0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Contribution |

Different Patterns of Duplicate Publication:  An Analysis of Articles Used in Systematic Reviews FREE

Erik von Elm, MD; Greta Poglia; Bernhard Walder, MD; Martin R. Tramèr, MD, DPhil
[+] Author Affiliations

Author Affiliations: Division of Anesthesiology, Department of Anesthesiology, Pharmacology, and Surgical Intensive Care, Geneva University Hospitals, Geneva, Switzerland. Dr von Elm is now with the Department of Social and Preventive Medicine, University of Bern, Bern, Switzerland; and Mrs Poglia is now with the Department of Psychiatry, Geneva University Hospitals, Geneva, Switzerland.


JAMA. 2004;291(8):974-980. doi:10.1001/jama.291.8.974.
Text Size: A A A
Published online

Context Duplicate publication is publication of an article that overlaps substantially with an article published elsewhere. Patterns of duplication are not well understood.

Objective To investigate duplication patterns and propose a decision tree for classification.

Data Sources We searched a comprehensive list of systematic reviews (1989 through August 15, 2002) in anesthesia and analgesia that is accessible on the Internet. We selected published full articles of duplicates that had been identified in these systematic reviews. Abstracts, letters, or book chapters were excluded.

Study Selection and Data Extraction Authors of 56 (40%) of 141 systematic reviews acknowledged identification of duplicates. Duplication patterns were identified independently by all investigators comparing samples and outcomes of pairs of duplicates and main articles. Information on cross-reference, sponsorship, authorship, and publication characteristics was extracted from the articles.

Data Synthesis The 56 systematic reviews included 1131 main articles (129 337 subjects) and excluded 103 duplicates (12 589 subjects) that originated from 78 main articles. Sixty articles were published twice, 13 three times, 3 four times, and 2 five times. We identified 6 duplication patterns: (1A) identical samples and identical outcomes (21 pairs); (1B) same as 1A but several duplicates assembled (n = 16); (2) identical samples and different outcomes (n = 24); (3A) increasing sample and identical outcomes (n = 11); (3B) decreasing sample and identical outcomes (n = 11); (4) different samples and different outcomes (n = 20). The prevalence of covert duplicate articles (without a cross-reference to the main article) was 5.3% (65/1234). Of the duplicates, 34 (33%) were sponsored by the pharmaceutical industry, and 66 (64%) had authorship that differed partly or completely from the main article. The median journal impact factor was 1.8 (range, 0.1-29.5) for duplicates and 2.0 (range, 0.4-29.5) for main articles (P = .13). The median annual citation rate was 1.7 (range, 0-27) for duplicates and 2.1 (range, 0-31) for main articles (P = .45). The median number of authors was 4 (range, 1-14) for duplicates and 4 (range, 1-15) for corresponding main articles (P = .02). The median delay in publication between main articles and duplicates was 1 year (range, 0-7 years).

Conclusions Duplication goes beyond simple copying. Six distinct duplication patterns were identified after comparing study samples and outcomes of duplicates and corresponding main articles. Authorship was an unreliable criterion. Duplicates were published in journals with similar impact factors and were cited as frequently as main articles.

Figures in this Article

Duplicate publication is the publication of an article that overlaps substantially with an article published elsewhere.1 This practice may be acceptable in particular situations. However, authors must acknowledge the main article overtly by using a cross-reference. Covert duplicate publication has been widely disapproved.2,3 This practice is wasteful of the time and resources of editors, peer reviewers, and readers, and it is misleading because undue weight is given to observations that are being reported repeatedly. When duplicates are inadvertently included in a systematic review, the conclusion of that systematic review may change.4 Finally, covert duplicate publication is dishonest; it undermines the integrity of science.5

Little is known about patterns of duplicate publication. Also, characteristics of duplicates are not well understood, and there is no common agreement on how to classify them. We set out to investigate patterns of duplicate publication and to propose a decision tree for their classification. We have chosen systematic reviews as a source of information because duplicates are often identified during the rigorous process of a systematic review.6

Identification of Duplicates

We used a comprehensive list of systematic reviews (1989 through August 15, 2002) in perioperative medicine (anesthesia, analgesia, and critical care) that is regularly updated through searches in electronic databases, hand-searching of specialty journals, and contact with experts.7 The average methodological quality of these reviews was considered satisfactory.8

We selected all systematic reviews of anesthesia and analgesia topics that acknowledged identification of duplicates. If there was no information on duplicates, we contacted the authors of the reviews and asked them if there were none. We only considered duplicates that were published as full articles. We excluded abstracts, letters, and book chapters. We also disregarded a duplicate when it was excluded from a review for reasons that were not related to duplication (ie, for validity reasons). We regarded duplicates as such independent of whether they had a cross-reference or not. If systematic reviews had overlapping topics and included the same articles, we considered each article only once. We did not search systematically for additional duplicates. We obtained hard copies of all duplicates and of corresponding main articles.

Characteristics of Duplicates and of Main Articles

We identified clusters (ie, groups of ≥2 articles) that originated from a single study. We then designated duplicates and corresponding main articles within each cluster. Several duplicates could originate from a main article, and several main articles could be the origin of a duplicate. We regarded the oldest or the largest article of a cluster as the main article, irrespective of whether it had been considered the main article or duplicate by the authors of the systematic reviews.

From each main article and duplicate, we extracted information on cross-reference, sponsorship, publication characteristics, and authors. A cross-reference was considered clear if the corresponding article was acknowledged and referenced (for instance, in the bibliography or in a footnote) and the link between the 2 articles was evident.1 It was considered unclear if the corresponding article was referenced, but the relationship between the articles was obscured. Pharmaceutical sponsorship was assumed if (1) it was disclosed as such; (2) a pharmaceutical company provided funds or study material; (3) the publishing journal was sponsored (for instance, the article appeared in a journal supplement); or (4) an author was an employee of a pharmaceutical company. All other funding was regarded as nonpharmaceutical. Impact factors were taken from the Institute for Scientific Information Journal Citation Report,9 but they were coded as "missing" for journal supplements. Citation numbers were taken from the Science Citation Index Expanded10 and were converted to annual rates. We compared authors of duplicates and main articles; depending on the degree of similarity, we distinguished between articles as having complete, incomplete, or no matching of authorship.

