Scalp metastasis as initial presentation of neuroendocrine carcinoma.

Neuroendocrine carcinomas are a rare, heterogenous group of malignancies that arise from neuroendocrine cells throughout the body. Cutaneous metastasis of neuroendocrine carcinoma is uncommon and they can be easily misdiagnosed as benign epidermal cysts or Merkel cell carcinoma. Collectively, histopathology, immunochemical profile, biochemical markers, and nuclear imaging can guide the diagnosis of neuroendocrine metastasis and localization of primary tumors.

Privileged Functional Connectivity between the Visual Word Form Area and the Language System.

The visual word form area (VWFA) is a region in the left occipitotemporal sulcus of literate individuals that is purportedly specialized for visual word recognition. However, there is considerable controversy about its functional specificity and connectivity, with some arguing that it serves as a domain-general, rather than word-specific, visual processor. The VWFA is a critical region for testing hypotheses about the nature of cortical organization, because it is known to develop only through experience (i.e., reading acquisition), and widespread literacy is too recent to have influenced genetic determinants of brain organization. Using a combination of advanced fMRI analysis techniques, including individual functional localization, multivoxel pattern analysis, and high-resolution resting-state functional connectivity (RSFC) analyses, with data from 33 healthy adult human participants, we demonstrate that (1) the VWFA can discriminate words from nonword letter strings (pseudowords); (2) the VWFA has preferential RSFC with Wernicke's area and other core regions of the language system; and (3) the strength of the RSFC between the VWFA and Wernicke's area predicts performance on a semantic classification task with words but not other categories of visual stimuli. Our results are consistent with the hypothesis that the VWFA is specialized for lexical processing of real words because of its functional connectivity with Wernicke's area.SIGNIFICANCE STATEMENT The visual word form area (VWFA) is critical for determining the nature of category-related organization of the ventral visual system. However, its functional specificity and connectivity are fiercely debated. Recent work concluded that the VWFA is a domain-general, rather than word-specific, visual processor with no preferential functional connectivity with the language system. Using more advanced techniques, our results stand in stark contrast to these earlier findings. We demonstrate that the VWFA is highly specialized for lexical processing of real words, and that a fundamental factor driving this specialization is its preferential intrinsic functional connectivity with core regions of the language system. Our results support the hypothesis that intrinsic functional connectivity contributes to category-related specialization within the human ventral visual system.

Verbal Thinking and Inner Speech Use in Autism Spectrum Disorder.

The extent to which cognition is verbally mediated in neurotypical individuals is the subject of debate in cognitive neuropsychology, as well as philosophy and psychology. Studying "verbal thinking" in developmental/neuropsychological disorders provides a valuable opportunity to inform theory building, as well as clinical practice. In this paper, we provide a comprehensive, critical review of such studies among individuals with autism spectrum disorder (ASD). ASD involves severe social-communication deficits and limitations in cognitive/behavioural flexibility. The prevailing view in the field is that neither cognition nor behaviour is mediated verbally in ASD, and that this contributes to diagnostic features. However, our review suggests that, on the contrary, most studies to date actually find that among people with ASD cognitive task performance is either a) mediated verbally in a typical fashion, or b) not mediated verbally, but at no obvious cost to overall task performance. Overall though, these studies have methodological limitations and thus clear-cut conclusions are not possible at this stage. The aim of the review is to take stock of existing empirical findings, as well as to help develop the directions for future research that will resolve the many outstanding issues in this field.

Functional connectivity constrains the category-related organization of human ventral occipitotemporal cortex.

One of the most robust and oft-replicated findings in cognitive neuroscience is that several spatially distinct, functionally dissociable ventral occipitotemporal cortex (VOTC) regions respond preferentially to different categories of concrete entities. However, the determinants of this category-related organization remain to be fully determined. One recent proposal is that privileged connectivity of these VOTC regions with other regions that store and/or process category-relevant properties may be a major contributing factor. To test this hypothesis, we used a multicategory functional magnetic resonance imaging (MRI) localizer to individually define category-related brain regions of interest (ROIs) in a large group of subjects (n = 33). We then used these ROIs in resting-state functional connectivity MRI analyses to explore spontaneous functional connectivity among these regions. We demonstrate that during rest, distinct category-preferential VOTC regions show differentially stronger functional connectivity with other regions that have congruent category-preference, as defined by the functional localizer. Importantly, a "tool"-preferential region in the left medial fusiform gyrus showed differentially stronger functional connectivity with other left lateralized cortical regions associated with perceiving and knowing about common tools-posterior middle temporal gyrus (involved in perception of nonbiological motion), lateral parietal cortex (critical for reaching, grasping, manipulating), and ventral premotor cortex (involved in storing/executing motor programs)-relative to other category-related regions in VOTC of both the right and left hemisphere. Our findings support the claim that privileged connectivity with other cortical regions that store and/or process category-relevant properties constrains the category-related organization of VOTC.

