Bibliometric Evaluation of Articles on Postoperative Delirium

Introduction

Postoperative delirium (POD), a standard complication in aged surgical sufferers, is characterised by acute and fluctuating change of psychological state with inadequate consciousness and a focus. POD can enhance the incidence of different postoperative problems, which prolongs hospital keep, will increase medical care prices, and impacts the prognosis.^1–3 A examine that included over 20000 aged sufferers from 30 hospitals indicated that the general incidence of POD was roughly 12%.⁴ Moreover, it was estimated that greater than 312 million sufferers worldwide underwent surgical procedure in 2012, with a dramatic enhance of 33.6% prior to now 8 years.⁵ The worldwide development of growing old is just not slowing down, with the proportion of the aged inhabitants estimated to achieve as much as 16% in 2050, which signifies that there will likely be extra aged sufferers present process surgical procedures.⁶ Though a lot effort has been dedicated to analysis on POD, there are not any particular preventive measures. Extra research are nonetheless wanted.

Bibliometric evaluation is a technique for evaluating tutorial output, analysis traits, and analysis influence and is broadly used within the analysis of scientific analysis efficiency in sure fields. Extremely cited articles can point out important alerts in regards to the analysis standing and traits in a sure area. Till now, there have been plentiful authentic investigations and secondary research specializing in the mechanisms, threat components, prediction, prevention, and remedy of POD. A bibliometric evaluation of POD was printed final yr, by which research from 2000–2020 had been included.⁷ Nonetheless, a lot of novel articles emerged after 2020, together with high research printed in JAMA, JAMA Surgical procedure, and the British Journal of Anesthesiology.^8–10 These research not solely present important steerage on apply but in addition deliver new hotspots within the POD area. In view of the necessary sensible significance of POD and inadequate measures, we qualitatively and quantitatively analyzed the 100 most steadily cited articles on POD. We hope to assist researchers acquire a greater understanding of the present state of affairs and traits of POD, and additional associated research sooner or later can do extra to the prevention of POD.

Strategies

Database and Retrieval Ways

Net of Science (WoS), a well-liked database for evaluating the output, high quality, and legal guidelines of scientific analysis growth, was chosen as the info supply. We used the components “postoperative delirium (Title), post-anesthesia delirium (Title), or post-surgery delirium (Title)” to go looking in WoS Core Assortment. The print quotation index database was not excluded. Information acquisition was performed on 7 November 2023.

Information Assortment and Evaluation

Contemplating that there could also be some traditional articles that had been printed a long time in the past, we didn’t limit the publication yr. Firstly, we sorted the searched articles by setting the quotation frequency in descending order. The primary 100 articles had been chosen for evaluation. Key gadgets corresponding to creator, article title, supply title (journal identify), publication yr, key phrases, establishment, nation/area, quotation occasions, 180-day utilization rely, and since 2013 utilization rely of the top-100 cited articles had been mechanically extracted. Secondly, gadgets corresponding to publication sort, proof degree of the articles, and the influence issue (IF) of the journals had been recognized and extracted by two investigators, respectively. Lastly, disagreements of the 2 investigators had been rechecked and resolved by dialogue and session.

The utilization rely, a parameter of the extent of curiosity in a selected merchandise on the WoS platform, displays the variety of occasions the article has met a consumer’s data calls for as demonstrated by clicking hyperlinks to the full-length article on the writer’s web site (through direct hyperlink or open-Url) or by saving the article to be used in a bibliographic administration instrument (through direct export or in a format to be imported later). Specifically, the utilization rely is just not the identical with quotation occasions. To some extent, it’s extra prone to symbolize the standard of articles and has been utilized in bibliographic analyses.¹¹ The utilization counts for the completely different variations of the identical merchandise on the WoS platform are unified. The utilization counts are up to date each day.

Publications had been firstly divided into authentic and secondary research by knowledge supply. The research had been then labeled by examine design, particularly randomized managed trial (RCT), cohort examine, case-control examine, cross-sectional examine, case report, and case collection, and so forth. To provide a extra intuitive cognition of proof degree, we lastly allotted the research right into a high-level group (at least grade 2 within the Oxford Centre for Proof-Primarily based Drugs (OCEBM)¹² system) and a low-level group.

For those who didn’t present key phrases, Key phrases Plus, a perform of WoS to optimize literature retrieval and enhance the accuracy and relevance, was used to replenish.¹³ Subsequently, the key phrases within the current examine had been really composed of creator key phrases and Key phrases Plus. Journal IF (model 2022) was acquired from the WoS.

