Publication: an ethical imperative

Registration of intervention trials of Traditional Chinese Medicine for four neurological diseases on Chinese Clinical Trial Registry and ClinicalTrials.gov: a narrative review

OBJECTIVE

To analyze the current status of clinical trial registration of Traditional Chinese Medicine (TCM) for the treatment of neurological diseases.

METHODS

Interventional clinical trials of TCM treatment for ischemic stroke, hemorrhagic stroke, vascular cognitive impairment, tension-type headache before September 22, 2020 on the platform of Chinese Clinical Trial Registry (ChiCTR), and ClinicalTrials.gov were searched. Two researchers independently selected the literature and extracted data.

RESULTS

A total of 180 interventional clinical trials were included for analysis. Out of 180 trials, 127 were from ChiCTR and 53 from ClinicalTrials.gov. The countries primary sponsoring the included trials were China (176, 97.8%), and the common categories of primary sponsors were hospital (131, 72.8%). Among the study design, the largest proportion of allocation was randomized (172, 95.6%), interventional model assignment was parallel (163, 90.6%), masking was double blind 49 (27.2%), and the sample size was ≤ 400 (144, 80.0%). The trials were most carried out at a single center (102, 56.7%). Among the included studies, 112 (62.2%) registered on ChiCTR attached the ethical approval documents. In terms of trial stages, 50 (27.7%) studies were in phase IV. The mostly used intervention was Chinese herbal medicines (99, 55%), acupuncture (68, 37.8%) was the second. By searching the registration number on China National Knowledge Infrastructure Database and PubMed, 38 (21.1%) registered trials were published, including 25 protocol studies and 14 research results with one (NCT02275949) published both the protocol and the results.

CONCLUSIONS

Irregular and inadequate reporting, untimely update and publication, insufficient information on traditional medicine unique characteristics, and lack of international collaborations are the problems existing in the interventional clinical registration trials of traditional medicine treatment on neurological diseases. More efforts need to be made from the above aspects to standardize and improve the registration of traditional medicine trials.

Publication bias in pediatric emergence delirium: a cross-sectional analysis of ClinicalTrials.gov and ClinicalTrialsRegister.eu

OBJECTIVES

Emergence delirium (ED) is a frequent and potentially serious complication of general anaesthesia in children. Although there are various treatment strategies, no general management recommendations can be made. Selective reporting of study results may impair clinical decision-making. We, therefore, analysed whether the results of completed registered clinical studies in patients with paediatric ED are publicly available or remain unpublished.

DESIGN

Cross-sectional analysis.

SETTING

ClinicalTrials.gov and ClinicalTrialsRegister.eu.

PARTICIPANTS AND OUTCOME MEASURES

We determined the proportion of published and unpublished studies registered at ClinicalTrials.gov and ClinicalTrialsRegister.eu that were marked as completed by 1st September 2018. The major trial and literature databases were used to search for publications. In addition, the study investigators were contacted directly. For published trials, time to publication was calculated as the difference in months between study completion date and publication date.

RESULTS

Of the 44 registered studies on paediatric ED, only 24 (54%) were published by September 2019. Published trials contained data from n=2556 patients, whereas n=1644 patients were enrolled in unpublished trials. Median time to publication was 19 months. Studies completed in recent years were published faster, but still only 9 of 24 trials were published within 12 months of completion.

CONCLUSION

There is a distinct publication gap in clinical research in paediatric ED that may have an impact on meta-analyses and clinical practice.

Publication status of completed registered studies in paediatric appendicitis: a cross-sectional analysis

OBJECTIVE

Appendicitis is considered the most frequent surgical emergency in children. While the management of paediatric appendicitis is evolving, the precise amount of unpublished completed trials, potentially introducing bias into meta-analyses, is unknown. Controversial issues include the appropriate choice of surgical procedures, criteria for diagnosis of appendicitis, the role of antibiotic treatment and pain management. Selective reporting may introduce bias into evidence-based clinical decision-making, and the current, precise extent of unpublished results in paediatric appendicitis is unknown. We therefore assessed the publication status of completed clinical studies involving children registered on ClinicalTrials.gov.

DESIGN

Cross sectional analysis. STrengthening the Reporting of OBservational studies in Epidemiology criteria were applied for design and analysis.

SETTING AND PARTICIPANTS

ClinicalTrials.gov was queried for completed studies which were matched to publications on ClinicalTrials.gov, PubMed or Google Scholar. If no publication could be identified, principal investigators were contacted.

INTERVENTIONS/EXPOSURE

Observational analysis.

PRIMARY AND SECONDARY OUTCOME MEASURES

The proportion of published and unpublished studies was calculated. Subgroup analysis included studies on surgical procedures, diagnosis, antibiotic treatment and pain management.

RESULTS

Out of n=52 completed clinical studies involving children with appendicitis, n=33 (63%) were published and n=19 (37%) were unpublished. Eighty-three per cent (n=43/52) of clinical trials assessed the above-listed controversial issues. Diagnostic studies were most rigorously published (91% of trials reported), data on surgical procedures, antibiotic and pain management were less transparent. Sixty-six per cent of interventional studies and 60% of randomised studies were published. Median time-to-publication, for example, the delay between completion of the trial until public availability of the results was 24 (IQR 12-36), range 2-92 months.