Decision Tree and Duplication Patterns

Using a randomly chosen subset of 25 clusters, 2 of the authors (G.P. and B.W.) searched for suitable criteria to define the link between duplicates and main articles. The matching of study samples and the matching of study outcomes were the best criteria that we found. Four combinations and thus duplication patterns were possible: (1) identical samples and identical outcomes; (2) identical samples and different outcomes; (3) different samples and identical outcomes; and (4) different samples and different outcomes.

Analysis

All investigators independently read all main articles and duplicates, designated clusters, assembled pairs of duplicates and main articles within each cluster, and applied the proposed decision tree to assign each duplicate to 1 of the 4 proposed duplication patterns. Consensus was reached by discussion. If there was uncertainty about duplication, we asked the authors of the suspicious articles for clarification. Data from pairs of main articles and duplicates were compared using the Wilcoxon signed rank test; for clusters with 2 or more duplicates, mean values of data from duplicates were taken. P<.05 indicated statistical significance. All statistical analyses were performed using STATA statistical software (Version 8, STATA Corp, College Station, Tex).

Identification of Duplicates

Of 141 systematic reviews, 42 reported spontaneously on duplicates (Figure 1). We contacted the principal authors of the other 99 and 69 (70%) responded. Fourteen had identified duplicates without reporting on them. Thus, authors of 56 (40%) of 141 systematic reviews acknowledged identification of duplicates.1166 These reviews were published between 1989 and 2000 and covered a wide range of topics in anesthesia and analgesia (Table 1). Forty-six reviews (82%) considered data from randomized controlled trials and a meta-analysis. The authors of the 56 reviews regarded 1234 articles as potentially valid and eligible for inclusion. However, 1131 were main articles with data on 129 337 subjects and 103 were recognized as duplicates with data on 12 589 subjects. Thus, the prevalence of duplicates independent of whether they had a cross-reference or not was 8.3% and duplicated data was 8.9% (Table 1).

Figure 1. Flowchart of Systematic Reviews
Graphic Jump Location
Characteristics of Duplicates and of Main Articles

The 103 duplicates originated from 78 main articles; thus, there were 181 articles in 78 clusters. Data from 60 articles were published twice, 13 three times, 3 four times, and 2 five times.

Sixty-three percent of the duplicates had no cross-reference at all (Table 2); the prevalence of covert duplication in this cohort of systematic reviews was 5.3% (65/1234). Twelve percent of the duplicates were translations. Of those, only 1 had a clear cross-reference. Thirty-four (33%) declared pharmaceutical sponsorship; of those, 16 were published in a supplement. The number of authors of main articles was higher (median, 4; range, 1-15) than that of corresponding duplicates (median, 4; range, 1-14) (P = .02). For 64% of pairs of duplicates and corresponding main articles, there was no matching or only incomplete matching of authorship. The median number of duplicated subjects was 56 (range, 1-1044). The median year of publication of main articles was 1989 (range, 1971-1998) and duplicates was 1990 (range, 1973-1999). The median delay in publication between duplicates and corresponding main articles was 1 year (range, 0-7 years). Two thirds of duplicates were published within 2 years before or after the corresponding main article (Figure 2). Median annual citation rates of duplicates and main articles were similar (1.7 vs 2.1; P = .45). Median impact factors of the publishing journals were also similiar (1.8 vs 2.0; P = .13). Most journals that published duplicates and main articles belonged to the Journal Citation Report subject categories of anesthesiology, critical care medicine, general and internal medicine, pharmacology and pharmacy, and surgery.9 The median impact factor of theses journals was 0.9 (range, 0-29.5).

Table Graphic Jump LocationTable 2. Characteristics of Main Reports and Duplicates*
Figure 2. Delay in Years of Publication Between Main Reports and Duplicates
Graphic Jump Location
Percentages on the top of columns are cumulative relative frequencies.
Decision Tree and Duplication Patterns

The decision tree eventually yielded 6 distinct patterns of duplication (ie, 4 patterns according to the possibilities of combinations of similarity of study sample and similarity of study outcomes and 2 subgroups) (Figure 3). All pairs of duplicates and main articles could be assigned to 1 of the 6 patterns; none of the articles fell into several categories.

Figure 3. Decision Tree for Identification of Patterns of Duplicate Publication
Graphic Jump Location

Patterns showed particular characteristics (Table 2). A pattern 1A duplicate was a reproduction of an already published article using an identical sample and outcomes. The first published article was considered the main article. Most 1A duplicates (76%) had no cross-reference at all to the main article. Almost one third (29%) were translations; only 1 had a cross-reference. Pattern 1B duplicates were similar to 1A duplicates. However, 2 or more main articles were assembled to produce yet another article. We regarded all contributing articles as main articles, independent of order of publication. Pattern 1B duplicates had the highest proportion of pharmaceutical sponsorship (81%)—63% were published in supplements and had pharmaceutical sponsorship. Pattern 1B had the highest number of duplicated subjects (median, 169), and their delay in publication was shortest (median, 0.5 years). There was the smallest number of authors (median, 1), and the highest proportion of articles with nonmatching authorship (31%). Pattern 2 duplicates originated from 1 study sample but reported on different outcomes. The first published article was considered the main article. Pattern 2 duplicates had the highest proportion of unclear cross-references (25%), a high proportion of nonpharmaceutical sponsorship (38%), and the lowest annual citation rate (median, 1.1). Pattern 3A and 3B duplicates were about increasing or decreasing trial size. Pattern 3A consisted of expanded articles that were written when new data were added to a preliminary article. These articles had the longest delay in publication (median, 2 years), the highest annual citation rate (median, 3.2), and were published in journals with the highest impact factors (median, 2.7). Pattern 3B consisted of articles that documented parts of a large trial and reported identical outcomes. None of these duplicates had a clear cross-reference, 55% declared pharmaceutical sponsorship, 45% were translations (none of which had a cross-reference), and the number of duplicated subjects was high (median, 105). In two 3B clusters, authors selected 2 or more (but not all) groups of an already published randomized trial to produce a new article. For both 3A and 3B patterns, the article reporting on the largest study sample was regarded as main article, independent of whether it was published before or after the duplicate. In pattern 4 duplicates, both samples and outcomes were different from the main article. Confirmation of duplication was only possible through contact with the original authors. These duplicates had a high proportion of nonpharmaceutical sponsorship (55%) and incomplete matching of authors (75%). The article reporting on the largest study sample was regarded as main article.

