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Communicating the Significance of Research Questions: Insights from Peer Review at a Flagship Journal

• Published: 17 March 2020
• Volume 18 , pages 11–24, ( 2020 )

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• Jinfa Cai 1 ,
• Stephen Hwang 1 ,
• James Hiebert 1 ,
• Charles Hohensee 1 ,
• Anne Morris 1 &
• Victoria Robison 1  

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Significant research in science and mathematics education should advance the field’s knowledge and understanding of the teaching and learning of science and mathematics. How, then, should the significance of a research question in science and mathematics education be assessed? And, when disseminating the findings of research, how should the significance of the research questions be communicated? In this study, we analyzed peer reviews to answer these questions. Our analysis revealed the main issues peer reviewers identify about research questions and the ways they are communicated during the dissemination of research. The findings provide insights for new and experienced researchers about communicating the significance of research questions, and they also illustrate how reviewer comments in peer-reviewed journals can provide a window into the field’s frontiers.

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International Perspectives on Peer Review as Quality Enhancement

Towards Article Acceptance: Avoiding Common Pitfalls in Submissions to Mathematical Thinking and Learning

Response-Able (Peer) Reviewing Matters in Higher Education: A Manifesto

1 This includes manuscripts that were resubmitted for review after the authors had completed major revisions in response to a prior decision of Revise and Resubmit.

2 Manuscripts resubmitted for review after the authors completed major revisions in response to a prior decision of Revise and Resubmit undergo full peer review by three to five reviewers in the same way as new submissions.

3 As noted above in the results, in the initial editorial screening of manuscripts for this journal, a certain percentage of manuscripts are desk rejected because the editor judges that they have serious flaws or because the work does not move the field of research in mathematics education forward in significant ways. These manuscripts are therefore not sent out for external peer review (and thus were not included in our analysis for this paper). Were they to be sent for peer review, our results would likely have included a much larger number of reviewer comments about the significance of the research questions.

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Jinfa Cai, Stephen Hwang, James Hiebert, Charles Hohensee, Anne Morris & Victoria Robison

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This work was supported in part by the National Science Foundation under Grant No. 1941494. Any opinions, findings, and conclusions are those of the authors and do not necessarily reflect the views of the National Science Foundation.

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Cai, J., Hwang, S., Hiebert, J. et al. Communicating the Significance of Research Questions: Insights from Peer Review at a Flagship Journal. Int J of Sci and Math Educ 18 (Suppl 1), 11–24 (2020). https://doi.org/10.1007/s10763-020-10073-x

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Received : 14 October 2019

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Published : 17 March 2020

Issue Date : May 2020

DOI : https://doi.org/10.1007/s10763-020-10073-x

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RCT indicates randomized clinical trial.

eFigure. Core Search Strategy for Structured Literature Search

eTable. Additional RCT Questions, Ranked by Overall Score

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Coon ER , McDaniel CE , Paciorkowski N, et al. Prioritization of Randomized Clinical Trial Questions for Children Hospitalized With Common Conditions : A Consensus Statement . JAMA Netw Open. 2024;7(5):e2411259. doi:10.1001/jamanetworkopen.2024.11259

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Prioritization of Randomized Clinical Trial Questions for Children Hospitalized With Common Conditions : A Consensus Statement

• 1 Department of Pediatrics, Intermountain Primary Children’s Hospital, Salt Lake City, Utah
• 2 Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
• 3 Division of Hospital Medicine, Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle
• 4 Department of Pediatrics, Rochester General Hospital, Rochester, New York
• 5 Section of Hospital Medicine, Children’s Hospital Colorado, University of Colorado, Aurora
• 6 Section of Emergency Medicine, Children’s Hospital Colorado, University of Colorado, Aurora
• 7 Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
• 8 The Hospital for Sick Children and Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
• 9 Pediatric Hospital Medicine, University of Florida COM-Jacksonville, Jacksonville
• 10 Department of Pediatrics, St Charles Hospital, Bend, Oregon
• 11 Division of Pediatric Hospital Medicine, Stanford University School of Medicine, Stanford, California
• 12 Dartmouth Health, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire
• 13 Division of Pediatric Hospital Medicine, University of Nebraska Medical Center, Omaha
• 14 Division of Pediatric Hospital Medicine, University of California, San Francisco
• 15 Department of Pediatrics, Golisano Children’s Hospital, Rochester, New York
• 16 Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York

Question   What are the most important and feasible randomized clinical trial (RCT) questions for children hospitalized with common conditions?

Findings   In this consensus statement, a 3-stage modified Delphi process involving multidisciplinary input from 46 individuals across 30 institutions produced 62 unique RCT questions, ranked according to importance and feasibility.

Meaning   These RCT questions can guide investigators and funders in conducting impactful trials to improve care and outcomes for children hospitalized with common conditions.

Importance   There is a lack of randomized clinical trial (RCT) data to guide many routine decisions in the care of children hospitalized for common conditions. A first step in addressing the shortage of RCTs for this population is to identify the most pressing RCT questions for children hospitalized with common conditions.

Objective   To identify the most important and feasible RCT questions for children hospitalized with common conditions.

Design, Setting, and Participants   For this consensus statement, a 3-stage modified Delphi process was used in a virtual conference series spanning January 1 to September 29, 2022. Forty-six individuals from 30 different institutions participated in the process. Stage 1 involved construction of RCT questions for the 10 most common pediatric conditions leading to hospitalization. Participants used condition-specific guidelines and reviews from a structured literature search to inform their development of RCT questions. During stage 2, RCT questions were refined and scored according to importance. Stage 3 incorporated public comment and feasibility with the prioritization of RCT questions.

Main Outcomes and Measures   The main outcome was RCT questions framed in a PICO (population, intervention, control, and outcome) format and ranked according to importance and feasibility; score choices ranged from 1 to 9, with higher scores indicating greater importance and feasibility.

Results   Forty-six individuals (38 who shared demographic data; 24 women [63%]) from 30 different institutions participated in our modified Delphi process. Participants included children’s hospital (n = 14) and community hospital (n = 13) pediatricians, parents of hospitalized children (n = 4), other clinicians (n = 2), biostatisticians (n = 2), and other researchers (n = 11). The process yielded 62 unique RCT questions, most of which are pragmatic, comparing interventions in widespread use for which definitive effectiveness data are lacking. Overall scores for importance and feasibility of the RCT questions ranged from 1 to 9, with a median of 5 (IQR, 4-7). Six of the top 10 selected questions focused on determining optimal antibiotic regimens for 3 common infections (pneumonia, urinary tract infection, and cellulitis).

Conclusions and Relevance   This consensus statementhas identified the most important and feasible RCT questions for children hospitalized with common conditions. This list of RCT questions can guide investigators and funders in conducting impactful trials to improve care and outcomes for hospitalized children.

Randomized clinical trials (RCTs) are the criterion standard design to determine the efficacy or effectiveness of a given intervention. Although the number of RCTs involving adult participants has increased over time, the number of RCTs involving children has stalled in the last 2 decades. 1 The relative lack of RCTs including children results in pediatric clinicians more often having to make medical decisions based on observational studies, adult studies, or expert opinion.

Children are vulnerable to morbidity and mortality while hospitalized, making hospitalized children a priority population for RCTs. The pediatric RCTs that have led to the greatest recent improvements in outcomes for hospitalized children have focused on novel therapeutics for severe but relatively uncommon conditions, such as cystic fibrosis 2 and neuromuscular disease. 3 Randomized clinical trials for the most common pediatric conditions that lead to hospitalization are comparatively scarce. 4 For example, based on prevalence of disease, there are several hundred fewer RCTs than would be expected for childhood respiratory infections. 4

A first step toward conducting more RCTs involving common pediatric conditions for hospitalized children is to prioritize research questions for researchers and funders. The objective of this consensus statement was to identify the most important and feasible RCT questions for children hospitalized with common conditions.

In this consensus statement, we report on a 3-stage modified Delphi process conducted from January 1 to September 29, 2022 ( Figure ), and modeled after previous prioritization efforts incorporating clinician, researcher, and patient-parent perspectives. 5 - 7 Construction of RCT questions occurred during stage 1, followed by evaluation of trial question importance in stage 2 and feasibility in stage 3. This study was reviewed by the University of Utah institutional review board and received an exemption determination because the research included only interactions involving educational tests, survey procedures, interview procedures, or observation of public behavior. Participants provided written consent and were offered a $250 gift card for participating in the conference series.

We used purposive sampling to recruit study participants. The study team developed an initial expertise-based list of clinicians and researchers who were invited to participate. Patient-parent partners with affiliations to the study team and their institutions were also invited to participate. We then used a snowball sampling procedure to recruit participants with additional perspectives and expertise as needed. Participant race and ethnicity were reportedby the participants themselves. The US Department of Health and Human Services Office of Minority Health categories for race and ethnicity were used. These variables were collected as a measure of the diversity of conference participants. Ensuring a diversity of backgrounds and perspectives was prioritized in recruitment. For example, in addition to diversity of gender, race, and ethnicity, we sought diversity by clinical background (eg, nurses, pharmacists, and physicians) and practice environment (eg, children’s hospital and community hospital). Inclusion of community hospital participants was a priority because most children, particularly those hospitalized for common conditions, receive their care in settings other than freestanding children’s hospitals. 8

We began stage 1 of our modified Delphi process in January 2022 by identifying common pediatric conditions to serve as the basis for generating RCT questions. We used national hospitalization utilization data to identify the 10 most common pediatric conditions leading to hospitalization. 9 , 10 We excluded conditions for which surgical or other specialist clinicians may lead management (eg, appendicitis, diabetic ketoacidosis, and epilepsy). After applying this exclusion, we found that the 10 most common pediatric conditions (in decreasing order of prevalence) were birth hospitalization, bronchiolitis, pneumonia, asthma, mood disorders, cellulitis, neonatal hyperbilirubinemia, urinary tract infection, gastroenteritis, and septicemia. Together, these conditions accounted for more than 75% of all pediatric hospitalizations annually in the US. 9 , 10

A medical librarian (E.F.) performed structured literature searches for each condition. The medical librarian hand-searched the reference lists provided with each condition’s diagnosis and treatment summaries in Dynamed and UpToDate, 2 evidence-based clinical resources. Next, the librarian created structured literature searches in PubMed to capture relevant guidelines or evidence syntheses for each condition. The core strategy is available in the eFigure in Supplement 1 . Four authors (E.R.C., C.E.M., N.P., and S.V.K.) with pediatric hospital medicine expertise reviewed the search results and selected 3 to 5 high-yield resources for each condition that were most pertinent to understanding the evidence gaps related to diagnosis or management of each condition. For example, clinical practice guidelines with a section devoted to evidence gaps or research needs existed for most conditions and were included in the high-yield resources.

