Development and Considerations for Virtual Reality Simulations for Resuscitation Training and Stress Inoculation.

INTRODUCTION: Resuscitation simulations immerse learners into the complexity of emergency patient management. Head-Mounted Display Virtual Reality (VR) has been used for stress inoculation therapy for phobias and posttraumatic stress disorder. However, VR for stress inoculation in resuscitation leadership training has not been studied. We sought to develop VR simulation for stress inoculation, as exposure therapy training, for resuscitations. METHODS: We explain the conceptual design, development, production, and initial evaluation process for 2 VR simulations in infant status epilepticus and pediatric anaphylactic shock. We further describe deliberate game mechanic choices to maximize psychological fidelity. In-virtual reality performance data for time-to-critical actions and stress physiology markers (heart rate, salivary cortisol) were collected from expert pediatric emergency physicians and novice pediatric residents. Data were analyzed to examine differences between the 2 groups for both outcome types to determine the extent of stress response or performance deficit the VR induced. RESULTS: Multiple difficulties and distractions were designed for the 2 scenarios; we evaluated the highest difficulty and environmental distraction versions. Between 19 expert physicians and 15 novice physicians, no performance differences were found in typical airway, breathing, and circulation actions. Residents preferred more lorazepam first-line antiepileptics than attendings (P = 0.003) and performed a cricothyrotomy later than attendings (P = 0.02). Residents, however, manifested higher salivary cortisol levels than attendings (+0.07 µg/dL, 95% confidence interval = 0.03-0.12, P = 0.001). CONCLUSIONS: A VR resuscitation simulation manifested expected stress physiology changes in physicians. Further evaluation is needed to determine the effect of VR simulation as longitudinal stress inoculation for healthcare providers.

Comparisons of Stress Physiology of Providers in Real-Life Resuscitations and Virtual Reality-Simulated Resuscitations.

BACKGROUND: Virtual reality (VR) is a promising simulation medium for high-stakes, low-frequency events such as pediatric resuscitation. The psychological fidelity of VR compared with a real resuscitation in an emergency department (ED) is relatively unknown. The objective was to determine whether stress physiology changes were equivalent between ED and VR resuscitations. METHODS: This was a single-site pilot equivalence study evaluating head-mounted VR resuscitation scenarios using board-certified/eligible pediatric ED physicians. Subjects had heart rates (HRs) and salivary cortisol levels recorded throughout 8-hour evening ED shifts and during one 1-hour VR session. Additional samples and subjective workload perception (NASA Task Load Index) were collected for critical resuscitations. A delta HR and delta cortisol level described the difference in mean HR and mean cortisol level between shifts with and shifts without resuscitations. Another delta calculation was performed from pre-VR to post-VR. Nonparametric univariate statistics was examined for significant differences in delta HR or cortisol levels between the ED setting and VR. RESULTS: Sixteen subjects had 69 shifts monitored with 31 resuscitations. In the ED, delta HR was +13.9 bpm (P < 0.001) and delta cortisol was +0.10 µg/dL (P = 0.006). In VR, delta HR was +6.5 bpm (P < 0.001) but minimal delta cortisol (-0.02 µg/dL, P = 0.05). Emergency department resuscitations both HR and cortisol levels were more than VR resuscitations (P < 0.03). NASA Task Load Index scores were higher in VR resuscitations with +26 score difference (P = 0.01). CONCLUSIONS: Virtual reality resuscitations increase HR but show less stress physiology changes than ED resuscitations within an actual 8-hour shift. Further inquiry into stress physiology and optimal VR simulation is warranted.

Cervix Stromal Cells and the Progesterone Receptor A Isoform Mediate Effects of Progesterone for Prepartum Remodeling.

The prepartum transition from a soft to ripening cervix is an inflammatory process that occurs well before birth when systemic progesterone is near peak concentration. This 2-part study first determined that stromal fibroblasts but not macrophages in the cervix have progesterone receptors (PRs). Neither the number of PR cells in cervix sections nor the relative abundance or ratio of nuclear PR isoforms (PR-A/PR-B) were diminished in mice between day 15 of pregnancy and term. Second in mice lacking PR-B ( Pgrtm20mc), the number of cells that expressed the PR-A isoform were maintained during this period of prepartum cervix remodeling. Thus, progesterone effects to sustain pregnancy, as well as soften and ripen the cervix, are mediated by a stable stromal cell population that expresses PR-A and, through interactions with resident macrophages, are likely to mediate inflammatory ripening processes in preparation for birth.