This study aimed to explore the inhibitory effect of BBR and probiotics on the growth of colon cancer cells in vitro and in vivo, and the regulatory influence on the gut microbiome and butyrate production.An increasing number of evidence has revealed that the gut microbiome functions in immunity, inflammation, metabolism, and homeostasis and is considered to be crucial due to its balance between human health and diseases such as cancer, leading to the emergence of treatments that target intestinal microbiota. Probiotics are one of them. However, many challenges remain regarding the effects of probiotics in cancer treatment. Berberine (BBR), a natural extract of Rhizoma Coptidis and extensively used in the treatment of gastrointestinal diseases, has been found to have antitumor effects in vitro model. A total of 44 nude mice and HT29 cells were divided into control, model, model + BBR, model + probiotics, and model + combination of BBR with probiotics (CBPs). Live combined Bifidobacterium, Lactobacillus, and Enterococcus powder (LCBLEP) was used as a probiotic preparation. LCBLEP was cultured in the liquid medium under anaerobic conditions (the number of viable bacteria should reach 1 × 108CFU), and the supernatant was collected, and it is called probiotic supernatant (PS). Model + BBR and model + probiotics groups were treated with BBR and LCBLEP or PS for 4 weeks in vivo or 48, 72, and 96 h in vitro, respectively. Tumor volume or cell proliferation was measured. Gut microbiota was pyrosequenced using a 16S rDNA amplicon. HDAC1 mRNA level in HT29 cells and sodium butyrate (SB) expression in the serum of mice was detected by QPCR and ELISA.Colon cancer cell line HT29 was used to establish a xenograft model of nude mice and an p > 0.05), especially at 14 days. The inhibitory effect of LCBLEP on tumor growth was more significant, especially at 11–21 days (p < 0.05). Inhibition of BBR on in vitro proliferation was concentration-dependent. The suppression of 75% probiotic supernatant (PS) on the proliferation was the most significant. The supplement of LCBLEP significantly increased the richness and evenness of the gut microbe. BBR dramatically increased the abundance of Bacteroidetes and Proteobacteria, with reduced Ruminococcus, followed by the LCBLEP. The LCBLEP reduced the relative abundance of Verrucomicrobia and Akkermansia, and the CBP also promoted the relative level of Bacteroidetes but reduced the level of Verrucomicrobia and Akkermansia. BBR and LCBLEP or CBP improved the alpha and beta diversity and significantly affected the biomarker and metabolic function of the gut microbe in nude mice with colon cancer. The level of HDAC1 mRNA was reduced in HT29 cells treated with BBR or PS (p < 0.05), the mice treated with BBR revealed a significantly increased concentration of SB in serum (p < 0.05), and the inhibitory effect of SB on the proliferation of HT29 cells was stronger than panobinostat and TSA.The treatment of BBR and CBP reduced the growth of neoplasms in mice to a different extent (Although the combination of BBR and probiotics has no advantage in inhibiting tumor growth compared with the drug alone, BBR can be used as a regulator of the intestinal microbiome similar to the probiotics by mediating the production of SB during reducing the growth of colon cancer. So far, cancer remains a major global killer. Colorectal cancer (CRC) is the third most common cancer type (10.2%) and the second most fatal cancer worldwide (9.2%) . The exp11–1012cells). An increasing number of potent evidence has revealed that a strong correlation existed between the intestinal microbiome including specific microbes and the occurrence of colon cancer. Dysbacteriosis in the gut including changes in microbiome structure and function has been found to promote carcinogenesis , and next-generation probiotics  is a commercial probiotic preparation (the brand name is Peifeikang) and is used widely in a clinic. Several research studies have demonstrated that these probiotics have the potential to reduce the enteropathogenic complications in patients with colon cancer undergoing surgery or inhibit the growth of the cancer cells through the creation of the integrity of intestinal mucosal, promotion of the immune, and production of antitumor metabolites, then preventing the progress of the CRC (Live combined  the CRC .Coptis chinensis (Huanglian), has long been used to treat digestive diseases as an ancient antidiarrheal medication in China (Berberine (BBR), a natural plant alkaloid extracted from in China . In addiin China . Animal in China . Given tin China . HoweverBifidobacterium (BNCC232112), Lactobacillus (BNCC336974) and Enterococcus (BNCC192631) powder (LCBLEP), MRS medium dry powder (0016), and Intestinal Bacterial Enrichment Broth  were purchased from Guangzhou Leisha Biological Technology Co., Ltd. Nucleic acid extraction or purification reagent, Agencourt AMPure XP60ml Kit, Qubit dsDNAHS Assay Kit, NovaSeq 6000 S4 Reagent Kit (300 cycle) were purchased from Guhe of China (GHFDE100), Beckman Coulter (A63881), Life tech (Q32851), and Illumina (20012866), respectively. Mouse sodium butyrate (SB) ELISA Kit was from MEIMIAN Biotechnology Co., Ltd (MM-46099M1). A total number of three HDAC inhibitors, such as panobinostat (LBH589), sodium butyrate, trichostatin A (TSA), were obtained from Beyotime .Human colonic cancer cell line HT29 (JNO-21409) was obtained from Guangzhou Genio Biological Technology Co., Ltd. BALB/c nude mice aged 4–5 weeks were collected from Guangdong Yaokang Biotechnology Co., Ltd. Fetal bovine serum was purchased from Gibco (10099-141). BBR was purchased from Northeast Pharmaceutical Group Shenyang First Pharmaceutical Co. Ltd. Live combined 6/ml. The cell suspension with 0.2 ml was inoculated subcutaneously on the back of nude mice for 4 weeks. Tumor growth was observed weekly and tumor size was also measured. All animals’ performances were conducted in accordance with animal ethics.Animal feeding and management were carried out in accordance with “laboratory animal environment and facilities” (GB 14925-2010). The colon cancer cell line HT29 was conventionally cultured, and the cells were collected after digestion with trypsin until 80–90% of the culture flask was filled and resuspended with PBS to 2–5 × 108CFU), the culture supernatant was collected, and it is probiotic supernatant (PS). HT29 cells were treated with 120 μmol/L, 280 μmol/L, 420 μmol/L BBR, 22.1 μmol/L cetuximab, and 25, 50, and 75% PS (diluted with culture medium) for 48, 72, 96 h, respectively. Morphological changes were observed using an inverted phase-contrast microscope  (10 × 20). The cell proliferation rate of each group was detected by methylthiazolyldiphenyl-tetrazolium bromide (MTT).After the mixed probiotics  were cultured in the liquid medium under anaerobic conditions (the number of viable bacteria should reach 1 × 10n = 8), model group (n = 9), model + BBR (n = 9), model + LCBLEP , and model + Combination of BBR with LCBLEP . In the model group, the xenograft model was constructed according to the above method. In the Model + BBR and Model + LCBLEP groups, the mice were, respectively, treated with BBR (78 mg/kg) and LCBLEP (7.8 × 106 CFU/kg) by gavage at the beginning of modeling. A normal control group was injected subcutaneously with the same volume of normal saline. At the end of modeling, the feces of mice were collected for gut microbiome detection. Then, the nude mice were anesthetized by intraperitoneal injection of chloral hydrate to obtain tumor tissues and then sacrificed through cervical dislocation. There was no abnormal death of animals in the process of modeling.A number of 44 BALB/c nude mice  were randomly divided into five groups, namely, normal control  and incubated at 37°C for 4 h. The culture supernatant was removed from the well, and 150 μl DMSO was added. OD values were detected at 490-nm wavelength. Alternatively, the wells were added with 100 μl of CCK-8 solution  to each well and cultured at 37°C for 2 h, and then, OD values were detected at 450-nm wavelength.The mice were killed through disconnecting cervical vertebra and the corresponding serum samples were obtained. In total, 10 μl sample with 40 μl sample diluent were added into each well of the enzyme plate which has been precoated with mice SB-specific monoclonal capture antibody. Then, 100 μl horseradish peroxidase (HRP)-labeled mice SB antibody was added and incubated at 37°C for 1 h, and the plate was washed 3 times. Color developer solution was added at 100 μl/well and incubated at room temperature for 15 min. After 50 μl/well stop buffer was added for 5 min, OD values were detected at 450-nm wavelength.Feces from nude mice were collected and stored in a special sample preservation solution. Nucleic acid extraction reagent  was used for DNA extraction, and the NanoDrop luminance meter  was used to determine the concentration and quality of DNA.Nuclease-free water was used to dilute the primers to 1 μm and gDNA to 5 ng/μl. The primers _read2_sequence_GGACTACHVGGGT WTCTAAT) used for PCR had been fused with the V4 universal primers of Illumina sequencing platform. A total of 50 μl PCR reaction system was prepared using Phusion High-Fidelity PCR Master Mix with HF buffer, and PCR amplification was performed. Then, PCR products were detected by 1% agarose gel electrophoresis with a sample loading of 2 μl.Totally, 0.85x AMPure XP Beads were added to the remaining PCR products and mixed for at least 10 times. The PCR tubes were placed at room temperature for 5 min and then placed on the magnetic bead plate until the liquid became clear (about 5 min). The PCR tubes were mixed with 200 μl of 80% alcohol and washed for 30 s, and then, the liquid was carefully sucked out and discarded. The PCR tubes on the magnetic bead plates were dried until the beads were cracked completely (about 5 min). About 17 μl of nuclease-free water was added to the dried beads, and the beads were blended. The PCR tubes were put on the magnetic bead plates for separation, and after the liquid became clear, 15 μl liquid was transferred into the new PCR tube.2O. The PCR system was amplified according to the following conditions: pre-denaturation for 30 s at 98°C, followed by 30 cycles. PCR products were purified with AMPure XP Beads  and quantified using the Qubit dsDNA HS Assay Kit. After quantification, Illumina NovaSeq 6000 paired-end 2 × 150-bp platform was used for sequencing.Forward primer 515F (5′-GTGCCAGCMGCCGCGGTAA-3′) and reverse primer 806R (5′-GGactachVGGGTWTCTAAT-3′) were used for PCR amplification of V4 region of bacterial 16S rRNA gene. Barcode was synthesized into the sequence using a 7-bp specific sequence. A total of 50 μl PCR reaction system included 25 μl of Phusion High-Fidelity PCR Master Mix with HF Buffer, 3 μl (1 μm) of F/R primers, 10 μl of DNA sample, and 12 μl of ddH–△△Ct = 2–[(△Ct) Test–(△Ct) Control].The Gene sequence of HDAC1 was researched in NCBI, and its primer  was designed with Primer 5. After the cells were treated, 1 ml TRIzol was added to obtain RNA. The cDNA reverse transcription and QPCR amplification test were performed as follows: thermal denaturation at 95°C for 120 s 1 cycle, degeneration of 95°C for 15 s, anneal extends 60°C for 30 s, and dissolution curve at 60–95°C. Target gene amplification was performed by the computer. The relative expression of the HDAC1 gene was calculated as follows: 2The data of each sample from the original data according to the barcode sequence and primer sequence were split. After the barcode and primer sequences