We divided participants into small groups (n = 10) for each condition, making sure that community and children’s hospital clinicians were represented in each small group. Each small group had at least 1 researcher with peer-reviewed publication expertise for that condition. Small groups had 2 months to review their high-yield resources, share additional resources with one another, and meet virtually to generate a list of at least 3 RCT questions for their assigned condition.

We conducted a virtual conference in June 2022 for stage 2 of our modified Delphi process. The purpose of stage 2 was to refine the RCT questions generated in stage 1 and evaluate them in terms of importance. Stage 2 was grounded within a framework of 6 guiding questions ( Box 1 ). This framework mirrored existing quality domains developed by the National Academy of Medicine. 11 Small groups took turns presenting their RCT questions to conference participants, sharing their impression of the importance of each question, receiving input from conference participants, and refining the questions. For each condition, patient-parent partners were asked to comment on patient centeredness of the presented RCT questions. We prioritized parent input within the discussion of each condition to ensure RCT questions were relevant and important to families. At the conclusion of the first conference, individual participants anonymously scored all the RCT questions for importance on a scale of 1 to 9, with 9 indicating the highest level of importance. To establish external validity of the generated questions, the RCT questions were then distributed for public comment to the American Academy of Pediatrics Society of Hospital Medicine listserv (approximately 4000 members). We invited listserv members to provide input and feedback on the generated questions through 3 mechanisms: (1) scoring each question on the same importance scale, (2) providing commentary on the questions, and (3) offering suggestions of additional important questions for consideration.

Framework for Evaluating the Importance of the RCT Question

To what extent will this RCT…

Answer a question that patients and their families care about (patient centeredness)?

Improve the patient experience?

Improve important clinical outcomes?

Increase efficiency or reduce variation in care delivery?

Improve safety?

Promote diversity, equity, and inclusion?

Abbreviation: RCT, randomized clinical trial.

We conducted a second virtual conference in September of 2022 for stage 3 of our modified Delphi process. The purpose of stage 3 was to incorporate feasibility into the prioritization of the RCT questions. The public comment and ratings of RCT questions generated in stage 2 were reviewed for incorporation and consideration. Small groups were given time to discuss the feasibility of their RCT questions guided by 3 core questions ( Box 2 ). Small groups group-scored each of their RCT questions on a feasibility scale of 1 to 9, where scores higher than 6 indicated RCT questions that were feasible for all 3 core feasibility questions, scores of 4 to 6 indicated RCT questions with a feasibility concern in 1 core feasibility question, and scores lower than 4 indicated RCT questions with a feasibility concern in more than 1 core feasibility question. Small groups then reported to the full group of conference participants, sharing their impressions and scores for the feasibility of each RCT question, with further input from conference participants.

Framework for Evaluating the Feasibility of the RCT Question

How straightforward, or not, would it be to administer the proposed intervention and control group requirements at your institution? Are the intervention and controls doable at your institution?

In your usual practice, how commonly do you care for patients who would be eligible for this trial (eg, weekly, monthly, and yearly)?

What challenges, if any, do you anticipate for collection of outcomes data in this trial?

At the conclusion of this conference, participants were provided the summary scores and comments related to the importance and feasibility of each question and asked to submit a final overall score for each question. This scoring was individual and anonymous, using a 1 to 9 scale, with higher scores indicating the most important and feasible RCT questions.

A total of 46 individuals from 30 different institutions participated in our modified Delphi process. Participants included children’s hospital (n = 14) and community hospital (n = 13) pediatricians, parents of hospitalized children (n = 4), other clinicians (ie, nurse and pharmacist; n = 2), biostatisticians (n = 2), and other researchers (eg, trialists and research coordinators; n = 11). Pediatric clinical expertise represented by these participants included hospital medicine (n = 27), general pediatrics (n = 3), infectious disease (n = 2), emergency medicine (n = 1), and critical care (n = 1). Participant geographic representation included Canada (n = 4) and all 4 US Census Bureau regions: West (n = 24), Midwest (n = 7), Northeast (n = 7), and South (n = 4). Conference participants who shared their demographic data (n = 38) self-identified as women (24 of 38 [63%]) and men (14 of 38 [37%]) and as having the following races and ethnicities: Asian ([4 of 38] 11%), Black or African American ([3 of 38] 8%), Hispanic ([2 of 38] 5%), Native Hawaiian or Other Pacific Islander ([1 of 38] 3%), and White ([30 of 38] 79%). A total of 115 listserv respondents provided comments and/or ratings of RCT questions generated in stage 2 of the modified Delphi process.

This process produced 62 unique RCT questions. Participant scores for the importance of each RCT question ranged from 1 to 9, with a median of 5 (IQR, 3-7). Participant overall scores, incorporating both importance and feasibility of the RCT question, ranged from 1 to 9, with a median of 5 (IQR, 4-7). The 10 RCT questions with the highest overall mean scores are summarized in the Table in a PICO (population, intervention, control, and outcome) format. The remaining 52 questions generated by this work and their mean scores are displayed in the eTable in Supplement 1 .

A total of 7 of 62 questions (11%) scored higher than 6 for importance. Five of those questions also had overall scores higher than 6, and all 5 of those questions were in the top 10 RCT questions by overall score. Six of the top 10 selected questions focused on determining optimal antibiotic regimens for 3 common infections (pneumonia, urinary tract infection, and cellulitis). Two questions scored higher than 6 for importance but decreased below 6 after considering feasibility. These 2 questions involved antibiotic duration for children with bacteremia or meningitis and ultimately ranked 25th and 29th (eTable in Supplement 1 ).

For this consensus statement, we led a national, 3-stage modified Delphi process involving interdisciplinary, expert stakeholders, including patient-parent partners, to identify the most important and feasible RCT questions for children hospitalized with common conditions. Most of the RCT questions that we identified were pragmatic, comparing interventions in widespread use for which definitive effectiveness data are lacking. Our findings serve as an empirical foundation to guide investigators and funders in conducting impactful trials that improve outcomes for children hospitalized with common conditions.

The present research prioritization effort differs from existing prioritization studies in several fundamental ways. Some prior studies have focused on understanding condition prevalence, care variation, and costs for pediatric hospitalizations as a means to prioritize specific conditions for research. 9 , 12 , 13 Identification of condition-specific research topics or questions was outside the scope of these studies. Other prioritization studies have focused on broader (eg, all of pediatrics 6 ) or narrower (eg, chronic conditions 14 and palliative care 15 ) sets of conditions or settings that overlap with hospitalization (eg, emergency care 16 and patient safety 17 ). Nearly all existing prioritization studies, including a recent study focused on hospitalized children, 7 have produced priority topic areas (eg, What methods of communication are most effective between patients and clinicians?), as opposed to specific PICO-framed questions. Questions developed within existing prioritization studies were also not honed for a specific empirical research strategy, such as RCTs. To our knowledge, our research prioritization is unique in its focus on hospitalized children with common conditions and its development of specific PICO-framed questions designed to be readily answered in RCTs.

The questions that were prioritized in this process reflect broad goals of improving the value of care delivered to hospitalized children by avoiding unnecessary treatments. Six of the top 10 selected questions focused on determining optimal antibiotic regimens for 3 common infections (pneumonia, urinary tract infection, and cellulitis). There is wide variation in antibiotic prescribing for these infections, raising concerns for potential antibiotic overtreatment and its detrimental effects for children (antibiotic-associated adverse effects), families (stress and costs), and communities (emergence of resistant organisms). 18 , 19 A growing body of RCT literature is demonstrating that less-aggressive antibiotic regimens are safe and effective for serious infections among adults (eg, pneumonia, bacteremia, osteomyelitis, and endocarditis), but trials on this topic remain rare for children, to our knowledge. 20 , 21

To address this ambitious list of RCT questions, investigators will likely need to augment traditional RCT designs with innovative and efficient RCT approaches. Many of the RCT questions developed in this study have natural overlap and could be considered for funding mechanisms that can support addressing multiple trial questions in a single application. For example, platform trials examine multiple research questions for a single condition. 22 Given that the present work generated multiple RCT questions for each condition, platform RCTs might be an efficient design to address more than 1 of these RCT questions at once. Similarly, factorial RCT designs could be used to address multiple questions at once when understanding the synergistic effect of 2 or more interventions is key. 23 As an example, 3 of the top 6 RCT questions developed here involve children hospitalized with urinary tract infections and their antibiotic regimens. The single condition entity and similar interventions could lend themselves to a platform or factorial design. Randomized clinical trial questions developed here may also lend themselves to a high-efficiency randomized controlled (HEROIC) trial approach, which uses a dispersed enrollment strategy to efficiently conduct pragmatic RCTs. 24

The consensus statement has several important limitations. First, these RCT questions will require further refinement as the trial is designed, including additional definitions for each intervention and careful consideration of the right primary outcome. Second, our consideration of feasibility focused on trial infrastructure (the ability to recruit, administer intervention or control, and collect data). This feasibility assessment was within the scope of conference participant skills and resources. During formal trial design or preparation, an additional feasibility assessment would be completed, including human participants protection review, confirmation of adequate numbers of eligible participants at proposed study sites, formal sample size estimates, power calculations, and budget or cost estimates. These considerations will undoubtedly influence the feasibility of each RCT question. Third, conference participants were diverse in many ways but did not represent all perspectives pertinent to RCT question generation in this population. Fourth, RCT question development was organized around common conditions. Undoubtedly, there are additional important and feasible questions that are not condition based (eg, RCTs comparing processes such as transitions of care) or that are focused on less-common conditions. Fifth, our 3-stage process could have been subject to anchoring bias, in which decisions made early in the process by smaller numbers of participants are difficult to reconsider later in the process. Sixth, investigators who pursue the RCTs described in this study will still contend with pervasive impediments to RCTs for children, such as relatively modest disease prevalence, lower frequency of objective outcome measures (eg, mortality), and fewer sources of funding compared with RCTs for adult populations. For example, the 2 questions that scored higher than 6 for importance but then ultimately decreased below 6 after considering feasibility involved less-common subpopulations of hospitalized children (children with bacteremia or meningitis). For RCT questions with particularly low feasibility scores, observational study designs might be more practical.

