Abstract

Background: Research is a central component of neurosurgical training and practice and is increasingly viewed as a quintessential indicator of academic productivity. In this study, we focus on identifying the current status and challenges of neurosurgical research in Iraq.

Methods: An online PubMed Medline database search was conducted to identify all articles published by Iraq-based neurosurgeons between 2003 and 2020. Information was extracted in relation to the following parameters: authors, year of publication, author’s affiliation, author’s specialty, article type, article citation, journal name, journal impact factor, and topic. This data were then tabulated and analyzed.

Results: Between 2003 and 2021, a total of 52 PubMed indexed papers were published from Iraq. All publications have been clustered in the period of 2012–2020. From 2012 to 2016, only four papers were published, one per year. The number of publications increased from 2017 to 2021, with an average of 12 publications per year. The most common article type was “case reports” (n = 14). Neurotrauma (n = 10) and vascular neurosurgery (n = 10) were the two most common topics. Most of the studies came from the city of Bagdad (n = 46), with just nine studies coming from peripheral governorates. The Neurosurgery Teaching Hospital in Bagdad was the neurosurgery center with the highest research output (n = 38).

Conclusion: The number of publications per year has been showing a, relatively, promising trend since 2012. However, to promote sustained growth in academic productivity, a strategic plan that acknowledges the political, financial, and health-system-related challenges are urgently needed.

Keywords: Iraq, Neurosurgery, PubMed, Research papers

INTRODUCTION

Clinical research is attracting growing attention worldwide, with a staggering number of studies continuously fuelling the literature. Each year, approximately 800,000 papers are added to PubMed, the comprehensive database of medical articles compiled by the US National Library of Medicine.[ 68 ] Neurosurgery is one of the fields that have witnessed substantial growth over the past few decades, with a proportionate rise in the number of landmark studies published each year.[ 60 ]

In Iraq, contemporary neurosurgery was founded in 1966. Over the past few decades, the population demands for neurosurgical care has increased enormously, in conjunction with the ongoing war and armed conflict in the region. This review was designed with the following questions in mind: (1) what is the current status of neurosurgery publications from Iraq? (2) What are the current trends? (3) What is the most common type of neurosurgical research conducted in Iraq (design and topic wise)? (4) Are there regional disparities in the output of neurosurgery research? (5) Are there differences in research productivity between neurosurgery centers around the country?

To the best of our knowledge, this is the first paper on this topic. Our purpose is not only to estimate the academic productivity of neurosurgeons in Iraq over the past two decades but also to underline the current challenges facing clinical research in general and neurosurgical research in particular in Iraq and to suggest potential solutions.

MATERIALS AND METHODS

An online PubMed Medline database search was conducted by the first and second authors of the paper using various combinations of the following keywords: “Neurosurgery” “Neurosurgeon” “Neurological surgery” “Iraq,” “Iraqi.” The search results were filtered to include only studies published between May 2003 and October 2021. Next, a PubMed search by author name was done for all neurosurgeons and neurosurgery residents practicing in Iraq, based on the registry data available from the Iraqi association of neurological surgeons, to retrieve further studies not covered by the search terms.

The inclusion criteria were (1) papers describing neurosurgery research (2) research conducted in Iraq-based neurosurgery services, and (2) papers with, at least, one of the coauthors being a neurosurgeon practicing in Iraq.

The exclusion criteria were (1) research conducted on non-Iraqi patients, and (2) commentaries, and news accounts. A search for the specialty and affiliation of all coauthors was then carried out to account for Iraq-based coauthors, including neurosurgeons, neurosurgery residents, and medical students [ Figure 1 ]. Information was extracted in relation to the following parameters: authors, year of publication, author’s affiliation, author’s specialty, type of article, article type, article citation, journal name, journal impact factor, and topic. This data were then tabulated and analyzed.

