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Research trends related to emergence agitation in the post-anaesthesia care unit from 2001 to 2023: A bibliometric analysis

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Published/Copyright: September 2, 2024
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Open Medicine
From the journal Open Medicine Volume 19 Issue 1

Abstract

Background

Emergence agitation (EA) is a behavioural disturbance encountered during the recovery phase of patients following general anaesthesia. It is characterised by restlessness, involuntary limb movements, and drainage tube withdrawal and may significantly harm patients and medical staff. The mechanism of EA has not been fully understood and is still a challenging subject for researchers.

Methods

We extracted relevant publications published between 1 January 2001 and 31 December 2023 on the Web of Science Core Collection platform. VOSviewer software was utilised to analyse the retrieved literature and predict the development trends and hotspots in the field.

Results

The results show that the number of publications grew annually, with China contributing the most, followed by the United States and South Korea. The co-occurrence of keywords “children,” “propofol,” “risk factors” are current research hotspots. Owing to its self-limiting and short-duration characteristics, EA lacks standardised clinical time guidelines and objective assessment tools, which may be the focus of future research in this field.

Conclusions

Understanding the research hotspots and the latest progress in this field, this study will help to continuously improve the clinical understanding and management of EA, and help to timely identify environmental risk factors for EA in clinical practice.

Keywords: emergence agitation; VOSviewer; bibliometric analysis; Web of Science Core Collection; global trends

1 Introduction

Emergence agitation (EA) is an acute mental disorder that occurs during the period of recovery from general anaesthesia. It is characterised by the co-occurrence of excitement, agitation, and disorientation, accompanied by involuntary limb movement, crying or groaning, and other inappropriate behaviours [1]. At this time, patients are in the recovery stage of consciousness, muscle strength, and internal environment, and they lack self-awareness and protective reflexes. This can easily lead to self-removal of oxygen masks, tracheal catheters, infusion lines, catheters, and gastric tubes, and other adverse consequences, resulting in hypoxia, surgical incision dehiscence and bleeding, and other complications, affecting patients’ surgical recovery time and even be life-threatening [2]. Thus, the effective prevention and timely treatment of restlessness during recovery in patients under general anaesthesia has become a key quality indicator for resuscitation. Understanding the hotspots and new progress in this field is helpful in identifying and dealing with the potential risk factors of EA and helping patients under general anaesthesia recover better. Therefore, this study used the Web of Science Core Collection (WoSCC) platform to comprehensively analyse the research status of EA.

The WoSCC is recognised as the most reliable and influential database platform for obtaining global-level academic information [3]. It can conduct multi-angle and visual panoramic analyses of search results and summarise the development trends of related research fields, subject distribution, and relevant journal contributions. Through a multi-angle and comprehensive in-depth analysis, the developmental trend and current situation of the discipline can be revealed at the macro-level [4].

Bibliometrics is a discipline that studies the distribution, structure, and relationship of literature and information using quantitative analysis methods such as mathematics and statistics. It then discusses and evaluates the trends and rules of research development [5]. The results of bibliometric analysis have been applied in multiple medical fields, such as oncology, orthopaedics, nursing, and basic medicine [6–9]. However, bibliometric studies on EA are lacking. Therefore, this study aimed to conduct a systematic analysis of EA research to identify research trends and hotspots in this field and highlight new directions for future research.

2 Methods

2.1 Study search and selection

All studies related to EA from 1 January 2001 to 31 December 2023 were extracted from the WoSCC (including Science Citation Index Expanded, Social Sciences Citation Index, and Conference Proceedings Citation Index-Science). The constructed retrieval formula is as follows: TS = (agitation OR delirium) AND TS = (emergence) AND DOP = (2001-01-01/2023-12-31) AND LA = (English). “Tab-delimited files” for document export and ‘full records and cited references’ for record content were selected. A total of 1,241 records conforming to the standards were imported into VOSviewer, along with the publication information, literature sources, cooperation information, keywords, and other literature content. A flowchart of the literature selection process is shown in Figure 1.

Figure 1 Literature screening flow chart.
Figure 1

Literature screening flow chart.

2.2 Bibliometric analysis

VOSviewer version 1.6.19 (Centre for Science and Technology Studies, Leiden University; based on JAVA) is a bibliometric analysis software that creates web-based maps and provides visualisations (network, coverage, and density visualisations) of maps and exploration maps to help researchers evaluate literature research directions and hotspots [10]. VOSviewer draws a clustering graph based on the literature co-citation principle, where each colour represents a subtopic, and each node represents a literature. The larger the node, the more cited the literature; the closer the node examples, the closer the relationship between the literature; and the thicker the line, the more co-cited the two literatures. Keyword co-occurrence clustering maps are used to show the degree of correlation between research topics. The author collaboration network map can identify representative authors and research teams in a research field.

3 Results

3.1 Global publication trend

As shown in Figure 2, the number of publications in the EA field is generally increasing, and researchers’ interest in the field continues to grow. From seven articles in 2001 to 138 in 2023, the number of publications increased by approximately 20 times in 23 years. During 2019–2022, the growth rate of the cited frequency was higher than that of the number of publications. The 1,241 literature that met the requirements were cited 29,308 times, with an average of 23.62 times; the total h-index was 77.

Figure 2 Times cited and publications over time.
Figure 2

Times cited and publications over time.

3.2 Analysis of distribution of co-authors and institutions

Between 2001 and 2023, approximately 1,532 institutions from 66 different countries/regions produced literature on EA. The analysis was of co-authorship; the minimum required number of documents by an author was three, and the minimum number of publications by an institution was five. Out of the 5,900 authors analysed, 154 met the threshold, and of the 1,532 institutions, 96 met the threshold. Hee-soo Kim of the Department of Anesthesia and Pain Medicine at the Seoul National University Hospital published the most papers (11 articles), followed by Ji-Hyun Lee from the same hospital (9 articles). The authors with the most publications are shown in Table 1. The top ten universities in terms of the number of published papers are shown in Table 2, among which the top three are Yonsei University (31 articles), Sichuan University (23 articles), and Seoul National University (21 articles). Figure 3 shows that there is less cooperation among scholars; cooperation among authors is limited to internal members, and no real academic community has been formed. According to Figure 4, there is a certain degree of cooperation among the major issuing institutions but without a central trend.

