Developing a Virtual Reality Simulation System for Preoperative Planning of Robotic-Assisted Thoracic Surgery.

Background. Robotic-assisted thoracic surgery (RATS) is now standard for lung cancer treatment, offering advantages over traditional methods. However, RATS's minimally invasive approach poses challenges like limited visibility and tactile feedback, affecting surgeons' navigation through com-plex anatomy. To enhance preoperative familiarization with patient-specific anatomy, we devel-oped a virtual reality (VR) surgical navigation system. Using head-mounted displays (HMDs), this system provides a comprehensive, interactive view of the patient's anatomy pre-surgery, aiming to improve preoperative simulation and intraoperative navigation. Methods. We integrated 3D data from preoperative CT scans into Perspectus VR Education software, displayed via HMDs for in-teractive 3D reconstruction of pulmonary structures. This detailed visualization aids in tailored preoperative resection simulations. During RATS, surgeons access these 3D images through Tile-ProTM multi-display for real-time guidance. Results. The VR system enabled precise visualization of pulmonary structures and lesion relations, enhancing surgical safety and accuracy. The HMDs offered true 3D interaction with patient data, facilitating surgical planning. Conclusions. VR sim-ulation with HMDs, akin to a robotic 3D viewer, offers a novel approach to developing robotic surgical skills. Integrated with routine imaging, it improves preoperative planning, safety, and accuracy of anatomical resections. This technology particularly aids in lesion identification in RATS, optimizing surgical outcomes.

A Large-Scale, Multiplayer Virtual Reality Deployment: A Novel Approach to Distance Education in Human Anatomy.

The arrival of COVID-19 restrictions and the increasing demand of online instruction options posed challenges to education communities worldwide, especially in human anatomy. In response, Colorado State University developed and deployed an 8-week-long large-scale virtual reality (VR) course to supplement online human anatomy instruction. Students (n = 75) received a VR-capable laptop and head-mounted display and participated in weekly synchronous group laboratory sessions with instructors. The software enabled students to remotely collaborate in a common virtual space to work with human anatomy using an artist-rendered cadaver. Qualitative data were collected on student engagement, confidence, and reactions to the new technology. Quantitative data assessed student knowledge acquisition and retention of anatomical spatial relationships. Results indicated that students performed better in the online course (mean = 82.27%) when compared to previous in-person laboratories (mean = 80.08%). The utilization of VR promoted student engagement and increased opportunities for student interaction with teaching assistants, peers, and course content. Notably, students reported benefits that focused on unique aspects of their virtual learning environment, including the ability to infinitely scale the cadaver and walk inside and around anatomical structures. Results suggested that using VR was equivalent to 2D methods in student learning and retention of anatomical relationships. Overall, the virtual classroom maintained the rigor of traditional gross anatomy laboratories without negatively impacting student examination scores and provided a high level of accessibility, without compromising learner engagement. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-023-01751-w.

Removal of a foreign body by rigid bronchoscope after virtual reality-aided presurgical planning: A case report.

Flexible bronchoscopy is becoming increasingly important for the removal of airway foreign bodies. However, in cases of risk of coughing during the procedure, rigid bronchoscopic intervention should be performed under general anesthesia. A 22-year-old man presented with history of several episodes of fever, for which he was administered antibiotics at a private clinic. In an annual chest X-ray and chest computed tomography examination, a foreign body, which appeared to be an orthodontic appliance, was discovered in the left main bronchus. It was deemed difficult to remove the foreign body using flexible bronchoscopy because of granulation tissue formation. Therefore, the patient was referred to our institution. We simulated the clinical situation using virtual reality, which indicated that the proximal and distal metallic parts of the appliance had grown into the bronchial mucosa. First, we inserted a rigid bronchoscope under general anesthesia and cut the granulation tissue using an insulation-tipped diathermic knife. Thereafter, we removed the appliance with grasping forceps under rigid bronchoscope guidance. In cases of risk of foreign body encroachment into the bronchial mucosa or granulation tissue development, rigid bronchoscopic intervention is effective. Furthermore, a VR-based intervention may be a useful option in such cases.

