key: cord-0846963-3qgx4z58 authors: Djoutsop, Olga Mbougo; Mbougo, Jolyvette Voufo; Kanmounye, Ulrick Sidney title: Global head and neck surgery research during the COVID pandemic: A bibliometric analysis date: 2021-07-09 journal: Ann Med Surg (Lond) DOI: 10.1016/j.amsu.2021.102555 sha: ef2b5b7ed3bd140bc7c564233286996b7a863686 doc_id: 846963 cord_uid: 3qgx4z58 BACKGROUND: Before the COVID-19 pandemic, access to otolaryngology and head-and-neck surgery was limited in low- and middle-income countries (LMICs). The pandemic has increased the burden on LMIC health systems by causing unanticipated expenses, delayed care, and changes in research activity. We aimed to assess the landscape of global ENT research during the pandemic. MATERIALS AND METHODS: The authors developed a search strategy composed of the following keywords: “otolaryngology,” “head and neck surgery,” and “low- and middle-income countries.” Then, they searched eleven citation databases via the Web of Science from January 01, 2020, to May 03, 2021. They imported the result as metadata into VosViewer and ran bibliometric analyses to identify the most influential institutions, countries, and themes. RESULTS: During the study period, 3077 articles were published. Two hundred eighty-nine articles (9%) mentioned COVID-19 explicitly. The second most common theme was pediatric ENT (223 articles, 7%). The United States had the most publications [1616 articles, 12,033 citations, and 2986 total link strength (TLS)], followed by China (336 articles, 10,981 citations, and 571 TLS). South Africa, the first African country, was fourth (302 articles, 699 citations, and 908 TLS), while Brazil, the first South American country, was seventh (158 articles, 582 citations, and 376 TLS). The most prolific institution was the National Institute of Allergy and Infectious Diseases (186 articles, 1110 citations, and 674 TLS). CONCLUSION: COVID-19 was the most common research theme during the pandemic, surpassing pediatric ENT. The COVID-19 pandemic has impacted global health, economics, and social fabric adversely. At the time of submission, there have been 168 million cases, 3.5 million deaths, more than 4.9% loss in the gross domestic product of our nations, and exacerbation of inequities in our societies [1] [2] [3] . Low-and middle-income countries (LMICs) have been affected disproportionately by COVID-19 due primarily to insufficient vaccines and insufficient public health emergency preparedness [4] [5] [6] [7] [8] [9] . In addition, the pandemic has diverted resources from infrastructure, education, and other health priorities. This double burden is concerning for LMICs, especially with regards to surgical care [10] . More than 5 billion people lack access to safe, timely, and affordable surgical care worldwide, and two-thirds of the unmet surgical need is in LMICs [11] . There has been significant progress towards reducing this unmet need; however, the COVID-19 pandemic has caused the cancellation or postponement of 28.4 million surgeries globally and increased patient mortality rates by almost 273% [12, 13] . Otolaryngology -head, and neck surgery (OHNS) has been affected more than most surgical specialties due principally to higher occupational risks [14] . Furthermore, the COVID-19 pandemic has impacted OHNS This manuscript reports findings in accordance with the 2020 Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement [16] . Scientometrics is a subfield within bibliometrics that measures and analyzes scholarly literature to identify the most influential articles, authors, academic institutions, and themes [17] . Scientometrics provides quantitative and qualitative insight into the key actors within a field and interactions between these key actors. The interactions between key actors are computed and visualized as network maps [18] . These network maps represent the actors as nodes (circles) and the interactions between actors as links (lines) [18] . Actors that share similar features are grouped into clusters (nodes of the same color), and the influence or centrality of a node is expressed as a link strength [19] . The authors searched eleven citation databases via the Web of Science core collection from January 01, 2020, to May 03, 2021, for the terms "otolaryngology," "head and neck surgery," and "low-and middleincome countries" (Appendix 1, search strategy). They downloaded the article metadata in groups of 500 as text files. Next, the text files were imported into VOSViewer (Centre for Science and Technology Studies, Leiden University, The Netherlands), a scientometric freeware for the social network analysis. Network maps of the articles, their cited references, authors, author affiliations, and keywords were generated. Also, quantitative measures were computed, including the number of publications, number of citations, and total link strength. The authors used SPSS v.26 for Windows (IBM, WA, USA) to calculate summary descriptive statistics to compare differences in the bibliometric data by region and income