Top-down methods to analyze post-mortem tissue and bottom-up approaches with the potential to provide molecular insights on the organization of plaque-like particles are compared. Finally, a network analysis of Aβ-interacting partners with enriched functional and structural key words is presented.Alzheimer’s disease (AD) is pathologically defined by the presence of fibrillar amyloid β (Aβ) peptide in extracellular senile plaques and tau filaments in intracellular neurofibrillary tangles. Extensive research has focused on understanding the assembly mechanisms and neurotoxic effects of Aβ during the last decades but still we only have a brief understanding of the disease associated biological processes. This review highlights the many other constituents that, beside Aβ, are accumulated in the plaques, with the focus on extracellular proteins. All living organisms rely on a delicate network of protein functionality. Deposition of significant amounts of certain proteins in insoluble inclusions will unquestionably lead to disturbances in the network, which may contribute to AD and copathology. This paper provide a comprehensive overview of extracellular proteins that have been shown to interact with Aβ and a discussion of their potential roles in AD pathology. Methods that can expand the knowledge about  Alzheimer’s disease (AD) is the most prevalent cause of dementia today, affecting close to 50 million people worldwide . Consideet al. in plaques the year after [et al. [The connection between dementia and the pathological protein inclusions that signify AD was first reported by Alois Alzheimer in 1906 . Howeverar after . Tau was [et al. . The obs [et al. –16 suggeβ in vitro and highlight potential connections to AD pathology reported in the literature.Based on the pathological and genetic findings, research around Aβ turned into a very popular field with thousands of papers published every year. Among the more important progress made within the biochemistry of AD are the determination of high-resolution structures of Aβ amyloid –20, the The identification of Aβ in senile plaques from post-mortem tissue was indeed a breakthrough in the molecular description of AD. However, Aβ was not the first protein to be associated with plaques. Immunoglobulins and complement proteins had already been detected , 27. In e.g. comparison with LCM of tissue just outside the plaques [For the early identification studies, analysis of samples from dedicated purification protocols or immunohistochemical investigation of tissues were used Fig. . Althoug plaques , 32 or wet al. in 2004 reported 488 proteins found in plaques [et al., and employing a different sample preparation protocol, only found Aβ in the plaque cores [Increased sensitivity of MS instrument has also lead to an increasing number of identified proteins. The pioneering study by Liao  plaques  while Xi plaques , 33. Notue cores . Hence, neuritic or dense core plaques are formed around a core of fibrillar Aβ structure and have neighboring reactive astrocytes and activated microglial cells. Diffuse plaques are poorly marginated assemblies of filamentous Aβ, which is weakly stained by amyloid-specific dyes, and do not have associated toxicities as the neuritic plaque. The diffuse plaques often lack of neuritic elements, nevertheless, diffuse neuritic plaques can be observed in advanced AD. Yet another class are the cerebrovascular Aβ deposits, in the course of CAA. There are, however, limitations in the possibilities to acquire a detailed molecular understanding of the plaque structures. For examples, which components are directly sequestered by Aβ amyloid fibrils, which components may be more loosely bound or bound to some of the already sequestered proteins and which components just happened to be localized in vicinity of the plaques? Crosslinking protocols could potentially resolve some of these question [Investigations of post-mortem tissues are extremely important since they are authentic samples. There are endless opportunities to compare different tissues, different classes of plaques, different individuals etc. This is important since the molecular assembly of all plaque types is not the same , 35. Thequestion , 37. Sucquestion , 39 but e.g. Ref. [in situ deposits of fibrillar proteins that also include organelle structures such as endoplasmic reticulum, ribosomes and proteasomes [e.g. for investigating co-localization, can also be achieved in electron microscopy through immunolabeling with colloidal gold. Hence, imaging of senile plaques with molecular resolution may soon give us the first glimpses of the arrangement of the different molecular components.Microscopy offers many opportunities to analyze the presence of different components and their structural properties with spatial resolution. Combining specific antibodies and various amyloid probes with conformation-dependent optical properties allows for imaging of heterogeneities within single plaques  for the understanding of the pathology as a detailed understanding of the Aβ amyloid formation process. Any pathological process triggered by Aβ  must proceed via interactions with other biomolecules. Hence, it is not enough to know which proteins are found in the plaques (or close to them) we must also decipher how they are organized and what functional consequences the deposition has for each protein, process and biological pathway. Therefore, biochemical model systems that can capture these effects are, and will continue to be, important for the progress of AD research.in vitro studies of interactions between biomolecules and with the opportunity to derive structural as well as functional parameters. One of the challenges when approaching systems, such as senile plaques, is the complexity in terms of the number of different components. There is always a balance between the simplicity of an in vitro model and its ability to capture biologically relevant features. If we accept that Aβ fibril formation is a central process in the pathology, that should also be the starting point for building in vitro models. Studies of Aβ fibrillation have been a popular field for quite some time. The progress in these studies has provided in-depth understanding of how Aβ, and proteins in general, assemble into amyloid fibrils. Although the experiments are typically carried out in pure systems with the addition of only a few additional components, the mechanism rapidly become very complex. Fibrillation of Aβ in in vivo–like environments, e.g. CSF [There are many methods that enable e.g. CSF , has demet al. studied intracellular protein aggregation in a cell model and found a correlation between the toxicity of artificial β-sheet proteins and their ability to sequester cellular proteins [1-antitrypsin, the FAS4 domain from human cornea and the human hormone glucagon [In a pioneering study from 2012, Olzscha proteins . Experimproteins , 47. Recproteins . Interesproteins . In anotproteins . In a foproteins . Other sglucagon –54.et al. demonstrated that flow-cytometry could be used to isolate “plaque particles” formed around Aβ, α-synuclein, tau or cholesterol added to serum samples [et al. [The amyloid corona concept offers a new and interesting perspective on the assembly of plaque-like multiprotein aggregates and could potentially be the starting point for studying plaque formation with molecular resolution. However, the methods to identify, analyze and quantify the components need to be developed and advantages and drawbacks of each approach evaluated. Common separation methods are filtration , 54, cen samples . In addi samples . A centr [et al.  shows thTaken together, it is clear that there is an emerging interest to explore the composition and organization of amyloid protein coronae, which opens opportunities to acquire new knowledge about the multicomponent structures of senile plaques and new insights about AD pathology.in vitro studies as Aβ-interacting proteins in human biofluids, including plasma, serum, and CSF. These studies have reported more than a hundred different proteins with the ability to interact with different conformations of Aβ. The majority of these proteins are also known to be present in senile plaques. As the survey is limited to proteins from biofluids, cell-surface receptors and intracellular proteins are naturally excluded unless they are also secreted to the fluid. Nevertheless, a brief discussion of these proteins is included in a separate section. The plaques also contain many non-protein components, including proteoglycans, nucleic acids, lipids and metal ions. For more details about these classes of molecules we refer to recent reviews: [As already stated, thousands of proteins have been identified in post-mortem plaque tissue. A comprehensive review of these proteins is not feasible. Instead we chose to apply a bottom-up perspective and investigate the set of proteins found by recent reviews: , 58.at least two separate studies in Table In this section, we will discuss the implicatiyuulators of Aβ fibrillogenesis. The proteins are categorized and presented according to their main biological functions. We have listed the proteins that are found in the literature to interact with Aβ in Immunoglobulins were among the first proteins to be identified in senile plaques , 27 and Auto-antibodies against Aβ were first reported in 1993  and someMoreover, Aβ is not the only antigen for AD-related autoantibodies. Immunoglobulin response against several other proteins/structures, e.g. oxidized low-density lipoprotein, RAGE, and S100b, have also been found , potentiComplement activation is critical in normal inflammatory responses to injury and in removing apoptotic cells, tissue debris, and other macromolecular aggregates. Likewise, complement proteins have fundamental roles in the development and protection of the central nervous system. Inappropriate activation of the complement system in the brain may cause neuroinflammation, or even neuronal cell death. Activation of the neuronal complement in AD brain is supported by the identification of several initial and terminal proteins of complement cascade, including complement 1q (C1q) , 70, 73,in vivo [in vitro [C1q has been found highly increased in human and mouse brains with age , 146 andin vivo  and C1q in vitro . Hence, in vitro .in vitro [e.g., C1s and C4, in human plasma in a dose-dependent manner [In addition to C1q, Aβ can bind several other complement proteins in vitro , 72, 75.t manner . Aβ-medit manner , and theLike C1q, C3 may also damage synapses during the aging process since the protein is found to be increased in the brain and CSF of AD patients as well as mouse models of AD . Indeed,in vitro [in vitro findings. ACT was found to promote Aβ deposition, particularly in hippocampus, in a double ACT/APP transgenic mouse model compared to the mouse that only express APP [Alpha 1-antichymotrypsin (ACT) is an inflammatory protein and belongs to the serine protease