Developing a Framework for the Design and Deployment of Virtual Reality (VR) in Clinical Education.

The emerging cost-effective and powerful standalone VR hardware is an increasingly viable supplement to traditional clinical educational modalities. These traditional approaches are effective but can be limited by the cost of simulation infrastructure, the requirement to attend at fixed times and locations and instructor availability present challenges in meeting the needs of clinicians. One barrier facing educators looking to develop bespoke VR-based solutions is the lack of guidelines around their design, development, deployment, and evaluation. Our team has produced and deployed a number of VR-based educational applications. Through reflecting on findings from surveys, interviews, observation, we summarise a range of insights into the complexity and nuances of the clinical VR design and deployment in a framework that can inform and guide educators, clinicians and developers looking to create their own VR applications for use in healthcare.

Global perspectives of the impact of the COVID-19 pandemic on learning science in higher education.

The COVID-19 pandemic required higher education institutions to rapidly transition to Emergency Remote Instruction (ERI) with little preparation. Discussions are now underway globally to learn the lessons of COVID-19 and to use this knowledge to shape the future of learning science in higher education. In this study, we examined the experiences of instructors and students to ERI in three universities across three continents-America, Europe, and Australia. We measured the instructional strategies used by instructors including assessment types, and interaction opportunities during and outside class schedules. We also measured the learning challenges experienced by students including planning, distractions, technology, learning resources, their views on educational quality and what characterized quality interactions during ERI. Our findings suggest that most instructional strategies used by instructors changed little during ERI, although the nature of instructor and student interactions during class relied more heavily on technology. Students reported significant learning challenges which included distractions from their physical and social media environments and access to technology. Both instructors and students reported that interactions with each other and their peers were concerningly low, albeit similar to pre COVID-19 pandemic levels. There were differences in the perceptions of instructors and students on whether instructor-student interactions were better or worse online. Common among all universities, there was a large proportion of students reporting mental health and work-related stress. Lessons to be learned from the COVID-19 pandemic include ensuring more support for instructors to implement effective and equitable pedagogies and an increased recognition of the importance of practicals, and the social, interactive and hands-on aspects of learning science in higher education. We predict that the incorporation of active learning pedagogies and strategies which increase student engagement and foster a sense of belonging will be ongoing global challenges for learning science in a post COVID-19 campus.

Comparison of Grip Strength, Forearm Muscle Activity, and Shock Transmission between the Forehand Stroke Technique of Experienced and Recreational Tennis Players Using a Novel Wearable Device.

Upper limb tennis injuries are primarily chronic, resulting from repetitive overuse. We developed a wearable device which simultaneously measures risk factors (grip strength, forearm muscle activity, and vibrational data) associated with elbow tendinopathy development resulting from tennis players' technique. We tested the device on experienced (n = 18) and recreational (n = 22) tennis players hitting forehand cross-court at both flat and topspin spin levels under realistic playing conditions. Using statistical parametric mapping analysis, our results showed that all players showed a similar level of grip strength at impact, regardless of spin level, and the grip strength at impact did not influence the percentage of impact shock transfer to the wrist and elbow. Experienced players hitting with topspin exhibited the highest ball spin rotation, low-to-high swing path brushing action, and shock transfer to the wrist and elbow compared to the results obtained while hitting the ball flat, or when compared to the results obtained from recreational players. Recreational players exhibited significantly higher extensor activity during most of the follow through phase compared to the experienced players for both spin levels, potentially putting them at greater risk for developing lateral elbow tendinopathy. We successfully demonstrated that wearable technologies can be used to measure risk factors associated with elbow injury development in tennis players under realistic playing conditions.

Student responses to creative coding in biomedical science education.

