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Abstract Abstract reasoning is a key ability for an intelligent system. Large language models (LMs) achieve above-chance performance on abstract reasoning tasks but exhibit many imperfections. However, human abstract reasoning is also imperfect. Human reasoning is affected by our real-world knowledge and beliefs, and shows notable “content effects”; humans reason more reliably when the semantic content of a problem supports the correct logical inferences. These content-entangled reasoning patterns are central to debates about the fundamental nature of human intelligence. Here, we investigate whether language models—whose prior expectations capture some aspects of human knowledge—similarly mix content into their answers to logic problems. We explored this question across three logical reasoning tasks: natural language inference, judging the logical validity of syllogisms, and the Wason selection task. We evaluate state of the art LMs, as well as humans, and find that the LMs reflect many of the same qualitative human patterns on these tasks—like humans, models answer more accurately when the semantic content of a task supports the logical inferences. These parallels are reflected in accuracy patterns, and in some lower-level features like the relationship between LM confidence over possible answers and human response times. However, in some cases the humans and models behave differently—particularly on the Wason task, where humans perform much worse than large models, and exhibit a distinct error pattern. Our findings have implications for understanding possible contributors to these human cognitive effects, as well as the factors that influence language model performance.

During extended motor adaptation, learning appears to saturate despite persistence of residual errors. This adaptation limit is not fixed but varies with perturbation variance; when variance is high, residual errors become larger. These changes in total adaptation could relate to either implicit or explicit learning systems. Here, we found that when adaptation relied solely on the explicit system, residual errors disappeared and learning was unaltered by perturbation variability. In contrast, when learning depended entirely, or in part, on implicit learning, residual errors reappeared. Total implicit adaptation decreased in the high-variance environment due to changes in error sensitivity, not in forgetting. These observations suggest a model in which the implicit system becomes more sensitive to errors when they occur in a consistent direction. Thus, residual errors in motor adaptation are at least in part caused by an implicit learning system that modulates its error sensitivity in response to the consistency of past errors. Human motor adaptation reaches an upper limit. Albert et al. report that this limit is linked to implicit learning. When perturbations are variable, the adaptation limit decreases as subconscious learning systems become less sensitive to error.

Motor imagery, that is the mental rehearsal of a motor skill, can lead to improvements when performing the same skill. Here we show a powerful and complementary role, in which motor imagery of different movements after actually performing a skill allows learning that is not possible without imagery. We leverage a well-studied motor learning task in which subjects reach in the presence of a dynamic (force-field) perturbation. When two opposing perturbations are presented alternately for the same physical movement, there is substantial interference, preventing any learning. However, when the same physical movement is associated with follow-through movements that differ for each perturbation, both skills can be learned. Here we show that when subjects perform the skill and only imagine the follow-through, substantial learning occurs. In contrast, without such motor imagery there was no learning. Therefore, motor imagery can have a profound effect on skill acquisition even when the imagery is not of the skill itself. Our results suggest that motor imagery may evoke different neural states for the same physical state, thereby enhancing learning.