inhibitor family. Like the complement-related inflammatory proteins, ACT is often found in AD plaques , 66, 67.in vitro , 63–65 ain vitro . Mouse mress APP .In summary, Aβ interacts with several proteins associated with innate immune response and inflammation and could thereby trigger and modulate neuroinflammation, which is a critical part of AD pathogenesis.Lipids have central roles in cell signaling as well as many physiological processes related to normal brain development and functions . Bindinget al. [in vitro binding of apoE to Aβ and demonstrated that the binding event required residues 12–28 of Aβ. The binding affinity of apoE to Aβ was found to be in the order of apoE2 > apoE3 ≫ apoE4, which inversely correlated with the risk of developing AD [in vitro, though the actual effect of apoE on Aβ aggregation is contentious. Some of the studies suggest that the binding of apoE to Aβ increases Aβ oligomerization [in vivo. A transgenic mouse model expressing apoE4 (E4FAD) showed compact and greater Aβ deposits while apoE2 (E2FAD) and apoE3 (E3FAD) expressing mice exhibited diffuse plaque type [in vivo likely take place during the early stage (seeding stage) of amyloid development [ApoE exists in three isoforms—apoE2, apoE3, and apoE4. The protein plays a role in Aβ metabolism and clearance, in which apoE4 is the least efficient variant and thereby represents an increased risk of developing AD , 169. Stet al.  reportedoping AD , 172. Horization , and subrization , 175. Inrization . Mouse mque type . The astque type . Howeverelopment . Besideselopment .Contrary to the aggregation promoting effect, apoE has also been found to have an inhibitory effect on Aβ fibrillation in some studies –182. ThiIn vitro studies support this protective mechanism since many studies have shown that CLU can bind Aβ and protect against Aβ aggregation [in vivo. The astrocytic overexpression of CLU in APP/PS1 transgenic mouse (APP/PS1AAV-CLU) showed a significant reduction of total and fibrillar Aβ in cortex and hippocampus compared to APP/PS1AAV-GFP control [i.e., substantial increase of amyloid plaque load in both cortex and hippocampus of APP/PS1; Clu+/− mice [−/− mice [−/− mice that showed impaired Aβ clearance [Like apoE, CLU is also a key player in AD pathology and capable of modifying Aβ aggregation. However, CLU may have beneficial roles in AD. The protein has a chaperone function that can specifically inhibit the elongation of Aβ fibrils  and it iregation , 189 as regation . Transge control . Moreove control . In supp+/− mice , and in −/− mice . Further−/− mice , which ilearance . The eviin vitro [In addition to apoE and CLU, several other apolipoproteins including apoA-I, apoA-II, apoA-IV, apoB-100, apoC-I, apoC-II, apoC-III, apoC-IV, and apoD are in the center of interest in the field of AD research. Accumulation of these proteins in amyloid deposits may disturb the brain lipid metabolism and thereby cause cognitive dysfunction. These proteins can also bind Aβ and modulate its aggregation and toxicity. For example, apoA-I, an abundant plasma protein, can bind Aβ and inhibit its fibrillation . The morin vitro .−/−) augments the Aβ burden and aggravates neuronal loss in the brain compared to 5×FAD APP/PS1 transgenic mice with apoA-IV [The internalization of Aβ is considered as one of the contributing factors to the toxicity and cell damage in AD. Hence, inhibition of such events may be beneficial against AD. ApoA-II, while forming complex with apoE, appears to have inhibitory effects on Aβ internalization in cell culture . Likewis apoA-IV . This mo apoA-IV . Besides apoA-IV , 89, 92  apoA-IV , 96 wereTaken together, the close links between the apolipoproteins apoE and CLU, and various aspects of Aβ biochemistry may explain their special recognition as genetic risk factors. Accumulation of these, and other apolipoproteins, in plaques may affect the lipid metabolism and thereby also neuronal function and plasticity.Vascular dysfunction is commonly observed in AD and may precede onset of the disease . Aβ can via CD11b-CD18 microglia activation. In contrast, the inhibition of fibrinogen-CD11b binding led to improved cognition in the animals [in vivo Aβ-fibrinogen interactions. In vitro, binding of Aβ to fibrinogen results in the fibrillation of fibrinogen and Aβ itself [Fibrinogen has a central role in the hemostasis process and is also implicated in AD pathogenesis. In a recent study, fibrinogen was shown to induce spine elimination and to promote synapse loss in a 5×FAD transgenic mouse model  animals . Fibrino animals , indicatβ itself . Biochemβ itself . It is lβ itself . Hence, β itself .Plasminogen and antithrombin are parts of negative feedback loops in the coagulation cascade. Both of these proteins can bind Aβ , 56, 109in vitro [Alpha-1-antitrypsin (A1AT) and alpha-2-macroglobulin (α2M) can modulate inflammation, proteostasis, and apoptosis. Both proteins show potential as AD biomarkers , 107, cain vitro , 204. Moin vitro , 106.Hence, co-aggregation of Aβ and blood coagulations proteins may contribute to CAA development and thereby enhance the cognitive deficiencies. However, disturbances of the hemostasis machinery could also impede the coagulation cascade and lead to an increased risk of micro hemorrhage, which is also reported for AD patients .Although the proteins in this category have their main roles intracellularly, they can also be secreated or located to the cell surface. Their extracellular concentrations may also increase as result of neuronal death and lysis . Dysfunce.g., oxidation and glycation) can interact with several molecular partners that are associated with normal cellular as well as pathogenic functions [in vitro and GAPDH, when co-administered with Aβ into C57BL/6J mice, showed increased Aβ induced neurotoxicity compared to the mice that were treated with either Aβ or GAPDH alone [GAPDH is an enzyme, which in its modified forms  is expressed on the surface of several cell types, including neurons, and acts as a receptor and activator of plasminogen . It has in vitro [Procollagen C-endopeptidase enhancer 1 (PCPE1) is a glycoprotein involved in procollagen processing. In addition to its role in procollagens maturation, PCPE1 is thought to have additional functions  reinforcin vitro , 56 and in vitro , 60, 66.Binding of metabolic enzymes to amyloid plaques could certainly disturbed their functions and reduce neuron viability. It is, however, not clear how sequestration of extracellular enzymes would affect intracellular processes. The GAPDH and ENO1 examples illustrate that these proteins may have other biological functions that are yet not fully understood.in vitro studies.Alteration or interruption of the transport pathways for nutrition and essential biomolecules can have adverse effects on cell viability. Several proteins with transport as main functions have been found in post-mortem plaques and their binding to Aβ have been confirmed by in vitro and promote its aggregation [Hemoglobin (Hb) is the major transporter of oxygen to the body tissues, including brain tissue. In brain, Hb is expressed in specific cells, such as neurons , 222, anregation , 226. HeHb degradation can lead to release of heme and redox-active iron that can trigger the formation of reactive oxygen species and oxidative stress. Indeed, dysfunctional iron homeostasis is part of the AD pathology , 228. He−/−) mice showed a twofold increase in iron-loaded oligodendrocytes in the basal ganglia and thalamus compared to wild-type mice, which verified that Hpx is involved in heme scavenging in brain [in vitro data [D) is 0.30 μM [in vitro Aβ fibrillation [Protection against the release of heme is achieved through the proteins haptoglobin (Hpt) and hemopexin (Hpx), that are both found to be binding partners of Aβ fibrils. Hpt is well known for binding free hemoglobin after the intravascular hemolysis thereby preventing iron loss  while Hpin brain . Hpt appin brain . The Aβ-tro data . The bin 0.30 μM . Moreoveillation  and Aβ cillation . Hpt as illation , which cIn vitro studies showed that albumin inhibits Aβ fibrillation by binding to the monomer [In vivo studies corroborates in vitro finding as a 3×Tg mouse model treated with human serum albumin exhibit reduced Aβ deposition and ameliorated cognitive impairment. Moreover, SHSY5Y cell line treated with human serum albumin resulted in a reduction in Aβ toxicity [Serum albumin is abundant in both plasma and CSF where it binds and transports a range of different molecules, including Aβ . The pro monomer , or by b monomer , 242. Intoxicity . Notablytoxicity , and evitoxicity . In additoxicity , 118. A toxicity . More retoxicity , and theD of 28 nM [in vitro studies showed that TTR can inhibit Aβ fibrillation in buffer and CSF [Transthyretin (TTR) is a tetrameric protein predominantly produced in the liver and functions as a carrier of thyroxine and retinol in plasma and CSF . TTR binof 28 nM . The binof 28 nM  and in v and CSF , 250. TT and CSF . The pro and CSF . Moreove and CSF . The TTR and CSF  and TTR  and CSF .Other transporter proteins such as inter-alpha-trypsin inhibitor heavy chain H2 (ITIH2) and serotransferrin are found in senile plaques , 59, 66.Taken together, the described examples highlight two classes of transport proteins that may have key roles in AD pathology: transporters of Aβ could affect its clearance and accumulation while dysfunctional iron transporters are linked to oxidative stress and neuronal damage.Neurosecretory protein VGF is a nerve growth factor that regulates neuronal development and activity through processing of the precursor protein into bioactive peptides. One such peptide, TLQP-21, has been shown to enhance Aβ clearance through microglial phagocytosis and to promote fibrillar Aβ uptake by microglial BV2 cells through a complement C3a receptor-1 (C3aR1)-dependent mechanism . A more in vitro Aβ fibrillation and Aβ-induced neurotoxicity in Neuro2a cell cultures [e.g., IAPP and α-synuclein [Like VGF, proSAAS is a proteolytically processed protein with the main function in the neuroendocrine secretory pathway . It is rcultures . Furtherynuclein , 266.Neural cell adhesion molecule 1 (NCAM1) is an important component of the central nervous system (CNS) extracellular interface but also found in soluble form in CSF and plasma. NCAM1 has key roles in modulation neuron-neuron adhesion, neurite outgrowth, synaptic plasticity, as well as in learning and memory and is also associated with several neurological disorders . It inteBrevican and neurocan are chondroitin sulfate proteoglycans specifically expressed in the brain and neural tissues. They are involved in CNS development, cell migration, maturation, and tissue homeostasis and are key components of perineuronal nets . It is ki.e., α–,β–,γ–secretase, as APP and generates a range of fragments [in vitro [Amyloid-like protein 1 (APLP1) is a transmembrane protein, which belongs to the amyloid precursor protein gene family. Members