Introducing Virtual Reality in a STEMI Coronary Syndrome Course: Qualitative Evaluation with Nurses and Doctors.

In the increasing number of medical education topics taught with virtual reality (VR), the prehospital management of ST-segment elevation myocardial infarction (STEMI) had not been considered. This article proposes an implemented VR system for STEMI training and introduces it in an institutional course addressed to emergency nurses and case manager (CM) doctors. The system comprises three different applications to, respectively, allow (a) the course instructor to control the conditions of the virtual patient, (b) the CM to communicate with the nurse in the virtual field and receive from him/her the patient's parameters and electrocardiogram, and (c) the nurse to interact with the patient in the immersive VR scenario. We enrolled 17 course participants to collect their perceptions and opinions through a semistructured interview. The thematic analysis showed the system was appreciated (n = 17) and described as engaging (n = 4), challenging (n = 5), useful to improve self-confidence (n = 4), innovative (n = 5), and promising for training courses (n = 10). Realism was also appreciated (n = 13), although with some drawbacks (e.g., oversimplification; n = 5). Overall, participants described the course as an opportunity to share opinions (n = 8) and highlight issues (n = 4) and found it useful for novices (n = 5) and, as a refresh, for experienced personnel (n = 6). Some participants suggested improvements in the scenarios' type (n = 5) and variability (n = 5). Although most participants did not report usage difficulties with the VR system (n = 13), many described the need to get familiar with it (n = 13) and the specific gestures it requires (n = 10). Three suffered from cybersickness.

Improving Knowledge Retention and Perceived Control through Serious Games: a Study about Assisted Emergency Evacuation.

Digital games for education and training, also called serious games (SGs), have shown beneficial effects on learning in several studies. In addition, some studies are suggesting that SGs could improve user's perceived control, which affects the likelihood that the learned content will be applied in the real world. However, most SG studies tend to focus on immediate effects, providing no indication on knowledge and perceived control over time, especially in contrast with nongame approaches. Moreover, SG research on perceived control has focused mainly on self-efficacy, disregarding the complementary construct of locus of control (LOC). This paper advances both lines of research, assessing user's knowledge and LOC over time, with a SG as well as traditional printed materials that teach the same content. Results show that the SG was more effective than printed materials for knowledge retention over time, and a better retention outcome was found also for LOC. An additional contribution of the paper is the proposal of a novel SG that targets the inclusivity goal of safe evacuation for all, extending SG research to a domain not dealt with before, i.e. assisting persons with disabilities in emergencies.

A mobile app for home-based exercise in spinal cord injured persons: Proposal and pilot study.

BACKGROUND AND OBJECTIVE: To preserve cardiovascular health in persons with spinal cord injury (SCI), it is important to promote physical activity programs adapted to them. Home-based exercise programs allow patients to perform clinician-prescribed physical activity without going to a hospital. However, they make it difficult for the clinician to guide and monitor the patient. To face this issue, this paper proposes a novel smartphone-based mobile application (Fisiofriend), and evaluates its feasibility with a pilot study in a real clinical intervention. METHODS: Fourteen SCI male subjects were involved in a 6-weeks home-based intervention, based on upper limbs exercises: 7 subjects (APP group) used Fisiofriend, and 7 subjects used traditional pictorial instructions on paper (PAPER group). At the beginning (t1) and end (t2) of the study period, we measured: (i) biceps and triceps brachii strength and endurance parameters with an isokinetic dynamometer (Biodex System 4), (ii) O2 maximal consumption with a crank ergometer stress test (VO2000, Medgraphics). Moreover, we collected subjective data about subjects' perception of the support (app or paper) in the home-based program. RESULTS: Physiological results were encouraging for both groups. Questionnaire data suggests a possible advantage of the app in terms of pleasantness, engagement and perception of positive effects. Practical clinical experience with the subjects and their informal reports highlighted which features of the app could be of particular benefit in real interventions, as we discuss in the paper. CONCLUSIONS: The study showed the feasibility of using a mobile app in home-based exercise programs involving SCI patients. We discuss implications of introducing such kind of apps into clinical practice.

Learning Safety Through Public Serious Games: A Study of "Prepare for Impact" on a Very Large, International Sample of Players.

