Using human observations with instrument-based metrics to understand changing rainfall patterns

Shifting precipitation regimes are a well-documented and pervasive consequence of climate change. Subsistence-oriented communities worldwide can identify changes in rainfall patterns that most affect their lives. Here we scrutinize the importance of human-based rainfall observations (collated through a literature review spanning from 1994 to 2013) as climate metrics and the relevance of instrument-based precipitation indices to subsistence activities. For comparable time periods (1955-2005), changes observed by humans match well with instrumental records at same locations for well-established indices of rainfall (72% match), drought (76%), and extreme rainfall (81%), demonstrating that we can bring together human and instrumental observations. Many communities (1114 out of 1827) further identify increased variability and unpredictability in the start, end, and continuity of rainy seasons, all of which disrupt the cropping calendar, particularly in the Tropics. These changes in rainfall patterns and predictability are not fully captured by existing indices, and their social-ecological impacts are still understudied.

Genetic architecture of routinely acquired blood tests in a British South Asian cohort

Understanding the genetic basis of routinely-acquired blood tests can provide insights into several aspects of human physiology. We report a genome-wide association study of 42 quantitative blood test traits defined using Electronic Healthcare Records (EHRs) of ~50,000 British Bangladeshi and British Pakistani adults. We demonstrate a causal variant within the PIEZO1 locus which was associated with alterations in red cell traits and glycated haemoglobin. Conditional analysis and within-ancestry fine mapping confirmed that this signal is driven by a missense variant - chr16-88716656-G-TT - which is common in South Asian ancestries (MAF 3.9%) but ultra-rare in other ancestries. Carriers of the T allele had lower mean HbA1c values, lower HbA1c values for a given level of random or fasting glucose, and delayed diagnosis of Type 2 Diabetes Mellitus. Our results shed light on the genetic basis of clinically-relevant traits in an under-represented population, and emphasise the importance of ancestral diversity in genetic studies.

Development and evaluation of an emergency department serious game for undergraduate medical students

BACKGROUND

Serious games are risk-free environments training various medical competencies, such as clinical reasoning, without endangering patients' safety. Furthermore, serious games provide a context for training situations with unpredictable outcomes. Training these competencies is particularly important for healthcare professionals in emergency medicine.

METHODS

Based on these considerations, we designed, implemented, and evaluated a serious game in form of an emergency department, containing the features of a virtual patient generator, a chatbot for medical history taking with self-formulated questions, artificially generated faces based on an artificial intelligence algorithm, and feedback for students. The development process was based on an already existing framework resulting in an iterative procedure between development and evaluation. The serious game was evaluated using the System Usability Scale and the User Experience Questionnaire.

RESULTS

The System Usability Scale provided a substantial result for the usability. In terms of the user experience, four scales yielded positive results, whereas two scales yielded neutral results.

CONCLUSION

The evaluation of both usability and user experience yielded overall positive results, while simultaneously identifying potential areas for improvement. Further studies will address the implementation of additional game design elements, and testing student learning outcome.

Sharing Is Caring? International Society for Pharmacoepidemiology Review and Recommendations for Sharing Programming Code

PURPOSE

There is increasing recognition of the importance of transparency and reproducibility in scientific research. This study aimed to quantify the extent to which programming code is publicly shared in pharmacoepidemiology, and to develop a set of recommendations on this topic.

METHODS

We conducted a literature review identifying all studies published in Pharmacoepidemiology and Drug Safety (PDS) between 2017 and 2022. Data were extracted on the frequency and types of programming code shared, and other key open science practices (clinical codelist sharing, data sharing, study preregistration, and stated use of reporting guidelines and preprinting). We developed six recommendations for investigators who choose to share code and gathered feedback from members of the International Society for Pharmacoepidemiology (ISPE).

RESULTS

Programming code sharing by articles published in PDS ranged from 1.8% in 2017 to 9.5% in 2022. It was more prevalent among articles with a methodological focus, simulation studies, and papers which also shared record-level data.