of this family are known to play critical roles in the development of nervous system, the formation and function of synapses, including synaptic plasticity, learning, and memory . APLP1 iragments , but notragments . Immunocragments , 278. APin vitro , 52, 56,in vitro .The accumulation of neural proteins in plaques provides a direct link between protein aggregation and reduced neuronal functions. Some of the proteins may also have neuroprotective effects that are lost upon their inactivation.The extracellular matrix (ECM) proteins and proteoglycans are often found in senile plaques and it has been confirmed that Aβ, and in particular its aggregated forms, can bind a range of ECM-associated proteins . InteracProteoglycans are thought to play functional roles in cell-cell and cell-matrix interactions in the brain. Moreover, proteoglycans appear to modulate Aβ aggregation and deposition and to play roles in Aβ internalization and cytotoxicity –283. A tIn vitro studies reported that agrin can bind Aβ and accelerate its fibrillation as well as protect fibrils from proteolytic degradation [in vivo Aβ deposition. Endothelial overexpression of agrin in AD transgenic mouse resulted in reduced Aβ accumulation, and conversely, mouse lacking endothelial expression of agrin showed an increased Aβ deposition in the brain [D of 3.5 nM [Agrin is a heparan sulphate proteoglycan present in different areas of the brain including microvasculature but its functions in the brain remains unclear . The proradation . Curioushe brain . Howeverf 3.5 nM ) comparef 3.5 nM , 126. Inf 3.5 nM . Moreovef 3.5 nM , 127, whf 3.5 nM .Likewise, glypican-1 (Gpc-1) seems to be predominant in senile plaques  and cerein vitro [in vivo has not been investigated broadly although the interaction likely also occurs in the AD brain. The binding of decorin to Aβ may account for the deposition of Aβ in cerebrovascular amyloid deposit in AD [Yet another proteoglycan family protein, decorin, is also found in senile plaques , 129 andin vitro , 128. HoCartilage acidic protein 1 (CRTAC1), an extracellular matrix protein in the β-propeller protein family, is present in the brain, but its function remains unclear . Neverthvia glatiramer acetate (GA) or GA- and bone marrow-derived monocytes treatments) resulted in reduced plaque burden in ADtg mice compared to mice treated with phosphate buffer. These mice also showed improved phagocytotic clearance of Aβ [Osteopontin (OPN), a protein with its main role in bone tissue structure, has been confirmed to be elevated in AD patients and there are findings that link the OPN expression to the Aβ load . It is lce of Aβ .Galectin-3-binding protein (G3BP) was just recently shown to inhibit the processing of APP into Aβ by direct interaction with APP . Co-depoe.g. vitronectin, osteopontin, fibulin-1 and galectin-3-binding protein, are known to also regulate complement system, immune response, inflammatory response or hemostasis and could thereby contribute to AD pathology through these processes [in vitro. However, the physiological significance of these proteins in AD still needs to be elucidated.Some cell adhesion proteins, rocesses , 301–303In summary, it is not surprising that many ECM- or cell-surface proteins are found in plaques but several of these proteins appear to be actively involved in the initiation and buildup of Aβ aggregates. A better understanding of these interactions may reveal ways to delay the plaque pathology.ca. 50% decline of Aβ plaque burden in the cortex of Cys68+APP23+ transgenic mice overexpressing human CysC compared to Cys68−APP23+ mice [In addition to the proteins reviewed above, several proteins with confirmed binding to Aβ as well as presence in senile plaques, fall outside the functional categories in Table 23+ mice . Besides23+ mice . Apart f23+ mice .in vitro studies [in vitro [Gelsolin is a ubiquitous actin-binding protein present in plasma and CSF as a secretory protein , 311. Th studies , 56, 135in vitro . Periphein vitro . Anotherin vitro . These s−/−) serum amyloid A amyloidosis mouse. Amyloid deposition in mice lacking SAP was found to be delayed and reduced compared to (SAP+/−) control [D of 6 nM [in vitro studies suggests that SAP accelerates Aβ fibrillation and stabilizes fibrils against proteolytic degradation [Serum amyloid P component (SAP) is an important regulator of the innate immune system. Nonfibrillar SAP is a universal component of all amyloid deposits, including parenchymal and vascular Aβ deposit in AD , 317–319 control . However of 6 nM . Evidencradation , 322. SAradation . Besidesradation , 325. SAradation .in vitro studies have demonstrated its binding to Aβ [Secreted frizzled-related protein 3 is involved in the Wnt signaling pathway . This pang to Aβ , 52, 56,ng to Aβ .e.g., olfactomedin-like protein 3), cell mobility , and antimicrobial and proteolytic activity  are found in senile plaques and bound to Aβ in vitro, nevertheless, their links with AD is still scarcely described in the literature.Other proteins with fundamental roles in early development (e.g. [vide infra). Tau has already been mentioned as the main component in neurofibrillary tangles but it has also been found in plaques [Finally, we want to briefly mention two important proteins that are not included in Table e.g. , 331. Ale.g. , 333 bute.g. . Lewy boe.g. . In vitr plaques . This co plaques , 51, 56.KEGG pathway is “Staphylococcus aureus infection”, which may indicate that Aβ fibrils could trigger responses similar to bacteria infection.In order to gain new insights from the assembled list of proteins we analyzed it (with the immunoglobulins excluded) by the STRING protein network tool . The nete.g., Toll-like receptors (TLRs), scavenger receptors such as CD36 and TREM2 [Although Aβ amyloid plaques are per definition extracellular inclusions, investigations of plaques from brain tissue have revealed the presence of a large number of intracellular proteins. These are clearly parts of the plaques as they have been found by top-down studies of tissue –33 and Fnd TREM2 –345. Thend TREM2 .Fig. 5Ie.g., [An alternative route involves intracellular Aβ accumulation Fig. . Aβ is pe.g., –354). The.g., . Taken tIn vitro biochemical binding studies of intracellular proteins similar to those in biological fluids are few. Olschza et al. reported some proteins interacting with Aβ in human embryonic kidney 293 (HEK293T) cells, including translation initiation factors, chromatin regulators, RNA processing proteins, mitochondrial membrane proteins and chaperones. It is not clear, however, what form(s) of Aβ that was responsible for the interactions [e.g., from comparison of different cell types or even subcellular compartment.ractions . Anotherractions . They foboth bottom-up and top-down approaches.Just by recognizing the normal and potential abnormal functions of the proteins listed in Table In vitro binding studies suggest that many proteins can bind Aβ with KD in the μM-nM range, which suggest specific binding event rather than unspecific sequestration. Within the network there are also many proteins where mutual interactions are part of their biological function. Such interactions could be important in recruiting certain proteins to the plaques.Among the outstanding questions regarding the molecular perspective are to decipher the details of the architecture of the multicomponent plaques; are they just random aggregates of sequestered proteins or is there some kind of order? in vivo or plaque-like particles in vitro are known to form amyloid themselves and to be associated with amyloid diseases. This group of proteins include immunoglobulins, apolipoproteins , serum amyloid A, fibrinogen, cystatin C, gelsolin, and transthyretin. Notably, NAC (i.e. α-synuclein) [More knowledge is also needed regarding whether the bound proteins retain their native structure or if the interaction can lead to misfolding. It is intriguing that many of the proteins that associate with senile plaques nuclein) , 333 is nuclein) , 212, canuclein)  and vitrnuclein) . So far in vitro. Moreover, surface-catalyzed secondary nucleation seems to be a critical part in the amplification of Aβ aggregates [How is further Aβ aggregation affected by the binding of other proteins? As described above many of the sequestered proteins are known to affect Aβ aggregation gregates  and thatgregates  is indeeEmbracing the multiprotein nature of amyloid deposits also expand the therapeutic opportunities. All proteins on the list are potential drug targets. Therapeutic effects could be achieved by inhibit binding or by modulating protein functions to restore loss-of-function effects or counteract toxic gain-of-function effects. Having the highly connected functional network in mind, even small alterations in the composition of plaques could have significant effects on the pathology.


The concept of enhanced recovery after surgery (ERAS) has been proposed to provide guidance for the improved postoperative rehabilitation of patients with occipitocervical region disease (ORD).n = 73), ameliorated group (n = 70), and ERAS group (n = 65). We compiled a range of data relating to demographics and postoperative changes in hemoglobin and albumin, surgery duration, intraoperative blood loss, number of postoperative hospitalization days and expenses, readmission rates, and visual analog scale pain symptoms. Data were statistically evaluated using one‐way analysis of variance with Student–Newman–Keuls‐q post hoc tests or chi‐square tests.This study retrospectively investigated 208 consecutive patients (116 men and 92 women) ranging in age from 22 to 76 years with ORD between July 2014 and June 2017 in our medical center, who were divided into three groups that received different preoperative, intraoperative, and postoperative management plans: traditional group (P = 0.235), gender (P = 0.691), body mass index (P = 0.723), American Society of Anesthesiologists grade (0.747), lesion character (P = 0.337) and lesion site (P = 0.957) between the three groups. Within a 6 months follow‐up period, there was no significant difference between the three groups in terms of surgery duration (P = 0.225), blood loss (P = 0.172), changes in hemoglobin (P = 0.255) and albumin (P = 0.178). However, postoperative hospitalization days (P = 0.000), postoperative costs (P = 0.019) and improvement of pain symptoms (P = 0.000) in ERAS group were significantly lower or higher than those in traditional group or ameliorated group, respectively. There were 29 (39.73%), 22 (31.43%), and 13 (20.00%), recorded cases of postoperative complications in traditional group, ameliorated group and ERAS group, respectively; complications in ERAS group were significantly lower than those in other two groups (P = 0.043). Moreover, all of the complications were mitigated effectively by the infusion of fluid, analgesia, treatment of infections, or antiemetic medications. There were 2 (2.74%), 3 (4.29%) and 2 (3.08%), recorded