Recent years have witnessed a growing interest in serious games (SGs), i.e., digital games for education and training. However, although the potential scalability of SGs to large player populations is often praised in the literature, available SG evaluations did not provide evidence of it because they did not study learning on large, varied, international samples in naturalistic conditions. This article considers a SG that educates players about aircraft cabin safety. It presents the first study of learning in a SG intervention conducted in naturalistic conditions with a very large, worldwide sample, which includes 45,000 players who accepted to answer a knowledge questionnaire before and after playing the game, and more than 400,000 players whose in-game behavior was analyzed. Results show that the SG led to improvement in players' knowledge, assessed with different metrics. Moreover, analysis of repeated play shows that participants improved their in-game safety behavior over time. We also focus on the role of making errors in the game, showing how they led to improvement in knowledge. Finally, we highlight the theoretical models, such as error-based learning and Protection Motivation Theory, that oriented the game design, and can be reused to create SGs for other domains.

Locomotion in Place in Virtual Reality: A Comparative Evaluation of Joystick, Teleport, and Leaning.

Recent VR head-mounted displays for consumers feature 3-DOF or 6-DOF head tracking. However, position tracking (when available) is limited to a small area. Moreover, in small or cluttered physical spaces, users can safely experience VR only by staying in place, standing or seated. Different locomotion techniques have been proposed to allow users to explore virtual environments by staying in place. Two in-place locomotion techniques, frequently employed in the literature and in consumer applications, are based on joystick and teleport. Some authors explored leaning with the aim of proposing a more natural in-place locomotion technique. However, more research is needed to understand the effects of the three techniques, since no user study thoroughly compared them all together on a variety of fundamental aspects. Therefore, this paper presents a comparative evaluation with 75 users, assessing the effects of the three techniques on performance, sickness, presence, usability, and different aspects of comfort. Performance of teleport was better than the other techniques, and performance of leaning was better than joystick. Teleport also caused less nausea than the other techniques. Unexpectedly, no significant differences were found for presence. Teleport received a higher usability score than the other techniques. Finally, the techniques had different effects on comfort that we discuss in detail.

A virtual reality methodology for cardiopulmonary resuscitation training with and without a physical mannequin.

BACKGROUND: Cardiopulmonary resuscitation (CPR) is an emergency procedure that can increase survival after a cardiac arrest. Performing CPR effectively requires both procedural knowledge and manual skills. Traditional CPR training methodology includes lessons led by instructors and supervised practice on mannequins, thus requiring considerable resources. OBJECTIVE: This paper proposes a new methodology for low-cost CPR training based on virtual reality (VR) with and without the addition of a physical mannequin. Moreover, it describes an experimental evaluation of the methodology that assessed gain in manual skills during training, transfer of procedural knowledge and manual skills in a final assessment, and changes in self-efficacy with three measurements over time (pre-training, post-training, and post-assessment). METHODS: We implemented a VR application that supports the proposed methodology, and can thus be used with or without a mannequin. The experimental evaluation involved 30 participants who tried CPR in VR twice, performing two repetitions of 30 chest compressions per trial. Half participants tried the VR application with the mannequin and half without it. Final assessment required all participants to perform CPR on the mannequin without the assistance of VR. To assess self-efficacy, participants filled in a questionnaire at the three times of measurement. RESULTS: Mixed-design ANOVAs showed effects of repetition, effects of group, or interaction between the two variables on manual skills assessed during training. In the final assessment, participants in both groups correctly remembered most of the steps of the procedure. ANOVAs revealed differences between the two groups only in pressure-related skills (better with mannequin) and in the number of wrong steps added to the procedure (better without mannequin). Mixed-design ANOVA showed a self-efficacy increase in both groups after training, which was maintained after final assessment. CONCLUSIONS: The proposed VR methodology for CPR training has a positive effect on procedural knowledge, manual skills, and self-efficacy, with as well as without the physical mannequin. Trials on a mannequin are required to understand the correct pressure for chest compression. This supports the adoption of the proposed VR methodology to reduce instructor and mannequin time required to teach CPR to trainees.

Smartphone-Based Therapeutic Exercises for Men Affected by Premature Ejaculation: A Pilot Study.