CONCLUSION

Programming code sharing is rare but increasing in pharmacoepidemiology studies published in PDS. We recommend improved reporting of whether code is shared and how available code can be accessed. When sharing programming code, we recommend the use of permanent digital identifiers, appropriate licenses, and, where possible, adherence to good software practices around the provision of metadata and documentation, computational reproducibility, and data privacy.

Impact of COVID-19 on recorded blood pressure screening and hypertension management in England: an analysis of monthly changes in the quality and outcomes framework indicators in OpenSAFELY

BACKGROUND

The COVID-19 pandemic disrupted cardiovascular disease management in primary care in England.

OBJECTIVE

To describe the impact of the pandemic on blood pressure screening and hypertension management based on a national quality of care scheme (Quality and Outcomes Framework, QOF) across key demographic, regional and clinical subgroups.

METHODS

With NHS England approval, a population-based cohort study was conducted using OpenSAFELY-TPP on 25.2 million NHS patients registered at general practices (March 2019 to March 2023). We examined monthly changes in recorded blood pressure screening in the preceding 5 years in patients aged ≥45 years and recorded the hypertension prevalence and the percentage of patients treated to target (≤140/90 mmHg for patients aged ≤79 years and ≤150/90 mmHg for patients aged ≥80 years) in the preceding 12 months.

RESULTS

The percentage of patients aged ≥45 years who had blood pressure screening recorded in the preceding 5 years decreased from 90% (March 2019) to 85% (March 2023). Recorded hypertension prevalence was relatively stable at 15% throughout the study period. The percentage of patients with a record of hypertension treated to target in the preceding 12 months reduced from a maximum of 71% (March 2020) to a minimum of 47% (February 2021) in patients aged ≤79 years and from 85% (March 2020) to a minimum of 58% (February 2021) in patients aged ≥80 years before recovery. Blood pressure screening rates in the preceding 5 years remained stable in older people, patients with recorded learning disability or care home status.

CONCLUSIONS

The pandemic substantially disrupted hypertension management QOF indicators, which is likely attributable to general reductions of blood pressure measurement including screening. OpenSAFELY can be used to continuously monitor changes in national quality-of-care schemes to identify changes in key clinical subgroups early and support prioritisation of recovery from care disrupted by COVID-19.

Incidence of diabetes after SARS-CoV-2 infection in England and the implications of COVID-19 vaccination: a retrospective cohort study of 16 million people

BACKGROUND

Some studies have shown that the incidence of type 2 diabetes increases after a diagnosis of COVID-19, although the evidence is not conclusive. However, the effects of the COVID-19 vaccine on this association, or the effect on other diabetes subtypes, are not clear. We aimed to investigate the association between COVID-19 and incidence of type 2, type 1, gestational and non-specific diabetes, and the effect of COVID- 19 vaccination, up to 52 weeks after diagnosis.

METHODS

In this retrospective cohort study, we investigated the diagnoses of incident diabetes following COVID-19 diagnosis in England in a pre-vaccination, vaccinated, and unvaccinated cohort using linked electronic health records. People alive and aged between 18 years and 110 years, registered with a general practitioner for at least 6 months before baseline, and with available data for sex, region, and area deprivation were included. Those with a previous COVID-19 diagnosis were excluded. We estimated adjusted hazard ratios (aHRs) comparing diabetes incidence after COVID-19 diagnosis with diabetes incidence before or in the absence of COVID-19 up to 102 weeks after diagnosis. Results were stratified by COVID-19 severity (categorised as hospitalised or non-hospitalised) and diabetes type.