Figure 1:

The search methodology

RESULTS

Between 2003 and 2021, a total of 52 PubMed indexed papers were published from Iraq.[ 1 , 2 , 4 - 10 , 35 - 17 , 20 , 24 , 26 - 64 , 21 - 34 ] All publications have been clustered in the period of 2012–2021. From 2012 to 2016, only four papers were published, one per year. The number of publications increased from 2017 to 2021, with an average of seven papers per year.

The most common type of articles was “case report” (n = 14), followed by “letter-to-editor,” (n = 13), “prospective cohort” (n = 4), “case series” (n = 4), and “case-control studies” (n = 4). Only one randomized controlled trial has been published.

Neurotrauma (n = 10) and vascular neurosurgery (n = 10) were the two most common topics followed by general neurosurgery (n = 8), cranial/tumor (n = 6), and spine (n = 6). Four papers on neuroimaging and endoscopic neurosurgery were written, each with two publications. A paper was published on each of the following topics: functional neurosurgery, radiosurgery, stem cell research, and neurosurgery applications for gene therapy [ Table 1 ].

Table 1:

PubMed-indexed Neurosurgery papers published by Iraq-based neurosurgeons between 2003 and 2020.

The 40 papers were produced by a total of 30 authors, including three neurosurgery residents. The number of publications per author ranged between 1 and 21 (median = 1). Most of the studies came from the city of Bagdad (n = 46), with just nine studies coming from peripheral governorates. The Neurosurgery Teaching Hospital in Bagdad was the neurosurgery center with the highest research output (n = 38).

DISCUSSION

This review is the first to assess the academic productivity of neurosurgeons and neurosurgery residents in Iraq from 2003 to 2021. It focuses on neurosurgical research but also seeks to shed light on the disadvantaged place of clinical research in the country. PubMed was used to achieve the objective of this study. PubMed is a reputable, reliable database that is playing an important role in the current scholarly communication landscape.[ 68 ] The timeframe was set for the war in 2003 to the present as this represents a different era in terms of documentation, logistics, and health system set-up. The analysis found that only 30 out of a total of 200 neurosurgeons currently practicing in Iraq and three out of 100 neurosurgery residents had PubMed-indexed publications. Despite the absence of a standard minimum, this number is small, not only when compared with international research productivity but also when viewed in the context of a country that has been a war zone for decades and is, hence, a fertile ground for clinical research.[ 54 , 61 ] Participating in clinical research is one of the board certification requirements, and each resident has to have at least one original paper. However, such research rarely gets published. At present, no Iraqi neurosurgery journal exists and none of the local journals have been indexed in PubMed.

Of the published studies, neurotrauma was chosen more often than other topics, perhaps not surprisingly, given the frequency of neurotrauma cases in the country. The reporting of such cases is still strikingly scarce, however, especially when viewed in the context of a war-afflicted country. In Iraq, neurosurgical case volume and profile are different from those encountered in other “traditional” war zones. A series of injures that are foreign to most neurosurgeons is witnessed daily, including blast bombings and severe penetrating craniofacial injuries caused by unusual grenades such as tear gas canisters.[ 1 , 6 , 39 ] More attention needs to be paid to the reporting, collection, and documentation of these cases, as they have the potential to refine trauma management protocols nationally and globally. However, before this potential can be harnessed the challenges facing neurosurgical research need to be identified and addressed.

Importantly, this low status of clinical research is not unique to neurosurgery but is likely a universal problem across other specialty surgeries. Factors that are hindering neurosurgical research in Iraq are manifold: (i) poor health system infrastructure, (ii) human resource shortages, including insufficient cadre of research expertise, (iii) absence of comprehensive patient data recording systems, (iv) difficulties around outcome measurement and patient follow-up, (v) deficits in research funding, (vi) deprioritization of research, (vii) regulatory and bioethical considerations, (viii) lack of international research collaborations, (ix) inadequate opportunities for training and capacity building, (x) limited access to current evidence, and (xi) under-representation in editorial and decision-making process.[ 3 , 11 , 18 , 23 , 25 , 56 , 65 - 67 ]