were cut off, Vsearch v2.4.4 was used to splicing the reads of each sample to obtain the original Tags data (Raw Tags). Simultaneously, the control and filtration of the sequence quality were performed. The criteria for screening low-quality sequences were as follows: the sequences less than 150 bp, the average mass value less than 20, the sequences containing unclear bases, and the mononucleotide repeats containing > 8 bp were screened; the chimeric sequences were also removed and the final valid data (Effective Tags) were obtained.Quantitative Insights Into Microbial Ecology (QIIME) software was used to calculate the alpha diversity index of operational taxonomic unit (OTU) level, including Chao1, ACE, PD_whole_tree, Shannon, and Simpson, then, the curve of ranked abundance was formed, and the dilution curve was drawn. The difference analysis of the alpha diversity index between the groups was used to compare OTU abundance and evenness between the samples. The beta diversity analysis was performed using QIMME software to calculate the UniFrac distance measure . Principt-test and the Monte Carlo permutation test were used to draw a box plot to compare UniFrac distance differences between groups. The Kruskal method of the R stats package was used to compare the differences in taxonomic phylum, class, order, family, and genus between samples and groups. In LDA effect size (LEfSe) analysis, the LEfSe default setting was employed to detect the differences in classification units between the groups. In random forest analysis, the R package default setting was used to compare the differences between groups. ANOVA was used to compare tumor volumes and cellular proliferation inhibition rate between groups, and least significant difference (LSD) was served to perform the multiple comparisons. p-value < 0.05 was considered to be statistically significant.The in vitro.The cultured HT29 cells were treated with BBR or PS with different concentrations, the diverse cellular morphology was observed compared with the control , and celAs shown in As observed in Firmicutes, Verrucomicrobia, and Clostridia was significantly increased in the xenograft model of colon cancer in nude mice. On the contrary, the abundance of Bacteroidetes and Proteobacteria was decreased in the model, which was improved by the treatment of BBR instead of LCBLEP. The addition of probiotics reduced the relative abundance of Verrucomicrobia. The CBP also promoted the relative level of Bacteroidetes but reduced the level of Verrucomicrobia, which was consistent with that of probiotics. In class, compared with the control, the relative abundance of Bacteroides was significantly reduced in the model, which was reversed by the treatment of BBR. The upregulated abundance of Clostridia and Verrucomicrobiae was observed in the model; however, the reduction of the level of Clostridia instead of Verrucomicrobiae existed in the treatment of BBR. The ingestion of probiotics decreased the relative level of Verrucomicrobiae. Interestingly, the CBP increased the relative abundance of Bacteroidia and decreased the level of both Clostridia and Verrucomicrobiae compared with the model. These phenomena in the class were consistent with that in the classification of the order. In the family, promotion of relative abundance of Verrucomicrobiaceae and Ruminococcaceae and downregulation of relative level of Bacteroidaceae were found in the model in contrast to the control. The level of Ruminococcaceae was reduced by BBR. The treatment of LCBLEP only reduced the relative level of Verrucomicrobiaceae, which was consistent with that of the CBP. In genus, the relative abundance of Akkermansia, Oscillospira, and Ruminococcus was significantly increased in the model, whereas the level of Bacteroides was dramatically decreased compared to the control. The CBP significantly decreased the level of Akkermansia, followed by the LCBLEP. The CBP also obviously increased the level of Bacteroides, followed by the BBR and LCBLEP, but BBR reduced the relative abundance of Ruminococcus, followed by the LCBLEP.As shown in Staphylococcus, Odoribacter, and Corynebacterium had a very high abundance and played a similar role as a class, whereas Prevotella, Megamonas and Haemophilus, Acinetobacter, Parabacteroides, and Enterococcus played the other similar role as an alternative class. Interestingly, these microbes with high abundance were downregulated by BBR and LCBLEP. This effect was observed in the microbes with low abundance which were also mediated by BBR or LCBLEP, especially the CBP. Some microbes that include Adlercreutzia, Clostridium, and Lactobacillus were promoted by the treatment of CBP.Next, we performed a standardized cluster analysis to understand the similarity between samples and the similarity of gut microbiota composition at the genus level, and the results are shown in Alpha diversity, an analysis of species diversity in a single sample, is calculated and assessed by the richness and diversity of the microbe through a series of statistical indices. The diversity index measures the heterogeneity of a community. So far, commonly used measure indictors for alpha diversity include Chao1, Shannon, and Simpson. Chao1 is used to measure community richness, whereas Shannon and Simpson are adopted to assess community diversity.p < 0.01).Wilcoxon test was conducted for each index of alpha diversity, and then, the alpha diversity index with significant differences was screened. The results are revealed in p < 0.05). Compared with the control, the beta diversity in the model group was significantly reduced, which was improved by the treatment of BBR and probiotics.Inconsistent with alpha diversity, beta diversity aimed to compare the differences between multiple groups of samples. Principal component analysis (PCA) and principal coordinate analysis (PCoA) were used to analyze the difference in beta diversity between groups as the two kinds of multivariate statistical methods. As shown in Psychrobacter, Moraxellaceae, Odoribacteraceae, and Odoribacter. Verrucomicrobiaceae, Verrucomicrobiales, Verrucomicrobiae, Verrucomicrobia, and Akkermansia, were the primary biomarkers in the group treated with BBR. On the contrary, Clostridia, Firmicutes, Clostridiales, and Coprococcus were the markers in the mice intervened with LCBLEP. However, the biomarkers in the group treated with CBP were significantly different from the other groups, including Rikenellaceae, Bacilli, Lactobacillales, Anaeroplasmataceae, Anaeroplasmatales, Anaeroplasma, Tenericutes, Mollicutes, Ruminococcus, Lactobacillaceae, Lactobacillus, and Rikenella.Biomarkers, namely, the dominant species with significant difference between groups, were screened through LEfSe analysis. As shown in Bacteroidetes, Firmicutes, Tenericutes, and Verrucomicrobia. These species were dysregulated in the nude mouse model of colon cancer but modulated by BBR or LCBLEP. BBR significantly promoted the relative abundance of Bacteroidetes but inhibited the level of Firmicutes, which was consistent with that of CBP. In class, the relative abundance of Bacteroidia and Mollicutes was increased by BBR, with decreased Clostridia. The treatment of CBP obviously promoted the relative level of Mollicutes but decreased the abundance of Verrucomicrobiae. Similarly, these dominant species in the order were Bacteroidales, Lactobacillales, Clostridiales, Campylobacterales, Anaeroplasmatales, Mol_RF39, and Verrucomicrobiales. The abundance of Anaeroplasmatales was dramatically increased by the CBP, with decreased Verrucomicrobiales. In family, these biomarkers reduced by BBR included Porphyromonadaceae, Rikenellaceae, and Odoribacteraceae, as well as Lactobacillaceae and Anaeroplasmataceae were increased. Compared with the model, reduction of Porphyromonadaceae, Odoribacteraceae, Verrucomicrobiaceae, and Moraxellaceae by probiotics was found, with increased Anaeroplasmataceae. Surprisingly, no influence of BBR or LCBLEP on the markers including Bacteroidaceae, Paraprevotellaceae, and Helicobacteraceae was observed in contrast to the model group. Similarly, the effect of BBR or LCBLEP on the biomarkers in genus involving Bacteroides, Prevotella, and Proteus was also not observed compared with the model. BBR decreased the abundance of Parabacteroides, Rikenella, Odoribacter, Coprococcus, Ruminococcus, and Psychrobacter, with increased Anaeroplasma and Lactobacillus, whereas the relative level of Parabacteroides, Odoribacter, Ruminococcus, Akkermansia, and Psychrobacter was reduced by treatment of LCBLEP compared to the model group. Besides, we found that the relative abundance of Moraxellaceae and Psychrobacter was dramatically high and dominant biomarkers in the gut of colon cancer.Next, the biomarkers were selected between groups according to the species classification level . In phylR = 0.194, p < 0.05). However, what were the predominant species used for classification. A random forest classification tree was adopted. As revealed in Peptococcaceae was the dominant microbe playing important role in the grouping, followed by Acinetobacter and Rikenella. How effective were these major biomarkers in a grouping? We found that these biomarkers demonstrated some accuracy in the diagnosis of all groups   was used to test whether the difference between groups was significantly greater than the difference within groups. As shown in  > 0.85) .Odsoribacteraceae, Dehalobacteriaceae, and Proteobacteria were the predominant intestinal microbes in colon cancer, whereas only Verrucomicrobiaceae was dominant in the gut treated by BBR. The main species in the gut treated by LCBLEP were Desulfovibrionaceae, Ruminococcaceae, and Lachnospiraceae, which was partly shared with that of the intestine intervened by CBP where Anaeroplasmataceae, Coriobacteriaceae, and Rikenellaceae were also predominant.In this study, we performed an evolutionary tree of species by GraPhlan to find the dominant species more visually in each group . OdsoribIntestinal microbe plays an important role in regulating intestinal cell metabolism. We performed a PICRUSt function prediction based on a 16S rDNA sequence to obtain enrichment of functional genes of KEGG metabolic pathways in level 3. The results are presented in p < 0.05), which was significantly repressed by the intervention of the LCBLEP. However, the treatment of BBR instead of LCBLEP inhibited the biosynthesis of stilbenoid diarylheptanoid and gingerol. Interestingly, the influence of LCBLEP on the metabolisms of gut microbe was similar to that of CBP.Next, we established box diagrams of significant differences for function prediction with KEGG level 3 of species between groups at the genus level. As revealed in p < 0.05), whereas Gram-positive bacteria, stress tolerance, mobile elements, aerobic bacteria, and biofilm formation were upregulated (p < 0.05). On the contrary, BBR upregulated the relative abundance of Gram-negative bacteria, potential pathogenic bacteria, facultative bacteria, aerobic bacteria, and biofilm formation and downregulated the level of Gram-positive bacteria, mobile elements, and anaerobic bacteria. These effects of BBR were opposite to that of LCBLEP. However, the influence of CBP on the phenotype of intestine microbe was different from that of BBR or LCBLEP. CBP partly neutralized the effect of BBR and LCBLEP, such as gram-negative and -positive bacteria, aerobic bacteria, anaerobic bacteria, and biofilm formation. Interestingly, significant upregulation of facultative bacteria and downregulation of mobile elements were found in