CONCLUSION

Despite the importance of appendicitis in clinical practice for the paediatric surgeon, there remains scientific uncertainty due to unpublished clinical trial results with room for improvement in the future. These data are helpful in framing the shifting paradigms in paediatric appendicitis because it adds transparency to the debate.

Randomized clinical trials in orthodontics are rarely registered a priori and often published late or not at all

A priori registration of randomized clinical trials is crucial to the transparency and credibility of their findings. Aim of this study was to assess the frequency with which registered and completed randomized trials in orthodontics are published. We searched ClinicalTrials.gov and ISRCTN for registered randomized clinical trials in orthodontics that had been completed up to January 2017 and judged the publication status and date of registered trials using a systematic protocol. Statistical analysis included descriptive statistics, chi-square or Fisher exact tests, and Kaplan-Meier survival estimates. From the 266 orthodontic trials registered up to January 2017, 80 trials had been completed and included in the present study. Among these 80 included trials, the majority (76%) were registered retrospectively, while only 33 (41%) were published at the time. The median time from completion to publication was 20.1 months (interquartile range: 9.1 to 31.6 months), while survival analysis indicated that less than 10% of the trials were published after 5 years from their completion. Finally, 22 (28%) of completed trials remain unpublished even after 5 years from their completion. Publication rates of registered randomized trials in orthodontics remained low, even 5 years after their completion date.

The use of study registration and protocols in plastic surgery research: A systematic review

BACKGROUND

In 2013, the Declaration of Helsinki changed to mandate that all research studies involving human subjects, rather than just clinical trials alone, must have a protocol registered in a publicly accessible database prior to the enrolment of the first patient. The objective of this work was to assess the number of research studies involving human participants published in leading journals of plastic surgery that had either published a protocol or registered a protocol with a publicly accessible database.

MATERIALS AND METHODS

This systematic review examined all research articles involving human participants published in Plastic and Reconstructive Surgery, The Journal of Plastic Reconstructive and Aesthetic Surgery and The Annals of Plastic Surgery from 1st April 2014-31st March 2015. The primary outcome measure was whether each study had either published or registered a protocol with any mainstream registry database. ClinicalTrials.gov, the International Standard Randomized Control Trial Number (ISRCTN) registry, the WHO (World Health Organisation) International Clinical Trials Registry Platform, The Cochrane Collaboration, the Research Registry, PROSPERO and PubMed were all reviewed.

RESULTS

Of 595 included articles, the most common study designs were case series (n = 185, 31.1%). There were 24 randomized controlled trials (RCTs, 4.0%). A total of 24 studies had a protocol registered (4.0%). The most common database to register a protocol was with ClinicalTrials.gov (n = 17). The study design that most commonly had a registered protocol was the RCT (n = 8 of 24, 33.3% of RCTs). Three studies published a protocol in a journal (0.6%).

CONCLUSION

Publication or registration of protocols for recent studies involving human participants in major plastic surgery journals is low. There is considerable scope to improve this and guidance is provided.

Reporting Compliance of Stroke Trials: Cross-Sectional Analysis

BACKGROUND

The FDA mandates timely reporting of all clinical trials conducted in the United States. However, often the results are not reported in a timely manner, resulting in wastage of finite resources. We assessed the reporting of results of completed stroke trials and compared the reporting trends between U.S. and non-U.S. stroke trials.

METHODS

We assessed consecutive clinical stroke trials registered as completed in ClinicalTrials.gov between January 1, 2008 and January 1, 2015. Descriptive data collected included study phase, study type, participant age, number of enrolled patients, study locations, start and primary completion dates, result availability, time to reporting (months), sponsorship, funding sources, and publication status. We also performed manual search for stroke trials in Pubmed, Web of Science, and Google scholar.

RESULTS

Out of a total 140 completed trials, 39 trials (35,359 patients) involved at least 1 U.S. center and 101 trials (58,542 patients) were conducted in non-U.S. centers. Of the trials involving at least a single U.S. center, 31 of 39 (79%) reported their results, whereas only 6 of 31 (19%) reported their results within 1 year. Of the trials conducted at non-U.S. centers, 72 of 101 (71%) reported their results, whereas results for 24 of 72 (33%) trials were available within a year of completion. The time to reporting of results was significantly lower for all the included clinical trials in the 2012-2014 period (P < .001, Cohen's d = .726) as compared to the 2008-2011 period.

CONCLUSION

Only one-fifth of completed stroke trials involving at least a single U.S. center report their results within 1 year. Additionally, every fifth completed trial involving stroke patients at U.S. centers remain unreported.

The ethics of reporting all the results of clinical trials

INTRODUCTION OR BACKGROUND

The terms 'publication bias' and 'reporting bias' describe aspects of a phenomenon by which data from trials are not publicized, and so remain inaccessible. This may generate a false impression about the world; but those facts may have important implications for clinical decisions. Thus, the bias may leave patients worse off than they might be.

SOURCES OF DATA

Published journal articles.

AREAS OF AGREEMENT

There is general agreement that the phenomenon happens, and that to the extent that it happens, it is undesirable for moral rather than simply epistemic reasons.

GROWING POINTS

There is a growing demand across the board for data to be better publicized.