In this consensus statement, we have identified the most important and feasible RCT questions for children hospitalized with common conditions. These conditions are responsible for more than three-fourths of pediatric hospitalizations. Answering these pressing questions with RCTs has great potential to improve care and outcomes for hospitalized children.

Accepted for Publication: March 13, 2024.

Published: May 15, 2024. doi:10.1001/jamanetworkopen.2024.11259

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Coon ER et al. JAMA Network Open .

Corresponding Author: Eric R. Coon, MD, MS, Department of Pediatrics, University of Utah School of Medicine, 100 N Mario Capecchi Dr, Salt Lake City, UT 84113 ( [email protected] ).

Author Contributions: Dr Coon had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Coon, McDaniel, Paciorkowski, Jennings, Wilson, Kaiser.

Acquisition, analysis, or interpretation of data: Coon, McDaniel, Paciorkowski, Grimshaw, Frakes, Ambroggio, Auger, Cohen, Garber, Gill, Joshi, Leyenaar, McCulloh, Pantell, Sauers-Ford, Schroeder, Srivastava, Wang, Wilson, Kaiser.

Drafting of the manuscript: Coon, Frakes, Gill, Pantell.

Critical review of the manuscript for important intellectual content: Coon, McDaniel, Paciorkowski, Grimshaw, Frakes, Ambroggio, Auger, Cohen, Garber, Gill, Jennings, Joshi, Leyenaar, McCulloh, Sauers-Ford, Schroeder, Srivastava, Wang, Wilson, Kaiser.

Statistical analysis: Coon.

Obtained funding: Coon, Wilson, Kaiser.

Administrative, technical, or material support: Grimshaw, Ambroggio, Gill, McCulloh, Wilson, Kaiser.

Supervision: Wilson, Kaiser.

Conflict of Interest Disclosures: Dr Ambroggio reported receivng grants from Pfizer Inc outside the submitted work. Dr Cohen reported being a member of the Committee to Evaluate Drugs, which provides advice to the Ministry of Health on Ontario’s Public Drug Policy. Dr Gill reported receiving grants from Physicians’ Services Incorporated Foundation, Canadian Institutes of Health Research (CIHR), and Hospital for Sick Children outside the submitted work. Dr McCulloh reported receiving grants from the National Institutes of Health from the Office of the Director during the conduct of the study and grants from Merck Inc outside the submitted work. Dr Schroeder reported receiving grants from the Patient-Centered Outcomes Research Institute outside the submitted work. Dr Srivastava reported being a physician founder of the IPASS Patient Safety Institute, and his equity is owned by his employer, Intermountain Health, outside the submitted work; receiving grants from the Patient-Centered Outcomes Research Institute, National Institutes of Health, and Centers for Disease Control and Prevention; and receiving monetary awards, honoraria, and travel reimbursement from multiple academic and professional organizations for teaching and consulting on quality of care and spreading evidence-based best practices in health systems and pediatric hospital medicine. No other disclosures were reported.

Funding/Support: This study was financially supported by the Agency for Healthcare Research and Quality, US Department of Health and Human Services and the Division of Pediatric Hospital Medicine, the University of California San Francisco.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Group Information: The members of the RCT conference series group are listed in Supplement 2 .

Disclaimer: The contents are those of the authors. They may not reflect the policies of the US Department of Health and Human Services or the US government.

Data Sharing Statement: See Supplement 3 .

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Preparing the Future Workforce in Drug Research and Development

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Despite advances over the past several decades, the clinical trials enterprise has struggled to meet the needs of an increasingly diverse U.S. population. To help address this issue, a 2023 National Academies workshop sought to identify the expertise and disciplines needed to achieve the aspirations for a transformed clinical trials enterprise by 2030 and enable a workforce that can better support the evolving needs of drug R&D - one that is resilient, culturally aware, anti-racist, and interdisciplinary. The workshop, hosted by the Forum on Drug Discovery, Development, and Translation and Roundtable on Black Men and Black Women in Science, Engineering, and Medicine explored strategies to bolster workforce capacity and challenges and opportunities associated with supporting the next-generation drug R&D workforce.

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Cultural Relativity and Acceptance of Embryonic Stem Cell Research

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There is a debate about the ethical implications of using human embryos in stem cell research, which can be influenced by cultural, moral, and social values. This paper argues for an adaptable framework to accommodate diverse cultural and religious perspectives. By using an adaptive ethics model, research protections can reflect various populations and foster growth in stem cell research possibilities.

INTRODUCTION

Stem cell research combines biology, medicine, and technology, promising to alter health care and the understanding of human development. Yet, ethical contention exists because of individuals’ perceptions of using human embryos based on their various cultural, moral, and social values. While these disagreements concerning policy, use, and general acceptance have prompted the development of an international ethics policy, such a uniform approach can overlook the nuanced ethical landscapes between cultures. With diverse viewpoints in public health, a single global policy, especially one reflecting Western ethics or the ethics prevalent in high-income countries, is impractical. This paper argues for a culturally sensitive, adaptable framework for the use of embryonic stem cells. Stem cell policy should accommodate varying ethical viewpoints and promote an effective global dialogue. With an extension of an ethics model that can adapt to various cultures, we recommend localized guidelines that reflect the moral views of the people those guidelines serve.

Stem cells, characterized by their unique ability to differentiate into various cell types, enable the repair or replacement of damaged tissues. Two primary types of stem cells are somatic stem cells (adult stem cells) and embryonic stem cells. Adult stem cells exist in developed tissues and maintain the body’s repair processes. [1] Embryonic stem cells (ESC) are remarkably pluripotent or versatile, making them valuable in research. [2] However, the use of ESCs has sparked ethics debates. Considering the potential of embryonic stem cells, research guidelines are essential. The International Society for Stem Cell Research (ISSCR) provides international stem cell research guidelines. They call for “public conversations touching on the scientific significance as well as the societal and ethical issues raised by ESC research.” [3] The ISSCR also publishes updates about culturing human embryos 14 days post fertilization, suggesting local policies and regulations should continue to evolve as ESC research develops. [4]  Like the ISSCR, which calls for local law and policy to adapt to developing stem cell research given cultural acceptance, this paper highlights the importance of local social factors such as religion and culture.

I.     Global Cultural Perspective of Embryonic Stem Cells

Views on ESCs vary throughout the world. Some countries readily embrace stem cell research and therapies, while others have stricter regulations due to ethical concerns surrounding embryonic stem cells and when an embryo becomes entitled to moral consideration. The philosophical issue of when the “someone” begins to be a human after fertilization, in the morally relevant sense, [5] impacts when an embryo becomes not just worthy of protection but morally entitled to it. The process of creating embryonic stem cell lines involves the destruction of the embryos for research. [6] Consequently, global engagement in ESC research depends on social-cultural acceptability.

a.     US and Rights-Based Cultures

In the United States, attitudes toward stem cell therapies are diverse. The ethics and social approaches, which value individualism, [7] trigger debates regarding the destruction of human embryos, creating a complex regulatory environment. For example, the 1996 Dickey-Wicker Amendment prohibited federal funding for the creation of embryos for research and the destruction of embryos for “more than allowed for research on fetuses in utero.” [8] Following suit, in 2001, the Bush Administration heavily restricted stem cell lines for research. However, the Stem Cell Research Enhancement Act of 2005 was proposed to help develop ESC research but was ultimately vetoed. [9] Under the Obama administration, in 2009, an executive order lifted restrictions allowing for more development in this field. [10] The flux of research capacity and funding parallels the different cultural perceptions of human dignity of the embryo and how it is socially presented within the country’s research culture. [11]

b.     Ubuntu and Collective Cultures

African bioethics differs from Western individualism because of the different traditions and values. African traditions, as described by individuals from South Africa and supported by some studies in other African countries, including Ghana and Kenya, follow the African moral philosophies of Ubuntu or Botho and Ukama , which “advocates for a form of wholeness that comes through one’s relationship and connectedness with other people in the society,” [12] making autonomy a socially collective concept. In this context, for the community to act autonomously, individuals would come together to decide what is best for the collective. Thus, stem cell research would require examining the value of the research to society as a whole and the use of the embryos as a collective societal resource. If society views the source as part of the collective whole, and opposes using stem cells, compromising the cultural values to pursue research may cause social detachment and stunt research growth. [13] Based on local culture and moral philosophy, the permissibility of stem cell research depends on how embryo, stem cell, and cell line therapies relate to the community as a whole. Ubuntu is the expression of humanness, with the person’s identity drawn from the “’I am because we are’” value. [14] The decision in a collectivistic culture becomes one born of cultural context, and individual decisions give deference to others in the society.

Consent differs in cultures where thought and moral philosophy are based on a collective paradigm. So, applying Western bioethical concepts is unrealistic. For one, Africa is a diverse continent with many countries with different belief systems, access to health care, and reliance on traditional or Western medicines. Where traditional medicine is the primary treatment, the “’restrictive focus on biomedically-related bioethics’” [is] problematic in African contexts because it neglects bioethical issues raised by traditional systems.” [15] No single approach applies in all areas or contexts. Rather than evaluating the permissibility of ESC research according to Western concepts such as the four principles approach, different ethics approaches should prevail.