the gut treated with CBP, compared to that of BBR or LCBLEP. Besides, BBR, LCBLEP, and CBP inhibited the relative level of stress tolerance, especially LCBLEP and CBP.Another analysis of the metabolic function of gut microbiota was performed through the comparison of phenotypic classification based on BugBase (an online 16S function prediction tool), and the results are shown in p < 0.05), whereas this phenomenon was not found in the cells with cetuximab treatment (p < 0.05), which brought us a clue that BBR might upregulate or increased some products leading to suppression of HDACs such as HDAC1. As shown in the serum of mice (p < 0.05) followed by the combination of BBR with LCBLEP. Next, we selected three kinds of HDAC inhibitors, LBH589, sodium butyrate, and trichostatin A. Our observation found that the inhibitory effect of SB on the proliferation of HT29 cells was stronger than LBH and TSA, and this effect was time-dependent  were produced by beneficial bacteria including Eubacterium, Roseburia, and Rikenella (Lachnospira was observed in the gut of colon mice or patients with cancer (Adlercreutzia, Lactobacillus, and Rikenella families, compared with that of BBR and LCBLEP. These results have concluded that the combination of BBR and probiotics has a greater effect on the regulation of bacterial dysregulation in the process of inhibiting colon cancer growth.In addition, we found other bacteria increased by BBR, such as ikenella , and theikenella . Similarh cancer , which wHealthy gut microbiota is described by metabolic function. Antimicrobial peptides and immunomodulatory compounds produced by the beneficial microbiome can affect the mucosal immune system, regulating their anticancer effects. Microbiota and its related metabolites are not only closely related to carcinogenesis by inducing inflammation and immune disorders, leading to genetic instability . Therefo+ bacteria, facultatively anaerobic bacteria, aerobic bacteria and repress the G– bacteria, mobile elements, and anaerobic bacteria, compared with the model. Bacteroidetes are G- bacteria and Firmicutes are G +, combining with the effect of BBR on the other bacteria including Verrucomicrobiaceae, Akkermansia, and Enterobacteriaceae, etc. These indicate that BBR has a broad spectrum of regulation on bacterial species.However, the phenotypic effects of BBR on the metabolic functions of bacterial community are very significant. Our observations reveal that BBR can obviously promote the abundance of microbiota including GBiofilm formation can destroy the mucus layer of the colon, strengthening cytotoxicity or genotoxicity through enhancement of colonic epithelial invasion, inflammation, and abnormal immune response . These pL. monocytogenes causes H3K18 deacetylation of many genomic proteins in colon cells, including SMAD1, IRF2, SMARCA2, and CXCL12 (Clostridium in the intestinal microbe and increasing butyric-producing bacteria may be a treatment strategy for CRC. Furthermore, our results have also found that probiotic was inferior to BBR in increasing butyrate production, suggesting that BBR inhibits the growth of colon cancer cells through the regulation of SB production and HDAC1 expression.An increasing number of extensive evidence has demonstrated that metabolites of gut microbes play vital roles in maintaining healthy intestinal homeostasis and preventing colon carcinogenesis. Butyrate can serve as a fuel source for intestinal epithelial cells  and haved CXCL12 . ReducedIn conclusion, BBR and probiotics can reduce the growth of colon cancer cells, with more potent effect of the latter. Besides, BBR and probiotics can mediate the composition, structure, abundance, biological diversity, and metabolic function of gut microbiome in nude mice with colon cancer, which is more significant in the mice treated with the combination of BBR with probiotics. Therefore, BBR can also be used as a regulator of intestinal microbiome similar to the probiotics. However, the influence of combination of the two on the growth of neoplasm in nude mice is not obvious, suggesting that the combination of BBR and probiotics has no advantage in inhibiting tumor growth compared with drug alone. Besides, BBR instead of probiotics can significantly increase the level of SB production inhibiting the HDAC1 expression, and the inhibitory effect of SB on the growth of colon cancer cells was stronger than LBH and TSA. Based on the current research results, we believe that the mechanism of BBR and probiotics inhibiting the growth of colon cancer cells should be inconsistent. BBR inhibits the growth either through its direct cytotoxic effects or by increasing SB production, while the mechanisms by which probiotics inhibit the growth of cancer cells are likely to work through something other than increased SB production, such as production of SCFAs , regulatin vivo experiments was performed in our design. In addition, the comparison between LCBLEP and other control probiotic strains with proven anti-colon cancer effects, and the performance of cytotoxicity assay of probiotics on normal cells and other different cancer cell lines are our negligence in this study, which will be considered in further research.Unfortunately, no drug positive control for The authors acknowledge that the data presented in this study must be deposited and made publicly available in an acceptable repository, prior to publication. Frontiers cannot accept a manuscript that does not adhere to our open data policies.The animal study was reviewed and approved by the Laboratory Animal Ethics Committee, Shenzhen University Health Science Center.CH was responsible for the research protocol design and collection of data. YS was responsible for the verification of manuscripts. S-RL, Z-XC, and H-FL were responsible for figure making and layout. W-ZS was responsible for the procurement of reagents or materials. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Objectives: This study aimed to analyze the prevalence of rheumatic diseases and its correlation with temperature and humidity among middle-aged and elderly adults in China from a spatial perspective.Methods: Data on rheumatic diseases among middle-aged and elderly adults were sourced from the 2018 China Health and Retirement Longitudinal Study (CHARLS). Moran’s I was applied to explore the spatial autocorrelation of rheumatic diseases. Spatial lag model (SLM) was established to probe the correlation between rheumatic diseases and temperature and humidity.Results: The age-standardized prevalence of rheumatic diseases was 33.2% for middle-aged and elderly adults in China, varying from 12.0% to 51.4% depending on regions. The Global Moran’s I was 0.506 (p = 0.001). Average temperature had negative correlation while average relative humidity had positive correlation with age-standardized prevalence of rheumatic diseases in the SLM.Conclusion: The age-standardized prevalence of rheumatic diseases of middle-aged and elderly adults showed spatial autocorrelation in China. We recommend taking measures to prevent rheumatic diseases for the middle-aged and elderly adults, especially for those living in cold and humid regions. Rheumatic diseases are autoimmune and inflammatory diseases that include a wide range of painful bone and joint diseases, surrounding soft tissue diseases, and systemic medical conditions, such as osteoarthritis (OA) and rheumatoid arthritis (RA) . RheumatAccording to previous studies, rheumatic diseases have a high prevalence and disability rate, which brings a heavy disease burden to individuals, families, and society , 4. GlobIn previous studies, gender and education attainment played an important role in contributing the cause of rheumatic diseases , 14. WomI for RA in Alberta, Canada was 0.15 (p < 0.05); compared with the metro areas (RR: 10.69), a higher rate was observed in rural areas (RR: 14.46) [p = 0.012) [The prevalence of rheumatic diseases are significantly regionally heterogeneous , 20. The: 14.46) . Geograp= 0.012) . These s= 0.012) , 24.This study intended to explore the prevalence of rheumatic diseases among middle-aged and elderly adults in China and to examine its correlation with temperature and humidity from a spatial perspective. We hope to provide scientific reference for comprehensive prevention and control of rheumatic diseases.2 with a population of over 1.4 billion. The climate of China is complex, diverse, and differs geographically—varying between tropical, subtropical, warm temperate, middle temperate, cold temperate, and Qinghai-Tibet plateau climate.The People’s Republic of China is located in the east of Asia between 73°33′E and 135°05′E longitude, and 3°51′N and 53°33′N. The total area is 9.6 million kmThe data on rheumatic diseases sourced from the 2018 China Health and Retirement Longitudinal Study (CHARLS), which covered 28 provinces (cities and autonomous regions) and 23,000 participants, were widely used and recognized in academia. According to the age classification standards issued by the World Health Organization (WHO), the middle-aged and elderly adults in this study were people aged 45 and older. The proportion of illiterate population was used to represent education attainment. Illiterate refers to no formal education. The proportion of living with a partner was used to represent the marital status. The above data were all from CHARLS.Average temperature and average relative humidity data were obtained from China Health Statistical Yearbook.The missing values in rheumatic disease data were supplemented by recalling the follow-up information of research subjects in the CHARLS 2013 and 2015 data. Using the 2010 Chinese population census data for age standardization, we calculated the age-standardized prevalence and drew a spatial distribution map to describe the prevalence and regional differences of rheumatic diseases.I for rheumatic diseases, average temperature, and average relative humidity. Local indicators of spatial association (LISA) cluster map were used to explore the spatial cluster types and specific cluster location of diseases in the study area.In order to explore the information about spatial autocorrelation, we calculated the Moran’s I to determine whether spatial regression models should be performed and the Lagrange Multiplier test was used to select an optimal model from the spatial lag model (SLM) and spatial error model (SEM). If the Moran’s I of residuals of the OLS model shows spatial autocorrelation, the spatial regression models were used. Then, if the Lagrange Multiplier-error is statistically significant, the SEM would be selected; and if the Lagrange Multiplier-lag is statistically significant, the SLM would be selected.Firstly, the ordinary least squares (OLS) model was used to explore the correlation between average temperature, average relative humidity, and the age-standardized prevalence of rheumatic diseases. The residuals of the OLS model were tested by Moran’s p ≤ 0.05. The OLS model takes the following form:Secondly, the spatial regression model (SLM or SEM) was applied to fit disease data, and the results were compared with that of the OLS model. The level of statistical significance was defined as The general form of spatial lag model (SLM):α is an intercept; β is the regression parameters; X is the independent variables, including average temperature, average relative humidity, the proportion of men, illiteracy rate and the proportion of living with partner; ε is the random error term; W1 and W2 are the spatial weights; W1Y is the spatial lag term; ρ is the spatial