Biomedical science students need to learn to code. Graduates face a future where they will be better prepared for research higher degrees and the workforce if they can code. Embedding coding in a biomedical curriculum comes with challenges. First, biomedical science students often experience anxiety learning quantitative and computational thinking skills and second biomedical faculty often lack expertise required to teach coding. In this study, we describe a creative coding approach to building coding skills in students using the packages of Processing and Arduino. Biomedical science students were taught by an interdisciplinary faculty team from Medicine and Health, Science and Architecture, Design and Planning. We describe quantitative and qualitative responses of students to this approach. Cluster analysis revealed a diversity of student responses, with a large majority of students who supported creative coding in the curriculum, a smaller but vocal cluster, who did not support creative coding because either the exercises were not sufficiently challenging or were too challenging and believed coding should not be in a Biomedical Science curriculum. We describe how two creative coding platforms, Processing and Arduino, embedded and used to visualize human physiological data, and provide responses to students, including those minority of students, who are opposed to coding in the curriculum This study found a variety of students responses in a final year capstone course of an undergraduate Biomedical Science degree where future pathways for students are either in research higher degrees or to the workforce with a future which will be increasingly data driven.

An idea to explore: Interdisciplinary capstone courses in biomedical and life science education.

While biomedical and life science research have embraced interdisciplinarity as the means to solving pressing 21st century complex challenges, interdisciplinarity in undergraduate education has been more difficult to implement. As a consequence, disciplinary rather than interdisciplinary capstones have become ubiquitous. Disciplinary capstones are valuable for students because they enable them to integrate knowledge and skills within the discipline, but they are also limiting because the integration is within rather than across disciplines. In contrast to a capstone, which involves a single discipline, interdisciplinary capstones require two or more disciplines to combine and integrate across disciplinary boundaries. Interdisciplinarity, where two of more disciplines come together, is difficult to implement in the biomedical and life science curricula because student majors and finances are administered in ways, which reinforce institutional organization of schools and faculties and prevent collaboration. Here in this "idea to explore" we provide an interdisciplinary capstone model where students enroll in disciplinary courses, but then these disciplinary courses and students collaborate on interdisciplinary real-world problems. This interdisciplinary capstone model was implemented across two diverse and large biomedical and life science schools within two faculties in a research intensive, metropolitan university. This approach allows for integration of the biomedical, social and ethical perspectives required when solving problems in the real world, such as COVID-19. Interdisciplinary learning also better prepares students for higher degree research and future careers. Overcoming disciplinary curriculum silos and faculty barriers is critical if we are to meet expectations of acquiring interdisciplinarity as a key competency.

Designing Virtual Reality-Based Conversational Agents to Train Clinicians in Verbal De-escalation Skills: Exploratory Usability Study.

BACKGROUND: Violence and aggression are significant workplace challenges faced by clinicians worldwide. Traditional methods of training consist of "on-the-job learning" and role-play simulations. Although both approaches can result in improved skill levels, they are not without limitation. Interactive simulations using virtual reality (VR) can complement traditional training processes as a cost-effective, engaging, easily accessible, and flexible training tool. OBJECTIVE: In this exploratory study, we aimed to determine the feasibility of and barriers to verbal engagement with a virtual agent in the context of the Code Black VR application. Code Black VR is a new interactive VR-based verbal de-escalation trainer that we developed based on the Clinical Training Through VR Design Framework. METHODS: In total, 28 participants with varying clinical expertise from 4 local hospitals enrolled in the Western Sydney Local Health District Clinical Initiative Nurse program and Transition to Emergency Nursing Programs and participated in 1 of 5 workshops. They completed multiple playthroughs of the Code Black VR verbal de-escalation trainer application and verbally interacted with a virtual agent. We documented observations and poststudy reflection notes. After the playthroughs, the users completed the System Usability Scale and provided written comments on their experience. A thematic analysis was conducted on the results. Data were also obtained through the application itself, which also recorded the total interactions and successfully completed interactions. RESULTS: The Code Black VR verbal de-escalation training application was well received. The findings reinforced the factors in the existing design framework and identified 3 new factors-motion sickness, perceived value, and privacy-to be considered for future application development. CONCLUSIONS: Verbal interaction with a virtual agent is feasible for training staff in verbal de-escalation skills. It is an effective medium to supplement clinician training in verbal de-escalation skills. We provide broader design considerations to guide further developments in this area.