AREAS TIMELY FOR DEVELOPING RESEARCH

There is room for further work on how protocols requiring that data be publicized might be enforced; should it be statutory, or non-statutory? Who should decide what should be made public? There is also room for work on what it is necessary to share, and on whether and how IP law should be reformed.

Ten Years after the International Committee of Medical Journal Editors' Clinical Trial Registration Initiative, One Quarter of Phase 3 Pediatric Epilepsy Clinical Trials Still Remain Unpublished: A Cross Sectional Analysis

INTRODUCTION

Although selective reporting of clinical trial results introduces bias into evidence based clinical decision making, publication bias in pediatric epilepsy is unknown today. Since there is a considerable ambiguity in the treatment of an important and common clinical problem, pediatric seizures, we assessed the public availability of results of phase 3 clinical trials that evaluated treatments of seizures in children and adolescents as a surrogate for the extent of publication bias in pediatric epilepsy.

METHODS

We determined the proportion of published and unpublished study results of phase 3 clinical trials that were registered as completed on ClinicalTrials.gov. We searched ClinicalTrials.gov, PubMed, and Google Scholar for publications and contacted principal investigators or sponsors. The analysis was performed according to STROBE criteria.

RESULTS

Considering studies that were completed before 2014 (N = 99), 75 (76%) pediatric phase 3 clinical trials were published but 24 (24%) remained unpublished. The unpublished studies concealed evidence from 4,437 patients. Mean time-to-publication was 25 SD ± 15.6 months, more than twice as long as mandated.

CONCLUSION

Ten years after the ICMJE's clinical trials registration initiative there is still a considerable amount of selective reporting and delay of publication that potentially distorts the body of evidence in the treatment of pediatric seizures.

Dissemination of Research Results: On the Path to Practice Change

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Can UK NHS research ethics committees effectively monitor publication and outcome reporting bias?

Background

Publication and outcome reporting bias is often caused by researchers selectively choosing which scientific results and outcomes to publish. This behaviour is ethically significant as it distorts the literature used for future scientific or clinical decision-making. This study investigates the practicalities of using ethics applications submitted to a UK National Health Service (NHS) research ethics committee to monitor both types of reporting bias.

Methods

As part of an internal audit we accessed research ethics database records for studies submitting an end of study declaration to the Hampshire A research ethics committee (formerly Southampton A) between 1st January 2010 and 31st December 2011. A literature search was used to establish the publication status of studies. Primary and secondary outcomes stated in application forms were compared with outcomes reported in publications.

Results

Out of 116 studies the literature search identified 57 publications for 37 studies giving a publication rate of 32 %. Original Research Ethics Committee (REC) applications could be obtained for 28 of the published studies. Outcome inconsistencies were found in 16 (57 %) of the published studies.

Conclusions

This study showed that the problem of publication and outcome reporting bias is still significant in the UK. The method described here demonstrates that UK NHS research ethics committees are in a good position to detect such bias due to their unique access to original research protocols. Data gathered in this way could be used by the Health Research Authority to encourage higher levels of transparency in UK research.

Non-publication of large randomized clinical trials: cross sectional analysis

OBJECTIVE

To estimate the frequency with which results of large randomized clinical trials registered with ClinicalTrials.gov are not available to the public.

DESIGN

Cross sectional analysis

SETTING

Trials with at least 500 participants that were prospectively registered with ClinicalTrials.gov and completed prior to January 2009.

DATA SOURCES

PubMed, Google Scholar, and Embase were searched to identify published manuscripts containing trial results. The final literature search occurred in November 2012. Registry entries for unpublished trials were reviewed to determine whether results for these studies were available in the ClinicalTrials.gov results database.

MAIN OUTCOME MEASURES

The frequency of non-publication of trial results and, among unpublished studies, the frequency with which results are unavailable in the ClinicalTrials.gov database.

RESULTS

Of 585 registered trials, 171 (29%) remained unpublished. These 171 unpublished trials had an estimated total enrollment of 299,763 study participants. The median time between study completion and the final literature search was 60 months for unpublished trials. Non-publication was more common among trials that received industry funding (150/468, 32%) than those that did not (21/117, 18%), P=0.003. Of the 171 unpublished trials, 133 (78%) had no results available in ClinicalTrials.gov.

CONCLUSIONS

Among this group of large clinical trials, non-publication of results was common and the availability of results in the ClinicalTrials.gov database was limited. A substantial number of study participants were exposed to the risks of trial participation without the societal benefits that accompany the dissemination of trial results.

Learning from failure--rationale and design for a study about discontinuation of randomized trials (DISCO study)

BACKGROUND

Randomized controlled trials (RCTs) may be discontinued because of apparent harm, benefit, or futility. Other RCTs are discontinued early because of insufficient recruitment. Trial discontinuation has ethical implications, because participants consent on the premise of contributing to new medical knowledge, Research Ethics Committees (RECs) spend considerable effort reviewing study protocols, and limited resources for conducting research are wasted. Currently, little is known regarding the frequency and characteristics of discontinued RCTs.