The eroded health-care system infrastructure and inadequate human resources in hospitals are two of the main challenges facing clinical research in Iraq. Decades of war, sectorial violence, terrorism, and political instability have stretched our health-care system to its limits, leaving understaffed, cash-starved, and overcrowded hospitals in conducive to establishing any sustainable clinical research activity.[ 11 , 66 ] To address some of these challenges, health system recovery must be a top priority in the country’s infrastructure repair agenda. The solution to the human resource shortage is not a straightforward one. This shortage is primarily due to the steady exodus of well-trained doctors, which may serve as the proximal cause of the system’s collapse.[ 11 , 23 ] The key driver for this trend is the security threats to health workers who are being killed, abducted, or targeted, forcing them to flee the country to safer places.[ 65 ] In an attempt to antagonize this trend and rejuvenate the field of neurosurgery, a nation-wide mentorship program aimed at attracting medical students and junior doctors to neurosurgery was established in 2018 by the primary author of this article; the long-term impact of this program and similar initiatives is yet to be seen.

The lack of comprehensive patient information systems is further compounding the situation. Non-standardized, paper-based, and hand-written clinical notes are often inaccurate, mostly illegible, and difficult to trace as they may be located in various hospital departments, making them a hazard to patient safety and a dissuasive barrier to clinical research. As such, more systematic steps need to be undertaken to standardize data collection and computerize patient records taking into account the technical difficulties, time limitations, and specifications of the local health system.

Inadequate outcome measures and follow-up systems represent another hindrance to clinical research in the country. Factors contributing to this problem include understaffing, overload, lack of detailed handover documentation, incomprehensive discharge plans, and non-systemized task delegation. As such, outcomes such as infection rates, morbidity, and long-term mortality are difficult to ascertain. Addressing this problem calls for a multi-level action plan involving the participation of regulatory, administrative, and senior staff with a view to developing reliable patient follow-up systems.

Funding is another critical challenge facing clinical research. Iraq is, by definition, a resource-rich country.[ 3 , 25 ] However, the widespread corruption in the government system ensures that little, if any, of the national funds reach their designated targets.[ 3 , 25 ]As such, research funding has been deprioritized over the decades to further hinder any genuine research efforts. Much of the current research is being self-funded, with researchers resorting to research designs with minimal funding requirements. Our review shows that case reports and Letter-to-editor papers were collectively the most chosen research design, with only one randomized controlled trial and no systematic reviews. International partnerships and research collaborations may provide a temporary solution to this problem, besides their potential role in building research capacity, encouraging and facilitating research reporting, and providing adequate training opportunities.[ 58 ]

On the brighter side, efforts to revive the specialty are being made by our local neurosurgeons, harnessing available resources to “do more with less.” Many examples evidence this; in 2017, the country has witnessed the birth of the first neurosurgery book to be authored by an Iraq-based neurosurgeon, the primary author of this manuscript. The book has received international recognition, inspiring further successful attempts.[ 35 , 33 , 53 ] Another step forward is the establishment of the association of neurological surgeons in Iraq in 2013. Furthermore, as shown in this review, a previously unwitnessed involvement of junior doctors and medical students in neurosurgery research is being noticed.

Despite the multitude of challenges faced by neurosurgical research in Iraq, there is a definite, although sluggish, rate of progress, relative to the previous decade. Nonetheless, critical, multi-level, and restorative steps are required to promote and enable research reporting at an internationally-comparable rate.

Study limitations

Many articles not published in PubMed-indexed journals were not captured in this review. Likewise, theses, dissertations, and essays were not included. The use of PubMed as the primary search engine was justified by the fact that high levels of corruption in the country could lead to the publication of several papers in predatory, temporary-cited, or local journals. However, the study should serve as an initial guide to the current state of neurosurgical research in the country and encourage more action to invest in the field at the national and international levels.

CONCLUSION

The number of publications per year has been showing a, relatively, promising trend since 2012. However, to promote sustained growth in academic productivity, a strategic plan that acknowledges the political, financial, and health-system-related challenges are urgently called for.