IntroductionRecent guidelines have been published by the British Heart Rhythm Society regarding the perioperative management of patients with an ICD. The presence of these devices may present a problem when patients undergo procedures or operations in which they are exposed to EMI (electromagnetic interference). The most common source of EMI in a theatre setting is surgical diathermy. EMI can cause the device to function inappropriately.The current guidelines offer clinicians a pragmatic approach to managing patients with an ICD in situ who present for surgery. It is an updated version of prior guidelines published in 2016 (table 3). The risk of surgical diathermy causing device malfunction is inversely proportional to the distance between the operating site and the device itself. This principle is reflected in the current guidelines which recommend not reprogramming pacemakers or deactivating ICD’s when the site of the operation is below the diaphragm. Rather surgery should proceed ahead with a clinical magnet available should it be required. This goal of this audit was to assess our compliance with this guideline recommendation in patients who present for surgery in Beaumont Hospital. Our focus was the response to patients in whom the planned operating site was below the diaphragm. Our hypothesis was that many of these patients had ICDs deactivated when the evidence base would suggest that this approach is not necessary.MethodsA logbook of device reprogramming requests was examined from October 2022 to October 2020. The patients name and date of scheduled operation was cross referenced with the Tpro dictation data base to determine the site and type of surgical operation. The changes made to the device (therapies off or asynchronous pacing) were noted. In cases where only partial documentation was available the Heart Rhythm Ireland online data base was used.ResultsBetween the 1st December 2020 and 30th October 2022, 29 documented requests were made to the Cardiology Department requesting ICD reprogramming prior to surgery (table 2) . There were 4 cases where it was not clear where the site of surgery was due to incomplete documentation. In the remaining patients, 22 had surgery below the diaphragm and 3 had surgery above the diaphragm (table 1). In all surgeries below the diaphragm, therapies function of the device was deactivated.Abstract 49 Table 1Site of SurgerySurgical Site Therapies deactivated (n=) Above diaphragm 3 Below diaphragm 22 Unclear 4 Abstract 49 Table 2Patient characteristics N = Male 25 Female 4 Age – years (mean and SD) 73.6 (9.10) Surgical Speciality Orthopaedics 7 General Surgery 7 Vascular 4 Plastics 3 ENT 1 Urology 4 Unknown 3 Device CRT - D 11 ICD 13 Unknown 5 Device Manufacturer Boston 9 Abbot (St Jude) 10 Medtronic 5 Unknown 5 Abstract 49 Table 3Management algorithm for patients presenting for surgery with a CIED. (adapted from Thomas et al, Anaesthesia 2022) Pacemaker Implantable Defibrillator Pacing dependent Not dependent Pacing dependent Not dependent Surgery above umbilicus Consider reprogrammed to fixed rate if prolonged diathermy anticipated Monitor during surgery to ensure no inhibition of pacemaker. No reprogramming Deactivation of ICD. Consider reprogramming to fixed rate pacing Or Magnet application as alternative only if prolonged diathermy not anticipated Deactivation of ICD Or Magnet application Surgery below the umbilicus Monitor during surgery to ensure no inhibition of pacemaker. No reprogramming. Clinical magnet should be available Monitor during surgery to ensure no inhibition of pacemaker. No reprogramming Monitor during surgery to ensure no inhibition of pacemaker or inappropriate therapies. Reasonable not to deactivate ICD. Clinical magnet should be available Monitor during surgery to ensure no inhibition of pacemaker or inappropriate therapies. Reasonable not to deactivate ICD. Clinical magnet should be available ConclusionOur audit demonstrates that a large number of ICD’s are unnecessarily deactivated prior to surgery. In fact, all 29 patients in this audit had their device deactivated regardless of the site of surgery. This is contrary to current guidelines. When the surgical operation is below the diaphragm, the risk of EMI is extremely low. The current evidence recommends close monitoring intraoperatively with immediate availability of a clinical magnet rather than deactivation of therapies. The deactivation of an ICD prior to surgery is both labour and time intensive. In some circumstances it is justified, however as our data shows there are many instances where it is performed unnecessarily with no clinical benefit to the patient.Compliance with these guidelines will have an immediate positive impact on patient flow through the hospital and significantly reduce the number of requests for ICD reprogramming to the Cardiology department (figure 1).Abstract 49 Figure 1Suggested management flowchart for patients with a CIED presenting electively for surgery (adopted from Thomas et al, Anaesthesia 2022)[Figure omitted. See PDF]

