Retractions in the medical literature: how can patients be protected from risk?

A randomized trial alerting authors, with or without coauthors or editors, that research they cited in systematic reviews and guidelines has been retracted

Retracted clinical trials may be influential in citing systematic reviews and clinical guidelines. We assessed the influence of 27 retracted trials on systematic reviews and clinical guidelines (citing publications), then alerted authors to these retractions. Citing publications were randomized to up to three e-mails to contact author with/without up to two coauthors, with/without the editor. After one year we assessed corrective action. We included 88 citing publications; 51% (45/88) had findings likely to change if retracted trials were removed, 87% (39/45) likely substantially. 51% (44/86) of contacted citing publications replied. Including three authors rather than the contact author alone was more likely to elicit a reply (P = 0.03). Including the editor did not increase replies (P = 0.66). Whether findings were judged likely to change, and size of the likely change, had no effect on response rate or action taken. One year after e-mails were sent only nine publications had published notifications. E-Mail alerts to authors and editors are inadequate to correct the impact of retracted publications in citing systematic reviews and guidelines. Changes to bibliographic and referencing systems, and submission processes are needed. Citing publications with retracted citations should be marked until authors resolve concerns.

Analysis of retracted articles in the ophthalmic literature

BACKGROUND

To evaluate the frequency and reason for retraction of ophthalmology publications.

METHODS

Two independent reviewers retrieved data from PubMed and Medline using appropriate keywords. Statistical analysis was carried out using Mann-Whitney U test. A total of 83 articles were selected for the analysis between 1994 and 2019. Articles were retracted after a median of 1 year (IQR 4.0), and 55 (66.3%) articles were published in the year 2010 or after.

RESULTS

Forty-eight (57.8%) articles were original articles. The most common subspecialties involved were basic science (51.8%), followed by vitreoretinal diseases (13.3%) and cornea and external diseases (7.1%). Fraudulent data were the cause of retraction in 22 (26.5%) articles, and 14 articles (16.87%) were retracted because of plagiarism. Thirteen articles (15.7%) were retracted due to errors in the data calculations, and ten (12.04%) were found to be duplicate submissions of previously published articles by the same author, while five articles (6.02%) had authorship disputes. Thirty-nine (46.9%) retracted articles were published in a journal with an impact factor greater than 2. The median number of citations received by the retracted articles was 2.0 (IQR 9.0).

CONCLUSIONS

We conclude that the number of retractions in the ophthalmic literature have increased since 2010, though relatively limited information is available on the retracted articles. There is a need to strictly follow the current guidelines for providing the reasons for retraction and displaying retraction notices both in PubMed and on the journal websites.

Plagiarism, Fake Peer-Review, and Duplication: Predominant Reasons Underlying Retractions of Iran-Affiliated Scientific Papers

Retractions of scientific papers published by some Iran-affiliated scientists in the preceding decade have attracted much attention and publicity; however, the reasons for these retractions have not been documented. We searched the Retraction Watch Database to enumerate the retracted Iran-affiliated papers from December 2001 to December 2019 and aimed to outline the predominant reasons for retractions. The reasons included fake peer-review, authorship dispute, fabricated data, plagiarism, conflict of interest, erroneous data, and duplication. The Fisher's exact test was used to investigate the associations between retractions and their underlying reasons. We selected P < 0.05 to indicate the statistically significant differences. We found 697 retracted papers. Duplication (27%), plagiarism (26%), and fake peer-review (21%) were the most frequent reasons for retractions. Our study highlights the importance of urgent intervention to prevent the misconduct and questionable research practices that lead to retractions in Iran. Continually educating the scientists and postgraduate students about the ethics and norms of scientific publishing is an important measure to ensure publication of reliable, worthy, and impactful papers.

An investigation into the impact and implications of published papers from retracted research: systematic search of affected literature

OBJECTIVE

Analyses of the impact of a body of clinical trial reports subject to research misconduct have been few. Our objective was to examine the impact on clinically relevant research of a group of researchers' trial reports ('affected trial reports') affected by research misconduct, and whether identification of misconduct invoked a reappraisal.

DESIGN

In 2016, we used five databases and search engines to identify 'citing publications', that is, guidelines, systematic and other reviews, and clinical trials citing any of 12 affected trial reports, published 1998-2011, eventually retracted for research misconduct. The affected trial reports were assessed more likely to have had impact because they had hip fracture outcomes and were in journals with impact factor >4. Two authors assessed whether findings of the citing publications would change if the affected trial reports were removed. In 2018, we searched for evidence that the citing publications had undertaken a reassessment as a result of the potential influence of the affected trial reports.