METHODS/DESIGN

Our aims are, first, to determine the prevalence of RCT discontinuation for specific reasons; second, to determine whether the risk of RCT discontinuation for specific reasons differs between investigator- and industry-initiated RCTs; third, to identify risk factors for RCT discontinuation due to insufficient recruitment; fourth, to determine at what stage RCTs are discontinued; and fifth, to examine the publication history of discontinued RCTs.We are currently assembling a multicenter cohort of RCTs based on protocols approved between 2000 and 2002/3 by 6 RECs in Switzerland, Germany, and Canada. We are extracting data on RCT characteristics and planned recruitment for all included protocols. Completion and publication status is determined using information from correspondence between investigators and RECs, publications identified through literature searches, or by contacting the investigators. We will use multivariable regression models to identify risk factors for trial discontinuation due to insufficient recruitment. We aim to include over 1000 RCTs of which an anticipated 150 will have been discontinued due to insufficient recruitment.

DISCUSSION

Our study will provide insights into the prevalence and characteristics of RCTs that were discontinued. Effective recruitment strategies and the anticipation of problems are key issues in the planning and evaluation of trials by investigators, Clinical Trial Units, RECs and funding agencies. Identification and modification of barriers to successful study completion at an early stage could help to reduce the risk of trial discontinuation, save limited resources, and enable RCTs to better meet their ethical requirements.

Professionals and the public: power or partnership in health research?

RATIONALE, AIMS AND OBJECTIVES

Involving members of the public in health research is said to produce higher quality research of greater clinical relevance. However, many of the anecdotal accounts of public involvement published in the academic literature to date have focused on the process of recruiting and involving members of the public and the effect of participation on these individuals rather than on how public involvement influenced the research process or outcomes. To strengthen the evidence base, there is clearly a need for more formal methods of capturing and documenting the impact of public involvement in health research.

METHODS

In the first half of this paper, we discuss the importance of public involvement in health research and critically review the literature to identify current barriers to its successful implementation. In the second half, we present a conceptual model for evaluating and reporting the impact of public involvement in health research. Developed from our examination of the academic literature, we provide empirical support for the model by applying it to our recent experience of conducting a clinically based falls prevention study with members of the public.

RESULTS

The conceptual model presented in this paper proposes key concepts and terminology that promote consistency when evaluating and reporting the impact of public involvement in health research. Reflecting on the experiential learning process, we demonstrate how the model promotes conceptual clarity whilst permitting the degree of flexibility required when working in a diverse culture such as the National Health Service.

CONCLUSION

If more evidence can be provided that public involvement enhances research processes and outcomes, researchers may be less inclined to treat this initiative as something they have to do in order to satisfy funding agencies and regulatory bodies and actively embrace this phenomenon, producing accounts of successful public involvement that transcend current barriers to its successful implementation.

Guidelines for controlled trials of drugs in tension-type headache: second edition

The Clinical Trials Subcommittee of the International Headache Society published its first edition of the guidelines on controlled trials of drugs in tension-type headache in 1995. These aimed 'to improve the quality of controlled clinical trials in tension-type headache', because 'good quality controlled trials are the only way to convincingly demonstrate the efficacy of a drug, and form the basis for international agreement on drug therapy'. The Committee published similar guidelines for clinical trials in migraine and cluster headache. Since 1995 several studies on the treatment of episodic and chronic tension-type headache have been published, providing new information on trial methodology for this disorder. Furthermore, the classification of the headaches, including tension-type headache, has been revised. These developments support the need for also revising the guidelines for drug treatments in tension-type headache. These Guidelines are intended to assist in the design of well-controlled clinical trials in tension-type headache.

Two prognostic indicators of the publication rate of clinical studies were available during ethical review

OBJECTIVE

To identify prognostic indicators of the publication rate of clinical studies, available to research ethics committees (RECs) during review.

STUDY DESIGN AND SETTING

Retrospective survival study of a random sample of 100 studies, approved by a Dutch academic REC, with follow-up information by questionnaire and bibliographic searches. Multivariate Cox regression analysis of the association between publication rate and seven factors available during review: six study characteristics and the number of letters sent by the committee during review representing the length of the review process.

RESULTS

Two factors were associated with publication rate: studies with possible therapeutic benefit to participants were less likely to be published than nontherapeutic studies (adjusted hazard ratio [AHR]: 0.16; 95% confidence interval [CI]: 0.03-0.54); with every letter sent, publication was less likely (AHR: 0.46 per letter; 95% CI: 0.17-0.98). Possibly, studies with more-than-minimal burdens to participants were more likely to be published than studies with minimal burdens (AHR: 3.90, 95% CI: 1.03-16.64).

CONCLUSION

We identified two prognostic indicators of publication rate. After suitable replication, RECs might explore using prognostic indicators, such as these, to target study protocols at high risk for nonpublication. Discussing the risk of nonpublication with investigators could help prevent nonpublication.

A systematic review of clinical trials of pharmacological interventions for acute ischaemic stroke (1955-2008) that were completed, but not published in full

BACKGROUND

We assessed the prevalence, and potential impact of, trials of pharmacological agents for acute stroke that were completed but not published in full. Failure to publish trial data is to be deprecated as it sets aside the altruism of participants' consent to be exposed to the risks of experimental interventions, potentially biases the assessment of the effects of therapies, and may lead to premature discontinuation of research into promising treatments.