Another consideration is the socio-economic standing of countries. In parts of South Africa, researchers have not focused heavily on contributing to the stem cell discourse, either because it is not considered health care or a health science priority or because resources are unavailable. [16] Each country’s priorities differ given different social, political, and economic factors. In South Africa, for instance, areas such as maternal mortality, non-communicable diseases, telemedicine, and the strength of health systems need improvement and require more focus. [17] Stem cell research could benefit the population, but it also could divert resources from basic medical care. Researchers in South Africa adhere to the National Health Act and Medicines Control Act in South Africa and international guidelines; however, the Act is not strictly enforced, and there is no clear legislation for research conduct or ethical guidelines. [18]

Some parts of Africa condemn stem cell research. For example, 98.2 percent of the Tunisian population is Muslim. [19] Tunisia does not permit stem cell research because of moral conflict with a Fatwa. Religion heavily saturates the regulation and direction of research. [20] Stem cell use became permissible for reproductive purposes only recently, with tight restrictions preventing cells from being used in any research other than procedures concerning ART/IVF.  Their use is conditioned on consent, and available only to married couples. [21] The community's receptiveness to stem cell research depends on including communitarian African ethics.

c.     Asia

Some Asian countries also have a collective model of ethics and decision making. [22] In China, the ethics model promotes a sincere respect for life or human dignity, [23] based on protective medicine. This model, influenced by Traditional Chinese Medicine (TCM), [24] recognizes Qi as the vital energy delivered via the meridians of the body; it connects illness to body systems, the body’s entire constitution, and the universe for a holistic bond of nature, health, and quality of life. [25] Following a protective ethics model, and traditional customs of wholeness, investment in stem cell research is heavily desired for its applications in regenerative therapies, disease modeling, and protective medicines. In a survey of medical students and healthcare practitioners, 30.8 percent considered stem cell research morally unacceptable while 63.5 percent accepted medical research using human embryonic stem cells. Of these individuals, 89.9 percent supported increased funding for stem cell research. [26] The scientific community might not reflect the overall population. From 1997 to 2019, China spent a total of $576 million (USD) on stem cell research at 8,050 stem cell programs, increased published presence from 0.6 percent to 14.01 percent of total global stem cell publications as of 2014, and made significant strides in cell-based therapies for various medical conditions. [27] However, while China has made substantial investments in stem cell research and achieved notable progress in clinical applications, concerns linger regarding ethical oversight and transparency. [28] For example, the China Biosecurity Law, promoted by the National Health Commission and China Hospital Association, attempted to mitigate risks by introducing an institutional review board (IRB) in the regulatory bodies. 5800 IRBs registered with the Chinese Clinical Trial Registry since 2021. [29] However, issues still need to be addressed in implementing effective IRB review and approval procedures.

The substantial government funding and focus on scientific advancement have sometimes overshadowed considerations of regional cultures, ethnic minorities, and individual perspectives, particularly evident during the one-child policy era. As government policy adapts to promote public stability, such as the change from the one-child to the two-child policy, [30] research ethics should also adapt to ensure respect for the values of its represented peoples.

Japan is also relatively supportive of stem cell research and therapies. Japan has a more transparent regulatory framework, allowing for faster approval of regenerative medicine products, which has led to several advanced clinical trials and therapies. [31] South Korea is also actively engaged in stem cell research and has a history of breakthroughs in cloning and embryonic stem cells. [32] However, the field is controversial, and there are issues of scientific integrity. For example, the Korean FDA fast-tracked products for approval, [33] and in another instance, the oocyte source was unclear and possibly violated ethical standards. [34] Trust is important in research, as it builds collaborative foundations between colleagues, trial participant comfort, open-mindedness for complicated and sensitive discussions, and supports regulatory procedures for stakeholders. There is a need to respect the culture’s interest, engagement, and for research and clinical trials to be transparent and have ethical oversight to promote global research discourse and trust.

d.     Middle East

Countries in the Middle East have varying degrees of acceptance of or restrictions to policies related to using embryonic stem cells due to cultural and religious influences. Saudi Arabia has made significant contributions to stem cell research, and conducts research based on international guidelines for ethical conduct and under strict adherence to guidelines in accordance with Islamic principles. Specifically, the Saudi government and people require ESC research to adhere to Sharia law. In addition to umbilical and placental stem cells, [35] Saudi Arabia permits the use of embryonic stem cells as long as they come from miscarriages, therapeutic abortions permissible by Sharia law, or are left over from in vitro fertilization and donated to research. [36] Laws and ethical guidelines for stem cell research allow the development of research institutions such as the King Abdullah International Medical Research Center, which has a cord blood bank and a stem cell registry with nearly 10,000 donors. [37] Such volume and acceptance are due to the ethical ‘permissibility’ of the donor sources, which do not conflict with religious pillars. However, some researchers err on the side of caution, choosing not to use embryos or fetal tissue as they feel it is unethical to do so. [38]

Jordan has a positive research ethics culture. [39] However, there is a significant issue of lack of trust in researchers, with 45.23 percent (38.66 percent agreeing and 6.57 percent strongly agreeing) of Jordanians holding a low level of trust in researchers, compared to 81.34 percent of Jordanians agreeing that they feel safe to participate in a research trial. [40] Safety testifies to the feeling of confidence that adequate measures are in place to protect participants from harm, whereas trust in researchers could represent the confidence in researchers to act in the participants’ best interests, adhere to ethical guidelines, provide accurate information, and respect participants’ rights and dignity. One method to improve trust would be to address communication issues relevant to ESC. Legislation surrounding stem cell research has adopted specific language, especially concerning clarification “between ‘stem cells’ and ‘embryonic stem cells’” in translation. [41] Furthermore, legislation “mandates the creation of a national committee… laying out specific regulations for stem-cell banking in accordance with international standards.” [42] This broad regulation opens the door for future global engagement and maintains transparency. However, these regulations may also constrain the influence of research direction, pace, and accessibility of research outcomes.

e.     Europe

In the European Union (EU), ethics is also principle-based, but the principles of autonomy, dignity, integrity, and vulnerability are interconnected. [43] As such, the opportunity for cohesion and concessions between individuals’ thoughts and ideals allows for a more adaptable ethics model due to the flexible principles that relate to the human experience The EU has put forth a framework in its Convention for the Protection of Human Rights and Dignity of the Human Being allowing member states to take different approaches. Each European state applies these principles to its specific conventions, leading to or reflecting different acceptance levels of stem cell research. [44]

For example, in Germany, Lebenzusammenhang , or the coherence of life, references integrity in the unity of human culture. Namely, the personal sphere “should not be subject to external intervention.” [45]  Stem cell interventions could affect this concept of bodily completeness, leading to heavy restrictions. Under the Grundgesetz, human dignity and the right to life with physical integrity are paramount. [46] The Embryo Protection Act of 1991 made producing cell lines illegal. Cell lines can be imported if approved by the Central Ethics Commission for Stem Cell Research only if they were derived before May 2007. [47] Stem cell research respects the integrity of life for the embryo with heavy specifications and intense oversight. This is vastly different in Finland, where the regulatory bodies find research more permissible in IVF excess, but only up to 14 days after fertilization. [48] Spain’s approach differs still, with a comprehensive regulatory framework. [49] Thus, research regulation can be culture-specific due to variations in applied principles. Diverse cultures call for various approaches to ethical permissibility. [50] Only an adaptive-deliberative model can address the cultural constructions of self and achieve positive, culturally sensitive stem cell research practices. [51]

II.     Religious Perspectives on ESC

Embryonic stem cell sources are the main consideration within religious contexts. While individuals may not regard their own religious texts as authoritative or factual, religion can shape their foundations or perspectives.

The Qur'an states:

“And indeed We created man from a quintessence of clay. Then We placed within him a small quantity of nutfa (sperm to fertilize) in a safe place. Then We have fashioned the nutfa into an ‘alaqa (clinging clot or cell cluster), then We developed the ‘alaqa into mudgha (a lump of flesh), and We made mudgha into bones, and clothed the bones with flesh, then We brought it into being as a new creation. So Blessed is Allah, the Best of Creators.” [52]

Many scholars of Islam estimate the time of soul installment, marked by the angel breathing in the soul to bring the individual into creation, as 120 days from conception. [53] Personhood begins at this point, and the value of life would prohibit research or experimentation that could harm the individual. If the fetus is more than 120 days old, the time ensoulment is interpreted to occur according to Islamic law, abortion is no longer permissible. [54] There are a few opposing opinions about early embryos in Islamic traditions. According to some Islamic theologians, there is no ensoulment of the early embryo, which is the source of stem cells for ESC research. [55]

In Buddhism, the stance on stem cell research is not settled. The main tenets, the prohibition against harming or destroying others (ahimsa) and the pursuit of knowledge (prajña) and compassion (karuna), leave Buddhist scholars and communities divided. [56] Some scholars argue stem cell research is in accordance with the Buddhist tenet of seeking knowledge and ending human suffering. Others feel it violates the principle of not harming others. Finding the balance between these two points relies on the karmic burden of Buddhist morality. In trying to prevent ahimsa towards the embryo, Buddhist scholars suggest that to comply with Buddhist tenets, research cannot be done as the embryo has personhood at the moment of conception and would reincarnate immediately, harming the individual's ability to build their karmic burden. [57] On the other hand, the Bodhisattvas, those considered to be on the path to enlightenment or Nirvana, have given organs and flesh to others to help alleviate grieving and to benefit all. [58] Acceptance varies on applied beliefs and interpretations.

Catholicism does not support embryonic stem cell research, as it entails creation or destruction of human embryos. This destruction conflicts with the belief in the sanctity of life. For example, in the Old Testament, Genesis describes humanity as being created in God’s image and multiplying on the Earth, referencing the sacred rights to human conception and the purpose of development and life. In the Ten Commandments, the tenet that one should not kill has numerous interpretations where killing could mean murder or shedding of the sanctity of life, demonstrating the high value of human personhood. In other books, the theological conception of when life begins is interpreted as in utero, [59] highlighting the inviolability of life and its formation in vivo to make a religious point for accepting such research as relatively limited, if at all. [60] The Vatican has released ethical directives to help apply a theological basis to modern-day conflicts. The Magisterium of the Church states that “unless there is a moral certainty of not causing harm,” experimentation on fetuses, fertilized cells, stem cells, or embryos constitutes a crime. [61] Such procedures would not respect the human person who exists at these stages, according to Catholicism. Damages to the embryo are considered gravely immoral and illicit. [62] Although the Catholic Church officially opposes abortion, surveys demonstrate that many Catholic people hold pro-choice views, whether due to the context of conception, stage of pregnancy, threat to the mother’s life, or for other reasons, demonstrating that practicing members can also accept some but not all tenets. [63]

Some major Jewish denominations, such as the Reform, Conservative, and Reconstructionist movements, are open to supporting ESC use or research as long as it is for saving a life. [64] Within Judaism, the Talmud, or study, gives personhood to the child at birth and emphasizes that life does not begin at conception: [65]

“If she is found pregnant, until the fortieth day it is mere fluid,” [66]

Whereas most religions prioritize the status of human embryos, the Halakah (Jewish religious law) states that to save one life, most other religious laws can be ignored because it is in pursuit of preservation. [67] Stem cell research is accepted due to application of these religious laws.

