- Email: [email protected]
Plastic surgery spin : Suppressing clarity
Journal of Plastic, Reconstructive & Aesthetic Surgery (2015) 68, 292e294
LETTER FROM AMERICA
Plastic surgery spin : Suppressing clarity Wiki the word spin and you will find definitions for it from areas as far afield as politics and physics.1
What is spin? When I studied organic chemistry in college, I learned that spin was how nuclear magnetic resonance imaging (NMR) worked by applying high strength magnetic fields to protons. Years later the acronym was changed from NMR to MRI so that patients undergoing imaging studies based upon nuclear magnetic resonance of the hydrogen nuclei in their bodies would not be frightened by entering large machines named nuclear. A spin-doctor is not a radiologist with special expertise in interpreting MRIs. A spin-doctor is a specialist in public relations. A nephew of Sigmund Freud, Edward Bernays, pioneered techniques of mass persuasion and wrote a seminal book, Propaganda. Bernays’ biography is, “The Father of Spin: Edward L. Bernays and the Birth of Public Relations”. Spin is designed to sow the seeds of confusion. Spin should not be confused with other forms of bias that yield discordant results. A recent meta-analysis of complications of breast reconstruction with acellular dermal matrix (ADM) found that there were fewer complications with ADM in those articles in which the authors reported a conflict of interest than in those articles in which authors reported no such conflict.2 This is not spin. Rather, researchers on evidence-based medicine define spin as: “The use of specific reporting strategies, from whatever motive, to highlight that the experimental treatment is beneficial, despite a statistically nonsignificant difference for the primary outcome, or to distract the reader from statistically nonsignificant results.”3
Spin in press releases Bernays claimed credit for perfecting the press release as an effective means of swaying public opinion. Press releases can be valuable if they provide journalists with a basis for understanding scientific articles and deciding if
their findings are newsworthy. Today, leading medical publishers such as BMJ and JAMA maintain specific websites for the press releases to registered journalists.4,5 These publishers typically prepare press releases for articles that will be published and issue the press releases that are subject to the authors’ approval. Other press releases can be likened to parenteral nutrition. It is a form of food, for which no higher cortical functions are required to assess its quality. Any organism in a persistent vegetative state can absorb parenteral nutrition as long as its gut functions. Researchers have investigated the quality of press releases by assessing their spin using the above definition. The researchers found that 47% of press releases for articles reporting randomized control trials had some type of spin.6
Spinning research While we might expect that press releases would have spin, what about randomized control trials themselves? Perhaps because we plastic surgeons have a dearth of blinded randomized control trials in our specialty, we place greater value in them.7 After all, by their very nature, randomized control trials are supposed to be less biased than observational studies. Sadly, recent findings indicate that spinning in randomized control trials extends beyond randomization by spinning a wheel. Indeed, what researchers have learned about randomized control trials should make us revisit the blind trust that we have placed in them. Boutron et al., who coined the above definition of spin, studied all randomized control trials found in MEDLINE in December 2006 whose primary outcome had statistically nonsignificant results. In other words, the results suggested that the findings could have been caused by random chance. Yet, they found spin in 37.5% of the results reported in the abstracts and in 58.3% of the abstract’s conclusions.a The most frequently
a The complete results with 95% confidence intervals are: 18% (95% CI, 10.0e28.9) of the titles, 37.5%(95% CI, 26.4e49.7) of the results reported in the abstracts and in 58.3% (95% CI, 46.1e69.8) of the abstract’s conclusions.
http://dx.doi.org/10.1016/j.bjps.2014.10.029 1748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Letter from America used spinning strategy was to blithely ignore the primary outcome that the trial was supposed to measure and highlight something else that was statistically significant.
Does trial registration provide spin prophylaxis?
293 “Studies without statistically significant results for the primary outcome used spin in 71% of cases. Furthermore, 33% (43/132) of reports of wound RCTs did not specify a primary outcome and there was evidence of spin and selective outcome reporting in the abstracts.”11
Solutions
Mandatory trial registration was thought to be a means of preventing this type of “changing horses midstream”. If a researcher had to include in his trial registration what primary outcome he would be measuring before he began his trial, and he had to list that outcome in a publicly available database, then any attempts to change the primary outcome would be readily known. This seemingly simple strategy for removing spin is incorporated into the Declaration of Helsinki. It states that not only must all trials be registered in a publicly available database, but also that they must be registered before the trials commence.8 How successful has mandatory trial registration been at eliminating this type of spin? This year a research letter in JAMA compared the primary outcomes that had been registered in Clinicaltrials.gov with the primary outcomes reported in a sample of 96 trials published in high impact journals such as JAMA, The New England Journal of Medicine and Lancet.9 (These were journals with impact factors greater than 10; JPRAS’ impact factor is less than 2.) They found that 51 of 132 (38.6%) primary end points were inconsistent.