Table 1

Top ten authors in terms of publication

Author Documents Citations Total link strength
Kim, Hee-soo 11 117 28
Lee, Ji-hyun 9 85 27
Kim, Jin-tae 8 76 26
Mihara, Takahiro 8 68 22
Garcia, Paul S. 7 65 9
Goto, Takahisa 7 68 21
Kreuzer, Matthias 7 58 14
Mckay, Adam 7 77 10
Ponsford, Jennie 7 155 10
Yao, Yusheng 7 121 3
Table 2

Top ten organisations in terms of publication

Organisations Documents Citations Total link strength
Yonsei Univ 31 735 9
Sichuan Univ 23 160 4
Seoul Natl Univ 21 371 8
Shanghai Jiao Tong Univ 21 107 13
Harvard Med Sch 18 445 17
Capital Med Univ 17 104 5
Korea Univ 15 220 8
Zhejiang Univ 14 165 6
Chongqing Med Univ 13 88 6
Sun Yat Sen Univ 13 105 3
Figure 3 Analysis of co-author distribution.
Figure 3

Analysis of co-author distribution.

Figure 4 Analysis of the organisation’s distribution of co-authors.
Figure 4

Analysis of the organisation’s distribution of co-authors.

3.3 Analysis of country distribution

To some extent, the number of EA publications in different countries reflects the research situation in this field. When the minimum number of publications by a country was set to a default of five, 34 countries met the threshold. In Figure 5, each node represents a country, and the size of the node represents the number of published papers in this country. China had the largest number of nodes, with 340 published papers, accounting for 27.4% of the total number. This was followed by the US with 303 publications and South Korea with 117. The number of publications in other countries is listed in Table 3. Figure 5 shows that the United States and China cooperated closely, followed by the United States and Canada. There were 151 connections between 66 countries, with a total link strength of 338, among which connections between European and American countries were the most frequent.

Figure 5 Analysis of country distribution.
Figure 5

Analysis of country distribution.

Table 3

Top ten countries in terms of publication

Country Documents Citations Total link strength Percentage
Peoples R China 340 2,989 33 27.4
USA 303 11,847 97 21.32
South Korea 117 2,053 10 9.43
Turkey 59 1,347 6 5.36
Canada 56 2,086 56 4.75
Germany 56 1,673 55 4.75
Australia 55 1,327 47 4.43
England 47 1,212 61 3.79
Japan 41 794 6 3.3
France 36 1,092 19 2.9

3.4 Analysis of journals

Over the past 23 years, 429 journals have published articles on EA. Table 4 lists the ten journals with the highest number of published articles, along with their impact factor (IF), Quartile in category (2022). The top five journals are Pediatric Anesthesia, Anesthesia and Analgesia, BMC Anesthesiology, European Journal of Anesthesiology, and British Journal of Anaesthesia. Among the top ten journals in terms of the number of publications, the highest IF was for the British Journal of Anaesthesia, followed by the Journal of Clinical Anesthesia, Anesthesia and Analgesia. The IF scores of the above three journals were all greater than 5, and they were all rated Q1 in the Journal Citation Reports classification for 2022.

Table 4

Top ten journals in terms of publication

Journal title Documents Citations IF (2022) Quartile in category (2022)
Pediatric Anesthesia 105 3,160 1.7 Q4
Anesthesia and Analgesia 44 2,970 5.9 Q1
BMC Anesthesiology 43 399 2.2 Q3
European Journal of Anaesthesiology 33 594 3.6 Q2
British Journal of Anaesthesia 32 2,202 9.8 Q1
Acta Anaesthesiologica Scandinavica 31 878 2.1 Q4
Journal of Clinical Anesthesia 27 418 6.7 Q1
Journal of Perianesthesia Nursing 25 177 1.7 Q3
Medicine 24 209 1.6 Q3
Journal of Anesthesia 22 562 2.8 Q3

3.5 Analysis of keywords

In bibliometrics, the analysis of keywords is critical because it serves as the core of the article and is more representative in the presentation of domain analysis due to its more condensed information [11]. VOSviewer was used to extract and create statistics on the keywords in the included literature. The minimum number of keyword occurrences was set as five by default. A total of 3,931 keywords were found, and 361 met the threshold; the top 30 high-frequency keywords are listed in Table 5. The size of each node represents the weight of the keyword, and the distance between the two nodes represents the connection between the two keywords; the closer the connection, the shorter the distance. The colour of the node represents the respective clustering. The cluster size was adjusted to 25, and four clusters were generated, as shown in Figure 6. Keyword overlay visualisation takes the score values for the average year of the keyword and colour-maps them to examine emerging themes within the research domain and the temporal evolution of the research direction. The closer the node is to yellow, the more novel the theme is, as shown in Figure 7. Density visualisation was used to examine the density of studies within the domain. The larger (smaller) the number of neighbouring items and the higher (lower) their weights, the closer the colour of the point is to yellow (blue), as shown in Figure 8.

Table 5

Frequency of keywords

Rank Keywords Frequency of occurrence Total linkage strength
1 Children 369 3,264
2 Emergence agitation 358 3,184
3 Delirium 284 2,470
4 Propofol 280 2,599
5 Anaesthesia 261 2,190
6 Emergence delirium 256 2,068
7 Surgery 235 2,130
8 Sevoflurane 234 2,259
9 Dexmedetomidine 223 2,085
10 Agitation 215 1,894
11 Sevoflurane anaesthesia 197 1,903
12 General-anaesthesia 187 1,698
13 Recovery 157 1,358
14 Prevention 141 1,363
15 Paediatric-patients 135 1,403
16 Halothane 128 1,283
17 Midazolam 127 1,282
18 Pain 127 1,101
19 Risk factors 120 984
20 Sedation 106 893
21 Desflurane 105 1,052
22 Preoperative anxiety 102 940
23 Ketamine 95 838
24 Double-blind 92 776
25 Emergence 91 680
26 Induction 89 824
27 Fentanyl 87 887
28 Postoperative delirium 84 661
29 Paediatric anaesthesia 82 707
30 Premedication 82 861
Figure 6 Frequency analysis of keyword occurrence.
Figure 6

Frequency analysis of keyword occurrence.

