Paediatric resident workflow observations in a community-based hospital.

OBJECTIVE: Residency graduates need to demonstrate competence in prioritising safe patient care through appropriate management of multiple competing tasks and workflow interruptions. This pilot study aimed to characterise and correlate interruptions in paediatric resident workflow at an academically affiliated, community-based hospital. METHODS: One of three trained observers followed a resident physician during a convenience sample of 1-2 hour increments, either in the emergency department or on the wards, and recorded all observed activities and interruptions using an established time-motion tool. All participants completed a baseline Multi-Tasking Ability Test (MTAT) and pre-observation and post-observation surveys. Statistical approach included descriptive statistics, logistic regression, mixed model and ORs. RESULTS: 18 paediatric residents were observed for 57.5 total hours (an average of 3.2 hours/resident) which included 329 interruptions, defined as any external event drawing the resident's attention away from a primary task. Interruptions occurred an average of 5.9 times per resident per hour. Interrupted primary tasks were not resumed during the observation period 11% of the time. A personal/social-related interruption yielded an OR of 0.29 that the resident will return to a primary task within 5 min (p=0.007) when compared with patient-related verbal interruptions by the medical team. The MTAT Score indicated decreased efficiency for interns versus postgraduate year 2 residents (p=0.029). Residents' MTAT Scores did not correlate with their time to return to a primary task following an interruption (p=0.11). CONCLUSIONS: Paediatric resident workflow interruptions in the hospital were observed to occur frequently and should be expected. Personal/social interruptions were most likely to delay prompt return to a primary task. The MTAT Score, although improved between the first 2 years of residency training, did not correlate with efficient return to a primary task. Interruption management and mitigation strategies should be developed as part of a standardised residency task management curriculum.

Low mortality in SARS-CoV-2 infected heart transplant recipients at a single center.

Immunosuppressed heart transplant (HT) recipients are thought to be at higher risk of infection and mortality from SARS-CoV-2 infection coronavirus disease 2019 (COVID-19); however, evidence guiding management of HT patients are limited. Retrospective search of electronic health records from February 2020 to February 2021, identified 28 HT recipients out of 400 followed by UC San Diego who tested positive for SARS-CoV-2. Patient demographics, COVID-19 directed therapies, hospital course and outcomes were compared to control HT recipients who tested negative for SARS-CoV-2 during the same period (n = 80). Among 28 HT recipients who tested positive for SARS-CoV-2, 15 were admitted to the hospital and 13 were monitored closely as outpatients. Among inpatients, five developed severe illness and two died (7% mortality). Nine patients were treated with remdesivir, and four received dexamethasone and remdesivir. Two outpatients received neutralizing monoclonal antibody therapy and one outpatient received dexamethasone for persistent dyspnea. Immunosuppressed HT recipients, especially Hispanic patients and patients with higher body mass index, were at greater risk of infection and mortality from COVID-19 than the general population. Use of remdesivir and dexamethasone may have improved outcomes in our HT recipients compared to HT recipients at other centers.

Sound-Making Actions Lead to Immediate Plastic Changes of Neuromagnetic Evoked Responses and Induced ß-Band Oscillations during Perception.

Auditory and sensorimotor brain areas interact during the action-perception cycle of sound making. Neurophysiological evidence of a feedforward model of the action and its outcome has been associated with attenuation of the N1 wave of auditory evoked responses elicited by self-generated sounds, such as talking and singing or playing a musical instrument. Moreover, neural oscillations at ß-band frequencies have been related to predicting the sound outcome after action initiation. We hypothesized that a newly learned action-perception association would immediately modify interpretation of the sound during subsequent listening. Nineteen healthy young adults (7 female, 12 male) participated in three magnetoencephalographic recordings while first passively listening to recorded sounds of a bell ringing, then actively striking the bell with a mallet, and then again listening to recorded sounds. Auditory cortex activity showed characteristic P1-N1-P2 waves. The N1 was attenuated during sound making, while P2 responses were unchanged. In contrast, P2 became larger when listening after sound making compared with the initial naive listening. The P2 increase occurred immediately, while in previous learning-by-listening studies P2 increases occurred on a later day. Also, reactivity of ß-band oscillations, as well as θ coherence between auditory and sensorimotor cortices, was stronger in the second listening block. These changes were significantly larger than those observed in control participants (eight female, five male), who triggered recorded sounds by a key press. We propose that P2 characterizes familiarity with sound objects, whereas ß-band oscillation signifies involvement of the action-perception cycle, and both measures objectively indicate functional neuroplasticity in auditory perceptual learning.SIGNIFICANCE STATEMENT While suppression of auditory responses to self-generated sounds is well known, it is not clear whether the learned action-sound association modifies subsequent perception. Our study demonstrated the immediate effects of sound-making experience on perception using magnetoencephalographic recordings, as reflected in the increased auditory evoked P2 wave, increased responsiveness of ß oscillations, and enhanced connectivity between auditory and sensorimotor cortices. The importance of motor learning was underscored as the changes were much smaller in a control group using a key press to generate the sounds instead of learning to play the musical instrument. The results support the rapid integration of a feedforward model during perception and provide a neurophysiological basis for the application of music making in motor rehabilitation training.

Patient DF's visual brain in action: Visual feedforward control in visual form agnosia.

Patient DF, who developed visual form agnosia following ventral-stream damage, is unable to discriminate the width of objects, performing at chance, for example, when asked to open her thumb and forefinger a matching amount. Remarkably, however, DF adjusts her hand aperture to accommodate the width of objects when reaching out to pick them up (grip scaling). While this spared ability to grasp objects is presumed to be mediated by visuomotor modules in her relatively intact dorsal stream, it is possible that it may rely abnormally on online visual or haptic feedback. We report here that DF's grip scaling remained intact when her vision was completely suppressed during grasp movements, and it still dissociated sharply from her poor perceptual estimates of target size. We then tested whether providing trial-by-trial haptic feedback after making such perceptual estimates might improve DF's performance, but found that they remained significantly impaired. In a final experiment, we re-examined whether DF's grip scaling depends on receiving veridical haptic feedback during grasping. In one condition, the haptic feedback was identical to the visual targets. In a second condition, the haptic feedback was of a constant intermediate width while the visual target varied trial by trial. Despite this incongruent feedback, DF still scaled her grip aperture to the visual widths of the target blocks, showing only normal adaptation to the false haptically-experienced width. Taken together, these results strengthen the view that DF's spared grasping relies on a normal mode of dorsal-stream functioning, based chiefly on visual feedforward processing.