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Uygur J, Stuart E, De Paor M, Wallace E, Duffy S, O'Shea M, Smith S, Pawlikowska T. A Best Evidence in Medical Education systematic review to determine the most effective teaching methods that develop reflection in medical students: BEME Guide No. 51. Med Teach 2019; 41:3-16. [PMID: 30634872 DOI: 10.1080/0142159x.2018.1505037] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
INTRODUCTION Reflection is thought to be an essential skill for physicians. Although much has been written about it, there is little concurrence about how to best teach reflection in medical education. The aim of this review was to determine: (i) which educational interventions are being used to develop reflection, (ii) how is reflection being assessed, and (iii) what are the most effective interventions. METHODS Inclusion criteria comprised: (i) undergraduate medical students, (ii) a teaching intervention to develop reflection, and (iii) assessment of the intervention. A review protocol was developed and nine databases were searched. Screening, data extraction, and analysis procedures were performed in duplicate. Due to the heterogeneity of studies, a narrative synthesis approach was performed for the study analysis. RESULTS Twenty-eight studies met the inclusion criteria. The interventions in these studies had at least of two of the following components related to reflection: (i) introduction, (ii) trigger, (iii) writing, (iv) guidelines, (v) small group discussion, (vi) tutor and (vii) feedback. Three validated rubrics were used to assess reflective writing in these studies. CONCLUSIONS The strongest evidence from studies in this review indicates that guidelines for, and feedback on, reflective writing improve student reflection.
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Affiliation(s)
- Jane Uygur
- a Department of General Practice , RCSI , Dublin , Ireland
| | - Ellen Stuart
- a Department of General Practice , RCSI , Dublin , Ireland
| | | | - Emma Wallace
- a Department of General Practice , RCSI , Dublin , Ireland
| | - Seamus Duffy
- a Department of General Practice , RCSI , Dublin , Ireland
| | - Marie O'Shea
- b Health Professions Education Centre, RCSI , Dublin , Ireland
| | - Susan Smith
- a Department of General Practice , RCSI , Dublin , Ireland
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Bongard E, van der Velden AW, Cook J, Saville B, Beutels P, Munck Aabenhus R, Brugman C, Chlabicz S, Coenen S, Colliers A, Davies M, De Paor M, De Sutter A, Francis NA, Glinz D, Godycki-ćwirko M, Goossens H, Holmes J, Ieven M, de Jong M, Lindbaek M, Little P, Martinón-Torres F, Moragas A, Pauer J, Pfeiferová M, Radzeviciene-Jurgute R, Sundvall PD, Torres A, Touboul P, Varthalis D, Verheij T, Butler CC. Antivirals for influenza-Like Illness? A randomised Controlled trial of Clinical and Cost effectiveness in primary CarE (ALIC 4 E): the ALIC 4 E protocol. BMJ Open 2018; 8:e021032. [PMID: 30002007 PMCID: PMC6089276 DOI: 10.1136/bmjopen-2017-021032] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 05/01/2018] [Accepted: 06/14/2018] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Effective management of seasonal and pandemic influenza is a high priority internationally. Guidelines in many countries recommend antiviral treatment for older people and individuals with comorbidity at increased risk of complications. However, antivirals are not often prescribed in primary care in Europe, partly because its clinical and cost effectiveness has been insufficiently demonstrated by non-industry funded and pragmatic studies. METHODS AND ANALYSIS Antivirals for influenza-Like Illness? An rCt of Clinical and Cost effectiveness in primary CarE is a European multinational, multicentre, open-labelled, non-industry funded, pragmatic, adaptive-platform, randomised controlled trial. Initial trial arms will be best usual primary care and best usual primary care plus treatment with oseltamivir for 5 days. We aim to recruit at least 2500 participants ≥1 year presenting with influenza-like illness (ILI), with symptom duration ≤72 hours in primary care over three consecutive periods of confirmed high influenza incidence. Participant outcomes will be followed up to 28 days by diary and telephone. The primary objective is to determine whether adding antiviral treatment to best usual primary care is effective in reducing time to return to usual daily activity with fever, headache and muscle ache reduced to minor severity or less. Secondary objectives include estimating cost-effectiveness, benefits in subgroups according to age (<12, 12-64 and >64 years), severity of symptoms at presentation (low, medium and high), comorbidity (yes/no), duration of symptoms (≤48 hours/>48-72 hours), complications (hospital admission and pneumonia), use of additional prescribed medication including antibiotics, use of over-the-counter medicines and self-management of ILI symptoms. ETHICS AND DISSEMINATION Research ethics committee (REC) approval was granted by the NRES Committee South Central (Oxford B) and Clinical Trial Authority (CTA) approval by The Medicines and Healthcare products Regulatory Agency. All participating countries gained national REC and CTA approval as required. Dissemination of results will be through peer-reviewed scientific journals and conference presentations. TRIAL REGISTRATION NUMBER ISRCTN27908921; Pre-results.
