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authors, with or without coauthors or editors, that research they cited in systematic reviews and guidelines has been retracted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.

Procrastination and inconsistency: Expressions of concern for publications with compromised integrity

Expressions of concern (EoC) can reduce the adverse effects of unreliable publications by alerting readers to concerns about publication integrity while assessment is undertaken. We investigated the use of EoC for 463 publications by two research groups for which we notified concerns about publication integrity to 142 journals and 44 publishers between March 2013 and February 2020. By December 2021, 95 papers had had an EoC, and 83 were retracted without an EoC. Median times from notification of concerns to EoC (10.4mo) or retraction without EoC (13.1mo) were similar. Among the 95 EoCs, 29 (30.5%) were followed by retraction after a median of 5.4mo, none was lifted, and 66 (69.5%) remained in place after a median of 18.1mo. Publishers with >10 notified publications issued EoCs for 0-81.8% of papers: for several publishers the proportions of notified papers for which EoCs were issued varied considerably between the 2 research groups. EoCs were issued for >30% of notified publications of randomized clinical trials and letters to the editor, and <20% of other types of research. These results demonstrate inconsistent application of EoCs between and within publishers, and prolonged times to issue and resolve EoCs.

Statistical Techniques to Assess Publication Integrity in Groups of Randomised Trials: A Narrative Review

Objective To describe statistical tools available for assessing publication integrity of groups of randomised controlled trials (RCTs) Study Design Narrative review Results Freely available statistical tools have been developed that compare the observed distributions of baseline variables with the expected distributions that would occur if successful randomisation occurred. For continuous variables, the tools assess baseline means, baseline p-values, and the occurrence of identical means and/or SD. For categorical variables, they assess baseline p-values, frequency counts for individual or all variables, numbers of trial participants randomised or withdrawing, and compare reported with independently calculated p-values. The tools have been used to identify publication integrity concerns in RCTs from individual groups, and performed at an acceptable level in discriminating intentionally fabricated baseline summary data from data from genuine RCTs. The tools can be used when concerns have been raised about RCT(s) from an individual/group and when the whole body of their work is being examined, when conducting systematic reviews, and could be adapted to aid screening of RCTs at journal submission. Conclusion Statistical tools are useful for the assessment of publication integrity of groups of RCTs.

Ten Years later: Assessments of the integrity of publications from one research group with multiple retractions

When a research group has multiple retracted publications and/or research misconduct by a member is evident, there is a risk that its other publications are unreliable, so a comprehensive assessment of the group's publications is advisable. We analyzed the comprehensiveness of assessment of the integrity of 300 publications by a research group with numerous retractions and known research misconduct, for 292 of which we raised concerns to publishers and academic institutions between 3/2013 and 2/2020. By 4/2023, 91 (30%) publications had not been assessed by either publisher or academic institution. Publishers had assessed 185 (63%) publications. The 4 academic institutions had assessed 5/36 (14%), 56/216 (26%), 30/50 (60%) and 40/66 (61%) publications. Unprompted assessments, those undertaken without our notification of concerns, occurred for 24 (8%) publications, 3 (1%) by publishers and 21 (7%) by academic institutions. Among 32 journals with ≥2 affected publications, no unprompted assessments of the remaining publication(s) occurred after notification of concerns about the index publication(s). Publishers retracted 58/84 (69%) publications which institutions also assessed and decided needed no editorial action. These analyses demonstrate the failure of publishers and institutions to comprehensively and spontaneously determine the integrity of publications in a setting of known misconduct and multiple retractions.

Responses to concerns raised about publications don't address the concerns raised

Recently in the Journal, Amanda Williams described her experience of raising concerns about a group of trials with "untrustworthy data". We were inspired by the work of Williams and colleagues to examine these and other trials by the same research group. Similar to Williams, we found that the patterns of reported data differed from the patterns expected to arise from valid randomisation. We also identified a high proportion of reported baseline p-values for categorial variables that differed from independently calculated p-values. We reported these findings to the affected journals but none of the concerns were addressed and no action will be taken about the majority. Despite the large number of unresolved concerns about these trials, readers will be unaware of the issues, which seems entirely unsatisfactory.

Distributions of baseline categorical variables were different from the expected distributions in randomized trials with integrity concerns

BACKGROUND AND OBJECTIVES

Comparing observed and expected distributions of baseline continuous variables in randomized controlled trials (RCTs) can be used to assess publication integrity. We explored whether baseline categorical variables could also be used.

METHODS

The observed and expected (binomial) distribution of all baseline categorical variables were compared in four sets of RCTs: two controls, and two with publication integrity concerns. We also compared baseline calculated and reported P-values.

RESULTS

The observed and expected distributions of baseline categorical variables were similar in the control datasets, both for frequency counts (and percentages) and for between-group differences in frequency counts. However, in both sets of RCTs with publication integrity concerns, about twice as many variables as expected had between-group differences in frequency counts of one or 2, and far fewer variables than expected had between-group differences of >4 (P < 0.001 for both datasets). Furthermore, about one in six reported P-values for baseline categorial variables differed by > 0.1 from the calculated P-value in trials with publication integrity concerns.

CONCLUSION

Comparing the observed and expected distributions and reported and calculated P-values of baseline categorical variables may help in the assessment of publication integrity of a body of RCTs.

Increased workload without clinical benefit: Results following implementation of the ACR-TIRADS system for thyroid nodules

OBJECTIVE

The ACR-TIRADS system for stratifying thyroid nodule malignancy risk has been widely promoted and implemented. We audited its introduction at a large public hospital in Auckland, New Zealand.

