Development and evaluation of an educational game to support pharmacy students.

INTRODUCTION: United Kingdom pharmacy students need to efficiently navigate the British National Formulary (BNF), a standard medicines reference source. "Pharmacy Challenge" is a web-based prototype game based on the BNF. This research aimed to evaluate the game in terms of design, content, and impact on students' performance and confidence. METHODS: Evaluation was comprised of three phases: implementation, perception, and impact. Game design and evaluation methods were modelled using adapted elements of the Relevance Embedding Translation Adaption Immersion and Naturalisation framework. Qualitative and quantitative questionnaires were utilised to assess students' perceptions of the game and its role in their education and to evaluate changes in confidence and performance after playing the game. Quizzes were developed to determine changes in performance. RESULTS: The questionnaire evaluation (n = 152) found students' confidence increased significantly (p < .05) in speed of using, knowledge of BNF sections, extracting information, and knowing where to look for the answer. Most students (88%) felt they had learnt something new and 86% felt that it reinforced their learning. A significant (p < .05) increase in pre- and post- BNF quiz marks was observed. CONCLUSIONS: Statistically significant improvement in students' perceived confidence was noted. The study identified design elements such as the need for a simple interface to encourage engagement. The prototype has undergone a design transformation based on the feedback provided and is now released under the name "DOSE" with a bank of 300 questions, improved graphics, a leadership board, and medals.

Creating a Theoretically Grounded, Gamified Health App: Lessons From Developing the Cigbreak Smoking Cessation Mobile Phone Game.

BACKGROUND: Gaming techniques are increasingly recognized as effective methods for changing behavior and increasing user engagement with mobile phone apps. The rapid uptake of mobile phone games provides an unprecedented opportunity to reach large numbers of people and to influence a wide range of health-related behaviors. However, digital interventions are still nascent in the field of health care, and optimum gamified methods of achieving health behavior change are still being investigated. There is currently a lack of worked methodologies that app developers and health care professionals can follow to facilitate theoretically informed design of gamified health apps. OBJECTIVE: This study aimed to present a series of steps undertaken during the development of Cigbreak, a gamified smoking cessation health app. METHODS: A systematic and iterative approach was adopted by (1) forming an expert multidisciplinary design team, (2) defining the problem and establishing user preferences, (3) incorporating the evidence base, (4) integrating gamification, (5) adding behavior change techniques, (6) forming a logic model, and (7) user testing. A total of 10 focus groups were conducted with 73 smokers. RESULTS: Users found the app an engaging and motivating way to gain smoking cessation advice and a helpful distraction from smoking; 84% (62/73) of smokers said they would play again and recommend it to a friend. CONCLUSIONS: A dedicated gamified app to promote smoking cessation has the potential to modify smoking behavior and to deliver effective smoking cessation advice. Iterative, collaborative development using evidence-based behavior change techniques and gamification may help to make the game engaging and potentially effective. Gamified health apps developed in this way may have the potential to provide effective and low-cost health interventions in a wide range of clinical settings.

The regulation of trophoblast migration across endothelial cells by low shear stress: consequences for vascular remodelling in pregnancy.

AIMS: In early human pregnancy placental trophoblasts migrate along uterine spiral arteries (SAs) and remodel these vessels into wide-bore conduits in a process essential for successful pregnancy. Until 10-12 weeks gestation trophoblasts plug spiral arteries, resulting in slow, high-resistance blood flow. This work examined the consequences of these low shear stress conditions on trophoblast migration, adhesion molecule expression, and attraction to chemotactic factors. METHODS AND RESULTS: Trophoblasts were cultured on fibronectin or human endothelial cells for 6-12 h under 0.5-6 dyne/cm(2) shear stress using the BioFlux200 system, and imaged by time-lapse microscopy. Computer-based imaging algorithms were developed to automatically quantify migration. Chemotaxis assays were run using parallel flow. Trophoblasts cultured on fibronectin or endothelial cells did not undergo directional migration in 0.5 and 2 dyne/cm(2) cultures; however, in 4 and 6 dyne/cm(2) trophoblasts migrated with the direction of flow (n= 4, P< 0.001). Shear stresses did not affect the speed of trophoblast migration, or adhesion molecule expression (E-selectin, α(4), ß(1), and α(v)ß(3) integrin). Trophoblasts cultured on endothelial cells migrated into media containing interleukin-8, macrophage chemoattractant protein-1, or Regulated-upon-Activation-Normal-T-cell-Expressed-and-Secreted (RANTES) (n= 5, P< 0.05). CONCLUSIONS: Shear stress increases trophoblast migration in the direction of flow, challenging the idea that trophoblasts migrate down spiral arteries retrograde to flow. This suggests that low shear stresses generated by trophoblast plugging of spiral arteries in the first trimester may favour arterial remodelling by preventing the migration with flow seen at higher shear stresses, allowing trophoblasts to migrate down the arteries in response to alternate stimuli such as uterine or endothelial cell-derived chemotactic factors.

The use of anthropometric proportion indices in the measurement of facial attractiveness.