Research Devices

VOSviewer, which was developed by Van Eck and Waltman, can be utilized to assemble and think about bibliometric maps.¹⁴ Within the current examine, VOSviewer (model 1.6.19) was used to attract diagrams for key phrases co-occurrence, creator co-operation, creator co-citation, and establishment cooperation. CiteSpace, a instrument developed by Chen, can produce figures to visually current the relationships between scientific literatures.¹⁵ CiteSpace (model 6.1. R6) software program was used to visualise theme burst. The particular parameters in CiteSpace had been set just like these utilized in a earlier examine.¹⁶ In addition to, Excel was used for the fundamental analyses.

Outcomes

In whole, 1890 articles on POD had been discovered within the WoS core database on 7 November 2023. The highest-100 cited ones are proven within the Supplementary Sheet 1.

Quotation Occasions and Publication Yr

The chosen articles had been printed between 1981 and 2022. As proven in Figure 1, with a lot of 11, 2011 was the most efficient yr for extremely cited articles. Citations ranged from 83 to 718 within the WoS Core Assortment. Nonetheless, the utilization of those articles was comparatively low with the best rely of 140 and the bottom rely of three since January 2013. The best utilization rely was 20 within the final 180 days. The above-mentioned data might be discovered within the Supplementary Sheet 1. We additionally displayed the ten most steadily cited articles in Table 1 and the ten most consistently used articles since January 2013 in Table 2 respectively.

Table 2 The 10 Most Frequently Used Articles Since January 2013

Figure 1 Distribution of the 100 articles by publication year.

Study Type

All the 100 articles were clinical related studies. There were 73 original studies and 27 secondary studies. As shown in Figure 2A, there have been 2 retrospective database evaluation research, 14 critiques, 18 randomized managed trials (RCTs), 1 pilot examine, 9 meta-analysis or systematic overview research, 4 tips, 42 cohort research, 3 case-control research, and seven case reviews or case collection research. Moreover, 73 research had high-level proof, whereas 27 research had low-level proof (Figure 2B).

Figure 2 Proportion of the study types. (A) proportions for different designed studies. (B) proportions for study with different evidence levels.

Country/Region and Institution

Information on the author, institution, and country of the articles was analyzed. The United States of America (USA) was the most productive country with 54 top-100 cited articles (Table 3). Germany ranked second (13), adopted by Canada (9), the UK (UK) (7), China (7), Denmark (6), and the Netherlands (6) (Table 3). The highest-10 establishments of publication counts are offered in Figure 3A. Harvard College, with 16 articles dedicated to the best contribution of the 100 publications. The second is the College of California with 14 publications, whereas Johns Hopkins College and Beth Israel Deaconess Medical Heart got here third with 9 publications. We additionally analyzed the co-authorship of organizations utilizing VOSviewer. Figure 3B reveals the community visualization of the organizations’ co-authorships. The 207 organizations shaped 52 clusters, and completely different colours symbolize completely different clusters, as proven in Figure 3B. Within the determine, nodes consult with organizations, circle colour refers to clustering, and hyperlink thickness refers to co-authorship power. For instance, Harvard College, Beth Israel Deaconess Medical Heart, Hebrew Rehabilitation Heart for Aged, Brown College, Mount Sinai Hospital, and Brigham and Ladies’s Hospital shaped blue clusters and had a robust co-authorship, whereas the College of California, Purdue College, and Duke College constructed the yellow cluster. The biggest cluster included 20 gadgets and the smallest cluster included 1 merchandise.

Table 3 The 10 Countries/Regions with Most Publications

Figure 3 The visualized analyses of institution. (A) the top-10 institution with publications. (B) organization cooperation network.

Author Analyses

The Top-11 authors was presented in the Table 4. Marcantonio Edward R printed 11 articles and ranked No. 1 by way of article quantity, adopted by Leung Jacqueline M (10) and Inouye Sharon Ok (9). The 11 authors all come from the USA. To higher replicate the contribution and affect of creator’s analysis, we additionally analyzed the co-citation of authors by VOS viewer and offered the community visualization in Figure 4. Inouye Sharon Ok had probably the most citations and strongest co-citation power. Marcantonio Edward R additionally had a robust interplay with different researchers.

Table 4 The Top-11 Authors by Publication Counts

Figure 4 Network visualization of author co-citation. Co-citation: The relatedness of items is determined based on the number of times they are cited together.