METHODS

We searched the Cochrane Stroke Group's Specialised Register of Trials in June 2008 for completed trials of pharmacological interventions for acute ischaemic stroke, and searched MEDLINE and EMBASE (January 2007 - March 2009) for references to recent full publications. We assessed trial completion status from trial reports, online trials registers and correspondence with experts.

RESULTS

We identified 940 trials. Of these, 125 (19.6%, 95% confidence interval 16.5-22.6) were completed but not published in full by the point prevalence date. They included 16,058 participants (16 trials had over 300 participants each) and tested 89 different interventions. Twenty-two trials with a total of 4,251 participants reported the number of deaths. In these trials, 636/4251 (15.0%) died.

CONCLUSIONS

Our data suggest that, at the point prevalence date, a substantial body of evidence that was of relevance both to clinical practice in acute stroke and future research in the field was not published in full. Over 16,000 patients had given informed consent and were exposed to the risks of therapy. Responsibility for non-publication lies with investigators, but pharmaceutical companies, research ethics committees, journals and governments can all encourage the timely publication of trial data.

Reporting bias in medical research - a narrative review

Reporting bias represents a major problem in the assessment of health care interventions. Several prominent cases have been described in the literature, for example, in the reporting of trials of antidepressants, Class I anti-arrhythmic drugs, and selective COX-2 inhibitors. The aim of this narrative review is to gain an overview of reporting bias in the medical literature, focussing on publication bias and selective outcome reporting. We explore whether these types of bias have been shown in areas beyond the well-known cases noted above, in order to gain an impression of how widespread the problem is. For this purpose, we screened relevant articles on reporting bias that had previously been obtained by the German Institute for Quality and Efficiency in Health Care in the context of its health technology assessment reports and other research work, together with the reference lists of these articles.We identified reporting bias in 40 indications comprising around 50 different pharmacological, surgical (e.g. vacuum-assisted closure therapy), diagnostic (e.g. ultrasound), and preventive (e.g. cancer vaccines) interventions. Regarding pharmacological interventions, cases of reporting bias were, for example, identified in the treatment of the following conditions: depression, bipolar disorder, schizophrenia, anxiety disorder, attention-deficit hyperactivity disorder, Alzheimer's disease, pain, migraine, cardiovascular disease, gastric ulcers, irritable bowel syndrome, urinary incontinence, atopic dermatitis, diabetes mellitus type 2, hypercholesterolaemia, thyroid disorders, menopausal symptoms, various types of cancer (e.g. ovarian cancer and melanoma), various types of infections (e.g. HIV, influenza and Hepatitis B), and acute trauma. Many cases involved the withholding of study data by manufacturers and regulatory agencies or the active attempt by manufacturers to suppress publication. The ascertained effects of reporting bias included the overestimation of efficacy and the underestimation of safety risks of interventions.In conclusion, reporting bias is a widespread phenomenon in the medical literature. Mandatory prospective registration of trials and public access to study data via results databases need to be introduced on a worldwide scale. This will allow for an independent review of research data, help fulfil ethical obligations towards patients, and ensure a basis for fully-informed decision making in the health care system.

Searching for unpublished trials in Cochrane reviews may not be worth the effort

OBJECTIVE

To assess the value of searching for unpublished data by exploring the extent to which Cochrane reviews include unpublished data and by evaluating the quality of unpublished trials.

STUDY DESIGN AND SETTING

We screened all 2,462 completed Cochrane reviews published since 2000 in the Cochrane Database of Systematic Reviews Issue 3, 2006. In a random sample (n=61) of 292 reviews, including unpublished trials, we studied all 116 references.

RESULTS

Unpublished trials make up 8.8% of all included trials in our sample. Thirty-eight percent of the "unpublished" trials have in fact been published. Allocation concealment was "unclear" or not adequate in 54.3% and 61.3% reported blinding. In 47.2% reported withdrawal rates were >20%. Trials that were eventually published had larger mean population sizes (P-value, 0.02). Of the reported sponsors, 87.3% were drug companies. Methodological quality and publication bias are mentioned in half of the reviews and explored in a third. Quality ratings did not have consequences for pooling, because 82.8% was included in the forest plots.

CONCLUSIONS

A minority of Cochrane reviews include "unpublished trials" and many of these are eventually published. Truly unpublished studies have poor or unclear methodological quality. Therefore, it may be better to invest in regular updating of reviews, rather than in extensive searching for unpublished data.

Attitudes of research ethics board chairs towards disclosure of research results to participants: results of a national survey

BACKGROUND

The offer of aggregate study results to research participants following study completion is increasingly accepted as a means of demonstrating greater respect for participants. The attitudes of research ethics board (REB) chairs towards this practice, although integral to policy development, are unknown.

OBJECTIVES

To determine the attitudes of REB chairs and the practices of REBs with respect to disclosure of results to research participants.

DESIGN

A postal questionnaire was distributed to the chairs of English-language university-based REBs in Canada. In total, 88 REB chairs were eligible. The questionnaire examined respondents' attitudes towards offering participants completed study results, methods for delivering this information, and barriers to disclosing results.