Declaration of patient consent

Patient’s consent not required as patients identity is not disclosed or compromised.

Financial support and sponsorship

Publication of this article was made possible by the James I. and Carolyn R. Ausman Educational Foundation.

Conflicts of interest

There are no conflicts of interest.

References

1. Abdali HA, Hoz SS, Moscote-Salazar LR. Cranial gravitational (falling) bullet injuries: Point of view. J Neurosci Rural Pract. 2018. 9: 278-80

2. Aktham A, AbdulAzeez MM, Hoz SS. Surgical intervention of intracerebral hematoma caused by ruptured middle cerebral artery aneurysm in neurosurgery teaching hospital, Baghdad, Iraq. Neurol India. 2020. 68: 124-31

3. Akunjee M, Ali A. Healthcare under sanctions in Iraq: An elective experience. Med Confl Surviv. 2002. 18: 249-57

4. Al-Azzawi IS, Al-Tamimi MA. The first Iraqi experience in sacral neuromodulation for patients with lower urinary tract dysfunction. Arab J Urol. 2018. 16: 391-6

5. Al-Baldawi IA. Bi-nostril transseptal endoscopic approach to the sphenoidal gate. A new technique. Acta Neurochir (Wien). 2017. 159: 1247-52

6. Alhillo HT, Arnaout MM, Radhi HS, Al-Dhahir MA, MoscoteSalazar LR, Hoz SS. Direct head injury caused by a tear gas cartridge. Questions on safety: A case report from Iraq and review of the literature. J Clin Neurosci. 2018. 56: 179-82

7. Alhillo HT, Sadik HA, Gheni TN, Hoz SS. Rare occurrence of a huge traumatic extradural haematoma in a patient with an ipsilateral sylvian arachnoid cyst. BMJ Case Rep. 2018. 11: bcr2018227525

8. Aljuboori Z, Hoz S, Boakye M. Failure of C2-3 anterior arthrodesis for the treatment of atypical Hangman’s fractures: A three case series. Surg Neurol Int. 2020. 11: 52

9. Al-Khafaji A, Hoz S, Al-Awadi O, Al-Sharshahi Z. Alwitri: The father of modern neurosurgery in Iraq. Surgical Surg Neurology Neurol InternationalInt. 2021. 12: 66

10. Al-Khafaji AO, Al-Sharshahi ZF, Lee RP, Alsubaihawi ZA, Dolachee AA, Hoz SS. Unilateral absence of the internal carotid artery associated with anterior communicating artery aneurysms: Systematic review and a proposed management algorithm. Surg Neurol Int. 2020. 11: 221

11. Al-Khalisi N. The Iraqi medical brain drain: A cross-sectional study. Int J Health Serv. 2013. 43: 363-78

12. Al-Sharshahi Z, Al-Hemiery H, Albaqer H, Hamandi Y, AlAwadi O, Hoz S. Following the footprints of pioneers on neurosurgery in Iraq: Abdul Hadi Al-Khalili. Surgical Surg Neurology Neurol International. 2021. 12: 110

13. Al-Sharshahi ZF, Hoz SS, Alrawi MA, Sabah MA, Albanaa SA, Moscote-Salazar LR. The use of non-living animals as simulation models for cranial neurosurgical procedures: A literature review. Chin Neurosurg J. 2020. 6: 24

14. Al-Tameemi HN, Al-Essawi S, Shukri M, Naji FK. Using magnetic resonance myelography to improve interobserver agreement in the evaluation of lumbar spinal canal stenosis and root compression. Asian Spine J. 2017. 11: 198-203

15. Arkawazi BM, Faraj MK, Al-Attar Z, Hussien HA. Short term effectiveness of gamma knife radiosurgery in the management of brain arteriovenous malformation. Open Access Maced J Med Sci. 2019. 7: 3221-4