Journal, if and JCR Category Quartile

These articles came from 47 journals, top journals such as Lancet, New England Journal of Medicine, JAMA-Journal of the American Medical Association, and the British Medical Journal. The highest IF was 168.9, while the lowest was 1.018. The mean IF of these journals was 18.04. The JCR categories included: (1) Anaesthesiology, (2) Surgery, (3) Geriatrics & Gerontology, (4) Medicine, General & Internal, (5) Gerontology, (6) Psychiatry, (7) Critical care medicine, (8) Cardiac & Cardiovascular systems, (9) Respiratory system, (10) Clinical neurology, (11) Orthopedics, (12) Multidisciplinary sciences, (13) Psychology, (14) Peripheral vascular disease, and (15) Neurosciences. Except 1 journal did not have a location in JCR Category Quartile system, 30 journals were in the Q1 zone, 10 in Q2, 5 in Q3, and 1 in Q4. Besides, the top-10 journals on IF are shown in Table 5.

Table 5 Top-10 Journals on if

Keywords Analyses

Finally, we conducted a co-occurrence analysis of all keywords through VOSviewer to reveal the impacts and trends. The more frequently a keyword is used, the closer relationship will be between the two keywords in co-occurrence analysis. The minimum number of occurrences of a keyword was set as 3 and 84 keywords were screened out. The keywords formed six clusters and the network visualization of keywords co-occurrence is shown in Figure 5A. The key phrase with the best look (31) and hyperlink power (193) was “delirium” (Figure 5B). The highest-10 co-occurrence key phrases additionally included “risk-factors”, “surgical procedure”, “confusion evaluation technique”, “aged sufferers”, “hip fracture”, “intensive care unit”, “cardiac surgical procedure”, “common anesthesia”, and “threat” Figure 5B). With a view to higher perceive the traits in analysis matters over time, we used CiteSpace to investigate the key phrases burst. In Figure 6, 25 key phrases with the best burst power are proven within the first column. The key phrases with the longest quotation burst period are “open-heart surgical procedure” and “prognosis”. They had been broadly centered from 1992–2005. In the latest years, “double blind” and “cardiac surgical procedure” have change into booming analysis matters. It’s value noting that this was the second outbreak of the key phrases “cardiac surgical procedure”.

Figure 5 Information of keywords co-occurrence. (A) Keywords co-occurrence network. (B) Top-10 keywords of total link strength.

Figure 6 Top-25 keywords with the strongest citation bursts. Year, the year that a keyword was firstly cited; strength, the citation burst strength of keywords; begin and end, the duration of keywords burst.

Discussion

In the present study, we searched the articles on POD in the WoS database and selected the top-100 cited ones to do bibliometric analysis. We mainly analyzed the total citations, publication year, usage count, study type, author, institution, country/region, journal, and keywords.

The citation count of an article is regarded as a symbol of contribution to the scientific field. Analysis of the most frequently cited articles is able to help readers understand the research status, discover hotspots, and identify trends in a certain problem.¹⁷ The highest-1 cited article was printed in 2012 and entitled “Cognitive trajectories after postoperative delirium”,¹⁸ by which POD was decided to trigger cognitive incapacity after cardiac surgical procedure. This examine transferred a message that POD was not solely an acute complication, but in addition a threat issue for long-term damage. The highest-1 used article since 2013 was printed in 2017 and entitled “European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium”.¹⁹ This examine supplied highly effective recommendation on the prevention and remedy of POD, which is important to scientific apply. Analyses of publication yr indicated that the variety of high-quality research tended to be secure, however the proportion of articles from the final 5 years was solely 11%. Newly printed articles want time to be cited may be a purpose. Nonetheless, the utilization rely was comparatively low when put next with the quotation rely, which signifies that researchers nonetheless have to discover extra fascinating, vital, and meticulously designed research.

Via the analyses of nations and establishments, we discovered that the USA printed probably the most articles, cooperated with a number of top-10 international locations and would proceed to play a dominant function in researches on POD. The proportion of articles printed by the highest 10 international locations was greater than 90%. The international locations with higher contributions had been primarily concentrated in North America and Europe. The contribution of China can also be growing. Researches on POD from growing international locations have been broadly carried out. We counted the variety of articles printed by the authors and analyzed the co-citation of every creator. Inouye had probably the most citations and printed 3 articles with an IF above 100 among the many top-100 articles. In an article printed by Inouye and Maybrier on Lancet,²⁰ a multicenter worldwide randomized trial advised that intraoperative administration of a single subanesthetic dose of ketamine didn’t forestall delirium, however may trigger hurt by inducing unfavourable experiences.

All the top-100 cited articles on POD had been clinical-related research. The examine sort is decided by the examine design. The outcomes of our examine indicated that a big proportion of the 100 research had a excessive degree of proof, which is analogous to a earlier bibliometric evaluation of delirium.¹⁶ We did not classify the research by degree of proof that proposed by the OCEBM.¹² As a result of some research had been troublesome to allocate to a selected degree. For instance, a meta-analysis by Janssen et al²¹ included 31 RCTs and 4 before-and-after research. In accordance with the examine design of 4 before-and-after research, the before-and-after examine was primarily based on cohort research.^22–25 Nonetheless, meta-analysis of RCTs and cohort examine was not matched with grading standards. So, we allotted this examine into the high-level of proof group.

