COVID-19 and Sleep: A Global Outlook

Description:

This book examines the correlation of the coronavirus disease-19 [CE1] [AAS2] (COVID-19) infection with sleep, circadian rhythm, and sleep disorders. The chapters of the book explore sleep problems during the COVID-19 pandemic and its association with psychological distress and also review the prevalence of clinical cases of insomnia, anxiety, and depression in COVID-19 patients. The book further presents the correlation between sleep, circadian rhythms, and immunity that contributes toward more severe COVID-19. It summarizes the evidence on the interplay between circadian biology, sleep, and COVID-19. The chapters of the book discuss the relationship between obstructive sleep apnea (OSA) and adverse COVID-19 outcomes. Towards the end, the book presents studies on the anti-inflammatory, antioxidant, and immunotropic properties of melatonin and provides mechanistic insights into the potential therapeutic use of melatonin during the SARS-CoV-2 infection. The last chapter describes the publication output of sleep-related research during the pandemic and provides an overview and trends on sleep and covid-19 publication output. This book is an excellent source for neurologists, sleep specialists, and public health specialists.

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Preface

The editors are pleased to present the first edition of COVID-19 and Sleep: A Global Outlook, which has been included in the prestigious Progress in Sleep Research series. As editors, we are pleased about this decision as our volume fits perfectly in this landmark biomedicine and clinical sciences series from Springer.

All animal species require sleep, which shows that sleep is essential for maintaining essential functions. However, the time people spend sleeping at night is decreasing, and this trend is becoming more pronounced in modern 24-h societies. According to epidemiological and experimental studies, sleep deprivation has been linked to deleterious effects on physical and mental health, well-being, longevity, and general health-related quality of life.

Immune interactions related to sleep are a common occurrence in real life and conventional wisdom. Being sick makes us sleepy and want to sleep more, which is why getting a good night’s sleep is sometimes referred to as “nature’s best medicine” for infections. It is believed that improving sleep during an infection will act as a feedback loop for the immune system to support host defense. Therefore, sleep promotes host resistance against infection and inflammatory stimuli by acting as an immune-supportive mechanism. Indeed, sleep influences several immune parameters, is linked to a lower risk of illness, and can enhance the course of infection and the effectiveness of vaccinations.

Numerous research conducted over the past few decades have explicitly demonstrated that sleep and immunity have mutually beneficial interactions. Notably, sleep and the immune system seem to work in tandem, particularly when the body is fending off illness. Immune system operations are strongly regulated by sleep and the circadian (~24-h periodicity) rhythm, which affects how well our body defends itself innately and adaptively. Along these lines, chronic sleep deprivation is believed to impair our body’s immune system, making us more susceptible to infections such as the common cold. The immune system is stimulated by microbial challenges, which results in an inflammatory response. This reaction can either increase sleep duration and intensity or interrupt sleep depending on its severity and time course. A chronic inflammatory state and an increased risk for infectious/ inflammatory pathologies, such as cardiometabolic, neoplastic, autoimmune, and neurodegenerative dysfunctions, have been linked to sleep deprivation and altered innate and adaptive immunological parameters.

To enhance physical and mental well-being across animal species, including humans, sleep quality and adaptation to individual and environmental conditions are crucial. The connection between sleep and the immune system and how sleep disruptions may upset the delicate balance with serious consequences for health outcomes have been the subject of growing evidence in recent years.

Sleep has drawn particular attention in recent years due to its possible impact on the immune system. Several studies have shown that lack of sleep alters several immune system components, including the percentages of cell subpopulations and cytokine levels, making people less resistant to infections, particularly viral infections [1]. Additionally, the immune response to infections affects sleep patterns, indicating a possible bidirectional relationship between sleep and immune responses [2].

In this specialized volume, the editors have come together to address the current coronavirus disease (COVID-19) pandemic crisis. COVID-19 transformed into a horrible global public health problem that impacted the general people’s and healthcare professionals’ sleep and mental health. This stressful situation significantly impacted everyone’s everyday activities and sleep patterns, affecting hundreds of millions worldwide. Moreover, systematic reviews have reported a high prevalence of sleep problems globally, with the most affected groups being patients with COVID-19 and healthcare workers, in addition to the general public [3–5]. During the pandemic and lockdown, insomnia symptoms, circadian rhythm disruption, dream recall frequency, and nightmares were common. Additionally, subsequent studies suggested that some sleep disorders could be linked to COVID-19. For example, evidence suggests that OSA patients may be more likely to experience severe COVID-19 [6].

