Anesthetic Management for Ventricular Tachycardia Ablation: A National Anesthesia Clinical Outcomes Registry Analysis.

OBJECTIVES: The authors analyzed anesthetic management trends during ventricular tachycardia (VT) ablation, hypothesizing that (1) monitored anesthesia care (MAC) is more commonly used than general anesthesia (GA); (2) MAC uses significantly increased after release of the 2019 Expert Consensus Statement on Catheter Ablation of Ventricular Arrhythmias; and (3) anesthetic approach varies based on patient and hospital characteristics. DESIGN: Retrospective study. SETTING: National Anesthesia Clinical Outcomes Registry data. PARTICIPANTS: Patients 18 years or older who underwent elective VT ablation between 2013 and 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Covariates were selected a priori within multivariate models, and interrupted time-series analysis was performed. Of the 15,505 patients who underwent VT ablation between 2013 and 2021, 9,790 (63.1%) received GA. After the 2019 Expert Consensus Statement on Catheter Ablation of Ventricular Arrhythmias supported avoidance of GA in idiopathic VT, no statistically significant increase in MAC was evident (immediate change in intercept post-consensus statement release adjusted odds ratio 1.41, p = 0.1629; change in slope post-consensus statement release adjusted odds ratio 1.06 per quarter, p = 0.1591). Multivariate analysis demonstrated that sex, American Society of Anesthesiologists physical status, age, and geographic location were statistically significantly associated with the anesthetic approach. CONCLUSIONS: GA has remained the primary anesthetic type for VT ablation despite the 2019 Expert Consensus Statement on Catheter Ablation of Ventricular Arrhythmias suggested its avoidance in idiopathic VT. Achieving widespread clinical practice change is an ongoing challenge in medicine, emphasizing the importance of developing effective implementation strategies to facilitate awareness of guideline release and subsequent adherence to and adoption of recommendations.

Anesthetic Choice for Cardiovascular Implantable Electronic Device Placement and Lead Removal: A National Anesthesia Clinical Outcomes Registry Analysis.

OBJECTIVE: The authors evaluated the anesthetic approach for cardiovascular implantable electronic device (CIED) placement and transvenous lead removal, hypothesizing that monitored anesthesia care is used more frequently than general anesthesia. DESIGN: A retrospective study. SETTING: National Anesthesia Clinical Outcomes Registry data. PARTICIPANTS: Adult patients who underwent CIED (permanent cardiac pacemaker or implantable cardioverter-defibrillator [ICD]) placement or transvenous lead removal between 2010 and 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Covariates were selected a priori within multivariate models to assess predictors of anesthetic type. A total of 87,530 patients underwent pacemaker placement, 76,140 had ICD placement, 2,568 had pacemaker transvenous lead removal, and 4,861 had ICD transvenous lead extraction; 51.2%, 45.64%, 16.82%, and 45.64% received monitored anesthesia care, respectively. A 2%, 1% (both p < 0.0001), and 2% (p = 0.0003) increase in monitored anesthesia care occurred for each 1-year increase in age for pacemaker placement, ICD placement, and pacemaker transvenous lead removal, respectively. American Society of Anesthesiologists (ASA) physical status ≤III for pacemaker placement, ASA ≥IV for ICD placement, and ASA ≤III for pacemaker transvenous lead removal were 7% (p = 0.0013), 5% (p = 0.0144), and 27% (p = 0.0247) more likely to receive monitored anesthesia care, respectively. Patients treated in the Northeast were more likely to receive monitored anesthesia care than in the West for all groups analyzed (p < 0.0024). Male patients were 24% less likely to receive monitored anesthesia care for pacemaker transvenous lead removal (p = 0.0378). For every additional 10 pacemaker or ICD lead removals performed in a year, a 2% decrease in monitored anesthesia care was evident (p = 0.0271, p < 0.0001, respectively). CONCLUSIONS: General anesthesia still has a strong presence in the anesthetic management of both CIED placement and transvenous lead removal. Anesthetic choice, however, varies with patient demographics, hospital characteristics, and geographic region.

Effect of frequency and rhythmicity on flicker light-induced hallucinatory phenomena.