Figure 7 Analysis of changes in keywords by year.
Figure 7

Analysis of changes in keywords by year.

Figure 8 Analysis of keyword hotspot.
Figure 8

Analysis of keyword hotspot.

4 Discussion

This study applied the bibliometric analysis method of VOSviewer to analyse the annual publication amount, journal distribution, publication institution and country distribution, high-frequency keyword analysis, keyword contribution clustering, timeline, and density visualisation analysis and comprehensively sorted out the EA-related research results. This will help readers understand the research status, trends, and hotspots in this field.

The number of publications in the field of EA has increased annually over the past 5 years, indicating that the development of EA-related research is rapid and that the field of EA has received increasing attention from researchers. The bibliometric analysis of journals not only reflects the academic influence of journals in the research field but also helps researchers select their contributions. Furthermore, the IF is a general international index for the overall evaluation of journals. It is not only an indicator of the usefulness and degree of the journals, but it is also a crucial indicator of the academic level of journals and the quality of papers. Therefore, our bibliometric analysis and examination of the IF highlight the validity of the current research on EA. Notably, Pediatric Anesthesia, with relatively low influence, was the journal with the largest number of publications. This suggests that research on children’s EA requires more attention.

EA is inappropriate behaviour in the anaesthesia recovery period, manifested as excitement, agitation, and disorientation; inappropriate behaviour, such as involuntary limb movements, irrational speech, crying or moaning, delusional thinking, and so on; serious cases can cause harm to the patient and related nursing staff; and patients can remove the mask and pull out the catheter, resulting in hypoxia, wound opening, bleeding, and other serious consequences. Although the mechanisms through which EA occurs are unclear [12,13], several factors are associated with postoperative agitation. Recent studies suggest that postoperative pain and the pharmacokinetics and pharmacodynamics of anaesthetics are related to EA. Lim et al. [14] found that sevoflurane may induce hyperexcitatory behaviour after anaesthesia by enhancing the depolarisation or excitation effect of some 1-aminobutyric acid neurons in the neocortex of the brain. Based on animal model studies, neuroinflammation and neurotransmitters may be one of the pathophysiological mechanisms of EA, which requires more evidence from human studies [15–17]. Furthermore, previous studies and clinical reviews found that the occurrence of EA may be related to multiple risk factors, such as age, sex, type of surgery, method of anaesthesia, use of anaesthetic drugs, preoperative mental state, and preoperative drug use [2,18,19]. The prevention, timely identification, and control of EA are key, and the combination of prevention and control can minimise the incidence of EA.

As shown in Figure 7, the risk factors leading to EA have been the focus of research in recent years. Among adult patients, the incidence of EA is higher in men than in women, and EA is more common in children than in adults [2,18]. Different types of surgery, due to differences in surgical sites, often need intraoperative indwelling drainage tubes or indwelling gauze haemostasis. Therefore, patients often feel pain, which influences the occurrence of EA. Voepel-Lewis et al. [20], in a prospective cohort study of 521 children aged 3–7 years who underwent general anaesthesia for outpatient surgery, found that ophthalmological and otorhinolaryngological procedures were associated with EA. Among these, otorhinolaryngological procedures have been shown to be an independent risk factor for EA. Figure 6 shows that the keywords “adenotonsillectomy,” “adenoidectomy,” “tonsillectomy,” and “surgery” have high frequencies of occurrence, indicating that they are the current research hotspots. In addition, different surgical methods of the same type of surgery may affect the occurrence of EA [21]. There are studies [19,22] retrospectively compared the risk of EA in patients undergoing open gastrectomy (OG) with those undergoing laparoscopic gastrectomy and found that the higher incidence of EA in patients with OG may be related to diaphragmatic motor dysfunction caused by postoperative incision.

Ramroop et al. [23] showed that compared to elective surgery, the higher incidence of EA after emergency surgery is related to inadequate preoperative preparation and uncorrected internal environment disorders in patients undergoing emergency surgery. The use of narcotic drugs is an important risk factor for EA. Keywords such as “dexmedetomidine,” “sevoflurane anaesthesia,” “halothane,” “desflurane,” “sufentanil,” “propofol,” “sevoflurane,” “intraoperative dexmedetomidine,” and “fentanyl” have the highest frequency, indicating that these are the current research hotspots. Inhaled anaesthetics are widely used, especially for paediatric patients, because of their rapid-acting and counteracting advantages. However, the use of volatile anaesthetics increases the risk of EA compared to total intravenous anaesthesia (TIVA) [24,25]. The solubility of different drugs in the blood can affect the incidence of EA. A randomised, double-blind study of 144 adult patients undergoing orthodontic surgery noted a lower incidence of EA with desflurane than with sevoflurane anaesthesia [26]. Some studies have shown that the incidence of EA in children under desflurane anaesthesia is higher than that of those under sevoflurane anaesthesia, and children under desflurane anaesthesia can wake up faster, which may be caused by different subjects, different types of surgery, and different rating scales used. Hence, the conclusions are inconsistent, and relevant research conclusions need to be further verified [27,28]. Inadequate analgesia is an essential factor in EA, and the effective use of opioids suggests that pain is associated with postoperative agitation [29]. A prospective, randomised, double-blind, multicentre study of the incidence of EA after adenoidectomy and tonsillectomy in children under general anaesthesia found that nalbuphine reduced the incidence of EA by reducing postoperative pain [12]. Although postoperative pain is a key trigger of EA, painless surgery can also cause it. Dalens et al. [30] demonstrated that children under sevoflurane anaesthesia may develop EA during an MRI examination; therefore, the mechanism of pain and EA requires further examination.