Perceptual expertise and top-down expectation of musical notation engages the primary visual cortex.

Most theories of visual processing propose that object recognition is achieved in higher visual cortex. However, we show that category selectivity for musical notation can be observed in the first ERP component called the C1 (measured 40-60 msec after stimulus onset) with music-reading expertise. Moreover, the C1 note selectivity was observed only when the stimulus category was blocked but not when the stimulus category was randomized. Under blocking, the C1 activity for notes predicted individual music-reading ability, and behavioral judgments of musical stimuli reflected music-reading skill. Our results challenge current theories of object recognition, indicating that the primary visual cortex can be selective for musical notation within the initial feedforward sweep of activity with perceptual expertise and with a testing context that is consistent with the expertise training, such as blocking the stimulus category for music reading.

Barriers, Facilitators, and Preferences for Mental Health Services Among Patients With Systemic Lupus Erythematosus: A Qualitative Study.

OBJECTIVE: Although patients with systemic lupus erythematosus (SLE) experience high levels of depression and anxiety disorders, evidence concerning patient perceptions of facilitators and barriers to effective uptake of mental health services (eg, referral to therapists and psychiatrists, psychoeducational interventions, or support groups) is limited. METHODS: We conducted semistructured qualitative interviews with 15 adults with SLE to explore patient experiences and perceptions of mental health services to identify facilitators and barriers to accessing mental health care among patients with SLE. Qualitative interviews were conducted via telephone and audio recorded for transcription and directed content analysis using NVivo software by two coders. RESULTS: The median age of the 15 participants was 48 years, 87% were female, 33% identified as Black or African American, and 33% identified as Hispanic or Latino. Qualitative themes were organized into three domains: barriers, facilitators, and preferences for mental health services. Barriers to the use of mental health services include mental health stigma, sociodemographic factors, lack of autonomy, and time commitment. Facilitators to the use of mental health services included strong relationships with their rheumatologists and mental health care clinician experience with patients with SLE. Preferences for mental health services included education-based formats, mental health providers who work with patients with SLE, peer group formats, demographically and disease-matched psychological resources, and an emphasis on non-disease-related activities. CONCLUSION: In the setting of persistent unmet psychosocial needs of patients living with SLE, data from this qualitative study will inform the development and refinement of mental health interventions that bolster psychological wellbeing in the SLE population.

Dysregulation of mTOR signaling mediates common neurite and migration defects in both idiopathic and 16p11.2 deletion autism neural precursor cells.

Autism spectrum disorder (ASD) is defined by common behavioral characteristics, raising the possibility of shared pathogenic mechanisms. Yet, vast clinical and etiological heterogeneity suggests personalized phenotypes. Surprisingly, our iPSC studies find that six individuals from two distinct ASD subtypes, idiopathic and 16p11.2 deletion, have common reductions in neural precursor cell (NPC) neurite outgrowth and migration even though whole genome sequencing demonstrates no genetic overlap between the datasets. To identify signaling differences that may contribute to these developmental defects, an unbiased phospho-(p)-proteome screen was performed. Surprisingly despite the genetic heterogeneity, hundreds of shared p-peptides were identified between autism subtypes including the mTOR pathway. mTOR signaling alterations were confirmed in all NPCs across both ASD subtypes, and mTOR modulation rescued ASD phenotypes and reproduced autism NPC-associated phenotypes in control NPCs. Thus, our studies demonstrate that genetically distinct ASD subtypes have common defects in neurite outgrowth and migration which are driven by the shared pathogenic mechanism of mTOR signaling dysregulation.