autoregressive parameter of W1Y; W2ε is the spatial error term; λ is the autoregressive coefficient of W2ε; and errors in μ are individually independent and obeying normal distribution.The general form of spatial error model (SEM):IBM SPSS 25.0 was used for descriptive analysis of the age-standardized prevalence of rheumatic diseases. ArcGIS 10.6.1 was used for spatial autocorrelation analysis and drawing the spatial distribution map. GeoDa 1.14.0 was used for spatial regression analysis.In 2018, the age-standardized prevalence of rheumatic diseases among middle-aged and elderly adults in China was 33.2%, and varied with provincial-level regions from 12.0% to 51.4% .I for the age-standardized prevalence of rheumatic diseases, average temperature, and average relative humidity were 0.506 (p = 0.001), 0.763 (p = 0.001), and 0.705 (p = 0.001), respectively, indicating the existence of spatial autocorrelation at the provincial scale. The LISA cluster map showed significant core clustering of high-high, low-low, and high-low of the age-standardized prevalence of rheumatic diseases  had a significantly negative correlation with the age-standardized prevalence of rheumatic diseases. However, the global Moran’s I for the residual of OLS model was 0.195, indicating the existence of spatial autocorrelation and a necessity for spatial regression analysis. We then applied SLM instead of SEM according to the results of Lagrange Multiplier test .Statistical results of the OLS model  demonstrp = 0.046) and illiteracy rate (p = 0.015) had a significantly positive correlation with the age-standardized prevalence of rheumatic diseases, while the average temperature (p = 0.013) and the proportion of men (p = 0.012) had a significantly negative correlation according to the results of SLM. The global Moran’s I for the residual of SLM was −0.092, indicating that there was no spatial autocorrelation . It indicated that the residual was not independent and does not meet the analysis conditions of OLS [I for the residual of SLM was −0.092 (p = 0.372). It demonstrated that SLM could analyze the spatial autocorrelation of rheumatic diseases by constructing the spatial lag term of the dependent variable [This study explored the prevalence of rheumatic diseases among middle-aged and elderly adults in China and its correlation with temperature and humidity using a spatial regression model based on follow-up data from 28 provinces (cities and autonomous regions) from CHARLS 2018. We found that the age-standardized prevalence of rheumatic diseases is spatially autocorrelated and heterogenous. Gender, education attainment, marital status, and humidity were not correlated with age-standardized prevalence of rheumatic diseases in the results of the OLS, which were inconsistent with other studies –15, 17. s of OLS . The SLMs of OLS , 16, 17.variable .The age-standardized prevalence in Sichuan and Chongqing was the highest at above 50%, while the age-standardized prevalence in Beijing and Shanghai was the lowest at less than 20%. In terms of spatial distribution, with Sichuan and Chongqing as the center, the prevalence in the surrounding regions gradually decreased. LISA cluster map showed that high-high clustering model of rheumatic disease was distributed in Xinjiang, Sichuan, Chongqing, Yunnan, and Guizhou. The prevalence of rheumatic diseases was high in these regions and their adjacent regions. The high-low clustering model of rheumatic disease was distributed in Inner Mongolia and Heilongjiang. The prevalence of rheumatic diseases in these regions was high but low in the adjacent regions. The low-low clustering model of rheumatic disease was distributed in Liaoning, Beijing, Jiangsu, Anhui, and Hebei. The prevalence of rheumatic diseases was low in these regions and their adjacent regions. A similar distribution pattern of rheumatic diseases was revealed in several studies. This may be related to the extensive area with very complex climate and environment in China , 25. Ourp = 0.015) had positive correlation with the age-standardized prevalence of rheumatic diseases. Most of the population with lower education attainment lack sufficient awareness of rheumatic diseases and do not pay enough attention to their own health conditions, which may promote the occurrence of rheumatic diseases [p = 0.012) had negative correlation with the age-standardized prevalence of rheumatic diseases. Estrogens can stimulate humoral immune responses while androgens can exert suppressive effects on both humoral and cellular immune responses, making women more susceptible to rheumatic diseases. The differences in physiological structure and lifestyle habits may also lead to higher risk for women, a fact that was consistent with the conclusions drawn by Falsarella et al. [Additionally, the illiteracy rate  and smaller AIC (191.611 vs. 204.253) performed better than OLS model. In addition, these factors, considered to be related to rheumatic diseases in previous research, were still discovered in SLM but not statistically significant in OLS. The coefficient ρ of the spatial lag term in SLM was 0.72 (p = 0.001), indicating that changes in these factors will not only influence the prevalence of rheumatic diseases in this region (the direct effect), but also influence the prevalence of adjacent regions (the indirect effect). Therefore, we have reason to believe that spatial analysis methods like SLM can provide a new perspective for the current research on disease distribution and influencing factors, from which more disease information can be discovered.Relying on big data and artificial intelligence technology, we can acquire large-scale and complex disease data. Research proves that these disease data are spatially autocorrelated, rather than simply assuming they are independent of each other. When we take into account the spatial autocorrelation, apparently, some traditional statistical analysis methods are no longer applicable. In this paper, we used SLM and OLS models to research the prevalence of rheumatic diseases, respectively. SLM with the larger There are limitations that ought to be acknowledged in this study. Firstly, the data that we obtained from CHARLS 2018 were from self-reported cases without further verifying the types of rheumatic diseases, this may have biased the prevalence preventing the analysis of specific types of rheumatic diseases. Secondly, the data of annual temperature and average relative humidity did not fully reflect the real regional differences in environmental factors. Thirdly, our study was a cross-sectional study that explored the group correlations, ignoring the effects of time factors and individual susceptibility to rheumatic diseases. Fourthly, we were unable to analyze the relationship between rheumatic diseases and other factors such as BMI, occupation, and others because of the data availability. Lastly, SLM assumed that the effect of independent variables on rheumatic diseases was consistent for all regions, which ignored the spatial non-stationarity. Thus, in further research, a local spatial regression model, such as geographically weighted regression model (GWR), could be used to explore the local effects of influencing factors.This study provided comprehensive evidence that the age-standardized prevalence of rheumatic diseases had spatial autocorrelation. The exploration of spatial regression predictors identified that the age-standardized prevalence of rheumatic diseases was positively correlated with the average relative humidity, while negatively correlated with the average temperature. These findings can provide a reference to facilitate better understanding of prevalence and to make more effective strategies to control rheumatic diseases. Policies such as strengthening publicity and education on rheumatic diseases and maintaining the air humidity and temperature at an appropriate level in living and working environments should be implemented to reduce the burden on bones, joints, and muscles. We should pay more attention to, and increase the allocation of health resources for, regions with a high prevalence of middle-aged and elderly adults with a high risk of rheumatic diseases.


Background: Employing network pharmacology in neurodegenerative diseases (NDs) has been extensively studied recently. However, no comprehensive study has conducted on this subject employing bibliometrics so far. The purpose of this study was to find out the developmental trends and hotspots, and to predict potential research directions in this filed.Methods: Relevant research were collected from the Web of Science Core Collection Bibliometrics and visual analysis were executed using CiteSpace, VOSviewer, Histcite and R-bibliometrix.Results: A total of 420 English articles on network pharmacology in NDs published in 2008–2022 were obtained from the WOSCC database. From 2008 to 2022, annual publications showed a steady growing trend, especially in 2014–2022. China, Beijing Univ Chinese Med, Frontiers in Pharmacology, and Geerts H are the most prolific country, institution, journal, and author, respectively. China, Nucleic Acids Research, and Hopkins AL are the most highly cited country, journal, and author, respectively. Moreover, network pharmacology and Alzheimer’s disease are the focal areas of current researches according to analysis of co-cited references and keywords. Finally, in the detection of burst keywords, systems pharmacology and database are new approaches to disease and drug research, while traditional Chinese medicine (TCM) and Alzheimer’s disease are hot research directions. The above keywords are speculated to be the research frontiers.Conclusion: Network pharmacology and Alzheimers’ disease are the main topics of researches on network pharmacology in NDs. Network pharmacology and the TCM treatment of Alzheimer’s disease have been the recent research hotspots. To sum up, the potential for exploring TCM treatment of AD with network pharmacology is huge. Neurodegenerative diseases (NDs) refers to a range of brain and spinal cord diseases caused by progressive neuronal damage . It is cTraditional Chinese medicine (TCM) is marked by its complex components, multiple targets and complicated pathways of activation . TraditiIn contrast to traditional reviews, bibliometrics analyzes published articles information and related data, applying statistical methods to describe or visualize the relationship between articles . BibliomRelevant data was searched and obtained from the WoSCC in 2008–2022. Literature retrieval was conducted within a day (4 September 2022) to avoid fluctuations in rapid updates of publications. The search formula was constructed to TS=  AND TS= (“network pharmacology” OR “systems pharmacology” OR “network medicine”). A total of 752 articles were retrieved, the main types of literatures chosen for our study were articles and reviews, and the language was confined to English. Two researchers (ZJ and HSY) independently performed the original literatures search and identify any possible errors and discrepancies. Besides, they read the titles, abstracts, and even the full texts of paper to filter out papers that are closely related to our subject. Only 420 publications were enrolled. The detailed retrieval process was shown in In this study, visual analysis was constructed using Microsoft Office Excel 2019, HistCite (version 2009.08.24), VOSviewer (version1.6.18), CiteSpace (version6.1), and Bibliometrix 4.1.0 Packages based on the R language.Microsoft Excel was employed to make the tables and display the information of countries, authors, institutions and references.HistCite, a document indexing and analysis software designed to process information from literature searches, helps scholars master the historical development of a field and identifies highly cited research and scholars . In presVosviewer, a software for building a visual bibliometric network based on network data , is hireCiteSpace is a citation analysis software based on scientometrics, data, and information visualization to visualize the distribution, patterns, and relationships of scientific knowledge . It can The bibliometrix package in R 4.1.0 was used to automate the transformation and analysis of bibliographic information for selected publications, including institutional and periodical outputs, as well as author impact indicators. Indicators including number of publications and number of citations were used to evaluate the impact factors of the authors. The h-index commonly used to assess the level of academic output of a researcher , higher n = 1934), and TLCS peaked in 2018 (n = 31). 