INTRODUCTION: Smartphone-delivered healthcare interventions allow patients to access services on demand when needed, improving motivation and compliance. However, the use of mobile health apps has been scarcely explored in sexual medicine. AIM: To evaluate the effects of integrating psychological treatment for premature ejaculation (PE) with a mobile coaching app that offers therapeutic exercises on the patient's smartphone. METHODS: This study comprised 35 heterosexual men with primary psychogenic PE (mean age 34 years, standard deviation = 9.15). All patients entered a cycle of 15 sessions of psychodynamic psychotherapy integrating behavioral therapy, each lasting about 45 minutes. The patients were randomly assigned to 2 groups, each of which performed daily homework exercises (physiotherapy exercises for reinforcing the pelvic floor muscles and cognitive exercises for distancing from sexual failure.) The first group (15 patients) received verbal and printed instructions only (treatment as usual-TAU), whereas the second group (17 patients) experienced the exercises with guidance from the mobile app (app). In both groups, the exercises started after the seventh session. Patients were advised to perform the exercises 3 times a day for 3 months. MAIN OUTCOME MEASURES: The primary outcome measures were the Premature Ejaculation Diagnostic Tool and the Premature Ejaculation Profile. RESULTS: Analysis of the data revealed significant pre-post improvements in Premature Ejaculation Diagnostic Tool and Premature Ejaculation Profile scores for the app group compared with those of the TAU group (P < .01). The frequency of patients with no-PE condition for the app group after treatment was significantly higher than the frequency of patients with no-PE condition for the TAU group (P < .001). CONCLUSION: Results suggest that a mobile coaching app performs better than TAU in improving both the behavioral skills of ejaculatory delay and sexual self-confidence within a psychological treatment for PE. Future studies should collect follow-up data and explore the potential of mobile coaching apps in combined pharmacotherapy and psychotherapy interventions. Optale G, Burigat S, Chittaro L. et al. Smartphone-Based Therapeutic Exercises for Men Affected by Premature Ejaculation: A Pilot Study. J Sex Med 2020;8:461-471.

Effects of Different Types of Virtual Reality Display on Presence and Learning in a Safety Training Scenario.

The increasing availability of head-mounted displays (HMDs) for home use motivates the study of the possible effects that adopting this new hardware might have on users. Moreover, while the impact of display type has been studied for different kinds of tasks, it has been scarcely explored in procedural training. Our study considered three different types of displays used by participants for training in aviation safety procedures with a serious game. The three displays were respectively representative of: (i) desktop VR (a standard desktop monitor), (ii) many setups for immersive VR used in the literature (an HMD with narrow field of view and a 3-DOF tracker), and (iii) new setups for immersive home VR (an HMD with wide field of view and 6-DOF tracker). We assessed effects on knowledge gain, and different self-reported measures (self-efficacy, engagement, presence). Unlike previous studies of display type that measured effects only immediately after the VR experience, we considered also a longer time span (2 weeks). Results indicated that the display type played a significant role in engagement and presence. The training benefits (increased knowledge and self-efficacy) were instead obtained, and maintained at two weeks, regardless of the display used. The paper discusses the implications of these results.

Neuroanatomical basis of concern-based altruism in virtual environment.

Costly altruism entails helping others at a cost to the self and prior work shows that empathic concern (EC) for the well-being of distressed and vulnerable individuals is one of the primary motivators of such behavior. However, extant work has investigated costly altruism with paradigms that did not feature self-relevant and severe costs for the altruist and have solely focused on neurofunctional, and not neuroanatomical, correlates. In the current study, we used a contextually-rich virtual reality environment to study costly altruism and found that individuals who risked their own lives in the virtual world to try to save someone in danger had enlarged right anterior insula and exhibited greater empathic concern than those who did not. These findings add to the growing literature showing the role of caring motivation in promoting altruism and prosociality and its neural correlates in the right anterior insula.

MotorBrain: A mobile app for the assessment of users' motor performance in neurology.

BACKGROUND AND OBJECTIVE: Human motor skills or impairments have been traditionally assessed by neurologists by means of paper-and-pencil tests or special hardware. More recently, technologies such as digitizing tablets and touchscreens have offered neurologists new assessment possibilities, but their use has been restricted to a specific medical condition, or to stylus-operated mobile devices. The objective of this paper is twofold. First, we propose a mobile app (MotorBrain) that offers six computerized versions of traditional motor tests, can be used directly by patients (with and without the supervision of a clinician), and aims at turning millions of smartphones and tablets available to the general public into data collection and assessment tools. Then, we carry out a study to determine whether the data collected by MotorBrain can be meaningful for describing aging in human motor performance. METHODS: A sample of healthy participants (N= 133) carried out the motor tests using MotorBrain on a smartphone. Participants were split into two groups (Young, Old) based on their age (less than or equal to 30 years, greater than or equal to 50 years, respectively). The data collected by the app characterizes accuracy, reaction times, and speed of movement. It was analyzed to investigate differences between the two groups. RESULTS: The app does allow measuring differences in neuromotor performance. Data collected by the app allowed us to assess performance differences due to the aging of the neuromuscular system. CONCLUSIONS: Data collected through MotorBrain is suitable to make meaningful distinctions among different kinds of performance, and allowed us to highlight performance differences associated to aging. MotorBrain supports the building of a large database of neuromotor data, which can be used for normative purposes in clinical use.

