Publications pattern of clinical epilepsy research in Saudi Arabia

Objective: To assess the progress in the field clinical epilepsy in Saudi Arabia, by analyzing in depth the research output productivity and publication pattern, and to identify the current situation of epilepsy research and offer solutions. Method: Literature search strategy was designed to retrieve accessible articles that are related to epilepsy utilizing PubMed, Google Scholar, and Embase. The retrieved articles were analyzed with several parameters, then evaluated using Oxford Center of Evidence Based Medicine level of evidence scale. Results: Of all identified articles, 90 were conducted in Kingdom of Saudi Arabia and therefore were included. The included articles had a frequency of only 3.5 publications per year, and growth of 24.4% between the periods of 1990-2003 and 2004-2016. Only 13.3% of the articles were related to surgical epilepsy but the majority (86.7%) were related to medical epilepsy. Many articles (53.3%) were level III studies. The most common study design was retrospective studies in 35.6%, and the citations number ranged from 1–289 (Mean=7). Conclusion: Pattern of publications in clinical epilepsy researches revealed a slow growth rate in the frequency and a lower significance in the quality throughout the past 26 years. Active institutional and national promotion of clinical research is needed to help assess and therefore improve the quality of the provided epilepsy services.

of the field of epilepsy, including both surgical and medical aspects, is essential for patients' wellbeing, and this can be monitored by assessing research output in the field and analyzing such production. Studies of publication patterns in epilepsy are lacking, there are only some scarce studies that addressed such an issue. 4 Our main objective is to evaluate the improvement of the field epilepsy in Saudi Arabia, by analyzing in depth the research output and publication pattern, and to analyze the current situation of epilepsy research and offer solutions.