2014–2022 was a period of stable development in this field with 394 publications. However, TGCS and TLCS fluctuated during this period. The above results showed that although the number of citations fluctuated, the overall volume continued to grow sharply.A total of 420 English articles related to the network pharmacology in NDs were included. From 2008 to 2022, a total of 53 countries participated in the research on network pharmacology in NDs. The United States had close connections with European countries . China wInformation visualization helps to identify influential institutions and clarify their cooperation. Chinese institutions are the main driving force in this area and top three institutions ranked by centrality were China Acad Chinese Med Sci (0.06), Guangzhou Univ Chinese Med (0.04) and Beijing Univ Chinese Med (0.03) ; Table 2A total of 2,511 authors contributed to researches on network pharmacology in NDs. Geerts H, from the United States, had the largest number of publications (25), followed by Fang JS (12) and Spiros A (12) . Moreove. The distribution of scientific journal issues is shown in a double map overlay  and journal quartiles from the 2021 Journal Citation Reports. The top three high-yield journals were Frontiers in Pharmacology (IF5.988), Evidence-based Complementary and Alternative Medicine (IF2.650), and Journal of Ethnopharmacology (IF5.195). The top 10 most productive journals in . The di overlay . The douFurthermore, we build a timeline for clusters in According to visual analysis of keywords by CiteSpace , networkBurst keywords detection can reveal the evolution of the topic, predict the development directions and excavate potential flash point. As shown in In this research, we utilized the method of bibliometrics to objectively analyze literatures allied to the network pharmacology in NDs. Our results suggested that the number of annual publications in this field had increased significantly in recent years, which showed that this field was receiving more and more attention. The number of publications and citations in a certain research field are considered to be significant index to evaluate academic reputation and scientific research ability of a country or institution . China rIn addition, our results indicated that Geerts H was the most influential author. He focused on Alzheimer’s drug research and made important contributions to the treatment of NDs. He devoted himself to using systems pharmacology to develop integrated models of compounds, mechanisms, and disease-level data , exploreIn this research, most prolific journals were divided into Q1 or Q2, and Alzheimer & Dementia (IF16.655) had the highest IF. Frontiers in Pharmacology (IF5.998) were the journal with top production, noting that many high-quality articles had been published about this filed. Although Evidence-based Complimentary and Alternative Medicine (IF2.650) had 33 publications, its IF values were less than 5. Maintaining the quality of the work as well as increasing the output will help enhancing the academic impact of journal. Among the most commonly cited journals, Nature (IF69.504), Science (IF63.714) and Nucleic Acids Research (IF19.160) had IF values higher than 15, indicating that the quality of the evidences from the above periodicals was high, and had strong persuasiveness and influence.The analysis of co-cited articles and literature cluster reflect the core content and hot topics in a field, and the highly cited documents can prompt the core research and high-intensity burst can represent emerging academic hotspots. . Top thrAdditionally, “network pharmacology” (Cluster ID 0#) with 68 references was the largest cluster, which covered network pharmacology in the applications of drug discovery, protein, gene etc. Peng Zeng et al. revealed the key components in Ginkgo Folium and its mechanism in the treatment of AD employing network pharmacology . SzklarcBased on the joint analysis of keywords’ frequency and emergence, the study on therapy for AD especially TCM draw extensive attention recently. These TCM therapy of AD included the follow aspects: 1) reducing the deposition of Aβ peptide and removing the hyperphosphorylation TAU protein: gypenosides XVII enhanced the autophagy dependent removal of Aβ through TFEB activation . GeniposThis study visualized the relationships between network pharmacology and NDs to understand their trends and hotspots through the use of bibliometrics. However, there are a few shortcomings to this study. For instance, due to the limitations of current scientific measurement software, it is difficult to analyze data from multiple databases simultaneously, so this study only utilized the WOSCC database. Moreover, this study only included articles and reviews, not abstracts, conferences, or books. Therefore, more comprehensive studies and databases could be undertaken in the future for more complete and accurate analysis.In conclusion, researches on NDs employing network pharmacology have been extensively conducted, and the number of articles retrieved has shown a clear increasing trend, especially in 2014–2022. China was the most prolific country, while Chinese Academy of Sciences also made important research achievements, which was important force in the development of this field. Moreover, Geerts H was the leader in this field by publishing the most articles. The main research focuses in this area are the development and application of network pharmacology and the treatment of AD. Medication of NDs, especially TCM, will become the focus of future research. In addition, the application of network pharmacology in Chinese herbal compound have great research prospects. Collectively, our study conducted a systematic visualization of literatures on network pharmacology in NDs, showed the main aspects of the subject and provides the direction and reference for further researches into diseases and drugs.


A balanced scorecard (BSC) is a comprehensive performance evaluation (PE) tool. A recent review summarized that a balanced consideration of PE from six perspectives in hospitals must be considered: financial, customer, internal, external, knowledge and growth, and managerial. However, patients were rarely engaged in BSC implementations. This research aims to engage Palestinian patients in BSC implementation to develop recommendations for policy makers.In this cross-sectional study, the BSC-PATIENT survey was distributed between January and October 2021. We evaluated patients' experiences and their attitudes toward BSC dimensions (BSCP ATT). The differences in evaluations based on admission status were analyzed using the Mann-Whitney U test. Causal relationships between patients' experiences and attitudes were analyzed using multiple linear regression. We tested the multicollinearity of the model. Path analysis was performed to understand the BSC strategic maps based on the Palestinian patients' evaluations.t = 13.543, P < 0.001), patient care , services , and building  had the highest impact on BSCP ATT. The price had only a weak negative influence . Accessibility to hospitals did not have any impact on BSCP ATT. Significant differences between inpatient and outpatients' evaluations in regard to experiences related to patient care (P = 0.042), services (P < 0.001), accessibility (P < 0.001), and BSCP ATT (P = 0.003) were found.Out of 1,000 surveys, 740 were retrieved. The mean scores for Palestinian patient experiences evaluation showed that the services experience factor had the highest score (87.7 ± 17.7), and the patient care experience factor had the lowest score (57 ± 34.5). Patient experiences collectively predicted 56.4% of the variance in the BSCP ATT. The experience factors of information (β = 0.400, BSC-PATIENT successfully engaged patients in BSC PE at Palestinian hospitals. This research provides strong evidence for the impact of patients' information experience on their attitudes. Palestinian health policy makers must prioritize the design and delivery of patient education programs into their action plans and encourage a two-way information communication with patients. Strong evidence for patient care, services, and building experiences role in improving patients' attitudes was found. Managers should enhance patients' feedback and engagement culture in Palestinian hospitals. The health care system in the Occupied Palestinian Territories (OPT) is described to be fragile and incoherent , 2. ThisThe coronavirus COVID-19) outbreak placed additional burdens on the world's health care system due to the limited capacity of hospital beds and the increased psychological stress of health care workers (HCWs) during the pandemic  outbreak. There iOne of the strategic managerial tools that was implemented globally by many hospitals and utilized KPIs for the performance evaluation (PE) of HCOs is the balanced scorecard (BSC) . When NoIn the BSC second generation, researchers demonstrated the existence of causal links between the KPIs of these perspectives . These cPatient engagement has been an evolutionary topic in recent years , 26. PolThe absence of patient engagement in BSC deployments and the lack of validated tools for this purpose , 28 promThere is a difference between patients' experiences and attitudes. An event that was lived through is referred to as an experience . The heaA review  exploredIn Palestine, researchers mainly focused solely on evaluating patient satisfaction. There is a lack of research in OPT that differentiates between patients' experiences and attitudes. This hindered Palestinian health policymakers from determining which patient experiences shape their attitudes. In addition, studies engaging patients in the PE of Palestinian hospitals are scarce. To the best of our knowledge, there has not yet been any research conducted in Palestine or anywhere else in the world that involves patients in BSC implementations using a survey , 24. ThiThis cross-sectional multisite design study is a part of a broad project , 24, 37.Since it was infeasible and geographically challenging to reach all hospitals in OPT, convenience sampling was used to choose 18 hospitals. Nevertheless, we took into consideration that our hospital sample has a variety of hospital sizes, locations, and administrative types. For that, the maximum variation sampling approach was utilized . Therefoz score was 1.96 at a 95% confidence interval (CI). Therefore, the number of patients required to conduct the study was 385. The authors were concerned about the poor survey