We have read with attention and surprise the letter from Dr M. Pulido1 commenting on our article “Significant Contribution of Spanish Dermatology Toward Understanding COVID-19: A Bibliometric Study of PubMed-Indexed Articles.”2 The purpose of our study was to examine the contributions Spanish dermatology has made to the understanding of COVID-19.
We would like to respond to the correspondent's objections point by point.
Dr Pulido first calls attention to the small number of articles (254) we analyzed. She reports that after applying the same search criteria she retrieved 103 707 articles and that Spanish researchers contributed 3813 of them (3.67%). Her main error was in not faithfully reproducing our search criteria, including not limiting the search to the same time period we specified. As she states in her letter, she used only the Boolean operator OR between our search terms (SARS-CoV-2, COVID-19, skin, cutaneous, and dermato-). Thus, all the articles whose titles included any one of those terms were retrieved. The search Dr Pulido performed found all studies with titles containing the words skin, cutaneous or dermato- (whether or not were related to the infection of interest) as well as all those related to COVID-19 (regardless of what specialty or knowledge area had produced them). This is the explanation for the very large number of titles found. Our study's aim had been to find articles discussing cutaneous changes related to COVID-19, i.e., SARS-CoV-2 infection. To that end, the search strategy we used was as follows: SARS-CoV-2[Title] OR COVID-19[Title] ANDskin[Title] OR cutaneous[Title] OR dermato[Title]. The criteria Dr Pulido applied thus differed from ours. Clearly, it would be astonishing if Spanish dermatologists had published 3813 studies by February 24 of this year (the starting date was not indicated).
The second objection the writer makes concerns the categories we analyzed, specifically articles making direct clinical contributions versus other articles without such direct contributions. Case reports and case series were classified in the first category, regardless of what section of a journal or format they were published in or how the journal labeled them. Clinical contributions could appear as letters, clinical studies, epidemiological studies, or other types. Articles that did not make direct clinical contributions were reviews, commentaries, and opinion pieces. Dr Pulido wrote that this classification was “questionable and lacks interest.”* We strongly disagree. The classification does not impugn the second category. It merely underlines the fact that for clinicians it is of primary importance to recognize, describe, and classify cutaneous manifestations associated with a new disease in its early days. Such knowledge, grounded in direct clinical experience, is key to managing symptoms in patients with this disease. Precisely here, Spanish dermatologists played a prominent role, as we point out in our discussion: 81% of Spanish contributions were in this category. Also relevant is that many dermatologists were involved directly in the care of COVID-19 patients during the first wave. We are convinced of the importance of highlighting this contribution. In fact, a pioneering article, one that influenced later descriptions because it offered the first classification of cutaneous manifestations of COVID-19, was by Galván Casas et al.3 Published in the British Journal of Dermatology in July 2020, it appeared in the epidemiology subsection.
Dr Pulido also wrote that it was “a serious flaw and very ill-advised” that we associated scientific output with countries’ populations. We also disagree with this opinion. Does the same merit derive from the 32 articles published from Spain (with 47.3 million inhabitants) as to the 38 articles published from the United States, where the population is 7-fold greater, at 328.4 million? We analyzed the results just as prevalence, incidence, and mortality are conventionally analyzed when comparing findings between countries and other geographic areas, by adjusting for population (per 100000 population). With regard to the correlations of incidence and mortality with scientific output that we mentioned in our article, we point out that we hedged our statement, saying that “associations between publication output and incidence and mortality rates must be interpreted more cautiously given that the accuracy of epidemiological data is highly disputed.” Based on those associations, we only concluded that the countries that contribute more to the literature on dermatology and COVID-19 are those which are more severely impacted by the infection.
We were also criticized for not describing more precisely the research designs of articles we cited in order to compare our findings for Spanish medicine to the contributions of authors around the world. If we did not do so, the reason lies in the word limits for scientific and clinical letters in Actas Dermo-Sifiliográficas. In order to avoid exceeding the word limit, we concentrated on what was relevant to our aim: reflecting on how these other studies ranked Spanish dermatology's output, showing that our specialty's proportional contribution was greater than the collective output of all Spanish specialties. Dr Pulido then makes several comments on 3 of the articles we cited. When citing Liu et al.4 we pointed out that Spain was ranked 15th, which we wished to emphasize, whereas Dr Pulido notes that Spain's visibility was 0.5%, a figure that is accurate but does not provide much information.
Dr Pulido further mentions that Wang et al.5 evaluated “exclusively preprints found in a variety of online platforms.” That affirmation is incorrect. As the authors explained, their search was done in Science Citation Index Expanded, of the Web of Knowledge, and in addition — but not exclusively — in 4 preprint platforms. Table 1 of that article shows how each country ranks in each of the databases, clearly placing Spain between seventh and ninth positions, depending on the database as we stated in our article. In Science Citation Index Expanded, Spain ranked eighth.
The only shortcoming we must admit to is that the articles analyzed by Haghani et al.6 do indeed include some on coronaviruses in general, not only the coronavirus responsible for COVID-19. In this case the comparison has much less value.
We believe both the research design we used and the results we reported were entirely valid and appropriate to the objective of our study. We think that this reply to Dr Pulido's letter clarifies the points called into question.
Finally, since Dr Pulido raised the issue of the peer reviewers for Actas Dermo-Sifiliográficas, we wish to rise up in their defense. Peer review is an altruistic, praiseworthy undertaking that requires time and effort. It helps to improve the quality of published articles, as it did ours, and we wish to express our gratitude for that help.