DESIGN

Audit of outcomes following thyroid nodule fine needle aspiration (FNA) before/after ACR-TIRADS.

PATIENTS

Individuals undergoing thyroid FNA 2017-2019.

MEASUREMENTS

From medical records, we obtained details from the pre-FNA ultrasound (nodule size, TIRADS points/levels, radiologist recommendation for FNA), Bethesda (B) cytology classification, histology and post-FNA follow-up.

RESULTS

Four hundred and twenty-two individuals had 564 FNAs, 163 had surgery and 54 (13%) had cancer in the primary nodule. 37/54 (69%) cancers were papillary thyroid carcinoma (median size 25 mm, 87% ≥10 mm, 61% ≥20 mm). Following ACR-TIRADS introduction, FNA recommendations increased greater than twofold, FNAs performed by 71%-83%, and the monthly rate of FNAs and operations by 60% and 40%, respectively. However, the proportion of cancers/FNA remained similar (9.9% post-TIRADS vs. 8.7% pre-TIRADS). The proportions of FNA results remained stable for B2-B4 categories, but doubled (11% vs. 5%) for B5-B6: 15 FNAs were needed to identify an additional B5/B6 lesion. TIRADS-5 nodules had a higher proportion of B5/B6 (20%) and a lower proportion of B2 (30%) than TIRADS-3 (2%, 57%, respectively) and TIRADS-4 (9%, 56%) nodules. About 5 additional cancers/year were diagnosed, but they were more often small (49% vs. 8% <2 cm, 17% vs. 0% <1 cm).

CONCLUSION

ACR-TIRADS introduction increased workload (FNAs and operations), without increasing the proportion of cancers/FNA. It led to a few more cancers being diagnosed, but many were small and of uncertain clinical significance.

Zoledronate Reduces Height Loss Independently of Vertebral Fracture Occurrence in a Randomized Trial in Osteopenic Older Women

Vertebral fractures are associated with height loss, reduced quality of life, and increased mortality and are an important endpoint for osteoporosis trials. However, height loss is associated with quality of life and mortality independent of associations with fracture. We have used data from a recent 6-year trial of zoledronate in 2000 osteopenic women aged >65 years to assess the impact of the semiquantitative and quantitative components of the definition of vertebral fracture on the outcome of that trial, to determine what factors impacted on height loss and to test whether height loss can be used as a surrogate for vertebral fracture incidence. In the trial protocol, an incident vertebral fracture was defined as a change in Genant grade plus both a 20% and 4 mm decrease in a vertebral height. The addition of the quantitative criteria reduced the number of fractures detected but did not change the size of the anti-fracture effect (odds ratios of 0.49 versus 0.45) nor the width of the confidence intervals for the odds ratios. Multivariate analysis of baseline predictors of height change showed that age accelerated height loss (p < 0.0001) and zoledronate reduced it (p = 0.0001). Incident vertebral fracture increased height loss (p = 0.0005) but accounted for only 0.7% of the variance in height change, so fracture could not be reliably inferred from height loss. In women without incident vertebral fractures, height loss was still reduced by zoledronate (height change: zoledronate, -1.23; placebo -1.51 mm/yr, p < 0.0001). This likely indicates that zoledronate prevents a subtle but widespread loss of vertebral body heights not detected by vertebral morphometry. Because height loss is associated with quality of life and mortality independent of associations with fracture, it is possible that zoledronate impacts on these endpoints via its effects on vertebral body integrity. © 2022 American Society for Bone and Mineral Research (ASBMR).

Is PHARMAC's decision-making fair, cost-effective and clinically effective? Observations from the real world

Nil.

Diversity of invited speakers at endocrinology conferences

OBJECTIVE

To assess diversity of gender and geographical location of institutional affiliation among invited speakers at major international endocrinology conferences.

DESIGN AND METHODS

Descriptive study of characteristics of invited speakers at eight general and discipline-specific endocrinology conferences held annually in Europe and North America 2013-2019. Main outcomes were gender, geographical location of institutional affiliation and frequency of repeat presentations among invited speakers.

RESULTS

Of 2375 invited speakers who gave 3522 presentations, 843 (35.5%) were women. Five hundred and ninety-four (25.0%) speakers gave >1 presentation at any conference. The proportion of women speakers declined as the number of presentations per speaker increased. Of speakers giving two and seven presentations, respectively, 36.0% and 20.0% were women. 52.9% of speakers were from institutions in North America, and 25.6% from institutions in Western Europe. Fewer than 5% of speakers were from institutions in each of Eastern Europe, Asia, South America, Africa and Oceania. The proportions of speakers who were women and from each geographical area were unchanged over 7 years. Up to one in three speakers gave >1 presentation at an individual conference (range 9.9%-32.2%).

CONCLUSIONS

Women and speakers from institutions outside of North America and Western Europe are underrepresented among invited speakers at major international endocrinology conferences. Longitudinal data indicate no change in either speaker characteristic over the time period examined. These underrepresentations are more marked among speakers who give repeat presentations.