16. Arnaout MM, Hoz SS, Bessar AA, Agrawal A, AbdulAzeez MM, Moscote-Salazar LR. Extrusion of a peritoneal catheter of a ventriculoperitoneal shunt from the urethra. Neurology Neurol India. 2021. 69: 214-6

17. Baba-Rasul I, Ameen HM, Khazendar A, Hasan SO. A rare case of isolated lower segment transverse sacral fracture in a 12-year-old girl and its management by fixation with K-wire. World Neurosurg. 2017. 97: 758.e1-5

18. Burnham GM, Lafta R, Doocy S. Doctors leaving 12 tertiary hospitals in Iraq 2004-2007. Soc Sci Med. 2009. 69: 172-7

19. Darwazeh R, Wei M, Zhong J, Zhang Z, Lv F, Darwazeh M. Significant injury of the mammillothalamic tract without injury of the corticospinal tract after aneurysmal subarachnoid hemorrhage: A retrospective diffusion tensor imaging study. World Neurosurg. 2018. 114: e624-30

20. Dimitrov A, Dolachee AA, AbdulAzeez MM, Hoz SS, NarvaezRojas A, Satyarthee GD. Dos and don’ts of virtual reality-based simulators for cranial tumor surgery. Neurol India. 2018. 66: 1857-8

21. Dimitrov A, Dolachee AA, AbdulAzeez MM, Hoz SS, NarvaezRojas A, Satyarthee GD. Dos and don’ts don’ts of virtual reality-based simulators for cranial tumor surgery. Neurology India. 2018. 66: 1857-8

22. Dolachee AA, Hoz SS, Lafta GA. Primary intraosseous osteolytic meningioma without an evidence of soft tissue invasion. Clinical Clin Case Reports. 2021. 9: 845-7

23. Doocy S, Malik S, Burnham G. Experiences of Iraqi doctors in Jordan during conflict and factors associated with migration. Am J Disaster Med. 2010. 5: 41-7

24. Duarte-Valdivieso NC, Wong HF, Moscote-Salazar LR, Hoz SS, Calderon-Miranda WG, Lee A. Left persistent primitive trigeminal artery with a large wide-neck aneurysm presenting as opercular syndrome. Neurol India. 2019. 67: 315-6

25. Dyer O. Iraqi healthcare system still crippled five years after invasion, says report. BMJ. 2008. 336: 113

26. Essa ZM, Al-Hashimi AF, Nema IS. Dermatomal versus mixed somatosensory evoked potentials in the diagnosis of lumbosacral spinal canal stenosis. J Clin Neurophysiol. 2018. 35: 388-98

27. Fahad EM, Hashm ZM, Nema IM. Cervical spinal stenosis and risk of pulmonary dysfunction. Int J Crit Illn Inj Sci. 2020. 10: 16-9

28. Faraj MK, Hoz SS, Mohammad AJ. The use of three-dimensional anatomical patient-specific printed models in surgical clipping of intracranial aneurysm: A pilot study. Surg Neurol Int. 2020. 11: 381

29. Faraj MK, Sagban WJ. Endoscopic transsphenoidal approach to skull base lesions. A clinical prospective study. Neurosciences (Riyadh). 2018. 23: 35-8

30. Hamawandi SA, Sulaiman II, Al-Humairi AK. Microdecompression versus open laminectomy and posterior stabilization for multilevel lumbar spine stenosis: A randomized controlled trial. Pain Res Manag. 2019. 2019: 7214129

31. Hamawandi SA, Sulaiman , Al-Humairi AK. Open fenestration discectomy versus microscopic fenestration discectomy for lumbar disc herniation: A randomized controlled trial. BMC Musculoskelet DisordMusculoskeletal Disorders. 2020. 21: 384

32. Hammadi AA, Marino A, Farhan S. Clinical response of 277 patients with spinal cord injury to stem cell therapy in Iraq. Int J Stem Cells. 2012. 5: 76-8

33. Howard BM. Vascular neurosurgery: In multiple-choice questions. Neurosurgery. 2018. 82: E123-4

34. Hoz S, Aljuboori Z, Albanaa S, Al-Sharshahi Z, Alrawi M, Neamah A A. Ruptured giant aneurysm of a cortical middle cerebral artery: A case report. Surgical Surg Neurology Neurol International. 2021. 12: 95

35. Hoz S, Dolachee AA, Salih HR, Aljuboori ZS, Selbi WD, AlDayri G.editors. Pineal Neurosurgery. Berlin: Springer International Publishing; 2020. p.