Methods. Study design and search strategy.
This study was carried out between September -December 2016 at king Abdulaziz university hospital, Jeddah, Kingdom of Saudi Arabia. A search strategy was designed to retrieve all articles that are related to either medical or surgical epilepsy. Databases were accessed and the following phrases were utilized: "Search term" AND "Saudi Arabia". Time interval was restricted to 1/1/1990-31/12/2016. Each article was identified by abstract screening, then inclusion criteria was applied, followed by accessing the full-text to retrieved more data.
Inclusion/exclusion criteria. Articles in clinical epilepsy, published between January 1990 and December 2016 in English were included. Moreover, only publications with a first author affiliated with a Saudi institution, and a population studied residing in a Saudi institution were included. Also, to be included, the study should be conducted in part in Saudi Arabia. The published article should have a full text available and accessible for further analysis.
Publications published before January 1990, related to the basic neuroscience aspects of epilepsy, study population based in a geographical area outside Saudi Arabia, and articles with no available full text were excluded.
Information sources. Systemic search was carried out to retrieve each relevant article using both PubMed, Google Scholar, and Embase, by using search terms developed by the research team and related to both surgical and medical epilepsy (Table 1). Articles were reviewed by 2 independent reviewers, and graded using Oxford Centre for Evidence-Based Medicine -Levels of Evidence Scale. 5 Study selection process. After the review process, studies that are published in English, medical or surgical epilepsy related, published between January 1990 and December 2016, with the first author being affiliated with a Saudi institution, are included for final analysis.
Data items and data collection process. Several parameters were collected from each article such as journal name, impact factor, year of publication, the affiliation of the first author, city, study design, population, citation numbers, study title, database, and corresponding sector. Those parameters were collected in Microsoft Excel spreadsheet.   Results. Out of 2231 articles identified in our literature search, only 90 met the eligibility criteria of this study. The rest of screened studies were excluded due to the failure to meet the preset inclusion criteria (Figure 1) Forty-three )47.8%( of publications output was from Riyadh 43 )47.8%(, followed by Jeddah 26 )28.9%(, Al-Khobar 6 )6.7%(, Abha 3 )3.33%(, and the remainder of 12 )13.3%( from 9 different cities. (Table 3 Gupta et al 4 were the first to discuss epilepsy research output restricted to a certain geographical location, namely, India. In their methodology they only used  Considering the previously mentioned publications, our obtained results are inferior in terms of frequency being 90 articles in comparison to 1550 in India, and 702 in Iran, even though, we included a wide timeframe; 26 years. On the other hand, our obtained results were superior in terms of average citations number per publication being 14.8, in comparison to 2.77 in India, and 4.56 in Iran. Moreover, the most cited article included in our study received 289, unlike India, which received 217, and Iran, which received 109. Nevertheless, there was no mention of LOE in the previously mentioned studies.
In our opinion, retrieving article from only a single database would result in missing some articles, which in turn lead to giving a wrong estimate of the research output. Moreover, relying only on citation numbers as a sole quality indicator would not be sufficient, and has to be coupled with LOE to serve such a purpose.
When comparing the LOE of the obtained data of this current study, with other studies that dealt with the issue of quality of publications in neurosurgery, orthopedics, and plastic surgery, it has been found that unlike these studies, where all articles are of level IV, most of the articles in epilepsy represent level III. [7][8][9][10][11] Moreover, there was tendency in the field of epilepsy to publish retrospective studies, rather than case reports in the studies mentioned above. [7][8][9][10][11] Looking at the impact of Saudi epilepsy publications on international literature, it appears that impact is modest )citations numbers range 1-289(, and only one article by Panayiotopoulos et al, 12 which has citations number of 289, approaching but not reaching to be a citation classic. Citation classics are defined as the articles that get cited more than 400 times. 13 A point worth mentioning, Saudi authors tend to publish in Saudi journals, this might be attributed to the issue that the topic of papers would be of interest for physicians residing in Saudi Arabia rather than global community. These journals might have low IF or no IF at all, so the comparison of impact regarding Saudi epilepsy publications must be interpreted with caution.
The field of epilepsy surgery has started in Saudi Arabia in 1998. 14 Looking at epilepsy surgery publication in Saudi Arabia, we find that it constitutes a very low number being only 12 articles, including literature review articles, in 26 years. These articles are characterized to be produced from centers with advanced capabilities in epilepsy surgery such as King Faisal Specialist Hospital and Research Centre )KFSH&RC(. This clarifies many points such that epilepsy surgery in Saudi Arabia is still a new field, with the need of centers with advanced capabilities, and that there are only few epilepsy surgeons in the country.
Epilepsy research in Saudi Arabia faces 2 main problems, the issue of quantity of publications, and their quality. Moreover, Saudi Arabia has an established epilepsy society, which can be the solution to the previously mentioned problems as follow: )1( development of data registry unit that can aid researchers in producing high-quality studies, )2( helping the collaboration of different centers in different parts of the kingdom in conducting RCT, 13,14 )3( developing in collaboration with training centers to develop in-training research fellowships focusing on different aspects of epilepsy, 13,14 )4( finally, offering summer medical students epilepsy research programs, to build an interest in research and epilepsy in young aspiring students. 13,14 In regard epilepsy surgery, the problem is more fundamental involving many aspects; finical, logistic, ethical, and governmental, which is beyond the scope of this paper. Finally, only digital available data was included in this study. This study has limitations; firstly, the data of this current study did not include other basic sciences types of publications such as animal studies and lab bench studies, as it might of strong study design, good data collection, and solid recommendation that can affect both patient care and publication pattern, regardless of it being of level V-LOE in scales designed only for clinical articles. The factor of bias cannot be eliminated.
We conclude from this review that the publications' pattern of clinical epilepsy revealed a slow growth rate in the frequency of research with a lower significance in the quality throughout the past 26 years. The current growth of epilepsy centers in Saudi Arabia and posttraining epilepsy fellowship program should encourage and promote a larger scale and higher quality research. The active roles of leading institutions should embrace promotion of clinical research to help assess and therefore improve the quality of the provided epilepsy services.