response rate during the pandemic and opted to distribute 1,000 surveys. The patients were chosen because they were willing to take part in this study.The sample size was determined using a Steven K. Thompson sample size calculation . The popIn this research, we employed the Arabic version survey, which was designed and validated to engage patients in hospital PE at the BSC implementations (BSC-PATIENT) . The valThe BSC-PATIENT validation revealed that the patient experiences loaded on seven factors: information experience (INFO EXR), price experience (PR EXR), patient experience (PT EXR), access experience (ACC EXR), service experience (SERV EXR), building environment experience (BUILENV EXR), and building capacity experience (BUILCAP EXR). The validation also revealed that all the Palestinian patients' attitudes loaded on one factor, BSCP ATT, except the patient image toward the technology (TECH IMAGE) and complications (COMP IMAGE), which loaded separately. In this research, we analyzed the effect of experience on BSCP ATT. We were not able to assess the influence of the management experience, which is represented by the administrative type in this study. This is because eight hospitals have permission constraints that prevent us from releasing any PE results connected to the hospitals' names or administrative types at the time being.The first five authors were responsible for the data collection. A 3-h training session on BSC, data collecting procedures, and ethical considerations was provided by the lead author to the other authors prior to data collection. The coauthors were assigned tasks and hospitals based on where they lived: eastern Jerusalem and the northern, middle, and southern parts of the West Bank. The exclusion of the Gaza Strip was based on political and logistical reasons. In addition, five hospitals were excluded: two military hospitals that had not yet opened, one psychiatric hospital, and two rehabilitation hospitals.Printed surveys were given to respondents between January and October of 2021 instead of delivering the questions through email to prevent non-response bias . To miniA Palestinian patient who was at least 15 years old and of any gender was eligible for participation in the study. Outpatients should either have completed receiving medical care at the hospital being evaluated or should have received medical care at the evaluated hospital at least once in the past and returned there for additional treatment. Patients classified as inpatients must have been hospitalized for at least 1 day. The following departments were covered: pediatrics, gynecology, internal medicine, and surgery. Additionally, the emergency room was included. The patient companions were responsible for filling out the survey in the emergency room. One parent of each child was asked to complete the surveys in the pediatrics unit. The other surveys were completed by the patients themselves; in the instance that patients were unable to fill out the survey themselves, the data collector or a member of the patient's family read the survey to them and then completed the surveys based on the patient's responses. To make a distinction, a question was added that asked the responder if their answers were based on their personal experiences, the experiences of their family members, or the experiences of their friends.The data were coded by the first author. The normality of the data was tested by employing the Shapiro-Wilk test. Additionally, frequencies were calculated for the categorical patient-sociodemographic questions. The experiences and attitudes answers were converted to scale measures. For the 3-point Likert scale, “No” answers were coded as zero, “Yes” answers were coded as 100, and “I do not know” as 50. Frequencies for each question were calculated. Then, the mean score and standard deviation (SD) of each factor in both inpatient and outpatient categories were calculated based on the average of their underlying questions . Cronbacr) was used to test the association strength between the independent factors or the dependent and independent factors. Then, r was described as negligible when r < 0.2, low (r = 0.2–0.49), moderate (r = 0.5–0.69), high (r = 0.7–0.85), or very high (r = 0.86–1.00). The cause-and-effect relationship was tested through a multiple linear regression with a P-value <0.05 for statistical significance and 95% CI. A path analysis is suggested to enhance the conceptual understanding and communication of regression results using an illustration The Institutional Review Board (IRB) was issued on May 31 of 2020 by the Research and Ethics Committee at An Najah National University's Faculty of Medicine and Health Sciences with a reference code number . After that, we requested authorization to conduct the research at the public hospitals from the Palestinian Ministry of Health. Then, the request was submitted to every hospital individually, independent of its administrative type classification. Between June and December 2020, requests were to 15 hospitals on the West Bank and 3 hospitals in Jerusalem. Additionally, all of the patients provided written, informed consent to participate in the study that was in line with the Declaration of Helsinki ethical principles . PatientThe response rate was 74%. The Shapiro-Wilk test result was significant, which revealed that the data were not normally distributed, so we decided to use non-parametric tests in the subsequent stages.The characteristics and sociodemographic characteristics of the patients are shown in The percentage of respondents' answers per question, as well as the means and SDs of the experience and attitudes factors, are shown in The variance analysis showed significant mean rank differences between inpatients and outpatients at the PTEXR, ACCEXR, SERVEXR, and BSCPATT. In general, the mean rank evaluation for all factors was higher for the inpatients see .Spearman correlations between the experience factors were either negligible or weak. The correlation between INFOEXR and PTEXR was moderate. The correlations between the experience and attitude factors were either negligible or low, except between INFOEXR and BSCPATT, and PTEXR and BSCPATT were moderate. See the correlogram in F = 160.522, P < 0.001]. Looking at the unique individual contributions of the predictors, the results show that INFO EXR , PT EXR , SERV EXR , and BUIL EXR  positively predicted BSCPATT. However, PREXR  had a weak negative influence on BSCPATT. The ACCEXR effect was not significant  on 31 May 2020. The patients/participants provided their written informed consent to participate in this study.This paper's conception was planned by FA. Additionally, FA, HN, SA, YA, and MA were responsible for obtaining hospital approval and data collection. FA was responsible for statistical analysis, interpretation of data, and writing the final draft. FA, HN, SA, YA, MA, DS, IB, and DE substantially revised the final manuscript draft. FA, HN, SA, YA, MA, DS, IB, and DE approved the submitted version and agreed to be personally accountable for the author's contributions and to ensure that the accuracy and integrity of any part of the work were appropriately investigated and resolved.This research was financed by the Thematic Excellence Program 2021 Health Sub-Programme of the Ministry for Innovation and Technology in Hungary, within the framework of the EGA-10 project of the University of Pécs and the National Laboratory on Human Reproduction (RRF-2.3.1-21-2022-00012) Program. Data collection expenses were personally funded by FA.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Physical activity is essential for a healthy life and quality of life, representing a fundamental role in individuals' physical and mental health. Concomitantly, the physical therapist, through the promotion of physical activity and exercise, can improve mental health, an essential factor in the current pandemic, triggering anxiety, fear, and depression crisis.To verify physical activity among Portuguese physical therapists and its association with mental health during pandemic times.An online questionnaire was applied through social media to all Portuguese physical therapists between October 21, 2021, and January 14, 2022. It contained general characterization questions of the sample, the IPAQ-SF questionnaire to assess physical activity levels, the Goldberg General Health Questionnaire (GHQ-28), which assesses the levels of mental health and the WHO Well-Being Index (WHO-5) to assess the subjective wellbeing.r = −0.571, p = 0.000).The sample totaled 286 respondents , with a mean age of 33. Of the total answers, 82% practiced physical activity, 45% had moderate levels of physical activity, and 19% vigorous. Physical therapists in these categories had lower values in the GHQ-28 and higher in the WHO-5. Those with better mental health also showed better subjective wellbeing (The data obtained showed that physical therapists mostly have moderate and vigorous levels of physical activity and that physical activity positively influences individuals' mental health and wellbeing, which proved to be a key factor due to the pandemic situation. Physical activity (PA) is defined by the World Health Organization (WHO)  as any mHealth professionals are held responsible for promoting PA in their clinical practice to reduce non-communicable diseases and improve individuals' quality of life, reducing physical inactivity and sedentary lifestyles, which have become a severe public health problem with high costs to society , 5.Once confronted with the diseases triggered by physical inactivity, health professionals are in a favorable position to advise sedentary individuals to become more active and initiate behavioral changes regarding PA .Physical therapists are qualified health professionals who prescribe PA to prevent or treat comorbidities and promote health . This stThe current COVID-19 pandemic, first reported in December 2019 in China . PandemiHowever, the confinement proved to be a barrier to maintaining an active lifestyle, because outdoor health activities started to trigger worries and fears . This brAccording to WHO (2022) “Mental health is a state of mental wellbeing that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community. It is an integral component of health and wellbeing that underpins our individual and collective abilities to make decisions, build relationships and shape the world we live in. Mental health is a basic human right, and it is crucial to personal, community and socio-economic development .” WellbeThe pandemic due to COVID-19, brought with it implications in several factors, and one of the main ones was the mental health implication, with an increase in stress in the short and long term. According to statistics, during the 1st year of the pandemic, anxiety and depressive disorders increased by about 25% .p < 0.0001), and this was found in all age groups and particularly in males. A significant positive correlation was also found between PA variation and general wellbeing , which suggested that the decrease in PA levels, led to a negative impact on the psychological health and wellbeing of the population. In summary, after analyzing the results it was found that maintaining regular PA was critical for physical and mental health during the COVID-19 pandemic , sitting, and using technology, pre, and post-COVID-19. They also questioned individuals on PA guidelines, stress, loneliness, positive mental health, social connectedness, and depressive and anxiety symptoms. Individuals were divided