Original Article Footprint of Reports From Low- and Low- to Middle-Income Countries in the Neurosurgical Data: A Study From 2015 to 2017 Franco Servadei1, Maria Pia Tropeano1,2, Riccardo Spaggiari1, Delia Cannizzaro1, Asra Al Fauzi3, Abdul Hafid Bajamal3, Tarik Khan4, Angelos G. Kolias2,5, Peter J. Hutchinson2,5 - OBJECTIVE: In 2015, the Lancet Commission on Global LMICs and LICs). A few reports studies had been generated Surgery highlighted the disparities in surgical care by collaboration with HIC neurosurgeons. worldwide. The aim of the present study was to investigate - CONCLUSIONS: Our results have shown that research the research productivity of low-income countries (LICs) studies from LMICs are underrepresented. Understanding and low- to middle-income countries (LMICs) in selected and discussing the reasons for this underrepresentation journals representing the worldwide neurosurgical data are necessary to start addressing the disparities in and their ability to report and communicate globally the neurosurgical research and care capacity. Future engage- existing differences between high-income countries (HICs) ments from international journals, more partnership and LMICs. collaboration from HICs, and tailored funding to support - METHODS: We performed a retrospective bibliometric investigators, collaborations, and networks could be of analysis using PubMed and Scopus databases to record all help. the reports from 2015 to 2017 by investigators affiliated with neurosurgical departments in LICs and LMICs. - RESULTS: A total of 8459 reports by investigators self- identified as members of neurosurgery departments worldwide were identified. Of these, 6708 reports were INTRODUCTION included in accordance with our method in the final n 2015, the Lancet Commission on Global Surgery high- analysis. The systematic search resulted in 459 studies lighted the disparities in surgical care worldwide.1 reported by LICs and LMICs. Of these, 334 reports were I Subsequently, the neurosurgical community started giving fi included for the full text evaluation. Of the 6708 reports, 303 more attention to the current capacity and de cit in the (4.52%) had been reported with an LMIC affiliation and only provision of essential neurosurgical care, focusing, in particular, on low- to middle-income countries (LMICs).2 Recently, Dewan 31 (0.46%) with an LIC. The leading countries were India et al.3 showed that 44% of neurosurgeons worldwide were based with 182 (54.5% among LMICs and LICs; 2.71% overall), in high-income countries (HICs). An increasing number of followed by Egypt at 66 (19.76% among the LMICs and LICs; studies have reported disparities in epidemiology, patient man- 0.98% overall), with a large difference compared with other agement, neurosurgical procedures, and complications between countries such as Uganda at 9 (2.69% among the LMICs and HICs and LMICs.3 Nevertheless, these data have been limited, LICs) and Tunisia and Pakistan at 8 each (2.4% among the because the contribution from LMICs to the neurosurgical data Key words Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom; 3 - Developing countries Department of Neurosurgery, Dr. Soetomo Academic Medical Center Hospital, University of 4 - Education Airlangga, Surabaya, Indonesia; Department of Neurosurgery, North Western General and 5 - Global neurosurgery Research Hospital, Peshawar, Pakistan; Division of Neurosurgery, Department of Clinical ’ - Literature Neurosciences, Addenbrooke s Hospital and University of Cambridge, Cambridge, United - World health Kingdom To whom correspondence should be addressed: Maria Pia Tropeano, M.D. Abbreviations and Acronyms [E-mail: [email protected]] HIC: High-income country Citation: World Neurosurg. (2019) 130:e822-e830. LIC: Low-income country https://doi.org/10.1016/j.wneu.2019.06.230 LMIC: Low-to middle-income country Journal homepage: www.journals.elsevier.com/world-neurosurgery TBI: Traumatic brain injury Available online: www.sciencedirect.com ª From the 1Department of Neurosurgery, Humanitas Clinical and Research Hospital and 1878-8750/$ - see front matter 2019 Elsevier Inc. All rights reserved. Humanitas University, Milan, Italy; 2National Institute for Health Research Global Health e822 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.06.230 ORIGINAL ARTICLE FRANCO SERVADEI ET AL. REPORTS FROM LICS AND LMICS has been modest. Among the most cited systematic reviews and LIC and LMIC Productivity meta-analyses, no first author from LMICs has been found.4 When an article had been reported by >1 author affiliated with Focusing on the reported neurosurgical data, the publication neurosurgical departments in LICs and LMICs, the first author output of LMICs has been very limited. Among the top 20 most