Keywords
Bibliometrics - Emergencies - Neurology - Central Nervous System Diseases/Diagnosis
and Therapy - Evidence-based Medicine - Critical Care/Standards
Palavras-chave
Bibliometria - Emergências - Neurologia - Doenças do Sistema Nervoso Central/Diagnóstico
e Terapia - Medicina Baseada em Evidências - Cuidados Críticos/Normas
INTRODUCTION
In 2012, the first edition of Emergency neurological life support (ENLS) protocols was published in Neurocritical Care, the official journal of the Neurocritical Care Society.[1] They were launched as a compilation of the core issues that should be addressed
within the first hours of neurological emergencies, as recommended by experts and
available evidence. Analogous to the Advanced Cardiovascular Life Support (ACLS) and
Advanced Trauma Life Support (ATLS), the ENLS aims to standardize the initial approach
to neurological emergencies.[2]
[3]
Bibliometric analysis is a way to quantify research output and impact and has attracted
the attention of the scientific community in recent years.[4]
[5]
[6]
[7] There is no consensus on how to perform this kind of study, where a high number
of different variables may be assessed, depending on the purpose. For instance, relying
on the number of articles, citations, and derived metrics allows for the quantification
of the most prominent journals, countries, and research types in a specific field.
Recently, several bibliometric analyses have been published in the fields of neurology,[8]
[9] neurosurgery,[10]
[11] and neurocritical care.[12]
Unfortunately, the ENLS is relatively recent and is not as widespread as the ACLS
and ATLS. However, it is mentioned by several recent guidelines within neurocritical
care research,[13]
[14]
[15] demonstrating interest in standardized and systematic approaches to critically ill
neurological patients. We are unaware of studies that assessed the repercussions of
the ENLS in the scientific literature. Therefore, we aim to evaluate such impact through
a bibliometric analysis.
METHODS
Search strategy
We searched Elsevier's Scopus on October 19th, 2022 for articles mentioning ENLS in any part of the manuscript (title, abstract,
keywords, text, or references). The exact search string is shown in Supplementary
Material (https://www.arquivosdeneuropsiquiatria.org/wp-content/uploads/2023/10/ANP-2023.0104-Supplementary-Material.docx). Documents were excluded if they did not mention ENLS in any of these parts. Non-English
studies, book chapters, conference abstracts, symposiums, discussion panels, erratum
articles, as well as articles that could not have their full texts retrieved were
also excluded.
Bibliometric analysis
The full text of all included articles was analyzed. The following variables were
obtained from each article: number of citations; number of citations per year; number
of publications per year; year of publication; research type; research subtype; country
of corresponding author and its income category and world region; journal of publication
and its 5-year impact factor (IF); and local of appearance of ENLS (title, abstract,
keywords, text, or references). The number of citations per year was not retrieved
from articles published in 2022. Research types were classified as Primary, Secondary,
Case Report, Animal/In vitro/Simulations, or Editorial/Comment. Research subtypes
of primary research were further categorized as Interventional or Observational, while
the subtypes of secondary research were subdivided into Narrative Review, Guideline/Consensus/Recommendations,
and Systematic Review. The income category of countries and definition of world regions
were retrieved from a Web site of World Bank Country and Lending Groups classifications (https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups) in October 2022. The 5-year IF was obtained from the Journal Citation Reports Web site (https://jcr.clarivate.com/jcr/home) in November 2022. Besides the analysis of all articles, we also performed a separate
analysis of articles that were ENLS protocols.
Statistical analysis
We used SPSS version 23.0 for Windows for statistical analysis. We used Prism Graphpad for creating charts. For continuous variables, we obtained the mean, 95% confidence
interval (95%CI), and percentiles 25th, 50th, and 75th. Continuous variables presented
an asymmetrical distribution (p < 0.001 on Kolmogorov-Smirnov test). Correlations were determined using Spearman rank correlation. We used the Mann-Whitney and Kruskal-Wallis tests for comparison of two means and three or more means, respectively. Pairwise
post-hoc comparisons were performed after Kruskal-Wallis test. The level of significance was set at 5%.
