Using Immersive Virtual Reality Distraction to Reduce Fear and Anxiety before Surgery.

Presurgical anxiety is very common and is often treated with sedatives. Minimizing or avoiding sedation reduces the risk of sedation-related adverse events. Reducing sedation can increase early cognitive recovery and reduce time to discharge after surgery. The current case study is the first to explore the use of interactive eye-tracked VR as a nonpharmacologic anxiolytic customized for physically immobilized presurgery patients. Method: A 44-year-old female patient presenting for gallbladder surgery participated. Using a within-subject repeated measures design (treatment order randomized), the participant received no VR during one portion of her preoperative wait and interactive eye-tracked virtual reality during an equivalent portion of time in the presurgery room. After each condition (no VR vs. VR), the participant provided subjective 0-10 ratings and state-trait short form Y anxiety measures of the amount of anxiety and fear she experienced during that condition. Results: As predicted, compared to treatment as usual (no VR), the patient reported having 67% lower presurgical anxiety during VR. She also experienced "strong fear" (8 out of 10) during no VR vs. "no fear" (0 out of 10) during VR. She reported a strong sense of presence during VR and zero nausea. She liked VR, she had fun during VR, and she recommended VR to future patients during pre-op. Interactive VR distraction with eye tracking was an effective nonpharmacologic technique for reducing anticipatory fear and anxiety prior to surgery. The results add to existing evidence that supports the use of VR in perioperative settings. VR technology has recently become affordable and more user friendly, increasing the potential for widespread dissemination into medical practice. Although case studies are scientifically inconclusive by nature, they help identify new directions for future larger, carefully controlled studies. VR sedation is a promising non-drug fear and anxiety management technique meriting further investigation.

Adding tactile feedback increases avatar ownership and makes virtual reality more effective at reducing pain in a randomized crossover study.

Severe pain is a widespread health problem in need of novel treatment approaches. In the current study we used real water to give virtual objects (i.e., animated virtual water) more realistic physical properties (wet liquid qualities). Healthy volunteers aged 18-34 participated in a within-subject randomized study comparing participants' worst pain during brief thermal stimuli with (1) No Immersive Virtual Reality (VR), versus (2) during VR + no tactile feedback versus (3) VR + real water (with tactile feedback from co-located real objects). Tactile feedback significantly decreased pain intensity (VR analgesia, p < 0.01), compared to VR with no tactile feedback, and compared to No VR (baseline). Tactile feedback made the virtual water feel significantly more real, increased participant's sense of presence, and both VR conditions were distracting (significantly reduced accuracy on an attention demanding task). As a non-pharmacologic analgesic, mixed reality reduced pain by 35% in the current study, comparable to the analgesia from a moderate dose of hydromorphone in previous published experimental studies. Tactile feedback also significantly increased avatar embodiment, the participants illusion of ownership of the virtual hands, which has potential to improve the effectiveness of avatar therapy for chronic pain in future studies. Mixed reality should be tested as treatment in pain patients.

The Emerging Role of Virtual Reality as an Adjunct to Procedural Sedation and Anesthesia: A Narrative Review.

Over the past 20 years, there has been a significant reduction in the incidence of adverse events associated with sedation outside of the operating room. Non-pharmacologic techniques are increasingly being used as peri-operative adjuncts to facilitate and promote anxiolysis, analgesia and sedation, and to reduce adverse events. This narrative review will briefly explore the emerging role of immersive reality in the peri-procedural care of surgical patients. Immersive virtual reality (VR) is intended to distract patients with the illusion of "being present" inside the computer-generated world, drawing attention away from their anxiety, pain, and discomfort. VR has been described for a variety of procedures that include colonoscopies, venipuncture, dental procedures, and burn wound care. As VR technology develops and the production costs decrease, the role and application of VR in clinical practice will expand. It is important for medical professionals to understand that VR is now available for prime-time use and to be aware of the growing body in the literature that supports VR.

Gene-expression correlates of the oscillatory signatures supporting human episodic memory encoding.

In humans, brain oscillations support critical features of memory formation. However, understanding the molecular mechanisms underlying this activity remains a major challenge. Here, we measured memory-sensitive oscillations using intracranial electroencephalography recordings from the temporal cortex of patients performing an episodic memory task. When these patients subsequently underwent resection, we employed transcriptomics on the temporal cortex to link gene expression with brain oscillations and identified genes correlated with oscillatory signatures of memory formation across six frequency bands. A co-expression analysis isolated oscillatory signature-specific modules associated with neuropsychiatric disorders and ion channel activity, with highly correlated genes exhibiting strong connectivity within these modules. Using single-nucleus transcriptomics, we further revealed that these modules are enriched for specific classes of both excitatory and inhibitory neurons, and immunohistochemistry confirmed expression of highly correlated genes. This unprecedented dataset of patient-specific brain oscillations coupled to genomics unlocks new insights into the genetic mechanisms that support memory encoding.