The occurrence of EA is related to multiple factors, and the timely identification of risk factors and timely diagnosis will help to better prevent and deal with this phenomenon. Currently, EA does not have globally uniform diagnostic criteria, and the scoring scales used by children and adults are different. Paediatric anaesthesiologists generally agree that the psychologically-tested Pediatric Anesthesia Emergence Delirium (PAED) scale developed in 2004 is the most effective and reliable one [31,32], and it can be used for children over 2 years of age [33]. The scale includes five items on consciousness and cognition, psychomotor behaviour, and emotional change, and the scores for each item are added together to obtain the PAED score. The higher the score, the heavier the EA degree [33]. However, the shortcomings of the PAED score are that it is too subjective, there are differences between evaluators, and some behaviours in the evaluation indicators overlap with other postoperative negative behaviours. There is controversy about the threshold value of the PAED score criteria [32–34]. The main tools used to evaluate EA in adults include the Richmond agitation sedation scale and sedation-agitation scale, both of which are subjective rating scales to evaluate the depth of sedation in ICU patients [35,36]. The reliability of the scale is high, but the reliability of the diagnosis of EA in convalescent patients under general anaesthesia is unknown. The subjective sedation assessment scale commonly used in clinical practice is simple and fast but has some problems; therefore, it is necessary to introduce objective assessment tools, such as the bispectral index and quantitative electroencephalogram, to assist in the diagnosis of EA and improve its diagnostic accuracy [18,37,38]. Therefore, the timely detection of patients with EA and effective interventions are needed.

Understanding the pathogenesis and mechanisms of EA and its active prevention and treatment are of great significance for patient safety and surgical success. Pharmacological and non-pharmacological methods are the directions of our efforts, and studies have demonstrated that TIVA is more appropriate than inhalational anaesthesia for high-risk EA [39]. However, further rigorous prospective research comparing the effects of balanced anaesthesia and TIVA on EA is required [40]. The use of propofol throughout anaesthesia may mitigate EA in paediatric patients undergoing general anaesthesia; however, further investigation is warranted to determine its efficacy in adult populations [18,41].

“Fentanyl” was a keyword with a high frequency of occurrence. A meta-analysis of randomised controlled trials found that prophylactic fentanyl administration reduced the incidence of EA after sevoflurane anaesthesia [42]. Furthermore, dexmedetomidine is a highly selective α2-adrenoreceptor agonist with sympathetic, inhibitory, analgesic, and sedative effects [43]. A randomised controlled study involving 100 adult patients undergoing nasal surgery demonstrated that the intraoperative infusion of dexmedetomidine maintained stable haemodynamics and reduced the incidence of EA without delaying extubation [44]. Non-pharmacological methods, such as informing patients of predictable postoperative pain or discomfort, removing the indwelling catheter as soon as possible, and the presence of parents during anaesthesia induction and resuscitation, can reduce the incidence of EA [18,45,46].

EA is a common pathological state after general anaesthesia. The pathogenesis and diagnostic criteria of EA in adults have not yet been clarified. Whether the changes in brain electrical activity and brain metabolism are potential mechanisms needs clinical verification and further research. At present, there are many subjective evaluation scales for sedation of patients, which are simple and quick to use, but they are not widely used in EA patients, and lack of reliability and validity verification of clinical data. In the future, the subjective scale assessment combined with objective sedation monitoring methods can be widely studied in clinical practice to guide the treatment of EA.

5 Conclusion

This study used bibliometric methods to analyse the characteristics and evolution of international research in the past 22 years and summarises the global research trends and hotspots of EA, and provide important references for researchers in this field to understand the advantageous clusters and new research directions in this field. China, with the largest number of articles (340), made the largest contribution. The most authoritative findings are available in the British Journal of Anaesthesia and the Journal of Clinical Anesthesia. Hee-soo Kim and Ji-hyun Lee published the most papers in this field, with a focus on EA in children, halothane, adenotonsillectomy for timely identification of risk factors, and management of EA high-risk patients (application of drug and non-drug strategy). The diagnostic criteria for EA in adults are not yet clear and more reliable, and effective objective monitoring indicators need to be explored to predict and prevent EA. The primary limitation of this study is that only the literature of the WoSCC database was retrieved to ensure the standardisation of data, and this data lacked certain integrity. Second, with English literature as the data source and non-English literature excluded, the research results are not comprehensive.

# These authors have contributed equally to this work.

Acknowledgements

The authors appreciate the support provided by Dr Shi Mingsong for the writing assistance and proofreading the article.

  1. Funding information: This study was supported by the Health Commission of Sichuan Province, China, under Grant No. 20PJ260.

  2. Author contributions: Conceptualisation: L.L.C.; methodology: L.L.C., Y.H.R., and H.H.; software: L.L.C. and F.W.; validation: J.D. and F.W.; formal analysis: L.L.C. and Y.H.R.; investigation: L.L.C., Y.H.R., M.H., and H.P.H.; resources: M.H., H.P.H., F.W., and Y.H.R.; data collection: L.L.C. and Y.H.R.; writing – original draft preparation: L.L.C.; writing – review and editing: L.L.C., Y.H.R., M.H., and H.P.H.; visualisation: F.W., J.D., H.P.H., and L.L.C.; supervision: M.H. and H.P.H.; project administration: M.H. and H.P.H.; and funding acquisition: H.P.H. All the authors have read and agreed to the published version of this manuscript.

  3. Conflict of interest: The authors declare no conflicts of interest.

  4. Data availability statement: The data could be obtained from the corresponding authors.

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Received: 2024-04-08
Revised: 2024-07-31
Accepted: 2024-07-31
Published Online: 2024-09-02

© 2024 the author(s), published by De Gruyter

This work is licensed under the Creative Commons Attribution 4.0 International License.