RESULTS
General results
After applying eligibility criteria to the 618 retrieved documents, a total of 429
articles were included. Of these, we could not obtain the full texts of 8 articles.
The remaining 421 documents had their full texts retrieved and analyzed. The mean
number of citations per article was 17.46 (95% CI = 8.20–26.72; 25th percentile: 1;
50th percentile: 5; 75th percentile: 15), while the mean number of citations per year
per article was 4.05 (95% CI = 2.50–5.61; 25th percentile: 0.57; 50th percentile:
1.61; 75th percentile: 3.80). The ten most cited articles are detailed in [Table 1]. There is an increasing number of publications mentioning ENLS over the years, as
shown in [Figure 1].
Table 1
The ten articles mentioning the Emergency neurological life support with the highest number of citations
|
Title
|
Journal
|
No of citations
|
Country
|
Year
|
|
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline
for Healthcare Professionals from the American Heart Association/American Stroke Association
|
Stroke
|
1833
|
USA
|
2015
|
|
The European guideline on management of major bleeding and coagulopathy following
trauma: Fourth edition
|
Critical Care
|
638
|
Switzerland
|
2016
|
|
Traumatic spinal cord injury: An overview of pathophysiology, models and acute injury
mechanisms
|
Frontiers in Neurology
|
332
|
Canada
|
2019
|
|
Association between hyperoxia and mortality after stroke: A multicenter cohort study
|
Critical Care Medicine
|
169
|
USA
|
2014
|
|
Significance of arterial hyperoxia and relationship with case fatality in traumatic
brain injury: A multicentre cohort study
|
Journal of Neurology, Neurosurgery and Psychiatry
|
95
|
USA
|
2014
|
|
Prehospital use of cervical collars in trauma patients: A critical review
|
Journal of Neurotrauma
|
93
|
Norway
|
2014
|
|
Intracerebral hemorrhage: An update on diagnosis and treatment
|
Expert Review of Neurotherapeutics
|
92
|
UK
|
2019
|
|
The critical care management of poor-grade subarachnoid hemorrhage
|
Critical Care
|
84
|
Canada
|
2016
|
|
High-dose midazolam infusion for refractory status epilepticus
|
Neurology
|
74
|
USA
|
2014
|
|
The critical care management of spontaneous intracranial hemorrhage: A contemporary
review
|
Critical Care
|
74
|
Canada
|
2016
|
Figure 1 Longitudinal pattern of publications mentioning Emergency Neurological Life Support from 2012 to 2021.
Journal and 5-year impact factor
Articles were published in 204 different journals, with a mean IF of 5.141 (95%CI = 4.189–6.093;
25th percentile: 2.879; 50th percentile: 3.748; 75th percentile: 4.764). The most
prolific journal was Neurocritical Care (15.91%; N = 67/421) ([Table 2]). Of these, 45 were official ENLS publications (protocols, descriptions of the ENLS,
or descriptions of its updates). Considering only other publications (22 articles),
Neurocritical Care remains the most prolific. A total of 49 journals did not have a 5-year IF. There
was no correlation between the number of articles and 5-year IF ([Figure 2]).