FINDINGS

16 669 943 people were included in the pre-vaccination cohort (Jan 1, 2020-Dec 14, 2021), 12 279 669 in the vaccinated cohort, and 3 076 953 in the unvaccinated cohort (both June 1-Dec 14, 2021). In the pre-vaccination cohort, aHRs for the incidence of type 2 diabetes after COVID-19 (compared with before or in the absence of diagnosis) declined from 4·30 (95% CI 4·06-4·55) in weeks 1-4 to 1·24 (1·14-1.35) in weeks 53-102. aHRs were higher in unvaccinated people (8·76 [7·49-10·25]) than in vaccinated people (1·66 [1·50-1·84]) in weeks 1-4 and in patients hospitalised with COVID-19 (pre-vaccination cohort 28·3 [26·2-30·5]) in weeks 1-4 declining to 2·04 [1·72-2·42] in weeks 53-102) than in those who were not hospitalised (1·95 [1·78-2·13] in weeks 1-4 declining to 1·11 [1·01-1·22] in weeks 53-102). Type 2 diabetes persisted for 4 months after COVID-19 in around 60% of those diagnosed. Patterns were similar for type 1 diabetes, although excess incidence did not persist beyond 1 year after a COVID-19 diagnosis.

INTERPRETATION

Elevated incidence of type 2 diabetes after COVID-19 is greater, and persists for longer, in people who were hospitalised with COVID-19 than in those who were not, and is markedly less apparent in people who have been vaccinated against COVID-19. Testing for type 2 diabetes after severe COVID-19 and the promotion of vaccination are important tools in addressing this public health problem.

FUNDING

UK National Institute for Health and Care Research, UK Research and Innovation (UKRI) Medical Research Council, UKRI Engineering and Physical Sciences Research Council, Health Data Research UK, Diabetes UK, British Heart Foundation, and the Stroke Association.

Identification of patients undergoing chronic kidney replacement therapy in primary and secondary care data: validation study based on OpenSAFELY and UK Renal Registry

Objective

To validate primary and secondary care codes in electronic health records to identify people receiving chronic kidney replacement therapy based on gold standard registry data.

Design

Validation study using data from OpenSAFELY and the UK Renal Registry, with the approval of NHS England.

Setting

Primary and secondary care electronic health records from people registered at 45% of general practices in England on 1 January 2020, linked to data from the UK Renal Registry (UKRR) within the OpenSAFELY-TPP platform, part of the NHS England OpenSAFELY covid-19 service.

Participants

38 745 prevalent patients (recorded as receiving kidney replacement therapy on 1 January 2020 in UKRR data, or primary or secondary care data) and 10 730 incident patients (starting kidney replacement therapy during 2020), from a population of 19 million people alive and registered with a general practice in England on 1 January 2020.

Main outcome measures

Sensitivity and positive predictive values of primary and secondary care code lists for identifying prevalent and incident kidney replacement therapy cohorts compared with the gold standard UKRR data on chronic kidney replacement therapy. Agreement across the data sources overall, and by treatment modality (transplantation or dialysis) and personal characteristics.

Results

Primary and secondary care code lists were sensitive for identifying the UKRR prevalent cohort (91.2% (95% confidence interval (CI) 90.8% to 91.6%) and 92.0% (91.6% to 92.4%), respectively), but not the incident cohort (52.3% (50.3% to 54.3%) and 67.9% (66.1% to 69.7%)). Positive predictive values were low (77.7% (77.2% to 78.2%) for primary care data and 64.7% (64.1% to 65.3%) for secondary care data), particularly for chronic dialysis (53.7% (52.9% to 54.5%) for primary care data and 49.1% (48.0% to 50.2%) for secondary care data). Sensitivity decreased with age and index of multiple deprivation in primary care data, but the opposite was true in secondary care data. Agreement was lower in children, with 30% (295/980) featuring in all three datasets. Half (1165/2315) of the incident patients receiving dialysis in UKRR data had a kidney replacement therapy code in the primary care data within three months of the start date of the kidney replacement therapy. No codes existed whose exclusion would substantially improve the positive predictive value without a decrease in sensitivity.