RESULTS

By 2016 the affected trial reports were cited in 1158 publications, including 68 systematic reviews, meta-analyses, narrative reviews, guidelines and clinical trials. We judged that 13 guidelines, systematic or other reviews would likely change their findings if the affected trial reports were removed, and in another eight it was unclear if findings would change. By 2018, only one of the 68 citing publications, a systematic review, appeared to have undertaken a reassessment, which led to a correction.

CONCLUSIONS

We found evidence that this group of affected trial reports distorted the evidence base. Correction of these distortions is slow, uncoordinated and inconsistent. Unless there is a rapid, systematic, coordinated approach by bibliographic databases, authors, journals and publishers to mitigate the impact of known cases of research misconduct, patients, other researchers and their funders may continue to be adversely affected.

Antigen-based immunotherapies do not prevent progression of recent-onset autoimmune diabetes: a systematic review and meta-analysis

We performed a systematic review and meta-analysis to assess the efficacy and safety of antigen-based immunotherapies in tertiary prevention of autoimmune diabetes. We searched for randomised controlled trials testing antigen-based immunotherapies in patients with recent-onset type 1 diabetes or latent autoimmune diabetes of adults in MEDLINE, COCHRANE and EMBASE databases, trial registries, conference proceedings and reference lists of pertinent records. Primary outcomes were fasting and stimulated C-peptide (after glucagon or mixed meal stimulation). Change in glycosylated haemoglobin (HbA_1c), daily insulin needs and incidence of any or severe hypoglycaemic events or severe adverse events were secondary outcomes. Fifteen studies were included in the meta-analysis. Overall, there was no difference in fasting [weighted mean difference (WMD) 0.01 nmol/L; 95 % confidence interval (CI) -0.09, 0.11; I ² = 73 %] or mixed meal stimulated C-peptide (WMD 0.02 nmol/L/min; 95 % CI -0.08, 0.12; I ² = 50 %) compared with placebo. Glucagon stimulated C-peptide was maintained higher (WMD 0.13 nmol/L/min; 95 % CI 0.05, 0.21; I ² = 0 %) in patients treated with Diapep277. Moreover, there was no change in daily insulin needs (WMD 0.02 IU/kg; 95 % CI -0.04, 0.09; I ² = 51 %) or HbA_1c (WMD -0.06 %; 95 % CI -0.35, 0.23; I ² = 42 %) vs. placebo. Finally, there was no effect on the incidence of severe hypoglycaemic events or overall serious adverse events [risk ratio 0.94, 95 % CI 0.62, 1.41; I ² = 0 % and 0.87; 95 % CI 0.53, 1.44; I ² = 0 %, respectively). Antigen-based immunotherapies are not effective in preventing the progression of autoimmune diabetes in newly diagnosed patients.

A 'reluctant' critical review: 'Manual for evidence-based clinical practice (2015)'

BACKGROUND

The Users' Guides to the Medical Literature Manual has been a major influence on the teaching and practice of health care globally.

METHODS

The 3rd edition of the multi-authored Manual was reviewed using the principles outlined in Evidence-based Medicine (EBM) texts. One 'clinical scenario' was selected for critical appraisal, as were several chapters; objectivity was enhanced by citing references to support opinions. RESULTS (SUMMARY OF THE APPRAISAL): (1) Strengths: Clinical pearls, too numerous to list.

EXAMPLES

(i) evidence is never enough to drive clinical decision making; (ii) do not rush to adopt new interventions; and (iii) question efficacy data based only on surrogate markers. (2) Weaknesses: The Manual shares shortcomings of textbooks discussed by Straus et al.: (i) references may not be current, important ones may be excluded and citations may be selective; (ii) often, opinion-based; and (iii) delays between revisions. (3) Notable omissions: Little or no discussion of: (i) important segments of the population: those <18 years of age, >65 years of age and those with multimorbidity; (ii) surgical disciplines; (iii) Greenhalgh et al.'s essay on EBM; (iv) alternate views on the hierarchy of evidence; and (vi) critical thinking. (4) Additional issues: (i) Omission of important references on dabigatran (clinical scenario: chapter 13.1); (ii) authors' advice (Chapter 13.3) to 'bypass the discussion section of published research'; and (iii) the advocacy of pre-appraised sources of evidence and network meta-analysis without warnings about limitations, are critiqued.