Developing a virtual reality simulation system for preoperative planning of thoracoscopic thoracic surgery.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) has become a standard approach for the treatment of lung cancer. However, its minimally invasive nature limits the field of view and reduces tactile feedback. These limitations make it vital that surgeons thoroughly familiarize themselves with the patient's anatomy preoperatively. We have developed a virtual reality (VR) surgical navigation system using head-mounted displays (HMD). The aim of this study was to investigate the potential utility of this VR simulation system in both preoperative planning and intraoperative assistance, including support during thoracoscopic sublobar resection. METHODS: Three-dimensional (3D) polygon data derived from preoperative computed tomography data was loaded into BananaVision software developed at Colorado State University and displayed on an HMD. An interactive 3D reconstruction image was created, in which all the pulmonary structures could be individually imaged. Preoperative resection simulations were performed with patient-individualized reconstructed 3D images. RESULTS: The 3D anatomic structure of pulmonary vessels and a clear vision into the space between the lesion and adjacent tissues were successfully appreciated during preoperative simulation. Surgeons could easily evaluate the real patient's anatomy in preoperative simulations to improve the accuracy and safety of actual surgery. The VR software and HMD allowed surgeons to visualize and interact with real patient data in true 3D providing a unique perspective. CONCLUSIONS: This initial experience suggests that a VR simulation with HMD facilitated preoperative simulation. Routine imaging modalities combined with VR systems could substantially improve preoperative planning and contribute to the safety and accuracy of anatomic resection.

Immersive 3-Dimensional Virtual Reality Modeling for Case-Specific Presurgical Discussions in Cerebrovascular Neurosurgery.

BACKGROUND: Adequate surgical planning includes a precise understanding of patient-specific anatomy and is a necessity for neurosurgeons. Although the use of virtual reality (VR) technology is emerging in surgical planning and education, few studies have examined the effectiveness of immersive VR during surgical planning using a modern head-mounted display. OBJECTIVE: To investigate if and how immersive VR aids presurgical discussions of cerebrovascular surgery. METHODS: A multiuser immersive VR system, BananaVisionTM, was developed and used during presurgical discussions in a prospective patient cohort undergoing cerebrovascular surgery. A questionnaire/interview was administered to multiple surgeons after the surgeries to evaluate the effectiveness of the VR system compared to conventional imaging modalities. An objective assessment of the surgeon's knowledge of patient-specific anatomy was also conducted by rating surgeons' hand-drawn presurgical illustrations. RESULTS: The VR session effectively enhanced surgeons' understanding of patient-specific anatomy in the majority of cases (83.3%). An objective assessment of surgeons' presurgical illustrations was consistent with this result. The VR session also effectively improved the decision-making process regarding minor surgical techniques in 61.1% of cases and even aided surgeons in making critical surgical decisions about cases involving complex and challenging anatomy. The utility of the VR system was rated significantly higher by trainees than by experts. CONCLUSION: Although rated as more useful by trainees than by experts, immersive 3D VR modeling increased surgeons' understanding of patient-specific anatomy and improved surgical strategy in certain cases involving challenging anatomy.

Table Quizzes as an Assessment Tool in the Gross Anatomy Laboratory.

Using cadaveric instruction in a graduate-level anatomy course is an expensive and time-consuming undertaking. While this is a worthwhile endeavor, most first-year medical students and students in the health fields struggle with the independent, self-directed learning approach in the cadaveric laboratory, and going beyond rote memorization of the material. As such, effective assessment tools that maximize student learning in the cadaveric laboratory are critical, especially if no lecture component is present. Dissection quality often reflects student attention to detail and therefore may be tied to overall performance in the course. The aim of this study was to investigate the relationship between weekly table quizzes and the overall student outcomes in a graduate biomedical human dissection class as well as examining the benefits and implications of this approach. In this course, a uniquely structured weekly quiz assessed dissection quality and probed student understanding in human anatomy. Student data compiled from 5 years of dissection courses were analyzed to evaluate the relationship between performance in the weekly assessment and on the unit examinations. The results showed a statistically significant relationship between the weekly quizzes and the student examinations at the end of each dissection block in 2013, 2015, 2016, and 2017. The data suggest a potential correlation between performance on weekly quizzes and on unit examinations. The unique nature of the table quizzes provides the students with the opportunity to practice the retrieval of their knowledge, feel more guided throughout their dissection, and receive immediate feedback on their performance. This assessment tool also provides a way to predict student outcomes and an opportunity for early intervention to help at-risk students. The analysis of this research study contributes to the need for more data on the usage of assessment tools in a graduate human dissection class.

A Systematic Approach to Teaching Case Studies and Solving Novel Problems.