There are no ready solutions to prevent spin. It continues to insidiously insinuate itself into our literature. If you beat it down, it will always rise up like “Whack-a-Mole”. One thing is certain, we should not rely upon abstracts alone, but we must constantly compare abstracts to text bodies and ask the generic question “Do the cuffs and collars match?” If the answer is no, then there is spin. Leonard McCoy, the ship’s surgeon on Star Trek, could make diagnoses with his hand-held Tricorder. Until somebody develops a spin detector app for our smartphones, we plastic surgeons will have to use the organ that we have much expertise in repairing and replacing to recognize spin d our noses.12 The best that we can do as editors, reviewers and readers is to have a heightened awareness of what spin does. Fortunately, plastic surgeons have a unique aide memoire to assist us: “plastic surgery spin” is an anagram for “suppressing clarity”.
Do meta-analyses decrease spin?
Not required.
There is spin in randomized control trials, but perhaps there is less spin in meta-analyses? After all, when a metaanalysis is done, the reviewers are supposed to carefully measure the quality of the underlying studies and independently extract the data. Unfortunately, the answer is no. When researchers compared meta-analyses of antihypertensive drugs by their results and conclusions they found that while the meta-analyses of a drug with ties to a drug company had the same results as meta-analyses without such ties, the conclusions of the meta-analyses with financial ties were more likely to have favorable conclusions. As the authors wrote:
Financial disclosure
“These findings suggest discordance between the data that underlie the results and the interpretation, or “spin,” of these data that constitute the conclusions.”10
The plastic surgery puddle If you consider the turbulence of ocean waves to be an analogy for the spin of blockbuster drugs with millions of dollars in sales, then you could surmise that plastic surgery products occupy a mere puddle with little depth and no waves. That would be a bad analogy. Spin is alive and well even in our small corner of the universe. Looking at lowly leg and foot ulcers that some of us treat, researchers found:
Ethics approval
None.
Reference 1. http://en.wikipedia.org/wiki/Spin. [accessed 18.10.14]. 2. Lopez J, Prifogle E, Nyame TT, Milton J, May JW. The impact of conflicts of interest in plastic surgery: an analysis of acellular dermal matrix, implant-based breast reconstruction. Plast Reconstr Surg 2014;133:1328e34. 3. Boutron I, Dutton S, Ravaud P, Altman DG. Reporting and interpretation of randomized controlled trials with statistically nonsignificant results for primary outcomes. J Am Med Assoc 2010 May 26;303(20):2058e64. 4. http://www.bmj.com/about-bmj/resources-authors/mediareleases. [accessed 18.10.14]. 5. http://media.jamanetwork.com/. [accessed 18.10.14]. 6. Yavchitz A, Boutron I, Bafeta A, et al. Misrepresentation of randomized controlled trials in press releases and news coverage: a cohort study. PLoS Med 2012;9:e1001308. 7. Freshwater MF, Garcia-Zalisnak DE, Gonza ´lez-Ortiz NE. Failure of plastic surgical clinical trials to document compliance with international ethical guidelines: a systematic review. J Plast Reconstr Aesthet Surg 2013;66:3e8. 8. Freshwater MF. DOH: preventing ethical pitfalls while advancing plastic surgery research. J Plast Reconstr Aesthet Surg 2013;66:589e91. 9. Becker JE, Krumholz HM, Ben-Josef G, Ross JS. Reporting of results in ClinicalTrials.gov and high-impact journals. J Am Med Assoc 2014;311:1063e5.
294 10. Yank V, Rennie D, Bero L. Financial ties and concordance between results and conclusions in meta-analyses: retrospective cohort study. BMJ 2007 Dec 8;335(7631):1202e5. 11. Lockyer S, Hodgson R, Dumville JC, Cullum N. “Spin” in wound care research: the reporting and interpretation of randomized controlled trials with statistically non-significant primary outcome results or unspecified primary outcomes. Trials 2013;14:371. 12. Freshwater MF. Gillies 2.0dsenses and Sherlock Holmes. J Plast Reconstr Aesthet Surg 2010;63:1399e400.
