Emergency manual peri-crisis use six years following implementation: Sustainment of an intervention for rare crises.

STUDY OBJECTIVE: Use of cognitive aids during emergencies increases key actions and decreases omissions, both known to save lives. With little known about emergency manual (EM) clinical use, we aimed to help answer "Will EMs be used peri-crisis at a meaningful frequency?" and to explore clinical sustainment. DESIGN: Prospective, observational study. SETTING: Operating Rooms. PATIENTS: All patients undergoing anesthesia at a major academic medical center during the study periods; ∼75,000 cases. INTERVENTION & MEASUREMENTS: To understand the initial and sustainment phases of EM implementation, we placed a question regarding EM use at the end of every anesthetic case to prospectively measure EM use at: implementation, one-year later, and six years post-implementation. MAIN RESULTS: For more than twenty-four thousand cases in each approximately 6-month study period, EMs were used peri-crisis (before, during or after a perioperative crisis) in 145 cases initially (0.55%; SE 0.045%), 42 cases one-year later (0.17%; SE 0.026%), and 57 cases (0.21%; SE 0.028%) six years post-implementation. Peri-crisis EM uses dropped 0.38% (97.5% CI: 0.26%, 0.49%) from initial to one-year post-implementation. After that, peri-crisis EM uses did not differ significantly from one-year to six years post-implementation, showing sustainment [increased 0.04% (97.5% CI: -0.05%, 0.12%)]. Among cases with cardiac arrest or CPR, as a subset proxy for relevant crises, EMs were used in 7/13 such cases initially (54%, SE 13.6%), 8/20 one-year later (40%; SE 10.9%) and 7/13 six years later (54%; SE 13.6%). CONCLUSIONS: After an initial expected drop, EM peri-crisis use six years post-implementation was: sustained without intensive additional efforts, averaged ∼10 times per month at a single institution, and was reported in more than half of cases with cardiac arrest or CPR. Peri-crisis use of EMs is appropriately rare, though for relevant crises can have substantial positive impacts as described in prior literature. The sustained use of EMs may be related to increasing cultural acceptance of EMs, as reflected in survey result trends and broader cognitive aid literature.

Participant Perceptions of Augmented Reality Simulation for Cardiac Anesthesiology Training: A Prospective, Mixed-Methods Study.

Background: Simulations are a critical component of anesthesia education, and ways to broaden their delivery and accessibility should be studied. The primary aim was to characterize anesthesiology resident, fellow, and faculty experience with augmented reality (AR) simulations. The secondary aim was to explore the feasibility of quantifying performance using integrated eye-tracking technology. Methods: This was a prospective, mixed-methods study using qualitative thematic analysis of user feedback and quantitative analysis of gaze patterns. The study was conducted at a large academic medical center in Northern California. Participants included 7 anesthesiology residents, 6 cardiac anesthesiology fellows, and 5 cardiac anesthesiology attendings. Each subject participated in an AR simulation involving resuscitation of a patient with pericardial tamponade. Postsimulation interviews elicited user feedback, and eye-tracking data were analyzed for gaze duration and latency. Results: Thematic analysis revealed 5 domains of user experience: global assessment, spectrum of immersion, comparative assessment, operational potential, and human-technology interface. Participants reported a positive learning experience and cited AR technology's portability, flexibility, and cost-efficiency as qualities that may expand access to simulation training. Exploratory analyses of gaze patterns suggested that trainees had increased gaze duration of vital signs and gaze latency of malignant arrythmias compared with attendings. Limitations of the study include lack of a control group and underpowered statistical analyses of gaze data. Conclusions: This study suggests positive user perception of AR as a novel modality for medical simulation training. AR technology may increase exposure to simulation education and offer eye-tracking analyses of learner performance.

Brain Mechanisms of Attention Orienting Following Frustration: Associations With Irritability and Age in Youths.