according to United States PA guidelines, ≥8 h/day sitting, or ≥8 h/day in front of a screen, pre-, and post-COVID-19. It was found that 62% of the participants were female, aged 18–24 years (16.6% of the sample), and older than 75 years (9.3%). According to participants' responses regarding PA, those who were active before COVID-19 reported decreased practice after COVID-19 [mean change: −32.3% ], while those who were previously inactive reported no differences [+2.3% ]. In summary, improving/maintaining PA practice and limiting time in front of the screen may reduce negative effects on mental health in situations of drastic social change . This is a non-random sample, auto-selection sampling type  , it is eing type .Inclusion criteria were being a physical therapist. The exclusion criteria were not accepting the Informed Consent form to continue filling out the online questionnaire.Data were collected using an online questionnaire developed on the Google forms platform, and data were collected from October 21, 2021, to January 14, 2022. The questionnaire was disseminated through digital platforms, Facebook (different groups), and WhatsApp. It was requested to be disseminated through the various higher education institutions that teach the physiotherapy course in Portugal, as well as the physiotherapists' association APFisio, through its newsletter on 06/12/2021.The questionnaire was composed of four parts: general characterization; the International Physical Activity Questionnaire (IPAQ-SF), the Goldberg's General Health Questionnaire (GHQ-28), and the WHO Well-Being Index (WHO-5).Sample characterization questions were asked: age, gender, and professional experience .The International Physical Activity Questionnaire (IPAQ-SF) was used to assess PA in its short form. It followed the classification indicated in several studies –28 and aThe official IPAQ scoring protocol suggests that individuals should be divided into three levels of PA:(a) Three days minimum of vigorous PA and energy expenditure of 1,500 MET-min/week;(b) A minimum of 7 days of PA, comprising a combination of moderate PA, vigorous PA, and walking, achieving a minimum of 3,000 MET-min/week.- Vigorously Active Level (VA):(a) Three or more days of vigorous PA, with a minimum time of 20 min/day;(b) Five or more days of moderate PA, vigorous PA, or walking, reaching a minimum of 30 min/day;(c) Five or more days of PA per week  for a minimum of 600 MET-min/week.- Moderately Active Level (MA):(a) Participants whose energy expenditure does not reach PA values can be included in any previous categories.- Insufficiently Active Level (IA):We prioritized this questionnaire due to her short form and because it is less expensive . After aThe Goldberg's General Health Questionnaire (GHQ-28) was used to evaluate Mental Health. It presents 28 questions divided into four subscales that assess four dimensions: somatic symptoms subscale (questions 1–7), anxiety and insomnia subscale (questions 8–14), social dysfunction subscale (questions 15–21), and major depression subscale (questions 22–28) –35.The questionnaire created by Goldberg and Hiller in 1979  uses a LSeveral studies refer to different cut-off points for each subscale, 4/5 , or 5/6 It is a self-administered questionnaire that allows the assessment of mental health or psychological wellbeing among the general population in non-psychiatric settings, such as public health and primary health care .It is a clinical assessment method that allows quick results to identify possible psychiatric cases to be subsequently diagnosed .In this study, the Portuguese version  of the GWHO Well-Being Index (five) (WHO-5) , 1998 veThis index is widely used in research worldwide, its first publication dating from 1998, and has been translated into more than 30 languages . It was WHO-5 consists of five positively worded questions that ask which way is closest to how the individual has felt over the past 2 weeks. The values are scored on a six-point Likert-type scale ranging from 0 (Never) to 5 (All the time). Questions scores can be modified on a scale from 0 to 100, where higher scores indicate a better level of wellbeing , 44, 45.The online questionnaire was anonymized to safeguard the privacy of the participants. It included a brief description of the study, its objective, and the informed consent, following the Helsinki Declaration (dated 1964).This study was submitted to the Ethics Committee (EC) and the Scientific-Technical Council of the Escola Superior de Tecnologia da Saúde de Lisboa (ESTeSL)—IPL, obtaining a favorable opinion (CE-ESTeSL-N°30-2021 on 08/10/2021).Results were analyzed in the Statistical Package for Social Sciences (IBM SPSS Statistics), version 26.n, %) for qualitative data was used, and mean and standard deviation for quantitative data was employed. Data normality was verified using the Kolmogorov-Smirnov test.The results were considered significant at a 5% significance level. To characterize the sample, frequency analysis . Three participants answered, “I do not want to participate in this study, or I am not a physical therapist,” so they ended the questionnaire, therefore, they were excluded from the study. Thus, the final sample consisted of 286 participants. Of the total respondents, 82.2% were female, and 17.8% were male, ranging from 21 to 67 years (33 ± 10 years). The age of the participants was defined as young adults (≥40 years), adults (41–60 years), and over 60 years . In the sample, on average, ages are lower and there is a higher percentage of women. However, despite the differences, the trend of the sample is the same as the population.In relation to the population of physiotherapists registered in the physiotherapists' order, the average age is 34.4+-9.1 years, with 26.1% men and 73.9% women. Regarding these values, statistically significant differences were detected in the study sample  indicated they practiced PA, while 51 (17.8%) did not practice any PA . RegardiRegarding the PA levels of the Portuguese physical therapists, it was found that most (45.1%) of the participants had moderate levels of PA, 36.4% were IA (Insufficiently active), and 18.5% were VA (Vigorously active) .It was also possible to analyze from the IPAQ-SF questionnaire the minutes per day spent in sedentary behavior, namely sitting, presenting a range value between 15 and 1,200-min sitting (221 ± 175) .The mental health of physical therapists was assessed through the GHQ-28, obtaining the following data: In the subscale of Somatic Symptoms, a mean of 4.87 ± 3 was acquired; regarding Anxiety and Insomnia, a mean of 6.53 ± 5 was obtained, and in the subscale of Social Dysfunction 8.64 ± 3, and the Severe Depression they presented the lowest value of 1.62 ± 3. To these answers corresponded the total (mean) value of the scale of 22 ± 9 points .Regarding the mental health of Portuguese physical therapists, the following GHQ-28 results were obtained .In the analysis of wellbeing through the WHO-5, most participants found results between 51 and 75% (59 ± 19), thus verifying a medium/high sense of wellbeing since 0 represents the worst and 100 represents the best sense of wellbeing .The association between PA levels and mental health was analyzed through IPAQ-SF and GHQ-28 results, and the following was found.p = 0.007]. The multiple comparisons test regarding PA levels found significant differences between the category IA and MA individuals (p = 0.012) and between IA and VA individuals (p = 0.005). Individuals in the IA category showed higher values on the Somatic Symptoms subscale than individuals practicing PA of moderate or vigorous intensity (Regarding Somatic Symptoms (GHQ-28) differed between at least two groups of the levels of PA [ntensity .p = 0.021]. The multiple comparisons concluded that there are significant differences when comparing individuals with insufficient levels of PA (IA) and MA (p = 0.005). In this subscale, it was observed that MA individuals presented the best results   , i.e., tp = 0.518] and Severe Depression [p = 0.148], there were no significant differences between the three levels of PA.In the subscale of Social Dysfunction [p = 0.009]. When the test of multiple comparisons was used, there was a significant difference between IA and MA individuals (p = 0.007), in which it was verified that IA individuals presented higher values in the total score of the scale than MA individuals , analyzing that the individuals who are in category IA presented lower values in the questionnaire, therefore a lower sense of wellbeing, the same was verified between IA and VA (p < 0.001)  questionnaire and PA levels revealed differences between at least one of the groups [< 0.001) .This study was developed to verify Portuguese physical therapists' physical activity levels (PA) and their association with mental health during the pandemic.A sample of 286 physical therapists was obtained, of which the majority (82.2%) were female and 17.8% male. The study by Kgokong et al. , with idRegarding the age of the participants, the age group that presented the fewest answers to the questionnaire was the group over 61 years old, with only one respondent. Younger physical therapists adhered more significantly, with 80.7% of participants aged 40 years or younger. This leads to considering that younger individuals have a greater propensity and willingness to answer online questionnaires or higher use of digital platforms.In our sample, 82.2% practice PA, while 17.8% reported they do not practice any PA, as well as, in the study by Black et al. , in whicWhen analyzing the study by Chevan and Haskvitz , physicaBy calculating the PA levels of the physical therapists in the present study, based on the duration (minutes), frequency (per week), and MET intensity (MET.min/week) , it was When we analyzed the values obtained by the PTs in our study, we found that the scale from somatic symptoms to major depression and the total value of the scale was below the cutoff point, which would be expected since we were analyzing data from a population with no diagnosis of mental illness .When comparing the results of the present study with the values obtained by Ribeiro and Amaro , who assThese results suggest that physical therapists have a lower incidence of symptoms compatible with emotional disorders than social workers  and a hiPA is essential not only for physical health but also for mental health . Thus, iIt has been found that individuals with lower PA values are more likely to be emotionally disturbed concerning somatization .When we analyze the anxiety and insomnia scale, MA subjects have lower values on this subscale than IA subjects, showing less anxiety and insomnia symptoms.When looking at the total scale score, individuals who are MA have lower scores on the scale than AI individuals. Furthermore, studies indicate , 37 highr = 0.07541, p = 0.0002).Analysis of subjective wellbeing (WHO-5) and the levels of PA (IPAQ-SF) results confirmed. That is, physical therapists who were IA had lower feelings of subjective wellbeing when compared to physical therapists who were MA and VA. Also, in a recent study  that anaIt is believed that the main limitation of this study will be our sample size since, to be representative of the population in question , we would need at least 385 individuals.Also, the type of data collection may generate biases since there is the possibility that the people who make up the sample are selected by convenience and not randomly. Furthermore, to justify the lower number of individuals in older age groups, we believe