Dietary calcium intake and change in bone mineral density in older adults: a systematic review of longitudinal cohort studies

Many older adults do not achieve recommended intakes of calcium and there is some concern over the potential impact of this on bone health. The objective of this review was to examine evidence from cohort studies on the relationship between calcium intake and change in bone mineral density (BMD) in older adults, something not undertaken in the last two decades. Data sources included Ovid Medline, Embase, and PubMed and references from retrieved reviews and articles. The final search was performed in February 2021. We included cohort studies of calcium intake in participants aged >50 years with change in BMD over ≥1 year as an outcome. We identified 23 studies of women and 7 of men. Most studies found no association between calcium intake and change in BMD in women (71%) or men (71%). Among women, five studies reported high rates (>30% of participants) of hormone treatment or osteoporosis therapy (HT/OT) use; 80% of these studies reported a positive association between calcium intake and change in BMD, compared with 10% of studies in which HT/OT use was low. No study in women in which the mean age was >60 years reported a positive association between calcium intake and change in BMD. We conclude that calcium intake across the ranges consumed in these studies (mean intake in all but one study >500 mg/day) is not an important determinant of bone loss, particularly among women >60 years. The positive findings in studies with high rates of HT/OT use are likely to arise from confounding as a result of co-administration of calcium supplements with these medications.

Bone Mineral Density and Bone Turnover 10 Years After a Single 5 mg Dose or Two 5-Yearly Lower Doses of Zoledronate in Osteopenic Older Women: An Open-Label Extension of a Randomized Controlled Trial

Intravenous zoledronate reduces fracture risk (5 mg at 18-month intervals) and prevents bone loss (doses of 1 to 5 mg for 3 to >5 years), but the duration of action of a single 5 mg dose and the effects of lower doses beyond 5 years are unknown. We report the second open-label extension (years 5 to 10) of a 2-year randomized, multidose, placebo-controlled, double-blinded trial. A total of 116 older women who completed 5 years of participation either continued observation without further treatment (zoledronate 5 mg and placebo at baseline) or received repeat doses of 1 or 2.5 mg zoledronate (zoledronate 1 mg and zoledronate 2.5 mg at baseline, respectively). Outcomes were spine, hip, and total body bone mineral density (BMD) and serum markers of bone turnover. After a single 5 mg dose of zoledronate, mean BMD at the lumbar spine and total hip was maintained at or above baseline levels for 9 and 10 years, respectively. The mean level of the bone resorption marker β-C-terminal telopeptide of type I collagen (β-CTX) was at least 25% lower than that in the placebo group for 9 years. In women administered 5-yearly doses of 2.5 mg zoledronate, mean BMD at the total hip and lumbar spine was maintained at or above baseline levels for 9 and 10 years, respectively. Redosing with 1 or 2.5 mg zoledronate at 5 years reduced bone turnover markers for 3 to 4 years. BMD increased for 3 to 4 years after redosing with 1 mg zoledronate. In the group given 5-yearly 2.5 mg zoledronate, β-CTX was at least 20% lower than that in the placebo group for 10 years. Both a single baseline 5 mg dose of zoledronate and 5-yearly doses of 1 and 2.5 mg zoledronate prevented bone loss at hip and spine for 8 to 10 years in older postmenopausal women. Clinical trials to evaluate the effects on fracture risk of these very infrequent and lower doses of zoledronate are justified. © 2021 American Society for Bone and Mineral Research (ASBMR).

Vitamin D deficiency, supplementation and testing: have we got it right in New Zealand?

BACKGROUND

Severe prolonged vitamin D deficiency can cause rickets or osteomalacia. Both can be prevented by sunshine exposure or vitamin D supplementation. Although New Zealand guidance does not recommend vitamin D supplementation for the general population, it can be considered for individuals at risk of vitamin D deficiency. Routine measurement of 25-hydroxyvitamin D (25OHD) is also considered unnecessary.

METHODS

We investigated the rates of vitamin D supplementation, rickets and osteomalacia in New Zealand, and of 25OHD results in Auckland, over the last two decades.

RESULTS

Vitamin D prescriptions increased 14-fold, from 86,295/year to 1,215,507/year, between 2003 and 2019, with medication costs alone in 2019 being >$1 million. Despite these changes, the annual prevalence of hospital admissions for rickets, osteomalacia and unspecified vitamin D deficiency remained low and stable (10-20/year). 25OHD concentrations increased between 2002 and 2003 and between 2009 and 2019, and in the later time-period, 25OHD tests mainly identified individuals without vitamin D deficiency (40-50% >75nmol/L, 65-70% >50nmol/L and only 7-12.5% <25nmol/L).

CONCLUSIONS

Osteomalacia and rickets persist at low rates despite widespread, increasingly costly vitamin D supplementation and testing, which largely identifies individuals without vitamin D deficiency. These results suggest that vitamin D guidance and practice in New Zealand should change.

Prevalence of biochemical osteomalacia in adults undergoing vitamin D testing

OBJECTIVE

Prolonged severe vitamin D deficiency can cause osteomalacia, but the 25-hydroxyvitamin D (25OHD) concentration below which this occurs is unknown. We investigated the prevalence of biochemical osteomalacia in adults with a measurement of 25OHD.

DESIGN, MEASUREMENT, AND PATIENTS

25OHD results between 1/1/2009 and 15/6/2020 were obtained from the regional laboratory database, together with measurements of serum calcium, parathyroid hormone (PTH) and alkaline phosphatase (ALP) within 6 months of the index 25OHD. We defined biochemical osteomalacia as all 3 of: albumin-adjusted serum calcium (aCa)<2.0 mmol/L, PTH>7.3 pmol/L and ALP>150 IU/L. Possible osteomalacia was 2/3 criteria with the other test not done. 25OHD measurements associated with significant renal impairment, elevated hepatic transaminases or hypercalcaemia were excluded.