We systematically analyzed a cohort of 103 duplicates and 78 corresponding main articles and were able to identify 6 mutually exclusive patterns of duplication. Our decision tree was based on 2 criteria: similarity of study samples and similarity of study outcomes. Authorship was not a suitable criterion; depending on the duplication pattern, authors of between 18% and 57% of duplicates and main articles matched completely.

Some duplication patterns showed typical features. A pattern 1A duplicate, for instance, corresponds to what is usually known as a copy. For pattern 1B, it may be assumed that an author who is not necessarily involved in research or development of a drug is asked by a pharmaceutical company to assemble some main articles on that drug for a publicity article. The duplicate is then typically published in a sponsored supplement. Both short delay between the publication of main articles and duplicates and changing authorship make it difficult to identify duplication through peer review. Also, supplements are not always peer-reviewed.67 Pattern 2 duplicates represent the well-known fragmentation of scientific information; this may lead to what was previously termed the least publishable unit.68 This practice was associated with nonpharmaceutical sponsorship and unclear or missing cross-references. Publicly funded researchers may be driven to produce multiple articles to justify previously received grants. Pattern 3A duplication has been described as a meat extender.69 It is the expanding of a preliminary article through the addition of more data to produce the definitive article. These duplicates were published in journals with the highest impact factors and the articles had the highest citation rates, suggesting that they were about new and perhaps innovative treatments. Early dissemination of preliminary data about new treatments is often warranted. However, this does not justify the high rate of articles without a cross-reference to the preliminary article. Pattern 3B may be seen as the opposite of pattern 3A. Typically, a multicenter trial (the main article) is fragmented and individual parts (the duplicates) are published separately; this has been called disaggregation.5 Multicenter trials are often multinational, large, and sponsored by pharmaceutical companies. Indeed, 3B duplicates were often translations, included a high number of duplicated subjects, and were frequently sponsored by the pharmaceutical industry. Pattern 4 was the most chaotic practice described herein; both study sample and outcomes of duplicates and main articles were different despite evidence that both articles originated from the same study. Definite confirmation was only possible through contact with the authors. It was particularly disturbing that all pattern 3B and 4 duplicates were described as randomized controlled trials, although it was impossible to maintain the initial study architecture, and thus randomization. Authors of systematic reviews may choose to exclude a duplicate cluster when these patterns are involved.

We do not know if these cases of duplication happened deliberately, accidentally, or by negligence. Duplicate publication may be acceptable to foster dissemination of important scientific information, for instance, through translation of a pivotal trial into another language. Then, however, we would expect a cross-reference to unmistakably show the relationship between the translation (ie, the duplicate) and the main article. There were 12 translations; only 1 had a cross-reference to the main article. Seventeen percent of duplicates cited the corresponding main article but left the reader unaware of the relationship between the 2 articles. In another study, partial referencing was found in 11% of duplicates.70 Sixty-three percent of the duplicates had no cross-reference at all to the main article; the prevalence of covert duplication in the reviewed literature was 5%. Estimates of duplicate publication have been reported by others who concentrated on (1) a particular drug class6 or a single drug4; (2) the literature in nursing71 or surgery72; or (3) 1 journal.70,7375 To adequately appraise the significance of our estimate, 2 issues have to be considered. First, as in previous studies,6 our estimate concerns covert duplication. Second, we focused on published full articles that were considered for inclusion in systematic reviews. Most reviews included randomized controlled trials only. Also, impact factors of the journals that published main articles and duplicates were higher than those of all journals in the corresponding categories of the Journal Citation Report. This suggests that articles from mainly higher ranking journals were included in these systematic reviews. Impact factors and citation rates of duplicates and main articles were similar; it is tempting to believe that duplicates are often cited erroneously by authors who believe that they are citing a main article.4

Limitations

There are several limitations to this study. First, we focused on articles from anesthesia and analgesia; the proposed classification may not be generalizable to other clinical areas. Second, further studies may find yet another pattern of duplication or a combination of those described herein; additional criteria may help to refine our classification. Third, we analyzed duplicates that were identified in a published list of systematic reviews in perioperative medicine7; selection bias cannot be ruled out. However, this is unlikely because these reviews had been gathered through systematic searches and the list had not been compiled with the purpose of studying duplicate publication. Fourth, our estimate of covert duplicate publication may be flawed. We may have overestimated the true prevalence because we included systematic reviews only when duplication was acknowledged. Or, we may have underestimated the true prevalence because many reviews did not include any statement about duplicate articles. Even after contact with the authors of the reviews, it was sometimes unclear if they knew about this potential pitfall. Some had identified duplicates but they, or the editors and peer reviewers, did not judge the information important enough to be mentioned in the article. Also, we ignored duplicates that were excluded from the systematic reviews for validity reasons or that were abstracts, letters, or book chapters. Fifth, we did not quantify the impact of covert duplicate publication on systematic reviews. It has been shown previously that removing duplicated data may change the results of a systematic review.4 It was not our intention to replicate this finding.

Conclusion

Duplicate publication in the medical literature is a reality, but it may not necessarily be harmful. However, to produce an article that overlaps substantially with an already published article without adequate cross-referencing is misconduct. We have shown that duplication goes beyond simple copying. The proposed classification distinguishes mutually exclusive patterns of duplicate publication and may become a useful tool for those who have to deal with duplication (ie, editors, peer reviewers, and authors) in systematic reviews. Because systematic reviews are produced by conducting an exhaustive literature search and critical appraisal, they are an effective way to unearth duplication. Indeed, authors of systematic reviews frequently encounter serious difficulties while dealing with duplicate articles;4,5,76,77 they should be encouraged to make duplication public. A statement on duplication could also be included in the Quality of Reporting of Meta-analyses checklist for the reporting of systematic reviews.78 Exposure of cases of duplicates is likely to improve awareness and lower the tolerance of this publication malpractice.