Designing Serious Games for Safety Education: "Learn to Brace" versus Traditional Pictorials for Aircraft Passengers.

Serious games for safety education (SGSE) are a novel tool for preparing people to prevent and\or handle risky situations. Although several SGSE have been developed, design and evaluation methods for SGSE need to be better grounded in and guided by safety-relevant psychological theories. In particular, this paper focuses on threat appeals and the assessment of variables, such as safety locus of control, that influence human behavior in real risky situations. It illustrates how we took into account such models in the design and evaluation of "Learn to Brace", a first-of-its-kind serious game that deals with a major problem in aviation safety, i.e. the scarce effectiveness of the safety cards used by airlines. The study considered a sample of 48 users: half of them received instructions about the brace position through the serious game, the other half through a traditional safety card pictorial. Results showed that the serious game was much more effective than the traditional instructions both in terms of learning and of changing safety-relevant perceptions, especially safety locus of control and recommendation perception.

Assessing Knowledge Retention of an Immersive Serious Game vs. a Traditional Education Method in Aviation Safety.

Thanks to the increasing availability of consumer head-mounted displays, educational applications of immersive VR could now reach to the general public, especially if they include gaming elements (immersive serious games). Safety education of citizens could be a particularly promising domain for immersive serious games, because people tend not to pay attention to and benefit from current safety materials. In this paper, we propose an HMD-based immersive game for educating passengers about aviation safety that allows players to experience a serious aircraft emergency with the goal of surviving it. We compare the proposed approach to a traditional aviation safety education method (the safety card) used by airlines. Unlike most studies of VR for safety knowledge acquisition, we do not focus only on assessing learning immediately after the experience but we extend our attention to knowledge retention over a longer time span. This is a fundamental requirement, because people need to retain safety procedures in order to apply them when faced with danger. A knowledge test administered before, immediately after and one week after the experimental condition showed that the immersive serious game was superior to the safety card. Moreover, subjective as well as physiological measurements employed in the study showed that the immersive serious game was more engaging and fear-arousing than the safety card, a factor that can contribute to explain the obtained superior retention, as we discuss in the paper.

Brain activity and prosocial behavior in a simulated life-threatening situation.

To study the neuronal basis of altruistic behavior, we investigated functional connectivity within brain networks of participants who exhibited either a self-benefit behavior or an altruistic one in a life-threatening situation simulated in a virtual environment. In particular, participants were asked to evacuate a virtual building on fire and, without being previously informed, they were faced with a decision on whether to stop and help a trapped virtual human, at the possible cost of losing their own life in the virtual experience. Group independent component analysis (gICA) applied on blood-oxygen-level-dependent (BOLD) functional images revealed significant differences between the group of participants who showed selfish behavior and those who acted prosocially. Specifically, an increased functional connectivity in the salience network, comprising the anterior insula (AI) and the anterior mid cingulate cortex (aMCC), was observed in the selfish group compared to the prosocial one. Conversely, higher ICA weights in the medial prefrontal cortex and temporo-parietal junction (TPJ), were observed in the prosocial group. The findings show that an increased functional connectivity of the salience network, which suggests an enhanced sensitivity to the threatening situation and potential danger for the individual, resulted in more selfish choices, while the engagement of the medial prefrontal and temporo-parietal cortices subserved prosocial behavior, possibly due to their role in perspective-taking. The study provides the first online neurophysiological measurement of prosocial decision-making during threatening situations, opening new avenues to the investigation of neuronal substrates of complex social behaviors.

Affective basis of judgment-behavior discrepancy in virtual experiences of moral dilemmas.

Although research in moral psychology in the last decade has relied heavily on hypothetical moral dilemmas and has been effective in understanding moral judgment, how these judgments translate into behaviors remains a largely unexplored issue due to the harmful nature of the acts involved. To study this link, we follow a new approach based on a desktop virtual reality environment. In our within-subjects experiment, participants exhibited an order-dependent judgment-behavior discrepancy across temporally separated sessions, with many of them behaving in utilitarian manner in virtual reality dilemmas despite their nonutilitarian judgments for the same dilemmas in textual descriptions. This change in decisions reflected in the autonomic arousal of participants, with dilemmas in virtual reality being perceived more emotionally arousing than the ones in text, after controlling for general differences between the two presentation modalities (virtual reality vs. text). This suggests that moral decision-making in hypothetical moral dilemmas is susceptible to contextual saliency of the presentation of these dilemmas.

Evaluation of a 3D serious game for advanced life support retraining.