RESULTS

110,046 25OHD measurements were identified over the 11.5 years period. After removal of ineligible measurements, 42,171 25OHD measurements from 32,386 individuals with at least 2 of aCa, PTH and ALP were included in analyses. Median 25OHD was 63 nmol/L; 8% were <25 nmol/L, and 33% were <50 nmol/L. Five index 25OHD measurements met the definition of biochemical osteomalacia, and another 11 were possible osteomalacia. After reviewing available clinical records for these 16 episodes, we classified 9 cases as osteomalacia and 7 as other diagnoses. Thus, the prevalence of biochemical osteomalacia was 0.02% (9/42,171) for 25OHD measurements and 0.23% (8/3432) for 25OHD<25 nmol/L. All cases of osteomalacia with 25OHD measurements prior to supplementation had 25OHD≤18 nmol/L.

CONCLUSION

The prevalence of biochemical osteomalacia is very low, even in individuals with 25OHD<25 nmol/L.

Participant injury in clinical trials conducted in New Zealand for the benefit of manufacturers: an unfair system?

A patient with a long-standing medical condition was enrolled in a clinical trial, deemed as conducted for the benefit of the manufacturer. The patient entered the trial and, shortly afterward, developed a severe illness that left him with a significant permanent disability. Clinical investigators and clinicians not involved in the trial believed the illness was related to trial participation. Because the trial was for the manufacturer's benefit, the participant was not eligible for compensation from the Accident Compensation Corporation (ACC). Discussions with the trial sponsor took many years to resolve. This case highlights the numerous barriers faced by patients seeking compensation from trial sponsors for adverse events probably resulting from trial participation. Legal changes are required to resolve this situation. Without such changes, potential participants and researchers should consider carefully whether to participate and invite people to participate in trials conducted for the benefit of a manufacturer, as there may be little support available should a trial-related illness occur.

Identical summary statistics were uncommon in randomized trials and cohort studies

OBJECTIVE

To examine the proposition that identical summary statistics (mean and/or SD) in different randomized controlled trials (RCT) or clinical cohorts can be explained by common or homogeneous source populations.

STUDY DESIGN

We estimated the probability of identical summary data in studies with high proportions of identical summary statistics, in simulations, and in control datasets.

RESULTS

The probability of both an identical mean and an identical SD for a variable in separate RCT is low (<~3%), unless the variable is rounded to 1 significant figure. In two RCT with identical summary statistics for 16 of 39 shared variables, simulations indicated the probability of the observed matches was <1 in 100,000. In 34 clinical cohorts with publication integrity concerns, the proportion of summary statistics from variables reported in ≥10 studies that were identical in ≥2 cohorts were high (42% for means, 52% for SD, and 29% for both), and improbable based on simulations and comparisons to control datasets.

CONCLUSIONS

The likelihood of multiple identical summary statistics within an individual RCT or across a body of RCT or cohort studies by the same research group is low, especially when both the mean, and the SD are identical, unless the variables are rounded to 1 significant figure.

Citation of retracted publications: A challenging problem

Scientific publications with compromised integrity should be retracted. Papers citing retracted publications might need correction if findings depend on the retracted publication. While many studies have reported on post-retraction citations, few have focused on citations made before the retraction. We investigated the citation profile for a research group with 113 published concerns regarding publication integrity (CRPI). We identified 376 of their source publications that were cited by 5577 articles, and whether the source publication had a published CRPI. Of 6926 references to a source publication in these citing articles, for 3925 (57%) the source article had a published CRPI, while for 3001 (43%) it did not. Of these 3925 references, 3688 were in citing articles published before the source article CRPI was published. 166 citing articles containing 198 references to source publications were published after the corresponding source article CRPI was published (range 1-5 such references/article; 19/166 (11%) articles had >1 reference). In summary, many articles cite retracted publications, with the majority of these references occurring before the retraction. However, very few publications assess the impact of the retracted citations, even though the findings of many might be altered, at least in part, by removal of the retracted citation.

Predictors of Fracture in Older Women With Osteopenic Hip Bone Mineral Density Treated With Zoledronate

A recent analysis has found that during treatment with denosumab, women attaining higher bone densities (BMD) are less likely to have incident fractures. We have reexamined this important question using data from our recent trial of zoledronate in osteopenic women. One thousand women randomized to treatment with zoledronate were followed for 6 years. Of those, 122 sustained fragility fractures during follow-up. Baseline age, nonvertebral fracture history, total hip BMD, and calculated fracture risk were all significantly different between those who had fractures during the study and those who did not. BMDs achieved during the study were higher in those without incident fractures. However, achieved BMDs were very closely related to baseline values (r = 0.93, p < 0.0001). The increase in BMD during zoledronate treatment was not different between those who had incident fractures and those who did not (0.15 < p < 0.78), and change in BMD was not predictive of fracture (univariate logistic regression analysis). Stepwise regression analysis of all baseline variables showed the best independent predictors of fracture to be age (odds ratio [OR] = 1.08, 95% confidence interval [CI] 1.04-1.13, p = 0.0003), baseline spine BMD (OR = 0.81, 95% CI 0.67-0.96, p = 0.016), and history of nonvertebral fracture (OR = 1.69, 95% CI 1.06-2.69, p = 0.028). Addition of change in BMD to this model did not improve its predictive power. If changes in BMD were included in the stepwise regression analysis of baseline variables, they did not emerge as significant predictors of fracture. It is concluded that age, fracture history, and baseline BMD determine the risk of new fractures. Differences in achieved BMD between those who do or do not fracture arise from the close relationship between baseline and achieved BMDs. These findings suggest that targeting any particular BMD during treatment is unlikely to be a useful or valid strategy. © 2020 American Society for Bone and Mineral Research (ASBMR).

Population vitamin D supplementation in UK adults: too much of nothing?

Topics for DTB review articles are selected by DTB's editorial board to provide concise overviews of medicines and other treatments to help patients get the best care. Articles include a summary of key points and a brief overview for patients. Articles may also have a series of multiple choice CME questions.