Table 2
Articles, citations, citations per article, and 5-year destiny journal impact factor
analysis of publications mentioning the Emergency neurological life support stratified by journals. N = 421
|
Journal
|
Articles (% of total)
|
Citations per article, mean
|
Citations per year per article, mean
|
Destiny journal 5-year IF, mean
|
|
Neurocritical Care
|
67 (15.91)
|
3.74
|
2.33
|
3.75
|
|
Emergency Medicine Clinics of North America
|
10 (2.38)
|
2.67
|
3.03
|
2.68
|
|
Seminars in Neurology
|
9 (2.14)
|
4.02
|
1.18
|
4.02
|
|
Current Treatment Options in Neurology
|
8 (1.90)
|
3.79
|
2.07
|
3.80
|
|
Frontiers in Neurology
|
8 (1.90)
|
4.32
|
16.88
|
4.32
|
|
CONTINUUM Lifelong Learning in Neurology
|
7 (1.66)
|
NA
|
4.98
|
NA
|
|
Critical Care
|
6 (1.43)
|
14.08
|
30.47
|
14.08
|
|
Current Opinion in Critical Care
|
6 (1.43)
|
3.97
|
4.35
|
3.98
|
|
Journal of Stroke and Cerebrovascular Diseases
|
6 (1.43)
|
2.50
|
1.69
|
2.50
|
|
Neurologic Clinics
|
6 (1.43)
|
4.51
|
2.80
|
4.51
|
|
Resuscitation
|
6 (1.43)
|
6.35
|
1.47
|
6.36
|
|
World Neurosurgery
|
6 (1.43)
|
2.33
|
1.41
|
2.33
|
|
Journal of Neurology
|
5 (1.19)
|
6.17
|
3.11
|
6.17
|
|
Scientific Reports
|
4 (0.95)
|
5.51
|
2.66
|
5.51
|
|
Critical Care Clinics
|
4 (0.95)
|
4.76
|
4.22
|
4.76
|
Abbreviations: ENLS, Emergency Neurological Life Support. IF, Impact Factor.
Note: *Only citations up to 2021 were computed (N = 392 articles).
Figure 2 Correlation between the number of articles mentioning Emergency Neurological Life Support (ENLS) with the 5-year Impact Factors of destiny journals. Each small circle indicates
a separate journal. Only journals with five or more articles were considered. ENLS
protocols were excluded from the analysis.
Country, region, and income category
[Table 3] presents the most prominent countries, regions, and income categories within ENLS
research. Articles were published by authors from 41 different countries. The USA
was, by far, the most prolific (53.92%; N = 227/421 articles). The region with the highest number of papers was North America
(57.96%; N = 244/421 articles). High-income countries were the most prolific (80.05%; N = 337/421 articles). There were no papers from low-income countries. Articles published
by high-income countries had a higher mean number of citations and a higher mean number
of citations per year than those published by middle-income countries ([Figures 3A] and [3B]). Conversely, there was no difference in the mean 5-year IF between income categories
([Figure 3C]). All of the ten most cited papers were published by authors from high-income countries.
Table 3
Articles, citations, citations per year, and 5-year destiny journal impact factor
analysis of publications mentioning the Emergency neurological life support (ENLS) research stratified by 15 countries with highest number of publications in
the field, by world region and by country income. N = 421
|
Variable
|
Articles (% of total)
|
Citations per article, mean
|
Citations per year per article*, mean
|
Destiny journal 5-year IF, mean
|
|
Country
|
USA
|
227 (53.92)
|
20.11
|
3.94
|
5.46
|
|
China
|
34 (8.08)
|
6.67
|
2.31
|
4.08
|
|
Italy
|
19 (4.51)
|
7.94
|
2.82
|
3.88
|
|
Canada
|
17 (4.04)
|
45.07
|
12.30
|
7.32
|
|
South Korea
|
13 (3.09)
|
11.62
|
3.69
|
3.56
|
|
India
|
12 (2.85)
|
3.16
|
1.65
|
2.39
|
|
Japan
|
12 (2.85)
|
6.41
|
1.66
|
4.04
|
|
Brazil
|
9 (2.14)
|
14.56
|
5.64
|
3.90
|
|
Germany
|
9 (2.14)
|
9.11
|
2.29
|
4.53
|
|
Switzerland
|
7 (1.66)
|
102.14
|
17.64
|
7.46
|
|
UK
|
7 (1.66)
|
19.57
|
6.51
|
3.73
|
|
Australia
|
5 (1.19)
|
2.40
|
0.29
|
3.89
|
|
Egypt
|
5 (1.19)
|
0.20
|
0.00
|
N/A
|
|
France
|
4 (0.95)
|
3.75
|
2.25
|
5.17
|
|
Poland
|
4 (0.95)
|
9.00
|
1.20
|
2.47
|
|
World region
|
East Asia & Pacific
|
69 (16.39)
|
6.89
|
2.24
|
3.95
|
|
Europe & Central Asia
|
67 (15.91)
|
20.00
|
4.84
|
4.39
|
|
Latin America & Caribbean
|
15 (3.56)
|
11.46
|
4.66
|
4.27
|
|
Middle East & North Africa
|
7 (1.66)
|
7.14
|
4.40
|
8.76
|
|
North America
|
244 (57.96)
|
21.52
|
4.53
|
5.59
|
|
South Asia
|
17 (4.04)
|
3.05
|
1.32
|
2.35
|
|
Sub-Saharan
|
2 (0.47)
|
4.50
|
0.90
|
2.80
|
|
Country income
|
High income
|
337 (80.05)
|
20.25
|
4.40
|
5.21
|
|
Upper middle income
|
56 (13.30)
|
7.55
|
2.95
|
4.11
|
|
Lower middle income
|
28 (6.65)
|
3.64
|
1.77
|
3.19
|
Abbreviations: ENLS, Emergency Neurological Life Support. IF, Impact Factor; N/A,
Not applicable.