IntroductionInpatient telemetry monitoring makes up a large portion of non-invasive cardiology investigations available to general medical teams. Studies have shown that clinical care changes in 7–30% of patients may be attributed to telemetry findings. Overuse of telemetry amongst hospital patients results in longer waiting times for telemetry to other patients, prolongs length of admission and cost of healthcare. Although some centres have local proformas regarding the use of this limited resource, there are no standardised guidelines regarding its use in Irish hospitals. Furthermore, there is a lack of European guidelines on telemetry use.Aims and MethodsProspectively analyse the inpatient telemetry requests and use over a 60-day period in a single centre to identify areas of improvement. The aim of the audit was to create a standardised proforma for prioritisation of telemetry requests using American Heart Association (AHA) and British Heart Rhythm Society (BHRS) telemetry guidelines. Consecutive data was prospectively collected on telemetry use in a single centre using electronic health systems and patient records.ResultsA total of 10,796 telemetry hours of data was recorded and reviewed from 241 patients during the period. Demographics as per table 1. The mean time waiting for telemetry was 23.1hrs (+/- 21.8hrs). The mean time on telemetry was 44.8hrs (+/- 39.3hrs) with 0.385 arrythmias per telemetry day or 77 patients (32%) with an arrythmia detected. There was a change in management enacted in 70 patients (29%) due to telemetry findings. This included titration of medications in 54 patients (22%), diagnosis of new atrial fibrillation in 14 patients (5.8%), further diagnostics in 14 patients (5.8%), reversion to sinus rhythm in 9 patients (3.7%) and device insertion in 4 patients (1.6%). A total of 30 patient requests did not receive telemetry, 6 patients had telemetry refused due to inappropriate requests, 4 patients refused telemetry when offered to them, 14 patients had been discharged home when a box was assigned to them, 6 patients had electrolytes that had normalised prior to telemetry being made available. 202 (84%) of requests met criteria for telemetry according to BHRS and AHA guidelines. Of the 39 requests that did not meet criteria for telemetry as per guidelines, there was a change to patient management based on findings in 4 cases. 6 requests were monitored for shorter than the recommended duration. 66 telemetry requests were monitored for longer than the recommended duration.Abstract 36 Table 1Patient demographicsConclusionsTelemetry monitoring in-hospital is a valuable but limited resource with potential for overuse. Judicious telemetry use with suggested prioritisation (figure 1) and prescription of telemetry rather than automatic approval may result in better patient outcomes. A re-audit to complete the process after hospital staff education and implementation of new telemetry form will be carried out to evaluate the results.Abstract 36 Figure 1Telemetry use with suggested prioritisation[Figure omitted. See PDF]

IntroductionThe 2021 ESC guidelines on heart failure (HF) recommend the sodium-glucose co-transporter 2 inhibitor (SGLT2i) dapagliflozin or empagliflozin be added to ACE-I/ARNI/beta-blocker/MRA in patients with HFrEF. Additionally, the 2022 AHA/ACC/HFSA guidelines advise SGLT2i use should be considered for patients with HFmrEF/HFpEF. At the national adult Duchenne Muscular Dystrophy (DMD) multidisciplinary clinic, patients with HF secondary to DMD had not yet been started on an SGLT2i. Limited data exists regarding the use, tolerability and understanding of this medication in DMD. Over the past year, patients with DMD-associated HF attending for review were considered for SGLT2i commencement. This audit assesses compliance to recent changes in evidence-based guidelines and tolerability in adult patients with DMD in Ireland.MethodsAll patients with DMD attending from 01/05/22 - 01/05/23 were included. Data was collected from medical records and phone interviews with a proforma questionnaire.ResultsTwenty-eight patients with DMD attended the clinic with an average age of 22.3 years (range 16–34). Nine (32.1%) had HFpEF (LVEF >50%), 15 (53.6%) had HFmrEF and four (14.2%) had HFrEF.Prior to initiation of SGLT2i, 89.3% (n=25) were on a beta blocker (the remaining three patients tolerated ivabradine), 100% (n=28) were on an ACE inhibitor, and 96.4% (n=27) were on an MRA. Twenty-four patients (85.6%) had an SGLT2i prescribed during the study. Four patients were not started on the medication, due to incontinence (2), UTI (1) and patient preference not to start (1). Only two patients discontinued the medication. One patient stopped after four days, the other after two weeks, both due to hypotension and dizziness. Two brothers elected not to start the prescribed medication. Two others, who had an SGLT2i prescribed recently, have not yet started due to dose adjustments to other medications but plan to start later. No other adverse effects, genitourinary infections or ketoacidosis were reported. The majority (90%) of patients and guardians understood the indication for starting the medication. All patients on the medication reported excellent compliance (100%). While 81.8% of patients and their guardians could name common side effects of the medication, only 45.4% understood ‘sick day rules’. Since starting the medication none of the patients on an SGLT2i have been hospitalised for HF. Most patients not currently taking an SGLT2i said they would be open to discussing it at their next clinic appointment.(figures 1 and 2)Abstract 55 Figures 1 and 2Results[Figure omitted. See PDF]ConclusionsOur study provides unique early insights on the safety and tolerability of SGLT2 inhibitors in a DMD cohort. Only two patients were unable to tolerate the SGLT2i. However, better education is needed for DMD patients and their guardians around ‘sick day rules’ and potential side effects of SGLT2 inhibitors. We also found that there was excellent adherence to the other pillars of guideline-directed medical therapy for HF in this patient cohort.