Thyroid ultrasound and nodule malignancy risk: a "real world" assessment of ultrasound reporting and agreement of ultrasound-based malignancy risk estimates with cytology and histology findings

AIMS

Thyroid nodule malignancy risk is increasingly estimated using ultrasound characteristics. We assessed ultrasound reports of nodules and compared ultrasound-based malignancy risk assessments with cytology and histology findings.

METHODS

We identified patients with thyroid ultrasound (55% by private provider, 45% by DHB) and cytology at CMDHB over 18 months. Malignancy risk for each nodule was categorised based on the ultrasound report, then using ultrasound images with the local CMDHB approach and American Thyroid Association guidelines, and then was compared with cytology/histology results.

RESULTS

36/91 nodules (84 patients) had abnormal (Bethesda 3-6) cytology. Forty-eight patients (54 nodules) underwent thyroid surgery and 13 nodules (12 patients) had thyroid cancers. Most ultrasound reports did not mention nodule malignancy risk characteristics (range 13-98%) or a malignancy risk estimate (66/91). 12/33 nodules with benign (Bethesda 2) cytology and 18/36 nodules with abnormal (Bethesda 3-6) cytology were considered intermediate/high risk of malignancy by ultrasound; none and seven, respectively, had cancer identified subsequently. In 18 nodules considered low risk by ultrasound, four cancers were identified.

CONCLUSIONS

Most ultrasound reports contained insufficient information about nodule malignancy risk to allow an independent assessment. Agreement between cytological/histological findings and malignancy risk estimates using ultrasound was not high.

Nitrates Do Not Affect Bone Density or Bone Turnover in Postmenopausal Women: A Randomized Controlled Trial

Organic nitrates have been reported to have significant effects on bone mineral density (BMD) and bone turnover in previous clinical trials. However, results are inconsistent and some trials with strikingly positive results have been retracted because of scientific misconduct. As preparation for a potential fracture prevention study, we set out to determine the lowest effective dose and the most effective and acceptable nitrate preparation. We undertook a 1-year, double-blind, randomized, placebo-controlled trial of three different nitrate preparations and two different doses in osteopenic postmenopausal women, with a planned 1-year observational extension. The primary endpoint was change in BMD at the lumbar spine, and secondary endpoints included BMD changes at other sites, changes in bone turnover markers, and adverse events. A total of 240 eligible women who tolerated low-dose oral nitrate treatment in a 2-week run-in period were randomized to five different treatment groups or placebo. Over 12 months, there were no statistically significant between-group differences in changes in BMD at any site and no consistent differences in bone turnover markers. When the active treatment groups were pooled, there were also no differences in changes in BMD or bone turnover markers between nitrate treatment and placebo. Eighty-eight (27%) women withdrew during the run-in phase, with the majority because of nitrate-induced headache, and 41 of 200 (21%) women randomized to nitrate treatment withdrew or stopped study medication during the 1-year study compared with 1 of 40 (2.5%) in the placebo group. In summary, organic nitrates do not have clinically relevant effects on BMD or bone turnover in postmenopausal women and were poorly tolerated. These results call into question the validity of previous clinical research reporting large positive effects of nitrates on BMD and bone turnover. © 2020 American Society for Bone and Mineral Research.

Long-Term Stable Bone Mineral Density in HIV-Infected Men Without Risk Factors for Osteoporosis Treated with Antiretroviral Therapy

INTRODUCTION

Most prospective studies of bone mineral density (BMD) in HIV-infected cohorts taking antiretroviral therapy (ART) have been of short duration, typically < 3 years. Such studies have reported short-term stable or increasing BMD. We assessed whether this BMD stability persists for > 10 years in middle-aged and older men established on ART.

METHODS

A 12-year, prospective, longitudinal study in 44 HIV-infected men treated with ART who had measurements of BMD at the lumbar spine, proximal femur and total body at baseline, 2, 6 and 12 years.

RESULTS

At baseline, the mean age of participants was 49 years, the mean duration of HIV infection was 8 years, and the mean duration of ART was 50 months. After 12 years, BMD increased by 6.9% (95% CI 3.4 to 10.3) at the lumbar spine, and remained stable (range of BMD change: - 0.6% to 0.0%) at the total hip, femoral neck and total body. Only two individuals had a decrease of > 10% in BMD at any site during follow-up and both decreases in BMD were explained by co-morbid illnesses.

CONCLUSIONS

BMD remained stable over 12 years in middle-aged and older HIV-infected men treated with ART. Monitoring BMD in men established on ART who do not have risk factors for BMD loss is not necessary.

Anti-fracture efficacy of zoledronate in subgroups of osteopenic postmenopausal women: secondary analysis of a randomized controlled trial

BACKGROUND

We recently reported that the administration of zoledronate every 18 months to osteopenic older women reduces the incidence of fractures.

OBJECTIVE

Here, we present a more detailed analysis of that trial to determine whether baseline clinical characteristics impact on the anti-fracture efficacy of this intervention.

METHODS

This is a prospective, randomized, placebo-controlled, double-blind trial in osteopenic postmenopausal women aged ≥ 65 years, to determine the anti-fracture efficacy of zoledronate. 2000 women were recruited using electoral rolls and randomized to receive 4 infusions of either zoledronate 5 mg or normal saline, at 18-month intervals. Each participant was followed for 6 years. Calcium supplements were not supplied.