Letter from America M. Felix Freshwater Voluntary Professor of Surgery, University of Miami School of Medicine, 9155 S Dadeland Blvd, Suite 1404, Miami FL 33156-2739, USA E-mail address: [email protected] 19 October 2014
LETTER FROM AMERICA
Plastic surgery spin : Suppressing clarity Wiki the word spin and you will find definitions for it from areas as far afield as politics and physics.1
What is spin? When I studied organic chemistry in college, I learned that spin was how nuclear magnetic resonance imaging (NMR) worked by applying high strength magnetic fields to protons. Years later the acronym was changed from NMR to MRI so that patients undergoing imaging studies based upon nuclear magnetic resonance of the hydrogen nuclei in their bodies would not be frightened by entering large machines named nuclear. A spin-doctor is not a radiologist with special expertise in interpreting MRIs. A spin-doctor is a specialist in public relations. A nephew of Sigmund Freud, Edward Bernays, pioneered techniques of mass persuasion and wrote a seminal book, Propaganda. Bernays’ biography is, “The Father of Spin: Edward L. Bernays and the Birth of Public Relations”. Spin is designed to sow the seeds of confusion. Spin should not be confused with other forms of bias that yield discordant results. A recent meta-analysis of complications of breast reconstruction with acellular dermal matrix (ADM) found that there were fewer complications with ADM in those articles in which the authors reported a conflict of interest than in those articles in which authors reported no such conflict.2 This is not spin. Rather, researchers on evidence-based medicine define spin as: “The use of specific reporting strategies, from whatever motive, to highlight that the experimental treatment is beneficial, despite a statistically nonsignificant difference for the primary outcome, or to distract the reader from statistically nonsignificant results.”3
Spin in press releases Bernays claimed credit for perfecting the press release as an effective means of swaying public opinion. Press releases can be valuable if they provide journalists with a basis for understanding scientific articles and deciding if
their findings are newsworthy. Today, leading medical publishers such as BMJ and JAMA maintain specific websites for the press releases to registered journalists.4,5 These publishers typically prepare press releases for articles that will be published and issue the press releases that are subject to the authors’ approval. Other press releases can be likened to parenteral nutrition. It is a form of food, for which no higher cortical functions are required to assess its quality. Any organism in a persistent vegetative state can absorb parenteral nutrition as long as its gut functions. Researchers have investigated the quality of press releases by assessing their spin using the above definition. The researchers found that 47% of press releases for articles reporting randomized control trials had some type of spin.6
Spinning research While we might expect that press releases would have spin, what about randomized control trials themselves? Perhaps because we plastic surgeons have a dearth of blinded randomized control trials in our specialty, we place greater value in them.7 After all, by their very nature, randomized control trials are supposed to be less biased than observational studies. Sadly, recent findings indicate that spinning in randomized control trials extends beyond randomization by spinning a wheel. Indeed, what researchers have learned about randomized control trials should make us revisit the blind trust that we have placed in them. Boutron et al., who coined the above definition of spin, studied all randomized control trials found in MEDLINE in December 2006 whose primary outcome had statistically nonsignificant results. In other words, the results suggested that the findings could have been caused by random chance. Yet, they found spin in 37.5% of the results reported in the abstracts and in 58.3% of the abstract’s conclusions.a The most frequently
a The complete results with 95% confidence intervals are: 18% (95% CI, 10.0e28.9) of the titles, 37.5%(95% CI, 26.4e49.7) of the results reported in the abstracts and in 58.3% (95% CI, 46.1e69.8) of the abstract’s conclusions.
http://dx.doi.org/10.1016/j.bjps.2014.10.029 1748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Letter from America used spinning strategy was to blithely ignore the primary outcome that the trial was supposed to measure and highlight something else that was statistically significant.
Does trial registration provide spin prophylaxis?
293 “Studies without statistically significant results for the primary outcome used spin in 71% of cases. Furthermore, 33% (43/132) of reports of wound RCTs did not specify a primary outcome and there was evidence of spin and selective outcome reporting in the abstracts.”11
Solutions
Mandatory trial registration was thought to be a means of preventing this type of “changing horses midstream”. If a researcher had to include in his trial registration what primary outcome he would be measuring before he began his trial, and he had to list that outcome in a publicly available database, then any attempts to change the primary outcome would be readily known. This seemingly simple strategy for removing spin is incorporated into the Declaration of Helsinki. It states that not only must all trials be registered in a publicly available database, but also that they must be registered before the trials commence.8 How successful has mandatory trial registration been at eliminating this type of spin? This year a research letter in JAMA compared the primary outcomes that had been registered in Clinicaltrials.gov with the primary outcomes reported in a sample of 96 trials published in high impact journals such as JAMA, The New England Journal of Medicine and Lancet.9 (These were journals with impact factors greater than 10; JPRAS’ impact factor is less than 2.) They found that 51 of 132 (38.6%) primary end points were inconsistent.
