Does epidemiological evidence support the success story of Uganda's response to COVID-19?

Uganda has received praise for its success in dealing with the COVID-19 pandemic. This opinion piece uses publically available data from Johns Hopkins University to suggest that it is far from clear whether the Public Health and Social Measures (PHSM) introduced in Uganda influenced the course of the first outbreak. In addition, the analysis of data from the second and third waves in Uganda suggest that government action had little or no effect on these outbreaks. The dominant narrative of successful PHSM, therefore, needs to be reconsidered, and alternative explanations for the low rates of COVID-19-related mortality in the country need to be further understood.

The effectiveness of using virtual patient educational tools to improve medical students' clinical reasoning skills: a systematic review.

BACKGROUND: Use of virtual patient educational tools could fill the current gap in the teaching of clinical reasoning skills. However, there is a limited understanding of their effectiveness. The aim of this study was to synthesise the evidence to understand the effectiveness of virtual patient tools aimed at improving undergraduate medical students' clinical reasoning skills. METHODS: We searched MEDLINE, EMBASE, CINAHL, ERIC, Scopus, Web of Science and PsycINFO from 1990 to January 2022, to identify all experimental articles testing the effectiveness of virtual patient educational tools on medical students' clinical reasoning skills. Quality of the articles was assessed using an adapted form of the MERSQI and the Newcastle-Ottawa Scale. A narrative synthesis summarised intervention features, how virtual patient tools were evaluated and reported effectiveness. RESULTS: The search revealed 8,186 articles, with 19 articles meeting the inclusion criteria. Average study quality was moderate (M = 6.5, SD = 2.7), with nearly half not reporting any measurement of validity or reliability for their clinical reasoning outcome measure (8/19, 42%). Eleven articles found a positive effect of virtual patient tools on reasoning (11/19, 58%). Four reported no significant effect and four reported mixed effects (4/19, 21%). Several domains of clinical reasoning were evaluated. Data gathering, ideas about diagnosis and patient management were more often found to improve after virtual patient use (34/47 analyses, 72%) than application of knowledge, flexibility in thinking and problem-solving (3/7 analyses, 43%). CONCLUSIONS: Using virtual patient tools could effectively complement current teaching especially if opportunities for face-to-face teaching or other methods are limited, as there was some evidence that virtual patient educational tools can improve undergraduate medical students' clinical reasoning skills. Evaluations that measured more case specific clinical reasoning domains, such as data gathering, showed more consistent improvement than general measures like problem-solving. Case specific measures might be more sensitive to change given the context dependent nature of clinical reasoning. Consistent use of validated clinical reasoning measures is needed to enable a meta-analysis to estimate effectiveness.

Online patient simulation training to improve clinical reasoning: a feasibility randomised controlled trial.

BACKGROUND: Online patient simulations (OPS) are a novel method for teaching clinical reasoning skills to students and could contribute to reducing diagnostic errors. However, little is known about how best to implement and evaluate OPS in medical curricula. The aim of this study was to assess the feasibility, acceptability and potential effects of eCREST - the electronic Clinical Reasoning Educational Simulation Tool. METHODS: A feasibility randomised controlled trial was conducted with final year undergraduate students from three UK medical schools in academic year 2016/2017 (cohort one) and 2017/2018 (cohort two). Student volunteers were recruited in cohort one via email and on teaching days, and in cohort two eCREST was also integrated into a relevant module in the curriculum. The intervention group received three patient cases and the control group received teaching as usual; allocation ratio was 1:1. Researchers were blind to allocation. Clinical reasoning skills were measured using a survey after 1 week and a patient case after 1 month. RESULTS: Across schools, 264 students participated (18.2% of all eligible). Cohort two had greater uptake (183/833, 22%) than cohort one (81/621, 13%). After 1 week, 99/137 (72%) of the intervention and 86/127 (68%) of the control group remained in the study. eCREST improved students' ability to gather essential information from patients over controls (OR = 1.4; 95% CI 1.1-1.7, n = 148). Of the intervention group, most (80/98, 82%) agreed eCREST helped them to learn clinical reasoning skills. CONCLUSIONS: eCREST was highly acceptable and improved data gathering skills that could reduce diagnostic errors. Uptake was low but improved when integrated into course delivery. A summative trial is needed to estimate effectiveness.

Suspicious business: COVID-19 vaccination in Palabek refugee settlement, northern Uganda.