Both research and practical experience in education support the use of case studies in the classroom to engage students and develop critical thinking skills. In particular, working through case studies in scientific disciplines encourages students to incorporate knowledge from a variety of backgrounds and apply a breadth of information. While it is recognized that critical thinking is important for student success in professional school and future careers, a specific strategy to tackle a novel problem is lacking in student training. We have developed a four-step systematic approach to solving case studies that improves student confidence and provides them with a definitive road map that is useful when solving any novel problem, both in and out of the classroom. This approach encourages students to define unfamiliar terms, create a timeline, describe the systems involved, and identify any unique features. This method allows students to solve complex problems by organizing and applying information in a logical progression. We have incorporated case studies in anatomy and neuroanatomy courses and are confident that this systematic approach will translate well to courses in various scientific disciplines.

Use of Short Animal-Themed Videos to Enhance Veterinary Students' Mood, Attention, and Understanding of Pharmacology Lectures.

Professional DVM training is inherently stressful and challenging for students. This study evaluated a simple intervention-short breaks during a veterinary pharmacology lecture course in the form of funny/cute animal videos (Mood Induction Procedures, or MIP)-to assess for potential impact on students' mood, interest in material, and perceived understanding of material. Ten YouTube video clips showing cats or dogs were selected to influence students' affective states. The videos were shown in a required pharmacology class offered during the fall semester of the second year of the DVM program at a large, land-grant institution in the western US. The student cohort consisted of 133 students (20 males, 113 females). Twenty days of the course were randomly chosen for the study and ranged from weeks 2 to 13 of the semester. Sessions in which the videos were played were alternated with sessions in which no video was played, for a total of 10 video days and 10 control days. There were significant differences in all three post-class assessment measures between the experimental (video) days and the control days. Results suggest that showing short cute animal videos in the middle of class positively affected students' mood, interest in material, and self-reported understanding of material. While the results of this study are limited to one student cohort at one institution, the ease of implementation of the technique and relatively low stakes support incorporation of the MIP technique across a variety of basic and clinical science courses.

Nasal chemosensory cells use bitter taste signaling to detect irritants and bacterial signals.

The upper respiratory tract is continually assaulted with harmful dusts and xenobiotics carried on the incoming airstream. Detection of such irritants by the trigeminal nerve evokes protective reflexes, including sneezing, apnea, and local neurogenic inflammation of the mucosa. Although free intra-epithelial nerve endings can detect certain lipophilic irritants (e.g., mints, ammonia), the epithelium also houses a population of trigeminally innervated solitary chemosensory cells (SCCs) that express T2R bitter taste receptors along with their downstream signaling components. These SCCs have been postulated to enhance the chemoresponsive capabilities of the trigeminal irritant-detection system. Here we show that transduction by the intranasal solitary chemosensory cells is necessary to evoke trigeminally mediated reflex reactions to some irritants including acyl-homoserine lactone bacterial quorum-sensing molecules, which activate the downstream signaling effectors associated with bitter taste transduction. Isolated nasal chemosensory cells respond to the classic bitter ligand denatonium as well as to the bacterial signals by increasing intracellular Ca(2+). Furthermore, these same substances evoke changes in respiration indicative of trigeminal activation. Genetic ablation of either G alpha-gustducin or TrpM5, essential elements of the T2R transduction cascade, eliminates the trigeminal response. Because acyl-homoserine lactones serve as quorum-sensing molecules for gram-negative pathogenic bacteria, detection of these substances by airway chemoreceptors offers a means by which the airway epithelium may trigger an epithelial inflammatory response before the bacteria reach population densities capable of forming destructive biofilms.

Tonic activity of Galpha-gustducin regulates taste cell responsivity.

The taste-selective G protein, alpha-gustducin (alpha-gus) is homologous to alpha-transducin and activates phosphodiesterase (PDE) in vitro. alpha-Gus-knockout mice are compromized to bitter, sweet and umami taste stimuli, suggesting a central role in taste transduction. Here, we suggest a different role for Galpha-gus. In taste buds of alpha-gus-knockout mice, basal (unstimulated) cAMP levels are high compared to those of wild-type mice. Further, H-89, a cAMP-dependent protein kinase inhibitor, dramatically unmasks responses to the bitter tastant denatonium in gus-lineage cells of knockout mice. We propose that an important role of alpha-gus is to maintain cAMP levels tonically low to ensure adequate Ca2+ signaling.

Nasal solitary chemoreceptor cell responses to bitter and trigeminal stimulants in vitro.

