Trends and relevance in the bladder and bowel dysfunction literature: PlumX metrics contrasted with fragility indicators.
INTRODUCTION
The concepts of fragility index (FI) and fragility quotient (FQ) have been previously described. PlumX metrics encompass online "footprints" of research in addition to traditional citations. Herein we explore PlumX metrics against the quality of BBD literature.


OBJECTIVE
To explore altmetrics against the quality of bladder and bowel dysfunction (BBD) literature.


STUDY DESIGN
A literature search was conducted using Pubmed, Medline, Embase for BBD and related terms. A total of 54,045 abstracts were screened, followed by 693 full text reviews and data extraction from 126. Studies were included if they reported on 2 groups being compared, had dichotomous outcomes, and had significant results.


RESULTS
The median FI score was 4 (0-500) and there were 20 studies which had a FI of 0. The FQ had a median of 0.04 (0-0.32). PlumX usage was 263 ± 540, captures were 45 ± 60 and social media attention was 2 ± 2. Overall, 42% of papers were clinical trials (RCTs). When compared to other study designs, we noted a significant difference in PlumX captures (57 ± 72 RCT vs. 35 ± 47 other; p = 0.03). RCTs had higher usage, social media engagement and citations however, the differences were not significant. H-Index had a significant correlation with FI (p = 0.036), however correlations for PlumX usage and captures, while modestly positive (0.04-0.10) for the FI and FQ, were not significant. A comparison of FI and FQ by topic can be reviewed in the Summary Table.


DISCUSSION
When considering the FI and FQ robustness indicators of the BBD literature, we found similarities when compared to other studies. It was reported that overall, the hydronephrosis literature was fragile with many studies requiring only a few events to nullify significance, regardless of the study design. Similarly, in a review of pediatric vesicoureteral reflux (VUR) clinical trials, results were also fragile. When comparing fragility measures to altmetric variables we noted that despite the growing popularity of altmetrics, citation counts, and h-indices remain the traditional measures to monitor research consumption. There has been a reported correlation between manuscript citation counts, author h-index, altmetrics measures in several specialties and across many domains of research including medical sciences, arts, and the humanities, however in the present study only weak correlations were noted.


CONCLUSION
The body of BBD comparative studies is fragile in keeping with other pediatric urology literature populations. Despite fragile results, RCTs generate slightly moreattention as measured by select PlumX metrics. These results suggest the need for including fragility measures in our literature, aiming to focus attention towards more robust articles.