CONCLUSION

The Manual has several clinical pearls but readers should also be aware of shortcomings.

Reference accuracy: authors', reviewers', editors', and publishers' contributions

Scientific authors are responsible for the accuracy of their writings and references to others' works. However, relying on authors is not enough when it comes to processing their manuscripts. Joint efforts of authors, peer reviewers, editors, and publishers throughout the publishing process may prevent most reference errors. This article analyzes essential aspects of bibliographic management and focuses on the importance of validating references by all stakeholders of scholarly publishing.

Evidence-informed person-centred health care (part II): are 'cognitive biases plus' underlying the EBM paradigm responsible for undermining the quality of evidence?

INTRODUCTION

Recently, some leaders of the evidence-based medicine (EBM) movement drew attention to the "unintended" negative consequences associated with EBM. The term 'cognitive biases plus' was introduced in part I to encompass cognitive biases, conflicts of interests, fallacies and certain behaviours.

HYPOTHESIS

'Cognitive biases plus' in those closely involved in creating and promoting the EBM paradigm are responsible for their (1) inability to anticipate and then recognize flaws in the tenets of EBM; (2) discounting alternative views; and (3) delaying reform.

METHODS

A narrative review style was used, with methods as in part I.

APPRAISAL OF LITERATURE

Over the past two decades there has been mounting qualitative and quantitative methodological evidence to suggest that the faith placed in (1) the EBM hierarchy with randomized controlled trials and systematic reviews at the summit; (2) the reliability of biostatistical methods to quantitate data; and (3) the primacy of sources of pre-appraised evidence, is seriously misplaced. Consequently, the evidence that informs person-centred care is compromised.

DISCUSSION

Arguments focusing on 'cognitive biases plus' are offered to support our hypothesis. To the best of our knowledge, EBM proponents have not provided an explanation.

CONCLUSIONS

Reform is urgently needed to minimize continuing risks to patients. If our hypothesis is correct, then in addition to the suggestions made in part I, deficiencies in the paradigm must be corrected. Meaningful solutions are only possible if the biases of scientific inbreeding and groupthink are minimized by collaboration between EBM leaders and those who have been sounding warning bells.

Evidence-informed person-centered healthcare part I: do 'cognitive biases plus' at organizational levels influence quality of evidence?

INTRODUCTION

There is increasing concern about the unreliability of much of health care evidence, especially in its application to individuals.

HYPOTHESIS

Cognitive biases, financial and non-financial conflicts of interest, and ethical violations (which, together with fallacies, we collectively refer to as 'cognitive biases plus') at the levels of individuals and organizations involved in health care undermine the evidence that informs person-centred care.

METHODS

This study used qualitative review of the pertinent literature from basic, medical and social sciences, ethics, philosophy, law etc.

RESULTS

Financial conflicts of interest (primarily industry related) have become systemic in several organizations that influence health care evidence. There is also plausible evidence for non-financial conflicts of interest, especially in academic organizations. Financial and non-financial conflicts of interest frequently result in self-serving bias. Self-serving bias can lead to self-deception and rationalization of actions that entrench self-serving behaviour, both potentially resulting in unethical acts. Individuals and organizations are also susceptible to other cognitive biases. Qualitative evidence suggests that 'cognitive biases plus' can erode the quality of evidence.

CONCLUSIONS

'Cognitive biases plus' are hard wired, primarily at the unconscious level, and the resulting behaviours are not easily corrected. Social behavioural researchers advocate multi-pronged measures in similar situations: (i) abolish incentives that spawn self-serving bias; (ii) enforce severe deterrents for breaches of conduct; (iii) value integrity; (iv) strengthen self-awareness; and (v) design curricula especially at the trainee level to promote awareness of consequences to society. Virtuous professionals and organizations are essential to fulfil the vision for high-quality individualized health care globally.