Note: *Only citations up to 2021 were computed (N = 392 articles).
Figure 3 (A) Mean number of citations per article according to country income of articles
mentioning Emergency Neurological Life Support (ENLS). Only citations up to 2021 were computed (N = 392 articles). (B) Mean number of citations per year per article according to country
income of articles mentioning ENLS. Only citations up to 2021 were computed (N = 392 articles). (C) Mean 5-year destiny journal impact factor according to country
income of articles mentioning ENLS. Data in A and B utilize complete years up to 2021
for analysis; discrepancies in article counts may be due to additional reports retrieved
up to the search date in 2022.
Research type and subtype
The research types and subtypes of papers mentioning ENLS are detailed in [Table 4]. The most frequent research type was secondary research (57.48%; N = 242/421 articles), followed by primary research (30.64%; N = 129/421 articles). Among primary research articles, the research subtype with the
greatest number of articles was Observational (92.25%; N = 119/129). Among secondary research, in turn, the most common research subtype was
Narrative Review (71.90%; N = 174/242). Primary and secondary research were the study types of three and seven
articles, respectively, of the ten most cited. There were no trials or systematic
reviews from middle-income countries.
Table 4
Articles, citations, citations per article, and 5-year destiny journal impact factor
analysis of publications mentioning the Emergency neurological life suppor
t (ENLS) stratified by research type and subtype. N = 421
|
Research type/subtype
|
Articles (% of total)
|
Citations per article, mean
|
Citations per year per article*, mean
|
Destiny journal 5-year IF, mean
|
|
Animal/in vitro/simulations
|
16 (3.80)
|
1.83
|
6.37
|
3.84
|
|
Case report
|
17 (4.04)
|
0.57
|
0.47
|
1.36
|
|
Editorial
|
17 (4.04)
|
1.48
|
5.47
|
13.36
|
|
Primary
|
129 (30.64)
|
2.38
|
9.42
|
3.95
|
|
Interventional
|
10 (2.38)
|
2.13
|
8.80
|
4.00
|
|
Observational
|
119 (28.27)
|
2.40
|
9.47
|
3.94
|
|
Secondary
|
242 (57.48)
|
5.51
|
24.28
|
5.19
|
|
Guideline/consensus/recommendation
|
53 (12.59)
|
9.32
|
60.28
|
4.15
|
|
Narrative review
|
174 (41.33)
|
4.35
|
14.72
|
5.42
|
|
Systematic review
|
15 (3.56)
|
4.50
|
11.66
|
6.64
|
Abbreviations: ENLS, Emergency Neurological Life Support. IF, Impact Factor.
Note: *Only citations up to 2021 were computed (N = 392 articles).