Conclusions

Codes used in primary and secondary care data failed to identify a small proportion of prevalent patients receiving kidney replacement therapy. Codes also identified many patients who were not recipients of chronic kidney replacement therapy in UKRR data, particularly dialysis codes. Linkage with UKRR kidney replacement therapy data facilitated more accurate identification of incident and prevalent kidney replacement therapy cohorts for research into this vulnerable population. Poor coding has implications for any patient care (including eligibility for vaccination, resourcing, and health policy responses in future pandemics) that relies on accurate reporting of kidney replacement therapy in primary and secondary care data.

Ethnic differences in depression and anxiety among adults with atopic eczema: Population-based matched cohort studies within UK primary care

BACKGROUND

Evidence demonstrates that individuals with atopic eczema (eczema) have increased depression and anxiety; however, the role of ethnicity in these associations is poorly understood. We aimed to investigate whether associations between eczema and depression or anxiety differed between adults from white and minority ethnic groups in the UK.

METHODS

We used UK Clinical Practice Research Datalink GOLD to conduct matched cohort studies of adults (≥18 years) with ethnicity recorded in primary care electronic health records (April 2006-January 2020). We matched (age, sex, practice) adults with eczema to up to five adults without. We used stratified Cox regression with an interaction between eczema and ethnicity, to estimate hazard ratios (HRs) for associations between eczema and incident depression and anxiety in individuals from white ethnic groups and a pooled minority ethnic group (adults from Black, South Asian, Mixed and Other groups).

RESULTS

We identified separate cohorts for depression (215,073 with eczema matched to 646,539 without) and anxiety (242,598 with eczema matched to 774,113 without). After adjusting for matching variables and potential confounders (age, sex, practice, deprivation, calendar period), we found strong evidence (p < 0.01) of ethnic differences in associations between eczema and depression (minority ethnic groups: HR = 1.33, 95% CI = 1.22,1.45; white ethnic groups: HR = 1.15, 95% CI = 1.12,1.17) and anxiety (minority ethnic groups: HR = 1.41, 95% CI = 1.28,1.55; white ethnic groups: HR = 1.17, 95% CI = 1.14,1.19).

CONCLUSIONS

Adults with eczema from minority ethnic groups appear to be at increased depression and anxiety risk compared with their white counterparts. Culturally adapted mental health promotion and prevention strategies should be considered in individuals with eczema from minority ethnic groups.

Impact of the COVID-19 pandemic on antipsychotic prescribing in individuals with autism, dementia, learning disability, serious mental illness or living in a care home: a federated analysis of 59 million patients' primary care records in situ using OpenSAFELY

BACKGROUND

The COVID-19 pandemic affected how care was delivered to vulnerable patients, such as those with dementia or learning disability.

OBJECTIVE

To explore whether this affected antipsychotic prescribing in at-risk populations.

METHODS

With the approval of NHS England, we completed a retrospective cohort study, using the OpenSAFELY platform to explore primary care data of 59 million patients. We identified patients in five at-risk groups: autism, dementia, learning disability, serious mental illness and care home residents. We calculated the monthly prevalence of antipsychotic prescribing in these groups, as well as the incidence of new prescriptions in each month.

FINDINGS

The average monthly rate of antipsychotic prescribing increased in dementia from 82.75 patients prescribed an antipsychotic per 1000 patients (95% CI 82.30 to 83.19) in January-March 2019 to 90.1 (95% CI 89.68 to 90.60) in October-December 2021 and from 154.61 (95% CI 153.79 to 155.43) to 166.95 (95% CI 166.23 to 167.67) in care homes. There were notable spikes in the rate of new prescriptions issued to patients with dementia and in care homes. In learning disability and autism groups, the rate of prescribing per 1000 decreased from 122.97 (95% CI 122.29 to 123.66) to 119.29 (95% CI 118.68 to 119.91) and from 54.91 (95% CI 54.52 to 55.29) to 51.04 (95% CI 50.74 to 51.35), respectively.

