Research highlights – 29 September 2010

Research questions “Research highlights” is a weekly round-up of research papers appearing in the print BMJ. We start off with this week’s research questions, before providing more detail on some individual research papers and accompanying articles.

Assessing workplace based assessment
For doctors, learning doesn’t stop after medical school: they have to complete courses, take professional exams, and keep up to date with good medical practice throughout their careers. One contribution to continuing professional development is “workplace based assessments,” in which a doctor’s day to day clinical performance and competence is evaluated in context. However, it’s fair to say that workplace based assessment is very time consuming and not very popular with either junior doctors or consultants.

Perhaps those who struggle with these assessments should pay heed to Alice Miller and Julian Archer’s research into how workplace based assessment affects physician education and performance. The authors conducted a systematic review of 16 studies, 15 of which were non-comparative descriptive or observational studies. They found that although most doctors considered that multisource feedback had educational value, there was little evidence that such feedback resulted in change in practice. However, doctors were more likely to report changing their practice when feedback was credible and accurate or when coaching was provided to help subjects identify their strengths and weaknesses.

Most notably, individual factors had a profound effect on the magnitude of doctors’ response to feedback, indicating that perhaps trainers need to tailor their responses to trainees to get the best performance. However, elsewhere in this week’s journal, T Horsley and colleagues argue that continuing professional development procedures like workplace based assessment should be more standardised, in particular across Europe.

Oseltamivir: another piece of the puzzle

In 2009 pandemic influenza A(H1N1) virus spread rapidly, resulting in millions of cases and more than 18,000 deaths in over 200 countries. Despite governments around the world spending billions of pounds on antivirals, the extent to which these drugs benefit otherwise healthy individuals with a mild 2009 H1N1 remains unknown, although these people represent the reservoir from which infection is transmitted to others.

Hongjie Yu and colleagues reviewed the medical records of 1291 patients in China who had laboratory confirmed mild H1N1 infection during the 2009 pandemic. Using multivariable logistic regression they found that oseltamivir treatment was a significant protective factor against subsequent development of radiographic pneumonia. This protective effect was seen in all patients, including those who started treatment more than two days after onset of symptoms—an interesting finding in view of the drive to start treatment as early as possible during the pandemic. They also found that treatment started within two days reduced the duration of fever and RNA viral shedding, and that 2009 H1N1 might be shed longer than seasonal influenza virus.
The authors, however, stress that their findings should be interpreted with caution. The study had some flaws, including its retrospective design and the fact that not all patients underwent chest radiography. They call for continued investigation into the effectiveness of antiviral treatment “to allow for improvement both in clinical treatment and public health guidance.”

It’s a call we support. A Cochrane review (2009;339:b5106) and investigation (2009;339:b5387) published in the BMJ last year questioned the evidence for the effectiveness and safety of oseltamivir. The inquiry into why relevant data were not publicly available for review cast doubt on the processes by which the drug had been evaluated, regulated, and promoted (BMJ 2009;339:b5351). The availability of new data will help to build a truer picture of the drug’s capabilities, so we welcome new high quality studies on the effectiveness of oseltamivir. But the authors are right to be cautious—and questions still remain over the public availability of data about the drug. As with all BMJ research papers, we are making this study freely available online for further scrutiny.

Research online: For these and other new research articles see

Reducing cardiovascular risk through diet in India
Circumstantial evidence indicates that poor diet in early life might increase a person’s sensitivity to lifestyle related risk factors for cardiovascular disease. Sanjay Kinra and colleagues sought to clarify this hypothesis by following up mothers and their offspring in the south of India who took part in a community trial of nutritional supplementation in 1987-90 (doi:10.1136/bmj.a605). They found that improving the protein-calorie intake of pregnant women and young children as part of other public health programmes was associated with a more favourable profile of cardiovascular risk factors in adolescence. Given that this intervention was cheap and relatively easy to implement, this approach could be an important tool for primary prevention of cardiovascular diseases in low income and middle income countries.

Osteoarthritis: evidence into practice

A poll by Journal Watch asked doctors whether the findings of Simon Wandel and colleagues’ meta-analysis —which indicated no benefit from chondroitin or glucosamine—would affect what they recommended to patients with osteoarthritis. Of 438 responders, 53% said they would stop recommending glucosamine and chondroitin to patients on the basis of this evidence; 27% said they’d keep recommending them; and 19% said the information was not applicable to their practice.