Flicker light stimulation (FLS) uses stroboscopic light on closed eyes to induce transient visual hallucinatory phenomena, such as the perception of geometric patterns, motion, and colours. It remains an open question where the neural correlates of these hallucinatory experiences emerge along the visual pathway. To allow future testing of suggested underlying mechanisms (e.g., changes in functional connectivity, neural entrainment), we sought to systematically characterise the effects of frequency (3 Hz, 8 Hz, 10 Hz and 18 Hz) and rhythmicity (rhythmic and arrhythmic conditions) on flicker-induced subjective experiences. Using a novel questionnaire, we found that flicker frequency and rhythmicity significantly influenced the degree to which participants experienced simple visual hallucinations, particularly the perception of Klüver forms and dynamics (e.g., motion). Participants reported their experience of geometric patterns and dynamics was at highest intensity during 10 Hz rhythmic stimulation. Further, we found that frequency-matched arrhythmic FLS strongly reduced these subjective effects compared to equivalent rhythmic stimulation. Together, these results provide evidence that flicker rhythmicity critically contributes to the effects of FLS beyond the effects of frequency alone, indicating that neural entrainment may drive the induced phenomenal experience.

Persistent Left Superior Vena Cava Draining Directly Into the Left Atrium With Occluded Coronary Sinus.

Combined persistent left superior vena cava entering the left atrium with a congenitally atretic coronary sinus is a rare imaging finding. In the absence of a significant right-to-left shunt, it is generally asymptomatic and can be an incidental discovery. Assessing the anatomy of the cardiac vasculature is crucial before transcutaneous cardiac procedures. (Level of Difficulty: Intermediate.).

Using Extended Reality to Study the Experience of Presence.

Extended reality (XR), encompassing various forms of virtual reality (VR) and augmented reality (AR), has become a powerful experimental tool in consciousness research due to its capability to create holistic and immersive experiences of oneself and surrounding environments through simulation. One hallmark of a successful XR experience is when it elicits a strong sense of presence, which can be thought of as a subjective sense of reality of the self and the world. Although XR research has shed light on many factors that may influence presence (or its absence) in XR environments, there remains much to be discovered about the detailed and diverse phenomenology of presence, and the neurocognitive mechanisms that underlie it. In this chapter, we analyse the concept of presence and relate it to the way in which humans may generate and maintain a stable sense of reality during both natural perception and virtual experiences. We start by reviewing the concept of presence as developed in XR research, covering both factors that may influence presence and potential ways of measuring presence. We then discuss the phenomenological characteristics of presence in human consciousness, drawing on clinical examples where presence is disturbed. Next, we describe two experiments using XR that investigated the effects of sensorimotor contingency and affordances on a specific form of presence related to the sense of objects as really existing in the world, referred to as 'objecthood'. We then go beyond perceptual presence to discuss the concept of 'conviction about reality', which corresponds to people's beliefs about the reality status of their perceptual experiences. We finish by exploring how the novel XR method of 'Substitutional Reality' can allow experimental investigation of these topics, opening new experimental directions for studying presence beyond the 'as-if' experience of fully simulated environments.

Modelling phenomenological differences in aetiologically distinct visual hallucinations using deep neural networks.

Visual hallucinations (VHs) are perceptions of objects or events in the absence of the sensory stimulation that would normally support such perceptions. Although all VHs share this core characteristic, there are substantial phenomenological differences between VHs that have different aetiologies, such as those arising from Neurodegenerative conditions, visual loss, or psychedelic compounds. Here, we examine the potential mechanistic basis of these differences by leveraging recent advances in visualising the learned representations of a coupled classifier and generative deep neural network-an approach we call 'computational (neuro)phenomenology'. Examining three aetiologically distinct populations in which VHs occur-Neurodegenerative conditions (Parkinson's Disease and Lewy Body Dementia), visual loss (Charles Bonnet Syndrome, CBS), and psychedelics-we identified three dimensions relevant to distinguishing these classes of VHs: realism (veridicality), dependence on sensory input (spontaneity), and complexity. By selectively tuning the parameters of the visualisation algorithm to reflect influence along each of these phenomenological dimensions we were able to generate 'synthetic VHs' that were characteristic of the VHs experienced by each aetiology. We verified the validity of this approach experimentally in two studies that examined the phenomenology of VHs in Neurodegenerative and CBS patients, and in people with recent psychedelic experience. These studies confirmed the existence of phenomenological differences across these three dimensions between groups, and crucially, found that the appropriate synthetic VHs were rated as being representative of each group's hallucinatory phenomenology. Together, our findings highlight the phenomenological diversity of VHs associated with distinct causal factors and demonstrate how a neural network model of visual phenomenology can successfully capture the distinctive visual characteristics of hallucinatory experience.