that older individuals are more reluctant to answer this questionnaire or are fewer users of existing digital platforms.Our study, had only the purpose of analyze levels of PA in Portuguese physical therapists and related mental health and wellbeing in a pandemic context but a limitation founded was the lack of covariates  as a threat to internal validity. This should be taken in account in future studies.The results obtained may thus serve as a basis for future studies, which should be carried out with a more significant sample of the population, and perhaps through another type of data collection (random) to obtain more significant values and a more heterogeneous sample.To our knowledge, this is the first study that evaluates the physical activity levels of physical therapists in Portugal and especially relates this data to mental health during a time that involved so many changes in how they live and work.The present study show that PA positively influences physical therapists' mental health, as well as their feeling and wellbeing, which are critical factors given to the pandemic situation. Moreover, most physical therapists seem to be aware of regular PA practice, although there is still space for improvement since almost 40% of insufficiently active physical therapists are yet absent.Since PA influences mental health, the physical therapist as a health professional needs to have good levels of mental health to provide better care to their users. According to the results and considering that most physical therapists have moderate and vigorous levels of PA, the profession is in a beneficial position regarding mental health and wellbeing.Mental health and physical inactivity are two challenges for public health, mainly due to its social and economic determinants, which have worsened in the current pandemic of COVID-19. Thus, it would be relevant to review the physical therapist's performance as health promotors, so that through the prescription and counseling of PA, it is possible to reduce the incidence of disease and improve the physical and mental health of the general population.The raw data supporting the conclusions in this paper will be made available by the authors without undue reservation.LA designed the study, designed the questionnaire, analyzed and interpreted the results, and wrote the manuscript. EC helped with statistical analysis of results. MT and AG revised the study and all the manuscript and with LA approved the final version. All authors contributed to the article and approved the submitted version.This project was supported by FCT/MCTES (UIDB/05608/2020 and UIDP/05608/2020).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Background: Regulation of autophagy affects the progression of atherosclerosis. In recent years, research on autophagy in atherosclerosis has been widely concerned. However, there is no bibliometric analysis in this field.Objective: The purpose of this study was to explore the general situation, hot spots, and trends of the research in this field through bibliometric analysis.Methods: Articles related to autophagy in atherosclerosis from 2012 to 2021 were retrieved from the Web of Science Core Collection. VOSviewer and CiteSpace were used for data analysis and visualization of countries, institutions, authors, keywords, journals, and citations.Results: A total of 988 articles were obtained in the last 10 years. The number of publications and citations increased rapidly from 2012 to 2021, especially after 2019. The most productive countries, institutions, journals, and authors were the People’s Republic of China, Shandong University, Arteriosclerosis Thrombosis and Vascular Biology, and Wim Martinet, respectively. The primary keywords were “oxidative stress,” “apoptosis,” “activated protein kinase,” and “inflammation.” The burst detection analysis of keywords found that “SIRT1” and “long non-coding RNA” might be regarded as the focus of future research.Conclusion: This is the first bibliometric analysis of autophagy in atherosclerosis, which reports the hot spots and emerging trends. The interaction between oxidative stress and autophagy, programmed cell death, and activated protein kinases are considered to be the current research priorities. Molecular mechanisms and therapeutic target for the intervention of atherosclerosis by regulating autophagy will become an emerging research direction. Atherosclerosis is a chronic disease caused by inflammation and lipid deposition , which mThe pathogenesis of atherosclerosis is complex and diverse, and its molecular mechanism has not yet been fully elucidated . Early sAs mentioned above, considerable research efforts have been directed at autophagy in atherosclerosis. The precise regulation of autophagic flux provides new ideas for developing anti-atherosclerosis drugs . HoweverBibliometrics is an emerging knowledge synthesis approach that identifies publications’ quantitative and qualitative attributes  and explData from this study were extracted from the Web of Science Core Collection (WoSCC). The search formula was set as “{[TS = (atherosclerosis)] AND [TS = (autophagy OR autophage OR autophagocytosis)] AND PY = (2012–2021)}” Conditions were set for all articles published between 1 January 2012 and 31 December 2021, with no restrictions on language and article type. A total of 988 articles were obtained, and all the records and cited articles were exported in plain text files. The exported records were named after “download_*.txt” for subsequent analysis.This study performed bibliometric and visual analyses based on Microsoft Excel 2016, CiteSpace 5.8. R3 (64 bit), and VOSviewer 1.6.18.Microsoft Excel was used to analyze annual publications and citations, literature type, country distribution, and language.k = 25).Based on CiteSpace, we conducted the collaboration network analysis of countries and institutions, co-occurrence analysis of keywords, and co-citation analysis of references. Each node in the visual map represents the country, institution, author, and other subjects to which it belongs. Its size indicates the frequency of appearance. In networks, betweenness centrality measures how central a vertex is about shortest paths . The nodVOSviewer was used to analyze and visually display large-scale data samples in intuitive forms such as overlay visualization, network visualization, and density visualization. In this study, VOSviewer was used to obtain the co-occurrence network of authors, authors, journals, keywords and references, as well as the density map of co-cited journals.A total of 988 articles were retrieved from 2012 to 2021. The annual number of publications has generally increased from 2012 onwards, except in 2019 . A totalThere were 293 institutions from 54 countries that published literature related to autophagy in atherosclerosis. Among them , the mosThree hundred ninety-one authors contributed to the study of autophagy in atherosclerosis, with Wim Martinet, Guido R Y De Meyer, and Babak Razani as the most prolific authors. The co-authorship network is depicted in The authors with the highest co-citations and the top 10 most cited authors are presented in Arteriosclerosis Thrombosis and Vascular Biology has the largest number of publications, with 24 articles. Followed by Frontiers in Pharmacology (22), Oxidative Medicine and Cellular Longevity (22), and Autophagy (21). About one-fifth of the literature was from the top 10 journals. The average impact factor (IF) of the top 10 journals was 6.60, and the average H-index was 142.8. Cell biology, biochemistry, and molecular biology are the main journal categories. A total of 118 journals were cited more than 100 times. The top three co-cited journals were Journal of Biological Chemistry, Circulation Research, and Autophagy . This indicates that in the field of metabolic biology, autophagy and atherosclerosis are highly correlated.A total of 142 articles were cited more than ten times. In this study, we analyzed the literature related to autophagy in atherosclerosis in the past decade by bibliometric methods. A total of 988 publications from the WoSCC were obtained. According to our results, annual publications and citations increased significantly from 2012 to 2021, especially after 2019. The People’s Republic of China, with the largest number of publications, has greatly contributed to the research on autophagy in atherosclerosis. In addition, nine of the top 10 prolific institutions were from the People’s Republic of China, such as Shandong University, the University of South China, and Shanghai Jiaotong University. This indicates that autophagy has gained increasing attention from Chinese research institutions in the study of atherosclerosis mechanisms in recent years. However, countries from North America and Europe had a higher centrality ranking than countries from other regions, indicating that they attached more importance to international exchanges and cooperation. Although China is developing rapidly and occupying a dominant position in this field, its regional collaboration and academic influence still need to be improved. The above shows that the current research is imbalanced in international distribution.in situ measurement of autophagy . Autophagy was founded in 2005, and it has become an authoritative journal in this field. Arteriosclerosis Thrombosis and Vascular Biology was the most prolific journal, and its IF was 8.311. This journal was sponsored by the American Heart Association and focused on vascular diseases related to arteriosclerosis and thrombosis. In addition, most active journals belong to specialized categories. Some multi-disciplinary journals, such as Scientific Reports and PloS One, also reported high-quality research on autophagy in atherosclerosis. Autophagy in atherosclerosis is a young and growing research topic involving multiple categories such as molecular biology, cell biology, biochemistry and medicine. The development of this research topic was published in journals from different disciplines, indicating that the pathogenesis and treatment of atherosclerosis received extensive attention from researchers. Besides, multi-disciplinary journals have a broader readership  Interaction between oxidative stress and autophagy , includiAfter the burst detection analysis of keywords, we believe that sirtuins and long non-coding RNA (lncRNA) are emerging trends and development directions in the future. Sirtuins are closely related to aging, lifespan, and metabolism , and havThere are a few potential limitations to this study. First, the data for bibliometric analysis were only from the WoSCC. Second, our search strategy may not cover all the research in this field. Third, some publication types, such as corrections and retractions, can interfere with the results of data analysis. Fourth, our analysis may miss the latest research advances due to the rapid expansion.As far as we know, this study is the first comprehensive bibliometric analysis of autophagy in atherosclerosis from 2012 to 2021. By using CiteSpace and VOSviewer, we identified the knowledge distribution characteristics of autophagy in atherosclerosis. “Oxidative stress,” “apoptosis,” “activated protein kinase,” and “inflammation” are hot topics in this field. In addition, targeted therapy for atherosclerosis and the development of new drugs based on autophagy regulation will be the focus of future research, especially in sirtuins and lncRNA. In summary, this study provides valuable information for summarizing research progress and exploring future research directions.