FINDINGS

The response rate was 89.8%. Chairs were highly supportive (94.8%) of offering results to research participants. Only 19.5% of chairs responded that a policy or guideline that governed the return of research results to participants existed at their institution. Most chairs (72.0%) supported the idea of their REB instituting a set of guidelines recommending that researchers offer results to participants in a lay format. Chairs identified the major impediments to the implementation of programmes offering to return results to participants as being financial cost (57.5%) and retaining contact with research participants (78.1%).

CONCLUSIONS

University-based REB chairs overwhelmingly support the offer of research results to participants. This is incongruent with the frequent lack of existing REB guidelines recommending this practice. REBs should support guidelines that diminish identified barriers and promote consistency in offering to return results.

Writing good abstracts

INTRODUCTION

Writing an abstract means to extract and summarize (AB - absolutely, STR - straightforward, ACT - actual data presentation and interpretation). Thousands of abstracts are submitted to stroke conferences each year. The following suggestions may improve the chances of your work being selected for presentation, and to communicate results in the most efficient and unambiguous way. TITLE AND STRUCTURE: Make the title dynamic and informative, rather than descriptive. Structure the abstract following the IMRaD (Introduction, Methods, Results and Discussion) principle for your future original paper where background would become Introduction and conclusions would enter Discussion. Select the appropriate category for submission carefully. This determines which experts grade the abstract and the session where your competitors represent their work. If selected appropriately, your abstract is more likely to be graded by peers with similar interests and familiarity with your work or field. Methods should describe the study design and tools of data acquisition shortly, not data.

RESULTS

Provide data that answer the research question. Describe most important data with numbers and statistics. Make your point with data, not speculations and opinions. Abbreviations should be avoided and only be used after they have been spelled out or defined. Common mistakes include failure to state the hypothesis, rationale for the study, sample size and conclusions. Highlight the novelty of your work by carefully chosen straightforward wording.

CONCLUSIONS

Conclusions have to be based on the present study findings. Make sure your abstract is clear, concise and follows all rules. Show your draft to colleagues for critique, and if you are not a native English speaker show it to a person who can improve/correct your text. Remember that accepted abstracts of completed original research should be followed by published original papers - if this is not intended or fails, it may indicate an impaired ability to succeed in scientific writing and an academic career.

Publish and perish: a case study of publication ethics in a rural community

BACKGROUND

Health researchers must weigh the benefits and risks of publishing their findings.

OBJECTIVE

To explore differences in decision making between rural health researchers and managers on the publication of research from small identifiable populations.

METHOD

A survey that investigated the attitudes of Australian rural general practitioners (GPs) to nurse practitioners was explored. Decisions on the study's publication were analysed with bioethical principles and health service management ethical decision-making models.

RESULTS

Response rate was 78.5% (62/79 GPs). 84-94% of GP responders considered it to be undesirable for nurse practitioners to initiate referrals to medical specialists (n=58), to initiate diagnostic imaging (n=56) and to prescribe medication (n=52). BIOETHICAL ANALYSIS: It was concluded that the principle of beneficence outweighed the principle of non-maleficence and that a valid justification for the publication of these results existed. DECISION-MAKING MODELS OF HEALTH SERVICE MANAGERS: On the basis of models of ethical decision making in health service management, the decisions of the area's health managers resulted in approval to publish this project's results being denied. This was because the perceived risks to the health service outweighed benefits. Confidentiality could not be ensured by publication under a regional nom de plume.

CONCLUSIONS

A conflict of interests between rural researchers and health managers on publication of results is shown by this case study. Researchers and managers at times owe competing duties to key stakeholders. Both weigh the estimated risks and benefits of the effect of research findings. This is particularly true in a rural area, where identification of the subjects becomes more likely.

Delay and failure to publish dental research

OBJECTIVE

To investigate the incidence and time taken to full publication of abstracts presented at dental scientific meetings.

DESIGN

A retrospective observational study.

SETTING

All abstracts from the 1993 proceedings of the European Orthodontic Society (EOS) and European Organisation for Caries Research (ORCA) and a 10% random sample of abstracts from the International Association for Dental Research (IADR) conferences.

METHODS

A cross-referenced Medline search of abstract title and authors was undertaken to determine whether abstracts had been published as full papers. Searches were censored 1 year prior to and 5 years post publication as an abstract. Publication rate was compared between abstracts presented orally and as posters.

MAIN OUTCOME MEASURES

Publication as a full paper and time taken to publication.

RESULTS

546 abstracts were investigated. 252 abstracts (46.1%) were found as full reports. Median time to publication of all abstracts was 18 months (IQR 9, 30 months). 99 of the oral abstracts (57%) and 153 (41%) of the poster abstracts were published. Relative Risk Oral vs Poster=1.37 CI (1.19, 1.55).

CONCLUSION

More than half of the research presented at EOS, IADR and ORCA in 1993 remained unpublished 5 years after presentation at the conference. Oral presentations were published more frequently than poster presentations.

Methodological quality and reporting of ethical requirements in phase III cancer trials

BACKGROUND

The approval of a research ethics committee (REC) and obtaining informed consent from patients (ICP) could be considered the main issues in the ethics of research with human beings. The aim of this study was to assess both methodological quality and ethical quality, and also to assess the relationship between these two qualities in randomised phase III cancer trials.

METHOD

Methodological quality (Jadad score) and ethical quality (Berdeu score) were assessed for all randomised controlled trials (RCTs) published in 10 international journals between 1999 and 2001 (n = 231).