affiliation was chosen. If the other authors were affiliated with an publishing countries in the neurosurgical data in 2011, just 1 LIC or LMIC, but not the first author, we assigned the report to the country (India) belonged to the LMICs or low-income country with the highest number of authors. In rare cases of un- countries (LICs).5 certainty, the report was reviewed to determine the relevant Therefore, we conducted a bibliometric analysis of reports contribution from each author and country for that specific study. from LICs and LMICs to investigate the research productivity of these countries in the worldwide neurosurgical data and their Focus by Topic ability to publish and communicate globally the existing differ- Analysis of the focus by topic was performed by grouping the ences between HICs and LMICs. In addition, we sought to MeSH terms according to neurosurgical subspecialty. We classi- determine the contribution, in terms of the generation of fied the collected articles into 9 topics: trauma (further divided knowledge, of LMICs and LICs to the neurosurgical data reported into traumatic brain injury [TBI] and spine injury), tumor (further in international medical journals and in which LMICs and LICs is divided into brain tumor and spine tumor, including both ma- this research performed. Moreover, we sought to determine lignant conditions [e.g., glioblastoma multiforme] and benign whether the knowledge of the clinical management of neuro- conditions [e.g., cysts and pituitary adenomas]), vascular neuro- surgical disease in these countries could be the basis for any surgery (e.g., arteriovenous malformations, cerebral aneurysms, further intervention aimed to improve neurosurgical education subarachnoid hemorrhage, endovascular procedures, cerebral and patients care. ischemia), functional neurosurgery (e.g., stereotactic radiosurgery, deep brain stimulation, epilepsy, intractable pain), pediatrics (all subspecialties concerning children and adolescents), hydroceph- MATERIALS AND METHODS alus (in adults, including studies of endoscopic third ven- We performed a bibliometric analysis of reports from publicly triculostomy, cerebrospinal fluid shunts), spine (e.g., all available databases (i.e., Scopus and PubMed). From 2015 to 2017, nontraumatic pathologic features affecting the spine but excluding Scopus and PubMed studies reported by investigators affiliated tumors), infection (i.e., all reports whose main topic was an with neurosurgical departments in LICs and LMICs were included. infective process), and miscellaneous (i.e., reports of neurosur- This method has been described in part previously.6,7 The reports gical conditions in different hospitals, a history of neurosurgery in indexed by Scopus and PubMed include the author’s departmental specific countries, peripheral nerve pathologic features, central location (i.e., city, state, country). This field was used to deter- nervous system plasticity, neurosurgical training). mine the country of origin. The distribution of countries into LIC and LMIC groups was performed using the World Bank classifi- RESULTS cation2 (Figure 1). Only reports defined as “journal articles” were included (i.e., original research articles, reviews, trials, and other LMIC and LIC Productivity scientific reports). Occasionally, journals report nonscientific From January 1, 2015 to December 31, 2017, a total of 8459 reports information, such as bibliographies, news items, comments, by investigators who had self-identified as members of neuro- and roll calls of reviewers. These are not indexed as “journal surgery departments worldwide were identified in 17 journals us- articles” and, thus, were excluded. We chose 14 neurosurgical ing our study method. After title and abstract screening, 1751 journals and 3 general medical journals from the Journal of reports had been eliminated, and 6708 were included in the final Citation Reports 2015, primarily using ranking according to their analysis. The systematic search resulted in 459 studies reported by impact factor. Those with the highest ranking for medicine (New LICs and LMIC. After title and abstract screening of these 459 England Journal of Medicine, Lancet, and Journal of the American studies, 125 were excluded, leaving 334 studies for full text eval- Medical Association), neurology and neurosurgery (Lancet Neurology, uation. The PRISMA (preferred reporting items for systematic Journal of American Medical Association Neurology, Journal of Neurology, reviews and meta-analyses) method is shown in Figure 2. Of the Neurosurgery, and Psychiatry, Journal of Neurosurgery, Neurosurgery, 6708 studies, 303 (4.52%) had been reported with an LMIC World of Neurosurgery, Acta Neurochirurgica, Neurosurgery Focus, affiliation and