cases of re‐admission in traditional group, ameliorated group and ERAS group, respectively, but there were no statistically significant differences when compared across the three groups (P = 0.866).There were no significant differences in terms of age (ERAS can provide benefits when it applied to patients undergoing ORD surgery mainly in terms of reducing postoperative complications, however, ERAS does not increase the economic burden of patients or decrease the risk of readmission. This study investigated 208 consecutive patients to provide guidance for the improved postoperative rehabilitation of patients with occipitocervical region disease. We found enhanced recovery after surgery can provide benefits when it applied to patients undergoing occipitocervical surgery mainly in terms of reducing postoperative complications. With recent developments in medical technology, the number of patients undergoing surgery of the craniocervical junction region is increasing year‐by‐year. This has increased the rate of treatment success for a variety of conditions, including atlantoaxial fractures, occipitocervical deformities, immune diseases, and subtentorial tumorsIn recent years, the concept of enhanced recovery after surgery (ERAS) has offered the potential to address these postoperative problems in many fields of surgery through the reduction of traumatic stress and the incidence of complicationsThis study retrospectively analyzed data from 208 patients who had undergone occipitocervical junction surgery, with or without ERAS. The clinical variables studied included blood loss, postoperative complications, nutritional status, hospital stay, and hospitalization costs. These variables were compared among different groups in order to: (i) provide better guidance for the postoperative rehabilitation of such patients; (ii) propose further discussions on the future of ERAS protocols for occipitocervical junction diseases; and (iii) optimize and increase the widespread implementation of ERAS protocols.n = 55), including occipital meningiomas (n = 28), tumors of the cerebellar vermis (n = 10), cerebellar hemorrhages (n = 13), and Chiari malformations (n = 4). The lesions were located in the occipital bone and atlas (n = 88), including Klippel–Feil malformations (n = 12), bone fractures and/or dislocation (n = 38), single basilar invaginations (n = 13), basilar invaginations complicated by atlantoaxial instability (n=18), and basilar invaginations complicated by platybasia (n = 7). The pathology was centered in the atlas and/or axis (n = 65), including odontoid process fractures (n = 31), atlantoaxial dislocations (n = 12), atlantoaxial instability (n = 8), and odontoid deformities (n = 14).This retrospective study evaluated 301 patients with occipitocervical junction diseases who were treated between July 2014 and June 2017 in the orthopedic department and neurosurgery department of the Sichuan Provincial People's Hospital. Informed consent was provided by the patients prior to surgery. We also obtained approval from the institutional review board of our hospital to carry out this research. The study subjects consisted of 116 men and 92 women (age range: 22 to 76 years) who met the inclusion and exclusion criterion. Their diagnoses included lesions of the occipital bone (Inclusion criteria: (i) atlantoaxial fracture and dislocation; (ii) occipitocervical deformity; (iii) single rheumatoid lesions of the occipitocervical junction; and (iv) subtentorial tumors.Exclusion criteria: (i) patients with complete neurological damage; (ii) fracture and/or dislocation of the upper cervical spine with poly trauma; (iii) surgery without opening spinal canal; (iv) malignant tumors and infectious diseases; (v) complications of diabetes mellitus, or more than two systematic medical diseases; (vi) a history of blood or albumin (ALB) transfusion: and (vii) incomplete hospitalization data.Surgical indications included severe pain, neurological deficits, and instability of the spine, as well as lesions in the posterior cranial fossa, meningiomas without calcification but more than 2 cm in diameter, cerebellar hemorrhage over 10 ml in volume, and Arnold–Chiari malformation with progressive dyspnea, syringomyelia, and deformities of the foramen magnum.The local availability of X‐ray, computed tomography (CT), magnetic resonance imaging, and CT angiography was necessary. There were two common manifestations of these diseases in imaging findings: (i) the imaging findings of spinal instability included change of radian, a step‐like connecting line at the posterior edge of the vertebral body, bilateral sign of posterior margin of vertebral body and the double features of the facet joints of the cervical spine; and (ii) the abnormal mesenchymal or nerve tissues around the lesions in magnetic resonance imaging examinations included high signals from brain tissues, spinal cord, ligaments, or muscles under the T2 WI.Skull traction bows were used after anesthesia, and the patients were placed in the prone position on the operating room table. Then, the patients were fixed in an appropriate position such that the shoulders were parallel, and the cervical spine was without deflection or rotation.In the early stages of surgery, the occipital bone and upper cervical vertebra were exposed through a posterior median approach. The subsequent procedures were determined by the following types of lesions: (i) patients with upper cervical trauma had pedicle or occipital screws placed under navigation, and their subsequent procedures included reduction, fixation, and the placement of bone grafts; (ii) for patients with occipitocervical malformations, both resection of the posterior arch of the atlas, and the enlargement of the foramen magnum with a high‐speed drill, were necessary for nerve decompression. As for those with Chari malformation, the fourth ventricle central aqueduct and the superior cervical medulla were explored after the hernia had been removed under microscopy. Then, screws were placed, and reduction and fixation were executed, supplemented with large bone grafts from the iliac crest; and (iii) for occipital lesions, the occipital bone was trimmed using a rongeur, the lesions were resected, and the dura was repaired.n = 73), ameliorated group (n = 70), and ERAS group (n = 65)  Table .We scrutinized each patient's medical chart and recorded selected demographic data including age, gender, body mass index and American Society of Anesthesiologists grade to ensure the homogeneity of patients' condition Table .The duration of the surgical procedure and intraoperative blood loss were used to assess surgery performance. The change of postoperative hemoglobin and ALB were recorded to detect patients' nutritional status.Adverse consequences that occurred during the surgical treatment of these diseases were recorded to evaluate the surgery safety.The number of days hospitalization postoperatively and postoperative expenses were collected to investigate patients' burden.Visual analogue scale was adopted to assess the surgical site pain within six months after surgery. Out of a total score of 10, 0 corresponds to no pain, 1–3 points to mild pain, 4–6 points to moderate pain, 7–9 points to severe pain, and 10 refers to unbearable pain. Readmission episodes were collected to evaluate curative effect.q post hoc test or chi‐square tests. All analyses were performed using Statistical Product and Service Solutions software, version 16.0  and P < 0.05 was considered to be statistically significant.Data were expressed as mean ± standard deviation. The differences in means between groups were statistically evaluated by one‐way analysis of variance with the Student–Newman–Keuls‐P = 0.235). There were no significant gender differences between the three groups (P = 0.691). Moreover, there were no significant differences between the three groups in terms of American Society of Anesthesiologists grade (P = 0.747). Furthermore, there were no significant differences in terms of lesion character, and lesion site between the three groups . The mean blood loss during surgery in the traditional group, ameliorated group and ERAS group was 1004.20 ± 217.91, 940.51 ± 246.84, and 939.42 ± 239.32 mL, respectively; there was no statistically significant difference between the three groups (P = 0.172). The mean hemoglobin reductions in the patients one week after surgery in traditional group, ameliorated group and ERAS group was 23.25 ± 10.83, 21.02 ± 10.13, and 20.20 ± 12.74 g/L, respectively (P = 0.255). The mean ALB reductions in the three groups one week after surgery was 9.41 ± 4.81, 8.03 ± 4.95, and 8.46 ± 3.63 g/L, in traditional group, ameliorated group and ERAS group, respectively (P = 0.178); there were no statistically significant differences between the three groups.The key point of surgery is to ensure careful operation in this area to avoid nerve injury. The mean surgery time in traditional group, ameliorated group and ERAS group was 179.95 ± 45.37, 184.62 ± 66.08, and 169.28 ± 42.26 min, respectively; there was no statistically significant difference between the three groups (P = 0.043). The complications mostly involved the leakage of cerebrospinal fluid, incision complications , organ infections (mainly were pneumonia and urinary tract infection), and nausea or vomiting (Table There were 29 (39.73%), 22 31.43%), and 13 (20.00%), recorded cases of postoperative complications in the traditional group, ameliorated group, and ERAS group, respectively. Moreover, the ERAS group decreased by 55.17% and 40.91% lower than the other two groups, these differences were significant  while the mean postoperative costs in the traditional group, ameliorated group and ERAS group, were 19387.60 ± 4076.32, 18017.33 ± 3288.02, and 17962.48 ± 2525.35 RMB, respectively (P = 0.019); the ERAS group decreased by 17.42% and 11.36%, 7.35% and 0.30% lower than other two groups in terms of days and costs, respectively. These differences were statistically significant.Furthermore, the mean duration of postoperative hospitalization in the traditional group, ameliorated group and ERAS group, was 17.39 ± 3.37, 16.20 ± 3.56, and 14.36 ± 2.57 days, respectively (P = 0.000); the ERAS group increased by 51.28% and 37.74% more than other two groups, the difference was statistically significant. There were two (2.74%), three (4.29%) and two (3.08%), recorded cases of re‐admission in the traditional group, ameliorated group and ERAS group, respectively, but there were no statistically significant differences when compared across the three groups (P = 0.866).The improvement of visual analog scale in the traditional group, ameliorated group and ERAS group, was 2.34 ± 1.47, 2.57 ± 1.21, 3.54 ± 1.54, respectively  at Sichuan Provincial People's Hospital, Sichuan Academy of Medical Science, Chengdu, People's Republic of China. Written and informed consent was obtained from all patients for the publication of this study.


