Key Takeaways & Executive Findings
- •• The commentary identifies critical methodological flaws in a published meta-analysis on stem cell therapy for diabetic foot, including misinterpretation of forest plot results due to inadequate RevMan knowledge. • It emphasizes the necessity of applying continuity correction for zero-event trials to ensure accurate pooled estimates in meta-analyses. • The authors advocate for improved presentation of forest plots to enhance readability and interpretability in scientific publications. • Registration of systematic review protocols with PROSPERO or INPLASY is strongly recommended to increase transparency and reduce bias.
Abstract
In the study published by Sun et al., a systematic review and meta-analysis illustrated the advantageous of stem cell therapy in diabetic foot and can improve the quality of life of patients. Nevertheless, the authors had a lack of knowledge regarding the methodology of the meta-analysis, which had four main aspects: (1) The textual report is inconsistent with the forest plot results, i.e., the authors have insufficient knowledge of RevMan. (2) The "zero event" needs to be corrected for summary analysis. (3) Lack of aesthetics in the forest plots. (4) Registration is recommended for systematic reviews and meta-analyses.
1. Introduction
We read the recent article published by Sun et al. [1], which specifies from a meta-analysis that stem cells are significantly more effective than traditional methods in treating diabetic foot and can improve patient's quality of life after treatment. We congratulate Sun et al. for their results, but several methodological issues with the article need to be highlighted so as not to mislead the readers.
First, a fatal error lies in the authors' lack of awareness about the Revman software. Taking Fig. 3 as an example, the summary diamond falls on the "Control[control]" side, so the result of the forest plot should be that "the healing rate of ulcers or wounds in the control group was higher than in the cell-treated group", but the authors report the opposite. In fact, when using Revman's forest plot, we need to consider whether the outcome is a "favorable event" or an "unfavorable event" [2]. Obviously, the healing rate of ulcers or wounds is a "favorable event," and the label of the forest plot needs to be revised.
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Yan Bai, Fan Zhang (2026). Comment on "Effectiveness and safety of stem cell therapy for diabetic foot: a meta-analysis update". Stem Cell Research & Therapy. https://doi.org/10.1186/s13287-023-03608-w
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Frequently Asked Questions
What are the main methodological issues highlighted in the commentary?
The commentary identifies four main issues: (1) inconsistency between textual report and forest plot results due to insufficient RevMan knowledge, (2) lack of correction for zero-event trials, (3) poor aesthetics in forest plots, and (4) absence of protocol registration.
Why is the correction for zero-event trials important in meta-analysis?
Zero-event trials can bias the pooled effect estimate if not handled properly. The continuity correction method, such as adding 0.5 to each cell, is recommended to include such trials and avoid overestimation of treatment effects.
What is the significance of registering a systematic review protocol?
Registering a protocol with PROSPERO or INPLASY enhances transparency, reduces risk of bias, and prevents duplication, thereby improving the overall quality and credibility of the systematic review.
How can forest plots be improved for better readability?
Forest plots should be visually clear, with properly aligned labels, visible summary diamonds, and appropriate scaling. Using software features like scroll bars can help ensure all elements are displayed correctly.
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