A Bibliometric Analysis of an International Research Ethics Trainee Program

We used bibliometric analysis to evaluate the citations associated with publications by trainees in the Fogarty International Center's International Research Ethics Education and Curriculum Development program. Papers published between 2004 and 2008 were identified for analysis. The outcome measures were total citations, h-index, and i-10. A total of 328 manuscripts were identified, with a yearly average of 66 publications and 363 citations. The median number of citations per paper is 3 (IQR Q1–Q3:6). 12.6% (n = 53) of papers were cited over 10 times and the h-index is 22, indicating that 22 papers had been cited at least 22 times. The data indicate that trainees have been productive and contributed to the scholarly literature. Future studies to benchmark this performance with other bioethics education programs are required to make interpretation of citation analysis more meaningful.

Application of methods for central statistical monitoring in clinical trials

Background

On-site source data verification is a common and expensive activity, with little evidence that it is worthwhile. Central statistical monitoring (CSM) is a cheaper alternative, where data checks are performed by the coordinating centre, avoiding the need to visit all sites. Several publications have suggested methods for CSM; however, few have described their use in real trials.

Methods

R-programs were created to check data at either the subject level (7 tests within 3 programs) or site level (9 tests within 8 programs) using previously described methods or new ones we developed. These aimed to find possible data errors such as outliers, incorrect dates, or anomalous data patterns; digit preference, values too close or too far from the means, unusual correlation structures, extreme variances which may indicate fraud or procedural errors and under-reporting of adverse events. The methods were applied to three trials, one of which had closed and has been published, one in follow-up, and a third to which fabricated data were added. We examined how well the methods work, discussing their strengths and limitations.

Results

The R-programs produced simple tables or easy-to-read figures. Few data errors were found in the first two trials, and those added to the third were easily detected. The programs were able to identify patients with outliers based on single or multiple variables. They also detected (1) fabricated patients, generated to have values too close to the multivariate mean, or with too low variances in repeated measurements, and (2) sites which had unusual correlation structures or too few adverse events. Some methods were unreliable if applied to centres with few patients or if data were fabricated in a way which did not fit the assumptions used to create the programs. Outputs from the R-programs are interpreted using examples.

Limitations

Detecting data errors is relatively straightforward; however, there are several limitations in the detection of fraud: some programs cannot be applied to small trials or to centres with few patients (<10) and data falsified in a manner which does not fit the program’s assumptions may not be detected. In addition, many tests require a visual assessment of the output (showing flagged participants or sites), before data queries are made or on-site visits performed.

Conclusions

CSM is a worthwhile alternative to on-site data checking and may be used to limit the number of site visits by targeting only sites which are picked up by the programs. We summarise the methods, show how they are implemented and that they can be easy to interpret. The methods can identify incorrect or unusual data for a trial subject, or centres where the data considered together are too different to other centres and therefore should be reviewed, possibly through an on-site visit.

Promoting research integrity in Africa: an African voice of concern on research misconduct and the way forward

African researchers and their collaborators have been making significant contributions to useful research findings and discoveries in Africa. Despite evidence of scientific misconduct even in heavily regulated research environments, there is little documented information that supports prevalence of research misconduct in Africa. Available literature on research misconduct has focused on the developed world, where credible research integrity systems are already in place. Public attention to research misconduct has lately increased, calling for attention to weaknesses in current research policies and regulatory frameworks. Africa needs policies, structural and governance systems that promote responsible conduct of research. To begin to offset this relative lack of documented evidence of research misconduct, contributors working in various research institutions from nine African countries agreed to share their experiences to highlight problems and explore the need to identify strategies to promote research integrity in the African continent. The experiences shared include anecdotal but reliable accounts of previously undocumented research misconduct, including some 'normal misbehavior' of frontline staff in those countries. Two broad approaches to foster greater research integrity are proposed including promotion of institutional and individual capacity building to instil a culture of responsible research conduct in existing and upcoming research scientist and developing deterrent and corrective policies to minimize research misconduct and other questionable research practices. By sharing these experiences and through the strategies proposed, the authors hope to limit the level of research misconduct and promote research integrity in Africa.

Writing for publication in a medical journal

The essence of writing for publication in the medical field is distilled into a dozen precepts to guide the anxious author. These precepts focus on the attitude of the writer, rather than the mechanics of writing. A medical author must strive to be the following: Original, honest, innovative, organized, careful, clear, modest, fair-minded, frank, persistent, rigorous, and realistic. These attributes are essential because there is a new climate of skepticism among the lay public as to the validity of scientific and medical claims. This climate has encouraged journal editors to be demanding of authors and to be especially vigilant about plagiarism; originality of all contributions is therefore essential.