OBJECTIVE: Childhood irritability is a common, impairing problem with changing age-related manifestations that predict long-term adverse outcomes. However, more investigation of overall and age-specific neural correlates is needed. Because youths with irritability exhibit exaggerated responses to frustrating stimuli, the authors used a frustration functional MRI (fMRI) paradigm to examine associations between irritability and neural activation and tested the moderating effect of age. METHOD: The authors studied a transdiagnostic sample of 195 youths with varying levels of irritability (disruptive mood dysregulation disorder, N=52; anxiety disorder, N=42; attention deficit hyperactivity disorder, N=40; and healthy volunteers, N=61). Irritability was measured by parent and child reports on the Affective Reactivity Index. The fMRI paradigm was a cued-attention task differentiating neural activity in response to frustration (rigged feedback) from activity during attention orienting in the trial following frustration. RESULTS: Whole-brain activation analyses revealed associations with irritability during attention orienting following frustration. Irritability was positively associated with frontal-striatal activation, specifically in the dorsolateral prefrontal cortex, inferior frontal gyrus, and caudate. Age moderated the association between irritability and activation in some frontal and posterior regions (the anterior cingulate cortex, medial frontal gyrus, cuneus, precuneus, and superior parietal lobule [F=19.04-28.51, df=1, 189, partial eta squared=0.09-0.13]). Specifically, higher irritability was more strongly related to increased activation in younger youths compared with older youths. CONCLUSIONS: Following frustration, levels of irritability correlated with activity in neural systems mediating attention orienting, top-down regulation of emotions, and motor execution. Although most associations were independent of age, dysfunction in the anterior cingulate cortex and posterior regions was more pronounced in young children with irritability.

Age-related differences in the neural correlates of trial-to-trial variations of reaction time.

Intra-subject variation in reaction time (ISVRT) is a developmentally-important phenomenon that decreases from childhood through young adulthood in parallel with the development of executive functions and networks. Prior work has shown a significant association between trial-by-trial variations in reaction time (RT) and trial-by-trial variations in brain activity as measured by the blood-oxygenated level-dependent (BOLD) response in functional magnetic resonance imaging (fMRI) studies. It remains unclear, however, whether such "RT-BOLD" relationships vary with age. Here, we determined whether such trial-by-trial relationships vary with age in a cross-sectional design. We observed an association between age and RT-BOLD relationships in 11 clusters located in visual/occipital regions, frontal and parietal association cortex, precentral/postcentral gyrus, and thalamus. Some of these relationships were negative, reflecting increased BOLD associated with decreased RT, manifesting around the time of stimulus presentation and positive several seconds later. Critically for present purposes, all RT-BOLD relationships increased with age. Thus, RT-BOLD relationships may reflect robust, measurable changes in the brain-behavior relationship across development.

Medial prefrontal cortex lesions impair decision-making on a rodent gambling task: reversal by D1 receptor antagonist administration.

Decision-making is a complex cognitive process that is impaired in a number of psychiatric disorders. In the laboratory, decision-making is frequently assessed using "gambling" tasks that are designed to simulate real-life decisions in terms of uncertainty, reward and punishment. Here, we investigate whether lesions of the medial prefrontal cortex (PFC) cause impairments in decision-making using a rodent gambling task (rGT). In this task, rats have to decide between 1 of 4 possible options: 2 options are considered "advantageous" and lead to greater net rewards (food pellets) than the other 2 "disadvantageous" options. Once rats attained stable levels of performance on the rGT they underwent sham or excitoxic lesions of the medial PFC and were allowed to recover for 1 week. Following recovery, rats were retrained for 5 days and then the effects of a dopamine D1-like receptor antagonist (SCH23390) or a D2-like receptor antagonist (haloperidol) on performance were assessed. Lesioned rats exhibited impaired decision-making: they made fewer advantageous choices and chose the most optimal choice less frequently than did sham-operated rats. Administration of SCH23390 (0.03 mg/kg), but not haloperidol (0.015-0.03 mg/kg) attenuated the lesion-induced decision-making deficit. These results indicate that the medial PFC is important for decision-making and that excessive signaling at D1 receptors may contribute to decision-making impairments.