Pediatric Stapes Surgery: Hearing and Surgical Outcomes in Endoscopic vs Microscopic Approaches.

OBJECTIVE: To compare endoscopic and microscopic pediatric stapes surgery. STUDY DESIGN: Case series with chart review. SETTING: Two academic otology practices. SUBJECTS AND METHODS: Surgical and hearing outcomes were compared for consecutive children (<18 years) undergoing microscopic and endoscopic stapes surgery. The main outcome measure was closure of the air-bone gap (ABG) to ≤20 dB. RESULTS: Twenty-two endoscopic surgeries (17 stapedectomies, 4 stapedotomies, and 1 stapes mobilization) and 52 microscopic surgeries (30 stapedectomies, 19 stapedotomies, and 3 stapes mobilizations) were performed. Patient demographics, history of ipsilateral middle ear surgery, and revision stapes surgery status were similar. The most common diagnosis for the endoscopic group and microscopic group were congenital stapes footplate fixation (45.5%) and juvenile otosclerosis (46.2%), respectively. Preoperative ABGs in the endoscopic (37.7 dB) and microscopic (32.8 dB) groups (P = .170) were similar. There were no major complications, including facial nerve injury or anacusis, in the endoscopic group. Postoperative sensorineural hearing loss (>15 dB) did not occur in any patients in the endoscopic group but was present in 2 patients in the microscopic group (P = .546). Improvement in pure-tone average (25.9 dB vs 18.5 dB, P = .382) and ABG (21.7 dB vs 14.7 dB, P = .181) was similar, and postoperatively, the median ABG was 11.3 dB and 15.0 dB for endoscopic and microscopic cases (P = .703), respectively. ABG closure to ≤20 dB (72.7% vs 65.2%, P = .591) was also similar. CONCLUSION: Pediatric endoscopic stapes surgery is safe and hearing outcomes are similar to the microscopic approach when performed by experienced endoscopic ear surgeons.

Endoscopic Removal of an Epithelial Cyst of the Zygoma.

This study elaborates a brief overview of epithelial cysts in the bones of the skull and describes an unusual patient with an epidermoid cyst of the zygoma. This report focuses on an endoscopic preauricular infratemporal fossa approach for resection of a left epidermoid cyst of the zygoma. Preoperative magnetic resonance imaging and computed tomography imaging as well as intraoperative endoscopic images and movie were demonstrated. The epithelial cyst was successfully removed from the patient using a minimally invasive approach utilizing endoscopes. No complications were encountered. The possible causes of this rare presentation and minimal surgical removal utilizing endoscopes were discussed in this study. According to the authors, this is the first reported study of endoscopic removal of an epidermoid cyst from the zygomatic root. The patient's previous surgical history of a tympanoplasty could have contributed to the unusual location of the lesion.

Novel transcriptional networks regulated by CLOCK in human neurons.

The molecular mechanisms underlying human brain evolution are not fully understood; however, previous work suggested that expression of the transcription factor CLOCK in the human cortex might be relevant to human cognition and disease. In this study, we investigated this novel transcriptional role for CLOCK in human neurons by performing chromatin immunoprecipitation sequencing for endogenous CLOCK in adult neocortices and RNA sequencing following CLOCK knockdown in differentiated human neurons in vitro. These data suggested that CLOCK regulates the expression of genes involved in neuronal migration, and a functional assay showed that CLOCK knockdown increased neuronal migratory distance. Furthermore, dysregulation of CLOCK disrupts coexpressed networks of genes implicated in neuropsychiatric disorders, and the expression of these networks is driven by hub genes with human-specific patterns of expression. These data support a role for CLOCK-regulated transcriptional cascades involved in human brain evolution and function.

Fragile X mental retardation protein regulates synaptic and behavioral plasticity to repeated cocaine administration.

Repeated cocaine exposure causes persistent, maladaptive alterations in brain and behavior, and hope for effective therapeutics lies in understanding these processes. We describe here an essential role for fragile X mental retardation protein (FMRP), an RNA-binding protein and regulator of dendritic protein synthesis, in cocaine conditioned place preference, behavioral sensitization, and motor stereotypy. Cocaine reward deficits in FMRP-deficient mice stem from elevated mGluR5 (or GRM5) function, similar to a subset of fragile X symptoms, and do not extend to natural reward. We find that FMRP functions in the adult nucleus accumbens (NAc), a critical addiction-related brain region, to mediate behavioral sensitization but not cocaine reward. FMRP-deficient mice also exhibit several abnormalities in NAc medium spiny neurons, including reduced presynaptic function and premature changes in dendritic morphology and glutamatergic neurotransmission following repeated cocaine treatment. Together, our findings reveal FMRP as a critical mediator of cocaine-induced behavioral and synaptic plasticity.