Although the clinical presentation of individuals with autism spectrum disorder (ASD) can vary widely, the core features are repetitive behaviors and difficulties with social interactions and communication. In most cases, the cause of autism is unknown. However, in some cases, such as a form of ASD known as 16p11.2 deletion syndrome, specific genetic changes are responsible. Despite this variability in possible causes and clinical manifestations, the similarity of the core behavioral symptoms across different forms of the disorder indicates that there could be a shared biological mechanism. Furthermore, genetic studies suggest that abnormalities in early fetal brain development could be a crucial underlying cause of ASD. In order to form the complex structure of the brain, fetal brain cells must migrate and start growing extensions that ultimately become key structures of neurons. To test for shared biological mechanisms, Prem et al. reprogrammed blood cells from people with either 16p11.2 deletion syndrome or ASD with an unknown cause to become fetal-like brain cells. Experiments showed that both migration of the cells and their growth of extensions were similarly disrupted in the cells derived from both groups of individuals with autism. These crucial developmental changes were driven by alterations to an important signaling molecule in a pathway involved in brain function, known as the mTOR pathway. However, in some cells the pathway was overactive, whereas in others it was underactive. To probe the potential of the mTOR pathway as a therapeutic target, Prem et al. tested drugs that manipulate the pathway, finding that they could successfully reverse the defects in cells derived from people with both types of ASD. The discovery that a shared biological process may underpin different forms of ASD is important for understanding the early brain changes that are involved. A common target, like the mTOR pathway, could offer hope for treatments for a wide range of ASDs. However, to translate these benefits to the clinic, further research is needed to understand whether a treatment that is effective in fetal cells would also benefit people with autism.

Real-world scene representations in high-level visual cortex: it's the spaces more than the places.

Real-world scenes are incredibly complex and heterogeneous, yet we are able to identify and categorize them effortlessly. In humans, the ventral temporal parahippocampal place area (PPA) has been implicated in scene processing, but scene information is contained in many visual areas, leaving their specific contributions unclear. Although early theories of PPA emphasized its role in spatial processing, more recent reports of its function have emphasized semantic or contextual processing. Here, using functional imaging, we reconstructed the organization of scene representations across human ventral visual cortex by analyzing the distributed response to 96 diverse real-world scenes. We found that, although individual scenes could be decoded in both PPA and early visual cortex (EVC), the structure of representations in these regions was vastly different. In both regions, spatial rather than semantic factors defined the structure of representations. However, in PPA, representations were defined primarily by the spatial factor of expanse (open, closed) and in EVC primarily by distance (near, far). Furthermore, independent behavioral ratings of expanse and distance correlated strongly with representations in PPA and peripheral EVC, respectively. In neither region was content (manmade, natural) a major contributor to the overall organization. Furthermore, the response of PPA could not be used to decode the high-level semantic category of scenes even when spatial factors were held constant, nor could category be decoded across different distances. These findings demonstrate, contrary to recent reports, that the response PPA primarily reflects spatial, not categorical or contextual, aspects of real-world scenes.

How do emergency medicine applicants evaluate residency programs in the post-COVID-19 era?

Objectives: Pandemic disruptions to interviews and away rotations led applicants to rely on alternative sources of information about residency programs. We sought to compare program characteristics important to emergency medicine (EM)-bound applicants from before and after the pandemic. We also investigated the sources of information pandemic impacted applicants used during residency recruitment. Methods: This was a multi-institutional, cross-sectional survey of applicants to EM residency programs. We asked applicants about important factors in choosing a program and compared their response to results from 2019 National Residency Match Program. We also asked about alternative information sources used during this time of restricted access to programs of interest. Results: We surveyed 414 applicants from 40 medical schools and attained a response rate of 38.4%. Compared to 2019 applicants, our respondents identified morale of residents and quality of faculty as important factors in choosing a residency. Our subjects cited websites of the program and hospital affiliate, current residents, faculty/mentor advice, Reddit, and Doximity as sources of program information. Conclusions: Compared to 2019, our EM-bound applicants who, because of the pandemic, were unable to visit programs of interest valued resident morale and faculty quality as factors in choosing a residency program. Without in-person visits, our subjects also had to use both virtual resources (e.g., websites) and traditional sources (e.g., mentor advice) to investigate a program's culture, reputation, and diversity and inclusion. Residency programs should monitor their online presence now that this has become an alternative source of information for applicants during curtailment of in-person visits.

Mobile Phone-Based Intervention Among Adolescents Living With Perinatally Acquired HIV Transitioning from Pediatric to Adult Care: Protocol for the Interactive Transition Support for Adolescents Living With HIV using Social Media (InTSHA) Study.