We recognize that all religions contain subsets and sects. The variety of environmental and cultural differences within religious groups requires further analysis to respect the flexibility of religious thoughts and practices. We make no presumptions that all cultures require notions of autonomy or morality as under the common morality theory , which asserts a set of universal moral norms that all individuals share provides moral reasoning and guides ethical decisions. [68] We only wish to show that the interaction with morality varies between cultures and countries.

III.     A Flexible Ethical Approach

The plurality of different moral approaches described above demonstrates that there can be no universally acceptable uniform law for ESC on a global scale. Instead of developing one standard, flexible ethical applications must be continued. We recommend local guidelines that incorporate important cultural and ethical priorities.

While the Declaration of Helsinki is more relevant to people in clinical trials receiving ESC products, in keeping with the tradition of protections for research subjects, consent of the donor is an ethical requirement for ESC donation in many jurisdictions including the US, Canada, and Europe. [69] The Declaration of Helsinki provides a reference point for regulatory standards and could potentially be used as a universal baseline for obtaining consent prior to gamete or embryo donation.

For instance, in Columbia University’s egg donor program for stem cell research, donors followed standard screening protocols and “underwent counseling sessions that included information as to the purpose of oocyte donation for research, what the oocytes would be used for, the risks and benefits of donation, and process of oocyte stimulation” to ensure transparency for consent. [70] The program helped advance stem cell research and provided clear and safe research methods with paid participants. Though paid participation or covering costs of incidental expenses may not be socially acceptable in every culture or context, [71] and creating embryos for ESC research is illegal in many jurisdictions, Columbia’s program was effective because of the clear and honest communications with donors, IRBs, and related stakeholders.  This example demonstrates that cultural acceptance of scientific research and of the idea that an egg or embryo does not have personhood is likely behind societal acceptance of donating eggs for ESC research. As noted, many countries do not permit the creation of embryos for research.

Proper communication and education regarding the process and purpose of stem cell research may bolster comprehension and garner more acceptance. “Given the sensitive subject material, a complete consent process can support voluntary participation through trust, understanding, and ethical norms from the cultures and morals participants value. This can be hard for researchers entering countries of different socioeconomic stability, with different languages and different societal values. [72]

An adequate moral foundation in medical ethics is derived from the cultural and religious basis that informs knowledge and actions. [73] Understanding local cultural and religious values and their impact on research could help researchers develop humility and promote inclusion.

IV.     Concerns

Some may argue that if researchers all adhere to one ethics standard, protection will be satisfied across all borders, and the global public will trust researchers. However, defining what needs to be protected and how to define such research standards is very specific to the people to which standards are applied. We suggest that applying one uniform guide cannot accurately protect each individual because we all possess our own perceptions and interpretations of social values. [74] Therefore, the issue of not adjusting to the moral pluralism between peoples in applying one standard of ethics can be resolved by building out ethics models that can be adapted to different cultures and religions.

Other concerns include medical tourism, which may promote health inequities. [75] Some countries may develop and approve products derived from ESC research before others, compromising research ethics or drug approval processes. There are also concerns about the sale of unauthorized stem cell treatments, for example, those without FDA approval in the United States. Countries with robust research infrastructures may be tempted to attract medical tourists, and some customers will have false hopes based on aggressive publicity of unproven treatments. [76]

For example, in China, stem cell clinics can market to foreign clients who are not protected under the regulatory regimes. Companies employ a marketing strategy of “ethically friendly” therapies. Specifically, in the case of Beike, China’s leading stem cell tourism company and sprouting network, ethical oversight of administrators or health bureaus at one site has “the unintended consequence of shifting questionable activities to another node in Beike's diffuse network.” [77] In contrast, Jordan is aware of stem cell research’s potential abuse and its own status as a “health-care hub.” Jordan’s expanded regulations include preserving the interests of individuals in clinical trials and banning private companies from ESC research to preserve transparency and the integrity of research practices. [78]

The social priorities of the community are also a concern. The ISSCR explicitly states that guidelines “should be periodically revised to accommodate scientific advances, new challenges, and evolving social priorities.” [79] The adaptable ethics model extends this consideration further by addressing whether research is warranted given the varying degrees of socioeconomic conditions, political stability, and healthcare accessibilities and limitations. An ethical approach would require discussion about resource allocation and appropriate distribution of funds. [80]

While some religions emphasize the sanctity of life from conception, which may lead to public opposition to ESC research, others encourage ESC research due to its potential for healing and alleviating human pain. Many countries have special regulations that balance local views on embryonic personhood, the benefits of research as individual or societal goods, and the protection of human research subjects. To foster understanding and constructive dialogue, global policy frameworks should prioritize the protection of universal human rights, transparency, and informed consent. In addition to these foundational global policies, we recommend tailoring local guidelines to reflect the diverse cultural and religious perspectives of the populations they govern. Ethics models should be adapted to local populations to effectively establish research protections, growth, and possibilities of stem cell research.

For example, in countries with strong beliefs in the moral sanctity of embryos or heavy religious restrictions, an adaptive model can allow for discussion instead of immediate rejection. In countries with limited individual rights and voice in science policy, an adaptive model ensures cultural, moral, and religious views are taken into consideration, thereby building social inclusion. While this ethical consideration by the government may not give a complete voice to every individual, it will help balance policies and maintain the diverse perspectives of those it affects. Embracing an adaptive ethics model of ESC research promotes open-minded dialogue and respect for the importance of human belief and tradition. By actively engaging with cultural and religious values, researchers can better handle disagreements and promote ethical research practices that benefit each society.

This brief exploration of the religious and cultural differences that impact ESC research reveals the nuances of relative ethics and highlights a need for local policymakers to apply a more intense adaptive model.

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[5] Concerning the moral philosophies of stem cell research, our paper does not posit a personal moral stance nor delve into the “when” of human life begins. To read further about the philosophical debate, consider the following sources:

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[7] Socially, at its core, the Western approach to ethics is widely principle-based, autonomy being one of the key factors to ensure a fundamental respect for persons within research. For information regarding autonomy in research, see: Department of Health, Education, and Welfare, & National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1978). The Belmont Report. Ethical principles and guidelines for the protection of human subjects of research.; For a more in-depth review of autonomy within the US, see: Beauchamp, T. L., & Childress, J. F. (1994). Principles of Biomedical Ethics . Oxford University Press.

[8] Sherley v. Sebelius , 644 F.3d 388 (D.C. Cir. 2011), citing 45 C.F.R. 46.204(b) and [42 U.S.C. § 289g(b)]. https://www.cadc.uscourts.gov/internet/opinions.nsf/6c690438a9b43dd685257a64004ebf99/$file/11-5241-1391178.pdf

[9] Stem Cell Research Enhancement Act of 2005, H. R. 810, 109 th Cong. (2001). https://www.govtrack.us/congress/bills/109/hr810/text ; Bush, G. W. (2006, July 19). Message to the House of Representatives . National Archives and Records Administration. https://georgewbush-whitehouse.archives.gov/news/releases/2006/07/20060719-5.html

[10] National Archives and Records Administration. (2009, March 9). Executive order 13505 -- removing barriers to responsible scientific research involving human stem cells . National Archives and Records Administration. https://obamawhitehouse.archives.gov/the-press-office/removing-barriers-responsible-scientific-research-involving-human-stem-cells

[11] Hurlbut, W. B. (2006). Science, Religion, and the Politics of Stem Cells.  Social Research ,  73 (3), 819–834. http://www.jstor.org/stable/40971854

[12] Akpa-Inyang, Francis & Chima, Sylvester. (2021). South African traditional values and beliefs regarding informed consent and limitations of the principle of respect for autonomy in African communities: a cross-cultural qualitative study. BMC Medical Ethics . 22. 10.1186/s12910-021-00678-4.

[13] Source for further reading: Tangwa G. B. (2007). Moral status of embryonic stem cells: perspective of an African villager. Bioethics , 21(8), 449–457. https://doi.org/10.1111/j.1467-8519.2007.00582.x , see also Mnisi, F. M. (2020). An African analysis based on ethics of Ubuntu - are human embryonic stem cell patents morally justifiable? African Insight , 49 (4).