Inadvertent Intraoperative Defibrillation Secondary to Electrocautery Grounding Pad Placement.

Intraoperative defibrillation secondary to the usage of electrocautery in a patient with a cardiovascular implantable electronic device is a rare occurrence, and below-the-umbilicus electrocautery use causing inadvertent defibrillation is a near-zero risk. Defibrillation secondary to electrodispersive pad (EDP) radiofrequency dispersion has only ever been theorized. In this report, we describe the case of a 67-year-old male with an automatic implantable cardioverter defibrillator (AICD) undergoing a robotic-assisted left anterior total hip arthroplasty for left hip osteoarthritis who experienced inadvertent intraoperative defibrillation concurrent with electrocautery usage. The defibrillations ceased following contralateral EDP repositioning and application of a donut magnet overlying the patient's AICD.

Long-haul COVID: healthcare utilization and medical expenditures 6 months post-diagnosis.

BACKGROUND: Despite extensive evidence that COVID-19 symptoms may persist for up to a year, their long-term implications for healthcare utilization and costs 6 months post-diagnosis remain relatively unexplored. We examine patient-level association of COVID-19 diagnosis association of COVID-19 diagnosis with average monthly healthcare utilization and medical expenditures for up to 6 months, explore heterogeneity across age groups and determine for how many months post-diagnosis healthcare utilization and costs of COVID-19 patients persist above pre-diagnosis levels. METHODS: This population-based retrospective cohort study followed COVID-19 patients' healthcare utilization and costs from January 2019 through March 2021 using claims data provided by the COVID-19 Research Database. The patient population includes 250,514 individuals infected with COVID-19 during March-September 2020 and whose last recorded claim was not hospitalization with severe symptoms. We measure the monthly number and costs of total visits and by telemedicine, preventive, urgent care, emergency, immunization, cardiology, inpatient or surgical services and established patient or new patient visits. RESULTS: The mean (SD) total number of monthly visits and costs pre-diagnosis were .4783 (4.0839) and 128.06 (1182.78) dollars compared with 1.2078 (8.4962) visits and 351.67 (2473.63) dollars post-diagnosis. COVID-19 diagnosis associated with .7269 (95% CI, 0.7088 to 0.7449 visits; P < .001) more total healthcare visits and an additional $223.60 (95% CI, 218.34 to 228.85; P < .001) in monthly costs. Excess monthly utilization and costs for individuals 17 years old and under subside after 5 months to .070 visits and $2.77, persist at substantial levels for all other groups and most pronounced among individuals age 45-64 (.207 visits and $73.43) and 65 years or older (.133 visits and $60.49). CONCLUSIONS: This study found that COVID-19 diagnosis was associated with increased healthcare utilization and costs over a six-month post-diagnosis period. These findings imply a prolonged burden to the US healthcare system from medical encounters of COVID-19 patients and increased spending.

Local Supply Of Postdischarge Care Options Tied To Hospital Readmission Rates.

The extent to which patients' risk for readmission after a hospitalization is influenced by local availability of postdischarge care options is not currently known. We used national, hospital-level data to assess whether the supply of postdischarge care options in hospitals' catchment areas was associated with readmission rates for Medicare patients after hospitalizations for acute myocardial infarction, heart failure, or pneumonia. Overall, readmission rates were negatively associated with per capita supply of primary care physicians (-0.16 percentage points per standard deviation) and licensed nursing home beds (-0.09 percentage points per standard deviation). In contrast, readmission rates were positively associated with per capita supply of nurse practitioners (0.09 percentage points per standard deviation). Our results suggest potential modifications to the Hospital Readmissions Reduction Program to account for local health system characteristics when assigning penalties to hospitals.

Anesthetic Choice for Atrial Fibrillation Ablation: A National Anesthesia Clinical Outcomes Registry Analysis.