Diabetes mellitus-related cardiomyopathy (DMCMP), defined as left ventricular (LV) dysfunction caused by hyperglycemia in the absence of coronary artery disease, leads to heart failure (HF). Previous studies have shown that treatment with sodium-glucose co-transporter 2 inhibitor (SGLT2i) reduces the risk of exacerbation of HF. The beneficial effects of SGLT2i on HF depend not only on indirect actions such as osmotic diuresis but also on direct actions on the myocardium, leading to improvements in LV function. However, it remains unclear whether SGLT2i treatment is equally effective in any phase of DMCMP. The aim of this observational study was to compare the efficacy of SGLT2i treatment on LV dysfunction between early and advanced DMCMP.Thirty-five symptomatic non-ischemic HF patients with LV ejection fraction > 40% and type 2 diabetes mellitus (T2DM) treated with empagliflozin (EMPA group) and 20 controls treated without SGLT2i were enrolled. According to the myocardial extracellular volume fraction (ECV), a reliable marker of cardiac fibrosis quantified by cardiac magnetic resonance, the EMPA group was further divided into early DMCMP  and advanced DMCMP  groups and followed up prospectively. Echocardiography was performed at baseline and after 12 months. LV function assessed as LV global longitudinal strain (LVGLS) and the ratio of early diastolic mitral inflow velocity to early diastolic mitral annular velocity (E/e′) were compared.2 = 0.65, p < 0.001). At baseline, each group had a similar background. After 12 months, the EMPA group, especially the early DMCMP group, showed remarkable improvements in LVGLS (ΔLVGLS: 2.9 ± 3.0% (EMPA) vs. 0.6 ± 2.2% (controls), p = 0.005, and 4.6 ± 1.5% (early DMCMP) vs. 1.6 ± 3.3% (advanced DMCMP), p = 0.003) and E/e′ .ECV was strongly correlated with T2DM duration (rThe positive effects of empagliflozin on LV dysfunction were more remarkable in early than in advanced DMCMP. Early intervention of SGLT2i for DMCMP may be preferable. Type 2 diabetes mellitus (T2DM) is an important risk factor for the development of cardiovascular disease and heart failure (HF) . DiabeteSeveral mega-trials have shown that treatment with sodium-glucose co-transporter 2 inhibitor (SGLT2i) reduces the risk of major adverse cardiovascular events, including exacerbation of HF –8. FurthHowever, it remains unclear whether SGLT2i treatment is equally effective in any phase of DMCMP. The aim of this study was to compare the efficacy of SGLT2i treatment on LV dysfunction between the early and advanced phases of DMCMP.This was a prospective observational study conducted at a single center. Consecutive symptomatic HF patients with T2DM who were hospitalized in Fujieda Municipal General Hospital (Japan) were screened for eligibility. The diagnosis of T2DM was based on the World Health Organization criteria . After a2; (15) malignant tumor or inflammatory disease; (16) pregnancy; (17) refusal to provide informed consent, and (18) history of myocardial infarction, cerebral infarction, pancreatitis, or hospitalization for HF. To exclude patients with coronary artery disease, coronary angiography was performed in all participants. Patients with ≥ 90% coronary artery stenosis were excluded. Patients with 75% stenosis were also excluded if a > 10% ischemic area matched with angiography results was proven by myocardial perfusion scintigraphy. Regarding hypertensive heart disease, patients with diastolic blood pressure ≥ 90 mmHg were excluded  pg/mL vs. − 302 [188–574] pg/mL, p = 0.910, and − 305 [201–400] pg/mL vs. − 398 [143–537] pg/mL, p = 0.594, Table There were no significant differences between the EMPA and control groups, and between the early and advanced DMCMP groups in NYHA class after 12 months (1.3 ± 0.4 vs. 1.3 ± 0.5, The present study showed positive effects of empagliflozin on LV functional parameters. Furthermore, the improvements were more remarkable in the early DMCMP group than in the advanced DMCMP group. HF parameters, such as NYHA class and BNP, were equally improved in both the early and advanced DMCMP groups.Hyperglycemia causes LV dysfunction, which leads to the development of DMCMP . LV diasIn this study, symptomatic HF patients with T2DM were enrolled. Thus, although we named the group of patients with ECV ≤ 30% as the early DMCMP group, they were not strictly in the early phase. Their ECV values were as high as those reported in a previous report of patients with T2DM and normal LV function , but theIn line with previous reports using dapagliflozin , 12, theIt is hypothesized that the direct cardiac effects of SGLT2i depend on a reduction in intracellular sodium by inhibiting NHE-1, which is expressed in the heart and vasculature . In patiConsidering that there were no significant intergroup differences in ΔHbA1c, the reverse LV remodeling through the inhibition of NHE-1 was independent of the main effect of SGLT2i: glycemic control by blocking glucose reabsorption through SGLT2. Side effects, such as osmotic diuresis and inhibition of NHE, may be the reason why SGLT2i treatment is associated with lowering the risk of HF exacerbation regardless of the presence or absence of T2DM. The composite of direct and indirect cardiac actions of SGLT2i could improve HF parameters even in patients with advanced DMCMP.LV longitudinal myocardial dysfunction and diastolic dysfunction are clinically important markers observed from the preclinical phase of DMCMP , 5, leadβ-blocker could also have affected the result. Although a multivariate analysis adjusted for baseline characteristics should be performed to evaluate the effective factors for improving LV function, it was not possible because of the limited number of cases. Second, contrast-enhanced CMR was not carried out in the control group patients. Due to a lack of ECV evaluation in the control group, assessments with an interaction test were not possible. Furthermore, a myocardial biopsy was not performed in this study. Although we performed coronary angiography and CMR to increase the diagnostic accuracy of DMCMP, the possibility that patients with other cardiomyopathies were still included cannot be denied, especially in the control group assessed without LGE. Third, we performed only a short-term assessment of LV function. If the follow-up period was longer, LV functional parameters might have improved further in the advanced DMCMP group.This study has some limitations. First, this was a small observational study conducted at a single center. Therefore, several biases were possible. For instance, the advanced DMCMP group characteristics, including lower baseline LVEF, could have affected various outcomes. Although the EMPA group tended to have more remarkable improvements in E/eʹ than the control group, the difference was not significant, in contrast to a previous report . We consEmpagliflozin had positive effects on LV function that were more remarkable in the early DMCMP group with normal ECV values than in the advanced DMCMP group with elevated ECV values. The ECV increase was strongly correlated with T2DM duration. Thus, early SGLT2i administration for patients with HF and T2DM may be preferable.


Correction to: Global Health 17, 105 (2021)https://doi.org/10.1186/s12992-021-00747-8Following publication of the original article , the autNamely, in the Projecting Demand section of the Background, the ‘ξpt predictor variables were lagged’ had been written in place of ‘Predictor variables were lagged’. While in the opening paragraph of the Discussion ‘2.86 Saudi nurses per 1,000’ had been erroneously written instead of ‘0.86 Saudi nurses per 1,000’.The original article has since been updated to amend these errors.


It was found that both PSs generated singlet oxygen and revealed moderate affinity toward the lipid-like compartment. Between November 2018 and October 2020, 12 patients with verified non-muscle invasive bladder cancer (NMIBC) were treated by TURB combined with FD and PDT. Eight patients received “Fotoran e6” intravenously, while four patients received intravesical PSs. The patient ages were between 31 and 79 years, with a median age of 64.5 years (mean 61.3 ± 14.2). The total light dose was 150 J/cm2 for the local irradiation of the tumor bed with a red light at the λ = 660 nm wavelength, and 10–25 J/cm2 were additionally delivered for diffuse irradiation of the entire bladder mucosa. At the median follow-up period of 24 months , 11 patients remained tumor-free. One 79-year-old patient developed a recurrence without progression to the muscle layer. This pilot study shows that the TURB + FD + PDT technique is an effective and safe option for the first-line treatment of superficial bladder tumors.Bladder cancer is a common disease with a high recurrence rate. In order to improve the treatment of superficial bladder tumors, we evaluated the efficacy and safety of transurethral resection (TURB) followed by fluorescence diagnosis (FD) and photodynamic therapy (PDT) with chlorin e Bladder cancer (BC) is known to be the eleventh most commonly diagnosed malignancy worldwide ,2,3, aff1O2 [1O2 rapidly induces significant toxicity, leading to cell death via apoptosis, necrosis, or autophagy [The TURB + FD + PDT treatment with photosensitizers of the second generation is considered a safe and efficient alternative to TURB + BSG or TURB + CT, especially among patients with recurrent bladder cancer and patients with malignancies that are resistant to BCG or chemotherapy ,5,6,7,8.1O2 . The lat1O2 ,22,23,24utophagy ,21,24. Iutophagy ,17. It iMost of the photoactive molecules in PDT have a tetrapyrrole structure similar to that in natural dyes, such as hemoglobin or chlorophyll. These species are capable of being locally or systemically administered into a malignant tissue ,9,17. Th6 derivatives, were found to be more efficient and safe [The first-generation PSs, based on a porphyrin platform, had long-lasting skin photosensitivity and relatively low absorbance in red light ,17. The and safe ,5,6,7,8.and safe ,8. Howevviz. “Fotoditazin”, and “Fotoran e6”,  and also by the decision of the Ethical Committee of ISMA . Twelve patients with the histologically verified T1 NMIBC were recruited from the urological clinic of the Ivanovo regional hospital. All of them had had no prior BCG treatment. According to the WHO grading ,4, 8 pat6” was provided by the “RANFARMA” company  as a solid powder mixed with polyvinylpyrrolidone as an appropriate carrier. Both PSs were also purchased in their pure solid state . 1-Octanol  was dried with 4 Å molecular sieves and distilled under reduced pressure at 355 K. The phosphate saline buffer (PSB) pH = 7.4  was prepared by dissolving pure solid forms in one liter of freshly bidistilled water [“Fotoditazin” was purchased from the “VETA-GRAND LLC” company  as a 5 mg/mL concentrate. This solution was stable in the dark at 283 K for one year. “Fotoran eed water ,15. 