Effects of air pollution on human health - Mechanistic evidence suggested by in vitro and in vivo modelling.

Airborne particulate matter (PM) comprises both solid and liquid particles, including carbon, sulphates, nitrate, and toxic heavy metals, which can induce oxidative stress and inflammation after inhalation. These changes occur both in the lung and systemically, due to the ability of the small-sized PM (i.e. diameters ≤2.5 µm, PM2.5) to enter and circulate in the bloodstream. As such, in 2016, airborne PM caused ∼4.2 million premature deaths worldwide. Acute exposure to high levels of airborne PM (eg. during wildfires) can exacerbate pre-existing illnesses leading to hospitalisation, such as in those with asthma and coronary heart disease. Prolonged exposure to PM can increase the risk of non-communicable chronic diseases affecting the brain, lung, heart, liver, and kidney, although the latter is less well studied. Given the breadth of potential disease, it is critical to understand the mechanisms underlying airborne PM exposure-induced disorders. Establishing aetiology in humans is difficult, therefore, in-vitro and in-vivo studies can provide mechanistic insights. We describe acute health effects (e.g. exacerbations of asthma) and long term health effects such as the induction of chronic inflammatory lung disease, and effects outside the lung (e.g. liver and renal change). We will focus on oxidative stress and inflammation as this is the common mechanism of PM-induced disease, which may be used to develop effective treatments to mitigate the adverse health effect of PM exposure.

XR game development as a tool for authentic, experiential, and collaborative learning.

This brief review provides insights into the recent advances made by the Unity game engine into education and the ways that learning resources can be used to teach novice bioscience students to use the VR/AR affordances of the platform. We present our own practises for implementation of a novel gamification task for final-year bioscience students and reflect on the changes we have had to make in order to overcome challenges presented by the COVID-19 pandemic.

Particulate Matter, an Intrauterine Toxin Affecting Foetal Development and Beyond.

Air pollution is the 9th cause of the overall disease burden globally. The solid component in the polluted air, particulate matters (PMs) with a diameter of 2.5 µm or smaller (PM2.5) possess a significant health risk to several organ systems. PM2.5 has also been shown to cross the blood-placental barrier and circulate in foetal blood. Therefore, it is considered an intrauterine environmental toxin. Exposure to PM2.5 during the perinatal period, when the foetus is particularly susceptible to developmental defects, has been shown to reduce birth weight and cause preterm birth, with an increase in adult disease susceptibility in the offspring. However, few studies have thoroughly studied the health outcome of foetuses due to intrauterine exposure and the underlying mechanisms. This perspective summarises currently available evidence, which suggests that intrauterine exposure to PM2.5 promotes oxidative stress and inflammation in a similar manner as occurs in response to direct PM exposure. Oxidative stress and inflammation are likely to be the common mechanisms underlying the dysfunction of multiple systems, offering potential targets for preventative strategies in pregnant mothers for an optimal foetal outcome.

Bioscience education 2030 and beyond: Where will technology take the curriculum?

This brief review explores the ever-increasing role that technological affordances may play in the 21C biochemistry and molecular biology curriculum. We consider the need to develop digital and creative fluencies in our students and the importance of creativity and visualization in learning science. The potential of virtual reality (VR) platforms to complement these goals are discussed with a number of examples. Finally, we look into the future where to see how VR might fit into a future curriculum.

Exploring User Needs in the Development of a Virtual Reality-Based Advanced Life Support Training Platform: Exploratory Usability Study.