RESULTS

The mean Jadad score was 9.86 +/- 1.117. The methodological quality was poor in 75 RCTs (Jadad score <9). The mean Berdeu score was 0.42 +/- 0.133. The mean ethical quality score for poor methodological quality RCTs (n = 75) was 0.39 +/- 0.133; it was 0.43 +/- 0.133 for good (n = 156) methodological quality RCTs (p = 0.07). There was improvement in ethical quality according to the year of commencement of the trials (p < 0.001). There was no correlation between methodological quality and the number of participating patients (R2 = 0.003, p = 0.78), between ethical quality and the number of participating patients (R2 = 0.003, p = 0.76 ), or between ethical quality and methodological quality (R2 = 0.012, p = 0.1). ICP and REC approval were not obtained for 21 and 77 trials respectively.

CONCLUSION

The association between methodological quality and the reporting of ethical requirements probably reflects the respect shown for patients during the whole research process. These results suggest that closer attention to the conduct of clinical research, as well as the reporting of its ethical aspects, is needed.

Intellectual property and the commercialization of research and development

Concern about the commercialization of research is rising, notably in testing new drugs. The problem involves oversimplified, polarizing assumptions about research and development (R&D) and intellectual property (IP). To address this problem this paper sets forth a more complex three phase RT&D process, involving Scientific Research (R), Technological Innovation (T), and Commercial Product Development (D) or the RT&D process. Scientific research and innovation testing involve costly intellectual work and do not produce free goods, but rather require IP regulation. RT&D processes involve an unrecognized IP shift from a common IP right in public goods like information and knowledge to private IP in products and other hard assets. The question then is, what kind of IP right: private or common? Since scientific research and innovation testing require openness about adverse findings, and wide, low cost diffusion of results, they require a common, inclusive IP right. Common IP is appropriate to both sharing knowledge goods and recovering the cost of production. Research is furthermore compatible with commercialization and support by other social interests. On the other hand it is incompatible with the exclusionary private IP rights that permit restrictive publication or total suppression of information. Private IP rather than commercialization conflicts with the openness requirements of scientific research and innovation testing. Commercial funding, however, is in principle compatible with research and testing, especially when regulated by a common IP right. This reflects a pragmatic view of the fundamental interconnections of knowledge and other social interests.

How to write a research paper

BACKGROUND

Busy strokologists often find little time for scientific writing. They sometimes develop a mental condition equivalent to that known by neurologists as writer's cramp. It may result in permanent damage to academic career. This paper provides advice how to prevent or treat this condition.

METHODS

Prepare your manuscript following the IMRaD principle (Introduction, Methods, Results, and Discussion), with every part supporting the key message. When writing, be concise. Clearly state your methods here, while data belong to Results. Successful submissions combine quality new data or new thinking with lucid presentation.

RESULTS

Provide data that answer the research question. Describe here most important numeric data and statistics, keeping in mind that the shorter you can present them, the better. The scientific community screens abstracts to decide which full text papers to read. Make your point with data, not arguments.

CONCLUSIONS

Conclusions have to be based on the present study findings. The time of lengthy and unfounded speculations is over. A simple message in a clearly written manuscript will get noticed and may advance our understanding of stroke.

Publication bias: raising awareness of a potential problem in dental research

With the development of evidence-based dentistry it is important to consider how accurate and representative our published pool of evidence is. In this article we will describe publication bias and discuss the causes and potential effects it may have upon the pool of scientific evidence available in dentistry.

Ethics on the floor

The work of the 'Human Research Ethics Committee' (HREC) is expanding as the dimensions of ethical practice and research grow in the clinical arena. Over the past five years, the demands on practitioners and ethics committee members have expanded, as the general public demands accountability on the part of clinical and other researchers. This paper presents a case study of an ethics committee in an Area Health Service in Sydney. It represents the views of the members as to why they see their job as important, what aspects are difficult, how they delineate between ethical/legal and scientific issues, and what are the major stumbling blocks for them in enacting their membership of a HREC. The data for the case study was collected using interviews with nine out of eleven members. The audio taped interviews were transcribed, the text thematically analysed for commonalities and contrasts, and a description of the members' perspective on various issues written. Issues emerging include: amount of material members read prior to the committee meeting, the difficulty in educating practitioners (all researchers) to write information sheets that are simple and comprehensible to laypersons, the payment of subjects for their time, the appropriate amount of monitoring to be applied on each project, the difficulty in letting researchers know that the ethics committee is committed to encouraging research and that its questions are intended to ensure the best possible project answering the researchers' questions/aims is conducted, and the slow or no response by researchers to ethics committee questions. The findings imply that reviewing research proposals for their ethical value is individual and members of human research ethics committees need to synthesise these in a committee context to make informed decisions.