1,3-UV-Vis spectra were recorded with a D8 spectrophotometer , both in 1-octanol (OctOH) and water, at 293 K. Fluorescence spectra were registered with a CM 2203 spectrofluorimeter . ΦΔ) was determined using an indirect chemical method, which was similar to the technique described elsewhere [ΦΔ value equaling 0.65 [kd, were evaluated in terms of the first-order exponential decay model. All the photobleaching experiments were repeated 5 to 6 times. The ΦΔ values were computed as follows:IP values were estimated numerically by: λ1 and λ2 are the initial and final wavelengths of the region where the spectra of the LED panel and the PS studied overlap each other, I0 (λ) is the intensity of the panel between 590 and 720 nm as a function of λ, and A is the optical density of a solution.The singlet oxygen quantum yield  between OctOH and phosphate saline buffer modeling the PS transfer from an aqueous to a lipid-like environment [mOctOH and maq are the solute equilibrium molalities in OctOH and PSB, respectively. The equilibrium concentration of both PSs was analyzed spectrophotometrically. The partition coefficients . However, four allergic patients preferred to receive the PSs via the intravesical route. Before intravenous administration, both photosensitizers were dissolved in 200 mL of saline and then carefully administrated via slow infusion through an antecubital vein over 20–25 min at a dose of 0.7–1.4 mg/kg. During this procedure, each patient was monitored for adverse effects, such as drug hypersensitivity, tachycardia, or hypotension [6” dissolved in 100 mL of saline. After 1.5–2 h, the bladder was drained again, and the manipulations mentioned above were initiated 1 h later. “Fotoran eotension . Betweenλ = 400 ± 1 nm or λ = 660 ± 1 nm was applied  and treatment (PDT) modes, a dual-channel, medical-grade ALXT-Elomed diode laser  emitting at lied see . Before er model ,28 -band at 660 nm, induced by π-π*-electron transfers, is within the so-called optical window of tissue [1O2. The values of the 1O2 quantum yield (ΦΔ) given in 1O2, while the other ones transfer to their ground state mainly via fluorescence [The absorption spectra of both PSs are very similar and typical of chlorin macrocycles ,31. Figuf tissue ,30,31. Trescence ,23. Henca, which is almost insoluble in an aqueous medium. Both “Fotoditazin” and “Fotoran e6” demonstrate moderate affinity toward the lipid-like compartment (P~2). These values are larger than those for the di- or tri-cationic chlorins (see P~9). This PS behavior is well-correlated with the fact that more hydrophobic MCh binds mainly to low-density lipoproteins in the vascular system, whereas anionic chlorin e6 is transported by serum albumin [rins see  but are  albumin ,33,34. P~2). Hence, one may assume that such anionic PSs should be taken up by cancer cells mainly via endocytosis inducing photochemical damage in tumors via the Type II process of photochemical reactions and mainly targeting cytosol but not the mitochondria of malignant cells [Thus, we see that both anionic PSs generate singlet oxygen with a sufficient quantum yield, demonstrate good absorption and fluorescence spectra for clinical utilization, and show a tendency to be localized in a lipid-like medium. However, their affinity toward a lipid-like compartment is rather weak . One bedridden patient with several chronic diseases developed one histological recurrence without progression to the muscle layer. This patient underwent an additional TURB procedure. There were no recurrences in the other 11 patients during the follow-up period. Thus, TURB combined with intraoperative FD and PDT has reduced the recurrence rate of superficial bladder cancer to 9% for the one-year period of follow-up vs. 24–38% for the patients with T1 tumors who received TURB + CT [unds see . This fa6” and “Fotoditazin” have good absorption of red light and fluorescence in the optical window of tissue. They generate singlet oxygen with a sufficient quantum yield and demonstrate moderate affinity toward a lipid-like compartment. (b) The pilot clinical study shows that TURB + FD + PDT with both PSs is a safe and tolerable modality for treating NMIBC. This technique seems to be highly efficient and of low toxicity compared to the standard treatment [In conclusion, we can state the following as a result of the present and earlier studies using natural chlorin photosensitizers. (a) Our physicochemical results indicate that both “Fotoran ereatment ,4,5. It reatment . Hence, reatment , could p


In a cultural heritage context, fatty acids are usually found as breakdown products of lipid-containing organic remains in archaeological findings, binders in aged oil paintings, and additives in modern art-related materials. They may further interact with the ionic environment transforming into metal soaps, a process that has been recognized as a threat in aged paintings but has received less attention in archaeological objects. The investigation of the above related categories of materials with infrared spectroscopy can provide an overall picture of the organic components’ identity and demonstrate their condition and prehistory. The capability of investigating and distinguishing fatty acids and their metal soaps through their rich infrared features, such as the acidic carbonyl, the carboxylate shifts, the variable splits of alkyl chain stretching, bending, twisting, wagging, and rocking vibrations, as well as the hydroxyl peak envelopes and acid dimer bands, allows for their direct detailed characterization. This paper reviews the infrared spectra of selected saturated fatty monoacids and diacids, and their corresponding sodium, calcium, and zinc salts and, supported by newly recorded data, highlights the significance of their spectroscopic features. Lipids (glycerol triesters), existing as organic residues in archaeological findings  or as binders in oil paintings, are prone to hydrolytic damage producing free fatty acids (FA) ,2,3,4. FThe analytical investigation of organic archaeological residues has received attention due to the resilience of organic molecules, such as lipids and their breakdown products, which helps researchers access information on dietary habits, rituals, and other practices developed by cultures of the past ,13,14,15The acquisition of infrared spectra significantly assists analytical efforts, such as the ones mentioned above. Although detailed infrared analysis, such as the chemical mapping of paint cross-sections has been successfully conducted ,47,48, tIn addition, advanced technological capabilities have led to the development of reflection-based techniques in combination with microscopy ,66,67,68In the field of art, infrared spectroscopy has played a significant role in identifying and studying the binding media in oil paintings ,69,70, aThis paper reviews the infrared spectra of selected fatty monoacids, diacids, and their sodium, calcium, and zinc salts, and points out their detailed features for detecting these compounds directly in their samples and further assessing their structural condition. The rich information gained through the close inspection of spectroscopic features can help researchers benefit in their investigations to a level beyond typical infrared screening.The intermolecular attraction of acidic carbonyls due to hydrogen bonding induces a dimerization phenomenon where FA associate in a handshake mode forming head-to-head molecular pairs (or ‘dimers’) ,84,85,86Carboxylic acids carry a hydrogen bond donor (the OH group) and a hydrogen bond acceptor (C=O) within the same unit and are, therefore, ideal molecules for studying the phenomenon. First, as a profound manifestation of the hydrogen bonding attraction, the hydroxyl stretch is considerably downshifted, compared to their ‘free’ state, and characteristically broadened ,95,101. The infrared spectra of saturated fatty acids (sFA) have been studied and their features have been previously reported ,110,111.In sFA, the zig-zag hydrocarbon chains assume an overall linear direction, which generally allows for close chain approaching in the bulk phases, and finally, for diverse polymorphic structures, which subtly differ for odd- and even-numbered acids ,115,116.To better study FA infrared spectra, the spectra can be divided into seven regions, each generally having a particular vibrational character. Maxima and assignments are shown in −1 with a vague maximum of around 3050–3000 cm−1  and methylene (CH2) vibrations, each of these sub-categorized into antisymmetric (asym-) and symmetric (sym-) vibrations [vasCH2 maxima for acids C3 and C4, with only α- and β- methylene groups (spectra not shown here), appear as high as 2990 and 2973 cm−1, respectively [2 groups that build longer chains contribute to the methylene stretching band with a maxima around 2932 cm−1 . Moreover, the intensity ratios of methylene over methyl peaks are related to the number of CH2 groups in the chain, thus reflecting the hydrocarbon chain length.A trend for vC‒O) is generally observed around 1710–1700 cm−1   C14–C24 c, which −1 for all sFA due to the symmetric in-plane bending (or ‘scissoring’) mode, as shown in −1 is observed. For longer alkyl chain acids, the band is resolved in two sub-bands (~1473 and 1464 cm−1) with a contribution of the α-CH2 group at ~1411 cm−1. On the other hand, the CH3 symmetric bend (the ‘umbrella’ vibration) appears at around 1370–1350 cm−1, while the antisymmetric appears at 1473 cm−1 [−1 region, showing bands more clearly for the crystallizable FAs.The methylene vibration is typically observed at 1465–1430 cm473 cm−1 ,127,128;−1 which better resolves upon chain increase; double-split CH2 twisting peaks are observed in C14:0-C18:0, while four-split are observed in C24:0.This region is characteristic of crystallizable compounds and materials containing long saturated hydrocarbon chains; as a typical feature, band splitting in the form of band progressions appears  shown i. Early s−1 are observed [w1, w2, etc.) increases with increasing hydrocarbon chain length , 29 (C12), 24 (C16), 18 (C18), and 13 cm−1 (C24). The progressions may be stronger in well-crystallized samples, for instance, when the crystalline state is slowly formed upon the annealing of a fatty acid melt [A similar phenomenon is even more pronounced for the methylene wagging vibrations, where extensive splitting in the form of progressions at 1320–1160 cmobserved ,110,131.cid melt ,132,133;vC‒O) at around 1100 cm−1 and appears as a medium peak  and 1075–1122 cm−1 (stronger). The latter upshifts upon moving from C10:0 to C18:0, while in C24:0 this peak almost disappears  is observed as a medium, relatively broad peak at ~1431 cm−1 [δoop C‒O‒H), which typically appears as a weak peak at around 690 cm−1 and is also responsible for a medium-strong broad peak at 943–935 cm−1 [The C‒O‒H in-plane bending vibration . On the other hand, non-crystallizable sFA, such as C8:0 and C9:0  show a relatively uniform broad band at 1380–1180 cm−1 with poorly resolved shoulders (−1), and the rocking vibration is not split  appear for any solid-state FA , the rocking band splits for chains longer than C14, as shown in g in 10K ), the roKsp of the order of 10−17 mol3/L3). Other metal soaps can also be expected, such as copper, aluminum, cobalt, and iron [Fatty acids can be transformed into FAMS in the presence of metals ,136 and and iron ,139,145.and iron . In the and iron . FinallyThe infrared spectra of FAMS have been studied to some extent ,138,147.