OBJECTIVE: The authors evaluated the type of anesthesia administered in atrial fibrillation ablation, hypothesizing that monitored anesthesia care is used less frequently than general anesthesia. DESIGN: A retrospective study. SETTING: National Anesthesia Clinical Outcomes Registry data, which are multi-institutional from across the United States. PARTICIPANTS: Adult patients who underwent elective atrial fibrillation ablation between 2013 and 2018. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: National Anesthesia Clinical Outcomes Registry data were evaluated, and covariates were selected a priori within multivariate models to assess for predictors of anesthetic type. A total of 54,321 patients underwent atrial fibrillation ablation; 3,251 (6.0%) received monitored anesthesia care. Patients who received monitored anesthesia care were more likely to be >80 years old (12.4% v 4.9%; p < 0.0001), female (36.1% v 34.3%; p < 0.0001), have American Society of Anesthesiologists physical status >III (17.28% v 10.48%; p < 0.0001), and reside in urban areas (62.23% v 53.37%; p < 0.0001). They received care in the Northeast (17.6% v 10.1%; p < 0.0001) at low-volume centers (median 224 v 284 procedures; p < 0.0001). Multivariate analysis revealed that each five-year increase in age, being female, and having an American Society of Anesthesiologists physical status >III resulted in a 7% (p < 0.0001), 9% (p = 0.032), and 200% (p < 0.0001) increased odds of receiving monitored anesthesia care, respectively. Requiring additional ablation of atria or of a second arrhythmia and residing outside the Northeast resulted in a decreased odds of monitored anesthesia care (adjusted odds ratio 0.24 [p=0.002] and < 0.5 [p < 0.03], respectively). For each 50 cases performed annually at a center, the odds decreased by 5% (p = 0.005). CONCLUSIONS: General anesthesia is the most common type of anesthesia administered for atrial fibrillation ablation. The type of anesthesia administered, however, varies with patient, procedural, and hospital characteristics.

HRS White Paper on Clinical Utilization of Digital Health Technology.

This collaborative statement from the Digital Health Committee of the Heart Rhythm Society provides everyday clinical scenarios in which wearables may be utilized by patients for cardiovascular health and arrhythmia management. We describe herein the spectrum of wearables that are commercially available for patients, and their benefits, shortcomings and areas for technological improvement. Although wearables for rhythm diagnosis and management have not been examined in large randomized clinical trials, undoubtedly the usage of wearables has quickly escalated in clinical practice. This document is the first of a planned series in which we will update information on wearables as they are revised and released to consumers.

Public policy and economic dynamics of COVID-19 spread: A mathematical modeling study.

With the COVID-19 pandemic infecting millions of people, large-scale isolation policies have been enacted across the globe. To assess the impact of isolation measures on deaths, hospitalizations, and economic output, we create a mathematical model to simulate the spread of COVID-19, incorporating effects of restrictive measures and segmenting the population based on health risk and economic vulnerability. Policymakers make isolation policy decisions based on current levels of disease spread and economic damage. For 76 weeks in a population of 330 million, we simulate a baseline scenario leaving strong isolation restrictions in place, rapidly reducing isolation restrictions for non-seniors shortly after outbreak containment, and gradually relaxing isolation restrictions for non-seniors. We use 76 weeks as an approximation of the time at which a vaccine will be available. In the baseline scenario, there are 235,724 deaths and the economy shrinks by 34.0%. With a rapid relaxation, a second outbreak takes place, with 525,558 deaths, and the economy shrinks by 32.3%. With a gradual relaxation, there are 262,917 deaths, and the economy shrinks by 29.8%. We also show that hospitalizations, deaths, and economic output are quite sensitive to disease spread by asymptomatic people. Strict restrictions on seniors with very gradual lifting of isolation for non-seniors results in a limited number of deaths and lesser economic damage. Therefore, we recommend this strategy and measures that reduce non-isolated disease spread to control the pandemic while making isolation economically viable.

Neurophenomenology of induced and natural synaesthesia.

People with synaesthesia have additional perceptual experiences, which are automatically and consistently triggered by specific inducing stimuli. Synaesthesia therefore offers a unique window into the neurocognitive mechanisms underlying conscious perception. A long-standing question in synaesthesia research is whether it is possible to artificially induce non-synaesthetic individuals to have synaesthesia-like experiences. Although synaesthesia is widely considered a congenital condition, increasing evidence points to the potential of a variety of approaches to induce synaesthesia-like experiences, even in adulthood. Here, we summarize a range of methods for artificially inducing synaesthesia-like experiences, comparing the resulting experiences to the key hallmarks of natural synaesthesia which include consistency, automaticity and a lack of 'perceptual presence'. We conclude that a number of aspects of synaesthesia can be artificially induced in non-synaesthetes. These data suggest the involvement of developmental and/or learning components in the acquisition of synaesthesia, and they extend previous reports of perceptual plasticity leading to dramatic changes in perceptual phenomenology in adults. This article is part of a discussion meeting issue 'Bridging senses: novel insights from synaesthesia'.