category. Regions and income categories were defined using the World Banks categorization by continent (East Asia and Pacific, Europe and Central Asia, Latin America & the Caribbean, Middle East and North Africa, North America, South Asia, and Sub-Saharan Africa) and by country income (Low-income economies, Lower-middle-income economies, Upper-middle-income economies, and High-income economies) [20] . These comparisons were made using the Kruskal-Wallis test and a threshold of significance of 0.05. This scientometric analysis was a secondary analysis of bibliometric data that did not have animal or human data. Hence, ethical approval was not necessary. Taiwan 42 126 195 Tanzania 42 60 168 Indonesia 38 50 171 Nigeria 37 232 155 Vietnam 34 185 198 Greece 32 270 173 Scotland 32 146 165 Argentina 31 56 108 Colombia 31 79 92 Austria 30 81 187 Denmark 30 113 157 Cameroon 28 92 150 Ethiopia 27 144 97 Ghana 27 84 158 Bangladesh 25 116 80 Ecuador 25 17 65 Mali 25 44 94 Ukraine 24 27 70 Chile 23 52 73 Philippines 23 38 109 Finland 22 162 124 Botswana 21 71 84 Cambodia 20 3 30 27 Armenia 3 0 1 Burundi 3 2 15 Estonia 3 5 10 Georgia 3 20 48 Laos 3 6 20 Luxembourg 3 21 26 Namibia 3 2 8 North Ireland 3 19 12 Oman 3 2 13 Panama 3 31 19 Cape Verde 2 2 3 Fiji 2 0 4 Gabon 2 10 27 Grenada 2 0 1 Guatemala 2 0 2 Iceland 2 3 8 Kazakhstan 2 1 2 Moldova 2 18 19 Palestine 2 The search strategy returned 3077 results. A handful of articles reported on COVID-19-related OHNS (n = 289 articles, 9%), and the second most common theme was pediatric OHNS (223 articles, 7%). The remaining articles reported allergic and atopic disorders and infectious diseases in OHNS patients (ex: HIV, malaria, and tuberculosis) (Fig. 1 ). Authors affiliated with American institutions published the most [1616 articles, 12,033 citations, and 2986 total link strength (TLS)], followed by China (336 articles, 10,981 citations, and 571 TLS). South Africa, the first African country, was fourth (302 articles, 699 citations, and 908 TLS), while Brazil, the first South American country, was seventh (158 articles, 582 citations, and 376 TLS) ( Table 1) . There were statistically significant differences between the regions in terms of the number of articles (P = 0.016), citations (P = 0.013), and total link strength (P = 0.001) (Fig. 2) . Similarly, there were statistically significant differences between income categories regarding citations (Median: high-income = 81 vs. upper-middle-income = 19, vs. lowermiddle-income = 28.5, vs. low-income = 30; P = 0.002) and total link strength (Median: high-income = 75 vs. upper-middle-income = 40, vs. lower-middle-income = 51.5, vs. low-income = 39.5; P = 0.013). However, there was no evidence to support the differences between income categories for the number of published articles (Median: highincome = 16 vs. upper-middle-income = 7, vs. lower-middle-income = 9, vs. low-income = 12; P = 0.098). The most prolific institution was the National Institute of Allergy and Infectious Diseases (186 articles, 1110 citations, and 674 TLS). The first African institution was the University of Witwatersrand (99 articles, 148 citations, and 538 TLS) and the Hallym University (53 articles, 66 citations, and 281 TLS) was the first Southeast Asian university ( Table 2 ). The social network map of academic institutions showed high connectivity resulting from academic collaborations (Fig. 3) . The We analyzed LMIC-related OHNS research output during the COVID-19 pandemic. We found that a fraction of the LMIC-related OHNS research was focused on COVID-19, while the rest covered allergology and pediatric OHNS. Authors affiliated with high-income country (HIC) institutions published more articles than their colleagues affiliated with LMIC institutions. North American institutions had the highest median academic output, followed by East and South Asian institutions. Additionally, citations and TLS were correlated with country income and region -North American HIC institutions had the highest citations and TLS. The study of clinical OHNS and its public health implications worldwide is called global OHNS or global ENT surgery. Global OHNS researches, educates, and advocates for universal access to OHNS care and improved health outcomes [21] . Global OHNS was born from the global surgery movement and has since emancipated to form a self-sufficient field. This expansion has been spearheaded by the Global OHNS initiative, an international collaborative that promotes research, education, policymaking, and advocacy in OHNS to increase access to safe, timely, and affordable OHNS care [22] . Research is a critical component of the global OHNS strategy. Its value resides in its ability to quantify the burden of OHNS globally, inform health policies, guide clinical practice in low-resource settings, and propose innovative solutions to common global OHNS problems [21] . Examples of relevant research include Patterson et al.'s [23] landmark study quantifying the global burden of OHNS cancers. The authors found that increasing the specialist