Dichotomised debates in public health discourse regarding COVID-19 vaccine supply and vaccine hesitancy do not capture the realities of vaccine uptake in Palabek refugee settlement, northern Uganda. Issues of supply, which analyse manufacture and distribution, foreground global inequalities and political influences. In contrast, vaccine hesitancy, emphasing rectifying deficiencies in knowledge and trust, leaves little room for the politics that shape vaccine uptake. The 'vaccine anxieties' framework problematises these dichotomised debates and proposes consideration of bodily, social and political dimensions. This article builds on the vaccine anxieties framework in relation to ethnographic research conducted in Palabek. Using the worldview of Acholi refugees from South Sudan, a focus on 'suspicious business' demonstrates that debates surrounding vaccine supply and hesitancy are intertwined, and, additionally, suggests spiritual elements should be paid greater attention. In Palabek, inconsistencies in distribution directly impacted vaccine uptake. Furthermore, vaccine interventions that built on deficiency models did not work. Vaccine uptake was inseparable from its biopolitical context that continued to perpetuate the same unequal dynamics of power and control that kept wealth circulating amongst certain powers, whilst others faced worsening precarity but remained perpetual recipients of humanitarian assistance and global health intervention, with little prospect of meaningful change. Suspicious business captures fluid dynamics that move between spiritual and physical realms, capturing wider geopolitical dynamics as they are revealed in everyday lives. In doing so, this flexible approach reveals the centrality of the politics of COVID-19, whilst constantly incorporating evolving dynamics. This flexibility provides potential for improving vaccine uptake, if wider geopolitical inequalities are addressed.

How do people who use drugs experience treatment? A qualitative analysis of views about opioid substitution treatment in primary care (iCARE study).

OBJECTIVE: To understand the most significant aspects of care experienced by people in opioid substitution treatment (OST) in primary care settings. DESIGN: Semistructured individual interviews were conducted, following the critical incidents technique. Interview transcripts were analysed following a thematic analysis approach. PARTICIPANTS: Adults aged 18 years or older, receiving OST in UK-based primary care services. RESULTS: Twenty-four people in OST were interviewed between January and March 2019. Participants reported several aspects which were significant for their treatment, when engaging with the primary care service. These were grouped into 10 major themes: (1) humanised care; (2) individual bond/connection with the professional; (3) professionals' experience and knowledge; (4) having holistic care; (5) familiarity; (6) professionals' commitment and availability to help; (7) anonymity; (8) location; (9) collaborative teamwork; and (10) flexibility and changes around the treatment plan. CONCLUSIONS: This study included first-hand accounts of people who use drugs about what supports them in their recovery journey. The key lessons learnt from our findings indicate that people who use drugs value receiving treatment in humanised and destigmatised environments. We also learnt that a good relationship with primary care professionals supports their recovery journey, and that treatment plans should be flexible, tailor-made and collaboratively designed with patients.

Pharmacologic intervention for retained placenta: a systematic review and meta-analysis.

OBJECTIVE: To assess the effectiveness and safety of pharmacologic interventions for the treatment of retained placenta (when the placenta remains undelivered after 30 minutes of active management of the third stage of labor). DATA SOURCES: We searched: 1) Cochrane Central Register of Controlled Trials (CENTRAL), 2) Cochrane Pregnancy and Childbirth Group's Trials Register, 3) EMBASE, and 4) MEDLINE from inception to June 2014. METHODS OF STUDY SELECTION: Randomized controlled trials comparing a pharmacologic intervention(s) with a placebo for the treatment of retained placenta were included. TABULATION, INTEGRATION, AND RESULTS: Sixteen randomized controlled trials, including 1,683 participants, were included. Study characteristics and quality were recorded. The meta-analysis was based on random-effects methods for pooled data. There were no statistically significant differences in the requirement to perform manual removal of a placenta in patients treated with oxytocin (55% compared with 60%; relative risk [RR] 0.86, 95% confidence interval [CI] 0.73-1.02; 10 randomized controlled trials [RCTs]), prostaglandins (44% compared with 55%; RR 0.82, 95% CI 0.58-1.15; four RCTs), nitroglycerin (85% compared with 80%; RR 1.06, 95% CI 0.80-1.41; one RCT), or oxytocin and nitroglycerin (52% compared with 79%; RR 0.23, 95% CI 0.01-8.48; two RCTs) compared with placebo. There was limited reporting of secondary outcomes. CONCLUSION: As opposed to the use of oxytocin as part of the active management of the third stage of labor that has been shown to diminish bleeding in the third stage, once the diagnosis of retained placenta has been made, no pharmacologic treatment has been shown to be effective. When retained placenta is diagnosed, immediate manual removal of the placenta should be considered. SYSTEMATIC REVIEW REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews, http://www.crd.york.ac.uk/PROSPERO/, CRD42014010641.