[14] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics , 22 (2), 112–122. https://doi.org/10.1111/dewb.12324

[15] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics, 22(2), 112–122. https://doi.org/10.1111/dewb.12324

[16] Jackson, C.S., Pepper, M.S. Opportunities and barriers to establishing a cell therapy programme in South Africa.  Stem Cell Res Ther   4 , 54 (2013). https://doi.org/10.1186/scrt204 ; Pew Research Center. (2014, May 1). Public health a major priority in African nations . Pew Research Center’s Global Attitudes Project. https://www.pewresearch.org/global/2014/05/01/public-health-a-major-priority-in-african-nations/

[17] Department of Health Republic of South Africa. (2021). Health Research Priorities (revised) for South Africa 2021-2024 . National Health Research Strategy. https://www.health.gov.za/wp-content/uploads/2022/05/National-Health-Research-Priorities-2021-2024.pdf

[18] Oosthuizen, H. (2013). Legal and Ethical Issues in Stem Cell Research in South Africa. In: Beran, R. (eds) Legal and Forensic Medicine. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-32338-6_80 , see also: Gaobotse G (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[19] United States Bureau of Citizenship and Immigration Services. (1998). Tunisia: Information on the status of Christian conversions in Tunisia . UNHCR Web Archive. https://webarchive.archive.unhcr.org/20230522142618/https://www.refworld.org/docid/3df0be9a2.html

[20] Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[21] Kooli, C. Review of assisted reproduction techniques, laws, and regulations in Muslim countries.  Middle East Fertil Soc J   24 , 8 (2020). https://doi.org/10.1186/s43043-019-0011-0 ; Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[22] Pang M. C. (1999). Protective truthfulness: the Chinese way of safeguarding patients in informed treatment decisions. Journal of medical ethics , 25(3), 247–253. https://doi.org/10.1136/jme.25.3.247

[23] Wang, L., Wang, F., & Zhang, W. (2021). Bioethics in China’s biosecurity law: Forms, effects, and unsettled issues. Journal of law and the biosciences , 8(1).  https://doi.org/10.1093/jlb/lsab019 https://academic.oup.com/jlb/article/8/1/lsab019/6299199

[24] Wang, Y., Xue, Y., & Guo, H. D. (2022). Intervention effects of traditional Chinese medicine on stem cell therapy of myocardial infarction.  Frontiers in pharmacology ,  13 , 1013740. https://doi.org/10.3389/fphar.2022.1013740

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[28] Zhang, J. Y. (2017). Lost in translation? accountability and governance of Clinical Stem Cell Research in China. Regenerative Medicine , 12 (6), 647–656. https://doi.org/10.2217/rme-2017-0035

[29] Wang, L., Wang, F., & Zhang, W. (2021). Bioethics in China’s biosecurity law: Forms, effects, and unsettled issues. Journal of law and the biosciences , 8(1).  https://doi.org/10.1093/jlb/lsab019 https://academic.oup.com/jlb/article/8/1/lsab019/6299199

[30] Chen, H., Wei, T., Wang, H.  et al.  Association of China’s two-child policy with changes in number of births and birth defects rate, 2008–2017.  BMC Public Health   22 , 434 (2022). https://doi.org/10.1186/s12889-022-12839-0

[31] Azuma, K. Regulatory Landscape of Regenerative Medicine in Japan.  Curr Stem Cell Rep   1 , 118–128 (2015). https://doi.org/10.1007/s40778-015-0012-6

[32] Harris, R. (2005, May 19). Researchers Report Advance in Stem Cell Production . NPR. https://www.npr.org/2005/05/19/4658967/researchers-report-advance-in-stem-cell-production

[33] Park, S. (2012). South Korea steps up stem-cell work.  Nature . https://doi.org/10.1038/nature.2012.10565

[34] Resnik, D. B., Shamoo, A. E., & Krimsky, S. (2006). Fraudulent human embryonic stem cell research in South Korea: lessons learned.  Accountability in research ,  13 (1), 101–109. https://doi.org/10.1080/08989620600634193 .

[35] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6

[36] Association for the Advancement of Blood and Biotherapies.  https://www.aabb.org/regulatory-and-advocacy/regulatory-affairs/regulatory-for-cellular-therapies/international-competent-authorities/saudi-arabia

[37] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia.  BMC medical ethics ,  21 (1), 35. https://doi.org/10.1186/s12910-020-00482-6

[38] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia. BMC medical ethics , 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6

Culturally, autonomy practices follow a relational autonomy approach based on a paternalistic deontological health care model. The adherence to strict international research policies and religious pillars within the regulatory environment is a great foundation for research ethics. However, there is a need to develop locally targeted ethics approaches for research (as called for in Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6), this decision-making approach may help advise a research decision model. For more on the clinical cultural autonomy approaches, see: Alabdullah, Y. Y., Alzaid, E., Alsaad, S., Alamri, T., Alolayan, S. W., Bah, S., & Aljoudi, A. S. (2022). Autonomy and paternalism in Shared decision‐making in a Saudi Arabian tertiary hospital: A cross‐sectional study. Developing World Bioethics , 23 (3), 260–268. https://doi.org/10.1111/dewb.12355 ; Bukhari, A. A. (2017). Universal Principles of Bioethics and Patient Rights in Saudi Arabia (Doctoral dissertation, Duquesne University). https://dsc.duq.edu/etd/124; Ladha, S., Nakshawani, S. A., Alzaidy, A., & Tarab, B. (2023, October 26). Islam and Bioethics: What We All Need to Know . Columbia University School of Professional Studies. https://sps.columbia.edu/events/islam-and-bioethics-what-we-all-need-know

[39] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics.  Research Ethics ,  17 (2), 228-241.  https://doi.org/10.1177/1747016120966779

[40] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics.  Research Ethics ,  17 (2), 228-241.  https://doi.org/10.1177/1747016120966779

[41] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[42] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[43] The EU’s definition of autonomy relates to the capacity for creating ideas, moral insight, decisions, and actions without constraint, personal responsibility, and informed consent. However, the EU views autonomy as not completely able to protect individuals and depends on other principles, such as dignity, which “expresses the intrinsic worth and fundamental equality of all human beings.” Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3

[44] Council of Europe. Convention for the protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine (ETS No. 164) https://www.coe.int/en/web/conventions/full-list?module=treaty-detail&treatynum=164 (forbidding the creation of embryos for research purposes only, and suggests embryos in vitro have protections.); Also see Drabiak-Syed B. K. (2013). New President, New Human Embryonic Stem Cell Research Policy: Comparative International Perspectives and Embryonic Stem Cell Research Laws in France.  Biotechnology Law Report ,  32 (6), 349–356. https://doi.org/10.1089/blr.2013.9865

[45] Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3

[46] Tomuschat, C., Currie, D. P., Kommers, D. P., & Kerr, R. (Trans.). (1949, May 23). Basic law for the Federal Republic of Germany. https://www.btg-bestellservice.de/pdf/80201000.pdf

[47] Regulation of Stem Cell Research in Germany . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-germany

[48] Regulation of Stem Cell Research in Finland . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-finland

[49] Regulation of Stem Cell Research in Spain . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-spain

[50] Some sources to consider regarding ethics models or regulatory oversights of other cultures not covered:

Kara MA. Applicability of the principle of respect for autonomy: the perspective of Turkey. J Med Ethics. 2007 Nov;33(11):627-30. doi: 10.1136/jme.2006.017400. PMID: 17971462; PMCID: PMC2598110.

Ugarte, O. N., & Acioly, M. A. (2014). The principle of autonomy in Brazil: one needs to discuss it ...  Revista do Colegio Brasileiro de Cirurgioes ,  41 (5), 374–377. https://doi.org/10.1590/0100-69912014005013

Bharadwaj, A., & Glasner, P. E. (2012). Local cells, global science: The rise of embryonic stem cell research in India . Routledge.

For further research on specific European countries regarding ethical and regulatory framework, we recommend this database: Regulation of Stem Cell Research in Europe . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-europe   

[51] Klitzman, R. (2006). Complications of culture in obtaining informed consent. The American Journal of Bioethics, 6(1), 20–21. https://doi.org/10.1080/15265160500394671 see also: Ekmekci, P. E., & Arda, B. (2017). Interculturalism and Informed Consent: Respecting Cultural Differences without Breaching Human Rights.  Cultura (Iasi, Romania) ,  14 (2), 159–172.; For why trust is important in research, see also: Gray, B., Hilder, J., Macdonald, L., Tester, R., Dowell, A., & Stubbe, M. (2017). Are research ethics guidelines culturally competent?  Research Ethics ,  13 (1), 23-41.  https://doi.org/10.1177/1747016116650235

[52] The Qur'an  (M. Khattab, Trans.). (1965). Al-Mu’minun, 23: 12-14. https://quran.com/23

[53] Lenfest, Y. (2017, December 8). Islam and the beginning of human life . Bill of Health. https://blog.petrieflom.law.harvard.edu/2017/12/08/islam-and-the-beginning-of-human-life/

[54] Aksoy, S. (2005). Making regulations and drawing up legislation in Islamic countries under conditions of uncertainty, with special reference to embryonic stem cell research. Journal of Medical Ethics , 31: 399-403.; see also: Mahmoud, Azza. "Islamic Bioethics: National Regulations and Guidelines of Human Stem Cell Research in the Muslim World." Master's thesis, Chapman University, 2022. https://doi.org/10.36837/ chapman.000386

[55] Rashid, R. (2022). When does Ensoulment occur in the Human Foetus. Journal of the British Islamic Medical Association , 12 (4). ISSN 2634 8071. https://www.jbima.com/wp-content/uploads/2023/01/2-Ethics-3_-Ensoulment_Rafaqat.pdf.

[56] Sivaraman, M. & Noor, S. (2017). Ethics of embryonic stem cell research according to Buddhist, Hindu, Catholic, and Islamic religions: perspective from Malaysia. Asian Biomedicine,8(1) 43-52.  https://doi.org/10.5372/1905-7415.0801.260

[57] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[58] Lecso, P. A. (1991). The Bodhisattva Ideal and Organ Transplantation.  Journal of Religion and Health ,  30 (1), 35–41. http://www.jstor.org/stable/27510629 ; Bodhisattva, S. (n.d.). The Key of Becoming a Bodhisattva . A Guide to the Bodhisattva Way of Life. http://www.buddhism.org/Sutras/2/BodhisattvaWay.htm

[59] There is no explicit religious reference to when life begins or how to conduct research that interacts with the concept of life. However, these are relevant verses pertaining to how the fetus is viewed. (( King James Bible . (1999). Oxford University Press. (original work published 1769))

Jerimiah 1: 5 “Before I formed thee in the belly I knew thee; and before thou camest forth out of the womb I sanctified thee…”

In prophet Jerimiah’s insight, God set him apart as a person known before childbirth, a theme carried within the Psalm of David.

Psalm 139: 13-14 “…Thou hast covered me in my mother's womb. I will praise thee; for I am fearfully and wonderfully made…”

These verses demonstrate David’s respect for God as an entity that would know of all man’s thoughts and doings even before birth.

[60] It should be noted that abortion is not supported as well.

[61] The Vatican. (1987, February 22). Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation Replies to Certain Questions of the Day . Congregation For the Doctrine of the Faith. https://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19870222_respect-for-human-life_en.html

[62] The Vatican. (2000, August 25). Declaration On the Production and the Scientific and Therapeutic Use of Human Embryonic Stem Cells . Pontifical Academy for Life. https://www.vatican.va/roman_curia/pontifical_academies/acdlife/documents/rc_pa_acdlife_doc_20000824_cellule-staminali_en.html ; Ohara, N. (2003). Ethical Consideration of Experimentation Using Living Human Embryos: The Catholic Church’s Position on Human Embryonic Stem Cell Research and Human Cloning. Department of Obstetrics and Gynecology . Retrieved from https://article.imrpress.com/journal/CEOG/30/2-3/pii/2003018/77-81.pdf.