OHNS workforce by 10% would reduce the OHNS cancer mortality-to-incidence ratio by 0.76% [23] . Another equally important article was Kligerman et al. [24] on challenges faced by LMIC OHNS specialists during the COVID-19 pandemic. In this commentary, the authors highlighted the nefarious impact of COVID-19 morbidity and mortality on the OHNS specialist workforce in LMICs. They proposed interventions to decrease occupational risks in this population, and they shared the experiences of OHNS specialists in LMICs who have successfully implemented these solutions [24] . The thematic analysis of LMIC-related OHNS articles published during the COVID-19 pandemic revealed that global OHNS and its synonyms are seldom used. This finding highlights the need for increased advocacy and education within global surgery, especially in regions where the burden of OHNS disorders is highest. Hence, advocacy efforts should target OHNS specialists, trainees, and medical students interested in OHNS living in LMICs especially, in Asia [23] . These targeted education and advocacy efforts can be facilitated by organized OHNS societies globally and globally. Global neurosurgery has done this successfully through the World Federation of Neurosurgical Societies (WFNS). The WFNS created an ad-hoc committee composed of global neurosurgery stakeholders. The committee and other global neurosurgery actors have created a global neurosurgery journal, organized sessions at major neurosurgery conferences, sponsor training in LMICs, and policymaking at the World Health Organization [25] [26] [27] . In addition, these efforts have led to an exponential increase in PubMed indexed global neurosurgery research [28] . The current academic global OHNS is skewed in favor of HICs. The global OHNS community should seek to involve LMICs institutions and researchers more often. The list of influential institutions and authors in this study can help HIC institutions and authors identify prolific LMIC colleagues to set up new research collaborations. Furthermore, the social network map of academic institutions (Fig. 3) shows the degrees of relationship between institutions. It can be used to identify intermediary acquaintances who can facilitate introductions between institutions that have not worked together in the past. Priority should be given to collaborations between institutions belonging to different clusters, especially between LMIC institutions. Similarly, the country list (Table 1) can identify priority countries for research capacity-building efforts. This scientometric analysis of global OHNS during the COVID-19 pandemic presented bibliometric data disaggregated regionally and economically. Publication and citation data are influenced by multiple factors, including the journal impact factor, open access, and language. Total link strength Comoros 1 12 24 El Salvador 1 0 3 French Guiana 1 11 4 Guyana 1 11 4 Jamaica 1 1 1 Kyrgyzstan 1 108 23 Libya 1 0 1 Malta 1 17 17 Mauritania 1 0 5 Mauritius 1 15 20 Niger 1 2 9 Seychelles 1 12 24 Somalia 1 1 0 Syria 1 6 0 Yemen 1 0 2 Our findings should be interpreted with caution because we limited our analysis to the COVID-19 pandemic. There is documented evidence that scholarly output and citations increased during the pandemic, so the metrics are probably higher than before the pandemic [15] . Notwithstanding, we expect the increase to be the same across regions and income categories. Hence, the differences between the regions and income groups should be the same pre-pandemic and during the pandemic. We identified influential themes, prolific authors, and institutions within global OHNS using scientometrics. The COVID-19 global OHNS literature has diverse authors; however, HIC and North American institutions contribute much more to the scholarly output than LMIC institutions. This geographical disparity is a cause of concern. Fortunately, the diverse and highly connected social network of global OHNS contributors suggests this disparity can be solved easily. Not applicable. None. OMD and JVM contributed to data collection, analysis and manuscript writing. USK conceptualized, administered and supervised the project, interpreted and validated the data, and wrote the manuscript. 1. Name of the registry: 2. Unique Identifying number or registration ID: 3. Hyperlink to your specific registration (must be publicly accessible and will be checked): Not commissioned, externally peer reviewed. We declare no conflict of interest. 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The case of Cameroon, Iran research by diverting resources to COVID-19, reducing participation in interventional research due to social distancing and stay-at-home orders, and review and publication delays due to a surge in article submissions [15] .The authors sought to identify trends in OHNS research from LMIC researchers and institutions and about OHNS practice in LMICs during the COVID-19 pandemic. They did this using a scientometric analysis of all LMIC-related OHNS research during the said period. None.