The term “long COVID” has recently appeared, reflecting the persistence of some symptoms, after recovery from the acute illness, for weeks to months following a relapsing and remitting course. It has been shown that sleep problems may persist months after COVID-19 infection [7]. A recent international survey of 14,000 participants from 16 nations reported that long-lasting sleep problems, such as insomnia and excessive daytime sleepiness in COVID-19 patients, were linked to the disease’s severity [8].

Moreover, the quarantine, curfew, and infection control measures have changed the medical practice during the pandemic, affecting sleep medicine practice and the performance of diagnostic and therapeutic sleep medicine procedures. Therefore, to meet the pandemic’s demands and unforeseen circumstances, COVID-19 required a significant adjustment in healthcare policies and practices, such as the complete shift to home sleep apnea testing and telemedicine [9, 10].

To address current pandemics and upcoming ones, it is therefore vital to compile all of this accumulating data for academics and practitioners in one volume. This volume combines novel basic research and clinical aspects and is the first of its kind to take a critical look at the rapidly expanding areas linking COVID-19 with sleep science, sleep disorders, and sleep medicine practice. The practical importance and the availability of new data were taken into consideration while selecting the topics for this volume, though the majority of authors emphasize the need for more research. The volume brings together leading international scientists and clinical researchers to present research at the forefront of this field and explore the ramifications of advances in these cutting-edge areas, as well as their implications for an improved treatment paradigm. Additionally, each contributor represents a particular area of expertise in the study of sleep and COVID-19 and hails from a different world region. We expect this volume to provide an authoritative reference resource for researchers, practitioners, trainees, and students.

This specialty volume covers a wide range of important topics related to COVID- 19 and sleep, including the link between sleep and circadian rhythm with the immune system, sleep disturbances and circadian rhythm disorders in various populations during the COVID-19 pandemic, impact of COVID-19 infection and pandemic on common sleep disorders, management of sleep disorders during the COVID-19 pandemic, role of telemedicine in the management of sleep disorders during pandemics, running of sleep medicine services during pandemics, and positive airway pressure management and the risk of aerosol during pandemics. This volume will be a great addition to the growing data on the impact of COVID-19 on sleep, sleep disorders, and sleep medicine.

We consider ourselves fortunate to have compiled this volume. We learned a lot while editing this important volume as part of our assignment. We sincerely hope that readers will find this volume extremely useful as a research and clinical resource. We sincerely hope that this volume will be useful to researchers and clinicians in the field. However, as the topic is evolving, this book aims as well to spark further discussion and stimulate more research ideas.