RESULTS

Fragility fractures (either vertebral or nonvertebral) occurred in 190 women in the placebo group (227 fractures) and in 122 women in the zoledronate group (131 fractures), odds ratio (OR) 0.59 (95%CI 0.46, 0.76; P < 0.0001). There were no significant interactions between baseline variables (age, anthropometry, BMI, dietary calcium intake, baseline fracture status, recent falls history, bone mineral density, calculated fracture risk) and the treatment effect. In particular, the reduction in fractures appeared to be independent of baseline fracture risk, and numbers needed to treat (NNT) to prevent one woman fracturing were not significantly different across baseline fracture risk tertiles.

CONCLUSIONS

The present analyses indicate that the decrease in fracture numbers is broadly consistent across this cohort. The lack of relationship between NNTs and baseline fracture risk calls into question the need for BMD measurement and precise fracture risk assessment before initiating treatment in older postmenopausal women.

Effects of Intravenous Zoledronate on Bone Turnover and Bone Density Persist for at Least 11 Years in HIV-Infected Men

Previously we reported the results of a 4-year extension of a 2-year randomized placebo-controlled trial showing that the antiresorptive effects of two annual 4-mg doses of zoledronate in HIV-infected men persisted for at least 5 years after the second dose. We set out to determine whether the effects on BMD and bone turnover persist beyond 10 years. We invited all participants in the original trial known to be alive and living in New Zealand to attend an additional visit approximately 12 years after trial entry and 11 years after their second dose of study medication. The outcome measures were BMD at the lumbar spine, proximal femur, and total body, and markers of bone turnover. Twenty-five of the 43 men originally enrolled in the trial attended the final visit, representing 25 of 31 (81%) participants alive and residing in New Zealand at the time. The average duration of follow-up was 12.4 years. At the final visit, BMD remained higher in the zoledronate group than the placebo group (lumbar spine 3.7%, 95% CI, 0.1 to 7.3; total hip 3.7%, 95% CI, 1.2 to 6.2; femoral neck 5.0%, 95% CI, 2.1 to 7.9; total body 2.4%, 95% CI, 0.7 to 4.0), and the between-group differences in BMD remained stable between 6 and 12 years. Serum CTx remained lower in the zoledronate group than the placebo group between 6 and 12 years and, at the final visit, was 45% lower (95% CI, 25 to 64) than the placebo group. P1NP was 26% (95% CI, 4 to 48) lower in the zoledronate group than the placebo group at the final visit. In summary, two annual 4-mg doses of zoledronate have effects on bone turnover and BMD in men that persist for at least 11 years after the second dose. © 2019 American Society for Bone and Mineral Research.

Publication rates after the first retraction for biomedical researchers with multiple retracted publications

Retraction of scientific publications can unmask scientific misconduct. We undertook a survey of publication rates, for authors with multiple retractions in the biomedical literature, to determine whether they changed after authors' first retractions. We collected publication and citation data from Scopus for 100 authors with multiple retractions (either >10 retractions or 2-5 retractions) in the Retraction Watch database. Publication rates increased until the year of the first retraction and decreased rapidly thereafter. By 4 years after the first retraction, the proportion of authors actively publishing at least one paper/year was <50%, annual publication rates were <50% of the pre-retraction rate, and only 22% of authors had a publication rate >50% of their pre-retraction rate. There was no difference in the decline in publication rates between authors associated with a retraction for misconduct and those not associated with such a retraction. After the first retraction, citation rates of retracted papers declined whereas those of unretracted papers by the same authors remained unchanged. In summary, publication rates of authors with multiple retractions, most of whom were associated with scientific misconduct, declined rapidly after their first retraction but a small minority continued to publish regularly.

Fracture Prevention with Zoledronate in Older Women with Osteopenia

BACKGROUND

Bisphosphonates prevent fractures in patients with osteoporosis, but their efficacy in women with osteopenia is unknown. Most fractures in postmenopausal women occur in those with osteopenia, so therapies that are effective in women with osteopenia are needed.

METHODS

We conducted a 6-year, double-blind trial involving 2000 women with osteopenia (defined by a T score of -1.0 to -2.5 at either the total hip or the femoral neck on either side) who were 65 years of age or older. Participants were randomly assigned to receive four infusions of either zoledronate at a dose of 5 mg (zoledronate group) or normal saline (placebo group) at 18-month intervals. A dietary calcium intake of 1 g per day was advised, but calcium supplements were not provided. Participants who were not already taking vitamin D supplements received cholecalciferol before the trial began (a single dose of 2.5 mg) and during the trial (1.25 mg per month). The primary end point was the time to first occurrence of a nonvertebral or vertebral fragility fracture.

RESULTS

At baseline, the mean (±SD) age was 71±5 years, the T score at the femoral neck was -1.6±0.5, and the median 10-year risk of hip fracture was 2.3%. A fragility fracture occurred in 190 women in the placebo group and in 122 women in the zoledronate group (hazard ratio with zoledronate, 0.63; 95% confidence interval, 0.50 to 0.79; P<0.001). The number of women that would need to be treated to prevent the occurrence of a fracture in 1 woman was 15. As compared with the placebo group, women who received zoledronate had a lower risk of nonvertebral fragility fractures (hazard ratio, 0.66; P=0.001), symptomatic fractures (hazard ratio, 0.73; P=0.003), vertebral fractures (odds ratio, 0.45; P=0.002), and height loss (P<0.001).

CONCLUSIONS

The risk of nonvertebral or vertebral fragility fractures was significantly lower in women with osteopenia who received zoledronate than in women who received placebo. (Funded by the Health Research Council of New Zealand; Australian New Zealand Clinical Trials Registry number, ACTRN12609000593235 .).