International Committee of Medical Journal Editors.  Uniform requirements for manuscripts submitted to biomedical journals. Available at: http://www.icmje.org. Accessibility verified February 2, 2004.
PubMed
 Definition of "sole contribution."  N Engl J Med.1969;281:676-677.
 Guidelines for the Conduct of Research in the Intramural Research Program at NIH.  3rd ed. Bethesda, Md: National Institutes of Health; 1997.
Tramèr MR, Reynolds DJ, Moore RA, McQuay HJ. Impact of covert duplicate publication on meta-analysis: a case study.  BMJ.1997;315:635-640.
PubMed
Huston P, Moher D. Redundancy, disaggregation, and the integrity of medical research.  Lancet.1996;347:1024-1026.
PubMed
Gøtzsche PC. Multiple publication of reports of drug trials.  Eur J Clin Pharmacol.1989;36:429-432.
PubMed
 List of systematic reviews in anesthesia, analgesia and critical care. Available at: http://www.hcuge.ch/anesthesie/anglais/evidence/arevusyst.htm. Accessed August 15, 2002.
Choi PT, Halpern SH, Malik N, Jadad AR, Tramèr MR, Walder B. Examining the evidence in anesthesia literature: a critical appraisal of systematic reviews.  Anesth Analg.2001;92:700-709.
PubMed
 ISI Journal Citation Report: Science edition 2001. Available at: http://www.isinet.com. Accessed January 12, 2002.
 ISI Web of Science: Science Citation Index expanded. Available at: http://www.isinet.com. Accessed January 12, 2002.
Aspinall RL, Goodman NW. Denial of effective treatment and poor quality of clinical information in placebo controlled trials of ondansetron for postoperative nausea and vomiting: a review of published trials.  BMJ.1995;311:844-846.
PubMed
Eberhart LH, Morin AM, Seeling W, Bothner U, Georgieff M. Meta-analysis of controlled randomized studies on droperidol for prevention of postoperative phase vomiting and nausea.  Anasthesiol Intensivmed Notfallmed Schmerzther.1999;34:528-536.
PubMed
Domino KB, Anderson EA, Polissar NL, Posner KL. Comparative efficacy and safety of ondansetron, droperidol, and metoclopramide for preventing postoperative nausea and vomiting: a meta-analysis.  Anesth Analg.1999;88:1370-1379.
PubMed
Figueredo ED, Canosa LG. Ondansetron in the prophylaxis of postoperative vomiting: a meta-analysis.  J Clin Anesth.1998;10:211-221.
PubMed
Figueredo E, Canosa LG. Prevention or treatment of postoperative vomiting using ondansetron? a mathematical assessment.  J Clin Anesth.1999;11:24-31.
PubMed
Figueredo E, Canosa L. Prophylactic ondansetron for postoperative emesis: meta-analysis of its effectiveness in patients with previous history of postoperative nausea and vomiting.  Acta Anaesthesiol Scand.1999;43:637-644.
PubMed
Henzi I, Walder B, Tramèr MR. Metoclopramide in the prevention of postoperative nausea and vomiting: a quantitative systematic review of randomized, placebo-controlled studies.  Br J Anaesth.1999;83:761-771.
PubMed
Henzi I, Sonderegger J, Tramèr MR. Efficacy, dose-response, and adverse effects of droperidol for prevention of postoperative nausea and vomiting.  Can J Anaesth.2000;47:537-551.
PubMed
Loewen PS, Marra CA, Zed PJ. 5-HT3 receptor antagonists vs traditional agents for the prophylaxis of postoperative nausea and vomiting.  Can J Anaesth.2000;47:1008-1018.
PubMed
Tramèr M, Moore A, McQuay H. Propofol anaesthesia and postoperative nausea and vomiting: quantitative systematic review of randomized controlled studies.  Br J Anaesth.1997;78:247-255.
PubMed
Tramèr MR, Reynolds DJ, Moore RA, McQuay HJ. Efficacy, dose-response, and safety of ondansetron in prevention of postoperative nausea and vomiting: a quantitative systematic review of randomized placebo-controlled trials.  Anesthesiology.1997;87:1277-1289.
PubMed
Tramèr MR, Moore RA, Reynolds DJ, McQuay HJ. A quantitative systematic review of ondansetron in treatment of established postoperative nausea and vomiting.  BMJ.1997;314:1088-1092.
PubMed
Tramèr MR, Reynolds DJ, Moore RA, McQuay HJ. When placebo controlled trials are essential and equivalence trials are inadequate.  BMJ.1998;317:875-880.
PubMed
Alderson P, Bunn F, Lefebvre C.  et al.  Human albumin solution for resuscitation and volume expansion in critically ill patients.  Cochrane Database Syst Rev.2002;1:CD001208.
Cochrane Injuries Group Albumin Reviewers.  Human albumin administration in critically ill patients: systematic review of randomised controlled trials.  BMJ.1998;317:235-240.
PubMed
Alderson P, Schierhout G, Roberts I, Bunn F. Colloids versus crystalloids for fluid resuscitation in critically ill patients.  Cochrane Database Syst Rev.2000;2:CD000567.
Schierhout G, Roberts I. Fluid resuscitation with colloid or crystalloid solutions in critically ill patients: a systematic review of randomised trials.  BMJ.1998;316:961-964.
PubMed
Bunn F, Alderson P, Hawkins V. Colloid solutions for fluid resuscitation.  Cochrane Database Syst Rev.2003;1:CD001319.
PubMed
Choi PT, Yip G, Quinonez LG, Cook DJ. Crystalloids vs colloids in fluid resuscitation: a systematic review.  Crit Care Med.1999;27:200-210.
PubMed
Velanovich V. Crystalloid versus colloid fluid resuscitation: a meta-analysis of mortality.  Surgery.1989;105:65-71.
PubMed
Wade CE, Kramer GC, Grady JJ, Fabian TC, Younes RN. Efficacy of hypertonic 7.5% saline and 6% dextran-70 in treating trauma: a meta-analysis of controlled clinical studies.  Surgery.1997;122:609-616.
PubMed
Whatling PJ. Intravenous fluids for abdominal aortic surgery.  Cochrane Database Syst Rev.2000;4:CD000991.
PubMed
Edwards JE, Oldman A, Smith L.  et al.  Single dose oral aspirin for acute pain.  Cochrane Database Syst Rev.2000;2:CD002067.
Edwards JE, Oldman AD, Smith LA.  et al.  Oral aspirin in postoperative pain: a quantitative systematic review.  Pain.1999;81:289-297.
PubMed
Edwards JE, Loke YK, Moore RA, McQuay HJ. Single dose piroxicam for acute postoperative pain.  Cochrane Database Syst Rev.2000;4:CD002762.
PubMed
Collins SL, Edwards JE, Moore RA, McQuay HJ. Single dose dextropropoxyphene, alone and with paracetamol (acetaminophen), for postoperative pain.  Cochrane Database Syst Rev.2000;2:CD001440.
Collins SL, Edwards JE, Moore RA, McQuay HJ. Single-dose dextropropoxyphene in post-operative pain: a quantitative systematic review.  Eur J Clin Pharmacol.1998;54:107-112.
Moore A, Collins S, Carroll D, McQuay H, Edwards J. Single dose paracetamol (acetaminophen), with and without codeine, for postoperative pain.  Cochrane Database Syst Rev.2000;2:CD001547.
Moore A, Collins S, Carroll D, McQuay H. Paracetamol with and without codeine in acute pain: a quantitative systematic review.  Pain.1997;70:193-201.