OBJECTIVE: Advanced life support (ALS) knowledge and skills decrease in as little as three months, but only a few ALS providers actually attend retraining courses. We assess the effectiveness of a 3D serious game as a new tool for frequent ALS retraining. METHODS: We developed a 3D serious game for scenario-based ALS retraining. The serious game, called EMSAVE, was designed to promote self-correction while playing. We organized a retraining course in which 40 ALS providers played two cardiac arrest scenarios with EMSAVE and took a test with 38 multiple-choice questions before and after playing. We administered the same test again 3 months later to evaluate retention. Participants also rated EMSAVE and the overall retraining experience. RESULTS: After using EMSAVE, the number of correct answers per participant increased by 4.8 (95%CI +3.4, +6.2, p<0.001) and all but one participant improved. After 3 months, despite an expected decrease in ALS knowledge and skills (-1.9 correct answers, 95%CI -0.6, -3.3, p<0.01), there was a significant retention benefit (+2.9 correct answers per participant, 95%CI +1.5, +4.2, p<0.001). Moreover, all but one participant regarded EMSAVE as a valuable tool to refresh ALS knowledge and skills, and 85% of participants were also willing to devote 1h/month to retrain with the serious game. CONCLUSIONS: A 3D serious game for scenario-based retraining proved effective to retrain in ALS and supported retention of acquired knowledge and skills at 3 months. EMSAVE also positively engaged and motivated participants.

Changing heartbeat perception to induce anxiety in virtual environments.

In this paper, we first propose a general technique to induce anxiety in virtual environments (VEs) which exploits auditory heartbeat perception and biofeedback. Then, we consider a VE that reproduces a real-world anxiety-inducing experience (being suddenly surrounded by smoke during a fire evacuation of a building), and we describe an experiment that contrasts 3 conditions: (i) an augmentation of the VE with a bar that indicates when the user's avatar gets hurt, (ii) an augmentation of the VE with the typical audio visual stimuli which are employed in violent videogames when the user's avatar gets hurt, (iii) introduction of the proposed biofeedback technique in the previous condition. We carry out an electrodermal analysis showing that the introduction of the proposed technique produces much higher physiological arousal in terms of skin conductance level (SCL) than the other two conditions. Subjective measures of users' state anxiety are consistent with the recorded physiological reactions.

MOPET: a context-aware and user-adaptive wearable system for fitness training.

OBJECTIVE: Cardiovascular disease, obesity, and lack of physical fitness are increasingly common and negatively affect people's health, requiring medical assistance and decreasing people's wellness and productivity. In the last years, researchers as well as companies have been increasingly investigating wearable devices for fitness applications with the aim of improving user's health, in terms of cardiovascular benefits, loss of weight or muscle strength. Dedicated GPS devices, accelerometers, step counters and heart rate monitors are already commercially available, but they are usually very limited in terms of user interaction and artificial intelligence capabilities. This significantly limits the training and motivation support provided by current systems, making them poorly suited for untrained people who are more interested in fitness for health rather than competitive purposes. To better train and motivate users, we propose the mobile personal trainer (MOPET) system. METHODS AND MATERIAL: MOPET is a wearable system that supervises a physical fitness activity based on alternating jogging and fitness exercises in outdoor environments. By exploiting real-time data coming from sensors, knowledge elicited from a sport physiologist and a professional trainer, and a user model that is built and periodically updated through a guided autotest, MOPET can provide motivation as well as safety and health advice, adapted to the user and the context. To better interact with the user, MOPET also displays a 3D embodied agent that speaks, suggests stretching or strengthening exercises according to user's current condition, and demonstrates how to correctly perform exercises with interactive 3D animations. RESULTS AND CONCLUSION: By describing MOPET, we show how context-aware and user-adaptive techniques can be applied to the fitness domain. In particular, we describe how such techniques can be exploited to train, motivate, and supervise users in a wearable personal training system for outdoor fitness activity.

VU-flow: a visualization tool for analyzing navigation in virtual environments.

This paper presents a tool for the visual analysis of navigation patterns of moving entities, such as users, virtual characters, or vehicles in 3D Virtual Environments (VEs). The tool, called VU-Flow, provides a set of interactive visualizations that highlight interesting navigation behaviors of single or groups of moving entities that were the VE together or separately. The visualizations help to improve the design of VEs and to study the navigation behavior of users, e.g., during controlled experiments. Besides VEs, the proposed techniques could also be applied to visualize real-world data recorded by positioning systems, allowing one to employ VU-Flow in domains such as urban planning, transportation, and emergency response.