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https://doi.org/10.1515/med-2024-1021
Keywords for this article
emergence agitation; VOSviewer; bibliometric analysis; Web of Science Core Collection; global trends
Creative Commons
BY 4.0

Articles in the same Issue

  1. Research Articles
  2. EDNRB inhibits the growth and migration of prostate cancer cells by activating the cGMP-PKG pathway
  3. STK11 (LKB1) mutation suppresses ferroptosis in lung adenocarcinoma by facilitating monounsaturated fatty acid synthesis
  4. Association of SOX6 gene polymorphisms with Kashin-Beck disease risk in the Chinese Han population
  5. The pyroptosis-related signature predicts prognosis and influences the tumor immune microenvironment in dedifferentiated liposarcoma
  6. METTL3 attenuates ferroptosis sensitivity in lung cancer via modulating TFRC
  7. Identification and validation of molecular subtypes and prognostic signature for stage I and stage II gastric cancer based on neutrophil extracellular traps
  8. Novel lumbar plexus block versus femoral nerve block for analgesia and motor recovery after total knee arthroplasty
  9. Correlation between ABCB1 and OLIG2 polymorphisms and the severity and prognosis of patients with cerebral infarction
  10. Study on the radiotherapy effect and serum neutral granulocyte lymphocyte ratio and inflammatory factor expression of nasopharyngeal carcinoma
  11. Transcriptome analysis of effects of Tecrl deficiency on cardiometabolic and calcium regulation in cardiac tissue
  12. Aflatoxin B1 induces infertility, fetal deformities, and potential therapies
  13. Serum levels of HMW adiponectin and its receptors are associated with cytokine levels and clinical characteristics in chronic obstructive pulmonary disease
  14. METTL3-mediated methylation of CYP2C19 mRNA may aggravate clopidogrel resistance in ischemic stroke patients
  15. Understand how machine learning impact lung cancer research from 2010 to 2021: A bibliometric analysis
  16. Pressure ulcers in German hospitals: Analysis of reimbursement and length of stay
  17. Metformin plus L-carnitine enhances brown/beige adipose tissue activity via Nrf2/HO-1 signaling to reduce lipid accumulation and inflammation in murine obesity
  18. Downregulation of carbonic anhydrase IX expression in mouse xenograft nasopharyngeal carcinoma model via doxorubicin nanobubble combined with ultrasound
  19. Feasibility of 3-dimensional printed models in simulated training and teaching of transcatheter aortic valve replacement
  20. miR-335-3p improves type II diabetes mellitus by IGF-1 regulating macrophage polarization
  21. The analyses of human MCPH1 DNA repair machinery and genetic variations
  22. Activation of Piezo1 increases the sensitivity of breast cancer to hyperthermia therapy
  23. Comprehensive analysis based on the disulfidptosis-related genes identifies hub genes and immune infiltration for pancreatic adenocarcinoma
  24. Changes of serum CA125 and PGE2 before and after high-intensity focused ultrasound combined with GnRH-a in treatment of patients with adenomyosis
  25. The clinical value of the hepatic venous pressure gradient in patients undergoing hepatic resection for hepatocellular carcinoma with or without liver cirrhosis
  26. Development and validation of a novel model to predict pulmonary embolism in cardiology suspected patients: A 10-year retrospective analysis
  27. Downregulation of lncRNA XLOC_032768 in diabetic patients predicts the occurrence of diabetic nephropathy
  28. Circ_0051428 targeting miR-885-3p/MMP2 axis enhances the malignancy of cervical cancer
  29. Effectiveness of ginkgo diterpene lactone meglumine on cognitive function in patients with acute ischemic stroke
  30. The construction of a novel prognostic prediction model for glioma based on GWAS-identified prognostic-related risk loci
  31. Evaluating the impact of childhood BMI on the risk of coronavirus disease 2019: A Mendelian randomization study
  32. Lactate dehydrogenase to albumin ratio is associated with in-hospital mortality in patients with acute heart failure: Data from the MIMIC-III database
  33. CD36-mediated podocyte lipotoxicity promotes foot process effacement
  34. Efficacy of etonogestrel subcutaneous implants versus the levonorgestrel-releasing intrauterine system in the conservative treatment of adenomyosis
  35. FLRT2 mediates chondrogenesis of nasal septal cartilage and mandibular condyle cartilage
  36. Challenges in treating primary immune thrombocytopenia patients undergoing COVID-19 vaccination: A retrospective study
  37. Let-7 family regulates HaCaT cell proliferation and apoptosis via the ΔNp63/PI3K/AKT pathway
  38. Phospholipid transfer protein ameliorates sepsis-induced cardiac dysfunction through NLRP3 inflammasome inhibition
  39. Postoperative cognitive dysfunction in elderly patients with colorectal cancer: A randomized controlled study comparing goal-directed and conventional fluid therapy
  40. Long-pulsed ultrasound-mediated microbubble thrombolysis in a rat model of microvascular obstruction
  41. High SEC61A1 expression predicts poor outcome of acute myeloid leukemia
  42. Comparison of polymerase chain reaction and next-generation sequencing with conventional urine culture for the diagnosis of urinary tract infections: A meta-analysis
  43. Secreted frizzled-related protein 5 protects against renal fibrosis by inhibiting Wnt/β-catenin pathway
  44. Pan-cancer and single-cell analysis of actin cytoskeleton genes related to disulfidptosis
  45. Overexpression of miR-532-5p restrains oxidative stress response of chondrocytes in nontraumatic osteonecrosis of the femoral head by inhibiting ABL1
  46. Autologous liver transplantation for unresectable hepatobiliary malignancies in enhanced recovery after surgery model
  47. Clinical analysis of incomplete rupture of the uterus secondary to previous cesarean section
  48. Abnormal sleep duration is associated with sarcopenia in older Chinese people: A large retrospective cross-sectional study
  49. No genetic causality between obesity and benign paroxysmal vertigo: A two-sample Mendelian randomization study
  50. Identification and validation of autophagy-related genes in SSc
  51. Long non-coding RNA SRA1 suppresses radiotherapy resistance in esophageal squamous cell carcinoma by modulating glycolytic reprogramming
  52. Evaluation of quality of life in patients with schizophrenia: An inpatient social welfare institution-based cross-sectional study
  53. The possible role of oxidative stress marker glutathione in the assessment of cognitive impairment in multiple sclerosis