Effects of vitamin D supplementation on musculoskeletal health: a systematic review, meta-analysis, and trial sequential analysis

BACKGROUND

The effects of vitamin D on fractures, falls, and bone mineral density are uncertain, particularly for high vitamin D doses. We aimed to determine the effect of vitamin D supplementation on fractures, falls, and bone density.

METHODS

In this systematic review, random-effects meta-analysis, and trial sequential analysis, we used findings from literature searches in previously published meta-analyses. We updated these findings by searching PubMed, Embase, and Cochrane Central on Sept 14, 2017, and Feb 26, 2018, using the search term "vitamin D" and additional keywords, without any language restrictions. We assessed randomised controlled trials of adults (>18 years) that compared vitamin D with untreated controls, placebo, or lower-dose vitamin D supplements. Trials with multiple interventions (eg, co-administered calcium and vitamin D) were eligible if the study groups differed only by use of vitamin D. We excluded trials of hydroxylated vitamin D analogues. Eligible studies included outcome data for total or hip fractures, falls, or bone mineral density measured at the lumbar spine, total hip, femoral neck, total body, or forearm. We extracted data about participant characteristics, study design, interventions, outcomes, funding sources, and conflicts of interest. The co-primary endpoints were participants with at least one fracture, at least one hip fracture, or at least one fall; we compared data for fractures and falls using relative risks with an intention-to-treat analysis using all available data. The secondary endpoints were the percentage change in bone mineral density from baseline at lumbar spine, total hip, femoral neck, total body, and forearm.

FINDINGS

We identified 81 randomised controlled trials (n=53 537 participants) that reported fracture (n=42), falls (n=37), or bone mineral density (n=41). In pooled analyses, vitamin D had no effect on total fracture (36 trials; n=44 790, relative risk 1·00, 95% CI 0·93-1·07), hip fracture (20 trials; n=36 655, 1·11, 0·97-1·26), or falls (37 trials; n=34 144, 0·97, 0·93-1·02). Results were similar in randomised controlled trials of high-dose versus low-dose vitamin D and in subgroup analyses of randomised controlled trials using doses greater than 800 IU per day. In pooled analyses, there were no clinically relevant between-group differences in bone mineral density at any site (range -0·16% to 0·76% over 1-5 years). For total fracture and falls, the effect estimate lay within the futility boundary for relative risks of 15%, 10%, 7·5%, and 5% (total fracture only), suggesting that vitamin D supplementation does not reduce fractures or falls by these amounts. For hip fracture, at a 15% relative risk, the effect estimate lay between the futility boundary and the inferior boundary, meaning there is reliable evidence that vitamin D supplementation does not reduce hip fractures by this amount, but uncertainty remains as to whether it might increase hip fractures. The effect estimate lay within the futility boundary at thresholds of 0·5% for total hip, forearm, and total body bone mineral density, and 1·0% for lumbar spine and femoral neck, providing reliable evidence that vitamin D does not alter these outcomes by these amounts.

INTERPRETATION

Our findings suggest that vitamin D supplementation does not prevent fractures or falls, or have clinically meaningful effects on bone mineral density. There were no differences between the effects of higher and lower doses of vitamin D. There is little justification to use vitamin D supplements to maintain or improve musculoskeletal health. This conclusion should be reflected in clinical guidelines.

FUNDING

Health Research Council of New Zealand.

Outcomes, Interventions and Funding in Randomised Research Published in High-Impact Journals

Background

Randomised clinical trials are pivotal in guiding clinical practice. Trials with surrogate outcomes and industry sponsorship might be less reliable than those with hard outcomes and independent sponsorship. The types of interventions evaluated in randomised clinical trials might not reflect the diversity of those employed in clinical practice.

Methods

We assessed the types of primary outcome, types of intervention and sponsorship of 360 randomised clinical trials evaluating 416 interventions, published in seven major general medical journals and 10 speciality medical journals in five clinical disciplines.

Results

Primary outcomes were surrogate in 223/360 (62%) trials. Neither type of journal nor source of sponsorship was associated with type of primary outcome. Among the interventions evaluated, 233/416 (56%) were drugs, 17/416 (4%) devices and 49/416 (12%) procedures. The majority of trials were non-industry funded (220/360, 61%). Trials of drug interventions and those with industry sponsorship were more common in specialty than general journals (68% vs 48% and 55% vs 25%, respectively). Industry sponsorship was not associated with results for the primary outcome but was strongly associated with trials of drugs and devices.

Within the groups of both general and speciality journals, there were wide ranges in the prevalence of industry funding (7–63% and 37–70%, respectively), but in all cases the prevalence of hard primary outcomes was <40%.

Conclusions

Most randomised clinical trials published in influential journals reported surrogate primary outcomes and assessed drug interventions. Trials that evaluated devices and procedures were infrequently published, despite the prominence of each type of intervention in clinical practice. Industry funding was more common for trials published in specialty than general journals but was not associated with more positive results for primary outcomes or with a greater preponderance of surrogate outcomes.

Assessment of research waste part 1: an exemplar from examining study design, surrogate and clinical endpoints in studies of calcium intake and vitamin D supplementation

BACKGROUND

Research waste is estimated to be very common, but assessments of its prevalence and scope are rare. As an example, we assessed research waste in clinical research on calcium intake (assessing study design and endpoint type) and vitamin D supplementation (assessing endpoint type).

METHODS

We examined 404 randomised controlled trials (RCTs) and observational studies of calcium intake (diet or supplements) and bone mineral density (BMD) or fracture, and 547 RCTs of vitamin D supplements, and assessed the proportion of studies that used surrogate or clinical endpoints. For studies with BMD or fracture as an endpoint, we estimated when the 'tipping' point occurred indicating the need for RCTs with fracture as an endpoint (based on cumulative meta-analyses of BMD RCTs, and chronological review of observational studies), and whether each study published at least 5y after the tipping point was novel, added new clinical knowledge or was research waste.