36. Hoz S, Moscote-Salazar LR. Prevention of neurotrauma: An evolving matter. J Neurosci Rural Pract. 2017. 8: S141-3

37. Hoz SS, Aktham AA, Al-Sharshahi ZF, Esene IN, Mahoney D, Chaurasia B. The most recommended neuroanatomy resources for neurosurgeons: An international survey. Surg Neurol Int. 2021. 12: 11

38. Hoz SS, Aljuboori Z, Al-Sharshahi ZF, Salih HR, Alrawi MA. The four-handed technique in microsurgery, a useful addition to the vascular neurosurgeon armamentarium. Br J Neurosurg. 2021. 2021: 1-2

39. Hoz SS, Aljuboori ZS, Dolachee AA, Al-Sharshahi ZF, Alrawi MA, Al-Smaysim AM. Fatal penetrating head injuries caused by projectile tear-gas canisters. World Neurosurg. 2020. 138: e119-23

40. Hoz SS, Alkhaleeli AA, Aktham A. Prolonged survival after surgical resection of cerebral metastasis from melanoma with multisystemic metastasis already present: A case report and literature review. Sao Paulo Med J. 2018. 136: 372-5

41. Hoz SS, Alramadan AH, Hadi AQ, Salazar LR. Cisternostomy in neurosurgery: A new proposed general classification based on mechanism and indications of the cisternostomy proper. J Neurosci Rural Pract. 2018. 9: 650-2

42. Hoz SS, Al-Sharshahi ZF, Albanaa SA. Neurosurgery in Iraq at the time of Corona. Surg Neurol Int. 2020. 11: 103

43. Hoz SS, Al-Sharshahi ZF, Al-Juboori Z, Albanaa SA, Al-Awadi OM. The history and current status of neurosurgery in Iraq. World Neurosurg. 2020. 140: 353-6

44. Hoz SS, Al-Sharshahi ZF, Al-Khafaji AO. Head injuries caused by the ritual of Tatbir: A neurosurgical perspective. Br J Neurosurg. 2020. 2020: 1-2

45. Hoz SS, Al-Sharshahi ZF, Alrawi MA, Al-Dhahir MA. Traumatic acute extracranial cerebral herniation: How much do we know?. Surg Neurol Int. 2021. 12: 63

46. Hoz SS, Al-Sharshahi ZF, Dolachee AA, Al-Smaysim AM, Matti WE, Bydon A. Blast-induced traumatic brain injuries: Experience from the deadliest suicide double-car bomb attack in Iraq. World Neurosurg. 2020-2021. 145: e192-201

47. Hoz SS, Al-Sharshahi ZF, Dolachee AA, Chotai S, Salih H, Albanaa SA. Transposition of vessels for microvascular decompression of posterior fossa cranial nerves: Review of literature and intraoperative decision-making scheme. World Neurosurg. 2020. 145: 64-72

48. Hoz SS, Al-Sharshahi ZF, Dolachee AA, Matti WE.editors. Letter to the editor: “Beyond containment: Tracking the impact of coronavirus disease 2019 (COVID-19) on neurosurgery services in Iraq”. World Neurosurg. 2020. 143: 619-20

49. Hoz SS, Al-Sharshahi ZF.editors. Letter to the editor “neurosurgical subspecialty-tailored mentoring approaches: Current status and future demands”. World Neurosurg. 2020. 141: 564-5