  54. Compilation of a self-management assessment scale for postoperative patients with aortic dissection
  55. Left atrial appendage closure in conjunction with radiofrequency ablation: Effects on left atrial functioning in patients with paroxysmal atrial fibrillation
  56. Effect of anterior femoral cortical notch grade on postoperative function and complications during TKA surgery: A multicenter, retrospective study
  57. Clinical characteristics and assessment of risk factors in patients with influenza A-induced severe pneumonia after the prevalence of SARS-CoV-2
  58. Analgesia nociception index is an indicator of laparoscopic trocar insertion-induced transient nociceptive stimuli
  59. High STAT4 expression correlates with poor prognosis in acute myeloid leukemia and facilitates disease progression by upregulating VEGFA expression
  60. Factors influencing cardiovascular system-related post-COVID-19 sequelae: A single-center cohort study
  61. HOXD10 regulates intestinal permeability and inhibits inflammation of dextran sulfate sodium-induced ulcerative colitis through the inactivation of the Rho/ROCK/MMPs axis
  62. Mesenchymal stem cell-derived exosomal miR-26a induces ferroptosis, suppresses hepatic stellate cell activation, and ameliorates liver fibrosis by modulating SLC7A11
  63. Endovascular thrombectomy versus intravenous thrombolysis for primary distal, medium vessel occlusion in acute ischemic stroke
  64. ANO6 (TMEM16F) inhibits gastrointestinal stromal tumor growth and induces ferroptosis
  65. Prognostic value of EIF5A2 in solid tumors: A meta-analysis and bioinformatics analysis
  66. The role of enhanced expression of Cx43 in patients with ulcerative colitis
  67. Choosing a COVID-19 vaccination site might be driven by anxiety and body vigilance
  68. Role of ICAM-1 in triple-negative breast cancer
  69. Cost-effectiveness of ambroxol in the treatment of Gaucher disease type 2
  70. HLA-DRB5 promotes immune thrombocytopenia via activating CD8+ T cells
  71. Efficacy and factors of myofascial release therapy combined with electrical and magnetic stimulation in the treatment of chronic pelvic pain syndrome
  72. Efficacy of tacrolimus monotherapy in primary membranous nephropathy
  73. Mechanisms of Tripterygium wilfordii Hook F on treating rheumatoid arthritis explored by network pharmacology analysis and molecular docking
  74. FBXO45 levels regulated ferroptosis renal tubular epithelial cells in a model of diabetic nephropathy by PLK1
  75. Optimizing anesthesia strategies to NSCLC patients in VATS procedures: Insights from drug requirements and patient recovery patterns
  76. Alpha-lipoic acid upregulates the PPARγ/NRF2/GPX4 signal pathway to inhibit ferroptosis in the pathogenesis of unexplained recurrent pregnancy loss
  77. Correlation between fat-soluble vitamin levels and inflammatory factors in paediatric community-acquired pneumonia: A prospective study
  78. CD1d affects the proliferation, migration, and apoptosis of human papillary thyroid carcinoma TPC-1 cells via regulating MAPK/NF-κB signaling pathway
  79. miR-let-7a inhibits sympathetic nerve remodeling after myocardial infarction by downregulating the expression of nerve growth factor
  80. Immune response analysis of solid organ transplantation recipients inoculated with inactivated COVID-19 vaccine: A retrospective analysis
  81. The H2Valdien derivatives regulate the epithelial–mesenchymal transition of hepatoma carcinoma cells through the Hedgehog signaling pathway
  82. Clinical efficacy of dexamethasone combined with isoniazid in the treatment of tuberculous meningitis and its effect on peripheral blood T cell subsets
  83. Comparison of short-segment and long-segment fixation in treatment of degenerative scoliosis and analysis of factors associated with adjacent spondylolisthesis
  84. Lycopene inhibits pyroptosis of endothelial progenitor cells induced by ox-LDL through the AMPK/mTOR/NLRP3 pathway
  85. Methylation regulation for FUNDC1 stability in childhood leukemia was up-regulated and facilitates metastasis and reduces ferroptosis of leukemia through mitochondrial damage by FBXL2
  86. Correlation of single-fiber electromyography studies and functional status in patients with amyotrophic lateral sclerosis
  87. Risk factors of postoperative airway obstruction complications in children with oral floor mass
  88. Expression levels and clinical significance of serum miR-19a/CCL20 in patients with acute cerebral infarction
  89. Physical activity and mental health trends in Korean adolescents: Analyzing the impact of the COVID-19 pandemic from 2018 to 2022
  90. Evaluating anemia in HIV-infected patients using chest CT
  91. Ponticulus posticus and skeletal malocclusion: A pilot study in a Southern Italian pre-orthodontic court
  92. Causal association of circulating immune cells and lymphoma: A Mendelian randomization study
  93. Assessment of the renal function and fibrosis indexes of conventional western medicine with Chinese medicine for dredging collaterals on treating renal fibrosis: A systematic review and meta-analysis
  94. Comprehensive landscape of integrator complex subunits and their association with prognosis and tumor microenvironment in gastric cancer
  95. New target-HMGCR inhibitors for the treatment of primary sclerosing cholangitis: A drug Mendelian randomization study
  96. Population pharmacokinetics of meropenem in critically ill patients
  97. Comparison of the ability of newly inflammatory markers to predict complicated appendicitis
  98. Comparative morphology of the cruciate ligaments: A radiological study
  99. Immune landscape of hepatocellular carcinoma: The central role of TP53-inducible glycolysis and apoptosis regulator
  100. Serum SIRT3 levels in epilepsy patients and its association with clinical outcomes and severity: A prospective observational study
  101. SHP-1 mediates cigarette smoke extract-induced epithelial–mesenchymal transformation and inflammation in 16HBE cells
  102. Acute hyper-hypoxia accelerates the development of depression in mice via the IL-6/PGC1α/MFN2 signaling pathway
  103. The GJB3 correlates with the prognosis, immune cell infiltration, and therapeutic responses in lung adenocarcinoma
  104. Physical fitness and blood parameters outcomes of breast cancer survivor in a low-intensity circuit resistance exercise program
  105. Exploring anesthetic-induced gene expression changes and immune cell dynamics in atrial tissue post-coronary artery bypass graft surgery
  106. Empagliflozin improves aortic injury in obese mice by regulating fatty acid metabolism
  107. Analysis of the risk factors of the radiation-induced encephalopathy in nasopharyngeal carcinoma: A retrospective cohort study