CONCLUSION AND IMPLICATIONS

We observed a spike in antipsychotic prescribing in the dementia and care home groups, which correlated with lockdowns and was likely due to prescribing of antipsychotics for palliative care. We observed gradual increases in antipsychotic use in dementia and care home patients and decreases in their use in patients with learning disability or autism.

People at a persistent pain service can walk it, but some struggle to talk about it: Reliability, detectable difference and clinically important difference of the six-minute walk test

OBJECTIVES

The six-minute walk test (6MWT) is a commonly used measure of functional capacity. This study is the first to investigate the test-retest reliability, minimal detectable difference (MDD) and the minimal clinically important difference (MCID) for people attending a persistent pain service. Relationships between change in 6MWT performance and change in self-reported physical, functional and psychological outcome measures were also explored.

METHODS

A cross-sectional repeated measures design was used with people having >9 months of pain attending an 8-week outpatient persistent pain programme. For reliability and MDD, 27 people were recruited, for MCID calculations, 32 people were recruited. The MCID was examined by dichotomising people into "improvers", or "non-improvers" based upon the Global Rating of Change (GRC) in physical abilities score.

RESULTS

The mean (SD) 6MWT distance was 389.4 (93.6) m at programme start, and 427.8 (83.0) m at week eight completion. The test-retest reliability was good (intraclass correlation coefficient = 0.89) and the MDD = 86.1 m. As there was no relationship between change in 6MWT distance and GRC physical abilities at week eight (r = 0.132, p = 0.472) the MCID could not be calculated. Furthermore, no relationships were found between change in 6MWT distance and other self-reported measures. Changes in GRC physical abilities and 6MWT were frequently discordant, with increased 6MWT for 7/11 "GRC non-improvers" and decreased 6MWT for 7/21 "GRC improvers".

CONCLUSIONS

Amongst this cohort, change in physical ability may or may not be reflected by self-reported change. Objective tests of physical ability are recommended for people attending pain services, and validated tests should align with intervention aims.

Sharing study materials in health and medical research

Making study materials available allows for a more comprehensive understanding of the scientific literature. Sharing can take many forms and include a wide variety of outputs including code and data. Biomedical research can benefit from increased transparency but faces unique challenges for sharing, for instance, confidentiality concerns around participants' medical data. Both general and specialised repositories exist to aid in sharing most study materials. Sharing may also require skills and resources to ensure that it is done safely and effectively. Educating researchers on how to best share their materials, and properly rewarding these practices, requires action from a variety of stakeholders including journals, funders and research institutions.

Describing the population experiencing COVID-19 vaccine breakthrough following second vaccination in England: a cohort study from OpenSAFELY

BACKGROUND

While the vaccines against COVID-19 are highly effective, COVID-19 vaccine breakthrough is possible despite being fully vaccinated. With SARS-CoV-2 variants still circulating, describing the characteristics of individuals who have experienced COVID-19 vaccine breakthroughs could be hugely important in helping to determine who may be at greatest risk.

METHODS

With the approval of NHS England, we conducted a retrospective cohort study using routine clinical data from the OpenSAFELY-TPP database of fully vaccinated individuals, linked to secondary care and death registry data and described the characteristics of those experiencing COVID-19 vaccine breakthroughs.

RESULTS

As of 1st November 2021, a total of 15,501,550 individuals were identified as being fully vaccinated against COVID-19, with a median follow-up time of 149 days (IQR: ​107-179). From within this population, a total of 579,780 (<4%) individuals reported a positive SARS-CoV-2 test. For every 1000 years of patient follow-up time, the corresponding incidence rate (IR) was 98.06 (95% CI 97.93-98.19). There were 28,580 COVID-19-related hospital admissions, 1980 COVID-19-related critical care admissions and 6435 COVID-19-related deaths; corresponding IRs 4.77 (95% CI 4.74-4.80), 0.33 (95% CI 0.32-0.34) and 1.07 (95% CI 1.06-1.09), respectively. The highest rates of breakthrough COVID-19 were seen in those in care homes and in patients with chronic kidney disease, dialysis, transplant, haematological malignancy or who were immunocompromised.