BACKGROUND: Adolescents living with perinatally acquired HIV often have poor retention in care and viral suppression during the transition from pediatric to adult-based care. OBJECTIVE: The aim of this study is to evaluate a mobile phone-based intervention, Interactive Transition Support for Adolescents Living With HIV using Social Media (InTSHA), among adolescents living with perinatally acquired HIV as they transition from pediatric to adult care in South Africa. METHODS: InTSHA uses encrypted, closed group chats delivered via WhatsApp (Meta Platforms Inc) to develop peer support and improve communication between adolescents, their caregivers, and health care providers. The intervention is based on formative work with adolescents, caregivers, and health care providers and builds on several existing adolescent support programs as well as the Social-ecological Model of Adolescent and Young Adult Readiness for Transition (SMART). The final InTSHA intervention involves 10 modules conducted weekly through moderated WhatsApp group chats with adolescents and separately with their caregivers. We will randomly assign 80 South African adolescents living with perinatally acquired HIV who are aware of their HIV status and aged between 15 and 19 years to receive either the intervention (n=40) or standard of care (n=40). RESULTS: We will measure acceptability of the intervention as the primary outcome and evaluate feasibility and preliminary effectiveness for retention in care and viral suppression after completion of the intervention and at least 6 months after randomization. In addition, we will measure secondary outcomes evaluating the impact of the InTSHA intervention on peer support, self-esteem, depression, stigma, sexual education, connection to health care providers, and transition readiness. Enrollment began on April 15, 2021. As of December 31, 2021 a total of 78 out of expected 80 participants have been enrolled. CONCLUSIONS: If successful, the intervention will be evaluated in a fully powered randomized controlled trial with a larger number of adolescents from urban and rural populations to further evaluate the generalizability of InTSHA. TRIAL REGISTRATION: ClinicalTrials.gov NCT03624413; https://clinicaltrials.gov/ct2/show/NCT03624413. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/35455.

Autism NPCs from both idiopathic and CNV 16p11.2 deletion patients exhibit dysregulation of proliferation and mitogenic responses.

Neural precursor cell (NPC) dysfunction has been consistently implicated in autism. Induced pluripotent stem cell (iPSC)-derived NPCs from two autism groups (three idiopathic [I-ASD] and two 16p11.2 deletion [16pDel]) were used to investigate if proliferation is commonly disrupted. All five individuals display defects, with all three macrocephalic individuals (two 16pDel, one I-ASD) exhibiting hyperproliferation and the other two I-ASD subjects displaying hypoproliferation. NPCs were challenged with bFGF, and all hyperproliferative NPCs displayed blunted responses, while responses were increased in hypoproliferative cells. mRNA expression studies suggest that different pathways can result in similar proliferation phenotypes. Since 16pDel deletes MAPK3, P-ERK was measured. P-ERK is decreased in hyperproliferative but increased in hypoproliferative NPCs. While these P-ERK changes are not responsible for the phenotypes, P-ERK and bFGF response are inversely correlated with the defects. Finally, we analyzed iPSCs and discovered that 16pDel displays hyperproliferation, while idiopathic iPSCs were normal. These data suggest that NPC proliferation defects are common in ASD.

Physician Wellness Measures and Clinical Performance on a Critically Ill Simulated Patient: Does a Lack of Well-Being Impact Patient Care?

BACKGROUND/OBJECTIVE: Burnout is common among resident physicians, which has the potential to translate into diagnostic and management errors. Our study investigates the relationship between sleepiness, depression, anxiety, burnout, and lack of professional fulfillment with clinical performance during a critically ill patient simulation. Methods/Approach: Emergency medicine residents were recruited to participate in a high-fidelity simulation case of a critically ill patient. A survey with validated wellbeing measures (National Institutes of Health Patient-Reported Outcomes Measurement Information System (NIH PROMIS), Linzer burnout measure, and professional fulfillment index) was administered prior to the simulation. Each encounter was video-recorded and analyzed by two blinded raters based on a binary critical-actions checklist. Time-to-intubation, management errors, and misdiagnosis rates were assessed. RESULTS: Twenty residents participated, with most subjects endorsing sleepiness (70%) and less than half reporting depression (40%) and anxiety (45%). Burnout was identified to be in 50% of participants by the Linzer measure and 85% by the professional fulfillment index. No significant difference was found between mean performance scores in sleepy, depressed, and anxious cohorts in comparison to groups without those symptoms. Similarly, burnout and professional fulfillment did not yield any significant difference, nor did comparisons with time to intubation, management errors, and frequency of misdiagnosis. CONCLUSION: Resident burnout, depression, anxiety, sleepiness, and lack of professional fulfillment did not appear to have a measurable impact on clinical performance in managing a critically ill patient. There is no evidence from this study that the lack of resident physician well-being adversely impacts patient care by increasing errors in management or misdiagnoses during this high-fidelity simulation.