ENLS occurrences and ENLS protocols
ENLS appeared more often in the References section, followed by the Text section ([Figure 4]). A total of 10.69% (N = 45/421 articles) were ENLS official publications. Of them, 41 were ENLS protocols
and 4 were descriptions of the ENLS or descriptions of its updates. The ENLS Protocols
were published by Neurocritical Care journal, receiving a mean number of citations of 13.13 (95% CI = 10.38–15.89; 25th
percentile: 6.50; 50th percentile: 9.00; 75th percentile: 19.00) and a mean number
of citations per year of 1.95 (95% CI = 1.53–2.37; 25th percentile: 0.93; 50th percentile:
1.60; 75th percentile: 2.73). Except for Pharmacotherapy - which had two published versions (2015 and 2017) -, all protocols had three published
versions (2012, 2015, and 2017). In the first two editions, there was a “Traumatic
Brain Injury” protocol. The third version, in turn, was named “Severe Traumatic Brain
Injury.” The protocol with the highest mean number of citations among all versions
was Intracranial Hypertension and Herniation (32.67 citations), followed by Intracerebral
Hemorrhage (22.33 citations) ([Table 5]). A total of 73.87% (N = 311/421) articles only mentioned ENLS in the References section. When excluding
ENLS official publications, only 65 articles (17.29%) mentioned ENLS in sections other
than references.
Figure 4 Section of appearance of Emergency Neurological Life Support in the included articles.
Table 5
Emergency neurological life support modules and their mean number of citations per article and mean number of citations
per year per article
|
ENLS module
|
Mean number of citations per article
|
Mean number of citations per year per article
|
|
Intracranial hypertension and herniation
|
32.67
|
4.61
|
|
2012
|
29
|
2.90
|
|
2015
|
50
|
7.14
|
|
2017
|
19
|
3.80
|
|
Intracerebral hemorrhage
|
22.33
|
3.11
|
|
2012
|
32
|
3.20
|
|
2015
|
15
|
2.14
|
|
2017
|
20
|
4.00
|
|
Airway, ventilation, and sedation
|
19.67
|
2.82
|
|
2012
|
26
|
2.60
|
|
2015
|
13
|
1.85
|
|
2017
|
20
|
4.00
|
|
Status epilepticus
|
18.67
|
2.82
|
|
2012
|
16
|
1.60
|
|
2015
|
20
|
2.85
|
|
2017
|
20
|
4.00
|
|
Traumatic brain injury*
|
16
|
2.38
|
|
2012
|
20
|
2.00
|
|
2015
|
8
|
1.14
|
|
2017
|
20
|
4.00
|
|
Traumatic spine injury
|
14.67
|
2.23
|
|
2012
|
16
|
1.60
|
|
2015
|
9
|
1.28
|
|
2017
|
19
|
3.80
|
|
Resuscitation following cardiac arrest
|
13.67
|
1.85
|
|
2012
|
18
|
1.80
|
|
2015
|
15
|
2.14
|
|
2017
|
8
|
1.60
|
|
Pharmacotherapy
|
12.00
|
1.97
|
|
2015
|
15
|
2.14
|
|
2017
|
9
|
1.80
|
|
General
|
9.25
|
2.00
|
|
2012
|
17
|
1.70
|
|
2015
|
7
|
1.00
|
|
2017
|
4
|
0.80
|
|
2020
|
9
|
4.50
|
|
Meningitis and encephalitis
|
8.67
|
1.25
|
|
2012
|
10
|
1.00
|
|
2015
|
8
|
1.14
|
|
2017
|
8
|
1.60
|
|
Subarachnoid hemorrhage
|
7.67
|
1.17
|
|
2012
|
7
|
0.70
|
|
2015
|
7
|
1.00
|
|
2017
|
9
|
1.80
|
|
Approach to the patient with coma
|
7.00
|
0.85
|
|
2012
|
13
|
1.30
|
|
2015
|
6
|
0.86
|
|
2017
|
2
|
0.40
|
|
Acute ischemic stroke
|
5.67
|
0.82
|
|
2012
|
6
|
0.60
|
|
2015
|
6
|
0.86
|
|
2017
|
5
|
1.00
|
|
Acute non-traumatic weakness
|
5.67
|
0.84
|
|
2012
|
6
|
0.60
|
|
2015
|
5
|
0.71
|
|
2017
|
6
|
1.20
|
|
Spinal cord compression
|
4.33
|
0.56
|
|
2012
|
8
|
0.80
|
|
2015
|
2
|
0.28
|
|
2017
|
3
|
0.60
|
Abbreviations: ENLS, emergency neurological life support.