PubMed
Dexter F. Regional anesthesia does not significantly change surgical time versus general anaesthesia: a meta-analysis of randomized studies.  Reg Anesth Pain Med.1998;23:439-443.
Rodgers A, Walker N, Schug S.  et al.  Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials.  BMJ.2000;321:1493.
PubMed
Parker MJ, Urwin SC, Handoll HH, Griffiths R. General versus spinal/epidural anaesthesia for surgery for hip fractures in adults.  Cochrane Database Syst Rev.2000;2:CD000521.
Urwin SC, Parker MJ, Griffiths R. General versus regional anaesthesia for hip fracture surgery: a meta-analysis of randomized trials.  Br J Anaesth.2000;84:450-455.
PubMed
Sorenson RM, Pace NL. Anesthetic techniques during surgical repair of femoral neck fractures: a meta-analysis.  Anesthesiology.1992;77:1095-1104.
PubMed
Forgie MA, Wells PS, Laupacis A, Fergusson D.for the International Study of Perioperative Transfusion (ISPOT) Investigators.  Preoperative autologous donation decreases allogeneic transfusion but increases exposure to all red blood cell transfusion.  Arch Intern Med.1998;158:610-616.
PubMed
Levi M, Cromheecke ME, de Jonge E.  et al.  Pharmacological strategies to decrease excessive blood loss in cardiac surgery: a meta-analysis of clinically relevant endpoints.  Lancet.1999;354:1940-1947.
PubMed
Laupacis A, Fergusson D.for the International Study of Peri-operative Transfusion (ISPOT) Investigators.  Drugs to minimize perioperative blood loss in cardiac surgery: meta-analyses using perioperative blood transfusion as the outcome.  Anesth Analg.1997;85:1258-1267.
PubMed
Laupacis A, Fergusson D.for the International Study of Peri-operative Transfusion (ISPOT) Investigators.  Erythropoietin to minimize perioperative blood transfusion: a systematic review of randomized trials.  Transfus Med.1998;8:309-317.
PubMed
Fergusson D, van Walraven C, Coyle D, Laupacis A.for the International Study of Peri-operative Transfusion (ISPOT) Investigators.  Economic evaluations of technologies to minimize perioperative transfusion: a systematic review of published studies.  Transfus Med Rev.1999;13:106-117.
PubMed
Halpern SH, Leighton BL, Ohlsson A, Barrett JF, Rice A. Effect of epidural vs parenteral opioid analgesia on the progress of labor: a meta-analysis.  JAMA.1998;280:2105-2110.
PubMed
Howell CJ, Chalmers I. A review of prospectively controlled comparisons of epidural with non-epidural forms of pain relief during labour.  Int J Obstet Anesth.1992;1:93-110.
Howell CJ. Epidural versus non-epidural analgesia for pain relief in labour.  Cochrane Database Syst Rev.2000;2:CD000331.
PubMed
Kalso E, Tramèr MR, Carroll D, McQuay HJ, Moore RA. Pain relief from intra-articular morphine after knee surgery: a qualitative systematic review.  Pain.1997;71:127-134.
PubMed
Meiser A, Laubenthal H. Klinische Studien zur peripheren Wirksamkeit von Opioiden nach Kniegelenk-Operationen.  Anaesthesist.1997;46:867-879.
Tangkanakul C, Counsell C, Warlow C. Carotid endarterectomy performed under local anaesthetic compared to general anaesthetic.  Eur J Vasc Endovasc Surg.1997;13:491-499.
PubMed
Tangkanakul C, Counsell C, Warlow C. Local versus general anaesthesia for carotid endarterectomy.  Cochrane Database Syst Rev.2000;2:CD000126.
Ballantyne JC, Carr DB, deFerranti S.  et al.  The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials.  Anesth Analg.1998;86:598-612.
PubMed
Curatolo M, Petersen-Felix S, Scaramozzino P, Zbinden AM. Epidural fentanyl, adrenaline and clonidine as adjuvants to local anaesthetics for surgical analgesia: meta-analyses of analgesia and side-effects.  Acta Anaesthesiol Scand.1998;42:910-920.
PubMed
Ling E, Arellano R. Systematic overview of the evidence supporting the use of cerebrospinal fluid drainage in thoracoabdominal aneurysm surgery for prevention of paraplegia.  Anesthesiology.2000;93:1115-1122.
PubMed
Mantha S, Roizen MF, Barnard J, Thisted RA, Ellis JE, Foss J. Relative effectiveness of four preoperative tests for predicting adverse cardiac outcomes after vascular surgery: a meta-analysis.  Anesth Analg.1994;79:422-433.
PubMed
McQuay HJ, Carroll D, Moore RA. Injected morphine in postoperative pain: a quantitative systematic review.  J Pain Symptom Manage.1999;17:164-174.
PubMed
Picard PR, Tramèr MR. Prevention of pain on injection with propofol: a quantitative systematic review.  Anesth Analg.2000;90:963-969.
Robinson BJ, Uhrich TD, Ebert TJ. A review of recovery from sevoflurane anaesthesia: comparison with isoflurane and propofol including meta-analysis.  Acta Anaesthesiol Scand.1999;43:185-190.
PubMed
Smith AF, Pittaway A.J. Premedication for anxiety in adult day surgery.  Cochrane Database Syst Rev.2000;3:CD002192.
Van der Mast RC, Roest FH. Delirium after cardiac surgery: a critical review.  J Psychosom Res.1996;41:13-30.
PubMed
Wulf H. Epidural anaesthesia and spinal haematoma.  Can J Anaesth.1996;43:1260-1271.
PubMed
Bero LA, Galbraith A, Rennie D. The publication of sponsored symposiums in medical journals.  N Engl J Med.1992;327:1135-1140.
PubMed
Broad WJ. The publishing game: getting more for less.  Science.1981;211:1137-1139.
PubMed
Huth EJ. Irresponsible authorship and wasteful publication.  Ann Intern Med.1986;104:257-259.
PubMed
Bailey BJ. Duplicate publication in the field of otolaryngology—head and neck surgery.  Otolaryngol Head Neck Surg.2002;126:211-216.
PubMed
Blancett SS, Flanagin A, Young RK. Duplicate publication in the nursing literature.  Image J Nurs Sch.1995;27:51-56.
PubMed
Schein M, Paladugu R. Redundant surgical publications: tip of the iceberg?  Surgery.2001;129:655-661.
PubMed
Waldron T. Is duplicate publishing on the increase?  BMJ.1992;304:1029.
PubMed
Barnard H, Overbeke AJ. Duplicate publication of original manuscripts in and from the Nederlands Tijdschrift voor Geneeskunde.  Ned Tijdschr Geneeskd.1993;137:593-597.
PubMed
Bloemenkamp DG, Walvoort HC, Hart W, Overbeke AJ. Duplicate publication of articles in the Dutch Journal of Medicine in 1996.  Ned Tijdschr Geneeskd.1999;143:2150-2153.
PubMed
Jefferson T. Redundant publication in biomedical sciences: scientific misconduct or necessity?  Sci Eng Ethics.1998;4:135-140.
PubMed
Duggan L, Fenton M, Dardennes RM, El-Dosoky A, Indran S. Olanzapine for schizophrenia.  Cochrane Database Syst Rev.2000;2:CD001359.
PubMed
Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup DF. Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM Statement: Quality of Reporting of Meta-analyses.  Lancet.1999;354:1896-1900.
PubMed