−1 for the calcium salt, and ~3565–3580 and 1620–1600 cm−1 for the zinc salt). Spectra are shown in Although soap spectra generally share similar features, diagnostically significant differences can be observed regarding the carboxylate and some of the hydrocarbon chain vibrations. Moreover, in the case of the bivalent ions Ca and Zn, hydrated salts were produced, as evidenced by the intense, broad, crystalline water peaks (at ~3440 and ~1626 cmasvCOO−) and symmetric (svCOO−) carboxylate vibrations at 1575–1530 and 1460–1400 cm−1, respectively.The carboxylate bands typically exist in pairs corresponding to the antisymmetric (Δ (‘delta’) value, depends on the coordination symmetry; the lower the symmetry, the higher the Δ. More specifically, carboxylates may assume various symmetry levels based on whether they exist in a pure ionic form  or metal-coordinated forms such as the unidentate, the chelate bidentate, and the bridging bidentate [The coordination geometry plays a significant role in the band maxima ,148,149.identate ,151  but gen−1 and 1425 cm−1 for vasCOO− and vsCOO−, respectively [−1  and 1435 and 1419 cm−1 (vsCOO−), indicating two different denticities in the coordination structure (−1 for the antisymmetric band) [For the calcium soaps, double-splitting is observed for all FAMS at 1580 and 1542 cmtructure . Splittiic band) . Since tic band) ,143,144,vasCOO−) and 1398 cm−1 (vsCOO−). However, in the case of the shorter-chain fatty acid salts (C82Zn and C102Zn), splitting is observed at 1550 and 1532 cm−1 (vasCOO−), and 1410 and 1399 cm−1 (vsCOO−) [The zinc salts  in most (vsCOO−) ,73,155.asym- and sym- carboxylate bands of the divalent metal salts into doublets has been previously observed and attributed to bidentate and unidentate salt types , suggesting higher-symmetry bidentate coordination. The differences in separation values between the sodium and the divalent salts are marginal as they are comparable with the wavenumber uncertainty limit . Our data shows a deviation for the C8Zn and C9Zn salts, showing Δν values at 131 cm−1.The calcium and zinc salts show similar Δv decreases when soaps are formed in an amorphous molecular vicinity  [As a general remark, the carboxylate bands can be significantly broadened and shifted so that Δ medium) ,73,160.2 antisymmetric stretching band in FAMS shows fewer components and lower variability in their maxima than those in FAs. Spectra are shown in −1), while for the more distanced ones, these are downshifted at approximately 2920 cm−1. Notably, for the sodium salts of fatty acids with chains shorter than C14, the peaks are resolved to ~2957, 2940, and 2920 cm−1. The sym- CH2 stretching typically appears at 2857–2850 cm−1, and the CH3 stretching appears at 2956 (asym-) and 2874 cm−1 (sym-).As a general remark, the CH−1 , 1468–1473 cm−1 , and 1456–1467 cm−1 , respectively, while the methyl bending is either very weak or not observed at all. This region is shown in −1 as progressions of four or five peaks, which are quite intense for Ca and Zn salts. The wagging vibrations are also observed as progressions, generally at 1270–1180 cm−1, similar to those of the corresponding FA, although relatively weaker and at numbers that follow the n/1 pattern . The weak bands at 870–860 cm−1 are assigned to the coupling between δCH3 and vC-C [−1 is observed only for zinc salts  acids, are standard oxidation products of polyunsaturated fatty acids ,84,162. −1, downshifted compared to monoacids due to more efficient hydrogen bonding between carboxyl groups. According to their structural characteristics, carboxyl groups are associated with intense intermolecular hydrogen bonding, resulting in monoclinic crystals. As seen in The acidic carbonyl absorption for diacids is observed at ~1695 cm−1. On the other hand, and in contrast to monoacids, the hydroxyl dimer band is structured, showing at least seven characteristic satellite bands spanning the 2810–2459 cm−1 region  in azelaic acid, while they show a uniform peak in suberic acid (1333 cm−1). The wagging vibrations are triply split in both acids at 1290–1250 cm−1. The rocking vibration appears as two medium-weak peaks at ~796 and 725 cm−1 for both acids with no evident splitting.The methylene bending vibrations are observed as doubly split bands at ~1470 and 1410 cm−1 c. The twδC‒O‒H) appears as an obscure band at 1425 and 1435 cm−1, for C8di and C9di, respectively [−1 for azelaic, while it is not observed for suberic acid  and 920 cm−1 (azelaic).The hydroxyl bending  and 1416–1405 (sym-) (asym-) and 1431–1410 (sym-) for calcium and ~1551–1534 (asym-) and 1412–1400 (sym-) for zinc. By analogy to monoacid salts, the splitting can be attributed to differences in coordination geometry. The splitting value (Δvsplit) is 40 cm−1 for the calcium salts, while it is significantly smaller, ~18 cm−1, for the zinc salts.Similarly, with the previous cases, suberate , and azelate  salts with sodium, calcium, and zinc were also synthesized in the laboratory . As seen in the spectra of ectively a. The caym- pair c. For th5 (sym-) c. On the2 stretching band is split into four components for the calcium salts at 2978–2907 cm−1, four components for sodium, and three for zinc salts at 2940–2905 cm−1 (see 2 bending band (scissoring) is also structured at 1463–1405 cm−1, with the suberate band being more extended than the azelate. The methylene twisting is observed as a single peak at ~1360 cm−1 for most salts, while wagging appears as a progression at 1318–1195 cm−1, significantly more extended for the azelates. Finally, the CH2 rocking is observed at 725–705 cm−1 for the sodium and calcium diacid salts and 747, 723 cm−1 for the zinc salts.Most methylene bands in diacid salts are characteristically structured, possibly as a result of interactions in the crystalline phase . The antcm−1 see b. The CH3(CH2)6COOH or C8:0, ≥99%), nonanoic, or pelargonic (CH3(CH2)7COOH or C9:0, ≥99%), decanoic, or capric (CH3(CH2)8COOH or C10:0, >98.0%), dodecanoic, or lauric (CH3(CH2)10COOH or C12:0, ≥99%), tetradecanoic, or myristic (CH3(CH2)12COOH or C14:0, ≥99%), hexadecanoic, or palmitic (CH3(CH2)14COOH or C16:0, ≥99%), octadecanlic, or stearic (CH3(CH2)16COOH or C18:0, ≥98.5%), tetracosanoic, or lignoceric (CH3(CH2)22COOH or C24:0, ≥99%), octanedioic, or suberic (C6H12(COOH)2 or C8di, 98%), and nonanedioic, or azelaic (C7H14(COOH)2 or C9di, 98%).Fatty acids were purchased from Sigma-Aldrich : octanoic, or caprylic , water , calcium chloride , zinc chloride , ethanol , chloroform , xylene , and acetone .Sodium salts of fatty acids C8:0–C24:0 were prepared by adding 0.1 mmol of the corresponding acids to 1 mL of sodium hydroxide 0.1 M solutions in ethanol (Honeywell); for the diacid (C8di and C9di) sodium salts, two equivalents of the base was added. The solutions were initially warmed up to 80 °C on a heating plate, followed by sonication for 15 min. When precipitation was complete, the products were investigated with infrared spectroscopy, where the full conversion to the sodium salt was confirmed for all cases.The calcium and zinc salts of fatty acids C8:0–C24:0 were prepared by substitution upon mixing aqueous solutions of the corresponding sodium salts (prepared in the previous step and pre-heated on a plate for full solubilization) with aqueous solutions of calcium chloride  and zinc chloride . The mixtures were sonicated until full conversion was evident through infrared spectroscopy. Infrared spectra of obtained salts (shown in this paper) were in agreement with the literature ,83,84,85−1, 32 scans, and 4 cm−1 resolution. Spectra of acids are shown normalized on the carbonyl peak. Spectra of salts are shown normalized on the highest carboxylate peak. Deconvolution of the C‒H region (3000–2800 cm−1) was done using the Peak Fitting application of GRAMS/AI (Thermo) software, using a mixed Gaussian (50%) and Lorentzian (50%) function, at low sensitivity. In all cases, the standard error was lower than 0.00647, while R2 was better than 0.9987.All samples were in powder form and analyzed according to the following procedure: each sample was mixed with KBr, pulverized in a pestle and mortar, and pressed in a 13 mm disc using a hydraulic press. Infrared spectra of the KBr discs were recorded in transmission mode using a Perkin Elmer Spectrum GX 1 FTIR spectrometer equipped with a DTGS detector at 4000–650 cmThe investigation of fatty acids and their metal salts as degradation products of fatty substances in oil paintings and particular archaeological objects can be of high importance. This work explores the usability of infrared spectroscopy for characterizing these compounds in related complex samples. The spectra of some typical fatty monoacids, diacids, and their sodium, calcium, and zinc salts are investigated, and their features were examined in terms of their diagnostic usability.−1 (C14–C24); these are further downshifted to 1694–1695 cm−1 in diacids. Crystallization and effective molecular associations in the higher members are key factors for this phenomenon, and in some cases, they are inhibited due to unfavorable molecular environments; acidic carbonyl maxima are relatively high, at ~1710 cm−1. The same phenomenon also causes broadening of the dimer band at 945–920 cm−1.Intermolecular interactions are fundamental for the acidic carbonyl maxima, which downshift from 1713 (for C9 monoacid) to 1703 cm−1, respectively), often existing in doublets, with separations (Δv) depending on the metal. The distinctly higher frequency  and as a relatively broad band involving the bending vibrations at ~940 cm−1.In salts, carboxylate absorptions exist in antisymmetric-symmetric pairs (at 1590–1530 and 1436–1398 cmThe various C‒H vibrations significantly depend on monoacid chain lengths and intermolecular interactions among them. In crystallizable samples, splitting in stretching, bending, and rocking vibrations and the characteristic progressions in twisting and wagging for the longer-alkyl chain acids are often a diagnostic asset. Diacids also show splittings but no progressions. Progressions are also expected in metal monoacid soaps, although significantly weaker and more elusive, and therefore, their diagnostic capability is limited.The rich spectroscopic features of fatty acids and their salts significantly benefit their diagnostic use. A close inspection of an infrared spectrum recorded from complex samples containing fatty acids, or their metal salts, can provide direct evidence for their condition.