DISCUSSION
In this bibliometric study, we considered that the number of publications mentioning
ENLS is low, with the majority of articles mentioning it only in the references section.
However, this repercussion is increasing, demonstrating a growing interest in this
subject ([Figure 1]). Articles were mainly published in journals of intensive care medicine, neurology,
neurosurgery, and emergency medicine. The majority of articles - including the most
prominent - were published by authors from high-income countries. The majority of
papers were secondary research, with narrative review as the most frequent subtype.
Neurocritical Care is the official journal of the Neurocritical Care Society, which is responsible for publishing ENLS protocols and other ENLS official publications.[1] Our study demonstrated that this was the journal with the greatest number of articles
mentioning ENLS ([Table 2]), even when not considering ENLS official publications. In addition, we did not
find a correlation between destiny journal 5-year IF and the number of publications
([Figure 2]). In fact, journals related to a specific field tend to have a lower IF than general
medicine journals.[16] It does not mean, however, that these journals are less important. Actually, very
specific journals - such as Neurocritical Care - attract more frequently the attention of a relatively small number of readers (i.e.,
subspecialists) in comparison with more general journals. Also, IF varies widely across
specialties, precluding generalized comparisons. For example, while the greatest IF
of a neurosurgical journal is 5.526, a total of 17 cardiology journals and 31 oncology
journals have an IF greater than 10 (data retrieved from https://jcr.clarivate.com/jcr/home).
In our study, high-income countries were the most prolific and the USA was the most
prominent country ([Table 3]). In addition, studies from high-income countries had a higher mean number of citations
per article and a higher mean number of citations per year per article than studies
from middle-income countries ([Figures 3A] and [3B]). Several prior bibliometric analyses of neurology and neurosurgery topics also
showed that the USA was, by far, the most prominent country.[9]
[10]
[12] The majority of papers mentioning ENLS were secondary research and a great portion
were narrative reviews, which have a shallow level of evidence. Among primary research
papers, we identified only 10 interventional - all of them from high-income countries
([Table 4]). Actually, conducting original research in neurocritical care is challenging, especially
interventional studies. It requires specialized training as well as specific resources
to provide high-quality care, which are often scarce in developing countries.[17]
[18]
The “first hour” of neurological emergencies is critical, since a fast workup may
significantly improve patients' outcomes. For instance, the recognition of ventilatory
distress in patients with acute non-traumatic weakness may lead to timely intubation.[19] Similarly, the detection of early signs of intracranial hypertension in a patient
with severe traumatic brain injury would possibly prevent brain herniation.[20] By recognizing the importance of this fast workup, health professionals and institutions
would probably increase their interest in ENLS certification and training. In the
current study, “Intracranial Hypertension and Herniation” ([Table 5]) was the ENLS module with the greatest impact. This is one of the most basic and
general modules, since various brain pathologies may lead ultimately to intracranial
hypertension and brain herniation.
Even with the overt importance of a proper systematic and concise approach for neurologic
emergencies, the demand for certification on ENLS is still limited when compared with
its analogs in trauma and advanced cardiovascular support (ATLS and ACLS, respectively).
This fact may find an explanation in the time of activity of each program. The ATLS
was introduced in 1980[3] and has now been taught to more than 1 million physicians in more than 80 countries
worldwide (data retrieved from facs.org/quality-programs/trauma/education/advanced-trauma-life-support/
in December 2022).[3] Likewise, the ACLS was presented in the middle 70s as the result of the second National
Conference held on cardiopulmonary resuscitation (CPR) and emergency cardiac care
(ECC) in 1973, which recommended delivery of advanced cardiac life support by trained
personnel be required of all life-support units and hospitals on an integrated, community-wide
basis and that training in CPR and techniques of ECC be under standards set by the
AHA.[21]
[22] Every year, the ACLS course is cumulatively accessed throughout the world by over
1.3 million candidates.[22] As ENLS consolidates over the following years in different localities, advocacy
efforts and community engagement seem to be the most promising way to foretaste acute
neurological care, as done by ATLS and ACLS.