BACKGROUND: Traditional methods of delivering Advanced Life Support (ALS) training and reaccreditation are resource-intensive and costly. Interactive simulations and gameplay using virtual reality (VR) technology can complement traditional training processes as a cost-effective, engaging, and flexible training tool. OBJECTIVE: This exploratory study aimed to determine the specific user needs of clinicians engaging with a new interactive VR ALS simulation (ALS-SimVR) application to inform the ongoing development of such training platforms. METHODS: Semistructured interviews were conducted with experienced clinicians (n=10, median age=40.9 years) following a single playthrough of the application. All clinicians have been directly involved in the delivery of ALS training in both clinical and educational settings (median years of ALS experience=12.4; all had minimal or no VR experience). Interviews were supplemented with an assessment of usability (using heuristic evaluation) and presence. RESULTS: The ALS-SimVR training app was well received. Thematic analysis of the interviews revealed five main areas of user needs that can inform future design efforts for creating engaging VR training apps: affordances, agency, diverse input modalities, mental models, and advanced roles. CONCLUSIONS: This study was conducted to identify the needs of clinicians engaging with ALS-SimVR. However, our findings revealed broader design considerations that will be crucial in guiding future work in this area. Although aligning the training scenarios with accepted teaching algorithms is important, our findings reveal that improving user experience and engagement requires careful attention to technology-specific issues such as input modalities.

Medical negligence laws and virtual reality in healthcare.

BACKGROUND: As technological innovation increases the availability of novel therapeutic options in general practice, healthcare professionals will need to equip themselves with a sound understanding of their professional legal duties in light of emerging medical technologies, including virtual reality (VR). OBJECTIVE: Using a case study of VR to augment analgesia in burn treatment, this article examines how medical negligence laws apply to the use of new technology in healthcare settings. DISCUSSION: While there is currently no positive duty on healthcare professionals to use VR when treating patients, healthcare professionals may be held liable for harm arising from negligent advice or treatment using VR technology. The case study illustrates the flexible nature of negligence principles in adapting to harms arising from new risks such as simulation sickness. Specific warnings and standards of best practice will need to be developed if VR becomes a feature of general practice.

Virtual Reality interventions for acute and chronic pain management.

Virtual Reality (VR) is now consumer ready and nearing ubiquity. In terms of clinical applications, several studies suggest that VR can be effective as a complementary adjunct or alternative non-pharmacologic analgesic in a range of pain-inducing procedures and in management of chronic pain. The increasing affordability and quality of portable VR headsets and the ongoing utility of pain therapy signals an exciting future for the use of VR for analgesia. However, further research is needed to establish its long-term benefits if VR is to be adopted into mainstream protocols for analgesia management. This research requires a range of study designs with collection of patient self-report and clinical data together to develop bespoke interventions for different cohorts.

The Ubiquitin Proteasome System Is a Key Regulator of Pluripotent Stem Cell Survival and Motor Neuron Differentiation.

The ubiquitin proteasome system (UPS) plays an important role in regulating numerous cellular processes, and a dysfunctional UPS is thought to contribute to motor neuron disease. Consequently, we sought to map the changing ubiquitome in human iPSCs during their pluripotent stage and following differentiation to motor neurons. Ubiquitinomics analysis identified that spliceosomal and ribosomal proteins were more ubiquitylated in pluripotent stem cells, whilst proteins involved in fatty acid metabolism and the cytoskeleton were specifically ubiquitylated in the motor neurons. The UPS regulator, ubiquitin-like modifier activating enzyme 1 (UBA1), was increased 36-fold in the ubiquitome of motor neurons compared to pluripotent stem cells. Thus, we further investigated the functional consequences of inhibiting the UPS and UBA1 on motor neurons. The proteasome inhibitor MG132, or the UBA1-specific inhibitor PYR41, significantly decreased the viability of motor neurons. Consistent with a role of the UPS in maintaining the cytoskeleton and regulating motor neuron differentiation, UBA1 inhibition also reduced neurite length. Pluripotent stem cells were extremely sensitive to MG132, showing toxicity at nanomolar concentrations. The motor neurons were more resilient to MG132 than pluripotent stem cells but demonstrated higher sensitivity than fibroblasts. Together, this data highlights the important regulatory role of the UPS in pluripotent stem cell survival and motor neuron differentiation.

Proximal tubular epithelial cells preferentially endocytose covalently-modified albumin compared to native albumin.