CONCLUSIONS

While the majority of COVID-19 vaccine breakthrough cases in England were mild, some differences in rates of breakthrough cases have been identified in several clinical groups. While it is important to note that these findings are simply descriptive and cannot be used to answer why certain groups have higher rates of COVID-19 breakthrough than others, the emergence of the Omicron variant of COVID-19 coupled with the number of positive SARS-CoV-2 tests still occurring is concerning and as numbers of fully vaccinated (and boosted) individuals increases and as follow-up time lengthens, so too will the number of COVID-19 breakthrough cases. Additional analyses, to assess vaccine waning and rates of breakthrough COVID-19 between different variants, aimed at identifying individuals at higher risk, are needed.

OpenSAFELY: impact of national guidance on switching anticoagulant therapy during COVID-19 pandemic

BACKGROUND

Early in the COVID-19 pandemic, the National Health Service (NHS) recommended that appropriate patients anticoagulated with warfarin should be switched to direct-acting oral anticoagulants (DOACs), requiring less frequent blood testing. Subsequently, a national safety alert was issued regarding patients being inappropriately coprescribed two anticoagulants following a medication change and associated monitoring.

OBJECTIVE

To describe which people were switched from warfarin to DOACs; identify potentially unsafe coprescribing of anticoagulants; and assess whether abnormal clotting results have become more frequent during the pandemic.

METHODS

With the approval of NHS England, we conducted a cohort study using routine clinical data from 24 million NHS patients in England.

RESULTS

20 000 of 164 000 warfarin patients (12.2%) switched to DOACs between March and May 2020, most commonly to edoxaban and apixaban. Factors associated with switching included: older age, recent renal function test, higher number of recent INR tests recorded, atrial fibrillation diagnosis and care home residency. There was a sharp rise in coprescribing of warfarin and DOACs from typically 50-100 per month to 246 in April 2020, 0.06% of all people receiving a DOAC or warfarin. International normalised ratio (INR) testing fell by 14% to 506.8 patients tested per 1000 warfarin patients each month. We observed a very small increase in elevated INRs (n=470) during April compared with January (n=420).

CONCLUSIONS

Increased switching of anticoagulants from warfarin to DOACs was observed at the outset of the COVID-19 pandemic in England following national guidance. There was a small but substantial number of people coprescribed warfarin and DOACs during this period. Despite a national safety alert on the issue, a widespread rise in elevated INR test results was not found. Primary care has responded rapidly to changes in patient care during the COVID-19 pandemic.

Embracing artificial intelligence- how can we make it inclusive and relevant for real world dermatological practice?

Artificial intelligence (AI) developments are rapidly advancing with algorithms capable of out-performing dermatologists in specific contrived challenges, but where prospective evaluation in real-world settings remain limited. Professional bodies have a role to encourage AI approaches to address clinical unmet needs, improve quality of care, and enhance patient experience without compromising safety. In 2019, the American Academy of Dermatology advocated principles of human-centred design for augmented intelligence innovations (1) emphasising the importance of synergy between dermatologist and the computer. More recently, the British Association of Dermatologists highlighted the weak current evidence-base supporting effectiveness of AI interventions in routine clinical practice and encouraged clinicians to independently evaluate the evidence prior to adoption (2).

Incidence of acute complications of herpes zoster among immunocompetent adults in England: a matched cohort study using routine health data

BACKGROUND

Herpes zoster can cause rare but serious complications; the frequency of these complications has not been well described.

OBJECTIVES

To quantify the risks of acute non-postherpetic neuralgia (PHN) zoster complications, to inform vaccination policy.