50. Hoz SS, Baban K, Sabah M, Aktham A, Narvaez-Rojas AR, Moscote-Salazar LR. Delayed progressive intraparenchymal tension pneumocephalus after craniotomy for recurrent pituitary macroadenoma: A case report. Bull Emerg Trauma. 2018. 6: 174-7

51. Hoz SS, Dolachee AA, Abdali HA, Kasuya H. An enemy hides in the ceiling; pediatric traumatic brain injury caused by metallic ceiling fan: Case series and literature review. Br J Neurosurg. 2019. 33: 360-4

52. Hoz SS, Tamer WA, Al-Awadi OM, Al-Sharshahi ZF, Dolachee AA. Neurosurgery training in war-torn countries: A perspective from Iraq and Syria. Surg Neurol Int. 2020. 11: 430

53. Hoz SS.editors. Vascular Neurosurgery in Multiple Choice Questions. Switzerland: Springer; 2017. p.

54. Jamjoom AA, Wiggins AN, Loan JJ, Emelifeoneu J, Fouyas IP, Brennan PM. Academic productivity of neurosurgeons working in the United Kingdom: Insights from the H-index and its variants. World Neurosurg. 2016. 86: 287-93

55. Kadhim AHK, Neamah MJ, Nema IS. Cranial falling bullet injuries, a series of 30 cases in Iraq. Br J Neurosurg. 2020. 34: 135-41

56. Kapp C. Anarchy pushes Iraqi health system to brink of collapse. Lancet. 2003. 361: 1351

57. Khazendar A, Ameen HM, Jabbar NI, Hasan SO, Ahmed TS, Ali AA. Upper lumbar mature cystic teratoma: A case report. World Neurosurg. 2016. 96: 609.e7-11

58. Kot FC. The perceived benefits of international partnerships in Africa: A case study of two public Universities in Tanzania and the democratic republic of Congo. High Educ Policy. 2015. 29: 41-62

59. Lafta GA, Dolachee AA. Supratentorial intracerebral hemorrhage as a complication of infratentorial tumor removal: A case report. International Int Journal of Surgery Surg Case Reports. 2020. 75: 1-3

60. Ponce FA, Lozano AM. Highly cited works in neurosurgery. Part I: The 100 top-cited papers in neurosurgical journals. J Neurosurg. 2010. 112: 223-32

61. Sarkiss CA, Riley KJ, Hernandez CM, Oermann EK, Ladner TR, Bederson JB. Academic productivity of US neurosurgery residents as measured by H-index: Program ranking with correlation to faculty productivity. Neurosurgery. 2017. 80: 975-84

62. Satyarthee GD, Moscote-Salazar LR, Escobar-Hernandez N, Aquino-Matus J, Puac-Polanco PC, Hoz SS. A giant occipital encephalocele in neonate with spontaneous hemorrhage into the encephalocele sac: Surgical management. J Pediatr Neurosci. 2017. 12: 268-70

63. Shamran HA, Ghazi HF, Al-Salman A, Al-Juboory AA, Taub DD, Price RL. Single nucleotide polymorphisms in IL-10, IL-12p40, and IL-13 genes and susceptibility to Glioma. Int J Med Sci. 2015. 12: 790-6

64. Shamran HA, Hamza SJ, Yaseen NY, Al-Juboory AA, Taub DD, Price RL. Impact of single nucleotide polymorphism in IL-4, IL-4R genes and systemic concentration of IL-4 on the incidence of glioma in Iraqi patients. Int J Med Sci. 2014. 11: 1147-53

65. Webster P. Medical faculties decimated by violence in Iraq. CMAJ. 2009. 181: 576-8

66. Webster P. Reconstruction efforts in Iraq failing health care. Lancet. 2009. 373: 617-20

67. Webster PC. Iraq’s health system yet to heal from ravages of war. Lancet. 2011. 378: 863-6

68. Williamson PO, Minter CIJ. Exploring PubMed as a reliable resource for scholarly communications services. J Med Libr Assoc. 2019. 107: 16-29