Nasal trigeminal chemosensitivity in mice and rats is mediated in part by epithelial solitary chemoreceptor (chemosensory) cells (SCCs), but the exact role of these cells in chemoreception is unclear. Histological evidence suggests that SCCs express elements of the bitter taste transduction pathway including T2R (bitter taste) receptors, the G protein alpha-gustducin, PLCbeta2, and TRPM5, leading to speculation that SCCs are the receptor cells that mediate trigeminal nerve responses to bitter taste receptor ligands. To test this hypothesis, we used calcium imaging to determine whether SCCs respond to classic bitter-tasting or trigeminal stimulants. SCCs from the anterior nasal cavity were isolated from transgenic mice in which green fluorescent protein (GFP) expression was driven by either TRPM5 or gustducin. Isolated cells were exposed to a variety of test stimuli to determine which substances caused an increase in intracellular Ca2+ ([Ca2+]i). GFP-positive cells respond with increased [Ca2+]i to the bitter receptor ligand denatonium and this response is blocked by the PLC inhibitor U73122. In addition, GFP+ cells respond to the neuromodulators adenosine 5'-triphosphate and acetylcholine but only very rarely to other bitter-tasting or trigeminal stimuli. Our results demonstrate that TRPM5- and gustducin-expressing nasal SCCs respond to the T2R agonist denatonium via a PLC-coupled transduction cascade typical of T2Rs in the taste system.

Amiloride-sensitive channels in type I fungiform taste cells in mouse.

BACKGROUND: Taste buds are the sensory organs of taste perception. Three types of taste cells have been described. Type I cells have voltage-gated outward currents, but lack voltage-gated inward currents. These cells have been presumed to play only a support role in the taste bud. Type II cells have voltage-gated Na+ and K+ current, and the receptors and transduction machinery for bitter, sweet, and umami taste stimuli. Type III cells have voltage-gated Na+, K+, and Ca2+ currents, and make prominent synapses with afferent nerve fibers. Na+ salt transduction in part involves amiloride-sensitive epithelial sodium channels (ENaCs). In rodents, these channels are located in taste cells of fungiform papillae on the anterior part of the tongue innervated by the chorda tympani nerve. However, the taste cell type that expresses ENaCs is not known. This study used whole cell recordings of single fungiform taste cells of transgenic mice expressing GFP in Type II taste cells to identify the taste cells responding to amiloride. We also used immunocytochemistry to further define and compare cell types in fungiform and circumvallate taste buds of these mice. RESULTS: Taste cell types were identified by their response to depolarizing voltage steps and their presence or absence of GFP fluorescence. TRPM5-GFP taste cells expressed large voltage-gated Na+ and K+ currents, but lacked voltage-gated Ca2+ currents, as expected from previous studies. Approximately half of the unlabeled cells had similar membrane properties, suggesting they comprise a separate population of Type II cells. The other half expressed voltage-gated outward currents only, typical of Type I cells. A single taste cell had voltage-gated Ca2+ current characteristic of Type III cells. Responses to amiloride occurred only in cells that lacked voltage-gated inward currents. Immunocytochemistry showed that fungiform taste buds have significantly fewer Type II cells expressing PLC signalling components, and significantly fewer Type III cells than circumvallate taste buds. CONCLUSION: The principal finding is that amiloride-sensitive Na+ channels appear to be expressed in cells that lack voltage-gated inward currents, likely the Type I taste cells. These cells were previously assumed to provide only a support function in the taste bud.

TRPV1 receptors and nasal trigeminal chemesthesis.

The trigeminal nerve responds to a wide variety of irritants. Trigeminal nerve fibers express several receptors that respond to chemicals, including TRPV1 (vanilloid) receptors, acid-sensing ion channels, P2X (purinergic) receptors, and nicotinic acetylcholine receptors. In order to assess whether TRPV1 plays a role in responses to a broad array of substances, TRPV1 (along with green fluorescent protein) was expressed in human embyonic kidney cells (HEK) 293t cells which were then stimulated with diverse trigeminal irritants. Calcium imaging was used to measure responses to capsaicin, amyl acetate, cyclohexanone, acetic acid, toluene, benzaldehyde, (-)-nicotine, (R)-(+)-limonene, (R)-(-)-carvone, and (S)-(+)-carvone. Three irritants (acetic acid and the 2 carvones) stimulated nontransfected controls. Two irritants (capsaicin and cyclohexanone) stimulated only transfected cells. The response could be eliminated with capsazepine, a TRPV1 blocker. The 5 remaining irritants were nonstimulatory in both nontransfected and transfected cells. Because all the compounds tested on HEK cells elicited neural responses from the ethmoid branch of the trigeminal nerve in rats, the 5 nonstimulatory compounds must do so by a non-TRPV1 receptor. These results suggest that TRPV1 serves as a receptor for both cyclohexanone and capsaicin in trigeminal nerve endings.