Table of contents :
Foreword
Preface
References
Acknowledgements
About This Volume
Contents
Editors and Contributors
Chapter 1: The Effect of Sleep Disruption and Circadian Misalignment on the Immune System
1.1 Introduction
1.2 Immune Regulation by Sleep
1.3 Sleep Disruption and Immune Consequences
1.4 Circadian Clock Regulation of the Immune System
1.5 Immune Responses Under Circadian Misalignment
1.6 Conclusion and Perspectives
References
Chapter 2: Changes in the Sleep and Circadian Pattern of Sleep During the COVID-19 Pandemic
2.1 Introduction
2.2 Pandemic Effects on Sleep Quality and Sleep Problems
2.2.1 Insomnia Symptoms During the Pandemic
2.2.2 Dreams and Nightmares During the Pandemic
2.2.3 Sleep Quality During the Pandemic
2.2.4 Parasomnias During the Pandemic
2.2.5 Sleep Apnea Symptoms During the Pandemic
2.2.6 Fatigue and Excessive Daytime Sleepiness During the Pandemic
2.3 Pandemic Effects on Sleep-Wake Behavior and Sleep Duration in General Population
2.3.1 Sleep Duration During the Pandemic
2.3.2 Sleep Schedules During the Pandemic
2.4 Pandemic Effects on Sleep and Mental Well-Being Among Different Circadian Types
2.4.1 Sleep-Wake Behavior During the Pandemic by Circadian Type
2.4.2 Sleep Quality and Sleep Problems During the Pandemic by Circadian Type
2.4.3 Mental Well-Being During the Pandemic by Circadian Type
2.5 Conclusion
References
Chapter 3: Anxiety and Depression During the COVID-19 Pandemic and Their Impact on Sleep
3.1 Introduction
3.2 Overview of Anxiety
3.3 Relationship Between Sleep Disorders and Anxiety
3.4 Prior to the Pandemic
3.5 During the Pandemic
3.6 Management of Anxiety
3.7 Overview of Depression
3.8 Relationship Between Sleep Disorders and Depression
3.9 Prior to the Pandemic
3.10 During the Pandemic
3.11 Management of Depression
3.12 Non-pharmacological Interventions
3.13 Pharmacological Interventions
3.14 Conclusion
References
Chapter 4: Sleep Problems During the COVID-19 Pandemic in Children and Adolescents
4.1 Importance of Sleep and Circadian Rhythm in the Maintenance of Well-Being and Its Effect on Cognition
4.2 Sleep Architecture and Development in the Pediatric Population
4.3 Common Sleep Issues in Children and Adolescents During the Pre-pandemic Era
4.3.1 Typically Developing Children and Adolescents
4.3.2 Children with Neurodevelopmental Disorders (NDDs)
4.4 The Spectrum of Sleep Problems in Children and Adolescents During the COVID-19 Pandemic
4.4.1 Typically Developing Younger Children (Toddlers, Preschoolers)
4.4.1.1 Sleep-Wake Schedule, Sleep Quality, and Duration
4.4.2 Healthy School-Goers and Adolescents
4.4.2.1 Sleep-Wake Schedule
4.4.2.2 Sleep Duration and Quality
4.4.2.3 Insomnia
4.4.3 Children and Adolescents with Neurodevelopmental Disorders
4.4.3.1 Attention Deficit Hyperactivity Disorder (ADHD)
4.4.3.2 Autism Spectrum Disorders (ASD)
4.4.3.3 Cerebral Palsy (CP)
4.4.4 Metrics for Sleep Evaluation in Children and Adolescents
4.5 Prevalence of Primary Sleep Disorders in Children and Adolescents Amid the COVID-19 Pandemic
4.6 Impact of Acute SARS-CoV-2 Infection and Long-COVID on Sleep in Children and Adolescents
4.7 Epidemiological Characteristics of Sleep Difficulties in Children and Adolescents
4.8 Risk Factors and Predictors for Sleep Issues Due to the COVID-19 Pandemic and Its Psychopathological Basis in Children and…
4.8.1 Environmental Factors
4.8.2 Parent Factors
4.8.3 Child Factors and Psychopathological Basis of Sleep Issues
4.9 Diagnostic Approach and Recommendations for Pediatric Sleep Issues During the COVID-19 Pandemic
4.10 Role of Telehealth in Sleep Medicine Practice
4.11 Consequences of Altered Sleep Patterns Due to the COVID-19 Pandemic on Neurodevelopmental Trajectory
4.12 Transition to the Post-pandemic Era
References
Chapter 5: Sleep Disturbances Among Healthcare Workers During the COVID-19 Pandemic