Rapid Cycle Deliberate Practice in Virtual Reality: Teaching Transvenous Pacemaker Insertion to Emergency Medicine Residents.

Introduction Transvenous pacemaker insertion is a critical life-saving procedure that is infrequently performed. Traditional mannequin-based training paradigms are resource intensive and sometimes inadequate due to time constraints. Rapid Cycle Deliberate Practice (RCDP) is an effective teaching modality for highly scripted procedures. We propose using a simulation-based technique of RCDP in virtual reality (VR) to teach this procedure. Methods Sixteen emergency medicine residents were recruited. A pre-survey was administered at the start of the session, followed by a baseline task trainer checklist-based assessment. This checklist was created based on expert consensus. Participants then underwent the RCDP VR intervention with a subsequent repeat checklist-based assessment as well as a post-survey.  Results Post-test scores were found to be significantly higher than pre-test scores after residents completed VR deliberate practice simulation (19.5±3.5 vs 24.1±2.0; p<0.001). Subanalysis did not reveal any significant difference based on post-graduate year, previous performance of procedure on a live patient, or previous VR experience. The experience increased participant feelings of preparedness and comfort in performing the procedure (2-disagree vs 4-agree) based on a 5-point Likert scale.  Conclusions Virtual reality using RCDP to teach transvenous pacemaker insertion demonstrated an improvement in task trainer performance. Further investigation into whether this translates into better patient outcomes or can be generalized to other procedures needs to be considered.

Assessment of Entrustable Professional Activities Using a Web-Based Simulation Platform During Transition to Emergency Medicine Residency: Mixed Methods Pilot Study.

BACKGROUND: The 13 core entrustable professional activities (EPAs) are key competency-based learning outcomes in the transition from undergraduate to graduate medical education in the United States. Five of these EPAs (EPA2: prioritizing differentials, EPA3: recommending and interpreting tests, EPA4: entering orders and prescriptions, EPA5: documenting clinical encounters, and EPA10: recognizing urgent and emergent conditions) are uniquely suited for web-based assessment. OBJECTIVE: In this pilot study, we created cases on a web-based simulation platform for the diagnostic assessment of these EPAs and examined the feasibility and acceptability of the platform. METHODS: Four simulation cases underwent 3 rounds of consensus panels and pilot testing. Incoming emergency medicine interns (N=15) completed all cases. A maximum of 4 "look for" statements, which encompassed specific EPAs, were generated for each participant: (1) performing harmful or missing actions, (2) narrowing differential or wrong final diagnosis, (3) errors in documentation, and (4) lack of recognition and stabilization of urgent diagnoses. Finally, we interviewed a sample of interns (n=5) and residency leadership (n=5) and analyzed the responses using thematic analysis. RESULTS: All participants had at least one missing critical action, and 40% (6/15) of the participants performed at least one harmful action across all 4 cases. The final diagnosis was not included in the differential diagnosis in more than half of the assessments (8/15, 54%). Other errors included selecting incorrect documentation passages (6/15, 40%) and indiscriminately applying oxygen (9/15, 60%). The interview themes included psychological safety of the interface, ability to assess learning, and fidelity of cases. The most valuable feature cited was the ability to place orders in a realistic electronic medical record interface. CONCLUSIONS: This study demonstrates the feasibility and acceptability of a web-based platform for diagnostic assessment of specific EPAs. The approach rapidly identifies potential areas of concern for incoming interns using an asynchronous format, provides feedback in a manner appreciated by residency leadership, and informs individualized learning plans.

360 virtual reality pediatric mass casualty incident: A cross sectional observational study of triage and out-of-hospital intervention accuracy at a national conference.