The accessibility of ENLS protocols may indeed influence their adoption and utilization
in the scientific and medical communities. The protocols, devised by the Neurocritical
Care Society, are not widely and freely available but rather necessitate a purchase.
This financial barrier could potentially limit the dissemination and implementation
of ENLS, particularly in low- and middle-income countries or among individual practitioners
and smaller healthcare establishments with restricted budget allocations for accessing
scientific materials. It is plausible that this financial aspect could subsequently
influence the number of research articles discussing or utilizing ENLS, as the researchers
might prefer or be constrained to utilize freely accessible guidelines and protocols.
Thus, while ENLS provides a structured and standardized approach toward managing neurological
emergencies, its broader impact on clinical practices and research might be restrained
by its limited accessibility. Future initiatives or collaborations that facilitate
wider, cost-effective access to these protocols might enhance their reach and implementation
globally, fostering further research and potentially elevating patient care standards
in neurological emergencies.
In the authors' opinion, the repercussions of ENLS on scientific literature are still
low. The majority of papers only mentioned ENLS in the references section ([Figure 4]). When excluding ENLS official publications, only 65 articles mentioned ENLS in
the title, abstract, keywords, or text. The ENLS protocols are being updated constantly
and the number of certified professionals is increasing. However, only 34 institutions
in the USA and 9 in other countries require ENLS certification for some or all of
their students and/or care providers (data retrieved from https://enls.neurocriticalcare.org/about/enls-institutions in December 2022). In addition, live ENLS courses have been held in 35 countries
(data retrieved from https://enls.neurocriticalcare.org/about/statistics in December 2022). Therefore, there is still much to be done to ensure ENLS dissemination
and that more institutions recognize the importance of this certification.
Limitations
The present bibliometric study has some limitations. First, only one database (Elsevier's Scopus) was used. However, this is one of the most comprehensive databases that track citation
patterns, including over 71.2 million records post-1969 with reference.[23] The decision to utilize Scopus exclusively was also influenced by its comprehensive
inclusion of databases such as Medline and Embase, as well as its provision of reliable
citation count data, crucial for executing robust bibliometric analyses. It's noteworthy
that other databases like Lilacs and Scielo, while being significant, do not offer
citation count data, and Google Scholar, which encompasses a wide range of internet
references, was not chosen to ensure the impact assessment remained strictly within
the bounds of scientific literature. Second, we considered only the country and its
respective region and income category based on the corresponding author's affiliation.
These affiliations may differ from other authors who also contributed to the studies.
Third, recent articles did not have the same time exposure when compared with older
articles, certainly affecting the total number of citations. Therefore, we also analyzed
the number of citations per year per article, which helps to minimize these discrepancies.
Fourth, only English-language articles were included. Articles published in other
languages would possibly impact our findings. Fifth, we evaluated the repercussions
of ENLS only on the scientific literature.
In conclusion, we found that the ENLS repercussion on the scientific literature is
low, although increasing. The majority of papers that mentioned ENLS were secondary
research and were mainly published by authors from high-income countries. Most articles
only mentioned ENLS in the references section. Usually, the health professionals responsible
for the initial management of neurocritically ill patients are not specialists in
neurocritical care, who are frequently contacted after the first measures. Therefore,
not only neurocritical care specialists but also all professionals who are likely
to be exposed to scenarios of neurological emergencies should receive ENLS training.
To increase the ENLS repercussion and training, some measures might be useful. We
suggest making ENLS training a requirement for emergency department and intensive
care professionals; making ENLS available in several languages, and adding regional
particularities to the protocols with partnerships with local medical societies.
Bibliographical Record
Miguel Bertelli Ramos, Matheus Machado Rech, João Paulo Mota Telles, Willian Medeiros
Moraes, Manoel Jacobsen Teixeira, Eberval Gadelha Figueiredo. Repercussions of the
Emergency neurological life support on scientific literature: a bibliometric study. Arq Neuropsiquiatr 2024; 82: s00431777110.
DOI: 10.1055/s-0043-1777110