5.1 Introduction
5.2 Epidemiology
5.2.1 Prevalence During the COVID-19 Pandemic
5.2.2 Prevalence After the COVID-19 Pandemic
5.2.3 Prevalence by Population
5.2.4 Prevalence by Country
5.2.5 Prevalence by Mental Health Condition
5.2.6 Prevalence by Outcome Measure Used
5.2.7 Prevalence by HCW Characteristics
5.3 Etiology (Risk Factors)
5.3.1 Importance of Risk Factors
5.3.2 General Risk Factors for Sleep Disturbance
5.3.3 Risk Factors Identified During COVID-19
5.3.4 Strength of Risk Factors
5.3.5 Personal (Sociodemographic) Factors
5.3.6 Societal (Social) Factors
5.3.7 Organizational (Occupational) Factors
5.4 Etiology (Mechanisms Involved)
5.4.1 Why Sleep Disturbance Occurs
5.4.2 High Risk of SARS-CoV-2 Infection
5.4.3 Changes in Sleep-Related Factors
5.4.4 Comorbid Psychological Distress
5.5 Impact of Sleep Dysfunction
5.5.1 The Personal Impact of Sleeplessness
5.5.2 Socioeconomic Impact of Sleeplessness
5.5.3 Organizational Impact of Sleeplessness
5.6 Management
5.6.1 Preventing the Development of Sleep Problems
5.6.2 Managing the Development of Sleep Problems
5.6.3 Managing the Development of Psychological Distress
5.6.4 Sleep in a Post-COVID World
References
Chapter 6: Sleep Disturbances Among Patients with COVID-19 Infection
6.1 Introduction
6.2 Background
6.3 Insomnias
6.4 Sleep Duration
6.5 Sleep Quality
6.6 Other Sleep Disorders in COVID-19
6.6.1 Restless Leg Syndrome (RLS)
6.6.2 Obstructive Sleep Apnea (OSA)
6.6.3 Somnolence
6.7 Narcolepsy
6.8 Management Considerations
References
Chapter 7: Sleep Patterns and Sleep Disturbances During the Lockdown Periods
7.1 Lockdown and Sleep: The Perfect Storm
7.2 Sleep Disturbances During the Lockdown
7.3 The Sleep Duration Paradox
7.4 Changes in Sleep Schedule and Social Jet lag
7.5 The Chronotype Matter
7.6 The Impact of Working/Schooling Adjustments
7.7 The Role of Daylight Exposure
7.8 The Screen Time Effect
References
Chapter 8: Impact of COVID-19 Mobility Restrictions on Sleep and Well-Being
8.1 Introduction
8.2 Mobility Restrictions Resulted in Later and Longer Sleep in Adults
8.2.1 Evidence from Surveys
8.2.2 Evidence from Consumer Sleep Technology
8.3 Mobility Restrictions Were Often Associated with Poorer Quality Sleep
8.4 Pandemic Effects on Sleep in Older Adults
8.5 Pandemic Effects on the Sleep of Children and Adolescents
8.6 Sleep-Related Characteristics
8.6.1 Preexisting Insomnia
8.6.2 Chronotype
8.7 Lessons for Post-pandemic Sleep Health
8.7.1 Hybrid Work
8.7.2 School Arrangements
8.7.3 Setting Time Cues
8.8 Conclusion
References
Chapter 9: Sleep Disturbances and COVID-19 Vaccines
9.1 Sleep and the Immune System
9.2 Sleep and Vaccination
9.3 COVID-19 Pandemic and Sleep
References
Chapter 10: Structural Inequity and Racial/Ethnic Disparities in Sleep Health During the COVID-19 Pandemic
10.1 Overview of Racial/Ethnic Disparities in Sleep Health Before the COVID-19 Pandemic
10.1.1 Documented Early Life Sleep Disparities Before the COVID-19 Pandemic
10.2 Racial/Ethnic Disparities in Sleep During the COVID-19 Pandemic
10.3 Sleep Disparities During the COVID-19 Pandemic from a Socioecological Perspective
10.3.1 Individual Level
10.3.1.1 Sex/Gender and Sexual Orientation
10.3.1.2 Socioeconomic Status (SES)
10.3.1.3 Health Conditions
10.3.2 Household Structure and Family
10.3.2.1 Caregivers
10.3.3 Community
10.3.4 Society
10.3.4.1 Racism and COVID-19-Related Discrimination
10.3.4.2 Labor and Employment
Healthcare Workers
10.3.4.3 Neighborhood Built Environment
10.3.4.4 Education Access and Quality
10.4 Gaps in the Literature on Sleep Disparities During the COVID-19 Pandemic
10.5 Future Research Directions
10.6 Conclusion
References
Chapter 11: The Effect of Cognitive-Behavioral Therapy and Coping Strategies on Sleep Disturbances During the COVID-19 Pandemic
11.1 Introduction