Figures

Figure 1. Flowchart of Systematic Reviews
Graphic Jump Location
Figure 2. Delay in Years of Publication Between Main Reports and Duplicates
Graphic Jump Location
Percentages on the top of columns are cumulative relative frequencies.
Figure 3. Decision Tree for Identification of Patterns of Duplicate Publication
Graphic Jump Location

Tables

Table Graphic Jump LocationTable 2. Characteristics of Main Reports and Duplicates*

References

International Committee of Medical Journal Editors.  Uniform requirements for manuscripts submitted to biomedical journals. Available at: http://www.icmje.org. Accessibility verified February 2, 2004.
PubMed
 Definition of "sole contribution."  N Engl J Med.1969;281:676-677.
 Guidelines for the Conduct of Research in the Intramural Research Program at NIH.  3rd ed. Bethesda, Md: National Institutes of Health; 1997.
Tramèr MR, Reynolds DJ, Moore RA, McQuay HJ. Impact of covert duplicate publication on meta-analysis: a case study.  BMJ.1997;315:635-640.
PubMed
Huston P, Moher D. Redundancy, disaggregation, and the integrity of medical research.  Lancet.1996;347:1024-1026.
PubMed
Gøtzsche PC. Multiple publication of reports of drug trials.  Eur J Clin Pharmacol.1989;36:429-432.
PubMed
 List of systematic reviews in anesthesia, analgesia and critical care. Available at: http://www.hcuge.ch/anesthesie/anglais/evidence/arevusyst.htm. Accessed August 15, 2002.
Choi PT, Halpern SH, Malik N, Jadad AR, Tramèr MR, Walder B. Examining the evidence in anesthesia literature: a critical appraisal of systematic reviews.  Anesth Analg.2001;92:700-709.
PubMed
 ISI Journal Citation Report: Science edition 2001. Available at: http://www.isinet.com. Accessed January 12, 2002.
 ISI Web of Science: Science Citation Index expanded. Available at: http://www.isinet.com. Accessed January 12, 2002.
Aspinall RL, Goodman NW. Denial of effective treatment and poor quality of clinical information in placebo controlled trials of ondansetron for postoperative nausea and vomiting: a review of published trials.  BMJ.1995;311:844-846.
PubMed
Eberhart LH, Morin AM, Seeling W, Bothner U, Georgieff M. Meta-analysis of controlled randomized studies on droperidol for prevention of postoperative phase vomiting and nausea.  Anasthesiol Intensivmed Notfallmed Schmerzther.1999;34:528-536.
PubMed
Domino KB, Anderson EA, Polissar NL, Posner KL. Comparative efficacy and safety of ondansetron, droperidol, and metoclopramide for preventing postoperative nausea and vomiting: a meta-analysis.  Anesth Analg.1999;88:1370-1379.
PubMed
Figueredo ED, Canosa LG. Ondansetron in the prophylaxis of postoperative vomiting: a meta-analysis.  J Clin Anesth.1998;10:211-221.
PubMed
Figueredo E, Canosa LG. Prevention or treatment of postoperative vomiting using ondansetron? a mathematical assessment.  J Clin Anesth.1999;11:24-31.
PubMed
Figueredo E, Canosa L. Prophylactic ondansetron for postoperative emesis: meta-analysis of its effectiveness in patients with previous history of postoperative nausea and vomiting.  Acta Anaesthesiol Scand.1999;43:637-644.
PubMed
Henzi I, Walder B, Tramèr MR. Metoclopramide in the prevention of postoperative nausea and vomiting: a quantitative systematic review of randomized, placebo-controlled studies.  Br J Anaesth.1999;83:761-771.
PubMed
Henzi I, Sonderegger J, Tramèr MR. Efficacy, dose-response, and adverse effects of droperidol for prevention of postoperative nausea and vomiting.  Can J Anaesth.2000;47:537-551.
PubMed
Loewen PS, Marra CA, Zed PJ. 5-HT3 receptor antagonists vs traditional agents for the prophylaxis of postoperative nausea and vomiting.  Can J Anaesth.2000;47:1008-1018.
PubMed
Tramèr M, Moore A, McQuay H. Propofol anaesthesia and postoperative nausea and vomiting: quantitative systematic review of randomized controlled studies.  Br J Anaesth.1997;78:247-255.
PubMed
Tramèr MR, Reynolds DJ, Moore RA, McQuay HJ. Efficacy, dose-response, and safety of ondansetron in prevention of postoperative nausea and vomiting: a quantitative systematic review of randomized placebo-controlled trials.  Anesthesiology.1997;87:1277-1289.
PubMed
Tramèr MR, Moore RA, Reynolds DJ, McQuay HJ. A quantitative systematic review of ondansetron in treatment of established postoperative nausea and vomiting.  BMJ.1997;314:1088-1092.
PubMed
Tramèr MR, Reynolds DJ, Moore RA, McQuay HJ. When placebo controlled trials are essential and equivalence trials are inadequate.  BMJ.1998;317:875-880.
PubMed
Alderson P, Bunn F, Lefebvre C.  et al.  Human albumin solution for resuscitation and volume expansion in critically ill patients.  Cochrane Database Syst Rev.2002;1:CD001208.