BackgroundThe use of pulse field ablation in pulmonary vein isolation for treating atrial fibrillation is becoming more widespread. This method may create larger, more uniform, and deeper lesions compared to other techniques. Consequently, it could lead to the formation of a narrow conductive isthmus on the posterior wall, potentially heightening the likelihood of arrhythmias.MethodsElectroanatomic mapping of the left atrium during coronary sinus pacing was performed before and after pulsefield ablation pulmonary vein isolation using the Carto electroanatomic mapping system and using a Pentaray mapping catheter. Electroanatomic maps were converted into an OpenEP format and analysed using EPWorkbench. The posterior wall conducting channel was measured as the distance between 0.5mV isolines atthree levels (roof, mid and inferior). Conducting channel width was defined as the average of these three measurements and also quantified as a proportion of the inter-vein distance. Conduction velocity within the posterior wall region was quantified pre- and post-ablation. (See image 1)ResultsAnalysis was completed in 35 patients (77% male, mean age 60.8 years, range 24–80 years). As expected the conduction channel width was significantly reduced post pulse fi eld ablation with the channel width approximately 38% of the pre-ablation width. (table 1)ConclusionsFollowing pulse field ablation pulmonary vein isolation there is a wide range of conducting channel widths remaining on the posterior wall, with conduction properties of these channels unchanged from pre-ablation. Further research is needed to identify whether a specific minimum channel width impacts conduction properties and increases the likelihood of atrial tachycardia in patients following pulse field ablation.Abstract 83 Table 1[Image Omitted. See PDF.]Abstract 83 Image 1[Image Omitted. See PDF.]

IntroductionA higher right ventricular (RV) pacing burden in those with permanent pacemakers for bradyarrhythmia results in increased pacing induced cardiomyopathy, atrial fibrillation and mortality. This process may necessitate upgrade to a biventricular system in time, as the cardiomyopathy progresses. Physiological conduction system pacing targets such as His-bundle pacing (HBP) or Left Bundle Branch Area Pacing (LBBAP) have been shown to generate comparatively narrower QRS complexes and thus mitigate this cardiomyopathy development. The 2021 ESC guidelines have a class 2b indication for consideration of HBP as an alternative to RV pacing in those with AV block and left ventricular ejection fraction >40%, who are anticipated to have >20% ventricular pacing burden. This promising data is put in perspective with the findings of the MELOS trial, presented at EHRA 2022. This large study (2533 patients) demonstrated a much higher rate of lead related complications (8.2%) related to LBBAP than standard RV implantation techniques, even in an experienced centre.PurposeTo retrospectively identify ECG, echocardiographic, permanent pacemaker (PPM) setting and patient factors associated with high RV pacing burden that may aid selection of those who may benefit greatest from LBBAP.MethodsWe retrospectively identified 300 consecutive patients who underwent cardiac implantable electronic device insertion in our Electrophysiology Lab and followed their pacing check data for 3 years, from the years 2017–2020/21. We excluded patients who underwent generator replacements, in addition to those who had biventricular devices or implantable cardioverter defibrillators inserted. We collated ECG, echo, past medical history, pacing indications and settings for each patient. Pacing check data for each patient was gathered for a three-year follow up period. Data were analysed using SPSS v.26.Results160 patients met inclusion criteria. Those with an RV pacing burden >20% were categorised group one (n=85) and those with <20% in group two (n=75). Baseline characteristics of these two groups are compared in table 1. Our analysis showed that significant differences between these groups included a lower mean HR (55.1 ± 17.8 vs 57.63 ± 17.4) with a more prolonged PR interval (225.7 ± 8.34 vs. 188.6 ± 6.62) or AF/AFL on admission ECG (32% vs 7%). There were more males with a greater mean age (76.6 ± 8.4 vs 71.23 ± 12.3) in the higher VP group, and they demonstrated more incidence of dilated RA/RV on echo (Enlarged RA = 30.5%; Enlarged RV = 23.6% vs 10% and 8.4% respectively). There were significant differences in PPM indications and setting between groups, with the higher VP groups having PPM inserted for persistent high-grade AV block (CHB = 31.5% vs 4.9% and Mobitz 2 = 9.6% vs 0%) and had less MVP mode activated (Mode switch algorithm = 13.3% vs 71%).Abstract 6 Table 1Admission ECG, Past medical history, bradyarrhythmia indications for PPM, echo data, medications, settings and follow up VP burden for both groups. * Denotes significance. Other* = Admission rhythm other than SR or AF such as junctional tachycardia, ventricular escape rhythms etcConclusionLBBAP lead implantation by an experienced operator should be strongly considered as a first line pacing strategy in those with persistent high grade AV nodal conduction disease such as Mobitz 2 and CHB.PPM settings should be optimised to take advantage of anti-ventricular pacing algorithms to minimise excessive RV pacing.RVP is currently an acceptable alternative to CSP for those with bradyarrhythmia indications who are expected to have RVP burden of less than 20%, due to it’s higher implant success and low complication rates. This may change in future as LBBAP techniques are refined.