  108. Reproductive outcomes in women with BRCA 1/2 germline mutations: A retrospective observational study and literature review
  109. Evaluation of upper airway ultrasonographic measurements in predicting difficult intubation: A cross-section of the Turkish population
  110. Prognostic and diagnostic value of circulating IGFBP2 in pancreatic cancer
  111. Postural stability after operative reconstruction of the AFTL in chronic ankle instability comparing three different surgical techniques
  112. Research trends related to emergence agitation in the post-anaesthesia care unit from 2001 to 2023: A bibliometric analysis
  113. Frequency and clinicopathological correlation of gastrointestinal polyps: A six-year single center experience
  114. ACSL4 mediates inflammatory bowel disease and contributes to LPS-induced intestinal epithelial cell dysfunction by activating ferroptosis and inflammation
  115. Affibody-based molecular probe 99mTc-(HE)3ZHER2:V2 for non-invasive HER2 detection in ovarian and breast cancer xenografts
  116. Effectiveness of nutritional support for clinical outcomes in gastric cancer patients: A meta-analysis of randomized controlled trials
  117. The relationship between IFN-γ, IL-10, IL-6 cytokines, and severity of the condition with serum zinc and Fe in children infected with Mycoplasma pneumoniae
  118. Paraquat disrupts the blood–brain barrier by increasing IL-6 expression and oxidative stress through the activation of PI3K/AKT signaling pathway
  119. Sleep quality associate with the increased prevalence of cognitive impairment in coronary artery disease patients: A retrospective case–control study
  120. Dioscin protects against chronic prostatitis through the TLR4/NF-κB pathway
  121. Association of polymorphisms in FBN1, MYH11, and TGF-β signaling-related genes with susceptibility of sporadic thoracic aortic aneurysm and dissection in the Zhejiang Han population
  122. Application value of multi-parameter magnetic resonance image-transrectal ultrasound cognitive fusion in prostate biopsy
  123. Laboratory variables‐based artificial neural network models for predicting fatty liver disease: A retrospective study
  124. Decreased BIRC5-206 promotes epithelial–mesenchymal transition in nasopharyngeal carcinoma through sponging miR-145-5p
  125. Sepsis induces the cardiomyocyte apoptosis and cardiac dysfunction through activation of YAP1/Serpine1/caspase-3 pathway
  126. Assessment of iron metabolism and iron deficiency in incident patients on incident continuous ambulatory peritoneal dialysis
  127. Tibial periosteum flap combined with autologous bone grafting in the treatment of Gustilo-IIIB/IIIC open tibial fractures
  128. The application of intravenous general anesthesia under nasopharyngeal airway assisted ventilation undergoing ureteroscopic holmium laser lithotripsy: A prospective, single-center, controlled trial
  129. Long intergenic noncoding RNA for IGF2BP2 stability suppresses gastric cancer cell apoptosis by inhibiting the maturation of microRNA-34a
  130. Role of FOXM1 and AURKB in regulating keratinocyte function in psoriasis
  131. Parental control attitudes over their pre-school children’s diet
  132. The role of auto-HSCT in extranodal natural killer/T cell lymphoma
  133. Significance of negative cervical cytology and positive HPV in the diagnosis of cervical lesions by colposcopy
  134. Echinacoside inhibits PASMCs calcium overload to prevent hypoxic pulmonary artery remodeling by regulating TRPC1/4/6 and calmodulin
  135. ADAR1 plays a protective role in proximal tubular cells under high glucose conditions by attenuating the PI3K/AKT/mTOR signaling pathway
  136. The risk of cancer among insulin glargine users in Lithuania: A retrospective population-based study
  137. The unusual location of primary hydatid cyst: A case series study
  138. Intraoperative changes in electrophysiological monitoring can be used to predict clinical outcomes in patients with spinal cavernous malformation
  139. Obesity and risk of placenta accreta spectrum: A meta-analysis
  140. Shikonin alleviates asthma phenotypes in mice via an airway epithelial STAT3-dependent mechanism
  141. NSUN6 and HTR7 disturbed the stability of carotid atherosclerotic plaques by regulating the immune responses of macrophages
  142. The effect of COVID-19 lockdown on admission rates in Maternity Hospital
  143. Temporal muscle thickness is not a prognostic predictor in patients with high-grade glioma, an experience at two centers in China
  144. Luteolin alleviates cerebral ischemia/reperfusion injury by regulating cell pyroptosis
  145. Therapeutic role of respiratory exercise in patients with tuberculous pleurisy
  146. Effects of CFTR-ENaC on spinal cord edema after spinal cord injury
  147. Irisin-regulated lncRNAs and their potential regulatory functions in chondrogenic differentiation of human mesenchymal stem cells
  148. DMD mutations in pediatric patients with phenotypes of Duchenne/Becker muscular dystrophy
  149. Combination of C-reactive protein and fibrinogen-to-albumin ratio as a novel predictor of all-cause mortality in heart failure patients
  150. Significant role and the underly mechanism of cullin-1 in chronic obstructive pulmonary disease
  151. Ferroptosis-related prognostic model of mantle cell lymphoma
  152. Observation of choking reaction and other related indexes in elderly painless fiberoptic bronchoscopy with transnasal high-flow humidification oxygen therapy
  153. A bibliometric analysis of Prader-Willi syndrome from 2002 to 2022
  154. The causal effects of childhood sunburn occasions on melanoma: A univariable and multivariable Mendelian randomization study
  155. Oxidative stress regulates glycogen synthase kinase-3 in lymphocytes of diabetes mellitus patients complicated with cerebral infarction
  156. Role of COX6C and NDUFB3 in septic shock and stroke
  157. Trends in disease burden of type 2 diabetes, stroke, and hypertensive heart disease attributable to high BMI in China: 1990–2019
  158. Purinergic P2X7 receptor mediates hyperoxia-induced injury in pulmonary microvascular endothelial cells via NLRP3-mediated pyroptotic pathway
  159. Investigating the role of oviductal mucosa–endometrial co-culture in modulating factors relevant to embryo implantation
  160. Analgesic effect of external oblique intercostal block in laparoscopic cholecystectomy: A retrospective study
  161. Elevated serum miR-142-5p correlates with ischemic lesions and both NSE and S100β in ischemic stroke patients
  162. Correlation between the mechanism of arteriopathy in IgA nephropathy and blood stasis syndrome: A cohort study