Cochrane Injuries Group Albumin Reviewers.  Human albumin administration in critically ill patients: systematic review of randomised controlled trials.  BMJ.1998;317:235-240.
PubMed
Alderson P, Schierhout G, Roberts I, Bunn F. Colloids versus crystalloids for fluid resuscitation in critically ill patients.  Cochrane Database Syst Rev.2000;2:CD000567.
Schierhout G, Roberts I. Fluid resuscitation with colloid or crystalloid solutions in critically ill patients: a systematic review of randomised trials.  BMJ.1998;316:961-964.
PubMed
Bunn F, Alderson P, Hawkins V. Colloid solutions for fluid resuscitation.  Cochrane Database Syst Rev.2003;1:CD001319.
PubMed
Choi PT, Yip G, Quinonez LG, Cook DJ. Crystalloids vs colloids in fluid resuscitation: a systematic review.  Crit Care Med.1999;27:200-210.
PubMed
Velanovich V. Crystalloid versus colloid fluid resuscitation: a meta-analysis of mortality.  Surgery.1989;105:65-71.
PubMed
Wade CE, Kramer GC, Grady JJ, Fabian TC, Younes RN. Efficacy of hypertonic 7.5% saline and 6% dextran-70 in treating trauma: a meta-analysis of controlled clinical studies.  Surgery.1997;122:609-616.
PubMed
Whatling PJ. Intravenous fluids for abdominal aortic surgery.  Cochrane Database Syst Rev.2000;4:CD000991.
PubMed
Edwards JE, Oldman A, Smith L.  et al.  Single dose oral aspirin for acute pain.  Cochrane Database Syst Rev.2000;2:CD002067.
Edwards JE, Oldman AD, Smith LA.  et al.  Oral aspirin in postoperative pain: a quantitative systematic review.  Pain.1999;81:289-297.
PubMed
Edwards JE, Loke YK, Moore RA, McQuay HJ. Single dose piroxicam for acute postoperative pain.  Cochrane Database Syst Rev.2000;4:CD002762.
PubMed
Collins SL, Edwards JE, Moore RA, McQuay HJ. Single dose dextropropoxyphene, alone and with paracetamol (acetaminophen), for postoperative pain.  Cochrane Database Syst Rev.2000;2:CD001440.
Collins SL, Edwards JE, Moore RA, McQuay HJ. Single-dose dextropropoxyphene in post-operative pain: a quantitative systematic review.  Eur J Clin Pharmacol.1998;54:107-112.
Moore A, Collins S, Carroll D, McQuay H, Edwards J. Single dose paracetamol (acetaminophen), with and without codeine, for postoperative pain.  Cochrane Database Syst Rev.2000;2:CD001547.
Moore A, Collins S, Carroll D, McQuay H. Paracetamol with and without codeine in acute pain: a quantitative systematic review.  Pain.1997;70:193-201.
PubMed
Dexter F. Regional anesthesia does not significantly change surgical time versus general anaesthesia: a meta-analysis of randomized studies.  Reg Anesth Pain Med.1998;23:439-443.
Rodgers A, Walker N, Schug S.  et al.  Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials.  BMJ.2000;321:1493.
PubMed
Parker MJ, Urwin SC, Handoll HH, Griffiths R. General versus spinal/epidural anaesthesia for surgery for hip fractures in adults.  Cochrane Database Syst Rev.2000;2:CD000521.
Urwin SC, Parker MJ, Griffiths R. General versus regional anaesthesia for hip fracture surgery: a meta-analysis of randomized trials.  Br J Anaesth.2000;84:450-455.
PubMed
Sorenson RM, Pace NL. Anesthetic techniques during surgical repair of femoral neck fractures: a meta-analysis.  Anesthesiology.1992;77:1095-1104.
PubMed
Forgie MA, Wells PS, Laupacis A, Fergusson D.for the International Study of Perioperative Transfusion (ISPOT) Investigators.  Preoperative autologous donation decreases allogeneic transfusion but increases exposure to all red blood cell transfusion.  Arch Intern Med.1998;158:610-616.
PubMed
Levi M, Cromheecke ME, de Jonge E.  et al.  Pharmacological strategies to decrease excessive blood loss in cardiac surgery: a meta-analysis of clinically relevant endpoints.  Lancet.1999;354:1940-1947.
PubMed
Laupacis A, Fergusson D.for the International Study of Peri-operative Transfusion (ISPOT) Investigators.  Drugs to minimize perioperative blood loss in cardiac surgery: meta-analyses using perioperative blood transfusion as the outcome.  Anesth Analg.1997;85:1258-1267.
PubMed
Laupacis A, Fergusson D.for the International Study of Peri-operative Transfusion (ISPOT) Investigators.  Erythropoietin to minimize perioperative blood transfusion: a systematic review of randomized trials.  Transfus Med.1998;8:309-317.
PubMed
Fergusson D, van Walraven C, Coyle D, Laupacis A.for the International Study of Peri-operative Transfusion (ISPOT) Investigators.  Economic evaluations of technologies to minimize perioperative transfusion: a systematic review of published studies.  Transfus Med Rev.1999;13:106-117.
PubMed