RESULTS

Observational studies of calcium intake and BMD or fracture outnumbered RCTs by 3.3-4.5 times. For both calcium intake and vitamin D supplements, studies using surrogate endpoints outnumbered studies using clinical endpoints by 1.6-3 times. Of 41 RCT publications of calcium intake and BMD or fracture published at least 5y after the tipping point in 1994, we considered that 19 (46%) lacked novelty, another 13 (32%) added no new clinical knowledge, and 30 (73%) were research waste. Of 204 observational study publications of calcium intake and BMD or fracture, 197 (96%) lacked novelty, another 5 (2%) added no new clinical knowledge, and 202 (99%) were research waste. Of 39 RCTs of vitamin D supplementation and BMD or fracture published at least 5y after the tipping point in 1999, 14 (36%) lacked novelty, another 13 (33%) added no new clinical knowledge, and 27 (69%) were research waste.

CONCLUSIONS

A high proportion of studies of calcium intake since 2000 (95%) and trials of vitamin D supplements since 2005 (69%) on BMD or fracture represent research waste.

Assessment of research waste part 2: wrong study populations- an exemplar of baseline vitamin D status of participants in trials of vitamin D supplementation

BACKGROUND

Research waste can occur when trials are conducted in the wrong populations. Vitamin D deficient populations are most likely to benefit from vitamin D supplementation. We investigated waste attributable to randomised controlled trials (RCTs) of supplementation in populations that were not vitamin D deficient.

METHODS

In December 2015, we searched Pubmed, recent systematic reviews, and three trial registries for RCTs of vitamin D with clinical endpoints in adults, and 25-hydroxvitamin D (25OHD) survey data relevant to large (N ≥ 1000) RCTs. We investigated the proportion of RCTs that studied vitamin D deficient populations, temporal trends in baseline 25OHD, and whether investigators in large RCTs considered relevant 25OHD survey data or systematic reviews in their trial justifications.

RESULTS

Of 137 RCTs of vitamin D with clinical endpoints, 118 (86%) reported baseline mean/median 25OHD, which was < 25, 25-49, 50-74, and ≥ 75 nmol/L in 12 (10%), 62 (53%), 36 (31%), and 8 (7%) RCTs, respectively. In 70% of RCTs, baseline 25OHD was > 40 nmol/L. Baseline 25OHD increased over time. Before 2006, 38%, 62%, 0% and 0% of RCTs had baseline 25OHD < 25, 25-49, 50-74, and ≥ 75 nmol/L respectively; in 2011-15, the respective proportions were 9%, 49%, 37%, and 6%. Of 12 RCTs with baseline 25OHD < 25 nmol/L, 8 had neutral findings. Of 25 large RCTs (18 completed, 7 ongoing), 1 was undertaken in a vitamin D deficient population, 3 in vitamin D insufficient populations, and 17 had, or probably will have, baseline 25OHD > 40 nmol/L. 44% (8/18) of large completed RCTs cited relevant prior population 25OHD data, and only 3/10 (30%) relevant prior systematic reviews.

CONCLUSIONS

Up to 70% of RCTs of vitamin D with clinical endpoints, 71% of large completed RCTs, and 100% of ongoing large RCTs could be considered research waste because they studied cohorts that were not vitamin D deficient.

A randomised investigation of journal responses to academic and journalist enquiry about possible scientific misconduct

Objective

We investigated whether responses about possible scientific misconduct from journals to journalists would differ in speed, usefulness, and tone from responses to academics. Twelve journals that published 23 clinical trials about which concerns had been previously raised were randomly assigned to enquiries by a journalist or academics. Emails were sent every 3 weeks to the journal editor. We recorded the time for the journal to respond, and two investigators independently assessed the usefulness and tone of the journal responses.

Results

10/12 journals responded: 3 after one email, 5 after two emails, and 2 after three emails (median time from first email to response: 21 days; no difference in response times to journalist or academics, P = 0.25). Of the 10 responses, 8 indicated the journal was investigating, 5 had a positive tone, 4 a neutral tone, and 1 a negative tone. Five of the enquiries by the academics produced information of limited use and 1 no useful information, whereas none of the 6 journalist enquiries produced useful information (P = 0.015). None of the 10 responses was considered very useful. In conclusion, journal responses to a journalist were less useful than those to academics in understanding the status or outcomes of journal investigations.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3613-1) contains supplementary material, which is available to authorized users.

Calcium supplementation in osteoporosis: useful or harmful?

Osteoporosis and fragility fractures are important social and economic problems worldwide and are due to both the loss of bone mineral density and sarcopenia. Indeed, fragility fractures are associated with increased disability, morbidity and mortality. It is known that a normal calcium balance together with a normal vitamin D status is important for maintaining well-balanced bone metabolism, and for many years, calcium and vitamin D have been considered crucial in the prevention and treatment of osteoporosis. However, recently, the usefulness of calcium supplementation (alone or with concomitant vitamin D) has been questioned, since some studies reported only weak efficacy of these supplementations in reducing fragility fracture risk. On the other hand, besides the gastrointestinal side effects of calcium supplements and the risk of kidney stones related to use of co-administered calcium and vitamin D supplements, other recent data suggested potential adverse cardiovascular effects from calcium supplementation. This debate article is focused on the evidence regarding both the possible usefulness for bone health and the potential harmful effects of calcium and/or calcium with vitamin D supplementation.