Sensorimotor contingency modulates breakthrough of virtual 3D objects during a breaking continuous flash suppression paradigm.

To investigate how embodied sensorimotor interactions shape subjective visual experience, we developed a novel combination of Virtual Reality (VR) and Augmented Reality (AR) within an adapted breaking continuous flash suppression (bCFS) paradigm. In a first experiment, participants manipulated novel virtual 3D objects, viewed through a head-mounted display, using three interlocking cogs. This setup allowed us to manipulate the sensorimotor contingencies governing interactions with virtual objects, while characterising the effects on subjective visual experience by measuring breakthrough times from bCFS. We contrasted the effects of the congruency (veridical versus reversed sensorimotor coupling) and contingency (live versus replayed interactions) using a motion discrimination task. The results showed that the contingency but not congruency of sensorimotor coupling affected breakthrough times, with live interactions displaying faster breakthrough times. In a second experiment, we investigated how the contingency of sensorimotor interactions affected object category discrimination within a more naturalistic setting, using a motion tracker that allowed object interactions with increased degrees of freedom. We again found that breakthrough times were faster for live compared to replayed interactions (contingency effect). Together, these data demonstrate that bCFS breakthrough times for unfamiliar 3D virtual objects are modulated by the contingency of the dynamic causal coupling between actions and their visual consequences, in line with theories of perception that emphasise the influence of sensorimotor contingencies on visual experience. The combination of VR/AR and motion tracking technologies with bCFS provides a novel methodology extending the use of binocular suppression paradigms into more dynamic and realistic sensorimotor environments.

Neurite orientation and dispersion density imaging (NODDI) detects cortical and corticospinal tract degeneration in ALS.

BACKGROUND: Corticospinal tract (CST) degeneration and cortical atrophy are consistent features of amyotrophic lateral sclerosis (ALS). We hypothesised that neurite orientation dispersion and density imaging (NODDI), a multicompartment model of diffusion MRI, would reveal microstructural changes associated with ALS within the CST and precentral gyrus (PCG) 'in vivo'. METHODS: 23 participants with sporadic ALS and 23 healthy controls underwent diffusion MRI. Neurite density index (NDI), orientation dispersion index (ODI) and free water fraction (isotropic compartment (ISO)) were derived. Whole brain voxel-wise analysis was performed to assess for group differences. Standard diffusion tensor imaging (DTI) parameters were computed for comparison. Subgroup analysis was performed to investigate for NODDI parameter differences relating to bulbar involvement. Correlation of NODDI parameters with clinical variables were also explored. The results were accepted as significant where p<0.05 after family-wise error correction at the cluster level, clusters formed with p<0.001. RESULTS: In the ALS group NDI was reduced in the extensive regions of the CST, the corpus callosum and the right PCG. ODI was reduced in the right anterior internal capsule and the right PCG. Significant differences in NDI were detected between subgroups stratified according to the presence or absence of bulbar involvement. ODI and ISO correlated with disease duration. CONCLUSIONS: NODDI demonstrates that axonal loss within the CST is a core feature of degeneration in ALS. This is the main factor contributing to the altered diffusivity profile detected using DTI. NODDI also identified dendritic alterations within the PCG, suggesting microstructural cortical dendritic changes occur together with CST axonal damage.

Organ-mounted robot localization via function approximation.

BACKGROUND: Organ-mounted robots adhere to the surface of a mobile organ as a platform for minimally invasive interventions, providing passive compensation of physiological motion. This approach is beneficial during surgery on the beating heart. Accurate localization in such applications requires accounting for the heartbeat and respiratory motion. Previous work has described methods for modeling quasi-periodic motion of a point and registering to a static preoperative map. The existing techniques, while accurate, require several respiratory cycles to converge. METHODS: This paper presents a general localization technique for this application, involving function approximation using radial basis function (RBF) interpolation. RESULTS: In an experiment in the porcine model in vivo, the technique yields mean localization accuracy of 1.25 mm with a 95% confidence interval of 0.22 mm. CONCLUSIONS: The RBF approximation provides accurate estimates of robot location instantaneously.

Amiodarone is associated with adverse outcomes in patients with sustained ventricular arrhythmias upgraded to cardiac resynchronization therapy-defibrillators.