Halpern SH, Leighton BL, Ohlsson A, Barrett JF, Rice A. Effect of epidural vs parenteral opioid analgesia on the progress of labor: a meta-analysis.  JAMA.1998;280:2105-2110.
PubMed
Howell CJ, Chalmers I. A review of prospectively controlled comparisons of epidural with non-epidural forms of pain relief during labour.  Int J Obstet Anesth.1992;1:93-110.
Howell CJ. Epidural versus non-epidural analgesia for pain relief in labour.  Cochrane Database Syst Rev.2000;2:CD000331.
PubMed
Kalso E, Tramèr MR, Carroll D, McQuay HJ, Moore RA. Pain relief from intra-articular morphine after knee surgery: a qualitative systematic review.  Pain.1997;71:127-134.
PubMed
Meiser A, Laubenthal H. Klinische Studien zur peripheren Wirksamkeit von Opioiden nach Kniegelenk-Operationen.  Anaesthesist.1997;46:867-879.
Tangkanakul C, Counsell C, Warlow C. Carotid endarterectomy performed under local anaesthetic compared to general anaesthetic.  Eur J Vasc Endovasc Surg.1997;13:491-499.
PubMed
Tangkanakul C, Counsell C, Warlow C. Local versus general anaesthesia for carotid endarterectomy.  Cochrane Database Syst Rev.2000;2:CD000126.
Ballantyne JC, Carr DB, deFerranti S.  et al.  The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials.  Anesth Analg.1998;86:598-612.
PubMed
Curatolo M, Petersen-Felix S, Scaramozzino P, Zbinden AM. Epidural fentanyl, adrenaline and clonidine as adjuvants to local anaesthetics for surgical analgesia: meta-analyses of analgesia and side-effects.  Acta Anaesthesiol Scand.1998;42:910-920.
PubMed
Ling E, Arellano R. Systematic overview of the evidence supporting the use of cerebrospinal fluid drainage in thoracoabdominal aneurysm surgery for prevention of paraplegia.  Anesthesiology.2000;93:1115-1122.
PubMed
Mantha S, Roizen MF, Barnard J, Thisted RA, Ellis JE, Foss J. Relative effectiveness of four preoperative tests for predicting adverse cardiac outcomes after vascular surgery: a meta-analysis.  Anesth Analg.1994;79:422-433.
PubMed
McQuay HJ, Carroll D, Moore RA. Injected morphine in postoperative pain: a quantitative systematic review.  J Pain Symptom Manage.1999;17:164-174.
PubMed
Picard PR, Tramèr MR. Prevention of pain on injection with propofol: a quantitative systematic review.  Anesth Analg.2000;90:963-969.
Robinson BJ, Uhrich TD, Ebert TJ. A review of recovery from sevoflurane anaesthesia: comparison with isoflurane and propofol including meta-analysis.  Acta Anaesthesiol Scand.1999;43:185-190.
PubMed
Smith AF, Pittaway A.J. Premedication for anxiety in adult day surgery.  Cochrane Database Syst Rev.2000;3:CD002192.
Van der Mast RC, Roest FH. Delirium after cardiac surgery: a critical review.  J Psychosom Res.1996;41:13-30.
PubMed
Wulf H. Epidural anaesthesia and spinal haematoma.  Can J Anaesth.1996;43:1260-1271.
PubMed
Bero LA, Galbraith A, Rennie D. The publication of sponsored symposiums in medical journals.  N Engl J Med.1992;327:1135-1140.
PubMed
Broad WJ. The publishing game: getting more for less.  Science.1981;211:1137-1139.
PubMed
Huth EJ. Irresponsible authorship and wasteful publication.  Ann Intern Med.1986;104:257-259.
PubMed
Bailey BJ. Duplicate publication in the field of otolaryngology—head and neck surgery.  Otolaryngol Head Neck Surg.2002;126:211-216.
PubMed
Blancett SS, Flanagin A, Young RK. Duplicate publication in the nursing literature.  Image J Nurs Sch.1995;27:51-56.
PubMed
Schein M, Paladugu R. Redundant surgical publications: tip of the iceberg?  Surgery.2001;129:655-661.
PubMed
Waldron T. Is duplicate publishing on the increase?  BMJ.1992;304:1029.
PubMed
Barnard H, Overbeke AJ. Duplicate publication of original manuscripts in and from the Nederlands Tijdschrift voor Geneeskunde.  Ned Tijdschr Geneeskd.1993;137:593-597.
PubMed
Bloemenkamp DG, Walvoort HC, Hart W, Overbeke AJ. Duplicate publication of articles in the Dutch Journal of Medicine in 1996.  Ned Tijdschr Geneeskd.1999;143:2150-2153.
PubMed
Jefferson T. Redundant publication in biomedical sciences: scientific misconduct or necessity?  Sci Eng Ethics.1998;4:135-140.
PubMed
Duggan L, Fenton M, Dardennes RM, El-Dosoky A, Indran S. Olanzapine for schizophrenia.  Cochrane Database Syst Rev.2000;2:CD001359.
PubMed
Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup DF. Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM Statement: Quality of Reporting of Meta-analyses.  Lancet.1999;354:1896-1900.
PubMed
CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 106

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
JAMAevidence.com

Users' Guides to the Medical Literature
Example of a Decision Tree

Users' Guides to the Medical Literature