Ethics in exercise science research

Ethical evaluation is a vital but sometimes neglected component of research policy in the exercise sciences. This article reviews some issues in human research, with particular reference to studies undertaken by the exercise scientist. The typical composition and functions of the research review committee are examined in the context of individual and institutional ethical norms. In multicentre trials, there are often problems in coordinating ethical approval between institutions. On-going monitoring of research may have value in the detection of fraud. A reduction in the secrecy of committee proceedings would allow a closer auditing of the research review process. Authors need to give more thought to developing appropriate research questions. Scarce resources may be wasted because of inappropriate study design or an inadequate statistical analysis of the results. The costs of any proposed investigation must be weighed carefully against possible benefits. Confidentiality is particularly important when collecting data at the worksite or over the internet. Informed consent should be based on a full disclosure of risks; the participant should be competent to understand the nature and magnitude of these risks, and undue pressure to participate in an experiment must be avoided. The opposition to placebo trials expressed in the Declaration of Helsinki requires careful consideration of the use of control groups, since regular exercise is known to benefit health. If research is conducted in under-developed societies, the standards of treatment of the participants should match those expected in developed societies. The publication of findings must be fair and well balanced; examples of fraud and misconduct continue to be reported. Some journals apparently still publish papers, even if they have not received an initial institutional review. Editors should restore meaning to the word 'author', avoid the bias to a publication of 'positive' results, limit the impact of commercial sponsorship on reporting and curtail the current trend to redundant presentations and publications. Development of academic courses in research ethics may help to avoid some of these abuses.

Publishing ethics in psychiatry

OBJECTIVE

The ethics of publishing in psychiatry has gained only limited attention. We examine, in a historical context, pertinent ethical problems and offer a series of recommendations for dealing with them.

METHOD

The study was conducted by exploration of medical databases and websites, and systematic discussion with ethicists, legal experts, publishers and researchers.

RESULTS

Serious 'publishing misconduct' appears to have been rare in the psychiatric literature, but any occurrence of redundant publication, plagiarism and publication of fraudulent or inhumane research is disturbing and should be prevented. Difficulties around authorship, sensitive use of language, conflict of interest and bias in the publishing process are additional issues claiming our attention.

CONCLUSIONS

A clearly articulated publishing ethos is desirable. Potential strategies to achieve this include devising guidelines on publishing ethics, teaching the subject to new writers, journals committing themselves to the ethical dimension of their operations, and penalising colleagues who violate agreed principles of good conduct.

Bias in reporting clinical trials

AIMS

The primary aim of the present study was to identify possible occurrence of selective reporting of the results of clinical trials to the Finnish National Agency for Medicines. Selective reporting may lead to poorly informed action or inaction by regulatory authorities.

METHODS

In 1987, 274 clinical drug trials were notified to the Finnish National Agency for Medicines. By December 1993, final reports had been received from 68 of these trials and statements that the trial had been suspended from 24 trials. The sponsors of the non-reported trials were requested to report the outcome. The outcomes, if any, of all reported and non-reported trials were classified as positive, inconclusive or negative.

RESULTS

The total number of trials with positive, inconclusive or negative outcome were 111, 33 and 44, respectively; the outcomes of 86 trials could not be assessed. Final reports were received from 42/111 (38%) trials with positive, 6/33 (18%) with inconclusive and 9/44 (20%) with negative outcomes.

CONCLUSIONS

Substantial evidence of selective reporting was detected, since trials with positive outcome resulted more often in submission of final report to regulatory authority than those with inconclusive or negative outcomes.

Are research ethics committees behaving unethically? Some suggestions for improving performance and accountability

The results of recent empirical investigations in research synthesis imply that research ethics committees are behaving unethically by endorsing new research which is unnecessary and by acquiescing in biased under-reporting of research which they have approved. The performance and accountability of research ethics committees would be improved if they required those proposing research to present systematic reviews of relevant previous research in support of their applications; to summarise the results of these reviews in the information prepared for potential participants; to register new controlled trials at inception; and to ensure that the results of these trials are made publicly available within a reasonable period of time after completion of data collection.

Pharmaceutical trials in general practice: the first 100 protocols. An audit by the clinical research ethics committee of the Royal College of General Practitioners

OBJECTIVE

To assess the outcome of 100 general practice based, multicentre research projects submitted to the ethics committee of the Royal College of General Practitioners by pharmaceutical companies or their agents between 1984 and 1989.

DESIGN

Analysis of consecutive submitted protocols for stated objectives, study design, and outcomes; detailed review of committee minutes and correspondence in relation to amendment and approval; assessment of final reports submitted at conclusion of studies.

SUBJECTS

82 finally approved protocols, embracing 34,523 proposed trial subjects and 1195 proposed general practice investigators.

MAIN OUTCOME MEASURES

Success at enrolling subjects and investigators; commencement and completion data; validity of final report's assessment of efficacy, safety, tolerability, and acceptability; and method of use and dissemination of findings.

RESULTS

18 studies were not approved and 45 had to be amended. Randomised controlled trials comprised 46 of the original submissions. Remuneration considerations, inadequate information or consent sheets, pregnancy safety, the need to discontinue existing therapy, and suboptimal scientific content were major reasons for rejecting studies or asking for amendments. Of the 82 approved studies 8 were not started. Shortfalls of investigators (of 39%) and trial subjects (of 37%) and an overall 23% withdrawal rate were responsible for a significant incidence of inconclusive results. Within the six year follow up interval, only 19 of the studies had been formally published.

CONCLUSIONS

This audit identified substantial ethical concerns in the process of approving multicentre general practice pharmaceutical research.

Ethical imperative to publish extends to academics too

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