OBJECTIVE: With adolescent mass casualty incidents (MCI) on the rise, out-of-hospital readiness is critical to optimize disaster response. We sought to test the feasibility and acceptability of a 360 Virtual Reality (360 VR) platform for disaster event decisionmaking. METHODS: This was a cross-sectional observational assessment of a subject's ability to triage and perform out-of-hospital interventions using a 360 VR MCI module. A convenience sample of attendees was recruited over 1.5 days from the American College of Emergency Physicians (ACEP) national conference in San Diego, CA. RESULTS: Two hundred and seven (207) subjects were enrolled. Ninety-six (46%) subjects identified as attendings, 66 (32%) as residents, 13 (6%) as medical students, 4 (2%) as emergency medical technicians and 28 (14%) as other. When comparing mean scores between groups, physicians who were <40 years old had mean scores higher than physicians who were >40 years old (8.7 vs 6.5, P < 0.001). Residents achieved higher scores than attendings (8.6 vs 7.5, P = 0.005). Based on a 5-point Likert scale, participants felt the 360 VR experience was engaging (median = 5) and enjoyable (median = 5). Most felt that 360 VR was more immersive than mannequin-based simulation training (median = 5). CONCLUSION: We conclude that 360 VR is a feasible platform for assessing triage and intervention decisionmaking for adolescent MCIs. It is well received by subjects and may have a role as a training and education tool for disaster readiness. In this era of distanced learning, 360 VR is an attractive option for future immersive educational experiences.

Subclinical eating disorder traits are correlated with cortical thickness in regions associated with food reward and perception.

Behavioral traits associated with various forms of psychopathology are conceptualized as dimensional, varying from those present in a frank disorder to subclinical expression. Demonstrating links between these behavioral traits and neurobiological indicators, such as brain structure, provides one form of validation for this view. However, unlike behavioral dimensions associated with other forms of psychopathology (e.g., autism spectrum disorder, attention deficit hyperactivity disorder, antisocial disorders), eating disorder traits have not been investigated in this manner in spite of the potential that such an approach has to elucidate etiological mechanisms. Therefore, we examined for the first time neural endophenotypes of Anorexia Nervosa and Bulimia via dimensional traits (measured using the Eating Disorders Inventory-3) in a large subclinical sample of young adults (n = 456 and n = 247, respectively; ages = 18-22 years) who each provided a structural magnetic resonance imaging scan. Cortical thickness was quantified at 81,924 vertices across the cortical surface. We found: 1) increasing eating disorder traits correlated with thinner cortex in the insula and orbitofrontal cortex, among other regions, and 2) using these regions as seeds, increasing eating disorder trait scores negatively modulated structural covariance between these seed regions and other cortical regions linked to regulatory and sensorimotor functions (e.g., frontal and temporal cortices). These findings parallel those found in the clinical literature (i.e., thinner cortex in these food-related regions in individuals with eating disorders) and therefore provide evidence supporting the dimensional view of behavioral traits associated with eating disorders. Extending this approach to genetic and neuroimaging genetics studies holds promise to inform etiology.

DebriefLive: A Pilot Study of a Virtual Faculty Development Tool for Debriefing.

INTRODUCTION: The quality of healthcare simulation learning relies heavily on effective debriefers. Traditional methods of faculty development in debriefing lack a structured approach to achieve expertise via graduated and reflective practice. METHODS: The Simulation Learning, Education and Research Network (SimLEARN) developed DebriefLive, a virtual teaching environment, bringing together faculty and participant debriefers from across the Veterans Health Administration. Recorded simulation sessions were viewed followed by the opportunity for participant debriefers to debrief virtual learners. Participant debriefers were then provided structured and objective debriefings of the debriefings with the added opportunity for immediate practice. Program evaluation data for the pilot sessions were collected via electronic survey including a mix of Likert scale questions as well as short answer responses. RESULTS: On a 7-point Likert scale, participant debriefers (n = 15) rated the content as effective (mean = 6.67, SD = 0.47) and appropriate to their level (mean = 6.47, SD = 0.47). The technology of video-based scenarios (mean = 6.6, SD = 0.61), followed by avatar-based debriefing sessions (mean = 6.6, SD = 0.8), was felt to be accurate and appropriate. All participants would agree or strongly agree with recommending this training program to colleagues. CONCLUSIONS: Simulation instructors and fellows across the spectrum of the Veterans Health Administration found the innovative computer-based faculty development program DebriefLive acceptable as well as effective in increasing self-efficacy in debriefing. DebriefLive is an innovative and potentially disruptive tool, combining best practices in simulation theory and virtual technologies, for the training and assessment of debriefers.