The co-occurrence evaluation of all key phrases might assist analyze growth traits and hotspots within the area. The focuses of POD researches had been threat components and kind of operation. It’s little question that preoperative evaluation of threat components might assist with stopping POD. Widespread threat components corresponding to tobacco publicity, the necessity for vascular surgical procedure, superior age, cognitive impairment, higher preoperative useful limitations, a historical past of preoperative delirium, coronary heart failure, whole hip arthroplasty, and morphine utilization had been extra prone to induce delirium after surgical procedure.^26–28 The components resulting in POD had been too advanced and will have a critical complication for the sufferers. Thus, researchers can discover the prevention of POD aiming at numerous threat components. Efforts of stopping POD have expanded by current investigation of novel pharmacological and non-pharmacological methods.²⁹ Non-pharmacological interventions embody behavioral interventions, monitoring gadgets, rehabilitation, environmental diversifications, psychological and social help, treatment reductions, complementary and different drugs, and system and course of adjustments.³⁰ As for pharmacologic remedy, dexmedetomidine has been accepted as a promising agent, not just for the prevention but in addition for the remedy of ICU-delirium.^31,32 Nonetheless, a RCT performed by Stacie et al³³ advised that intraoperative dexmedetomidine didn’t forestall POD. Future trials are warranted to refine the proof relating to the function of dexmedetomidine in stopping or treating delirium. In addition to, acetaminophen, ramelteon, gabapentin, statins, clonidine, and melatonin additionally present some promise as prophylactic brokers for POD.^34,35 Pharmacological remedy as an efficient prevention technique might change into a hotspot of POD analysis. The surgical procedure sort for POD investigation primarily centered on main coronary heart surgical procedures. The explanation could also be that cognitive impairment is widespread after a cardiac surgical procedure.¹⁸ With two bursts, cardiac surgical procedure might proceed to be a preferential mediator for POD researches. Nonetheless, non-cardiac surgical procedure, corresponding to hip fractures and colorectal surgical procedure, has change into a trending analysis matter.

As well as, we analyzed the IF, JCR, class and JCR class quartiles of the journals to replicate the extent of those articles, present the significance of POD, and assist researchers make a more sensible choice of submission. There have been 9 articles from 4 journals with an IF above 100. The newest one was printed within the JAMA -Journal of the American Medical Affiliation.⁸ On this scientific examine, intravertebral anesthesia with out sedation bought comparable incidence of POD to that of common anesthesia for aged sufferers who underwent hip fracture surgical procedure. Thus, POD may not be a consideration for the selection of the anesthesia technique. In addition to, greater than 80% of the journals had been situated within the Q1 and Q2 zone of the JCR class.

Limitations

There are some limitations value noting within the current examine. Firstly, the quotation and utilization rely of articles are up to date each day, some articles with low citations printed in the previous few years might change into extremely cited ones. Contemplating this issue, the bibliometric evaluation of articles on POD must be up to date sooner or later to establish the most recent traits. Secondly, we looked for articles within the WoS Core Assortment. Articles from different databases could also be omitted, which is inevitable in bibliometrics.

Conclusion

We performed the analyses of top-100 cited articles on POD from completely different views. On the premise of those analyses, we recognized the present orientation and hotspots of POD. Danger components and prevention of POD might proceed to be scorching analysis instructions. Double-blind scientific trials primarily based on cardiac surgical procedure should still be the mainstream of researches on POD. Furthermore, main orthopedic and belly surgical procedures are relevant candidates.

Dietary supplements

Supplementary Sheet 1, bibliometric traits of the 100 articles.

Information Sharing Assertion

The authors state that each one related knowledge are included on this article and supplementary file.

Acknowledgments

This paper has been uploaded to Analysis Sq. as a preprint: https://www.researchsquare.com/article/rs-3887909/v1.

Creator Contributions

All authors made a big contribution to the work reported, whether or not that’s within the conception, examine design, execution, acquisition of knowledge, evaluation, and interpretation, or in all these areas; took half in drafting, revising, or critically reviewing the article; gave last approval of the model to be printed; have agreed on the journal to which the article has been submitted; and comply with be accountable for all features of the work.

Funding

This work was supported by Main Program of Nationwide Pure Science Basis of China (No.82293640, No. 82293643).

Disclosure

The authors verify that they don’t have any conflicts of curiosity on this examine.

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