METHODS

We conducted a cohort study among unvaccinated immunocompetent adults with incident zoster, and age-, sex- and practice-matched control adults without zoster, using routinely collected health data from the UK Clinical Practice Research Datalink (years 2001 to 2018). Crude attributable risks of complications were estimated as the difference between Kaplan-Meier-estimated 3-month cumulative incidences in patients with zoster vs. controls. We used Cox models to obtain hazard ratios for our primary outcomes in patients with and without zoster. Primary outcomes were ocular, neurological, cutaneous, visceral and zoster-specific complications. We also assessed whether antivirals during acute zoster protected against the complications.

RESULTS

In total 178 964 incident cases of zoster and 1 799 380 controls were included. The absolute risks of zoster-specific complications within 3 months of zoster diagnosis were 0·37% [95% confidence interval (CI) 0·34-0·39] for Ramsay Hunt syndrome, 0·01% (95% CI 0·0-0·01) for disseminated zoster, 0·04% (95% CI 0·03-0·05) for zoster death and 0·97% (95% CI 0·92-1·00) for zoster hospitalization. For other complications, attributable risks were 0·48% (95% CI 0·44-0·51) for neurological complications, 1·33% (95% CI 1·28-1·39) for ocular complications, 0·29% (95% CI 0·26-0·32) for cutaneous complications and 0·78% (95% CI 0·73-0·84) for visceral complications. Attributable risks were higher among patients > 50 years old. Patients with zoster had raised risks of all primary outcomes relative to controls. Antiviral prescription was associated with reduced risk of neurological complications (hazard ratio 0·61, 95% CI 0·53-0·70).

CONCLUSIONS

Non-PHN complications of zoster were relatively common, which may affect cost-effectiveness calculations for zoster vaccination. Clinicians should be aware that zoster can lead to various complications, besides PHN.

Effectiveness of a serious game addressing guideline adherence: cohort study with 1.5-year follow-up

BACKGROUND

Patients presenting with acute shortness of breath and chest pain should be managed according to guideline recommendations. Serious games can be used to train clinical reasoning. However, only few studies have used outcomes beyond student satisfaction, and most of the published evidence is based on short-term follow-up. This study investigated the effectiveness of a digital simulation of an emergency ward regarding appropriate clinical decision-making.

METHODS

In this prospective trial that ran from summer 2017 to winter 2018/19 at Göttingen Medical University Centre, a total of 178 students enrolled in either the fourth or the fifth year of undergraduate medical education took six 90-min sessions of playing a serious game ('training phase') in which they managed virtual patients presenting with various conditions. Learning outcome was assessed by analysing log-files of in-game activity (including choice of diagnostic methods, differential diagnosis and treatment initiation) with regard to history taking and patient management in three virtual patient cases: Non-ST segment elevation myocardial infarction (NSTEMI), pulmonary embolism (PE) and hypertensive crisis. Fourth-year students were followed up for 1.5 years, and their final performance was compared to the performance of students who had never been exposed to the game but had otherwise taken the same five-year undergraduate course.

RESULTS

During the training phase, overall performance scores increased from 57.6 ± 1.1% to 65.5 ± 1.2% (p < 0.001; effect size 0.656). Performance remained stable over 1.5 years, and the final assessment revealed a strong impact of ever-exposure to the game on management scores (72.6 ± 1.2% vs. 63.5 ± 2.1%, p < 0.001; effect size 0.811). Pre-exposed students were more than twice as likely to correctly diagnose NSTEMI and PE and showed significantly greater adherence to guideline recommendations (e.g., troponin measurement and D-dimer testing in suspected PE).

CONCLUSIONS

The considerable difference observed between previously exposed and unexposed students suggests a long-term effect of using the game although retention of specific virtual patient cases rather than general principles might partially account for this effect. Thus, the game may foster the implementation of guideline recommendations.

Barely sufficient practices in scientific computing

The importance of software to modern research is well understood, as is the way in which software developed for research can support or undermine important research principles of findability, accessibility, interoperability, and reusability (FAIR). We propose a minimal subset of common software engineering principles that enable FAIRness of computational research and can be used as a baseline for software engineering in any research discipline.