This study used anthropometric data in the form of Farkas' proportion indices in order to quantify facial attractiveness, and to relate measured change through surgery, to clinical judgement. Standardized photographs of 15 orthognathic patients were used in album form and rated by 10 experienced clinicians: album 1 for facial attractiveness (before surgery) and album 2 for improvement in facial attractiveness (before and after surgery). Twenty-five proportion indices were selected and linear measurements recorded from the pre- and post-surgical photographs. The corresponding change in indices and in clinicians' scores were compared. The clinicians' assessment of the degree of improvement in facial appearance achieved through surgery, related closely to the scores produced by the change in proportion indices (r = 0.698, P = 0.004). Clinical assessment demonstrated a clear inverse relationship between initial attractiveness rating and the degree of improvement achieved through orthognathic surgery (r = -0.781, P = 0.001). The results showed good repeatability in terms of clinical assessment, photography and digitization. The method would appear to have potential for further development, possibly into a 'facial attractiveness index' for the objectives of quantification of improvement achieved through treatment.

A computerized photographic assessment of the relationship between skeletal discrepancy and mandibular outline asymmetry.

The aim of this study was to investigate the relationship between mandibular outline asymmetry and skeletal discrepancy in a sample of orthodontic patients (33 females, 33 males) aged from 8 to 19 years. Skeletal discrepancy was assessed in both the anteroposterior and vertical planes, using standard cephalometric analyses. All were photographed under standardized conditions and the photographs were then digitized for analysis using a computerized system to assess differences in four variables (area, perimeter, compactness and moment-ratio) between the right and left sides of the mandibular outline. The results showed good repeatability of the photographic, cephalometric and digitization methods. A statistically significant relationship was found between mandibular outline asymmetry and both anteroposterior and vertical skeletal discrepancy in this sample, when compared with patients with an average skeletal pattern. There appeared to be a statistically significant relationship between a reduced ANB angle (< 3 degrees) and mandibular outline asymmetry (P = 0.051), as well as between an increase in lower face height and mandibular asymmetry (P = 0.023).

Comparison of radiographic and photographic measurement of mandibular asymmetry.

This study compared measurement of mandibular asymmetry by digitization of mandibular outlines from standardized facial photographs and posteroanterior cephalometric radiographs. Four ratios were used in calculating asymmetry: area (relative size of right and left mandibular segments), perimeter or length of outlines, compactness (shape), and moment. The records of 28 patients with varying degrees of asymmetry were used. A significant relationship was found for 3 of the ratios (area, compactness, and moment) between measurements from photographs and radiographs. A further comparison showed that measurements from the radiographs correlated more closely with those from photographs when the mastoid processes were used as a baseline, rather than latero-orbitale. Repeatability of mandibular outline digitization proved satisfactory. Although digitization from standardized photographs is the preferred approach, the results indicated that posteroanterior cephalometric radiographs can be used similarly. Unlike other cephalometric analyses for mandibular asymmetry, this method avoids problems of landmark identification, thus presenting a clinically useful method of quantifying asymmetry, eg, in auditing the surgical-orthodontic correction of asymmetry or monitoring change over time.

Mandibular outline assessment in three groups of orthodontic patients.

The feasibility of using computer-based parameters for quantifying mandibular asymmetry was investigated. Four methods of calculating asymmetry were used, based on the digitized facial photographs of three groups of patients: those with no observable asymmetry, a group with mild asymmetry, and a group presenting for orthognathic surgery. Three of the methods involved right/left difference ratios, namely, area, perimeter length, and compactness. The fourth, moment ratio (centre of area), was expressed as a percentage. Repeatability of both photography and digitization proved satisfactory, the standard deviation of the differences between repeated photographs being 0.016 and 0.014 for area and compactness ratios, respectively. Area, perimeter, and compactness successfully discriminated between the three groups. For area, median ratios (deviations from 1.00) for the 'normal', 'mild asymmetry', and 'surgical' groups were 0.015, 0.030, and 0.078, respectively. Those patients in the surgical group for whom asymmetry correction had been the main reason for surgery recorded higher asymmetry scores than the other subjects in that group. Moment ratio did not adequately distinguish between the three groups. Better repeatability for digitization was found when a baseline involving the ear insertions was used, than either the outer or inner canthi of the eyes. The potential uses of this approach are presented in relation to clinically relevant mild asymmetry, as well as auditing the outcome of surgical correction.

Outcome measurement in the correction of mandibular asymmetry.

This study related clinical assessments of the severity of mandibular asymmetry with computerized measurements, obtained by digitizing mandibular outlines from standardized facial photographs. Four ratios were calculated: area (size), compactness (shape), perimeter (length of outline), and moment (center of area). When comparing clinical severity with computer assessment, significant correlations were observed; those for area and compactness were the highest. Sixteen patients subsequently underwent corrective surgery, and their ratios were used to relate the degree of improvement to the original severity of the asymmetry. The posttreatment ratios were also used to audit the outcome, comparing the patients' scores as a group with results previously obtained from patients with normal symmetry and mild asymmetry. Posttreatment outcomes were significantly different from the normal outline group but were comparable with outcomes of patients with mild mandibular asymmetry. The system provided a sensitive, noninvasive method of assessing treatment change and could be useful in providing an objective means of quantifying treatment outcomes.