and OC had two false-positives and one false-negative. The accuracies of LUS and OC were comparable except for a slightly better positive predictive value of LUS (100% versus 77.8%; p>0.1). In a literature review, 12 recent prospective studies comparing LUS and OC and three studies on open intraoperative ultrasonography were reviewed. Twelve studies of LUS with a total of 2,059 patients demonstrated results similar to the present study. The success rate was 88% to 100% for both tests. The time for LUS was approximately 7 minutes, about half of the time needed for OC. Overall, LUS was associated with fewer false-positive results than OC; the positive predictive value and specificity of LUS were better, while the sensitivity and negative predictive value of LUS and OC were comparable. OC detected ductal variations or anomalies more distinctly than LUS. Compared with open intraoperative ultrasonography, LUS had a slightly lower success rate and required a slightly longer time because it was technically more demanding, but the two procedures had a similar accuracy for diagnosing bile duct calculi. CONCLUSIONS: Because of their different advantages and disadvantages, LUS and OC can be used in a complementary manner. There is a learning curve for LUS because of its technical difficulty. Once learned, however, LUS can be used as the primary screening procedure for bile duct calculi because of its safety, speed, and cost-effectiveness. OC can be used selectively, particularly when ductal anatomic variations or anomalies or bile duct injuries are suspected.

Cholangiography↗

PubMed2002

Colonoscopy training: the need for patience (patients).

BACKGROUND: The insertion of a colonoscope to the caecum is a difficult technique to teach and to learn. The most commonly used criterion for proficiency is completion rate and early experience is often discouraging. In order to document the learning curve and better define normal progress for the early learning experience, the performance of trainees during their first 100-125 cases was recorded. METHODS: The completion rate and time for office colonoscopy were recorded prospectively over a 5-year period for each of 18 trainees. Trainees' experience was analysed in groups of 25 cases, numbered chronologically. Completion rate was defined as the number of examinations completed to the caecum by the trainee expressed as a percentage of the number completed by the staff. RESULTS: The mean overall completion rate for trainees was 56.4% (range 27.8-83.9%). For the first five groups of 25 cases, the percentage completion rates (in order from first 25 cases to fifth 25 cases) were 43.1, 52.6, 49.3, 61.8 and 75.1%, respectively. There was a wide variation in completion rates between trainees, but no difference in time taken. (Time for trainees to complete the procedure, in order from the first 25 cases to fifth 25 cases: 18.7, 19.1, 19.4, 17.6 and 17.1 min, respectively.) CONCLUSIONS: Early experience in colonoscopy can be discouraging. At least 100 cases are needed to attain a level of proficiency that enables completion in two-thirds of cases, whereas 125 cases lead to an average completion rate of 75%.

Cecum↗