Mouse taste cells with G protein-coupled taste receptors lack voltage-gated calcium channels and SNAP-25.

BACKGROUND: Taste receptor cells are responsible for transducing chemical stimuli from the environment and relaying information to the nervous system. Bitter, sweet and umami stimuli utilize G-protein coupled receptors which activate the phospholipase C (PLC) signaling pathway in Type II taste cells. However, it is not known how these cells communicate with the nervous system. Previous studies have shown that the subset of taste cells that expresses the T2R bitter receptors lack voltage-gated Ca2+ channels, which are normally required for synaptic transmission at conventional synapses. Here we use two lines of transgenic mice expressing green fluorescent protein (GFP) from two taste-specific promoters to examine Ca2+ signaling in subsets of Type II cells: T1R3-GFP mice were used to identify sweet- and umami-sensitive taste cells, while TRPM5-GFP mice were used to identify all cells that utilize the PLC signaling pathway for transduction. Voltage-gated Ca2+ currents were assessed with Ca2+ imaging and whole cell recording, while immunocytochemistry was used to detect expression of SNAP-25, a presynaptic SNARE protein that is associated with conventional synapses in taste cells. RESULTS: Depolarization with high K+ resulted in an increase in intracellular Ca2+ in a small subset of non-GFP labeled cells of both transgenic mouse lines. In contrast, no depolarization-evoked Ca2+ responses were observed in GFP-expressing taste cells of either genotype, but GFP-labeled cells responded to the PLC activator m-3M3FBS, suggesting that these cells were viable. Whole cell recording indicated that the GFP-labeled cells of both genotypes had small voltage-dependent Na+ and K+ currents, but no evidence of Ca2+ currents. A subset of non-GFP labeled taste cells exhibited large voltage-dependent Na+ and K+ currents and a high threshold voltage-gated Ca2+ current. Immunocytochemistry indicated that SNAP-25 was expressed in a separate population of taste cells from those expressing T1R3 or TRPM5. These data indicate that G protein-coupled taste receptors and conventional synaptic signaling mechanisms are expressed in separate populations of taste cells. CONCLUSION: The taste receptor cells responsible for the transduction of bitter, sweet, and umami stimuli are unlikely to communicate with nerve fibers by using conventional chemical synapses.

Morphologic characterization of rat taste receptor cells that express components of the phospholipase C signaling pathway.

Rat taste buds contain three morphologically distinct cell types that are candidates for taste transduction. The physiologic roles of these cells are, however, not clear. Inositol 1,4,5-triphosphate (IP(3)) has been implicated as an important second messenger in bitter, sweet, and umami taste transductions. Previously, we identified the type III IP(3) receptor (IP(3)R3) as the dominant isoform in taste receptor cells. In addition, a recent study showed that phospholipase Cbeta(2) (PLCbeta(2)) is essential for the transduction of bitter, sweet, and umami stimuli. IP(3)R3 and PLCbeta(2) are expressed in the same subset of cells. To identify the taste cell types that express proteins involved in PLC signal transduction, we used 3,3'diaminobenzidine tetrahydrochloride immunoelectron microscopy and fluorescence microscopy to identify cells with IP(3)R3. Confocal microscopy was used to compare IP(3)R3 or PLCbeta(2) immunoreactivity with that of some known cell type markers such as serotonin, protein gene-regulated product 9.5, and neural cell adhesion molecule. Here we show that a large subset of type II cells and a small subset of type III cells display IP(3)R3 immunoreactivity within their cytoplasm. These data suggest that type II cells are the principal transducers of bitter, sweet, and umami taste transduction. However, we did not observe synapses between type II taste cells and nerve fibers. Interestingly, we observed subsurface cisternae of smooth endoplasmic reticulum at the close appositions between the plasma membrane of type II taste cells and nerve processes. We speculate that some type II cells may communicate to the nervous system via subsurface cisternae of smooth endoplasmic reticulum in lieu of conventional synapses.