11.2 Epidemiological Data on Sleep and Mental Health During the COVID-19 Pandemic
11.3 Circadian Rhythms Disorders During the COVID-19 Pandemic
11.4 Parasomnias
11.5 Insomnia, Anxiety, and Depression in Health Staff
11.6 Long COVID-19 and Sleep
11.7 Sleep-Disordered Breathing
11.8 Movement Disorders Related to Sleep
11.9 Insomnia
11.10 Stress: General Considerations
11.11 Stress and Repercussions on Health
11.12 Stress Coping Strategies
11.13 Psychological Treatment of Sleep Disorders
11.14 Sleep Disorders and Coping Strategies During the Pandemic
11.15 Discussion
11.16 Research Agenda
11.17 Conclusion
References
Chapter 12: Sleep and Circadian Rhythm in Post-COVID-19 Patients
12.1 Introduction
12.2 Circadian Rhythm Sleep-Wake Disorders
12.3 Post COVID-19 Condition
12.4 Post-COVID-19 condition and Sleep-Circadian Rhythm Disorders
12.4.1 Epidemiology
12.4.2 Risk Factors for the Development of Sleep-Wake Cycle Disorder
12.4.3 Comorbid Conditions
12.4.4 The Pattern of Sleep Cycle Disturbance in the Post-COVID State
12.4.5 Pathophysiology of Post-COVID-19 Circadian Rhythms Disturbances
12.4.6 The Primary Mechanism of Circadian Sleep Disturbances in Post-COVID Conditions
12.4.7 Possible Health Consequences of the Post-COVID Sleep Cycle Disturbances
12.4.8 Diagnosis of Circadian Rhythms in Post-COVID Patients
12.4.9 Investigations to Diagnose Circadian Rhythm Disorders
12.4.10 Countermeasures Against the Development of Rhythm Disturbances
12.5 Chronobiology
12.5.1 Melatonin
12.6 Conclusion
References
Chapter 13: COVID-19 and Obstructive Sleep Apnoea
13.1 Introduction
13.2 Susceptibility to SARS-CoV-2 Infection
13.3 Inflammation in OSA and COVID-19
13.4 OSA as a Risk Factor for Poor Outcomes in COVID-19
13.5 Does Treating OSA Reduce the Risk of Severe COVID-19?
13.6 Cardiovascular Interactions Between COVID-19 and OSA
13.7 Access to OSA Services and CPAP Usage During the Pandemic
13.8 Impact of COVID-19 on Established OSA Therapy
13.9 OSA and Post-COVID Complications
13.10 OSA and Vaccine Response
13.11 Conclusion
References
Chapter 14: The Correlation Between COVID-19 Infection and Restless Legs Syndrome
14.1 Introduction
14.2 RLS and COVID-19
References
Chapter 15: What Happened to Central Disorders of Hypersomnolence During the COVID-19 Pandemic?
15.1 Pitfalls in the Management of Central Disorders of Hypersomnolence During the COVID-19 Pandemic
15.2 Impact of COVID-19 Pandemic on Narcolepsy: Challenges or Opportunity?
15.2.1 A Focus on the Self-Reported Sleep Schedule, Excessive Daytime Sleepiness, and Medication Intake
15.2.2 A Focus on Objective Sleep Parameters
15.3 Idiopathic Hypersomnia and the COVID-19 Pandemic
15.4 Overall Conclusion
15.5 Perspective on Telemedicine During (and After) COVID-19
References
Chapter 16: Sleep, Physical Activity, and Dietary Patterns During COVID-19 Pandemic
16.1 Sleep
16.2 Physical Activity
16.3 Dietary Pattern
16.4 Interaction Between Sleep, Physical Activity, and Dietary Pattern
References
Chapter 17: Impact of Screen Time During the Pandemic of COVID-19 on Sleep Habits
17.1 Introduction
17.2 Increasing Screen Time During the COVID-19 Pandemic
17.3 Impact of Increased Screen Time on Overall Health
17.4 Impact of Increased Screen Time on Sleep Parameters
17.4.1 Children and Adolescents
17.4.2 Adults
17.4.2.1 Relationship Between Sleep Latency and Screen Time
17.4.2.2 Relationship Between Delayed Bedtime and Screen Time
17.4.2.3 Relationship Between Sleep Duration and Screen Time
17.4.2.4 Relationship Between Wake Time and Screen Time
17.4.2.5 Relationship Between Sleep Quality and Screen Time
17.5 Practical Recommendations
17.6 Conclusion
References
Chapter 18: Dreams and Nightmares During the COVID-19 Pandemic
18.1 Method
18.1.1 Participants
18.1.2 Materials
18.2 Study 1: A Qualitative Close Read for Content Categories
18.2.1 Procedure
18.2.1.1 Results