There are various treatments for facial nerve palsy, and research into this topic is ongoing. In the present study, we carried out bibliometric and visualized analyses to identify the trends of research into facial nerve palsy treatment.To identify articles, the SCOPUS database was searched for articles published from its inception to December 27, 2020. The search was conducted twice, with Search 1 investigating general treatment trends and Search 2 narrowing the scope to complementary and alternative treatment. The extracted keywords were analyzed using the Visualization Of Similarities (VOS) viewer. Through analysis of keywords, research hotspots in the treatment of facial nerve palsy were identified.A total of 1609 and 223 articles were identified in Searches 1 and 2, respectively. The number of articles published each year showed a tendency to increase, and most of the studies were only conducted in a few countries. In terms of subject area, “medicine” was overwhelmingly the most common(77.6%). Based on the analysis of 316 keywords in Search1, “medication treatment,” and “complementary and alternative treatment” were the hotspots of research.This study provides the overall trends of facial nerve palsy treatment. To date, research on medication treatment has been main focus, and antiviral use among medication treatment and complementary and alternative treatment has emerged in recent years. The first search was performed to identify the general treatment trends for facial nerve palsy, using the following search terms: TITLE  AND ABS (treat∗ OR therapy OR intervention OR medication) (Search 1). In the second search, to focus on the trends of complementary and alternative treatment for facial nerve palsy, we narrowed down the scope of the search, using the following search terms: TITLE  AND ABS (treat∗ OR therapy OR intervention OR medication) AND ALL  (Search 2). The search was limited to “TITLE” to exclude articles with low relevance. All articles identified in these searches were included in the analysis without article type or language restrictions. Ultimately, 1609 articles were identified in Search 1 and 223 in Search 2. All of these articles were included in the subsequent analysis.The SCOPUS database was searched on December 27, 2020 to identify articles published from its inception to December 27, 2020. We chose the SCOPUS database because of its accuracy and widespread inclusion of medical articles, which make it suitable for bibliometric analysis.2.2Information on the articles, such as year, research area, journal title, country, institution, authors, and basic statistics was derived using the intrinsic function of SCOPUS. to conduct a co-occurrence analysis. All terms that met the minimum number of occurrences were included in the analysis without restrictions on relevance score. As a normalization method, “association strength” was applied, and the minimum cluster size was set to 30. In the co-occurrence network map, the terms were expressed as nodes, with higher frequency terms having a larger node size. Nodes that were close to each other indicated high relevance, and lines connecting nodes indicated that the terms co-occurred.The identified articles were imported to the VOS viewer 1.6.16 , a software useful for bibliometric mapping,.Before full-scale analysis, terms related to databases such as “China National Knowledge Infrastructure (CNKI),” “Cochrane library,” and “Latin American and Caribbean Health Sciences Literature (LILACS)” were excluded, as were terms related to the basic structure of articles, such as “study design” and “trial registration,” and terms that were meaningless to the analysis, such as “January,” “February,” and so on. A thesaurus file was created and applied to the analysis so that synonyms could be unified into 1 term. For example, “idiopathic facial paralysis,” “idiopathic peripheral facial paralysis,” “idiopathic facial nerve paralysis,” and “idiopathic facial palsy” were unified as “Bell's palsy.” Full terms and abbreviations were also unified, such as “Ramsay Hunt Syndrome” and “RHS,” “electromyography,” and “EMG,” and so on.2.3Ethical approval was not necessary because this study did not involve human or animal research.33.1A total of 1609 and 223 articles were obtained in Searches 1 and 2, respectively. An article published in 1950 was the earliest in Search 1, while an article published in 1975 was the earliest in Search 2. Although there were some variations, particularly in Search 2, the number of articles published showed an overall tendency to increase annually, and the largest number of articles was published in 2020, with 111 and 28 in Searches 1 and 2, respectively , followed by Japan  and China . Among the 43 countries in Search 2, China published the largest number of articles, with 86 (38.6%), followed by the United States  and South Korea . Although there were differences in the exact rankings of the top 11 countries between the searches, 10 of the top 11 countries were the same. The most productive countries are listed in Tables 3.3.2In Searches 1 and 2, 160 and 21 institutions published >3 articles, respectively. In Search 1, among 160 institutions, Kyung Hee University published the largest number of articles 25; 1.6%), followed by Yamagata University Faculty of Medicine  and Sichuan University 14; 0.9%). In Search 2, among the 21 institutions, Chengdu University of Traditional Chinese Medicine published the largest number of articles , followed by Sichuan University  and Kyung Hee University . Although there were changes in the top 13institutions per search, the same 7 were ranked in the top 13 in both searches. The most prolific institutions are shown in Tables ; 0.9%. I; 1.6%, f3.3.3In Searches 1 and 2, 159 and 14 authors published more than three articles, respectively. Among the 159 authors in Search 1, Yeo SG published the largest number of articles, with 16 (1.0%), followed by Aoyagi M . Among the 14 authors in Search 2, Li C, Li Y, and Zhou D published the largest number of articles, with five each (2.2%). The most prolific authors are listed in Tables 3.4In the present study; terms that met a minimum number of occurrences threshold were defined as keywords and used to identify research hotspots in the treatment of facial nerve palsy in each analysis.3.4.1Terms with at least 20 occurrences in the titles and abstracts of the articles were defined as keywords, resulting in 316 extractions. The co-occurrence of these 316 terms was analyzed using the VOS viewer . The top 5 terms were “acyclovir” (235 times), “prednisolone” (211 times), “antiviral agent” (190 times), “prednisone” (161 times), and “steroid” (161 times). Based on the average publication year, the 5 most recent terms were “famciclovir” (2013.04), “electroacupuncture” (2011.23), “moxibustion” (2011.04), “glucocorticoid” (2010.79), “methylprednisolone” (2010.63), whereas the 5 earliest terms were “corticotrophin” (1980.30), “cortisone” (1994.71), “electric stimulation therapy” (2001.36), “hydrocortisone” (2003.64), “prednisone” (2003.78). Based on average citation counts, the 5 most common terms were “massage” (41.22), “drug combination” (30.22), “anti-inflammatory agents” (29.71), “cortisone” (26.62), and “prednisone” (26.13), whereas and the 5 least common terms were “electroacupuncture” (2.74), “conservative treatment” (6.12), “acupuncture” (7.09), “moxibustion” (7.92), and “antibiotic agent” (8.27).We also created a co-occurrence network map of 30 items using VOS viewer Fig. A. The maIn Figure The overlay visualization in Figure 3.4.2Terms related to treatment that appeared >2 times in the articles’ keywords among the 223 articles in Search 2 were extracted. As a result, 32 items were derived . These 32 keywords were divided into 4 main categories: “nutrient,” “traditional Chinese medicine,” “rehabilitation,” and “eye care.” Moreover, the specific elements of each category could be discerned, for example, “thiamine,” “ascorbic acid,” and “vitamin B” in the “nutrient” category, “herbal medicine,” “laser acupuncture” and “thread embedding acupuncture” in the “traditional Chinese medicine” category, “low-level laser therapy” and “biofeedback” in the “rehabilitation” category, and “eye protection” and “tarsorrhaphy” in the “eye care” category.We also created a co-occurrence network map of the 32 items using VOS viewer Fig. A. In ove4,23Medication treatments, including steroids and antivirals, can be applied during the acute period of facial nerve palsy, and several of the treatments that are subsequently administered to promote recovery are complementary and alternative treatment.This study comprised a bibliometric and visualized analysis to identify research trends in facial nerve palsy treatment. Over time, research has shown an increasing tendency, with the largest number of articles published in 2020 in both searches. Nonetheless, more research will be needed to ensure that that this trend continues in future. The proportion of articles attributed to the top 10 institutions or authors was not so large. With regards to country, the top 3 countries accounted for 41.8% and 63.2% of the total in Searches 1 and 2, respectively. Ten of the top 11 countries were same in both searches, so most research on facial nerve palsy has only been conducted in a few countries.Based on the number of published articles, “medicine” was the most actively studied subject area. In terms of journals, even the top five journals represented did not have a high proportion of the total, indicating that articles have been published across diffuse journals. However, with the exception of only one, all of the top 10 journals were otolaryngology-related, suggesting that the subject focus of the journal tended to be similar across the articles. Additionally, otolaryngology may have accounted for a large portion of articles in the “medicine” subject area.In the 1609 articles obtained in Search 1, we conducted co-occurrence analysis twice. The results of the 2 analyses were the same in the large framework, but this approach allowed us to better understand the research trends and hotspots associated with the treatment of facial nerve palsy.,25 In the “medication treatment” category, we identified the most commonly used drugs for core treatment in clinical practice, as well as terms such as “evidence,” “randomized controlled trial,” “meta analysis,” and “systematic review.” These terms tended to appear relatively recently, indicating that the studies in this category with a fairly high level of evidence were conducted recently.,6,26–28 In the “complementary and alternative treatment” category, terms such as “acupuncture,” “rehabilitation,” “electroacupuncture,” “physical therapy,” and “low level laser therapy” were included.–32 Moreover, this category showed a tendency towards more recent studies, just as with “medication treatment”. In other words, the research areas on the treatment of facial nerve palsy that are presently being focused on were “medication treatment” and “complementary and alternative treatment,” indicating the probable direction of future research.Firstly, through a co-occurrence analysis of the 316 keywords extracted from the titles and abstracts, we discovered 4 major treatment categories: pathophysiology, surgical treatment, complementary and alternative treatment, and medication treatment. In the “pathophysiology” category terms such as “diabetes mellitus,” “pregnancy” and “hypertension” were included, as research has been conducted into the underlying diseases that could affect prognosis in treatment.With a second analysis of 30 keywords extracted from the author keywords, the 4 main areas of research into the treatment of facial nerve palsy were more clearly identified: “steroids,” “antivirals,” “surgical treatment,” and “complementary and alternative treatment.”,33,34Later average publication years were probably associated with lower average citation counts. However, the most recent keyword, “famciclovir” (2013.04) had a relatively high citation count (22.00), whereas “prednisolone” (2008.45) had a large number of citations (22.86) in a relatively short period of time. Meanwhile, “electroacupuncture” (2011.23) had a citation count of 2.74 and “acupuncture” (2010.49) a citation count of 7.09, which rank among lower numbers of citations. Taken together, low citation count likely indicates that the study quality was relatively poor, and continuous research will be necessary in areas that have recently been studied but do not yet have sufficient qualitative evidence such as “complementary and alternative treatment”.,35,36In the second search, to find out more about the trends in complementary and alternative treatment, we narrowed the scope of the search, with the minimum occurrence number being lowered to 2 to extract even small frequency keywords. When analyzing 32 keywords, the average publication year was more recent, while the average citation count was low. For example, the citation count of “thread-embedding acupuncture” (2019.50) was 0.00, while that of “ascorbic acid” (2016.67) was 0.33, that of “laser acupuncture” (2015.50) was 1.50 and that of “low-level laser therapy” (2018.25) was 4.75. As mentioned earlier, further research is necessary to improve the quality of the studies and to establish a basis for these treatments.The present study had several limitations. The article search was only conducted in one database, and because only a fraction of the data were extracted, namely country, institution, author, and keyword, the main trends could be identified. However, these did not fully reflect the full substance of the present research. In addition, subjective perspectives of authors were involved, such as setting the minimum number of occurrences in the process of extracting keywords, setting counting method, and minimizing cluster size in the process of organizing the network map.Nevertheless, it is meaningful that the study identified research trends in the treatment of facial nerve palsy and direction to future research including the latest articles.5,34The present study investigated the overall trends of facial nerve palsy treatment using bibliometric and visualized analyses. In particular, the areas focused on in research so far were determined using analysis of keywords. To date, research on medication treatment has been the main focus, and antiviral use among medication treatment and complementary and alternative treatment has emerged in recent years. However, research on complementary and alternative treatment is still lacking, and the quality of the research is relatively low compared to that in research on medication treatment.,23,37 Considering that 30% of patients with facial nerve palsy have sequelae that reduce their quality of life and cause psychological problems, any treatment additional to medication that can promote patient recovery is important. It follows that research into medication, which is the hotspot of present research trends, needs to continue, whereas more efforts should be made to conduct high-quality research into complementary and alternative treatment.Medication treatment, including steroids and antivirals, can be applied during the acute period of facial nerve palsy, and many of the treatments that are subsequently administered are complementary and alternative treatments.H-NK: Writing-Original Draft, Investigation, Data Curation; J-HK: Investigation, Data Curation; BG: Conceptualization, Methodology, Formal analysis, Investigation, Writing-Review & Editing; S-SN: Writing-Review & Editing, Supervision, Project administration, Funding acquisition. All authors approved the final manuscript.Conceptualization: Bonhyuk Goo.Data curation: Ha-Na Kim, Jung-Hyun Kim.Formal analysis: Bonhyuk Goo.Funding acquisition: Sang-Soo Nam.Investigation: Ha-Na Kim, Jung-Hyun Kim, Bonhyuk Goo.Methodology: Bonhyuk Goo.Project administration: Sang-Soo Nam.Supervision: Sang-Soo Nam.Writing – original draft: Ha-Na Kim.Writing – review & editing: Bonhyuk Goo, Sang-Soo Nam.