Point-of-Care Ultrasound Needs Assessment, Curriculum Design, and Curriculum Assessment in a Large Academic Internal Medicine Residency Program.

OBJECTIVES: Internal medicine (IM) residency point-of-care ultrasound (POCUS) curricula are being developed but often are limited in scope or components. In this article, we discuss the demonstration of a need for POCUS training in our large academic IM residency program; the development of a longitudinal curriculum; and the impact of the curriculum on POCUS knowledge, use, and confidence. METHODS: In 2014, we designed a cross-sectional POCUS survey and knowledge test for all IM residents at the University of California, San Francisco. The results of this assessment drove the design of a longitudinal POCUS curriculum that included a 2-hour workshop for all IM interns and a 1-month elective offered to all IM residents. Residents were tested on their POCUS knowledge and image interpretation before the elective and were given the same test 6 months after the elective. The posttest included a survey of self-reported POCUS use and confidence. RESULTS: In the needs assessment, residents scored a mean of 27% on the knowledge test, and across all applications the percentage of residents reporting confidence in their POCUS skills was lower than the percentage reporting use of the application in clinical practice. Residents scored a mean of 37% on the elective pretest and 74% on the posttest, an increase of 37% (95% confidence interval 31.6-42.8, P < 0.001), with improvements seen across all applications. After the elective, self-reported use of POCUS and confidence in POCUS skills were increased for the applications, using the needs assessment as an approximate baseline. For core cardiac and pulmonary applications, 76% to 95% of residents, depending on application, reported "high" or "very high" use and 79% to 100% reported "high" or "very high" confidence in their POCUS skills. CONCLUSIONS: We used a needs assessment to guide the development of a longitudinal, multidisciplinary POCUS curriculum. Residents who completed all components showed substantial long-term gains in knowledge in all major applications and high use of and confidence in cardiac and pulmonary applications.

Altered synaptic dynamics during normal brain aging.

What is the neuroanatomical basis for the decline in brain function that occurs during normal aging? Previous postmortem studies have blamed it on a reduction in spine density, though results remain controversial and spine dynamics were not assessed. We used chronic in vivo two-photon imaging of dendritic spines and axonal boutons in somatosensory cortex for up to 1 year in thy1 GFP mice to test the hypothesis that aging is associated with alterations in synaptic dynamics. We find that the density of spines and en passant boutons (EPBs) in pyramidal cells increases throughout adult life but is stable between mature (8-15 months) and old (>20 months) mice. However, new spines and EPBs are two to three times more likely to be stabilized over 30 d in old mice, although the long-term retention (over months) of stable spines is lower in old animals. In old mice, spines are smaller on average but are still able to make synaptic connections regardless of their size, as assessed by serial section electron microscopy reconstructions of previously imaged dendrites. Thus, our data suggest that age-related deficits in sensory perception are not associated with synapse loss in somatosensory cortex (as might be expected) but with alterations in the size and stability of spines and boutons observed in this brain area. The changes we describe here likely result in weaker synapses that are less capable of short-term plasticity in aged individuals, and therefore to less efficient circuits.

COVID-19 coagulopathy and thrombosis: Analysis of hospital protocols in response to the rapidly evolving pandemic.

As the Coronavirus disease 2019 (COVID-19) pandemic spread to the US, so too did descriptions of an associated coagulopathy and thrombotic complications. Hospitals created institutional protocols for inpatient management of COVID-19 coagulopathy and thrombosis in response to this developing data. We collected and analyzed protocols from 21 US academic medical centers developed between January and May 2020. We found greatest consensus on recommendations for heparin-based pharmacologic venous thromboembolism (VTE) prophylaxis in COVID-19 patients without contraindications. Protocols differed regarding incorporation of D-dimer tests, dosing of VTE prophylaxis, indications for post-discharge pharmacologic VTE prophylaxis, how to evaluate for VTE, and the use of empiric therapeutic anticoagulation. These findings support ongoing efforts to establish international, evidence-based guidelines.

Circuit level defects in the developing neocortex of Fragile X mice.

Subtle alterations in how cortical network dynamics are modulated by different behavioral states could disrupt normal brain function and underlie symptoms of neuropsychiatric disorders, including Fragile X syndrome (FXS). Using two-photon calcium imaging and electrophysiology, we recorded spontaneous neuronal ensemble activity in mouse somatosensory cortex. Unanesthetized Fmr1(-/-) mice exhibited abnormally high synchrony of neocortical network activity, especially during the first two postnatal weeks. Neuronal firing rates were threefold higher in Fmr1(-/-) mice than in wild-type mice during whole-cell recordings manifesting Up/Down states (slow-wave sleep, quiet wakefulness), probably as a result of a higher firing probability during Up states. Combined electroencephalography and calcium imaging experiments confirmed that neurons in mutant mice had abnormally high firing and synchrony during sleep. We conclude that cortical networks in FXS are hyperexcitable in a brain state-dependent manner during a critical period for experience-dependent plasticity. These state-dependent network defects could explain the intellectual, sleep and sensory integration dysfunctions associated with FXS.