[63] Smith, G. A. (2022, May 23). Like Americans overall, Catholics vary in their abortion views, with regular mass attenders most opposed . Pew Research Center. https://www.pewresearch.org/short-reads/2022/05/23/like-americans-overall-catholics-vary-in-their-abortion-views-with-regular-mass-attenders-most-opposed/

[64] Rosner, F., & Reichman, E. (2002). Embryonic stem cell research in Jewish law. Journal of halacha and contemporary society , (43), 49–68.; Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[65] Schenker J. G. (2008). The beginning of human life: status of embryo. Perspectives in Halakha (Jewish Religious Law).  Journal of assisted reproduction and genetics ,  25 (6), 271–276. https://doi.org/10.1007/s10815-008-9221-6

[66] Ruttenberg, D. (2020, May 5). The Torah of Abortion Justice (annotated source sheet) . Sefaria. https://www.sefaria.org/sheets/234926.7?lang=bi&with=all&lang2=en

[67] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[68] Gert, B. (2007). Common morality: Deciding what to do . Oxford Univ. Press.

[69] World Medical Association (2013). World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA , 310(20), 2191–2194. https://doi.org/10.1001/jama.2013.281053 Declaration of Helsinki – WMA – The World Medical Association .; see also: National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. (1979).  The Belmont report: Ethical principles and guidelines for the protection of human subjects of research . U.S. Department of Health and Human Services.  https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/read-the-belmont-report/index.html

[70] Zakarin Safier, L., Gumer, A., Kline, M., Egli, D., & Sauer, M. V. (2018). Compensating human subjects providing oocytes for stem cell research: 9-year experience and outcomes.  Journal of assisted reproduction and genetics ,  35 (7), 1219–1225. https://doi.org/10.1007/s10815-018-1171-z https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6063839/ see also: Riordan, N. H., & Paz Rodríguez, J. (2021). Addressing concerns regarding associated costs, transparency, and integrity of research in recent stem cell trial. Stem Cells Translational Medicine , 10 (12), 1715–1716. https://doi.org/10.1002/sctm.21-0234

[71] Klitzman, R., & Sauer, M. V. (2009). Payment of egg donors in stem cell research in the USA.  Reproductive biomedicine online ,  18 (5), 603–608. https://doi.org/10.1016/s1472-6483(10)60002-8

[72] Krosin, M. T., Klitzman, R., Levin, B., Cheng, J., & Ranney, M. L. (2006). Problems in comprehension of informed consent in rural and peri-urban Mali, West Africa.  Clinical trials (London, England) ,  3 (3), 306–313. https://doi.org/10.1191/1740774506cn150oa

[73] Veatch, Robert M.  Hippocratic, Religious, and Secular Medical Ethics: The Points of Conflict . Georgetown University Press, 2012.

[74] Msoroka, M. S., & Amundsen, D. (2018). One size fits not quite all: Universal research ethics with diversity.  Research Ethics ,  14 (3), 1-17.  https://doi.org/10.1177/1747016117739939

[75] Pirzada, N. (2022). The Expansion of Turkey’s Medical Tourism Industry.  Voices in Bioethics ,  8 . https://doi.org/10.52214/vib.v8i.9894

[76] Stem Cell Tourism: False Hope for Real Money . Harvard Stem Cell Institute (HSCI). (2023). https://hsci.harvard.edu/stem-cell-tourism , See also: Bissassar, M. (2017). Transnational Stem Cell Tourism: An ethical analysis.  Voices in Bioethics ,  3 . https://doi.org/10.7916/vib.v3i.6027

[77] Song, P. (2011) The proliferation of stem cell therapies in post-Mao China: problematizing ethical regulation,  New Genetics and Society , 30:2, 141-153, DOI:  10.1080/14636778.2011.574375

[78] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[79] International Society for Stem Cell Research. (2024). Standards in stem cell research . International Society for Stem Cell Research. https://www.isscr.org/guidelines/5-standards-in-stem-cell-research

[80] Benjamin, R. (2013). People’s science bodies and rights on the Stem Cell Frontier . Stanford University Press.

Mifrah Hayath

SM Candidate Harvard Medical School, MS Biotechnology Johns Hopkins University

Olivia Bowers

MS Bioethics Columbia University (Disclosure: affiliated with Voices in Bioethics)

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Magnon-mediated topological superconductivity in a quantum wire

Florinda viñas boström and emil viñas boström, phys. rev. research 6 , l022042 – published 16 may 2024.

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Many emergent phases of matter stem from the intertwined dynamics of quasiparticles. Here we show that a topological superconducting phase emerges as the result of interactions between electrons and magnons in a quantum wire and a helical magnet. The magnon-mediated interaction favors triplet superconductivity over a large magnetic phase space region, and stabilizes topological superconductivity over an extended region of chemical potentials. The superconducting gap depends exponentially on the spin-electron coupling, allowing it to be enhanced through material engineering techniques.

• Received 5 December 2023
• Revised 28 March 2024
• Accepted 2 May 2024

DOI: https://doi.org/10.1103/PhysRevResearch.6.L022042

Published by the American Physical Society under the terms of the Creative Commons Attribution 4.0 International license. Further distribution of this work must maintain attribution to the author(s) and the published article's title, journal citation, and DOI. Funded by Bibsam .

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• 1 Institut für Mathematische Physik, Technische Universität Braunschweig , D-38106 Braunschweig, Germany
• 2 Division of Solid State Physics and NanoLund, Lund University , Box 118, S-221 00 Lund, Sweden
• 3 Nano-Bio Spectroscopy Group, Departamento de Física de Materiales, Universidad del País Vasco , 20018 San Sebastian, Spain
• 4 Max Planck Institute for the Structure and Dynamics of Matter , Luruper Chaussee 149, 22761 Hamburg, Germany
• * [email protected]
• † [email protected]

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• Superconductivity

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Principles of magnon-mediated superconductivity. (a) Experimental setup with a quantum wire in proximity to a helical magnet. (b) The helical magnetic order (orange arrows) induces an effective spin-orbit interaction and Zeeman splitting of the electronic bands via the spin-electron coupling g . Magnon fluctuations around the equilibrium magnetic order provide an effective attractive interaction among the electrons (blue arrows). (c) Due to the noncollinear magnetic structure, magnon fluctuations mediate scattering between electrons with arbitrary spin projections σ i .

Parameter dependence of magnon-mediated superconductivity. (a) Electronic band structure for a spin-electron coupling g = 150  meV and a spiral momentum q = π / 3 a . (b) Electronic band structure around k = 0 for a spin-electron coupling g = 150  meV and spiral momenta q = 0.44 π / a (green), q = 0.5 π / a (gray), and q = 0.57 π / a (blue). The red-dashed line indicates the chemical potential μ = − 1.4  eV. (c) Symmetry of the dominant superconducting gap as a function of spin-electron coupling g and spiral momentum q , for a chemical potential μ = − 1.4  eV. (d) Magnitude of the dominant superconducting gap as a function of spin-electron coupling g and spiral momentum q , for a chemical potential μ = − 1.4  eV. The gray-dashed lines indicate the positions of the van Hove singularities. In all panels the spin length is S = 1 , the electronic hopping is t = 1  eV, and the exchange interaction is J = 10  meV.

Topological phase diagram of magnon-mediated superconductivity as a function of spin-electron coupling g and chemical potential μ . The magnetic spiral has a wave length L = 8 and momentum q = π / ( 4 a ) . The light regions show the trivial phase, while the dark regions correspond to a topological phase. The spin length is S = 1 and the electronic hopping t = 1  eV.

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Research questions, hypotheses and objectives

Patricia farrugia.

* Michael G. DeGroote School of Medicine, the

Bradley A. Petrisor

† Division of Orthopaedic Surgery and the

Forough Farrokhyar

‡ Departments of Surgery and

§ Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont

Mohit Bhandari

There is an increasing familiarity with the principles of evidence-based medicine in the surgical community. As surgeons become more aware of the hierarchy of evidence, grades of recommendations and the principles of critical appraisal, they develop an increasing familiarity with research design. Surgeons and clinicians are looking more and more to the literature and clinical trials to guide their practice; as such, it is becoming a responsibility of the clinical research community to attempt to answer questions that are not only well thought out but also clinically relevant. The development of the research question, including a supportive hypothesis and objectives, is a necessary key step in producing clinically relevant results to be used in evidence-based practice. A well-defined and specific research question is more likely to help guide us in making decisions about study design and population and subsequently what data will be collected and analyzed. 1

Objectives of this article

In this article, we discuss important considerations in the development of a research question and hypothesis and in defining objectives for research. By the end of this article, the reader will be able to appreciate the significance of constructing a good research question and developing hypotheses and research objectives for the successful design of a research study. The following article is divided into 3 sections: research question, research hypothesis and research objectives.

Research question

Interest in a particular topic usually begins the research process, but it is the familiarity with the subject that helps define an appropriate research question for a study. 1 Questions then arise out of a perceived knowledge deficit within a subject area or field of study. 2 Indeed, Haynes suggests that it is important to know “where the boundary between current knowledge and ignorance lies.” 1 The challenge in developing an appropriate research question is in determining which clinical uncertainties could or should be studied and also rationalizing the need for their investigation.

Increasing one’s knowledge about the subject of interest can be accomplished in many ways. Appropriate methods include systematically searching the literature, in-depth interviews and focus groups with patients (and proxies) and interviews with experts in the field. In addition, awareness of current trends and technological advances can assist with the development of research questions. 2 It is imperative to understand what has been studied about a topic to date in order to further the knowledge that has been previously gathered on a topic. Indeed, some granting institutions (e.g., Canadian Institute for Health Research) encourage applicants to conduct a systematic review of the available evidence if a recent review does not already exist and preferably a pilot or feasibility study before applying for a grant for a full trial.