There are no ready solutions to prevent spin. It continues to insidiously insinuate itself into our literature. If you beat it down, it will always rise up like “Whack-a-Mole”. One thing is certain, we should not rely upon abstracts alone, but we must constantly compare abstracts to text bodies and ask the generic question “Do the cuffs and collars match?” If the answer is no, then there is spin. Leonard McCoy, the ship’s surgeon on Star Trek, could make diagnoses with his hand-held Tricorder. Until somebody develops a spin detector app for our smartphones, we plastic surgeons will have to use the organ that we have much expertise in repairing and replacing to recognize spin d our noses.12 The best that we can do as editors, reviewers and readers is to have a heightened awareness of what spin does. Fortunately, plastic surgeons have a unique aide memoire to assist us: “plastic surgery spin” is an anagram for “suppressing clarity”.
Do meta-analyses decrease spin?
Not required.
There is spin in randomized control trials, but perhaps there is less spin in meta-analyses? After all, when a metaanalysis is done, the reviewers are supposed to carefully measure the quality of the underlying studies and independently extract the data. Unfortunately, the answer is no. When researchers compared meta-analyses of antihypertensive drugs by their results and conclusions they found that while the meta-analyses of a drug with ties to a drug company had the same results as meta-analyses without such ties, the conclusions of the meta-analyses with financial ties were more likely to have favorable conclusions. As the authors wrote:
Financial disclosure
“These findings suggest discordance between the data that underlie the results and the interpretation, or “spin,” of these data that constitute the conclusions.”10
The plastic surgery puddle If you consider the turbulence of ocean waves to be an analogy for the spin of blockbuster drugs with millions of dollars in sales, then you could surmise that plastic surgery products occupy a mere puddle with little depth and no waves. That would be a bad analogy. Spin is alive and well even in our small corner of the universe. Looking at lowly leg and foot ulcers that some of us treat, researchers found:
Ethics approval
None.
Reference 1. http://en.wikipedia.org/wiki/Spin. [accessed 18.10.14]. 2. Lopez J, Prifogle E, Nyame TT, Milton J, May JW. The impact of conflicts of interest in plastic surgery: an analysis of acellular dermal matrix, implant-based breast reconstruction. Plast Reconstr Surg 2014;133:1328e34. 3. Boutron I, Dutton S, Ravaud P, Altman DG. Reporting and interpretation of randomized controlled trials with statistically nonsignificant results for primary outcomes. J Am Med Assoc 2010 May 26;303(20):2058e64. 4. http://www.bmj.com/about-bmj/resources-authors/mediareleases. [accessed 18.10.14]. 5. http://media.jamanetwork.com/. [accessed 18.10.14]. 6. Yavchitz A, Boutron I, Bafeta A, et al. Misrepresentation of randomized controlled trials in press releases and news coverage: a cohort study. PLoS Med 2012;9:e1001308. 7. Freshwater MF, Garcia-Zalisnak DE, Gonza ´lez-Ortiz NE. Failure of plastic surgical clinical trials to document compliance with international ethical guidelines: a systematic review. J Plast Reconstr Aesthet Surg 2013;66:3e8. 8. Freshwater MF. DOH: preventing ethical pitfalls while advancing plastic surgery research. J Plast Reconstr Aesthet Surg 2013;66:589e91. 9. Becker JE, Krumholz HM, Ben-Josef G, Ross JS. Reporting of results in ClinicalTrials.gov and high-impact journals. J Am Med Assoc 2014;311:1063e5.
294 10. Yank V, Rennie D, Bero L. Financial ties and concordance between results and conclusions in meta-analyses: retrospective cohort study. BMJ 2007 Dec 8;335(7631):1202e5. 11. Lockyer S, Hodgson R, Dumville JC, Cullum N. “Spin” in wound care research: the reporting and interpretation of randomized controlled trials with statistically non-significant primary outcome results or unspecified primary outcomes. Trials 2013;14:371. 12. Freshwater MF. Gillies 2.0dsenses and Sherlock Holmes. J Plast Reconstr Aesthet Surg 2010;63:1399e400.
Letter from America M. Felix Freshwater Voluntary Professor of Surgery, University of Miami School of Medicine, 9155 S Dadeland Blvd, Suite 1404, Miami FL 33156-2739, USA E-mail address: [email protected] 19 October 2014