Neurochemical profiling of dopaminergic neurons in the forebrain of a cichlid fish, Astatotilapia burtoni.

Across vertebrates, the mesolimbic reward system is a highly conserved neural network that serves to evaluate the salience of environmental stimuli, with dopamine as the neurotransmitter most relevant to its function. Although brain regions in the dopaminergic reward system have been well characterized in mammals, homologizing these brain areas with structures in teleosts has been controversial, especially for the mesencephalo-diencephalic dopaminergic cell populations. Here we examine the neurochemical profile of five dopaminergic cell groups (Vc, POA, PPr, TPp, pTn) in the model cichlid Astatotilapia burtoni to better understand putative homology relationships between teleosts and mammals. We characterized in the adult brain the expression patterns of three genes (etv5, nr4a2, and pitx3) that either specify dopaminergic cell fate or maintain dopaminergic cell populations. We then determined whether these genes are expressed in dopaminergic cells. We find many striking similarities in these gene expression profiles between dopaminergic cell populations in teleosts and their putative mammalian homologs. Our results suggest that many of these dopaminergic cell groups are indeed evolutionarily ancient and conserved across vertebrates.

Female preference for males depends on reproductive physiology in the African cichlid fish Astatotilapia burtoni.

Mate choice is fundamental to sexual selection, yet little is known about underlying physiological mechanisms that influence female mating decisions. We investigated the endocrine underpinnings of female mate choice in the African cichlid Astatotilapia burtoni, a non-seasonal breeder. In addition to profiling behavioral and hormonal changes across the female reproductive cycle, we tested two hypotheses regarding possible factors influencing female mate choice. We first asked whether female mate choice is influenced by male visual and/or chemical cues. A. burtoni females were housed for one full reproductive cycle in the center of a dichotomous choice apparatus with a large (attractive) or small (unattractive) conspecific male on either side. Females associated mostly with small, less attractive males, but on the day of spawning reversed their preference to large, attractive males, with whom they mated almost exclusively, although this choice depended on the relative amount of androgens released into the water by small males. We next asked whether male behavior or androgen levels change in relation to the stimulus females' reproductive state. We found that stimulus male aggression decreased and reproductive displays increased as the day of spawning approached. Moreover male testosterone levels changed throughout the females' reproductive cycle, with larger males releasing more testosterone into the water than small males. Our data suggest that female association in a dichotomous choice assay is only indicative of the actual mate choice on the day of spawning. Furthermore, we show that male behavior and hormone levels are dependent on the reproductive state of conspecific females.

Characterization of the dopaminergic system in the brain of an African cichlid fish, Astatotilapia burtoni.

Catecholamines, such as dopamine, are evolutionarily ancient neurotransmitters that play an essential role in mediating behavior. In vertebrates, dopamine is central to the nigrostriatal motor and mesolimbic reward systems. Despite its importance, the distribution of the dopaminergic system has not been well studied in the teleost brain. The African cichlid fish Astatotilapia burtoni has become an important model system in social neuroscience and lends itself to uncovering how social decisions are implemented in the brain. To understand better where dopamine acts to regulate social behavior in this species, we have determined the distribution of putative dopaminergic cells and fibers (by tyrosine hydroxylase immunohistochemistry) and dopamine receptors (by in situ hybridization for the D(1A) and D(2) dopamine receptor subtypes) throughout the forebrain and part of the mesencephalon of A. burtoni. Tyrosine hydroxylase immunoreactivity was evident in several regions of the fore- and midbrain, in support of putative homologies to tetrapods. Additionally, the D(1A) and D(2) receptors were identified in brain regions known to modulate social behavior in other vertebrates, including the proposed teleost homologues of the mammalian amygdalar complex, hippocampus, striatum, preoptic area, anterior hypothalamus, ventromedial hypothalamus, and ventral tegmental area/substantia nigra pars compacta. Tyrosine hydroxylase-immunoreactive fibers as well as D(1A) and D(2) receptor expression overlap almost completely in their distribution. These results significantly extend our understanding of the distribution of the dopaminergic system in the teleost brain and suggest a conserved role of dopamine in modulating behavior across vertebrates.