INTRODUCTION: Amiodarone reduces recurrent ventricular tachyarrhythmias (VTA) but may worsen cardiovascular outcomes in heart failure (HF) patients. Cardiac resynchronization therapy (CRT) may also be antiarrhythmic. When patients with prior sustained VTA are upgraded to CRT defibrillators (CRT-D) from conventional implantable cardioverter-defibrillators (ICDs), should concomitant amiodarone be continued or is CRT's antiarrhythmic potential sufficient? METHODS AND RESULTS: We identified 67 patients from a prospective CRT registry with spontaneous sustained VTA, New York Heart Association (NYHA) II-IV HF, and left bundle-branch block (LBBB) who were upgraded to CRT defibrillators from conventional ICDs. We compared changes in QRS duration and left ventricular ejection fraction (LVEF) pre- and post-CRT, time to death, transplant or ventricular assist device (VAD), and time to recurrent VTA therapies between 37 patients continuing amiodarone therapy and 30 amiodarone-naïve patients. Amiodarone-treated patients had worse renal function and a higher prevalence of prior VTA storm compared with amiodarone-naïve patients. After CRT, amiodarone-treated patients demonstrated less QRS narrowing (8 vs 20 ms; P = 0.021) and less LVEF improvement (-2.7 vs +5.2%; P = 0.006). Over 29 months, 31 (47%) patients died and 13 (20%) received transplant or VAD. Risk of death, transplant, or VAD was greater in amiodarone-treated than -naïve patients (corrected hazard ratio [HR], 2.14; 95% confidence interval [CI], 1.12-4.11; P = 0.022). Appropriate CRT-D therapies occurred in 37 (55%) patients; amiodarone use was not associated time to first therapy (HR, 1.13; 95% CI, 0.59-2.16; P = 0.72). CONCLUSION: In patients with sustained VTA and LBBB upgraded from conventional ICDs to CRT defibrillators, concomitant amiodarone use is associated with less QRS narrowing, less LVEF improvement, greater risk of death, transplant, or VAD, and similar risk of recurrent VTA.

Miniaturized Robotic End-Effector with Piezoelectric Actuation and Fiber Optic Sensing for Minimally Invasive Cardiac Procedures.

Each year 35,000 cardiac ablation procedures are performed to treat atrial fibrillation through the use of catheter systems. The success rate of this treatment is highly dependent on the force which the catheter applies on the heart wall. If the magnitude of the applied force is much higher than a certain threshold the tissue perforates, whereas if the force is lower than this threshold the lesion size may be too large and is inconsistent. Furthermore, studies have shown large variability in the applied force from trained physicians during treatment, suggesting that physicians are unable to manually regulate the levels of the force at the site of treatment. Current catheter systems do not provide the physicians with active means for contact force control and are only at most aided by visual feedback of the forces measured in situ. This paper discusses a novel design of a robotic end-effector that integrates mechanisms of sensing and actively controlling of the applied forces into a miniaturized compact form. The required specifications for design and integration were derived from the current application under investigation. An off-the-shelf miniature piezoelectric motor was chosen for actuation, and a force sensing solution was developed to meet the specifications. Experimental characterization of the actuator and the force sensor within the integrated setup show compliance with the specifications and pave the way for future experimentation where closed-loop control of the system can be implemented according to the contact force control strategies for the application.

Response to Ruby et al: On a 'failed' attempt to manipulate conscious perception with transcranial magnetic stimulation to prefrontal cortex.

Does disruption of prefrontal cortical activity using transcranial magnetic stimulation (TMS) impair visual metacognition? An initial study supporting this idea (Rounis, Maniscalco, Rothwell, Passingham, & Lau, 2010) motivated an attempted replication and extension (Bor, Schwartzman, Barrett, & Seth, 2017). Bor et al. failed to replicate the initial study, concluding that there was not good evidence that TMS to dorsolateral prefrontal cortex impairs visual metacognition. This failed replication has recently been critiqued by some of the authors of the initial study (Ruby, Maniscalco, & Peters, 2018). Here we argue that these criticisms are misplaced. In our response, we encounter some more general issues concerning good practice in replication of cognitive neuroscience studies, and in setting criteria for excluding data when employing statistical analyses like signal detection theory. We look forward to further studies investigating the role of prefrontal cortex in metacognition, with increasingly refined methodologies, motivated by the discussions in this series of papers.