Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: There is a worldwide shortage of health workers, requiring innovative education solutions. Serious gaming and gamification education has the potential to provide a quality, cost-effective, novel approach, which is flexible, portable, enjoyable, and allows interaction with tutors and peers. Objective: The aim of this systematic review was to evaluate the effectiveness of serious gaming/gamification for health professions education compared with traditional learning, other types of digital education , or other serious gaming/gamification interventions, in terms of patient outcomes, knowledge, skills, professional attitudes and satisfaction (primary outcomes) and education economics outcomes and adverse events (secondary outcomes). Methods: A comprehensive search of MEDLINE, EMBASE, Web of Knowledge, Educational Resources Information Centre, Cochrane Central Register of Controlled Trials, PsycINFO and CINAHL from 1990 to August 2017 was conducted. Randomized controlled trials (RCTs) and cluster RCTs (cRCTs) were eligible for inclusion. Two reviewers independently searched, screened, assessed study quality and extracted data. Meta-analysis was not deemed appropriate due to heterogeneity of populations, interventions, comparisons and outcomes and a narrative synthesis is presented. Results: Twenty-seven RCTs and 3 cRCTs with 3634 participants were included. One study reported a small statistically significant difference between serious gaming and digital education for primary care physicians in time to blood pressure control among a subgroup of their patients already taking antihypertensive medications. There was evidence of moderate to large magnitude of effect from five studies evaluating individually delivered interventions for objectively measured knowledge compared with traditional learning. There was also evidence of small to large magnitude of effect from ten studies for improved skills compared with traditional learning. Two and four studies respectively suggested equivalence between interventions and controls. Evidence suggested serious gaming was at least as effective as other digital education modalities for these outcomes. There was insufficient evidence to conclude whether one type of serious gaming/gamification intervention is more effective than any other. There was limited evidence measuring effects on professional attitudes. Serious gaming/gamification may improve satisfaction but evidence was again limited. Evidence was low or very low quality for all outcomes. Quality of evidence was downgraded due to imprecision, inconsistency and study limitations. Conclusions: Serious gaming/gamification appears to be at least as effective as controls, and in many studies more effective, for improving knowledge, skills and satisfaction. However, the available evidence is mostly of low quality and calls for further rigorous, theory driven research.

School gardening programmes are increasingly popular, with suggested benefits including healthier eating and increased physical activity. Our objectives were to understand the health and well-being impacts of school gardens and the factors that help or hinder their success. We conducted a systematic review of quantitative and qualitative evidence (PROSPERO CRD42014007181). We searched multiple databases and used a range of supplementary approaches. Studies about school gardens were included if they reported on physical or mental health or well-being. Quantitative studies had to include a comparison group. Studies were quality appraised using appropriate tools. Findings were narratively synthesised and the qualitative evidence used to produce a conceptual framework to illustrate how benefits might be accrued. Evidence from 40 articles (21 quantitative studies; 16 qualitative studies; 3 mixed methods studies) was included. Generally the quantitative research was poor. Evidence for changes in fruit and vegetable intake was limited and based on self-report. The qualitative research was better quality and ascribed a range of health and well-being impacts to school gardens, with some idealistic expectations for their impact in the long term. Groups of pupils who do not excel in classroom activities were thought to particularly benefit. Lack of funding and over reliance on volunteers were thought to threaten success, while involvement with local communities and integration of gardening activities into the school curriculum were thought to support success. More robust quantitative research is needed to convincingly support the qualitative evidence suggesting wide ranging benefits from school gardens.

Background: There is currently conflicting evidence surrounding the effects of obesity on postoperative outcomes. Previous studies have found obesity to be associated with adverse events, but others have found no association. The aim of this study was to determine whether increasing body mass index (BMI) is an independent risk factor for development of major postoperative complications. Methods: This was a multicentre prospective cohort study across the UK and Republic of Ireland. Consecutive patients undergoing elective or emergency gastrointestinal surgery over a 4-month interval (October–December 2014) were eligible for inclusion. The primary outcome was the 30-day major complication rate (Clavien–Dindo grade III–V). BMI was grouped according to the World Health Organization classification. Multilevel logistic regression models were used to adjust for patient, operative and hospital-level effects, creating odds ratios (ORs) and 95 per cent confidence intervals (c.i.). Results: Of 7965 patients, 2545 (32·0 per cent) were of normal weight, 2673 (33·6 per cent) were overweight and 2747 (34·5 per cent) were obese. Overall, 4925 (61·8 per cent) underwent elective and 3038 (38·1 per cent) emergency operations. The 30-day major complication rate was 11·4 per cent (908 of 7965). In adjusted models, a significant interaction was found between BMI and diagnosis, with an association seen between BMI and major complications for patients with malignancy (overweight: OR 1·59, 95 per cent c.i. 1·12 to 2·29, P = 0·008; obese: OR 1·91, 1·31 to 2·83, P = 0·002; compared with normal weight) but not benign disease (overweight: OR 0·89, 0·71 to 1·12, P = 0·329; obese: OR 0·84, 0·66 to 1·06, P = 0·147). Conclusion: Overweight and obese patients undergoing surgery for gastrointestinal malignancy are at increased risk of major postoperative complications compared with those of normal weight.

Background and Aims: There is concern that young people may be attracted to e‐liquid flavours, prompting long‐term vaping in naive users and potentially subsequent tobacco smoking. We aimed to review the use of e‐liquid flavours by young people and describe associations with uptake or cessation of both regular vaping and tobacco smoking, adverse effects and subjective experiences.Design: Systematic review, including interventional, observational and qualitative studies reporting on the use of e‐cigarette flavours by young people (aged < 18 years).Setting: Studies published in English language from any country or cultural setting.Participants: Young people and their carers (aged < 18 years).Measurements: A meta‐analysis was not possible due to substantial heterogeneity, inconsistency in reporting of flavour categorizations and non‐interventional study designs; thus, we narratively report findings.Findings: In total, 58 studies were included. The quality of the evidence was extremely low. Most (n = 39) studies were cross‐sectional survey designs. In total, 11 longitudinal cohort studies assessed trajectories; eight qualitative studies reported on user experiences. Studies reported views and experiences of a total of 512 874 young people. Both cross‐sectional and longitudinal studies suggested that flavours are important for initiation and continuation of vaping. Qualitative evidence shows interest and enjoyment in flavours. There was judged to be insufficient evidence that use of e‐liquid flavours specifically is associated with uptake of smoking. No studies found clear associations between flavours and cessation in this population. We found no included reports of adverse effects of flavours.Conclusions: Flavours may be an important motivator for e‐cigarette uptake, but the role of flavours in tobacco smoking uptake or cessation is unclear. The quality of the evidence on use of e‐cigarette flavours by young people is low overall.