AIM: Albumin can be covalently modified at surface lysine residues and thus the circulation contains a mixture of native albumin (i.e. not modified) and albumin with varying degrees of modification. Uptake and lysosomal degradation of glomerular filtered albumin by proximal tubular cells via the megalin scavenger receptor is considered an important mechanism to limit albumin loss in the urine. However, whether this is a general mechanism of tubular uptake of albumin or if this is restricted to modified albumin is unknown. To address this question, we investigated the uptake of modified versus native albumin by proximal tubular cells. METHODS: A well-characterized proximal tubular cell model of albumin uptake was used to compare the uptake of modified albumin (covalent labelling of lysine residues with fluorescent probes) to that of native recombinant human albumin (rHA) labelled with 14 C during protein synthesis (14 C-rHA). RESULTS: Opossum kidney (OK) cells showed significant uptake of fluorescence-labelled albumin via an endocytosis mechanism. This uptake was inhibited by an equimolar ratio of different types of covalently modified albumin; however, purified bovine serum albumin and rHA failed to compete with the uptake of fluorescence-labelled albumin. In contrast, OK cells failed to endocytose native 14 C-rHA despite efficiently endocytosing covalently modified rHA. CONCLUSION: Our studies show that OK cells preferentially endocytose covalently-modified albumin compared to native albumin. This apparent selectivity of the megalin scavenger receptor complex suggests a specific role for this pathway in the removal of modified albumin from the circulation.

Reduced tubular degradation of glomerular filtered plasma albumin is a common feature in acute and chronic kidney disease.

Tubular epithelial cells take up and degrade plasma albumin filtered by the glomerulus. Tubular damage resulting in reduced albumin uptake or degradation has been suggested as one mechanism contributing to albuminuria in kidney disease. This study investigated whether tubular albumin uptake or degradation is altered in acute and chronic glomerular disease. Mouse models of acute glomerular injury (anti-GBM disease and LPS-induced albuminuria) and chronic disease (streptozotocin-induced diabetes and db/db mice) were examined. Mice were injected intravenously with Alexa-albumin plus DQ-albumin and killed 20 minutes later. Tubular uptake of albumin (Alexa-albumin) and albumin degradation (Dye Quenched (DQ)-albumin) was assessed in tissue sections via confocal microscopy. Tubular uptake of Alexa-albumin in the models of diabetic nephropathy was not different to normal mice. However, the fluorescence signal resulting from degradation of DQ-albumin was significantly reduced in db/db mice, and the ratio of degraded to intact albumin was reduced in both models. The ratio of degraded to intact albumin in tubules was also reduced in the anti-GBM model. In the LPS model, both tubular uptake and degradation of albumin were significantly reduced, with a substantial reduction in the ratio of degraded to intact albumin in tubules. LPS stimulation of cultured tubular epithelial cells inhibited albumin uptake, indicating a direct role for LPS in modifying tubular handling of albumin. In conclusion, reduced degradation of filtered albumin in the proximal tubule is a common feature of glomerular diseases. This may be a general mechanism whereby tubular dysfunction contributes to the development of albuminuria.

Correction: Insulin and diet-induced changes in the ubiquitin-modified proteome of rat liver.

[This corrects the article DOI: 10.1371/journal.pone.0174431.].

Insulin and diet-induced changes in the ubiquitin-modified proteome of rat liver.

Ubiquitin is a crucial post-translational modification regulating numerous cellular processes, but its role in metabolic disease is not well characterized. In this study, we identified the in vivo ubiquitin-modified proteome in rat liver and determined changes in this ubiquitome under acute insulin stimulation and high-fat and sucrose diet-induced insulin resistance. We identified 1267 ubiquitinated proteins in rat liver across diet and insulin-stimulated conditions, with 882 proteins common to all conditions. KEGG pathway analysis of these proteins identified enrichment of metabolic pathways, TCA cycle, glycolysis/gluconeogenesis, fatty acid metabolism, and carbon metabolism, with similar pathways altered by diet and insulin resistance. Thus, the rat liver ubiquitome is sensitive to diet and insulin stimulation and this is perturbed in insulin resistance.