A Modified Delphi Study to Prioritize Content for a Simulation-based Pediatric Curriculum for Emergency Medicine Residency Training Programs.

OBJECTIVES: Pediatric training is an essential component of emergency medicine (EM) residency. The heterogeneity of pediatric experiences poses a significant challenge to training programs. A national simulation curriculum can assist in providing a standardized foundation of pediatric training experience to all EM trainees. Previously, a consensus-derived set of content for a pediatric curriculum for EM was published. This study aimed to prioritize that content to establish a pediatric simulation-based curriculum for all EM residency programs. METHODS: Seventy-three participants were recruited to participate in a three-round modified Delphi project from 10 stakeholder organizations. In round 1, participants ranked 275 content items from a published set of pediatric curricular items for EM residents into one of four categories: definitely must, probably should, possibly could, or should not be taught using simulation in all residency programs. Additionally, in round 1 participants were asked to contribute additional items. These items were then added to the survey in round 2. In round 2, participants were provided the ratings of the entire panel and asked to rerank the items. Round 3 involved participants dichotomously rating the items. RESULTS: A total of 73 participants participated and 98% completed all three rounds. Round 1 resulted in 61 items rated as definitely must, 72 as probably should, 56 as possibly could, 17 as should not, and 99 new items were suggested. Round 2 resulted in 52 items rated as definitely must, 91 as probably should, 120 as possibly could, and 42 as should not. Round 3 resulted in 56 items rated as definitely must be taught using simulation in all programs. CONCLUSIONS: The completed modified Delphi process developed a consensus on 56 pediatric items that definitely must be taught using simulation in all EM residency programs (20 resuscitation, nine nonresuscitation, and 26 skills). These data will serve as a targeted needs assessment to inform the development of a standard pediatric simulation curriculum for all EM residency programs.

Music Intervention as a Tool in Improving Patient Experience in Palliative Care.

BACKGROUND:: The pain, anxiety, and stress associated with end-of-life care are paramount issues to address for both patients and their families. Reduction in these factors could translate to improved quality of life. OBJECTIVE:: We studied the effect of adding music to standard care for patients receiving a hospice or palliative care consult at 2 hospitals in the Care New England health-care system. In this mixed quantitative and qualitative study, we implemented live music intervention sessions. DESIGN/MEASUREMENTS:: Outcomes include symptom burden pre- and post-intervention using the Edmonton Symptom Assessment Scale, opioid use in equivalent time periods before and after the music intervention, and qualitative personal narratives of patients' and families' experiences with the music. RESULTS:: There were significant decreases in pain, anxiety, nausea, shortness of breath, and feelings of depression along with significant increase in feelings of well-being. Opioid use in time periods after the music intervention trended toward decreased usage when compared to the equivalent time period before. Finally, compiled personal narratives of patients' and families' experiences of the music intervention demonstrated common themes of spirituality, comfort, relaxation, escape, and reflection. CONCLUSIONS:: This project demonstrated the beneficial effects of music in a patient population that struggles with symptom management when only pharmacologic management is used. These data elucidate biological and psychosocial factors that are positively impacted by the intervention. With additional evidence in music as well as other artistic modalities, it is promising that arts-based programs in inpatient hospice and palliative care settings will continue to expand and flourish.

Interfering With Inner Speech Selectively Disrupts Problem Solving and Is Linked With Real-World Executive Functioning.

Purpose: According to Vygotskian theory, verbal thinking serves to guide our behavior and underpins critical self-regulatory functions. Indeed, numerous studies now link inner speech usage with performance on tests of executive function (EF). However, the selectivity of inner speech contributions to multifactorial executive planning performance and links with real-world functioning are limited. Therefore, the present study seeks to fill this gap in our knowledge. Method: Fifty-one adults completed the Tower of London under 2 conditions, (a) articulatory suppression and (b) foot tapping, and provided self-ratings of real-world executive functioning (utilizing the Behavior Rating Inventory of Executive Function-Adult Version; Roth, Isquith, & Gioia, 2006). Results: Interfering with inner speech selectively disrupted Tower of London performance over and above a simultaneous motor task (i.e., foot tapping). Furthermore, this selectivity in performance was linked with real-world self-monitoring. Conclusion: These results provide further evidence for specific links between verbal thinking and EF (particularly using multifactorial tasks of planning) and suggest that inner speech might serve as a key intervention target in clinical disorders where EF deficits are prominent.