Knowledge about a tool’s dynamics can be acquired from the visual configuration of the tool and through physical interaction. Here, we examine how visual information affects the generalization of dynamic learning during tool use. Subjects rotated a virtual hammer-like object while we varied the object dynamics separately for two rotational directions. This allowed us to quantify the coupling of adaptation between the directions, that is, how adaptation transferred from one direction to the other. Two groups experienced the same dynamics of the object. For one group, the object’s visual configuration was displayed, while for the other, the visual display was uninformative as to the dynamics. We fit a range of context-dependent state-space models to the data, comparing different forms of coupling. We found that when the object’s visual configuration was explicitly provided, there was substantial coupling, such that 31% of learning in one direction transferred to the other. In contrast, when the visual configuration was ambiguous, despite experiencing the same dynamics, the coupling was reduced to 12%. Our results suggest that generalization of dynamic learning of a tool relies, not only on its dynamic behaviour, but also on the visual configuration with which the dynamics is associated.

IntroductionRight ventricular pacing has disadvantages of causing electric and mechanical dyssynchrony, which exacerbates the risk of atrial fibrillation (AF), heart failure (HF), and mortality.1 Physiological pacing activates the normal cardiac conduction, thereby providing synchronised contraction of the ventricles.2 A novel approach to physiological pacing is left bundle branch area pacing (LBBP) that has advantages over HIS bundle pacing including superior implant parameters and stability and allows pacing immediately beyond the commonest level of conduction block in LBBB.3,4 Early large registry data has been promising, particularly in the LBBB resynchronization cohorts, CRT non-responders and CRT bail-out population5.AimsProspectively analyse LBBP implantation parameters and early outcomes in patients undergoing LBBP implantation across two centres.MethodsData was prospectively collected at two sites using local electronic records, EP recording system (Prucka) and echocardiography. Patient baseline ejection fraction (EF), QRS duration, PR interval, New York Heart Association (NYHA) status, LV End diastolic volume (EDV) and left ventricular internal diameter in diastole (LVIDd) were recorded. QRS duration, left ventricular activation time (LVAT), V1-V6 interpeak and device parameters were recorded at implant. EF, NYHA status, LVIDd and device parameters were recorded after a six-week follow-up. Paired T-test on EF and NYHA status values were performed.ResultsA total of 17 patients underwent LBBP. Demographics as per table 1. There was a reduction in mean QRS from 158.7 (+/- 40.4) to 116.4 (+/-18.9). No significant change in device parameters was noted at 6 weeks. The mean LVAT was 86ms (+/- 13.9), LVAT drop >10ms was seen in all cases, mean V6–1 interpeak was 41ms (+/- 9.9). Fixation beats were seen in 12 cases (70%). 6 of the patients had prior devices that were upgraded. Implant parameters as per table 2.1 patient had a complication of lead dislodgement requiring repositioning. 7 out of 9 heart failure patients with CRT indication had follow up echocardiography performed at 6-week follow. Subgroup analysis on this cohort is shown in figures 1 and 2. There was a statistically significant decrease in NYHA status from 2.7 to 1.6 (P=0.022) in this group with a decrease in NYHA class seen in 6 out of 7 patients. Mean EF improved from 17% to 27% (p= 0.08).Abstract 48 Table 1CRT, LBBBAbstract 48 Table 2Implant parametersAbstract 48 Figure 1HFrEF (heart failure with reduced ejection fraction) subgroup analysis[Figure omitted. See PDF]Abstract 48 Figure 2HFrEF (heart failure with reduced ejection fraction) subgroup analysis[Figure omitted. See PDF]ConclusionsShort term data in a real-world Irish population who received LBBP is promising and feasible. Many questions remain including ideal implant parameters, patient selection criteria, and long-term durability of left bundle leads. Further research, particularly well powered randomized controlled trials and longer term follow up is needed to establish medium term and long-term safety and efficacy.