18.3 Study 2: Computer Text Analysis Comparison with Pre-pandemic Dreams
18.3.1 Procedure
18.3.2 Results
18.4 Study 3: Comparison of COVID-19 Pandemic Dreams with Tweets About the COVID-19 Pandemic
18.4.1 Procedure
18.4.2 Results
18.5 Discussion
References
Chapter 19: The Impact of COVID-19 Pandemic on Sleep Medicine Services
19.1 Introduction
19.2 Alterations in Healthcare Resources in Sleep Medicine
19.3 Clinic Services
19.4 Sleep Laboratory Services
19.5 Positive Airway Pressure
19.6 Durable Medical Equipment (DME) Companies
19.7 Disparity, Sleep Medicine, and Overall Impact of the Pandemic
19.8 Summary and Future Directions
References
Chapter 20: Protocols for Sleep Medicine Services During COVID-19 and Pandemics
20.1 Introduction
20.2 Center Preparedness
20.2.1 Staff Training, Logistics, and Infection Control
20.2.1.1 Staff Training, Mitigation, and Welfare
20.2.1.2 Logistics: Supply, Monitoring, and Optimal Use
20.2.1.3 Infection Control: From Equipment Handling to Screening
20.2.1.4 Sleep Center Screening and Hygiene Protocols
20.3 Epidemiological Inputs and Sleep Medicine Inpatient Services
20.3.1 Home Sleep Apnea Testing
20.3.2 Outpatient Consultation and Follow-Up Services
20.4 Conclusion
References
Chapter 21: Management of Hospital and Home Positive Airway Pressure Machines During Pandemics
21.1 Introduction
21.2 Aerosols
21.2.1 At Home
21.2.2 In Hospitals
21.2.3 Environmental Control in Hospitals (Heating, Ventilation, and Air-Conditioning)
21.3 A Summary of Management Strategies According to Various Organizations
21.4 Practical Key Messages
References
Chapter 22: Telemedicine and Telemonitoring of Sleep Disorders During the COVID-19 Pandemic
22.1 Introduction
22.2 COVID-19 Pandemic and Sleep Services
22.2.1 Sleep Services at the Beginning and During the Pandemic Phase
22.2.2 Reopening of Sleep Services
22.3 Telemedicine: Concept and Definitions
22.4 Requirements of Telehealth
22.5 Applications of Telemedicine in Sleep
22.5.1 Telehealth and Sleep-Disordered Breathing
22.6 Telehealth and Insomnia
22.7 Summary
References
Chapter 23: Changes in Positive Airway Pressure Application and Practices in Individuals with Sleep-Related Breathing Disorder…
23.1 COVID-19 Transmission Risk Associated with Positive Airway Pressure Use
23.2 Importance of Obstructive Sleep Apnea Treatment
23.3 Impact of the COVID-19 Pandemic on the Diagnosis and Management of Sleep-Related Breathing Disorder
23.4 Positive Airway Pressure Use During the COVID-19 Pandemic
23.5 Positive Airway Pressure Use During Active COVID-19 Infection
23.6 Risk Factors Associated with Reduced Use of Positive Airway Pressure During the Pandemic
23.7 Conclusion
References
Chapter 24: Melatonin´s Benefits as a Treatment for COVID-19 Pandemic and Long COVID
24.1 Introduction
24.2 Mechanism of Action of Melatonin in Acute SARS-CoV-2 Infection
24.2.1 Virus Entrance and Replication
24.2.2 Cytokine Storm
24.3 Melatonin in the ICU
24.4 Clinical Trials Using Melatonin in Acute COVID-19 Disease
24.5 Melatonin and Long COVID
24.6 Conclusions
References
Chapter 25: Overview and Trends on Sleep and COVID-19 Publication Output
25.1 Introduction
25.2 Sleep Medicine Publication Through the Pandemic
25.2.1 First Era: Sleep Medicine Publication in the First Months of the Pandemic
25.2.2 Second Era: Infodemic and Preprints in Sleep Medicine
25.2.3 Third Era: Consolidation of the Relations Between Sleep and COVID-19
25.3 How Authors Dealt with Research During the Pandemic
25.3.1 Motivations to Publish
25.3.2 Speculative Research
25.3.3 Research Methods
25.3.3.1 Research on Medical Personnel
25.3.3.2 Online Surveys
25.3.3.3 Database Research
25.3.3.4 Real-World Evidence
25.3.3.5 Systematic Reviews and Meta-analyses
25.4 Journals
25.5 Publication Output Analysis
25.5.1 Number of Articles Published
25.5.2 Research Quality
25.6 Conclusion
References