In-depth knowledge about a subject may generate a number of questions. It then becomes necessary to ask whether these questions can be answered through one study or if more than one study needed. 1 Additional research questions can be developed, but several basic principles should be taken into consideration. 1 All questions, primary and secondary, should be developed at the beginning and planning stages of a study. Any additional questions should never compromise the primary question because it is the primary research question that forms the basis of the hypothesis and study objectives. It must be kept in mind that within the scope of one study, the presence of a number of research questions will affect and potentially increase the complexity of both the study design and subsequent statistical analyses, not to mention the actual feasibility of answering every question. 1 A sensible strategy is to establish a single primary research question around which to focus the study plan. 3 In a study, the primary research question should be clearly stated at the end of the introduction of the grant proposal, and it usually specifies the population to be studied, the intervention to be implemented and other circumstantial factors. 4

Hulley and colleagues 2 have suggested the use of the FINER criteria in the development of a good research question ( Box 1 ). The FINER criteria highlight useful points that may increase the chances of developing a successful research project. A good research question should specify the population of interest, be of interest to the scientific community and potentially to the public, have clinical relevance and further current knowledge in the field (and of course be compliant with the standards of ethical boards and national research standards).

FINER criteria for a good research question

Adapted with permission from Wolters Kluwer Health. 2

Whereas the FINER criteria outline the important aspects of the question in general, a useful format to use in the development of a specific research question is the PICO format — consider the population (P) of interest, the intervention (I) being studied, the comparison (C) group (or to what is the intervention being compared) and the outcome of interest (O). 3 , 5 , 6 Often timing (T) is added to PICO ( Box 2 ) — that is, “Over what time frame will the study take place?” 1 The PICOT approach helps generate a question that aids in constructing the framework of the study and subsequently in protocol development by alluding to the inclusion and exclusion criteria and identifying the groups of patients to be included. Knowing the specific population of interest, intervention (and comparator) and outcome of interest may also help the researcher identify an appropriate outcome measurement tool. 7 The more defined the population of interest, and thus the more stringent the inclusion and exclusion criteria, the greater the effect on the interpretation and subsequent applicability and generalizability of the research findings. 1 , 2 A restricted study population (and exclusion criteria) may limit bias and increase the internal validity of the study; however, this approach will limit external validity of the study and, thus, the generalizability of the findings to the practical clinical setting. Conversely, a broadly defined study population and inclusion criteria may be representative of practical clinical practice but may increase bias and reduce the internal validity of the study.

PICOT criteria 1

A poorly devised research question may affect the choice of study design, potentially lead to futile situations and, thus, hamper the chance of determining anything of clinical significance, which will then affect the potential for publication. Without devoting appropriate resources to developing the research question, the quality of the study and subsequent results may be compromised. During the initial stages of any research study, it is therefore imperative to formulate a research question that is both clinically relevant and answerable.

Research hypothesis

The primary research question should be driven by the hypothesis rather than the data. 1 , 2 That is, the research question and hypothesis should be developed before the start of the study. This sounds intuitive; however, if we take, for example, a database of information, it is potentially possible to perform multiple statistical comparisons of groups within the database to find a statistically significant association. This could then lead one to work backward from the data and develop the “question.” This is counterintuitive to the process because the question is asked specifically to then find the answer, thus collecting data along the way (i.e., in a prospective manner). Multiple statistical testing of associations from data previously collected could potentially lead to spuriously positive findings of association through chance alone. 2 Therefore, a good hypothesis must be based on a good research question at the start of a trial and, indeed, drive data collection for the study.

The research or clinical hypothesis is developed from the research question and then the main elements of the study — sampling strategy, intervention (if applicable), comparison and outcome variables — are summarized in a form that establishes the basis for testing, statistical and ultimately clinical significance. 3 For example, in a research study comparing computer-assisted acetabular component insertion versus freehand acetabular component placement in patients in need of total hip arthroplasty, the experimental group would be computer-assisted insertion and the control/conventional group would be free-hand placement. The investigative team would first state a research hypothesis. This could be expressed as a single outcome (e.g., computer-assisted acetabular component placement leads to improved functional outcome) or potentially as a complex/composite outcome; that is, more than one outcome (e.g., computer-assisted acetabular component placement leads to both improved radiographic cup placement and improved functional outcome).

However, when formally testing statistical significance, the hypothesis should be stated as a “null” hypothesis. 2 The purpose of hypothesis testing is to make an inference about the population of interest on the basis of a random sample taken from that population. The null hypothesis for the preceding research hypothesis then would be that there is no difference in mean functional outcome between the computer-assisted insertion and free-hand placement techniques. After forming the null hypothesis, the researchers would form an alternate hypothesis stating the nature of the difference, if it should appear. The alternate hypothesis would be that there is a difference in mean functional outcome between these techniques. At the end of the study, the null hypothesis is then tested statistically. If the findings of the study are not statistically significant (i.e., there is no difference in functional outcome between the groups in a statistical sense), we cannot reject the null hypothesis, whereas if the findings were significant, we can reject the null hypothesis and accept the alternate hypothesis (i.e., there is a difference in mean functional outcome between the study groups), errors in testing notwithstanding. In other words, hypothesis testing confirms or refutes the statement that the observed findings did not occur by chance alone but rather occurred because there was a true difference in outcomes between these surgical procedures. The concept of statistical hypothesis testing is complex, and the details are beyond the scope of this article.

Another important concept inherent in hypothesis testing is whether the hypotheses will be 1-sided or 2-sided. A 2-sided hypothesis states that there is a difference between the experimental group and the control group, but it does not specify in advance the expected direction of the difference. For example, we asked whether there is there an improvement in outcomes with computer-assisted surgery or whether the outcomes worse with computer-assisted surgery. We presented a 2-sided test in the above example because we did not specify the direction of the difference. A 1-sided hypothesis states a specific direction (e.g., there is an improvement in outcomes with computer-assisted surgery). A 2-sided hypothesis should be used unless there is a good justification for using a 1-sided hypothesis. As Bland and Atlman 8 stated, “One-sided hypothesis testing should never be used as a device to make a conventionally nonsignificant difference significant.”

The research hypothesis should be stated at the beginning of the study to guide the objectives for research. Whereas the investigators may state the hypothesis as being 1-sided (there is an improvement with treatment), the study and investigators must adhere to the concept of clinical equipoise. According to this principle, a clinical (or surgical) trial is ethical only if the expert community is uncertain about the relative therapeutic merits of the experimental and control groups being evaluated. 9 It means there must exist an honest and professional disagreement among expert clinicians about the preferred treatment. 9

Designing a research hypothesis is supported by a good research question and will influence the type of research design for the study. Acting on the principles of appropriate hypothesis development, the study can then confidently proceed to the development of the research objective.

Research objective

The primary objective should be coupled with the hypothesis of the study. Study objectives define the specific aims of the study and should be clearly stated in the introduction of the research protocol. 7 From our previous example and using the investigative hypothesis that there is a difference in functional outcomes between computer-assisted acetabular component placement and free-hand placement, the primary objective can be stated as follows: this study will compare the functional outcomes of computer-assisted acetabular component insertion versus free-hand placement in patients undergoing total hip arthroplasty. Note that the study objective is an active statement about how the study is going to answer the specific research question. Objectives can (and often do) state exactly which outcome measures are going to be used within their statements. They are important because they not only help guide the development of the protocol and design of study but also play a role in sample size calculations and determining the power of the study. 7 These concepts will be discussed in other articles in this series.

From the surgeon’s point of view, it is important for the study objectives to be focused on outcomes that are important to patients and clinically relevant. For example, the most methodologically sound randomized controlled trial comparing 2 techniques of distal radial fixation would have little or no clinical impact if the primary objective was to determine the effect of treatment A as compared to treatment B on intraoperative fluoroscopy time. However, if the objective was to determine the effect of treatment A as compared to treatment B on patient functional outcome at 1 year, this would have a much more significant impact on clinical decision-making. Second, more meaningful surgeon–patient discussions could ensue, incorporating patient values and preferences with the results from this study. 6 , 7 It is the precise objective and what the investigator is trying to measure that is of clinical relevance in the practical setting.

The following is an example from the literature about the relation between the research question, hypothesis and study objectives:

Study: Warden SJ, Metcalf BR, Kiss ZS, et al. Low-intensity pulsed ultrasound for chronic patellar tendinopathy: a randomized, double-blind, placebo-controlled trial. Rheumatology 2008;47:467–71.

Research question: How does low-intensity pulsed ultrasound (LIPUS) compare with a placebo device in managing the symptoms of skeletally mature patients with patellar tendinopathy?

Research hypothesis: Pain levels are reduced in patients who receive daily active-LIPUS (treatment) for 12 weeks compared with individuals who receive inactive-LIPUS (placebo).

Objective: To investigate the clinical efficacy of LIPUS in the management of patellar tendinopathy symptoms.

The development of the research question is the most important aspect of a research project. A research project can fail if the objectives and hypothesis are poorly focused and underdeveloped. Useful tips for surgical researchers are provided in Box 3 . Designing and developing an appropriate and relevant research question, hypothesis and objectives can be a difficult task. The critical appraisal of the research question used in a study is vital to the application of the findings to clinical practice. Focusing resources, time and dedication to these 3 very important tasks will help to guide a successful research project, influence interpretation of the results and affect future publication efforts.

Tips for developing research questions, hypotheses and objectives for research studies

• Perform a systematic literature review (if one has not been done) to increase knowledge and familiarity with the topic and to assist with research development.
• Learn about current trends and technological advances on the topic.
• Seek careful input from experts, mentors, colleagues and collaborators to refine your research question as this will aid in developing the research question and guide the research study.
• Use the FINER criteria in the development of the research question.
• Ensure that the research question follows PICOT format.
• Develop a research hypothesis from the research question.
• Develop clear and well-defined primary and secondary (if needed) objectives.
• Ensure that the research question and objectives are answerable, feasible and clinically relevant.

FINER = feasible, interesting, novel, ethical, relevant; PICOT = population (patients), intervention (for intervention studies only), comparison group, outcome of interest, time.

Competing interests: No funding was received in preparation of this paper. Dr. Bhandari was funded, in part, by a Canada Research Chair, McMaster University.