  163. Risk factors for progressive kyphosis after percutaneous kyphoplasty in osteoporotic vertebral compression fracture
  164. Predictive role of neuron-specific enolase and S100-β in early neurological deterioration and unfavorable prognosis in patients with ischemic stroke
  165. The potential risk factors of postoperative cognitive dysfunction for endovascular therapy in acute ischemic stroke with general anesthesia
  166. Fluoxetine inhibited RANKL-induced osteoclastic differentiation in vitro
  167. Detection of serum FOXM1 and IGF2 in patients with ARDS and their correlation with disease and prognosis
  168. Rhein promotes skin wound healing by activating the PI3K/AKT signaling pathway
  169. Differences in mortality risk by levels of physical activity among persons with disabilities in South Korea
  170. Review Articles
  171. Cutaneous signs of selected cardiovascular disorders: A narrative review
  172. XRCC1 and hOGG1 polymorphisms and endometrial carcinoma: A meta-analysis
  173. A narrative review on adverse drug reactions of COVID-19 treatments on the kidney
  174. Emerging role and function of SPDL1 in human health and diseases
  175. Adverse reactions of piperacillin: A literature review of case reports
  176. Molecular mechanism and intervention measures of microvascular complications in diabetes
  177. Regulation of mesenchymal stem cell differentiation by autophagy
  178. Molecular landscape of borderline ovarian tumours: A systematic review
  179. Advances in synthetic lethality modalities for glioblastoma multiforme
  180. Investigating hormesis, aging, and neurodegeneration: From bench to clinics
  181. Frankincense: A neuronutrient to approach Parkinson’s disease treatment
  182. Sox9: A potential regulator of cancer stem cells in osteosarcoma
  183. Early detection of cardiovascular risk markers through non-invasive ultrasound methodologies in periodontitis patients
  184. Advanced neuroimaging and criminal interrogation in lie detection
  185. Maternal factors for neural tube defects in offspring: An umbrella review
  186. The chemoprotective hormetic effects of rosmarinic acid
  187. CBD’s potential impact on Parkinson’s disease: An updated overview
  188. Progress in cytokine research for ARDS: A comprehensive review
  189. Utilizing reactive oxygen species-scavenging nanoparticles for targeting oxidative stress in the treatment of ischemic stroke: A review
  190. NRXN1-related disorders, attempt to better define clinical assessment
  191. Lidocaine infusion for the treatment of complex regional pain syndrome: Case series and literature review
  192. Trends and future directions of autophagy in osteosarcoma: A bibliometric analysis
  193. Iron in ventricular remodeling and aneurysms post-myocardial infarction
  194. Case Reports
  195. Sirolimus potentiated angioedema: A case report and review of the literature
  196. Identification of mixed anaerobic infections after inguinal hernia repair based on metagenomic next-generation sequencing: A case report
  197. Successful treatment with bortezomib in combination with dexamethasone in a middle-aged male with idiopathic multicentric Castleman’s disease: A case report
  198. Complete heart block associated with hepatitis A infection in a female child with fatal outcome
  199. Elevation of D-dimer in eosinophilic gastrointestinal diseases in the absence of venous thrombosis: A case series and literature review
  200. Four years of natural progressive course: A rare case report of juvenile Xp11.2 translocations renal cell carcinoma with TFE3 gene fusion
  201. Advancing prenatal diagnosis: Echocardiographic detection of Scimitar syndrome in China – A case series
  202. Outcomes and complications of hemodialysis in patients with renal cancer following bilateral nephrectomy
  203. Anti-HMGCR myopathy mimicking facioscapulohumeral muscular dystrophy
  204. Recurrent opportunistic infections in a HIV-negative patient with combined C6 and NFKB1 mutations: A case report, pedigree analysis, and literature review
  205. Letter to the Editor
  206. Letter to the Editor: Total parenteral nutrition-induced Wernicke’s encephalopathy after oncologic gastrointestinal surgery
  207. Erratum
  208. Erratum to “Bladder-embedded ectopic intrauterine device with calculus”
  209. Retraction
  210. Retraction of “XRCC1 and hOGG1 polymorphisms and endometrial carcinoma: A meta-analysis”
  211. Corrigendum
  212. Corrigendum to “Investigating hormesis, aging, and neurodegeneration: From bench to clinics”
  213. Corrigendum to “Frankincense: A neuronutrient to approach Parkinson’s disease treatment”
  214. Special Issue The evolving saga of RNAs from bench to bedside - Part II
  215. Machine-learning-based prediction of a diagnostic model using autophagy-related genes based on RNA sequencing for patients with papillary thyroid carcinoma
  216. Unlocking the future of hepatocellular carcinoma treatment: A comprehensive analysis of disulfidptosis-related lncRNAs for prognosis and drug screening
  217. Elevated mRNA level indicates FSIP1 promotes EMT and gastric cancer progression by regulating fibroblasts in tumor microenvironment
  218. Special Issue Advancements in oncology: bridging clinical and experimental research - Part I
  219. Ultrasound-guided transperineal vs transrectal prostate biopsy: A meta-analysis of diagnostic accuracy and complication rates
  220. Assessment of diagnostic value of unilateral systematic biopsy combined with targeted biopsy in detecting clinically significant prostate cancer
  221. SENP7 inhibits glioblastoma metastasis and invasion by dissociating SUMO2/3 binding to specific target proteins
  222. MARK1 suppress malignant progression of hepatocellular carcinoma and improves sorafenib resistance through negatively regulating POTEE
  223. Analysis of postoperative complications in bladder cancer patients
  224. Carboplatin combined with arsenic trioxide versus carboplatin combined with docetaxel treatment for LACC: A randomized, open-label, phase II clinical study
  225. Special Issue Exploring the biological mechanism of human diseases based on MultiOmics Technology - Part I
  226. Comprehensive pan-cancer investigation of carnosine dipeptidase 1 and its prospective prognostic significance in hepatocellular carcinoma
  227. Identification of signatures associated with microsatellite instability and immune characteristics to predict the prognostic risk of colon cancer
  228. Single-cell analysis identified key macrophage subpopulations associated with atherosclerosis
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