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Affiliation(s)
- Emily Bongard
- The Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Alike W van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Johanna Cook
- The Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ben Saville
- Berry Consultants, Austin, Texas, USA
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Philippe Beutels
- Centre for Health Economics Research and Modelling Infectious Diseases (CHERMID), Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | | | - Curt Brugman
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Slawomir Chlabicz
- Department of Family Medicine and Community Nursing, Medical University of Bialystok, Bialystok, Poland
| | - Samuel Coenen
- Centre for General Practice, Department of Primary and Interdisciplinary Care (ELIZA), University of Antwerp, Antwerp, Belgium
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Annelies Colliers
- Centre for General Practice, Department of Primary and Interdisciplinary Care (ELIZA), University of Antwerp, Antwerp, Belgium
| | | | - Muireann De Paor
- Department of General Practice, Royal College of Surgeons in Ireland School of Medicine, Dublin, Ireland
| | - An De Sutter
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - Nick A Francis
- Department of Population Medicine, Cardiff University School of Medicine, Cardiff, UK
| | - Dominik Glinz
- University of Basel, Basel, Switzerland
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Maciek Godycki-ćwirko
- Department of Family and Community Medicine, Medical University of Lodz, Lodz, Poland
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Jane Holmes
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Margareta Ieven
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Menno de Jong
- Department of Medical Microbiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Morten Lindbaek
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Paul Little
- Primary Care and Population Science, University of Southampton, Southampton, UK
| | | | - Ana Moragas
- Primary Healthcare Centre Jaume I, Universitat Rovira i Virgili, Tarragona, Catalonia, Spain
| | | | - Markéta Pfeiferová
- Institute of General Practice, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | | | - Pär-Daniel Sundvall
- Närhälsan, Research and Development Primary Health Care, Region Västra Götaland, Research and Development Center Södra Älvsborg, Borås, Sweden
- Department of Public Health and Community Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Antoni Torres
- Department of Pulmonology, Hospital Clínic de Barcelona, Universitat de Barcelona and IDIBAPS, Barcelona, Spain
| | - Pia Touboul
- Department of Public Health, University Hospital of Nice, Nice, France
- Department of Teaching and Research in General Practice, University of Côte d’Azur, Nice, France
| | | | - Theo Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Christopher C Butler
- The Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Abstract
BACKGROUND Infectious mononucleosis (IM) is a clinical syndrome, usually caused by the Epstein Barr virus (EPV), characterised by lymphadenopathy, fever and sore throat. Most cases of symptomatic IM occur in older teenagers or young adults. Usually IM is a benign self-limiting illness and requires only symptomatic treatment. However, occasionally the disease course can be complicated or prolonged and lead to decreased productivity in terms of school or work. Antiviral medications have been used to treat IM, but the use of antivirals for IM is controversial. They may be effective by preventing viral replication which helps to keep the virus inactive. However, there are no guidelines for antivirals in IM. OBJECTIVES To assess the effects of antiviral therapy for infectious mononucleosis (IM). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3, March 2016), which contains the Cochrane Acute Respiratory Infections (ARI) Group's Specialised Register, MEDLINE (1946 to 15 April 2016), Embase (1974 to 15 April 2016), CINAHL (1981 to 15 April 2016), LILACS (1982 to 15 April 2016) and Web of Science (1955 to 15 April 2016). We searched the World Health Organization (WHO) International Clinical Trials Registry Platform and ClinicalTrials.gov for completed and ongoing trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing antivirals versus placebo or no treatment in IM. We included trials of immunocompetent participants of any age or sex with clinical and laboratory-confirmed diagnosis of IM, who had symptoms for up to 14 days. Our primary outcomes were time to clinical recovery and adverse events and side effects of medication. Secondary outcomes included duration of abnormal clinical examination, complications, viral shedding, health-related quality of life, days missing from school or work and economic outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, assessed the included studies' risk of bias and extracted data using a customised data extraction sheet. We used the GRADE criteria to rate the quality of the evidence. We pooled heterogeneous data where possible, and presented the results narratively where we could not statistically combine data. MAIN RESULTS We included seven RCTs with a total of 333 participants in our review. Three trials studied hospitalised patients, two trials were conducted in an outpatient setting, while the trial setting was unclear in two studies. Participants' ages ranged from two years to young adults. The type of antiviral, administration route, and treatment duration varied between the trials. The antivirals in the included studies were acyclovir, valomaciclovir and valacyclovir. Follow-up varied from 20 days to six months. The diagnosis of IM was based on clinical symptoms and laboratory parameters.The risk of bias for all included studies was either unclear or high risk of bias. The quality of evidence was graded as very low for all outcomes and so the results should be interpreted with caution. There were statistically significant improvements in the treatment group for two of the 12 outcomes. These improvements may be of limited clinical significance.There was a mean reduction in 'time to clinical recovery as assessed by physician' of five days in the treatment group but with wide confidence intervals (CIs) (95% CI -8.04 to -1.08; two studies, 87 participants). Prospective studies indicate that clinical signs and symptoms may take one month or more to resolve and that fatigue may be persistent in approximately 10% of patients at six-month follow-up, so this may not be a clinically meaningful result.Trial results for the outcome 'adverse events and side effects of medication' were reported narratively in only five studies. In some reports authors were unsure whether an adverse event was related to medication or complication of disease. These results could not be pooled due to the potential for double counting results but overall, the majority of trials reporting this outcome did not find any significant difference between treatment and control groups.There was a mean reduction in 'duration of lymphadenopathy' of nine days (95% CI -11.75 to -6.14, two studies, 61 participants) in favour of the treatment group.In terms of viral shedding, the overall effect from six studies was that viral shedding was suppressed while on antiviral treatment, but this effect was not sustained when treatment stopped.For all other outcomes there was no statistically significant difference between antiviral treatment and control groups. AUTHORS' CONCLUSIONS The effectiveness of antiviral agents (acyclovir, valomaciclovir and valacyclovir) in acute IM is uncertain. The quality of the evidence is very low. The majority of included studies were at unclear or high risk of bias and so questions remain about the effectiveness of this intervention. Although two of the 12 outcomes have results that favour treatment over control, the quality of the evidence of these results is very low and may not be clinically meaningful. Alongside the lack of evidence of effectiveness, decision makers need to consider the potential adverse events and possible associated costs, and antiviral resistance. Further research in this area is warranted.
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Affiliation(s)
- Muireann De Paor
- RCSI Medical SchoolHRB Centre for Primary Care Research, Department of General Practice123 St. Stephens GreenDublin 2Ireland
| | - Kirsty O'Brien
- RCSI Medical SchoolHRB Centre for Primary Care Research, Department of General Practice123 St. Stephens GreenDublin 2Ireland
| | - Tom Fahey
- RCSI Medical SchoolHRB Centre for Primary Care Research, Department of General Practice123 St. Stephens GreenDublin 2Ireland
| | - Susan M Smith
- RCSI Medical SchoolHRB Centre for Primary Care Research, Department of General Practice123 St. Stephens GreenDublin 2Ireland
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